Vitamin D Status and Cardiovascular Disease in College Athletes After SARS-CoV-2 Infection.

OBJECTIVE: To evaluate the association between vitamin D status and CV disease after COVID-19 in college athletes. DESIGN: Retrospective cohort study. SETTING: National College Athletic Association Division-I college athletes from a single academic institution. PATIENTS: A total of 157 athletes (60 female; median age: 20 years) from 9 sports with a positive SARS-CoV-2 test, cardiac magnetic resonance imaging (CMR), and vitamin D level. INDEPENDENT VARIABLES: Serum 25-hydroxyvitamin D level (primary); age, sex (regression models). MAIN OUTCOMES MEASURES: Differences in age, sex, race, ethnicity, myocarditis, pericarditis, and CMR metrics by vitamin D status were analyzed. Regression models were used to assess the relationship between vitamin D status and CMR metrics accounting for age and sex. RESULTS: Low vitamin D (LVD) was found in 33 (21.0%) of athletes, particularly Black males (P < 0.001). Athletes with LVD had higher biventricular and lower mid-ventricular extracellular volumes, but these differences were not significant when corrected for age and sex. Athletes with LVD had higher left ventricle (LV) mass (P < 0.001) and LV mass index (P = 0.001) independent of age and sex. Differences in global circumferential strain were noted but are likely clinically insignificant. Vitamin D status did not associate with myocarditis and pericarditis (P = 0.544). CONCLUSIONS: LVD is common in athletes, particularly in Black males. Although athletes with LVD had higher LV mass, cardiac function and tissue characterization did not differ by vitamin D status. Future studies are needed to determine if the differences in LV mass and LV mass index by vitamin D status are clinically significant. This study suggests that vitamin D status does not impact the development of myocarditis or pericarditis after COVID-19 infection.

Is a Failed Spinal Attempt Associated With a Worse Clinical Course Following Primary Total Hip and Knee Arthroplasty?

BACKGROUND: Spinal anesthesia (SA) is the preferred anesthesia modality for total joint arthroplasty (TJA). However, studies establishing SA as preferential may be subject to selection bias given that general anesthesia (GA) is often selectively utilized on more difficult, higher-risk operations. The optimal comparison group, therefore, is the patient converted to GA due to a failed attempt at SA. The purpose of this study was to determine risk factors and outcomes following failed SA with conversion to GA during primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: A consecutive cohort of 4,483 patients who underwent primary TJA at our institution was identified (2,004 THA and 2,479 TKA). Of these patients, 3,307 underwent GA (73.8%), 1,056 underwent SA (23.3%), and 130 patients failed SA with conversion to GA (2.90%). Primary outcomes included rescue analgesia requirement in the postanesthesia care unit (PACU), time to ambulation, pain scores in the PACU, estimated blood loss, and 90-day complications. RESULTS: Risk factors for SA failure included older age and a higher comorbidity burden. Failure of SA was associated with increased estimated blood loss, rescue intravenous opioid use, and time to ambulation when compared to the successful SA group in both THA and TKA patients (P < .001). The anesthesia modality was not associated with significant differences in PACU pain scores. The 90-day complication rate was similar between the failed SA and GA groups. There was a higher incidence of postoperative pain prompting unplanned visits and thromboembolism when comparing failed SA to successful SA in both THA and TKA patients (P < .05). CONCLUSIONS: In our series, patients who had failed SA demonstrated inferior outcomes to patients receiving successful SA and similar outcomes to patients receiving GA who did not have an SA attempt. This emphasizes the importance of success in the initial attempt at SA for optimizing outcomes following TJA.

Caregiving and Obesity among Black American Adults.

Black American adults often report higher rates of obesity and caregiving compared with other racial or ethnic groups. Consequently, many Black American caregivers and care recipients are obese or have obesity-related chronic conditions (e.g., diabetes, hypertension). This study investigated associations between caregiving and obesity among Black Americans, including the role of health behaviors and chronic conditions. The sample included data from 2015 and 2017 Behavioral Risk Factor Surveillance System for non-Hispanic Black (NHB) or African American adult caregivers (n = 2,562) and noncaregivers (n = 7,027). The association between obesity (dependent variable) and caregiving status, fruit consumption, vegetable consumption, physical activity, and number of chronic conditions (independent variables) were evaluated using hierarchical binomial logistic regressions. Caregiving, being female, and chronic conditions were associated with higher odds of obesity, while physical activity was associated with lower odds of obesity. Physical activity, diet, and chronic conditions did not account for differences in obesity among caregiving and noncaregiving Black Americans. Increasing understanding of health behaviors and chronic disease burden of NHB caregivers has implications for programs aiming to improve obesity-related outcomes for caregivers and recipients. Future research should investigate multilevel factors that contribute to observed differences.

Impact of Racial/Ethnic Disparities on Patient-Reported Outcomes Following Cervical Spine Surgery: QOD Analysis.

STUDY DESIGN: Retrospective analysis of data from the cervical module of a National Spine Registry, the Quality Outcomes Database. OBJECTIVE: To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at one year after cervical spine surgery. SUMMARY OF BACKGROUND DATA: Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and a prolonged length of stay after cervical spine surgery compared with Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic, and other non-Hispanic groups ( i.e . Asian) remains unclear. MATERIALS AND METHODS: PROMs were used to assess disability (neck disability index) and neck/arm pain preoperatively and one-year postoperative. Primary outcomes were disability and pain, and not being satisfied from preoperative to 12 months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups [Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)] with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving a minimal clinically important difference one-year postoperatively. RESULTS: On average, the sample of 14,429 participants had significant reductions in pain and disability, and 87% were satisfied at one-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30%-70%) compared with NHW. NHB had 50% higher odds of worse disability scores compared with NHW. NHA reported similar disability and neck pain outcomes compared with NHW. CONCLUSIONS: Hispanic and NHB patients had worse patient-reported outcomes one year after cervical spine surgery compared with NHW individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for NHA patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.

Clinical Effectiveness of Anterior Cervical Discectomy and Fusion Using Tritanium C Anterior Cervical Cage vs. PEEK Cage.

Introduction: Anterior cervical discectomy and fusion (ACDF) has proven to be a clinically efficient and cost-effective method for treating patients with degenerative cervical spine conditions. New intervertebral implant products are being developed to improve fusion and stability while decreasing complications. This study assesses the effectiveness of Tritanium C (Tri-C) Anterior Cervical Cage (Stryker) in the treatment of degenerative disk disease (DDD) of the cervical spine compared with polyetheretherketone (PEEK) cages. Methods: A retrospective cohort analysis was conducted using data prospectively collected from two institutions. Patients who underwent ACDFs for DDD using either the Tri-C cage or PEEK cage were identified. The patients' demographics, comorbidities, operative variables, and baseline patient-reported outcomes (PROs) were collected. PROs included the Neck Disability Index (NDI) and numeric rating scale (NRS) for neck and arm pain. The primary outcomes included 3- and 12-month PROs as well as the rates of 90-day readmission, 90-day reoperation, and perioperative complication. The radiographic outcomes included rates of subsidence, cage movement, and successful fusion within 12 months. Multivariate linear regression models were run to identify variables predictive of 12-month PROs. Results: A total of 275 patients who underwent ACDF were included in this study and were divided into two groups: PEEK (n=213) and Tri-C (n=62). Both groups showed improvement in neck and arm pain and NDI postoperatively. When Tri-C and PEEK were compared, no significant differences were observed in the 3- or 12-month changes in neck or arm pain or NDI. Furthermore, there were no differences in the rates of 90-day readmission, 90-day reoperation, and perioperative complication. Regression analysis revealed that Tri-C vs. PEEK was not a significant predictor of any outcome. Conclusions: Our results indicate that the use of porous titanium Tri-C cage during ACDFs is an effective method for managing cervical DDD in terms of PROs, perioperative morbidity, and radiologic parameters. No significant difference was observed in any clinical outcome between patients undergoing ACDF using the Tri-C cage and those in whom the PEEK cage was used. Level of Evidence: III.

The Combined Influence of Sleep Disturbance and Depression on 12-month Outcomes after Lumbar Spine Surgery.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To examine the combined influence of preoperative sleep disturbance and depression on 12-month patient-reported outcomes after lumbar spine surgery (LSS). SUMMARY OF BACKGROUND DATA: Psychological and behavioral factors are considered major risk factors of poor outcome after LSS. However, there is a need to explore the combined effects of preoperative factors such as sleep disturbance and depression. Understanding the influence of sleep disturbance and depression can inform evidence-based preoperative assessment and shared-decision making of preoperative and postoperative treatment. METHODS: Data from 700 patients undergoing LSS were analyzed. Preoperative sleep disturbance and depression were assessed with PROMIS subscales. Established thresholds defined patients with moderate/severe symptoms. Outcomes for disability (Oswestry Disability Index) and back and leg pain (Numeric Rating Scales) were assessed preoperatively and at 12 months. Separate multivariable linear regressions examined the influence of each factor on 12-month outcomes with and without accounting for the other, and in combination as a 4-level variable: 1) moderate/severe sleep disturbance alone, 2) moderate/severe depression alone, 3) both moderate/severe sleep disturbance and depression, 4) no moderate/severe sleep disturbance or depression. RESULTS: Preoperative sleep disturbance and depression were associated with 12-month disability and pain (P<0.05). After accounting for depression, preoperative sleep disturbance remained associated with disability, while preoperative depression adjusting for sleep disturbance remained associated with all outcomes (P<0.05). Patients reporting both moderate/severe sleep disturbance and moderate/severe depression had 12.6 points higher disability and 1.5 points higher back and leg pain compared to patients without moderate/severe sleep disturbance or depression. CONCLUSION: The combination of sleep disturbance and depression impacts postoperative outcomes considerably. The high-risk group of patients with moderate/severe sleep disturbance and depression could benefit from targeted treatment strategies.

Impact of occupational characteristics on return to work for employed patients after elective cervical spine surgery.

OBJECTIVE: In a cohort of employed patients undergoing elective cervical spine surgery with an uncomplicated postoperative course, the authors sought to determine the demographic, functional, and occupational characteristics associated with return to work (RTW) following surgery. METHODS: A retrospective cohort study of prospectively collected data was undertaken of patients undergoing elective cervical spine surgery for degenerative disease in the Quality Outcomes Database. Study inclusion criteria were: 1) employed prior to surgery and planned to RTW, 2) no unplanned readmissions, 3) achieved 30% improvement on the Neck Disability Index (NDI), and 4) were satisfied with the surgical outcome at 3 or 12 months postoperatively. A multivariable Cox regression model was built using demographic, functional, operative, and occupational characteristic to predict time to RTW. RESULTS: Of 5110 included patients, 4788 (93.7%) returned to work within 12 months, with a median time of 35 (IQR 19-60) days. Patients who did RTW were significantly younger (51.3 ± 9.4 vs 55.8 ± 9.6 years, p < 0.001), more often underwent an anterior approach (85.8% vs 80.7%, p = 0.009), were significantly more privately insured (82.1% vs 64.0%, p < 0.001), and were less likely to have workers' disability insurance (6.7% vs 14.6%, p < 0.001) compared with patients who did not RTW. On multivariable Cox regression, demographic factors associated with a longer RTW were older age (hazard ratio [HR] 0.99, 95% CI 0.99-1.00, p < 0.001) and Black race (HR 0.71, 95% CI 0.62-0.81, p < 0.001). Male sex was associated with a shorter RTW time (HR 1.19, 95% CI 1.11-1.26, p < 0.001). Regarding baseline functional status, worse preoperative NDI (HR 0.99, 95% CI 0.99-0.99, p < 0.001) was associated with a longer RTW, whereas the absence of myelopathy was associated with a shorter RTW (HR 1.17, 95% CI 1.09-1.25, p < 0.001). Having a sedentary (HR 1.81, 95% CI 1.65-1.99, p < 0.001), light-intensity (HR 1.60, 95% CI 1.45-1.76, p < 0.001), and medium-intensity (HR 1.11, 95% CI 1.01-1.22, p = 0.037) occupation was associated with a shorter RTW time compared with a heavy-intensity occupation at any time point. Heavy-intensity occupations were independently the strongest predictor of longer RTW. Similar predictors of shorter RTW were found in a subanalysis of occupation intensity and among operative approaches used. CONCLUSIONS: Among patients undergoing elective degenerative cervical spine surgery who had favorable surgical outcomes and planned to RTW before surgery, 94% had a successful RTW. Age was the strongest predictor of lower odds of RTW. Regarding time to RTW, having a sedentary, light-intensity, or medium-intensity occupation was associated with a shorter RTW time compared with a heavy-intensity occupation. These findings highlight the importance of considering the demographic and occupational characteristics when predicting postoperative RTW in patients with satisfactory surgical outcomes.

Comparing the Upper Instrumented Vertebrae Tilt Angle vs Screw Angle in the Development of Proximal Junction Kyphosis After Adult Spinal Deformity Surgery: Which Matters More?

BACKGROUND: We sought to determine which aspect of the upper instrumented vertebrae (UIV)-tilt angle or screw angle-was more strongly associated with: (1) proximal junctional kyphosis/failure (PJK/F), (2) other mechanical complications and reoperations, and (3) patient-reported outcome measures (PROMs). METHODS: A single-institution, retrospective cohort study was undertaken for patients undergoing adult spinal deformity (ASD) surgery from 2011 to 2017. Only patients with UIV at T7 or below were included. The primary exposure variables were UIV tilt angle (the angle of the UIV inferior endplate and the horizontal) and UIV screw angle (the angle of the UIV screws and superior endplate). Multivariable logistic regression included age, body mass index, osteopenia/osteoporosis, postoperative sagittal vertical axis, postoperative pelvic-incidence lumbar lordosis mismatch, UIV tilt angle, and UIV screw angle. RESULTS: One hundred and seventeen patients underwent adult spinal deformity surgery with a minimum of 2-year follow-up. A total of 41 patients (35.0%) had PJK and 26 (22.2%) had PJF. (1) UIV tilt angle: 96 (82.1%) had lordotic UIV tilt angles, 6 (5.1%) were neutral, and 15 (12.8%) were kyphotic. (2) UIV screw angle: 38 (32.5%) had cranially directed screws, 4 (3.4%) were neutral, and 75 (64.1%) were caudally directed. Both lordotic-angled UIV endplate (OR = 1.06, 95% CI = 1.01-1.12, and P = 0.020) and cranially directed screws (OR = 1.19, 95% CI = 1.07-1.33, and P < 0.001) were associated with higher odds of PJK, with a more pronounced effect of UIV screw angle compared with UIV tilt angle (Wald test, 9.40 vs 4.42). Similar results were found for PJF. Neither parameter was associated with other mechanical complications, reoperations, or patient-reported outcome measures. CONCLUSIONS: UIV screw angle was more strongly associated with development of PJK/F compared with tilt angle. Overall, these modifiable parameters are directly under the surgeon's control and can mitigate the development of PJK/F. CLINICAL RELEVANCE: Surgeons may consider selecting a UIV with a neutral or kyphotically directed UIV tilt angle when performing ASD surgery with a UIV in the lower thoracic or lumbar region, as well as use UIV screw angles that are caudally directed, for the purprose of decreasing the risk of developing PJK/F.

Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis.

STUDY DESIGN: A retrospective cohort study using prospectively collected data. OBJECTIVE: The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes. MATERIALS AND METHODS: The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF. RESULTS: Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF. CONCLUSIONS: In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.

Impact of Unplanned Readmission on Patient-Reported Outcomes After Cervical Spine Surgery: A National Study of 13 355 Patients.

BACKGROUND AND OBJECTIVES: Although risk factors for unplanned readmission after cervical spine surgery have been widely reported, less is known about how readmission itself affects patient-reported outcome measures (PROMs). Using the Quality Outcomes Database registry of patients undergoing elective cervical spine surgery, we sought to (1) determine the impact of unplanned readmission on PROMs and (2) compare the effect of specific readmission reasons on PROMs. METHODS: An observational study was performed using a multi-institution, retrospective registry for patients undergoing cervical spine surgery. The occurrence of 90-day unplanned readmission classified into medical, surgical, pain only, and no readmissions was the exposure variable. Outcome variables included 12-month PROMs of Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck/arm pain, EuroQol-5D (EQ-5D), and patient dissatisfaction. Multivariable models predicting each PROM were built using readmission reasons controlling for demographics, clinical characteristics, and preoperative PROMs. RESULTS: Data from 13 355 patients undergoing elective cervical spine surgery (82% anterior approach and 18% posterior approach) were analyzed. Unplanned readmission within 90 days of surgery occurred in 3.8% patients, including medical (1.6%), surgical (1.8%), and pain (0.3%). Besides medical reasons, wound infection/dehiscence was the most common reason for unplanned readmission for the total cohort (0.5%), dysphagia in the anterior approach (0.6%), and wound infection/dehiscence in the posterior approach (1.5%). Based on multivariable regression, surgical readmission was significantly associated with worse 12-month NDI, NRS-neck pain, NRS-arm pain, EQ-5D, and higher odds of dissatisfaction. Pain readmissions were associated with worse 12-month NDI and NRS-neck pain scores, and worse dissatisfaction. For specific readmission reasons, pain, surgical site infection/wound dehiscence, hematoma/seroma, revision surgery, deep vein thrombosis, and pulmonary embolism were significantly associated with worsened 12-month PROMs. CONCLUSION: In patients undergoing elective cervical spine surgery, 90-day unplanned surgical and pain readmissions were associated with worse 12-month PROMs compared with patients with medical readmissions and no readmissions.