Resilience and Patient-Reported Outcomes in Patients Undergoing Orthopedic Hand Surgery.

BACKGROUND: Previous studies have examined the impact of resiliency on postoperative outcomes in other orthopedic domains, but none to date have done so for hand surgery. METHODS: We performed a retrospective analysis of prospectively collected data of patients undergoing hand surgery at a single institution. We included patients with complete preoperative outcomes scores and 6-month follow-up. All patients completed the Brief Resilience Scale (BRS), Disabilities of the Arm, Shoulder, and Hand (DASH) Score, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Veterans RAND 12-Item Health Survey (VR-12), and Numeric Rating Scale (NRS) for pain. Patients were stratified into high-resiliency (HR) and low-resiliency (LR) groups based on the preoperative BRS score, and outcomes between groups were compared. RESULTS: We identified 91 patients who underwent hand procedures and completed full preoperative and postoperative outcomes measures. There were no observed preoperative differences between the groups in all outcomes scores except the VR-12 Mental Component Score. Postoperatively, the HR group had superior DASH, QuickDASH, and VR-12 (mental and physical component) scores than the LR group. Postoperative pain, as measured by the NRS, was significantly lower in the HR group despite there being no preoperative difference. A larger percentage of patients in the HR group met the minimal clinically important difference in all outcomes except for the VR-12 Mental Component Scores. CONCLUSIONS: Patients with high preoperative resilience appear to have significantly better clinical outcomes following hand surgery with superior DASH, QuickDASH, and VR-12 scores at 6-month follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic study/Level IV evidence.

Late tibial interference screw extrusion following anterior cruciate ligament reconstruction: A case report.

Introduction: Interference screws are used as back-up fixation in anterior cruciate ligament reconstructions. Historically these were composed of metal, but recently surgeons have switched to using bioabsorbable screws as they cause less symptoms and are biomedically advantageous. Usually these screws are absorbed by the body within one to two years after surgery. Case Presentation: A 32-year-old male presented with aseptic extrusion of his intact tibial bioabsorbable interference screw eight years following successful anterior cruciate ligament reconstruction. Management and Outcomes: Patient underwent laboratory evaluation and magnetic resonance imaging to rule out infection as an underlying cause. He went on to heal the wound without complication. Conclusion: Late aseptic extrusion of tibial interference screw can occur; however, infectious etiologies should be carefully ruled out.

Surgical Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Surgical Microscope vs Surgical Loupes: A Comparative Study.

BACKGROUND: Minimally invasive transforaminal interbody fusion (MIS-TLIF) is an effective procedure for lumbar spine diseases. The procedure can be done using a surgical microscope (SM) or surgical loupes (SL) magnification. However, there are no studies that compared outcomes between using these 2 magnifying devices in the MIS-TLIF procedure. The purpose of this study was to compare clinical outcomes, perioperative complications, and radiographic parameters of MIS-TLIF using SM compared with SL magnification. METHODS: We included all patients undergoing 1-level MIS-TLIF between January 2017 and December 2019. Type of magnification (SM vs SL), operative time, blood loss, perioperative complications, cross-sectional area of the spinal canal, and fusion rates were analyzed. Clinical outcomes measurement using the visual analog scale (VAS) and Oswestry Disability Index (ODI) were compared between groups. RESULTS: A total of 100 patients had underwent MIS-TLIF (SM group: 62; SL group: 38). Operative time (SM: 182.7 ± 41.5 vs SL: 165.6 ± 32.6 minutes, P = 0.043) was significantly shorter in the SL group, with a mean difference of 17.2 minutes and a 10.4% increase in operative time between SL and SM. Blood loss (SM: 187.4 ± 176.4 vs SL: 215.6 ± 99.4 mL, P = 0.36) was not different between groups, with a mean difference of 28.2 mL. Both the SM group and SL group demonstrated no significant differences in improvement from baseline in VAS back, VAS legs, ODI score, and cross-sectional area of the spinal canal. There was also no significant difference in complication rates and fusion rates between groups. CONCLUSIONS: Our study found no difference between intraoperative use of SL compared with SM in clinical outcomes through the 12-month follow-up timepoint. However, the use of SM resulted in an increased average operative time of 17 minutes compared with the SL group. CLINICAL RELEVANCE: Intraoperative use of SM and SL magnification in MIS-TLIF provides similar outcomes except prolonged operative time in the SM group.

Physician-Rating Websites and Social Media Usage: A Global Survey of Academic Orthopaedic Surgeons: AOA Critical Issues.

ABSTRACT: The relationship between orthopaedic surgeons and the internet is complicated. Social media allows surgeons to educate their patients while marketing to them at the same time. Conversely, patients are able to better communicate with their surgeons while anonymously rating their service and expertise. This study aims to look at the complex relationship between surgeons and social media use.

Is Self-reported Return to Duty an Adequate Indicator of Return to Sport and/or Return to Function in Military Patients?

BACKGROUND: In the military, return-to-duty status has commonly been used as a functional outcome measure after orthopaedic surgery. This is sometimes regarded similarly to return to sports or as an indicator of return to full function. However, there is variability in how return-to-duty data are reported in clinical research studies, and it is unclear whether return-to-duty status alone can be used as a surrogate for return to sport or whether it is a useful marker for return to full function. QUESTIONS/PURPOSES: (1) What proportion of military patients who reported return to duty also returned to athletic participation as defined by self-reported level of physical activity? (2) What proportion of military patients who reported return to duty reported other indicators of decreased function (such as nondeployability, change in work type or level, or medical evaluation board)? METHODS: Preoperative and postoperative self-reported physical profile status (mandated physical limitation), physical activity status, work status, deployment status, military occupation specialty changes, and medical evaluation board status were retrospectively reviewed for all active-duty soldiers who underwent orthopaedic surgery at Madigan Army Medical Center, Joint Base Lewis-McChord from February 2017 to October 2018. Survey data were collected on patients preoperatively and 6, 12, and 24 months postoperatively in all subspecialty and general orthopaedic clinics. Patients were considered potentially eligible if they were on active-duty status at the time of their surgery and consented to the survey (1319 patients). A total of 89% (1175) were excluded since they did not have survey data at the 1 year mark. Of the remaining 144 patients, 9% (13) were excluded due to the same patient having undergone multiple procedures, and 2% (3) were excluded for incomplete data. This left 10% (128) of the original group available for analysis. Ninety-eight patients reported not having a physical profile at their latest postoperative visit; however, 14 of these patients also stated they were retired from the military, leaving 84 patients in the return-to-duty group. Self-reported "full-time duty with no restrictions" was originally used as the indicator for return to duty; however, the authors felt this to be too vague and instead used soldiers' self-reported profile status as a more specific indicator of return to duty. Mean length of follow-up was 13 ± 3 months. Eighty-three percent (70 of 84) of patients were men. Mean age at the preoperative visit was 35 ± 8 years. The most common surgery types were sports shoulder (n = 22) and sports knee (n = 14). The subgroups were too small to analyze by orthopaedic procedure. Based on active-duty status and requirements of the military profession, all patients were considered physically active before their injury or surgery. Return to sport was determined by asking patients how their level of physical activity compared with their level before their injury (higher, same, or lower). We identified the number of other indicators that may suggest decreased function by investigating change in work type/level, self-reported nondeployability, or medical evaluation board. This was performed with a simple survey. RESULTS: Of the 84 patients reporting return to duty at the final follow-up, 67% (56) reported an overall lower level of physical activity. Twenty-seven percent (23) reported not returning to the same work level, 32% (27) reported being nondeployable, 23% (19) reported undergoing a medical evaluation board (evaluation for medical separation from the military), and 11% (9) reported a change in military occupation specialty (change of job description). CONCLUSION: Return to duty is commonly reported in military orthopaedics to describe postoperative functional outcome. Although self-reported return to duty may have value for military study populations, based on the findings of this investigation, surgeons should not consider return to duty a marker of return to sport or return to full function. However, further investigation is required to see to what degree this general conclusion applies to the various orthopaedic subspecialties and to ascertain how self-reported return to duty compares with specific outcome measures used for particular procedures and subspecialties. LEVEL OF EVIDENCE: Level IV, therapeutic study.

High Resiliency Linked to Short-Term Patient Reported Outcomes and Return to Duty Following Arthroscopic Knee Surgery.

INTRODUCTION: Resilience is a psychometric construct of a patient's ability to recover from adversity and has been used to predict outcomes but its use in orthopedics has been limited. The purpose of this study was to examine the association between resilience and outcomes. MATERIALS AND METHODS: We performed a retrospective analysis of prospectively collected data of patient who underwent sports knee surgery at a single institution performed by 6 orthopedic surgeons from January 2017 to December 2017. We included active-duty patients with complete preoperative outcomes and a minimum of 6 month follow-up. All patients completed the Brief Resilience Scale (BRS), Veteran's Rand-12 (VR-12), Patient-Reported Outcomes Measurement Information System 43 (PROMIS-43), International Knee Documentation Committee function score (IKDC), and Knee Injury and Osteoarthritis Outcome Score (KOOS). Patients were divided into low resilience (LR) and high resilience (HR) groups based on a score of less than 24 for low and greater than or equal to 24 according to BRS. Outcomes were then compared. RESULTS: We identified 50 active-duty patients who had complete preoperative and postoperative outcomes at a minimum of 6 months. Mean preoperative and postoperative BRS were significantly different (25.8 HR v 18.6 LR, p < 0.001). We found a difference in postop KOOS in pain, sports, and short form (pain 70.9 HR v 55.7 LR, p = 0.03; sports 50.3 HR v 32.2 LR, p = 0.03; short form (72.1 HR v 62.5 LR, p = 0.04). Similarly, there was a significant difference in postoperative IKDC score (58.0 HR v 44.0 LR, p = 0.03). Similarly we found significant differences in postoperative PROMIS-43 (anxiety 44.4 HR v 60.3 LR, p = 0.004; depression 41.6 HR v 58.1 LR, p = 0.004; fatigue 45.1 HR v 58.6 LR, p = 0.001; sleep 52.6 HR v 62.5 LR, p = 0.02; social participation 36.2 HR v 47.6 LR, p < 0.001). Postoperative VR-12 mental was also statistically different between the two groups (53.5 HR v 41.6 LR; p = 0.01). In addition, 2.3% of the HR group changed MOS as a result of their sports knee surgery compared to 22.2% of the LR group. CONCLUSIONS: Active-military patients with high preoperative resilience appear to have significantly better early postoperative outcomes following sports knee surgery in terms of PROMIS-43, KOOS, and IKDC. There was also a lower rate of changing MOS secondary to sports knee surgery in patients with high resilience.

VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain.

DESCRIPTION: In September 2017, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved the joint Clinical Practice Guideline (CPG) for Diagnosis and Management of Low Back Pain. This CPG was intended to provide healthcare providers a framework by which to evaluate, treat, and manage patients with low back pain (LBP). METHODS: The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through September 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. A patient focus group was also convened to ensure patient values and perspectives were considered when formulating preferences and shared decision making in the guideline. RECOMMENDATIONS: The VA/DOD LBP CPG provides evidence-based recommendations for the diagnostic approach, education and self-care, non-pharmacologic and non-invasive therapy, pharmacologic therapy, dietary supplements, non-surgical invasive therapy, and team approach to treatment of low back pain.

Postoperative Seroma Formation After Posterior Cervical Fusion with Use of RhBMP-2: A Report of Two Cases.

CASE: We present 2 cases of postoperative seroma formation following posterior cervical fusion with the use of recombinant human bone morphogenetic protein-2 (rhBMP-2). CONCLUSION: Although some who advocate for the off-label use of rhBMP-2 in patients undergoing posterior cervical spine fusion believe it to be safe, relatively little has been published regarding complication rates. We believe that rhBMP-2 carries a risk of seroma formation in patients who undergo posterior cervical fusion, which necessitates the use of a postoperative drain. Surgeons should have a low threshold for obtaining postoperative magnetic resonance imaging in a symptomatic patient.

Awareness of middle sacral artery pathway: A cadaveric study of the presacral area.

PURPOSE: To assess the anatomic path of the middle sacral artery (MSA) at the presacral area and its relationship to the spinal midline during an axial lumbar interbody fusion (AxiaLif) approach. METHODS: Fifty human cadavers (25 males, 25 females) were used in this study. A transabdominal approach was used to expose the anterior aspect of the L5/S1 intervertebral disc and the presacral space. We measured the size and distance from the spinal midline at the following positions: (a) middle of the L5/S1 disc level, (b) 1 cm below the sacral promontory (SP), and (c) 2 cm below the SP. Each parameter was measured three times by two observers, and the mean value analyzed. RESULTS: The MSA was present and originated from the left common iliac artery in all cadavers with a mean width of 2.14 mm. The position of the MSA in relation to the midline was most commonly on the left side (LS, 56%) followed by the right side (RS, 34%) and midline (ML, 10%). In the LS group, the distance from the midline is relatively constant in the three measured positions with a mean value of (a) 1.78 mm (range, 0-8.17 mm), (b) 2.08 mm (range, 0-7.10 mm), and (c) 2.06 mm (range, 0-9.76 mm). In the RS group, the distance from the midline increased from cephalad to caudad, with a mean value of (a) 1.44 mm (range, 0-9.64 mm), (b) 2.19 mm (range, 0-9.95 mm), and (c) 2.92 mm (range, 0-10.03 mm). CONCLUSIONS: Our study found the presacral anatomic path of the MSA was most commonly at the left of midline. In addition, the right-sided MSA variant had increasing distance from the midline along its anatomic path from cephalad to caudad. Our findings suggest an AxiaLif approach at the left of midline may place the MSA at greatest risk.

Lumbar computed tomography scans are not appropriate surrogates for bone mineral density scans in primary adult spinal deformity.

OBJECTIVE The authors examined the correlation between lumbar spine CT Hounsfield unit (HU) measurements and bone mineral density measurements in an adult spinal deformity (ASD) population. METHODS Patients with ASD were identified in the records of a single institution. Lumbar CT scans were reviewed, and the mean HU measurements from L1-4 were recorded. Bone mineral density (BMD) was assessed using femoral neck and lumbar spine dual-energy x-ray absorptiometry (DEXA). The number of patients who met criteria for osteoporosis was determined for each imaging modality. RESULTS Forty-eight patients underwent both preoperative DEXA and CT scanning. Forty-three patients were female and 5 were male. Forty-seven patients were Caucasian and one was African American. The mean age of the patients was 62.1 years. Femoral neck DEXA was more likely to identify osteopenia (n = 26) than lumbar spine DEXA (n = 8) or lumbar CT HU measurements (n = 6) (p < 0.001). There was a low-moderate correlation between lumbar spine CT and lumbar spine DEXA (r = 0.463, p < 0.001), and there was poor correlation between lumbar spine CT and femoral neck DEXA (r = 0.303, p = 0.036). CONCLUSIONS Despite the opportunistic utility of lumbar spine CT HU measurements in identifying osteoporosis in patients undergoing single-level fusion, these measurements were not useful in this cohort of ASD patients. The correlation between femoral neck DEXA and HU measurements was poor. DEXA assessment of BMD in ASD patients is essential to optimize the care of these complicated cases.

Biomechanical Stability of a Stand-Alone Interbody Spacer in Two-Level and Hybrid Cervical Fusion Constructs.

STUDY DESIGN: In vitro human cadaveric biomechanical analysis. OBJECTIVE: To evaluate the segmental stability of a stand-alone spacer (SAS) device compared with the traditional anterior cervical plate (ACP) construct in the setting of a 2-level cervical fusion construct or as a hybrid construct adjacent to a previous 1-level ACP construct. METHODS: Twelve human cadaveric cervical spines (C2-T1) were nondestructively tested with a custom 6-degree-of-freedom spine simulator under axial rotation (AR), flexion-extension (FE), and lateral bending (LB) at 1.5 N m loads. After intact analysis, each specimen underwent instrumentation and testing in the following 3 configurations, with each specimen randomized to the order of construct: (A) C5-7 SAS; (B) C5-6 ACP, and C6-7 SAS (hybrid); (C) C5-7 ACP. Full range of motion (ROM) data at C5-C7 was obtained and analyzed by each loading modality utilizing mean comparisons with repeated measures analysis of variance with Sidak correction for multiple comparisons. RESULTS: Compared with the intact specimen, all tested constructs had significantly increased segmental stability at C5-C7 in AR and FE ROM, with no difference in LB ROM. At C5-C6, all test constructs again had increased segmental stability in FE ROM compared with intact (10.9° ± 4.4° Intact vs SAS 6.6° ± 3.2°, P < .001; vs.Hybrid 2.9° ± 2.0°, P = .005; vs ACP 2.1° ± 1.4°, P < .001), but had no difference in AR and LB ROM. Analysis of C6-C7 ROM demonstrated all test groups had significantly greater segmental stability in FE ROM compared with intact (9.6° ± 2.7° Intact vs SAS 5.0° ± 3.0°, P = .018; vs Hybrid 5.0° ± 2.7°, P = .018; vs ACP 4.4° ± 5.2°, P = .005). Only the hybrid and 2-level ACP constructs had increased stability at C6-C7 in AR ROM compared with intact, with no difference for all test groups in LB ROM. Comparison between test constructs demonstrated no difference in C5-C7 and C6-C7 segmental stability in all planes of motion. However, at C5-C6 comparison between test constructs found the 2-level SAS had significantly less segmental stability compared to the hybrid (6.6° ± 3.2° vs 2.9° ± 2.0°, P = .025) and ACP (6.6° ± 3.2° vs 2.1° ± 1.4°, P = .004). CONCLUSIONS: Our study found the currently tested SAS device may be a reasonable option as part of a 2-level hybrid construct, when used below an adjacent 1-level ACP, but should be used with careful consideration as a 2-level SAS construct. Consequences of decreased segmental stability in FE are unknown; however, optimal immediate fixation stability is an important surgical principle to avoid loss of fixation, segmental kyphosis, interbody graft subsidence, and pseudarthrosis.

Outcomes Following Arthrodesis for Atlanto-Axial Osteoarthritis.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: We set out to evaluate the radiographic and patient-reported outcomes following C1-C2 arthrodesis for atlantoaxial osteoarthritis (AAOA) using modern instrumentation and techniques. SUMMARY OF BACKGROUND DATA: Few studies have evaluated outcomes following C1-C2 arthrodesis for AAOA using modern surgical fixation techniques. METHODS: Retrospective analysis of all patients following C1-C2 arthrodesis with recalcitrant AAOA from a single center, single surgeon from 2002 to 2012. Preoperative, immediate and final follow-up postoperative radiographic images were evaluated. Patient-reported outcomes scores were assessed preoperative, 1-year, and final postoperative follow-up. RESULTS: We found a total of 14 patients (13 female, 1 male) with average follow-up of 2.96 ±â€Š2.26 years and mean age at surgery of 71.8 ±â€Š9.3 years old. The most common construct was posterior C1-C2 bilateral screw-rod construct (SRC) (n = 9), and there were 3 patients with transarticular screw (TAS) constructs, and 2 patients with hybrid fixation (unilateral SRC and contralateral TAS). Mean change from baseline to final follow-up for Numeric Pain Rating Scale (NRS) was -4.7 ±â€Š2.1, and Neck Disability Index (NDI) was -21.0 ±â€Š13.6, with 11 (78.6%) patients demonstrated a substantial clinical benefit (change in NDI ≥ 10). There were no differences from baseline to all follow-up time points for SF-12 Physical and Mental Component Scores. All patients had evidence of solid C1-C2 arthrodesis and stable fixation at final follow-up, with no significant change in subaxial sagittal alignment. There were no perioperative or postoperative complications. CONCLUSION: We report one of the largest series evaluating patient-reported outcomes in patients following arthrodesis for AAOA using modern C1-C2 fixation techniques. Our study found C1-C2 arthrodesis for AAOA to be safe and effective, with a significant improvement in patient-reported pain and neck disability and most patients reporting substantial clinical benefit. LEVEL OF EVIDENCE: 4.

Neurologic Deficits Have a Negative Impact on Patient-Related Outcomes in Primary Presentation Adult Symptomatic Lumbar Scoliosis Surgical Treatment at One-Year Follow-up.

STUDY DESIGN: A retrospective analysis of prospective, multicenter National Institute of Health clinical trial. OBJECTIVE: The aim of this study was to assess the rate of neurologic complications and impact of new neurologic deficits on 1-year postoperative patient-reported outcomes (PROs). SUMMARY OF BACKGROUND DATA: There are limited studies evaluating the impact of new neurologic deficits on PROs following surgery for primary presentation adult lumbar scoliosis. METHODS: Patients were divided into two groups: new postoperative neurological deficit (Def) or no deficit (NoDef). Preoperative and 1-year follow-up PROs were analyzed [Scoliosis Research Society (SRS) Questionnaire, Oswestry Disability Index (ODI), Short Form-12 Physical/Mental Health Composite Scores (PCS/MCS), and back/leg pain Numerical Rating Scale (NRS)]. RESULTS: One hundred forty-one patients: 14 Def (9.9%), 127 NoDef (90.1%). No differences were observed in demographic, radiographic, or PRO data between groups preoperatively. Def group had longer surgical procedures (8.3 vs. 6.9 hours, P = 0.030), greater blood loss (2832 vs. 2606 mL, P = 0.022), and longer hospitalizations (10.6 vs. 7.8 days, P = 0.004). NoDef group reported significant improvement in all PROs from preop to 1-year postoperative. Def group only had improvement in SRS Pain (2.7 preop to 3.4 postop, P = 0.037) and self-image domains (2.7 to 3.6, p = 0.004), and NRS back pain (6.6 to 3.2, P = 0.004) scores with significant worsening of NRS leg pain (4.1 to 6.1, P = 0.045). Group comparisons of 1-year postop PROs found that Def group reported more NRS leg pain (6.1 vs. 1.7, P < 0.001) and worse outcomes than NoDef group for ODI (35.7 vs. 23.1, P = 0.016) and PCS (32.6 vs. 41.9, P = 0.007). CONCLUSION: We found a 9.9% rate of new neurologic deficits following surgery for symptomatic primary presentation adult lumbar scoliosis, much higher than previous studies. Most neurologic deficits improved by 1-year follow-up, but appeared to have a dramatic negative impact on PROs, with increased postoperative leg pain and greater patient-perceived pathology reported in patients experiencing neurological deficits compared with those who did not. LEVEL OF EVIDENCE: 3.

Complications Associated With Bone Morphogenetic Protein in the Lumbar Spine.

Complications associated with the use of recombinant human bone morphogenetic protein in the lumbar spine include retrograde ejaculation, ectopic bone formation, vertebral osteolysis and subsidence, postoperative radiculitis, and hematoma and seroma. These complications are controversial and remain widely debated. This article discusses the reported complications and possible implications for the practicing spine surgeon. Understanding the complications associated with the use of recombinant human bone morphogenetic protein and the associated controversies allows for informed decision making by both the patient and the surgeon. [Orthopedics. 2017; 40(2):e229-e237.].

Baseline Patient-Reported Outcomes Correlate Weakly With Radiographic Parameters: A Multicenter, Prospective NIH Adult Symptomatic Lumbar Scoliosis Study of 286 Patients.

STUDY DESIGN: Prospective, cross-sectional study. OBJECTIVE: The aim of the study was to determine which radiographic parameters drive patient-reported outcomes (PROs) in primary presentation adult symptomatic lumbar scoliosis (ASLS). SUMMARY OF BACKGROUND DATA: Previous literature suggests correlations between PROs and sagittal plane deformity (sagittal vertical axis [SVA], pelvic incidence-lumbar lordosis [PI-LL] mismatch, pelvic tilt [PT]). Prior work included revision and primary adult spinal deformity patients. The present study addresses only primary presentation ASLS. METHODS: Prospective baseline data were analyzed on 286 patients enrolled in an NIH RO1 clinical trial by nine centers from 2010 to 2014. INCLUSION CRITERIA: 40 to 80 years old, lumbar Cobb (LC) 30° or higher and Scoliosis Research Society-23 score 4.0 or less in Pain, Function or Self-Image domains, or Oswestry Disability Index (ODI) 20 or higher. Patients were primary presentation (no prior spinal deformity surgery) and had complete baseline data: standing coronal/sagittal 36" radiographs and PROs (ODI, Scoliosis Research Society-23, Short Form-12). Correlation coefficients were calculated to evaluate relations between radiographic parameters and PROs for the study population and a subset of patients with ODI 40 or higher. Analysis of variance was used to identify differences in PROs for radiographic modifier groups. RESULTS: Mean age was 60.3 years. Mean spinopelvic parameters were: LL = -39.2°; SVA = 3.1 cm; sacral slope = 32.5°; PT = 23.9°; PI-LL mismatch = 16.8°. Only weak correlations (0.2-0.4) were identified between population sacral slope, SVA and SVA modifiers, and SRS function. SVA and SVA modifiers were weakly associated with ODI. Although there were more correlations in subset analysis of high-symptom patients, all were weak. Analysis of variance identified significant differences in ODI reported by SVA modifier groups. CONCLUSION: In primary presentation patients with ASLS and a subset of "high-symptom" patients (ODI ≥ 40), only weak associations between baseline PROs and radiographic parameters were identified. For this patient population, these results suggest regional radiographic parameters (LC, LL, PT, PI-LL mismatch) are not drivers of PROs and cannot be used to extrapolate effect on patient-perceived pathology. LEVEL OF EVIDENCE: 2.

Diagnosing the Undiagnosed: Osteoporosis in Patients Undergoing Lumbar Fusion.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: The aim of the study was to report the incidence of undiagnosed osteoporosis in patients undergoing lumbar spine fusion using computed tomography (CT) Hounsfield units (HU). SUMMARY OF BACKGROUND DATA: We used a recent technique utilizing HU to estimate bone mineral density (BMD) of the lumbar spine and hypothesized that this technique would reveal a high percentage of undiagnosed osteoporotic patients undergoing transforaminal lumbar interbody fusion (TLIF). METHODS: We reviewed patients older than 50 years undergoing TLIF from a single-center and multiple surgeons. We determined the mean HU of L4 on axial CT. Average HU values for patients with diagnosed lumbar osteoporosis (DEXA BMD <0.75 g/cm) were compared to patients with osteopenia and normal BMD (between 0.75 and 0.9 g/cm and >0.9 g/cm, respectively). The percentage of patients with HU values consistent with osteoporosis, but without any formal evaluation, was also calculated. RESULTS: Over 10 years, 143 patients older than 50 years underwent TLIF, and 128 had available perioperative lumbar CT scans. Men and Women comprised 60.2% and 39.8% of the population, respectively. Average age was 61.5 years (range: 50.0-83.5 years). Twenty-nine patients had both dual-energy X-ray absorptiometry and CT data available for analysis. There was a significant association with decreased HU in patients with lumbar BMD less than 0.75 g/cm (105.6 HU, 95% confidence interval [CI] 6.76) in comparison to patients with osteopenia (146.0 HU, 95% CI 4.09) and with normal BMD (165.9, 95% CI 21.35). Ten men (7.8%) and 15 women (11.7%) had HU values consistent with osteoporosis. Sixty-four percent of patients with osteoporotic HU values had never been formally evaluated for the disease. CONCLUSION: HU may be an alternative to screening preoperative dual-energy X-ray absorptiometry scan and can minimize costs and resource utilization. We found a large proportion of patients older than 50 years undergoing TLIF had HU levels consistent with undiagnosed osteoporosis of the lumbar spine. LEVEL OF EVIDENCE: 4.

Clinical and Radiographic Outcomes of Transforaminal Lumbar Interbody Fusion in Patients with Osteoporosis.

Study Design Retrospective review. Objective To compare clinical outcomes after transforaminal lumbar interbody fusion (TLIF) in patients with and patients without osteoporosis. Methods We reviewed all patients with 6-month postoperative radiographs and computed tomography (CT) scans for evaluation of the interbody cage. CT Hounsfield unit (HU) measurements of the instrumented vertebral body were used to determine whether patients had osteoporosis. Radiographs and CT scans were evaluated for evidence of implant subsidence, migration, interbody fusion, iatrogenic fracture, or loosening of posterior pedicle screw fixation. Medical records were reviewed for persistence of symptoms or recurrence of symptoms. Results The final data analysis included 18 (20.5%) patients with osteoporosis and 70 (79.5%) patients without osteoporosis. Males comprised 50% of patients with osteoporosis, and 64.3% of patients without osteoporosis. The mean age was significantly higher in the osteoporotic group (65.2 years) versus the nonosteoporotic group (56.9 years; p < 0.0001). We found significantly higher rates of subsidence (72.2 versus 45.7%, p = 0.05) and iatrogenic fractures (16.7% versus 1.4%, p = 0.03) in the osteoporotic group. In addition, the osteoporotic group had significantly higher radiographic complication rates compared with the nonosteoporotic group (77.8 versus 48.6%, p = 0.03). There was no difference between groups for revision surgery (16.6 versus 14.3%, p = 0.78) or postoperative symptoms (44.4% versus 50.0%, p = 0.69). Conclusions Our data demonstrated significantly increased rates of cage subsidence, iatrogenic fracture, and overall radiographic complications in patients with osteoporosis. However, these radiographic complications did not predispose patients with osteoporosis to an increased risk of surgical revision or worse clinical outcomes.