Impact of depression and anxiety on patient reported outcomes measures after lumbar fusion.

INTRODUCTION: Depression and anxiety are common in patients undergoing spinal surgery and might negatively impact outcomes. This study investigates the possible effect of these diagnoses on patient reported outcomes following lumbar fusion. METHODS: Retrospective review of a registry containing prospectively collected data of lumbar fusion procedures at a single institution was performed from 5/23/2012 to 6/15/2022. Patients with a minimum of two year follow up were included. Demographic information, diagnoses,medications, patient-reported outcomes measures (PROMs), and complications data at preoperative, three months, six months, one year, and two years postoperative were collected. Statistical analysis was performed using Student's T-tests, χ2, binomial correlation, odds ratios, logistic regression, and Mean Clinically Important Difference (MCID). RESULTS: A total of 156 patients were included (60 male, 96 female) with mean age 62.6±11.1 years at surgery. Thirty-nine (25%) had depression and/or anxiety (DA). Baseline Oswestry Disability Index (ODI) and EQ5D scores were significantly worse in the DA cohort compared to controls (ODI 51.1±18.3 vs. 42.9±15.8; p=0.010, EQ5D 0.46±0.21 vs. 0.57±0.21; p=0.005). Both cohorts experienced similar relative improvement at two years (delta ODI -18.2±27.9 vs. -17.8±22.1; p=0.924, EQ5D 6.8±33.8 vs 8.1±32.9; p=0.830). Absolute outcome scores were worse in the DA cohort at all intervals. DA were not independently predictive of changes in PROMs (delta ODI mean difference 4.49, r2=0.36, p=0.924). CONCLUSION: The present study showed similar improvement in PROMs following lumbar fusion for patients with anxiety and depression compared to healthy controls. These data suggest these patients are no less likely to benefit from appropriately planned lumbar fusion.

Preoperative Mobile Health Data Improve Predictions of Recovery From Lumbar Spine Surgery.

BACKGROUND AND OBJECTIVES: Neurosurgeons and hospitals devote tremendous resources to improving recovery from lumbar spine surgery. Current efforts to predict surgical recovery rely on one-time patient report and health record information. However, longitudinal mobile health (mHealth) assessments integrating symptom dynamics from ecological momentary assessment (EMA) and wearable biometric data may capture important influences on recovery. Our objective was to evaluate whether a preoperative mHealth assessment integrating EMA with Fitbit monitoring improved predictions of spine surgery recovery. METHODS: Patients age 21-85 years undergoing lumbar surgery for degenerative disease between 2021 and 2023 were recruited. For up to 3 weeks preoperatively, participants completed EMAs up to 5 times daily asking about momentary pain, disability, depression, and catastrophizing. At the same time, they were passively monitored using Fitbit trackers. Study outcomes were good/excellent recovery on the Quality of Recovery-15 (QOR-15) and a clinically important change in Patient-Reported Outcomes Measurement Information System Pain Interference 1 month postoperatively. After feature engineering, several machine learning prediction models were tested. Prediction performance was measured using the c-statistic. RESULTS: A total of 133 participants were included, with a median (IQR) age of 62 (53, 68) years, and 56% were female. The median (IQR) number of preoperative EMAs completed was 78 (61, 95), and the median (IQR) number of days with usable Fitbit data was 17 (12, 21). 63 patients (48%) achieved a clinically meaningful improvement in Patient-Reported Outcomes Measurement Information System pain interference. Compared with traditional evaluations alone, mHealth evaluations led to a 34% improvement in predictions for pain interference (c = 0.82 vs c = 0.61). 49 patients (40%) had a good or excellent recovery based on the QOR-15. Including preoperative mHealth data led to a 30% improvement in predictions of QOR-15 (c = 0.70 vs c = 0.54). CONCLUSION: Multimodal mHealth evaluations improve predictions of lumbar surgery outcomes. These methods may be useful for informing patient selection and perioperative recovery strategies.

Natural History of Degenerative Spondylolisthesis: A Systematic Review and Meta-analysis.

OBJECTIVE: The optimal treatment algorithm for patients with degenerative lumbar spondylolisthesis has not been clarified. Part of the reason for this is that the natural history of degenerative spondylolisthesis (DS) has not been sufficiently studied. Comprehension of the natural history is essential for surgical decision making. We aimed to determine 1) the proportion of patients that develop de novo DS during follow-up; and 2) the proportion of patients with progression of preexistent DS by conducting a systematic review and meta-analysis of the literature. METHODS: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Ovid, EMBASE, and the Cochrane Library were searched from their inception through April 2022. Demographic values of the study populations, grade of slip, rate of slippage before and after the follow-up period, and percentage of patients with slip in the populations at baseline and after follow-up were the extracted parameters. RESULTS: Of the 1909 screened records, eventually 10 studies were included. Of these studies, 5 reported the development of de novo DS and 9 reported on the progression of preexistent DS. Proportions of patients developing de novo DS ranged from 12% to 20% over a period ranging from 4 to 25 years. The proportion of patients with progression of DS ranged from 12% to 34% over a period ranging from 4 to 25 years. CONCLUSIONS: Systematic review and metanalysis of DS on the basis of radiologic parameters revealed both an increasing incidence over time and an increasing progression of the slip rate in up to a third of the patients older than 25 years, which is important for counseling patients and surgical decision making. Importantly, two thirds of patients did not experience slip progression.

Does axial cervical pain improve with surgical fusion? A meta-analysis.

OBJECTIVE: Axial neck pain is a prevalent condition that causes significant morbidity and productivity loss. This study aimed to review the current literature and define the impact of surgical intervention on the management of cervical axial neck pain. METHODS: A search was conducted of three databases (Ovid MEDLINE, Embase, and Cochrane) for randomized controlled trials and cohort studies written in the English language with a minimum 6-month follow-up. The analysis was limited to patients with axial neck pain/cervical radiculopathy and preoperative/postoperative Neck Disability Index (NDI) and visual analog scale (VAS) scores. Literature reviews, meta-analyses, systematic reviews, surveys, and case studies were excluded. Two patient groups were analyzed: the arm pain predominant (pAP) cohort and the neck pain predominant (pNP) cohort. The pAP cohort had preoperative VAS neck scores that were lower than the arm scores, whereas the pNP cohort was defined as having preoperative VAS neck scores higher than the arm scores. A 30% reduction in patient-reported outcome measure (PROM) scores from the baseline represented the minimal clinically important difference (MCID). RESULTS: Five studies met the inclusion criteria, involving a total of 5221 patients. Patients with pAP showed a slightly higher percent reduction in PROM scores from baseline than those with pNP. The NDI reduction in patients with pNP was 41.35% (mean change in NDI score 16.3/mean baseline NDI score 39.42) (p < 0.0001), whereas those with pAP had a reduction of 45.12% (15.86/35.15) (p < 0.0001). Surgical improvement was slightly but similarly greater in pNP patients compared with pAP patients (16.3 vs 15.86 points, respectively; p = 0.3193). Regarding VAS scores, patients with pNP had a greater reduction in neck pain, with a change from baseline of 53.4% (3.60/6.74, p < 0.0001), whereas those with pAP had a change from baseline of 50.3% (2.46/4.89, p < 0.0001). The difference in VAS scores for neck pain improvement was significant (3.6 vs 2.46, p < 0.0134). Similarly, patients with pNP had a 43.6% (1.96/4.5) improvement in VAS scores for arm pain (p < 0.0001), whereas those with pAP had 66.12% (4.43/6.7) improvement (p < 0.0001). The VAS scores for arm pain were significantly greater in patients with pAP (4.43 vs 1.96 points, respectively; p < 0.0051). CONCLUSIONS: Overall, despite significant variations in the existing literature, there is mounting evidence that surgical intervention can lead to clinically meaningful improvements in patients with primary axial neck pain. The studies suggest that patients with pNP tend to have better improvement in neck pain than in arm pain. In both groups, the average improvements exceeded the MCID values and reached substantial clinical benefit in all studies. Further research is necessary to identify which patients and underlying pathologies will benefit most from surgical intervention for axial neck pain because it is a multifaceted condition with many causes.

International and Multicenter Prospective Controlled Study of Dysphagia After Anterior Cervical Spine Surgery.

BACKGROUND: In the context of anterior approach to the cervical spine, dysphagia is a common complication and still without a clear distinction of risk factors. OBJECTIVE: To analyze the risk factors of dysphagia after cervical spine surgery. METHODS: Multicenter prospective study evaluated patients who underwent anterior cervical spine surgery for degenerative pathologies, studying surgical, anesthesia, base disease, and radiological variables (preoperatively, 24 hours, 1 and 3 weeks, and 6 months after surgery), with control group matched. Postoperative dysphagia was assessed by Swallowing Satisfaction Index and Swallowing Questionnaire; besides, based on multiple logistic regression model, a risk factor analysis correlation was applied. RESULTS: In total, 233 cervical patients were evaluated; most common level approached was C5-C6 (71.8%). All showed same decreasing trade for dysphagia incidence-with more cases on cervical group ( P < .05); severe cases were rare. At postoperative day 1, identified risk factors were approach to C3-C4 (4.11, P < .01), loss of preoperative cervical lordosis (2.26, P < .01), intubation attempts ≥2 (3.10, P < .01), and left side approach (1.85, P = .02); at day 7, body mass index ≥30 (2.29, P = .02), C3-C4 (3.42, P < .01), and length of surgery ≥90 minutes (2.97, P = .005); and at day 21, C3-C4 were kept as a risk factor (3.62, P < .01). CONCLUSION: A high incidence level of dysphagia was identified, having a clear decreasing trending (number of cases and severity) through postoperative time points; considering possible risk factors, strongest correlation was the approach at the C3-C4 level-statistically significant at the 24 hours, 7 days, and 21 days assessment.

Current and future applications of mobile health technology for evaluating spine surgery patients: a review.

Mobile health (mHealth) technology has assumed a pervasive role in healthcare and society. By capturing real-time features related to spine health, mHealth assessments have the potential to transform multiple aspects of spine care. Yet mHealth applications may not be familiar to many spine surgeons and other spine clinicians. Consequently, the objective of this narrative review is to provide an overview of the technology, analytical considerations, and applications of mHealth tools for evaluating spine surgery patients. Reflecting their near-ubiquitous role in society, smartphones are the most commonly available form of mHealth technology and can provide measures related to activity, sleep, and even social interaction. By comparison, wearable devices can provide more detailed mobility and physiological measures, although capabilities vary substantially by device. To date, mHealth evaluations in spine surgery patients have focused on the use of activity measures, particularly step counts, in an attempt to objectively quantify spine health. However, the correlation between step counts and patient-reported disease severity is inconsistent, and further work is needed to define the mobility metrics most relevant to spine surgery patients. mHealth assessments may also support a variety of other applications that have been studied less frequently, including those that prevent postoperative complications, predict surgical outcomes, and serve as motivational aids to patients. These areas represent key opportunities for future investigations. To maximize the potential of mHealth evaluations, several barriers must be overcome, including technical challenges, privacy and regulatory concerns, and questions related to reimbursement. Despite those obstacles, mHealth technology has the potential to transform many aspects of spine surgery research and practice, and its applications will only continue to grow in the years ahead.

Feasibility and Acceptability of a Preoperative Multimodal Mobile Health Assessment in Spine Surgery Candidates.

BACKGROUND: Rapid growth in smartphone use has expanded opportunities to use mobile health (mHealth) technology to collect real-time patient-reported and objective biometric data. These data may have important implication for personalized treatments of degenerative spine disease. However, no large-scale study has examined the feasibility and acceptability of these methods in spine surgery patients. OBJECTIVE: To evaluate the feasibility and acceptability of a multimodal preoperative mHealth assessment in patients with degenerative spine disease. METHODS: Adults undergoing elective spine surgery were provided with Fitbit trackers and sent preoperative ecological momentary assessments (EMAs) assessing pain, disability, mood, and catastrophizing 5 times daily for 3 weeks. Objective adherence rates and a subjective acceptability survey were used to evaluate feasibility of these methods. RESULTS: The 77 included participants completed an average of 82 EMAs each, with an average completion rate of 86%. Younger age and chronic pulmonary disease were significantly associated with lower EMA adherence. Seventy-two (93%) participants completed Fitbit monitoring and wore the Fitbits for an average of 247 hours each. On average, participants wore the Fitbits for at least 12 hours per day for 15 days. Only worse mood scores were independently associated with lower Fitbit adherence. Most participants endorsed positive experiences with the study protocol, including 91% who said they would be willing to complete EMAs to improve their preoperative surgical guidance. CONCLUSION: Spine fusion candidates successfully completed a preoperative multimodal mHealth assessment with high acceptability. The intensive longitudinal data collected may provide new insights that improve patient selection and treatment guidance.

Implementation of a spine triage program and its effect on outpatient radiology utilization.

OBJECTIVE: Clinical care pathways designed to triage spinal disorders have been shown to reduce wait times and improve patient satisfaction. The goal of this study was to perform an analysis of outpatient radiology costs before and after the implementation of a spine care triage pathway. METHODS: All imaging orders and surgical procedures were captured in a prospective spine registry for patients referred to the department of neurosurgery within a single academic center between July 1, 2017, and November 3, 2020. A spine triage algorithm was developed and implemented January 1, 2018. Healthcare utilization was recorded for 1 year after the first appointment in the department of neurosurgery. Imaging costs were estimated using publicly available data from the Centers for Medicare and Medicaid Services. Statistical analysis consisted of an independent sample t-test or randomization test for continuous variables and a chi-square test for categorical variables. RESULTS: A total of 3854 patients were included in this study. The mean age was 60 years (50.8% female) and 89.8% had undergone advanced imaging before being referred to the department of neurosurgery. In total, 12.6% of patients were referred with a specific surgical diagnosis (i.e., spinal stenosis, lumbar spondylolisthesis, etc.). During the pretriage phase 1810 patients were enrolled, and there were 2044 patients enrolled after the triage algorithm was implemented. Advanced imaging (CT or MRI) was ordered more frequently by providers before the triage program was initiated, with imaging ordered in 34% (617/1810) of patients pretriage versus 14.8% (302/2044) after the triage pathway was implemented (p < 0.001). The authors calculated a significant reduction in cost associated with reduced radiology utilization. Before triage, the cost of radiology utilization was $85,475/1000 patients compared with $40,107/1000 patients afterward (p < 0.001). The triage program did not change the utilization of surgery (14.6% before, 13.6% after). CONCLUSIONS: Among patients treated after a spinal triage program was implemented in a single neurosurgery department, there was a substantial reduction in the use of advanced imaging and a 50% reduction in cost associated with outpatient radiology utilization. The triage program did not change the rate of spine surgery being performed.

Evaluation of intervertebral body implant performance using active surveillance of electronic health records.

Objectives: To assess the feasibility of using electronic health record (EHR) derived clinical data within an active surveillance setting to evaluate the safety of a novel intervertebral body implant (IVBI) stabilization device. Design: Retrospective, longitudinal observational cohort study comparing clinical outcomes for patients seen through 1 year following spinal fusion surgery. Setting: Lahey Health network, which includes academic tertiary hospitals, outpatient clinics, and independent provider offices in the New England region of the USA. Participants: All spine surgery patients aged 18 or older who underwent thoracic or lumbar spinal arthrodesis surgeries were included. Main outcome measures: The clinical outcomes of patients treated with the CONCORDE Bullet (CB) interbody spine system (DePuy) between April 2015 and December 2018 were compared with those patients receiving alternative spine stabilization interbody device implants. The primary endpoint was reoperation rate at 1 year, with secondary endpoints including the requirement for blood transfusion during index hospitalization, 1 year rate of any cause hospitalization, 1 year rate of surgical site infection, and mortality at 1 year. Results: Among the 606 patients undergoing thoracic or lumbar spinal fusion surgery during the study period, 136 received only the CB. In comparison with patients who did not receive the CB, no significant differences were found in the rate of reoperation at 1 year or the rates of secondary safety outcomes. Conclusions: Data derived from the EHR can be successfully leveraged to assess the safety of IVBI devices, in this case demonstrating no significant differences in the rates of risk-adjusted safety endpoints between patients undergoing spinal surgery with the CB as compared with alternative spinal implants.

Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI): Validation of a Novel Scoring System Quantifying the Effect of Postarthrodesis Cervical Stiffness on Patient Quality of Life.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The aim was to create and validate a novel patient-reported outcome measure (PROM) focusing on stiffness-related patient functional limitations after cervical spine fusion. SUMMARY OF BACKGROUND DATA: Cervical arthrodesis is a common treatment for myelopathy/radiculopathy, however, results in increased neck stiffness as a collateral outcome. No current PROM exists quantifying the impact of postoperative stiffness on patient function. METHODS: The Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI) was created through a modified Delphi process. The resultant 10-item questionnaire yields a score out of 100 with higher scores indicating increased functional difficulty related to neck stiffness. Cross-sectional study of control and postoperative patients was completed for CSRS-CSDI validation. Retest reliability (intraclass correlation coefficient), internal consistency (Cronbach alpha), responsiveness (levels fused vs. CSRS-CSDI scores), and discriminatory validation (CSRS-CSDI vs. neck disability index) scores) were completed. RESULTS: Fifty-seven surgical and 24 control patients completed the questionnaire. Surgical patients underwent a variety of procedures: 11 (19%) motion preserving operations, nine (16%) subaxial 1-2 level fusions, seven (12%) subaxial 3-5 level fusions, five (9%) C1-subaxial cervical spine fusions, 20 (35%) C2-upper thoracic spine fusions, five (9%) occiput-subaxial or thoracic spine fusions. The questionnaire demonstrated high internal consistency (Cronbach alpha=0.92) and retest reliability (intraclass correlation coefficient=0.95, P <0.001). Good responsiveness validity with a significant difference between fusion cohorts was found ( P <0.001, rs =0.63). Patient CSRS-CSDI scores also correlated with neck disability index scores recorded ( P <0.001, r =0.70). CONCLUSION: This is the first study to create a PROM addressing the functional impact of cervical stiffness following surgical arthrodesis. The CSRS-CSDI was a reliable and valid measure of postoperative stiffness impact on patient function. This may prove useful in counseling patients regarding their expected outcomes with further investigation demonstrating its value in a prospective fashion.

Neurosurgical Study Design: Past and Future.

Clinical trials are performed to determine the safety, efficacy, or effectiveness of a medical or surgical intervention. A clinical trial is, by definition, prospective in nature with a uniform treatment of a defined patient cohort. The outcomes assessment should also be uniform. Often a control group is included. At present, the number of neurosurgical clinical trials is increasing, and the study designs have become more sophisticated. Historically, the standard of neurosurgical care has evolved from the findings from many case series and retrospective comparative studies. However, in the present report, we have focused exclusively on prospective clinical trials. An urgent need exists to understand how clinical trials have been performed in the past and how they can be improved to advance our neurosurgical practice. In the present review, we have discussed the barriers, successes, and failures regarding prospective clinical trials in neurosurgery with an outlook to the future.

Minimally Invasive Surgery for Spinal Metastasis: A Review.

OBJECTIVE: Minimally invasive surgery (MIS) techniques have advanced the treatment of metastatic diseases to the spine. The objective of this review is to describe clinical outcomes, benefits, and complications of these techniques. METHODS: All relevant clinical studies describing the role of MIS, computer-assisted navigation (CAN), robot-assisted (RA) procedures, and laser interstitial thermal therapy (LITT) in the treatment of metastatic spine diseases were identified from PubMed, MEDLINE, and relevant article bibliographies. RESULTS: For MIS articles, we filtered 1480 results and identified 26 studies. For CAN, we searched 464 articles to identify 18 articles for review. For RA, we searched 321 results to identify 7 studies for review. For LITT, we identified 21 articles for review. CONCLUSIONS: MIS for the treatment of spine metastasis has significant potential benefits in reducing surgical site infections, hospital stay, and blood loss without compromising instrument accuracy or overall outcomes. Overall, MIS and its adjuncts have the potential to reduce the risks involved in the treatment of patients with metastatic disease to the spinal column without compromising the benefits of decompression and stabilization of the spine.

Translating Data Analytics Into Improved Spine Surgery Outcomes: A Roadmap for Biomedical Informatics Research in 2021.

STUDY DESIGN: Narrative review. OBJECTIVES: There is growing interest in the use of biomedical informatics and data analytics tools in spine surgery. Yet despite the rapid growth in research on these topics, few analytic tools have been implemented in routine spine practice. The purpose of this review is to provide a health information technology (HIT) roadmap to help translate data assets and analytics tools into measurable advances in spine surgical care. METHODS: We conducted a narrative review of PubMed and Google Scholar to identify publications discussing data assets, analytical approaches, and implementation strategies relevant to spine surgery practice. RESULTS: A variety of data assets are available for spine research, ranging from commonly used datasets, such as administrative billing data, to emerging resources, such as mobile health and biobanks. Both regression and machine learning techniques are valuable for analyzing these assets, and researchers should recognize the particular strengths and weaknesses of each approach. Few studies have focused on the implementation of HIT, and a variety of methods exist to help translate analytic tools into clinically useful interventions. Finally, a number of HIT-related challenges must be recognized and addressed, including stakeholder acceptance, regulatory oversight, and ethical considerations. CONCLUSIONS: Biomedical informatics has the potential to support the development of new HIT that can improve spine surgery quality and outcomes. By understanding the development life-cycle that includes identifying an appropriate data asset, selecting an analytic approach, and leveraging an effective implementation strategy, spine researchers can translate this potential into measurable advances in patient care.

Are Lumbar Fusion Guidelines Followed? A Survey of North American Spine Surgeons.

OBJECTIVE: To evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America. METHODS: An anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics. RESULTS: A total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01). CONCLUSION: This study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation.

Cervical fusion for treatment of degenerative conditions: development of appropriate use criteria.

BACKGROUND CONTEXT: High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking. PURPOSE: Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine. STUDY DESIGN/SETTING: Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations. OUTCOME MEASURES: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters. METHODS: Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed. RESULTS: Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p<.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance. CONCLUSIONS: Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."