The attainment of a patient acceptable symptom state in patients undergoing revision spine fusion.

INTRODUCTION: Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision. METHODS: We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a distribution-based method at each postoperative time point. PASS was set at the threshold of ≤ 22. RESULTS: We identified 197 patients: 56% with ASD, 28% with recurrent stenosis, and 15% with pseudarthrosis. The MCID for ODI was 10.05 and 10.23 at three months and one year, respectively. In total, 61% of patients with ASD, 52% of patients with nonunion, and 65% of patients with recurrent stenosis achieved our cohort-specific MCID at one year postoperatively with ASD (p = 0.78). At one year postoperatively, 33.8% of ASD patients, 47.8% of nonunion patients, and 37% of patients with recurrent stenosis achieved PASS without any difference between indication (p = 0.47). CONCLUSIONS: The majority of patients undergoing revision spine fusion experience significant postoperative improvements regardless of the indication for revision. However, a large proportion of these patients do not achieve the patient acceptable symptom state. While revision spine surgery may offer substantial benefits, these results underscore the need to manage patient expectations.

Relating preoperative MCS-12 to microdiscectomy outcomes.

PURPOSE: To determine the impact of poor mental health on patient-reported and surgical outcomes after microdiscectomy. METHODS: Patients ≥ 18 years who underwent a single-level lumbar microdiscectomy from 2014 to 2021 at a single academic institution were retrospectively identified. Patient-reported outcomes (PROMs) were collected at preoperative, three-month, and one-year postoperative time points. PROMs included the Oswestry Disability Index (ODI), Visual Analog Scale Back and Leg (VAS Back and VAS Leg, respectively), and the mental and physical component of the short form-12 survey (MCS and PCS). The minimum clinically important differences (MCID) were employed to compare scores for each PROM. Patients were categorized as having worse mental health or better mental health based on a MCS threshold of 50. RESULTS: Of 210 patients identified, 128 (61%) patients had a preoperative MCS score ≤ 50. There was no difference in 90-day surgical readmissions or spine reoperations within one year. At 3- and 12-month time points, both groups demonstrated improvements in all PROMs (p < 0.05). At three months postoperatively, patients with worse mental health had significantly lower PCS (42.1 vs. 46.4, p = 0.004) and higher ODI (20.5 vs. 13.3, p = 0.006) scores. Lower mental health scores were associated with lower 12-month PCS scores (43.3 vs. 48.8, p < 0.001), but greater improvements in 12-month ODI (- 28.36 vs. - 18.55, p = 0.040). CONCLUSION: While worse preoperative mental health was associated with lower baseline and postoperative PROMs, patients in both groups experienced similar improvements in PROMs. Rates of surgical readmissions and reoperations were similar among patients with varying preoperative mental health status.

An international validation of the AO spine subaxial injury classification system.

PURPOSE: To validate the AO Spine Subaxial Injury Classification System with participants of various experience levels, subspecialties, and geographic regions. METHODS: A live webinar was organized in 2020 for validation of the AO Spine Subaxial Injury Classification System. The validation consisted of 41 unique subaxial cervical spine injuries with associated computed tomography scans and key images. Intraobserver reproducibility and interobserver reliability of the AO Spine Subaxial Injury Classification System were calculated for injury morphology, injury subtype, and facet injury. The reliability and reproducibility of the classification system were categorized as slight (ƙ = 0-0.20), fair (ƙ = 0.21-0.40), moderate (ƙ = 0.41-0.60), substantial (ƙ = 0.61-0.80), or excellent (ƙ = > 0.80) as determined by the Landis and Koch classification. RESULTS: A total of 203 AO Spine members participated in the AO Spine Subaxial Injury Classification System validation. The percent of participants accurately classifying each injury was over 90% for fracture morphology and fracture subtype on both assessments. The interobserver reliability for fracture morphology was excellent (ƙ = 0.87), while fracture subtype (ƙ = 0.80) and facet injury were substantial (ƙ = 0.74). The intraobserver reproducibility for fracture morphology and subtype were excellent (ƙ = 0.85, 0.88, respectively), while reproducibility for facet injuries was substantial (ƙ = 0.76). CONCLUSION: The AO Spine Subaxial Injury Classification System demonstrated excellent interobserver reliability and intraobserver reproducibility for fracture morphology, substantial reliability and reproducibility for facet injuries, and excellent reproducibility with substantial reliability for injury subtype.

The severity of preoperative anemia escalates risk of poor short-term outcomes after lumbar spine fusion.

OBJECTIVE: To evaluate how preoperative anemia severity affects 90-day outcomes of spinal fusion surgery. METHODS: A retrospective cohort study was conducted on adult lumbar fusion patients at a tertiary medical center. Patients were classified by World Health Organization anemia severity definitions for comparisons. Multivariate regression models were created to control for confounding variables, for all primary outcomes of transfusion requirements, non-home discharge, readmissions, complications, and length of stay. RESULTS: A total of 2582 patients were included: 2.7% with moderate-severe anemia, 11.0% with mild anemia, and 86.3% without anemia. Moderate-severe patients had the longest hospital stay (5.03 days vs 4.14 and 3.59 days, p < 0.001) and highest risk of transfusion (52.2% vs 13.0% vs 2.69%, p < 0.001), non-home discharge (39.1% vs 27.8% vs 15.4%, p < 0.001), readmission (7.25% vs 5.99% vs 3.36%, p = 0.023), and complications (13.0% vs 9.51% vs 6.20%, p = 0.012). On multivariable logistic regression, both patients with mild and moderate-severe anemia had an increased risk of transfusion (OR: 37.3, p < 0.001; OR: 5.25, p < 0.001, respectively) and non-home discharge (OR: 2.00, p = 0.021; OR: 1.71, p = 0.001, respectively) compared to patients without anemia. Anemia severity was not independently associated with complications or 90-day readmission. On multivariable linear regression, mild anemia (ß: 0.37, p = 0.001) and moderate-severe anemia (ß: 1.07, p < 0.001) were independently associated with length of hospital stay. CONCLUSION: Patients with moderate-severe preoperative anemia are at increased risk for longer length of stay, transfusions, and non-home discharge. Improved optimization of preoperative anemia may significantly reduce healthcare utilization, and surgeons should consider these risks in preoperative planning. LEVEL OF EVIDENCE: III.

The impact of cage positioning on lumbar lordosis and disc space restoration following minimally invasive lateral lumbar interbody fusion.

OBJECTIVE: The objective of this study was to evaluate patient and surgical factors that predict increased overall lumbar lordosis (LL) and segmental lordosis correction following a minimally invasive lateral lumbar interbody fusion (LLIF) procedure. METHODS: A retrospective review was conducted of all patients who underwent one- or two-level LLIF. Preoperative, initial postoperative, and 6-month postoperative measurements of LL, segmental lordosis, anterior disc height, and posterior disc height were collected from standing lateral radiographs for each patient. Cage placement was measured utilizing the center point ratio (CPR) on immediate postoperative radiographs. Spearman correlations were used to assess associations between cage lordosis and radiographic parameters. Multivariate linear regression was performed to assess independent predictors of outcomes. RESULTS: A total of 106 levels in 78 unique patients were included. Most procedures involved fusion of one level (n = 50, 64.1%), most commonly L3-4 (46.2%). Despite no differences in baseline segmental lordosis, patients with anteriorly or centrally placed cages experienced the greatest segmental lordosis correction immediately (mean anterior 4.81° and central 4.46° vs posterior 2.47°, p = 0.0315) and at 6 months postoperatively, and patients with anteriorly placed cages had greater overall lordosis correction postoperatively (mean 6.30°, p = 0.0338). At the 6-month follow-up, patients with anteriorly placed cages experienced the greatest increase in anterior disc height (mean anterior 6.24 mm vs posterior 3.69 mm, p = 0.0122). Cages placed more posteriorly increased the change in posterior disc height postoperatively (mean posterior 4.91 mm vs anterior 1.80 mm, p = 0.0001) and at 6 months (mean posterior 4.18 mm vs anterior 2.06 mm, p = 0.0255). There were no correlations between cage lordotic angle and outcomes. On multivariate regression, anterior cage placement predicted greater 6-month improvement in segmental lordosis, while posterior placement predicted greater 6-month improvement in posterior disc height. Percutaneous screw placement, cage lordotic angle, and cage height did not independently predict any radiographic outcomes. CONCLUSIONS: LLIF procedures reliably improve LL and increase intervertebral disc space. Anterior cage placement improves the lordosis angle greater than posterior placement, which better corrects sagittal alignment, but there is still a significant improvement in lordosis even with a posteriorly placed cage. Posterior cage placement provides greater restoration in posterior disc space height, maximizing indirect decompression, but even the anteriorly placed cages provided indirect decompression. Cage parameters including cage height, lordosis angle, and material do not impact radiographic improvement.

Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis.

PURPOSE: Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery. METHODS: We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale. RESULTS: Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses. CONCLUSION: Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates. LEVEL OF EVIDENCE: II.

Overview of Traumatic Brain Injury in American Football Athletes.

OBJECTIVE: The aim of this review is to provide a summary of the epidemiology, clinical presentation, pathophysiology, and treatment of traumatic brain injury in collision athletes, particularly those participating in American football. DATA SOURCES: A literature search was conducted using the PubMed/MEDLINE and Google Scholar databases for publications between 1990 and 2019. The following search phrases were used: "concussion," "professional athletes," "collision athletes," "mild traumatic brain injury," "severe traumatic brain injury," "management of concussion," "management of severe traumatic brain injury," and "chronic traumatic encephalopathy." Publications that did not present epidemiology, clinical presentation, pathophysiology, radiological evaluation, or management were omitted. Classic articles as per senior author recommendations were retrieved through reference review. RESULTS: The results of the literature review yielded 147 references: 21 articles discussing epidemiology, 16 discussing clinical presentation, 34 discussing etiology and pathophysiology, 10 discussing radiological evaluation, 34 articles for on-field management, and 32 articles for medical and surgical management. CONCLUSION: Traumatic brain injuries are frequent in professional collision athletes, and more severe injuries can have devastating and lasting consequences. Although sport-related concussions are well studied in professional American football, there is limited literature on the epidemiology and management of severe traumatic brain injuries. This article reviews the epidemiology, as well as the current practices in sideline evaluation, acute management, and surgical treatment of concussions and severe traumatic brain injury in professional collision athletes. Return-to-play decisions should be based on individual patient symptoms and recovery.

Anterior cervical discectomy and fusion is more effective than cervical arthroplasty in relieving atypical symptoms in patients with cervical spondylosis.

BACKGROUND AND PURPOSE: Patients with cervical spondylosis often present with concurrent 'atypical symptoms' of unknown etiology that have been associated with cervical spondylotic disease, including dizziness, headache, nausea, tinnitus, blurred vision, palpitations, and memory and gastrointestinal disturbances. Few studies have addressed whether surgical intervention to treat classic symptoms of cervical spondylosis can also effectively alleviate atypical symptoms. Accordingly, the purpose of this study is to compare the ability of cervical arthroplasty (CA) and anterior cervical discectomy and fusion (ACDF) to alleviate atypical symptoms associated with cervical spondylosis. MATERIALS AND METHODS: A retrospective analysis of 140 patients with cervical spondylosis and associated atypical symptoms was performed. Atypical symptoms were defined vertigo, headache, nausea and vomiting, tinnitus, blur vision, palpitation, hypomnesia, and gastroenteric disturbances not otherwise explained by medical comorbidities. Seventy-eight patients (55.7%) underwent ACDF and 62 (44.3%) patients underwent CA. Demographics, surgical characteristics, patient reported outcome measures (PROMs), radiographs, complication rates, and resolution in atypical symptoms were recorded and compared between groups. Atypical symptoms were assessed using a 20-point system. All the patients had a minimum of five years follow-up. RESULTS: VAS, SF-36, JOA, and NDI scores improved significantly in all the patients (p < 0.001). At the last follow-up, the fusion rate was 97% in the ACDF group. Atypical symptoms improved in both groups (p < 0.001), although the ACDF group demonstrated greater improvement in headache and vertigo resolution compared to the CA group (p < 0.0001). CONCLUSIONS: While both ACDF and CA are effective in alleviating atypical symptoms associated with cervical spondylosis, ACDF demonstrated greater improvements in atypical symptoms.

The Associations of Spine Surgeon Training, Office Wait Times, and Social Media Presence with Reviews on Physician Rating Websites.

This study evaluated the associations of demographics and social media (SM) usage on physician review websites for spine surgeons in New Jersey and Pennsylvania. Three physician rating websites were accessed to obtain training history, number of ratings/reviews, and overall rating (0-5). Surgeon web pages and publicly searchable SM accounts on Facebook (FB), Twitter (T), and/or Instagram (IG) were recorded. Of 246 spine surgeons included, 95.9% had a personal/institutional website while 12.2% were present on at least one SM platform. Physician age was inversely correlated with Healthgrades.com (HG), Vitals.com (V), and Google.com (G) ratings (p < 0.0001). Physicians with SM had higher ratings on HG (p = 0.006) and V (p = 0.006). Spine surgeons with SM received more ratings, comments, and higher scores than those without SM. All review sites agree that SM presence correlated with the number of ratings and comments across physician review websites, suggesting SM may influence patient feedback. (Journal of Surgical Orthopaedic Advances 31(4):256-262, 2022).

Variation in global treatment for subaxial cervical spine isolated unilateral facet fractures.

PURPOSE: To determine the variation in the global treatment practices for subaxial unilateral cervical spine facet fractures based on surgeon experience, practice setting, and surgical subspecialty. METHODS: A survey was sent to 272 members of the AO Spine Subaxial Injury Classification System Validation Group worldwide. Questions surveyed surgeon preferences with regard to diagnostic work-up and treatment of fracture types F1-F3, according to the AO Spine Subaxial Cervical Spine Injury Classification System, with various associated neurologic injuries. RESULTS: A total of 161 responses were received. Academic surgeons use the facet portion of the AO Spine classification system less frequently (61.6%) compared to hospital-employed and private practice surgeons (81.1% and 81.8%, respectively) (p = 0.029). The overall consensus was in favor of operative treatment for any facet fracture with radicular symptoms (N2) and for any fractures categorized as F2N2 and above. For F3N0 fractures, significantly less surgeons from Africa/Asia/Middle East (49%) and Europe (59.2%) chose operative treatment than from North/Latin/South America (74.1%) (p = 0.025). For F3N1 fractures, significantly less surgeons from Africa/Asia/Middle East (52%) and Europe (63.3%) recommended operative treatment than from North/Latin/South America (84.5%) (p = 0.001). More than 95% of surgeons included CT in their work-up of facet fractures, regardless of the type. No statistically significant differences were seen in the need for MRI to decide treatment. CONCLUSION: Considerable agreement exists between surgeon preferences with regard to unilateral facet fracture management with few exceptions. F2N2 fracture subtypes and subtypes with radiculopathy (N2) appear to be the threshold for operative treatment.

Regional and experiential differences in surgeon preference for the treatment of cervical facet injuries: a case study survey with the AO Spine Cervical Classification Validation Group.

PURPOSE: The management of cervical facet dislocation injuries remains controversial. The main purpose of this investigation was to identify whether a surgeon's geographic location or years in practice influences their preferred management of traumatic cervical facet dislocation injuries. METHODS: A survey was sent to 272 AO Spine members across all geographic regions and with a variety of practice experience. The survey included clinical case scenarios of cervical facet dislocation injuries and asked responders to select preferences among various diagnostic and management options. RESULTS: A total of 189 complete responses were received. Over 50% of responding surgeons in each region elected to initiate management of cervical facet dislocation injuries with an MRI, with 6 case exceptions. Overall, there was considerable agreement between American and European responders regarding management of these injuries, with only 3 cases exhibiting a significant difference. Additionally, results also exhibited considerable management agreement between those with ≤ 10 and > 10 years of practice experience, with only 2 case exceptions noted. CONCLUSION: More than half of responders, regardless of geographical location or practice experience, identified MRI as a screening imaging modality when managing cervical facet dislocation injuries, regardless of the status of the spinal cord and prior to any additional intervention. Additionally, a majority of surgeons would elect an anterior approach for the surgical management of these injuries. The study found overall agreement in management preferences of cervical facet dislocation injuries around the globe.

Cartilage repair in the degenerative ageing knee.

Background and purpose - Cartilage damage can develop due to trauma, resulting in focal chondral or osteochondral defects, or as more diffuse loss of cartilage in a generalized organ disease such as osteoarthritis. A loss of cartilage function and quality is also seen with increasing age. There is a spectrum of diseases ranging from focal cartilage defects with healthy surrounding cartilage to focal lesions in degenerative cartilage, to multiple and diffuse lesions in osteoarthritic cartilage. At the recent Aarhus Regenerative Orthopaedics Symposium (AROS) 2015, regenerative challenges in an ageing population were discussed by clinicians and basic scientists. A group of clinicians was given the task of discussing the role of tissue engineering in the treatment of degenerative cartilage lesions in ageing patients. We present the outcomes of our discussions on current treatment options for such lesions, with particular emphasis on different biological repair techniques and their supporting level of evidence. Results and interpretation - Based on the studies on treatment of degenerative lesions and early OA, there is low-level evidence to suggest that cartilage repair is a possible treatment for such lesions, but there are conflicting results regarding the effect of advanced age on the outcome. We concluded that further improvements are needed for direct repair of focal, purely traumatic defects before we can routinely use such repair techniques for the more challenging degenerative lesions. Furthermore, we need to identify trigger mechanisms that start generalized loss of cartilage matrix, and induce subchondral bone changes and concomitant synovial pathology, to maximize our treatment methods for biological repair in degenerative ageing joints.

A new perspective on intervertebral disc calcification-from bench to bedside.

Disc degeneration primarily contributes to chronic low back and neck pain. Consequently, there is an urgent need to understand the spectrum of disc degeneration phenotypes such as fibrosis, ectopic calcification, herniation, or mixed phenotypes. Amongst these phenotypes, disc calcification is the least studied. Ectopic calcification, by definition, is the pathological mineralization of soft tissues, widely studied in the context of conditions that afflict vasculature, skin, and cartilage. Clinically, disc calcification is associated with poor surgical outcomes and back pain refractory to conservative treatment. It is frequently seen as a consequence of disc aging and progressive degeneration but exhibits unique molecular and morphological characteristics: hypertrophic chondrocyte-like cell differentiation; TNAP, ENPP1, and ANK upregulation; cell death; altered Pi and PPi homeostasis; and local inflammation. Recent studies in mouse models have provided a better understanding of the mechanisms underlying this phenotype. It is essential to recognize that the presentation and nature of mineralization differ between AF, NP, and EP compartments. Moreover, the combination of anatomic location, genetics, and environmental stressors, such as aging or trauma, govern the predisposition to calcification. Lastly, the systemic regulation of calcium and Pi metabolism is less important than the local activity of PPi modulated by the ANK-ENPP1 axis, along with disc cell death and differentiation status. While there is limited understanding of this phenotype, understanding the molecular pathways governing local intervertebral disc calcification may lead to developing disease-modifying drugs and better clinical management of degeneration-related pathologies.

The Surgical Algorithm for the AO Spine Sacral Injury Classification System.

STUDY DESIGN: Global cross-sectional survey. OBJECTIVE: To establish a surgical algorithm for sacral fractures based on the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Spine Sacral Injury Classification System. SUMMARY OF BACKGROUND DATA: Although the AO Spine Sacral Injury Classification has been validated across an international audience of surgeons, a consensus on a surgical algorithm for sacral fractures using the Sacral AO Spine Injury Score (Sacral AOSIS) has yet to be developed. METHODS: A survey was sent to general orthopedic surgeons, orthopedic spine surgeons, and neurosurgeons across the five AO spine regions of the world. Descriptions of controversial sacral injuries based on different fracture subtypes were given, and surgeons were asked whether the patient should undergo operative or nonoperative management. The results of the survey were used to create a surgical algorithm based on each subtype's sacral AOSIS. RESULTS: An international agreement of 70% was decided on by the AO Spine Knowledge Forum Trauma experts to indicate a recommendation of initial operative intervention. Using this, sacral fracture subtypes of AOSIS 5 or greater were considered operative, while those with AOSIS 4 or less were generally nonoperative. For subtypes with an AOSIS of 3 or 4, if the sacral fracture was associated with an anterior pelvic ring injury (M3 case-specific modifier), intervention should be left to the surgeons' discretion. CONCLUSION: The AO Spine Sacral Injury Classification System offers a validated hierarchical system to approach sacral injuries. Through multispecialty and global surgeon input, a surgical algorithm was developed to determine appropriate operative indications for sacral trauma. Further validation is required, but this algorithm provides surgeons across the world with the basis for discussion and the development of standards of care and treatment.

Subfascial Lumbar Spine Drain Output Does Not Affect Outcomes After Incidental Durotomies in Elective Spine Surgery.

OBJECTIVE: Postoperative drains have long been regarded as a preventive measure to mitigate the risks of complications such as neurological impairment by reducing fluid accumulation following spine surgery. Our study aims to contribute to the existing body of knowledge by examining the effects of postoperative drain output on the 90-day postoperative outcomes for patients who experienced an incidental durotomy after lumbar decompression procedures, with or without fusion. METHODS: All patients aged ≥18 years with an incidental durotomy from spinal decompression with or without fusion surgery between 2017 and 2021 were retrospectively identified. The patient demographics, surgical characteristics, method of dural tear repair (DuraSeal, suture, and/or DuraGen), surgical outcomes, and drain data were collected via medical record review. Patients were grouped by readmission status and final 8-hour drain output. Those with a final 8-hour drain output of ≥40 mL were included in the high drain output (HDO) group and those with <40 mL were in the low drain output (LDO) group. RESULTS: There were no statistically significant differences in preoperative patient demographics, surgical characteristics, method of dural tear repair, length of stay (HDO, 4.02 ± 1.90 days; vs. LDO, 4.26 ± 2.10 days; P = 0.269), hospital readmissions (HDO, 10.6%; vs. LDO, 7.96%; P = 0.744), or occurrence of reoperation during readmission (HDO, 6.06%; vs. LDO, 2.65%; P = 0.5944) between the 2 groups. CONCLUSIONS: For patients undergoing primary lumbar decompression with or without fusion and experiencing an incidental durotomy, no significant association was found between the drain output and 90-day patient outcomes. Adequate fascial closure and the absence of symptoms may be satisfactory criteria for standard patient discharge regardless of drain output.

Implementation of a Private Payer Bundled Payment Model While Maintaining High-Value Lumbar Spinal Fusion.

STUDY DESIGN: Retrospective single-institution cohort. OBJECTIVE: To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion. METHODS: Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit. RESULTS: The net surplus was the lowest in Y1 ($2,395, P =0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P >0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N=37) in BPCI-A to 4.4% (N=6) in Y2 and 4.5% (N=3) Y3 of private bundles ( P <0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (ß: $11,728, P =0.001; ß: $11,643, P =0.002). Postoperatively, length of stay in days (ß: $-2,982, P <0.001), any readmission (ß: -$18,825, P =0.001), and discharge to AIR (ß: $-61,256, P <0.001) or SNF (ß: $-10,497, P =0.058) were all associated with a net deficit. CONCLUSIONS: Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems. LEVEL OF EVIDENCE: 3.

The Effect of Muscle Quality on Outcomes after Microdiscectomy.

OBJECTIVES: To investigate the relationship between muscle quality and 1) patient-reported outcomes and 2) surgical outcomes after lumbar microdiscectomy surgery. METHODS: Adult patients (≥18 years) who underwent lumbar microdiscectomy from 2014 to 2021 at a single academic institution were identified. Outcomes were collected during the preoperative, 3-month, 6-month, and 1-year postoperative periods. Those included were the Oswestry Disability Index (ODI), Visual Analog Scale Back and Leg (VAS-Back and VAS-Leg, respectively), and the mental and physical component of the short-form 12 survey (MCS and PCS). Muscle quality was determined by 2 systems: the normalized total psoas area (NTPA) and a paralumbar-based grading system. Surgical outcomes including 90-day surgical readmissions and 1-year reoperations were also collected. RESULTS: Of the 218 patients identified, 150 had good paralumbar muscle quality and 165 had good psoas muscle quality. Bivariant analysis demonstrated no difference between groups regarding surgical outcomes (P > 0.05). Multivariable analysis demonstrated that better paralumbar muscle quality was not associated with any consistent changes in patient reported outcomes. Higher NTPA was associated with improved PCS at 6 months (est. = 6.703, [95% CI: 0.759-12.646], P = 0.030) and 12 months (est. = 6.625, [95% CI: 0.845-12.405], P = 0.027). There was no association between muscle quality and surgical readmissions or reoperations. CONCLUSIONS: Our analysis demonstrated that higher psoas muscle quality was associated with greater physical improvement postoperatively. Muscle quality did not affect surgical readmissions or reoperations. Additional studies are needed for further assessment of the implications of muscle quality on postoperative outcomes.

A Longitudinal Evaluation of Coronavirus Disease 2019 and Its Effects on Spinal Decompressions With or Without Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The objectives were to (1) compare the safety of spine surgery before and after the emergence of coronavirus disease 2019 (COVID-19) and (2) determine whether patients with a history of COVID-19 were at increased risk of adverse events. SUMMARY AND BACKGROUND DATA: The COVID-19 pandemic had a tremendous impact on several health care services. In spine surgery, elective cases were canceled and patients received delayed care due to the uncertainty of disease transmission and surgical outcomes. As new coronavirus variants arise, health care systems require guidance on how to provide optimal patient care to all those in need of our services. PATIENTS AND METHODS: A retrospective review of patients undergoing spine surgery between January 1, 2019 and June 30, 2021 was performed. Patients were split into pre-COVID or post-COVID cohorts based on local government guidelines. Inpatient complications, 90-day readmission, and 90-day mortality were compared between groups. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome. RESULTS: A total of 2976 patients were included for analysis with 1701 patients designated as pre-COVID and 1275 as post-COVID. The pre-COVID cohort had fewer patients undergoing revision surgery (16.8% vs 21.9%, P < 0.001) and a lower home discharge rate (84.5% vs 88.2%, P = 0.008). Inpatient complication (9.9% vs 9.2%, P = 0.562), inpatient mortality (0.1% vs 0.2%, P = 0.193), 90-day readmission (3.4% vs 3.2%, P = 0.828), and 90-day mortality rates (0.8% vs 0.8%, P = 0.902) were similar between groups. Patients with positive COVID-19 tests before surgery had similar complication rates (7.7% vs 6.1%, P = 1.000) as those without a positive test documented. CONCLUSIONS: After the emergence of COVID-19, patients undergoing spine surgery had a greater number of medical comorbidities, but similar rates of inpatient complications, readmission, and mortality. Prior COVID-19 infection was not associated with an increased risk of postsurgical complications or mortality. LEVEL OF EVIDENCE: Level III.

The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury.

INTRODUCTION: Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI. METHODS: All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed. RESULTS: We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005). CONCLUSION: Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented.

Preoperative Oswestry Disability Index Should not be Utilized to Determine Surgical Eligibility for Patients Requiring Lumbar Fusion for Degenerative Lumbar Spine Disease.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate how preoperative Oswestry Disability Index (ODI) thresholds might affect minimal clinically important difference (MCID) achievement following lumbar fusion. SUMMARY OF BACKGROUND DATA: As payers invest in alternative payment models, some are suggesting threshold cutoffs of patient-reported outcomes (PROMs) in reimbursement approvals for orthopedic procedures. The feasibility of this has not been investigated in spine surgery. MATERIALS/METHODS: We included all adult patients undergoing one to three-level primary lumbar fusion at a single urban tertiary academic center from 2014 to 2020. ODI was collected preoperatively and one year postoperatively. We implemented theoretical threshold cutoffs at increments of 10. MCID was set at 14.3. The percent of patients meeting MCID were determined among patients "approved" or "denied" at each threshold. At each threshold, the positive predictive value (PPV) for MCID attainment was calculated. RESULTS: A total 1368 patients were included and 62.4% (N=364) achieved MCID. As the ODI thresholds increased, a greater percent of patients in each group reached the MCID. At the lowest ODI threshold, 6.58% (N=90) of patients would be denied, rising to 20.2%, 39.5%, 58.4%, 79.9%, and 91.4% at ODI thresholds of 30, 40, 50, 60, and 70, respectively. The PPV increased from 0.072 among patients with ODI>20 to 0.919 at ODI>70. The number of patients denied a clinical improvement in the denied category per patient achieving the MCID increased at each threshold (ODI>20: 1.96; ODI>30: 2.40; ODI>40: 2.75; ODI>50: 3.03; ODI>60: 3.54; ODI>70: 3.75). CONCLUSION: Patients with poorer preoperative ODI are significantly more likely to achieve MCID following lumbar spine fusion at all ODI thresholds. Setting a preoperative ODI threshold for surgical eligibility will restrict access to patients who may benefit from spine fusion despite ODI>20 demonstrating the lowest predictive value for MCID achievement. LEVEL OF EVIDENCE: 3.