Surgical Site Infection After Autologous Cranioplasty for Decompressive Craniectomy in Traumatic Brain Injury: A Retrospective Review of Two Level 1 Trauma Centers.

OBJECT: Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI). METHODS: A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05. RESULTS: A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate. CONCLUSIONS: The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible.

Association of osteopenia and osteoporosis with higher rates of pseudarthrosis and revision surgery in adult patients undergoing single-level lumbar fusion.

OBJECTIVE: Patients with osteopenia or osteoporosis who require surgery for symptomatic degenerative spondylolisthesis may have higher rates of postoperative pseudarthrosis and need for revision surgery than patients with normal bone mineral densities (BMDs). To this end, the authors compared rates of postoperative pseudarthrosis and need for revision surgery following single-level lumbar fusion in patients with normal BMD with those in patients with osteopenia or osteoporosis. The secondary outcome was to investigate the effects of pretreatment with medications that prevent bone loss (e.g., teriparatide, bisphosphonates, and denosumab) on these adverse outcomes in this patient cohort. METHODS: Patients undergoing single-level lumbar fusion between 2007 and 2017 were identified. Based on 1:1 propensity matching for baseline demographic characteristics and comorbidities, 3 patient groups were created: osteopenia (n = 1723, 33.3%), osteoporosis (n = 1723, 33.3%), and normal BMD (n = 1723, 33.3%). The rates of postoperative pseudarthrosis and revision surgery were compared between groups. RESULTS: The matched populations analyzed in this study included a total of 5169 patients in 3 groups balanced at baseline, with equal numbers (n = 1723, 33.3%) in each group: patients with a history of osteopenia, those with a history of osteoporosis, and a control group of patients with no history of osteopenia or osteoporosis and with normal BMD. A total of 597 complications were recorded within a 2-year follow-up period, with pseudarthrosis (n = 321, 6.2%) being slightly more common than revision surgery (n = 276, 5.3%). The odds of pseudarthrosis and revision surgery in patients with osteopenia were almost 2-fold (OR 1.7, 95% CI 1.26-2.30) and 3-fold (OR 2.73, 95% CI 1.89-3.94) higher, respectively, than those in patients in the control group. Similarly, the odds of pseudarthrosis and revision surgery in patients with osteoporosis were almost 2-fold (OR 1.92, 95% CI 1.43-2.59) and > 3-fold (OR 3.25, 95% CI 2.27-4.65) higher, respectively, than those in patients in the control group. Pretreatment with medications to prevent bone loss prior to surgery was associated with lower pseudarthrosis and revision surgery rates, although the differences did not reach statistical significance. CONCLUSIONS: Postoperative pseudarthrosis and revision surgery rates following single-level lumbar spinal fusion are significantly higher in patients with osteopenia and osteoporosis than in patients with normal BMD. Pretreatment with medications to prevent bone loss prior to surgery decreased these complication rates, although the observed differences did not reach statistical significance.

Atlantoaxial Rotatory Subluxation: A Review for the Pediatric Emergency Physician.

Pediatric emergency physicians must have a high clinical suspicion for atlantoaxial rotatory subluxation (AARS), particularly when a child presents with neck pain and an abnormal head posture without the ability to return to a neutral position. As shown in the neurosurgical literature, timely diagnosis and swift initiation of treatment have a greater chance of treatment success for the patient. However, timely treatment is complicated because torticollis can result from a variety of maladies, including: congenital abnormalities involving the C1-C2 joint or the surrounding supporting muscles and ligaments, central nervous system abnormalities, obstetric palsies from brachial plexus injuries, clavicle fractures, head and neck surgery, and infection. The treating pediatrician must discern the etiology of the underlying problem to determine both timing and treatment paradigms, which vary widely between these illnesses. We present a comprehensive review of AARS that is intended for pediatric emergency physicians. Management of AARS can vary widely bases on factors, such as duration of symptoms, as well as the patient's history. The goal of this review is to streamline the management paradigms and provide an inclusive review for pediatric emergency first responders.

Impact of subsidence on clinical outcomes and radiographic fusion rates in anterior cervical discectomy and fusion: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To provide a systematic review of published literature on the impact of subsidence on clinical outcomes and radiographic fusion rates after anterior cervical discectomy and fusion with plates or without plates. BACKGROUND: Subsidence of interbody implants is common after anterior cervical spine fusions. The impact of subsidence on fusion rates and clinical outcomes is unknown. METHODS: Systematic literature review on published articles on anterior cervical discectomy and fusion, which objectively measured graft subsidence, radiographic fusion rates, and clinical outcomes between April 1966 and December 2010. RESULTS: A total of 35 articles that measured subsidence and provided fusion rates and/or clinical outcomes were selected for inclusion. The mean subsidence rate ranged from 19.3% to 42.5%. The rate of subsidence based on the type of implant ranged from 22.8% to 35.9%. The incidence of subsidence was not impacted by the type of implant (P=0.98). The overall fusion rate of the combined studies was 92.8% and was not impacted by subsidence irrespective of subsidence definition or the measurement technique used (P=0.19). Clinical outcomes were evaluated in 27 of 35 studies with all studies reporting an improvement in patient outcomes postoperatively. CONCLUSIONS: Subsidence irrespective of the measurement technique or definition does not appear to have an impact on successful fusion and/or clinical outcomes. A validated definition and standard measurement technique for subsidence is needed to determine the actual incidence of subsidence and its impact on radiographic and clinical outcomes.

Initial experience with extreme angle cervical screw for treatment of trauma and cervical spondylosis.

In this study, we have described our initial experience and surgical technique of extreme angle screw placement in the cervical and upper thoracic spine of a cohort of patients undergoing posterior fusion. This extreme angle screw facilitates rod placement without need for any coronal contouring of the rod or offset connectors despite the varied entry site locations for posterior instrumentation and the different trajectories and pathways of these screws. From ruary 2011 to July 2011, extreme angle screws were placed in twenty consecutive adult patients who underwent posterior cervical, occipital-cervical or cervical-thoracic fusions. The primary diagnosis was cervical spondylotic myelopathy (13), trauma (4), and pseudoarthrosis with stenosis (3). Eight patients had gross instability. A total of 196 screws were placed; half of the cases involved instrumentation at or within the C3-7 segments (10) and the others included constructs extending to occipital bone, C2, T1, or T2 (10). Of all twenty cases, there were no perioperative hardware complications. At long-term follow-up, two patients required reoperation, one for hardware failure and the other for single level symptomatic pseudoarthrosis. We conclude that extreme angle screw use in the posterior cervical spine provides an evolution in posterior instrumentation that maximizes the biomechanical strength of a construct, allows for easy rod placement, and may improve the restoration of sagittal alignment. Overall, extreme angle screws facilitate rod placement even for screws offset from the natural plane of the rod, thereby avoiding the need for coronal contouring or placement of offset connectors.

Evaluation of ERAS protocol implementation on complex spine surgery complications and length of stay: a Single Institution Study.

BACKGROUND CONTEXT: With the goal of improving patient outcomes, the Integrated Spine Center at UT Southwestern Medical Center implemented an enhanced recovery after surgery (ERAS) protocol which includes pre- and post-surgery guidelines. Numerous studies have shown benefit of implementation of ERAS protocols to standardize perioperative care in line with best practices; however, the literature on complication rates, LOS, and readmissions shows mixed results. PURPOSE: The goal of this study was to investigate the impact of the ERAS protocol implementation on complication rates in the perioperative period, as well as hospital and ICU length of stay and hospital re-admission rates. STUDY DESIGN/SETTING: A retrospective cohort study was performed on all patients who underwent spine surgery between September 2016 and September 2021 at a single institution. Patients who met inclusion criteria were divided into non-ERAS and ERAS groups, and comparative statistics were used to evaluate ERAS protocol effectiveness. PATIENT SAMPLE: All patients who underwent spine surgery at UT Southwestern between September 2016 and September 2021 were evaluated for inclusion in the study. The patient sample was further refined to include only complex patient cases which were able to receive the full ERAS protocol (non-emergent admissions). OUTCOME MEASURES: Presence of absence of post-operative complications including surgical site infection, AKI, DVT, MI, sepsis, pneumonia, PE, stroke, shock, and other complications were compared between groups, as were hospital and ICU length of stay, and 7, 30, and 90 day readmissions. Self-reported or functional measures were not used in outcome evaluation. METHODS: A database of patient and surgery characteristics was built using an EMR query tool with spot checks performed by the authors. Control and treatment groups were matched for gender, age, BMI, ASA score, and surgery type. Total number of complication rates was compared between ERAS and non-ERAS groups, and comparative statistics were used to determine significance. RESULTS: Significant differences between ERAS versus non-ERAS groups were found in rates of UTI (6.8% vs. 3.1%, respectively; p=.031), constipation (20.6% vs. 11.4%, respectively; p=.001), and any complications (31.4% vs. 19.4%, respectively; p<.001). There was no significant difference in the rates of other complications, in length of hospital or ICU stay, or readmissions at 7, 30, and 90 days. CONCLUSIONS: Implementation of the ERAS protocol did not decrease complication rates or length of stay, and ERAS patients had significantly higher rates of UTI, constipation, and any complications. There may have been confounding factors due to the impact of COVID-19 on delivery of care, as well as misalignment between ERAS goals and outcome measures.

3D-Printed Spine Models for Planning Staged Minimally Invasive Transverse Process Resections for Bertolotti Syndrome: Technical Note.

Background: Three-dimensional (3D) printing has enabled numerous advances in spine surgery execution and education. However, few examples exist to outline how this technology can aid the performance of complex spine surgery using minimally invasive surgery (MIS) techniques. Therefore, we present a case that illustrates the benefits of 3D-printed spine model production before and after correction of a congenital lumbosacral anomaly using an MIS approach. Case Report: A 40-year-old woman with Bertolotti syndrome underwent a staged bilateral L6 MIS transverse process resection for the treatment of severe and progressive axial back pain which had repeatedly failed conservative management. 3D-printed spine models were used for pre- and post-operative surgical planning and patient counseling. Conclusion: 3D-printed spine models can aid in the planning of complex spine cases suited for an MIS approach.

Trends of the Oswestry Disability Index in Adult Spinal Deformity Patients: A 3-Year Study.

BACKGROUND: Patients with adult spinal deformity (ASD) undergoing operative treatment may have varying degrees of improvement in patient-reported outcomes. The Oswestry Disability Index (ODI) assesses improvement in quality of life. We aim to measure longitudinal outcomes of ODI scores over 3 years to determine if early ODI scores predict late ODI scores and to analyze longitudinal changes in ODI scores. METHODS: Two hundred thirty-five patients above the age of 18 who underwent surgical correction of ASD at a single institution from 2016 to 2021 and completed ODI questionnaires at follow-up appointments met inclusion criteria. ODI scores were included from follow-up visits at 0 months (immediately postoperative) and within ±1 month of 3, 6, 12, 18, 24, 30, and 36 months. Percent change in ODI from 0 months was calculated, and unpaired t tests were conducted. RESULTS: ODI scores increased by 8.8% immediately postoperatively, and the percent change from preoperative ODI scores at each subsequent visit were as follows: -11.1% at 3 months, -21.4% at 6 months, -25.4% at 12 months, -28% at 18 months, -31.3% at 24 months, -25.7% at 30 months, and -36.5% at 36 months. ODI scores at each follow-up visit showed significant improvement from baseline (P < 0.001). There was an improvement in scores from 3 to 6 months (P = 0.04), but no significant difference in 6-month interval visits following 6 months. CONCLUSIONS: Our results demonstrate a significant and sustained improvement in ODI scores over 3 years following surgical correction of ASD. ODI scores were stable after 6 months, indicating that ODI scores at 6 months may be predictive of scores out to 3 years postoperatively. Examining individual components of ODI sub-scores and comparing ODI results to other PROMs are critical to better assess long-term outcomes in ASD.

Identifying Correlation Among Patient-Reported Outcome Measures: A Study of PROMIS-29, ODI, and VAS in Adult Spinal Deformity Patients.

BACKGROUND: Adult spinal deformity (ASD) is becoming increasingly common in aging populations. Patient-reported outcome measures (PROMs) are self-reported patient surveys administered pre- and postoperatively that provide insight into patient improvement. We aim to compare 3 of the most utilized PROMs: PROMIS-29, Oswestry Disability Index (ODI), and Visual Analogue Scale (VAS), to investigate whether they provide unique and independent assessments of patient outcomes when assessed longitudinally. METHODS: We retrospectively reviewed a database of ASD at UT Southwestern Medical Center between 2016 and 2021. Adult patients (>18 years old) were included if they underwent long-segment (>4 levels) thoracolumbar fusion. PROMIS-29, ODI, and VAS scores were collected preoperatively and at 3-, 6-, 12-, 18-, 24-, 30-, and 36-month follow-ups. Scores were recorded ±1 month of the time points. Pearson correlation coefficients for each PROM were then calculated in a pairwise fashion. RESULTS: A total of 163 patients were included in our analysis. ODI and VAS showed significant covariance, with VAS Neck and VAS Back having Pearson coefficients of 0.95 and 0.94, respectively. ODI and PROMIS-29 also showed significant covariance, with Physical Function and ODI showing a Pearson coefficient of 0.95. PROMIS-29 and VAS demonstrated less correlation regarding Pain and Physical Function; however, they showed a significantly high Pearson coefficient when comparing VAS Back with PROMIS-29 Sleep and Pain Intensity (r = 0.97 and r = 0.96, respectively). CONCLUSIONS: All 3 PROMs demonstrated significant correlation over 36 months, indicating that simultaneous administration of each during follow-up is redundant. The measure that provided the least unique information was ODI, as both VAS and PROMIS-29 demonstrated similar progression and assessed additional metrics. PROMIS-29 provided the same information as VAS and ODI, with extra facets of patient-reported outcomes, indicating that it may be a more comprehensive measure of longitudinal patient improvement.

A 3-Year Study Investigating the Utility of Patient-Reported Outcomes Measurement Information System-29 for Long-Term Follow-Up in Adult Spinal Deformity.

BACKGROUND: Adult spinal deformity (ASD) significantly impacts the quality of life due to three-dimensional spinal abnormalities. Patient-reported outcome measures, such as the Patient-Reported Outcomes Measurement Information System (PROMIS-29), play a crucial role in assessing postoperative outcomes. This study aims to investigate trends in PROMIS-29 scores over 36 months in patients undergoing long-segment thoracolumbar fusion for ASD and provide insights into its long-term utility. METHODS: A retrospective study including 163 ASD patients undergoing long-segment thoracolumbar fusion was conducted. PROMIS-29 scores were collected at baseline and at postoperative (0-), 3-, 6-, 12-, 18-, 24-, 30-, and 36-month follow-ups. Statistical analyses was performed to assess significant score changes from baseline and in consecutive recordings. RESULTS: Significant improvements in all PROMIS-29 categories were observed at 36 months, with the greatest changes in pain intensity (-35.19%, P < 0.001), physical function (+29.13%, P < 0.001), and pain interference (-28.8%, P < 0.001). Between the 0 and 3 month mark, the greatest significant changes were recorded in pain intensity (-26.5%, P < 0.001), physical function (+24.3%, P < 0.001), and anxiety (-16.9%, P < 0.018). However, scores plateaued after the 3-month mark, with zero categories showing significant changes with subsequent consecutive recordings. CONCLUSIONS: PROMIS-29 scores demonstrated notable improvements in ASD patients particularly in pain intensity, pain interference, and physical function. However, scores plateaued beyond the 3-month mark, suggesting PROMIS-29's limited sensitivity to nuanced changes in long-term patient recovery. Future investigations exploring optimal combinations of patient reported outcome measures for comprehensive short- and long-term outcome assessments in ASD surgery would be beneficial.

Age is Associated with Level of First-Time Anterior Cervical Discectomy and Fusion: An Ordinal Analysis of Factors Influencing Timing of Cervical Degeneration.

BACKGROUND: Symptomatic cervical spondylosis is often treated with anterior cervical discectomy and fusion (ACDF). However, few factors can predict which cervical level will degenerate and require intervention. This analysis evaluates preprocedural factors associated with level of first-time single-level ACDF. METHODS: We performed a retrospective analysis of patients who underwent single-level ACDF without prior history of spine surgery. Mann Whitney U-tests and Spearman rank-order correlation were performed for analyses of associations between variables of interest and ACDF level. Adjusted odds-ratios were calculated by proportional-odds logistic regression, with age, sex, body mass index, current tobacco use, history of neck trauma, preoperative radicular symptoms, and preoperative myelopathic symptoms as covariates. RESULTS: One hundred forty-one patients met inclusion criteria, and age demonstrated a negative correlation with ACDF level, such that younger patients tended to have ACDF performed at inferior subaxial levels (P = 0.0006, rho = -0.31, moderately strong relationship). Patients with preoperative radicular symptoms and myelopathic symptoms were more likely to have ACDF performed at inferior (P = 0.0001) and superior (P < 0.0001) levels, respectively. Patient sex, body mass index, current tobacco use, and history of neck trauma were not predictive of ACDF level. When adjusting for the above variables in a proportional-odds ordinal logistic regression model, a one-year increase in age conferred a 4% increase in the odds of requiring an ACDF at a given superior level compared to the adjacent inferior level. CONCLUSIONS: Age is correlated with level of first-time single level ACDF. Individual subaxial levels may have unique biomechanical properties that influence degeneration.

Basilar Impression: A Systematic Review and Meta-Analysis of Clinical Features, Operative Strategies and Outcomes.

OBJECTIVE: Basilar Impression (BI) is a rare yet debilitating abnormality of the craniovertebral junction (CVJ), known to cause life-threatening medullary brainstem compression. Our study analyzes surgical approaches for BI and related outcomes. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to critically assess primary articles examining BI. RESULTS: We analyzed 87 patients from 65 articles, mostly female (55.17%) with a mean age of 46.31 ± 17.94 years, commonly presenting with motor (59.77%) and sensory deficits (55.17%). Commonly employed procedures included posterior occipitocervical fusion (24.14%), anterior decompression (20.69%), and combined anterior decompression with posterior fusion (21.84%). Patients who underwent anterior approaches were found to be older (55.38 ± 17.67 vs. 45.49 ± 18.78 years, p < 0.05) and had a longer duration from symptom onset to surgery (57.39 ± 64.33 vs. 26.02 ± 29.60 months, p < 0.05) compared to posterior approaches. Our analysis revealed a significant association between a longer duration from symptom onset to surgery and an increased likelihood of undergoing odontoidectomy and decompression (OR: 1.02, 95% CI: 1.00-1.03, p < 0.05). Furthermore, after adjusting for all other covariates, a history of rheumatoid arthritis and the use of a posterior approach were significantly associated with an elevated risk of postoperative complications (p < 0.05). CONCLUSIONS: The treatment approach to complex CVJ disease should be tailored to the surgeon's experience and the nature of the compressive pathology.

A Comparative Analysis of Frailty, Disability, and Sarcopenia With Patient Characteristics and Outcomes in Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective case series study. OBJECTIVES: This study aims to compare preoperative indices, including the modified frailty index-11 (mFI-11), modified frailty index-5 (mFI-5), Oswestry Disability Index (ODI), and psoas muscle index (PMI), as they relate to outcomes in adult spinal deformity (ASD) surgery. METHODS: We identified 235 patients who underwent thoracolumbar ASD surgery (≥4 levels). The mFI-11, mFI-5, ODI, and PMI were determined from preoperative visits and correlated to outcome measures, including perioperative transfusion, duration of anesthesia, hospital and ICU length of stay (LOS), discharge disposition, readmission, change in ODI at last follow-up, revision surgery, and mortality. RESULTS: Our cohort had a mean age of 69.6 years and a male:female ratio of 1:2 with 177 undergoing an index surgery and 58 patients presenting after a failed multilevel fusion. The average number of levels fused was 9.3. The mFI-11 and mFI-5 were similar in predicting the need for intraoperative and postoperative transfusion. However, the mFI-11 was able to predict longer ICU and hospital LOS and mortality. The average preoperative ODI was 44.9% with an average decrease of 10.1% at the last follow-up. Preoperative ODI was the most significant predictor of postoperative change of ODI. Sarcopenia, defined as the lowest quartile of PMI values measured at L3 and L4, was not associated with any meaningful outcomes. CONCLUSION: The mFI-11 better correlated with outcomes, indicating its increased prognostic value compared to other preoperative indices in ASD surgery. Preoperative ODI remains a significant predictor of postoperative change in ODI when evaluating ASD patients.

VertebralArtery Injury with Anterior Cervical Spine Operations: A Systematic Review of Risk Factors, Clinical Outcomes, and Management Strategies.

OBJECTIVE: Anterior cervical spine operations are commonly performed on cervical spine pathologies and to a large extent are safe and successful. However, these surgical procedures expose the vertebral artery, posing a risk of harm to it. METHODS: A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to critically assess primary articles discussing treatment strategies "vertebral artery injury" AND "anterior cervical spine" and develop a management strategy based on our experience and meta-analysis of the literature. In addition, we present an illustrative case of iatrogenic vertebral artery injury presenting with 6 to 7 months' history of progressive dysphagia was transferred to our care from an outside institution. RESULTS: Included and analyzed were 43 articles that detailed 75 cases involving vertebral artery injury (VAI) in anterior cervical spine operations. Preoperatively, frequent clinical findings reported were sensory deficit (26 patients [63.41%]), motor deficit (20 patients [48.78%]), and pain (17 patients [41.46%]). In total, 32 patients (50.00%) endured injury of their left VA, and 30 patients had a right VAI. The 2 common causes of VAI were drilling (24 patients [40.00%]) and instrumentation (8 patients [13.33%]). CONCLUSIONS: Altogether, our review recommends repair or tamponade packing with a hemostatic agent for primary management. Should tamponade packing with a hemostatic agent be used for primary management, secondary management should entail either repair, stenting occlusion, embolization, anticoagulants, or ligation. Further examination of this treatment strategy based on a larger cohort is necessary.

Alexa Irene Canady: First Female African American Neurosurgeon of the United States.

BACKGROUND: This historical account reviews the course and lasting impact of Dr. Alexa Irene Canady in neurosurgery. METHODS: The writing of this project was sparked by the discovery of original scientific and bibliographical information about Alexa Canady, the first female African-American neurosurgeon in the nation. This article is a thorough review of the literature and information on Canady, reflecting the breadth of these previous publications, and showcasing our viewpoints after comprehensive compilation of information. RESULTS: Our paper begins by introducing Dr. Alexa Irene Canady and her decision to pursue a career in medicine during her years in university; follows her journey through medical school and growing interests in neurosurgery; outlines her journey in residency; discusses her career as an established pediatric neurosurgeon at the University of Michigan; outlines her role in establishing a department of pediatric neurosurgery in Pensacola, Florida; and details the obstacles and challenges she faced throughout her career, as well as the barriers she broke along the way. CONCLUSIONS: Our article provides glimpses into the personal life and achievements of Dr. Alexa Irene Canady and her marked impact on the field of neurosurgery.

Impact of obesity on complications and surgical outcomes after adult degenerative scoliosis spine surgery.

OBJECTIVE: To compare perioperative outcomes of obese versus non-obese adult patients who underwent degenerative scoliosis spine surgery. METHODS: 235 patients who underwent thoracolumbar adult spinal deformity (ASD) surgery (≥4 levels) were identified and categorized into two cohorts based on their body mass indices (BMI): obese (BMI ≥30 kg/m2; n = 81) and non-obese (BMI <30 kg/m2; n = 154). Preoperative (demographics, co-morbidities, American Society of Anesthesiologists (ASA) score and modified frailty indices (mFI-5 and mFI-11)), intraoperative (estimated blood loss (EBL) and anesthesia duration), and postoperative (complication rates, Oswestry Disability Index (ODI) scores, discharge destination, readmission rates, and survival) characteristics were analyzed by student's t, chi-squared, and Mann-Whitney U tests. RESULTS: Obese patients were more likely to be Black/African-American (p < 0.05, OR:4.11, 95% CI:1.20-14.10), diabetic (p < 0.05, OR:10.18, 95% CI:4.38-23.68) and had higher ASA (p < .01) and psoas muscle indices (p < 0.0001). Furthermore, they had greater pre- and post-operative ODI scores (p < 0.05) with elevated mFI-5 (p < 0.0001) and mFI-11 (p < 0.01). Intraoperatively, obese patients were under anesthesia for longer time periods (p < 0.05) with higher EBL (p < 0.05). Postoperatively, while they were more likely to have complications (OR:1.77, 95% CI:1.01 - 3.08), had increased postop days to initiate walking (p < .05) and were less likely to be discharged home (OR:0.55, 95% CI:0.31-0.99), no differences were found in change in ODI scores or readmission rates between the two cohorts. CONCLUSIONS: Obesity increases pre-operative risk factors including ASA, frailty and co-morbidities leading to longer operations, increased EBL, higher complications and decreased discharge to home. Pre-operative assessment and systematic measures should be taken to improve peri-operative outcomes.

Household Income as a Predictor for Surgical Outcomes and Opioid Use After Spine Surgery in the United States.

STUDY DESIGN: Cross-Sectional Study. OBJECTIVES: Socioeconomic status (SES) is a fundamental root of health disparities, however, its effect on surgical outcomes is often difficult to capture in clinical research, especially in spine surgery. Here, we present a large single-center study assessing whether SES is associated with cause-specific surgical outcomes. METHODS: Patients undergoing spine surgery between 2015 and 2019 were assigned income in accordance with the national distribution and divided into quartiles based on the ZIP code-level median household income. We performed univariate, chi-square, and Analysis of Variance (ANOVA) analysis assessing the independent association of SES, quantified by household income, to operative outcomes, and multiple metrics of opioid consumption. RESULTS: 1199 patients were enrolled, and 1138 patients were included in the analysis. Low household income was associated with the greatest rates of 3-month opioid script renewal (OR:1.65, 95% CI:1.14-2.40). In addition, low-income was associated with higher rates of perioperative opioid consumption compared to higher income including increased mean total morphine milligram equivalent (MME) 252.25 (SD 901.32) vs 131.57 (SD 197.46) (P < .046), and inpatient IV patient-controlled analgesia (PCA) MME 121.11 (SD 142.14) vs 87.60 (SD 86.33) (P < .023). In addition, household income was independently associated with length of stay (LOS), and emergency room (ER) revisits with low-income patients demonstrating significantly longer postop LOS and increasing postoperative ER visits. CONCLUSIONS: Considering the comparable surgical management provided by the single institution, the associated differences in postoperative outcomes as defined by increased morbidities and opioid consumption can potentially be attributed to health disparities caused by SES.

Psoas Muscle Index as a Predictor of Perioperative Outcomes in Geriatric Patients Undergoing Spine Surgery.

STUDY DESIGN: Single-center retrospective study. OBJECTIVE: The objective of this study was to evaluate the association of psoas muscle mass defined sarcopenia with perioperative outcomes in geriatric patients undergoing elective spine surgery. METHODS: We included geriatric patients undergoing thoracolumbar spinal surgery. Total psoas surface area (TPA) was measured on preoperative axial computerized tomography or magnetic resonance imaging at the L3 vertebra and normalized to the L3 vertebral body area. Patients were divided into quartiles by normalized TPA, and the fourth quartile (Q4) was compared to quartiles 1-3 (Q1-3). Outcomes included perioperative transfusions, length of stay (LOS), delirium, pseudoarthrosis, readmission, discharge disposition, revision surgery, and mortality. RESULTS: Of the patients who met inclusion criteria (n = 196), the average age was 73.4 y, with 48 patients in Q4 and 148 patients in Q1-3. Q4 normalized TPA cut-off was <1.05. Differences in Q4 preoperative characteristics included significantly lower body mass index, baseline creatinine, and a greater proportion of females (Table 1). Q4 patients received significantly more postoperative red blood cell and platelet transfusions and had longer ICU LOS (P < .05; Table 2). There was no difference in intraoperative transfusion volumes, delirium, initiation of walking, discharge disposition, readmission, pseudoarthrosis, or revision surgery (Tables 2 and 3). Mortality during follow-up was higher in Q4 but was not statistically significant (P = .075). CONCLUSION: Preoperative TPA in geriatric patients undergoing elective spine surgery is associated with increased need for intensive care and postoperative blood transfusion. Preoperative normalized TPA is a convenient measurement and could be included in geriatric preoperative risk assessment algorithms.

Single Nucleotide Polymorphisms and Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis of the Literature.

STUDY DESIGN: Meta-analysis. OBJECTIVE: To determine the single nucleotide polymorphisms (SNPs) that are related to adult idiopathic scoliosis. SUMMARY AND BACKGROUND DATA: Adolescent idiopathic scoliosis (AIS) is considered one of the most prevalent spinal diseases. Even though the cause of AIS is yet to be determined, family history and sex have shown conclusive associations. Multiple studies have indicated that AIS is more prevalent in families where at least one other first-degree relative is similarly affected, indicating a possible genetic etiology to AIS. MATERIALS AND METHODS: Articles were collected from 3 different search engines and then processed in 2 stages for final article selection for quantitative analysis. Five different genetic models were represented to show the association between the different SNPs and AIS. The Hardy-Weinberg equilibrium was examined using Fisher exact test, with significance set at P <0.05. The final analysis paper's quality was evaluated using the Newcastle Ottawa Scale. Kappa interrater agreement was calculated to evaluate the agreement between authors. RESULTS: The final analysis comprised 43 publications, 19412 cases, 22005 controls, and 25 distinct genes. LBX1 rs11190870 T>C and MATN-1 SNPs were associated with an increased risk of AIS in one or all of the 5 genetic models. IGF-1 , estrogen receptor alfa, and MTNR1B , SNPs were not associated with AIS in all 5 genetic models. Newcastle Ottawa Scale showed good quality for the selected articles. Cohen k = 0.741 and Kappa interrater agreement of 84% showed that the writers were in strong agreement. CONCLUSIONS: There seem to be associations between AIS and genetic SNP. Further larger studies should be conducted to validate the results.

Image-Guided Percutaneous Multilevel Pediculosynthesis for Treatment of Contiguous Pedicle Stress Fractures: Technical Case Report.

BACKGROUND: Nontraumatic pedicle fracture is uncommon, with sparsely described cases of conservative management versus surgical treatment by open fusion or percutaneous fixation. METHODS: We report the case of a 60-year-old woman with nontraumatic L4 and L5 pedicle fracture who developed additional pedicle fractures at L3 while undergoing conservative management in a brace. The patient underwent percutaneous pediculosynthesis with screw fixation without fusion at L3-5 bilaterally. RESULTS: The treatment led to fracture healing with good radiographic result and resolution of her symptoms. CONCLUSIONS: A trial of conservative management is typically warranted in most cases of nontraumatic pedicle fracture, but there is risk of refractory or progressive symptoms and subsequent fracture. Minimally invasive fixation is a viable surgical option that can be used in multilevel fractures.