Faculty Bibliography

High-riding vertebral artery (HRVA) is an important anatomical variant of the vertebral artery that poses significant challenges during cervical spine surgery, particularly at the C1-C2 level, where it reduces the safe corridor for pedicle screw placement and increases the risk of arterial injury. This narrative review summarizes current evidence regarding the definition, prevalence, imaging identification, and surgical implications of HRVA, along with risk mitigation strategies. Radiographically, HRVA is most commonly defined by reduced C2 isthmus height (C2IsH) (≤5 mm) and/or internal height (C2InH) (≤2 mm) on computed tomography (CT) scans. Reported prevalence varies widely across populations, typically ranging from 10% to 25%, with higher rates observed in selected patient cohorts. The presence of HRVA necessitates careful perioperative planning, including comprehensive imaging and modification of surgical techniques, such as the use of alternative fixation strategies, including pars screws, laminar screws, navigation-assisted instrumentation, and artery mobilization. Advances in CT angiography (CTA), alternative fixation strategies, surgical navigation, and emerging predictive models may further improve risk stratification and operative safety. Recognition of HRVA and tailored surgical planning are essential to minimize the risk of vertebral artery injury (VAI) and to optimize patient outcomes in cervical spine surgery and instrumentation.

Endoscopic spine surgery (ESS) has emerged as a transformative approach in the treatment of spine pathology, offering advantages over traditional open surgical techniques. This review examines the historical development of ESS, highlighting key figures and milestones that have shaped its evolution. It explores different endoscopic techniques, including transforaminal, interlaminar, lumbar fusion, cervical, and thoracic approaches. The review also provides an overview of the ongoing debate between uniportal and biportal ESS, discussing the relative invasiveness, capabilities, costs, and learning curves. In addition, it examines the complication profiles of ESS compared with open surgery as well as the economic implications of these techniques. Finally, the review outlines future directions for ESS and the impact of enabling technology.

BACKGROUND/UNASSIGNED:open or minimally invasive (MIS) laminectomy using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS/UNASSIGNED:Using the ACS-NSQIP database from 2017 to 2022, Current Procedural Terminology (CPT) code of 63030 or 62380 were used to filter the dataset between open/tubular retractor-based and endoscopic single-level lumbar decompression cases, respectively. Overall, as collected, the endoscopic group consisted of 336 patients and the non-endoscopic group had 55,111 patients. The groups were compared to evaluate the patient characteristics and adverse events within 30 days after their operation. Outcome measures compared were operative time, length of stay (days), adverse outcomes [superficial infection, deep infection, organ/space infection, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, ventilator >48 hours, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke/cerebrovascular accident (CVA) accident, cardiac arrest, myocardial infarction, blood transfusion, deep vein thrombosis (DVT), sepsis, and septic shock], 30-day readmission, return to operating room (OR). RESULTS/UNASSIGNED:4.8%, P=0.01), with significantly lower rate of blood transfusions (P<0.05) compared to the non-endoscopic group. CONCLUSIONS/UNASSIGNED:Patients who underwent endoscopic lumbar decompression demonstrated a significantly lower rate of total adverse events and significantly lower rate of blood transfusions compared to their counterparts. This data from the ACS-NSQIP supports the reported benefits of endoscopic technique in the current literature. As endoscopic surgery becomes more widely utilized throughout the United States, more data will become available for further studies.

Endoscopic spine surgery (ESS) is growing in popularity worldwide. An expanding body of literature demonstrates rapid functional recovery with reduced morbidity compared to open techniques. Both full endoscopic spine surgery, or uniportal endoscopy, and unilateral biportal endoscopy (UBE) can be employed in conjunction with various navigation and enabling technologies for assistance with localization of anatomic orientation and assessment of the intraoperative target spinal pathology. This review article describes various navigation technologies in ESS, including 2-dimensional (2D) fluoroscopic imaging, 2D fluoroscopic navigation, 3-dimensional C-arm navigation, augmented reality, and spinal robotics. Employment of enabling navigation and emerging technology with the registration of patient-specific anatomy enables clear delineation of anatomic landmarks and facilitation of a successful procedure. Additionally, avoidance of common pitfalls during use of navigation systems in ESS is discussed in this review.

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.

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.

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: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.

Background Current research is limited in exploring the impact of social determinants of health (SDOH) on the discharge location within elective spine surgery. Further understanding of the influence of SDOH on disposition is necessary to improve outcomes. This study explores how SDOH influence discharge disposition for patients undergoing one- or two-level posterior interbody fusion (TLIF/PLIF). Methods This was a retrospective propensity-matched cohort study. Patients who underwent TLIF/PLIF between 2017 and 2020 at a single academic medical center were identified. The chart review gathered demographics, perioperative characteristics, intra/post-operative complications, discharge disposition, and 90-day outcomes. Discharge dispositions included subacute nursing facility (SNF), home with self-care (HSC), home with health services (HHS), and acute rehab facility (ARF). Demographic, perioperative, and disposition outcomes were analyzed by chi-square analysis and one-way ANOVA based on gender, race, and income quartiles. Results Propensity score matching for significant demographic factors isolated 326 patients. The rate of discharge to SNF was higher in females compared to males (25.00% vs 10.56%; p=0.001). Men were discharged to home at a higher rate than women (75.4% vs 61.95%; p=0.010). LatinX patients had the highest rate of home discharge, followed by Asians, Caucasians, and African Americans (83.33% vs 70.31% vs 66.45% vs 65.90%; p<0.001). The post hoc Tukey test demonstrated statistically significant differences between Asians and all other races in the context of age and BMI. Additionally, patients discharged to SNF showed the highest Charlson comorbidity index (CCI) score, followed by those at ARF, HHS, and HSC (4.36 vs 4.05 vs 2.87 vs 2.37; p<0.001). The estimated median income for the cohort ranged from $52,000 to $250,001, with no significant differences in income seen across comparisons. Conclusion Discharge disposition following one- or two-level TLIF/PLIF shows significant association with gender and race. No association was seen when comparing discharge rates among zip code-level median income quartiles.