Faculty Bibliography

OBJECTIVE:To evaluate the feasibility of same-day (postoperative day 0; POD0) physical therapy (PT) following lumbar fusion and to identify factors associated with failure to participate. METHODS:This retrospective study analyzed prospectively collected data from patients undergoing single-level posterior spinal fusion (PSF), with or without anterior (ALIF) or lateral (LLIF) interbody fusion, between January and December 2024 at a single institution. A standardized POD0 PT protocol was implemented for eligible patients. Patients were categorized into two groups: successful POD0 PT (ambulatory on POD0) and unable to participate. Demographic and surgical variables were compared between groups. Reasons for inability to participate were recorded and categorized. RESULTS:Among 129 patients in whom POD0 PT was attempted, 84 (65%) successfully participated, while 45 (35%) were unable. There were no significant differences in age, sex, BMI, ASA class, operative time, estimated blood loss, or surgical approach between groups. Patients who successfully completed POD0 PT had a significantly shorter hospital length of stay compared to those who did not (3.4 ± 1.6 vs 5.8 ± 2.9 days, P < 0.001), with no differences in complication rates, discharge disposition, emergency department visits, or reoperation rates. The most common barriers to POD0 PT were postoperative pain, medical issues (e.g., orthostatic hypotension, nausea, dizziness), and anesthesia-related somnolence. Less common factors included postoperative restrictions and logistical issues such as brace availability. CONCLUSIONS:POD0 PT following lumbar fusion is feasible in the majority of patients and is associated with a shorter hospital stay without increased complications. Failure to participate was not associated with the baseline patient or surgical characteristics evaluated in this study. Instead, the most common barriers were postoperative pain, transient medical issues, and anesthesia-related somnolence, suggesting that optimization of modifiable perioperative factors may improve the implementation of POD0 PT.

BACKGROUND:Prenatal exposures influence childhood neurodevelopment. Placental histopathology has been associated with abnormal early childhood neurodevelopment, albeit often confounded by prematurity and/or fetal growth restriction. Most pregnant people, however, have term births, and some of these children have abnormal neurodevelopment despite the absence of adverse birth outcomes. Leveraging placental histopathology may help distinguish infants at higher risk of subsequent neurodevelopmental impairment following a term birth. OBJECTIVE:To investigate the association of placental histopathology with a high-risk screen for abnormal early childhood neurodevelopment following a term birth. STUDY DESIGN/METHODS:The sample included singleton births at ≥37 weeks 0 days between 2020-2023 in the prospective, longitudinal multisite Environmental Influences on Child Health Outcomes (ECHO) Cohort. Children with available placental histopathologic data and whose birthing parent had completed at least one Ages & Stages Questionnaire-Third Edition (ASQ®-3) between 2-18 months of life were eligible for inclusion. Children diagnosed with hypoxic-ischemic encephalopathy after birth were excluded. Exposures were chronic placental inflammation, maternal or fetal acute inflammatory response, and maternal or fetal vascular perfusion. The primary outcome was a high-risk composite ASQ®-3 screen, defined as a high-risk score (≥2 standard deviations below the mean) on at least one of the five individual domains (communication, gross motor, fine motor, personal-social, and problem solving) on any ASQ®-3 questionnaire performed between 2-18 months of life. Individual ASQ®-3 domains were secondarily assessed. Generalized estimating equation models were used to calculate the odds of a high-risk screen for each outcome in children exposed versus unexposed to each placental histopathologic finding, adjusted for maternal age, education, insurance, depression, parity, child sex, and birthweight. RESULTS:). CONCLUSION/CONCLUSIONS:After a term birth, placental histopathology was not associated with a high-risk composite ASQ®-3 screen in children assessed at 2-18 months. However, chronic placental inflammation was positively associated with a high-risk composite score in children aged 12-18 months. This population may warrant enhanced surveillance, screening, and diagnostic follow up for neurodevelopmental impairment in early childhood.

OBJECTIVE:The aim of the study was to evaluate the safety and efficacy of initiating physical therapy (PT) on the day of surgery (i.e., postoperative day 0 [POD0]) in patients undergoing single-level lumbar fusion surgery, with a focus on hospital length of stay (LOS) and early postoperative outcomes. METHODS:The authors conducted a retrospective review of prospectively collected data from a single institution. Patients undergoing single-level lumbar fusion between August 2022 and December 2024 were included. Those with revision surgery, tumors, or infections were excluded. POD0 PT was implemented in January 2024. Patients treated prior to this date received POD1 PT. Demographic, surgical, and postoperative data were compared between the POD0 and POD1 PT groups. RESULTS:A total of 586 patients were analyzed (POD0, n = 84; POD1, n = 502). Baseline demographics and surgical characteristics were similar between the groups. The POD0 group had a significantly shorter LOS (mean 3.4 ± 1.6 vs 4.0 ± 2.7 days, p = 0.016), and the patients were more likely to be discharged home. No significant differences were found in postoperative complications, including cardiac, pulmonary, neurological, gastrointestinal, urinary, infectious, or mechanical issues. Rates of 30- and 90-day emergency department visits, readmissions, or reoperations were also comparable between the groups. CONCLUSIONS:Initiating PT on the day of surgery is associated with reduced LOS and an increased likelihood of home discharge, without increasing complications or worsening clinical outcomes. These findings support the safety and potential benefits of POD0 PT in enhancing early recovery following single-level lumbar fusion surgery.

BACKGROUND:Lumbar fusion eliminates motion at the operative level and is associated with altered load transfer and adjacent segment degeneration. Total joint replacement (TJR) of the lumbar spine is a motion segment reconstruction procedure performed via a bilateral transforaminal approach that allows direct neural decompression and replacement of both disc and facet function. This prospective investigational device exemption clinical trial compared TJR with a concurrent, propensity-score-weighted real-world evidence cohort treated with either instrumented transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody spine fusion (PLIF). METHODS:. RESULTS:= 0.04). CONCLUSIONS:Substantial decreases in back impairment and pain severity were realized in both study groups. However, longitudinal improvement in ODI significantly favored patients treated with TJR. CLINICAL RELEVANCE/CONCLUSIONS:Lumbar TJR combines decompression with motion preservation in a single procedure, potentially offering an alternative to fusion in selected patients. The advantage of utilizing a standard posterior operative approach with TJR is that it allows for direct decompression of the neural elements prior to implant placement. LEVEL OF EVIDENCE/METHODS:2b.

STUDY DESIGN/METHODS:Retrospective study. OBJECTIVE:Lumbar fusion surgery, while effective in certain cases, carries with it the risk of subsequent reoperation as well as functional limitations. Lumbar total joint replacement (TJR) has emerged as a potential alternative, to address many degenerative pathologies while preserving motion. This retrospective analysis of prospectively collected data evaluates the return-to-work (RTW) outcomes of patients undergoing lumbar TJR and measures the impact of various factors on the time to RTW. SUMMARY OF BACKGROUND DATA/BACKGROUND:A cohort of 56 patients who underwent lumbar TJR between 2017 and 2020 completed patient-reported outcomes (PRO) and occupation data was isolated. METHODS:Of which, 16 were retired and 8 were unemployed preoperatively, 32 were included in this study. PROs, including the Oswestry disability index (ODI), were collected preoperatively and at 3, 6, and 12 months postoperatively. Work intensity, age, number of levels treated, and other demographic variables were analyzed using one-way ANOVA to assess their influence on time to RTW. Generalized linear regression modeling and time-to-event analyses were conducted to compare the impact of ODI at different timepoints on the time to RTW. RESULTS:All evaluable patients (100%) were able to return-to-work within 6 months of lumbar TJR surgery, with 96.9% achieving RTW by 3 months. Lower ODI scores (15-17) at 3 and 6 months were associated with shorter time to RTW, emphasizing the importance of preoperative functional status. Kaplan-Meier survival analysis revealed significant variations in RTW probabilities based on mean ODI scores at 3 and 6 months postsurgery. CONCLUSIONS:Despite limitations, this study highlights the potential of lumbar TJR to facilitate timely RTW and improve functional outcomes in patients with lumbar degenerative conditions. Further research, including larger multicenter studies, is warranted to validate these findings and enhance our understanding of the safety and efficacy of lumbar TJR.

BACKGROUND/UNASSIGNED:Lumbar fusion remains a prevalent treatment for degenerative conditions; however, its limitations have sparked interest in alternative motion-sparing procedures. Our study evaluates 24-month postoperative patient-reported outcomes from an OUS pilot clinical study on a novel lumbar total joint replacement (TJR) for degenerative conditions. METHODS/UNASSIGNED:Data was collected from 63 patients, of which 56 patients fulfilled the inclusion criteria. Self-reported measures collected for this study are Oswestry Disability Index (ODI), Numeric Rating Scale (NRS), Minimal Symptom State (MSS), Minimal Clinical Important Difference (MCID), Substantial Clinical Benefit (SCB). This retrospective analysis of prospective, IRB-approved collected data reports 24 month patient-reported outcomes on a cohort receiving lumbar TJR. The cohort includes skeletally mature individuals who underwent lumbar TJR at 1-3 Lumbar levels (L1-S1) between 2008 and 2019. Conservative treatment was mandatory for at least 3 months unless facing a neurologic emergency or intractable pain. Descriptive analysis was performed for continuous variables and frequencies were calculated for categorical variables. RESULTS/UNASSIGNED:63 patients were treated with lumbar TJR and electively participated in data collection after 12 months. 56 patients, with age ranging from 19 to 82 years, and 93 levels were treated with lumbar TJR at 1-3 lumbar levels and had complete follow-up data at 12 and 24 m. No device-related adverse events were reported during the 12-to-24-month follow-up window. At 24 months, patients exhibited sustained clinical improvement in back pain, leg pain, and disability scores, similar to the 12-month observations. An overall improvement in Minimal Clinically Important Difference (MCID) was also noted. CONCLUSIONS/UNASSIGNED:Our study shows consistent improvement in PROs, indicating the clinical improvement of lumbar TJR at both the 12-month and 24-month follow-up points, compared to baseline. Acknowledging limitations, including the lack of comparative data with standard of care, these findings suggest that TJR may be a treatment option for indicated lumbar degenerative pathologies.

STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:The purpose of this study is to determine the utility of advanced imaging to confirm the placement of robotic pedicle screws. SUMMARY OF BACKGROUND DATA/BACKGROUND:With increasing robotic adoption, certain institutions and surgeons have developed protocols for obtaining 3D intraoperative imaging after robotic pedicle screw placement to ensure proper hardware placement. No studies have assessed the utility of these protocols relative to the potential risks of increased radiation exposure and operative time. The purpose of this study is to determine if we should be obtaining advanced imaging to confirm the placement of robotic pedicle screws. METHODS:This is a single institution retrospective cohort study of patients from May 2022 to July 2023 who underwent lumbar spinal fusion by a high-volume orthopedic spine surgeon at a level 1 metropolitan hospital. All cases used combined robotics and navigation systems for pedicle screw placement and intraoperative 3D imaging for evaluation of screw position. Pedicle screw accuracy was assessed using the Gertzbein and Robbins system (GRS). Acceptable pedicle screw position was defined as GRS A or B. RESULTS:Seventy patients with 354 robotically placed pedicle screws were assessed with intraoperative 3D fluoroscopy. All pedicle screws were placed in either a GRS type A or type B position. Three hundred forty-seven were placed in a GRS A classification (99.2%, 351/354), and 3 were placed in a GRS B classification (0.08% 3/354). No patients had screw-related complications. The average radiation dosage of 3D imaging was 289.7±164.6 mGy. CONCLUSION/CONCLUSIONS:The robotic system places pedicle screws accurately without 3D intraoperative imaging. Given the increased radiation and operative time associated with 3D imaging protocols 3D imaging scans should only be obtained in cases with heightened clinical concern. LEVEL OF EVIDENCE/METHODS:Level IV.

STUDY DESIGN/METHODS:system at a single institution. METHODS:A total of 95 patients (541 screws) who underwent RASS between 2021 and 2022 were included. Variables including operative time, robot registration time, screw placement time, fluoroscopy utilization, and complications were analyzed. Statistical analysis was performed using descriptive statistics and two-sample t-tests. RESULTS:The average operative time significantly decreased after the first 14 cases, indicating a learning curve. However, no significant improvement was observed in robot registration time. Notably, screw placement time significantly improved after approximately 13 cases. When controlling for the number of levels fused, the trends remained consistent. CONCLUSIONS:system and demonstrated rapid proficiency development. Our findings highlight the relatively quick learning curve of 1 RASS system.

PURPOSE:Prevalence of proximal junctional kyphosis (PJK) in Scheuermann's kyphosis (SK) varies between 24 and 40%. Multiple factors have been implicated, including kyphosis overcorrection, failure to include proximal end vertebra, and implant choice. This study aimed to determine the goal correction parameters based upon patients' pelvic incidence, and UIV to decrease PJK in Scheuermann's kyphosis. METHODS:X-ray and chart review of SK patients operated with all pedicle screw (PS), hybrid fixation (HF), and anterior/posterior fusions with hybrid fixation (AP). T1/T2 were grouped together as proximal fusion groups compared to T3 and distal groups. RESULTS:96 total patients: PS (n = 41), HF (n = 24), and AP (n = 31). Overall, at early postop 12 (12.5%) patients had PJK. At final follow-up, 33 (34.4%) had PJK. There was no significant difference between groups at early postop (p = 0.86) or final follow-up (p = 0.67). When correcting kyphosis-PI to > - 10.0° and UIV was chosen to be T1 or T2, PJK developed in 6.1% of patients at final follow-up; when fusing to T1/T2 but with kyphosis-PI < - 10.0°, 38.9% of patients developed PJK. With kyphosis-PI > - 10.0° and UIV at T3 or below, 37.0% of patients developed PJK at final follow-up. When fusing to T3 or below but failing to correct kyphosis-PI to > - 10.0°, 77.8% of patients developed PJK. CONCLUSION:Selecting proximal UIV and avoiding kyphosis-PI mismatch can significantly decrease the prevalence of PJK rather than surgical technique or implant choice. Surgeons treating SK should, therefore, aim to correct kyphosis closer to the patient's pelvic incidence and choose T2/T1 as UIV.