Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050.

BACKGROUND: Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States. METHODS: Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index. RESULTS: Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932). CONCLUSIONS: The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.

Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis.

Background: Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types. Methods: A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses. Results: Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007). Conclusions: Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.

Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer.

BACKGROUND: The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases. METHODS: This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals. RESULTS: A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients. DISCUSSION: Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.

External Validation of an Online Wound Infection and Wound Reoperation Risk Calculator After Metastatic Spinal Tumor Surgery.

STUDY DESIGN: This was a single-institutional retrospective cohort study. OBJECTIVE: Wound infections are common following spine metastasis surgery and can result in unplanned reoperations. A recent study published an online wound complication risk calculator but has not yet undergone external validation. Our aim was to evaluate the accuracy of this risk calculator in predicting 30-day wound infections and 30-day wound reoperations using our operative spine metastasis population. METHODS: An internal operative database was used to identify patients between 2012 and 2022. The primary outcomes were 1) any surgical site infection and 2) wound-related revision surgery within 30 days following surgery. Patient details were manually collected from electronic medical records and entered into the calculator to determine predicted complication risk percentages. Predicted risks were compared to observed outcomes using receiver operator characteristic (ROC) curves with areas under the curve (AUC). RESULTS: A total of 153 patients were included. The observed 30-day postoperative wound infection incidence was 5% while the predicted wound infection incidence was 6%. In ROC analysis, good discrimination was found for the wound infection model (AUC = 0.737; P = 0.024). The observed wound reoperation rate was 5% and the predicted wound reoperation rate was 6%. ROC analysis demonstrated poor discrimination for wound reoperations (AUC = 0.559; P = 0.597). CONCLUSIONS: The online wound-related risk calculator was found to accurately predict wound infections but not wound reoperations within our metastatic spine surgery cohort. We suggest that the model may be clinically useful despite underlying population differences, but further work must be done to generate and validate accurate prediction tools.

The Impact of Posterior Intervertebral Osteophytes on Patient-Reported Outcome Measures After L5-S1 Anterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: (1) To develop a reliable grading system to assess the severity of posterior intervertebral osteophytes and (2) to investigate the impact of posterior intervertebral osteophytes on clinical outcomes after L5-S1 decompression and fusion through anterior lumbar interbody fusion (ALIF) and minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF). BACKGROUND: There is limited evidence regarding the clinical implications of posterior lumbar vertebral body osteophytes for ALIF and MIS-TLIF surgeries and there are no established grading systems that define the severity of these posterior lumbar intervertebral osteophytes. PATIENTS AND METHODS: A retrospective analysis of patients undergoing L5-S1 ALIF or MIS-TLIF was performed. Preoperative and postoperative patient-reported outcome measures of the Oswestry Disability Index (ODI) and leg Visual Analog Scale (VAS) at 2-week, 6-week, 12-week, and 6-month follow-up time points were assessed. Minimal clinically important difference (MCID) for ODI of 14.9 and VAS leg of 2.8 were utilized. Osteophyte grade was based on the ratio of osteophyte length to foraminal width. "High-grade" osteophytes were defined as a maximal osteophyte length >50% of the total foraminal width. RESULTS: A total of 70 consecutive patients (32 ALIF and 38 MIS-TLIF) were included in the study. There were no significant differences between the two cohorts in patient-reported outcome measures or achievement of MCID for Leg VAS or ODI preoperatively or at any follow-ups. On multivariate analysis, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with leg VAS or ODI scores at any follow-up time point. In addition, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with the achievement of MCID for leg VAS or ODI at 6 months. CONCLUSION: ALIF and MIS-TLIF are both valid options for treating degenerative spine conditions and lumbar radiculopathy, even in the presence of high-grade osteophytes that significantly occupy the intervertebral foramen. LEVEL OF EVIDENCE: 3.

Does Wound VAC Temporization Offer Patient-Reported Outcomes Similar to Single-Stage Excision Reconstruction After Myxofibrosarcoma Resection?

BACKGROUND: Vacuum-assisted closure (VAC) temporization is a promising technique to achieve local control in aggressive soft tissue sarcomas. Despite its previously reported efficacy, adoption of VAC temporization remains limited, primarily due to the scarce literature on patient-reported outcomes (PROs) supporting its efficacy. This study compared the postoperative PROs after VAC temporization or single-stage (SS) excision and reconstruction for patients undergoing surgical resection for myxofibrosarcoma management. METHODS: A retrospective analysis of myxofibrosarcoma patients who underwent surgical resections at our institution from 2016 to 2022 was performed. Postoperative PROs collected prospectively for those treated with VAC temporization or SS excision/reconstruction were compared using a visual analog scale (VAS) for pain and three Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires: Global Health Short-Form Mental (SF Mental), Global Health Short-Form Physical (SF Physical), and Physical Function Short-Form 10a (SF 10a). Absolute and differential (postoperative minus preoperative) scores at the 1-month, 3-month, 6-month, 1-year, and 2-year time points were compared. RESULTS: The analysis included 79 patients (47 treated with VAC temporization and 32 treated with SS excision/reconstruction). All outcomes were similar between the groups except for physical function 1 year after surgery, in which the differential PROMIS SF 10a scores were higher in the SS group (p = 0.001). All the remaining absolute and differential PROMIS and VAS pain scores were similar between the groups at all time points. Postoperative complications did not differ between the groups. CONCLUSION: The PROs for physical and mental health, physical function, and pain were similar between the myxofibrosarcoma patients who had VAC temporization and those who had SS excision/reconstruction after surgical resection.

Racial Differences in Perioperative Complications, Readmissions, and Mortalities After Elective Spine Surgery in the United States: A Systematic Review Using AI-Assisted Bibliometric Analysis.

STUDY DESIGN: Systematic Review and Meta-analysis. OBJECTIVES: To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States. METHODS: PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients. RESULTS: 53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included. CONCLUSIONS: AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.

The prognostic role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune-inflammation index on short- and long-term outcome following surgery for spinal metastases.

OBJECTIVE: Inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) have shown promise in predicting mortality in various types of cancer. The purpose of this study was to assess NLR, PLR, and SII in predicting 30-day mortality and overall survival (OS) among surgically treated patients with spinal metastasis. METHODS: This was a retrospective study including 153 patients who underwent surgery for spinal metastasis between 2012 and 2022. Electronic medical records were manually reviewed, and NLR, PLR, and SII were calculated from preoperative neutrophil, platelet, and lymphocyte counts. Receiver operating characteristic curves with areas under the curve were generated to determine cutoff values. Logistic regression was used to determine the odds ratios (ORs) for 30-day mortality. The Kaplan-Meier method and Cox regression were used to determine the hazard ratio (HR) for OS limited to 5 years postoperatively. RESULTS: Preoperative cutoff values were as follows: NLR > 10.2, PLR > 260, and SII > 2900. Overall, 35.9% (55/153) of patients had elevated NLR, 45.7% (70/153) had elevated PLR, and 30.7% (47/153) had elevated SII. The overall 30-day mortality was 8.5% (13/153). After controlling for confounders such as performance status and primary tumor type, high NLR (OR 5.20, 95% CI 1.21-22.28; p = 0.026) and SII (OR 4.92, 95% CI 1.17-20.63; p = 0.029) were associated with increased odds of 30-day postoperative mortality. The median OS time in the study population was 26 months (95% CI 12-40 months). After controlling for confounders such as Eastern Cooperative Oncology Group status, primary tumor, and hypoalbuminemia, high NLR was associated with shorter OS (HR 2.23, 95% CI 1.48-3.97; p = 0.003). CONCLUSIONS: High preoperative NLR and SII were independently associated with 30-day postoperative mortality in this study. Elevated NLR was also found to be associated with shorter OS. The prognostic role of these metrics warrants further investigation.

Examining the safety profile of a standard dose tranexamic acid regimen in spine surgery.

OBJECTIVE: Perioperative blood loss during spinal surgery is associated with complications and in-hospital mortality. Weight-based administration of tranexamic acid (TXA) has the potential to reduce blood loss and related complications in spinal surgery; however, evidence for standardized dosing is lacking. The purpose of this study was to evaluate the impact of a standardized preoperative 2 g bolus TXA dosing regimen on perioperative transfusion, blood loss, thromboembolic events, and postoperative outcomes in spine surgery patients. METHODS: An institutional review board approved this retrospective review of prospectively enrolled adult spine patients (> 18 years of age). Patients were included who underwent elective and emergency spine surgery between September 2018 and July 2021. Patients who received a standardized 2 g dose of TXA were compared to patients who did not receive TXA. The primary outcome measure was perioperative transfusion. Secondary outcomes included estimated blood loss and thromboembolic or other perioperative complications. Descriptive statistics were calculated, and continuous variables were analyzed with the two-tailed independent t-test, while categorical variables were analyzed with the Fisher's exact test or chi-square test. Stepwise multivariate regression analysis was performed to examine independent risk factors for perioperative outcomes. RESULTS: TXA was administered to 353 of 453 (78%) patients, and there were no demographic differences between groups. Although the TXA group had more operative levels and a longer operative time, the transfusion rate was not different between the TXA and no-TXA groups (7.4% vs 8%, p = 0.83). Stepwise multivariate regression found that the number of operative levels was an independent predictor of perioperative transfusion and that both operative levels and operative time were correlated with estimated blood loss. TXA was not identified as an independent predictor of any postoperative complication. CONCLUSIONS: A standardized preoperative 2 g bolus TXA dosing regimen was associated with an excellent safety profile, and despite increased case complexity in terms of number of operative levels and operative time, patients treated with TXA did not require more blood transfusions than patients not treated with TXA.

The prognostic nutritional index (PNI) is independently associated with 90-day and 12-month mortality after metastatic spinal tumor surgery.

INTRODUCTION: Estimated postoperative survival is an important consideration during the decision-making process for patients with spinal metastases. Nutritional status has been associated with poor outcomes and limited survival in the general cancer population. The objective of this study was to evaluate the predictive utility of the prognostic nutritional index (PNI) for postoperative mortality after spinal metastasis surgery. METHODS: A total of 139 patients who underwent oncologic surgery for spinal metastases between April 2012 and August 2022 and had a minimum 90-day follow-up were included. PNI was calculated using preoperative serum albumin and total lymphocyte count, with PNI < 40 defined as low. The mean PNI of our cohort was 43 (standard deviation: 7.7). The primary endpoint was 90-day mortality, and the secondary endpoint was 12-month mortality. Multivariate logistic regression analyses were performed. RESULTS: The 90-day mortality was 27% (37/139), and the 12-month mortality was 56% (51/91). After controlling for age, ECOG performance status, total psoas muscle cross-sectional area (TPA), and primary cancer site, the PNI was associated with 90-day mortality [odds ratio 0.86 (95% confidence interval 0.79-0.94); p = 0.001]. After controlling for ECOG performance status and primary cancer site, the PNI was associated with 12-month mortality [OR 0.89 (95% CI 0.82-0.97); p = 0.008]. Patients with a low PNI had a 50% mortality rate at 90 days and an 84% mortality rate at 12 months. CONCLUSION: The PNI was independently associated with 90-day and 12-month mortality after metastatic spinal tumor surgery, independent of performance status, TPA, and primary cancer site.

Predictive value of six nutrition biomarkers in oncological spine surgery: a performance assessment for prediction of mortality and wound infection.

OBJECTIVE: Assessment of nutritional status is fundamental in cancer patients. The objective of this study was to assess the predictive ability of 6 nutritional biomarkers for postoperative mortality and wound infection after metastatic spinal tumor surgery. METHODS: A total of 139 patients who underwent oncological surgery for metastatic spine disease between April 2012 and August 2022 and had a minimum follow-up of 90 days were included. Six unique nutritional biomarkers were assessed: Prognostic Nutritional Index (PNI), Nutritional Risk Index (NRI), Controlling Nutritional Status Score (CONUT), total psoas cross-sectional area (TPA), body mass index (BMI), and body weight. Study endpoints were 90-day mortality rate, 12-month mortality rate, and wound infection. The discriminative ability of each of these markers was assessed with the c-statistic. A multivariate analysis was done for each of the biomarkers after a univariate analysis was first performed. RESULTS: The 90-day mortality rate was 27% (37 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.74), NRI (0.75), CONUT (0.71), TPA (0.64), BMI (0.59), and body weight (0.60). The 12-month mortality rate was 56% (51 of 91). The biomarkers and respective c-statistics were as follows: PNI (0.72), NRI (0.73), CONUT (0.70), TPA (0.63), BMI (0.59), and body weight (0.60). The wound infection rate was 8% (11 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.57), NRI (0.53), CONUT (0.55), TPA (0.57), BMI (0.48), and body weight (0.52). The PNI, NRI, and CONUT all predicted 90-day and 12-month mortality after multivariate regression analysis. No association between nutrition and wound infection was found. CONCLUSIONS: In this study, nutritional status was associated with postoperative mortality following oncological spine surgery. Three biomarkers predicted outcome independent of variables such as performance status or primary cancer. Future validation of these metrics is needed.

Postoperative Radiculitis After L5-S1 Anterior Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: This study aimed to examine postoperative radiculitis after isolated L5-S1 anterior lumbar interbody fusion (ALIF), determine which factors contribute to its development, and investigate the comparative outcomes of patients with versus without postoperative radiculitis. SUMMARY OF BACKGROUND DATA: Both standalone and traditionalALIF are common and safe lumbar spine fusion techniques. Although optimal safety and effectiveness are achieved through appropriate patient selection, postoperative radiculitis after L5-S1 ALIF is a potential complication that seems to be the least predictable in the absence of iatrogenic injury. PATIENTS AND METHODS: All adult patients (18-80 yr) with preoperative radiculopathies who underwent L5-S1 ALIF by 9 board-certified spine surgeons at a single academic institution from January 2016 to December 2021 with a minimum of 3 months follow-up were included. Patient records were assessed for data on clinical characteristics and patient-reported outcome scores (patient-reported outcome measures). All patient records were evaluated to determine whether postoperative radiculitis developed. Radiographic measurements using x-rays were completed using all available pre and postoperative imaging. Multivariable logistic regressions were performed utilizing radiculitis as the dependent variable and various independent predictor variables. RESULTS: One hundred forty patients were included, 48 (34%) patients developed postoperative radiculitis, with symptom onset and resolution occurring at 14.5 and 83 days, respectively. The two groups had no differences in preoperative or postoperative radiographic parameters. Multivariable regression showed 3 independent predictors of postoperative radiculitis: methylprednisolone use [OR: 6.032; (95% CI: 1.670-25.568)], increased implant height [OR: 1.509; (95% CI: 1.189-1.960)], and no posterior fixation [OR: 2.973; (95% CI: 1.353-0.806)]. CONCLUSIONS: Of the 34% of patients who developed postoperative radiculitis after L5-S1 ALIF, it resolved on average within 3 months of surgery. These findings may help reduce the risk of undue short-term morbidity after isolated L5-S1 ALIF by informing preoperative counseling and intraoperative decision-making.

Step-by-step guide to robotic-guided minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

Robotics in spinal surgery offers a promising potential to refine and improve the minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) technique. Suitable surgeons for this technique include those who are already familiar with robotic-guided lumbar pedicle screw placement and want to advance their skillset by incorporating posterior-based interbody fusion. We provide a step-by-step guide for robotic-guided MI-TLIF. The procedure is divided into 7 practical and detailed techniques. The steps in sequential order include: (I) planning trajectories for pedicle screws and the tubular retractor; (II) robotic-guided pedicle screw placement; (III) placement of tubular retractor; (IV) unilateral facetectomy using the surgical microscope; (V) discectomy & disc preparation; (VI) interbody implant insertion; and (VII) percutaneous rod placement. We standardize surgeon training in robotic MI-TLIF by teaching our spine surgery fellows these 7 key technical steps highlighted in this guide. Current-generation robotics offers integrated navigation capability, K-wireless placement of pedicle screws through a rigid robotic arm, compatibility with tubular retractor systems to perform facetectomy, and allows for placement of interbody devices. We have found robotic-guided MI-TLIF to be a safe procedure that allows for accurate and reliable pedicle screw placement, less collateral damage to the soft tissues of the low back, and decreased radiation exposure.

Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program.

Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods: We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results: A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions: The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Construct-to-construct biplanar cantilever technique for spinal deformity correction: illustrative case.

BACKGROUND: There is a continued trend toward posterior-only approaches for achieving spinal deformity correction of idiopathic scoliosis. We present a posteriorly based correction technique and en bloc translation reduction maneuver that can be useful in the management of kyphoscoliosis. OBSERVATIONS: A 50-year-old female with a past medical history of untreated adolescent idiopathic scoliosis since she was 12 years old presented to the clinic for evaluation of progressive thoracolumbar spinal deformity and worsening mid-to-low back pain. Standing scoliosis radiographs shows an 85° left lumbar curve with an apex at the L1-2 disk. There was a compensatory 58° right thoracic curve with an apex at T9, a -1.4 cm central vertical axis, and a focal kyphotic deformity of 86° from T11-L3 with a corresponding apex at the L1-2 disk. She was diagnosed with adult idiopathic scoliosis and indicated for a T9-L4 posterior spinal fusion with T11-L4 Smith-Peterson osteotomies. A simple en bloc reduction maneuver was used to translate the apex of the coronal deformity toward the midline and simultaneously correct the patient's focal kyphosis. LESSONS: A construct-to-construct biplanar cantilever technique is ideal for the treatment of kyphoscoliosis and can provide effective deformity correction in both the sagittal and coronal planes.

The L3 Flexion Angle Predicts Failure of Non-Operative Management in Patients with Tandem Spondylolithesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Determine impact of standard/novel spinopelvic parameters on global sagittal imbalance, health-related quality of life (HRQoL) scores, and clinical outcomes in patients with multi-level, tandem degenerative spondylolisthesis (TDS). METHODS: Single institution analysis; 49 patients with TDS. Demographics, PROMIS and ODI scores collected. Radiographic measurements-sagittal vertical axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, sagittal L3 flexion angle (L3FA) and L3 sagittal distance (L3SD). Stepwise linear multivariate regression performed using full length cassettes to identify demographic and radiographic factors predictive of aberrant SVA (≥5 cm). Receiver operative curve (ROC) analysis used to identify cutoffs for lumbar radiographic values independently predictive of SVA ≥5 cm. Univariate comparisons of patient demographics, (HRQoL) scores and surgical indication were performed around this cutoff using two-way Student's t-tests and Fisher's exact test for continuous and categorical variables, respectively. RESULTS: Patients with increased L3FA had worse ODI (P = .006) and increased rate of failing non-operative management (P = .02). L3FA (OR 1.4, 95% CI) independently predicted of SVA ≥5 cm (sensitivity and specifity of 93% and 92%). Patients with SVA ≥5 cm had lower LL (48.7 ± 19.5 vs 63.3 ± 6.9 mm, P < .021), higher L3SD (49.3 ± 12.9 vs 28.8 ± 9.2, P < .001) and L3FA (11.6 ± 7.9 vs -3.2 ± 6.1, P < .001) compared to patients with SVA ≤5 cm. CONCLUSIONS: Increased flexion of L3, which is easily measured by the novel lumbar parameter L3FA, predicts global sagittal imbalance in TDS patients. Increased L3FA is associated with worse performance on ODI, and failure of non-operative management in patients with TDS.

One-year Postoperative Radiographic and Patient-reported Outcomes Following Cervical Deformity Correction Are Not Affected by a Short-term Unplanned Return to the OR.

STUDY DESIGN: Retrospective analysis of a prospectively collected multicenter database. OBJECTIVE: The objective of this study was to assess the radiographic and health-related quality of life (HRQoL) impact of a short-term (<1 y) return to the operating room (OR) after adult cervical spine deformity (ACSD) surgery. SUMMARY OF BACKGROUND DATA: Returns to the OR within a year of ACSD correction can be particularly devastating to these vulnerable hosts as they often involve compromise of the soft tissue envelope, neurological deficits, or hardware failure. This work sought to assess the impact of a short-term reoperation on 1-year radiographic and HRQoL outcomes. MATERIALS AND METHODS: Patients operated on from January 1, 2013, to January 1, 2019, with at least 1 year of follow-up were included. The primary outcome was a short-term return to the OR. Variables of interest included patient demographics, Charlson Comorbidity Index, HRQoL measured with the modified Japanese Orthopaedic Association), Neck Disability Index, and EuroQuol-5D Visual Analog Scale (EQ-5D VAS) and radiographic outcomes, including T1 slope, C2-C7 sagittal Cobb angle, T1 slope-Cobb angle, and cervical sagittal vertical axis. Comparisons between those who did versus did not require a 1-year reoperation were performed using paired t tests. A Kaplan-Meier survival curve was used to estimate reoperation-free survival up to 2 years postoperatively. RESULTS: A total of 121 patients were included in this work (age: 61.9±10.1 yr, body mass index: 28.4±6.9, Charlson Comorbidity Index: 1.0±1.4, 62.8% female). A 1-year unplanned return to the OR was required for 28 (23.1%) patients, of whom 19 followed up for at least 1 year. Indications for a return to the OR were most commonly for neurological complications (5%), infectious/wound complications (5.8%), and junctional failure (6.6%) No differences in demographics, comorbidities, preoperative or 1-year postoperative HRQoL, or radiographic outcomes were seen between operative groups. CONCLUSION: Reoperation <1 year after ACSD surgery did not influence 1-year radiographic outcomes or HRQoL.

Should We Hire Our Current Fellow? Hiring Trends and Preferences in Spine Surgery.

OBJECTIVE: To provide insight into hiring trends/preferences in Academic Orthopaedic Spine Surgery after fellowship training. METHODS: Fellowship directors (FDs) listed by the North American Spine Society were surveyed regarding new faculty hiring preferences. Surveys were analyzed/stratified by response using the Kruskal-Wallis with Dunn multiple comparisons test, the Fisher exact test, and the Mann-Whitney U test for univariate comparisons. RESULTS: Thirty-two of 52 (61.5%) FDs responded. 32.3% of graduated fellows pursued academic medicine, which was preferred by FDs (3.59 ± 0.67; 1 to 5 scale). From 2015 to 2020, of the 2.25 ± 1.46 faculty members hired per program, 45.8% were former residents/fellows. Top listed hiring qualities were "strong recommendation from a trusted colleague" (84.4%), "prior personal experience, as a resident/fellow" (78.1%), and "amicable personality" (53.1%). Twelve (38%) answered "no", six (19%) "yes", and 14 (44%) "other", regarding if hiring former residents/fellows benefits the field of spine surgery. "Other" answers endorsing in-house hiring most commonly mentioned consistency/stability (28.6%) while those opposed most commonly mentioned lack of diversity of training/novel techniques (42.9%). When considering programmatic size, while the stated perception of FDs regarding in-house hiring at larger (>2 fellows) versus smaller (1 to 2 fellows) programs was equivalent, the mean percentage of in-house hires at larger programs (67.8% ± 35.8%) was significantly greater than that of smaller programs (33.3% ± 44.8%, P = 0.04). CONCLUSIONS: In-house hiring in spine surgery appears to occur more commonly than perceived by program leadership, particularly at larger fellowship programs. Further study of hiring preferences and their impact on the field of spine surgery is warranted. STUDY DESIGN: Prospective Survey Study.

Health Literacy in Orthopedic Surgery: A Systematic Review.

Background: Limited health literacy has been associated with adverse health outcomes. Undergoing orthopedic surgery often requires patients to make complex decisions and adhere to complicated instructions, suggesting that health literacy skills might have a profound impact on orthopedic surgery outcomes. Purpose: We sought to review the literature for studies investigating the level of health literacy in patients undergoing orthopedic surgery and also to assess how those studies report factors affecting health equity. Methods: We conducted a systematic search of PubMed, Embase, and Cochrane Library for all health literacy studies published in the orthopedic surgery literature up to February 8, 2022. Search terms included synonyms for health literacy and for all orthopedic surgery subspecialties. Two reviewers independently extracted study data in addition to indicators of equity reporting using the PROGRESS+ checklist (Place of Residence, Race/Ethnicity, Occupation, Gender/sex, Religion, Education, Social capital, Socioeconomic status, plus age, disability, and sexual orientation). Results: The search resulted in 616 studies; 9 studies remained after exclusion criteria were applied. Most studies were of arthroplasty (4/9; 44%) or trauma (3/9; 33%) patients. Validated health literacy assessments were used in 4 of the included studies, and only 3 studies reported the rate of limited health literacy in the patients studied, which ranged between 34% and 38.5%. At least one PROGRESS+ item was reported in 88% (8/9) of the studies. Conclusions: We found a paucity of appropriately designed studies that used validated measures of health literacy in the field of orthopedic surgery. The potential impact of health literacy on orthopedic patients and their outcomes has yet to be elucidated. Thoughtful, high-quality trials across diverse demographics and geographies are warranted.