Multilevel posterior spinal fusion following percutaneous third generation kyphoplasty complicated by vertebral compression fracture progression.

Newer third generation percutaneous kyphoplasty (PKs) may minimize risks associated with older generation kyphoplasties such as new adjacent fractures, fracture progression, cement leakage, neurologic sequelae, and kyphosis. Additionally, posterior pedicle spinal fusion (PPSF) may minimize risk of long-term complications following PKs while maximizing the benefits of stable spinal alignment. The patient developed adjacent fracture progression, posterior retropulsion, and kyphosis following third generation kyphoplasty. Vertebral compression fracture progression was corrected and prolonged symptomatic relief was successfully achieved with T11-L4 PPSF and L1-L2 laminectomy. Postoperative follow-ups at 2, 4, 7 weeks, 1 and 2 years showed continued symptomatic improvement in back pain with resolution of thigh and groin pain. This case supports the use of PPSF in third generation PK-related complications to provide long-term symptom relief and improve quality of life in patients with severe osteoporotic compression fractures.

Impact of the COVID-19 Pandemic on Outcomes and Perioperative Factors Associated with Posterior Cervical Fusion.

Introduction: While there is anecdotal evidence that the coronavirus disease 2019 (COVID-19) pandemic altered perioperative decision-making in patients requiring posterior cervical fusion (PCF), a national-level analysis to examine the significance of this hypothesis has not yet been conducted. This study aimed to determine the potential differences in perioperative variables and surgical outcomes of PCF performed before vs. during the COVID-19 pandemic. Methods: Adults who underwent PCF were identified in the 2019 (prepandemic) and 2020 (intrapandemic) NSQIP datasets. Differences in 30-day readmission, reoperation, and morbidity were evaluated using multivariate logistic regression. On the other hand, differences in operative time and relative value units (RVUs) were estimated using quantile regression. Furthermore, the odds ratios (OR) for length of stay (LOS) were estimated using negative binomial regression. Secondary outcomes included rates of nonhome discharge and outpatient surgery. Results: A total of 3,444 patients were included in this study (50.7% from 2020). Readmission, reoperation, morbidity, operative time, and RVUs per minute were similar between cohorts (p>0.05). The LOS (OR 1.086, p<0.001) and RVUs-per-case (coefficient +0.360, p=0.037) were significantly greater in 2020 compared to 2019. Operation year 2020 was also associated with lower rates of nonhome discharge (22.3% vs. 25.8%, p=0.017) and higher rates of outpatient surgery (4.8% vs. 3.0%, p=0.006). Conclusions: During the COVID-19 pandemic, a 28% decreased odds of nonhome discharge following PCF and a 72% increased odds of PCF being performed in an outpatient setting were observed. The readmission, reoperation, and morbidity rates remained unchanged during this period. This is notable given that patients in the 2020 group were more frail. This suggests that patients were shifted to outpatient centers possibly to make up for potentially reduced case volume, highlighting the potential to evaluate rehabilitation-discharge criteria. Further research should evaluate these findings in more detail and on a regional basis.

Robotic-Assisted Versus Fluoroscopic-Guided Surgery on the Accuracy of Spine Pedicle Screw Placement: A Systematic Review and Meta-Analysis.

Spinal fusion is a common method by which surgeons decrease instability and deformity of the spinal segment targeted. Pedicle screws are vital tools in fusion surgeries and advancements in technology have introduced several modalities of screw placement. Our objective was to evaluate the accuracy of pedicle screw placement in robot-assisted (RA) versus fluoroscopic-guided (FG) techniques. The PubMed and Cochrane Library databases were systematically reviewed from January 2007 through to August 8, 2022, to identify relevant studies. The accuracy of pedicle screw placement was determined using the Gertzbein-Robbins (GR) classification system. Facet joint violation (FJV), total case radiation dosage, total case radiation time, total operating room (OR) time, and total case blood loss were collected. Twenty-one articles fulfilled the inclusion criteria. Successful screw accuracy (GR Grade A or B) was found to be 1.02 (95% confidence interval: 1.01 - 1.04) times more likely with the RA technique. In defining accuracy solely based on the GR Grade A criteria, screws placed with RA were 1.10 (95% confidence interval: 1.06 - 1.15) times more likely to be accurate. There was no significant difference between the two techniques with respect to blood loss (Hedges' g: 1.16, 95% confidence interval: -0.75 to 3.06) or case radiation time (Hedges' g: -0.34, 95% CI: -1.22 to 0.53). FG techniques were associated with shorter operating room times (Hedges' g: -1.03, 95% confidence interval: -1.76 to -0.31), and higher case radiation dosage (Hedges' g: 1.61, 95% confidence interval: 1.11 to 2.10). This review suggests that RA may slightly increase pedicle screw accuracy and decrease per-case radiation dosage compared to FG techniques. However, total operating times for RA cases are greater than those for FG cases.

A National Database Retrospective Review of Short-Term Postoperative Mortality in the Geriatric Population: A Comparison Between Emergency Spine Fractures and Hip Fractures.

BACKGROUND: Mortality rates following emergency spine fracture surgery are high, especially in the elderly. However, how the postoperative mortality rate following spine fractures compares to other geriatric fractures such as hip fractures remains unclear. Therefore, this retrospective cohort study aimed to compare 30-day mortality rates and risk factors between emergency spine fracture versus hip fracture surgery in the elderly. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried between 2011 and 2021 for emergency spine fractures and hip fractures in the elderly. Univariate analyses evaluated demographic data, perioperative factors, comorbidities, and 30-day mortality rates as the primary outcomes. A multivariable regression model was then constructed to control for significant baseline and demographic differences and evaluate independent predictors of mortality. RESULTS: A total of 18,287 emergency hip fractures and 192 emergency spine fractures were included in our study. Univariate analysis demonstrated significant differences in female sex, body mass index (BMI), operation time, length of hospital stays, disseminated cancer, and functional dependence between spine and hip fractures. Thirty-day mortality rates were significantly higher in spine versus hip fractures (9.4% vs. 5%). Multivariate regression analysis demonstrated emergent spine fracture surgery, disseminated cancer, functional dependence, and length of stay as independent predictors of mortality in our cohort. Female sex, BMI, and operation time were protective factors for mortality in our cohort. CONCLUSIONS: Emergency spine fractures in the elderly represent an independent predictor for 30-day postoperative mortality compared to emergency hip fractures. Disseminated cancer, functional dependence, and length of stay were independent predictors of mortality while female sex, BMI, and operation time were protective factors. These data demonstrate the severity of injury and high rates of mortality that clinicians can use to counsel patients and their families.

Venous Anomalies Complicating Anterior Lumbar Interbody Fusion Exposures.

The effects of anomalous vasculature impeding optimal exposure to an anterior lumbar interbody fusion approach are limited in literature. We present five individual, unique cases of vascular anomalies in patients undergoing two-stage anterior-posterior lumbar interbody fusion. Cases 1, 2, 4, and 5 have yet to be described in literature in context of anterior lumbar interbody fusions. Case 3 presents anomalous vasculature that has only been described in two other case reports. Case 1 presents the right internal iliac vein originating from the left common iliac vein which was transected for L4-L5 vertebral disc exposure. Case 2 presents the left internal iliac vein originating from the right common iliac vein which required an oblique approach. Case 3 presents a duplicated inferior vena cava that was taken into account but did not interfere with the anterior retroperitoneal approach. Case 4 presents large osteophytes adhering to the left common iliac vein which limited safe dissection and mobilization. Case 5 presents the left internal iliac vein with a high takeoff spanning across the L5-S1 vertebral disc space and requiring transection. This case series highlights the need for preoperative imaging and a working detailed knowledge of anatomy to avoid damaging vasculature that can potentially lead to fatal consequences. The information given in this case series should inform both spine and vascular surgeons on proper preoperative planning. To maximize operative efficiency and safety, spine surgeons and vascular surgeons should collaborate to minimize surgical complications.

Lumbosacral Vertebral Osteomyelitis With Iliopsoas and Epidural Abscess Following Intravesical Bacillus Calmette-Guérin Therapy.

Intravesical Bacillus Calmette-Guérin (BCG) therapy is the gold-standard adjuvant therapy for patients with superficial or non-muscle-invasive bladder cancer. BCG is a live attenuated strain of Mycobacterium bovis, which induces an antitumor environment, effectively fighting malignant uroepithelial cells through cytotoxic reactions. However, BCG therapy may stimulate local or disseminated infections. In rare cases, vertebral osteomyelitis may arise in the thoracolumbar spine, mostly affecting older males. This is a case of an 84-year-old male patient who developed L5-S1 osteomyelitis with associated epidural and iliopsoas abscess. Symptoms manifested as severe low back pain and bilateral lower extremity weakness. This paper aims to raise awareness of and educate spine surgeons in recognizing this uncommon complication by taking into context a history of BCG therapy.

Interventional Therapy and Surgical Management of Lumbar Disc Herniation in Spine Surgery: A Narrative Review.

Significant advancements in lumbar disc herniation (LDH) management have been made in interventional pain therapy, operative therapy, peri-operative management, and cost analysis of various procedures. The present review aims to provide a concise narrative of all these topics, current trends, and possible future directions in the management of LDH. Interventional pain management using intradiscal injections often serves as a minimally invasive non-surgical approach. Surgical modalities vary, including traditional open laminectomy, microdiscectomy, endoscopic discectomy, tubular discectomy, percutaneous laser disc decompression, and transforaminal foraminotomy. Prevention of infections during surgery is paramount and is often done via a single-dose preoperative antibiotic prophylaxis. Recurrence of LDH post-surgery is commonly observed and thus mitigative strategies for prevention have been proposed including the use of annular closure devices. Finally, all treatments are well-associated with clear as well as hidden costs to the health system and society as described by billing codes and loss of patients' quality-adjusted life-years. Our summary of recent literature regarding LDH may allow physicians to employ up-to-date evidence-based practice in clinical settings and can help drive future advancements in LDH management. Future longitudinal and comprehensive studies elucidating how each type of treatments fare against different types of herniations are warranted.

Association between history of lumbar spine surgery and paralumbar muscle health: a propensity score-matched analysis.

BACKGROUND CONTEXT: Prior studies have suggested that muscle strength and quality may be associated with low back pain. Recently, a novel magnetic resonance imaging (MRI)-based lumbar muscle health grade was shown to correlate with health-related quality of life scores after spine surgery. However, the potential association between history of lumbar spine surgery and paralumbar muscle health requires further investigation. PURPOSE: To compare MRI-based paralumbar muscle health parameters between patients with versus without a history of surgery for degenerative lumbar spinal disease. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Consecutive series of patients who presented to the spine surgery clinic of a single surgeon. OUTCOME MEASURES: MRI-based measurements of paralumbar cross-sectional area (PL-CSA), Goutallier grade, lumbar indentation value (LIV). METHODS: A retrospective analysis was performed on a consecutive series of patients of a single surgeon, and patients were included based on availability of lumbar MRI. Axial T2-weighted lumbar MRIs were analyzed for PL-CSA, Goutallier classification, and LIV. Measurements were performed at the center of disc spaces from L1 to L5. Patients with and without history of spine surgery were matched based on age, sex, race, ethnicity, and body mass index (BMI) via propensity score matching. Normality of each muscle health variable was assessed using Kolmogorov-Smirnov test. Mann-Whitney U test or independent t-test performed to compare the matched cohorts, as appropriate. RESULTS: A total of 615 patients were assessed. For final analysis, 89 patients with a history of previous spine surgery were matched with 89 patients without a history of spine surgery. There were no statistically significant differences in age, sex, race, ethnicity, or BMI between the matched cohorts. History of spine surgery was generally associated with worse lumbar muscle health. At all 4 intervertebral levels between L1-L5, PL-CSA was significantly smaller among patients with history of spine surgery. At L4-L5, patients with prior spine surgery had significantly smaller PL-CSA/BMI. Patients with prior spine surgery were found to have greater fatty infiltration of the muscles, with higher average Goutallier grades at levels L1-L2, L2-L3, and L4-L5. In addition, history of spine surgery was associated with smaller LIV at L1-L2, L3-L4, and L4-L5. CONCLUSIONS: The current study demonstrates that history of lumbar spine surgery is associated with worse paralumbar muscle health based on quantitative and qualitative measurements on MRI. On average, patients with history of spine surgery were found to have smaller cross-sectional areas of the paralumbar muscles, greater amounts of fatty infiltration based on Goutallier classification, and smaller lumbar indentation values.

Influence of Demographic and Socioeconomic Factors on Hospital Distance for Total Knee Arthroplasty.

Background: Disparities exist in access to and outcomes following total knee arthroplasty. However, there is a paucity of data examining the relationship between travel distance and these disparities. Methods: We used the Healthcare Cost and Utilization Project, American Hospital Association, and UnitedStatesZipCodes.org Enterprise databases to gather patient demographic and postoperative outcomes data. We calculated the distance traveled between patient population-weighted zip code centroid points and the hospitals at which they received total knee arthroplasty. We then examined the association between travel distance and patient demographic characteristics as well as postoperative adverse outcomes. Results: Among of cohort of 384,038 patients, white patients (16.58 miles) traveled farther on average than Black (10.05) or Hispanic patients (10.54) (P < .0001). Medicare and commercial insurance coverage were associated with greater travel distance (P < .0001). Fewer medical comorbidities (P < .001) and residence in the highest-income areas (P < .0001) were associated with increased travel distance. Differences in postoperative complication rates related to travel distance were not clinically significant. Conclusions: Increased travel distance for total knee arthroplasty was associated with white race, commercial and Medicare insurance coverage, fewer medical comorbidities, and increased socioeconomic status. Future work is needed to determine the underlying causal mechanisms leading to these differences in access to specialized care.

Venous Thromboembolism Rates Have Not Decreased in Elective Lumbar Fusion Surgery from 2011 to 2020.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study aimed to (1) evaluate for any temporal trends in the rates of VTE, deep venous thrombosis (DVT), pulmonary embolism (PE), and mortality from 2011 to 2020 and (2) identify the predictors of VTE following lumbar fusion surgery. METHODS: Annual incidences of 30-day VTE, DVT, PE, and mortality were calculated for each of the operation year groups from 2011 to 2020. Multivariable Poisson regression was utilized to test the association between operation year and primary outcomes, as well as to identify significant predictors of VTE. RESULTS: A total of 121,205 patients were included. There were no statistically significant differences in VTE, DVT, PE, or mortality rates among the operation year groups. Multivariable regression analysis revealed that compared to 2011, operation year 2019 was associated with significantly lower rates of DVT. Age, BMI, prolonged operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking status, functional dependence, and chronic steroid use were identified as independent predictors of VTE following lumbar fusion. Female sex, Hispanic ethnicity, and outpatient surgery setting were identified as protective factors from VTE in this cohort. CONCLUSIONS: Rates of VTE after lumbar fusion have remained mostly unchanged between 2011 and 2020. Older age, higher BMI, longer operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking, functional dependence, and steroid use were independent predictors of VTE after lumbar fusion, while female sex, Hispanic ethnicity, and outpatient surgery were the protective factors.

Discharge to Rehabilitation Predicts Increased Morbidity in Patients Undergoing Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to compare 30-day readmission and postdischarge morbidity for posterior cervical decompression and fusion (PCDF) in patients who were discharged to home versus rehabilitation. SUMMARY OF BACKGROUND DATA: An increasing number of patients are being discharged to postacute inpatient care facilities following spine surgery. However, little research has been performed to evaluate the effect of this trend on short-term outcomes. MATERIALS AND METHODS: Patients who underwent PCDF from 2011 to 2018 were identified using the National Surgical Quality Improvements Program (NSQIP)-database. Regression was utilized to compare primary outcomes between home and rehabilitation groups and to control for predictors of outcomes. RESULTS: We identified 8912 patients. Unadjusted analysis revealed that rehabilitation-discharge patients had greater readmission (10.4% vs. 8.0%, P=0.002) and postdischarge morbidity (7.1% vs. 4.0%, P<0.001) rates. After controlling for patient-related factors, rehabilitation-discharge independently predicted postdischarge morbidity (P<0.001, odds ratio=2.232). Readmission no longer differed between groups (P=0.071, odds ratio=1.311). Rates of discharge to rehabilitation increased from 23.5% in 2011 to 25.3% in 2018, while postdischarge morbidity rates remained stagnant.Patients discharged to rehabilitation were older (66.9 vs. 59.4 y); more likely to be African American (21.4% vs. 13.8%) and have diabetes (27.1% vs. 17.5%), steroid use (6.4% vs. 4.7%, P=0.002), and American Society of Anaesthesiologists (ASA)-class ≥3 (80.2% vs. 57.7%); less likely to be male (53.9% vs. 57.4%, P=0.004) and smokers (20.3% vs. 26.6%); and had greater operative time (198 vs. 170 min) and length of hospital stay (5.9 vs. 3.3 d) (P<0.001). CONCLUSIONS: Despite controlling for significant factors, discharge to rehabilitation independently predicted a 2.2 times increased odds of postdischarge morbidity. Rates of discharge to rehabilitation increased overtime without an appreciable decrease in postdischarge morbidity, suggesting that greater resources are being utilized in the postacute care period without an obvious justification. Therefore, home-discharge should be prioritized after hospitalization for PCDF when feasible. These findings are notable in light of reform efforts aimed at reducing costs while improving quality of care.

Comparison of value per operative time between anterior lumbar interbody fusion and lumbar disc arthroplasty: A propensity score-matched analysis.

Context: Despite the growing evidence demonstrating its effectiveness, lumbar disc arthroplasty (LDA) rates have not increased significantly in recent years. A likely contributing factor is uncertainties related to reimbursement and insurers' denial of coverage due to fear of late complications, reoperations, and unknown secondary costs. However, no prior study has compared the physician reimbursement rates of lumbar fusion and LDA. Aim: The aim of this study was to compare the relative value units (RVUs) per min as well as 30-day readmission, reoperation, and morbidity rates between anterior lumbar interbody fusion (ALIF) and LDA. Settings and Design: This was a retrospective cohort study. Subjects and Methods: The current study utilizes data obtained from the National Surgical Quality Improvement Program database. Patients who underwent ALIF or LDA between 2011 and 2019 were included in the study. Statistical Analysis Used: Propensity score matching analysis was performed according to demographic characteristics and comorbidities. Matched groups were compared through Fisher's exact test and independent t-test for categorical and continuous variables, respectively. Results: Five hundred and two patients who underwent ALIF were matched with 591 patients who underwent LDA. Mean RVUs per min was significantly higher for ALIF compared to LDA. ALIF was associated with a significantly higher 30-day morbidity rate compared to LDA, while readmission and reoperation rates were statistically similar. ALIF was also associated with higher frequencies of deep venous thrombosis (DVT) and blood transfusions. Conclusions: ALIF is associated with significantly higher RVUs per min compared to LDA. ALIF is also associated with higher rates of 30-day morbidity, DVT, and blood transfusions, while readmission and reoperation rates were statistically similar.

Functional workspace and patient-reported outcomes improve after reverse and total shoulder arthroplasty.

BACKGROUND: Low-cost motion analysis systems (LCMASs) have emerged as easy and practical methods to measure the functional workspace (FWS). Thus, we ventured to apply an LCMAS, the Kinect2 gaming camera, to evaluate the FWS in patients with shoulder osteoarthritis (OA) and patients who underwent total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). METHODS: A cross-sectional study of participants with OA (n = 53), TSA (n = 70), and RTSA (n = 34) was performed. The FWS as measured by an LCMAS, the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, and the Patient-Reported Outcomes Measurement Information System (PROMIS) score were collected. For participants who underwent TSA or RTSA, the FWS was evaluated at 6, 12, and 24 months postoperatively. The correlation of the FWS with the ASES score and PROMIS score was determined. Significance was set at P < .05. RESULTS: Patients who underwent TSA or RTSA had a significantly higher FWS than patients with shoulder OA at almost all time points. Patients who underwent TSA had a significantly higher FWS than patients who underwent RTSA at 24 months after surgery. PROMIS and ASES scores showed strong correlations with the FWS in patients who underwent TSA (R = 0.75 [P < .001] and R = 0.83 [P < .001], respectively) and RTSA (R = 0.84 [P < .001] and R = 0.73 [P < .001], respectively). CONCLUSION: The FWS measured by an LCMAS is an easy and low-cost method to quantify the reachable space of the hand in patients and shows strong correlations with patient-reported outcome measures. This may be a useful tool to assess upper-extremity range of motion before and after shoulder arthroplasty.