Work relative value units and perioperative outcomes in patients undergoing brain tumor surgery.

The work relative value unit (wRVU) is a commonly cited surrogate for surgical complexity; however, it is highly susceptible to subjective interpretation and external forces. Our objective was to evaluate whether wRVU is associated with perioperative outcomes, including complications, after brain tumor surgery. The 2006-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients ≥ 18 years who underwent brain tumor resection. Patients were categorized into approximate quintiles based on total wRVU. The relationship between wRVU and several perioperative outcomes was assessed with univariate and multivariate analyses. Subgroup analyses were performed using a Current Procedural Terminology code common to all wRVU groups. The 16,884 patients were categorized into wRVU ranges 0-30.83 (4664 patients), 30.84-34.58 (2548 patients), 34.59-38.04 (3147 patients), 38.05-45.38 (3173 patients), and ≥ 45.39 (3352 patients). In multivariate logistic regression analysis, increasing wRVU did not predict more 30-day postoperative complications, except respiratory complications and need for blood transfusion. Linear regression analysis showed that wRVU was poorly correlated with operative duration and length of stay. On multivariate analysis of the craniectomy subgroup, wRVU was not associated with overall or respiratory complications. The highest wRVU group was still associated with greater risk of requiring blood transfusion (OR 3.01, p < 0.001). Increasing wRVU generally did not correlate with 30 days postoperative complications in patients undergoing any surgery for brain tumor resection; however, the highest wRVU groups may be associated with greater risk of respiratory complications and need for transfusion. These finding suggests that wRVU may be a poor surrogate for case complexity.

The impact of 5-aminolevulinic acid on extent of resection in newly diagnosed high grade gliomas: a systematic review and single institutional experience.

BACKGROUND: Glioma surgery at its nascency relied predominantly on visual and tactile feedback for the removal of grossly abnormal tissue. This technique has inherent limitations in delineating infiltrative tumor from normal brain, thus limiting the ability to achieve a gross total resection consistently. Since extent of resection (EOR) is consistently correlated with measures of survival, fluorescence-guided surgery shows promise in improving our ability to treat high-grade gliomas (HGG). 5-Aminolevulinic acid (5-ALA) is a prodrug preferentially metabolized by glioma cells that allows direct, real-time visualization of pathologic tissue through fluorescence under blue light. OBJECTIVE: To report the relationship between 5-ALA and EOR in newly diagnosed HGG. To report our institutional experience including nuances of workflow. METHODS: The authors performed a systematic review of the available literature between 1998 and 2018 to isolate studies addressing the impact of fluorescence-guided surgery with 5-ALA on the EOR in newly diagnosed HGG. Search strategy was in adherence to the preferred reporting items for systematic reviews and meta-analyses methodology. RESULTS: Out of 741 unique articles, eight fulfilled our strict inclusion criteria. Fluorescence-guided resection led to greater EOR in all studies, with six demonstrating statistical significance (p < 0.05). Two studies additionally demonstrated statistically significant increase in progression-free survival in the 5-ALA groups. CONCLUSIONS: 5-ALA has an unambiguously positive impact on improving EOR for newly diagnosed HGG. Since the nature of modern glioma surgery includes a complex arsenal of surgical adjuncts, 5-ALA is seldom examined in isolation and can be complemented by intraoperative MRI.

Predictors of adverse events after parotidectomy: a review of 2919 cases.

OBJECTIVE: There is a current paucity of large-scale, multi-institutional studies that explore the risk factors for major complications following parotidectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program participant use file was reviewed to identify all patients who had undergone parotidectomy between 2006 and 2011. Risk factors that predicted adverse events were estimated by using multivariate logistic regression. RESULTS: Of 2919 included patients, 202 patients experienced adverse outcomes within the first 30 days of surgery. These included surgical complications in 76 (2.6%) patients; medical complications in 90 (3.1%) patients; death in 7 (0.2%) patients; and reoperation in 77 (2.6%) patients. Predictors of any complication included disseminated cancer (odds ratio [OR] = 2.28; 95% confidence interval [CI], 1.05-4.95; P = .036) and increasing total relative value units (OR = 1.01; 95% CI, 1.00-1.02; P = .027). Active smoking was a major risk factor for surgical complications (OR = 1.81; 95% CI, 1.08-3.05; P = .025). Dyspnea (OR = 2.93; 95% CI, 1.37-6.27; P = .006) significantly predicted medical complications. CONCLUSION: Although complication rates after parotidectomy are generally low, avoidance of specific and nonspecific postoperative complications still remains an area for improvement. Future outcomes databases should include procedure-specific complications, including facial nerve injury.

Preoperative Albumin Alone is Not a Predictor of 30-Day Outcomes in Pressure Ulcer Patients: A Matched Propensity-Score Analysis of the 2006-2011 NSQIP Datasets.

BACKGROUND: While there has been a great deal of literature describing the relationship between nutritional status and development of pressure ulcers, statistically rigorous studies analyzing the relationship between hypoalbuminemia and outcomes are lacking. METHODS: The American College of Surgeons' multicenter, prospective, National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for treatment of pressure ulcers between 2006 and 2011. Matched propensity-score analysis was performed to match experimental groups with regard to preoperative comorbidities. Outcomes of interest included overall/surgical/medical complications and 30-day mortality. Multivariable logistic regression models were used to assess the independent association between hypoalbuminemia and outcomes. RESULTS: Over the 6-year study period, 551 patients met criteria for study inclusion. Median albumin level was 2.8 g/dL. Before propensity matching, multiple adverse outcomes were significantly elevated in patients with albumin levels below the median value (very-low albumin, or VLA), compared to control patients. However, after matching preoperative comorbidities, the differences in 30-day outcomes were eliminated. In both analyses, there was no significant difference in 30-day surgical complications. CONCLUSIONS: It is generally understood that hypoalbuminemic patients have elevated risks for surgical procedures. In pressure ulcer patients, it appears that these risks are not due to hypoalbuminemia alone, but rather a long list of attendant comorbidities. Consequently, hypoalbuminemia alone should not be used to determine the timing of a procedure for pressure ulcer surgery. Knowledge of these risks is necessary for patient counseling and surgical planning in this population.

Risk Factors for Complications Differ Between Stages of Tissue-Expander Breast Reconstruction.

BACKGROUND: Tissue-expander (TE) placement followed by implant exchange is currently the most popular method of breast reconstruction. There is a relative paucity of data demonstrating patient factors that predict complications specifically by stage of surgery. The present study attempts to determine what complications are most likely to occur at each stage and how the risk factors for complications vary by stage of reconstruction. METHODS: A retrospective chart review was performed on all 1275 patients who had TEs placed by the 2 senior authors between 2004 and 2013. Complication rates were determined at each stage of reconstruction, and these rates were further compared between patients who had pre-stage I radiation, post-stage I radiation, and no radiation exposure. Multivariate logistic regression was used to identify independent predictors of complications at each stage of reconstruction. RESULTS: A total of 1639 consecutive TEs were placed by the senior authors during the study period. The overall rate for experiencing a complication at any stage of surgery was 17%. Complications occurred at uniformly higher rates during stage I for all complications (92% stage I vs 7% stage II vs 1% stage III, P < 0.001). Predictors of stage I complications included increased body mass index [odds ratio (OR), 1.04; 95% confidence interval (CI), 1.01-1.07], current smoking status (OR, 3.0; 95% CI, 1.7-4.8), and higher intraoperative percent fill (OR, 3.3; 95% CI, 1.7-6.3). Post-stage I radiation was the only independent risk factor for a stage II complication (OR, 4.5; 95% CI, 1.4-15.2). CONCLUSIONS: Complications occur at higher rates after stage I than after stage II, and as expected, stage III complications are exceedingly rare. Risk factors for stage I complications are different from risk factors for stage II complications. Body mass index and smoking are associated with complications at stage I, but do not predict complications at stage II surgery. The stratification of risk factors by stage of surgery will help surgeons and patients better manage both risk and expectations.

Predictors of 61 unplanned readmission cases in microvascular free tissue transfer patients: multi-institutional analysis of 774 patients.

BACKGROUND: Unplanned readmissions serve as a marker for health care quality. Risk factors associated with unplanned readmission after microvascular free tissue transfer have never been examined. In this study, we sought to identify perioperative predictors of 30-day unplanned readmission in free flap patients. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who underwent microvascular free tissue transfer in 2011. Multivariate logistic regression models were used to estimate independent predictors of unplanned readmission. RESULTS: Among free flap patients, unplanned readmission rate was 7.9%. In multivariate analysis, the only factor that significantly predicted unplanned readmission (P < 0.05) was open wound/wound infection (odds ratio [OR] 2.71). Postoperative variables significantly associated with unplanned readmission included surgical complications (OR 5.43), medical complications (OR 5.62), and unplanned reoperation (OR 3.94). Flap failure was not associated with unplanned readmission. CONCLUSIONS: In our study, the presence of either open wound/wound infection, development of surgical complications, medical complications, and unplanned reoperations were associated with unplanned readmissions. Further research in predictive factors is suggested to avoid costly, unnecessary, and preventable readmissions.

Risk factors for not reaching minimal clinically important difference at 90 days and 1 year after elective lumbar spine surgery: a cohort study.

OBJECTIVE: Patient-perceived functional improvement is a core metric in lumbar surgery for degenerative disease. It is important to identify both modifiable and nonmodifiable risk factors that can be evaluated and possibly optimized prior to elective surgery. This case-control study was designed to study risk factors for not achieving the minimal clinically important difference (MCID) in Patient-Reported Outcomes Measurement Information System Function 4-item Short Form (PROMIS PF) score. METHODS: The authors queried the Michigan Spine Surgery Improvement Collaborative database to identify patients who underwent elective lumbar surgical procedures with PROMIS PF scores. Cases were divided into two cohorts based on whether patients achieved MCID at 90 days and 1 year after surgery. Patient characteristics and operative details were analyzed as potential risk factors. RESULTS: The authors captured 10,922 patients for 90-day follow-up and 4453 patients (40.8%) did not reach MCID. At the 1-year follow-up period, 7780 patients were identified and 2941 patients (37.8%) did not achieve MCID. The significant demographic characteristic-adjusted relative risks (RRs) for both groups (RR 90 day, RR 1 year) included the following: symptom duration > 1 year (1.34, 1.41); previous spine surgery (1.25, 1.30); African American descent (1.25, 1.20); chronic opiate use (1.23, 1.25); and less than high school education (1.20, 1.34). Independent ambulatory status (0.83, 0.88) and private insurance (0.91, 0.85) were associated with higher likelihood of reaching MCID at 90 days and 1 year, respectively. CONCLUSIONS: Several key unique demographic risk factors were identified in this cohort study that precluded optimal postoperative functional outcomes after elective lumbar spine surgery. With this information, appropriate preoperative counseling can be administered to assist in shaping patient expectations.

Predictors of readmission after breast reconstruction: a multi-institutional analysis of 5012 patients.

BACKGROUND: Recent health care legislation institutes penalties for surgical readmissions secondary to complications. There is a paucity of evidence describing risk factors for readmission after breast reconstruction procedures. METHODS: Patients undergoing breast reconstruction in 2011 were identified in the National Surgical Quality Improvement Program database. Patients were grouped as purely immediate implant/tissue-expander reconstructions or purely autologous reconstruction for analysis. Reconstructions involving multiple types of procedures were excluded due to difficulty with classification. Perioperative variables were analyzed using χ and Student t test as appropriate. Multivariate regression modeling was used to identify risk factors for readmission. RESULTS: Of 5012 patients meeting inclusion criteria, 3960 and 1052 underwent implant/expander and autologous reconstructions, respectively. Implant/expander and autologous cohorts experienced similar readmission rates (4.34% vs 5.32%, respectively; P = 0.18). However, autologous reconstructions experienced a higher rate of overall complications than implant/expander reconstructions (19.96% vs 5.86%, respectively; P < 0.05), as well as higher rates of reoperation (9.7% vs 6.5%, respectively; P < 0.05). Common predictors of readmission for implant/expander and autologous cohorts included operative time, American Society of Anesthesiologist class 3 and 4, and superficial surgical site infection. Smoking, sepsis, deep wound infection, organ space infection, and wound disruption were predictive of readmission for implant/expander reconstruction only, whereas hypertension was predictive of readmission after autologous reconstruction only. CONCLUSIONS: This is the first study of readmission rates after breast reconstruction. Knowledge of specific risk factors for readmission may improve patient outcomes, steer strategies for optimizing reconstructive outcomes, and minimize readmissions.

Impact of preoperative myocardial infarction on surgical outcomes in inpatient orthopaedic surgery.

PURPOSE: The purpose of this study was to evaluate the impact of a preoperative myocardial infarction (MI) on outcomes of inpatient orthopaedic operations. METHODS: The National Surgical Quality Improvement Program database was used to identify patients who underwent common orthopaedic operations from 2006 to 2010. Patient demographic data, comorbidities, complications, and lengths of stay were collected. Multivariate logistic regression and linear regression models were used to compare outcomes for patients with and without a history of MI in the six months prior to surgery. RESULTS: Of the 32,462 patients identified, 86 had sustained an MI in the six months prior to surgery. The MI cohort had no cardiac complications but had increased incidences of superficial surgical site infection, unplanned re-intubation, ventilator-assisted respiration for more than 48 hours, pneumonia, sepsis or septic shock, and postoperative mortality within 30 days of surgery, as well as prolonged lengths of stay. Following logistic regression to adjust for baseline differences, a history of MI showed no association with cardiac complications and was significantly associated with superficial surgical site infection (OR 3.6, 95% CI 1.1-11.8), ventilator dependence for over 48 hours (OR 4.0, 95% CI 1.1-14.0), and extended length of stay (median with interquartile range 4 [4-4] vs. 5 [5-5] days). CONCLUSIONS: A myocardial infarction within six months prior to orthopaedic surgery is not associated with a higher risk of 30-day perioperative cardiac complications; however, it is associated with increased rates of surgical site infection, prolonged ventilator dependence, and longer hospital stay.

Postoperative opioid prescription and patient-reported outcomes after elective spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery. METHODS: Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis. RESULTS: Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56). CONCLUSIONS: The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors' analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.

The Potential Negative Effects of Smoking on Cervical and Lumbar Surgery Beyond Pseudarthrosis: A Michigan Spine Surgery Improvement Collaborative Study.

OBJECTIVE: To review the Michigan Spine Surgery Improvement Collaborative registry to investigate the long-term associations between current smoking status and outcomes after elective cervical and lumbar spine surgery. METHODS: Using the Michigan Spine Surgery Improvement Collaborative, we captured all cases from January 1, 2017, to November 21, 2020, with outcomes data available; 19,251 lumbar cases and 7936 cervical cases were included. Multivariate regression analyses were performed to assess the relationship of smoking with the clinical outcomes. RESULTS: Current smoking status was associated with lower urinary retention and satisfaction for patients after lumbar surgery and was associated with less likelihood of achieving minimal clinically important difference in primary outcome measures including Patient-Reported Outcomes Measurement Information System, back pain, leg pain, and EuroQol-5D at 90 days and 1 year after surgery. Current smokers were also less likely to return to work at 90 days and 1 year after surgery. Among patients who underwent cervical surgery, current smokers were less likely to have urinary retention and dysphagia postoperatively. They were less likely to be satisfied with the surgery outcome at 1 year. Current smoking was associated with lower likelihood of achieving minimal clinically important difference in Patient-Reported Outcomes Measurement Information System, neck pain, arm pain, and EuroQol-5D at various time points. There was no difference in return-to-work status. CONCLUSIONS: Our analysis suggests that smoking is negatively associated with functional improvement, patient satisfaction, and return-to-work after elective spine surgery.

A Matched Cohort Analysis of Drain Usage in Elective Anterior Cervical Discectomy and Fusion: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study.

STUDY DESIGN: This is a retrospective, cohort analysis of multi-institutional database. OBJECTIVE: This study was designed to analyze the impact of drain use following elective anterior cervical discectomy and fusion (ACDF) surgeries. SUMMARY OF BACKGROUND DATA: After ACDF, a drain is often placed to prevent postoperative hematoma. However, there has been no high quality evidence to support its use with ACDF despite the theoretical benefits and risks of drain placement. METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried to identify all patients undergoing elective ACDF between February 2014 and October 2019. Cases were divided into two cohorts based on drain use. Propensity-score matching was utilized to adjust for inherent differences between the two cohorts. Measured outcomes included surgical site hematoma, length of stay, surgical site infection, dysphagia, home discharge, readmission within 30 days, and unplanned reoperation. RESULTS: We identified 7943 patients during the study period. Propensity-score matching yielded 3206 pairs. On univariate analysis of matched cohorts, there were no differences in rate of postoperative hematoma requiring either return to OR or readmission. We noted patients with drains had a higher rate of dysphagia (4.6% vs. 6.3%; P = 0.003) and had longer hospital stay (P < 0.001). On multivariate analysis, drain use was associated with significantly increased length of stay (relative risk 1.23, 95% confidence interval [CI] 1.13-1.34; P < 0.001). There were no significant differences in other outcomes measured. CONCLUSION: Our analysis demonstrated that drain use is associated with significant longer hospital stay.Level of Evidence: 3.

Analysis of Factors Associated with Return-to-Work After Lumbar Surgery up to 2-Years Follow-up: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study.

STUDY DESIGN: Michigan Spine Surgery Improvement Collaborative (MSSIC) prospectively collects data on all patients undergoing operations for degenerative and/or deformity indications. OBJECTIVE: We aimed to identify which factors are significantly associated with return-to-work after lumbar surgery at long-term follow-up. SUMMARY OF BACKGROUND DATA: Prior publications have created a clinically relevant predictive model for return-to-work, wherein education, gender, race, comorbidities, and preoperative symptoms increased likelihood of return-to-work at 3 months after lumbar surgery. We sought to determine if these trends 1) persisted at 1 year and 2 years postoperatively; or 2) differed among preoperatively employed versus unemployed patients. METHODS: MSSIC was queried for all patients undergoing lumbar operations (2014-2019). All patients intended to return-to-work postoperatively. Patients were followed for up to 2 years postoperatively. Measures of association were calculated with multivariable generalized estimating equations. RESULTS: Return-to-work increased from 63% (3542/5591) at 90 days postoperatively to 75% (3143/4147) at 1 year and 74% (2133/2866) at 2 years postoperatively. Following generalized estimating equations, neither clinical nor surgical variables predicted return-to-work at all three time intervals: 90 days, 1 year, and 2 years postoperatively. Only socioeconomic factors reached statistical significance at all follow-up points. Preoperative employment followed by insurance status had the greatest associations with return-to-work. In a subanalysis of patients who were preoperatively employed, insurance was the only factor with significant associations with return-to-work at all three follow-up intervals. The return-to-work rates among unemployed patients at baseline increased from 29% (455/1100) at 90 days, 44% (495/608) at 1 year, and 46% (366/426) at 2 years postoperatively. The only two significant factors associated with return-to-work at all three follow-up intervals were Medicaid, as compared with private insurance, and male gender. CONCLUSION: In patients inquiring about long-term return-to-work after lumbar surgery, insurance status represents the important determinant of employment status.Level of Evidence: 2.

Validation of the Benefits of Ambulation Within 8 Hours of Elective Cervical and Lumbar Surgery: A Michigan Spine Surgery Improvement Collaborative Study.

BACKGROUND: Early ambulation is considered a key element to Enhanced Recovery After Surgery protocol after spine surgery. OBJECTIVE: To investigate whether ambulation less than 8 hours after elective spine surgery is associated with improved outcome. METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried to track all elective cervical and lumbar spine surgery between July 2018 and April 2021. In total, 7647 cervical and 17 616 lumbar cases were divided into 3 cohorts based on time to ambulate after surgery: (1) <8 hours, (2) 8 to 24 hours, and (3) >24 hours. RESULTS: For cervical cases, patients who ambulated 8 to 24 hours (adjusted odds ratio [aOR] 1.38; 95% CI 1.11-1.70; P = .003) and >24 hours (aOR 2.20; 95% CI 1.20-4.03; P = .011) after surgery had higher complication rate than those who ambulated within 8 hours of surgery. Similar findings were noted for lumbar cases with patients who ambulated 8 to 24 hours (aOR 1.31; 95% CI 1.12-1.54; P < .001) and >24 hours (aOR 1.96; 95% CI 1.50-2.56; P < .001) after surgery having significantly higher complication rate than those ambulated <8 hours after surgery. Analysis of secondary outcomes for cervical cases demonstrated that <8-hour ambulation was associated with home discharge, shorter hospital stay, lower 90-day readmission, and lower urinary retention rate. For lumbar cases, <8-hour ambulation was associated with shorter hospital stay, satisfaction with surgery, lower 30-day readmission, home discharge, and lower urinary retention rate. CONCLUSION: Ambulation within 8 hours after surgery is associated with significant improved outcome after elective cervical and lumbar spine surgery.

Minimally Invasive Posterior Cervical Discectomy: 2-Dimensional Operative Video.

Minimally invasive posterior cervical microdiscectomy is an appropriate surgical approach for patients with foraminal stenosis from herniated disc with radicular symptoms that is not responsive to conservative management. While anterior cervical discectomy and fusion (ACDF) or arthroplasty is increasingly utilized to treat herniated disc, a posterior approach eliminates the risk of potential approach related injuries to the esophagus, carotid artery, or recurrent laryngeal nerve. Additional benefits of posterior decompression include avoidance of instrumentation, which represents an increased healthcare cost, as well as potential long-term risks of adjacent-level pathologies or device failures. A traditional open posterior cervical approach has the potential to cause significant postoperative pain due to dissection of the paraspinal musculature and the potential for disrupting the posterior tension band with inadvertent injury to the interspinous ligaments. Such disadvantages are reduced by utilizing the minimally invasive technique where a small tubular working channel is placed through a muscle splitting technique via a paramedian approach. This technique minimizes the need for muscle stripping, and thus decreases postoperative functional and structural disturbance. Discectomy in this case can also be safely performed with minimal retraction at the axilla of the nerve root. Additionally, this approach can be utilized in an ambulatory setting, which coupled with the lack of any additional instrumentation helps contribute to the overall healthcare cost savings of such a procedure. This video describes how the minimally invasive posterior cervical discectomy can be effectively and safely performed in this illustrative case. The patient consented to the procedure and publication.

The influence of sagittal spinopelvic alignment on patient discharge disposition following minimally invasive lumbar interbody fusion.

BACKGROUND: The aim of this study was to investigate the changes to spinopelvic sagittal alignment following minimally invasive (MIS) lumbar interbody fusion, and the influence of such changes on postoperative discharge disposition. METHODS: The Michigan Spine Surgery Improvement Collaborative was queried for all patients who underwent transforaminal lumbar interbody fusion (TLIF)or lateral lumbar interbody fusion (LLIF) procedures for degenerative spine disease. Several spinopelvic sagittal alignment parameters were measured, including sagittal vertical axis (SVA), lumbar lordosis, pelvic tilt, pelvic incidence, and pelvic incidence-lumbar lordosis mismatch. Primary outcome measure-discharge to a rehabilitation facility-was expressed as adjusted odds ratio (ORadj) following a multivariable logistical regression. RESULTS: Of the 83 patients in the study population, 11 (13.2%) were discharged to a rehabilitation facility. Preoperative SVA was equivalent. Postoperative SVA increased to 8.0 cm in the discharge-to-rehabilitation division versus a decrease to 3.6 cm in the discharge-to-home division (P<0.001). The odds of discharge to a rehabilitation facility increased by 25% for every 1-cm increase in postoperative sagittal balance (ORadj =1.27, P=0.014). The strongest predictor of discharge to rehabilitation was increasing decade of life (ORadj =3.13, P=0.201). CONCLUSIONS: Correction of sagittal balance is associated with greater odds of discharge to home. These findings, coupled with the recognized implications of admission to a rehabilitation facility, will emphasize the importance of spine surgeons accounting for SVA into their surgical planning of MIS lumbar interbody fusions.

The role of postoperative antibiotic duration on surgical site infection after lumbar surgery.

OBJECTIVE: Despite a general consensus regarding the administration of preoperative antibiotics, poorly defined comparison groups and underpowered studies prevent clear guidelines for postoperative antibiotics. Utilizing a data set tailored specifically to spine surgery outcomes, in this clinical study the authors aimed to determine whether there is a role for postoperative antibiotics in the prevention of surgical site infection (SSI). METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar operations performed for degenerative spinal pathologies over a 5-year period from 2014 to 2019. Preoperative prophylactic antibiotics were administered for all surgical procedures. The study population was divided into three cohorts: no postoperative antibiotics, postoperative antibiotics ≤ 24 hours, and postoperative antibiotics > 24 hours. This categorization was intended to determine 1) whether postoperative antibiotics are helpful and 2) the appropriate duration of postoperative antibiotics. First, multivariable analysis with generalized estimating equations (GEEs) was used to determine the association between antibiotic duration and all-type SSI with adjusted odds ratios; second, a three-tiered outcome-no SSI, superficial SSI, and deep SSI-was calculated with multivariable multinomial logistical GEE analysis. RESULTS: Among 37,161 patients, the postoperative antibiotics > 24 hours cohort had more men with older average age, greater body mass index, and greater comorbidity burden. The postoperative antibiotics > 24 hours cohort had a 3% rate of SSI, which was significantly higher than the 2% rate of SSI of the other two cohorts (p = 0.004). On multivariable GEE analysis, neither postoperative antibiotics > 24 hours nor postoperative antibiotics ≤ 24 hours, as compared with no postoperative antibiotics, was associated with a lower rate of all-type postoperative SSIs. On multivariable multinomial logistical GEE analysis, neither postoperative antibiotics ≤ 24 hours nor postoperative antibiotics > 24 hours was associated with rate of superficial SSI, as compared with no antibiotic use at all. The odds of deep SSI decreased by 45% with postoperative antibiotics ≤ 24 hours (p = 0.002) and by 40% with postoperative antibiotics > 24 hours (p = 0.008). CONCLUSIONS: Although the incidence of all-type SSI was highest in the antibiotics > 24 hours cohort, which also had the highest proportions of risk factors, duration of antibiotics failed to predict all-type SSI. On multinomial subanalysis, administration of postoperative antibiotics for both ≤ 24 hours and > 24 hours was associated with decreased risk of only deep SSI but not superficial SSI. Spine surgeons can safely consider antibiotics for 24 hours, which is equally as effective as long-term administration for prophylaxis against deep SSI.

Preoperative HbA1c > 8% Is Associated With Poor Outcomes in Lumbar Spine Surgery: A Michigan Spine Surgery Improvement Collaborative Study.

BACKGROUND: Preoperative hemoglobin A1c (HbA1c) is a useful screening tool since a significant portion of diabetic patients in the United States are undiagnosed and the prevalence of diabetes continues to increase. However, there is a paucity of literature analyzing comprehensive association between HbA1c and postoperative outcome in lumbar spine surgery. OBJECTIVE: To assess the prognostic value of preoperative HbA1c > 8% in patients undergoing elective lumbar spine surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) database was queried to track all elective lumbar spine surgeries between January 2018 and December 2019. Cases were divided into 2 cohorts based on preoperative HbA1c level (≤8% and >8%). Measured outcomes include any complication, surgical site infection (SSI), readmission (RA) within 30 d (30RA) and 90 d (90RA) of index operation, patient satisfaction, and the percentage of patients who achieved minimum clinically important difference (MCID) using Patient-Reported Outcomes Measurement Information System. RESULTS: We captured 4778 patients in this study. Our multivariate analysis demonstrated that patients with HbA1c > 8% were more likely to experience postoperative complication (odds ratio [OR] 1.81, 95% CI 1.20-2.73; P = .005) and be readmitted within 90 d of index surgery (OR 1.66, 95% CI 1.08-2.54; P = .021). They also had longer hospital stay (OR 1.12, 95% CI 1.03-1.23; P = .009) and were less likely to achieve functional improvement after surgery (OR 0.64, 95% CI 0.44-0.92; P = .016). CONCLUSION: HbA1c > 8% is a reliable predictor of poor outcome in elective lumbar spine surgery. Clinicians should consider specialty consultation to optimize patients' glycemic control prior to surgery.

Disparities in outcomes after spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: Most studies on racial disparities in spine surgery lack data granularity to control for both comorbidities and self-assessment metrics. Analyses from large, multicenter surgical registries can provide an enhanced platform for understanding different factors that influence outcome. In this study, the authors aimed to determine the effects of race on outcomes after lumbar surgery, using patient-reported outcomes (PROs) in 3 areas: the North American Spine Society patient satisfaction index, the minimal clinically important difference (MCID) on the Oswestry Disability Index (ODI) for low-back pain, and return to work. METHODS: The Michigan Spine Surgery Improvement Collaborative was queried for all elective lumbar operations. Patient race/ethnicity was categorized as Caucasian, African American, and "other." Measures of association between race and PROs were calculated with generalized estimating equations (GEEs) to report adjusted risk ratios. RESULTS: The African American cohort consisted of a greater proportion of women with the highest comorbidity burden. Among the 7980 and 4222 patients followed up at 1 and 2 years postoperatively, respectively, African American patients experienced the lowest rates of satisfaction, MCID on ODI, and return to work. Following a GEE, African American race decreased the probability of satisfaction at both 1 and 2 years postoperatively. Race did not affect return to work or achieving MCID on the ODI. The variable of greatest association with all 3 PROs at both follow-up times was postoperative depression. CONCLUSIONS: While a complex myriad of socioeconomic factors interplay between race and surgical success, the authors identified modifiable risk factors, specifically depression, that may improve PROs among African American patients after elective lumbar spine surgery.

Comparison of 30-day outcome following anterior cervical discectomy and fusion with or without instrumentation for cervical spondylosis: A review of 2352 elective cases.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure to address cervical myeloradiculopathy. However, 30-day outcomes after additional plating/instrumentation are not very clear. METHODS: The authors reviewed The National Surgical Quality Improvement Program database to identify all elective ACDF cases with or without instrumentation for patients having cervical spondylosis with or without myelopathy from 2011 to 2013 using current procedural terminology and International Classification of Disease-9 codes. We identified 2352 cases and subdivided these into two cohorts based on instrumentation procedures (588 cases without instrumentation and 1764 cases with instrumentation). Baseline differences in two cohorts were adjusted by propensity score matching analysis, yielding well-matched 583 pairs. RESULTS: Following propensity matching, the authors observed no significant difference in 30-day complication rates (prematch, 2.4% vs. 2.4%; and postmatch, 2.4% vs. 1.7%), readmission (prematch, 4.1% vs. 3.2%; and postmatch, 3.9% vs. 3.3%), and reoperation (prematch 0.9% vs. 1.8%; and postmatch 0.9% vs. 1.5%). CONCLUSION: Our results demonstrate similar 30-day outcomes in both cohorts and suggest that instrumentation can be safely implemented in the setting of ACDF.