An evidence based conceptual framework for the multifactorial understanding of proximal junctional kyphosis.

Introduction: Adult spinal deformity (ASD) is a debilitating pathology that arises from a variety of etiologies. Spinal fusion surgery is the mainstay of treatment for those who do not achieve symptom relief with conservative interventions. Fusion surgery can be complicated by a secondary deformity termed proximal junctional kyphosis (PJK). Research question: This scoping review evaluates the modern body of literature analyzing risk factors for PJK development and organizes these factors according to a multifactorial framework based on mechanical, tissue or demographic components. Materials and methods: An extensive search of the literature was performed in PubMed and Embase back to the year 2010. Articles were assessed for quality. All risk factors that were evaluated and those that significantly predicted the development of PJK were compiled. The frequency that a risk factor was predictive compared to the number of times it was evaluated was calculated. Results: 150 articles were reviewed. 57.3% of papers were of low quality. 76% of risk factors analyzed were focusing on the mechanical contribution to development of PJK versus only 5% were focusing on the tissue-based contribution. Risk factors that were most frequently predictive compared to how often they were analyzed were Hounsfield Units of vertebrae, UIV disc degeneration, paraspinal muscle cross sectional area and fatty infiltration, ligament augmentation, instrument characteristics, postoperative hip and lower extremity radiographic metrics, and postoperative teriparatide supplementation. Discussion and conclusion: This review finds a multifactorial framework accounting for mechanical, patient and tissue-based risk factors will improve the understanding of PJK development.

Patient-specific rods in adult spinal deformity: a systematic review.

PURPOSE: The purpose of this review was to evaluate the effectiveness of patient-specific rods for adult spinal deformity. METHODS: A systematic review of the literature was performed through an electronic search of the PubMed, Scopus, and Web of Science databases. Human studies between 2012 and 2023 were included. Sample size, sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), pelvic tilt (PT), operation time, blood loss, follow-up duration, and complications were recorded for each study when available. RESULTS: Seven studies with a total of 304 adult spinal deformity patients of various etiologies were included. All studies reported SVA, and PT; two studies did not report PI-LL. Four studies reported planned radiographic outcomes. Two found a significant association between preoperative plan and postoperative outcome in all three outcomes. One found a significant association for PI-LL alone. The fourth found no significant associations. SVA improved in six of seven studies, PI-LL improved in all five, and three of seven studies found improved postoperative PT. Significance of these results varied greatly by study. CONCLUSION: Preliminary evidence suggests potential benefits of PSRs in achieving optimal spino-pelvic parameters in ASD surgery. Nevertheless, conclusions regarding the superiority of PSRs over traditional rods must be judiciously drawn, given the heterogeneity of patients and study methodologies, potential confounding variables, and the absence of robust randomized controlled trials. Future investigations should concentrate on enhancing preoperative planning, standardizing surgical methodologies, isolating specific patient subgroups, and head-to-head comparisons with traditional rods to fully elucidate the impact of PSRs in ASD surgery.

Analysis of Personalized Interbody Implants in the Surgical Treatment of Adult Spinal Deformity.

STUDY DESIGN: Multicenter cohort. OBJECTIVES: A report from the International Spine Study Group (ISSG) noted that surgeons failed to achieve alignment goals in nearly two-thirds of 266 complex adult deformity surgery (CADS) cases. We assess whether personalized interbody spacers are associated with improved rates of achieving goal alignment following adult spinal deformity (ASD) surgery. METHODS: ASD patients were included if their surgery utilized 3D-printed personalized interbody spacer(s) and they met ISSG CADS inclusion criteria. Planned alignment was personalized by the surgeon during interbody planning. Planned vs achieved alignment was assessed and compared with the ISSG CADS series that used stock interbodies. RESULTS: For 65 patients with personalized interbodies, 62% were women, mean age was 70.3 years (SD = 8.3), mean instrumented levels was 9.9 (SD = 4.1), and the mean number of personalized interbodies per patient was 2.2 (SD = .8). Segmental alignment was achieved close to plan for levels with personalized interbodies, with mean difference between goal and achieved as follows: intervertebral lordosis = .9° (SD = 5.2°), intervertebral coronal angle = .1° (SD = 4.7°), and posterior disc height = -0.1 mm (SD = 2.3 mm). Achieved pelvic incidence-to-lumbar lordosis mismatch (PI-LL) correlated significantly with goal PI-LL (r = .668, P < .001). Compared with the ISSG CADS cohort, utilization of personalized interbodies resulted in significant improvement in achieving PI-LL <5° of plan (P = .046) and showed a significant reduction in cases with PI-LL >15° of plan (P = .012). CONCLUSIONS: This study supports use of personalized interbodies as a means of better achieving goal segmental sagittal and coronal alignment and significantly improving achievement of goal PI-LL compared with stock devices.

Integrating navigation assistance for redirecting freehanded spinal instrumentation: experience and technique.

Retrospective review of all spinal fusions > 3 levels involving the thoracolumbar and/or sacroiliac at a single institution, by a single surgeon between 3/12/2020 and 8/13/2021 were reviewed. All screws that were secondarily navigated after identified as misdirected on intraoperative CT scan were included. Neuromonitoring reports were culled for mA threshold to triggered EMG response for all redirected screws. Intraoperative, post-de novo screw placement images (fluoroscopy scout and intraoperative CT) and post-redirection intraoperative scoliosis films and post-operative scoliosis films were independently reviewed by a senior neuroradiologist. Fifty redirected screws in the thoracic, lumbar, sacral, and ilium were identified as misdirected and redirected via navigation. The new trajectory of all screws was confirmed satisfactory by independent review between a senior neuroradiologist and neurosurgeon. Four screws could not be verified by post-operative imaging (4/50, 8%). All triggered EMG stimulated > 15 mA. No screws required return to the operating room for revision. No patients experienced a post-operative deficit. Redirection of misdirected thoracolumbar and sacroiliac screws can be performed using intraoperative CT and navigation as a means to detect and directly visualize appropriate placement.

External Validation of the Global Alignment and Proportion Score as Prognostic Tool for Corrective Surgery in Adult Spinal Deformity: A Systematic Review and Meta-Analysis.

BACKGROUND: Since its proposal, the Global Alignment and Proportion (GAP) score has been the topic of several external validation studies, which have yielded conflicting results. Given the lack of consensus regarding this prognostic tool, the authors aim to assess the accuracy of GAP scores for predicting mechanical complications following adult spinal deformity correction surgery. METHODS: A systematic search was performed using PubMed, Embase, and Cochrane Library for the purpose of identifying all studies evaluating the GAP score as a predictive tool for mechanical complications. GAP scores were pooled using a random-effects model to compare patients reporting mechanical complications after surgery versus those reporting no complications. Where receiver operator curves were provided, the area under the curve (AUC) was pooled. RESULTS: A total of 15 studies featuring 2092 patients were selected for inclusion. Qualitative analysis using Newcastle-Ottawa criteria revealed moderate quality among all included studies (5.99/9). With respect to sex, the cohort was predominantly female (82%). The pooled mean age among all patients in the cohort was 58.55 years, with a mean follow-up of 33.86 months after surgery. Upon pooled analysis, we found that mechanical complications were associated with higher mean GAP scores, albeit minimal (mean difference = 0.571 [ 95% confidence interval: 0.163-0.979]; P = 0.006, n = 864). Additionally, age (P = 0.136, n = 202), fusion levels (P = 0.207, n = 358), and body mass index (P = 0.616, n = 350) were unassociated with mechanical complications. Pooled AUC revealed poor discrimination overall (AUC = 0.69; n = 1206). CONCLUSIONS: GAP scores may have a minimal-to-moderate predictive capability for mechanical complications associated with adult spinal deformity correction.

A New Objective Radiographic Criteria for Diagnosis of Adult Idiopathic Scoliosis: Apical Pedicle Diameter Asymmetry.

OBJECTIVE: We sought to test the hypothesis that a difference of ≥1 mm in pedicle diameter between the convex and concave pedicles at the apex of a lumbar curve is a sensitive and/or specific criteria for adult idiopathic scoliosis (AdIS). METHODS: Thirty-nine operative patients with adult deformity and lumbar major curves were identified. A chart review was performed. Radiographic measurements included lumbar Cobb, curve apex, and Cobb levels involved. Apical pedicle diameter at the concavity and convexity of the curve apex were measured. RESULTS: Among these 39 patients, the average Cobb angle was 48.3 degrees. Curve apex averaged at L1/2 (range L1-L3). The curves spanned 4.7 levels (range 3-7). Twenty-five curves had the apex to the left, while 14 had the apex to the right. The average pedicle diameter at the apex was 6.1 mm. Fourteen patients had apical pedicle diameter asymmetry (APDA) >1 mm. Most (7 of 8, or 87.5%) of the patients with a history of adult idiopathic scoliosis had APDA >1 mm. A minority (7 of 31, 22.5%) of patients without known history of adult idiopathic scoliosis had APDA >1 mm (P < 0.01). CONCLUSIONS: Apical pedicle diameter asymmetry is among the sensitive diagnostic criteria for AdIS and may be useful for differentiating lumbar major AdIS from degenerative lumbar scoliosis. The sensitivity of APDA >1 mm is 87.5%, with specificity of 77.4%. We propose a new, sensitive radiographic criterion for adult idiopathic scoliosis. A difference of ≥1 mm in pedicle diameter between the convex and concave pedicles at that apex of a lumbar curve has a sensitivity of 87.5% and specificity of 77.4% for patient-reported history of adolescent scoliosis. It can be a useful tool as exclusion criteria for studies on AdIS.

Safety and Efficacy of High-Dose Tranexamic Acid in Spine Surgery: A Retrospective Single-Institution Series.

OBJECTIVE: Currently, tranexamic acid (TXA) is the most widely used antifibrinolytic agent in spine surgery and has been proven to reduce perioperative blood loss. However, the safety of high-dose regimens remains in established. METHODS: A retrospective chart review was performed to identify all adult patients who underwent spine surgery with high-dose TXA (50 mg/kg loading dose, mg/kg/h maintenance dose) between September 2019 and March 2020. RESULTS: Thirty-six patients were treated with intraoperative high-dose TXA during the study period. The mean age was 56.6 (range: 22-82). Average body mass index was 27.2 (5.1) kg/m2. Average preoperative Charlson Comorbidity Index was 3.0 (2.7). The mean number of spinal levels operated on was 6.9 (4.3). Seven cases (19.4%) were revision surgeries. The mean intraoperative blood loss was 587.1 (900.0) mL, and total blood loss was 623.8 (991.9) mL. Postoperatively, time to ambulation was on average 1.7 (1.7) days. The mean total length of stay was 9.8 days (7.9, range 2-41). The most common indication for surgery was tumor (n = 9, 25%), followed by fracture (n = 8, 22.2%), deformity (n = 7, 19.4%), pseudarthrosis (n = 6, 16.7%), and symptomatic lumbar disc herniation (n = 2, 5.6%). There were no thromboembolic or other significant complications among the 36 patients. CONCLUSIONS: This retrospective case series demonstrates that the use of high-dose TXA provides is potentially safe and efficacious in adult patients undergoing complex spine surgeries. However, further investigations are required before the true safety and optimal dosing can be determined for high-dose TXA.

360 TOTUM ALIF for a Symptomatic Fractional Curve.

As patient-specific implants become a tool in the spine surgeon's arsenal, understanding how to effectively implement multiple systems in a single surgery requires careful planning. In Video 1, we describe our workflow for a total custom anterior lumbar interbody fusion, featuring patient-specific interbodies and rods. We discuss the required cross talk necessary to ensure maximum desired correction, as well as the logic for pursuing custom devices in this index case. Appropriate consent from the patient was obtained before the procedure.

Successful use of stereotactic navigation in posterior spinal fusion T10-S2 with bilateral iliac screw fixation in a patient with prior spinal surgeries and osteoporosis: A case report.

INTRODUCTION AND IMPORTANCE: Degenerative lumbar scoliosis is a prominent cause of adult spinal deformity with an increasing prevalence as the population ages. This pathology is associated with debilitating symptoms, including radicular back pain and lower extremity claudication. Surgical realignment of the spine and restoration of sagittal imbalance can reduce low back pain. Chronic sacroiliac dysfunction commonly causes low back radicular pain. We present a complicated case where stereotactic navigation facilitated an extensive fusion and decompression procedure for adult spinal deformity in an obese patient with multiple prior surgeries for scoliosis and sacroiliac joint pathology. CASE PRESENTATION: A 69-year-old, obese female with scoliosis refractory to multiple interventions presented with severe, radicular lower back pain. On examination of the right lower extremity (RLE), she had mild weakness (3/5 strength) and reduced sensation to light touch over its anterolateral aspect (dermatome L4). She was unable to perform single leg stance or tandem walk. Imaging revealed moderate mid-lumbar levoscoliosis, severe degenerative disc disease and facet hypertrophy changes in the setting of prior multilevel lumbar fusion, and consecutive nerve root impingement between L1 and L5 (worst at L3-4). DEXA scan was consistent with osteoporosis. The patient underwent lumbar laminectomy with posterior fusion of T10-ilium, transforaminal lumbar interbody fusion, osteotomy, and decompression using stereotactic navigation. The presence of SI titanium dowels from her previous SI fusion procedure posed a challenge with respect to achieving pelvic fixation. CLINICAL DISCUSSION: Iliac screw placement is a critical adjunctive to lumbosacral fusion, notably for prevention of pseudoarthrosis; however, patients with prior SI fusion may present a biomechanical challenge to surgeons due to obstruction of the surgical site. The O-arm neuronavigation system was successfully used to bypass this obstruction and provide sacroiliac fixation in this procedure. CONCLUSION: Stereotactic navigation (The O-arm Surgical Imaging System) can effectively be used to circumvent prior SI fusion in osteoporotic bone.

Recombinant Human Bone Morphogenetic Protein-2 Use in Adult Spinal Deformity Surgery: Comparative Analysis and Healthcare Utilization at 24 Months' Follow-up.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used to achieve fusion in adult spinal deformity (ASD) surgery. Our aim was to investigate the long-term impact of rhBMP-2 use for clinical outcomes and health care utilization in this patient population. METHODS: We conducted an analysis using MarketScan to identify health resource utilization of rhBMP-2 use for ASD after surgical intervention compared to fusion without rhBMP-2 at 24 months' follow-up. Outcomes assessed included length of stay, complications, pseudoarthrosis, reoperation, outpatient services, and health care payments. RESULTS: Of 7115 patients who underwent surgery for ASD, 854 received rhBMP-2 and 6261 were operated upon without use of rhBMP-2. One month after discharge, the rhBMP-2 cohort had a nonsignificant trend in fewer complications (15.38%) than those who did not receive rhBMP-2 (18.07%), P = .0558. At 12 months, pseudoarthrosis was reported in 2.8% of cases with no BMP and 01.14% of cases with BMP, P = .0048. Average payments at 12 months were $120 138 for the rhBMP-2 group and $118 373 for the no rhBMP-2 group, P = .8228. At 24 months, payments were $141 664 for the rhBMP-2 group and $144 179 for the group that did not receive rhBMP-2, P = .5946. CONCLUSIONS: In ASD surgery, use of rhBMP-2 was not associated with increased complications or reoperations at index hospitalization and 1-month follow-up. Overall payments, including index hospitalization, readmissions, reoperations, and outpatient services were not different compared to those without the use of rhBMP-2 at 12 months and 24 months after discharge.

Freehand Juxtapedicular Screws Placed in the Apical Concavity of Adult Idiopathic Scoliosis Patients: Technique, Computed Tomography Confirmation, and Radiographic Results.

OBJECTIVE: The purpose of this study is to highlight our technique for freehand placement of juxtapedicular screws along with intraoperative computed tomography (CT) and radiographic results. METHODS: Consecutive patients with adult idiopathic scoliosis undergoing primary surgery by the senior author were identified. All type D (absent/slit like channel) pedicles were identified on preoperative CT. Three-dimensional visualization software was used to measure screw angulation and purchase. Radiographs were measured by a fellowship trained spine surgeon. The freehand technique was used to place all screws in a juxtapedicular fashion without any fluoroscopic, radiographic, navigational or robotic assistance. RESULTS: Seventy-three juxtapedicular screws were analyzed. The most common level was T7 (9 screws) on the left and T5 (12 screws) on the right. The average medial angulation was 20.7° (range, 7.1°-36.3°), lateral vertebral body purchase was 13.4 mm (range, 0-28.9 mm), and medial vertebral body purchase was 21.1 mm (range, 8.9-31.8 mm). More than half (53.4%) of the screws had bicortical purchase. Two screws were lateral on CT scan, defined by the screw axis lateral to the lateral vertebral body cortex. No screws were medial. There was a difference in medial angulation between screws with (n = 58) and without (n = 15) lateral body purchase (22.0 ± 4.9 vs. 15.5 ± 4.5, p < 0.001). Three of 73 screws were repositioned after intraoperative CT. There were no neurovascular complications. The mean coronal cobb corrections for main thoracic and lumbar curves were 83.0% and 80.5%, respectively, at an average of 17.5 months postoperative. CONCLUSION: Freehand juxtapedicular screw placement is a safe technique for type D pedicles in adult idiopathic scoliosis patients.

Minimally invasive multiple-rod constructs with robotics planning in adult spinal deformity surgery: a case series.

PURPOSE: Multiple-rod constructs (MRCs) are often used in deformity correction for increased stability and rigidity. There are currently no reports showing minimally invasive placement of MRCs in adult deformity surgery and its technical feasibility through preoperative software planning. METHODS: Data were collected retrospectively from medical records of six consecutive patients who underwent minimally invasive MRCs with robotics planning by a single surgeon at an academic center between March-August 2020. RESULTS: A total of six patients (4 females, mean age 69.7 years) underwent minimally invasive long-segment (6 +) posterior fixation with multiple rods (3 +) using the Mazor X Stealth Edition robotics platform. Average follow-up was 14.3 months. All patients underwent oblique lumbar interbody fusion (OLIF) as a first stage, followed by second stage posterior fixation in the same day. The mean number of levels posteriorly instrumented was 8.8. One patient underwent 3 rod fixation (1 iliac, 2 S2AI) and 5 patients underwent quad rod fixation (2 iliac, 2 S2AI). The mean time to secure all rods was 8 min 36 s. Mean improvement in spinopelvic parameters was -4.9 cm sagittal vertical axis, 18.0° lumbar lordosis, and -10.7° pelvic tilt with an average pelvic incidence of 62.5°. Estimated blood loss (EBL) was 100-250 cc with no blood transfusions, and all but one patient ambulated on postoperative day 1 or 2. CONCLUSION: Spinal robotics brings us into a new era of minimally invasive construct design. To our knowledge, this is the first description of the technical feasibility of MRCs in minimally invasive adult spinal deformity surgery.

Minimally Invasive L5-S1 Oblique Lumbar Interbody Fusion With Simultaneous Robotic Single Position Posterior Fixation: 2-Dimensional Operative Video.

The unique anatomy at L5-S1 presents different challenges and considerations to be made when compared to other areas in the lumbar spine. In this way, the oblique lumbar interbody fusion (OLIF) is more closely related to a supine anterior lumbar interbody fusion (ALIF) except that the former is performed in a lateral position down a smaller minimally invasive retroperitoneal corridor. This lateral positioning at L5-S1, however, provides an opportunity for single-position surgery simultaneously with posterior fixation, which is not afforded by other approaches. We present here a case of a 57-yr-old male with a prior right-sided L5-S1 microdiscectomy who presents with worsening lumbar radiculopathy and foot drop. He subsequently underwent a minimally invasive L5-S1 OLIF with posterior instrumentation placed bilaterally while remaining in a single lateral position (Mazor X Stealth Edition, Medtronic, Dublin, Ireland). Both the anterior OLIF surgeon and posterior instrumentation surgeon were able to work simultaneously. There is currently a need for further high-quality operative videos showing the L5-S1 OLIF technique, and to our knowledge, this is the first video demonstrating a 2-surgeon near-simultaneous workflow approach using a spinal robotics platform at this level. There is no identifying information in this video. A patient consent was obtained for the surgical procedure and for publishing of the material included in the video.

Surgeons lack of agreement on determining preoperative radiographic and clinical shoulder balance in adolescent and adult idiopathic scoliosis patients.

PURPOSE: Preoperative shoulder balance is an important factor in determining the upper instrumented vertebrae (UIV). In adolescent and adult idiopathic scoliosis (AIS/AdIS) patients, we studied the intraobserver and interobserver reliability of spinal surgeons' assessment of preoperative shoulder balance using X-rays (XR) and anterior/posterior photographs. METHODS: An observational review of a prospective multicenter database (AIS Lenke Type 1/5/6) and prospective single-institution database (AdIS) was conducted. Ten spine surgeons reviewed AIS cases; 12 spine surgeons reviewed AdIS cases. Surgeons rated the higher shoulder: left/right/same/unsure. Reliability was calculated using Fleiss' kappa coefficient. RESULTS: Among 145 Type 1 AIS cases, intraobserver reliability was moderate-to-substantial: XR (κ = 0.59), anterior photographs (κ = 0.68), posterior photographs (k = 0.65). Interobserver reliability was fair to moderate for XR (κ = 0.31), anterior photographs (κ = 0.20), and posterior photographs (κ = 0.30). Among 52 Type 5/6 AIS cases, intraobserver reliability was substantial: XR (κ = 0.70), anterior photographs (κ = 0.76), posterior photographs (κ = 0.71). Interobserver reliability was fair to moderate for XR (κ = 0.49), anterior photographs (κ = 0.47), and posterior photographs (κ = 0.36). Among 66 AdIS cases, intraobserver reliability was substantial: XR (κ = 0.68), anterior photographs (κ = 0.67), posterior photographs (κ = 0.69). Interobserver reliability was moderate for XR (κ = 0.45), anterior photographs (κ = 0.43), posterior photographs (κ = 0.49). Within Type 1 AIS patients, attendings had better intraobserver reliabilities compared to fellows using X-rays (κ = 0.61 vs. 0.53), yet no effect of surgeon experience was seen with clinical photographs. CONCLUSION: Though surgeons' ability to agree with themselves was moderate to substantial, surgeons' ability to agree with each other was fair to moderate. Combined measures to assess preoperative shoulder balance are needed for UIV selection.

Simultaneous Robotic Single-Position Surgery With Oblique Lumbar Interbody Fusion With Software Planning: 2-Dimensional Operative Video.

The use of robotic guidance for spinal instrumentation is promising for its ability to offer the advantages of precision, accuracy, and reproducibility. This has become even more important in the era of lateral interbody surgery because spinal robotics opens up the possibility of a straightforward workflow for single-position surgery in the lateral position. We present here a case of a 72-yr-old woman who presented with an L4-5 spondylolisthesis with axial back pain and radiculopathy. She subsequently underwent an L4-5 oblique lumbar interbody fusion with L4-5 bilateral posterior instrumentation in a single lateral position (Mazor X Stealth Edition, Medtronic Sofamor Danek, Medtronic Inc, Dublin, Ireland). Due to the oblique lateral approach and posterior robotic assistance, both surgeons were able to work simultaneously for increased efficiency. To our knowledge, this is the first video demonstrating a two-surgeon simultaneous robotic single-position surgery with oblique lumbar interbody fusion using a spinal robotic platform. There is no identifying information in this video. Patient consent was obtained for the surgical procedure and for publishing of the material included in the video.

A new modular radiographic classification of adult idiopathic scoliosis as an extension of the Lenke classification of adolescent idiopathic scoliosis.

PURPOSE: To propose and test the reliability of a radiographic classification system for adult idiopathic scoliosis. METHODS: A three-component radiographic classification for adult idiopathic scoliosis consisting of curve type, a lumbosacral modifier, and a global alignment modifier is presented. Twelve spine surgeons graded 30 pre-marked cases twice, approximately 1 week apart. Case order was randomized between sessions. RESULTS: The interrater reliability (Fleiss' kappa coefficient) for curve type was 0.660 and 0.798, for the lumbosacral modifier 0.944 and 0.965, and for the global alignment modifier 0.922 and 0.916, for round 1 and 2 respectively. Mean intrarater reliability was 0.807. CONCLUSIONS: This new radiographic classification of adult idiopathic scoliosis maintains the curve types from the Lenke classification and introduces the lumbosacral and global alignment modifiers. The reliability of the lumbosacral modifier and global alignment modifier shows near perfect agreement, and sets the foundation for further studies to validate the reliability, utility, and applicability of this classification system.

Predictors of Patient Satisfaction in Spine Surgery: A Systematic Review.

BACKGROUND: Recently, there has been increased interest in patient satisfaction measures such as Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. In this systematic review, the spine surgery literature is analyzed to evaluate factors predictive of patient satisfaction as measured by these surveys. METHODS: A thorough literature search was performed in PubMed/MEDLINE, Google Scholar, and Cochrane databases. All English-language articles from database inception to July 2020 were screened for study inclusion according to PRISMA guidelines. RESULTS: Twenty-four of the 1899 published studies were included for qualitative analysis. There has been a statistically significant increase in the number of publications across years (P = 0.04). Overall, the studies evaluated the relationship between patient satisfaction and patient demographics (71%), preoperative and intraoperative clinical factors (21%), and postoperative factors (33%). Top positive predictors of patient satisfaction were patient and nursing/medical staff relationship (n = 4; 17%), physician-patient relationship (n = 4; 17%), managerial oversight of received care (n = 3; 13%), same sex/ethnicity between patient and physician (n = 2; 8%), and older age (n = 2; 8%). Top negative predictors of patient satisfaction were high Charlson Comorbidity Index/high disability/worse overall health functioning (n = 7; 29%), increased length of hospital stay (n = 4; 17%), high rating for pain/complications/readmissions (n = 4; 17%), and psychosocial factors (n = 3; 13%). CONCLUSIONS: There is heterogeneity in terms of different factors, both clinical and nonclinically related, that affect patient satisfaction ratings. More research is warranted to investigate the role of hospital consumer surveys in the spine surgical patient population.

Evaluating the Clinical Utility and Cost of Imaging Strategies in Adults with Newly Diagnosed Primary Intradural Spinal Tumors.

OBJECTIVE: In patients with new primary intradural spinal tumors, the best screening strategy for additional central nervous system (CNS) lesions is unclear. The goal of this study was to document the rate of additional CNS tumors in these patients. METHODS: Adults with primary intradural spinal tumors were retrospectively reviewed. Imaging strategy at diagnosis was classified as focused spine (cervical, thoracic, or lumbar), total spine, or complete neuraxis (brain and total spine). Tumor pathology, genetic syndromes, and presence of additional CNS lesions at diagnosis or follow-up were collected. RESULTS: The study comprised 319 patients with mean age of 51 years and mean follow-up of 41 months. In 151 patients with focused spine imaging, 3 (2.0%) were found to have new lesions with 2 (1.4%) requiring treatment. In 35 patients with total spine imaging, there were no additional lesions. In 133 patients with complete neuraxis imaging, 4 (3.0%) were found to have new lesions with 2 (1.5%) requiring treatment. There was no difference in the identification of new lesions (P = 0.542) or new lesions requiring treatment (P = 0.772) across imaging strategies. Among patients without genetic syndromes, rates of new lesions requiring treatment were 1.4% for focused spine, 0% for total spine, and 2.2% for complete neuraxis (P = 0.683). There were no cases of delayed identification causing risk to life or neurological function. Complete neuraxis imaging carried an increased charge of $4420 per patient. CONCLUSIONS: Among patients without an underlying genetic syndrome, the likelihood of identifying additional CNS lesions requiring treatment is low. In appropriate cases, focused spine imaging may be a more cost-effective strategy.