The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion.

PURPOSE: This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion. METHODS: A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model. RESULTS: Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis. CONCLUSION: Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.

Inflation-adjusted medicare physician reimbursement for adult spinal deformity surgery substantially declined from 2002 to 2020.

PURPOSE: Physician fees for orthopaedic surgeons by the Centers for Medicare and Medicaid Services (CMS) are increasingly scrutinized. The present retrospective review aims to assess whether adult spinal deformity (ASD) surgeries are properly valued for Medicare reimbursement. METHODS: Current Procedural Terminology (CPT) codes related to posterior fusion of spinal deformity of ≤ 6, 7-12, and ≥ 13 vertebral levels, as well as additional arthrodesis and osteotomy levels, were assessed for (1) Compound annual growth rate (CAGR) from 2002 to 2020, calculated using physician fee data from the CMS Physician Fee Schedule Look-Up Tool; and (2) work relative value units (RVUs) per operative minute, using data from the National Surgical Quality Improvement Program. RESULTS: From 2002 to 2020, all CPT codes for ASD surgery had negative inflation-adjusted CAGRs (range, - 18.49% to - 27.66%). Mean physician fees for spinal fusion declined by 26.02% (CAGR, - 1.66%) in ≤ 6-level fusion, 27.91% (CAGR, - 1.80%) in 7- to 12-level fusion, and 28.25% (CAGR, - 1.83%) ≥ 13-level fusion. Fees for both 7-12 (P < 0.00001) and ≥ 13 levels (P < 0.00001) declined more than those for fusion of ≤ 6 vertebral levels. RVU per minute was lower for 7- to 12-level and ≥ 13-level (P < 0.00001 for both) ASD surgeries than for ≤ 6-level. CONCLUSIONS: Reimbursement for ASD surgery declined overall. CAGR for fusions of ≥ 7 levels were lower than those for fusions of ≤ 6 levels. For 2012-2018, ≥ 7-level fusions had lower RVU per minute than ≤ 6-level fusions. Revaluation of Medicare reimbursement for longer-level ASD surgeries may be warranted. LEVEL OF EVIDENCE: III.

Abnormal Postoperative PROMIS Scores are Associated with Patient Satisfaction in Adult Spinal Deformity and Degenerative Spine Patients.

STUDY DESIGN: Retrospective review. OBJECTIVES: To evaluate 1) patient satisfaction after adult spine surgery; 2) associations between number of abnormal PROMIS domain scores and postoperative satisfaction; and 3) associations between normalization of a patient's worst preoperative PROMIS domain score and postoperative satisfaction. SUMMARY OF BACKGROUND DATA: Although "legacy" patient-reported outcome measures correlate with patient satisfaction after adult spine surgery, it is unclear whether PROMIS scores do. METHODS: We included 1119 patients treated operatively for degenerative spine disease (DSD) or adult spinal deformity (ASD) from 2014-2019 at our tertiary hospital who completed questionnaires preoperatively and at ≥1 postoperative timepoints up to 2 years. Postoperative satisfaction was measured in ASD patients using items 21 and 22 from the SRS 22-revised questionnaire and in DSD patients using the NASS Patient Satisfaction Index. "Worst" preoperative PROMIS domain was that with the greatest clinically negative deviation from the mean. "Normalization" was a postoperative score within 1 standard deviation of the general population mean. Multivariate logistic regression identified factors associated with satisfaction. RESULTS: Satisfaction was reported by 88% of DSD and 86% of ASD patients at initial postoperative follow-up; this proportion did not change during the first year after surgery. We observed an inverse relationship between postoperative satisfaction and number of abnormal PROMIS domains at all postoperative timepoints beyond 6 weeks. Only among ASD patients was normalization of the worst preoperative PROMIS domain associated with greater odds of satisfaction at all timepoints up to 1 year. CONCLUSION: The proportion of DSD and ASD patients satisfied postoperatively did not change from 6 weeks to 1 year. Normalizing the worst preoperative PROMIS domain and minimizing the number of abnormal postoperative PROMIS scores may reduce the number of dissatisfied patients. PROMIS data can guide perioperative patient management to improve satisfaction. LEVEL OF EVIDENCE: 3.

Predicting 30-day mortality after surgery for metastatic disease of the spine: the H2-FAILS score.

PURPOSE: Scoring systems for metastatic spine disease focus on predicting long- to medium-term mortality or a combination of perioperative morbidity and mortality. However, accurate prediction of perioperative mortality alone may be the most important factor when considering surgical intervention. We aimed to develop and evaluate a new tool, the H2-FAILS score, to predict 30-day mortality after surgery for metastatic spine disease. METHODS: Using the National Surgical Quality Improvement Program database, we identified 1195 adults who underwent surgery for metastatic spine disease from 2010 to 2018. Incidence of 30-day mortality was 8.7% (n = 104). Independent predictors of 30-day mortality were used to derive the H2-FAILS score. H2-FAILS is an acronym for: Heart failure (2 points), Functional dependence, Albumin deficiency, International normalized ratio elevation, Leukocytosis, and Smoking (1 point each). Discrimination was assessed using area under the receiver operating characteristic curve (AUC). The H2-FAILS score was compared with the American Society of Anesthesiologists Physical Status Classification (ASA Class), the 5-item modified Frailty Index (mFI-5), and the New England Spinal Metastasis Score (NESMS). Internal validation was performed using bootstrapping. Alpha = 0.05. RESULTS: Predicted 30-day mortality was 1.8% for an H2-FAILS score of 0 and 78% for a score of 6. AUC of the H2-FAILS was 0.77 (95% confidence interval: 0.72-0.81), which was higher than the mFI-5 (AUC 0.58, p < 0.001), ASA Class (AUC 0.63, p < 0.001), and NESMS (AUC 0.70, p = 0.004). Internal validation showed an optimism-corrected AUC of 0.76. CONCLUSIONS: The H2-FAILS score accurately predicts 30-day mortality after surgery for spinal metastasis. LEVEL OF EVIDENCE: Prognostic level III.

Uniportal, Transforaminal Endoscopic Thoracic Discectomy: Review and Technical Note.

Symptomatic thoracic disc herniations are a rare entity and their operative treatment is challenging. Open approaches, despite providing excellent access, are associated with significant access morbidity from thoracotomy, and this has led to an increased interest in minimally invasive techniques such as mini-open approach, thoracoscopic approach and the endoscopic approach. In this article, we describe the technical points for performing a transforaminal endoscopic thoracic discectomy and summarize its literature outcomes in the context of other minimally invasive approaches.

A Modified Endoscopic Access for Lumbar Foraminal Pathologies; Posterolateral "Intertransverse" Endoscopic Approach to Minimize Postoperative Dysesthesia Following Transforaminal Approach.

OBJECTIVE: To present an innovative, modified endoscopic approach for foraminal/extraforaminal pathologies, to reduce postoperative dysesthesia (POD) following the conventional transforaminal endoscopic approach (the access angle more than 45° from the midline), since POD is one of the major documented disadvantages that may compromise patient satisfaction. METHODS: We introduce a modified posterolateral technique, termed the intertransverse approach, utilizing a steeper access angle less than 25° through the intertransversarii muscle and the intertransverse space with expanding Kambin triangle via lateral facetectomy/foraminoplasty, to reduce dorsal root ganglion/exiting nerve root irritation under direct visualization and lower the incidence of POD. Consecutive patients undergoing endoscopic spine surgery via the intertransverse approach for foraminal and/or extraforaminal disc herniations or bony stenosis were retrospectively reviewed. Clinical outcomes were reviewed with the primary outcome being POD. RESULTS: Twenty-two patients were included in the review. Patients showed significantly improved clinical outcomes (visual analogue scale leg and back pain and Oswestry Disability Index) postoperatively. There was a low rate of dorsal root ganglion (DRG)-related POD (9.1%, 2 of 22) that was minimal and resolved soon. CONCLUSION: The inter-transverse endoscopic approach is feasible for lumbosacral foraminal and extraforaminal decompression with significantly improved clinical outcomes and the added advantage of a low rate of DRG-related POD compared to traditionally reported rates in the literature for the conventional transforaminal approach.

Disparities in Elective Spine Surgery for Medicaid Beneficiaries: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVES: We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF). METHODS: Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes. RESULTS: A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories. CONCLUSIONS: In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.

Preoperative patient activation predicts minimum clinically important difference for PROMIS pain and physical function in patients undergoing elective spine surgery.

BACKGROUND CONTEXT: Patient activation is a patient's willingness to take independent actions to manage their own health care. PURPOSE: The goal of this study is to determine whether preoperative patient activation measure (PAM) predicts minimum clinically important difference (MCID) for Patient-Reported Outcomes Measurement Information System (PROMIS) pain, physical function, depression, and anxiety for patients undergoing elective spine surgery. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: A single-institution, academic database of patients undergoing elective spine surgery. OUTCOME MEASURE: MCID at 1-year follow-up for PROMIS pain, physical function, depression and anxiety. METHODS: We retrospectively reviewed a single-institution, academic database of patients undergoing elective spine surgery. Preoperative patient activation was evaluated using the PAM-13 survey, which was used to stratify patients into four activation stages. Primary outcome variable was achieving MCID at 1-year follow-up for PROMIS pain and physical function. Multivariable logistic regression analysis was used to determine impact of patient activation on PROMIS pain and the physical function. RESULTS: Of the 430 patients, 220 (51%) were female with a mean age of 58.2±16.8. Preoperatively, 34 (8%) were in activation stage 1, 45 (10%) in stage 2, 98 (23%) in stage 3, and 253 (59%) in stage 4. At 1-year follow up, 248 (58%) achieved MCID for PROMIS physical function, 256 (60%) achieved MCID for PROMIS pain, 151 (35.28%) achieved MCID for PROMIS depression, and 197 (46%) achieved MCID for PROMIS anxiety. For PROMIS physical function, when compared to patients at stage 1 activation, patients at stage 2 (aOR:3.49, 95% CI:1.27, 9.59), stage 3 (aOR:3.54, 95% CI:1.40, 8.98) and stage 4 (aOR:7.88, 95% CI:3.29, 18.9) were more likely to achieve MCID. For PROMIS pain, when compared against patients at stage 1, patients at stage 3 (aOR:2.82, 95% CI:1.18, 6.76) and stage 4 (aOR:5.44, 95% CI:2.41, 12.3) were more likely to achieve MCID. For PROMIS depression, when compared against patients at stage 1, patients at stage 4 were more likely to achieve MCID (Adjusted Odds Ratio (aOR):2.59, 95% CI:1.08-6.19). For PROMIS anxiety, when compared against patients at stage 1, stage 3 (Adjusted Odds Ratio (aOR):3.21, 95% CI:1.20-8.57), and stage 4 (aOR:5.56, 95% CI:2.20-14.01) were more likely to achieve MCID. CONCLUSION: Patients at higher stages of activation were more likely to achieve MCID for PROMIS pain, physical function, depression, and anxiety at 1-year follow-up. Routine preoperative assessment of patient activation may help identify patients at risk of poor outcomes.

Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review.

BACKGROUND: Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI. OBJECTIVE: To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS: A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis. RESULTS: After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review. CONCLUSIONS: Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.

Risk of Malignant Transformation of Giant Cell Tumors of Bone Is 8 Times Lower with Megavoltage vs. Orthovoltage Radiation Therapy.

Background: The first-line treatment for most giant cell tumors (GCTs) of bone is surgical; radiotherapy (RT) is reserved for inoperable or refractory cases. While RT techniques have undergone a dramatic change over the past few decades, with the higher energy megavoltage RT replacing orthovoltage RT, concerns for high rates of malignant transformation following RT have limited its use. Evidence suggests a lower incidence of secondary malignancy after treatment with megavoltage compared with orthovoltage RT, but this has not been studied in GCTs. Our main purpose was to compare the incidence of malignant transformation of GCTB between patients treated with orthovoltage vs. megavoltage RT. Methods: A literature review was performed to identify studies reporting GCTBs treated with RT from 01/1900 through 12/2019. Studies that did not report RT modality or separate orthovoltage and megavoltage results were excluded. Included in the analysis were 6 patients from our institution. Primary outcome was the incidence of malignant transformation; secondary outcomes were time to transformation and incidence of local recurrence. Fisher's exact tests and independent sample t-tests were used, and significance was set at p < 0.05. Results: Twenty-two studies were included, which reported on 168 GCTBs treated with orthovoltage and 393 treated with megavoltage RT. Transformation incidence was 14% (n = 24) for orthovoltage and 1.8% (n = 7) for megavoltage RT, an 8-fold difference (odds ratio (OR) 9.1, 95% confidence interval (CI) 3.9-22, p < 0.001). Mean time to transformation was 8.7 years for orthovoltage and 11.2 years for megavoltage RT (p=0.28). Incidence of local recurrence was 38% (63/167) for orthovoltage and 17% (66/393) for megavoltage RT (OR 3.3, 95% CI 2.0-4.6, p < 0.001). Conclusions: The risk of developing a malignancy after RT of GCTB is 8 times lower with megavoltage than with orthovoltage. Malignant transformation with megavoltage, while not zero, is lower than that in historical series. Use of modern RT techniques in inoperable or refractory GCTB may be appropriate.

Increased Severity of Anemia Is Associated with Postoperative Complications following a Adult Spinal Deformity Surgery.

BACKGROUND: Anemia is a modifiable risk factor for postoperative complications following surgery. This study aimed to determine the impact of preoperative anemia severity on 30-day postoperative complications following adult spinal deformity (ASD) surgery. METHODS: Adults undergoing spinal fusion for ASD from 2012 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were substratified into 3 cohorts-non-anemia, mild anemia, and moderate-to-severe anemia-based on World Health Organization definitions. We assessed 30-day wound, cardiac, pulmonary, renal, and thromboembolic complications, as well as sepsis, mortality, postoperative transfusions, extended length of stay, and reoperation. Bivariate analyses and multivariable logistic regression were performed. RESULTS: Of 2173 patients, 1694 (78%) had no anemia, 307 (14%) had mild anemia, and 172 (8%) had moderate or severe anemia. Following adjustments, patients with mild anemia were more likely to have postoperative blood transfusions (odds ratio [OR] 1.80, P < 0.001) and extended length of stay (OR 1.43, P < 0.001). Patients with moderate-to-severe anemia were at increased risk of organ space infection (OR 3.27, P = 0.028), death (OR 13.15, P = 0.001), postoperative blood transfusion (OR 2.81, P < 0.001), and extended length of stay (OR 3.02, P < 0.001). CONCLUSIONS: We found a stepwise and approximately two-fold increase in the odds ratio of postoperative transfusion and length of stay with increasing severity of anemia. Moderate-to-severe anemia was associated with increased odds of death and organ space infection. Patients with moderate-to-severe anemia should be medically optimized before ASD surgery.

AM-PAC mobility scores predict non-home discharge following adult spinal deformity surgery.

BACKGROUND CONTEXT: Adult spinal deformity (ASD) surgery requires an extended recovery period and often non-routine discharge. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Inpatient Short Form (6-Clicks) is a prediction tool, validated for other orthopedic procedures, to assess a patient's ability to mobilize after surgery. PURPOSE: To assess the thresholds of AM-PAC scores that determine non-home discharge disposition in patients who have undergone ASD surgery. STUDY DESIGN: Retrospective review PATIENT SAMPLE: Ninety consecutive ASD patients with ≥5 levels fused who underwent surgery from 2015 to 2018, with postoperative AM-PAC scores measured before discharge, were included. OUTCOME MEASURES: Non-home discharge disposition METHODS: Patients with routine home discharge were compared to those with non-home discharge. Bivariate analysis was first conducted to compare these groups by preoperative demographics, comorbidities, radiographic alignment, surgical characteristics, HRQOLs, and AM-PAC measurements. Threshold linear regression with Bayesian information criteria was utilized to identify the optimal cutoffs for AM-PAC scores associated with increased likelihood of non-home discharge. Finally, multivariable analysis controlling for age, sex, comorbidities, levels fused, perioperative complication, and home support was conducted to assess each threshold. RESULTS: Thirty-six (40%) of 90 patients analyzed had non-home discharge. On bivariate analysis, first AM-PAC score (13.5 vs. 17), last AM-PAC score (17 vs. 20), and AM-PAC change per day (+.387 vs. +1) were all significantly associated with non-home discharge. Threshold regression identified that cutoffs of ≤15 for first AM-PAC score, <17 for last AM-PAC score, and <+0.625 for daily AM-PAC change were associated with non-home discharge. On multivariable analysis, first AM-PAC score ≤15 (odds ratio [OR] 11.28; confidence interval [CI] 2.96-42.99; p<.001), last AM-PAC score <17 (OR 33.57; CI 5.85-192.82; p<.001), and AM-PAC change per day <+0.625 (OR 6.24; CI 2.01-19.43; p<.001) were all associated with increased odds of non-home discharge. CONCLUSIONS: First AM-PAC score of 15 or less can help predict non-home discharge. A goal of daily AM-PAC increases of 0.625 points toward a final AM-PAC score of 17 can aid in achieving home discharge. The early AM-PAC mobility threshold of ≤15 may help prepare for non-home discharge, while AM-PAC daily changes per day <0.625 and final AM-PAC <17 may provide goals for mobility improvement during the early postoperative period in order to prevent non-home discharge.

Emergency Department Visits After Outpatient Spine Surgery.

STUDY DESIGN: A retrospective study. OBJECTIVE: This study sought to characterize the incidence and timing of postoperative emergency department (ED) visits after common outpatient spinal surgeries performed at ambulatory surgery centers (ASCs) and at hospital outpatient departments (HOPDs). SUMMARY OF BACKGROUND DATA: Outpatient spine surgery has markedly grown in popularity over the past decade. The incidence of ED visits after outpatient spine surgery is not well established. METHODS: This study was a retrospective analysis of a large commercial claims insurance database of patients 65 years old and below. Patients who underwent single-level anterior cervical discectomy and fusion, laminectomy, and microdiscectomy were identified. Incidence, timing, and diagnoses associated with ED visits within the postoperative global period (90 d) after surgery were assessed. RESULTS: In total, 202,202 patients received outpatient spine surgery (19.1% in ASC vs. 80.9% in HOPD). Collectively, there were 22,198 ED visits during the 90-day postoperative period. Approximately 9.0% of patients had at least 1 ED visit, and the incidence varied by procedure: anterior cervical discectomy and fusion 9.9%, laminectomy 9.5%, and microdiscectomy 8.5% ( P <0.0001). After adjusting for age, sex, and comorbidity index, the odds of at least 1 ED visit were higher among patients who received surgery at HOPD versus ASC for all 3 procedures. The majority (56.1%) ED visits occurred during the first month postoperatively; 30.8% (n=6841) occurred within the first week postoperatively, and 10.7% (n=2370) occurred on the same day as the surgery. Postoperative pain was the most common reason for ED visits. CONCLUSIONS: Among commercially insured patients who received outpatient spine surgery, the incidence of ED visits during the 90-day postoperative period was ~9%. Our results indicate opportunities for improved postoperative care planning after outpatient spinal surgery.

Adoption of awake spine surgery - trends from a national registry over 14 years.

BACKGROUND CONTEXT: Awake spine surgery is growing in popularity, and may facilitate earlier postoperative recovery, reduced cost, and fewer complications than spine surgery conducted under general anesthesia (GA). However, trends in the adoption of awake (ie, non-GA) spine surgery have not been previously studied. PURPOSE: To investigate temporal trends in non-GA spine surgery utilization and outcomes in the United States. STUDY DESIGN/SETTING: A retrospective observational study. PATIENT SAMPLE: Patients undergoing cervical or lumbar decompression or/and fusion from the American College of Surgeons National Surgical Quality Improvement Program database records dated 2005-2019. OUTCOME MEASURES: The primary outcome was the adoption trends of awake cervical and lumbar spine operations from 2005 to 2019. The secondary outcomes included the outcomes trends of 30-day complications, readmission rates, and length of stay in cervical and lumbar spine operations from 2005 to 2019. METHODS: Patients were stratified into two groups: GA and non-GA (regional, epidural, spinal, monitored anesthesia care/intravenous sedation). Pearson chi-square or Fisher exact test and independent-sample t test were used to compare demographics between groups. Jonckheere-Terpstra test was used to determine whether trends and outcomes of non-GA operations from 2005 to 2019 were statistically significant. No non-GA spine operations were reported in the database from 2005 to 2006. RESULTS: We included 301,521 patients who underwent cervical or lumbar spine operations from 2005 to 2019. GA was used in 294,903 (97.8%) operations; 6,618 (2.2%) operations were non-GA. Patients in the non-GA cohort were more likely to be younger (50.1 vs 57.2 years; p<.001), less likely to have American Society of Anesthesiologists classification ≥3 (39.7% vs 48.3%; p<.001), and to have lower BMI (27.8 vs 31.5 kg/m2; p<.001), outpatient admission status (10.8% vs 4.0%; p<.001), and fewer bleeding disorders (0.0% vs 1.2%; p<.001). The proportion of non-GA spine operations increased from nearly 0% in 2005 to 2.1% in 2019. The increase in non-GA operations was statistically significant in cervical (0.0%-1.1%) and lumbar (0.0%-2.9%) operations. For non-GA lumbar operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (19.1%-5.4%, p<.05; 5.9%-2.8%, p<.05; 30.9 hours-24.9 hours, p<.05, respectively). Similarly, for non-GA cervical operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (20.1%-6.1%, p<.05; 6.7%-3.7%, p<.05; 27.0-20.0 hours p<.05, respectively). CONCLUSIONS: Our trends analysis revealed increasing utilization and improved outcomes of non-GA spine surgery from 2005 to 2019; however, the proportion of non-GA spine operations remains small. Future research should investigate the barriers to adoption of non-GA spine surgery.

Applying to Fellowship During a Pandemic: Lessons Learned From the 2020-2021 Orthopaedic Spine Fellowship Application Cycle.

Introduction The COVID-19 pandemic resulted in a transition to a virtual format for all medical residency and fellowship application processes. Previous studies have discussed the successful implementation of virtual interviews, but a deep analysis of how the application process has changed for orthopedic surgery fellowship programs during the pandemic is lacking. The purpose of this study was to assess how COVID-19 impacted the orthopedic spine fellowship application and selection process. Methods A web-based survey was administered to the program directors of all 75 U.S. orthopedic surgery spine fellowship programs, which often can accept both orthopedic surgery and neurosurgery trained graduates. Questions focused on the changes from the 2019-2020 application cycle to the 2020-2021 cycle. We collected data on connecting with potential applicants, the general application process, and interviews offered by programs. Univariate analyses were used to compare data from the 2020-2021 cycle with the prior 2019-2020 cycle. Results Twenty-five of the 75 contacted program directors responded to our survey (33% response rate). The percentage of programs that offered virtual open houses/meet-and-greets increased from 20% in 2019-2020 to 52% in 2020-2021 (p=0.018). Social media use was unchanged (0.0% vs. 4.0%, p>0.05). Compared to the prior year, the number of interviews offered by programs increased by 1.5 (32.7 vs. 21.9 interviews, p=0.024). There were no significant differences in the numbers of applications received by programs, interview dates available, or separate interviews each candidate completed during an interview day (p>0.05 for all). The in-person interview was the most important factor in 2019-2020 for selecting applicants, whereas the virtual interview, letters of recommendation (LOR), and research were equally ranked as the most important factors in 2020-2021. Regarding interviews, 50% of respondents would "likely" consider virtual interviews as an option in addition to in-person interviews in the future, but most (55%) answered that it was "unlikely" that virtual interviews would entirely replace in-person interviews. Conclusion Spine fellowship programs were more likely to use virtual social events to recruit potential applicants, send out more interview invitations, and equally consider LOR and research with interview performance during an entirely virtual application cycle. Half of the program directors would consider offering virtual interviews as an option for future application cycles, which may help reduce costs associated with the process.

Factors associated with RVU generation in common sports medicine procedures.

INTRODUCTION: Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based. METHODS: We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour. RESULTS: Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time. CONCLUSION: wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.

Concomitant Cox-Maze IV and Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: In patients with hypertrophic obstructive cardiomyopathy, atrial fibrillation is associated with heart failure and increased late mortality. However, the role of surgical ablation in these patients is not well defined. The aim of this study was to evaluate the efficacy of the concomitant Cox-Maze IV procedure in patients undergoing septal myectomy for hypertrophic obstructive cardiomyopathy. METHODS: Between 2005 and 2019, 347 patients who underwent septal myectomy at a single institution (Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, MO) were retrospectively reviewed. For patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation who underwent a concomitant Cox-Maze IV procedure, freedom from atrial tachyarrhythmias (ATAs) on or off antiarrhythmic drugs (AADs) was evaluated annually. Predictors of ATA recurrence were identified using Fine-Gray regression, with death as a competing risk. RESULTS: A total of 42 patients underwent concomitant septal myectomy and Cox-Maze IV procedures. The majority of patients, 69% (29 of 42), had paroxysmal atrial fibrillation with a 2.5-year median duration. Operative mortality was 7% (3 of 42). New York Heart Association functional class was reduced after surgery (P < .01). Rates of freedom from recurrent ATAs at 1- and 5-year intervals were 93% (27 of 29) and 100% (14 of 14), respectively. Rates of freedom from ATAs and AADs were 83% (24 of 29) and 100% (14 of 14) at the same time points, respectively. Increased left atrial diameter predicted first ATA recurrence (P < .01). Cerebrovascular accident risk was lower in patients with atrial fibrillation who underwent concomitant Cox-Maze IV and septal myectomy relative to myectomy only (P = .02). CONCLUSIONS: Late freedom from ATAs on or off AADs was excellent after Cox-Maze IV and septal myectomy. Although there was a higher than expected rate of perioperative complications, the study results suggest that concomitant surgical ablation should be considered in selected patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation.

A guide to resecting tumors of the sciatic notch.

Sciatic notch tumors are rare and have numerous etiologies. Tumor presentation varies widely and no uniform recommendations exist for approaching resection. Most studies on the topic have been small case series, with the approach dictated by surgeon experience and comfort. We provide an overview of surgical approaches for resecting sciatic notch tumors reported in the literature, as well as a conceptual framework for application of these approaches based on standard oncologic principles. The advantages and disadvantages of each approach are described on the basis of anatomic location of the tumor. For tumors that span the notch with intra- and extra-pelvic extension, notchplasty is a novel technique that provides superior visualization and access for en-bloc excision.

Minimally Invasive Versus Full-Sternotomy Septal Myectomy for Hypertrophic Cardiomyopathy.

OBJECTIVE: Septal myectomy remains the criterion standard for the treatment of patients with hypertrophic obstructive cardiomyopathy refractory to medical therapy. There have been few reports of minimally invasive approaches. This study compared a minimally invasive septal myectomy performed at our institution with the traditional full-sternotomy approach. METHODS: Patients receiving a stand-alone septal myectomy were retrospectively reviewed from November 1999 to December 2016 (N = 120). Patients were stratified by surgical approach: traditional full sternotomy (n = 34) and ministernotomy (n = 86). Preoperative and perioperative variables were compared as well as follow-up symptomatic and echocardiographic outcomes. RESULTS: Both groups had a significant decrease in New York Heart Association class heart failure symptoms (P < 0.001). At a mean ± SD follow-up time of 2.0 ± 3.4 years, postoperative New York Heart Association class distribution was similar between ministernotomy and full sternotomy (P = 0.684). Follow-up resting left ventricular outflow tract gradient was also similar between ministernotomy and full sternotomy (11 mm Hg ± 15 vs 9 mm Hg ± 13, P = 0.381). Perioperatively, ministernotomy was not significantly different from full sternotomy in median cardiopulmonary bypass time (81 minutes vs 78 minutes, P = 0.101) but had a slightly longer median cross-clamp time (39 minutes vs 35 minutes, P = 0.017). Major complications were similar in the two groups. There was one 30-day mortality in the full-sternotomy group, but no in-hospital deaths. CONCLUSIONS: Septal myectomy performed using a minimally invasive approach has similar outcomes to the criterion standard operation done through a full sternotomy. It represents a feasible option for patients with hypertrophic obstructive cardiomyopathy unresponsive to medications.