Perioperative Infection Prophylaxis with Vancomycin is a Significant Risk Factor for Deep Surgical Site Infection in Spine Surgery.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The purpose of this study was to compare the efficacy of cefazolin versus vancomycin for perioperative infection prophylaxis. SUMMARY OF BACKGROUND DATA: The relative efficacy of cefazolin alternatives for perioperative infection prophylaxis is poorly understood. METHODS: This study was a single-center multi-surgeon retrospective review of all patients undergoing primary spine surgery from an institutional registry. Postoperative infection was defined by the combination of three criteria: irrigation and debridement within 3 months of the index procedure, clinical suspicion for infection, and positive intraoperative cultures. Microbiology records for all infections were reviewed to assess the infectious organism and organism susceptibilities. Univariate and multivariate analyses were performed. RESULTS: A total of 10,122 patients met inclusion criteria. The overall incidence of infection was 0.78%, with an incidence of 0.73% in patients who received cefazolin and 2.03% in patients who received vancomycin (OR 2.83, 95% CI 1.35-5.91, P-0.004). Use of IV vancomycin (OR 2.83, 95% CI 1.35-5.91, P=0.006), BMI (MD 1.56, 95% CI 0.32-2.79, P=0.014), presence of a fusion (OR 1.62, 95% CI 1.04-2.52, P=0.033), and operative time (MD 42.04, 95% CI 16.88-67.21, P=0.001) were significant risk factors in the univariate analysis. In the multivariate analysis, only non-cefazolin antibiotics (OR 2.48, 95% CI 1.18-5.22, P=0.017) and BMI (MD 1.56, 95% CI 0.32-2.79, P=0.026) remained significant independent risk factors. Neither IV antibiotic regimen nor topical vancomycin significantly impacted Gram type, organism type, or antibiotic resistance (P>0.05). The most common reason for antibiosis with vancomycin was a penicillin allergy (75.0%). CONCLUSIONS: Prophylactic antibiosis with IV vancomycin leads to a 2.5-times higher risk of infection compared to IV cefazolin in primary spine surgery. We recommend the routine use of IV cefazolin for infection prophylaxis, and caution against the elective use of alternative regimens like IV vancomycin unless clinically warranted.

Predictors of Nonhome Discharge After Cervical Disc Replacement.

STUDY DESIGN: Retrospective review of a national database. OBJECTIVE: The aim of this study was to identify the factors that increase the risk of nonhome discharge after CDR. SUMMARY OF BACKGROUND DATA: As spine surgeons continue to balance increasing surgical volume, identifying variables associated with patient discharge destination can help expedite postoperative placement and reduce unnecessary length of stay. However, no prior study has identified the variables predictive of nonhome patient discharge after cervical disc replacement (CDR). METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent primary 1-level or 2-level CDR between 2011 and 2020. Multivariable Poisson regression with robust error variance was employed to identify the predictors for nonhome discharge destination following surgery. RESULTS: A total of 7276 patients were included in this study, of which 94 (1.3%) patients were discharged to a nonhome destination. Multivariable regression revealed older age (OR: 1.076, P<0.001), Hispanic ethnicity (OR: 4.222, P=0.001), BMI (OR: 1.062, P=0.001), ASA class ≥3 (OR: 2.562, P=0.002), length of hospital stay (OR: 1.289, P<0.001), and prolonged operation time (OR: 1.007, P<0.001) as predictors of nonhome discharge after CDR. Outpatient surgery setting was found to be protective against nonhome discharge after CDR (OR: 0.243, P<0.001). CONCLUSIONS: Age, Hispanic ethnicity, BMI, ASA class, prolonged hospital stay, and prolonged operation time are independent predictors of nonhome discharge after CDR. Outpatient surgery setting is protective against nonhome discharge. These findings can be utilized to preoperatively risk stratify expected discharge destination, anticipate patient discharge needs postoperatively, and expedite discharge in these patients to reduce health care costs associated with prolonged length of hospital stay. LEVEL OF EVIDENCE: IV.

Isolated decompression for degenerative spondylolisthesis is less costly than fusion even with high revision rates.

BACKGROUND CONTEXT: Isolated decompression and decompression with instrumented fusion are accepted surgical treatments for lumbar spondylolisthesis. Although isolated decompression is a less costly solution with similar patient-reported outcomes, it is associated with higher rates of re-operation than primary fusion. PURPOSE: To determine the costs associated with primary decompression, primary fusion, and decompression and fusion for degenerative spondylolisthesis. We further sought to establish at what revision rate is primary decompression still a less costly surgical treatment for degenerative lumbar spondylolisthesis. STUDY DESIGN/SETTING: A retrospective database study of the Medicare Provider Analysis and Review (MEDPAR) limited data set. PATIENT SAMPLE: Patients who underwent single-level fusion or decompression for degenerative spondylolisthesis. OUTCOME MEASURES: Cost of surgical care. METHODS: All inpatient stays that underwent surgery for single-level lumbar/lumbosacral degenerative spondylolisthesis in the 2019 calendar year (n=6,653) were queried from the MEDPAR limited data set. Patients were stratified into three cohorts: primary decompression (n=300), primary fusion (n=5,757), and revision fusion (n=566). Univariate analysis was conducted to determine cost differences between these groups and results were confirmed with multivariable regression. An economic analysis was then done to determine at what revision rate would primary decompression still be a less costly treatment choice. RESULTS: on univariate analysis, the cost of primary single-level decompression for spondylolisthesis was $14,690±9,484, the cost of primary single-level fusion was $26,376±11,967, and revision fusion was $26,686±11,309 (p<0.001). on multivariate analysis, primary fusion was associated with an increased cost of $3,751, and revision fusion was associated with increased cost of $7,502 (95%ci: 2,990-4,512, p<0.001). economic analysis found that a revision rate less than or equal to 43.8% would still result in primary decompression being less costly for a practice than primary fusion for all patients. CONCLUSIONS: Isolated decompression for degenerative lumbar spondylolisthesis is a less costly treatment choice even with rates of revision fusion as high as 43.8%. This was true even with an assumed revision rate of 0% after primary fusion. This study solely looks at cost data, however, and many patients may still benefit from primary fusion when appropriately indicated.

Level-specific comparison of 3D navigated and robotic arm-guided screw placement: an accuracy assessment of 1210 pedicle screws in lumbar surgery.

BACKGROUND CONTEXT: Robotic spine surgery, utilizing 3D imaging and robotic arms, has been shown to improve the accuracy of pedicle screw placement compared to conventional methods, although its superiority remains under debate. There are few studies evaluating the accuracy of 3D navigated versus robotic-guided screw placement across lumbar levels, addressing anatomical challenges to refine surgical strategies and patient safety. PURPOSE: This study aims to investigate the pedicle screw placement accuracy between 3D navigation and robotic arm-guided systems across distinct lumbar levels. STUDY DESIGN: A retrospective review of a prospectively collected registry PATIENT SAMPLE: Patients undergoing fusion surgery with pedicle screw placement in the prone position, using either via 3D image navigation only or robotic arm guidance OUTCOME MEASURE: Radiographical screw accuracy was assessed by the postoperative computed tomography (CT) according to the Gertzbein-Robbins classification, particularly focused on accuracy at different lumbar levels. METHODS: Accuracy of screw placement in the 3D navigation (Nav group) and robotic arm guidance (Robo group) was compared using Chi-squared test/Fisher's exact test with effect size measured by Cramer's V, both overall and at each specific lumbosacral spinal level. RESULTS: A total of 321 patients were included (Nav, 157; Robo, 189) and evaluated 1210 screws (Nav, 651; Robo 559). The Robo group demonstrated significantly higher overall accuracy (98.6 vs. 93.9%; p<.001, V=0.25). This difference of no breach screw rate was signified the most at the L3 level (No breach screw: Robo 91.3 vs. 57.8%, p<.001, V=0.35) followed by L4 (89.6 vs. 64.7%, p<.001, V=0.28), and L5 (92.0 vs. 74.5%, p<.001, V=0.22). However, screw accuracy at S1 was not significant between the groups (81.1 vs. 72.0%, V=0.10). CONCLUSION: This study highlights the enhanced accuracy of robotic arm-guided systems compared to 3D navigation for pedicle screw placement in lumbar fusion surgeries, especially at the L3, L4, and L5 levels. However, at the S1 level, both systems exhibit similar effectiveness, underscoring the importance of understanding each system's specific advantages for optimization of surgical complications.

Opening Side of Unilateral Open-Door Laminoplasty Does Not Impact Improvement in Arm Pain or Space Available for the Spinal Cord.

Background/Objectives: There exists limited data guiding open-door laminoplasty. The objective of this study is to determine if open-door laminoplasty affects radiographic decompression or arm pain outcomes. Methods: Adult patients who underwent unilateral open-door laminoplasty cervical myelopathy were included. The side opened was dependent on surgeon discretion. We recorded preoperative side of symptoms, side of radiographic compression, arm pain scores, and canal diameter. Patients with open-side ipsilateral or contralateral to dominant symptoms or compression were compared to determine any effect on arm pain outcomes or spinal canal diameter. If the symptoms were equal bilaterally, patients were neutral. Results: A total of 167 patients were included, with an average age of 64 ± 11 years and average follow-up time of 64.5 ± 72 weeks. The average preoperative arm pain visual analog score (VAS) was 2.13 ± 2.86, and the average arm VAS after 6 months was 1.52 ± 2.68. For dominant symptoms, the ipsilateral, contralateral, and neutral groups had a significant improvement in arm VAS at >6 months postoperatively. For dominant compression, the ipsilateral and contralateral groups had a significant improvement in both arm VASs and canal diameter at >6 months postoperatively. No differences were seen between groups for either. We observed a significant correlation between size of plate and change in canal diameter; however, no differences were noted for arm pain. Conclusions: Laminoplasty may be effective in addressing radicular arm pain by increasing the spinal canal's diameter and space available for the cord. The laterality of open-door laminoplasty did not affect arm pain improvement or canal expansion.

Impact of age on comparative outcomes of decompression alone versus fusion for L4 degenerative spondylolisthesis.

PURPOSE: To compare the outcomes of decompression alone and fusion for L4-5 DLS in different age cohorts (< 70 years, ≥ 70 years). METHODS: This retrospective cohort study included patients who underwent minimally invasive decompression or fusion for L4-5 DLS and had a minimum of 1-year follow-up. Outcome measures were: (1) patient-reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale back and leg, VAS; 12-Item Short Form Survey Physical Component Score, SF-12 PCS), (2) minimal clinically important difference (MCID), (3) patient acceptable symptom state (PASS), (4) response on the global rating change (GRC) scale, and (5) complication rates. The decompression and fusion groups were compared for outcomes separately in the < 70-year and ≥ 70-year age cohorts. RESULTS: 233 patients were included, out of which 52% were < 70 years. Patients < 70 years showed non-significant improvement in SF-12 PCS and significantly lower MCID achievement rates for VAS back after decompression compared to fusion. Analysis of the ≥ 70-year age cohort showed no significant differences between the decompression and fusion groups in the improvement in PROMs, MCID/PASS achievement rates, and responses on GRC. Patients ≥ 70 years undergoing fusion had significantly higher in-hospital complication rates. When analyzed irrespective of the surgery type, both < 70-year and ≥ 70-year age cohorts showed significant improvement in PROMs with no significant difference. CONCLUSIONS: Patients < 70 years undergoing decompression alone did not show significant improvement in physical function and had significantly less MCID achievement rate for back pain compared to fusion. Patients ≥ 70 years showed no difference in outcomes between decompression alone and fusion.

Parotidectomy for deep lobe pleomorphic adenomas is associated with higher rates of complications and recurrence.

BACKGROUND: Pleomorphic adenoma (PA) is a common parotid tumor, yet due to the relative rarity of deep lobe PA (DLPA), there is a paucity of information about its clinical presentation and surgical outcomes. METHODS: We reviewed the charts of patients with previously untreated parotid PA between the years 1990 and 2015. Clinical parameters and surgical outcomes were compared between superficial lobe PA (SLPA) and DLPA. RESULTS: The cohort comprised 147 cases of DLPA and 222 cases of SLPA. DLPA were larger (median 2.6 cm vs. 2.0 cm, p < 0.001), more often discovered incidentally on imaging (33%, n = 48) and had unique presentations (pharyngeal mass, dysphagia, otalgia). Postsurgical complications were more frequently observed in DLPA (41% vs. 30% in SLPA, p = 0.025), mainly transient facial nerve weakness. DLPA also showed higher recurrence rates (n = 6, 4.1% vs. n = 1, 0.4%, p = 0.016). CONCLUSIONS: Parotidectomy for DLPA carries a higher risk of complications and recurrence compared to SLPA.

Morbidly Obese Patients Have Similar Clinical Outcomes and Recovery Kinetics After Minimally Invasive Decompression.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To study the impact of class 2/3 obesity (body mass index, BMI >35) on outcomes following minimally invasive decompression. SUMMARY OF BACKGROUND DATA: No previous study has analyzed the impact of class 2/3 obesity on outcomes following minimally invasive decompression. METHODS: Patients who underwent primary minimally invasive decompression were divided into 4 cohorts based on their BMI: normal (BMI 18.5 to <25), overweight (25 to <30), class 1 obesity (30 to <35), and class 2/3 obesity (BMI >35). Outcome measures were: 1) intraoperative variables: operative time, estimated blood loss (EBL); 2) patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS); 3) global rating change (GRC), minimal clinically important difference (MCID), and patient acceptable symptom state (PASS) achievement rates; 4) return to activities; and 5) complication and reoperation rates. RESULTS: 838 patients were included (226 normal, 357 overweight, 179 class 1 obesity, 76 class 2/3 obesity). Class 1 and 2/3 obesity groups had significantly greater operative times compared to the other groups. Class 2/3 obesity group had worse ODI, VAS back and SF-12 PCS preoperatively, worse ODI, VAS back, VAS leg and SF-12 PCS at <6 months, and worse ODI and SF-12 PCS at >6 months. However, they had significant improvement in all PROMs at both postoperative timepoints and the magnitude of improvement was similar to other groups. No significant differences were found in MCID and PASS achievement rates, likelihood of betterment on the GRC scale, return to activities, and complication/reoperation rates. CONCLUSIONS: Class 2/3 obese patients have worse PROMs pre- and post-operatively. However, they show similar improvement in PROMs, MCID and PASS achievement rates, likelihood of betterment, recovery kinetics, and complication/reoperation rates as other BMI groups following minimally invasive decompression.

Quality of ChatGPT Responses to Frequently Asked Questions in Carpal Tunnel Release Surgery.

Background: Although demonstrating remarkable promise in other fields, the impact of artificial intelligence (including ChatGPT in hand surgery and medical practice) remains largely undetermined. In this study, we asked ChatGPT frequently asked patient-focused questions surgeons may receive in clinic from patients who have carpel tunnel syndrome (CTS) and evaluated the quality of its output. Methods: Using ChatGPT, we asked 10 frequently asked questions that hand surgeons may receive in the clinic before carpel tunnel release (CTR) surgery. Included questions were generated from the authors' own experiences regarding conservative and operative treatment of CTS. Results: Responses from the following 10 questions were included: (1) What is CTS and what are its signs and symptoms? (2) What are the nonsurgical options for CTS? (3) Should I get surgery for CTS? (4) What is a CTR and how is it preformed? (5) What are the differences between open and endoscopic CTR? (6) What are the risks associated with CTR and how frequently do they occur? (7) Does CTR cure CTS? (8) How much improvement in my symptoms can I expect after CTR? (9) How long is the recovery after CTR? (10) Can CTS recur after surgery? Conclusions: Overall, the chatbot provided accurate and comprehensive information in response to most common and nuanced questions regarding CTS and CTR surgery, all in a way that would be easily understood by many patients. Importantly, the chatbot did not provide patient-specific advice and consistently advocated for consultation with a healthcare provider.

Preoperative Physical Therapy is Associated with Decreased Length of Stay and Improved Postoperative Mobility in Patients with Sarcopenia Undergoing Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the relationship between preoperative physical therapy (PT) and postoperative mobility, adverse events (AEs), and length of stay (LOS) among patients with low normalized total psoas area (NTPA) undergoing ASD surgery. SUMMARY OF BACKGROUND DATA: Sarcopenia as defined by low NTPA has been shown to predict poor perioperative outcomes following adult spinal deformity (ASD) surgery. However, there is limited evidence correlating the benefits of PT within the sarcopenic patient population. METHODS: NTPA was analyzed at the L3 and L4 mid-vertebral body on preoperative magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was used to determine gender-specific NTPA cut-off values for predicting perioperative AEs. Patients were categorized as having low NTPA if both L3 and L4 NTPA were below these cut-off values. Perioperative outcomes were compared between patients with low NTPA that underwent documented formal PT within 6 months prior to ASD surgery with those that did not. RESULTS: 103 patients (42 males, 61 females) met criteria for low NTPA for inclusion in the study, of which 42 underwent preoperative PT and 61 did not. The preoperative PT group had a shorter LOS (111.2±37.5 vs. 162.1±97.0 h, P<0.001), higher ambulation distances (feet) on postoperative day (POD) 1 (61.7±50.3 vs. 26.1±69.0, P<0.001), POD 2 (113.2±81.8 vs. 62.1±73.1, P=0.003), and POD 3 (126.0±61.2 vs. 91.2±72.6, P=0.029), and lower rates of total AEs (31.0% vs. 54.1%, P=0.003) when excluding anemia requiring transfusion. Multivariable analysis found preoperative PT to be the most significant predictor of decreased LOS (OR 0.32, P=0.013). CONCLUSION: Sarcopenic patients may benefit from formal preoperative PT prior to undergoing ASD surgery to improve early postoperative mobility, decrease AEs, and decrease LOS. LEVEL OF EVIDENCE: 3.

Practical Answers to Frequently Asked Questions in Anterior Cervical Spine Surgery for Degenerative Conditions.

INTRODUCTION: Surgical counseling enables shared decision making and optimal outcomes by improving patients' understanding about their pathologies, surgical options, and expected outcomes. Here, we aimed to provide practical answers to frequently asked questions (FAQs) from patients undergoing an anterior cervical diskectomy and fusion (ACDF) or cervical disk replacement (CDR) for the treatment of degenerative conditions. METHODS: Patients who underwent primary one-level or two-level ACDF or CDR for the treatment of degenerative conditions with a minimum of 1-year follow-up were included. Data were used to answer 10 FAQs that were generated from author's experience of commonly asked questions in clinic before ACDF or CDR. RESULTS: A total of 395 patients (181 ACDF, 214 CDR) were included. (1, 2, and 3) Will my neck/arm pain and physical function improve? Patients report notable improvement in all patient-reported outcome measures. (4) Is there a chance I will get worse? 13% (ACDF) and 5% (CDR) reported worsening. (5) Will I receive a significant amount of radiation? Patients on average received a 3.7 (ACDF) and 5.5 mGy (CDR) dose during. (6) How long will I stay in the hospital? Most patients get discharged on postoperative day one. (7) What is the likelihood that I will have a complication? 13% (8% minor and 5% major) experienced in-hospital complications (ACDF) and 5% (all minor) did (CDR). (8) Will I need another surgery? 2.2% (ACDF) and 2.3% (CDR) of patients required a revision surgery. (9 & 10) When will I be able to return to work/driving? Most patients return to working (median of 16 [ACDF] and 14 days [CDR]) and driving (median of 16 [ACDF] and 12 days [CDR]). CONCLUSIONS: The answers to the FAQs can assist surgeons in evidence-based patient counseling.

Temporal Trends of Improvement After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To analyze temporal trends in improvement after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Although several studies have shown that patients improve significantly after MIS TLIF, evidence regarding the temporal trends in improvement is still largely lacking. METHODS: Patients who underwent primary single-level MIS TLIF for degenerative conditions of the lumbar spine and had a minimum of 2-year follow-up were included. Outcome measures were: 1) patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS); 2) global rating change (GRC); 3) minimal clinically important difference (MCID); and 4) return to activities. Timepoints analyzed were preoperative, 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years. Trends across these timepoints were plotted on graphs. RESULTS: 236 patients were included. VAS back and VAS leg were found to have statistically significant improvement compared to the previous timepoint up to 3 months after surgery. ODI and SF-12 PCS were found to have statistically significant improvement compared to the previous timepoint up to 6 months after surgery. Beyond these timepoints, there was no significant improvement in PROMs. 80% of patients reported feeling better compared to preoperative by 3 months. >50% of patients achieved MCID in all PROMs by 3 months. Most patients returned to driving, returned to work, and discontinued narcotics at an average of 21, 20, and 10 days, respectively. CONCLUSIONS: Patients are expected to improve up to 6 months after MIS TLIF. Back pain and leg pain improve up to 3 months and disability and physical function improve up to 6 months. Beyond these timepoints, the trends in improvement tend to reach a plateau. 80% of patients feel better compared to preoperative by 3 months after surgery.

Impact of Preoperative Symptom Duration on Patient-Reported Outcomes Following Cervical Disc Replacement for Cervical Radiculopathy.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the impact of preoperative symptom duration on postoperative functional outcomes following cervical disc replacement (CDR) for radiculopathy. SUMMARY OF BACKGROUND DATA: CDR has emerged as a reliable and efficacious treatment option for degenerative cervical spine pathologies. The relationship between preoperative symptom duration and outcomes following CDR is not well established. METHODS: Patients with radiculopathy without myelopathy who underwent primary 1- or 2-level CDRs were included and divided into shorter (<6 mo) and prolonged (≥6 mo) cohorts based on preoperative symptom duration. Patient-reported outcome measures (PROMs) included Neck Disability Index (NDI), Visual Analog Scale (VAS) Neck and Arm. Change in PROM scores and minimal clinically important difference (MCID) rates were calculated. Analyses were conducted on the early (within 3 mo) and late (6 mo-2 y) postoperative periods. RESULTS: A total of 201 patients (43.6±8.7 y, 33.3% female) were included. In both early and late postoperative periods, the shorter preoperative symptom duration cohort experienced significantly greater change from preoperative PROM scores compared to the prolonged symptom duration cohort for NDI, VAS-Neck, and VAS-Arm. The shorter symptom duration cohort achieved MCID in the early postoperative period at a significantly higher rate for NDI (78.9% vs. 54.9%, P=0.001), VAS-Neck (87.0% vs. 56.0%, P<0.001), and VAS-Arm (90.5% vs. 70.7%, P=0.002). Prolonged preoperative symptom duration (≥6 mo) was identified as an independent risk factor for failure to achieve MCID at the latest timepoint for NDI (OR: 2.9, 95% CI: 1.2-6.9, P=0.016), VAS-Neck (OR: 9.8, 95% CI: 3.7-26.0, P<0.001), and VAS-Arm (OR: 7.5, 95% CI: 2.5-22.5, P<0.001). CONCLUSIONS: Our study demonstrates improved patient-reported outcomes for those with shorter preoperative symptom duration undergoing CDR for radiculopathy, suggesting delayed surgical intervention may result in poorer outcomes and greater postoperative disability. LEVEL OF EVIDENCE: III.

Clinical and Radiological Predictors of Slower and Non-Improvement Following Surgical Treatment of L4-5 Degenerative Spondylolisthesis: Preliminary Results.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To identify the predictors of slower and non-improvement following surgical treatment of L4-5 degenerative lumbar spondylolisthesis (DLS). SUMMARY OF BACKGROUND DATA: There is limited evidence regarding clinical and radiological predictors of slower and non-improvement following surgery for L4-5 DLS. METHODS: Patients who underwent minimally invasive decompression or fusion for L4-5 DLS and had a minimum of 1-year follow-up were included. Outcome measures were: (1) minimal clinically important difference (MCID), (2) patient acceptable symptom state (PASS), and (3) global rating change (GRC). Clinical variables analyzed for predictors were age, gender, body mass index (BMI), surgery type, comorbidities, anxiety, depression, smoking, osteoporosis, and preoperative patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS). Radiological variables analyzed were slip percentage, translational and angular motion, facet diastasis/cyst/orientation, laterolisthesis, disc height, scoliosis, main and fractional curve Cobb angles, and spinopelvic parameters. RESULTS: 233 patients (37% decompression, 63% fusion) were included. At <3 months, high pelvic tilt (PT) (OR 0.92, P 0.02) and depression (OR 0.28, P 0.02) were predictors of MCID non-achievement and GRC non-betterment, respectively. Neither retained significance at >6 months and hence, were identified as predictors of slower improvement. At >6 months, low preoperative VAS leg (OR 1.26, P 0.01) and high facet orientation (OR 0.95, P 0.03) were predictors of MCID non-achievement, high L4-5 slip percentage (OR 0.86, P 0.03) and L5-S1 angular motion (OR 0.78, P 0.01) were predictors of GRC non-betterment, and high preoperative ODI (OR 0.96, P 0.04) was a predictor of PASS non-achievement. CONCLUSIONS: High PT and depression were predictors of slower improvement and low preoperative leg pain, high disability, high facet orientation, high slip percentage, and L5-S1 angular motion were predictors of non-improvement. However, these are preliminary findings and further studies with homogeneous cohorts are required to establish these findings.

Psoas Muscle Health is Correlated with Time to Achieve MCID in Patients with Predominant Axial Back Pain Following Decompression Surgery: Early Results.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the impact of psoas muscle health (cross-sectional area, CSA) on achieving minimal clinically important differences (MCID) in patient-reported outcome measures (PROMs) following laminectomy for patients with predominant back pain (PBP) and leg pain (PLP). SUMMARY OF BACKGROUND DATA: Psoas muscle health is linked to postoperative outcomes in decompression patients, with MRI-based grading of psoas CSA correlating with these outcomes. However, evidence on its impact on symptomatic recovery, measured by PROMs, is lacking. METHODS: 106 patients with PBP (VAS back >VAS leg) and 139 patients with PLP (VAS leg >VAS back) who underwent laminectomy from 2017-2021 were included. Axial T2 MRI images were analyzed for psoas CSA using a validated method. Based on the lowest-quartile normalized total psoas area (NTPA) thresholds, patients were divided into "Good" and "Poor" muscle health groups. The correlation analyses were performed between the psoas CSA and changes in PROMs. Kaplan-Meier survival analysis was conducted to determine the probability of achieving MCID as a function of time. RESULTS: Of 106 PBP patients, 83 (78.3%) had good muscle health, 23 (21.6%) had poor muscle health. Of 139 PLP patients, 54 (38.8%) had good muscle health, 85 (61.1%) had poor muscle health. In the PBP group, older age was associated with poor muscle health (69.70±9.26 vs. 59.92±15.01, P=0.0002). For both cohorts, there were no differences in the rate of MCID achievement for any PROMs between the good and poor muscle health groups. In the PBP group, Kaplan-Meier analysis showed patients with good psoas health achieved MCID-VAS back and Oswestry Disability Index (ODI) in median times of 14 and 42 days (P=0.045 and 0.015), respectively. CONCLUSION: Good psoas muscle health is linked to faster attainment of MCID, especially in patients with PBP compared to PLP after decompression surgery. LEVEL OF EVIDENCE: 3.

Interventions for behavioral health comorbidities in the hospice setting: a scoping review.

BACKGROUND: Behavioral health (BH) comorbidities in hospice patients are widespread and impact important outcomes, including symptom burden, quality of life, and caregiver wellbeing. However, evidence-based BH interventions tailored for the hospice setting remain understudied. METHODS: We conducted a scoping review with the objective of mapping studies of interventions for BH comorbidities in the hospice setting. We included empirical studies among hospice patients of interventions with BH outcomes. We abstracted data on study design, intervention type, and patient characteristics. RESULTS: Our search generated 7,672 unique results, of which 37 were ultimately included in our analysis. Studies represented 16 regions, with the United Kingdom (n=13) most represented. The most frequent intervention type was complementary and alternative interventions (n=13), followed by psychotherapeutic interventions (n=12). Most of the studies were either pilot or feasibility investigations. Fifteen studies employed a randomized controlled trial design. The most frequently utilized measurement tools for BH outcomes included the Hospital Anxiety and Depression Scale and the Edmonton Symptom Assessment Scale. Seventeen studies demonstrated statistically significant results in a BH outcome measure. BH conditions prevalent among hospice patients that were the focus of intervention efforts included depression symptoms, anxiety symptoms, and general psychological distress. No study focused on trauma-related disorders or substance use disorders. CONCLUSIONS: This scoping review reveals a concerning gap in research regarding evidence-based BH interventions in hospice settings, especially in the U.S. Despite extensive utilization of hospice care services and the high prevalence of BH conditions among hospice patients, randomized controlled trials focused on improving BH outcomes remain scant. The current BH practices, like the widespread use of benzodiazepines and antipsychotics, may not be rooted in robust evidence, underscoring an urgent need for investment in hospice research infrastructure and tailored clinical trials to test behavioral approaches to mitigate mental health outcomes at the end of life.

Left-digit bias in surgical decision-making for lumbar spinal stenosis.

BACKGROUND CONTEXT: Left-digit bias is a behavioral heuristic or cognitive "shortcut" in which the leftmost digit of a number, such as patient age, disproportionately influences surgical decisions. PURPOSE: To determine if left-digit bias in patient age influences the decision to perform arthrodesis with instrumentation vs decompression in lumbar spinal stenosis (LSS). DESIGN: Retrospective cohort. PATIENT SAMPLE: Patients with an ICD-10 diagnosis of lumbar stenosis or spondylolisthesis identified in the 2017-2021 National Surgical Quality Improvement Program (NSQIP) database. OUTCOME MEASURES: The primary outcome was the percent of patients who underwent arthrodesis with instrumentation (AwI). Matched age group comparisons without left-digit differences (ie, 76/77 vs 78/79, 80/81 vs 82/83, etc.) were performed to isolate the effect of the heuristic. Secondary outcomes including peri-operative events and complications were also compared within AwI and decompression cohorts. METHODS: Using CPT codes, procedures were classified as either AwI or decompression. Patients were grouped into 6 cohorts based on 2-year age windows (74/75, 76/77, 78/79, 80/81, 82/83, 84/85). The cohorts were propensity matched with neighboring age groups based on the presence of spondylolisthesis, demographics, and comorbidities. The primary comparison was between those aged 78/79 vs 80/81. RESULTS: After matching, the primary cohort consisted of two groups of 1,550 patients (aged 78/79 and 80/81). Patients aged 80/81 were less likely to undergo AwI than patients aged 78/79 (23.5% vs 27.2%, p=.021). AwI procedures occurred at similar rates between age groups with the same left digit. Within the decompression and AwI cohorts, there were no differences in secondary outcomes between patients aged 78/79 and 80/81. CONCLUSIONS: LSS patients aged 80/81 are less likely to undergo AwI than patients aged 78/79, regardless of comorbidities. This was not seen when comparing patients with similar left digits in age. Until objective measures of physiologic capacity are established, left-digit bias may influence clinical decisions.

Chat Generative Pretraining Transformer Answers Patient-focused Questions in Cervical Spine Surgery.

STUDY DESIGN: Review of Chat Generative Pretraining Transformer (ChatGPT) outputs to select patient-focused questions. OBJECTIVE: We aimed to examine the quality of ChatGPT responses to cervical spine questions. BACKGROUND: Artificial intelligence and its utilization to improve patient experience across medicine is seeing remarkable growth. One such usage is patient education. For the first time on a large scale, patients can ask targeted questions and receive similarly targeted answers. Although patients may use these resources to assist in decision-making, there still exists little data regarding their accuracy, especially within orthopedic surgery and more specifically spine surgery. METHODS: We compiled 9 frequently asked questions cervical spine surgeons receive in the clinic to test ChatGPT's version 3.5 ability to answer a nuanced topic. Responses were reviewed by 2 independent reviewers on a Likert Scale for the accuracy of information presented (0-5 points), appropriateness in giving a specific answer (0-3 points), and readability for a layperson (0-2 points). Readability was assessed through the Flesh-Kincaid grade level analysis for the original prompt and for a second prompt asking for rephrasing at the sixth-grade reading level. RESULTS: On average, ChatGPT's responses scored a 7.1/10. Accuracy was rated on average a 4.1/5. Appropriateness was 1.8/3. Readability was a 1.2/2. Readability was determined to be at the 13.5 grade level originally and at the 11.2 grade level after prompting. CONCLUSIONS: ChatGPT has the capacity to be a powerful means for patients to gain important and specific information regarding their pathologies and surgical options. These responses are limited in their accuracy, and we, in addition, noted readability is not optimal for the average patient. Despite these limitations in ChatGPT's capability to answer these nuanced questions, the technology is impressive, and surgeons should be aware patients will likely increasingly rely on it.

Ninety Percent of Patients Are Satisfied With Their Decision to Undergo Spine Surgery for Degenerative Conditions.

STUDY DESIGN: Cross-sectional survey and retrospective review of prospectively collected data. OBJECTIVE: To explore how patients perceive their decision to pursue spine surgery for degenerative conditions and evaluate factors correlated with decisional regret. SUMMARY OF BACKGROUND DATA: Prior research shows that one-in-five older adults regret their decision to undergo spinal deformity surgery. However, no studies have investigated decisional regret in patients with degenerative conditions. METHODS: Patients who underwent cervical or lumbar spine surgery for degenerative conditions (decompression, fusion, or disk replacement) between April 2017 and December 2020 were included. The Ottawa Decisional Regret Questionnaire was implemented to assess prevalence of decisional regret. Questionnaire scores were used to categorize patients into low (<40) or medium/high (≥40) decisional regret cohorts. Patient-reported outcome measures (PROMs) included the Oswestry Disability Index, Patient-reported Outcomes Measurement Information System, Visual Analog Scale (VAS) Back/Leg/Arm, and Neck Disability Index at preoperative, early postoperative (<6 mo), and late postoperative (≥6 mo) timepoints. Differences in demographics, operative variables, and PROMs between low and medium/high decisional regret groups were evaluated. RESULTS: A total of 295 patients were included (mean follow-up: 18.2 mo). Overall, 92% of patients agreed that having surgery was the right decision, and 90% would make the same decision again. In contrast, 6% of patients regretted the decision to undergo surgery, and 7% noted that surgery caused them harm. In-hospital complications (P=0.02) and revision fusion (P=0.026) were significantly associated with higher regret. The medium/high decisional regret group also exhibited significantly worse PROMs at long-term follow-up for all metrics except VAS-Arm, and worse achievement of minimum clinically important difference for Oswestry Disability Index (P=0.007), Patient-Reported Outcomes Measurement Information System (P<0.0001), and VAS-Leg (P<0.0001). CONCLUSIONS: Higher decisional regret was encountered in the setting of need for revision fusion, increased in-hospital complications, and worse PROMs. However, 90% of patients overall were satisfied with their decision to undergo spine surgery for degenerative conditions. Current tools for assessing patient improvement postoperatively may not adequately capture the psychosocial values and patient expectations implicated in decisional regret.

Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting.

BACKGROUND CONTEXT: Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated. PURPOSE: This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021. OUTCOME MEASURES: Thirty-day rates of serious and minor adverse events, readmission, reoperation, non-home discharge, and mortality. METHODS: A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) non-home discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences. RESULTS: Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs. 11.8%) and OP (92.7% vs. 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and non-home discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=0.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, non-home discharge, or death (p>.050 for all). CONCLUSIONS: Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.