Faculty Bibliography

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: Although the health impact of adult symptomatic lumbar scoliosis (ASLS) is substantial, these patients often have other orthopedic disease burden that may further negatively impact their health-related quality of life (HRQL) and recovery following ASLS treatment. This additional disease burden has not been well quantified in the ASLS population. PURPOSE: To assess nonthoracolumbar orthopedic (NTO) disease burden in ASLS patients enrolled in a prospective multicenter study. STUDY DESIGN/SETTING: Retrospective review of prospective multicenter cohort. PATIENT SAMPLE: Patients enrolled in the ASLS prospective multicenter study of operative vs nonoperative treatment. OUTCOME MEASURES: Occurrence of non-thoracolumbar orthopedic events, Scoliosis Research Society-22r (SRS-22), Oswestry Disability Index (ODI), SF-12 physical component summary (PCS).
METHOD(S): The ASLS study is a prospective multicenter study to assess operative vs nonoperative treatment for ASLS, with randomized and observational arms. Patients recruited were 40-80 years old with ASLS, defined as a lumbar coronal Cobb >30degree and ODI >20 or SRS-22 <4.0 in pain, function and/or self-image domains. Incidence of NTO disease burden was assessed in the overall study population from enrollment up to 4-yr follow-up, with comparisons between as-treated operative and nonoperative patients combining randomized and observational cohorts. NTO events for this study only included orthopedic conditions requiring surgical treatment and fractures.
RESULT(S): Two hundred eighty-six patients (mean age 60 yrs, 90% women) were enrolled, with as-treated cohorts of 173 operative and 113 nonoperative patients, and 4-yr follow-up rate of 81%. At a mean follow-up of 3.8 yrs (SD=0.9 yrs), 108 NTO events were reported, affecting 71 (24.8%) patients. The most common NTO events included: arthroplasty (n=39), fractures (n=26), joint ligament/cartilage repair (n=13), cervical surgery (n=7), and carpal tunnel release (n=5). Patients with an NTO event were significantly older (63 vs 59 yrs, p<0.001), more likely to have any history of smoking (50.7% vs 32.1%, p=0.007), had worse baseline deformity based on SRS-Schwab PI-LL (p=0.002) and PT (p=0.012) modifiers, and had worse baseline function (SF-12 PCS, p=0.009). Patients with and without an NTO event did not differ based on ASLS operative vs nonoperative treatment (p=0.405), gender (p=0.491), BMI (p=0.441), or femoral neck t score (p=0.512). Patients undergoing an arthroplasty following study enrollment were not older (p=0.09) but were more likely to have any history of smoking (15.2% vs 7.2%, p=0.041), had worse baseline deformity based on SRS-Schwab PI-LL modifier (p=0.002), and had worse baseline pain (SRS-22 pain, p=0.017) and function (ODI, p=0.003).
CONCLUSION(S): ASLS patient have a high NTO disease burden, with almost 25% of patients in this prospective multicenter study having an orthopedic condition requiring surgical treatment or a fracture within 3.8 yrs following study enrollment. Patients with an NTO event were more likely to have any history of smoking and had worse baseline spinal deformity and disability. These conditions may further impact HRQL and recovery following ASLS treatment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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Background/UNASSIGNED:A variety of techniques have been utilized to improve the accuracy of pedicle screw instrumentation. Recently, a novel handheld computerized drill system, IntelliSense Drill Technology, has been used in orthopedic trauma to improve drilling accuracy and reduce radiation and iatrogenic injury. The specialized drill technology detects changes in cortical density to prevent inadvertent cortical violation. The aim of this study is to assess the ability of this system to identify pedicle trajectories in the thoracic and lumbar spine compared to a standard freehand technique. Methods/UNASSIGNED:Two spine surgeons, including 1 senior-level and 1 junior-level attending drilled pedicle screw tracts using a freehand technique and computerized drill technology in 4 cadaveric spines from T2 to S1. A total of 134 pedicle screws were placed, including 70 by the senior surgeon and 64 by the junior surgeon. Cortical violations were assessed using computed tomography after instrumenting each pedicle tract, and procedure time for insertion of pedicle screws was recorded. Results/UNASSIGNED: = .063). Conclusions/UNASSIGNED:We demonstrate the use of a novel drill technology for placement of pedicle screws in the thoracic and lumbar spine. After an initial learning curve, this technology is comparable to use of a freehand technique by both a senior-level and a junior-level attending surgeon in a cadaveric model. Further investigation is needed to identify the clinical role of this technology in spine surgery.

MINI: The ability of PROMIS to capture disability from cervical sagittal malalignment is unknown. Correlations between PROMIS domains and legacy outcome metrics with cervical sagittal alignment parameters were analyzed. PROMIS domains correlated strongly with legacy outcomes and PROMIS Pain Intensity correlated with worsening sagittal alignment in patients with cervical sagittal deformity.

BACKGROUND:Patients undergoing multilevel spine surgery are at risk for delayed extubation. OBJECTIVE:To evaluate the impact of type and volume of intraoperative fluids administered during multilevel thoracic and/or lumbar spine surgery on postoperative extubation status. METHODS:Retrospective evaluation of medical records of patients ≥ 18 yr undergoing ≥ 4 levels of thoracic and/or lumbar spine fusions was performed. Patients were organized according to postoperative extubation status: immediate (IMEX; in OR/PACU) or delayed (DEX; outside OR/PACU). Propensity score matched (PSM) analysis was performed to compare IMEX and DEX groups. Volume, proportion, and ratios of intraoperative fluids administered were evaluated for the associated impact on extubation status. RESULTS:A total of 246 patients (198 IMEX, 48 DEX) were included. PSM analysis demonstrated that increased administration of non-cell saver blood products (NCSB) and increased ratio of crystalloid: colloids infused were independently associated with delayed extubation. With increasing EBL, IMEX had a proportionate reduction in crystalloid infusion (R = -0.5, P < .001), while the proportion of crystalloids infused remained relatively unchanged for DEX (R = -0.27; P = .06). Twenty-six percent of patients receiving crystalloid: colloid ratio > 3:1 had DEX compared to none of those receiving crystalloid: colloid ratio ≤ 3:1 (P = .009). DEX had greater cardiac and pulmonary complications, surgical site infections and prolonged intensive care unit and hospital stay (P < .05). CONCLUSION/CONCLUSIONS:PSM analysis of patients undergoing multilevel thoracic and/or lumbar spine fusion demonstrated that increased administration of crystalloid to colloid ratio is independently associated with delayed extubation. With increasing EBL, a proportionate reduction of crystalloids facilitates early extubation.

STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:The goals of this study were to (1) evaluate pre-operative bone quality assessment and intervention practice over time and (2) review the current evidence for bone evaluation in spine fusion surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:Deformity spine surgery has demonstrated improved quality of life in patients however its cost has made it controversial. If pre-operative bone quality can be optimized then potentially these treatments could be more durable however, at present, no clinical practice guidelines have been published by professional spine surgical organizations. METHODS:A retrospective cohort review was performed on patients who underwent a minimum five-level primary or revision fusion. Pre-operative bone quality metrics were evaluated over time from 2012 - 2017 to find potential trends. Sub-group analysis was conducted based on age, gender, pre-operative diagnosis, and spine fusion region. RESULTS:Patient characteristics including pre-operative rates of pseudarthrosis and junctional failure did not change. An increasing trend of physician bone health documentation was noted (p = 0.045) but changes in other metrics were not significant. A gender bias favored females who had higher rates of pre-operative DXA studies (p = 0.001), Vitamin D 25-OH serum labs (p = 0.005), Vitamin D supplementation (p = 0.022), calcium supplementation (p < 0.001), antiresorptive therapy (p = 0.016), and surgeon clinical documentation of bone health (p = 0.008) compared to men. CONCLUSION/CONCLUSIONS:Our spine surgeons have increased documentation of bone health discussions but this has not affected bone quality interventions. A discrepancy exists favoring females over males in nearly all pre-operative bone quality assessment metrics. Pre-operative vitamin D level and BMD assessment should be considered in patients undergoing long fusion constructs however the data for bone anabolic and resorptive agents has less support. Clinical practice guidelines on pre-operative bone quality assessment spine patients should be defined. LEVEL OF EVIDENCE/METHODS:4.

Background/UNASSIGNED:Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes. Methods/UNASSIGNED:tests compared parameters between cohorts. Results/UNASSIGNED: < .001) compared to nonobese patients with PI-LL larger than age-adjusted ideal. Conclusions/UNASSIGNED:Regardless of malalignment severity, obese patients recruited lower-limb compensation more than nonobese patients. Obese patients with PI-LL mismatch larger than age-adjusted ideal also develop upper-cervical and cervicothoracic compensation for malalignment. Level of Evidence/UNASSIGNED:III. Clinical Relevance/UNASSIGNED:Clinical evaluation should extend to the cervical spine in obese patients not meeting age-adjusted sagittal alignment ideals.

STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:The objective of this study was to examine associations of gabapentin use with inpatient postoperative daily pain scores and opioid use in children undergoing PSF for AIS. SUMMARY OF BACKGROUND DATA/BACKGROUND:Gabapentin use in posterior spinal fusion (PSF) postoperative pain management for adolescent idiopathic scoliosis (AIS) is increasingly common in order to decrease opioid use and improve pain control, though there is conflicting data on dosing and effectiveness to support this practice in real world settings. METHODS:Retrospective cohort study of children aged 10 to 21 years undergoing PSF for AIS between January 2013 and June 2016 at an urban academic tertiary care center. Adjuvant gabapentin exposure was defined as at least 15 mg/kg/d by postoperative day (POD) 1 with an initial loading dose of 10 mg/kg on day of surgery. Primary outcomes were daily postoperative mean pain score and opioid use [morphine milligram equivalents/kg/day(mme/kg/d)]. Secondary outcomes were short and long-term complications. RESULTS:Among 129 subjects (mean age, 14.6 y, 74% female, mean coronal cobb, 55.2 degrees), 24 (19%) received gabapentin. Unadjusted GABA exposure was associated with significantly lower opioid use on POD1 and 2 (49% and 31%mme/kg/d, respectively) and lower pain scores (14%) on POD2. Adjusting for preexisting back pain, preoperative coronal Cobb angle, and site, GABA use was associated with significantly lower mean pain scores on POD1 through POD3 (-0.68, P=0.01; -0.86, P=0.002; -0.63, P=0.04). Gabapentin use was also associated with decreased opioid use on POD1 and POD2 (-0.39mme/kg/d, P<0.001; -0.27, P=0.02). There was no difference in complications by gabapentin exposure. CONCLUSIONS:Addition of gabapentin as adjuvant therapy for adolescent PSF, beginning on day of surgery, is associated with improved pain scores and decreased opioid use in the first 48 to 72 hours postoperatively. LEVEL OF EVIDENCE/METHODS:This is a retrospective cohort study, classified as Level III under "Therapeutic Studies Investigating the Results of a Treatment."

STUDY DESIGN/METHODS:Retrospective cohort study at a single institution. OBJECTIVE:To analyze the perioperative and postoperative outcomes of patients who underwent open transforaminal lumbar interbody fusion (O-TLIF) and bilateral minimally invasive (MIS) Wiltse approach TLIF (Wil-TLIF). SUMMARY OF BACKGROUND DATA/BACKGROUND:Several studies have compared Open TLIF to MIS TLIF, however, comparing the techniques using a large cohort of one-level TLIFs has not been fully explored. METHODS:We reviewed the charts of patients undergoing a single-level primary posterior lumbar interbody fusion between 2012 and 2017. The cases were categorized as Open TLIF (traditional midline exposure including lateral exposure of transverse processes) or bilateral paramedian Wiltse TLIF approach. Differences between groups were assessed by t-tests. RESULTS:227 patients underwent one-level primary TLIF (116 O-TLIF, 111 Wil-TLIF). There was no difference in age, gender, ASA or BMI between groups. Wil-TLIF had the lowest EBL (197 mL vs. 499 mL O-TLIF, p =  < .001), LOS (2.7 days vs. 3.6 days O-TLIF, p =  < .001), overall complication rate (12% vs. 24% O-TLIF, p = .015), minor complication rate (7% vs. 16% O-TLIF, p = .049), and 90-day readmission rate (1% vs. 8% O-TLIF, p = .012). Wil-TLIF was associated with the higher fluoroscopy time (83 sec vs. vs. 24 sec O-TLIF, p =  < .001). There was not a significant difference in operative time, intraoperative or neurological complications, extubation time, reoperation rate, or infection rate. CONCLUSIONS:In comparing Wiltse MIS TLIF to Open TLIF, the minimally invasive paramedian Wiltse approach demonstrated the lowest EBL, LOS, readmission rates and complications, but longer fluoroscopy times when compared to the traditional open approach. LEVEL OF EVIDENCE/METHODS:3.

The Press Ganey survey is the most widely used instrument for measuring patient satisfaction. Understanding the factors that influence these surveys may permit better use of survey results and may direct interventions to increase patient satisfaction. Press Ganey Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys administered to ambulatory spine surgery clinic patients within a large tertiary care network from May 2016 to September 2017 were retrospectively reviewed. Mean comparison testing was performed to measure associations between patient demographics and responses to "overall provider rating" and "recommend this provider's office" survey questions. Mean difference to achieve significance was set at α<0.05. A multivariate analysis was performed to determine independent factors. A total of 1400 survey responses from the offices of 11 orthopedic spine surgeons were included. Patients 18 to 34 years old had significantly lower responses to the overall provider rating question than older patients (P<.001), and increasing patient age was correlated with improved ratings. Highest education level was inversely correlated with satisfaction scores, with patients who had attained graduate level education having the lowest satisfaction scores (P=.001). Those with commercial insurance had significantly lower ratings for recommend this provider's office (P=.042) and overall provider rating (P=.022) questions than those with other insurance types. Patients administered the survey on paper had significantly lower ratings than those administered the survey online (P=.006). Provider ratings were significantly higher when the sex and ethnicity of the patient were concordant with the provider (P=.021). This study showed that independent, nonmodifiable factors such as age, education level, and survey mode were significantly associated with the satisfaction of ambulatory spine surgery clinic patients. [Orthopedics. 2019; 42(3):143-148.].