Faculty Bibliography

BACKGROUND: Hospital length of stay (LOS), 30-day readmission rate, and other metrics are increasingly being used to evaluate quality of surgical care. The factors most relevant to cervical spondylotic myelopathy (CSM) are not yet established. OBJECTIVE: To identify peri-operative factors associated with extended LOS and/or 30-day readmission following elective surgery for CSM. METHODS: Surgical CSM patients at institutions represented by the American-College-of-Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) from 2010-2012 were included. Patients with fracture, >/=9 levels fused, or cancer were excluded. Extended LOS was defined as 75th percentile of the cohort. Univariate analysis and multivariate logistic regression identified predictors for extended LOS, 30-day readmission, and reoperation. Linear regression modeling was used to evaluate variables. RESULTS: 3057 surgical CSM cases were isolated. Age (OR-1.496), diabetes (OR-1.691), American Society of Anesthesiologists (ASA) class (OR-2.081), posterior surgical approach (OR-2.695), and operative time (OR-1.008) were all positive predictors (P<0.05) for extended LOS (>/=4 days). 32% of the cohort (976 patients) had 30-day readmission data. Among these, 915 patients were not readmitted (93.8%), while 61 (6.2%) were. Diabetes (OR-1.460) and ASA-class (OR-2.539) were significant positive predictors for hospital readmission. Age (OR-0.918) was a negative predictor of re-operation in readmitted patients, and pulmonary comorbidities (OR-4.584) were a positive predictor (P<0.05). CONCLUSIONS: Patients with diabetes and higher ASA-Class were at increased risk for extended LOS and readmission within 30-days. Patients with increased operative time have greater risk for extended LOS. Pre-operative pulmonary comorbidities increased reoperation risk, while increased age reduced the risk. Attention to these factors may benefit CSM patients.

PURPOSE: Reciprocal mechanisms for standing alignment have been described in thoraco-lumbar deformity but have not been studied in patients with primary cervical deformity (CD). The purpose of this study is to report upper- and infra-cervical sagittal compensatory mechanisms in patients with CD and evaluate their changes post-operatively. METHODS: Global spinal alignment was studied in a prospective database of operative CD patients. Inclusion criteria were any of the following: cervical kyphosis (CK) > 10 degrees , cervical scoliosis > 10 degrees , cSVA (C2-C7 Sagittal vertical axis) > 4 cm or CBVA (Chin Brow Vertical Angle) > 25 degrees . For this study, patients who had previous fusion outside C2 to T4 segments were excluded. Patients were sub-classified by increasing severity of cervical kyphosis [CL (cervical lordosis): < 0 degrees , CK-low 0 degrees -10 degrees , CK-high > 10 degrees ] and cSVA (cSVA-low 0-4 cm, cSVA-mid 4-6 cm, cSVA-high > 6 cm) and were compared for pre- and 3-month post-operative regional and global sagittal alignment to determine compensatory recruitment. RESULTS: 75 CD patients (mean age 61.3 years, 56% women) were included. Patients with progressively larger CK had a progressive increase in C0-C2 (CL = 34 degrees , CK-low = 37 degrees , CK-high = 44 degrees , p = 0.004), C2Slope and T1Slope-CL (p < 0.05). As the cSVA increased, there was progressive increase in C2Slope, T1Slope and TS-CL (p < 0.05) and patients compensated through increasing C0-C2 (cSVA-low = 33 degrees , cSVA-mid = 40 degrees , cSVA-high = 43 degrees , p = 0.007) and pelvic tilt (cSVA-low = 14.9 degrees , cSVA-mid = 24.1 degrees , cSVA-high = 24.9 degrees , p = 0.02). At 3 months post-op, with significant improvement in cervical alignment, there was relaxation of C0-C2 (39 degrees -35 degrees , p = 0.01) which positively correlated with magnitude of deformity correction. CONCLUSIONS: Patients with cervical malalignment compensate with upper cervical hyper-lordosis, presumably for the maintenance of horizontal gaze. As cSVA increases, patients also tend to exhibit increased pelvic retroversion. Following surgical treatment, there was relaxation of upper cervical compensation.

INTRODUCTION/BACKGROUND:Patients with lumbar spine and hip disorders may, during the course of their treatment, undergo spinal fusion and THA. There is disagreement among prior studies regarding whether patients who undergo THA and spinal fusion are at increased risk of THA dislocation and other hip-related complications. QUESTIONS/ PURPOSES/UNASSIGNED:Is short or long spinal fusion associated with an increased rate of postoperative complications in patients who underwent a prior THA? PATIENTS AND METHODS/METHODS:A retrospective study of New York State's Department of Health database (SPARCS) was performed. SPARCS has a unique identification code for each patient, allowing investigators to track the patient across multiple admissions. The SPARCS dataset spans visit data of patients of all ages and races across urban and rural locations. The SPARCs dataset encompasses all facilities covered under New York State Article 28 and uses measures to further representative reporting of data concerning all races. Owing to the nature of the SPARCS dataset, we are unable to comment on data leakage, as there is no way to discern between a patient who does not subsequently seek care and a patient who seeks care outside New York State. ICD-9-Clinical Modification codes identified adult patients who underwent elective THA from 2009 to 2011. Patients who had subsequent spinal fusion (short: 2-3 levels, or long: ≥ 4 levels) with a diagnosis of adult idiopathic scoliosis or degenerative disc disease were identified. Forty-nine thousand nine hundred twenty patients met the inclusion criteria of the study. In our inclusion and exclusion criteria, there was no variation with respect to the distribution of sex and race across the three groups of interest. Patients who underwent a spinal procedure (short versus long fusion) had comparable age. However, patients who did not undergo a spinal procedure were older than patients who had short fusion (65 ± 12.4 years versus 63 ± 10.7 years; p < 0.001). Multivariate binary logistic regression models that controlled for age, sex, and Deyo/Charlson scores were used to investigate the association between spinal fusion and THA revisions, postoperative dislocation, contralateral THAs, and total surgical complications to the end of 2013. A total of 49,920 patients who had THAs were included in one of three groups (no subsequent spinal fusion: n = 49,209; short fusion: n = 478; long fusion: n = 233). RESULTS:Regression models revealed that short and long spinal fusions were associated with increased odds for hip dislocation, with associated odds ratios (ORs) of 2.2 (95% CI, 1.4-3.6; p = 0.002), and 4.4 (95% CI, 2.7-7.3; p < 0.001), respectively. Patients who underwent THA and spinal surgery also had an increased odds for THA revision, with ORs of 2.0 (95% CI, 1.4-2.8; p < 0.001) and 3.2 (95% CI, 2.1-4.8; p < 0.001) for short and long fusion, respectively. However, spinal fusions were not associated with contralateral THAs. Further, short and long spinal fusions were associated with increased surgical complication rates (OR = 2.8, 95% CI, 2.1-3.8, p < 0.001; OR = 5.3, 95% CI, 3.8-7.4, p < 0.001, respectively). CONCLUSION/CONCLUSIONS:We showed that spinal fusion in adults is associated with an increased frequency of complications and revisions in patients who have had a prior THA. Specifically, patients who had a long spinal fusion after THA had 340% higher odds of experiencing a hip dislocation and 220% higher odds of having to undergo a revision THA. Further research is necessary to determine whether this relationship is associated with the surgical order, or whether more patient-specific surgical goals of revision THA should be developed for patients with a spinal deformity. LEVEL OF EVIDENCE/METHODS:Level III, therapeutic study.

Study Design/UNASSIGNED:Retrospective radiological review. Purpose/UNASSIGNED:To quantify the effect of sitting vs supine lumbar spine magnetic resonance imaging (MRI) and change in anterior displacement of the psoas muscle from L1-L2 to L4-L5 discs. Overview of Literature/UNASSIGNED:Controversy exists in determining patient suitability for lateral lumbar interbody fusion (LLIF) based on psoas morphology. The effect of posture on psoas morphology has not previously been studied; however, lumbar MRI may be performed in sitting or supine positions. Methods/UNASSIGNED:A retrospective review of a single-spine practice over 6 months was performed, identifying patients aged between 18-90 years with degenerative spinal pathologies and lumbar MRIs were evaluated. Previous lumbar fusion, scoliosis, neuromuscular disease, skeletal immaturity, or intrinsic abnormalities of the psoas muscle were excluded. The anteroposterior (AP) dimension of the psoas muscle and intervertebral disc were measured at each intervertebral disc from L1-L2 to L4-L5, and the AP psoas:disc ratio calculated. The morphology was compared between patients undergoing sitting and/or supine MRI. Results/UNASSIGNED:Two hundred and nine patients were identified with supine-, and 60 patients with sitting-MRIs, of which 13 patients had undergone both sitting and supine MRIs (BOTH group). A propensity score match (PSM) was performed for patients undergoing either supine or sitting MRI to match for age, BMI, and gender to produce two groups of 43 patients. In the BOTH and PSM group, sitting MRI displayed significantly higher AP psoas:disc ratio compared with supine MRI at all intervertebral levels except L1-L2. The largest difference observed was a mean 32%-37% increase in sitting AP psoas:disc ratio at the L4-L5 disc in sitting compared to supine in the BOTH group (range, 0%-137%). Conclusions/UNASSIGNED:The psoas muscle and the lumbar plexus become anteriorly displaced in sitting MRIs, with a greater effect noted at caudal intervertebral discs. This may have implications in selecting suitability for LLIF, and intra-operative patient positioning.

STUDY DESIGN/METHODS:A retrospective study. OBJECTIVE:To examine the link between major complications, surgical techniques, and perioperative care in the intralesional spondylectomy of the upper cervical spine. SUMMARY OF BACKGROUND DATA/BACKGROUND:Spondylectomy has been demonstrated to prolong cancer-free survival in many patients with locally aggressive spinal tumors. However, the challenging nature of this surgical procedure and the potential for severe complications often limit its application in the upper cervical spine. METHODS:Nineteen patients with primary upper cervical tumors were treated with spondylectomy from March 2005 to August 2009, using either the anterior-posterior or posterior-anterior approach. Anterior procedures were transmandibular, transoral, or high retropharyngeal. Anterior reconstructions were performed in plates with iliac crest strut grafts, plates with mesh cages, and Harms mesh cages alone. Occipitocervical fixation was performed with Halo-vest application for postoperative immobilization. RESULTS:Vertebral artery injuries occurred unilaterally in 5 cases intraoperatively: 4 occurred in the anterior approach of anterior-posterior procedures. Fusion was achieved in 9 patients with intact internal instrumentation. Fusion with the anterior construct in a tilted position occurred in 3 patients, all of whom underwent anterior-posterior procedures with Halo-vest immobilization for less than 1 month. Nonunion occurred in 3 cases after the posterior-anterior procedure because of anterior bone graft absorption. Prolonged Halo-vest immobilization maintained postoperative stability. Failure of internal instrumentation occurred in 3 cases. Anterior construct dislocation and severe tilting occurred in 2 cases after the anterior-posterior procedure. Five patients had a local recurrence. All recurrent lesions were malignant tumors and occurred in regions where surgical exposure was inadequate with incomplete excision. CONCLUSION/CONCLUSIONS:The order of the surgical approach is a critical determinant of complications, fusion rates, choice of surgical technique, and reconstruction methods. The postoperative use of a Halo-vest is recommended. Local recurrence is associated with tumor malignancy and inadequate excision margin. LEVEL OF EVIDENCE/METHODS:4.

OBJECTIVE:History of previous cervical spine surgery is a frequently cited cause of worse outcomes after cervical spine surgery. The purpose of this study was to determine any differences in clinical outcomes after cervical spine surgery between patients with and without a history of previous cervical spine surgery. METHODS:A multicenter prospective database was reviewed retrospectively to identify patients with cervical spondylosis undergoing surgery with a minimum 2-year follow-up. Patients were divided into 2 groups: patients with (W) or without (WO) previous history of cervical spine surgery. Statistical analyses of Health-Related Quality of Life scores were analyzed with statistical software to fit linear mixed models for continuous longitudinal outcome. RESULTS:A total of 1286 patients (377 W, 909 WO) met criteria for inclusion. Overall, patients in both groups experienced an improvement in their Health-Related Quality of Life scores. However, patients in the W group had significantly decreased improvement compared with WO patients in the Neck Disability Index score and the following SF-36 domain scores: Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, Health Transition, and Physical Component Summary at all time points (P < 0.05). There was no statistically significant difference between the W and WO groups in operative time, estimated blood loss, length of stay, or complications (P > 0.05). CONCLUSIONS:Patients with a history of previous cervical spine surgery had inferior improvement in quality of life outcome scores. Patients with a history of previous surgical intervention who elect to undergo subsequent surgeries should be appropriately counseled about expected results.

Interest in the application of bundled payments to the field of spine surgery continues to grow. There may be great potential for cost-savings for spinal procedures under bundled payments. However, challenges such as heterogeneity of DRGs, complex procedures requiring lengthy recoveries, and appropriate outcomes measurement pose barriers to successful bundled payment design. In this paper, we review the challenges and opportunities posed by bundled payments in spine surgery. We also present several key considerations for policymakers interested in payment reform within spine surgery. Surgeon involvement will be critical in providing guidance for generating effective alternative payment models.

Nationwide utilization of spinal stereotactic body radiotherapy (SBRT) is not known; to address this void, the National Cancer Data Base (NCDB) from 2004 to 2013 was used for analysis. Spinal SBRT was defined as 1-5 fractions (14-32Gy) delivered to the cervical, thoracic, lumbar or sacral spine. From 2004 to 2013, 1044 patients received spinal SBRT, most commonly in single-fraction (38%), three-fraction (26%) and five-fractions (25%). Metastatic spinal disease most commonly originated from the lung (34%), kidney (14%), and blood (9%). The most common insurance status receiving spinal SBRT was private (44%) followed by Medicare (43%), with Medicaid (8%) a distant third. Fifty-six percent of patients were male, and 55% of patients were younger than age 65. 80% of patients were Caucasian, with 13% being African-American. The vast majority (74%) of patients had no Charlson/Deyo comorbidities. The incidence of spinal SBRT gradually increased over time, rising from 2% to 20% of cases from 2004 to 2013. Comprising only 1.4% of spinal metastases radiation in 2004, SBRT rose to a 5.8% share in 2013. In conclusion, SBRT for spine metastases in the United States has more than quadrupled in utilization over a recent ten-year span. Although the majority of spinal SBRT is multi-fraction, the most popular fractionation scheme was single-fraction. It has been most commonly used for Caucasian men under age 65 with private/Medicare insurance and no comorbidities. By far the most common origin of spinal metastases treated by SBRT was the lung, followed by renal cancer. These results provide a baseline for further prospective investigation.

OBJECTIVE Depression and anxiety have been demonstrated to have negative impacts on outcomes after spine surgery. In patients with cervical deformity (CD), the psychological and physiological burdens of the disease may overlap without clear boundaries. While surgery has a proven record of bringing about significant pain relief and decreased disability, the impact of depression and anxiety on recovery from cervical deformity corrective surgery has not been previously reported on in the literature. The purpose of the present study was to determine the effect of depression and anxiety on patients' recovery from and improvement after CD surgery. METHODS The authors conducted a retrospective review of a prospective, multicenter CD database. Patients with a history of clinical depression, in addition to those with current self-reported anxiety or depression, were defined as depressed (D group). The D group was compared with nondepressed patients (ND group) with a similar baseline deformity determined by propensity score matching of the cervical sagittal vertical axis (cSVA). Baseline demographic, comorbidity, clinical, and radiographic data were compared among patients using t-tests. Improvement of symptoms was recorded at 3 months, 6 months, and 1 year postoperatively. All health-related quality of life (HRQOL) scores collected at these follow-up time points were compared using t-tests. RESULTS Sixty-six patients were matched for baseline radiographic parameters: 33 with a history of depression and/or current depression, and 33 without. Depressed patients had similar age, sex, race, and radiographic alignment: cSVA, T-1 slope minus C2-7 lordosis, SVA, and T-1 pelvic angle (p > 0.05). Compared with nondepressed individuals, depressed patients had a higher incidence of osteoporosis (21.2% vs 3.2%, p = 0.028), rheumatoid arthritis (18.2% vs 3.2%, p = 0.012), and connective tissue disorders (18.2% vs 3.2%, p = 0.012). At baseline, the D group had greater neck pain (7.9 of 10 vs 6.6 on a Numeric Rating Scale [NRS], p = 0.015), lower mean EQ-5D scores (68.9 vs 74.7, p < 0.001), but similar Neck Disability Index (NDI) scores (57.5 vs 49.9, p = 0.063) and myelopathy scores (13.4 vs 13.9, p = 0.546). Surgeries performed in either group were similar in terms of number of levels fused, osteotomies performed, and correction achieved (baseline to 3-month measurements) (p < 0.05). At 3 months, EQ-5D scores remained lower in the D group (74.0 vs 78.2, p = 0.044), and NDI scores were similar (48.5 vs 39.0, p = 0.053). However, neck pain improved in the D group (NRS score of 5.0 vs 4.3, p = 0.331), and modified Japanese Orthopaedic Association (mJOA) scores remained similar (14.2 vs 15.0, p = 0.211). At 6 months and 1 year, all HRQOL scores were similar between the 2 cohorts. One-year measurements were as follows: NDI 39.7 vs 40.7 (p = 0.878), NRS neck pain score of 4.1 vs 5.0 (p = 0.326), EQ-5D score of 77.1 vs 78.2 (p = 0.646), and mJOA score of 14.0 vs 14.2 (p = 0.835). Anxiety/depression levels reported on the EQ-5D scale were significantly higher in the depressed cohort at baseline, 3 months, and 6 months (all p < 0.05), but were similar between groups at 1 year postoperatively (1.72 vs 1.53, p = 0.416). CONCLUSIONS Clinical depression was observed in many of the study patients with CD. After matching for baseline deformity, depression symptomology resulted in worse baseline EQ-5D and pain scores. Despite these baseline differences, both cohorts achieved similar results in all HRQOL assessments 6 months and 1 year postoperatively, demonstrating no clinical impact of depression on recovery up until 1 year after CD surgery. Thus, a history of depression does not appear to have an impact on recovery from CD surgery.