Comparative Utilization of Laminoplasty in the United States and Japan.

Introduction: Laminoplasty is a well-established technique used to manage cervical myelopathy (CM). Nevertheless, the degree to which United States surgeons have adopted laminoplasty from Japan to treat CM is less clear. The purpose of this study was to compare operative management strategies for CM in the United States (US) with Japan. Methods: This study used a retrospective cohort of 16,084 patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and 389,872 patients from the Japanese Diagnosis Procedure Combination (DPC) database from 2007 to 2015. Patients with the following diagnoses were collected: spondylosis with myelopathy (ICD-19; 721.1, ICD-10; M47.12) and disk herniation with myelopathy (ICD-9; 722.71, ICD-10; M50.00). The proportion of surgeries between Japan and the US was compared using a linear regression model controlling for year. Results: US surgeons utilized anterior procedures in 70% of cases compared to 9% in Japan (p<.001). In contrast, Japan had significantly more laminoplasties than the US (43% vs. 4%, respectively, p<.001). The percentage of laminoplasty in Japan (43%) relative to the percentage in the US (4%) was significantly different (p<.001). Accounting for increases in the number of total surgeries per year seen in the ACS-NSQIP and DPC databases, no specific surgery demonstrated a significant increase or decrease over the 8 years. Conclusions: Japanese surgeons employ laminoplasty to treat CM approximately ten times more frequently than US surgeons who prefer anterior procedures.

A Patient-specific Approach to Alignment and Proximal Junctional Kyphosis Risk Assessment in Adult Spinal Deformity Surgery: Development and Validation of a Predictive Tool.

STUDY DESIGN: This was a single-institution, retrospective cohort study. OBJECTIVE: We aimed to develop a predictive model for proximal junctional kyphosis (PJK) severity that considers multiple preoperative variables and modifiable surgical alignment. SUMMARY OF BACKGROUND DATA: PJK is a common complication following adult deformity surgery. Current alignment targets account for age and pelvic incidence but not other risk factors. MATERIALS AND METHODS: This is a single-institution, retrospective cohort study of adult deformity patients with a minimum 2-year follow-up undergoing instrumented fusion between 2009 and 2018. A proportional odds regression model was fit to estimate PJK probability and Hart-International Spine Study Group (ISSG) PJK severity score. Predictors included preoperative Charlson Comorbidity Index, vertebral Hounsfield Units near the upper instrumented vertebrae, pelvic incidence, T1-pelvic angle, and postoperative L1-L4 and L4-S1 lordosis. Predictor effects were assessed using adjusted odds ratios and a nomogram constructed for estimating PJK probability. Bootstrap resampling was used for internal validation. RESULTS: Of 145 patients, 47 (32%) developed PJK. The median PJK severity score was 6 (interquartile range, 4-7.5). After adjusting for predictors, Charlson Comorbidity Index, Hounsfield Units, preoperative T1-pelvic angle, and postoperative L1-L4 and L4-S1 lordosis were significantly associated with PJK severity ( P <0.05). After adjusting for potential overfitting, the model showed acceptable discrimination [ C -statistic (area under the curve)=0.75] and accuracy (Brier score=0.10). CONCLUSIONS: We developed a model to predict PJK probability, adjusted for preoperative alignment, comorbidity burden, vertebral bone density, and modifiable postoperative L1-L4 and L4-S1 lordosis. This approach may help surgeons assess the patient-specific risk of developing PJK and provide a framework for future predictive models assessing PJK risk after adult deformity surgery. LEVEL OF EVIDENCE: Level III.

When does CT myelography add value beyond MRI for lumbar degenerative disease?

BACKGROUND CONTEXT: In patients with lumbar spinal stenosis, it is crucial for clinicians to identify all symptomatic levels. Prior studies have demonstrated that CT myelography has a greater sensitivity in revealing stenosis (94.4%) compared to MRI (75.9%). However, this is an invasive test that should be used judiciously. No study has identified subgroups of patients that do or do not benefit from this additional invasive testing. PURPOSE: The objective of this study was to identify subgroups of patients with lumbar stenosis for whom CT myelogram could be expected to provide additional information following an MRI scan. STUDY DESIGN: Retrospective chart review. PATIENT SAMPLE: Consecutive series of patients with lumbar degenerative disease seen at a single multisurgeon tertiary spine center. OUTCOME MEASURES: Degree of stenosis on MRI or CT myelo. METHODS: Medical records were reviewed to collect standard demographic and surgical data and patient diagnoses. MRI and CT myelo obtained within 6 months of each other in patients >45 years old with a diagnosis of central stenosis, spondylolisthesis or degenerative scoliosis were reviewed. Each lumbar level was recorded as mild, moderate, or severe based on the radiologist's report. Fisher exact test was performed with change in recorded severity of stenosis from MRI to CT myelo as the primary outcome of interest. RESULTS: Of 269 patients, 207 (80%) had at least one level of moderate or severe central stenosis on MRI and 62 had mild or no stenosis on MRI. Of the 207, 139 (67%) had multilevel stenosis and 68 (33%) had single level stenosis. CT myelo identified a greater proportion of additional stenotic levels in patients with multilevel stenosis (80/139, 58%) compared to patients with single-level stenosis (27/68, 40%, p=.018). In 62 patients with a clinical diagnosis of lumbar stenosis but no moderate to severe stenosis on MRI, CT myelogram identified three additional stenotic levels (3/65, 5%, p=.836). CONCLUSIONS: CT myelography is not as useful in providing additional information in patients with no stenosis or single level stenosis as compared to patients with multilevel stenosis.

Optimal Trajectory and Length of S2 Alar Iliac Screws: A 3-Dimensional Computed-aided Design Study.

STUDY DESIGN: A radiographic study of computed tomography scans of the pelvis converted to 3-dimensional imaging. OBJECTIVE: The objective of this study was to determine the optimal length and trajectory of S2 alar iliac (S2AI) screws. SUMMARY OF BACKGROUND DATA: Solid pelvic fixation is a necessary component in thoracolumbar deformity surgery to protect sacral fixation and promote arthrodesis. The S2AI technique has been promoted as a way to reduce hardware prominence and instrumentation issues associated with traditional iliac fixation. MATERIALS AND METHODS: In total, 64 of 100 patients randomly selected from our institution's spine registry were able to be converted to 3-dimensional imaging. Virtual screws were then placed in the optimal position for an S2AI screw on each side of the pelvis. The lateral and inferior angles were measured off-axial and sagittal planes, respectively. The distances from the notch and the remaining available screw length were also recorded. RESULTS: The average patient age was 38±16 years. The average lateral angle was 42.5±2.0 degrees and the inferior angle was 18.2±1.8 degrees. The screws fit bilaterally in all 64 patients without cortical breach. The remaining available screw distance was measured in all patients and found to be 40.5±8.7 mm. The average distance from the sciatic notch was 13.8±4.1 mm. Men had significantly more potential screw length when compared with women. CONCLUSIONS: We found an average inferior angle of 18.2 degrees, which is less than the previously described angle range of 20-40 degrees. These findings suggest that an ideal trajectory may be significantly different than the previously described trajectory. We found that with the optimal trajectory, a 100 mm screw can fit in all patients without concern for cortical breach of the pelvis or violation of the hip joint.

Utility of Anxiety/Depression Domain of EQ-5D to Define Psychological Distress in Spine Surgery.

BACKGROUND: Prospective patient-reported outcomes (PROs) registries are central to emerging evidence-driven reform models. These registries entail significant operator and responder burden to capture PROs data. It is important to limit the number of PROs administered. We sought to determine whether the anxiety/depression domain of EQ-5D could be used to define preoperative psychological distress in patients undergoing elective spine surgery. METHODS: Patients undergoing elective spine surgery and enrolled into a prospective registry were analyzed. The 12-Item Short-Form Health Survey Mental Component Summary, Zung depression scale, Modified Somatic Perception Questionnaire, and EQ-5D were completed. The anxiety/depression domain of EQ-5D was used to define psychological distress; responses were captured as 1) not anxious or depressed, 2) moderately anxious or depressed, or 3) extremely anxious or depressed. Univariate correlation and proportional odds logistic regression analyses were conducted. RESULTS: Of 2470 included patients undergoing elective spine surgery, 45% (n = 1109) reported no psychological distress, 47% (n = 1168) reported moderate psychological distress, and 8% (n = 193) reported extreme psychological distress on EQ-5D. Psychological distress on EQ-5D had positive correlation with Zung depression scale (P < 0.0001, r = 0.620) and Modified Somatic Perception Questionnaire (P < 0.0001, r = 0.450) and negative correlation with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, r = -0.662). In proportional odds logistic regression models, EQ-5D psychological distress had significant correlations with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, C-index = 0.831), Zung depression scale (P < 0.0001, C-index = 0.802), and Modified Somatic Perception Questionnaire (P < 0.0001, C-index = 0.711). CONCLUSIONS: The anxiety/depression domain of EQ-5D could be used to categorize preoperative psychological distress. Spine registries could use this information to potentially limit the number of validated PROs administered.

Effect of Modified Japanese Orthopedic Association Severity Classifications on Satisfaction With Outcomes 12 Months After Elective Surgery for Cervical Spine Myelopathy.

STUDY DESIGN: This study retrospectively analyzes prospectively collected data. OBJECTIVE: Here, we aim to determine the influence of preoperative and 12-month modified Japanese Orthopedic Association (mJOA) on satisfaction and understand the change in mJOA severity classification after surgical management of degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: DCM is a progressive degenerative spine disease resulting from cervical cord compression. The natural progression of DCM is variable; some patients experience periods of stability, while others rapidly deteriorate following disease onset. The mJOA is commonly used to grade and categorize myelopathy symptoms, but its association with postoperative satisfaction has not been previously explored. METHODS: The quality and outcomes database (QOD) was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9 to 13), or severe (<9) categories on the mJOA scores. A McNemar-Bowker test was used to assess whether a significant proportion of patients changed mJOA category between preoperative and 12 months postoperative. A multivariable proportional odds ordinal logistic regression model was fitted with 12-month satisfaction as the outcome of interest. RESULTS: We identified 1963 patients who underwent elective surgery for DCM and completed 12-months follow-ups. Comparing mJOA severity level preoperatively and at 12 months revealed that 55% remained in the same category, 37% improved, and 7% moved to a worse category. After adjusting for baseline and surgery-specific variables, the 12-month mJOA category had the highest impact on patient satisfaction (P < 0.001). CONCLUSION: Patient satisfaction is an indispensable tool for measuring quality of care after spine surgery. In this sample, 12-month mJOA category, regardless of preop mJOA, was significantly correlated with satisfaction. Given these findings, it is important to advise patients of the probability that surgery will change their mJOA severity classification and the changes required to achieve postoperative satisfaction. LEVEL OF EVIDENCE: 3.

Emergency Department Visits After Elective Spine Surgery.

BACKGROUND: Emergency department (ED) overuse is a costly and often neglected source of postdischarge resource utilization after spine surgery. Failing to investigate drivers of ED visits represents a missed opportunity to improve the value of care in spine patients. OBJECTIVE: To identify the prevalence, drivers, and timing of ED visits following elective spine surgery. METHODS: Patients undergoing elective spine surgery for degenerative disease at a major medical center were enrolled in a prospective longitudinal registry. Patient and surgery characteristics, and patient-reported outcomes were recorded at baseline and 3 mo after surgery, along with self-reported 90-d ED visits. A multivariable regression model was used to identify independent factors associated with 90-d ED visits. For a sample of patients presenting to our institution's ED, charts were reviewed to identify the reason and time to ED postdischarge. RESULTS: Of 2762 patients, we found a 90-d ED visit rate of 9.4%. One-third of patients presented to our institution's ED and of these, 70% presented due to pain or medical concerns at 9 and 7 d postdischarge, respectively, with 60% presenting outside normal clinic hours. Independent risk factors for 90-d ED visits included younger age, preoperative opioid use, chronic obstructive pulmonary disorder, and more vertebral levels involved. CONCLUSION: Nearly 10% of elective spine patients had 90-d ED visits not requiring readmission. Pain and medical concerns accounted for 70% of visits at our center, occurring within 10 d of discharge. This study provides the clinical details and a timeline necessary to guide individualized interventions to prevent unnecessary, costly ED visits after spine surgery.

Causes and Timing of Unplanned 90-day Readmissions Following Spine Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to evaluate the causes, timing, and factors associated with unplanned 90-day readmissions following elective spine surgery. SUMMARY OF BACKGROUND DATA: Unplanned readmissions after spine surgery are costly and an important determinant of the value of care. Several studies using database information have reported on rates and causes of readmission. However, these often lack the clinical detail and actionable data necessary to guide early postdischarge interventions. METHODS: Patients undergoing elective spine surgery for degenerative disease at a major medical center were enrolled in a prospective longitudinal registry. Patient and surgery-specific characteristics, baseline, and 3-month patient-reported outcomes were prospectively recorded. Readmissions were reviewed retrospectively to establish the reason and time to readmission. A multivariable Cox proportional hazard model was created to analyze the independent effects of several factors on readmission. RESULTS: Of 2761 patients with complete 3-month follow-up, 156 had unplanned 90-day readmissions (5.6%). The most common reason was surgery-related (52%), followed by medical complications (38%) and pain (10%). Pain readmissions presented with a median time of 6 days. Medical readmissions presented at 12 days. Surgical complications presented at various times with wound complications at 6 days, cerebrospinal fluid leaks at 12 days, surgical site infections at 23 days, and surgical failure at 38 days. A history of myocardial infarction, osteoporosis, higher baseline leg and arm pain scores, longer operative duration, and lumbar surgery were associated with readmission. CONCLUSION: Nearly half of all unplanned 90-day readmissions were because of pain and medical complications and occurred with a median time of 6 and 12 days, respectively. The remaining 52% of readmissions were directly related to surgery and occurred at various times depending on the specific reason. This timeline for pain and medical readmissions represents an opportunity for targeted postdischarge interventions to prevent unplanned readmissions following spine surgery. LEVEL OF EVIDENCE: 3.

Incidence and Radiographic Predictors of Valgus Tibiotalar Tilt After Hindfoot Fusion.

BACKGROUND: The development of valgus tibiotalar tilt following hindfoot arthrodesis is rarely discussed in the literature. The purpose of this study was to determine the incidence of valgus tibiotalar tilt and to evaluate if there were any radiographic predictors for the development of valgus tibiotalar tilt. METHODS: Patients who underwent hindfoot fusion between January 1, 2004 and December 31, 2013 were identified. Charts were reviewed for demographic information and operative details. Preoperative and postoperative radiographs were reviewed for the development of tibiotalar tilt, and standardized measurements and angles were calculated. A total of 187 patients were included. There were 106 (56.7%) females and 81 (43.3%) males. The average age was 52 years (range, 11-82 years). The most common indication for surgery was adult-acquired flatfoot deformity (n = 92, 49.2%), followed by arthritis (n = 83, 44.4%). The most common procedure was triple arthrodesis (n = 101, 54%). Twenty-seven patients demonstrated tibiotalar tilt preoperatively. RESULTS: A total of 51 patients (27.3%) developed valgus tibiotalar tilt postoperatively at an average of 3.6 months after surgery. We found that an increase in the preoperative Meary (lateral talar-first metatarsal) angle (hazard ratio, 1.039; 95% confidence interval, 1.002-1.077; P < .05) was associated with the development of tibiotalar tilt. An increase in the postoperative Meary angle (hazard ratio, 1.052; 95% confidence interval, 0.999-1.108; P = .0528) approached significance for the development of tibiotalar tilt. CONCLUSION: The development of valgus tibiotalar tilt following hindfoot fusion was a notable phenomenon, occurring in 27% of our patient population. The preoperative Meary angle was the only radiographic measurement that was significantly associated with the development of valgus tibiotalar tilt, although the postoperative Meary angle approached significance. These findings should encourage surgeons to be aware of patients with large deformities and of their propensity to develop a valgus deformity about the ankle. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

No Incidence of Postoperative Knee Sepsis With Suprapatellar Nailing of Open Tibia Fractures.

OBJECTIVE: To evaluate the incidence of knee sepsis after suprapatellar (SP) nailing of open tibia fractures. DESIGN: Retrospective; Setting: ACS level 1 trauma center. PATIENTS/PARTICIPANTS: We reviewed 139 open tibia fractures that underwent SP nailing as definitive treatment over a 5-year period (January 1, 2011 to January 1, 2016). Most patients (90%, n = 126) underwent intramedullary nailing at the time of their initial surgery. We defined knee sepsis as intra-articular infection requiring operative debridement, either open or arthroscopically, within 1 month's time. INTERVENTION: Open tibia fractures treated with an SP tibial nail. MAIN OUTCOME MEASUREMENTS: Demographic data, fracture characteristics, Gustilo and Anderson classification of open fractures, and occurrence of knee sepsis. RESULTS: In 139 open tibia fractures, there were no cases of knee sepsis in the 30 days after treatment with an SP intramedullary nail. Eighty-seven percent of our cohort had Gustilo and Anderson type II (41%) or type III (46%) open fractures. Most open fractures (83%) underwent primary wound closure during the index procedures. Twenty-five limbs (18%) had evidence of infection at the open fracture site of their open fracture necessitating operative intervention and/or antibiotics: none, however, developed knee sepsis. CONCLUSIONS: Although the SP approach carries intra-articular risks, we found a low risk of knee sepsis using this technique in the treatment of open tibia fractures. Our data suggest that there is no greater risk of intra-articular infection using an SP portal as compared with an infrapatellar one. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Injury Rate and Patterns Among CrossFit Athletes.

BACKGROUND: CrossFit is a type of competitive exercise program that has gained widespread recognition. To date, there have been no studies that have formally examined injury rates among CrossFit participants or factors that may contribute to injury rates. PURPOSE: To establish an injury rate among CrossFit participants and to identify trends and associations between injury rates and demographic categories, gym characteristics, and athletic abilities among CrossFit participants. STUDY DESIGN: Descriptive epidemiology study. METHODS: A survey was conducted, based on validated epidemiologic injury surveillance methods, to identify patterns of injury among CrossFit participants. It was sent to CrossFit gyms in Rochester, New York; New York City, New York; and Philadelphia, Pennsylvania, and made available via a posting on the main CrossFit website. Participants were encouraged to distribute it further, and as such, there were responses from a wide geographical location. Inclusion criteria included participating in CrossFit training at a CrossFit gym in the United States. Data were collected from October 2012 to February 2013. Data analysis was performed using Fisher exact tests and chi-square tests. RESULTS: A total of 486 CrossFit participants completed the survey, and 386 met the inclusion criteria. The overall injury rate was determined to be 19.4% (75/386). Males (53/231) were injured more frequently than females (21/150; P = .03). Across all exercises, injury rates were significantly different (P < .001), with shoulder (21/84), low back (12/84), and knee (11/84) being the most commonly injured overall. The shoulder was most commonly injured in gymnastic movements, and the low back was most commonly injured in power lifting movements. Most participants did not report prior injury (72/89; P < .001) or discomfort in the area (58/88; P < .001). Last, the injury rate was significantly decreased with trainer involvement (P = .028). CONCLUSION: The injury rate in CrossFit was approximately 20%. Males were more likely to sustain an injury than females. The involvement of trainers in coaching participants on their form and guiding them through the workout correlates with a decreased injury rate. The shoulder and lower back were the most commonly injured in gymnastic and power lifting movements, respectively. Participants reported primarily acute and fairly mild injuries.

Articular shear of the anterior-inferior quadrant of the glenoid: a glenolabral articular disruption lesion variant.

Traumatic cartilage lesions of the shoulder, such as glenolabral articular disruption (GLAD), have previously been recognized in patients with shoulder instability. We describe a new lesion in which the entire anteroinferior quadrant of the glenoid articular cartilage is sheared off in association with an adjacent labral tear. Both patients were teenage athletes who were being treated arthroscopically for shoulder instability. Preoperative imaging showed some evidence of an articular cartilage lesion. One patient was treated with removal of an irreparable fragment and microfracture, while in the other case the cartilage flap was reattached to the glenoid with a chondral fixation device. This GLAD lesion variant is a serious cartilage injury to the shoulder in young athletes that may be subtle, but needs to be recognized for proper arthroscopic treatment.

Implications of 25% to 50% coronary stenosis with cardiac computed tomographic angiography in ED patients.

OBJECTIVE: The aim of this study was to determine if patients presenting with symptoms of acute coronary syndrome and found to have 25% to 50% diameter reduction with coronary computed tomographic angiography (CCTA) are likely to benefit from further diagnostic testing. METHODS: A registry study of 213 subjects (median age, 51 years; 53% women) with symptoms concerning for possible acute coronary syndrome with low-risk features found to have 25% to 50% maximal diameter stenosis on CCTA was performed at 2 academic medical centers. The analysis was approved by an institutional review board and was conducted with waiver of consent. The potential contribution of additional testing was determined by measuring the major adverse cardiac events (MACEs) from presentation through 30 days. The MACEs included myocardial infarction, coronary revascularization, unstable angina, and cardiovascular death. Sample size calculations were predicated on a 0% MACE rate leading to upper bounds of a 2-sided exact 95% confidence interval less than 2%. RESULTS: Thrombolysis in myocardial infarction risk score of less than 2 was present in 92% subjects, 70% (150 of 213) had 2 or more serial cardiac markers performed, and 40% (87 of 213) had stress testing or cardiac catheterization. The MACEs occurred in 1 (0.5%) of 213 subjects (95% confidence interval, 0%-2.6%) and was identified by an elevation of serial cardiac markers during the index hospitalization. No patients experienced cardiovascular death or required revascularization. CONCLUSIONS: In patients with emergent low-risk chest pain and 25% to 50% diameter coronary stenosis by CCTA, the rate of near-term MACE is very low. Serial cardiac markers may be beneficial in this subgroup. Routine provocative testing is unlikely to be beneficial during the index visit.

Young patients with chest pain: 1-year outcomes.

OBJECTIVE: Prior studies found that young adult chest pain patients without known cardiac disease with either no cardiac risk factors or a normal electrocardiogram (ECG) are at low risk (<1%) for acute coronary syndromes (ACS) and 30-day cardiovascular events. Longer-term event rates in this subset of patients are unknown. We hypothesized that patients younger than 40 years without past cardiac history and a normal ECG are at less than 1% risk for 1-year adverse cardiovascular events. METHODS: We conducted a prospective cohort study in an urban university emergency department evaluating patients younger than 40 years who received an ECG for evaluation of potential ACS. Cocaine users, cancer patients, and patients with a history of myocardial infarction or revascularization were excluded. Structured data collection at presentation included demographics, chest pain description, history, laboratory results, and ECG data. Hospital course was followed. Follow-up was obtained by telephone, record review, and social security death index search. Our main outcome was 1-year adverse cardiovascular events (death; acute myocardial infarction [AMI]; or revascularization-percutaneous coronary intervention [PCI] or coronary artery bypass graft). Descriptive statistics and 95% confidence intervals were used. RESULTS: Of 3846 chest pain patients, 609 met criteria. Of those, 35.5% were admitted. Patients had a mean age of 34.8 years (SD, 3.8 years). They were most often female (57.6%) and black (69.5%). There were 7 patients (1.1%; 95% CI, 0.5%-2.4%) with adverse cardiovascular events over the year. Of the subset of 560 patients with a normal/nonspecific ECG, there were 2 deaths (0.4%), 3 AMI (0.5%), and 2 PCIs (0.4%) by 1 year for a composite adverse cardiovascular event rate of 6 (1.1%; 95% CI, 0.4%-2.3%). Of the subset of 269 patients with no cardiac risk factors and a normal/nonspecific ECG, there were no deaths, 1 AMI, and 1 PCI for a composite adverse cardiovascular event rate at 1 year of 0.3% (0.01%-2.1%). The addition of an initial cardiac marker to this group resulted in a cohort that was event-free at 1 year (95% CI, 0%-1.4%). CONCLUSIONS: Patients younger than 40 years without a cardiac history who present to the ED with symptoms consistent with ACS but have either no risk factors or a normal or nonspecific ECG have a very low rate of adverse events during the subsequent year.

Relation between thrombolysis in myocardial infarction risk score and one-year outcomes for patients presenting at the emergency department with potential acute coronary syndrome.

The Thrombolysis in Myocardial Infarction (TIMI) score, derived from unstable angina/non-ST-segment elevation acute myocardial infarction patient population, predicts 14-day cardiovascular events. It has been validated in emergency department (ED) patients with potential acute coronary syndrome with respect to 30-day outcomes. Our objective was to determine whether the initial TIMI score could risk stratify ED patients with potential acute coronary syndrome with respect to the 1-year outcomes. This was a prospective cohort study of patients presenting to the ED with chest pain who underwent electrocardiography. Patients with ST-segment elevation myocardial infarction (acute myocardial infarction) were excluded. Follow-up was conducted by telephone and record review >1 year after the index visit. The main outcome was the 1-year mortality, nonfatal acute myocardial infarction, or revascularization stratified by the TIMI score. Of 2,819 patients, 253 (9%) met the composite outcome. The overall incidence of the composite 1-year outcome of death (n = 119), acute myocardial infarction (n = 96), and revascularization (n = 90) according to TIMI score was TIMI 0 (n = 1,162), 4%; TIMI 1 (n = 901), 8%; TIMI 2 (n = 495), 13%; TIMI 3 (n = 193), 23%; TIMI 4 (n = 60), 28%; and TIMI 5 to 7 (n = 8), 88% (p <0.001). In conclusion, in addition to risk stratifying ED patients with chest pain at the initial ED evaluation, the TIMI score can also predict the 1-year cardiovascular events in this patient population.