Faculty Bibliography

PURPOSE:This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery. METHODS:The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios. RESULTS:Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals. CONCLUSIONS:Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.

STUDY DESIGN:This was a retrospective cohort study. OBJECTIVE:The aim of this study was to compare the hospital charges and postoperative complications of minimally invasive surgery (MIS) and open approaches to sacroiliac joint (SIJ) fusion. SUMMARY OF BACKGROUND DATA:The data source utilized in this study is the Healthcare Cost and Utilization Project National Readmission Database (NRD) from 2016 and 2017. The NRD is a yearly nationally representative inpatient database from the Agency for Healthcare Research and Quality with information regarding patient demographics, diagnoses, procedures, and readmissions. MATERIALS AND METHODS:The 2016-2017 NRD was used to identify 2521 patients receiving SIJ fusion with open (n=1990) or MIS approaches (n=531) for diagnosed sacrum pain, sacroiliitis, sacral instability, or spondylosis after excluding for those who received prior SIJ fusion, those diagnosed with neoplasms or trauma of the pelvis or sacrum, and nonelective procedures. We then one-to-one propensity-matched the open (n=531) to the MIS approach (n=531) for age, sex, and Charlson Comorbidity Index. Statistical analysis was performed to compare total hospital charges, immediate surgical complications, nonelective readmission rate, and 30-, 90-, and 180-day postoperative complications between the 2 approaches. RESULTS:The mean total hospital charge was the only significant difference between 2 group. Open SIJ fusion had significantly higher charge compared with the MIS approach (open $101,061.90±$81,136.67; MIS $83,594.78±$49,086.00, P<0.0001). The open approach was associated with nonsignificant higher rates of novel lumbar pathology at 30-, 90-, and 180-day readmissions and revision surgeries at 30 and 180 days. MIS approach had higher rates nervous system complications at 30-, 90-, and 180-day readmission, as well as infection and urinary tract infection within 30 days, none being significant. Novel postprocedural pain was similar between the 2 groups at 90 and 180 days. CONCLUSIONS:The current study found that open SIJ fusion was associated with significantly higher hospital charges. Although no significant differences in postoperative complications were found, there were several notable trends specific to each surgical approach.

Background/UNASSIGNED:Modifiable risk factors (MRFs) represent patient variables associated with increased complication rates that may be prevented. There exists a paucity of studies that comprehensively analyze MRF subgroups and their independent association with postoperative complications in patients undergoing cervical spine surgery. Therefore, the purpose of this study is to compare outcomes between patients receiving cervical spine surgery with reported MRFs. Methods/UNASSIGNED:Retrospective analysis of the Nationwide Readmissions Database (NRD) from the years 2016 and 2017, a publicly available and purchasable data source, to include adult patients undergoing cervical fusion. MRF cohorts were separated into three categories: substance abuse (alcohol, tobacco/nicotine, opioid abuse); vascular disease (hypertension, dyslipidemia); and dietary factors (malnutrition, obesity). Three-way nearest-neighbor propensity score matching for demographics, hospital, and surgical characteristics was implemented. Findings/UNASSIGNED: = 0.0037). However, those with substance abuse had the highest readmission rate and were more commonly readmitted for delayed procedure-related infections. Interpretation/UNASSIGNED:A large proportion of patients who receive cervical spine surgery have potential MRFs that uniquely influence their postoperative outcomes. A thorough understanding of patient-specific MRF subgroups allows for improved preoperative risk stratification, tailored patient counseling, and postoperative management planning. Funding/UNASSIGNED:None.

BACKGROUND:Over the last several decades, various osteobiologics including allograft, synthetics, and growth factors have been used for lumbar spinal fusion surgery. However, the data on these osteobiologic products remain controversial with conflicting evidence in the literature. This study evaluates the influence of osteobiologic type selection on perioperative complications and hospital-reported charges in single-level and multilevel lumbar fusion. METHODS:Using the 2016 and 2017 Nationwide Readmission Database, we conducted a retrospective cohort analysis of 125,143 patients who received lumbar fusion with either autologous tissue substitute, nonautologous tissue substitute, or synthetic substitute. This cohort was split into single-level and multilevel fusion procedures, and one-to-one age and sex propensity score matching was implemented. This resulted in cohorts each consisting of 1967 patients for single-level fusion, and cohorts each consisting of 1657 patients for multilevel fusion. Statistical analysis included one-way analysis of variance and Tukey multiple comparisons of means. RESULTS:= .044) for single-level fusion compared with the nonautologous group. Lastly, for both cohorts, the total accrued inpatient hospital charges during admission for patients receiving nonautologous grafts were the most expensive and those for patients receiving autologous grafts were the least expensive. CONCLUSION/CONCLUSIONS:Significant differences were found between the groups with respect to rates of complications, including infection, postoperative pain, and neurologic injury. Furthermore, the hospital-reported charges of each procedure varied significantly. As the field of biologics continues to expand, it is important to continually evaluate the safety, efficacy, and cost-effectiveness of these novel materials and techniques. LEVEL OF EVIDENCE/METHODS:3 CLINICAL RELEVANCE: With increased utilization of osteobiologics and spinal fusion being a common procedure, longitudinal data on readmissions, and post-operative complications are critical in guiding evidence-based practice.

BACKGROUND:Malignant spinal tumors are common, continually increasing in incidence as a function of improved survival times for patients with cancer. Using predictive analytics and propensity score matching, we evaluated the influence of frailty on postoperative complications compared with age in patients with malignant neoplasms of the lumbar spine. METHODS:We used the Nationwide Readmissions Database from 2016 and 2017 to identify patients with malignant neoplasms of the lumbar spine who received a fusion procedure. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups. Propensity score matching for age, sex, Charlson Comorbidity Index, surgical approach, and number of levels fused was implemented between frail and nonfrail patients, identifying 533 frail patients and 538 nonfrail patients. The area under the curve (AUC) of each ROC served as a proxy for model performance. RESULTS:Frail patients reported significantly higher inpatient lengths of stay, costs, infection, posthemorrhagic anemia, and urinary tract infections (P < 0.05). In addition, frail patients were more often discharged to skilled nursing facilities and short-term hospitals compared with nonfrail patients (P < 0.0001). Regression models for mortality (AUC = 0.644), nonroutine discharge (AUC = 0.600), and acute infection (AUC = 0.666) were improved when using frailty as the primary predictor. These models were also improved using frailty when predicting 30-day readmission and 90-day hardware failure. CONCLUSIONS:Frailty demonstrated a significant relationship with increased postoperative patient complications, length of stay, costs, and acute complications in patients receiving fusion following resection of a malignant neoplasm of the lumbar spine region. Frailty demonstrated better predictive validity of outcomes compared with patient age.

OBJECTIVE:To evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America. METHODS:An anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics. RESULTS:A total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01). CONCLUSION/CONCLUSIONS:This study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation.

STUDY DESIGN:This was a large database study. OBJECTIVE:The objective of this study was to compare the incidence of complications and reoperation rates between the most common surgical treatments for cervical spondylotic myelopathy (CSM): anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and posterior laminectomy and fusion (Lamifusion). SUMMARY OF BACKGROUND DATA:CSM is a major contributor to disability and reduced quality of life worldwide. METHODS:Humana insurance database was queried for CSM diagnoses between 2007 and 2016. The initial population was divided based on the surgical treatment and matched for age, sex, and Charlson Comorbidity index. Specific postoperative complications or revisions were analyzed at individual time points. Pearson χ2 analysis with Yate continuity correction was used. RESULTS:Lamifusion had significantly higher rates of wound infection/disruption than ACDF or ACCF (5.03%, 2.19%, 2.29%; P=0.0008, 0.002, respectively) as well as iatrogenic deformity (4.75%, 2.19%, 2.10%; P=0.0036, 0.0013). Lamifusion also had a significantly higher rate of shock and same-day transfusion than ACDF (4.75%, 2.01%, P=0.0005), circulatory complications (2.01%, <1%, P=0.0183), and C5 palsy (4.84%, 1.74%, P≤0.0001). Compared with ACDF, Lamifusion had higher rates of hardware complication (3.29%, 2.01%, P=0.0468), and revision surgery (8.23% 5.85%, P=0.0395). Lamifusion had significantly lower rates of dysphagia than either ACDF (3.93% vs. 6.58%, P=0.0089) or ACCF (3.93% vs. 8.59%, P<0.0001). When comparing ACCF to ACDF, ACCF had significantly higher rates of circulatory complications (2.38%, <1%, P=0.0053), shock/same-day transfusion (3.2%, 2.0%, P=0.59), C5 palsy (3.47%, 1.74%, P=0.0108), and revision surgery (9.51%, 5.85%, P=0.0086). CONCLUSIONS:The data shows that posterior Lamifusion has higher overall rate of complications compared with ACDF or ACCF. Furthermore, when comparing the anterior approaches, ACDF was associated with lower rate of complication and revision. ACCF had the highest overall rate of revision surgery.

»:Lumbar disc herniation is one of the most common spinal pathologies, often occurring at the L4-L5 and L5-S1 levels. The highest incidence has been reported in patients between the fourth and sixth decades of life. »:The severity of symptoms is influenced by the patient's risk factors, the location, and the extent and type of disc herniation. »:Lumbar disc herniation can be effectively treated with multiple treatment protocols. In most cases, first-line treatment includes oral analgesic medication, activity modification, and physical therapy. When nonoperative treatments do not provide adequate relief, patients may elect to undergo a fluoroscopically guided contrast-enhanced epidural steroid injection. A subgroup of patients whose condition is refractory to any type of nonoperative modalities will proceed to surgery, most commonly an open or minimally invasive discectomy. »:The treatment algorithm for symptomatic lumbar disc herniation often is a stepwise approach: failure of initial nonoperative measures leads to more aggressive treatment when symptoms mandate and, as such, necessitates the use of a multidisciplinary team approach. The core team should consist of an interventional physiatrist, an orthopaedic surgeon, a physician assistant, and a physical therapist. Additional team members may include nurses, radiologists, neurologists, anesthesiologists, spine fellows, psychologists, and case managers. »:This review article describes a case scenario that uses a multidisciplinary team approach for the treatment of an acute L4-L5 disc herniation in a 31-year-old patient without any major comorbidities.

STUDY DESIGN/UNASSIGNED:Retrospective upright MRI study. OBJECTIVE/UNASSIGNED:To validate the presence of positive and negative nerve root sedimentation signs on multi-positional MRI in the upright position and explore the relationship between negative nerve root sedimentation and gravity. METHODS/UNASSIGNED:T2-weighted axial multi-positional images in the upright position at the intervertebral disc levels from L1-L2 to L4-L5 in 141 patients with non-specific low back pain were retrospectively assessed. A positive sedimentation sign was defined as the absence of nerve root sedimentation or the absence of dorsal conglomeration of nerve roots within the dural sac. A negative sedimentation sign was defined as nerve root sedimentation dorsally or dorso-laterally like a horseshoe. Intra-and inter-observer reliability was evaluated. The relationship between sedimentation sign and dural sac cross-sectional area (CSA), anterior-posterior (AP) diameter was also explored. RESULTS/UNASSIGNED:The kappa value of intra-observer reliability was 0.962 and inter-observer reliability was 0.925. Both positive and negative sedimentation signs did appear at all 4 lumbar levels, including L1/2, L2/3, L3/4 and L4/5. A positive sedimentation sign was associated with significantly decreased dural sac CSA and AP diameter at L2/3, L3/4 or L4/5 level when compared to negative sedimentation sign. CONCLUSIONS/UNASSIGNED:Both negative and positive sedimentation signs appeared at the L1/2, L2/3, L3/4, and L4/5 levels on the upright MRI, which suggested that the presence of nerve roots sedimenting dorsally in patients may not be associated with gravity. Moreover, the current study supports that sedimentation signs on multi-positional MRI images could have the same diagnostic functions as on MRI images.

STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:The aim of this study was to compare different aspects of fusion surgery in patients with osteoporosis with regard to graft subtype and surgical approach. SUMMARY OF BACKGROUND DATA/BACKGROUND:Osteoporosis and chronic lower back pain are common in elderly populations and significantly increase the risk of compression fractures within the spine. METHODS:Using the 2016-2017 National Readmission Database we identified 11,086 osteoporotic patients who received lumbar fusion using ICD-10 coding. Information regarding biologic graft type and surgical approach was collected. Patients were stratified by number of levels fused. Perioperative complications were collected at 30-, 90-, and 180-day follow-up intervals. Statistical analysis included univariate testing and multivariate regression modeling, controlling for patient demographics and comorbidities. RESULTS:Patients receiving single-level fusion with autologous grafts had higher rates of hardware failure (P = 0.00014) at 30-day follow-up and 90-day follow-up (P < 0.0001) and higher rates of lumbar vertebral fractures at 90-day follow-up (P = 0.045) compared to those treated with nonautologous grafts. Patients receiving lumbar fusion with anterior and posterior approaches had no difference in readmission or infection rates, but the anterior approach was associated with a higher cost. CONCLUSION/CONCLUSIONS:In this study, osteoporotic patients treated with autologous grafts had higher rates of complications compared to those treated with nonautologous grafts. Anterior and posterior approaches had similar complication rates; however, the anterior approach was associated with a higher total cost.Level of Evidence: 4.