Modified Frailty Index Does Not Provide Additional Value in Predicting Outcomes in Patients Undergoing Elective Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: To determine the predictive value of the modified Frailty Index (mFI) in evaluating sarcopenia and clinical outcomes in patients undergoing 1-level or 2-level transforaminal lumbar interbody fusion (TLIF). METHODS: Patients who underwent a 1-level or 2-level TLIF between 2012 and 2020 were retrospectively identified. Frailty was compared among groups using mFI, and sarcopenia was classified by the psoas muscle cross-sectional area. Bivariate statistics compared demographics, comorbidities, and clinical outcomes. A linear regression model was developed using the Charlson Comorbidity Index (CCI) or mFI as independent variables to determine potential predictors for improvement in 1-year patient-reported outcomes. RESULTS: Of 488 included patients, 60 were severely frail and 60 patients had sarcopenia, but sarcopenia was not associated with patient frailty (P = 0.469). Severely frail patients had worse baseline Oswestry Disability Index (ODI) (P < 0.001), Mental Component Score-12 (P = 0.001), and Physical Component Score-12 (P < 0.001), and worse improvement in ODI (P = 0.037), Physical Component Score-12 (P < 0.001), and visual analog scale (VAS) back (P = 0.007). mFI was an independent predictor of poorer improvement in VAS back and ODI, whereas age + CCI in addition predicted poorer improvement in VAS leg. Patients with higher mFI experienced longer length of stay, less frequent home discharge, and higher rates of complications, but similar readmission and reoperation rates. CONCLUSIONS: Frailer patients experience poorer improvement in back pain, physical functioning, and disability after TLIF. mFI and the combination of age and CCI comparably predict patient-reported outcomes but do not correlate to baseline sarcopenia. Frailty increased the risk of complications, length of hospital stay, and risk of nonhome discharge.

Does change in focal lordosis after spinal fusion affect clinical outcomes in degenerative spondylolisthesis?

Study Design: Retrospective cohort study. Objective: The objective of this study is to determine the effect of focal lordosis and global alignment and proportion (GAP) scores on patient reported outcome measures (PROMs) after posterior lumbar fusion for patients with 1- or 2-level lumbar degenerative spondylolisthesis (DS). Summary of Background Data: In patients with DS, improvements in spinopelvic parameters are believed to improve clinical outcomes. However, the effect of changing focal lordosis in patients with 1-or 2-level degenerative lumbar spondylolisthesis is unclear. Materials and Methods: Postoperative spinopelvic parameters and perioperative focal lordosis changes were measured for 162 patients at a single academic center from January 2013 to December 2017. Patients were divided into three groups: >2° (lordotic group), between 2° and -2° (neutral group), and -2°° (kyphotic group). Patients were then reclassified based on GAP scores. Recovery ratios (RR) and the number of patients achieving the minimal clinically important difference (MCID) were calculated for PROMs. Standard descriptive statistics were reported for patient demographics and outcomes data. Multiple linear regression analysis controlled for confounders. Alpha was set at P < 0.05. Results: There was no significant association between change in focal lordosis and surgical complications including adjacent segment disease (P = 0.282), instrumentation failure (P = 0.196), pseudarthrosis (P = 0.623), or revision surgery (P = 0.424). In addition, the only PROM affected by change in focal lordosis was Mental Component Scores (ΔMCS-12) (lordotic = 2.5, neutral = 8.54, and kyphotic = 5.96, P = 0.017) and RR for MCS-12 (lordotic = 0.02, neutral = 0.14, kyphotic 0.10, P = 0.008). Linear regression analysis demonstrated focal lordosis was a predictor of decreased improvement in MCS-12 (ß = -6.45 [-11.03- -1.83], P = 0.007). GAP scores suggested patients who were correctly proportioned had worse MCID compared to moderately disproportioned and severely disproportioned patients (P = 0.024). Conclusions: The change in focal lordosis not a significant predictor of change in PROMs for disability, pain, or physical function. Proportioned patients based on the GAP score had worse MCID for Oswestry Disability Index. Level of Evidence: III.

Comparison of Outcomes Including or Excluding the Level of Listhesis After ACDF in the Setting of Degenerative Spondylolisthesis.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The goal of this study is to evaluate the outcomes of patients with cervical degenerative spondylolisthesis (DS) undergoing anterior cervical discectomy and fusion (ACDF), specifically comparing surgeries that include versus exclude the DS level. SUMMARY OF BACKGROUND DATA: DS has been extensively studied in the lumbar spine associated with both back and leg pain leading to worse patient quality of life measures. Conversely, there is a relative dearth of literature regarding surgical and clinical outcomes in the setting of cervical DS. MATERIALS AND METHODS: A total of 315 patients undergoing ACDF between 2014 and 2018 with minimum of 1-year postoperative patient-reported outcome measures (PROMs) were retrospectively reviewed. Forty-six patients were found to have DS and were categorized based on whether an ACDF was performed at the same level (SL) or at a different level (DL) than the spondylolisthesis. Patient demographics, surgical parameters, preoperative and postoperative radiographs, and PROMs were compared between groups. RESULTS: Of the 315 patients, a total of 46 met the inclusion criteria including 21 SL and 25 DL patients. There were no significant differences in patient demographics between the groups. The SL cohort had a significantly worse preoperative sagittal vertical axis (SL: 34.4 vs. 26.1, P=0.025) but no difference in postoperative or delta sagittal vertical axis. Both patient cohorts reported significant postoperative improvement in all PROMs, except Short-Form 12 Mental Component Score in the SL group. There were no differences between the groups regarding Visual Analog Scale Neck, Visual Analog Scale Arm, Neck Disability Index, or Short-Form 12 Physical Component Score. Regression analysis demonstrated SL to be a significant negative predictor for improvement in Short-Form 12 Mental Component Score (ß: -11.27, P=0.10). CONCLUSION: Patients treated only at their neurologically symptomatic levels, excluding asymptomatic listhesis in their construct, can expect equivalent radiographic as well as physical function, disability, and pain outcomes 1 year after ACDF compared with patients whose listhetic level was included in their construct. LEVEL OF EVIDENCE: Level III.

How Does the Presence of a Surgical Trainee Impact Patient Outcomes in Lumbar Fusion Surgery?

BACKGROUND: While the impact of trainee involvement in other surgical fields is well established, there is a paucity of literature assessing this relationship in orthopaedic spine surgery. The goal of this study was to further elucidate this relationship. METHODS: A retrospective cohort study was initiated on patients undergoing 1-3 level lumbar spine fusion at a single academic center. Operative reports from cases were examined, and patients were divided into 2 groups depending on whether a fellow or resident (F/R) or a physician's assistant (PA) was used as the primary assist. Patients with less than 1-year follow-up were excluded. Multiple linear regression was used to assess change in each patient-reported outcome, and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. RESULTS: One hundred and seventy-two patients were included in the F/R group compared with 178 patients in the PA group. No differences existed between groups for total surgery time, length of stay, 30- or 90-day readmissions, infection, or revision rates. No differences existed between groups in terms of patient-reported outcomes preoperatively or postoperatively. In addition, presence of a surgical trainee was not a significant predictor of patient outcomes or rates of infection, overall revision, or 30- and 90-day readmission rates. CONCLUSIONS: The results of this study indicate the presence of an orthopaedic spine F/R does not increase complication rates and does not affect short-term patient-reported outcomes in lumbar decompression and fusion surgery. LEVEL OF EVIDENCE: 3.

How Does Smoking Influence Patient-reported Outcomes in Patients After Lumbar Fusion?

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The goal of this study was to determine the effect of smoking on patient-reported outcome measurements (PROMs) after lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: Although smoking is known to decrease fusion rates after lumbar fusion, there is less evidence regarding the influence of smoking on PROMs after surgery. METHODS: Patients undergoing between 1 and 3 levels of lumbar fusion were divided into 3 groups on the basis of preoperative smoking status: never smokers (NS); current smokers (CS); and former smokers (FS). PROMs collected for analysis include the Physical Component Score (PCS-12), Mental Component Score (MCS-12), Oswestry Disability Index (ODI), and Visual Analogue Scale back (VAS back) and leg (VAS leg) pain scores. Preoperative and postoperative PROMs were compared between groups. A multiple linear regression analysis was performed to determine whether preoperative smoking status was a predictor of change in PROM scores. RESULTS: A total of 220 (60.1%) NS, 52 (14.2%) CS, and 94 (25.7%) FS patients were included. Patients in most groups improved within each of the PROMs analyzed (P<0.05). VAS leg pain (P=0.001) was found to significantly differ between groups, with NS and FS having less disability than CS (3.6 vs. 2.0, P=0.010; and 3.6 vs. 2.4, P=0.022; respectively). Being a CS significantly predicted less improvement in ODI (P=0.035), VAS back (P=0.034), and VAS leg (P<0.001) compared with NS. In addition, NS had a significantly lower 30-day readmission rate than CS or FS (3.2% vs. 5.8% and 10.6%, respectively, P=0.029). CONCLUSION: CS exhibited worse postoperative VAS leg pain and a lower recovery ratio than never smokers. In addition, being in the CS group was a significant predictor of decreased improvement in ODI, VAS back, and VAS leg scores. LEVEL OF EVIDENCE: Level III.

Does Smoking Status Influence Health-Related Quality of Life Outcome Measures in Patients Undergoing ACDF?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: Whereas smoking has been shown to affect the fusion rates for patients undergoing an anterior cervical discectomy and fusion (ACDF), the relationship between smoking and health-related quality of life outcome measurements after an ACDF is less clear. The purpose of this study was to evaluate whether smoking negatively affects patient outcomes after an ACDF for cervical degenerative pathology. METHODS: Patients with tumor, trauma, infection, and previous cervical spine surgery and those with less than a year of follow-up were excluded. Smoking status was assessed by self-reported smoking history. Patient outcomes, including Neck Disability Index, Short Form 12 Mental Component Score, Short Form 12 Physical Component Score (PCS-12), Visual Analogue Scale (VAS) arm pain, VAS neck pain, and pseudarthrosis rates were evaluated. Outcomes were compared between smoking groups using multiple linear and logistic regression, controlling for age, sex, and body mass index (BMI), among other factors. A P value <.05 was considered significant. RESULTS: A total of 264 patients were included, with a mean follow-up of 19.8 months, age of 53.1 years, and BMI of 29.6 kg/m2. There were 43 current, 69 former, and 152 nonsmokers in the cohort. At baseline, nonsmokers had higher PCS-12 scores than current smokers (P = .010), lower VAS neck pain than current (P = .035) and former (P = .014) smokers, as well as lower VAS arm pain than former smokers (P = .006). Postoperatively, nonsmokers had higher PCS-12 scores than both current (P = .030) and former smokers (P = .035). Smoking status was not a significant predictor of change in patient outcome in multivariate analysis. CONCLUSIONS: Whereas nonsmokers had higher function and lower pain than former or current smokers preoperatively, smoking status overall was not found to be an independent predictor of outcome scores after ACDF. This supports the notion that smoking status alone should not deter patients from undergoing ACDF for cervical degenerative pathology.

Depression Identified on the Mental Component Score of the Short Form-12 Affects Health Related Quality of Life After Lumbar Decompression Surgery.

STUDY DESIGN: This was a retrospective comparative study. OBJECTIVE: The goal of this study was to further elucidate the relationship between preoperative depression and patient-reported outcome measurements (PROMs) following lumbar decompression surgery. SUMMARY OF BACKGROUND DATA: The impact of preoperative depression on PROMs after lumbar decompression surgery is not well established. METHODS: Patients undergoing lumbar decompression between 1 and 3 levels were retrospectively identified. Patients were split into 2 groups using a preoperative Mental Component Score (MCS)-12 threshold score of 45.6 or 35.0 to identify those with and without depressive symptoms. In addition, patients were also split based on a pre-existing diagnosis of depression in the medical chart. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared, and a multiple linear regression analysis was performed. RESULTS: A total of 184 patients were included, with 125 (67.9%) in the MCS-12 >45.6 group and 59 (32.1%) in the MCS-12 ≤45.6 group. The MCS-12 ≤45.6 and MCS<35.0 group had worse baseline Oswestry Disability Index (ODI) (P<0.001 for both) and Visual Analogue Scale Leg (P=0.018 and 0.024, respectively) scores. The MCS ≤45.6 group had greater disability postoperatively in terms of SF-12 Physical Component Score (PCS-12) (39.1 vs. 43.1, P=0.015) and ODI (26.6 vs. 17.8, P=0.006). Using regression analysis, having a baseline MCS-12 scores ≤45.6 before surgical intervention was a significant predictor of worse improvement in terms of PCS-12 [ß=-4.548 (-7.567 to -1.530), P=0.003] and ODI [ß=8.234 (1.433, 15.035), P=0.010] scores than the MCS-12 >45.6 group. CONCLUSION: Although all patients showed improved in all PROMs after surgery, those with MCS-12 ≤45.6 showed less improvement in PCS-12 and ODI scores.

Do Preoperative Epidural Steroid Injections Increase the Risk of Infection After Lumbar Spine Surgery?

STUDY DESIGN: Retrospective study. OBJECTIVE: To elucidate an association between preoperative lumbar epidural corticosteroid injections (ESI) and infection after lumbar spine surgery. SUMMARY OF BACKGROUND DATA: ESI may provide diagnostic and therapeutic benefit; however, concern exists regarding whether preoperative ESI may increase risk of postoperative infection. METHODS: Patients who underwent lumbar decompression alone or fusion procedures for radiculopathy or stenosis between 2000 and 2017 with 90 days follow-up were identified by ICD/CPT codes. Each cohort was categorized as no preoperative ESI, less than 30 days, 30 to 90 days, and greater than 90 days before surgery. The primary outcome measure was postoperative infection requiring reoperation within 90 days of index procedure. Demographic information including age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI) was determined. Comparison and regression analysis was performed to determine an association between preoperative ESI exposure, demographics/comorbidities, and postoperative infection. RESULTS: A total of 15,011 patients were included, 5108 underwent fusion and 9903 decompression only. The infection rate was 1.95% and 0.98%, among fusion and decompression patients, respectively. There was no association between infection and preoperative ESI exposure at any time point (1.0%, P = 0.853), ESI within 30 days (1.37%, P = 0.367), ESI within 30 to 90 days (0.63%, P = 0.257), or ESI > 90 days (1.3%, P = 0.277) before decompression surgery. There was increased risk of infection in those patients undergoing preoperative ESI before fusion compared to those without (2.68% vs. 1.69%, P = 0.025). There was also increased risk of infection with an ESI within 30 days of surgery (5.74%, P = 0.005) and when given > 90 days (2.9%, P = 0.022) before surgery. Regression analysis of all patients demonstrated that fusion (P < 0.001), BMI (P < 0.001), and CCI (P = 0.019) were independent predictors of postoperative infection, while age, sex, and preoperative ESI exposure were not. CONCLUSION: An increased risk of infection was found in patients with preoperative ESI undergoing fusion procedures, but no increased risk with decompression only. Fusion, BMI, and CCI were predictors of postoperative infection.Level of Evidence: 3.

Current incidence of adjacent segment pathology following lumbar fusion versus motion-preserving procedures: a systematic review and meta-analysis of recent projections.

BACKGROUND CONTEXT: Lumbar fusion has shown to be an effective surgical management option when indicated, improving patient outcomes and functional status. However, concerns of adjacent segment pathology (ASP) due to reduced mobility at the operated segment have fostered the emergence of motion-preserving procedures (MPP). PURPOSE: To assess rates of radiographic adjacent segment degeneration (ASDeg) and symptomatic adjacent segment disease (ASDis) as well as reoperation rates due to ASP in patients who have undergone lumbar fusion compared to motion-preservation for degenerative disorders. STUDY DESIGN: Systematic Review and Meta-Analysis. METHODS: Following PRISMA guidelines, a systematic review and meta-analysis was conducted to find current (1/2012-12/2019) retrospective cohort studies and randomized controlled trials evaluating rates of ASDeg, ASDis, and reoperations due to lumbar ASP. RESULTS: A total of 1,751 patients (791 underwent fusion surgery and 960 motion-preserving procedures) in 19 publications were included in the final analysis. Overall incidence rates of ASDeg, ASDis, and reoperation rates were 27.8%, 7.6%, and 4.6%, respectively. Results showed no significant difference between the lumbar fusion versus MPP cohorts in incidence of ASDeg (36.4% vs. 19.2%, p: 0.06), ASDis (10.7% vs. 4.42%, p: 0.25), or reoperation due to ASP (7.40% vs. 1.80%, p: 0.19). Fixed-effects analysis revealed patients who underwent MPP had significantly lower odds of ASDeg (OR: 2.57, CI: 1.95, 3.35, p<.05) and reoperations (OR: 3.18, CI: 1.63, 6.21, p<.05) compared to lumbar fusion patients. CONCLUSIONS: This meta-analysis revealed no statistically significant difference in incidence of ASDeg, ASDis, or reoperations due to ASP for patients after lumbar fusion versus MPP. Weighted analysis, however, showed that MPP patients had significantly lower odds of ASDeg and reoperations due to ASP. While previous studies have established the biomechanical efficacy of MPP on cadaveric models, further high-quality studies are required to evaluate the long-term consequences of these procedures on patient-reported outcomes, postoperative complications, and associated inpatient/outpatient costs.

The Impact of Multiple Comorbid Mental Health Disorders on Health-related Quality of Life Following ACDF.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The goal was to determine whether comorbid depression and/or anxiety influence outcomes after anterior cervical discectomy and fusion (ACDF) for patients with degenerative cervical pathology. BACKGROUND DATA: The role preoperative mental health has on patient reported outcomes after ACDF surgery is not well understood. METHODS: Patients undergoing elective ACDF for degenerative cervical pathology were identified. Patients were grouped based on their preoperative mental health comorbidities, including patients with no history, depression, anxiety, and those with both depression and anxiety. All preoperative medical treatment for depression and/or anxiety was identified. Outcomes including Physical Component Score (PCS-12), Mental Component Score (MCS-12), Neck Disability Index (NDI), Visual Analogue Scale neck pain score (VAS Neck ), and Visual Analogue Scale arm pain score (VAS Arm) were compared between groups from baseline to postoperative measurements using multiple linear regression analysis-controlling for factors such as age, sex, and body mass index, etc. A P-value <0.05 was considered statistically significant. RESULTS: A total of 264 patients were included in the analysis, with an average age of 53 years and mean follow-up of 19.8 months (19.0-20.6). All patients with a diagnosis of depression or anxiety also reported medical treatment for the disease. The group with no depression or anxiety had significantly less baseline disability than the group with 2 mental health diagnoses, in MCS-12 (P=0.009), NDI (P<0.004), VAS Neck (P=0.003), and VAS Arm (P=0.001) scores. Linear regression analysis demonstrated that increasing occurrence of mental health disorders was not a significant predictor of change over time for any of the outcome measures included in the analysis. CONCLUSIONS: Despite more severe preoperative symptoms, patients with a preoperative mental health disorder(s) demonstrated significant improvement in postoperative outcomes after ACDF. No differences were identified in postoperative outcomes between each of the groups. LEVEL OF EVIDENCE: Level III.

Proton Pump Inhibitor Use Affects Pseudarthrosis Rates and Influences Patient-Reported Outcomes.

STUDY DESIGN: Retrospective cohort review. OBJECTIVES: Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF. METHODS: A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables. RESULTS: Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups (P = .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P = .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores (P = .022). CONCLUSIONS: PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.

Are Outcomes of Anterior Cervical Discectomy and Fusion Influenced by Presurgical Depression Symptoms on the Mental Component Score of the Short Form-12 Survey?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The purpose of this study was to investigate whether preoperative depressive symptoms, measured by mental component score of the Short Form-12 survey (MCS-12), influence patient-reported outcome measurements (PROMs) following an anterior cervical discectomy and fusion (ACDF) surgery for cervical degeneration. SUMMARY OF BACKGROUND DATA: There is a paucity of literature regarding preoperative depression and PROMs following ACDF surgery for cervical degenerative disease. METHODS: Patients who underwent an ACDF for degenerative cervical pathology were identified. A score of 45.6 on the MCS-12 was used as the threshold for depression symptoms, and patients were divided into two groups based on this value: depression (MCS-12 ≤45.6) and nondepression (MCS-12 >45.6) groups. Outcomes including Neck Disability Index (NDI), physical component score of the Short Form-12 survey (PCS-12), and Visual Analogue Scale Neck (VAS Neck), and Arm (VAS Arm) pain scores were evaluated using independent sample t test, recovery ratios, percentage of patients reaching the minimum clinically important difference, and multiple linear regression - controlling for factors such as age, sex, and BMI. RESULTS: The depression group was found to have significantly worse baseline pain and disability than the nondepression group in NDI (P < 0.001), VAS Neck pain (P < 0.001), and VAS Arm pain (P < 0.001) scores. Postoperatively, both groups improved to a similar amount with surgery based on the recovery ratio analysis. The depression group continued to have worse scores than the nondepression group in NDI (P = 0.010), PCS-12 (P = 0.026), and VAS Arm pain (P = 0.001) scores. Depression was not a significant predictor of change in any PROMs based on regression analysis. CONCLUSION: Patients who presented with preoperative depression reported more pain and disability symptoms preoperatively and postoperatively; however, both groups achieved similar degrees of improvement. LEVEL OF EVIDENCE: 3.

How Does Body Mass Index Influence Outcomes in Patients After Lumbar Fusion?

STUDY DESIGN: Retrospective study. OBJECTIVE: The purpose of the present study is to determine how body mass index (BMI) affects patient-reported outcome measurements (PROMs) after lumbar fusions. SUMMARY OF BACKGROUND DATA: Although greater preoperative BMI is known to increase the rates of adverse events after surgery, there is a paucity of literature assessing the influence of BMI on PROMs after lumbar fusion. METHODS: Patients undergoing lumbar fusion surgery between 1 and 3 levels were retrospectively identified. PROMs analyzed were the Short Form-12 Physical Component Score, Mental Component Score, Oswestry Disability Index (ODI), and Visual Analog Scale Back and Leg pain scores. Patients were divided into groups based on preoperative BMI: class 1, BMI <25.0; class 2, BMI 25.0 to 29.9; class 3, BMI 30.0 to 34.9; and class 4, BMI ≥35.0. Absolute PROM scores, the recovery ratio, and the percentage of patients achieving minimum clinically important difference between groups were compared. RESULTS: A total of 54 (14.8%) patients in class 1, 140 (38.2%) in class 2, 109 (29.8%) in class 3, and 63 (17.2%) in class 4 were included. All patients improved after surgery across all outcome measures (P < 0.001) except for class 4 patients, who did not improve in terms of Short Form-12 Mental Component Score scores after surgery (P = 0.276). Preoperative Short Form-12 Physical Component Score (P = 0.002) and Oswestry Disability Index (P < 0.0001) scores were significantly different between BMI groups-with class 4 having worse disability than class 1 and 2. BMI was not a significant predictor for any outcome domain. Overall 30- and 90-day readmission rates were similar between groups, with a higher revision rate in the class 4 group (P = 0.036), due to a higher incidence of postoperative surgical site infections (P = 0.014). CONCLUSION: All patients undergoing short-segment lumbar fusion for degenerative disease improved to a similar degree with respect to PROMs. Those in the highest class of obesity (BMI ≥35.0) were, however, at a greater risk for postoperative surgical site infection. LEVEL OF EVIDENCE: 3.

Does an Uninstrumented Level Increase the Rate of Revision Surgery in a Multilevel Posterior Cervical Decompression and Fusion?

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The goal of this study is to determine if skipping a single level affects the revision rate for patients undergoing multilevel posterior cervical decompression and fusion (PCDF). SUMMARY OF BACKGROUND DATA: A multilevel PCDF is a common procedure for patients with cervical spondylotic myelopathy. With advanced pathology, it can be difficult to safely place screw instrumentation at every level increasing the risk of intraoperative and perioperative morbidity. It is unclear whether skipping a level during PCDF affects fusion and revision rates. PATIENTS AND METHODS: A cervical spine surgeries database at a single institution was used to identify patients who underwent ≥3 levels of PCDF. Inclusion criteria consisted of patients who had screws placed at every level or if they had a single level without screws bilaterally. Patients were excluded if the surgery was performed for tumor, trauma, or infection, and age below 18 years, or if there was <1 year of follow-up. RESULTS: A total of 157 patients met inclusion criteria, with 86 undergoing a PCDF with instrumentation at all levels and 71 that had a single uninstrumented level. Overall mean follow-up was 46.5±22.8 months. In patients with or without a skipped level, the revision rate was 25% and 26%, respectively (P<1.00). Univariate regression analysis demonstrated that proximal fixation level in the upper cervical region, having the fusion end at C7, prior surgery, and myelopathy were significant predictors of revision. Skipping a single level, however, was not predictive of revision. CONCLUSIONS: When performing a multilevel PCDF, there is no increase in the rate of revision surgery if a single level is uninstrumented. Conversely, other surgical factors, including the cranial and caudal levels, affect revision rates. In contrast to other reports, the C2 sagittal vertical axis did not affect reoperation rates. LEVEL OF EVIDENCE: Level IV.

The Total Cost to the Health Care System in Medicare and Medicaid Patients for the Treatment of Cervical Myelopathy.

INTRODUCTION: Cervical myelopathy is a common indication for spine surgery. Modern medicine demands high quality, cost-effective treatment. Most cost analyses fail to account for complication costs from nonoperative treatment. The purpose is to compare the total health care costs for operative versus nonoperative treatment of cervical myelopathy. METHODS: The Center for Medicare and Medicaid Services Carrier File from 2005 to 2012 was reviewed using the PearlDiver database, representing a 5% sampling of Medicare billings which diagnosed patients with cervical myelopathy by International Classification of Diseases 9 code. Patients were separated into operative and nonoperative cohorts, and the total health care expenditures per patient normalized to 2012 dollars were collected. RESULTS: A total of 3209 patients were included, and 1755 (55.87%) underwent surgery. A 6-year cost analysis performed on 309 patients over the age of 65 from 2006 undergoing surgery resulted in a nonsignificant increase in total health care expenditures ($166,192 vs. $153,556; P=0.45). Operative treatment had a net decrease in total health care costs following the first year of surgery. CONCLUSIONS: There is no significant difference in the total health care expenditures for operative versus nonoperative treatment of cervical myelopathy after 3 years. It is critical to understand that nonoperative treatment of this progressive disease leads to a substantial increase in total health care expenditures with increased risk of falls, injury, and further morbidity.

Medicaid Reimbursement for Common Orthopedic Procedures Is Not Consistent.

Two major forms of physician reimbursement include Medicare (MCR; federally funded) and Medicaid (MCD; state funded). The only oversight provided to individual states for setting MCD reimbursement is that it must provide a standard payment that does not negatively affect patient care. The goals of this study were to determine the variability of MCD reimbursement for patients who require orthopedic procedures and to assess how this compares with regional MCR reimbursement. Medicaid reimbursement rates from each state were obtained for total knee arthroplasty, total hip arthroplasty, anterior cruciate ligament repair, rotator cuff repair, anterior cervical decompression and fusion, posterior lumbar decompression, carpal tunnel release, distal radius open reduction and internal fixation, proximal femur open reduction and internal fixation, and ankle open reduction and internal fixation. Discrepancy in reimbursement for these procedures and overall differences in MCD vs MCR reimbursement were determined. Average MCD reimbursement was 81.9% of MCR reimbursement. There was significant variation between states (37.7% to 147% of MCR reimbursement for all 10 procedures). Twenty and 40 states provided less than 75% and 100% of MCR reimbursements, respectively. Medicaid valued knee arthroplasty (91.4% of MCR reimbursement) over other common procedures. Conversely, carpal tunnel release (74.1% of MCR reimbursement; P=.004) had the lowest reimbursements. The most interstate variation was noted for anterior cruciate ligament reimbursement, ranging from 20.6% to 229% of local MCR reimbursement. Disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to understand the impact of these significant differences. It is likely that these discrepancies lead to suboptimal access to necessary orthopedic care. [Orthopedics. 2019; 42(2):e193-e196.].

Longer Preoperative Duration of Symptoms Negatively Affects Health-related Quality of Life After Surgery for Cervical Radiculopathy.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine the effect of duration of symptoms (DOS) on health-related quality of life (HRQOL) outcomes for patients with cervical radiculopathy. SUMMARY OF BACKGROUND DATA: The effect of DOS has not been extensively evaluated for cervical radiculopathy. METHODS: A retrospective analysis of patients who underwent an anterior cervical decompression and fusion for radiculopathy was performed. Patients were grouped based on DOS of less than 6 months, 6 months to 2 years, and more than 2 years and HRQOL outcomes were evaluated. RESULTS: A total of 216 patients were included with a mean follow-up of 16.0 months. There were 86, 61, and 69 patients with symptoms for less than 6 months, 6 months to 2 years, and more than 2 years, respectively. No difference in the absolute postoperative score of the patient reported outcomes was identified between the cohorts. However, in the multivariate analysis, radiculopathy for more than 2 years predicted lower postoperative Short Form-12 Physical Component Score (P = 0.037) and Short Form-12 Mental Component Score (P = 0.029), and higher postoperative Neck Disability Index (P = 0.003), neck pain (P = 0.001), and arm pain (P = 0.004) than radiculopathy for less than 6 months. Furthermore, the recovery ratios for patients with symptoms for less than 6 months demonstrated a greater improvement in NDI, neck pain, and arm pain than for 6 months to 2 years (P = 0.041; 0.005; 0.044) and more than 2 years (P = 0.016; 0.014; 0.002), respectively. CONCLUSION: Patients benefit from spine surgery for cervical radiculopathy at all time points, and the absolute postoperative score for the patient reported outcomes did not vary based on the duration of symptoms; however, the regression analysis clearly identified symptoms for more than 2 years as a predictor of worse outcomes, and the recovery ratio was statistically significantly improved in patients who underwent surgery within 6 months of the onset of symptoms. LEVEL OF EVIDENCE: 3.

Utilization of Time-driven Activity-based Costing to Determine the True Cost of a Single or 2-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This is a prospective case series. OBJECTIVE: To determine the actual cost of performing 1- or 2-level anterior cervical discectomy and fusion (ACDF) using actual patient data and the time-driven activity-based cost methodology. SUMMARY OF BACKGROUND DATA: As health care shifts to use value-based reimbursement, it is imperative to determine the true cost of surgical procedures. Time-driven activity-based costing determines the cost of care by determining the actual resources used in each step of the care cycle. MATERIALS AND METHODS: In total, 30 patients who underwent a 1- or 2-level ACDF by 3 surgeons at a specialty hospital were prospectively enrolled. To build an accurate process map, a research assistant accompanied the patient to every step in the care cycle including the preoperative visit, the preadmission testing, the surgery, and the postoperative visits for the first 90 days. All resources utilized and the time spent with every member of the care team was recorded. RESULTS: In total, 27 patients were analyzed. Eleven patients underwent a single-level ACDF and 16 underwent a 2-level fusion. The total cost for the episode of care was $29,299±$5048. The overwhelming cost driver was the hospital disposable costs ($13,920±$6325) which includes every item used during the hospital stay. Intraoperative personnel costs including fees for the surgeon, resident/fellow, anesthesia, nursing, surgical technician, neuromonitoring, radiology technician and orderlies, accounted for the second largest cost at $6066±$1540. The total cost excluding hospital overhead and disposables was $9071±$1939. CONCLUSIONS: Reimbursement for a bundle of care surrounding a 1- or 2-level ACDF should be no less than $29,299 to cover the true costs of the care for the entire care cycle. However, this cost may not include the true cost of all capital expenditures, and therefore may underestimate the cost.

Are Patients Undergoing an Anterior Cervical Discectomy and Fusion Treated Differently at a Physician-owned Hospital?

STUDY DESIGN: Retrospective case-control study. BACKGROUND: Physician-owned specialty hospitals focus on taking care of patients with a select group of conditions. In some instances, they may also create a potential conflict of interest for the surgeon. The effect this has on the surgical algorithm for patients with degenerative cervical spine conditions has not been determined. METHODS: A retrospective review of all patients who underwent a 1- or 2-level anterior cervical discectomy and fusion between October 2009 and December 2014 at either a physician-owned specialty hospital or an independently owned community hospital were identified. Demographic information, the time course for treatment and the nonoperative treatment regimen were evaluated. RESULTS: In total, 115 patients undergoing surgery at a physician-owned specialty hospital and 149 patients undergoing surgery at an independent community hospital were identified. Demographic data between the groups including the presence of 12 medical comorbidities and insurance status was similar between the groups. The only difference that was identified was that patients at the surgeon-owned hospital were marginally younger than patients who had surgery at the independent hospital (49.7 vs. 50.0, P=0.048). No difference in the median number of months from the onset of symptoms to surgery (6.51 vs. 7.53 mo, respectively; P=0.55), from the onset of symptoms to the preoperative visit (6.02 vs. 6.02, P=0.64), or from the initial surgical consultation to surgery (0.99 vs. 1.02, P=0.31) was identified. No difference in the number of patients who underwent formal physical therapy (72.2% vs. 67.1%, P=0.42) or who had a cervical steroid injection (55.6% vs. 50.3%, P=0.25%) was identified between patients who had surgery at a physician-owned or independent hospital; however, patients who underwent surgery at the physician-owned hospital were more likely to have taken oral anti-inflammatories (93.0% vs. 83.9%, P=0.04). CONCLUSIONS: When comparing hospitals with similar resources, surgeons do not preferentially select younger, healthier patients with higher paying insurance to be treated at the physician-owned hospital. Furthermore, both the time from the onset of symptoms to surgery and the nonoperative treatment regimen were similar between patients treated at the 2 facilities.

Descriptive Analysis of Associated Factors for Urgent Versus Nonurgent Inpatient Spine Transfers to a Tertiary Care Hospital.

Patients with spine-associated symptoms are transferred regularly to higher levels of care for operative intervention. It is unclear what factors lead to the transfer of patients with spine pathology to level I care facilities, and which transfers are indicated. All patients with isolated spinal pathology who were transferred from 2011 to 2015 were reviewed. Patients were divided into urgent transfers, defined as anyone who required operative intervention, and nonurgent transfers. Two hundred twenty-seven patients were transferred for isolated spinal pathology over 51 months; 109 (48.0%) patients required urgent intervention and 118 (52.0%) patients required nonurgent care. No significant differences were found between groups in terms of private insurance, age, sex, race, or Charlson comorbidity index. The urgent group was less likely to have a traumatic chief complaint (57.8% vs 78.0%, P = .001). More than half of all spine patients who were transferred to a tertiary care center required minimal intervention.