A Comparison of Wound Complications Following Total Hip Arthroplasty Performed Through the Direct Anterior Versus Direct Lateral Approach.

Background: Some studies have suggested the risk of wound complications may be higher using the direct anterior (DA) approach to total hip arthroplasty (THA). This study aimed to compare the risk of early postoperative wound complications between the DA and direct lateral (DL) approaches to THA and to determine patient risk factors that may contribute to this problem. Methods: All patients who underwent primary THA with a single surgeon over a 5-year period were retrospectively reviewed. All patients were treated with either the DA or DL approach. Data collected included patient demographics, surgical approach, and wound status. There was a minimum follow-up of 6 weeks to allow for an adequate assessment of surgical wound healing. Univariate and multivariate analyses were used to compare the 2 approaches. Results: Five hundred seventy-nine patients (77.6%) who underwent DA approach and 167 patients (22.4%) who underwent DL approach were included. Patients who underwent DL approach had a higher body mass index and a higher rate of diabetes than those treated with the DA approach. Forty patients (6.9%) in the DA cohort and 14 (8.4%) in the DL cohort experienced early wound complications, P = .523. After controlling for potential confounding variables, the surgical approach was not an independent risk factor for early postoperative wound complications. Conclusions: While there have been concerns regarding use of the DA approach in patients with higher body mass index and certain medical comorbidities, the results of this study suggest the choice of surgical approach may have minimal effect on the rate of early postoperative wound complications.

Sex-based Difference in Response to Recombinant Human Bone Morphogenetic Protein-2 in a Rat Posterolateral Fusion Model.

STUDY DESIGN: This was a preclinical study. OBJECTIVE: Evaluate sex-dependent differences in the bone healing response to recombinant human bone morphogenetic protein-2 (rhBMP-2) in a rat posterolateral spinal fusion model. SUMMARY OF BACKGROUND DATA: Minimal and conflicting data exist concerning potential sex-dependent differences in rhBMP-2-mediated bone regeneration in the context of spinal fusion. MATERIALS AND METHODS: Forty-eight female and male Sprague-Dawley rats (N=24/group), underwent L4-L5 posterolateral fusion with bilateral placement of an absorbable collagen sponge, each loaded with 5 µg of bone morphogenetic protein-2 (10 µg/animal). At eight weeks postoperative, 10 specimens of each sex were tested in flexion-extension with quantification of range of motion and stiffness. The remaining specimens were evaluated for new bone growth and successful fusion via radiography, blinded manual palpation and microcomputed tomography (microCT). Laboratory microCT quantified bone microarchitecture, and synchrotron microCT examined bone microstructure at the 1 µm level. RESULTS: Manual palpation scores differed significantly between sexes, with mean fusion scores of 2.4±0.4 in females versus 3.1±0.6 in males ( P <0.001). Biomechanical stiffness did not differ between sexes, but range of motion was significantly greater and more variable for females versus males (3.7±5.6° vs. 0.27±0.15°, P <0.005, respectively). Laboratory microCT showed significantly smaller volumes of fusion masses in females versus males (262±87 vs. 732±238 mm 3 , respectively, P <0.001) but significantly higher bone volume fraction (0.27±0.08 vs. 0.12±0.05, respectively, P <0.001). Mean trabecular thickness was not different, but trabecular number was significantly greater in females (3.1±0.5 vs. 1.5±0.4 mm -1 , respectively, P <0.001). Synchrotron microCT showed fine bone structures developing in both sexes at the eight-week time point. CONCLUSIONS: This study demonstrates sex-dependent differences in bone regeneration induced by rhBMP-2. Further investigation is needed to uncover the extent of and mechanisms underlying these sex differences, particularly at different doses of rhBMP-2.

Preclinical Safety of a 3D-Printed Hydroxyapatite-Demineralized Bone Matrix Scaffold for Spinal Fusion.

STUDY DESIGN: Prospective, randomized, controlled preclinical study. OBJECTIVE: The objective of this study was to compare the host inflammatory response of our previously described hyperelastic, 3D-printed (3DP) hydroxyapatite (HA)-demineralized bone matrix (DBM) composite scaffold to the response elicited with the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in a preclinical rat posterolateral lumbar fusion model. SUMMARY OF BACKGROUND DATA: Our group previously found that this 3D-printed HA-DBM composite material shows promise as a bone graft substitute in a preclinical rodent model, but its safety profile had yet to be assessed. METHODS: Sixty female Sprague-Dawley rats underwent bilateral posterolateral intertransverse lumbar spinal fusion using with the following implants: 1) type I absorbable collagen sponge (ACS) alone; 2) 10 µg rhBMP-2/ACS; or 3) the 3DP HA-DBM composite scaffold (n = 20). The host inflammatory response was assessed using magnetic resonance imaging, while the local and circulating cytokine expression levels were evaluated by enzyme-linked immunosorbent assays at subsequent postoperative time points (N = 5/time point). RESULTS: At both 2 and 5 days postoperatively, treatment with the HA-DBM scaffold produced significantly less soft tissue edema at the fusion bed site relative to rhBMP-2-treated animals as quantified on magnetic resonance imaging. At every postoperative time point evaluated, the level of soft tissue edema in HA-DBM-treated animals was comparable to that of the ACS control group. At 2 days postoperatively, serum concentrations of tumor necrosis factor-α and macrophage chemoattractant protein-1 were significantly elevated in the rhBMP-2 treatment group relative to ACS controls, whereas these cytokines were not elevated in the HA-DBM-treated animals. CONCLUSION: The 3D-printed HA-DBM composite induces a significantly reduced host inflammatory response in a preclinical spinal fusion model relative to rhBMP-2.Level of Evidence: N/A.

Osteoinductivity and biomechanical assessment of a 3D printed demineralized bone matrix-ceramic composite in a rat spine fusion model.

We recently developed a recombinant growth factor-free bone regenerative scaffold composed of stoichiometric hydroxyapatite (HA) ceramic particles and human demineralized bone matrix (DBM) particles (HA-DBM). Here, we performed the first pre-clinical comparative evaluation of HA-DBM relative to the industry standard and established positive control, recombinant human bone morphogenetic protein-2 (rhBMP-2), using a rat posterolateral spinal fusion model (PLF). Female Sprague-Dawley rats underwent bilateral L4-L5 PLF with implantation of the HA-DBM scaffold or rhBMP-2. Fusion was evaluated using radiography and blinded manual palpation, while biomechanical testing quantified the segmental flexion-extension range-of-motion (ROM) and stiffness of the fused segments at 8-weeks postoperatively. For mechanistic studies, pro-osteogenic gene and protein expression at 2-days and 1-, 2-, and 8-weeks postoperatively was assessed with another cohort. Unilateral fusion rates did not differ between the HA-DBM (93%) and rhBMP-2 (100%) groups; however, fusion scores were higher with rhBMP-2 (p = 0.008). Both treatments resulted in significantly reduced segmental ROM (p < 0.001) and greater stiffness (p = 0.009) when compared with non-operated controls; however, the degree of stabilization was significantly higher with rhBMP-2 treatment relative to the HA-DBM scaffold. In the mechanistic studies, PLGA and HA scaffolds were used as negative controls. Both rhBMP-2 and HA-DBM treatments resulted in significant elevations of several osteogenesis-associated genes, including Runx2, Osx, and Alp. The rhBMP-2 treatment led to significantly greater early, mid, and late osteogenic markers, which may be the mechanism in which early clinical complications are seen. The HA-DBM scaffold also induced osteogenic gene expression, but primarily at the 2-week postoperative timepoint. Overall, our findings show promise for this 3D-printed composite as a recombinant growth factor-free bone graft substitute for spinal fusion. STATEMENT OF SIGNIFICANCE: Despite current developments in bone graft technology, there remains a significant void in adequate materials for bone regeneration in clinical applications. Two of the most efficacious bone graft options are the gold-standard iliac crest bone graft and recombinant human-derived bone morphogenetic protein-2 (rhBMP-2), available commercially as Infuse™. Although efficacious, autologous graft is associated with donor-site morbidity, and Infuse™ has known side effects related to its substantial host inflammatory response, possibly associated with a immediate, robust osteoinductive response. Hence, there is a need for a bone graft substitute that provides adequate osteogenesis without associated adverse events. This study represents a significant step in the design of off-the-shelf growth factor-free devices for spine fusion.

ERK1/2 phosphorylation predicts survival following anti-PD-1 immunotherapy in recurrent glioblastoma.

Only a subset of recurrent glioblastoma (rGBM) responds to anti-PD-1 immunotherapy. Previously, we reported enrichment of BRAF/PTPN11 mutations in 30% of rGBM that responded to PD-1 blockade. Given that BRAF and PTPN11 promote MAPK/ERK signaling, we investigated whether activation of this pathway is associated with response to PD-1 inhibitors in rGBM, including patients that do not harbor BRAF/PTPN11 mutations. Here we show that immunohistochemistry for ERK1/2 phosphorylation (p-ERK), a marker of MAPK/ERK pathway activation, is predictive of overall survival following adjuvant PD-1 blockade in two independent rGBM patient cohorts. Single-cell RNA-sequencing and multiplex immunofluorescence analyses revealed that p-ERK was mainly localized in tumor cells and that high-p-ERK GBMs contained tumor-infiltrating myeloid cells and microglia with elevated expression of MHC class II and associated genes. These findings indicate that ERK1/2 activation in rGBM is predictive of response to PD-1 blockade and is associated with a distinct myeloid cell phenotype.

Characterizing the host response to rhPDGF-BB in a rat spinal arthrodesis model.

BACKGROUND: Due to the constraints surrounding autograft bone, surgeons have turned to osteoinductive agents to augment spinal fusion. Reports of complications and questionable efficacy slowed the adoption of these alternatives. Recombinant human platelet-derived growth factor B homodimer (rhPDGF-BB) has been Food and Drug Administration (FDA)-approved (Augment) to promote fusion in other areas of orthopedics, but its characterization in spine fusion has not yet been tested. The purpose of this study is to characterize the host response to PDGF-BB in vivo. METHODS: Eighty female Fischer rats underwent L4-5 posterolateral fusion using one of four implant types: (a) iliac crest syngeneic allograft harvested from syngeneic donors, (b) ß-TCP/bovine collagen matrix (ß-TCP/Col) with sodium acetate buffer, (c) ß-TCP/Col with 0.3 mg/mL "low dose," or (d) ß-TCP/Col with 3.0 mg/mL "high dose" of rhPDGF-BB. Animals underwent magnetic resonance imaging (MRI) and serum cytokine quantification at 4, 7, 10, and 21 days, postoperatively. Tissues were processed for immunofluorescence staining for Ki67 and von Willebrand factor (vWF) to assess neovascularization. RESULTS: MRI demonstrated no differences in fluid accumulation among the four treatment groups at any of the time points. Serum cytokine analysis showed no clinically significant differences between treatment groups in 20 of the 27 cytokines. Inflammatory cytokines IFN-γ, IL-1ß, IL-18, MCP-1, MIP-1α, TNF-α were not induced by rhPDGF-BB. Histology showed no differences in cell infiltration, and Ki67 and vWF immunofluorescence staining was similar among groups. CONCLUSIONS: rhPDGF-BB delivered with a ß-TCP/Col matrix exerts no exaggerated systemic or local host inflammatory response when compared to iliac crest syngeneic allograft bone or the control carrier. rhPDGF-BB mixed with a ß-TCP/Col matrix could be a viable and safe biologic alternative to syngeneic allograft in spine fusion. Further studies need to be performed to evaluate efficacy in this setting.

The effect of local steroid application on bony fusion in a rat posterolateral spinal arthrodesis model.

INTRODUCTION: Local steroid administration during anterior cervical spine surgery has been shown to improve postoperative dysphagia. However, concerns over potential complications remain. This study aims to evaluate the effect of local steroid administration on bone regeneration and spine fusion in a preclinical model, as well as the impact on osteogenic differentiation of human bone marrow-derived mesenchymal stem cells (hBM-MSCs) in a 3D culture system. MATERIALS AND METHODS: Forty-five rats underwent bilateral L4-L5 posterolateral lumbar fusion (PLF) utilizing local delivery of low-dose recombinant human bone morphogenetic protein-2 (rhBMP-2; 0.5 µg/implant). Rats were divided into three groups: no steroid (control), low dose (0.5 mg/kg), and high dose (2.5 mg/kg) of triamcinolone. Bone growth and fusion were assessed using radiography, blinded manual palpation, and micro-CT analysis and were visualized by histology. The impact of triamcinolone exposure on osteogenic differentiation of hBM-MSCs was evaluated by gene expression analysis, alkaline phosphatase activity assay, and alizarin red staining. RESULTS: No significant differences in fusion scores or rates were seen in the low- or high-dose steroid treatment groups relative to untreated controls. Quantification of new bone formation via micro-CT imaging revealed no significant between-group differences in the volume of newly regenerated bone. Triamcinolone also had no negative impact on pro-osteogenic gene transcript levels, and ALP activity was enhanced in the presence of triamcinolone. Mineral deposition appeared comparable in cultures grown with and without triamcinolone. CONCLUSIONS: Local steroid application does not seem to inhibit rhBMP-2-mediated spine fusion in rats, though our study may not be adequately powered to detect differences in fusion as measured by manual palpation or bone volume as measured by micro-CT. These findings suggest that local triamcinolone may not increase pseudarthrosis in spine fusion procedures. Further large animal and clinical studies to verify its safety and efficacy are warranted.

Trends in national utilization of posterior lumbar fusion and 30-day reoperation and readmission rates from 2006-2016.

OBJECTIVE: The primary goal of this study is to determine trends in patient 30-day postoperative readmission and reoperation following elective posterior lumbar fusion (PLF) between 2006-2016. METHODS: We retrospectively identified patients in the ACS-NSQIP database who underwent elective, non-emergent PLF from 2006 to 2016. Descriptive statistical and time trend analyses were performed on demographic, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission within 30 days and secondary outcomes were medical and surgical complications reported within 30 days of the operation. Linear and binary logistic regression were performed to adjust for patient specific confounders. RESULTS: A total of 26,265 patients underwent elective PLF over the study period. Overall case volume increased from 0.02 % (n = 27) of all total cases in ACS-NSQIP in 2006 to 0.82 % (n = 8228) in 2016. Mean age increased from 51.22 [SE: 2.77] in 2006 to 60.57 [SE: 0.14] in 2016 (p < 0.001). For comorbidities, there was a decrease in smokers and increase in hypertension requiring medication and ASA Class 3. A readmission rate of around 5% per year did not vary significantly over the study period (p = 0.531). Unplanned reoperations declined from 7.4 % in 2006 to 3.1 % in 2016, but the overall trend from 2006 to 2016 was not statistically significant (p = 0.139). Reoperation demonstrated a significant association between age and BMI, but did not vary with admission year. Surgical site infections followed by hematomas and seromas were listed as the most common cause of both readmission and reoperation in PLF patients. CONCLUSION: Since the establishment of the ACS-NSQIP database, reoperation rates due to complications declined after 2006 and remained relatively stable. Readmissions were added as a variable in 2011 and had no significant changes over time.

Comparison of inpatient versus post-discharge venous thromboembolic events after spinal surgery: A single institution series of 6869 consecutive patients.

STUDY DESIGN: retrospective chart review. OBJECTIVE: We aimed to determine the perioperative risk factors that lead to inpatient or post-discharge venous thromboembolism (VTE) events after spinal surgery. SUMMARY OF BACKGROUND DATA: While many studies relate the risk factors in a post-surgical setting to the incidence of VTE, this study aims to separate these VTE into inpatient and post-discharge categories to examine timing and risk factors. METHODS: We analyzed 6869 patients from 2009 to 2015 using Current Procedural Technology codes from a single tertiary academic institution. Patients were stratified based on occurrence and setting of VTE then controlled for perioperative characteristics with exclusion criteria being patients undergoing minor spine surgeries or secondary procedures. RESULTS: In 170 VTE events, these factors were associated with increased risk for: Inpatient DVT only: IVC filter (OR 6.380 [3.414-11.924]), longer length of hospital stay (OR 1.083 [1.047-1.120]), a prior history of DVT (OR 3.640 [1.931-6.856]). Post-discharge DVT only: history of PE (OR 45.142 [6.785-300.351]), having a corpectomy (OR 26.670 [3.477-204.548]), and having an osteotomy (OR 18.877 [1.129-315.534]). Inpatient PE only: surgery >4 h (OR 30.820, p < 0.001), fracture (OR 6.913, p = 0.004), IVC filter (OR 3.135, p = 0.029). Post-discharge PE only: corpectomy (OR 541.271, p = 0.009), foraminotomy (OR 40.137, p = 0.013), EBL > 500cc (OR 2467.798, p = 0.002). Time to onset of VTE events was significantly longer for patients undergoing osteotomy (7.43 days) than for patients with fracture (4.28 days), which is consistent with our findings that fracture was an independent predictor of inpatient VTE, and osteotomy was an independent predictor of post-discharge VTE (p = 0.018). CONCLUSIONS: Time-to-VTE varies between types of surgeries. Some risk factors are independently associated with VTE at all times during the 30-day postoperative period, while other factors are only associated with either inpatient or post-discharge VTE. Those patients with high-risk features for post-discharge VTE merit increased study for thromboprophylaxis management.

Trends in National Use of Anterior Cervical Discectomy and Fusion from 2006 to 2016.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is the most common procedure for the treatment of degenerative cervical conditions. The objective of this study is to determine time-dependent trends in patient outcomes following ACDF for degenerative disease from 2006 to 2016. METHODS: We used the National Surgical Quality Improvement Program (NSQIP) database to retrospectively review all patients who underwent elective ACDF between 2006 and 2016. A descriptive statistical analysis followed by time trend analysis was performed on demographics, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission rates. Secondary outcomes were medical and surgical complications reported within 30 days of operation. RESULTS: A total of 36,854 patients underwent elective ACDF from the 2006 to 2016 NSQIP database. Mean age increased from 48.19 years [standard error: 1.49] in 2006 to 54.08 years [standard error: 0.12] in 2016 (P < 0.001). There was a significantly greater number of outpatient procedures from 2012 to 2016 (P < 0.001). The proportion of patients with American Society of Anesthesiologists classes 3/4 significantly increased over time (P < 0.001, P < 0.001, P = 0.005, respectively). Readmission risk, first documented in NSQIP in 2011, increased over time from 2011 to 2016 (P < 0.001). Unplanned reoperations have remained consistent at about 1.4%. Postoperative complications varied over time with no discernable patterns or trends. CONCLUSIONS: Since the establishment of the NSQIP database, there have been no considerable improvements in reoperation or postoperative complication rates based on available data, however, there have been increased rates of readmission. Changes in data collection and an aging patient population with greater burden of comorbidities could confound these trends.

Using machine learning to predict 30-day readmissions after posterior lumbar fusion: an NSQIP study involving 23,264 patients.

OBJECTIVE: Unplanned preventable hospital readmissions within 30 days are a great burden to patients and the healthcare system. With an estimated $41.3 billion spent yearly, reducing such readmission rates is of the utmost importance. With the widespread adoption of big data and machine learning, clinicians can use these analytical tools to understand these complex relationships and find predictive factors that can be generalized to future patients. The object of this study was to assess the efficacy of a machine learning algorithm in the prediction of 30-day hospital readmission after posterior spinal fusion surgery. METHODS: The authors analyzed the distribution of National Surgical Quality Improvement Program (NSQIP) posterior lumbar fusions from 2011 to 2016 by using machine learning techniques to create a model predictive of hospital readmissions. A deep neural network was trained using 177 unique input variables. The model was trained and tested using cross-validation, in which the data were randomly partitioned into training (n = 17,448 [75%]) and testing (n = 5816 [25%]) data sets. In training, the 17,448 training cases were fed through a series of 7 layers, each with varying degrees of forward and backward communicating nodes (neurons). RESULTS: Mean and median positive predictive values were 78.5% and 78.0%, respectively. Mean and median negative predictive values were both 97%, respectively. Mean and median areas under the curve for the model were 0.812 and 0.810, respectively. The five most heavily weighted inputs were (in order of importance) return to the operating room, septic shock, superficial surgical site infection, sepsis, and being on a ventilator for > 48 hours. CONCLUSIONS: Machine learning and artificial intelligence are powerful tools with the ability to improve understanding of predictive metrics in clinical spine surgery. The authors' model was able to predict those patients who would not require readmission. Similarly, the majority of predicted readmissions (up to 60%) were predicted by the model while retaining a 0% false-positive rate. Such findings suggest a possible need for reevaluation of the current Hospital Readmissions Reduction Program penalties in spine surgery.

Three-Dimensional Printing in Minimally Invasive Spine Surgery.

PURPOSE OF REVIEW: To summarize the recent advances in 3D printing technology as it relates to spine surgery and how it can be applied to minimally invasive spine surgery. RECENT FINDINGS: Most early literature about 3D printing in spine surgery was focused on reconstructing biomodels based on patient imaging. These biomodels were used to simulate complex pathology preoperatively. The focus has shifted to guides, templates, and implants that can be used during surgery and are specific to patient anatomy. However, there continues to be a lack of long-term outcomes or cost-effectiveness analyses. 3D printing also has the potential to revolutionize tissue engineering applications in the search for the optimal scaffold material and structure to improve bone regeneration without the use of other grafting materials. 3D printing has many potential applications to minimally invasive spine surgery requiring more data for widespread adoption.

The Experiential Benefit of an Orthopedic Trauma Fellowship: An Analysis of ACGME Case Log Data From 2006 to 2017.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has published orthopedic case log data since the 2006/2007 academic year. Here, we use this data to analyze the variability in orthopedic trauma case experience reported by orthopedic trainees and to better understand the impact of an orthopedic trauma fellowship on orthopedic surgical training. DESIGN, SETTING, AND PARTICIPANTS: Data were gathered from ACGME case log reports for orthopedic residents (reporting the cumulative case experience of graduating residents) and orthopedic trauma fellows (reporting the case experience of their fellowship year only) for all available years. RESULTS: The average orthopedic trauma fellow reported significantly more trauma cases in multiple body regions ("Pelvis/Hip", "Femur/Knee", and "Foot/Toes") and "Open Complex" reductions (as defined by the ACGME) in their 1 year of fellowship than the average resident reported in their 5 years of residency. CONCLUSION: On average, orthopedic trauma fellowships substantially increase the trauma case volumes of orthopedic trainees, especially with respect to lower extremity trauma.

Author Correction: Immune and genomic correlates of response to anti-PD-1 immunotherapy in glioblastoma.

In the version of this article originally published, the graph in Extended Data Fig. 2c was a duplication of Extended Data Fig. 2b. The correct version of Extended Data Fig. 2c is now available online.

Immune and genomic correlates of response to anti-PD-1 immunotherapy in glioblastoma.

Immune checkpoint inhibitors have been successful across several tumor types; however, their efficacy has been uncommon and unpredictable in glioblastomas (GBM), where <10% of patients show long-term responses. To understand the molecular determinants of immunotherapeutic response in GBM, we longitudinally profiled 66 patients, including 17 long-term responders, during standard therapy and after treatment with PD-1 inhibitors (nivolumab or pembrolizumab). Genomic and transcriptomic analysis revealed a significant enrichment of PTEN mutations associated with immunosuppressive expression signatures in non-responders, and an enrichment of MAPK pathway alterations (PTPN11, BRAF) in responders. Responsive tumors were also associated with branched patterns of evolution from the elimination of neoepitopes as well as with differences in T cell clonal diversity and tumor microenvironment profiles. Our study shows that clinical response to anti-PD-1 immunotherapy in GBM is associated with specific molecular alterations, immune expression signatures, and immune infiltration that reflect the tumor's clonal evolution during treatment.

Intervertebral disc herniation in elite athletes.

Intervertebral disc herniations are a common cause of neck and back pain in athletes. It is thought to be more prevalent in athletes than in the general population due to the consistent pressure placed on the spine and concurrent microtraumas that are unable to heal. Prevention focuses on neck and trunk stability and flexibility, training on proper technique, and rule changes to minimize catastrophic injuries. The evaluation for athletes includes a full neurologic exam and imaging. The imaging modality of choice is MRI, but CT myelography can be a useful alternative. Standard management includes a six week trial of conservative treatment with hiatus from injurious activity and anti-inflammatory medication. If nonoperative management fails, operative treatment has been shown to lead to excellent clinical outcomes in this patient population. Special consideration to prevention needs to be further analyzed. Furthermore, more robust studies on alternative non-operative and operative treatment modalities for this patient population are also needed.

Effects of the physician payments sunshine act on the patient experience and perception of care amongst neurosurgeons: A comparative study of online PRW ratings and industry payments.

OBJECTIVE: Growing relationships between industry related financial payments and physicians have become an increasingly controversial topic as they relate to clinical judgment and patient care. Our objective is to analyze and quantify the effects of physician reported industry payments on the patient experience and patient satisfaction as defined by Physician Rating Websites (PRW). PATIENTS AND METHODS: We analyzed physician-reported industry payments received by neurosurgeons over four consecutive years as defined by the Physician Payments Sunshine Act (PPSA). All board-certified neurosurgeons on three widely used PRWs were further identified. Data was collected on average rating, number of ratings and composite ratings. Demographic, training-related and practice-related data were also collected. Each physician was identified and matched to their individually reported payments from the PPSA database. RESULTS: Receiving higher amounts of industrial payments had no correlation to average PRW ratings, however was associated with receiving higher composite PRW ratings (p = 0.0389). Higher composite ratings (p = 0.0389), decreasing age (p = 0.005), being male (OR 1.7960, p = 0.005), completing a fellowship (OR 1.3310, p = 0.0085), having a more complete profile (OR 1.1121, p = 0.0057) and speaking more languages (OR 1.1253, p = 0.03802) all were correlated with receiving more total monetary payments. Training at a top 25 residency program was predictive of being in the bottom quartile of total monetary payments received (OR 1.676, p = 0.0002). CONCLUSIONS: Patient experience as defined by PRW ratings are likely not strongly influenced by industry related monetary payments, however some relationship may exist. Further study is needed to determine the true relationship between industry related monetary payments and the patient experience.

Venous thromboembolism events following spinal fractures: A single center experience.

OBJECTIVE: Venous thromboembolic events (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), are a major cause of readmission, morbidity, and mortality after spine surgery. Patients with spinal fractures are particularly at an increased risk for VTE. The objective of this study is to understand VTE risk factors in this patient population and to examine current institutional practices. PATIENTS AND METHODS: We retrospectively examined records from 195 consecutive patients with spinal fractures who underwent spinal stabilization surgeries- amongst a cohort of 6869 patients who underwent spinal surgery. We collected data on patient demographics, surgery, hospital course, and 30-day rates of VTE, readmission, reoperation. Multivariable logistic regression was used to identify independent predictors of each outcome. RESULTS: Among 195 patients undergoing surgery for spinal fractures, 9.2% experienced a VTE, compared to 2.3% among all other spine patients (OR 4.466, p < 0.0001). 48.7% spine fracture patients received chemoprophylactic anticoagulation, compared to 35.7% of all other spine patients (OR 2.657, p < 0.0001). Within 30 days of surgery, estimated blood loss (EBL) was associated with VTE (OR 1.001, p = 0.0415) and DVT (OR 1.001, p = 0.049), and comorbid cardiac disease burden showed a trend toward significance in predicting both VTE (OR 1.890, p = 0.0956) and DVT (OR 4.228, p = 0.0549). Number of levels in surgery predicted PE within 30 days of surgery (OR 1.573, p = 0.0107). CONCLUSIONS: Compared to all other patients undergoing spine surgery, patients with spinal fractures are more likely to receive chemoprophylactic anticoagulation, but nevertheless have a higher rate of VTE events. EBL and comorbid disease burden predict VTE events in patients with spine fractures.

Impact of resident participation on outcomes following lumbar fusion: An analysis of 5655 patients from the ACS-NSQIP database.

The role of resident involvement on patient safety, morbidity, and mortality in lumbar spinal surgery has been poorly defined in the literature. The objective of this study is to investigate the relationship between resident involvement in the operating room and 30-day complication rates in patients undergoing lumbar spinal fusion procedures. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to retrospectively identify all patients who underwent a lumbar spinal fusion from 2006 to 2013. A propensity score matching algorithm was employed to minimize baseline differences. Multivariate logistic regression analysis of unadjusted and propensity-matched groups was performed to examine the effect of resident participation on operative details and 30-day complication rates. A total of 5655 patients met the inclusion criteria and propensity score matching yielded 1965 well-matched pairs. Resident involvement in lumbar fusion procedures was not found to be a significant predictor for mortality or reoperation. It was found to be a significant predictor for increased hospital stay (matched non-resident 4.0 ±â€¯5.8 days vs. resident 4.6 ±â€¯4.3 days, p < 0.001), operative time (matched non-resident 198 ±â€¯102 min vs. resident 243 ±â€¯118 min, p < 0.001), sepsis (matched OR 4.36, 95% CI 2.10-9.05, p < 0.001), development of DVT/PE (matched OR 2.02, 95% CI 1.10-3.70, p = 0.023), and superficial surgical site infections (matched OR 1.78, 95% CI 1.04-3.06, p = 0.037). In conclusion, this large-scale, population-based study found that resident participation in the operating room was safe but increased the risk of 30-day complications and increased operative duration and length of hospital stay.