The odontoid-CSVL distance in a global population of asymptomatic volunteers: normative values and implications for spinal coronal alignment.

PURPOSE: In a population of asymptomatic volunteers across 5 countries, we sought to: (a) establish normative values of the Odontoid-Central Sacral Vertical Line (OD-CSVL) across patient factors, and (b) assess correlations of OD-CSVL with other radiographic parameters. METHODS: A prospective, cross-sectional study of asymptomatic adult volunteers, ages 18-80 years, were enrolled across 5 countries (France, Japan, Singapore, Tunisia, United States) forming the Multi-Ethnic Alignment Normative Study (MEANS) cohort. Included volunteers had no known spinal disorder(s), no significant neck/back pain (VAS ≤ 2; ODI ≤ 20), and no significant scoliosis (Cobb ≤ 20°). Radiographic measurements included commonly used coronal alignment parameters (mm) and angles (°). OD-CSVL was defined as the difference between the odontoid plumb line (line from the tip of the odontoid vertically down) and the CSVL (vertical line from the center of the sacrum). Chi-square, student's t tests, Kruskal-Wallis, Wilcoxon rank-sum, linear regression, and Pearson's correlation were used with significance at p < 0.05. RESULTS: 467 volunteers were included with normative OD-CSVL values by age decade, gender, BMI, and country. Mean ± SD OD-CSVL was 8.3 mm ± 6.5 mm and 31 (6.6%) volunteers were almost perfectly aligned (OD-CSVL < 1 mm). A linear relationship was seen between OD-CSVL with both age (p < 0.001) and BMI (p = 0.015). Significant variation was seen between OD-CSVL and 5 different ethnicities (p = 0.004). OD-CSVL correlated best with other coronal radiographic parameters, C7-CSVL (r = 0.743, p < 0.001), OD-knee (r = 0.230, p < 0.001), CAM-knee (r = 0.612, p < 0.001), and regional TL cobb angle (r = 0.4214, p = 0.005). CONCLUSION: Among asymptomatic volunteers, increased OD-CSVL was significantly associated with increased age, increased BMI, and ethnicity, but not gender. OD-CSVL correlated strongest with C7-CSVL, TL cobb angle, OD-knee, and CAM-knee. OD-CSVL. These results support further study of OD-CSVL in symptomatic adult spine deformity patients.

Evaluation of facet joints and segmental motion in patients with different grades of L5/S1 intervertebral disc degeneration: a kinematic MRI study.

PURPOSE: This study aimed to evaluate facet joint parameters and osteoarthritis grades, and segmental angular and translational motions among different grades of L5/S1 intervertebral disc (IVD) degeneration. METHODS: This retrospective study analysed kinematic magnetic resonance imaging (kMRI) images of the lumbar spine of 214 patients with low back pain. Degenerations of the L5/S1 IVDs and facet joints osteoarthritis were assessed using the Pfirrmann and Pathria grading scales, respectively. Facet joint parameters included facet joint angle and facet joint space width. Angular and translation segmental motions were measured using MRI Analyzer software. RESULTS: The mean age of the studied patients was 44.1 ± 13.9 years. Patients with L5/S1 disc degeneration were associated with higher odds of facet joint osteoarthritis (odds ratio = 2.28, 95% confidence interval = 1.23-4.23, P = 0.008). There was a positive correlation between L5/S1 disc degeneration grade and the facet joint grade (r = 0.365, P > 0.001). Grade IV facet joint osteoarthritis did not appear in grades I or II disc degeneration (P > 0.001). The average facet joint width decreased significantly with increasing Pfirrmann grading (P = 0.017). The difference in facet joint angle between groups was not statistically significant (P = 0.532). The differences in the angular and translational motions were not statistically significant (P = 0.530, and 0.510, respectively). CONCLUSION: A positive correlation exists between L5/S1 disc degeneration and facet joint osteoarthritis grades. The facet joint space width decreases significantly with increasing grade of disc degeneration.

Predictors of 30- and 90-day readmission following craniotomy for malignant brain tumors: analysis of nationwide data.

Hospital readmissions are a major contributor to increased health care costs and are associated with worse patient outcomes after neurosurgery. We used the newly released Nationwide Readmissions Database (NRD) to describe the association between patient, hospital and payer factors with 30- and 90-day readmission following craniotomy for malignant brain tumor. All adult inpatients undergoing craniotomy for primary and secondary malignant brain tumors in the NRD from 2013 to 2014 were included. We identified all cause readmissions within 30- and 90-days following craniotomy for tumor, excluding scheduled chemotherapeutic procedures. We used univariate and multivariate models to identify patient, hospital and administrative factors associated with readmission. We identified 27,717 admissions for brain tumor craniotomy in 2013-2014, with 3343 (13.2%) 30-day and 5271 (25.7%) 90-day readmissions. In multivariate analysis, patients with Medicaid and Medicare were more likely to be readmitted at 30- and 90-days compared to privately insured patients. Patients with two or more comorbidities were more likely to be readmitted at 30- and 90-days, and patients discharged to skilled nursing facilities or home health care were associated with increased 90-day readmission rates. Finally, hospital procedural volume above the 75th percentile was associated with decreased 90-day readmission rates. Patients treated at high volume hospitals are less likely to be readmitted at 90-days. Insurance type, non-routine discharge and patient comorbidities are predictors of postoperative non-scheduled readmission. Further studies may elucidate potentially modifiable risk factors when attempting to improve outcomes and reduce cost associated with brain tumor surgery.

Frailty as a Predictor of Postoperative Morbidity and Mortality in Patients Aged 80 Years and Older Undergoing Instrumented Fusion.

BACKGROUND AND OBJECTIVES: Degenerative spine disease is a leading cause of disability, with increasing prevalence in the older patients. While age has been identified as an independent predictor of outcomes, its predictive value is limited for similar older patients. Here, we aimed to determine the most predictive frailty score of adverse events in patients aged 80 and older undergoing instrumented lumbar fusion. METHODS: We proceeded with a multisite (3 tertiary academic centers) retrospective review including patients undergoing instrumented fusion aged 80 and older from January 2010 to present. A composite end point encompassing 30-day return to operating room, readmission, and mortality was created. We estimated the area under the receiver operating characteristic curve for frailty scores (Modified Frailty Index-5 [MFI-5], Modified Frailty Index-11 [MFI-11], and Charlson Comorbidity Index [CCI]) in relation to that composite score. In addition, we estimated the association between each score and the composite end point by means of logistic regression. RESULTS: A total of 153 patients with an average age of 85 years at the time of surgery were included. We observed a 30-day readmission rate of 11.1%, reoperation of 3.9%, and mortality of 0.6%. The overall rate of the composite end point at 30 days was 25 (15.1%). The AUC for MFI-5 was 0.597 (0.501-0.693), for MFI-11 was 0.620 (0.518-0.723), and for CCI was 0.564 (0.453-0.675). The association between the scores and composite end point did not reach statistical significance for MFI-5 (odds ratio [OR] = 1.45 [0.98-2.15], P = .061) and CCI (OR = 1.13 [0.97-1.31], P = .113) but was statistically significant for MFI-11 (OR = 1.46 [1.07-2.00], P = .018). CONCLUSION: This is the largest study comparing frailty index scores in octogenarians undergoing instrumented lumbar fusion. Our findings suggest that while MFI-11 score correlated with adverse events, the predictive ability of existing scores remains limited, highlighting the need for better approaches to identify select patients at age extremes.

Is There a Difference in Screw Accuracy, Robot Time Per Screw, Robot Abandonment, and Radiation Exposure Between the Mazor X and the Renaissance? A Propensity-Matched Analysis of 1179 Robot-Assisted Screws.

STUDY DESIGN: Prospective single-cohort analysis. OBJECTIVES: To compare the outcomes/complications of 2 robotic systems for spine surgery. METHODS: Adult patients (≥18-years-old) who underwent robot-assisted spine surgery from 2016-2019 were assessed. A propensity score matching (PSM) algorithm was used to match Mazor X to Renaissance cases. Preoperative CT scan for planning and an intraoperative O-arm for screw evaluation were preformed. Outcomes included screw accuracy, robot time/screw, robot abandonment, and radiation. Screw accuracy was measured using Vitrea Core software by 2 orthopedic surgeons. Screw breach was measured according to the Gertzbein/Robbins classification. RESULTS: After PSA, a total of 65 patients (Renaissance: 22 vs. X: 43) were included. Patient/operative factors were similar between robot systems (P > .05). The pedicle screw accuracy was similar between robots (Renaissance: 1.1%% vs. X: 1.3%, P = .786); however, the S2AI screw breach rate was significantly lower for the X (Renaissance: 9.5% vs. X: 1.2%, P = .025). Robot time per screw was not statistically different (Renaissance: 4.6 minutes vs. X: 3.9 minutes, P = .246). The X was more reliable with an abandonment rate of 2.3% vs. Renaissance:22.7%, P = .007. Radiation exposure were not different between robot systems. Non-robot related complications including dural tear, loss of motor/sensory function, and blood transfusion were similar between robot systems. CONCLUSION: This is the first comparative analyses of screw accuracy, robot time/screw, robot abandonment, and radiation exposure between the Mazor X and Renaissance systems. There are substantial improvements in the X robot, particularly in the perioperative planning processes, which likely contribute to the X's superiority in S2AI screw accuracy by nearly 8-fold and robot reliability by nearly 10-fold.

Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

OBJECTIVE: Evaluate clinical improvement as measured by patient-reported outcomes (PROs) during the 1 to 2-year interval. STUDY DESIGN: Retrospective Cohort. METHODS: A single-institution registry of ASD patients undergoing surgery was queried for patients with ≥6 level fusions. Demographics and radiographic variables were collected. PROs collected were the ODI and SRS-22r scores at: preoperative, 1-year and 2-years. Outcome measures of clinical improvement during the 1-2 year time interval were: 1) group medians, 2) percent minimum clinically important difference (MCID), and 3) percent minimal symptom scale (MSS)(ODI < 20 or SRS-pain + function >8). Wilcoxon rank-sum tests, chi-squared tests, Kruskal-Wallis tests, and logistic regression were performed. RESULTS: 157 patients undergoing ASD surgery with minimum of 1-year follow-up were included. Mean age was 53.2 and mean instrumented levels was 13.1. Preoperative alignment was: Neutral Alignment (NA) 49%, Coronal Malalignment (CM) 17%, Sagittal Malalignment (SM 17%), and Combined Coronal/Sagittal Malalignment (CCSM) 18%. Preoperative to 1-year, and preoperative to 2-years, all ODI/SRS-22r significantly improved (P < .001). In all patients, the only significant improvement in PROs between 1-and 2-year postoperative were those reaching ODI MCID (69% 1-year vs. 84% 2-years; P < .001). Subgroup analysis: ≥55 years had an improved median ODI (18 vs. 8; P = .047) and an improved percent achieving ODI MCID (73% vs. 84%, P = .048). CCSM patients experienced significant improvement in SRS-appearance score (75% vs. 100%; P = .050), along with those with severe preoperative SM >7.5 cm (73% vs. 100%; P = .032). CONCLUSIONS: Most ASD patients experience the majority of PRO improvement by 1-year postoperative. However, subsets of patients that may continue to improve up to 2-years postoperative include patients ≥55 years, combined coronal/sagittal malalignment, and those with severe sagittal malalignment ≥7.5 cm.

Postoperative coronal malalignment after adult spinal deformity surgery: incidence, risk factors, and impact on 2-year outcomes.

PURPOSE: To evaluate the incidence, risk factors, and patient-reported outcomes (PROs) of adult spinal deformity (ASD) patients with postoperative coronal malalignment. METHODS: A single-institution, retrospective cohort study of ASD patients undergoing ≥ 6 level fusions from 2015 to 2019 was undertaken. The primary outcome was postoperative coronal malalignment, defined as C7-coronal vertical axis (CVA) > 3 cm. Secondary outcomes included: complications, readmissions, reoperations, and 2-year PROs. RESULTS: A total of 243 ASD patients undergoing spinal surgery had preoperative and immediate postoperative measurements, and 174 patients (72%) had 2-year follow-up. Mean age was 49.3 ± 18.3yrs and mean instrumented levels was 13.5 ± 3.9. Mean preoperative CVA was 2.9 ± 2.7 cm, and 90 (37%) had preoperative coronal malalignment. Postoperative coronal malalignment occurred in 43 (18%) patients. Significant risk factors for postoperative coronal malalignment were: preoperative CVA (OR 1.21, p = 0.001), preoperative SVA (OR 1.05, p = 0.046), pelvic obliquity (OR 1.21; p = 0.008), Qiu B vs. A (OR 4.17; p = 0.003), Qiu C vs. A (OR 7.39; p < 0.001), lumbosacral fractional (LSF) curve (OR 2.31; p = 0.021), max Cobb angle concavity opposite the CVA (OR 2.10; p = 0.033), and operative time (OR 1.16; p = 0.045). Postoperative coronal malalignment patients were more likely to sustain a major complication (31% vs. 14%; p = 0.01), yet no differences were seen in readmissions (p = 0.72) or reoperations (p = 0.98). No significant differences were seen in 2-year PROs (p > 0.05). CONCLUSIONS: Postoperative coronal malalignment occurred in 18% of ASD patients and was most associated with preoperative CVA/SVA, pelvic obliquity, Qiu B/C curves, LSF curve concavity to the same side as the CVA, and maximum Cobb angle concavity opposite side of the CVA. Postoperative coronal malalignment was significantly associated with increased complications but not readmission, reoperation, or 2-year PROs.

Do Grip Strength Dynamometer Readings Improve After Cervical Spine Surgery?

STUDY DESIGN: Retrospective, cohort study. OBJECTIVES: Hand function can be difficult to objectively assess perioperatively. In patients undergoing cervical spine surgery by a single-surgeon, we sought to: (1) use a hand dynamometer to report pre/postoperative grip strength, (2) distinguish grip strength changes in patients with radiculopathy-only vs myelopathy, and (3) assess predictors of grip strength improvement. METHODS: Demographic and operative data were collected for patients who underwent surgery 2015-2018. Hand dynamometer readings were pre/postoperatively at three follow-up time periods (0-3 m, 3-6 m, 6-12 m). RESULTS: 262 patients (mean age of 59 ± 14 years; 37% female) underwent the following operations: ACDF (80%), corpectomy (25%), laminoplasty (19%), and posterior cervical fusion (7%), with 81 (31%) patients undergoing multiple operations in a single anesthetic setting. Radiculopathy-only was seen in 128 (49%) patients, and myelopathy was seen 134 (51%) patients. 110 (42%) had improved grip strength by ≥10-lbs, including 69/128 (54%) in the radiculopathy-only group, and 41/134 (31%) in the myelopathy group. Those most likely to improve grip strength were patients undergoing ACDF (OR 2.53, P = .005). Patients less likely to improve grip strength were older (OR = .97, P = .003) and underwent laminoplasty (OR = .44, 95% CI .23, .85, P = .014). Patients undergoing surgery at the C2/3-C5/6 levels and C6/7-T1/2 levels both experienced improvement during the 0-3-month time range (C2-5: P = .035, C6-T2: P = .015), but only lower cervical patients experienced improvement in the 3-6-month interval (P = .030). CONCLUSIONS: Grip strength significantly improved in 42% of patients. Patients with radiculopathy were more likely to improve than those with myelopathy. Patients undergoing surgery from the C2/3-C5/6 levels and the C6/7-T1/2 levels both significantly improved grip strength at 3-month postoperatively.

Management of Anticoagulation/Antiplatelet Medication and Venous Thromboembolism Prophylaxis in Elective Spine Surgery: Concise Clinical Recommendations Based on a Modified Delphi Process.

STUDY DESIGN: Delphi method. OBJECTIVE: To gain consensus on the following questions: (1) When should anticoagulation/antiplatelet (AC/AP) medication be stopped before elective spine surgery?; (2) When should AC/AP medication be restarted after elective spine surgery?; (3) When, how, and in whom should venous thromboembolism (VTE) chemoprophylaxis be started after elective spinal surgery? SUMMARY OF BACKGROUND DATA: VTE can lead to significant morbidity after adult spine surgery, yet postoperative VTE prophylaxis practices vary considerably. The management of preoperative AC/AP medication is similarly heterogeneous. MATERIALS AND METHODS: Delphi method of consensus development consisting of three rounds (January 26, 2021, to June 21, 2021). RESULTS: Twenty-one spine surgeons were invited, and 20 surgeons completed all rounds of questioning. Consensus (>70% agreement) was achieved in 26/27 items. Group consensus stated that preoperative Direct Oral Anticoagulants should be stopped two days before surgery, warfarin stopped five days before surgery, and all remaining AC/AP medication and aspirin should be stopped seven days before surgery. For restarting AC/AP medication postoperatively, consensus was achieved for low-risk/medium-risk/high-risk patients in 5/5 risk factors (VTE history/cardiac/ambulation status/anterior approach/operation). The low/medium/high thresholds were POD7/POD5/POD2, respectively. For VTE chemoprophylaxis, consensus was achieved for low-risk/medium-risk/high-risk patients in 12/13 risk factors (age/BMI/VTE history/cardiac/cancer/hormone therapy/operation/anterior approach/staged separate days/staged same days/operative time/transfusion). The one area that did not gain consensus was same-day staged surgery. The low-threshold/medium-threshold/high-threshold ranges were postoperative day 5 (POD5) or none/POD3-4/POD1-2, respectively. Additional VTE chemoprophylaxis considerations that gained consensus were POD1 defined as the morning after surgery regardless of operating finishing time, enoxaparin as the medication of choice, and standardized, rather than weight-based, dose given once per day. CONCLUSIONS: In the first known Delphi study to address anticoagulation/antiplatelet recommendations for elective spine surgery (preoperatively and postoperatively); our Delphi consensus recommendations from 20 spine surgeons achieved consensus on 26/27 items. These results will potentially help standardize the management of preoperative AC/AP medication and VTE chemoprophylaxis after adult elective spine surgery.

Bone flap perfusion assessment using near-infrared fluorescence imaging.

BACKGROUND: Microsurgical vascularized bone flaps are a versatile technique for reconstructing large bone defects. However, the assessment of perfusion is challenging, because clinical examination is difficult intraoperatively and often not possible postoperatively. Therefore, it is important to develop techniques to assess the perfusion of vascularized bone flaps and potentially improve the surgical outcomes. Near-infrared (NIR) fluorescence imaging has previously been shown to provide real-time, intraoperative evaluation of vascular perfusion. The present pilot study investigated the ability of NIR imaging to assess the perfusion of vascularized bone flaps. METHODS: Vascularized bone flaps were created in female Yorkshire pigs using well-established models for porcine forelimb osteomyocutaneous flap allotransplantation (n = 8) and hindlimb fibula flaps (n = 8). Imaging of the bone flaps was performed during harvest using the FLARE intraoperative fluorescence imaging system after systemic injection of indocyanine green. Perfusion was also assessed using the standard of care by clinical observation and Doppler ultrasonography. NIR fluorescence perfusion assessment was confirmed by intermittent clamping of the vascular pedicle. RESULTS: NIR fluorescence imaging could identify bone perfusion at the cut end of the osteotomy site. When the vascular pedicle was clamped or ligated, NIR imaging demonstrated no fluorescence when injected with indocyanine green. With clamp removal, the osteotomy site emitted fluorescence, indicating bone perfusion. The results using fluorescence imaging showed 100% agreement with the clinical observation and Doppler findings. CONCLUSIONS: Vascularized bone transfers have become an important tool in reconstructive surgery; however, no established techniques are available to adequately assess perfusion. The results of our pilot study have indicated that NIR imaging can provide real-time, intraoperative assessment of bone perfusion.

Face transplant perfusion assessment using near-infrared fluorescence imaging.

BACKGROUND: Composite tissue allografts (CTAs) including partial face transplantation have been achieved clinically. However, risks of complications including tissue ischemia, rejection, and transplant failure are significant. Safe and effective techniques to assess perfusion are needed to decrease complications in composite tissue flaps. Near-infrared (NIR) fluorescence imaging has been previously shown to provide a real-time, intraoperative evaluation of perfusion. This study investigates the use of NIR imaging in partial face CTA harvest. METHODS: We created hemifacial CTAs (n = 8) using an established porcine model. This included ear cartilage, nerve, lymphoid tissue, muscle, and skin with perfusion by the carotid artery and external jugular vein. We injected animals systemically with indocyanine green and obtained NIR fluorescence images simultaneously with color video. In addition, we assessed the elevated hemifacial flaps using standard of care (i.e., clinical examination and Doppler). RESULTS: Flap design was facilitated by NIR imaging with localization of perforators to the hemifacial CTA flap. In particular, an arterial and venous phase could be clearly identified. We assessed perfusion of the flap by NIR fluorescence intensity after injection of indocyanine green. Sequential clamping of the artery and vein confirmed correlation of perfusion deficits with NIR imaging as well as with clinical examination and Doppler. CONCLUSIONS: Evaluation and assessment of perfusion are important in facial transplantation. The results from our pilot study indicate that NIR imaging has the capability to assess perfusion of partial facial CTAs. This emergent technology shows promise in assessing tissue perfusion in a composite flap.

Lumbar discectomies in elite rowers: presentation, operative treatment, and return to play.

OBJECTIVE: In a cohort of elite rowers requiring lumbar spine surgery, we report information regarding: (1) presentation, (2) operative treatment, and (3) return to play (RTP). METHODS: All competitive rowers undergoing spine surgery at a single academic institution from 2015 to 2020 were analyzed. Three rowers underwent spine surgery during the allotted time period. Demographic, clinical, operative, and RTP data was recorded. Each athlete's self-reported level of effort/performance was assessed before and after surgery. First RTP was defined as the time of initial return to rowing activities, and full RTP was defined as the time of unrestricted return to rowing activities. Descriptive statistics were performed. RESULTS: The three collegiate rowers ranged from 20- to 21-year-old, each with L5/S1 disc herniations. Preoperative pain levels ranged from 8 to 10, and inciting injury events included back squats, front squats, and rowing during the 'finish' stage. Each athlete underwent a minimally invasive, unilateral L5/S1 decompression, partial medial facetectomy, and partial discectomy with microscopic-assistance. First RTP ranged from 4-6 months, with full RTP at 6-8 months. Pain dissipated to the 0-1 range at full RTP. Final effort/performance improved from 10-60% mid-injury to 90-100% at full RTP. Each athlete's 2000m row time showed a decline mid-injury and an improvement to at or within 10 s of their pre-injury time. CONCLUSIONS: Drawing from three collegiate rowers who underwent lumbar decompression surgery, each athlete successfully returned to rowing, with initial RTP in the 4-6 months range and full RTP in the 6-8 months range. Performance levels rebounded to near or better than pre-injury performance. The results of this small case series warrant replication in larger, multi-institutional samples.

Semiautomated intraoperative measurement of Cobb angle and coronal C7 plumb line using deep learning and computer vision for scoliosis correction: a feasibility study.

OBJECTIVE: Scoliosis is a degenerative disease with a 3D deformity in the alignment of the spinal column. Surgical spinal correction outcomes are heavily dependent on the surgeon's expertise and use of visual cues because of time requirements, lack of automation, and radiation exposure associated with current intraoperative measurement techniques. In this study, the authors sought to validate a novel, nonradiographic, and semiautomated device that measures spinal alignment intraoperatively using deep learning and computer vision. METHODS: To obtain spinal alignment metrics intraoperatively, the surgeon placed 3D-printed markers made of acrylonitrile butadiene styrene (ABS) plastic at designated locations in the surgical field. With the high-definition camera of the device, the surgeon can take an image of the markers in the surgical field. Images are processed through a computer vision model that detects the location of the markers and calculates the Cobb angle and coronal plumb line. The marker detection model was trained on 100 images and tested on 130 images of the ABS markers in various conditions. To verify the Cobb angle calculation, 50 models of angle templates from 0° to 180° in 3.6735° increments were created for testing. To verify the plumb line calculation, 21 models of plumb line measurements from -10 to +10 cm in increments of 1 cm were created for testing. A validation study was performed on a scoliotic cadaver model, and the radiographic calculations for Cobb angle and plumb line were compared with the device's calculations. RESULTS: The area under the curve for the marker detection model was 0.979 for Cobb angle white, 0.791 for Cobb angle black, and 1 for the plumb line model. The average absolute difference between expected and measured Cobb angles on the verification models was 1.726° ± 1.259°, within the clinical acceptable error of 5°. The average absolute difference between the expected and measured plumb lines on the verification models was 0.415 ± 0.255 cm. For the cadaver validation study, the differences between the radiographic and device calculations for the Cobb angle and plumb line were 2.78° and 0.29 cm, respectively. CONCLUSIONS: The authors developed and validated a nonradiographic, semiautomated device that utilizes deep learning and computer vision to measure spinal metrics intraoperatively.

Evaluation of coronal alignment from the skull using the novel orbital-coronal vertical axis line.

OBJECTIVE: When treating patients with adult spinal deformity (ASD), radiographic measurements evaluating coronal alignment above C7 are lacking. The current objectives were to: 1) describe the new orbital-coronal vertical axis (ORB-CVA) line that evaluates coronal alignment from cranium to sacrum, 2) assess correlation with other radiographic variables, 3) evaluate correlations with patient-reported outcomes (PROs), and 4) compare the ORB-CVA with the standard C7-CVA. METHODS: A retrospective cohort study of patients with ASD from a single institution was undertaken. Traditional C7-CVA measurements were obtained. The ORB-CVA was defined as the distance between the central sacral vertical line and the vertical line from the midpoint between the medial orbital walls. The ORB-CVA was correlated using traditional coronal measurements, including C7-CVA, maximum coronal Cobb angle, pelvic obliquity, leg length discrepancy (LLD), and coronal malalignment (CM), defined as a C7-CVA > 3 cm. Clinical improvement was analyzed as: 1) group means, 2) minimal clinically important difference (MCID), and 3) minimal symptom scale (MSS) (Oswestry Disability Index < 20 or Scoliosis Research Society-22r Instrument [SRS-22r] pain + function domains > 8). RESULTS: A total of 243 patients underwent ASD surgery, and 175 had a 2-year follow-up. Of the 243 patients, 90 (37%) had preoperative CM. The mean (range) ORB-CVA at each time point was as follows: preoperatively, 2.9 ± 3.1 cm (-14.2 to 25.6 cm); 1 year postoperatively, 2.0 ± 1.6 cm (-12.4 to 6.7 cm); and 2 years postoperatively, 1.8 ± 1.7 cm (-6.0 to 11.1 cm) (p < 0.001 from preoperatively to 1 and 2 years). Preoperative ORB-CVA correlated best with C7-CVA (r = 0.842, p < 0.001), maximum coronal Cobb angle (r = 0.166, p = 0.010), pelvic obliquity (r = 0.293, p < 0.001), and LLD (r = 0.158, p = 0.006). Postoperatively, the ORB-CVA correlated only with C7-CVA (r = 0.629, p < 0.001) and LLD (r = 0.153, p = 0.017). Overall, 155 patients (63.8%) had an ORB-CVA that was ≥ 5 mm different from C7-CVA. The ORB-CVA correlated as well and sometimes better than C7-CVA with SRS-22r subdomains. After multivariate logistic regression, a greater ORB-CVA was associated with increased odds of complication, whereas C7-CVA was not associated with any of the three clinical outcomes (complication, readmission, reoperation). A larger difference between the ORB-CVA and C7-CVA was significantly associated with readmission and reoperation after univariate and multivariate logistic regression analyses. A threshold of ≥ 1.5-cm difference between the preoperative ORB-CVA and C7-CVA was found to be predictive of poorer outcomes. CONCLUSIONS: The ORB-CVA correlated well with known coronal measurements and PROs. ORB-CVA was independently associated with increased odds of complication, whereas C7-CVA was not associated with any outcomes. A ≥ 1.5-cm difference between the preoperative ORB-CVA and C7-CVA was found to be predictive of poorer outcomes.

Understanding the role of pelvic obliquity and leg length discrepancy in adult spinal deformity patients with coronal malalignment: unlocking the black box.

OBJECTIVE: This study had 3 objectives: 1) to describe pelvic obliquity (PO) and leg-length discrepancy (LLD) and their relationship with coronal malalignment (CM); 2) to report rates of isolated PO and PO secondary to LLD; and 3) to assess the importance of preoperative PO and LLD in postoperative complications, readmission, reoperation, and patient-reported outcomes. METHODS: Patients undergoing surgery (≥ 6-level fusions) for adult spinal deformity at a single institution were reviewed. Variables evaluated were as follows: 1) PO, angle between the horizontal plane and a line touching bilateral iliac crests; and 2) LLD, distance from the head to the tibial plafond. Coronal vertical axis (CVA) and sagittal vertical axis measurements were collected, both from C7. The cutoff for CM was CVA > 3 cm. The Oswestry Disability Index (ODI) was collected preoperatively and at 2 years. RESULTS: Of 242 patients undergoing surgery for adult spinal deformity, 90 (37.0%) had preoperative CM. Patients with preoperative CM had a higher PO (2.8° ± 3.2° vs 2.0° ± 1.7°, p = 0.013), a higher percentage of patients with PO > 3° (35.6% vs 23.5%, p = 0.044), and higher a percentage of patients with LLD > 1 cm (21.1% vs 9.8%, p = 0.014). Whereas preoperative PO was significantly positively correlated with CVA (r = 0.26, p < 0.001) and maximum Cobb angle (r = 0.30, p < 0.001), preoperative LLD was only significantly correlated with CVA (r = 0.14, p = 0.035). A total of 12.2% of patients with CM had significant PO and LLD, defined as follows: PO ≥ 3°; LLD ≥ 1 cm. Postoperatively, preoperative PO was significantly associated with both postoperative CM (OR 1.22, 95% CI 1.05-1.40, p = 0.008) and postoperative CVA (ß = 0.14, 95% CI 0.06-0.22, p < 0.001). A higher preoperative PO was independently associated with postoperative complications after multivariate logistic regression (OR 1.24, 95% CI 1.05-1.45, p = 0.010); however, 2-year ODI scores were not. Preoperative LLD had no significant relationship with postoperative CM, CVA, ODI, or complications. CONCLUSIONS: A PO ≥ 3° or LLD ≥ 1 cm was seen in 44.1% of patients with preoperative CM and in 23.5% of patients with normal coronal alignment. Preoperative PO was significantly associated with preoperative CVA and maximum Cobb angle, whereas preoperative LLD was only associated with preoperative CVA. The direction of PO and LLD showed no consistent pattern with CVA. Preoperative PO was independently associated with complications but not with 2-year ODI scores.

A multicenter study of the 5-year trends in robot-assisted spine surgery outcomes and complications.

Background: Although a growing amount of literature that suggests robots are safe and can achieve comparable outcomes to conventional techniques, much of this literature is limited by small sample sizes and single-surgeon or single center series. Furthermore, it is unclear what the impact of robotic technology has made on operative and clinical outcomes over time. This is the first and largest multicenter study to examine the trends in outcomes and complications after robot-assisted spine surgery over a 5-year period. Methods: Adult (≥18 years old) patients who underwent spine surgery with robot-assistance between 2015 and 2019 at four unique spine centers. The robotic systems used included the Mazor Renaissance, Mazor X, and Mazor Stealth Edition. Patients with incomplete data were excluded from this study. The minimum follow-up was 90 days. Results: A total of 722 adult patients were included (117 Renaissance, 477 X, 128 Stealth). Most patient and operative factors (e.g., sex, tobacco status, total instrumented levels, and pelvic fixation,) were similar across the years. Mean ± standard deviation Charlson comorbidity index (CCI) was 1.5±1.5. The most commonly reported diagnoses included high grade spondylolisthesis (40.6%), degenerative disc disease (18.4%), and degenerative scoliosis (17.6%). Mean (standard deviation) number of instrumented levels was 3.8±3.4. From 2015 to 2019, average robot time per screw improved from 7.2 to 5.5 minutes (P=0.004, R2=0.649). Average fluoroscopy time per screw improved from 15.2 to 9.4 seconds (P=0.002). Rates of both intraoperative screw exchange for misplaced screw (2015-2016: 2.7%, 2019: 0.8%, P=0.0115, R2=0.1316) and robot abandonment (2015-2016: 7.1%, 2019: 1.1%, P=0.011, R2=0.215) improved significantly over time. The incidence of other intraoperative complications (e.g., dural tear, loss of motor/sensory function, blood transfusion) remained consistently low, but similar throughout the years. The length of stay (LOS) decreased by nearly 1 day from 2015 to 2019 (P=0.007, R2=0.779). 90-day reoperation rates did not change significantly. Conclusions: At four institutions among seven surgeons, we demonstrate robot screw accuracy, reliability, operative efficiency, and radiation exposure improved significantly from 2015 to 2019. 90-day complication rates remained low and LOS decreased significantly with time. These findings further validate continued usage of robot-assisted spine surgery and the path toward improved value-based care.

What Is the Comparison in Robot Time per Screw, Radiation Exposure, Robot Abandonment, Screw Accuracy, and Clinical Outcomes Between Percutaneous and Open Robot-Assisted Short Lumbar Fusion?: A Multicenter, Propensity-Matched Analysis of 310 Patients.

STUDY DESIGN: Multicenter cohort. OBJECTIVE: To compare the robot time/screw, radiation exposure, robot abandonment, screw accuracy, and 90-day outcomes between robot-assisted percutaneous and robot-assisted open approach for short lumbar fusion (1- and 2-level). SUMMARY OF BACKGROUND DATA: There is conflicting literature on the superiority of robot-assisted minimally invasive spine surgery to open techniques. A large, multicenter study is needed to further elucidate the outcomes and complications between these two approaches. METHODS: We included adult patients (≥18 yrs old) who underwent robot-assisted short lumbar fusion surgery from 2015 to 2019 at four independent institutions. A propensity score matching algorithm was employed to control for the potential selection bias between percutaneous and open surgery. The minimum follow-up was 90 days after the index surgery. RESULTS: After propensity score matching, 310 patients remained. The mean (standard deviation) Charlson comorbidity index was 1.6 (1.5) and 53% of patients were female. The most common diagnoses included high-grade spondylolisthesis (grade >2) (48%), degenerative disc disease (22%), and spinal stenosis (25%), and the mean number of instrumented levels was 1.5(0.5). The operative time was longer in the open (198 min) versus the percutaneous group (167 min, P value = 0.007). However, the robot time/screw was similar between cohorts (P value > 0.05). The fluoroscopy time/ screw for percutaneous (14.4 s) was longer than the open group (10.1 s, P value = 0.021). The rates for screw exchange and robot abandonment were similar between groups (P value > 0.05). The estimated blood loss (open: 146 mL vs. percutaneous: 61.3 mL, P value < 0.001) and transfusion rate (open: 3.9% vs. percutaneous: 0%, P value = 0.013) were greater for the open group. The 90-day complication rate and mean length of stay were not different between cohorts (P value > 0.05). CONCLUSION: Percutaneous robot-assisted spine surgery may increase radiation exposure, but can achieve a shorter operative time and lower risk for intraoperative blood loss for short-lumbar fusion. Percutaneous approaches do not appear to have an advantage for other short-term postoperative outcomes. Future multicenter studies on longer fusion surgeries and the inclusion of patient-reported outcomes are needed.Level of Evidence: 3.

Chronic Aspiration Pneumonitis Caused by Spontaneous Cerebrospinal Fluid Fistulae of the Skull Base.

OBJECTIVES/HYPOTHESIS: Spontaneous cerebrospinal fluid (CSF) leaks of the skull base are associated with obesity, multiparity, and elevated intracranial pressure. Although spontaneous CSF leaks often present with rhinorrhea, they can be an underdiagnosed cause of chronic aspiration pneumonitis, a complication that has not been previously reported in detail. STUDY DESIGN: Retrospective case series. METHODS: The authors retrospectively reviewed all patients undergoing surgical repair of CSF fistulae at the University of Southern California between 2011 and 2018 to identify those presenting with pulmonary symptoms including dyspnea, aspiration, chronic cough, and shortness of breath caused by chronic noniatrogenic CSF pneumonitis. RESULTS: Symptomatic chronic pneumonitis was evident in six of 20 patients with spontaneous CSF rhinorrhea. Five women (mean body mass index = 36) had CSF leaks arising from the fovea ethmoidalis (n = 4) and lateral sphenoid region (n = 1). One man had a middle fossa floor dehiscence draining through the eustachian tube. All patients had bilateral ground-glass opacities in their lungs on computed tomography imaging that were attributed to spontaneous CSF fistulae arising from noniatrogenic skull base defects, and one patient underwent a biopsy of a lung lesion at another hospital showing chronic bronchiolitis and adjacent peribronchiolar metaplasia. Five patients underwent endoscopic endonasal repair using an autologous fascial graft and pedicled nasoseptal flap, and one underwent craniotomy for repair. All patients underwent successful repair with no complications or evidence of recurrence. Upon repair of the spontaneous CSF leaks, both pneumonitis symptoms and ground-glass opacities on imaging resolved in all six cases. CONCLUSIONS: Skull base CSF fistulae should be considered as a reversible cause of chronic pneumonitis that is not alleviated or worsens with standard treatment. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:462-466, 2021.

Incidence and risk factors of iatrogenic coronal malalignment after adult spinal deformity surgery: a single-center experience.

OBJECTIVE: The authors' objectives were: 1) to evaluate the incidence and risk factors of iatrogenic coronal malalignment (CM), and 2) to assess the outcomes of patients with all three types of postoperative CM (iatrogenic vs unchanged/worsened vs improved but persistent). METHODS: A single-institution, retrospective cohort study was performed on adult spinal deformity (ASD) patients who underwent > 6-level fusion from 2015 to 2019. Iatrogenic CM was defined as immediate postoperative C7 coronal vertical axis (CVA) ≥ 3 cm in patients with preoperative CVA < 3 cm. Additional subcategories of postoperative CM were unchanged/worsened CM, which was defined as immediate postoperative CVA within 0.5 cm of or worse than preoperative CVA, and improved but persistent CM, which was defined as immediate postoperative CVA that was at least 0.5 cm better than preoperative CVA but still ≥ 3 cm; both groups included only patients with preoperative CM. Immediate postoperative radiographs were obtained when the patient was discharged from the hospital after surgery. Demographic, radiographic, and operative variables were collected. Outcomes included major complications, readmissions, reoperations, and patient-reported outcomes (PROs). The t-test, Kruskal-Wallis test, and univariate logistic regression were performed for statistical analysis. RESULTS: In this study, 243 patients were included, and the mean ± SD age was 49.3 ± 18.3 years and the mean number of instrumented levels was 13.5 ± 3.9. The mean preoperative CVA was 2.9 ± 2.7 cm. Of 153/243 patients without preoperative CM (CVA < 3 cm), 13/153 (8.5%) had postoperative iatrogenic CM. In total, 43/243 patients (17.7%) had postoperative CM: iatrogenic CM (13/43 [30.2%]), unchanged/worsened CM (19/43 [44.2%]), and improved but persistent CM (11/43 [25.6%]). Significant risk factors associated with iatrogenic CM were anxiety/depression (OR 3.54, p = 0.04), greater preoperative sagittal vertical axis (SVA) (OR 1.13, p = 0.007), greater preoperative pelvic obliquity (OR 1.41, p = 0.019), lumbosacral fractional (LSF) curve concavity to the same side of the CVA (OR 11.67, p = 0.020), maximum Cobb concavity opposite the CVA (OR 3.85, p = 0.048), and three-column osteotomy (OR 4.34, p = 0.028). In total, 12/13 (92%) iatrogenic CM patients had an LSF curve concavity to the same side as the CVA. Among iatrogenic CM patients, mean pelvic obliquity was 3.1°, 4 (31%) patients had pelvic obliquity > 3°, mean preoperative absolute SVA was 8.0 cm, and 7 (54%) patients had preoperative sagittal malalignment. Patients with iatrogenic CM were more likely to sustain a major complication during the 2-year postoperative period than patients without iatrogenic CM (12% vs 33%, p = 0.046), yet readmission, reoperation, and PROs were similar. CONCLUSIONS: Postoperative iatrogenic CM occurred in 9% of ASD patients with preoperative normal coronal alignment (CVA < 3 cm). ASD patients who were most at risk for iatrogenic CM included those with preoperative sagittal malalignment, increased pelvic obliquity, LSF curve concavity to the same side as the CVA, and maximum Cobb angle concavity opposite the CVA, as well as those who underwent a three-column osteotomy. Despite sustaining more major complications, iatrogenic CM patients did not have increased risk of readmission, reoperation, or worse PROs.

Return to golf after adult degenerative and deformity spine surgery: a preliminary case series of how surgery impacts golf play and performance.

BACKGROUND: Golf is a commonly played sport among older adults, and degenerative and/or deformity spine pathology can severely impact older individuals' ability to play golf. In a cohort of self-identified, avid golfers undergoing degenerative or deformity spine surgery, we report their: (I) presentation, (II) operative treatment, and (III) return-to-play (RTP) process. METHODS: A retrospective case series of self-identified, avid golfers undergoing spine surgery at a single institution from 2015-2019 was undertaken. Demographic, presenting, operative, RTP data, along with numerical rating scale (NRS) pain scores were collected. The first and full RTP time postoperatively, in addition to the following golf metrics: 18-hole rounds per month, handicap, and self-perceived effort/performance were obtained. RESULTS: A total of 6 golfers were included, 3 undergoing each degenerative and deformity operations. Mean age was 60 years, and 5 of 6 (83%) patients were female. All patients were self-identified, avid golfers with a mean experience of 31 years. Mean preoperative NRS back/neck pain was 9.7, which decreased to 0.8 postoperatively (P<0.001). Players undergoing smaller operations (lumbar fusion/cervical laminoplasty) returned to golf sooner than patients undergoing larger deformity corrections, with a mean first RTP of 4.3 months for degenerative patients vs. 9.7 months among deformity patients. All patients played either the same or more rounds of golf after surgery once they reached full RTP. The handicap of all players improved after surgery to better than before surgery, except for one high-level golfer with a handicap of 9 preoperatively that went to 15 postoperatively following an extensive revision deformity reconstruction. CONCLUSIONS: All patients returned to playing golf at or more frequently than their preoperative status. Degenerative patients returned to play sooner than deformity patients. All patients performed at a higher level after surgery, except for one high-level golfer whose handicap worsened slightly. These data provide baseline information for future prospective studies of golfers undergoing spine surgery.