Faculty Bibliography

Background/UNASSIGNED:Outpatient anterior cervical discectomy and fusion (ACDF) is performed frequently, with studies demonstrating similar complication and readmission rates compared to traditional admission. Advantages include cost effectiveness, as well as lower risk of nosocomial infections and medical errors, which lead to quicker recovery and higher patient satisfaction. Protocols are needed to ensure that outpatient ACDF occurs safely. The objective of this study was to develop and implement a protocol with patient selection and discharge criteria for patients undergoing same-day discharge (SDD) ACDF and assess readmission rates. Methods/UNASSIGNED:A retrospective chart review was performed to identify patients undergoing 1 or 2 level primary ACDF between March 2016 and March 2017 who were eligible for SDD according to the institutional protocol (Figure 1, Table 2). Patients with identical surgery and discharge dates were grouped as SDD, and admitted patients were grouped as same-day admission (SDA). Using our electronic health record's analytics, readmissions in the 90-day postoperative period were identified. Results/UNASSIGNED:= .86). Conclusions/UNASSIGNED:The results of this study support the feasibility of outpatient ACDF and add a patient selection and discharge criteria to the literature. Proper identification of suitable patients using our protocol results in a noninferior readmission rate, allowing surgeons to continue to safely perform these surgeries with a low readmission rate. Level of Evidence/UNASSIGNED:3. Clinical Relevance/UNASSIGNED:SDD is safe in the appropriate patient population.

Background/UNASSIGNED:Robotic-guided navigation systems for pedicle screw placement has gained recent interest to ensure accuracy and safety and diminish radiation exposure. There have been no published studies using a new combined robotics and navigation system (Globus ExcelsiusGPS system). The purpose of this study was to demonstrate safety with this system. Methods/UNASSIGNED:This is a case series of consecutive patients at a single institution from February 1, 2018, to August 31, 2018. All patients who had planned placement of thoracic and lumbar pedicle screws using the combined robotics-navigation system were included. Chart review was performed for operative details. A subgroup analysis was performed on patients with postoperative computed tomography (CT) scans to assess screw placement accuracy using the Gertzbein and Robbins system. Acceptable pedicle screw position was defined as grade A or B. Results/UNASSIGNED:One hundred six patients were included, with 636 pedicle screws, 6 iliac screws, and 1 S2AI screw. Five cases were aborted for technical issues. In the remaining 101 patients, 88 patients had screws placed using preoperative CT planning and 13 patients using intraoperative fluoroscopy planning. All screws except for 5 pedicle screws in 2 patients were placed successfully using the robot (99%). These 5 pedicle screws were placed by converting to a fluoro-guided technique without robotic assistance. Eighty-six patients had screws placed using a percutaneous technique, and 15 patients had screws placed using an open technique. Ninety-eight patients underwent interbody placement: 28 anterior lumbar interbody fusions (ALIFs), 12 lateral lumbar interbody fusions (LLIFs), and 58 transforaminal lumbar interbody fusions (TLIFs). All ALIFs and LLIFs were performed prior to placement of the screws. Four LIF patients had screws placed in the lateral position. No patients had screw-related complications intraoperatively or postoperatively, and no patients returned to the operating room for screw revision. Thirteen patients underwent postoperative CT for various reasons. Of the 66 pedicle screws that were examined with postoperative CT, all screws (100%) had acceptable position. Conclusion/UNASSIGNED:This study demonstrates that the combined robotics and navigation system is a novel technology that can be utilized to place pedicle screws and pelvic screws safely and has the potential to reduce screw-related complications. Level of Evidence/UNASSIGNED:4 (case series).

Study Design/UNASSIGNED:Retrospective study of consecutive patients at a single institution.Objective: Examine the effect of minimally invasive surgery (MIS) versus open transforaminal lumbar interbody fusion (TLIF) surgery on long-term postoperative narcotic consumption. Objective/UNASSIGNED:Examine the effect of minimally invasive versus open TLIF on short-term postoperative narcotic consumption. Methods/UNASSIGNED:Differences between MIS and open TLIF, including inpatient opioid and nonopioid analgesic use, discharge opioid use, and postdischarge duration of narcotic usage were compared using appropriate statistical methods. Results/UNASSIGNED:= .018) compared with MIS TLIF. Conclusion/UNASSIGNED:Patients undergoing MIS TLIF required less inpatient opioids and had a decreased incidence of opioid dependence at 3-month follow-up. Patients with preoperative opioid use undergoing MIS TLIF are less likely to require long-term opioids.

BACKGROUND CONTEXT/BACKGROUND:Chin-Brow Vertical Angle (CBVA) is not routinely measured on radiographs even though it is a strong assessor of horizontal gaze. STUDY DESIGN/METHODS:Retrospective cohort study of patients with full-body stereoradiographs and a primary cervical diagnosis at the time of presentation. PURPOSE/OBJECTIVE:Assess the utility of McGregor's Slope (McGS) and Slope of Line of Sight (SLS) as surrogate markers for the CBVA in cervical spine pathology METHODS: A retrospective review of patients with full-body stereoradiographs was performed. Patients were ≥18 years of age with a primary cervical diagnosis. Analysis of CBVA, McGS, and SLS was conducted as markers of horizontal gaze. Sagittal alignment was characterized by: pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), T1-pelvic angle (TPA), sagittal vertical axis (SVA), T2-T12 thoracic kyphosis, C2-C7 SVA (cSVA), C2-C7 Cervical lordosis, T1-Slope minus Cervical Lordosis (TS-CL), and C2-Slope (C2S). A subgroup analysis was performed in patients with cervical deformity (CD). Independent samples t-tests and paired t-tests compared radiographic alignment. Pearson correlations characterized linear relationships. Linear regression analysis identified relationships between the parameters. RESULTS:In all, 329 patients were identified with primary cervical spine diagnoses. CBVA was visible in 171 patients (52.0%), McGS in 281 (85.4%) and SLS in 259 (78.7%). Of the 171 patients with visible CBVA, the mean CBVA was 2.30± 7.7, mean McGS was 5.02±8.1 and mean SLS was -1.588±2.03. CBVA strongly correlated with McGS (r=0.83) and SLS (r=0.89) with p<0.001. McGS positively correlated with SLS (r = 0.89, p=0.001). CONCLUSIONS:This study demonstrates that McGS and SLS serve as strong, positive correlates for CBVA. The reported mean differences between these measurements provide a useful conversion, broadening CBVA's use as a radiographic assessment of horizontal gaze.

In the current value-based healthcare climate where spine surgery is shifting to the ambulatory setting, factors influencing postop length of stay (LOS) are important to surgeons and hospital administrators. Pre-op patient factors including diagnosis of radiculopathy and myelopathy have yet to be investigated in this context. Operative pts ≥ 18Y with primary diagnoses of cervical myelopathy (M), radiculopathy (R), or myeloradiculopathy (MR) were included and propensity score matched by invasiveness score (Mirza et al.). Top-quartile LOS was defined as extended. M&R patients were compared using Chi² & independent t-tests. Univariate tests assessed differences in preop patient and surgical data in M&R pts and extended/non-extended LOS. Stepwise regression analysis explored factors predictive of LOS. 718 operative pts (54.5 yrs, 41.1%F, 29.1 kg/m², mean CCI 1.11) included (177 M, 383 R, and 158 MR). After PSM, 345 patients remained (115 in each diagnosis). 102 patients had E-LOS (Avg: 5.96 days), 41 M patients (mean 7.1 days), 28 R (5.9 days), and 33 MR (4.6 days). Regression showed predictors of E-LOS in R pts (R²â€¯= 0.532, p = 0.043): TS-CL, combined and posterior approach, LIV, UIV, op time, Lactated Ringer's, postoperative complications. Predictors of E-LOS in M pts (R²â€¯= 0.230, p < 0.001): age, CCI, combined and posterior approach, levels fused, UIV, EBL, neuro and any postop complications. Predictors of E-LOS in MR patients (R²â€¯= 0.152, p < 0.001): age, kyphosis, combined approach, UIV, LIV, levels fused, EBL and op time. Independent of invasiveness, patients with a primary diagnosis of myelopathy, though older aged and higher comorbidity profile, had consistently longer overall postop LOS when compared to radiculopathy or myeloradiculopathy patients.

BACKGROUND:Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. METHODS:A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval). RESULTS:In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P<0.001), had fewer comorbidities (P<0.001), and sustained similar complication incidence. In the 10 and over age analysis, CS patients similarly had shorter fusions, but greater comorbidities, and significantly more complications (odds ratio, 1.6; confidence interval, 1.4-1.8). CONCLUSIONS:CS patients have higher in-hospital complication rates. With more comorbidities, these patients have increased risk of sustaining procedure-related complications such as shock, infection, and Adult Respiratory Distress Syndrome. These data help to counsel patients and their families before spinal fusion. LEVEL OF EVIDENCE/METHODS:Level III-retrospective review of a prospectively collected database.

BACKGROUND CONTEXT: Intraoperative CT image-guided navigation (IGN) and robotic assistance have been increasingly implemented during spine surgery to improve accuracy in pedicle screw positioning. However, studies have shown that they increase operative time and ionizing radiation exposure, and it remains controversial whether they improve patient outcomes. PURPOSE: Assess use of IGN and robotic assistance in posterior lumbar surgery and their relationship with patient radiation exposure and perioperative outcomes. STUDY DESIGN/SETTING: Retrospective cohort study at single institution. PATIENT SAMPLE: A total of 165 patients undergoing 1- or 2-level posterior spinal fusion, with or without TLIF. OUTCOME MEASURES: Preoperative CT scan utilization and radiation dose, intraoperative radiation dose (fluoroscopy and/or CT) and total-procedure radiation dose (sum of preoperative CT and intraoperative radiation doses), levels fused, operative time, estimated blood loss (EBL), length of stay (LOS), postoperative complications.
METHOD(S): Patients >=18 years old undergoing 1- or 2-level posterior spinal fusion, with or without TLIF, in a 12-month period included. Chart review performed for pre- and intraoperative data on radiation dose and perioperative outcomes. All radiation doses quantified in milli-Grays (mGy). Univariate analysis and multivariate logistic regression analysis for categorical variables and one-way ANOVA for continuous variables utilized, with significance set at p<0.05.
RESULT(S): A total of 165 patients (51.83% F, 59.13+/-13.18yrs, BMI 29.43+/-6.72, Charlson comorbidity index [CCI] 1.20+/-1.56) were assessed: 12 IGN, 62 robotic, 56 open, 35 MIS without IGN/robotics. Lower proportion of women in open and MIS group (66.67% F IGN, 64.52% robotic, 38.18% open, 45.71% MIS, p=0.010). Younger patients in MIS group (63.42 yrs IGN, 61.74 robotic, 60.63 open, 50.63 MIS, p<0.001). MIS group had lowest mean posterior levels fused (1.42 IGN, 1.27 robotic, 1.32 open, 1.06 MIS, p=0.015). Total-procedure radiation (50.21mGy IGN, 59.84 robotic, 22.56 open, 82.02 MIS), total-procedure radiation/level fused (41.88mGy IGN, 51.18 robotic, 18.56 open, 79.41 MIS) and intraop radiation (44.69mGy IGN, 44.85 robotic, 14.81 open, 80.28 MIS) were lowest in the open group and highest in the MIS group compared to IGN and robotic (all p<0.001). A higher proportion of robotic and lower proportion MIS patients had preop CT (25% IGN, 82.26% robotic, 37.5% open, 8.57% MIS, p<0.001). EBL (441.67mL IGN, 380.24 robotic, 355.36 open, 162.14 MIS, p=0.002) and LOS (4.75 days IGN, 3.89 robotic, 3.89 open, 2.83 MIS, p=0.039) were lowest in the MIS group. Highest operative time for IGN patients (303.5 min vs 264.85 robotic, 229.91 open, 213.43 MIS p<0.001). No differences in BMI, CCI, postoperative complications (p=0.313, 0.051, 0.644, respectively).
CONCLUSION(S): IGN and robotic assistance in posterior lumbar fusion were associated with higher intraoperative and total-procedure radiation exposure than open cases without IGN/robotics, but significantly less than MIS without IGN/robotics, without differences in perioperative outcomes. While MIS procedures reported highest radiation exposure to patient, of more concern is that the proportion of total radiation dose applied to surgeon would also be considerably higher in MIS group. FDA DEVICE/DRUG STATUS: Brainlab Airo Mobile Intraoperative CT scanner (Approved for this indication).
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BACKGROUND CONTEXT: Prior adolescent idiopathic scoliosis (AIS) literature has demonstrated that patient satisfaction correlated weakly with individual SRS-22r domains and did not correlate with specific radiographic parameters. PURPOSE: The purpose of this study is to demonstrate the effect of residual deformity on patient satisfaction. We hypothesize that in patients with AIS, residual deformity maybe associated with worse satisfaction. STUDY DESIGN/SETTING: Retrospective analysis of a prospective AIS registry. PATIENT SAMPLE: A total of 1,229 Lenke 1 and 2 AIS patients with available radiographic data and SRS scores at the 2-year follow-up were included. OUTCOME MEASURES: Patient satisfaction using the SRS-22r satisfaction domain, categorized into 2 groups: Complete satisfaction (5/5) and incomplete satisfaction/dissatisfaction (<5).
METHOD(S): A total of 1,229 Lenke 1 and 2 AIS patients with available radiographic data and SRS scores at the 2-year follow-up were included. A score of 5 on the SRS-22r satisfaction domain at 2 years was considered "complete satisfaction," and anything below a score of 5 was considered "incomplete satisfaction/dissatisfaction." Radiographic parameters that were 2 standard deviations below the mean were deemed to have a "residual deformity." Univariate and binary logistic analyses were performed to assess the association of residual deformity with patient satisfaction.
RESULT(S): At the 2-year follow-up, 689 (60%) patients reported complete satisfaction, while 455 (40%) reported incomplete satisfaction/dissatisfaction. Radiographic factors associated with incomplete satisfaction/dissatisfaction were: residual trunk shift (OR 3.32, p=0.001) and residual major curve (OR 1.7, p=0.036). Patients with residual trunk shift and major curve also had worse SRS-22r self-image domain scores at the 2-year follow-up. Residual differences in shoulder height (p=0.534), T1 tilt angle (p=0.062), Apex to CSVL distance (p=0.969), and percent correction of the major curve (p=0.102) did not reach statistical significance for predicting incomplete satisfaction/dissatisfaction.
CONCLUSION(S): Residual curve (>34) and truncal shift (>2.2cm) impact patient satisfaction after surgery for AIS. These factors ought to be taken into account during surgical planning. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Persistent lumbopelvic malalignment following ASD-corrective surgery may impair quality of life and result in persistent pathologic compensation in the lower extremities. Patient-specific age- and BMI-adjusted alignment targets have been proposed to improve alignment outcomes; however, it is unclear whether reaching these postop targets reduces rates of pelvic nonresponse following surgery. PURPOSE: Assess the relationship between pelvic nonresponse to ASD-corrective surgery and persistent lower-extremity compensation. STUDY DESIGN/SETTING: Single center retrospective review. PATIENT SAMPLE: Fifty-eight ASD patients. OUTCOME MEASURES: Sagittal alignment.
METHOD(S): Included: surgical ASD patients with full-spine X-ray imaging at pre- and early postop follow-up (<1Y). Patients were grouped by postop improvement in PT, per SRS-Schwab Classification: those who did not improve (pelvic nonresponders, PNR), and those that did improve (pelvic responders, PR). Groups were propensity score matched for preop PT, and assessed for differences in demographics, surgical factors, and alignment (sagittal spinal and lower extremity) with means comparison tests. Rates of persistent postop lower extremity compensation (defined as no improvement in lower extremity alignment) were compared between groups. Subanalysis assessed the relationship between reaching postop age- and BMI-specific alignment targets and rates of pelvic nonresponse.
RESULT(S): Following propensity score matching, PNR (N=29) and PR (N=29) patients did not differ in age, sex, BMI or preop sagittal spinal alignment (all p>0.05); however, PNR patients presented with less knee flexion (9degree vs 14degree, p=0.043). Groups did not differ in levels fused (10.8 vs 10.8, p=0.974) or osteotomy (93% vs 92%, p=0.902). Postop, PNR patients had inferior lumbopelvic alignment in PT (30degree vs 17degree), PI-LL (17degree vs 3degree), and greater global malalignment for TPA (27degree vs 15degree, all p<0.001). For PNR patients, these changes in alignment were accompanied by greater compensatory anterior hip extension (53mm vs 31mm, p=0.021). PNR patients also showed greater pre- to postop increases in sacrofemoral angle (2degree vs -5degree), and smaller decreases in hip extension (-24mm vs -64mm), pelvic femoral angle (-1.4degree vs -3.8degree), and global sagittal angle (-3.5degree vs -8degree, all p<0.005), indicating persistent lower extremity compensation. PNR patients had higher rates of persistent postop lower extremity compensation for sacrofemoral angle (68% vs 25%), ankle flexion (64% vs 33%), and pelvic shift (28% vs 4%, all p<0.034). PNR and PR groups did not differ in rates of reaching age- and BMI specific ideal postop alignment for PT, SVA, TPA, or PI-LL (all p>0.05). For patients with severe preop SVA deformity, overcorrection relative to ideal postop PT targets was associated with lower rates of pelvic non-response (under: 12%, match: 18%, over: 71%, p<0.001). Lower rates of nonresponse were observed for patients with severe preop PT deformity overcorrected relative to ideal postop PI-LL (under: 0%, match: 30%, over: 70%, p=0.016).
CONCLUSION(S): Pelvic nonresponders following ASD-corrective surgery had higher rates of persistent compensatory action in the lower extremities. Patients with severe preop PT deformity who were surgically overcorrected with respect to ideal PI-LL had lower rates of postop pelvic nonresponse, indicating that for severely malalignmed patients, existing alignment targets may need to be adjusted to optimize alignment outcomes. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Antifibrinolytic agents are used during ASD surgery to minimize blood loss and transfusion requirements. Tranexamic acid (TXA) reduces the risk of blood loss and transfusion after ASD surgery, but there persists concern for prothrombotic effects, myocardial infarction, stroke, and postoperative neurologic events including seizures. PURPOSE: To investigate perioperative blood loss and transfusion after TXA for ASD surgery. STUDY DESIGN/SETTING: Retrospective review of prospectively collected single center database. PATIENT SAMPLE: 469 patients who received TXA, and 354 patients who did not receive TXA. OUTCOME MEASURES: Perioperative blood loss and blood product transfusion rate, and complications.
METHOD(S): Using a single-institution multi-surgeon database, we performed a retrospective review of patients undergoing ASD surgery from 2011-2018. We identified 469 patients who received TXA, and 354 patients who did not receive TXA. We investigated perioperative blood loss and blood product transfusion rate, and complications occurring after surgery.
RESULT(S): There was no significant difference in age, BMI, or frailty between the TXA (age: 45 +/- 23, BMI: 25 +/- 6) and non-TXA group (age: 47 +/- 24, BMI: 26 +/- 7). The prevalence of coronary artery disease, chronic kidney disease, and history of pulmonary embolism was higher in the non-TXA group, presumably due to surgeon preoperative screening, with no difference in other medical comorbidities. There were more revision surgeries and pelvic fixation procedures in the TXA group, with no other differences in surgical complexity. The group that received TXA had significantly lower EBL (1693 +/- 1343 mL vs 2009 +/- 1892 mL, p=0.019), and were transfused less platelets intraoperatively (.07 +/-.3 U vs 0.25 +/- 0.86 U, p=0.012). There was no difference in rates of perioperative pRBC transfusion between the groups. The most common complications in both groups were ileus and urinary retention. There was no difference in rate of thrombotic, cardiac, or renal complications, or seizures between the two groups. There was no significant difference in 90-day complication, readmission, or revision rates.
CONCLUSION(S): Among patients undergoing ASD surgery, TXA was associated with a lower estimated blood loss, without a higher risk for any morbid event. To our knowledge, this is the largest study to date to evaluate the safety of TXA for ASD surgery. FDA DEVICE/DRUG STATUS: Unavailable from authors at time of publication.
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