Faculty Bibliography

STUDY DESIGN/METHODS:Retrospective comparative; LOE-3. OBJECTIVE:The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following one- or two-level lumbar fusion has on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results. SUMMARY OF BACKGROUND DATA/BACKGROUND:Previous research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction. METHODS:A retrospective review of prospectively collected data was conducted on patients who underwent one- or two-level lumbar fusions L3-S1 between October 2014 and October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions more than two levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram morphine equivalents (MME). RESULTS:A total of 330 patients met inclusion criteria: 259 pre-protocol, 71 post-protocol. There were 256 one-level fusions and 74 two-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (P > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7% (95) pre-protocol to 59.2% (42) post-protocol; P < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL (P = 0.003). Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3% (P < 0.001). Average opioids prescribed on discharge in the pre-protocol period was 534 ± 425 MME, compared to after initiation of the protocol, that is 320 ± 174 MME (P < 0.001). There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol versus 4.51 ± 0.82 post-protocol (P = 0.986). CONCLUSION/CONCLUSIONS:A reduction in opioids prescribed at discharge after one- or two-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

BACKGROUND CONTEXT: Indirect decompression technique may be limited in that it does not include direct removal of the offending intervertebral disc or osteophyte protruding into the canal. PURPOSE: This study evaluates resolution of radiculopathy and perioperative complications in lumbar fusion with indirect or direct decompression techniques. STUDY DESIGN/SETTING: Retrospective analysis of large single center academic institution. PATIENT SAMPLE: This study included 116 single-level lumbar fusion patients with preoperative radiculopathy from 2012 to 2021. OUTCOME MEASURES: Resolution of radiculopathy, visual analog scores (VAS), perioperative complications, motor scores.
METHOD(S): Patients 18 years of age diagnosed with preoperative radiculopathy undergoing single-level lumbar fusion with up to two-year follow-up were grouped by indirect and direct decompression. Direct decompression group included TLIF with or without direct decompression procedure as well as ALIF and LLIF with direct decompression procedure. Indirect decompression group included ALIF and LLIF without direct decompression procedure. Propensity score matching (PSM) was used to control for differences in age between groups. Outcome measures were compared between groups using means comparison tests. Logistic regression analysis was used to correlate decompression type with symptom resolution over time.
RESULT(S): A total of 116 patients were included in this analysis: 58 direct decompression (mean 53.9y, 67.2% female) and 58 indirect decompression (mean 54.6y, 61.4% female). Direct decompression patients experienced greater blood loss relative to indirect decompression patients (242.4 +/- 128.5 vs 171.79 +/- 143.9 mL, p=0.007). Additionally, direct decompressionpatients experienced full resolution of radiculopathy at 3 months postop at a greater rate than those in the indirect decompression group (OR: 4.742, [1.97-11.41]; 53.1% vs 13.73%, p=0.002). At 6 months, direct decompression patients demonstrated a significantly larger reduction in VAS score 6 months postop (-2.889 +/- 2.3 vs -0.897 +/- 4.3, p=0.044). With regard to motor function, direct decompression patients had improved motor score with respect to the L5 dermatome at 6 months compared to indirect decompression patients (DELTAmotor score from baseline: 0.1714 +/- 0.453 vs -0.024 +/- 0.154, p=0.019).
CONCLUSION(S): Patients who underwent direct decompression experienced significantly greater resolution of preoperative lower extremity radiculopathy at 3 months compared with those who underwent ID alone. At 6 and 12 months, no differences were noted between the two groups. There were no differences in complication rates. At 6 months postop, direct decompression patients had greater improvement in preoperative motor deficit than ID patients. In particularly debilitated patients, these findings may influence surgeons to perform a direct decompression to achieve more rapid resolution of radiculopathy symptoms. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND:Deep surgical site infections (dSSI) following spinal laminectomy and fusion are serious complications associated with poor patient outcomes. The objective of this study is to investigate the monthly and seasonal variability of dSSI rates following common spinal surgeries to investigate the "July effect," which refers to the alleged increase in adverse health outcomes due to new hospital trainees at the beginning of the academic year. METHODS:We performed a retrospective analysis of patients who had a dSSI following laminectomy (without fusion) or spinal fusion (with or without laminectomy) at a single large urban academic medical center between January 2009 and August 2018. The change in dSSI rate over the entire study period was calculated. The monthly and seasonal variability of dSSI were assessed using a Poisson regression model to assess for the presence of the July effect. RESULTS:= 0.04 ). With July as the reference month, there was a significantly higher dSSI rate in April following spinal fusions. CONCLUSION/CONCLUSIONS:The overall decrease in dSSI rate over the study period is consistent with previous reports. The monthly analysis revealed no significant differences in either procedure, calling into question the July effect. CLINICAL RELEVANCE/CONCLUSIONS:This study is relevant to practicing spinal surgeons and can inform surgeons about seasonal data regarding dSSIs. LEVEL OF EVIDENCE: 3/METHODS/:

STUDY DESIGN/METHODS:Single-center retrospective cohort study. OBJECTIVES/OBJECTIVE:To evaluate inpatient MME administration associated with different lumbar spinal fusion surgeries. METHODS:< .05. RESULTS:= .009). There were no significant differences in MME/hour and incidence of ileus between all groups. CONCLUSION/CONCLUSIONS:Patients undergoing MIS TLIF had lower inpatient opioid intake compared to TP and SP ALIF/LLIF, as well as shorter LOS compared to all groups except SP ALIF/LLIF. Thus, it appears that the advantages of minimally invasive surgery are seen in minimally invasive TLIFs.

Abundant literature exists describing the incidence of dysphagia following anterior cervical surgery; however, there is a paucity of literature detailing the incidence of dysphagia following posterior cervical procedures. Further characterization of this complication is important for guiding clinical prevention and management. Patients ≥ 18 years of age underwent posterior cervical fusion with laminectomy or laminoplasty between C1-T1. Pre- and post-operative dysphagia was assessed by a speech language pathologist. The patient cohort was categorized by approach: Laminectomy + Fusion (LF) and Laminoplasty (LP). Patients were excluded from radiographic analyses if they did not have both baseline and follow-up imaging. The study included 147 LF and 47 LP cases. There were no differences in baseline demographics. There were three patients with new-onset dysphagia in the LF group (1.5% incidence) and no new cases in the LP group (p = 1.000). LF patients had significantly higher rates of post-op complications (27.9% LF vs. 8.5% LP, p = 0.005) but not intra-op complications (6.1% LF vs. 2.1% LP, p = 0.456). Radiographic analysis of the entire cohort showed no significant changes in cervical lordosis, cSVA, or T1 slope. Both group comparisons showed no differences in incidence of dysphagia pre and post operatively. Based on this study, the likelihood of developing dysphagia after LF or LP are similarly low with a new onset dysphagia rate of 1.5%.

STUDY DESIGN/METHODS:A single-center, retrospective review of prospectively collected data on patients who underwent single-level anterior cervical discectomy and fusions (ACDFs) between October 2014 and October 2019. OBJECTIVE:To investigate the effect of perioperative narcotic consumption and amount of narcotic prescribed at discharge on patient satisfaction with pain control after single-level ACDF. SUMMARY OF BACKGROUND DATA/BACKGROUND:Prior research has demonstrated that opioid prescription habits may be related to physician desire to produce superior patient satisfaction with pain control. METHODS:Patients with complete Press-Ganey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey information were analyzed. Inpatient opioid prescriptions were recorded and converted to milligram morphine equivalents (MME) and tablets of 5 mg oxycodone. HCAHPS scores were converted to a Likert-type 5-point scale. RESULTS:A total of 47 patients met inclusion criteria for this study. Average age was 48.1±10.9 y. Average inpatient opioids prescribed was 102±106 MME. Average opioids prescribed at discharge was 437±342 MME. No statistically significant correlation was found between satisfaction with pain control and opioid consumption while in the hospital [r=-0.106, P=0.483]. Similarly, there was no statistically significant correlation between satisfaction with pain control and opioids prescribed upon discharge [r=-0.185, P=0.219]. No statistically significant correlation was found between date of surgery and inpatient MME consumption [r=-0.113, P=0.450]. Interestingly, more opioids were prescribed at discharge the earlier the date of surgery [r=-0.426, P=0.003]. For every additional month further along in the study period, the odds of a patient reporting a top box score for satisfaction with pain control increased by 5.5% [P=0.025]. CONCLUSION/CONCLUSIONS:Our study found no correlation between patient satisfaction with pain control and inpatient opioid dosage or outpatient prescription dosage after single-level ACDF. Moreover, satisfaction with pain control increased over time despite a decrease in MME prescribed at discharge. This suggests that factors other than narcotic consumption play a more important role in patient satisfaction with pain control. LEVEL OF EVIDENCE/METHODS:Level III.

STUDYDESIGN/UNASSIGNED:Retrospective-comparative; LOE-3. OBJECTIVE:The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following 1-or-2-level lumbar fusion has on Hospital-Consumer-Assessment-of-Healthcare-Providers-and-Systems-(HCAHPS)-survey results. SUMMARY OF BACKGROUND DATA/BACKGROUND:Prior research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction. METHODS:A retrospective review of prospectively-collected data was conducted on patients who underwent 1-or-2-level lumbar fusions L3-S1 between October 2014-October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions > 2 levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram-morphine-equivalents (MME). RESULTS:330 patients met inclusion criteria, 259 pre-protocol, 71 post-protocol. There were 256 1-level fusions and 74 2-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (p > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7%(95) pre-protocol, to 59.2%(42) post-protocol; p < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL; p = 0.003. Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3%; p < 0.001. Average opioids prescribed on discharge in the pre-protocol period was was 534 ± 425 MME, compared to after initiation of the protocol it was 320 ± 174 MME; P < 0.001. There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol vs 4.51 ± 0.82 post-protocol; p = 0.986. CONCLUSION/CONCLUSIONS:A reduction in opioids prescribed at discharge after 1-or-2-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

STUDY DESIGN/METHODS:Retrospective cohort analysis. OBJECTIVE:To compare outcomes of plastic versus spine surgeon wound closure in revision 1 to 4 level thoracolumbar fusions. SUMMARY OF BACKGROUND DATA/BACKGROUND:Plastic surgeons perform layered musculocutaneous flap closures in high-risk spine patients such as revision posterior spinal fusion and complex deformity correction surgeries. Few studies have assessed outcomes of revision fusion performed with plastic surgical closures, particularly in nondeformity thoracolumbar spinal surgery. METHODS:A retrospective review of 1 to 4 level revision thoracolumbar fusion performed by Orthopedic or Neurosurgical spine surgeons. Patient charts were reviewed for demographics and perioperative outcomes. Patients were divided into two cohorts: wound closures performed by spine surgeons and those closed by plastic surgeons. Outcomes were analyzed before and after propensity score match for prior levels fused, iliac fixation, and levels fused at index surgery. Significance was set at P < 0.05. RESULTS:Three hundred fifty-seven (87.3%) spine surgeon (SS) and 52 (12.7%) plastic surgeon (PS) closures were identified. PS group had significantly higher number of levels fused at index (PS 2.7 ± 1.0 vs. SS 1.8 ± 0.9, P < 0.001) and at prior surgeries (PS 1.8 ± 1.2 vs. SS 1.0 ± 0.9, P < 0.001), and rate of iliac instrumentation (PS 17.3% vs. SS 2.8%, P < 0.001). Plastics closure was an independent risk factor for length of stay  > 5 days (odds ratio 2.3) and postoperative seroma formation (odds ratio 7.8). After propensity score match, PS had higher rates of seromas (PS 36.5% vs. SS 3.8%, P < 0.001). There were no differences between PS and SS groups in surgical outcomes, perioperative complication, surgical site infection, seroma requiring aspiration, or return to operating room at all time points until follow-up (P > 0.05 for all). CONCLUSION/CONCLUSIONS:Plastic spinal closure for 1 to 4 level revision posterior thoracolumbar fusions had no advantage in reducing wound complications over spine surgeon closure but increased postoperative seroma formation.Level of Evidence: 4.

BACKGROUND CONTEXT/BACKGROUND:The COVID-19 pandemic caused nationwide suspensions of elective surgeries due to reallocation of resources to the care of COVID-19 patients. Following resumption of elective cases, a significant proportion of patients continued to delay surgery, with many yet to reschedule, potentially prolonging their pain and impairment of function and causing detrimental long-term effects. PURPOSE/OBJECTIVE:The aim of this study was to examine differences between patients who have and have not rescheduled their spine surgery procedures originally cancelled due to the COVID-19 pandemic, and to evaluate the reasons for continued deferment of spine surgeries even after the lifting of the mandated suspension of elective surgeries. STUDY DESIGN/SETTING/METHODS:Retrospective case series at a single institution PATIENT SAMPLE: Included were 133 patients seen at a single institution where spine surgery was canceled due to a state-mandated suspension of elective surgeries from March to June, 2020. OUTCOME MEASURES/METHODS:The measures assessed included preoperative diagnoses and neurological dysfunction, surgical characteristics, reasons for surgery deferment, and PROMIS scores of pain intensity, pain interference, and physical function. METHODS:Patient electronic medical records were reviewed. Patients who had not rescheduled their canceled surgery as of January 31, 2021, and did not have a reason noted in their charts were called to determine the reason for continued surgery deferment. Patients were divided into three groups: early rescheduled (ER), late rescheduled (LR), and not rescheduled (NR). ER patients had a date of surgery (DOS) prior to the city's Phase 4 reopening on July 20, 2020; LR patients had a DOS on or after that date. Statistical analysis of the group findings included analysis of variance with Tukey's honestly significant difference (HSD) post-hoc test, independent samples T-test, and chi-square analysis with significance set at p≤.05. RESULTS:Out of 133 patients, 47.4% (63) were in the ER, 15.8% (21) in the LR, and 36.8% (49) in the NR groups. Demographics and baseline PROMIS scores were similar between groups. LR had more levels fused (3.6) than ER (1.6), p= .018 on Tukey HSD. NR (2.1) did not have different mean levels fused than LR or ER, both p= >.05 on Tukey HSD. LR had more three column osteotomies (14.3%) than ER and (1.6%) and NR (2.0%) p=.022, and fewer lumbar microdiscectomies (0%) compared to ER (20.6%) and NR (10.2%), p=.039. Other surgical characteristics were similar between groups. LR had a longer length of stay than ER (4.2 vs 2.4, p=.036). No patients in ER or LR had a nosocomial COVID-19 infection. Of NR, 2.0% have a future surgery date scheduled and 8.2% (4) are acquiring updated exams before rescheduling. 40.8% (20; 15.0% total cohort) continue to defer surgery over concern for COVID-19 exposure and 16.3% (8) for medical comorbidities. 6.1% (3) permanently canceled for symptom improvement. 8.2% (4) had follow-up recommendations for non-surgical management. 4.1% (2) are since deceased. CONCLUSION/CONCLUSIONS:Over 1/3 of elective spine surgeries canceled due to COVID-19 have not been performed in the 8 months from when elective surgeries resumed in our institution to the end of the study. ER patients had less complex surgeries planned than LR. NR patients continue to defer surgery primarily over concern for COVID-19 exposure. The toll on the health of these patients as a result of the delay in treatment and on their lives due to their inability to return to normal function remains to be seen.

OBJECTIVE:The goal of this study was to reliably predict sagittal and coronal spinal alignment with clinical photographs by using markers placed at easily localized anatomical landmarks. METHODS:A consecutive series of patients with adult spinal deformity were enrolled from a single center. Full-length standing radiographs were obtained at the baseline visit. Clinical photographs were taken with reflective markers placed overlying C2, S1, the greater trochanter, and each posterior-superior iliac spine. Sagittal radiographic parameters were C2 pelvic angle (CPA), T1 pelvic angle (TPA), and pelvic tilt. Coronal radiographic parameters were pelvic obliquity and T1 coronal tilt. Linear regressions were performed to evaluate the relationship between radiographic parameters and their photographic "equivalents." The data were reanalyzed after stratifying the cohort into low-body mass index (BMI) (< 30) and high-BMI (≥ 30) groups. Interobserver and intraobserver reliability was assessed for clinical measures via intraclass correlation coefficients (ICCs). RESULTS:A total of 38 patients were enrolled (mean age 61 years, mean BMI 27.4 kg/m2, 63% female). All regression models were significant, but sagittal parameters were more closely correlated to photographic parameters than coronal measurements. TPA and CPA had the strongest associations with their photographic equivalents (both r2 = 0.59, p < 0.001). Radiographic and clinical parameters tended to be more strongly correlated in the low-BMI group. Clinical measures of TPA and CPA had high intraobserver reliability (all ICC > 0.99, p < 0.001) and interobserver reliability (both ICC > 0.99, p < 0.001). CONCLUSIONS:The photographic measures of spinal deformity developed in this study were highly correlated with their radiographic counterparts and had high inter- and intraobserver reliability. Clinical photography can not only reduce radiation exposure in patients with adult spinal deformity, but also be used to assess deformity when full-spine radiographs are unavailable.