Trends for Spine Surgery for the Elderly: Implications for Access to Healthcare in North America

Trends and complications of three-column osteotomy in treating adult spinal deformity in elderly patients: A retrospective analysis

Aims & objectives

Sagittal imbalance linked to adult spinal deformity negatively affects quality of life and can be treated with 3CO techniques. While effective, these methods are invasive and can lead to high complications. Since 2010, a more patient-focused approach has grown in popularity, but its effects on elderly patients remain unclear. This retrospective study aimed to investigate the trend of three-column osteotomy (3CO) utilization in posterior long-segment fusion among different age groups. We also sought to determine the safety profile of 3CO by analyzing postoperative complications in the elderly population.

Materials & methods

The study assessed postoperative complications and long-term outcomes for elderly patients aged 70 and above who underwent 3CO as part of a posterior spinal instrumented fusion from 2010 to 2020 using multivariable logistic regression. A total of 2091 patients were identified for analysis.

Results

The Mann-Kendall trend test revealed a significant downward trend in 3CO interventions after 2017. Elderly patients demonstrated higher rates of medical complications compared to younger cohorts but had lower rates of surgical complications and reoperations. This pattern persisted even after adjusting for baseline comorbidity profiles. At the five-year mark, elderly patients (ages 70-84) exhibited reoperation rates similar to the middle-aged group (ages 55-69) but notably lower than those in patients younger than 55 years.

Conclusion

Aside from an increased risk of medical complications following 3CO, older patients were not at an increased risk of surgical complications, including pseudarthrosis, proximal junctional failure, and reoperation.

Assessing Surgical Outcomes in Cervical Degenerative Disease: The Role of Intraoperative Neurophysiological Monitoring

Background: Cervical degenerative disease is a common condition associated with significant morbidity, often presenting as neck pain, radiculopathy, or myelopathy. Its growing incidence, particularly in the aging population, has led to an increased demand for surgical interventions aimed at relieving neural compression and restoring spinal stability. Objective: This study aims to evaluate surgical outcomes in patients with degenerative cervical conditions, with a particular focus on the role of intraoperative neurophysiological monitoring (IONM) in preventing adverse neurological events both immediately postoperatively and at long-term follow-up. Methods: A retrospective analysis was performed on patients who underwent cervical spine surgery for degenerative conditions between January 2021 and June 2024. Data collected included demographics, comorbidities, surgical details, and intraoperative neurophysiological monitoring. Surgical outcomes were assessed using the modified Rankin Scale (mRS), Odom's Criteria, and the modified Japanese Association (mJOA) score. Results: Key findings demonstrated that advanced age and the presence of preoperative myelopathy were significantly associated with poorer postoperative outcomes across all evaluated measures. Conversely, factors such as gender, surgical approach, and the number of treated levels did not significantly influence recovery. Although intraoperative neurophysiological monitoring (IONM) did not show an immediate effect on postoperative outcomes, it was linked to prognostic value for long-term neurological status, suggesting a potential protective role in preserving neurological function. Conclusions: This study identifies age, preoperative functional status, and myelopathy as crucial predictors of postoperative recovery in cervical spine surgery for degenerative disease. These findings underscore the importance of early intervention in patients with myelopathy and highlight the complex role of IONM in improving long-term neurological outcomes. IONM changes may help identify patients at higher risk of poor recovery who could benefit from intensive postoperative rehabilitation. Further prospective studies are warranted to elucidate the complex interactions between patient characteristics and surgical factors in optimizing postoperative recovery.

Physical medicine and rehabilitation and interdisciplinary spine clinic referrals are associated with increased conversion to spine surgery

BACKGROUND

Currently, in the United States, many patients receive immediate referral to a spine surgeon upon concern for any spine pathology, prior to undergoing conservative management. However, research has demonstrated that referrals to spine surgeons for common problems such as low back pain are often not indicated. This situation leads to inefficient care, delayed conservative treatments, and longer wait times for available surgical consultations. Therefore, this highlights an opportunity to improve efficiency in care for patients and clinicians through proper triaging for spine surgery.

OBJECTIVE

To examine whether clinicians from physical medicine and rehabilitation (PM&R) and nonsurgical interdisciplinary spine clinics effectively triaged patients for spine surgeon evaluations.

DESIGN

Retrospective study (May 2022-April 2023) of consecutive new patients referred to a spine surgery clinic. Charts were evaluated to determine if surgery was indicated at the initial spine surgeon evaluation. The proportion of patients indicated for surgery was calculated based on the source of referral. An odds ratio (OR) of patients indicated for surgery was calculated to compare different specialty groupings.

SETTING

All new consecutive patients evaluated between May 2022 and April 2023 on the panels of two fellowship-trained orthopedic spine surgeons at a single outpatient clinic in the Pacific Northwest United States were included. Patients whose symptoms were associated with infections, trauma, and tumors were also excluded as these patients typically have elevated clinical acuity.

RESULTS

Of 503 patients, 247 (49.1%) were indicated for and underwent spine surgery within 6 months of initial evaluation. PM&R referrals were more likely to result in surgery compared to primary care physician referrals (OR, 2.88 [95% CI, 1.73-4.79]). Patients referred from interdisciplinary spine clinics were also more likely to undergo surgery compared to those referred by a primary care physician (OR, 2.36 [95% CI, 1.56-3.57]) or generalists (OR, 2.37 [95% CI, 1.58-3.57]).

CONCLUSION

Referrals from PM&R and interdisciplinary spine clinics were significantly associated with increased odds of being indicated for surgery at the time of initial evaluation with a spine surgeon. These findings highlight how interdisciplinary efforts may reduce the nonoperative consultations seen by surgical spine clinicians.

Full-endoscopic spinal decompression or discectomy show benefits regarding 30-day readmission rates when compared to other spine surgery techniques: a propensity score matched analysis

BACKGROUND AND CONTEXT

Unplanned readmission within 30 days following elective spine surgery is a key indicator of quality of care, as readmissions often signal early complications or poor recovery. The Hospital Readmission Reduction Program (HRRP) and the Centers for Medicare and Medicaid Services (CMS) utilizes this metric to assess hospital and surgeon performance.

PURPOSE

Here we aim to delineate quality of care metrics for full-endoscopic spine surgery (FESS) compared to traditional spine surgery.

DESIGN

The study was a retrospective multicenter analysis comparing outcomes of propensity matched cohorts.

PATIENT SAMPLE

The study included 908 FESS patients operated between 2014 and 2023 and a matched cohort of 73,906 non-FESS patients.

OUTCOME MEASURES

Our primary outcome measures were postoperative 30-day hospital readmissions and revision surgery. Furthermore, demographic data, hospitalization, surgical details and comorbidities were included.

METHODS

Data were collected from 6 participating institutions. Patients older than 18 years undergoing noninstrumented FESS spine surgeries for degenerative lumbar spinal pathologies from 2016 to 2023 were included. A matched non-FESS cohort was identified in the ACS-NSQIP database (2015-2019). Propensity-score matching was used to compare the cohorts.

RESULTS

Before matching, the 30-day readmission rate was significantly lower in the FESS cohort (1.1% vs 4.4%, p<.001), which remained consistent after matching (1.1% vs 4.5%, p<.001). The rate of 30-day surgical revisions was similar between cohorts (1.0% vs 1.1%, p=.63). Multivariate analysis indicated a significant correlation between FESS and reduced 30-day readmissions (odds ratio [OR] 0.28, 95% CI 0.14-0.57, p<.001).

CONCLUSION

This study is the first to compare 30-day hospital readmissions between FESS and nonendoscopic surgeries in a large, matched multicenter cohort. FESS significantly reduces both the length of postoperative hospital stay and 30-day readmission rates compared to nonendoscopic approaches, underscoring the safety and effectiveness of outpatient FESS. Future studies are needed to define the role of FESS in more complex spine procedures.

Loosening of stand-alone ALIF versus TLIF in degenerated lumbar human spines: an in vitro biomechanical study

PURPOSE

Biomechanical investigation is needed to determine whether stand-alone anterior lumbar interbody fusion with integrated screws (ALIF) is advisable for use in elderly patients. This study aimed to test three null hypotheses: (1) cyclic loading does not cause loosening of ALIF in degenerated lumbar specimens, (2) cyclic loading does not cause loosening in transforaminal lumbar interbody fusion (TLIF) in degenerated lumbar specimens, and (3) Neutral Zone (NZ) and Range of motion (ROM) of ALIF and TLIF do not differ after cyclic loading.

METHODS

Twelve fresh-frozen human cadaveric lumbar motion segments (L1-5, donors' age 76.1 ± 6.7 years; trabecular BMD 97.1 ± 36.9 mgHA/cm3) were utilized. NZ and ROM were assessed after ALIF or TLIF and following cyclic loading for flexion-extension (Flex-Ext), lateral bending (LB), and axial rotation (AR). Axial compression of 0-1150 N was applied over 2000 cycles. Loosening was defined as significant increase in NZ.

RESULTS

Cyclic loading significantly increased NZ of ALIF specimens in Flex-Ext (1.69 ± 1.81°, p =.048) and LB (1.84 ± 1.81°, p =.036), and showed a trend to significance in AR (0.46 ± 0.54°, p =.065). NZ of TLIF specimens did not increase significantly in any motion direction (p ≥.112). ROM and NZ did not differ significantly between ALIF and TLIF in post-cyclic states(p ≥.556).

CONCLUSION

Axial compression loading caused significant loosening of ALIF in Flex-Ext and LB, but not of TLIF in degenerated lumbar human cadaveric specimens. Hence, standalone ALIF cannot be recommended without reservation for the use in elderly patients with degenerative lumbar spines. However, the absolute differences between pre- and post-cyclic states were small, and ROM and NZ of ALIF after cyclic loading were comparable to TLIF.

Outcome and complication following single-staged posterior minimally invasive surgery in adult spinal deformity

BACKGROUND

The aging population is experiencing a rising incidence of musculoskeletal problems and degenerative spinal deformities. Adult spinal deformity (ASD) presents challenges, with associated risks in open surgery. Minimally invasive surgery (MIS) is becoming increasingly popular due to its positive outcomes and potential benefits. This study aims to explore the clinical outcome and complications of posterior approach MIS in patients with ASD.

METHODS

We conducted a retrospective analysis of patients with adult spinal deformity who underwent posterior minimally invasive surgery. 46 patients meeting the criteria were identified between June 2017 and September 2023. Comprehensive data were collected, including demographic details, surgical information, full-length radiographic measurements, and visual analog scale (VAS) pain scores. These data were obtained preoperatively, postoperatively, and at the final follow-up.

RESULTS

A total of 46 patients were included in the study, with a mean age of 68.58 years and a minimum follow-up period of 6 months. The mean operative time was 327 min, and the mean blood loss was 307 ml. Preoperative radiographic measurements were as follows: Coronal Cobb angle, 18.60 ± 11.35°; lumbar lordosis (LL), 22.79 ± 21.87°; pelvic incidence (PI), 53.05 ± 14.13°; PI-LL mismatch, 30.26 ± 23.48°; pelvic tilt (PT), 32.53 ± 10.38°; T1 pelvic angle (TPA), 31.91 ± 12.39°; and sagittal vertical axis (SVA), 77.77 ± 60.47 mm. At the final follow-up, coronal Cobb angle was 10.08 ± 6.47° (P <0.0001), LL was 26.16 ± 16.92° (P = 0.4293), PI was 54.17 ± 12.13° (P = 0.6965), PI-LL mismatch was 28.00 ± 17.03° (P = 0.6144), PT was 27.74 ± 10.24° (P = 0.0345), TPA was 25.10 ± 10.95 (P = 0.0090) and SVA was 47.91 ± 46.94 mm (P = 0.0129). Functional outcomes improved as well, with the mean Oswestry Disability Index (ODI) decreasing from 34.9 to 23.6 and the Visual Analog Scale (VAS) score for back pain reducing from 8.4 to 3.4. Surgical complications occurred in 39.1% of cases, with a low reoperation rate of 4.3%.

CONCLUSION

Single-staged posterior MIS effectively corrects global alignment in adult spinal deformities, satisfying patient demand and yielding positive clinical outcome with low re-operation rate.

Optimizing wound healing following lumbar spine surgery

The prevalence of open lumbar spine procedures has increased due to surgical advancements and an aging population. This study examined prophylactic closure by the plastic and reconstructive surgery (PRS) service compared to similar procedures from the National Surgical Quality Improvement Program (NSQIP) database. Patients who underwent lumbar spine surgery closed primarily by the PRS service at a large academic surgical center between January 2016 and June 2023 were included, while grafts or flaps were excluded. Charts were reviewed for demographics, preoperative risk factors, operative course, superficial surgical site infection (SSI), deep SSI, organ/space SSI, wound dehiscence, seroma, hematoma, cerebrospinal fluid leak, and medical complications. Unplanned readmission and revision surgeries related to the procedure were noted. Outcomes were assessed 30 days postoperatively. Outcomes within 30 days postoperatively were recorded in 46,006 NSQIP cases after matching by Current Procedural Terminology (CPT) and International Classification of Diseases - 10 (ICD-10) codes. A total of 888 consecutive lumbar surgery patients closed by PRS were reviewed. Wound-related revisional surgeries (1.2% vs. 2.6%, p = 0.013) and wound-related readmissions (1.5% vs. 4.2%, p < 0.001) were significantly lower for the PRS group than the NSQIP group. Transfusion (2.7% vs. 4.4%, p = 0.013) and urinary tract infection rates (0.2% vs. 1.3%, p = 0.005) were also lower for the PRS group. PRS closure also showed significantly decreased odds of revisional surgery (ß = 0.587, p = 0.021) and any wound infection (ß = 0.503, p = 0.026) after logistic regression. Thus, PRS closure of lumbar spine procedures may decrease the risk of wound-related revisional surgeries, readmissions, and infections. Therefore, this study supports the use of prophylactic PRS closure in such cases.

A Systematic Comparison of Age, Comorbidity and Frailty of Two Defined ICU Populations in the German Helios Hospital Group from 2016-2021

Background/Objectives: The demographic change raises concerns about the provision of adequate, long-term healthcare. Our study was driven by the decision to test other studies' findings about how patients' age and comorbidities are significantly increasing in German intensive care units (ICUs) over time. The goal of this study was to analyze the age and age-related characteristics, e.g., comorbidities and frailty, in ICU populations from 86 hospitals in the German Helios Group over a period of 6 years. Methods: For this retrospective observational study, we derived two different definitions of ICU cases, with (i) CodeBased ICU cases being defined by typical ICU procedures (e.g., OPS 8-980, 8-98f and/or duration of ventilation > 0 h) derived from the German administrative dataset of claims data according to the German Hospital Remuneration Act and (ii) BedBased ICU cases being based on the actual presence of a patient on a designated ICU bed; this was taken from the Helios hospital bed classification system. For each ICU definition, the size of the respective ICU population, age, Elixhauser Comorbidity Index (ECI) and Hospital Frailty Risk Score (HFR) were analyzed. Further patient characteristics, treatments and outcomes are reported. Trends in cases with and without COVID-19 were analyzed separately. Results: We analyzed a total of 6,204,093 hospital cases, of which 281,537 met the criteria for the CodeBased ICU definition and 457,717 for the BedBased ICU definition. A key finding of our study is that a change in age in absolute and relative terms is observable and statistically significant: the mean age of CodeBased ICU cases, 68.7 (14.4/-0.06), is marginally decreasing, and that of BedBased ICU cases, 69.1 (15.9/0.07) (both with a p-value of <0.001), is marginally increasing. Age analysis excluding COVID-19 cases does not change this key finding. A longitudinal analysis shows a continuously decreasing number of ICU admissions and a marginally positive trend of patients who are 60-69 and ≥80 years old: CodeBased ICU, 1.04/1.02; BedBased ICU, 1.03/1.03, all with a p-value of <0.001. A severity analysis based on the ECI and HFS shows that both are higher in CodeBased ICU cases (2021 ECI:18.0 (12.9); HFS: 10.7 (7.3); both p-values < 0.001) than in BedBased ICU cases (2021 ECI: 12.3 (12.4); HFS: 7.4 (7.1); p-values of 0.3 and 0.12). Further testing results per definition are reported. Conclusions: The observed age-related trends suggest that there has been a further increase in demand for intensive care from a frailer population. We recommend further studies to critically evaluate the increasing frailty within the ICU population and to test the associated presumed need for increased ICU capacities.

Augmenting Screw Technique to Prevent TLIF Cage Subsidence: A Biomechanical In Vitro Study

(1) Cage subsidence in spine surgery is a frequent clinical challenge. This study aimed to assess a novel screw augmentation technique for Transforaminal Lumbar Interbody Fusion in cadavers of reduced bone mineral density (BMD). (2) Forty human lumbar vertebrae (BMD 84.2 ± 24.4 mgHA/cm3, range 51-119 mgHA/cm3) were assigned to two groups: augmenting screw group and control group. The augmentation technique comprised placement of two additional subcortical screws. Ten constructs per group were loaded with a quasi-static load-to-failure protocol and other ten were cyclically loaded. Failure modes were documented. (3) During the quasi-static load-to-failure testing, the augmenting screw technique showed a significantly higher failure load (1426.0 ± 863.6 N) versus the conventional technique in the control group (682.2 ± 174.5 N, p = 0.032). Cyclic loading revealed higher number of cycles and corresponding load until reaching 5 mm subsidence and significantly higher number of cycles and corresponding load until reaching 10 mm subsidence for the augmenting screw technique (9645 ± 3050; 1164.5 ± 305.0 N) versus the conventional technique in the control group (5395 ± 2340; 739.5 ± 234.0 N, p < 0.05). Failure modes were different and showed bending of the augmenting screws, followed by cut-out. (4) The investigated augmenting screw technique demonstrated higher failure loads and cycles to failure against cage subsidence compared to conventional cage placement. Failure modes were different between the two techniques and may lead to a different kind of complications.

The Retrograde Approach of Surgical Paddle-Lead Placement for Spinal Cord Stimulation

INTRODUCTION

Standard anterograde placement of a surgical paddle lead (SPL) for spinal cord stimulation (SCS) can be challenging in patients with scarring from prior spine surgery, instrumentation obstructing the targeted level, or severe stenosis below the targeted level. One potential alternative is retrograde (caudal) insertion by performing laminotomies cephalad to the targeted levels. The literature is limited to only a small number of individual cases describing this technique. In this report, the authors present their experience over the last ten years of the retrograde insertion of SPLs for SCS.

MATERIALS AND METHODS

This is a retrospective study of 298 consecutive surgical paddle implants performed by a single neurosurgeon from 2013 to 2023 in an academic medical center.

RESULTS

A total of 26 patients underwent retrograde insertion of SPLs. The average patient age was 61 years, with women comprising 58% of cases. Three different manufacturers were used. The retrograde approach was planned before surgery in 96% of cases. The indications for the retrograde approach were 1) scarring from current or prior SCS leads placed from below in the standard anterograde fashion (46%); 2) scarring from prior extensive spine surgery and/or instrumentation (42%); 3) anatomical considerations of scoliosis and stenosis below the targeted levels or the requirement of high cervical stimulation (8%); or 4) intraoperative decision due to extensive scarring during planned anterograde placement (4%). The targeted spinal regions were thoracic (88%) or cervical (12%). There was one case of lead migration that required revision surgery. There were no paddle-lead fractures or deep surgical site infections.

CONCLUSIONS

The retrograde insertion of SPLs is a low-risk and feasible procedure that can be performed with minimal risk of lead migration, fracture, or deep surgical site infection. The retrograde strategy can be used in SPL trials or permanent placements.

Orthopedic surgery versus neurosurgery: Prevalence and surgical detail assessment of adult spinal fusion procedures

Background

A significant procedural overlap exists between orthopedic and neurosurgeons with both subspecialties performing adult spinal fusion procedures. However, the prevalence of varying adult spinal fusion procedures performed by orthopedic surgeons, relative to neurosurgeons, is unknown. This study sought to compare the prevalence of spinal fusion procedures among orthopedic and neurosurgeons.

Materials and Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for adult spinal fusion procedures from 2008 to 2016. Procedure prevalence, operative time, and hospital length of stay (LOS) were recorded and analyzed by surgical subspecialty. Spinal fusion cases investigated include all fusions, 2-3-level lumbar fusion, ≥4-level lumbar fusion, anterior cervical discectomy and fusion (ACDF), 3-6-level posterior cervical fusion, and ≥ 6-level posterior cervical fusion.

Results

67,775 spinal fusions were identified, of which 44,879 (66.2%) were performed by neurosurgeons and 22,896 (33.7%) were performed by orthopedic surgeons. Procedures that involved the lumbar spine were more likely to be performed by orthopedic surgeons while cervical fusions like ACDF were more likely to be performed by neurosurgeons. Orthopedic surgeons had significantly shorter operative times (124.0 vs. 134.0 min, P < 0.001) for 2-3-level lumbar fusions while having a similar patient LOS (4.3 vs. 4.2 days, P = 0.196). The remaining procedures saw no significant difference in operative time and patient LOS between orthopedic and neurosurgeons.

Conclusions

Neurosurgeons performed nearly double the amount of spinal fusion cases compared to orthopedic surgeons, with an even greater disparity seen in ACDFs, while orthopedic surgeons performed significantly more fusions of the lumbar spine. Orthopedic surgeons had shorter operative times for 2-3-level lumbar fusions.

Risk Factors Analysis and Nomogram Conduction for Major Adverse Events After Lumbar Fusion Surgery in Older Patients: A Prospective Cohort Study

OBJECTIVE

This study aimed to identify risk factors for major adverse events (AEs) after lumbar fusion surgery in patients aged 75 and older and evaluate the role of several common geriatric comprehensive assessment items in predicting postoperative major AEs.

METHODS

This is a prospective cohort study of patients aged ≥75 years who underwent open lumbar fusion for degenerative spine disease from August 2019 to August 2022. The primary outcome measure was the incidence of major postoperative AEs within 90 days after surgery. Clavien-Dindo III-IV complications and unplanned readmission were defined as major AEs. Patients' characteristics, laboratory tests, assessment results, and surgery-related variables were compared between the major AEs and the nonmajor AEs groups. Multivariable logistic regression analysis was used to identify independent risk factors for major AEs. The logistic regression model was evaluated in another prospective cohort of patients from October 2022 to October 2023.

RESULTS

A total of 301 patients (mean [SD] age, 79.7 [3.5] years; 60.5% male) were included in the study. Five features, including female (OR 1.99, P=0.040), higher body mass index (OR 1.090, P=0.024), frailty (OR 2.043, P =0.032), hypoalbuminemia (OR 2.489, P=0.040), and higher Charlson comorbidity index (OR 1.397, P=0.024), were independently associated with major AEs and were selected to develop a predictive nomogram of major AEs. The area under the curve values for the development set and validation set were 0.75 and 0.71, respectively.

CONCLUSIONS

Preoperative frailty, hypoalbuminemia, female sex, greater body mass index, and higher Charlson comorbidity index grade were risk factors for 90-day major AEs after lumbar fusion surgery in older patients. The predictive nomogram that we developed using this data can enhance preoperative risk counseling and optimization for older patients.

Proceedings of the 2024 Santa Fe Bone Symposium: Update on the Management of Osteoporosis and Rare Bone Diseases

The 24th Annual Santa Fe Bone Symposium (SFBS) was held in Santa Fe, New Mexico, USA, on August 2-3, 2024. This was a "hybrid" meeting, with in-person and real-time remote participants representing a broad range of geographical locations and medical disciplines. The focus was on new developments in the care of patients with osteoporosis, other metabolic bone diseases, and inherited skeletal disorders. The most current medical evidence was presented and discussed with consideration of implications for patient management. Topics included an update on clinical uses of osteoanabolic agents, management of patients discontinuing denosumab, bone health optimization for orthopedic surgery, estrogen and testosterone in the management of osteoporosis, osteoporosis treatment in the very old, overview of rare bone diseases, treat-to-target for osteoporosis, and a progress report on global activities of Bone Health ECHO. There were two highly interactive faculty panel discussions - one with case presentations by attendees and another with open microphone for all topics of interest. Endocrinology fellows, selected from attendees of the Santa Fe Fellows Workshop on Metabolic Bone Diseases, held the two days preceding the SFBS, participated with presentations of oral abstracts. Ancillary events addressed modern approaches to menopause and bone health, case studies of management of patients at very high fracture risk, and management of patients with rare bone diseases, such as hypophosphatasia, fibrodysplasia ossificans progressiva, X-linked hypophosphatemia, and hypoparathyroidism. These proceedings of the SFBS present the clinical highlights of the plenary sessions and the discussions that followed.

Optimizing Safe Opioid Prescribing: A Paradigm Shift in Buprenorphine Management for Orthopaedic Surgery

The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in perioperative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the perioperative period. The patient's buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a preoperative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Nonsteroidal anti-inflammatory drugs when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate-release opioids for breakthrough pain. Transdermal buprenorphine is emerging as an excellent option for the management of acute perioperative pain in both elective and nonelective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to 1 week during the postoperative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, transdermal buprenorphine patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, etc. As the stigma surrounding buprenorphine decreases, further opportunities for perioperative use may develop.

Paraspinal muscle fibre structural and contractile characteristics demonstrate distinct irregularities in patients with spinal degeneration and deformity

BACKGROUND

Paraspinal and spinopelvic muscular dysfunction are hypothesized to be a causative factor for spinal degeneration and deformity; however, our fundamental understanding of paraspinal muscle (dys)function remains limited.

METHODS

Twelve surgical patients with spinal degeneration were recruited and categorized into group DEG (four patients) with no sagittal imbalance and no usage of compensatory mechanisms; group DEG-COMP (four patients) with no sagittal imbalance through use of compensatory mechanisms; and group DEG-COMP-UNBAL (four patients) with sagittal imbalance despite use of compensatory mechanisms. From each patient, four biopsies were collected from right and left multifidus (MULT) and longissimus (LONG) for single fibre contractile and structural measurements.

RESULTS

Eight of 48 (17%) biopsies did not exhibit any contractile properties. Specific force was not different between groups for the MULT (p = 0.47) but was greater in group DEG compared to group DEG-COMP-UNBAL for the LONG (p = 0.02). Force sarcomere-length properties were unusually variable both within and amongst patients in all groups. Thin filament (actin) lengths were in general shorter and more variable than published norms for human muscle.

CONCLUSION

This study is the first to show a heightened intrinsic contractile muscle disorder (i.e. impaired specific force generation) in patients with spinal degeneration who are sagittally imbalanced (compared to patients without deformity). Additionally, there are clear indications that patients with spinal degeneration (all groups) have intrinsic force sarcomere-length properties that are dysregulated. This provides important insight into the pathophysiology of muscle weakness in this patient group.

One- and 2-year outcomes of lumbar facet arthroplasty versus spinal fusion in young (<65 years) and old (≥65 years) patients for the treatment of degenerative spondylolisthesis and stenosis

Background

Facet arthroplasty, an alternative to lumbar fusion, offers stabilization and preserves range of motion. This subanalysis of the TOPS IDE trial (FDA #G160168) compared facet arthroplasty, using the TOPS device, with a standard single-level transforaminal lumbar interbody fusion (TLIF) in patients stratified by age (<65 and ≥65 years) with symptomatic grade 1 degenerative spondylolisthesis with moderate to severe spinal stenosis at L2-5.

Methods

Patient-reported outcomes (PROMS), including Oswestry disability index (ODI), visual analog pain scales (VAS), and Zurich claudication questionnaires (ZCQ), were assessed at baseline and multiple postoperative timepoints. Radiographic evaluation of flexion/extension range of motion (ROM) occurred at baseline, 12 months, and 24 months. Data were analyzed following an intention-to-treat model. Significance was defined as p<.05.

Results

About 299 patients were included (TOPS=206, TLIF=93). The groups were similar at baseline. At 2 years, the TOPS group had a greater proportion of patients report ≥15-point improvement for ODI (93.8% versus 77.1%, p=.011) and ≥20-point improvement for VAS back (84.4% versus 61.8%, p=.014). At 1 year, TOPS group had a greater proportion of patients report clinically significant improvements in all ZCQ categories (91.6% versus 78.5%, p=.012). In patients <65 years, the TOPS group had improved PROMS compared to TLIF at 2 years; however, these differences were less pronounced in patients ≥65 years old. The TOPS groups preserved more ROM at 12 (2.8° 95%CI [1.87; 3.74], p<.0001) and 24 (2.99° 95%CI [1.82; 4.15], p<.0001) months compared to TLIF. ROM was similarly preserved in patients aged <65 and ≥65. The rate of adverse events did not differ significantly between treatment groups.

Conclusions

Facet arthroplasty preserves more ROM in all ages and leads to improved PROMS compared to TLIF, particularly in younger patients.

Organism-Inspired Antioxidant Bioadhesive with Strong Sealing Ability to Prevent Epidural Adhesion

Epidural adhesion or epidural fibrosis is the major reason for postoperative pain, which remains a clinically challenging problem. Current physical barriers fail to provide a satisfactory therapeutic outcome mainly due to their lack of adhesion, inability to prevent fluid leakage, and exhibiting limited antioxidant properties. Herein, we fabricated a cysteine-modified bioadhesive (SECAgel) with improved sealing and antioxidant properties for epidural adhesion prevention, inspired by the organism's antioxidant systems. The resulting SECAgel showed good injectability and in situ adhesion ability, effectively covering every corner of the irregular wound. Besides, it possessed efficient sealing properties (395.2 mmHg), effectively stopping blood leakage in the rabbit carotid artery transection model. The antioxidant experiments demonstrated that the SECAgel effectively scavenged various radicals and saved the cells from oxidative stress. Two animal models were used to show that the SECAgel effectively inhibited adhesion in both situations with and without cerebrospinal fluid leakage. The RNA sequencing analysis showed that SECAgel treatment effectively inhibited the expression of key genes related to adhesion development, inflammatory response, and oxidative stress. The SECAgel, together with good biocompatibility, can be a good candidate for preventing epidural adhesion in the clinic.

Orthopedic Frailty Score and adverse outcomes in patients with surgically managed isolated traumatic spinal injury

Background

With an aging global population, the prevalence of frailty in patients with traumatic spinal injury (TSI) is steadily increasing. The aim of the current study is to evaluate the utility of the Orthopedic Frailty Score (OFS) in assessing the risk of adverse outcomes in patients with isolated TSI requiring surgery, with the hypothesis that frailer patients suffer from a disproportionately increased risk of these outcomes.

Methods

The Trauma Quality Improvement Program database was queried for all adult patients (18 years or older) who suffered an isolated TSI due to blunt force trauma, between 2013 and 2019, and underwent spine surgery. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The association between the OFS and in-hospital mortality, complications, and failure to rescue (FTR) was determined using Poisson regression models, adjusted for potential confounding.

Results

A total of 43 768 patients were included in the current investigation. After adjusting for confounding, frailty was associated with a more than doubling in the risk of in-hospital mortality (adjusted incidence rate ratio (IRR) (95% CI): 2.53 (2.04 to 3.12), p<0.001), a 25% higher overall risk of complications (adjusted IRR (95% CI): 1.25 (1.02 to 1.54), p=0.032), a doubling in the risk of FTR (adjusted IRR (95% CI): 2.00 (1.39 to 2.90), p<0.001), and a 10% increase in the risk of intensive care unit admission (adjusted IRR (95% CI): 1.10 (1.04 to 1.15), p=0.004), compared with non-frail patients.

Conclusion

The findings indicate that the OFS could be an effective method for identifying frail patients with TSIs who are at a disproportionate risk of adverse events.

Level of evidence

Level III.

Current Status of Awake Spine Surgery: A Bibliometric Analysis

BACKGROUND

Spine surgery accounts for a large proportion of neurosurgical procedures, with approximately 313 million spine surgeries conducted annually worldwide. Considering delayed recovery and postoperative complications that are commonly reported, there has been a recent shift toward minimally invasive spine procedures conducted under local anesthesia. Despite proven success, there exists a limited body of literature on the use of awake surgery in spinal procedures.

METHODS

A bibliometric analysis was conducted to map the current landscape of work in this field. 190 articles were identified from the Web of Science (Clarivate, NY) database. A comprehensive bibliometric analysis was performed on a narrowed list of the most relevant articles using Bibliometrix, an R-based programming tool.

RESULTS

There has been a rise in academic papers published on the topic of awake spine surgery since 2016, with an increase in publication count by approximately 18% annually and each article cited approximately ten times on average to date. The year 2022 saw an uptick in publications, with 9 throughout the entire year. The most impactful article, with a total of 95 citations, was published by Sairyo et al.1 Thematic analysis revealed that the terms "lumbar spine" and "stenosis" are well-developed topics in the literature, whereas the topics of "complications," "fusion," and "cost-analysis" are less well-developed topics.

CONCLUSIONS

This study provides a comprehensive overview of the most-cited articles in the field of awake spine surgery. Specifically, it identifies areas that are well represented in the literature and those which are underrepresented and should be areas of continued future research.

Characterizing Negative Online Reviews of Spine Surgeons

DESIGN

Retrospective review.

OBJECTIVE

Characterize negative reviews of spine surgeons in the United States.

SUMMARY

Physician rating websites significantly influence the selection of doctors by other patients. Negative experiences are impacted by various factors, both clinical and nonclinical, geography, and practice structure. The purpose of this study was to evaluate and categorize negative reviews of spine surgeons in the United States, with a focus on surgical versus nonsurgical reviewers.

METHODS

Spine surgeons were selected from available online professional society membership directories. A search for reviews was performed on Healthgrades.com, Vitals.com, and RateMDs.com for the past 10 years. Free response reviews were coded by complaint, and qualitative analysis was performed. χ 2 and Fisher exact tests were used to compare categorical variables, and multiple comparisons were adjusted with Benjamini-Hochberg correction. A binary logistic regression model was performed for the top three most mentioned nonclinical and clinical complaint labels. A P -value <0.05 was considered statistically significant.

RESULTS

A total of 16,695 online reviews were evaluated, including 1690 one-star reviews (10.1%). Among one-star reviews, 64.7% were written by nonsurgical patients and 35.3% by surgical patients. Nonclinical and clinical comments constituted 54.9% and 45.1% of reviews, respectively. Surgeons in the South had more "bedside manner" comments (43.3%, P <0.0001), while Northeast surgeons had more "poor surgical outcome" remarks compared with all other geographic regions (14.4%, P <0.001). Practicing in the South and Northeast were independent predictors of having complaints about "bedside manner" and "poor surgical outcome," respectively.

CONCLUSION

Most one-star reviews of spine surgeons were attributed to nonsurgical patients, who tended to be unsatisfied with nonclinical factors, especially "bedside manner." However, there was substantial geographic variation. These results suggest that spine surgeons could benefit from focusing on nonclinical factors (bedside manner), especially among nonoperative patients, and that regional nuances should be considered in delivering spine care.

LEVEL OF EVIDENCE

Level- 5.

Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050

BACKGROUND

Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States.

METHODS

Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index.

RESULTS

Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932).

CONCLUSIONS

The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.

Spinal Anesthesia Reduces Perioperative Polypharmacy and Opioid Burden in Patients Over 65 Who Undergo Transforaminal Lumbar Interbody Fusion

BACKGROUND

Polypharmacy and opioid administration are thought to increase the risk of postoperative cognitive dysfunction and delirium in elderly patients. Spinal anesthesia (SA) holds potential to reduce perioperative polypharmacy in spine surgery. As more geriatric patients undergo spine surgery, understanding how SA can reduce polypharmacy and opioid administration is warranted. We aim to compare the perioperative polypharmacy and dose of administered opioids in patients ≥65 years who undergo transforaminal lumbar interbody fusion (TLIF) under SA versus general anesthesia (GA).

METHODS

A retrospective analysis of 200 patients receiving a single-surgeon TLIF procedure at a single academic center (2014-2021) was performed. Patients underwent the procedure with SA (n = 120) or GA (n = 80). Demographic, procedural, and medication data were extracted from the medical record. Opioid consumption was quantified as morphine milligram equivalents (MME). Statistical analyses included χ2 or Student's t-test.

RESULTS

Patients receiving SA were administered 7.45 medications on average versus 12.7 for GA patients (P < 0.001). Average perioperative opioid consumption was 5.17 MME and 20.2 MME in SA and GA patients, respectively (P < 0.001). The number of patients receiving antiemetics and opioids remained comparable postoperatively, with a mean of 32.2 MME in the GA group versus 27.5 MME in the SA group (P = 0.14). Antiemetics were administered less often as a prophylactic in the SA group (32%) versus 86% in the GA group (P < 0.001).

CONCLUSIONS

SA reduces perioperative polypharmacy in patients ≥65 years undergoing TLIF procedures. Further research is necessary to determine if this reduction correlates to a decrease the incidence of postoperative cognitive dysfunction and delirium.

A Randomized Controlled Trial Using Epidural Analgesia for Pain Relief After Lumbar Interlaminar Decompressive Spine Surgery: The RAPID trial

STUDY DESIGN

Prospective, double-blind randomized controlled trial.

OBJECTIVE

If an intraoperative single bolus of epidural bupivacaine can result in less postoperative pain following lumbar spinal decompression surgery.

SUMMARY OF BACKGROUND DATA

Adequate postoperative pain management following lumbar spinal decompression surgery is important, as it will lead to early mobilization, less complications, and a shorter hospital stay. Opioid consumption should be limited due to their frequently accompanied side effects and their addictive nature. During the final phase of lumbar decompression surgery, the epidural space becomes easily accessible. This might be an ideal moment for surgeons to administer an epidural bolus of analgesia as a safe and effective method for postoperative pain relief.

MATERIALS AND METHODS

In this trial, we compared a single intraoperative bolus of epidural analgesia using bupivacaine 0.25% to placebo (NaCl 0.9%) and its effect on postoperative pain following lumbar spinal decompression surgery. The primary outcome was the difference in Numeric (Pain) Rating Scale between the intervention and placebo groups during the first 48 hours after surgery.

RESULTS

Both the intervention group and the placebo group consisted of 20 randomized patients (N=40). Statistically significant lower mean Numeric (Pain) Rating Scale pain scores were observed in the intervention group in comparison with the control group (main effect group: -2.35±0.77, P =0.004). The average pain score was lower in the intervention group at all postoperative time points. No study-related complications occurred.

CONCLUSION

This randomized controlled trial shows that administrating a bolus of intraoperative epidural bupivacaine is a safe and effective method for reducing early postoperative pain following lumbar decompression surgery.

Sagittal Alignment in the Degenerative Lumbar Spine: Surgical Planning

➤ Sagittal alignment of the spine has gained attention in the field of spinal deformity surgery for decades. However, emerging data support the importance of restoring segmental lumbar lordosis and lumbar spinal shape according to the pelvic morphology when surgically addressing degenerative lumbar pathologies such as degenerative disc disease and spondylolisthesis.➤ The distribution of caudal lordosis (L4-S1) and cranial lordosis (L1-L4) as a percentage of global lordosis varies by pelvic incidence (PI), with cephalad lordosis increasing its contribution to total lordosis as PI increases.➤ Spinal fusion may lead to iatrogenic deformity if performed without attention to lordosis magnitude and location in the lumbar spine.➤ A solid foundation of knowledge with regard to optimal spinal sagittal alignment is beneficial when performing lumbar spinal surgery, and thoughtful planning and execution of lumbar fusions with a focus on alignment may improve patient outcomes.

Lumbar Decompression versus Decompression and Fusion in Octogenarians: Complications and Clinical Course With 3-Year Follow-Up

STUDY DESIGN

Retrospective review.

OBJECTIVES

This study aimed to assess and compare the clinical course and complications between surgical decompression and decompression with fusion in lumbar spine patients aged ≥80 years.

METHODS

A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2021. Logistic regression was used to identify potential risk factors for the occurrence of complications.

RESULTS

Over a 16-year period, 327 patients were allocated to the decompression only group and 89 patients were allocated to the decompression and instrumented fusion group. The study had a mean follow-up duration of 36.7 ± 12.4 months. When assessing the CCI, patients of the instrumentation group had fewer comorbidities (8.9 ± .5 points vs 6.2 ± 1.5 points; P < .001), significantly longer surgical duration (290 ± 106 minutes vs 145 ±50.2 minutes; P < .001), significantly higher volume of intraoperative blood loss (791 ± 319.3 ml vs 336.1 ± 150.8 ml; P < .001), more frequent intraoperative blood transfusion (7 ± 2.1% vs 16± 18.0%; P < .001), and extended stays in the intensive care unit and hospitalization rates. Logistic regression analysis revealed that surgical duration and extent of surgery were unique risk factors for the occurrence of complications.

CONCLUSIONS

Lumbar decompression and additional fusion in octogenarians are considerable treatment techniques; albeit associated with increased complication risks. Prolonged operative time and extent of surgery are critical confounding factors associated with higher rates of postoperative complications. Surgery should only be performed after careful outweighing of potential benefits and risks.

Percutaneous Computed Tomography-Guided Oxygen-Ozone (O2O3) Injection Therapy in Patients with Lower Back Pain-An Interventional Two-Year Follow-Up Study of 321 Patients

OBJECTIVES

To assess the effect of oxygen-ozone therapy guided by percutaneous Computed Tomography (CT) compared to corticosteroids in individuals experiencing lower back pain (LBP) not attributed to underlying bone-related issues.

METHODS

A total of 321 patients (192 males and 129 females, mean age: 51.5 ± 15.1 years) with LBP were assigned to three treatment groups: group A) oxygen-ozone only, group B) corticosteroids only, group C) oxygen-ozone and corticosteroids. Treatment was administered via CT-guided injections to the intervertebral disc (i.e., intradiscal location). Clinical improvement of pain and functionality was assessed via self-reported pain scales and magnetic resonance (MR) and CT imaging.

RESULTS

At all follow-up times, the mean score of the numeric rating scale and the total global pain scale (GPS) of study groups receiving oxygen-ozone (groups A and C) were statistically significantly lower than the study group receiving corticosteroids only (group B), with p < 0.001. There was a statistically significant difference between groups A and C at 30 days for the numeric rating scale.

CONCLUSIONS

The percutaneous application of oxygen-ozone in patients with LBP due to degeneration of the lumbosacral spine showed long-lasting significant pain reduction of up to two years post-treatment when compared to corticosteroids alone. Combination therapy of oxygen-ozone and corticosteroids can be useful as corticosteroids showed statistically significant improvement in LBP earlier than the oxygen-ozone-only treatment.

Utility of Surgical Risk Calculators in Spine Surgery in Patients Aged Over 80 Years: Analysis of SpineSage and ACS NSQIP

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To validate the predictive accuracy of both the SpineSage and ACS-NSQIP surgical risk calculators in patients over the age of 80 years, undergoing spine surgery for any reason.

METHODS

We included 210 consecutive patients treated with single-stage spine surgery at our institution between 2009 and 2019. The demographic details and preoperative characteristics of each patient were collected and reviewed for entry into both the SpineSage and ACS risk calculators. The estimated risk supplied by these calculators was compared to the observed rate of complications post-surgery. The main method of comparison was using receiver operating characteristic (ROC) curve analysis.

RESULTS

Complications were identified in 51 patients (24%). Most patients underwent surgery for a degenerative cause (71%), with the majority of procedures performed on the lumbosacral spine (66%). Receiver operating characteristic (ROC) curves were calculated to compare the outcomes of each tool. Area under the curve (AUC) analysis showed similar predictive accuracy between SpineSage and ACS when predicting overall complications (0.688; P < .001 vs 0.634; P = .021). AUC analysis demonstrated that SpineSage had better predictive accuracy when estimating risk of major complications (0.778; P = .037 vs 0.675; P = .001).

CONCLUSION

For the prediction of risks associated with spine surgery in those aged >80 years, SpineSage appears to be preferable to the ACS-NSQIP surgical risk calculator in this single centre cohort, SpineSage was more accurate in predicting the risk of serious medical complications. The accuracy of both of these tools could still be improved upon.

Is outpatient spine surgery associated with new, persistent opioid use in opioid-naïve patients? A retrospective national claims database analysis

BACKGROUND CONTEXT

Although spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting.

PURPOSE

To assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures.

STUDY DESIGN

Retrospective analysis using national administrative claims database.

PATIENT SAMPLE

A total of 390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery.

OUTCOME MEASURES

Patients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users.

METHODS

We utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors.

RESULTS

A total of 19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval {CI}: 0.69, 0.73], p < .001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < .001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < .001) were lower in the outpatient cohort compared to the inpatient.

CONCLUSION

Our results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification.

LEVEL OF EVIDENCE

Level III Prognostic Study.

MINI ABSTRACT

We utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.

Patient-specific Risk Factors Increase Episode of Care Costs After Lumbar Decompression

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression.

SUMMARY OF BACKGROUND DATA

Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression.

METHODS

Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05.

RESULTS

A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (β = $324.70, P < 0.001), comorbid depression (β = $4368.30, P = 0.037), revision procedures (β = $6538.43, P =0.012), increased hospital length of stay (per day) (β = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (β = $14,417.42, P = 0.001), incidence of a complication (β = $8178.07, P < 0.001), and readmission (β = $18,734.24, P < 0.001) within 90 days.

CONCLUSIONS

Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.

Psoas Muscle Index as a Predictor of Perioperative Outcomes in Geriatric Patients Undergoing Spine Surgery

STUDY DESIGN

Single-center retrospective study.

OBJECTIVE

The objective of this study was to evaluate the association of psoas muscle mass defined sarcopenia with perioperative outcomes in geriatric patients undergoing elective spine surgery.

METHODS

We included geriatric patients undergoing thoracolumbar spinal surgery. Total psoas surface area (TPA) was measured on preoperative axial computerized tomography or magnetic resonance imaging at the L3 vertebra and normalized to the L3 vertebral body area. Patients were divided into quartiles by normalized TPA, and the fourth quartile (Q4) was compared to quartiles 1-3 (Q1-3). Outcomes included perioperative transfusions, length of stay (LOS), delirium, pseudoarthrosis, readmission, discharge disposition, revision surgery, and mortality.

RESULTS

Of the patients who met inclusion criteria (n = 196), the average age was 73.4 y, with 48 patients in Q4 and 148 patients in Q1-3. Q4 normalized TPA cut-off was <1.05. Differences in Q4 preoperative characteristics included significantly lower body mass index, baseline creatinine, and a greater proportion of females (Table 1). Q4 patients received significantly more postoperative red blood cell and platelet transfusions and had longer ICU LOS (P < .05; Table 2). There was no difference in intraoperative transfusion volumes, delirium, initiation of walking, discharge disposition, readmission, pseudoarthrosis, or revision surgery (Tables 2 and 3). Mortality during follow-up was higher in Q4 but was not statistically significant (P = .075).

CONCLUSION

Preoperative TPA in geriatric patients undergoing elective spine surgery is associated with increased need for intensive care and postoperative blood transfusion. Preoperative normalized TPA is a convenient measurement and could be included in geriatric preoperative risk assessment algorithms.

Frailty Stratification Using the Modified 5-Item Frailty Index: Significant Variation within Frailty Patients in Spine Surgery

BACKGROUND

Frailty status has been associated with higher rates of complications after spine surgery. However, frailty patients constitute a heterogeneous group based on the combinations of comorbidities. The objective of this study is to compare the combinations of variables that compose the modified 5-factor frailty index score (mFI-5) based on the number of comorbidities in terms of complications, reoperation, readmission, and mortality after spine surgery.

METHODS

The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database from 2009-2019 was used to identify patients who underwent elective spine surgery. The mFI-5 item score was calculated and patients were classified according to number and combination of comorbidities. Multivariable analysis was used to assess the independent impact of each combination of comorbidities in the mFI-5 score on the risk of complications.

RESULTS

A total of 167, 630 patients were included with a mean age of 59.9 ± 13.6 years. The risk of complications was the lowest in patients with diabetes + hypertension (OR = 1.2) and highest in those with the combination of congestive heart failure (CHF), diabetes, chronic obstructive pulmonary disease (COPD), and dependent status (OR = 6.6); there was a high variation in complication rate based on specific combinations.

CONCLUSIONS

There is high variability in terms of relative risk of complications based on the number and combination of different comorbidities, especially with CHF and dependent status. Therefore, frailty status encompasses a heterogeneous group and sub-stratification of frailty status is necessary to identify patients with significantly higher risk of complications.

Geographic Distribution in Training and Practice of Academic Neurological and Orthopedic Spine Surgeons in the United States

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

This study aimed to stratify the geographic distribution of academic spine surgeons in the United States, analyzing how this distribution highlights differences in academic, demographic, professional metrics, and gaps in access to spine care.

METHODS

Spine surgeons were identified using American Association of Neurological Surgeons and American Academy of Orthopedic Surgeons databases, categorizing into geographic regions of training and practice. Departmental websites, National Institutes of Health (NIH) RePort Expenditures and Results, Google Patent, and NIH icite databases were queried for demographic and professional metrics.

RESULTS

Academic spine surgeons (347 neurological; 314 orthopedic) are predominantly male (95%) and few have patents (23%) or NIH funding (4%). Regionally, the Northeast has the highest proportion per capita (3.28 surgeons per million), but California is the state with the highest proportion (13%). The Northeast has the greatest regional retention post-residency at 74%, followed by the Midwest (59%). The West and South are more associated with additional degrees. Neurosurgery-trained surgeons hold more additional degrees (17%) than orthopedic surgeons (8%), whereas more orthopedic surgeons hold leadership positions (34%) than neurosurgeons (20%).

CONCLUSIONS

Academic spine surgeons are found at the highest proportion in the Northeast and California; the Northeast has the greatest regional retention. Spine neurosurgeons have more additional degrees, whereas spine orthopedic surgeons have more leadership positions. These results are relevant to training programs looking to correct geographic disparities, surgeons in search of training programs, or students in pursuit of spine surgery.

A decision tree analysis to predict clinical outcome of minimally invasive lumbar decompression surgery for lumbar spinal stenosis with and without coexisting spondylolisthesis and scoliosis

BACKGROUND CONTEXT

Implementing machine learning techniques, such as decision trees, known as prediction models that use logical construction diagrams, are rarely used to predict clinical outcomes.

PURPOSE

To develop a clinical prediction rule to predict clinical outcomes in patients who undergo minimally invasive lumbar decompression surgery for lumbar spinal stenosis with and without coexisting spondylolisthesis and scoliosis using a decision tree model.

STUDY DESIGN/SETTING

A retrospective analysis of prospectively collected data.

PATIENT SAMPLE

This study included 331 patients who underwent minimally invasive surgery for lumbar spinal stenosis and were followed up for ≥2 years at 1 institution.

OUTCOME MEASURES

Self-report measures: The Japanese Orthopedic Association (JOA) scores and low back pain (LBP)/leg pain/leg numbness visual analog scale (VAS) scores. Physiologic measures: Standing sagittal spinopelvic alignment, computed tomography, and magnetic resonance imaging results.

METHODS

Low achievement in clinical outcomes were defined as the postoperative JOA score at the 2-year follow-up <25 points. Univariate and multiple logistic regression analysis and chi-square automatic interaction detection (CHAID) were used for analysis.

RESULTS

The CHAID model for JOA score <25 points showed spontaneous numbness/pain as the first decision node. For the presence of spontaneous numbness/pain, sagittal vertical axis ≥70 mm was selected as the second decision node. Then lateral wedging, ≥6° and pelvic incidence minus lumbar lordosis (PI-LL) ≥30° followed as the third decision node. For the absence of spontaneous numbness/pain, sex and lateral olisthesis, ≥3mm and American Society of Anesthesiologists physical status classification system score were selected as the second and third decision nodes. The sensitivity, specificity, and the positive predictive value of this CHAID model was 65.1, 69.8, and 64.7% respectively.

CONCLUSIONS

The CHAID model incorporating basic information and functional and radiologic factors is useful for predicting surgical outcomes.

Glycerol induced paraspinal muscle degeneration leads to hyper-kyphotic spinal deformity in wild-type mice

Degenerative spinal disorders, including kyphotic deformity, are associated with a range of degenerative characteristics of the paraspinal musculature. It has therefore been hypothesized that paraspinal muscular dysfunction is a causative factor for degenerative spinal deformity; however, experimental studies demonstrating causative relationships are lacking. Male and female mice received either glycerol or saline injections bilaterally along the length of the paraspinal muscles at four timepoints, each separated by 2 weeks. Immediately after sacrifice, micro-CT was performed to measure spinal deformity; paraspinal muscle biopsies were taken to measure active, passive and structural properties; and lumbar spines were fixed for analysis of intervertebral disc (IVD) degeneration. Glycerol-injected mice demonstrated clear signs of paraspinal muscle degeneration and dysfunction: significantly (p < 0.01) greater collagen content, lower density, lower absolute active force, greater passive stiffness compared to saline-injected mice. Further, glycerol-injected mice exhibited spinal deformity: significantly (p < 0.01) greater kyphotic angle than saline-injected mice. Glycerol-injected mice also demonstrated a significantly (p < 0.01) greater IVD degenerative score (although mild) at the upper-most lumbar level compared to saline-injected mice. These findings provide direct evidence that combined morphological (fibrosis) and functional (actively weaker and passively stiffer) alterations to the paraspinal muscles can lead to negative changes and deformity within the thoracolumbar spine.

Decompression Alone in the Setting of Adult Degenerative Lumbar Scoliosis and Stenosis: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis (DLS) and stenosis is commonly performed, however, there is no summary of evidence for outcomes.

METHODS

A systematic search of English language medical literature databases was performed for studies describing outcomes of decompression alone in DLS, defined as Cobb angle >10˚, and 2-year minimum follow-up. Three outcomes were examined: 1) Cobb angle progression, 2) reoperation rate, and 3) ODI and overall satisfaction. Data were pooled and weighted averages were calculated to summarize available evidence.

RESULTS

Across 15 studies included in the final analysis, 586 patients were examined. Average preoperative and postoperative Cobb angles were 17.6˚ (Range: 12.7 - 25˚) and 18.0 (range 14.1 - 25˚), respectively. Average change in Cobb angle was an increase of 1.8˚. Overall rate of reoperation ranged from 3 to 33% with an average of 9.7%. Average ODI before surgery, after surgery, and change in scores were 56.4%, 27.2%, and an improvement of 29% respectively. Average from 8 studies that reported patient satisfaction was 71.2%.

CONCLUSIONS

Current literature on decompression alone in the setting of DLS is sparse and is not high quality, limited to patients with small magnitude of lumbar coronal Cobb angle, and heterogenous in the type of procedure performed. Based on available evidence, select patients with DLS who undergo decompression alone had minimal progression of Cobb angle, relatively low reoperation rate, and favorable patient-reported outcomes.

The "In-Parallel" Technique for Awake, Bilateral Simultaneous Minimally Invasive Transforaminal Lumbar Interbody Fusion and Multilevel Lumbar Decompression

BACKGROUND

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and MIS lumbar decompression have been successfully undertaken in the absence of general anesthesia in well-selected patients. By leveraging spinal anesthesia, surgeons may safely conduct surgeries on one- or two-level lumbar pathology. However, surgeries on more extensive pathology have not yet been described, because of concerns about the duration of efficacy of spinal anesthetic in the awake patient.

OBJECTIVE

To report the use of a novel awake technique for "in parallel," simultaneous lumbar spinal surgery on three-segment pathology.

METHODS

We describe concurrent performance of a dual microscopic, navigated MIS TLIF and MIS two-level decompression, using a combination of liposomal bupivacaine erector spinae block in conjunction with a spinal anesthetic.

RESULTS

We show that a left-sided, two-level MIS tubular microscopic decompression combined with a concurrent right-sided, transfacet MIS TLIF via a tubular microscopic approach was well tolerated in an 87-year-old patient with multilevel lumbar stenosis with a mobile spondylolisthesis.

CONCLUSION

We provide the first description of a dual-surgeon approach for minimally invasive spine surgery. This "in-parallel" technique-reliant on 2, independent spine surgeons-may aid in the performance of surgeries previously considered too extensive, given the time constraints of regional anesthesia and can be successfully applied to patients who otherwise may not be candidates for general anesthesia.

Accuracy of Rod Contouring to Desired Angles With and Without a Template: Implications for Achieving Desired Spinal Alignment and Outcomes

STUDY DESIGN

Biomechanical Study.

OBJECTIVE

The search for optimal spinal alignment has led to the development of sophisticated formulas and software for preoperative planning. However, preoperative plans are not always appropriately executed since rod contouring during surgery is often subjective and estimated by the surgeon. We aimed to assess whether rods contoured to specific angles with a French rod bender using a template guide will be more accurate than rods contoured without a template.

METHODS

Ten experienced spine surgeons were requested to contour two 125 × 5.5 mm Ti64 rods to 40°, 60° and 80° without templates and then 2 more rods using 2D metallic templates with the same angles. Rod angles were then measured for accuracy and compared.

RESULTS

Average angles for rods bent without a template to 40°, 60° and 80° were 60.2°, 78.9° and 97.5°, respectively. Without a template, rods were overbent by a mean of 18.9°. When using templates of 40°, 60° and 80°, mean bend angles were 41.5°, 59.1° and 78.7°, respectively, with an average underbend of 0.2°. Differences between the template and non-template groups for each target angle were all significant (p < 0.001).

CONCLUSIONS

Without the template, surgeons tend to overbend rods compared to the desired angle, while surgeons improved markedly with a template guide. This tendency to overbend could have significant impact on patient outcomes and risk of proximal junctional failure and warrants further research to better enable surgeons to more accurately execute preoperative alignment plans.

An Ensemble Learning Approach to Improving Prediction of Case Duration for Spine Surgery: Algorithm Development and Validation

BACKGROUND

Estimating surgical case duration accurately is an important operating room efficiency metric. Current predictive techniques in spine surgery include less sophisticated approaches such as classical multivariable statistical models. Machine learning approaches have been used to predict outcomes such as length of stay and time returning to normal work, but have not been focused on case duration.

OBJECTIVE

The primary objective of this 4-year, single-academic-center, retrospective study was to use an ensemble learning approach that may improve the accuracy of scheduled case duration for spine surgery. The primary outcome measure was case duration.

METHODS

We compared machine learning models using surgical and patient features to our institutional method, which used historic averages and surgeon adjustments as needed. We implemented multivariable linear regression, random forest, bagging, and XGBoost (Extreme Gradient Boosting) and calculated the average R², root-mean-square error (RMSE), explained variance, and mean absolute error (MAE) using k-fold cross-validation. We then used the SHAP (Shapley Additive Explanations) explainer model to determine feature importance.

RESULTS

A total of 3189 patients who underwent spine surgery were included. The institution's current method of predicting case times has a very poor coefficient of determination with actual times (R²=0.213). On k-fold cross-validation, the linear regression model had an explained variance score of 0.345, an R² of 0.34, an RMSE of 162.84 minutes, and an MAE of 127.22 minutes. Among all models, the XGBoost regressor performed the best with an explained variance score of 0.778, an R² of 0.770, an RMSE of 92.95 minutes, and an MAE of 44.31 minutes. Based on SHAP analysis of the XGBoost regression, body mass index, spinal fusions, surgical procedure, and number of spine levels involved were the features with the most impact on the model.

CONCLUSIONS

Using ensemble learning-based predictive models, specifically XGBoost regression, can improve the accuracy of the estimation of spine surgery times.

Evaluation of the degeneration of the multifidus and erector spinae muscles in patients with low back pain and healthy individuals

BACKGROUND

Although several studies have been conducted to determine the cause of low back pain (LBP), a sufficient correlation has not been found between research findings and symptoms. Therefore there seems to be a need for studies to explain the relationship between pain and morphological changes in the paraspinal muscles of patients with LBP through comparisons with healthy control subjects.

OBJECTIVE

The aim of this study was to examine degeneration in the lumbar musculus multifidus (LMF) and lumbar musculus erector spinae (LES) muscles in patients with chronic LBP with non-radiculopathy lumbar disc herniation (LDH), patients with mechanical LBP, and healthy individuals.

METHODS

The study included 35 patients with mechanical LBP, 38 patients with non-radiculopathy LDH, and a control group of 36 healthy participants. In all patients and the control group, evaluations were made on axial magnetic resonance imaging slices at L3-S1 level of the LMF and LES cross-sectional areas (CSA), total CSA (TCSA = LMF+LES), fat infiltrations and asymmetries.

RESULTS

The mean CSA values of the right and left LMF and LES showed significant differences between the groups (p< 0.001, p= 0.002, p= 0.002, p= 0.010, respectively). Fat infiltrations showed a difference between the right-left LMF and left LES groups (p= 0.007, p< 0.001, p= 0.026, respectively). Asymmetry was not observed between the CSA and TCSA of the right and left sides.

CONCLUSION

A correlation was found between fat infiltration in the LMF and mechanical LBP and LDH. However, no significant correlation was determined between LBP and the CSA and TCSA of the LMF and LES. This was thought to be due to an incorrect result of CSA and TCSA in the evaluation of muscle mass. Therefore, for a more accurate evaluation of muscle mass, it can be considered necessary to measure muscle atrophy associated with fat infiltration or functional CSA.

The 5-factor modified Frailty Index (mFI-5) predicts adverse outcomes after elective Anterior Lumbar Interbody Fusion (ALIF)

Background

The 5-factor modified frailty index (mFI-5) has been shown to be a concise and effective tool for predicting adverse events following various spine procedures. However, there have been no studies assessing its utility in patients undergoing anterior lumbar interbody fusion (ALIF). Therefore, the aim of this study was to analyze the predictive capabilities of the mFI-5 for 30-day postoperative adverse events following elective ALIF.

Methods

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2010 through 2019 to identify patients who underwent elective ALIF using Current Procedural Terminology (CPT) codes in patients over the age of 50. The mFI-5 score was calculated using variables for hypertension, congestive heart failure, comorbid diabetes, chronic obstructive pulmonary disease, and partially or fully dependent functional status which were each assigned 1 point. Univariate analysis and multivariate logistic regression models were utilized to identify the associations between mFI-5 scores, and 30-day rates of overall complications, readmissions, reoperations, and mortality.

Results

11,711 patients were included (mFI-5=0: 4,026 patients, mFI-5=1: 5,392, mFI-5=2: 2,102, mFI-5=3+: 187. Multivariate logistic regression revealed that mFI-5 scores of 1 (OR: 2.2, CI: 1.2-4.2, p=0.02), 2 (OR: 3.6, CI: 1.8-7.3, p<0.001), and 3+ (OR: 7.0, CI: 2.5-19.3, p<0.001) versus a score of 0 were significant predictors of pneumonia. An mFI-5 score of 2 (OR: 1.3; CI: 1.01-1.6, p=0.04), and 3+ (OR: 1.9; CI: 1.1-3.1; p=0.01) were both independent predictors of related readmissions. An mFI score of 3+ was an independent predictor of any complication (OR: 1.5, CI: 1.01-2.2, p=0.004), UTI (OR: 2.4, CI: 1.1-5.2, p=0.02), and unplanned intubation (OR: 4.5, CI: 1.3-16.1, p=0.02).

Conclusions

The mFI-5 is an independent predictor for 30-day postoperative complications, readmissions, UTI, pneumonia, and unplanned intubations following elective ALIF surgery in adults over the age of 50.

Real-world economic and clinical outcomes associated with current hemostatic matrix use in spinal surgery

Aim: Bleeding during spine surgery is controlled using topical hemostatic agents. Studies have reported outcomes between Surgiflo^® and Floseal, the most widely used flowable hemostatic matrices, but have not included the latest Surgiflo formulation which is more adherent to the bleeding surface than prior formulations. Materials & methods: A propensity score-matched analysis was conducted using the Premier Healthcare Database to compare economic and clinical outcomes of adults undergoing inpatient spinal surgery between 2013 and 2018 receiving current Surgiflo or Floseal. Results: This retrospective study included 28,910 patients in each group and found comparable outcomes for bleeding events, overall transfusion rate, inpatient mortality and readmissions between Surgiflo and Floseal. Surgiflo was associated with $430 (USD) lower hospitalization costs, shorter length of stay and shorter operating room time than Floseal.

How to start an awake spine program: Protocol and illustrative cases

Surgical techniques and technology are steadily improving, thereby expanding the pool of patients amenable for spine surgery. The growing and aging population in the United States further contributes to the increase in spine surgery cases. Traditionally, spine surgery is performed under general anesthesia. However, awake spinal surgery has recently gained traction due to evidence of decreased perioperative risks, postoperative opioid consumption, and costs, specifically in lumbar spine procedures. Despite the potential for improving outcomes, awake spine surgery has received resistance and has yet to become adopted at many healthcare systems. We aim to provide the fundamental steps in facilitating the initiation of awake spine surgery programs. We also present case reports of two patients who underwent awake spine surgery and reported improved clinical outcomes.

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Starting an Awake Spine program is feasible and may improve clinical outcomes.

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Awake Spine Surgery is associated with reduced cardiopulmonary complications and opioid consumption.

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Awake Spine Surgery is effective at reducing LOS, HAC, and cost of surgery.

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Awake Spine Surgery increases the pool of patients eligible for spinal procedures.

Geriatric relationship with inpatient opioid consumption and hospital outcomes after open posterior spinal fusion for adult spine deformity

OBJECTIVE

As the population ages, increasing attention has been placed on identifying risk factors for poor surgical outcomes in the elderly. The aim of this study was to assess the impact of geriatric status on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity.

METHODS

A retrospective study was performed using the Premier Healthcare Database (2016-2017). All adult patients who underwent thoracic/thoracolumbar fusion for spine deformity were identified using ICD-10-CM codes. Patients were categorized by age: 18-49 years-old (Young), 50-64 years-old (Older), and 65 + years-old (Geriatric). Patient demographics, comorbidities, hospital characteristics, intraoperative variables, adverse events (AEs), and healthcare resource utilization were assessed. Increased inpatient opioid use was categorized by MME (morphine milligram equivalents) admission consumption greater than the 75th percentile of the cohort. Multivariate logistic regression analysis was used to identify independent predictors of increased opioid usage, increased cost, and non-routine discharge (NRD).

RESULTS

Of the 1831 patients identified, 199 (10.9 %) were in the Young cohort, 599 (32.7 %) were in the Older cohort, and 1033 (56.4 %) were in the Geriatric cohort. The Geriatric cohort had a greater proportion of patients who were Non-Hispanic White (p < 0.001) and government-insured (p < 0.001). Comorbidities [CCI (p < 0.001)] and frailty [mFI-5 (p < 0.001)] increased with age. AEs occurred at similar rates between cohorts. A greater proportion of Older patients consumed an increased amount of MMEs during their hospital stay (Young: 24.9 % vs. Older: 33.1 % vs. Geriatric: 20.2 %, p < 0.001). A greater proportion of Geriatric patients experienced high costs (p = 0.018), longer LOS (p = 0.011), and 30-day readmission (p = 0.004) compared to other cohorts. A significantly greater proportion of the Geriatric cohort experienced NRD (Young: 25.3 % vs. Older: 58.8 % vs. Geriatric: 83.0 %, p < 0.001) On multivariate analysis, Geriatric age was independently associated with NRD (OR: 11.59, p < 0.001), and inversely associated with increased MME use (OR: 0.66, p = 0.038). However, Older age was independently associated with increased MME use (OR: 1.58, p = 0.026) and NRD (OR: 4.27, p < 0.001), though not increased cost (OR: 1.49, p = 0.077).

CONCLUSION

Our study demonstrates that geriatric patients may require fewer opioids than younger patients but require greater resource utilization on discharge. Additional studies investigating the impact of aging are necessary to improve patient risk stratification, healthcare delivery, and patient outcomes.

Patient-reported outcome measures in spine surgery: A systematic review

Background

Steadily increasing expenditure in the United States health-care system has led to a shift toward a value-based model that focuses on quality of care and cost-effectiveness. Operations involving the spine rank among some of the most common and expensive procedures performed in operating rooms nationwide. Patient-reported outcomes measures (PROMs) are a useful tool for reporting levels of outcome and analyzing patient recovery but are both under-utilized and nonstandardized in spine surgery.

Methods

We conducted a systematic review of the literature using the PubMed database, focusing on the most commonly utilized PROMs for spine disease as well as spinal deformity. The benefits and drawbacks of these PROMs were then summarized and compared.

Results

Spine-specific PROMs were based on the class of disease. The most frequently utilized PROMs were the Neck Disability Index and the modified Japanese Orthopaedic Association scale; the Oswestry Disability Index and the Roland-Morris Disability Questionnaire; and the Scoliosis Research Society 22-item questionnaire (SRS-22) for cervicothoracic spine disease, lumbar spine disease, and spinal deformity, respectively.

Conclusion

We found limited, though effective, use of PROMs targeting specific classes of disease within spine surgery. Therefore, we advocate for increased use of PROMs in spine surgery, in both the research and clinical settings. PROM usage can help physicians assess subjective outcomes in standard ways that can be compared across patients and institutions, more uniquely tailor treatment to individual patients, and engage patients in their own medical care.

Octogenarians Are Independently Associated With Extended LOS and Non-Routine Discharge After Elective ACDF for CSM

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the impact age has on LOS and discharge disposition following elective ACDF for cervical spondylotic myelopathy (CSM).

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) database from 2016 and 2017. All adult patients >50 years old undergoing ACDF for CSM were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then stratified by age: 50 to 64 years-old, 65 to 79 years-old, and greater than or equal to 80 years-old. Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total cost of admission were assessed.

RESULTS

A total of 14 865 patients were identified. Compared to the 50-64 and 65-79 year-old cohorts, the 80+ years cohort had a significantly higher rate of postoperative complication (50-64 yo:10.2% vs. 65-79 yo:12.6% vs. 80+ yo:18.9%, P = 0.048). The 80+ years cohort experienced significantly longer hospital stays (50-64 yo: 2.0 ± 2.4 days vs. 65-79 yo: 2.2 ± 2.8 days vs. 80+ yo: 2.3 ± 2.1 days, P = 0.028), higher proportion of patients with extended LOS (50-64 yo:18.3% vs. 65-79 yo:21.9% vs. 80+ yo:28.4%, P = 0.009), and increased rates of non-routine discharges (50-64 yo:15.1% vs. 65-79 yo:23.0% vs. 80+ yo:35.8%, P < 0.001). On multivariate analysis, age 80+ years was found to be a significant independent predictor of extended LOS [OR:1.97, 95% CI:(1.10,3.55), P = 0.023] and non-routine discharge [OR:2.46, 95% CI:(1.44,4.21), P = 0.001].

CONCLUSIONS

Our study demonstrates that octogenarian age status is a significant independent risk factor for extended LOS and non-routine discharge after elective ACDF for CSM.

Treatment of Hepatitis C Virus Prior to Posterior Lumbar Fusion: No Difference in Medical Outcomes or Reoperation

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To analyze and confirm the rates of postoperative complications of patients with hepatitis C virus (HCV) undergoing primary posterior lumbar fusion (PLF) and assess whether treatment of HCV before surgery reduces complications.

BACKGROUND CONTEXT

HCV causes chronic disease, leading to increased risk of cirrhosis and chronic illness. Currently, there is a lack of research regarding whether the patient's HCV is a modifiable risk factor for postoperative complications after spinal procedures.

METHODS

The Mariner database was utilized to find patients from 2010 to 2018 undergoing PLF with active follow-up for a year. Cases involving same-day revision procedures and patients with a history of spine, infection, trauma, human immunodeficiency virus, hepatitis B, or neoplasm were excluded. Patients with a history of HCV diagnosis were identified and further stratified whether they had prior treatment using the national drug codes for antiviral, interferons, or ribavirin. Patients with HCV were matched with those without respect to age, sex, and comorbidity of burden. Outcome measured included 90-day medical complications, infection, readmission, and 1-year reoperation.

RESULTS

There were 2,129 patients with HCV and 10,544 patients in the matched control group who underwent primary PLF. Out of the 2,129 patients, 469 (22.0.%) were treated with HCV medications before surgery. Patients with prior history of HCV had a significantly increased risk of wound complications (4.4% vs. 3.2%, odds ratio 1.56, 95% confidence interval 1.24-1.96, P=0.009), and infection (7.7% vs. 5.7%, odds ratio 1.26, 95% confidence interval 1.07-1.53, P=0.009) within 90 days of surgery. Patients treated before surgery did not have a difference in major (P=0.205) or minor medical complications (P=0.681) after surgery.

CONCLUSIONS

Patients with prior history of HCV are at increased risk for many complications after surgery; however, this risk factor does not seem to be modifiable as the treatment group did not experience any improvement in postoperative outcomes.

LEVEL OF EVIDENCE

Level III.

Hospital Frailty Risk Score and healthcare resource utilization after surgery for metastatic spinal column tumors

OBJECTIVE

The Hospital Frailty Risk Score (HFRS) was developed utilizing ICD-10 diagnostic codes to identify frailty and predict adverse outcomes in large national databases. While other studies have examined frailty in spine oncology, the HFRS has not been assessed in this patient population. The aim of this study was to examine the association of HFRS-defined frailty with complication rates, length of stay (LOS), total cost of hospital admission, and discharge disposition in patients undergoing spine surgery for metastatic spinal column tumors.

METHODS

A retrospective cohort study was performed using the years 2016 to 2019 of the National Inpatient Sample (NIS) database. All adult patients (≥ 18 years old) undergoing surgical intervention for metastatic spinal column tumors were identified using the ICD-10-CM diagnostic codes and Procedural Coding System. Patients were categorized into the following three cohorts based on their HFRS: low frailty (HFRS < 5), intermediate frailty (HFRS 5-15), and high frailty (HFRS > 15). Patient demographics, comorbidities, treatment modality, perioperative complications, LOS, discharge disposition, and total cost of hospital admission were assessed. A multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, nonroutine discharge, and increased cost.

RESULTS

Of the 11,480 patients identified, 7085 (61.7%) were found to have low frailty, 4160 (36.2%) had intermediate frailty, and 235 (2.0%) had high frailty according to HFRS criteria. On average, age increased along with progressively worsening frailty scores (p ≤ 0.001). The proportion of patients in each cohort who experienced ≥ 1 postoperative complication significantly increased along with increasing frailty (low frailty: 29.2%; intermediate frailty: 53.8%; high frailty: 76.6%; p < 0.001). In addition, the mean LOS (low frailty: 7.9 ± 5.0 days; intermediate frailty: 14.4 ± 13.4 days; high frailty: 24.1 ± 18.6 days; p < 0.001), rate of nonroutine discharge (low frailty: 40.4%; intermediate frailty: 60.6%; high frailty: 70.2%; p < 0.001), and mean total cost of hospital admission (low frailty: $48,603 ± $29,979; intermediate frailty: $65,271 ± $43,110; high frailty: $96,116 ± $60,815; p < 0.001) each increased along with progressing frailty. On multivariate regression analysis, intermediate and high frailty were each found to be significant predictors of both prolonged LOS (intermediate: OR 3.75 [95% CI 2.96-4.75], p < 0.001; high: OR 7.33 [95% CI 3.47-15.51]; p < 0.001) and nonroutine discharge (intermediate: OR 2.05 [95% CI 1.68-2.51], p < 0.001; high: OR 5.06 [95% CI 1.93-13.30], p = 0.001).

CONCLUSIONS

This study is the first to use the HFRS to assess the impact of frailty on perioperative outcomes in patients with metastatic bony spinal tumors. Among patients with metastatic bony spinal tumors, frailty assessed using the HFRS was associated with longer hospitalizations, more nonroutine discharges, and higher total hospital costs.

Minimally Invasive Spine Surgery: An Overview

Spinal surgery is undergoing a major transformation toward a minimally invasive paradigm. This shift is being driven by multiple factors, including the need to address spinal problems in an older and sicker population, as well as changes in patient preferences and reimbursement patterns. Increasingly, minimally invasive surgical techniques are being used in place of traditional open approaches due to significant advancements and implementation of intraoperative imaging and navigation technologies. However, in some patients, due to specific anatomic or pathologic factors, minimally invasive techniques are not always possible. Numerous algorithms have been described, and additional efforts are underway to better optimize patient selection for minimally invasive spinal surgery (MISS) procedures in order to achieve optimal outcomes. Numerous unique MISS approaches and techniques have been described, and several have become fundamental. Investigators are evaluating combinations of MISS techniques to further enhance the surgical workflow, patient safety, and efficiency.