Hospital Course and Complications of Subaxial Cervical Trauma Patients With Tetraplegia or Paraplegia: A Case Series and Literature Review.

STUDY DESIGN: A single-institution, retrospective cohort study. OBJECTIVE: The objective was to present demographic characteristics, mechanism of injuries, lengths of stay, intensive care unit (ICU) days, discharge locations, and causes of 90-day readmission for patients with subaxial spinal cord injuries resulting in paraplegia or tetraplegia. SUMMARY OF BACKGROUND DATA: Spinal cord injuries resulting in paraplegia or tetraplegia are rare injuries with debilitating outcomes. Numerous advances have occurred in caring for these patients, but patients still experience multiple complications. The severity of these injuries and numerous complications result in prolonged hospital stays and the need for extensive rehabilitation. METHODS: Twelve patients with subaxial spinal cord injury resulting in paraplegia or tetraplegia from a level 1 adult trauma center were reviewed. The primary outcomes included hospital length of stay, ICU days, intrahospital complications, 90-day readmission rates, and discharge location. We reviewed the literature for these outcomes in spinal cord injuries. RESULTS: For patients with subaxial spinal cord injuries resulting in paraplegia and tetraplegia, the average age was 36.0 years, and most were male [91.7% (11/12)]. The most common mechanism of injury was gunshot wounds[41.7% (5/12)]. Patients spent an average of 46.3 days in the hospital and 30.7 days in the ICU. Respiratory complications were the most common (9 patients). Fifty percent of patients (6/12) were discharged to the inpatient spinal cord rehab center, and 16.7% (2/12) expired while in the hospital. Two patients (20.0%) were readmitted within 90 days of discharge. CONCLUSIONS: Most patients with subaxial spinal cord injuries resulting in paraplegia or tetraplegia were young males with high-energy traumas. Many patients had intrahospital complications, and most were discharged to the hospital spinal rehab center. These findings likely stem from the severity of paraplegia and tetraplegia injuries and the need for rehabilitation.

The Surgical Outcomes of Pedicle Subtraction Osteotomy per Different First Assistant: Retrospective Analysis of 312 Cases.

INTRODUCTION: Pedicle subtraction osteotomies (PSOs) are complex spinal deformity surgeries that are associated with high complication rates. They are typically done by an experienced spine surgeon with another attending, resident, or physician assistant serving as the first assistant. The purpose of this study was to determine whether selecting a surgical team for single-level PSO based on case difficulty and fusion length could equalize intraoperative and perioperative outcomes among three groups: dual-attending (DA), attending and orthopaedic resident (RS), and attending and physician assistant (PA). METHODS: This study was a retrospective cohort analysis of 312 patients undergoing single-level thoracic or lumbar PSO from January 2007 to December 2020 by a fellowship-trained orthopaedic spine surgeon. Demographic, intraoperative, and perioperative data within 30 days and 2 years of the index procedure were analyzed. RESULTS: Patient demographics did not markedly differ between surgical groups. The mean cohort age was 64.5 years with BMI 31.9 kg/m 2 . Patients with the DA approach had a significantly longer surgical time (DA = 412 min vs. resident = 372 min vs. physician assistant = 323 min; P < 0.001). Patients within the DA group experienced a significantly lower rate of infection (DA = 2.1% [3/140] vs. RS = 7.9% [9/114] vs. PA = 1.7% [1/58], P = 0.043), surgical complication rate (DA = 26% [37/140] vs. RS = 41% [47/114] vs. PA = 33% [19/58], P < 0 .001), and readmission rate (DA = 6.4% [9/140] vs. RS = 12.3% [14/114] vs. PA = 19% [11/58] P = 0.030) within 30 days of surgery. No notable differences were observed among groups in 2-year complication, infection, readmission, or revision surgery rates. CONCLUSIONS: These study results support the DA surgeon approach. Resident involvement, even in less complex cases, can still negatively affect perioperative outcomes. Additional selection criteria development is needed.

Does Surgical Day of the Week Affect Hospital Course and Outcomes for Patients Undergoing Adult Spinal Deformity Surgery?

STUDY DESIGN: Retrospective Cohort Analysis. OBJECTIVES: Extended hospital length of stay (LOS) poses a significant cost burden to patients undergoing adult spinal deformity (ASD) surgery. The purpose of this study is to investigate the relationship between late-week surgery and LOS in patients undergoing ASD surgery. METHODS: 256 patients who underwent ASD surgery between January 2018 and December 2021 by a single fellowship-trained orthopedic spine surgeon comprised the patient sample. Demographics, intraoperative, and perioperative data were collected for the 256 patients who underwent ASD surgery. Patients were divided into two groups based on surgical day of the week: (1) Early-week (Monday/Tuesday) n = 126 and (2) Late-week (Thursday/Friday) n = 130. Descriptive statistics, T-tests, and linear and logistic regression models were used to analyze the data. RESULTS: Surgical details and sociodemographic characteristics did not differ between the groups. When controlling for TLIF/DLIF status and PSO status there was no difference in mean length of stay between the groups. The late-week group was associated with a greater risk of 30-day readmission, but there was no difference in complications, infections, or intraoperative complications. CONCLUSIONS: We found no difference in mean length of stay between surgeries performed early in the week vs late in the week. Although late-week surgeries had higher 30-day readmission risk, all other outcomes, including complication rates, showed no significant differences. When adequate weekend post-operative care is available, we do not advise restricting ASD surgeries to specific weekdays.

Predicting Complications in 153 Lumbar Pedicle Subtraction Osteotomies by a Single Surgeon Over a 6-Year Period.

INTRODUCTION: Pedicle subtraction osteotomy (PSO) is a complex surgical procedure that provides correction of moderate sagittal imbalance. Surgical complications have adverse effects on patient outcomes and healthcare costs, making it imperative for clinical researchers to focus on minimizing complications. However, when it comes to risk modeling of PSO surgery, there is currently no consensus on which patient characteristics or measures should be used. This study aimed to describe complications and compare the performance of various sociodemographic characteristics, surgical variables, and established risk indices in predicting postoperative complications, infections, and readmissions after lumbar PSO surgeries. METHODS: A review was conducted on 191 patients who underwent PSO surgery at a single institution by a single fellowship-trained orthopaedic spine surgeon between January 1, 2018, and December 31, 2021. Demographic, intraoperative, and postoperative data within 30 days, 1 year, and 2 years of the index procedure were evaluated. Descriptive statistics, t-test, chi-squared analysis, and logistic regression models were used. RESULTS: Intraoperative complications were significantly associated with coronary artery disease (odds ratios [OR] 3.95, P = 0.03) and operating room time (OR 1.01, P = 0.006). 30-day complications were significantly cardiovascular disease (OR 2.68, P = 0.04) and levels fused (OR 1.10, P = 0.04). 2-year complications were significantly associated with cardiovascular disease (OR 2.85, P = 0.02). 30-day readmissions were significantly associated with sex (4.47, 0.04) and length of hospital stay (χ2 = 0.07, P = 0.04). 2-year readmissions were significantly associated with age (χ2 = 0.50, P = 0.03), hypertension (χ2 = 4.64, P = 0.03), revision surgeries (χ2 = 5.46, P = 0.02), and length of hospital stay (χ2 = 0.07, P = 0.03). DISCUSSION: This study found that patients with coronary vascular disease and longer fusions were at higher risk of postoperative complications and patients with notable intraoperative blood loss were at higher risk of postoperative infections. In addition, physicians should closely follow patients with extended postoperative hospital stays, with advanced age, and undergoing revision surgery because these patients were more likely to be readmitted to the hospital.

Differences in Financial Conflicts of Interest Among Participants in a National Spine Conference.

STUDY: Retrospective Study. OBJECTIVE: At the North American Spine Society (NASS) conference, participants may influence spine surgery practices and patient care through their contributions. Therefore, their financial conflicts of interest are of notable interest. This study aims to compare the demographics and payments made to participating surgeons. METHODS: A list of 151 spine surgeons was created based on those who participated in the 2022 NASS conference. Demographic information was obtained from public physician profiles. General payments, research payments, associated research funding, and ownership interest were collected for each physician. Descriptive statistics and two-tailed t-tests were used. RESULTS: In 2021, 151 spine surgeon participants received industry payments, totaling USD 48 294 115. The top 10% of orthopedic surgeons receiving payments accounted for 58.7% of total orthopedic general value, while the top 10% of neurosurgeons accounted for 70.1%. There was no significant difference between these groups' general payment amounts. Surgeons with 21-30 years of experience received the most general funding. There was no difference in funding between surgeons in academic or private settings. For all surgeons, royalties accounted for the largest percentage of the general value exchanged, while food/beverage accounted for the largest percentage of transactions. CONCLUSIONS: Our study found that only years of experience had a positive association with general payments, and most monetary value belonged to a small handful of surgeons. These participants receiving significant money may promote techniques requiring products of companies providing their compensation. Future conferences may require disclosure policy changes so attendees understand the degree of funding participants receive.

In-Hospital Morbidity and Mortality of Traumatic Lower-Extremity Amputations.

Traumatic lower-extremity amputations often result in complications and surgical revisions. The authors report the in-hospital morbidity and mortality of traumatic lower-extremity amputations at a metropolitan level I trauma center for a large rural region and compare below-knee (BK) vs higher-level amputation complications. They retrospectively reviewed 168 adult patients during a 10-year period (2005 to 2015) who had a traumatic injury to the lower extremity that required an amputation. Main outcome measurements included amputation level, complication rates, intensive care unit (ICU) admission rates, length of stay, total trips to the operating room (OR), and Injury Severity Score (ISS). A total of 95 patients had through-knee/above-knee (TK/AK) amputations, and 73 patients had BK amputations. The majority of injuries occurred in the non-urban setting. The TK/AK group had higher ICU admission rates (76% vs 35%, P<.0001), longer overall hospital length of stay (22.0 vs 15.5 days, P=.01), more total OR trips (6.5 vs 5.0, P=.04), and higher ISS (17.0 vs 11.5, P<.0001). A complication was experienced by 64% of all patients during the initial hospitalization. The TK/AK group had higher complication rates than the BK group, including wound infection, pulmonary embolus, rhabdomyolysis, compartment syndrome, and death. Patients with TK/AK traumatic amputations have a greater burden of injury with higher complication rates, increased ICU admissions, increased length of stay, and increased ISS and require more return trips to the OR compared with patients with BK amputations. [Orthopedics. 2020;43(6):e561-e566.].

Demographic and Perioperative Factors Associated With Patient-reported Outcomes Measurement Information System (PROMIS) Survey Completion.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: To evaluate independent demographic and perioperative factors associated with lower Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) survey completion rates after spine surgery. SUMMARY OF BACKGROUND DATA: There has not been a study evaluating factors related to PROMIS PF survey completion following spine surgery. METHODS: Patients undergoing spine procedures were retrospectively reviewed. The number of PROMIS PF surveys that were completed at each time period and the number of surveys that were completed in succession starting with the first survey were tabulated and reported using descriptive statistics. Independent preoperative and perioperative factors associated with full survey completion up to the 12-month period were identified using χ analysis and Poisson regression with robust error variance. A final multivariate model was created using a backward, stepwise multivariate regression. RESULTS: A total of 713 patients were included. Variables positively associated with PROMIS survey completion were aged above 60 years and Patient Health Questionnaire (PHQ)-9≥10. African Americans and Hispanics were negatively associated with survey completion. Postoperative day 0 narcotic use ≥50 oral morphine equivalents was positively associated with survey completion, while outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion. In the final multivariate model, depression was the only variable that was positively associated, while both outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion. CONCLUSION: This study identified demographic and perioperative variables associated with PROMIS survey completion and response rates. Patients who underwent surgery in the outpatient setting and those with high preoperative radicular limb pain were less likely to complete surveys. Interestingly, patients with clinical signs of depression were more likely to fill out surveys. Understanding variables associated with survey completion may provide the clinician with insight into which demographic groups are the most at-risk for not responding to surveys.

Static Versus Expandable Devices Provide Similar Clinical Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Few studies have analyzed differences in radiographic parameters and patient-reported outcomes (PROs) between expandable and static interbody devices in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). QUESTIONS/PURPOSES: To evaluate differences in radiographic parameters and PROs following MIS TLIF between static and expandable interbody devices. METHODS: Patients undergoing primary, single-level MIS TLIF between 2014 and 2017 were retrospectively identified. Radiographic measurements including lumbar lordosis (LL), segmental lordosis (SL), disc height (DH), and foraminal height (FH) were performed on lateral radiographs before and after MIS TLIF with a static or expandable articulating interbody device. Radiographic outcomes and PROs were compared using paired and unpaired Student's t test. RESULTS: Thirty patients received expandable interbody devices and 30 patients received static interbody devices. The expandable device cohort exhibited significantly greater improvement in DH and FH at final follow-up compared with those receiving a static device. Both device cohorts experienced significant improvements in PROs at 6 months post-operatively. CONCLUSION: MIS TLIF with an expandable interbody device led to a greater increase of DH and FH than with a static interbody device. Patients undergoing MIS TLIF can expect similar improvements in PROs whether receiving a static or an expandable interbody device. Further studies are required to better understand improvements in clinical outcomes afforded by expandable interbody devices.

Improvements in Back and Leg Pain After Minimally Invasive Lumbar Decompression.

BACKGROUND: Few studies have quantified clinical improvement following minimally invasive lumbar decompression based on predominant back pain or leg pain. PURPOSE: To quantify improvement in patient-reported outcomes following minimally invasive lumbar decompression and determine the degree of improvement in back pain, leg pain, and disability in patients who present with predominant back pain or predominant leg pain. METHODS: Patients who underwent primary, one-level minimally invasive lumbar decompression for degenerative pathology were retrospectively reviewed. Comparisons of visual analog scale (VAS) back and leg pain scores, Oswestry Disability Index (ODI) scores, and Short Form-12 (SF-12) mental and physical component scores from pre-operative to 6-week, 12-week, 6-month, and 1-year follow-up. Subgroup analyses were performed for patients with predominant back pain or predominant leg pain. RESULTS: A total of 102 patients were identified. Scores on VAS back and leg pain, ODI, and SF-12 physical component improved from pre-operative to all post-operative time points. After 1 year, patients reported a 2.8-point (47%) reduction in back pain and a 4-point (61.1%) reduction in leg pain scores; 52 patients with predominant back pain and 50 patients with predominant leg pain reported reductions in pain throughout the year following surgery. In both the back and leg pain cohorts, patients experienced reductions in ODI during the first 6 months and throughout 1-year follow-up, respectively. The majority of patients achieved minimum clinically important difference, regardless of predominant symptom. CONCLUSIONS: Patients reported improvements in back and leg pain following minimally invasive lumbar decompression regardless of predominant presenting symptom; however, patients with predominant leg pain may experience greater improvement than those with predominant back pain.

Patient Perceptions of Physician Ownership in Spine Care.

STUDY DESIGN: This was a prospective study. OBJECTIVE: This study aims to determine the perspectives of patients seeking spine care in regard to physician ownership of surgical facilities and to understand the importance of disclosing financial conflicts. SUMMARY OF BACKGROUND DATA: There has been limited investigation regarding patient perceptions of the proprietary structure of surgical facilities. METHODS: Patients seeking treatment for spine pathology completed an 8-item survey. The questions assessed if patients acknowledged the owners of surgical facilities, if the patient thought knowledge of ownership is important, who they perceived as most qualified to own surgical facilities, preference of communication of ownership, and impact of facility ownership on care. RESULTS: A total of 200 patients completed the survey. When patients were asked whom they thought owned the hospital, most reported private hospital corporations followed by universities/medical schools and insurance companies. With regard to whom patients thought owned an ambulatory surgical center, most reported physicians, followed by private hospital corporations and individual investors. When asked how important it is to know the financial stakeholders of a surgical facility, 73.5% of patients stated "very important" or "somewhat important." Most patients reported they were not aware of who owned the facility. Regarding how facility owners should be communicated, 31.0% answered "written document," whereas 25.0% preferred verbal communication with the staff/surgeon. When asked how much impact the owner of a surgical facility has on their care, 38.0% of patients responded, "strong impact," followed by "moderate impact," (43.0%), and "little or no impact" (19.0%). Patients thought that physicians were the most qualified to own an ambulatory surgical center, followed by universities/medical schools and private hospital corporations. CONCLUSIONS: The pretreatment perception of patients referred to a spine clinic favored the opinion that physicians were the most qualified to own and manage surgical facilities. Therefore, physicians should be encouraged to share disclosures with patients as their ownership of surgical facilities is viewed favorably.

Minimally invasive lumbar decompression in an ambulatory surgery center.

BACKGROUND: There is limited data regarding clinical and surgical outcomes of minimally invasive lumbar decompression (MIS LD) as an outpatient procedure. In this context, our purpose is to evaluate a single surgeon's experience with performing MIS LD in the outpatient versus inpatient setting and determining if there are differences in surgical and clinical outcomes. METHODS: Patients undergoing primary, one- to three-level MIS LD were retrospectively reviewed and stratified by surgical setting: ambulatory surgical center (ASC) versus hospital. The cohorts were compared with respect to demographics, perioperative characteristics, complications, postoperative pain and narcotics consumption, and improvements in patient-reported outcomes. RESULTS: Five hundred and nine patients were included: 332 patients underwent surgery at an ASC and 177 patients underwent surgery at a hospital. The ASC patients were younger, more likely to be male, and carry Workers' Compensation insurance. The hospital patients were older, more likely to be diabetic, and had a greater comorbidity burden. Patients undergoing MIS LD in an ASC were less likely to have multi-level procedures and more likely to have decompression with discectomy compared to patients in the hospital cohort. There were two cases of superficial wound infection in the ASC cohort and a single case of a pulmonary embolus in the hospital cohort. Additionally, a total of 28 patients had recurrent herniated nucleus pulposus in the ASC cohort compared to 12 patients in the hospital cohort. There was one case of residual stenosis in the ASC cohort compared to eight cases in the hospital cohort. Both cohorts demonstrated similar preoperative ODI, VAS back pain, and VAS leg pain scores through 12-month follow-up. CONCLUSIONS: MIS LD is a safe and effective procedure in an ASC, however, appropriate patient selection and postoperative protocols are imperative in minimizing complications and optimizing safety and efficacy in the outpatient setting.

Device solutions for a challenging spine surgery: minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

INTRODUCTION: Lumbar interbody fusion remains a mainstay in the treatment of degenerative spinal pathology. Interbody devices are often used in an attempt to improve fusion rates and outcomes. Minimally invasive techniques lend unique advantages, but are challenging and often plagued with complications. Specifically, minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has a steep learning curve and there is a lack of concise information on solutions to optimize outcomes. AREAS COVERED: This review details an appropriate surgical technique of MIS TLIF and includes an overview of the components that go into a successful procedure. A thorough literature search of the PubMed database was completed to provide a comprehensive analysis of the interbody devices, posterolateral fixation, and osteobiologics. EXPERT OPINION: MIS TLIFs have demonstrated successful clinical and radiographic outcomes and have become a mainstay for treating various degenerative lumbar pathologies. As minimally invasive techniques continue to evolve, devices and biologics will continue to expand the indications for MIS TLIFs and will optimize long-term outcomes.

The Effect of Tobacco Use on Postoperative Pain Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To identify the differences in inpatient pain scores, narcotic consumption, and patient-reported outcomes (PROs) between tobacco users and nonusers following an anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Previous studies have investigated tobacco use as a risk factor for negative postsurgical outcomes following spine surgery; however, few studies have analyzed the effects of tobacco on pain following ACDF. METHODS: Patients undergoing primary, 1-level, or 2-level ACDF were retrospectively reviewed and stratified by tobacco use at the time of surgery. Inpatient pain scores and narcotic consumption were collected. Neck Disability Index and Visual Analogue Scale (VAS) neck and arm pain scores were collected preoperatively and at 6-week, 3-month, and 6-month follow-up visits. Differences in demographics and perioperative characteristics were assessed using χ analysis and multivariate linear regression. An association between immediate postoperative pain, narcotics consumption, and long-term PROs was tested for using multivariate linear regression. RESULTS: A total of 192 patients were included and stratified by tobacco use: tobacco (n=25) and nontobacco (n=167). There were no significant differences in demographic and perioperative characteristics. No statistical differences were observed in inpatient VAS pain scores and narcotic consumption on postoperative day 0 and postoperative day 1. Preoperative VAS neck pain and arm pain was greater in tobacco users, however, improvements in neck and arm pain were similar in the postoperative period through 6-month follow-up. In addition, no statistical differences in Neck Disability Index were observed preoperatively or at any postoperative time points. CONCLUSIONS: Our study suggests that tobacco use does not influence inpatient pain scores, narcotic consumption, and improvements in PROs following ACDF. As such, tobacco users and nonusers should receive similar postoperative pain management protocols following surgery. LEVEL OF EVIDENCE: Level III.

Sex Differences on Postoperative Pain and Disability Following Minimally Invasive Lumbar Discectomy.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine if sex is associated with differences in postoperative pain scores, narcotic consumption, and long-term improvements in pain and disability following minimally invasive lumbar discectomy (MIS LD). SUMMARY OF BACKGROUND DATA: There exists a question as to what extent sex influences surgical and clinical outcomes following MIS LD. METHODS: Patients undergoing primary, single-level MIS LD were retrospectively reviewed and stratified on the basis of sex. Immediate postoperative Visual Analog Scale (VAS) pain scores and narcotic consumption were collected. Patient-reported outcomes, including Oswestry Disability Index (ODI), 12-Item Short-Form- (SF-12) Physical Component Score, and VAS back and leg pain, were collected preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. Sex differences were tested for an association between immediate postoperative pain, narcotics utilization, and long-term improvements in patient-reported outcomes using linear regression. RESULTS: A total of 188 patients were included and 62.8% were male individuals. At the time of surgery, female individuals were older than male individuals (P=0.045). There were no observed differences in other demographic or perioperative characteristics between cohorts. Female individuals had similar inpatient VAS pain scores and narcotic consumption compared with male individuals. Female individuals had a higher ODI score than male individuals preoperatively, however, both cohorts had similar improvements in ODI at all postoperative time points. Both sexes had similar VAS back and leg pain and SF-12 PCS scores preoperatively and at all postoperative time points. CONCLUSIONS: Our study demonstrated that sex does not affect immediate postoperative pain, narcotic consumption, and long-term recovery following MIS LD. Female individuals demonstrated similar preoperative back and pain scores compared with male individuals but reported greater disability before surgery. However, both sexes experienced similar improvements in pain and disability at all follow-up time points through 12 months. The results of this study may enable providers to better counsel patients regarding the expected improvement in pain and disability.

Interbody options in lumbar fusion.

Interbody devices have revolutionized lumbar fusion surgery by enhancing mechanical stability, optimizing sagittal parameters, and maximizing fusion potential. There are several lumbar interbody fusion approaches available for varying pathologic etiologies, surgical index levels, or due to surgeon preference. With the advancement of spinal instrumentation and interbody devices, a variety of cage materials and dimensions have been engineered to accommodate various lumbar fusion approaches. The efficacy of a fusion is dependent on the shape, size, and material makeup of that interbody device. Since there are numerous cages available in today's market, it is important to find the optimal cage to best accommodate specific lumbar fusion cases. This review will explain the properties and future advancements of various interbody devices available for lumbar fusions.

Patient Perceptions of Iliac Crest Bone Grafting in Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The objective of this study was to determine patients' perception of iliac crest bone graft (ICBG) harvesting and donor site pain following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: The incidence of donor site pain has been debated in the literature because of the varying techniques associated with its harvest. METHODS: Patients undergoing primary, single-level MIS TLIF with ICBG were retrospectively identified. ICBG harvesting was performed using a percutaneous technique with a tubular retractor. A survey was administered to assess if patients could accurately describe which side of their iliac crest they believed was harvested, and if they were experiencing any pain perceived to be originating from the donor site. Patient characteristics were compared using χ analysis and independent t test. RESULTS: In total, 82 patients were included. The majority of patients had the ICBG harvested from the left iliac crest (97.5%). Approximately half of the patients correctly identified the side of harvest (50.6%). 48.1% of patients reported they were not confident or had guessed on their response. Patients that reported pain from the ICBG were more likely to feel confident or somewhat confident in their harvest site identification (57.9% vs. 46.3%) but less likely to be correct (36.8% vs. 63.4%) than patients without pain. 22 patients (27.8%) correctly identified the side of harvest without guessing. Of these, 11 (13.9%) reported pain. CONCLUSIONS: Approximately half of patients undergoing MIS TLIF with ICBG are able to correctly identify which side of their iliac crest was harvested. However, the majority of patients reporting pain were unable to correctly identify the side of harvest. This suggests that most patients are likely attributing other sources of pain to their ICBG. Therefore, rates of donor site pain may be over-reported in the current literature with contemporary harvesting techniques.

Swallowing Function Following Anterior Cervical Discectomy and Fusion With and Without Anterior Plating: A SWAL-QOL (Swallowing-Quality of Life) and Radiographic Assessment.

OBJECTIVE: Anterior cervical plating in anterior cervical discectomy and fusion (ACDF) procedures are associated with improved outcomes compared to stand-alone cages. However, concerns exist regarding increased rates of postoperative dysphagia following an ACDF. This study aims to quantify the effect of anterior plating on swallowing-quality of life (SWAL-QOL) scores and radiographic swelling assessments following a primary, single-level ACDF. METHODS: Patients retrospectively reviewed. Patients grouped into those receiving a cage or anterior plate. SWAL-QOL scores were recorded preoperatively and 6 weeks and 12 weeks postoperatively. Lateral radiographs were used to create a swelling index with a ratio of the prevertebral swelling distance to the anterior-posterior diameter of each involved vertebral body. An air index was created using the same methodology. Statistical analysis was performed using chi-square analysis and independent t-tests for categorical and continuous variables. RESULTS: Sixty-eight primary, single-level ACDF patients were included. Forty-one (60.3%) received a stand-alone cage and 27 (39.7%) received a cage with anterior plating. No differences in demographics, comorbidities, operative time, estimated blood loss, or length of hospital stay were identified between Cage and Plate cohorts. Finally, no differences were observed in postoperative SWAL-QOL scores or swelling and air indices between groups. CONCLUSION: The results demonstrate that patients undergoing a primary, single-level ACDF with or without anterior plating experience similar operative times and lengths of stay. Patients that receive a cage with anterior plating did not experience significant increases in dysphagia as measured by the SWAL-QOL questionnaire compared to patients that received a stand-alone cage. Furthermore, radiographic assessments of swelling are comparable.

Postoperative satisfaction following lumbar spinal fusion surgery: patient expectation versus actuality.

OBJECTIVE: Due to the reported benefits associated with minimally invasive spine surgery (MIS), patients seeking out minimally invasive surgery may have higher expectations regarding their outcomes. In this study the authors aimed to assess the effects of preoperative expectations and postoperative outcome actuality, and the difference between the two, on postoperative satisfaction following MIS for lumbar fusion procedures. METHODS: Patients scheduled for either a 1- or 2-level lumbar fusion MIS were administered confidential surveys preoperatively and at 6 months postoperatively. The surveys administered preoperatively consisted of 2 parts: preoperative patient-reported outcomes (PROs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) back pain, and VAS leg pain, and expected postoperative PROs. The surveys administered 6 months postoperatively consisted of 2 parts: postoperative PROs and satisfaction. Preoperative symptoms, expected postoperative symptoms, and actual postoperative symptoms were compared using paired t-tests. Pearson correlation was used to compare the association between 1) postoperative change in PROs and satisfaction, 2) expectation and satisfaction, 3) expectation-actuality discrepancy and satisfaction, and 4) actuality and satisfaction. RESULTS: In total, 101 patients completed all surveys. Patients expected to improve in all PROs from baseline, except for ODI personal care, in which they expected to get worse after surgery. In actuality, patients improved in all PROs from baseline, except for ODI personal care, in which they did not demonstrate improvement or worsening. Patients did not surpass any expectations regarding PRO improvement. The association between patient satisfaction and postoperative change was strong for the VAS back pain score, while ODI and VAS leg pain scores showed moderate correlations. Preoperative expectation and postoperative satisfaction demonstrated weak to moderate correlations for all outcome measures. All 3 PROs demonstrated moderate correlation between patient satisfaction and the expectation-actuality discrepancy. All 3 PROs demonstrated strong correlations between satisfaction and actual postoperative outcomes, with ODI having the strongest correlation. CONCLUSIONS: In this observational study, the authors determined that the actual postoperative results following surgery were strongly correlated with patient satisfaction, while the patients' expectation, the expectation-actuality discrepancy, and the postoperative improvement did not demonstrate strong correlations for all patient-reported outcome measures utilized in this study. The investigation results suggest that the most important indicator of how satisfied patients feel following surgery may be the actual outcome itself, rather than the preoperative expectation or the degree to which the expected result was met.

Comparative analysis of anterior cervical discectomy and fusion in the inpatient versus outpatient surgical setting.

OBJECTIVEIn a large, consecutive series of patients treated with anterior cervical discectomy and fusion (ACDF) performed by a single surgeon, the authors compared the clinical and surgical outcomes of patients who underwent ACDF in an inpatient versus outpatient setting.METHODSPatients undergoing primary ACDF were retrospectively reviewed and stratified by surgical setting: hospital or ambulatory surgical center (ASC). Data regarding perioperative characteristics, including hospital length of stay and complications, were collected. Neck Disability Index (NDI) and visual analog scale (VAS) scores were used to analyze neck and arm pain in the preoperative period and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Postoperative outcomes were compared using chi-square analysis and linear regression.RESULTSThe study included 272 consecutive patients undergoing a primary ACDF, of whom 172 patients underwent surgery at a hospital and 100 patients underwent surgery at an ASC. Patients undergoing ACDF in the hospital setting were older, more likely to be diabetic, and had a higher comorbidity burden. Patients receiving treatment in the ASC were more likely to carry Workers' Compensation insurance. Patients in the hospital cohort were more likely to have multilevel procedures, had greater blood loss, and experienced a longer length of stay. In the hospital cohort, 48.3% of patients were discharged within 24 hours, while 43.0% were discharged between 24 and 48 hours after admission. Both cohorts had similar VAS pain scores on postoperative day (POD) 0; however, the hospital cohort consumed more narcotics on POD 0. One patient in the ASC cohort had a pretracheal hematoma that was evacuated immediately in the same surgical center. There were 8 cases of dysphagia in the hospital cohort and 3 cases in the ASC cohort, all of which resolved before the 6-month follow-up. Both cohorts demonstrated similar NDI and VAS neck and arm pain scores preoperatively and at every postoperative time point.CONCLUSIONSAlthough patients undergoing ACDF in the hospital setting were older, had a greater comorbidity burden, and underwent surgery on more levels than patients undergoing ACDF at an outpatient center, this study demonstrated comparable surgical and clinical outcomes for both patient groups. Based on the results of this single surgeon's experience, 1- to 2-level ACDFs may be performed successfully in the outpatient setting in appropriately selected patient populations.

Safety and Efficacy of Revision Minimally Invasive Lumbar Decompression in the Ambulatory Setting.

STUDY DESIGN: A retrospective analysis. OBJECTIVE: The aim of this study was to investigate differences in perioperative outcomes between patients undergoing revision minimally invasive lumbar spine decompression (MIS LD) in the ambulatory and hospital-based surgical settings. SUMMARY OF BACKGROUND DATA: Revision LD has been associated with an increased risk of complications compared with primary LD. Furthermore, ambulatory primary LD has been demonstrated to be a safe and viable option in appropriately selected patients. However, there is a paucity of information comparing hospital-based versus ambulatory outcomes in revision LD. METHODS: A prospectively maintained surgical registry of patients undergoing revision MIS lumbar laminectomy and/or discectomy for degenerative pathology from 2013 to 2017 was retrospectively reviewed. Propensity score matching was performed to adjust for measured confounding variables, including patient age, comorbidity burden as measured by Charlson Comorbidity Index, and preoperative diagnosis. Differences in operative variables, complication rates, pain scores, narcotics consumption, and reoperation rates were assessed using Pearson Chi-squared analysis (categorical) and Student t test (continuous). RESULTS: Seventy patients were included, of whom 35 underwent revision MIS LD at a hospital-based center (HBC), and 35 underwent surgery at an ambulatory surgical center (ASC). HBC and ASC patients demonstrated similar postoperative visual analog scale pain scores and hourly narcotics consumption during surgical stay (P < 0.001). ASC patients exhibited a significantly shorter length of stay than hospital-based patients (2.7 vs. 11.6 hours, P < 0.001). CONCLUSION: Patients undergoing revision MIS LD in an ASC demonstrated similar perioperative outcomes as compared to patients undergoing revision MIS LD in a HBC. These results suggest that revision MIS LD can be performed safe and effectively in the ambulatory setting in an appropriately selected surgical population. Further study of patient outcomes following spine surgery performed outside of the traditional hospital setting is crucial, as the delivery of care in the ambulatory setting continues to grow in popularity. LEVEL OF EVIDENCE: 3.