The Incidence of Subsequent Cervical Spine Surgery after Cervical Disc Arthroplasty, a Minimum Two-year Follow-up.

To identify the risk factors and incidence of subsequent cervical spine surgery in patients undergoing primary cervical disc arthroplasty (CDA). We analyzed the 2005-2015 NYS SPARCS database. Patients were longitudinally followed to determine the incidence of re-operation. Univariate and Multivariate analyses were used to identify demographic risk factors. Eight-hundred and thirty-five CDA patients had a cervical spine re-operation rate of 7.5%; 4.4% re-operation rate at two-year follow-up. The most common cervical re-operation was a primary anterior cervical discectomy and fusion (ACDF) (76.2%). Patients who underwent re-operation were more likely to be younger (p = 0.034) and female (p = 0.007). Logistic regression analysis found only female sex to have increased odds of re-operation (odds ration = 2.10, 95% confidence interval 1.21-3.63). There was a 4.4% rate of subsequent cervical spine surgery following CDA at 2 years and a 7.5% rate of subsequent cervical spine surgery. The most common cervical spine procedure following CDA was ACDF. Female sex was the only patient demographic factor to significantly influence the odds of cervical spine re-operation. (Journal of Surgical Orthopaedic Advances 31(1):007-011, 2022).

Impact of the COVID-19 Pandemic on Outcomes and Perioperative Factors Associated with Posterior Cervical Fusion.

Introduction: While there is anecdotal evidence that the coronavirus disease 2019 (COVID-19) pandemic altered perioperative decision-making in patients requiring posterior cervical fusion (PCF), a national-level analysis to examine the significance of this hypothesis has not yet been conducted. This study aimed to determine the potential differences in perioperative variables and surgical outcomes of PCF performed before vs. during the COVID-19 pandemic. Methods: Adults who underwent PCF were identified in the 2019 (prepandemic) and 2020 (intrapandemic) NSQIP datasets. Differences in 30-day readmission, reoperation, and morbidity were evaluated using multivariate logistic regression. On the other hand, differences in operative time and relative value units (RVUs) were estimated using quantile regression. Furthermore, the odds ratios (OR) for length of stay (LOS) were estimated using negative binomial regression. Secondary outcomes included rates of nonhome discharge and outpatient surgery. Results: A total of 3,444 patients were included in this study (50.7% from 2020). Readmission, reoperation, morbidity, operative time, and RVUs per minute were similar between cohorts (p>0.05). The LOS (OR 1.086, p<0.001) and RVUs-per-case (coefficient +0.360, p=0.037) were significantly greater in 2020 compared to 2019. Operation year 2020 was also associated with lower rates of nonhome discharge (22.3% vs. 25.8%, p=0.017) and higher rates of outpatient surgery (4.8% vs. 3.0%, p=0.006). Conclusions: During the COVID-19 pandemic, a 28% decreased odds of nonhome discharge following PCF and a 72% increased odds of PCF being performed in an outpatient setting were observed. The readmission, reoperation, and morbidity rates remained unchanged during this period. This is notable given that patients in the 2020 group were more frail. This suggests that patients were shifted to outpatient centers possibly to make up for potentially reduced case volume, highlighting the potential to evaluate rehabilitation-discharge criteria. Further research should evaluate these findings in more detail and on a regional basis.

Comparison of Value per Operative Time between Primary and Revision Surgery for Adult Spinal Deformity: A Propensity Score-Matched Analysis.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To compare the relative value units (RVUs) per minute of operative time between primary and revision surgery for adult spinal deformity (ASD). OVERVIEW OF LITERATURE: Surgery for ASD is technically demanding and has high risks of complications and revision rates. This common need for additional surgery can increase the overall cost of care for ASD. RVU is used to calculate reimbursement from Medicare and to determine physician payments nationally. In calculating RVUs, the physician's work, the expenses of the physician's practice, and professional liability insurance. Cost effectiveness of surgeries for ASD have been evaluated, except for RVUs per minute compared between primary and revision surgery. METHODS: Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients aged ≥18 years who underwent surgery for spinal deformity between 2011 and 2019 were identified and included. To ensure a homogenous patient cohort, those who underwent anterior-only and concurrent anterior-posterior fusions were excluded. Propensity score matching analysis was performed, and Mann-Whitney U test, Pearson chi-square test, or Fisher's exact test were used to compare matched cohorts as appropriate. RESULTS: A total of 326 patients who underwent revision surgery were matched with 206 primary surgery patients via propensity score matching. Demographic characteristics, comorbidities, preoperative laboratory values, and readmission and reoperation rates were not significantly different between groups. The revision surgery group had significantly higher mean RVUs per minute than that of the primary surgery group (0.331 vs. 0.249, p <0.001), as well as rates of morbidity and blood transfusion. CONCLUSIONS: Compared to primary surgery, revision surgery for ASD is associated with significantly higher RVUs per minute and total RVUs and higher rates of 30-day morbidity and blood transfusions. Readmission and reoperation rates are similar between surgeries.

Comparison of Relative Value Units and 30-Day Outcomes Between Primary and Revision Pediatric Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to compare the relative value units (RVUs) and 30-day outcomes between primary and revision pediatric spinal deformity (PSD) surgery. SUMMARY OF BACKGROUND DATA: PSD surgery is frequently complicated by the need for reoperation. However, there is limited literature on physician reimbursement rates and short-term outcomes following primary versus revision spinal deformity surgery in the pediatric population. MATERIALS AND METHODS: This study utilizes data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database. Patients between 10 and 18 years of age who underwent posterior spinal deformity surgery between 2012 and 2018 were included. Univariate and multivariate regression were used to assess the independent impact of revision surgery on RVUs and postoperative outcomes, including 30-day readmission, reoperation, morbidity, and complications. RESULTS: The study cohort included a total of 15,055 patients, with 358 patients who underwent revision surgery. Patients in the revision group were more likely to be younger and male sex. Revision surgery more commonly required osteotomy (13.7% vs. 8.3%, P =0.002).Univariate analysis revealed higher total RVUs (71.09 vs. 60.51, P <0.001), RVUs per minute (0.27 vs. 0.23, P <0.001), readmission rate (6.7% vs. 4.0%, P =0.012), and reoperation rate (7.5% vs. 3.3%, P <0.001) for the revision surgery group. Morbidity rates were found to be statistically similar. In addition, deep surgical site infection, pulmonary embolism, and urinary tract infection were more common in the revision group. After controlling for baseline differences in multivariate regression, the differences in total RVUs, RVUs per minute, reoperation rate, and rate of pulmonary embolism between primary and revision surgery remained statistically significant. CONCLUSIONS: Revision PSD surgery was found to be assigned appropriately higher mean total RVUs and RVUs per minute corresponding to the higher operative complexity compared with primary surgery. Revision surgery was also associated with poorer 30-day outcomes, including higher frequencies of reoperation and pulmonary embolism. LEVEL OF EVIDENCE: Level III.

Navigated versus conventional pediatric spinal deformity surgery: Navigation independently predicts reoperation and infectious complications.

Context: Literature on treating pediatric spinal deformity with navigation is limited, particularly using large nationally represented cohorts. Further, the comparison of single-institution data to national-level database outcomes is also lacking. Aim: (1) To compare navigated versus conventional posterior pediatric deformity surgery based on 30-day outcomes and perioperative factors using the National Surgical Quality Improvement Program (NSQIP) database and (2) to compare the outcomes of the NSQIP navigated group to those of fluoroscopy-only and navigated cases from a single-institution. Settings and Design: Retrospective cohort study. Subjects and Methods: Pediatric patients who underwent posterior deformity surgery with and without navigation were included. Primary outcomes were 30-day readmission, reoperation, morbidity, and complications. The second part of this study included AIS patients < 18 years old at a single institution between 2015 and 2019. Operative time, length of stay, transfusion rate, and complication rate were compared between single-institution and NSQIP groups. Statistical Analysis Used: Univariate analyses with independent t-test and Chi-square or Fisher's exact test was used. Multivariate analyses through the application of binary logistic regression models. Results: Part I of the study included 16,950 patients, with navigation utilized in 356 patients (2.1%). In multivariate analysis, navigation predicted reoperation, deep wound infection, and sepsis. After controlling for operative year, navigation no longer predicted reoperation. In Part II of the study, 288 single institution AIS patients were matched to 326 navigation patients from the NSQIP database. Operative time and transfusion rate were significantly higher for the NSQIP group. Conclusions: On a national scale, navigation predicted increased odds of reoperation and infectious-related events and yielded greater median relative value units (RVUs) per case but had longer operating room (OR) time and fewer RVUs-per-minute. After controlling for operative year, RVUs-per-minute and reoperation rates were similar between groups. The NSQIP navigated surgery group was associated with significantly higher operative time and transfusion rates compared to the single-institution groups.

Impact of Navigation on 30-Day Outcomes for Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective database study. OBJECTIVE: Navigation has been increasingly used to treat degenerative disease, with positive radiographic and clinical outcomes and fewer adverse events and reoperations, despite increased operative time. However, short-term analysis on treating adult spinal deformity (ASD) surgery with navigation is limited, particularly using large nationally represented cohorts. This is the first large-scale database study to compare 30-day readmission, reoperation, morbidity, and value-per-operative time for navigated and conventional ASD surgery. METHODS: Adults were identified in the National Surgical Quality Improvement Program (NSQIP) database. Multivariate regression was used to compare outcomes between navigated and conventional surgery and to control for predictors and baseline differences. RESULTS: 3190 ASD patients were included. Navigated and conventional patients were similar. Navigated cases had greater operative time (405 vs 320 min) and mean RVUs per case (81.3 vs 69.7), and had more supplementary pelvic fixations (26.1 vs 13.4%) and osteotomies (50.3 vs 27.7%) (P <.001).In univariate analysis, navigation had greater reoperation (9.9 vs 5.2%, P = .011), morbidity (57.8 vs 46.8%, P = .007), and transfusion (52.2 vs 41.8%, P = .010) rates. Readmission was similar (11.9 vs 8.4%). In multivariate analysis, navigation predicted reoperation (OR = 1.792, P = .048), but no longer predicted morbidity or transfusion. Most reoperations were infectious and hardware-related. CONCLUSIONS: Despite controlling for patient-related and procedural factors, navigation independently predicted a 79% increased odds of reoperation but did not predict morbidity or transfusion. Readmission was similar between groups. This is explained, in part, by greater operative time and transfusion, which are risk factors for infection. Reoperation most frequently occurred for wound- and hardware-related reasons, suggesting navigation carries an increased risk of infectious-related events beyond increased operative time.

The 5-Item Modified Frailty Index Independently Predicts Morbidity in Patients Undergoing Instrumented Fusion following Extradural Tumor Removal.

Introduction: The management of spinal neoplasia consists of surgical, radiation, and systemic options. Little data exist to guide management based on overall health status, which is particularly challenging when patients who could benefit from surgery may be too frail for it. This study's objective was to evaluate the 5-Item Modified Frailty Index (mFI-5) as a predictor of 30-day morbidity in patients undergoing instrumented resection for metastatic extradural spinal tumors. Methods: Adults undergoing extradural tumor resection from the 2011 to 2019 National Surgical Quality Improvement Program datasets were identified by Current Procedural Terminology codes 63275-63278 with an adjunct instrumentation code (22840-22843). Patients were classified into frailty levels 0, 1, or 2+ based on mFI-5 scores of 0, 1, or 2-5, respectively. The primary outcome was morbidity. Secondary outcomes were readmission and reoperation. Multivariate modeling was utilized to analyze mFI-5 as a predictor of outcomes. The Akaike information criterion (AIC) was used to compare relative-model-fit based on frailty versus individual comorbidity variables to determine the optimal model. Chi-squared and Fisher's exact tests were used to establish significance between individual complications and frailty. Results: There were 874 patients. Readmission, reoperation, and morbidity rates were 19.5%, 5.0%, 52.3%, respectively. In multivariate analyses, mFI-5=1 (OR: 1.45, SE: 0.31, p=0.036), mFI-5=2+ (OR: 1.41, SE: 0.40, p=0.036), operative time (OR: 1.18, SE: 0.03, p≤0.001), and chronic steroid use (OR: 1.56, SE: 0.42, p=0.037) independently predicted morbidity. Elective surgery (OR: 0.61) was protective. Frailty did not predict readmission or reoperation. Frailty was found to be significantly associated with respiratory complications, urinary tract infections, cardiac events, and sepsis/septic shock specifically. Conclusions: mFI-5=1 independently predicted 45% increased odds of morbidity. mFI-5=2+ independently predicted 41% increased odds of morbidity. Further, every 30 additional minutes of operative time predicted 18% increased odds of morbidity, suggesting an increased risk of site-related complication events. Taken together, the mFI-5 serves as a valid predictor of morbidity in patients with extradural tumor undergoing instrumented excision.

Venous Thromboembolism Rates Have Not Decreased in Elective Lumbar Fusion Surgery from 2011 to 2020.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study aimed to (1) evaluate for any temporal trends in the rates of VTE, deep venous thrombosis (DVT), pulmonary embolism (PE), and mortality from 2011 to 2020 and (2) identify the predictors of VTE following lumbar fusion surgery. METHODS: Annual incidences of 30-day VTE, DVT, PE, and mortality were calculated for each of the operation year groups from 2011 to 2020. Multivariable Poisson regression was utilized to test the association between operation year and primary outcomes, as well as to identify significant predictors of VTE. RESULTS: A total of 121,205 patients were included. There were no statistically significant differences in VTE, DVT, PE, or mortality rates among the operation year groups. Multivariable regression analysis revealed that compared to 2011, operation year 2019 was associated with significantly lower rates of DVT. Age, BMI, prolonged operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking status, functional dependence, and chronic steroid use were identified as independent predictors of VTE following lumbar fusion. Female sex, Hispanic ethnicity, and outpatient surgery setting were identified as protective factors from VTE in this cohort. CONCLUSIONS: Rates of VTE after lumbar fusion have remained mostly unchanged between 2011 and 2020. Older age, higher BMI, longer operation time, prolonged length of stay, non-home discharge, anterior fusion, smoking, functional dependence, and steroid use were independent predictors of VTE after lumbar fusion, while female sex, Hispanic ethnicity, and outpatient surgery were the protective factors.

Comparative Analysis of 30-Day Readmission, Reoperation, and Morbidity between Posterior Cervical Decompression and Fusion Performed in Inpatient and Outpatient Settings.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To compare 30-day readmission, reoperation, and morbidity for patients undergoing posterior cervical decompression and fusion (PCDF) in inpatient vs. outpatient settings. OVERVIEW OF LITERATURE: PCDF has recently been increasingly performed in outpatient settings, often utilizing minimally invasive techniques. However, literature evaluating short-term outcomes for PCDF is scarce. Moreover, no currently large-scale database studies have compared short-term outcomes between PCDF performed in the inpatient and outpatient settings. METHODS: Patients who underwent PCDF from 2005 to 2018 were identified using the National Surgical Quality Improvement Program database. Regression analysis was utilized to compare primary outcomes between surgical settings and evaluate for predictors thereof. RESULTS: We identified 8,912 patients. Unadjusted analysis revealed that outpatients had lower readmission (4.7% vs. 8.8%, p =0.020), reoperation (1.7% vs. 3.8%, p =0.038), and morbidity (4.5% vs. 11.2%, p <0.001) rates. After adjusting for baseline differences, readmission, reoperation, and morbidity no longer statistically differed between surgical settings. Outpatients had lower operative time (126 minutes vs. 179 minutes) and levels fused (1.8 vs. 2.2) (p <0.001). Multivariate analysis revealed that age (p =0.008; odds ratio [OR], 1.012), weight loss (p =0.045; OR, 2.444), and increased creatinine (p <0.001; OR, 2.233) independently predicted readmission. The American Society of Anesthesiologists (ASA) classification of ≥3 predicted reoperation (p =0.028; OR, 1.406). Rehabilitation discharge (p <0.001; OR, 1.412), ASA-class of ≥3 (p =0.008; OR, 1.296), decreased hematocrit (p <0.001; OR, 1.700), and operative time (p <0.001; OR, 1.005) predicted morbidity. CONCLUSIONS: The 30-day outcomes were statistically similar between surgical settings, indicating that PCDF can be safely performed as an outpatient procedure. Surrogates for poor health predicted negative outcomes. These results are particularly important as we continue to shift spinal surgery to outpatient centers. This importance has been highlighted by the need to unburden inpatient sites, particularly during public health emergencies, such as the coronavirus disease 2019 pandemic.

Duration of Back Pain Symptoms and Its Relationship to Paralumbar Muscle Volume.

OBJECTIVE: Paralumbar muscle volume has been indicated as an important factor for patients reporting back pain. Our goal was to determine if there is a statistically significant relationship between the duration of patients' back pain symptoms (>12 weeks or ≤12 weeks) and paralumbar muscle volume. METHODS: In this retrospective cohort study, paralumbar muscles on axial T2-weighted lumbar magnetic resonance images were outlined using ImageJ to determine the paralumbar cross-sectional area (PL-CSA) and lumbar indentation value (LIV) at the center of disc spaces from L1 to L5. The Goutallier classification was determined by the primary author. Quantile regression was performed to compare the PL-CSA, PL-CSA normalized by body mass index, and LIV between the 2 cohorts. Cohort A consisted of patients reporting symptoms ≤12 weeks, and cohort B included patients with symptoms >12 weeks. Negative binomial regression was used to compare Goutallier class. RESULTS: A total of 551 patients operated on by a single surgeon with lumbar magnetic resonance imaging within the past 12 months and recorded duration of symptoms were included. Cohort A consisted of 229 patients (41.6%), and cohort B included 322 patients (58.4%). Statistical significance was not found at any lumbar level for PL-CSA, PL-CSA normalized by body mass index, Goutallier class, and LIV. CONCLUSIONS: Our results suggest that duration of symptoms may not be an accurate indicator for lumbar muscle volume. These novel findings are clinically valuable because lumbar muscle volume has been shown to be a marker for recovery. With this information, patients previously believed to be inoperable because of long-standing symptoms can be reevaluated.