Faculty Bibliography

PURPOSE/OBJECTIVE:Tethered cord syndrome (TCS) is an occult spinal dysraphism that includes low lying conus, tight filum terminale, lipomeningomyelocele, split cord malformations, dermal sinus tracts, and dermoids. This congenital disorder has been associated with musculoskeletal, neurological, and gastrointestinal abnormalities. This study presents a retrospective review of the prospectively collected data of TCS patients and their concurrent diagnoses or associated anomalies. METHODS:The National Inpatient Sample (NIS) database from 2003 to 2012 was used for data collection. Hospital- and year-adjusted weights allowed for accurate assessment of the incidence of TCS, as well as cardiac and gastrointestinal (GI) and genitourinary (GU) anomalies. K-means clustering analysis was run to discover patterns of concurrent cardiac, GI, GU, and other system anomalies in TCS patients. RESULTS:A total of 13,470 discharges with a diagnosis of TCS were identified in the NIS database, and at least one additional anomaly was identified in 40.7% of TCS patients. The most common secondary anomalies by system were: spine (24.48%), cardiac (6.27%), and urinary (5.37%). For patients with multiple anomalies, the most common combinations were GI and cardiac (4.55%), urinary and GI (4.26%), and urinary and cardiac (4.19%). The most common spinal association was spina bifida (13.65%). The most common neurological or musculoskeletal anomaly was any VACTERL association (13.45%). The top relation in GI and GU anomalies was cervix and female genitalia anomalies (69.1%). The most common specific anomalies were spina bifida, large intestine atresia, Rubenstein-Taybi syndrome, and atrial and ventral septal defects. CONCLUSION/CONCLUSIONS:This study provides a nationwide prospective on congenital anomalies and concurrent conditions present in tethered cord syndrome patients in the United States and demonstrates that 40.7% of TCS patients have at least one associated anomaly. The most common congenital anomalies studied were spina bifida, urogenital with or without cardiac septal defects, and cystourethral anomaly or cystic kidney disease with or without large intestinal atresia.

BACKGROUND CONTEXT: Adult spinal deformity is a complex pathology that often requires challenging surgical intervention for treatment. In patients with osteoporosis, there may be increased risk of complications and reoperations. Our study aimed to evaluate the effect of treating osteoporosis patients with bisphosphonate preoperatively on future reoperations. PURPOSE: Investigate the effect of preoperative bisphosphonate on osteoporosis patients undergoing corrective surgery for adult spinal deformity. STUDY DESIGN/SETTING: Retrospective review of the PearlDiver database between the years 2008-2015. PATIENT SAMPLE: This study included 2,842 adult spinal deformity patients. OUTCOME MEASURES: Ninety-day complications, reoperations.
METHOD(S): Adult spinal deformity patients undergoing a fusion were isolated using ICD-9 CM and CPT codes in the PearlDiver database between the years 2008-2015. Patients were stratified based on diagnosis of osteoporosis and whether there was a filled prescription for bisphosphonate 6 months prior to surgery. ASD patients with osteoporosis and bisphosphonate use who underwent corrective intervention were compared with age- and sex-matched cohorts of osteoporotic and nonosteoporotic controls with no bisphosphonate prescriptions. Means comparison tests compared differences in demographics, comorbidities, 90-day complications, and 2Y reoperation rates. Logistic regression analysis assessed the odds of complication and reoperations controlling for age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was set p<0.05.
RESULT(S): A total of 2,842 operative adult spinal deformity patients were isolated. Four hundred and six patients had osteoporosis and bisphosphonate use, 807 osteoporosis with no bisphosphonate use, and 1,629 non-osteoporosis patients. At baseline, osteoporosis patients had higher rates of obesity, diabetes, hyperlipidemia, and peripheral vascular disease compared to osteoporotic bisphosphonate cohort. There were no differences in 90-day complication rates or 2Y reoperations rates between osteoporosis bisphosphonate users and osteoporosis controls (p>0.05). Compared to nonosteoporotic patients, osteoporosis patients with bisphosphonate use trended toward lower rates of revisions at 1Y (5% vs 7%) and 2Y (7% vs 8%, both p>0.05).
CONCLUSION(S): In a matched cohort, osteoporosis patients treated preoperatively with bisphosphonates trended towards lower rates of revisions two years postoperatively compared to nonosteoporotic controls. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The impact of neuromuscular disorders such as multiple sclerosis (MS) on outcomes following anterior cervical discectomy and fusion (ACDF) is underreported. PURPOSE: Identify the impact of MS on two-year (2Y) postoperative complications and revisions following 2-3-level ACDF for cervical radiculopathy (CR) or myelopathy (CM). STUDY DESIGN/SETTING: Retrospective review of the New York State Statewide Planning and Research Cooperative System (SPARCS) database. PATIENT SAMPLE: Patients undergoing 2-3 level ACDF for CR/CM. OUTCOME MEASURES: Two-year postoperative complications and reoperations.
METHOD(S): Patients undergoing 2-3 level ACDF for CR/CM were identified from SPARCS. Patients with a baseline diagnosis of MS were also identified. Patients with infectious/traumatic/neoplastic were excluded. The remaining patients were 1:1 propensity score-matched (MS to no-MS) for age, sex, race, Deyo index and compared for rates of 2Y postoperative complications and reoperations. Logistic regression models were utilized to determine significant predictors of these outcomes.
RESULT(S): A total of 302 total patients were identified (MS, n=151; non-MS, n=151). MS patients were more frequently female (72.8% vs 27.2%, p<0.001). Age was comparable (50.1 vs 50.1 years, p=0.225). MS patients incurred higher charges for their surgical visit ($41,029 vs $31,654) and higher LOS (2.8 vs 2.2 days), both p<=0.016. They experienced higher rates of deep vein thrombosis (DVT) (3.3% vs 0%, p=0.02), with similar overall medical (19.2% vs 21.2%), surgical (7.9% vs 10.6%), and total complications (21.9% vs 25.8%), all p>0.05. MS patients had similar rates of 2Y revisions (6.6% vs 5.3%, p=0.627). MS was not associated with medical, surgical, or overall complications or revisions at minimum 2Y follow-up.
CONCLUSION(S): Despite differences in demographics and higher rates of postoperative DVT, MS patients experienced comparable postoperative course with respect to other individual and overall complications and revisions following 2-3-level CF for degenerative spinal pathologies. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Hospital acquired conditions (HACs) were established in the Affordable Care Act, and are defined as reasonably preventable complications that are nonreimbursable. In high risk patient populations for HACs, such as frail surgical spine patients, preoperative evaluation should consider modifiable factors. PURPOSE: To identify if optimizing the modifiable factors in the frailty index reduce the risk of developing HACs in population of surgical spine patients. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: This study included 196,523 elective spine surgery patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). OUTCOME MEASURES: Modifiable patient frailty factors: hypertension and diabetes mellitus; rates of HACs, superficial or deep surgical site infection (SSI), deep venous thromboembolism (VTE) and urinary tract infection (UTI), across frailty scores.
METHOD(S): Patients >18 years who underwent elective spine surgery were identified in ACS-NSQIP database from 2005-2016. HACs identified: SSI, VTE, and UTI. Patient frailty was assessed utilizing the modified NSQIP 5-factor frailty index. The modified frailty score (mFI-5) is assessed on a scale between 0 and 1 (no frailty [NF] <0.3, mild frailty [MF] 0.3-0.5, severe frailty [SF] >0.5). Descriptive analysis quantified rates of patient characteristics, operative details, and HAC prevalence. Stepwise linear regression models determined significant predictors of baseline frailty using controllable patient factors. HACs were compared between 'optimized' and 'non-optimized' frailty status in the cohort. Level of significance was set to P<0.05.
RESULT(S): A total of 196,523 patients (57+/-14.2 years, 30.4 kg/m², 48%F) met inclusion criteria. Overall, 5,720 (2.9%) of patients developed an HAC, the most common was an SSI (1.3%), followed by UTI (1.1%). When stratified by the mFI-5 frailty severity groups at baseline, 83.6% of patients were categorized NF, 15.1% MF and 1.3% SF. Within the frailty severity groups, prevalence of overall HACs increased significantly (NF: 2.64%, MF: 4.17%, 5.93%, p<0.001). Rates of all individual postoperative HACs assessed also increased with greater baseline frailty severity: SSI (NF: 1.14%, MF: 1.93%, SF: 2.39%, p<0.001), UTI (NF: 0.91%, MF: 1.66%, SF: 2.85%, p<0.001), VTE (NF: 0.68%, MF: 0.80%, SF: 1.16%, p=0.002). Stepwise linear regression models determined that diabetes mellitus (beta = 0.493) and hypertension (beta = 0.679) were the most significant predictors for increased baseline frailty by way of the mFI-5 NSQIP index (Final model: R2= 0.897). Of total patients, 47.2% had the optimal modifiable frailty factors (no history of diabetes or hypertension). The optimal frailty patients had significantly less overall incidence of SSI (2.03% vs 2.5%, p<0.001), UTI (0.65% vs 1.4%, p<0.001), DVT (0.56% vs 0.84%, p<0.001), and any overall HAC (2.18% vs 3.56%, p<0.001).
CONCLUSION(S): Stepwise linear regression models determined that hypertension and diabetes account for 89.7% of variance in baseline mFI-5 score. Patients with these optimal controllable factors had reduced incidence of all hospital acquired conditions. In order to optimize hospital resources and treatment outcomes, physicians and patients should be aware of the modifiable factors that contribute to a patient's frailty that can ultimately impact acquiring HACs. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: With a heightened focus on prescription narcotic use in the United States, concern among surgeons has increased regarding preoperative and postoperative usage. However, the literature is scarce on outcomes of preoperative and prolonged opioid usage in adult spinal deformity (ASD) patients. PURPOSE: Investigate effect of preoperative opioid usage on prolonged opioid use postoperatively and rates of reoperations. STUDY DESIGN/SETTING: Retrospective review of the PearlDiver Database 2008-2013. PATIENT SAMPLE: A total of 7,661 ASD patients. OUTCOME MEASURES: Reoperations, 90-day complications, comorbidity burden, prolonged opioid usage METHODS: ASD patients undergoing a fusion were isolated in the PearlDiver database between the years 2008-2013 using ICD-9 and CPT codes. Patients were stratified by prescription preoperative opioid use 3 months prior to surgery: (1) high frequency (>4 refills); (2) low frequency (1-3 refills); (3) opioid naive. Means comparison tests compared differences in demographics, complications, and reoperation rates. Logistic regression assessed the odds of complication and reoperations associated with preoperative frequency and prolonged opioid use (3 to 6 months postop), controlling for age, sex, and comorbidities.
RESULT(S): A total of 7,661 ASD patients were isolated; 2,342 patients were high frequency preop opioid users, 2,247 low frequency preop opioid users, and 3,072 opioid naive. At BL, high frequency preop opioid users had higher rates of obesity, diabetes mellitus, CHF, COPD, hypertension, smoking and alcohol use (all p<0.001). Compared to opioid naive patients, low frequency preop opioid users had higher rates of 90-day complications associated with hematoma and transfusion (p<0.05). High frequency preop opioid users relative to naive opioid users had significantly increased 90-day complication rates including pulmonary embolism, pneumonia, hematoma, and transfusions. High frequency opioid use was associated with increased odds of wound disruption (1.74[1.22-2.51]) and hospital readmission (1.42[1.22-1.64], both p<0.05). Additionally, high frequency opioid usage preop followed by prolonged opioid use postop was associated with increased odds of reoperations at 2Y relative to low frequency (1.67[1.34-2.10]) and opioid naive patients (1.83[1.40-2.42], both p<0.001).
CONCLUSION(S): Patients with high frequency preoperative opioid use are at increased risk of major complications within 90 days of surgery, prolonged use postoperatively, and increased risk of reoperations within two years. During preoperative risk assessment, providers should consider the effect of pre- and postoperative opioid usage on patient outcomes. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Surgical intervention of the cervical spine is a challenging procedure that can present postoperative complications such as dysphagia, swelling, and reoperations. However, the risk of reoperation can possibly be mitigated with the use of biologics to enhance fusion. There is paucity in the literature on long-term incidence of reoperations after application of BMP during ACDF. PURPOSE: To evaluate if bone morphogenetic protein usage during anterior cervical discectomy and fusion will decrease reoperation rates. STUDY DESIGN/SETTING: Retrospective review of the PearlDiver database between 2006-2014. PATIENT SAMPLE: Matched cohort of 35,544 ACDF patients. OUTCOME MEASURES: Reoperations.
METHOD(S): Patients undergoing an anterior cervical discectomy and fusion between the years 2006-2014 were isolated in the PearlDiver database. Patients receiving BMP operatively and a control with no BMP were matched for baseline demographics including age, sex, and comorbidities. A Kaplan Meier Survival analysis assessed five-Year Reoperation-Free Survival between BMP patients and controls. Statistical significance was set to p<0.05.
RESULT(S): A matched cohort of 35,544 ACDF patients was isolated. A total of 17,772 patients received BMP while undergoing cervical fusion and 17,772 did not receive any BMP during surgery. Patients did not differ in age, sex or comorbidities (p>0.05). Kaplan Meier survival analysis showed patients receiving BMP during cervical fusion were significantly more likely to remain reoperation free five years after index surgery (p<0.05). Overall, 91.3% of BMP patients remained reoperation free at five years.
CONCLUSION(S): For patients receiving bone morphogenetic protein during anterior cervical discectomy and fusion, Kaplan-Meier survival analysis following five years post index surgery had showed a 91.3% reoperation-free survivorship. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: MBDs are often implicated in or contribute to degenerative disc disease (DDD). Yet, there is limited long-term, postoperative outcome data on the impact of MBDs on 2-year outcomes following 2-3-level lumbar fusion for DDD. PURPOSE: To determine if DDD patients with MBDs have comparable outcomes to those without MBDs following lumbar fusion. STUDY DESIGN/SETTING: Retrospective cohort. PATIENT SAMPLE: New York State Statewide Planning and Research Cooperative System was reviewed from 2009-2013 to identify all patients with DDD who underwent short, lumbar fusion (2-3-levels) with >=2-year follow-up OUTCOME MEASURES: Two-year outcome rates (medical/surgical complications and reoperations).
METHOD(S): The New York State Statewide Planning and Research Cooperative System was reviewed from 2009-2013 to identify all patients with DDD who underwent short, lumbar fusion (2-3 levels) with >=2-year follow-up. Patients with and without MBD (vitamin D deficiency, hyperparathyroidism, osteomalacia, and rickets) were identified. Any patients with osteoporosis or other systemic/endocrine disorders affecting bone quality were excluded. Traumatic, infectious, and neoplastic surgical indications were excluded. Cohorts were compared for demographics and 2-year outcome rates (medical/surgical complications and reoperations). Logistic regression was used to identify covariates associated with medical/surgical complications and revisions.
RESULT(S): A total of 28,959 patients were included (MBD, n=380 (1.33%); no-MBD, n=28,579). MBD pts were older (56.4 vs 53.1 years) and more often female (65.5% vs 49.80%) than no-MBD pts (all p<0.001). MBD pts had longer hospital stays (4.57 days vs 4.11 days, p=0.026), but charges were similar. MBD pts incurred higher rates of wound complications (11.8% vs 6.0%), acute renal failure (11.1% vs 4.7%), pneumonia (9.2% vs 4.4%), and implant related complications (12.1% vs 7.0%); all p<0.001. Rates of pseudarthrosis, PE, pulmonary complications, and UTI were similar between groups. MBDs were associated with developing both medical complications (OR=1.55) and surgical complications (OR=1.79), both p<0.001.
CONCLUSION(S): MBD patients have an increased risk of 2-year postop comps and reoperations following short lumbar fusion for DDD compared to patients without MBD when controlling for demographics and comorbidity profile. These data underscore the importance of preoperative screening and optimization in this patient population. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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STUDY DESIGN/UNASSIGNED:Retrospective cohort study of prospective patients undergoing minimally invasive lumbar fusion at a single academic institution. OBJECTIVE/UNASSIGNED:To assess differences in perioperative outcomes between primary and revision MIS (minimally invasive surgical) lumbar interbody fusion patients and compare with those undergoing corresponding open procedures. METHODS/UNASSIGNED:Patients ≥18 years old undergoing lumbar interbody fusion were grouped by surgical technique: MIS or open. Patients within each group were propensity score matched for comorbidities and levels fused. Patient demographics, surgical factors, and perioperative complication incidences were compared between primary and revision cases using means comparison tests, as appropriate. RESULTS/UNASSIGNED:< .05). CONCLUSIONS/UNASSIGNED:Clinical outcomes of revision MIS lumbar interbody fusion were similar to those of primary surgery. Additionally, MIS techniques were associated with less EBL, shorter LOS, and fewer perioperative complications than corresponding open revisions.

There has been limited discussion as to whether spine surgery patients are benefiting from shorter in-patient hospital stays or if they are incurring higher rates of readmission and complications secondary to shortened length of stays. Included in this study were 237,446 spine patients >18yrs and excluding infection. Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission after initial surgery in all years at 12.44 ± 9.03 days. Pearson bivariate correlations between LOS ≤ 1 day and decreasing days to readmission was the strongest in 2016.). Logistic regression analysis found that LOS ≤ 1 day showed an overall increase in the odds of hospital readmission from 2012 to 2016 (2.29 [2.00-2.63], 2.33 [2.08-2.61], 2.35 [2.11-2.61], 2.27 [2.06-2.49], 2.33 [2.14-2.54], all p < 0.001).

BACKGROUND:Little is known of how frailty, a dynamic measure of physiological age, progresses relative to age or disability status. Operative treatment of adult spinal deformity (ASD) may play a role in frailty remediation and maintenance. PURPOSE/OBJECTIVE:Compare frailty status, severe frailty development, and factors influencing severe frailty development among ASD patients undergoing operative or non-operative treatment. DESIGN/METHODS:Retrospective review with maximum follow up of 3 years. SETTING/METHODS:Prospective, multicenter, ASD database. PARTICIPANTS/METHODS:Patients were consecutively enrolled from 13 participating centers. INCLUSION CRITERIA/METHODS:≥18 years undergoing either operative or non-operative treatment for ASD, exclusion criteria: spinal deformity of neuromuscular etiology, presence of active infection, or malignancy. The mean age of the participants analyzed were 54.9 for the operative cohort and 55.0 for the non-operative cohort. MAIN OUTCOMES/RESULTS:Frailty status, severe frailty development and factors influencing severe frailty development. METHODS:ASD patients (coronal scoliosis≥20°, sagittal vertical axis (SVA)≥5cm, Pelvic Tilt (PT)≥25°, or thoracic kyphosis≥60°) >18y/o, with Base Line (BL) frailty scores were included. Frailty was scored from 0-1 (not frail: <0.3, frail 0.3-0.5, severe frailty >0.5) through the use of ASD-FI which has been validated using the International Spine Study Group (ISSG) ASD database, European Spine Study Group (ESSG) ASD database, and the Scoli-RISK-1 Patient Database. The International Spine Study Group (ISSG) is funded through research grants from DePuy Synthes and individual donations, and supported the current work. Operative (Op) and Non-Operative (Non-Op) patients were propensity matched. T-tests compared frailty among treatment groups and BL, 1Y, 2Y, and ≥3Y. An actuarial Kaplan-Meier survivorship analysis with Log Rank (Mantel-Cox) test, adjusting for patients lost to follow-up, determined probability of severe frailty development. Multivariate Cox Regressions gauged the effect of sagittal malalignment, patient and surgical details on severe frailty development. RESULTS:The analysis includes 472 patients (236 Op, 236 Non-Op) selected by propensity score matching from a cohort of 1172. Demographics and comorbidities were similar between groups (p>0.05). Op exhibited decreased frailty at all follow up intervals compared to BL (BL:0.22 vs Y1:0.18; Y2:0.16; Y3:0.15, all p<0.001). Non-Op displayed similar frailty from BL to 2Y follow up, and increased frailty at 3Y follow up (0.23 vs 0.25, p=0.014). Compared to Non-Op, Op had lower frailty at 1Y (0.18 vs 0.24), 2Y (0.16 vs 0.23) and 3Y (0.15 vs 0.25) (all p<0.001). Cumulative probability of maintaining non-severe frailty was (Op:97.7%, Non-Op:94.5%) at 1Y, (Op:95.1%, Non-Op:90.4%) at 2Y, and (Op:95.1%, Non-Op:89.1%) at ≥3Y, (p=0.018). Amongst all patients, baseline depression (HR: 2.688[1.172-6.167], p=0.020), NRS back pain scores (HR: 1.247[1.012-1.537], p=0.039), and non-operative treatment (HR: 2.785[1.167-6.659], p=0.021) predicted severe frailty development with having a HR>1.0 and p-value<0.05. Among operative patients, 6-week postoperative residual SVA malalignment (SRS-Schwab SVA + modifier) (HR: 15.034[1.922-116.940], p=0.010) predicted severe frailty development indicated by having a HR>1.0 and p-value <0.05. CONCLUSIONS:Non-Op patients were more likely to develop severe frailty, and at a quicker rate. Baseline depression, increased NRS back pain scores, non-operative treatment, and postoperative sagittal malalignment at 6-week follow-up significantly predicted severe frailty development. Operative intervention and postoperative sagittal balance appear to play significant roles in frailty remediation and maintenance in adult spinal deformity patients. Frailty is one factor, in a multifactorial conservation, that may be considered when determining operative or non-operative values for ASD patients. Operating before the onset of severe frailty, may result in a lower complication risk and better long term clinical outcomes. LEVEL OF EVIDENCE/METHODS:III.