Faculty Bibliography

STUDYDESIGN/UNASSIGNED:Retrospective-comparative; LOE-3. OBJECTIVE:The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following 1-or-2-level lumbar fusion has on Hospital-Consumer-Assessment-of-Healthcare-Providers-and-Systems-(HCAHPS)-survey results. SUMMARY OF BACKGROUND DATA/BACKGROUND:Prior research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction. METHODS:A retrospective review of prospectively-collected data was conducted on patients who underwent 1-or-2-level lumbar fusions L3-S1 between October 2014-October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions > 2 levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram-morphine-equivalents (MME). RESULTS:330 patients met inclusion criteria, 259 pre-protocol, 71 post-protocol. There were 256 1-level fusions and 74 2-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (p > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7%(95) pre-protocol, to 59.2%(42) post-protocol; p < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL; p = 0.003. Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3%; p < 0.001. Average opioids prescribed on discharge in the pre-protocol period was was 534 ± 425 MME, compared to after initiation of the protocol it was 320 ± 174 MME; P < 0.001. There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol vs 4.51 ± 0.82 post-protocol; p = 0.986. CONCLUSION/CONCLUSIONS:A reduction in opioids prescribed at discharge after 1-or-2-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

BACKGROUND CONTEXT/BACKGROUND:The COVID-19 pandemic caused nationwide suspensions of elective surgeries due to reallocation of resources to the care of COVID-19 patients. Following resumption of elective cases, a significant proportion of patients continued to delay surgery, with many yet to reschedule, potentially prolonging their pain and impairment of function and causing detrimental long-term effects. PURPOSE/OBJECTIVE:The aim of this study was to examine differences between patients who have and have not rescheduled their spine surgery procedures originally cancelled due to the COVID-19 pandemic, and to evaluate the reasons for continued deferment of spine surgeries even after the lifting of the mandated suspension of elective surgeries. STUDY DESIGN/SETTING/METHODS:Retrospective case series at a single institution PATIENT SAMPLE: Included were 133 patients seen at a single institution where spine surgery was canceled due to a state-mandated suspension of elective surgeries from March to June, 2020. OUTCOME MEASURES/METHODS:The measures assessed included preoperative diagnoses and neurological dysfunction, surgical characteristics, reasons for surgery deferment, and PROMIS scores of pain intensity, pain interference, and physical function. METHODS:Patient electronic medical records were reviewed. Patients who had not rescheduled their canceled surgery as of January 31, 2021, and did not have a reason noted in their charts were called to determine the reason for continued surgery deferment. Patients were divided into three groups: early rescheduled (ER), late rescheduled (LR), and not rescheduled (NR). ER patients had a date of surgery (DOS) prior to the city's Phase 4 reopening on July 20, 2020; LR patients had a DOS on or after that date. Statistical analysis of the group findings included analysis of variance with Tukey's honestly significant difference (HSD) post-hoc test, independent samples T-test, and chi-square analysis with significance set at p≤.05. RESULTS:Out of 133 patients, 47.4% (63) were in the ER, 15.8% (21) in the LR, and 36.8% (49) in the NR groups. Demographics and baseline PROMIS scores were similar between groups. LR had more levels fused (3.6) than ER (1.6), p= .018 on Tukey HSD. NR (2.1) did not have different mean levels fused than LR or ER, both p= >.05 on Tukey HSD. LR had more three column osteotomies (14.3%) than ER and (1.6%) and NR (2.0%) p=.022, and fewer lumbar microdiscectomies (0%) compared to ER (20.6%) and NR (10.2%), p=.039. Other surgical characteristics were similar between groups. LR had a longer length of stay than ER (4.2 vs 2.4, p=.036). No patients in ER or LR had a nosocomial COVID-19 infection. Of NR, 2.0% have a future surgery date scheduled and 8.2% (4) are acquiring updated exams before rescheduling. 40.8% (20; 15.0% total cohort) continue to defer surgery over concern for COVID-19 exposure and 16.3% (8) for medical comorbidities. 6.1% (3) permanently canceled for symptom improvement. 8.2% (4) had follow-up recommendations for non-surgical management. 4.1% (2) are since deceased. CONCLUSION/CONCLUSIONS:Over 1/3 of elective spine surgeries canceled due to COVID-19 have not been performed in the 8 months from when elective surgeries resumed in our institution to the end of the study. ER patients had less complex surgeries planned than LR. NR patients continue to defer surgery primarily over concern for COVID-19 exposure. The toll on the health of these patients as a result of the delay in treatment and on their lives due to their inability to return to normal function remains to be seen.

STUDY DESIGN/METHODS:Retrospective cohort analysis. OBJECTIVE:To compare outcomes of plastic versus spine surgeon wound closure in revision 1 to 4 level thoracolumbar fusions. SUMMARY OF BACKGROUND DATA/BACKGROUND:Plastic surgeons perform layered musculocutaneous flap closures in high-risk spine patients such as revision posterior spinal fusion and complex deformity correction surgeries. Few studies have assessed outcomes of revision fusion performed with plastic surgical closures, particularly in nondeformity thoracolumbar spinal surgery. METHODS:A retrospective review of 1 to 4 level revision thoracolumbar fusion performed by Orthopedic or Neurosurgical spine surgeons. Patient charts were reviewed for demographics and perioperative outcomes. Patients were divided into two cohorts: wound closures performed by spine surgeons and those closed by plastic surgeons. Outcomes were analyzed before and after propensity score match for prior levels fused, iliac fixation, and levels fused at index surgery. Significance was set at P < 0.05. RESULTS:Three hundred fifty-seven (87.3%) spine surgeon (SS) and 52 (12.7%) plastic surgeon (PS) closures were identified. PS group had significantly higher number of levels fused at index (PS 2.7 ± 1.0 vs. SS 1.8 ± 0.9, P < 0.001) and at prior surgeries (PS 1.8 ± 1.2 vs. SS 1.0 ± 0.9, P < 0.001), and rate of iliac instrumentation (PS 17.3% vs. SS 2.8%, P < 0.001). Plastics closure was an independent risk factor for length of stay  > 5 days (odds ratio 2.3) and postoperative seroma formation (odds ratio 7.8). After propensity score match, PS had higher rates of seromas (PS 36.5% vs. SS 3.8%, P < 0.001). There were no differences between PS and SS groups in surgical outcomes, perioperative complication, surgical site infection, seroma requiring aspiration, or return to operating room at all time points until follow-up (P > 0.05 for all). CONCLUSION/CONCLUSIONS:Plastic spinal closure for 1 to 4 level revision posterior thoracolumbar fusions had no advantage in reducing wound complications over spine surgeon closure but increased postoperative seroma formation.Level of Evidence: 4.

OBJECTIVE:The goal of this study was to reliably predict sagittal and coronal spinal alignment with clinical photographs by using markers placed at easily localized anatomical landmarks. METHODS:A consecutive series of patients with adult spinal deformity were enrolled from a single center. Full-length standing radiographs were obtained at the baseline visit. Clinical photographs were taken with reflective markers placed overlying C2, S1, the greater trochanter, and each posterior-superior iliac spine. Sagittal radiographic parameters were C2 pelvic angle (CPA), T1 pelvic angle (TPA), and pelvic tilt. Coronal radiographic parameters were pelvic obliquity and T1 coronal tilt. Linear regressions were performed to evaluate the relationship between radiographic parameters and their photographic "equivalents." The data were reanalyzed after stratifying the cohort into low-body mass index (BMI) (< 30) and high-BMI (≥ 30) groups. Interobserver and intraobserver reliability was assessed for clinical measures via intraclass correlation coefficients (ICCs). RESULTS:A total of 38 patients were enrolled (mean age 61 years, mean BMI 27.4 kg/m2, 63% female). All regression models were significant, but sagittal parameters were more closely correlated to photographic parameters than coronal measurements. TPA and CPA had the strongest associations with their photographic equivalents (both r2 = 0.59, p < 0.001). Radiographic and clinical parameters tended to be more strongly correlated in the low-BMI group. Clinical measures of TPA and CPA had high intraobserver reliability (all ICC > 0.99, p < 0.001) and interobserver reliability (both ICC > 0.99, p < 0.001). CONCLUSIONS:The photographic measures of spinal deformity developed in this study were highly correlated with their radiographic counterparts and had high inter- and intraobserver reliability. Clinical photography can not only reduce radiation exposure in patients with adult spinal deformity, but also be used to assess deformity when full-spine radiographs are unavailable.

BACKGROUND:As the opioid crisis has gained national attention, there have been increasing efforts to decrease opioid usage. Simultaneously, patient satisfaction has been a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. The purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. METHODS:test of independence was used to compare percentages, and 1-way analysis of variance was used to compare means across quarters. RESULTS:value range, .359-.988). CONCLUSIONS:Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without affecting overall satisfaction rates. LEVEL OF EVIDENCE/METHODS:4. CLINICAL RELEVANCE/CONCLUSIONS:The opioid epidemic has highlighted the need to reduce opioid usage in orthopedic spine surgery. This study reviews the trends for inpatient management of post-op pain in orthopedic spine surgery patients in relation to patient satisfaction. There was a significant increase in non-opioid analgesic pain medications, and a reduction in opioids during the study period. During this time, patient satisfaction as measured by Press-Ganey surveys did not show a decrease. This demonstrates that treatment of post-operative pain in orthopedic spine surgery patients can be managed with less opioids, more multimodal analgesia, and patient satisfaction will not be affected.

BACKGROUND: Bone morphogenetic protein (BMP) and allograft containing mesenchymal stem cells (live cell) are popular biologic substitutes for iliac crest autograft used in transforaminal lumbar interbody fusion (TLIF). Use of these agents in the pathogenesis of postoperative radiculitis remains controversial. Recent studies have independently linked minimally invasive (MIS) TLIF with increased radiculitis risk compared to open TLIF. The purpose of this study was to assess the rate of postoperative radiculitis in open and MIS TLIF patients along with its relationship to concurrent biologic adjuvant use. METHODS: Patients ≥18 years undergoing single-level TLIF from June 2012 to December 2018 with minimum 1-year follow-up were included. Outcome measures were rate of radiculitis, intra- and postoperative complications, revision surgery; length of stay (LOS), and estimated blood loss (EBL). RESULTS:= .038, N = 336) compared to other combinations of surgical approach and biologic use. CONCLUSIONS: Neither the MIS approach nor BMP use is an independent risk factor for post-TLIF radiculitis. However, risk of radiculitis significantly increases when they are used in tandem. This should be considered when selecting biological adjuvants for MIS TLIF. LEVEL OF EVIDENCE/METHODS: 3.

STUDY DESIGN/METHODS:Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients. OBJECTIVE:Compare baseline and post-operative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the Health Related Quality of Life across different disease states. METHODS:Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery (THA, TKA) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL) and 6-month (6 M) PROMIS scores of Physical Function, Pain Interference, and Pain Intensity were determined. Paired t-tests compared differences in CCI, BL, 6 M, and change in PROMIS scores for spine and adult reconstruction procedures. RESULTS:304 spine surgery patients (Age=58.1 ± 15.6; 42.9% Female) and 347 adult reconstruction patients (Age=62.9 ± 11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to Physical Function [(21.0, 22.2, 9.07, 12.6, 10.4) vs (35.8, 35.0), respectively, p < .01], Pain Interference [(80.1, 74.1, 89.6, 92.5, 90.6) vs (64.0, 63.9), respectively, p < .01] and Pain Intensity [(53.0, 53.1, 58.3, 58.5, 56.1) vs (53.4, 53.8), respectively, p < .01]. At 6 M, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of Physical Function [(+8.7, +22.2, +9.7, +12.9, +12.1) vs (+5.3, +3.9), respectively, p < .01] and Pain Interference scores [(-15.4, -28.1, -14.7, -13.1, -12.3) vs (-8.3, -6.0), respectively, p < .01]. CONCLUSIONS:Spinal surgery patients had lower BL and 6 M PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients. LEVEL OF EVIDENCE/METHODS:3.

BACKGROUND CONTEXT: Recombinant human bone morphogenetic protein 2 (BMP) is increasingly utilized in minimally invasive (MIS) transforaminal lumbar interbody fusions (TLIF) in order to increase rate of fusion by promoting bone growth through the induction of osteoblast differentiation, awhile reducing morbidity related to iliac crest autograft. Despite these benefits, BMP use is still controversial due to its pro-inflammatory mechanism of action and potential to cause radiculitis. PURPOSE: To assess whether BMP is a risk factor for postoperative radiculitis in TLIF. STUDY DESIGN/SETTING: Single-center retrospective cohort study. PATIENT SAMPLE: A total of 397 TLIFs from June 2012 to December 2018. OUTCOME MEASURES: Perioperative clinical characteristics, post-operative risk of radiculitis and complication, and future reoperation rates.
METHOD(S): Patients >= 18 years-old undergoing elective single-level TLIFs from 2012 to 2018 were included. Outcome measures included perioperative clinical characteristics, postoperative risk of radiculitis and complication, and future reoperation rates. Radiculitis was defined the delayed onset of radicular symptoms postoperatively in patients whom had initial resolution of radicular symptoms immediately postoperatively, in the absence of persistent neurological compression on postoperative imaging. Statistical analyses included independent t-tests and chi-square analysis. Propensity score matching was utilized to control for demographic differences between the groups. Independent predictors for post-operative radiculitis were assessed by multivariate logistic regression. Significance set at p<0.05.
RESULT(S): A total of 397 cases were included in the study (59.33 +/- 13.49 mean age, 28.98 +/- 6.29 mean BMI, 52.90% female, 2.29 +/- 1.92 average Charleston comorbidity Index). There were 223 open procedures and 174 MIS. For the entire cohort, 238 cases utilized BMP and 159 did not, with 102 MIS pairing with BMP use. The MIS TLIFs had a higher percentage of BMP use than open TLIFs (58.6% vs 25.7%, p<0.001), lower estimated blood loss (212.28 +/- 193.79 mL vs 410.91 +/- 337.98 mL, p<0.001) higher fluoroscopy dosage (52.43 +/- 48.61mGy vs 16.77 +/- 27.84mGy, p<0.001), and a lower length of stay (3.20 +/- 2.55 days vs 4.11 +/- 2.52 days, p<0.001). There were no other differences in perioperative clinical characteristics. There was a significantly higher rate of postoperative radiculitis in the MIS TLIFs compared to open (12.6% vs 6.8%, p=0.046) and use of BMP compared to no BMP (13.2% vs 6.7%, p=0.029). There was a 15.7% radiculitis rate when MIS was paired with BMP use. There were no other notable differences in complication rates or rates of reoperation. Individually, MIS had a 12.6% radiculitis rate (p=0.046) and BMP use had a 13.2% rate (p=0.029). Propensity score match controlled for the significant difference in CCI between the MIS and open groups (N=168 each). Multivariate regression indicated that MIS (p=0.314) and BMP (p=0.109) were not independent predictors individually when controlling for age, gender, and BMI. When technique was paired with biologic use the regression revealed MIS + BMP is a risk factor of post-operative radiculitis (2.265(4.753-1.079), p=0.031).
CONCLUSION(S): While BMP and MIS technique were not independent risk factors for postoperative radiculitis, there is an increased risk of radiculitis when using BMP in MIS TLIF. 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.

INTRODUCTION/BACKGROUND:Patient reported outcomes measurement information system (PROMIS) is a quality of life metric that has gained increased popularity due to computer adaptive testing. Previous studies have shown that PROMIS correlates with Oswestry Disability Index (ODI) in patients with back pain and takes significantly less time to complete. However, the ability of PROMIS to capture disability from spinal malalignment relative to established metrics is unknown. The aim of the present study is to validate the correlation between ODI and PROMIS in patients with back pain, analyze correlations of PROMIS and legacy metrics to sagittal alignment, and identify major drivers of PROMIS scores and ODI in patients with back pain. METHODS:A retrospective review was conducted of a prospectively collected outcome measures database (PROMIS, ODI, VAS Back, VAS Leg, VAS Neck, and VAS Arm) of spine patients > 18 years. Inclusion criteria for the present study was a chief complaint of back pain and full length weight bearing X-rays within 30 days of health related quality of life (HRQL) completion. Demographic information, radiographic alignment, psychiatric diagnoses, and comorbidities were recorded. PROMIS metrics were correlated to legacy metrics (ODI and VAS). Next, outcome metrics were correlated with sagittal alignment variables T1 Pelvic Angle (TPA), SVA, PT, and PI-LL. Patients were grouped based on the presence of spinal deformity (defined radiographically as any one of SVA > 4 cm, PI-LL > 10°, PT > 20°) and mean HRQL scores were investigated for the adult spinal deformity (ASD) and non-ASD groups. Finally, drivers of PROMIS PF scores and ODI scores were determined using multiple stepwise regression. RESULTS: = 0.376, p < 0.001). CONCLUSIONS:In a cohort of 150 patients with back pain, PROMIS correlated strongly with legacy outcome metrics, including VAS and ODI. PROMIS PF correlated more strongly with sagittal malalignment than ODI. Additionally, patients with spinal deformity had significantly worse PROMIS PF scores but similar ODI scores as patients without ASD. Finally, sagittal alignment was found to be a significant driver of PROMIS PF scores but not ODI scores. PROMIS PF should be utilized as a disability assessment tool in patients with spinal deformity due to ease of use, strong correlations with legacy metrics, and ability to capture disability resulting from sagittal alignment.