Mobile health supported multi-domain recovery trajectories after major arthroplasty or spine surgery: a pilot feasibility and usability study.

BACKGROUND: Recovery after surgery intersects physical, psychological, and social domains. In this study we aim to assess the feasibility and usability of a mobile health application called PositiveTrends to track recovery in these domains amongst participants undergoing hip, knee arthroplasty or spine surgery. Our secondary aim was to generate procedure-specific, recovery trajectories within the pain and medication, psycho-social and patient-reported outcomes domain. METHODS: Prospective, observational study in participants greater than eighteen years of age. Data was collected prior to and up to one hundred and eighty days after completion of surgery within the three domains using PositiveTrends. Feasibility was assessed using participant response rates from the PositiveTrends app. Usability was assessed quantitatively using the System Usability Scale. Heat maps and effect plots were used to visualize multi-domain recovery trajectories. Generalized linear mixed effects models were used to estimate the change in the outcomes over time. RESULTS: Forty-two participants were enrolled over a four-month recruitment period. Proportion of app responses was highest for participants who underwent spine surgery (median = 78, range = 36-100), followed by those who underwent knee arthroplasty (median = 72, range = 12-100), and hip arthroplasty (median = 62, range = 12-98). System Usability Scale mean score was 82 ± 16 at 180 days postoperatively. Function improved by 8 and 6.4 points per month after hip and knee arthroplasty, respectively. In spine participants, the Oswestry Disability Index decreased by 1.4 points per month. Mood improved in all three cohorts, however stress levels remained elevated in spine participants. Pain decreased by 0.16 (95% Confidence Interval: 0.13-0.20, p < 0.001), 0.25 (95% CI: 0.21-0.28, p < 0.001) and 0.14 (95% CI: 0.12-0.15, p < 0.001) points per month in hip, knee, and spine cohorts respectively. There was a 10.9-to-40.3-fold increase in the probability of using no medication for each month postoperatively. CONCLUSIONS: In this study, we demonstrate the feasibility and usability of PositiveTrends, which can map and track multi-domain recovery trajectories after major arthroplasty or spine surgery.

Metformin extended-release versus immediate-release: An international, randomized, double-blind, head-to-head trial in pharmacotherapy-naïve patients with type 2 diabetes.

This international, randomized, double-blind trial (NCT01864174) compared the efficacy and safety of metformin extended-release (XR) and immediate-release (IR) in patients with type 2 diabetes. After a 4-week placebo lead-in, pharmacotherapy-naïve adults with glycated haemoglobin (HbA1c) at 7.0% to 9.2% were randomized (1:1) to receive once-daily metformin XR 2000 mg or twice-daily metformin IR 1000 mg for 24 weeks. The primary endpoint was change in HbA1c after 24 weeks. Secondary endpoints were change in fasting plasma glucose (FPG), mean daily glucose (MDG) and patients (%) with HbA1c <7.0% after 24 weeks. Overall, 539 patients were randomized (metformin XR, N = 268; metformin IR, N = 271). Adjusted mean changes in HbA1c, FPG, MDG and patients (%) with HbA1c <7.0% after 24 weeks were similar for XR and IR: -0.93% vs -0.96%; -21.1 vs -20.6 mg/dL (-1.2 vs -1.1 mmol/L); -24.7 vs -27.1 mg/dL (-1.4 vs -1.5 mmol/L); and 70.9% vs 72.0%, respectively. Adverse events were similar between groups and consistent with previous studies. Overall, metformin XR demonstrated efficacy and safety similar to that of metformin IR over 24 weeks, with the advantage of once-daily dosing.

Intraoperative Traction May Be a Viable Alternative to Anterior Surgery in Cerebral Palsy Scoliosis ≥100 Degrees.

BACKGROUND: For large scoliosis, 2 strategies to maximize correction include intraoperative traction and/or anterior release. It is unclear which patients will benefit the most form either approach. The purpose of our study is to compare the radiographic, perioperative clinical outcomes, and health-related quality of life (HRQoL) outcomes of 2 approaches when used in severe neuromuscular scoliosis in the setting of cerebral palsy (CP). METHODS: In total, 23 patients with minimum 2-year follow-up, major curves ≥100 degrees, and in whom treatment included posterior spinal fusion were evaluated. Eighteen were treated with posterior spinal fusion with intraoperative traction and 5 with anterior/posterior spinal fusion (APSF). The baseline characteristics, perioperative outcomes, and preoperative and 2-year follow-up data for HRQoL and radiographic measures were compared. RESULTS: The groups had similar age, sex, nutritional and seizure status, GMFCS level, and change in CPCHILD scores. The groups had similar curve magnitude (120 vs. 105 degrees, P=0.330) and flexibility (28% vs. 40%, P=0.090), but the APSF group had less pelvic obliquity (POB) (24 vs. 42 degrees, P=0.009). There were similar postoperative major curves (37 vs. 40 degrees, P=0.350), but greater correction in POB (33.5 vs. 14 degrees of correction, P=0.007) in the traction group. The APSF group had longer anesthesia times (669 vs. 415 min, P=0.005), but similar hospital stays, intensive care unit and days intubated, estimated blood loss, cell saver, and red blood cells used. Although the APSF group had twice the rate of complications (22% vs. 40%) during the first 90 days postoperatively, this did not reach statistical significance. CONCLUSIONS: Both intraoperative traction and anterior surgery were used to aid correction in severe CP scoliosis. Anterior surgery did not offer superior correction or better HRQoL, and was associated with increased operative times, whereas intraoperative traction was associated with greater correction of POB. Intraoperative traction may be a viable alternative to an anterior release in severe CP scoliosis. LEVEL OF EVIDENCE: Level II.

Low Back Pain in Adolescents: A 1-Year Analysis of Eventual Diagnoses.

BACKGROUND: Back pain in adolescents is very common and often seen in the office for evaluation of potential spinal pathology. Pediatric back pain has often thought to be from serious identifiable causes such as spondylolysis, spondylolisthesis, tumor, or infection. A follow-up analysis of adolescents initially presenting with back pain to their eventual subsequent diagnosis within 1 year has not been reported on a large scale with a national sample. METHODS: A national insurance database (PearlDiver Patient Records Database) was queried for ICD-9 codes to identify patients aged 10 to 19 years with back pain from 2007 to 2010. These patients were tracked for imaging obtained, and eventual development of subsequent associated spinal pathology diagnoses using CPT and ICD-9 codes for up to 1 year after initial presentation. RESULTS: A total of 215,592 adolescents were identified presenting with low back pain (LBP) from 2007 to 2010. Over 80% of adolescents with LBP had no identifiable diagnosis within 1 year. The most common associated subsequent diagnoses were lumbar strain/spasm (8.9%), followed by scoliosis (4.7%), lumbar degenerative disk disease (1.7%), and lumbar disk herniation (1.3%). The rates of all other diagnoses including spondylolysis, spondylolisthesis, infection, tumor, and fracture had <1% association with LBP. CONCLUSIONS: In conclusion, adolescent LBP is a common diagnosis for which underlying serious pathology is rare. The most common diagnosis aside from strain or muscle spasm associated with LBP are scoliosis and degenerative disk disease. Pediatric orthopaedists often are consulted on patients with LBP and should always have high suspicion for potential serious spinal pathology, but should recognize the most common etiologies of back pain in adolescence. LEVEL OF EVIDENCE: Level IV-case series.

Minimally Invasive Lateral Interbody Fusion in the Treatment of Scoliosis Associated with Myelomeningocele.

INTRODUCTION: Surgical correction of spinal deformity in myelomeningocele is associated with high rates of pseudarthrosis and implant failure. The anterior fusion is traditionally a wide exposure from the thorax to the sacrum. We report minimally invasive lateral interbody fusion (MILIF) to address the issue of fusion between vertebrae with marginal posterior elements while minimizing the morbidity of an open approach. MATERIALS AND METHODS: We performed a single-center, retrospective review of patients with myelomeningocele and severe scoliosis who underwent posterior spinal fusion (PSF) and staged MILIF for anterior fusion of the thoracolumbar/lumbar spine. We identified four patients with high risk of curve progression who met the following inclusion criteria: diagnosis of myelomeningocele, severe scoliosis (Cobb angle>70°), PSF using greater than 80% pedicle screws, age greater than 10 years at time of surgery, and a minimum follow-up of two years. Radiographic, clinical, and complication data were reviewed. RESULTS: All four patients achieved fusion (100%). The average age at index surgery was 12.8 years (range, 11-16) and follow-up was 3.2 years (range, 2-4.9). The average preoperative coronal Cobb angle measured 111° (range, 74-140°). The average postoperative Cobb angle at follow-up measured 37° (range, 23-42°). The MILIF procedure was performed an average of six months after the index procedure. After anterior fusion, all patients spent one day in the pediatric ICU and an average of 5.5 days in the hospital (range, 4-7). One patient (25%) developed a postoperative wound infection after PSF which required irrigation and debridement in the operating room. CONCLUSION: MILIF as an adjunct to posterior spinal fusion for severe scoliosis associated with myelomeningocele may provide acceptable fusion rates, curve correction, maintenance of correction at mid-term follow-up, and be associated with less morbidity than the traditional anterior approach.

Does Amicar affect blood loss in patients with adolescent idiopathic scoliosis treated with pedicle screws and Ponte osteotomies?

Amicar may affect estimated blood loss (EBL) and blood transfusion in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with pedicle screws and Ponte osteotomies. We performed a retrospective analysis of a prospectively collected, single-center database of 33 patients with main thoracic AIS treated with greater than 80% pedicle screws. Patients were divided into two groups based on whether they received Amicar (Yes), or did not receive any antifibrinolytics and Ponte osteotomies (No). Demographic, radiographic, and intraoperative data were compared between the two groups. Seventeen patients were treated with Amicar (Yes) (10 of whom had Ponte osteotomies) and 16 patients had neither antifibrinolytics nor Ponte osteotomies (No). The two groups had similar preoperative main Cobb angles, major curve flexibility, and gender. Despite longer operating times and a majority of patients receiving Ponte osteotomies, the Amicar group had a significantly lower EBL and homologous blood transfusion rate. Autologous transfusion volume was less in the Amicar group and trended toward significance. There were no differences in mean arterial pressure during surgery. There were no complications in either group. Amicar reduces EBL and homologous transfusion requirements in patients with main thoracic AIS undergoing PSF with pedicle screws and Ponte osteotomies.

Toll-like receptor 2 ligand pretreatment attenuates retinal microglial inflammatory response but enhances phagocytic activity toward Staphylococcus aureus.

Staphylococcus aureus is a leading cause of severe endophthalmitis, which often results in vision loss in some patients. Previously, we showed that Toll-like receptor 2 (TLR2) ligand pretreatment prevented the development of staphylococcal endophthalmitis in mice and suggested that microglia might be involved in this protective effect (Kumar A, Singh CN, Glybina IV, Mahmoud TH, Yu FS. J. Infect. Dis. 201:255-263, 2010). The aim of the present study was to understand how microglial innate response is modulated by TLR2 ligand pretreatment. Here, we demonstrate that S. aureus infection increased the CD11b(+) CD45(+) microglial/macrophage population in the C57BL/6 mouse retina. Using cultured primary retinal microglia and a murine microglial cell line (BV-2), we found that these cells express TLR2 and that its expression is increased upon stimulation with bacteria or an exclusive TLR2 ligand, Pam3Cys. Furthermore, challenge of primary retinal microglia with S. aureus and its cell wall components peptidoglycan (PGN) and lipoteichoic acid (LTA) induced the secretion of proinflammatory mediators (tumor necrosis factor alpha [TNF-α] and MIP-2). This innate response was attenuated by a function-blocking anti-TLR2 antibody or by small interfering RNA (siRNA) knockdown of TLR2. In order to assess the modulation of the innate response, microglia were pretreated with a low dose (0.1 or 1 µg/ml) of Pam3Cys and then challenged with live S. aureus. Our data showed that S. aureus-induced production of proinflammatory mediators is dramatically reduced in pretreated microglia. Importantly, microglia pretreated with the TLR2 agonist phagocytosed significantly more bacteria than unstimulated cells. Together, our data suggest that TLR2 plays an important role in retinal microglial innate response to S. aureus, and its sensitization inhibits inflammatory response while enhancing phagocytic activity.

Lumbar Spinal Steroid Injections and Infection Risk after Spinal Surgery: A Systematic Review and Meta-Analysis.

Lumbar spinal steroid injections (LSSI) are universally used as preferred diagnostic or therapeutic treatment options before major spinal surgeries. Some recent studies have reported higher risks of surgical-site infection (SSI) for spinal surgeries performed after injections, while others have overlooked such associations. The purpose of this study is to systematically review the literature and perform a meta-analysis to evaluate the associations between preoperative LSSI and postoperative infection following subsequent lumbar decompression and fusion procedures. Three databases, namely PubMed, Scopus, and Cochrane Library, were searched for relevant studies that reported the association of spinal surgery SSI with spinal injections. After the comprehensive sequential screening of the titles, abstracts, and full articles, nine studies were included in a systematic review, and eight studies were included in the meta-analysis. Studies were critically appraised for bias using the validated MINOR (methodological index for non-randomized studies) score. The odds ratio (OR) and 95% confidence interval (CI) were calculated. Subgroup analysis was performed according to the time between LSSI and surgery and the type of lumbar spine surgery. Meta-analysis showed that preoperative LSSI within 30 days of lumbar spine surgery was associated with significantly higher postoperative infection compared with the control group (OR,1.79; 95% CI, 1.08-2.96). Based on subgroup analysis, lumbar spine fusion surgery within 30 days of preoperative LSSI was associated with significantly high-infection rates (OR, 2.67; 95% CI, 2.12-3.35), while no association was found between preoperative LSSI and postoperative infection for lumbar spine decompression surgeries. In summary, given the absence of high-level studies in the literature, careful clinical interpretation of the results should be performed. The overall risk of SSI was slightly higher if the spinal surgery was performed within 30 days after LSSIs. The risk was higher for lumbar fusion cases but not for decompression-only procedures.

Establishment of reference CD4+ T cell values for adult Indian population.

BACKGROUND: CD4+ T lymphocyte counts are the most important indicator of disease progression and success of antiretroviral treatment in HIV infection in resource limited settings. The nationwide reference range of CD4+ T lymphocytes was not available in India. This study was conducted to determine reference values of absolute CD4+ T cell counts and percentages for adult Indian population. METHODS: A multicentric study was conducted involving eight sites across the country. A total of 1206 (approximately 150 per/centre) healthy participants were enrolled in the study. The ratio of male (N = 645) to female (N = 561) of 1.14:1. The healthy status of the participants was assessed by a pre-decided questionnaire. At all centers the CD4+ T cell count, percentages and absolute CD3+ T cell count and percentages were estimated using a single platform strategy and lyse no wash technique. The data was analyzed using the Statistical Package for the Social Scientist (SPSS), version 15) and Prism software version 5. RESULTS: The absolute CD4+ T cell counts and percentages in female participants were significantly higher than the values obtained in male participants indicating the true difference in the CD4+ T cell subsets. The reference range for absolute CD4 count for Indian male population was 381-1565 cells/µL and for female population was 447-1846 cells/µL. The reference range for CD4% was 25-49% for male and 27-54% for female population. The reference values for CD3 counts were 776-2785 cells/µL for Indian male population and 826-2997 cells/µL for female population. CONCLUSION: The study used stringent procedures for controlling the technical variation in the CD4 counts across the sites and thus could establish the robust national reference ranges for CD4 counts and percentages. These ranges will be helpful in staging the disease progression and monitoring antiretroviral therapy in HIV infection in India.

Patient-reported Outcomes Following Surgical Intervention for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis.

STUDY DESIGN: This was a systematic review and meta-analysis. OBJECTIVE: This study aims to perform a systematic review and quantitative meta-analysis of patient-reported outcome measures after spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Radiographic correction of scoliosis is extensively reported in the literature but there is a need to study the impact of spinal fusion on patient-reported outcome measures. Prior reviews lacked homogeneity in outcome measures, did not perform quantitative meta-analysis of pooled effect size, or interpret the results in light of minimally clinically important difference thresholds. MATERIALS AND METHODS: A systematic review of medical databases identified all studies that prospectively reported Scoliosis Research Society (SRS)-22 questionnaire data after spinal fusion for AIS. We screened 2314 studies for eligibility. Studies were included that reported preoperative and postoperative data at 24- or >60-month follow-up. Studies were excluded that failed to report means and SDs which were needed to calculate Cohen d effect sizes and 95% confidence intervals in estimating the magnitude and precision of the effect. RESULTS: A total of 7 studies met eligibility criteria for inclusion in quantitative meta-analysis of effect sizes and 95% confidence intervals. Patients report large improvements in total score, self-image, and satisfaction; and moderate improvements in pain, function and mental health at 2 and 5 years after spinal fusion for AIS. All domains showed statistically significant improvement at all times except function at >60 months. All domains surpassed the minimally clinically important difference at all times except mental health. CONCLUSIONS: Moderate evidence suggests that spinal fusion improves quality of life for adolescents with idiopathic scoliosis in medium and long-term follow-up. Our results may help inform patient expectations regarding surgery. OCEMB LEVEL OF EVIDENCE: Level I-systematic review and meta-analysis of prospective studies.

Risk of Surgical Site Infection and Mortality Following Lumbar Fusion Surgery in Patients With Chronic Steroid Usage and Chronic Methicillin-Resistant Staphylococcus aureus Infection.

STUDY DESIGN: A retrospective database analysis among Medicare beneficiaries OBJECTIVE.: The aim of this study was to determine the effect of chronic steroid use and chronic methicillin-resistant Staphylococcus aureus (MRSA) infection on rates of surgical site infection (SSI) and mortality in patients 65 years of age and older who were treated with lumbar spine fusion. SUMMARY OF BACKGROUND DATA: Systemic immunosuppression and infection focus elsewhere in the body are considered risk factors for SSI. Chronic steroid use and previous MRSA infection have been associated with an increased risk of SSI in some surgical procedures, but their impact on the risk of infection and mortality after lumbar fusion surgery has not been studied in detail. METHODS: The PearlDiver insurance-based database (2005-2012) was queried to identify 360,005 patients over 65 years of age who had undergone lumbar spine fusion. Of these patients, those who had been taking oral glucocorticoids chronically and those with a history of chronic MRSA infection were identified. The rates of SSI and mortality in these two cohorts were compared with an age- and risk-factor matched control cohort and odds ratio (OR) was calculated. RESULTS: Chronic oral steroid use was associated with a significantly increased risk of 1-year mortality [OR = 2.06, 95% confidence interval (95% CI) 1.13-3.78, P = 0.018] and significantly increased risk of SSI at 90 days (OR = 1.74, 95% CI 1.33-1.92, P < 0.001) and 1 year (OR = 1.88, 95% CI 1.41-2.01, P < 0.001). Chronic MRSA infection was associated with a significantly increased risk of SSI at 90 days (OR = 6.99, 95% CI 5.61-9.91, P < 0.001) and 1 year (OR = 24.0, 95%CI 22.20-28.46, P < 0.001) but did not significantly impact mortality. CONCLUSION: Patients over 65 years of age who are on chronic oral steroids or have a history of chronic MRSA infection are at a significantly increased risk of SSI following lumbar spine fusion. LEVEL OF EVIDENCE: 3.

Unplanned Immediate Return to Operating Room After Spine Surgery: Significance of Immediate Postoperative Radiographs.

STUDY DESIGN: Retrospective analysis; single center data. OBJECTIVE: The purpose of this study is to look at the utility and relevance of immediate postoperative radiographs in providing vital information leading to immediate revision after spine surgery. SUMMARY OF BACKGROUND DATA: Immediate postoperative radiographs are routinely obtained in the recovery room after spine surgery to verify the level, alignment of the spine, implant position, and the adequacy of the procedure. However, with the ability to utilize intraoperative fluoroscopy imaging for the same purpose, the requirement for immediate postoperative radiographs needs to be validated. The purpose of this study is to look at the utility and relevance of these postoperative radiographs in providing critical information that may warrant immediate intervention. METHODS: Retrospective analysis of all spine surgeries (elective and emergent), performed at a single center from 2011 to 2016, was done and cases returning to operating room within 48 hours were identified. Indication of immediate revision was reviewed and utility of immediate postoperative radiographs in guiding immediate revision was analyzed. RESULTS: A total of 1804 elective and urgent spinal surgeries were performed by seven surgeons. Twenty-two patients returned to operating room within 48 hours of their index procedures. Of these 22 cases, only two patients were noted to have positive findings on recovery room radiographs. The findings of suboptimal spinal alignment or failed instrumentation led to the immediate revision in both cases. Both cases involved instrumentation at cervicothoracic region and intraoperative imaging provided only limited visualization. CONCLUSION: Routine recovery room radiographs played a role in the decision to emergently return to the operating room in 0.10% (2/1804) cases at our institution. The potential benefit of immediate recovery room radiographs after spine surgery should be weighed against the added healthcare cost and patient discomfort associated with obtaining these radiographs routinely. Imaging may be delayed to a more elective time without any significant risk in majority of spine cases. LEVEL OF EVIDENCE: 3.

Drug resistance-associated genotypic alterations in the pol gene of HIV type 1 isolates in ART-naive individuals in North India.

ABSTRACT We genotyped the RT and PI regions of the pol gene of HIV-1 from treatment-naive infected individuals in North India and evaluated their possible physiological relevance and association with drug resistance. Plasma samples from 52 newly diagnosed HIV-1-infected drug-naive individuals were subjected to CD4(+) cell count and plasma viral load. For genotyping, the protease and RT regions of the pol gene were amplified from cDNA reverse transcribed from plasma viral RNA by single or nested polymerase chain reaction (PCR). Sequences of amplified products were analyzed for mutations using the Stanford DR and REGA database. Two out of 49 amplicons showed mutations at known "major" subtype B drug resistance positions (one each in protease and RT). In the protease region it showed a major drug resistance mutation at M46I as well as "minor" positions F53L and T74P. In the RT gene, one patient showed a mutation at major NNRTI position G190V. Forty-nine percent had mutations in the hinge (M36I, R41K, H69K) and alpha-helix (L89M) regions of the C-virus protease, which has been linked to increased catalytic activity. Our study indicates that a number of major mutations associated with resistance to PIs, NNRTIs, and NRTIs do exist, though at a low frequency, among HIV-1 isolates from treatment-naive individuals in North India. Many minor or accessory mutations related to resistance to PIs and NRTIs are also present as the variants. These results point to the greater biochemical fitness of subtype C protease and faster decrease in drug sensitivity.

Use of the "dual construct" for the management of complex spinal reconstructions.

BACKGROUND CONTEXT: Surgical management of complex spinal reconstructions remains a clinical challenge, as pseudoarthrosis with subsequent rod breakage can occur. Increased rod density in the form of "satellite" or "outrigger" rods have been described; however, rod-fracture above or below satellite rods persist and can result in dissociation of the construct, loss of correction, and recurrence of deformity. The use of four distinct and mechanically independent rods (dual construct) reduces this concern. Since the original case description in 2006, there have been no other studies that use the dual construct for the surgical management of complex spinal reconstructions. PURPOSE: The purpose of this study is to review the long-term experience and surgical technique using the dual construct, and to present our complications, rod fracture rates, and outcomes for the surgical management of complex spinal reconstructions. STUDY DESIGN: This study used a surgical technique with case series outcomes. PATIENT SAMPLE: Patients were from a single-institute who underwent dual construct between 2010 and 2014 and who were available for 2-year follow-up. OUTCOME MEASURES: Radiographic and functional outcomes, complications, rod fracture rates, and revision surgery rates were the outcome measures. METHODS: A retrospective review was conducted from a single institution between 2010 and 2014, with a subsequent 2-year follow-up period. Extensive review of patients' medical record, radiographs, and advanced imaging where available was performed. Medical record was evaluated for patient demographics, surgical procedure, and complications. Radiographic measurements included presence or absence of implant failure and proximal junctional kyphosis or distal junctional kyphosis. RESULTS: A total of 36 patients underwent surgical reconstruction. The average estimated blood loss was 1,856 cc (range, 400-4,000 cc). The average length of stay was 7.3 days (range, 4-22 days). Clinical follow-up reported 21 patients (58.3%) with no or minimal pain. There were six deaths during the follow-up unrelated to the index procedure. Radiographic follow-up revealed three patients (8.3%) with rod fracture; one patient with one rod fracture, and two patients with two rod fractures. No patient had three or all four rod fractures. There were no screw fractures. None of the patients with rod fractures required revision surgery. CONCLUSIONS: The biggest advantage of the dual construct is that rod breakage, although uncommon, is typically minimal, or asymptomatic, and more importantly does not result in loss of alignment, and therefore has not required revision surgery. The dual construct approach is a safe alternative to traditional two-rod constructs, with encouraging outcomes at follow-up.

Perioperative Complications Associated With Posterolateral Spine Fusions: A Study of Elderly Medicare Beneficiaries.

STUDY DESIGN: A retrospective database review. OBJECTIVE: The aim of this study was to compare the occurrence of complications in patients treated with one to two-level, three to seven-level, and more than eight level fusions. SUMMARY OF BACKGROUND DATA: Elderly patients constitute a rapidly growing demographic with an increasing need for spinal procedures. Complication rates for spinal surgery in elderly patients range from 37% to 80% with major complications occurring in 12% to 21% of patients. METHODS: The PearlDiver database (2005-2012) was utilized to compare perioperative complication rates in patients aged 65 years and older undergoing posterolateral fusion of one to two (n = 90,527); three to seven (n = 23,827), and more than eight (n = 2758) thoracolumbar levels. Cohorts were matched by demographics and comorbidities. Ninety-day medical and surgical complication and mortality rates were determined. RESULTS: In the full, unmatched cohort, the major complication rate was 15.9%, with matched cohorts of one to two, three to seven, and eight-level fusions associated with major complication rates of 12.5%, 20.5%, and 35.4%, respectively. Patients treated with 8+ level fusions had 3.8 and 2.1 times greater odds of developing a major complication than patients treated with 1 to 2 and 3 to 7-level fusions, respectively (P < 0.0001). Patients treated with more than eight-level fusions had 3.9 and 10.8 times increased odds of experiencing mortality than those treated with three to seven-level and one to two-level fusions, respectively. CONCLUSION: Elderly patients treated with spine fusions spanning more than eight levels experience significantly increased complication rates when compared with patients treated with fusions of shorter length. LEVEL OF EVIDENCE: 3.

Readmission Rates, Reasons, and Risk Factors Following Anterior Cervical Fusion for Cervical Spondylosis in Patients Above 65 Years of Age.

STUDY DESIGN: A retrospective database review. OBJECTIVE: The aim of this study was to determine readmission reasons and rates following primary, elective anterior cervical spinal fusion surgery for cervical spondylosis and determine risk factors predicting increased risk of 30-day readmission in an exclusively elderly population. SUMMARY OF BACKGROUND DATA: In the United States, there were almost 190,000 cervical spine procedures in 2009. Many cervical spine surgery patients are elderly, a demographic increasingly requiring surgery for degenerative cervical spine pathology. Unfortunately, this patient population is poorly studied, particularly concerning readmission rates. METHODS: Medicare data from 2005 to 2012 were queried for elderly patients (65-84 years) who underwent primary one to two and ≥three-level anterior cervical spine fusion surgeries for cervical spondylosis. Forty-five thousand two hundred eighty-four patients treated with one to two-level and 12,103 patients with ≥three-level anterior cervical fusion (ACF) were identified and included in two study cohorts. Reasons for and rates of readmission were determined within 30 days, 90 days, and one-year postoperatively. Risk factors for medical, surgical, and all 30-day readmissions were also determined, selecting from various comorbidities, demographics, and surgical variables. RESULTS: Readmission rates of 1.0% to 1.4%, 2.7% to 3.6%, and 13.2% to 14.1% were observed within 30 days, 90 days, and one year. Within 30 days, over 30% of patients from both study cohorts were readmitted for surgical reasons. Of surgical reasons for 30-day readmission, hematoma/seroma diagnoses were the most frequent (11.4%-15.4% of all readmissions). Male gender, diabetes mellitus, chronic pulmonary disease, obesity, and smoking history were all found to be predictive of all-cause readmissions. CONCLUSION: Unplanned 30-day readmission rates following primary, elective ACF in elderly patients is low and often due to medical reasons. Frequent surgical reasons for 30-day readmission include hematoma/seroma formation. Male gender and various comorbid diagnoses are significant predictors of all-cause readmissions within 30 days. LEVEL OF EVIDENCE: 3.

Complications and Mortality Following 1 to 2 Level Lumbar Fusion Surgery in Patients Above 80 Years of Age.

STUDY DESIGN: Retrospective database review. OBJECTIVE: To determine the 90-day complication rate and 90-day and 1-year mortality in patients 80 years of age and older who were treated with posterolateral lumbar spinal fusion surgery and to compare these rates against those of elderly patients ages 65 to 79. SUMMARY OF BACKGROUND DATA: Patients over 80 years of age specifically represent a substantial proportion of the US population, with over 11 million such individuals in 2010. Few studies have comprehensively assessed the morbidity associated with spinal fusion surgery in patients older than 80 years. METHODS: The PearlDiver database (2005-2012) was utilized to determine morbidity and mortality rates after posterolateral lumbar or lumbosacral spinal fusion surgery of 2-3 vertebrae. Patients 65 to 79 (72,547) and ≥80-year old (12,187) were selected. Charlson comorbidity index scores were analyzed and compared, as were various comorbid conditions 90-day complication rates and mortality at 90-days and 1 year compared between cohorts. RESULTS: The ≥80 year cohort had a higher average Charlson Comorbidity Index score than the 65 to 79 year cohort (7.99 vs. 6.54, P <0.0001). The proportion of patients experiencing at least one major complication was relatively increased by 45.6% in patients ≥80 year (13.87 vs. 9.52%; OR 1.53 95% CI 1.44 - 1.62 P <0.0001). Ninety-day (0.30 vs. 0.09%; OR: 3.50, 95% confidence interval: 2.33-5.26, P <0.0001) and 1-year (0.48 vs. 0.18%; OR: 2.58, 95% confidence interval: 1.90-3.52, P <0.0001) mortality were significantly higher in the ≥80 year cohort compared with the 65 to 79-year-old control group. CONCLUSION: Patients 80 years of age or older have significantly greater rates of major medical complication and mortality following 1 to 2 level lumbar spinal posterolateral fusion surgery compared with patients 65 to 79 years of age. LEVEL OF EVIDENCE: 3.

Complication and Reoperation Rates Following Surgical Management of Cervical Spondylotic Myelopathy in Medicare Beneficiaries.

STUDY DESIGN: Retrospective database review. OBJECTIVE: To compare complication and reoperation rates after anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCFs), and anterior cervical corpectomy and fusion (ACCF) for cervical spondylotic myelopathy (CSM) using a large national database of Medicare beneficiaries. SUMMARY OF BACKGROUND DATA: CSM is the most common cause of myelopathy in patients over 55 years and is considered the most common cause of spinal cord dysfunction in the world. Surgical treatment includes ACDF, PCF, or ACCF procedures. METHODS: The PearlDiver database (2005-2012) was utilized to determine revision rates after surgical treatment of CSM by one of the aforementioned surgical treatments. Specifically, 1 to 2 level ACDF, ACCF, and PCF and 3+ level PCF cohorts were included. Each cohort was stratified by the age of 65 years. Survivorship curves were graphed and compared. RESULTS: Of the patients younger than 65 years of age, there were 10,557 patients treated with 1 to 2 level ACDF procedures, 1319 patients with 1 to 2 level PCF procedures, 1203 patients with 1 to 2 level ACCF procedures, and 2312 patients treated with 3+ level PCF procedures. Of the elderly patients, 24,310 patients were treated with 1 to 2 level ACDFs, 4776 with 1 to 2 level PCF procedures, 3109 with 1 to 2 level ACCFs, and 7760 with 3+ level PCFs. Patients younger than 65 years of age were significantly more likely to have a reoperation procedure, than those 65 years or older when analyzing ACCF, ACDF, and 3+ level PCF procedures. ACCFs were significantly more likely than ACDFs to require reoperation. Patients treated with PCF were consistently more likely to have nondysphagia-related complications than those treated with ACDF. Rates of transfusion, dysphagia, and hematoma/seroma formation were significantly increased with ACCF compared with ACDF within the elderly population. CONCLUSION: The elderly are significantly less likely to have a revision surgery after surgical treatment for CSM. Patients treated with ACCF are more likely to need a revision than those treated with ACDF. LEVEL OF EVIDENCE: 3.

Factors Associated with Patient-Initiated Telephone Calls After Spine Surgery.

BACKGROUND: Telephone calls play a significant role in the follow-up care of postoperative patients. However, further data are needed to identify the determinants of patient-initiated telephone calls after surgery because these factors may also highlight potential areas of improvement in patient satisfaction and during the hospital discharge process. Therefore, the goal of this study is to determine the number of postoperative patient telephone calls within 14 days after surgery and establish the factors associated with patient-initiated calls and reasons for calling. METHODS: A retrospective chart review of all spine surgeries performed at our institution from January 1, 2014, through January 2, 2015, was completed. Patient demographics, perioperative and operative variables, and telephone encounter data were collected. The primary outcome was a patient-initiated telephone call within 14 days after surgery. Secondary outcomes included reporting and analyzing the reasons for patient phone calls, analyzing which procedures were associated with the most telephone calls, and conducting a multivariate analysis to determine independent risk factors for patient calls. RESULTS: Of the 488 patients who underwent surgical procedures, 222 patients (45.7%) made a telephone call within 14 days after surgery. There were 61 patients (27.48%) who called regarding pain control and 54 patients (23.87%) who called with bathing/dressing/wound questions. Other common categories include the following: other (21.17%), medication problems (15.77%), weight-bearing status/activity restrictions (5.14%), fever (3.15%), bowel management (1.35%), work notes (1.35%), and anticoagulation questions (0.45%). Factors associated with a telephone call within 14 days postoperatively included increased body mass index (P = 0.031), lower number of comorbidities (P = 0.043), telephone call within 2 weeks prior to surgery (P = 0.027), American Society of Anesthesiologists (ASA) score of 2 (P = 0.036), discharge disposition to home (P = 0.003), and elective procedure (P = 0.006). Multivariate analysis revealed that fusion procedures (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.05-4.45; P = 0.037) and ASA score of 3-4 (OR, 0.55; 95% CI, 0.31-0.96, P = 0.036) were independently associated with increased and decreased propensity, respectively, toward making a phone call within 2 weeks. CONCLUSIONS: Postoperative patient-initiated telephone calls within 14 days after spine surgery are very common, occurring after almost one half of all procedures. By evaluating such determinants, patient care can be improved by better addressing patient needs during and prior to discharge to prevent potential unnecessary postoperative calls and improve patient satisfaction.

The Association of Perioperative Glycemic Control with Deep Postoperative Infection After Anterior Cervical Discectomy and Fusion in Patients with Diabetes.

OBJECTIVE: To evaluate the association of perioperative hemoglobin A1c (HbA1c) level in patients with diabetes with the incidence of infection after anterior cervical discectomy and fusion requiring operative intervention, in addition to determining if a threshold level of HbA1c above which the risk of infection increases significantly exists. METHODS: A national administrative database was queried for patients who underwent primary anterior cervical discectomy and fusion with diabetes who had a perioperative HbA1c level recorded within 3 months of surgery. These patients were stratified based on their HbA1c level in 0.5-mg/dL increments from <5.49 mg/dL to >11.5 mg/dL. The incidence of infection requiring operative intervention within 1 year was then identified using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. A receiver operating characteristic (ROC) analysis was performed to determine a threshold value of the HbA1c level. RESULTS: A total of 3341 patients with a perioperative HbA1c level were included. The rate of deep infection requiring irrigation and debridement postoperatively stratified by HbA1c level ranged from a low of 1.5% to a high of 6.4% and was significantly correlated with increasing HbA1c levels (P = 0.005). The results of ROC analysis determined that the inflection point of the ROC curve corresponded to an HbA1c level higher than 7.5 mg/dL (P = 0.022; area under the curve, 0.67; specificity, 68%; sensitivity, 46%). CONCLUSIONS: The risk of deep postoperative infection in patients with diabetes mellitus increases as the perioperative HbA1c level increases. ROC analysis determined that a perioperative HbA1c level higher than 7.5 mg/dL could serve as a threshold for a significantly increased risk of infection.