Faculty Bibliography

STUDY DESIGN/METHODS:Retrospective analysis of retrospectively collected data. OBJECTIVE:To determine the effects of preoperative nonsteroidal anti-inflammatory drug (NSAID) use on estimated blood loss (EBL) and postoperative drain output in TLIF procedures. SUMMARY OF BACKGROUND DATA/BACKGROUND:Current standards of care recommend patients prescribed NSAIDs for chronic lower back pain discontinue NSAIDs at least 1 week before spine fusion surgery. The literature surrounding the effects of preoperative NSAID use is unclear, however, with dissonant findings regarding postoperative blood loss and complications. METHODS:A retrospective case review was performed on 429 cases of 1-level or 2-level TLIF, with patient NSAID use recorded within 3 days of surgery, at a single institution. Linear and logistic regressions were used to assess associations between NSAID use, patient and surgical characteristics, EBL, and drain output. RESULTS:NSAID use was significantly positively associated with drain output (P=0.03), with an approximate increase of 21±9.7 mL/day but no significant association with any postoperative complications (P=0.77). Drain output also had significant, independent positive associations with patient age (P=0.007), male sex (P<0.001), and a number of levels fused (P<0.001), and significant negative associations with robot-assisted (P<0.001) and minimally invasive (P=0.04) procedures. No significant association was detected between NSAID use and EBL (P=0.21), though EBL had significant positive associations with operative time (P<0.001) and levels fused (P<0.001), and multiple NSAIDs had a significant positive association with EBL (P<0.001). CONCLUSIONS:NSAID use had a statistically significant, but small, effect on drain output and no detectable effect on postoperative complications within 3 days of TLIF procedures, suggesting most patients can safely continue NSAID use up until their date of surgery. Future studies should further delineate the effects of preoperative NSAID use, such that a more refined risk profile could be developed from patient and surgical characteristics and NSAID use information.

Background Health literacy is "the degree to which individuals can obtain, process, and understand basic health information and services to make appropriate health decisions." Low health literacy is associated with adverse health outcomes, such as increased risk and length of hospitalization after abdominal surgery. However, the impact of health literacy on outcomes in the spine surgery patient population is understudied. This study seeks to evaluate the relationship between patients' health literacy scores and various outcomes, primarily a patient's Patient-Reported Outcomes Measurement Information System (PROMIS) score at their baseline visit with a spine surgeon. A greater understanding of the impact of health literacy on health outcomes may improve treatment for patients with lower health literacy. Methods This is a single-center retrospective study at New York University (NYU) Langone Orthopedic Center. A health literacy measurement survey (i.e., the Newest Vital Sign survey) was administered to English-speaking adult patients aged 18 years and older who presented to two attending spine surgeons between June 1, 2022, and August 15, 2022, as new or follow-up patients. The survey consists of six questions, and patients were categorized into two different health literacy levels based on the number of correct responses. A score of 0-3 suggests limited literacy, and a score of 4-6 indicates adequate literacy. Additional data collected include PROMIS at the patient's baseline appointment with the surgeon to create consistency between new and follow-up patients. Key demographic and clinical data were also collected. Univariate associations between health literacy and PROMIS scores were investigated using the Welch Two Sample t-test and Pearson's Chi-squared test. A multivariate analysis was carried out implementing a binary logistic regression model. Results This study included 57 patients with an average age of 57 years, 29 (51%) of whom identified as female. The racial breakdown of this cohort was 33 (58%) White, 11 (19%) Black, 5 (9%) Asian, and 5 (9%) Hispanic. The health literacy survey results demonstrated that 25 (44%) had limited health literacy, and 32 (56%) had adequate health literacy. Limited literacy patients were older (mean age of 62 years for Limited vs. 54 years for Adequate, P=0.024) and more likely to be patients of color (either Asian, Black, or Hispanic) (15 (60%) Limited vs. 6 (19%) Adequate, P = 0.002). Limited literacy patients also, on average, had a lower self-reported physical health score (36.6 for Limited vs. 41.2 for Adequate, P=0.050) and were more likely to have hypertension (20 (80%) Limited vs. 10 (31%) Adequate, P<0.001). A logistic regression model yielded an odds ratio of 1.16 between patient-reported physical health and health literacy, indicating that the odds of having adequate health literacy increase by about 16% for each unit increase in the Physical Health score. A Variance Inflation Factor (VIF) test was used and demonstrated minimal multicollinearity among the variables in the logistic regression. Conclusion This study shows that health literacy plays a significant role in health outcomes, especially in chronic health conditions like physical health for spine surgery patients and hypertension. These results align with the literature, showing how lower health literacy correlates with worse physical health scores and a greater incidence of hypertension.

BACKGROUND:Unilateral biportal endoscopic (UBE) microdiscectomy is an emerging minimally invasive surgery technique for treating symptomatic lumbar disc herniation. There is limited literature regarding outcomes. Here, we assess surgical outcomes and pain medication consumption for UBE vs. tubular lumbar microdiscectomy. METHODS:This was a retrospective cohort study of adult patients undergoing primary, single-level UBE or tubular lumbar microdiscectomy surgery at a high-volume institution between 2018 and 2023. Variables of interest included operative time, complications and reoperations, as well as postoperative opioid and nonopioid pain medication consumption from discharge to 6 months. Opioid consumption was converted to morphine milligram equivalents. Standard statistical analyses were performed for comparative analyses. RESULTS:One hundred two patients-48 UBE and 54 tubular-were included. Average operative time (minutes) was higher for UBE patients (133.1 UBE vs. 86.6 tubular, P < 0.001), which trended downward over time but did not reach statistical significance (P = 0.07). There were no differences in complication or reoperation rates. Average daily MME was lower from discharge to 2-week follow-up in the UBE group (11.1 v. 14.1, P = 0.02), but were comparative thereafter. Nonopioid medication prescription was lower in the UBE cohort from discharge to 2 weeks (70.8% vs. 92.6%, P = 0.01) and 2 to 6 weeks (52.1% vs. 85.2%, P < 0.001), with no significant differences thereafter. CONCLUSIONS:UBE microdiscectomy is associated with longer operating times. Both opioid and nonopioid pain medication consumption were lower for UBE patients during the initial postoperative period, perhaps owing to the less-invasive nature of the surgery.

Though the United States population has rapidly diversified in recent decades, the American physician workforce has been slow to follow. Orthopedic surgery and neurosurgery are 2 specialties which remain particularly homogenous, and the subset of orthopedic surgeons and neurosurgeons who pursue spine surgery is even less diverse, along many different demographic axes. To provide effective, innovative, and accessible care to the changing population, greater diversity in spine surgery is essential. This is achieved in part by recruitment, retention, and leadership sponsorship of a new generation of trainees and faculty who reflect the diversity of the patient population they will care for. For surgeons, workforce diversity means improved learning, innovation, and organizational performance. For patients, it means greater ability to access respectful, quality care. Investing in the future of spine surgery means creating a more diverse and inclusive field, 1 in which patients from all walks of life can say, "My doctor is different-like me."

BACKGROUND:The benefit of chemoprophylaxis (CPX) agents in preventing venous thromboembolism must be weighed against potential risks. Current literature regarding the efficacy of CPX after laminectomies with or without fusion is limited, with no clear consensus to inform guidelines. OBJECTIVE:This study evaluated the association between CPX and surgical complications after lumbar laminectomy with and without fusion. STUDY DESIGN/METHODS:Retrospective study of patients at a single large academic institution. METHODS:test following propensity score matching, and patients on CPX were further stratified by fusion status. RESULTS:The CPX group had higher body mass index and American Society of Anesthesiologists grades. Rates of venous thromboembolism, epidural hematomas, infections, postoperative incision and drainage, transfusions, wound dehiscence, and reoperation were not associated with CPX. Moist dressings were more frequent, and average days of drain duration were longer with CPX. Overall postoperative complication rate and length of stay (LOS) were greater with CPX. The fusion subgroup had a lower Charlson Comorbidity Index, had a lower American Society of Anesthesiologists grade, was younger, had more women, and underwent more minimally invasive laminectomies. While estimated blood loss, operative times, and LOS were significantly greater in the fusion group, there was no difference in rate of intraoperative and postoperative complications. CONCLUSION/CONCLUSIONS:CPX after lumbar laminectomies with or without fusion was not associated with increased rates of epidural hematomas, wound complications, or reoperation. Patients receiving CPX had more postoperative cardiac complications, but it is possible that surgeons were more likely to prescribe CPX for higher-risk patients. They also had higher rates of ileus and moist dressings, greater LOS, and longer length of drain duration. Patients who underwent lumbar laminectomy with fusion on CPX tended to be lower risk yet incurred greater blood loss, operative times, LOS, cardiac complications, and hematomas/seromas than patients not undergoing fusion. CLINICAL RELEVANCE/CONCLUSIONS:This retrospective study compared surgical complications of lumbar laminectomies in patients who received chemoprophylaxis vs patients who did not. Chemoprophylaxis was not associated with increased rates of epidural hematomas, wound complications, or reoperation, but it was associated with higher rates of postoperative cardiac complications and ileus.

BACKGROUND:Recombinant human bone morphogenetic protein 2 (rhBMP-2, or BMP for short) is a popular biological product used in spine surgeries to promote fusion and avoid the morbidity associated with iliac crest autograft. BMP's effect on pseudarthrosis in transforaminal lumbar interbody fusion (TLIF) remains unknown. OBJECTIVE:To assess the rates of pseudarthrosis in single-level TLIF with and without concurrent use of BMP. METHODS:analyses, and perioperative characteristics were analyzed by multiple logistic regression. RESULTS:= 0.002) increased the risk of reoperation for pseudarthrosis. CONCLUSIONS:BMP use did not reduce the rate of pseudarthrosis or the number of reoperations for pseudarthrosis in single-level TLIFs. Diabetes with end-organ damage was a significant risk factor for pseudarthrosis. CLINICAL RELEVANCE/CONCLUSIONS:BMP is frequently used "off-label" in transforaminal lumbar interbody fusion; however, little data exists to demonstrate its safety and efficacy in this procedure.

Achieving adequate hemostasis in spine surgery is critical for both the patient and surgeon. Currently, there are 2 major topical hemostatic matrix agents used in spine surgery"”Floseal (Baxter Healthcare, Deerfield, Illinois, USA) and Surgiflo (Ethicon Inc., Raritan, New Jersey, USA). While both products have been shown to be effective at achieving hemostasis, there is no consensus supporting the use of one agent over another in spine surgery. There are studies comparing outcomes and cost between Floseal and Surgiflo, but a significant portion of the studies have industry affiliations. Generally, existing literature reports low to moderate cost savings in favor of one agent or the other, with no clinically significant differences in patient-based outcomes such as postoperative hematomas. Animal model studies also suggest unique complications, including epidural fibrosis and associated nerve root compression with use of a flowable topical hemostatic agent. Further nonindustry-affiliated studies are warranted to compare efficacy, patient outcomes, cost analyses, and possible unique complications associated with the two hemostatic agents.

Recent decades have seen numerous significant advancements in the field of spinal and lumbar fusion surgeries, including the augmentation of surgical precision with robotic navigation. Use of robotic navigation in single-position lumbar fusion surgery (SPLS), which utilizes a lateral approach and requires no mid-procedure repositioning of the patient, has been shown to improve outcome measures and overall operative efficiency in addition to reducing patient time under anesthesia. Despite indications that robotically-assisted SPLS is superior to more traditional approaches in terms of cost and outcomes, relatively few surgeons currently utilize this innovative combination. This is largely attributed to the well-documented learning curve associated with robotically assisted surgery. In an attempt to mitigate this and reduce the barrier to entry for robotically-assisted spinal surgery, this report will give a detailed description of the workflow for SPLS procedures using robotic navigation. The authors will also give best-practice recommendations applicable for spine surgeons and surgical residents unfamiliar with surgical robotics systems.

Lower health literacy is associated with worse patient outcomes, yet physicians tend to overestimate patients"™ health literacy. To assess spine surgeons"™ ability to accurately estimate patients"™ health literacy, this study administered the Newest Vital Sign (NVS) to spine surgery patients and recorded 2 spine surgeons"™ estimations of those patients"™ health literacy levels. Spine surgeons"™ estimates were in moderate agreement with patients"™ NVS scores, and spine surgeons tended to overestimate patients"™ health literacy. Surgeons"™ estimates were more accurate for patients with the following characteristics: Adequate health literacy, White, age 60 and older, and male. These findings highlight the potential for routine NVS administration to promote health equity, quality, and safety in spine surgery.

STUDY DESIGN/METHODS:Retrospective analysis. OBJECTIVES/OBJECTIVE:To evaluate resolution of radiculopathy in one-level lumbar fusion with indirect or direct decompression techniques. METHODS:< .05. RESULTS:116 patients were included: 58 direct decompression (DD) (mean 53.9y, 67.2% female) and 58 indirect decompression (ID) (mean 54.6y, 61.4% female). DD patients experienced greater blood loss than ID. Additionally, DD patients were 4.7 times more likely than ID patients to experience full resolution of radiculopathy at 3 months post-op. By 6 months, DD patients demonstrated larger reductions in VAS score. With regard to motor function, DD patients had improved motor score associated with the L5 dermatome at 6 months relative to ID patients. CONCLUSIONS:Direct decompression was associated with greater resolution of radiculopathy in the near post-operative term, with no differences at long term follow-up when compared with indirect decompression. In particularly debilitated patients, these findings may influence surgeons to perform a direct decompression to achieve more rapid resolution of radiculopathy symptoms.