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.

STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:To develop parameter thresholds obtainable from cervical radiographs that correlate with concomitant thoracolumbar malalignment. SUMMARY OF BACKGROUND DATA/BACKGROUND:T1 slope (T1S) is typically discussed in the context of cervical deformity and correlated with health-related quality of life outcomes. Prior research suggests that T1S is related to global alignment; however, a definition for "high" T1S has not been established. Most patients undergoing cervical surgery do not undergo full-spine imaging; therefore, obtaining a parameter associated with thoracolumbar malalignment from cervical radiographs would be beneficial. METHODS:A database of preoperative adult spinal deformity (ASD) patients was analyzed. Measures obtained from standing lateral radiographs included T1S, thoracic kyphosis (TK), sagittal vertical axis (SVA), T1-pelvic angle (TPA), pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI-LL). Decision tree analysis was then used to determine the T1S corresponding to published thresholds for high TK (40 degrees), SVA (40 mm), TPA (25 degrees), and PT (25 degrees). Alignment between high and normal T1S patients was compared. RESULTS:Two hundred twenty-six preoperative patients were included (mean: 58±16 y 62%F). Larger T1S was correlated with greater SVA (r=0.365), TPA (r=0.302), TK (r=0.606), and PT (r=0.230) (all P<0.001). Decision tree analysis yielded a threshold of 30 degrees for high T1S, which 50% of patients had. Compared with patients with T1S <30 degrees, those with T1S >30 degrees had higher TK (41.5 vs. 25.8 degrees), SVA (78.7 vs. 33.7 mm), TPA (27.6 vs. 18.3 degrees), and PT (26.3 vs. 20.8 degrees), and PI-LL (18.2 vs. 11.7 degrees) (all P<0.05). Seventy-nine percent of patients with high T1S had high TK (T1S <30=13%), 69% had high SVA (T1S <30=38%), 66% had high TPA (T1S <30=37%), 60% had PT >25 degrees (T1S <30=42%), and 47% had PI-LL >20 degrees (T1S <30=34%) (all P<0.05). CONCLUSION/CONCLUSIONS:Higher T1S was associated with worse global alignment. T1S was most strongly associated with TK. A T1S=30 degrees corresponded to high TK, SVA, TPA, and PT thresholds. Therefore, surgeons should consider obtaining full-spine radiographs if a T1S >30 degrees is present on cervical imaging.

BACKGROUND:Biportal endoscopic transforaminal lumbar interbody fusion (BE-TLIF) is a minimally invasive surgical technique for treating degenerative lumbar spine conditions. It offers advantages such as reduced soft tissue trauma and lower infection rates, but certain technical aspects may be challenging. The current study aims to identify strategies to enhance the fusion rate in BE-TLIF by addressing these specific challenges. METHODS:A literature review was conducted on techniques to improve fusion rates in BE-TLIF. RESULTS:The review suggests that lateral-based portals supplemented with medial portals allowed for safe insertion of interbody cages with large footprint. Direct visualization of the disc space with a 30° endoscope assisted with better disc space preparation. Facetectomies performed with osteotomes, rather than burrs, ensured maximum retrieval of autologous bone graft. Utilizing bone morphogenetic proteins with sustained release carriers such as hydroxyapatite can be useful to increase fusion rates of BE-TLIF. CONCLUSIONS:To our knowledge, the current literature is the first comprehensive review of strategies to enhance fusion rates in BE-TLIF. The proposed techniques and biological adjuncts are effective means to address key challenges associated with the procedure, and such strategies would potentially shorten the learning curve and improve clinical outcomes. Further clinical studies are required to validate these findings and establish standardized protocols. CLINICAL RELEVANCE/CONCLUSIONS:These findings provide practical solutions to overcome common challenges in BE-TLIF. The suggested techniques would reduce the incidence of pseudarthrosis, improve patient outcomes, and ultimately offer a safer and more reliable option for lumbar interbody fusion patients.

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.

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.

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.

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.

PURPOSE/OBJECTIVE:Current literature suggests that biportal spinal endoscopy is safe and effective in treating lumbar spine pathology such as lumbar disc herniation, lumbar stenosis, and degenerative spondylolisthesis. No prior study has investigated the postoperative outcomes or complication profile of the technique as a whole. This study serves as the first comprehensive systematic review and meta-analysis of biportal spinal endoscopy in the lumbar spine. METHODS:A PubMed literature search provided over 100 studies. 42 papers were reviewed and 3673 cases were identified with average follow-up time of 12.5 months. Preoperative diagnoses consisted of acute disc herniation (1098), lumbar stenosis (2432), and degenerative spondylolisthesis (229). Demographics, operative details, complications, and perioperative outcome and satisfaction scores were analyzed. RESULTS:Average age was 61.32 years, 48% male. 2402 decompressions, 1056 discectomies, and 261 transforaminal lumbar Interbody fusions (TLIFs) were performed. Surgery was performed on 4376 lumbar levels, with L4-5 being most common(61.3%). 290 total complications occurred, 2.23% durotomies, 1.29% inadequate decompressions, 3.79% epidural hematomas, and < 1% transient nerve root injuries, infections, and iatrogenic instability. Significant improvement in VAS-Back, VAS-Leg, ODI, and Macnab Scores were seen across the cohort. CONCLUSION/CONCLUSIONS:Biportal spinal endoscopy is a novel method to address pathology in the lumbar spine with direct visualization through an endoscopic approach. Complications are comparable to previously published rates. Clinical outcomes demonstrate effectiveness. Prospective studies are required to assess the efficacy of the technique as compared to traditional techniques. This study demonstrates that the technique can be successful in the lumbar spine.