Chondrosarcoma of the Mobile Spine: An Update on Patients Treated at a Single Institution.

STUDY DESIGN: Retrospective study. OBJECTIVE: The objective is to report the clinical data for patients treated with mobile spine chondrosarcoma. SUMMARY OF BACKGROUND DATA: Chondrosarcoma of the mobile spine is a rare and challenging entity. A handful of case series have been published that report the clinical results of treatment, largely influenced by chondrosarcoma of the appendicular skeleton and pelvis. The clinical results of patients treated for chondrosarcoma of the mobile spine from our institution were published over ten years ago and this represents and update since that publication. METHODS: Inclusion criteria were adults patients treated for chondrosarcoma of the mobile spine at Massachusetts General Hospital between 2007-2020. Patients with large sacral tumors extending into the lumbar spine were excluded. Further, we excluded patients with metastatic chondrosarcoma undergoing palliative decompressions for neurologic instability or instrumented procedures for biomechanical instability. Therefore, only patients undergoing definitive surgery at the primary site of disease in the mobile spine were included. RESULTS: Twenty-four patients were included for review in this series. Seventeen of the 24 patients had their tumors excised with negative (R0) margins. Three of these 17 patients (18%) were dead of disease at final follow-up. There were two patients with R1 resections and five patients with R2 resections. Three of the 7 patients (43%) with positive margins were dead of disease at final follow-up. A Cox proportional hazard analysis indicated total radiation dose was a significant covariate (HR 1.18, 95% CI 1.01 - 1.39, P=0.03). CONCLUSION: We found higher percentages of overall survival with R0 tumor resection and lower histologic grade whereas development of metastatic disease was closely associated with local recurrence and poor survival. Despite the improvements in treatment paradigms, it is sobering that our findings largely mirror those of previous work considering patients treated between 1984 and 2006.

Unraveling molecular advancements in chordoma tumorigenesis and treatment response: a review of scientific discoveries and clinical implications.

Chordomas are tumors thought to originate from notochordal remnants that occur in midline structures from the cloves of the skull base to the sacrum. In adults, the most common location is the sacrum, followed by the clivus and then mobile spine, while in children a clival origin is most common. Most chordomas are slow growing. Clinical presentation of chordomas tend to occur late, with local invasion and large size often complicating surgical intervention. Radiation therapy with protons has been proven to be an effective adjuvant therapy. Unfortunately, few adjuvant systemic treatments have demonstrated significant effectiveness, and chordomas tend to recur despite intensive multimodal care. However, insight into the molecular underpinnings of chordomas may guide novel therapeutic approaches including selection for immune and molecular therapies, individualized prognostication of outcomes, and real-time noninvasive assessment of disease burden and evolution. At the genomic level, elevated levels of brachyury stemming from duplications and mutations resulting in altered transcriptional regulation may introduce druggable targets for new surgical adjuncts. Transcriptome and epigenome profiling have revealed promoter- and enhancer-dependent mechanisms of protein regulation, which may influence therapeutic response and long-term disease history. Continued scientific and clinical advancements may offer further opportunities for treatment of chordomas. Single-cell transcriptome profiling has further provided insight into the heterogeneous molecular pathways contributing to chordoma propagation. New technologies such as spatial transcriptomics and emerging biochemical analytes such as cell-free DNA have further augmented the surgeon-clinician's armamentarium by facilitating detailed characterization of intra- and intertumoral biology while also demonstrating promise for point-of-care tumor quantitation and assessment. Recent and ongoing clinical trials highlight accelerating interest to translate laboratory breakthroughs in chordoma biology and immunology into clinical care. In this review, the authors dissect the landmark studies exploring the molecular pathogenesis of chordoma. Incorporating this into an outline of ongoing clinical trials and discussion of emerging technologies, the authors aimed to summarize recent advancements in understanding chordoma pathogenesis and how neurosurgical care of chordomas may be augmented by improvements in adjunctive treatments.

Post-operative Patient Portal Messaging is Associated With Return to the Emergency Department After Lumbar Spine Surgery.

STUDY DESIGN: Retrospective study. OBJECTIVE: To explore the association between patients undergoing lumbar spine surgery who message their care team via an electronic patient portal (EPP) post-operatively and emergency department (ED) visits within 90 days of surgery. SUMMARY OF BACKGROUND DATA: Secure patient messaging through electronic patient portals has grown over recent years. Despite its frequent utilization by patients to engage with their care team, its association with clinical outcomes remains unknown in spine surgery. METHODS: This study was approved by our Institutional Review Board. Inclusion criteria were adults who underwent single-stage lumbar spine surgery between January 2016-June 2023. Patients with incomplete information, multi-stage surgeries, and those who died within 90 days of surgery were excluded. Patient sociodemographic, surgical, hospital readmission, and patient-provider engagement data were collected. RESULTS: A total of 13,135 patients were included. A total of 1,711 patients (13%) had a post-operative ED visit, and 4,791 patients (36%) used the patient portal to send a message after surgery. Sending a post-operative patient message after undergoing lumbar spine surgery was associated with an increased likelihood of having an ED visit that does not lead to readmission (1.29 (1.10-1.53), P = 0.002). Patients with high school degrees were more likely to have an ED visit without readmission (1.33 (1.08-1.65), P = 0.008). CONCLUSION: Patients at a higher risk of presenting to the ED post-operatively should be identified and may benefit from additional counseling and access to the care team virtually to limit unnecessary healthcare utilization. Focusing on patients who reach out via EPP messaging post-operatively may be a good target patient group to address first. Future research is needed to investigate the possible health literacy and other socioeconomic barriers affecting these patients so that appropriate, more cost-effective resources can be utilized to avoid clinically unnecessary and costly ED visits.

Assessing the variation and drivers of cost in 1-level lumbar fusion: a time-driven activity-based costing analysis.

BACKGROUND CONTEXT: As value-based health care arrangements gain traction in spine care, understanding the true cost of care becomes critical. Historically, inaccurate cost proxies have been used, including negotiated reimbursement rates or list prices. However, time-driven activity-based costing (TDABC) allows for a more accurate cost assessment, including a better understanding of the primary drivers of cost in 1-level lumbar fusion. PURPOSE: To determine the variation of total hospital cost, differences in characteristics between high-cost and non-high-cost patients, and to identify the primary drivers of total hospital cost in a sample of patients undergoing 1-level lumbar fusion. STUDY DESIGN/SETTING: Retrospective, multicenter (one academic medical center, one community-based hospital), observational study. PATIENT SAMPLE: A total of 383 patients undergoing elective 1-level lumbar fusion for degenerative spine conditions between November 2, 2021 and December 2, 2022. OUTCOME MEASURES: Total hospital cost of care (normalized); preoperative, intraoperative, and postoperative cost of care (normalized); ratio of most to least expensive 1-level lumbar fusion. METHODS: Patients undergoing a 1-level lumbar fusion between November 2, 2021 and December 2, 2022 were identified at two hospitals (one quaternary referral academic medical center and one community-based hospital) within our health system. TDABC was used to calculate total hospital cost, which was also broken up into: pre-, intra-, and postoperative timeframes. Operating surgeon and patient characteristics were also collected and compared between high- and non-high-cost patients. The correlation of surgical time and cost was determined. Multivariable linear regression was used to determine factors associated with total hospital cost. RESULTS: The most expensive 1-level lumbar fusion was 6.8x more expensive than the least expensive 1-level lumbar fusion, with the intraoperative period accounting for 88% of total cost. On average. the implant cost accounted for 30% of the total, but across the patient sample, the implant cost accounted for a range of 6% to 44% of the total cost. High-cost patients were younger (55 years [SD: 13 years] vs.63 years [SD: 13 years], p=.0002), more likely to have commercial health insurance (24 out of 38 (63%) vs. 181 out of 345 (52%), p=.003). There was a poor correlation between time of surgery (i.e., incision to close) and total overall cost (ρ: .26, p<.0001). Increase age (RC: -0.003 [95% CI: -0.006 to -0.000007], p=.049) was associated with decreased cost. Surgery by certain surgeons was associated with decreased total cost when accounting for other factors (p<.05). CONCLUSIONS: A large variation exists in the total hospital cost for patients undergoing 1-level lumbar fusion, which is primarily driven by surgeon-level decisions and preferences (e.g., implant and technology use). Also, being a "fast" surgeon intraoperatively does not mean your total cost is meaningfully lower. As efforts continue to optimize patient value through ensuring appropriate clinical outcomes while also reducing cost, spine surgeons must use this knowledge to lead, or at least be active participants in, any discussions that could impact patient care.

Limited health literacy results in lower health-related quality of life in spine patients.

BACKGROUND CONTEXT: Spinal conditions impact health-related quality of life (HRQoL). Patient education and counseling improve HRQoL, yet the effects may be limited for patients with inadequate health literacy (HL). Despite the established relationship between HRQoL and HL in other fields, research in the orthopedic spine population is lacking. PURPOSE: To investigate if limited HL results in lower HRQoL and to evaluate factors are associated with HRQoL in patients seen at an outpatient orthopedic spine center. STUDY DESIGN/SETTING: Prospective single-center cross-sectional study. PATIENT SAMPLE: Patients 18 years of age or older seen at a tertiary urban academic hospital- based multi-surgeon outpatient spine center. OUTCOME MEASURES: EQ-5D-5L health-related quality of life (HRQoL) questionnaire, and the Newest Vital Sign (NVS) HL assessment tool. METHODS: Between October 2022 and February 2023, consecutive English-speaking patients over the age of 18 and new to the outpatient spine clinic were approached for participation in this cross-sectional survey study. Patients completed a sociodemographic survey, EQ-5D-5L HRQoL questionnaire, and Newest Vital Sign (NVS) HL assessment tool. The EQ-5D-5L yields two continuous outcomes: an index score ranging from below 0 to 1 and a visual analog scale (EQ-VAS) score ranging from 0 to 100. The NVS scores were divided into limited (0-3) and adequate (4-6) HL. Multivariate linear regression with purposeful selection of variables was performed to identify independent factors associated with HRQoL. RESULTS: Out of 397 eligible patients, 348 (88%) agreed to participate and were included in statistical analysis. Limited HL was independently associated with lower EQ-5D-5L index scores (B=1.07 [95% CI 1.00-1.15], p=.049. Other factors associated with lower EQ-5D-5L index scores were being obese (BMI≥30), having housing concerns, and being an active smoker. Factors associated with lower EQ-VAS scores were being underweight (BMI<18.5), obese, having housing concerns, and higher updated Charlson comorbidity index (uCCI) scores. Being married was associated with higher EQ-VAS scores. CONCLUSIONS: Limited HL is associated with lower EQ-5D-5L index scores in spine patients, indicating lower HRQoL. To effectively apply HL-related interventions in this population, a better understanding of the complex interactions between patient characteristics, social determinants of health, and HRQoL outcomes is required. Further research should focus on interventions to improve HRQoL in patients with limited HL and how to accurately identify these patients. LEVEL OF EVIDENCE: Level II prognostic.

Machine learning-based detection of sarcopenic obesity and association with adverse outcomes in patients undergoing surgical treatment for spinal metastases.

OBJECTIVE: The distributions and proportions of lean and fat tissues may help better assess the prognosis and outcomes of patients with spinal metastases. Specifically, in obese patients, sarcopenia may be easily overlooked as a poor prognostic indicator. The role of this body phenotype, sarcopenic obesity (SO), has not been adequately studied among patients undergoing surgical treatment for spinal metastases. To this end, here the authors investigated the role of SO as a potential prognostic factor in patients undergoing surgical treatment for spinal metastases. METHODS: The authors identified patients who underwent surgical treatment for spinal metastases between 2010 and 2020. A validated deep learning approach evaluated sarcopenia and adiposity on routine preoperative CT images. Based on composition analyses, patients were classified with SO or nonsarcopenic obesity. After nearest-neighbor propensity matching that accounted for confounders, the authors compared the rates and odds of postoperative complications, length of stay, 30-day readmission, and all-cause mortality at 90 days and 1 year between the SO and nonsarcopenic obesity groups. RESULTS: A total of 62 patients with obesity underwent surgical treatment for spinal metastases during the study period. Of these, 37 patients had nonsarcopenic obesity and 25 had SO. After propensity matching, 50 records were evaluated that were equally composed of patients with nonsarcopenic obesity and SO (25 patients each). Patients with SO were noted to have increased odds of nonhome discharge (OR 6.0, 95% CI 1.69-21.26), 30-day readmission (OR 3.27, 95% CI 1.01-10.62), and 90-day (OR 4.85, 95% CI 1.29-18.26) and 1-year (OR 3.78, 95% CI 1.17-12.19) mortality, as well as increased time to mortality after surgery (12.60 ± 19.84 months vs 37.16 ± 35.19 months, p = 0.002; standardized mean difference 0.86). No significant differences were noted in terms of length of stay or postoperative complications when comparing the two groups (p > 0.05). CONCLUSIONS: The SO phenotype was associated with increased odds of nonhome discharge, readmission, and postoperative mortality. This study suggests that SO may be an important prognostic factor to consider when developing care plans for patients with spinal metastases.

Are Commonly Used Geographically Based Social Determinant of Health Indices in Orthopaedic Surgery Research Correlated With Each Other and With PROMIS Global-10 Physical and Mental Health Scores?

BACKGROUND: Geographically based social determinants of health (SDoH) measures are useful in research and policy aimed at addressing health disparities. In the United States, the Area Deprivation Index (ADI), Neighborhood Stress Score (NSS), and Social Vulnerability Index (SVI) are frequently used, but often without a clear reason as to why one is chosen over another. There is limited evidence about how strongly correlated these geographically based SDoH measures are with one another. Further, there is a paucity of research examining their relationship with patient-reported outcome measures (PROMs) in orthopaedic patients. Such insights are important in order to determine whether comparisons of policies and care programs using different geographically based SDoH indices to address health disparities in orthopaedic surgery are appropriate. QUESTIONS/PURPOSES: Among new patients seeking care at an orthopaedic surgery clinic, (1) what is the correlation of the NSS, ADI, and SVI with one another? (2) What is the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 physical and mental health scores and the NSS, ADI, and SVI? (3) Which geographically based SDoH index or indices are associated with presenting PROMIS Global-10 physical and mental health scores when accounting for common patient-level sociodemographic factors? METHODS: New adult orthopaedic patient encounters at clinic sites affiliated with a tertiary referral academic medical center between 2016 and 2021 were identified, and the ADI, NSS, and SVI were determined. Patients also completed the PROMIS Global-10 questionnaire as part of routine care. Overall, a total of 75,335 new patient visits were noted. Of these, 62% (46,966 of 75,335) of new patient visits were excluded because of missing PROMIS Global-10 physical and mental health scores. An additional 2.2% of patients (1685 of 75,335) were excluded because they were missing at least one SDoH index at the time of their visit (for example, if a patient only had a Post Office box listed, the SDoH index could not be determined). This left 35% of the eligible new patient visits (26,684 of 75,335) in our final sample. Though only 35% of possible new patient visits were included, the diversity of these individuals across numerous characteristics and the wide range of sociodemographic status-as measured by the SDoH indices-among included patients supports the generalizability of our sample. The mean age of patients in our sample was 55 ± 18 years and a slight majority were women (54% [14,366 of 26,684]). Among the sample, 16% (4381of 26,684) of patients were of non-White race. The mean PROMIS Global-10 physical and mental health scores were 43.4 ± 9.4 and 49.7 ± 10.1, respectively. Spearman correlation coefficients were calculated among the three SDoH indices and between each SDoH index and PROMIS Global-10 physical and mental health scores. In addition, regression analysis was used to assess the association of each SDoH index with presenting functional and mental health, accounting for key patient characteristics. The strength of the association between each SDoH index and PROMIS Global-10 physical and mental health scores was determined using partial r-squared values. Significance was set at p < 0.05. RESULTS: There was a poor correlation between the ADI and the NSS (ρ = 0.34; p < 0.001). There were good correlations between the ADI and SVI (ρ = 0.43; p < 0.001) and between the NSS and SVI (ρ = 0.59; p < 0.001). There was a poor correlation between the PROMIS Global-10 physical health and NSS (ρ = -0.14; p < 0.001), ADI (ρ = -0.24; p < 0.001), and SVI (ρ = -0.17; p < 0.001). There was a poor correlation between PROMIS Global-10 mental health and NSS (ρ = -0.13; p < 0.001), ADI (ρ = -0.22; p < 0.001), and SVI (ρ = -0.17; p < 0.001). When accounting for key sociodemographic factors, the ADI demonstrated the largest association with presenting physical health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001) and mental health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001), as confirmed by the partial r-squared values for each SDoH index (physical health: ADI 0.04 versus SVI 0.02 versus NSS 0.01; mental health: ADI 0.04 versus SVI 0.02 versus NSS 0.01). This finding means that as social deprivation increases, physical and mental health scores decrease, representing poorer health. For further context, an increase in ADI score by approximately 36 and 39 suggests a clinically meaningful (determined using distribution-based minimum clinically important difference estimates of one-half SD of each PROMIS score) worsening of physical and mental health, respectively. CONCLUSION: Orthopaedic surgeons, policy makers, and other stakeholders looking to address SDoH factors to help alleviate disparities in musculoskeletal care should try to avoid interchanging the ADI, SVI, and NSS. Because the ADI has the largest association between any of the geographically based SDoH indices and presenting physical and mental health, it may allow for easier clinical and policy application. CLINICAL RELEVANCE: We suggest using the ADI as the geographically based SDoH index in orthopaedic surgery in the United States. Further, we caution against comparing findings in one study that use one geographically based SDoH index to another study's findings that incorporates another geographically based SDoH index. Although the general findings may be the same, the strength of association and clinical relevance could differ and have policy ramifications that are not otherwise appreciated; however, the degree to which this may be true is an area for future inquiry.

Patient-Reported Outcomes Measurement Information System Physical Function and Global Physical Health Subscale Strongly Correlate and Perform Similarly to the Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form.

BACKGROUND: Arthroplasty surgeons use a variety of patient-reported outcome measures (PROMs) to assess functional well-being, including the Knee Injury and Osteoarthritis Outcome Score (KOOS) Physical Function short form (KOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PROMIS PF SF 10a), and PROMIS Global-10 Physical Health subscale. However, there is a paucity of literature assessing their concurrent validity and performance. METHODS: Between June 2016 and December 2020, patient visits at an arthroplasty clinic for knee concerns were identified. Patients who completed KOOS-PS, PROMIS PF SF 10a, and PROMIS Global-10, including its physical and mental health subscales, at the same visit were identified. Spearman rho (ρ) correlations were calculated and ceiling and floor effects identified. Overall, 5,303 patient encounters were included. RESULTS: Among physical function domains, strong correlation existed between the KOOS-PS and PROMIS PF SF 10a (ρ = 0.76, P < .001), KOOS-PS and PROMIS Global Physical Health (ρ = 0.71, P < .001), and PROMIS PF SF 10a and PROMIS Global Physical Health (ρ = 0.78, P < .001). No physical function-focused PROM had an appreciable floor effect (ie, at or more than 1%). The KOOS-PS had a small but measurable ceiling effect (n = 105 [2.0%]). CONCLUSIONS: All of the examined PROMs are acceptable to measure the functional status of patients with knee pathology, with the PROMIS Global-10 also being able to capture elements of mental health too. The PROMIS Global-10 may be of most value of the PROMs assessed, as the United States Centers for Medicare and Medicaid Services already incorporate the mental health component into new alternative payment models.

A deep learning approach using an ensemble model to autocreate an image-based hip fracture registry.

Objectives: With more than 300,000 patients per year in the United States alone, hip fractures are one of the most common injuries occurring in the elderly. The incidence is predicted to rise to 6 million cases per annum worldwide by 2050. Many fracture registries have been established, serving as tools for quality surveillance and evaluating patient outcomes. Most registries are based on billing and procedural codes, prone to under-reporting of cases. Deep learning (DL) is able to interpret radiographic images and assist in fracture detection; we propose to conduct a DL-based approach intended to autocreate a fracture registry, specifically for the hip fracture population. Methods: Conventional radiographs (n = 18,834) from 2919 patients from Massachusetts General Brigham hospitals were extracted (images designated as hip radiographs within the medical record). We designed a cascade model consisting of 3 submodules for image view classification (MI), postoperative implant detection (MII), and proximal femoral fracture detection (MIII), including data augmentation and scaling, and convolutional neural networks for model development. An ensemble model of 10 models (based on ResNet, VGG, DenseNet, and EfficientNet architectures) was created to detect the presence of a fracture. Results: The accuracy of the developed submodules reached 92%-100%; visual explanations of model predictions were generated through gradient-based methods. Time for the automated model-based fracture-labeling was 0.03 seconds/image, compared with an average of 12 seconds/image for human annotation as calculated in our preprocessing stages. Conclusion: This semisupervised DL approach labeled hip fractures with high accuracy. This mitigates the burden of annotations in a large data set, which is time-consuming and prone to under-reporting. The DL approach may prove beneficial for future efforts to autocreate construct registries that outperform current diagnosis and procedural codes. Clinicians and researchers can use the developed DL approach for quality improvement, diagnostic and prognostic research purposes, and building clinical decision support tools.

PROMIS Global Physical Health Subscale Strongly Correlates and Performs Similarly to the QuickDASH in Hand and Upper Extremity Patients.

BACKGROUND: The Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) is a validated, static hand and upper extremity patient-reported outcome measure (PROM) commonly used. However, with the growth of PROM implementation across orthopedic and plastic surgery clinics, it is beneficial to determine whether a more general PROM can be used to capture the same insights. This would ease implementation broadly. There is a paucity of literature assessing whether the QuickDASH and Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 are correlated and perform similarly. METHODS: Between June 2016 and December 2020, hand and upper extremity patients seeking care at clinics associated with a single quaternary academic medical center were identified. Those who completed the PROMIS Global-10 and QuickDASH as part of routine care were identified. The PROMIS Global-10 is divided into the PROMIS Global Physical Health and PROMIS Global Mental Health subscores. Spearman rho (ρ) correlations were calculated across PROMs, and ceiling and floor effects were determined. RESULTS: Across the 18 744 included patients, there was a strong correlation and strong-moderate correlation found between the QuickDASH and PROMIS Global Physical Health (ρ = 0.70, P < .001) and PROMIS Global Mental Health (ρ = 0.69, P < .001), respectively. Although small, QuickDASH demonstrates the worst floor effect (2.6%, [n = 478]), whereas PROMIS Global Mental Health demonstrated a much more notable ceiling effect (11%, [n = 2034]). CONCLUSIONS: The PROMIS Global-10 can be used to assess the functional status of patients presenting for hand and upper extremity concerns, while also capturing aspects of mental health. The PROMIS Global-10 may ease PROM implementation broadly.

Inpatient opioid use varies by construct length among laminoplasty versus laminectomy and fusion patients.

Background: Laminoplasty (LP) and laminectomy and fusion (LF) are utilized to achieve decompression in patients with symptomatic degenerative cervical myelopathy (DCM). Comparative analyses aimed at determining outcomes and clarifying indications between these procedures represent an area of active research. Accordingly, we sought to compare inpatient opioid use between LP and LF patients and to determine if opioid use correlated with length of stay. Methods: Sociodemographic information, surgical and hospitalization data, and medication administration records were abstracted for patients >18 years of age who underwent LP or LF for DCM in the Mass General Brigham (MGB) health system between 2017 and 2019. Specifically, morphine milligram equivalents (MME) of oral and parenteral pain medication given after arrival in the recovery area until discharge from the hospital were collected. Categorical variables were analyzed using chi-squared analysis or Fisher exact test when appropriate. Continuous variables were compared using Independent samples t tests and Mann-Whitney U tests. Results: One hundred eight patients underwent LF, while 138 patients underwent LP. Total inpatient opioid use was significantly higher in the LF group (312 vs. 260 MME, p=.03); this difference was primarily driven by higher postoperative day 0 pain medication requirements. Furthermore, more LF patients required high dose (>80 MME/day) regimens. While length of stay was significantly different between groups, with LF patients staying approximately 1 additional day, postoperative day 0 MME was not a significant predictor of this difference. When operative levels including C2, T1, and T2 were excluded, the differences in total opioid use and average length of stay lost significance. Conclusions: Inpatient opioid use and length of stay were significantly greater in LF patients compared to LP patients; however, when constructs including C2, T1, T2 were excluded from analysis, these differences lost significance. Such findings highlight the impact of operative extent between these procedures. Future studies incorporating patient reported outcomes and evaluating long-term pain needs will provide a more complete understanding of postoperative outcomes between these 2 procedures.

Evaluating and Comparing the Correlation and Performance of PROMIS and FAAM ADL in a Foot and Ankle Patient Population.

BACKGROUND: There is a paucity of literature assessing 2 of the commonly used static Patient-Reported Outcomes Measurement Information System (PROMIS) forms (PROMIS Global-10 and PROMIS Physical Function Short Form 10a [PF SF 10a]) and the Foot and Ankle Ability Measure Activities of Daily Living (FAAM ADL). METHODS: The PROMIS Global-10, PROMIS PF SF 10a, and FAAM ADL were compared among new foot and ankle patients. Spearman rho (ρ) correlations were calculated, and ceiling and floor effects were determined. RESULTS: The FAAM ADL demonstrated strong correlations with PROMIS PF SF 10a, P = .88, 95% confidence interval (CI): 0.86-0.90, P < .001, and PROMIS Global-10 Physical Health (P = .75, 95% CI: 0.71-0.78, p < .001). The FAAM ADL and PROMIS Global-10 Mental Health demonstrated a moderate correlation (P = .41, 95% CI: 0.34-0.47, P < .001). No PROM demonstrated an appreciable floor effect. The PROMIS Global-10 Physical Health demonstrated the lowest ceiling effect (n=11 [1.6%]). CONCLUSION: Because the PROMIS Global-10 captures physical health adequately, provides mental health insight, and performs as well (if not better), we recommend the PROMIS Global-10 among the PROMs studied.Level of Evidence: Level III.

Implication of nutritional status for adverse outcomes after surgery for metastatic spine tumors.

OBJECTIVE: Surgery for metastatic spinal tumors can have a substantial impact on patients' quality of life by alleviating pain, improving function, and correcting spinal instability when indicated. The decision to operate is difficult because many patients with cancer are frail. Studies have highlighted the importance of preoperative nutritional status assessments; however, little is known about which aspects of nutrition accurately inform clinical outcomes. This study investigates the interaction and prognostic importance of various nutritional and frailty measures in patients with spinal metastases. METHODS: A retrospective analysis of consecutive patients who underwent surgery for spinal metastases between 2014 and 2020 at the Massachusetts General Hospital was performed. Patients were stratified according to the New England Spinal Metastasis Score (NESMS). Frailty was assessed using the metastatic spinal tumor frailty index. Nutrition was assessed using the prognostic nutritional index (PNI), preoperative body mass index, albumin, albumin-to-globulin ratio, and platelet-to-lymphocyte ratio. Outcomes included postoperative survival and complication rates, with focus on wound-related complications. RESULTS: This study included 154 individuals (39% female; mean [SD] age 63.23 [13.14] years). NESMS 0 and NESMS 3 demonstrated the highest proportions of severely frail patients (56.2%) and nonfrail patients (16.1%), respectively. Patients with normal nutritional status (albumin-to-globulin ratio and PNI) had a better prognosis than those with poor nutritional status when stratified by NESMS. Multivariable regression adjusted for NESMS and frailty showed that a PNI > 40.4 was significantly associated with decreased odds of 90-day complications (OR 0.93, 95% CI 0.85-0.98). After accounting for age, sex, primary tumor pathology, physical function, nutritional status, and frailty, a preoperative nutrition consultation was associated with a decrease in postoperative wound-related complications (average marginal effect -5.00%; 95% CI -1.50% to -8.9%). CONCLUSIONS: The PNI was most predictive of complications and may be a key biomarker for risk stratification in the 90 days following surgery. Nutrition consultation was associated with a reduced risk of wound-related complications, attesting to the importance of this preoperative intervention. These findings suggest that nutrition plays an important role in the postsurgical course and should be considered when developing a treatment plan for spinal metastases.

Neurological Outcomes and the Need for Retreatments Among Multiple Myeloma Patients With High-Grade Spinal Cord Compression: Radiotherapy vs Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Up to 30% of Multiple Myeloma (MM) patients are expected to experience Epidural Spinal Cord Compression (ESCC) during the course of their disease. To prevent irreversible neurological damage, timely diagnosis and treatment are important. However, debate remains regarding the optimal treatment regimen. The aim of this study was to investigate the neurological outcomes and frequency of retreatments for MM patients undergoing isolated radiotherapy and surgical interventions for high-grade (grade 2-3) ESCC. METHODS: This study included patients with MM and high-grade ESCC treated with isolated radiotherapy or surgery. Pre- and post-treatment American Spinal Injury Association (ASIA) impairment scale and retreatment rate were compared between the 2 groups. Adjusted multivariable logistic regression was utilized to examine differences in neurologic compromise, pain, and retreatments. RESULTS: A total of 247 patients were included (Radiotherapy: n = 154; Surgery: n = 93). After radiotherapy, 82 patients (53%) achieved full neurologic function (ASIA E) at the end of follow-up. Of the surgically treated patients, 67 (64%) achieved full neurologic function. In adjusted analyses, patients treated with surgery were less likely to experience neurologic deterioration within 2 years (OR = .15; 95%CI .05-.44; P = .001) and had less pain (OR = .29; 95%CI .11-.74; P = .010). Surgical treatment was not associated with an increased risk of retreatments (OR = .64; 95%CI .28-1.47; P = .29) or death (HR = .62, 95%CI .28-1.38; P = .24). CONCLUSIONS: After adjusting for baseline differences, surgically treated patients with high-grade ESCC showed better neurologic outcomes compared to patients treated with radiotherapy. There were no differences in risk of retreatment or death.

Reliability of self-reported health literacy screening in spine patients.

BACKGROUND CONTEXT: Limited health literacy has previously been associated with increased health care utilization, worse general health status and self-reported health, and increased mortality. Identifying and accommodating patients with limited health literacy may offer an avenue towards mitigating adverse health outcomes and reduce unnecessary health care expenditure. Due to the challenges associated with implementation of lengthy health literacy assessments, the Brief Health Literacy Screening Instrument was developed. However, to our knowledge, there are no reports on the accuracy of this screening questionnaire, with or without the inclusion of sociodemographic characteristics, when predicting limited health literacy in orthopaedic spine patients. PURPOSE: To evaluate the reliability and predictive accuracy of self-reported health literacy screening questions with and without the inclusion of sociodemographic variables in orthopaedic spine patients. STUDY DESIGN: Cross-sectional. PATIENT SAMPLE: Patients seen at a tertiary urban academic hospital-based multi-surgeon spine center OUTCOME MEASURES: Brief Health Literacy Screening Instrument (BRIEF), and the Newest Vital Sign (NVS) health literacy assessment tool. METHODS: Between December 2021 and February 2022, consecutive English-speaking patients over the age of 18 presenting as new patients to an urban, hospital-based outpatient spine clinic were approached for participation. A sociodemographic survey, the BRIEF, and the NVS Health Literacy Assessment Tool were administered verbally. Simple and multivariable logistic regression was utilized to assess the accuracy of each BRIEF question individually, and collectively, at predicting limited health literacy as defined by the NVS. Further regression analysis included sociodemographic variables (age, body mass index, race, ethnicity, highest educational degree, employment status, marital status, annual household income, insurance status, and self-reported health. RESULTS: A total of 262 patients [mean age (years), 57 ± 17] were included in this study. One hundred thirty-four (51%) were male, 223 (85%) were White, and 151 (58%) were married. Patient BRIEF scores were as follows: 23 (9%) limited, 43 (16%) marginal, and 196 (75%) adequate. NVS scores identified 87 (33%) patients with possible limited health literacy. BRIEF items collectively demonstrated fair accuracy in the prediction of limited health literacy (area under the receiver operating characteristic curve, 0.76; 95% CI, 0.70-0.82). Individually, the fourth BRIEF item ("How confident are you in filling out medical forms by yourself?") was the best predictor of limited health literacy (area under the receiver operating characteristic curve, 0.67; 95% CI, 0.60-0.73). The predictive accuracy of the BRIEF items, both individually and collectively, increased with the inclusion of sociodemographic variables within the logistic regression. Specific characteristics independently associated with limited health literacy were self-identified Black race, retired or disabled employment status, single or divorced marital status, high school education or below, and self-reported "poor" health. CONCLUSIONS: Limited health literacy has implications for patient outcomes and health care costs. Our results show that the BRIEF questionnaire is a low-cost screening tool that demonstrates fair predictability in determining limited health literacy within a population of spine patients. Self-reported health literacy assessments may be more feasible in daily practice and easier to implement into clinical workflow.

Prevalence of and factors associated with limited health literacy in spine patients.

BACKGROUND: Limited health literacy exacerbates health inequity and has serious implications for patient care. It hinders successful communication and comprehension of relevant health information, which can lead to suboptimal care. Despite the evidence regarding the significance of health literacy, the topic has received little consideration in orthopedic spine patients. PURPOSE: To investigate the prevalence of and factors associated with limited health literacy among outpatients presenting to a tertiary urban academic hospital-based orthopedic spine center. STUDY DESIGN: Cross-sectionals. PATIENT SAMPLE: Patients 18 years of age or older seen at a tertiary urban academic hospital-based multi-surgeon outpatient spine center. OUTCOME MEASURES: The Newest Vital Sign (NVS) health literacy assessment. METHODS: Between December 2021 and March 2022, 447 consecutive English-speaking patients over the age of 18 years and new to the outpatient spine clinic were approached for participation in a cross-sectional survey study, of which 405 agreed to participate. Patients completed the Newest Vital Sign (NVS) health literacy assessment tool, the Rapid Estimation of Adult Literacy in Medicine Short Form (REALM-SF), and a sociodemographic survey (including race/ethnicity, level of education, employment status, income, and marital status). The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy. REALM-SF scores were classified into reading levels below ninth grade (0-6) or at least ninth grade (7). Additional demographic data was extracted from patient records. Online mapping tools were used to collect the Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI) for each patient. Subsequently, multivariable regression modeling was performed to identify independent factors associated with limited health literacy. RESULTS: The prevalence of limited health literacy in patients presenting to an urban academic outpatient spine center was 33% (135/405). Unadjusted analysis found that patients who were socioeconomically disadvantaged (eg, unemployed, lower household income, publicly insured and higher SVI) and had more unfavorable social determinant of health features (eg, housing concerns, higher ADI, less years of education, below ninth grade reading level, unmarried) had high rates of limited health literacy. Adjusted regression analysis demonstrated that limited health literacy was independently associated with higher ADI state decile, living less than 10 years at current address, having housing concerns, not being employed, non-native English speaking, having less years of education and below ninth grade reading level. CONCLUSIONS: This study found that a substantial portion of the patients presenting to an outpatient spine center have limited health literacy, more so if they are socially disadvantaged. Future efforts should investigate the impact of limited health literacy on access to care, treatment outcomes and health care utilization in orthopedic patients. Neighborhood social vulnerability measures may be a feasible way to identify patients at risk of limited health literacy in clinical practice and offer opportunities for tailored patient care. This may contribute to prioritizing the mitigation of disparities and aid in the development of meaningful interventions to improve health equity in orthopedics.

Does Nasal Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevent Deep Surgical Site Infections for Elective Cervical Spinal Fusion?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery. SUMMARY OF BACKGROUND DATA: Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. MATERIALS AND METHODS: Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates. RESULTS: This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA. CONCLUSIONS: There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.

The impact of radiotherapy on survival after surgical resection of chordoma with minimum five-year follow-up.

BACKGROUND CONTEXT: Local control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up. PURPOSE: The purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up. STUDY DESIGN/SETTING: Retrospective, single-center, cohort study. PATIENT SAMPLE: Patients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral. OUTCOME MEASURES: The outcome measures were local recurrence-free interval (LRFI) and overall survival (OS). METHODS: Demographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method. FUNDING STATEMENT: No funding was obtained for this work. RESULTS: Seventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1-24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810). CONCLUSION: Chordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence.