Publications by authors named "Aaron J Buckland"

89 Publications

Clinical photographs in the assessment of adult spinal deformity: a comparison to radiographic parameters.

J Neurosurg Spine 2021 May 14:1-5. Epub 2021 May 14.

Objective: The goal of this study was to reliably predict sagittal and coronal spinal alignment with clinical photographs by using markers placed at easily localized anatomical landmarks.

Methods: A consecutive series of patients with adult spinal deformity were enrolled from a single center. Full-length standing radiographs were obtained at the baseline visit. Clinical photographs were taken with reflective markers placed overlying C2, S1, the greater trochanter, and each posterior-superior iliac spine. Sagittal radiographic parameters were C2 pelvic angle (CPA), T1 pelvic angle (TPA), and pelvic tilt. Coronal radiographic parameters were pelvic obliquity and T1 coronal tilt. Linear regressions were performed to evaluate the relationship between radiographic parameters and their photographic "equivalents." The data were reanalyzed after stratifying the cohort into low-body mass index (BMI) (< 30) and high-BMI (≥ 30) groups. Interobserver and intraobserver reliability was assessed for clinical measures via intraclass correlation coefficients (ICCs).

Results: A total of 38 patients were enrolled (mean age 61 years, mean BMI 27.4 kg/m2, 63% female). All regression models were significant, but sagittal parameters were more closely correlated to photographic parameters than coronal measurements. TPA and CPA had the strongest associations with their photographic equivalents (both r2 = 0.59, p < 0.001). Radiographic and clinical parameters tended to be more strongly correlated in the low-BMI group. Clinical measures of TPA and CPA had high intraobserver reliability (all ICC > 0.99, p < 0.001) and interobserver reliability (both ICC > 0.99, p < 0.001).

Conclusions: The photographic measures of spinal deformity developed in this study were highly correlated with their radiographic counterparts and had high inter- and intraobserver reliability. Clinical photography can not only reduce radiation exposure in patients with adult spinal deformity, but also be used to assess deformity when full-spine radiographs are unavailable.
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http://dx.doi.org/10.3171/2020.11.SPINE201732DOI Listing
May 2021

The Ankle-Pelvic Angle (APA) and Global Lower Extremity Angle (GLA): Summary Measurements of Pelvic and Lower Extremity Compensation.

Int J Spine Surg 2021 Feb 12;15(1):130-136. Epub 2021 Feb 12.

Hospital for Joint Diseases at NYU Langone Medical Center, New York, New York.

Background: Adult sagittal spinal deformity (SSD) leads to the recruitment of compensatory mechanisms to maintain standing balance. After regional spinal compensation is exhausted, lower extremity compensation is recruited. Knee flexion, ankle flexion, and sacrofemoral angle increase to drive pelvic shift posterior and increase pelvic tilt. We aim to describe 2 summary angles termed ankle-pelvic angle (APA) and global lower extremity angle (GLA) that incorporate all aspects of lower extremity and pelvic compensation in a comprehensive measurement that can simplify radiographic analysis.

Methods: Full-body sagittal stereotactic radiographs were retrospectively collected and digitally analyzed. Spinal and lower extremity alignment were quantified with existing measures. Two angles-APA and GLA-were drawn as geometrically complementary angles to T1-pelvic angle (TPA) and global sagittal axis (GSA), respectively. Regression analysis was used to represent the predictive relationship between TPA and APA and between GSA and GLA.

Results: A total of 518 propensity score-matched patient records were available for analysis. Patients with lower extremity compensation had higher APA (21.83° versus 19.47°, = .007) and GLA (6.03° versus 1.19°, < .001) than those without compensation. APA and GLA demonstrated strong correlation with TPA ( = 0.81) and GSA ( = 0.77), respectively. Furthermore, the change between preoperative and postoperative values were strongly correlative between ΔAPA and ΔTPA ( = 0.71) and between ΔGLA and ΔGSA ( = 0.77). APA above 20.6° and GLA above 3.6° were indicative of lower extremity compensation. Patients with increased GLA values had significantly higher Oswestry Disability Index scores (48.67 versus 41.04, = .005).

Conclusions: TPA and GSA are measures of global spinal alignment and APA and GLA, respectively, and are geometrically complementary angles that vary proportionately to SSD and balance the body. APA and GLA increase in SSD patients with lower extremity compensation and decrease with corrective surgery.

Level Of Evidence: 4.

Clinical Relevance: APA and GLA offer a concise and simple method of communicating pelvic and lower extremity compensation.
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http://dx.doi.org/10.14444/8017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931699PMC
February 2021

The Patient-Reported Outcome Measurement Information System (PROMIS) Better Reflects the Impact of Length of Stay and the Occurrence of Complications Within 90 Days Than Legacy Outcome Measures for Lumbar Degenerative Surgery.

Int J Spine Surg 2021 Feb 12;15(1):82-86. Epub 2021 Feb 12.

Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York.

Background: The Patient-Reported Outcome Measurement Information System (PROMIS) and legacy outcome measures like the Oswestry Disability Index (ODI) have not been compared for their sensitivity in reflecting the impact of perioperative complications and length of stay (LOS) in a surgical thoracolumbar population. The purpose of this study is to assess the strength of PROMIS and ODI scores as they correlate with LOS and complication outcomes of surgical thoracolumbar patients.

Methods: Retrospective cohort study. Included: patients ≥18 years undergoing thoracolumbar surgery with available preoperative and 3-month postoperative ODI and PROMIS scores. Pearson correlation assessed the linear relationships between LOS, complications, and scores for PROMIS (physical function, pain intensity, pain interference) and ODI. Linear regression predicted the relationship between complication incidence and scores for ODI and PROMIS.

Results: Included: 182 patients undergoing thoracolumbar surgery. Common diagnoses were stenosis (62.1%), radiculopathy (48.9%), and herniated disc (47.8%). Overall, 58.3% of patients underwent fusion, and 50.0% underwent laminectomy. Patients showed preoperative to postoperative improvement in ODI (50.2 to 39.0), PROMIS physical function (10.9 to 21.4), pain intensity (92.4 to 78.3), and pain interference (58.4 to 49.8, all < .001). Mean LOS was 2.7 ± 2.8 days; overall complication rate was 16.5%. Complications were most commonly cardiac, neurologic, or urinary (all 2.2%). Whereas preoperative to postoperative changes in ODI did not correlate with LOS, changes in PROMIS pain intensity ( = 0.167, = .024) and physical function ( = -0.169, = .023) did. Complications did not correlate with changes in ODI or PROMIS score; however, postoperative scores for physical function ( = -0.205, = .005) and pain interference ( = 0.182, = .014) both showed stronger correlations with complication occurrence than ODI ( = 0.143, = .055). Regression analysis showed postoperative physical function ( = 0.037, = .005) and pain interference ( = 0.028, = .014) could predict complications; ODI could not.

Conclusions: PROMIS domains of physical function and pain interference better reflected perioperative complications and LOS than the ODI. These results suggest PROMIS may offer more utility as an outcomes assessment instrument.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/8011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931701PMC
February 2021

A Simpler, Modified Frailty Index Weighted by Complication Occurrence Correlates to Pain and Disability for Adult Spinal Deformity Patients.

Int J Spine Surg 2020 Dec;14(6):1031-1036

Department of Orthopedics, Hospital for Special Surgery, New York, New York.

Background: The Miller et al adult spinal deformity frailty index (ASD-FI) correlates with complication risk; however, its development was not rooted in clinical outcomes, and the 40 factors needed for its calculation limit the index's clinical utility. The present study aimed to develop a simplified, weighted frailty index for ASD patients METHODS: This study is a retrospective review of a single-center database. Component ASD-FI parameters contributing to overall ASD-FI score were assessed via Pearson correlation. Top significant, clinically relevant factors were regressed against ASD-FI score to generate the modified ASD-FI (mASD-FI). Component mASD-FI factors were regressed against incidence of medical complications, and factor weights were calculated from regression of these coefficients. Total mASD-FI score ranged from 0 to 21, and was calculated by summing weights of expressed parameters. Linear regression and published ASD-FI cutoffs generated corresponding mASD-FI frailty cutoffs: not frail (NF, <7), frail (7-12), severely frail (SF, >12). Analysis of variance assessed the relationship between frailty category and validated baseline measures of pain and disability at baseline.

Results: The study included 50 ASD patients. Eight factors were included in the mASD-FI. Overall mean mASD-FI score was 5.7 ± 5.2. Combined, factors comprising the mASD-FI showed a trend of predicting the incidence of medical complications (Nagelkerke = 0.558; Cox & Snell = 0.399; = .065). Breakdown by frailty category is NF (70%), frail (12%), and SF (18%). Increasing frailty category was associated with significant impairments in measures of pain and disability: Oswestry Disability Index (NF: 23.4; frail: 45.0; SF: 49.3; < .001), SRS-22r (NF: 3.5; frail: 2.6; SF: 2.4; = .001), Pain Catastrophizing Scale (NF: 41.9; frail: 32.4; SF: 27.6; < .001), and NRS Leg Pain (NF: 2.3; frail: 7.2; SF: 5.6; = .001).

Conclusions: This study modifies an existing ASD frailty index and proposes a weighted, shorter mASD-FI. The mASD-FI relies less on patient-reported variables, and it weights component factors by their contribution to adverse outcomes. Because increasing mASD-FI score is associated with inferior clinical measures of pain and disability, the mASD-FI may serve as a valuable tool for preoperative risk assessment.
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http://dx.doi.org/10.14444/7154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872408PMC
December 2020

Trends in Pain Medication Prescriptions and Satisfaction Scores in Spine Surgery Patients at a Single Institution.

Int J Spine Surg 2020 Dec;14(6):1023-1030

Department of Orthopedics, NYU Langone Orthopedic Hospital, New York University, New York, NY.

Background: As the opioid crisis has gained national attention, there have been increasing efforts to decrease opioid usage. Simultaneously, patient satisfaction has been a crucial metric in the American health care system and has been closely linked to effective pain management in surgical patients. The purpose of this study was to examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients.

Methods: A total of 1729 patients undergoing spine surgery between June 25, 2017, and June 30, 2018, at a single institution by surgeons performing ≥20 surgeries per quarter, with medication data during hospitalization available, were assessed. Patients were evaluated for nonopioid pain medication prescription rates and morphine milligram equivalents (MME) of opioids used during hospitalization. Of the total cohort, 198 patients were evaluated for Press Ganey Satisfaction Survey responses. A χ test of independence was used to compare percentages, and 1-way analysis of variance was used to compare means across quarters.

Results: The mean total MME per patient hospitalization was 574.46, with no difference between quarters. However, mean MME per day decreased over time ( = .048), with highest mean 91.84 in Quarter 2 and lowest 77.50 in Quarter 4. Among all procedures, acetaminophen, nonsteroidal anti-inflammatory drugs, and steroid prescription rates increased, whereas benzodiazepine and γ-aminobutyric acid-analog prescriptions decreased. There were no significant differences between quarters for mean hospital ratings ( = .521) nor for responses to questions from the Press Ganey Satisfaction Survey regarding how often staff talk about pain ( = .164), how often staff talk about pain treatment ( = .595), or whether patients recommended the hospital ( = .096). There were also no differences between quarters for responses in all other patient satisfaction questions ( value range, .359-.988).

Conclusions: Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, whereas satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use among providers and suggest the ability to do so without affecting overall satisfaction rates.

Level Of Evidence: 4.

Clinical Relevance: The opioid epidemic has highlighted the need to reduce opioid usage in orthopedic spine surgery. This study reviews the trends for inpatient management of post-op pain in orthopedic spine surgery patients in relation to patient satisfaction. There was a significant increase in non-opioid analgesic pain medications, and a reduction in opioids during the study period. During this time, patient satisfaction as measured by Press-Ganey surveys did not show a decrease. This demonstrates that treatment of post-operative pain in orthopedic spine surgery patients can be managed with less opioids, more multimodal analgesia, and patient satisfaction will not be affected.
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http://dx.doi.org/10.14444/7153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872404PMC
December 2020

Residual lumbar hyperlordosis is associated with worsened hip status 5 years after scoliosis correction in non-ambulant patients with cerebral palsy.

Spine Deform 2021 Feb 1. Epub 2021 Feb 1.

Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.

Background: Cerebral palsy (CP) is a static encephalopathy with progressive musculoskeletal pathology. Non-ambulant children (GMFCS IV and V) with CP have high rates of spastic hip disease and neuromuscular scoliosis. The effect of spinal fusion and spinal deformity on hip dislocation following total hip arthroplasty has been well studied, however in CP this remains largely unknown. This study aimed to identify factors associated with worsening postoperative hip status (WHS) following corrective spinal fusion in children with GMFCS IV and V CP.

Methods: Retrospective review of GMFSC IV and V CP patients in a prospective multicenter database undergoing spinal fusion, with 5 years follow-up. WHS was determined by permutations of baseline (BL), 1 year, 2 years, and 5 years hip status and defined by a change from an enlocated hip at BL that became subluxated, dislocated or resected post-op, or a subluxated hip that became dislocated or resected. Hip status was analyzed against patient demographics, hip position, surgical variables, and coronal and sagittal spinal alignment parameters. Cutoff values for parameters at which the relationship with hip status was significant was determined using receiver operating characteristic curves. Logistic regression determined odds ratios for predictors of WHS.

Results: Eighty four patients were included. 37 (44%) had WHS postoperatively. ROC analysis and logistic regression demonstrated that the only spinopelvic alignment parameter that significantly correlated with WHS was lumbar hyperlordosis (T12-L5) > 60° (p = 0.028), OR = 2.77 (CI 1.10-6.94). All patients showed an increase in pre-to-postop LL. Change in LL pre-to-postop was no different between groups (p = 0.318), however the WHS group was more lordotic at BL and postop (pre44°/post58° vs pre32°/post51° in the no change group). Age, sex, Risser, hip position, levels fused, coronal parameters, global sagittal alignment (SVA), thoracic kyphosis, and reoperation were not associated with WHS.

Conclusion: Postoperative hyperlordosis(> 60°) is a risk factor for WHS at 5 years after spinal fusion in non-ambulant CP patients. WHS likely relates to anterior pelvic tilt and functional acetabular retroversion due to hyperlordosis, as well as loss of protective lumbopelvic motion causing anterior femoracetabular impingement.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00281-4DOI Listing
February 2021

Patient Outcomes After Single-level Coflex Interspinous Implants Versus Single-level Laminectomy.

Spine (Phila Pa 1976) 2021 Jul;46(13):893-900

NYU Langone Health, Department of Orthopedics, Division of Spine, New York, NY.

Study Design: Retrospective cohort analysis.

Objective: The aim of this study was to compare postoperative outcomes of Coflex interspinous device versus laminectomy.

Summary Of Background Data: Coflex Interlaminar Stabilization device (CID) is indicated for one- or two-level lumbar stenosis with grade 1 stable spondylolisthesis in adult patients, as an alternative to laminectomy, or laminectomy and fusion. CID provides stability against progressive spondylolisthesis, retains motion, and prevents further disc space collapse.

Methods: Patients ≥18 years' old with lumbar stenosis and grade 1 stable spondylolisthesis who underwent either primary single-level decompression and implantation of CID, or single-level laminectomy alone were included with a minimum 90-day follow-up at a single academic institution. Clinical characteristics, perioperative outcomes, and postoperative complications were reviewed until the latest follow-up. χ2 and independent samples t tests were used for analysis.

Results: Eighty-three patients (2007-2019) were included: 37 cases of single-level laminectomy (48.6% female) were compared to 46 single-level CID (50% female). CID cohort was older (CID 69.0 ± 9.4 vs. laminectomy 64.2 ± 11.0, P = 0.042) and had higher American Society of Anesthesiologists (ASA) grade (CID 2.59 ± 0.73 vs. laminectomy 2.17 ± 0.48, P = 0.020). CID patients had higher estimated blood loss (EBL) (97.50 ± 77.76 vs. 52.84 ± 50.63 mL, P = 0.004), longer operative time (141.91 ± 47.88 vs. 106.81 ± 41.30 minutes, P = 0.001), and longer length of stay (2.0 ± 1.5 vs. 1.1 ± 1.0 days, P = 0.001). Total perioperative complications (21.7% vs. 5.4%, P = 0.035) and instrumentation-related complication was higher in CID (10.9% vs. 0% laminectomy group, P = 0.039). There were no other significant differences between the groups in demographics or outcomes.

Conclusion: Single-level CID devices had higher perioperative 90-day complications, longer operative time, length of stay, higher EBL compared to laminectomies alone. Similar overall revision and neurologic complication rates were noted compared to laminectomy at last follow-up.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003924DOI Listing
July 2021

Postoperative Prophylactic Antibiotics in Spine Surgery: A Propensity-Matched Analysis.

J Bone Joint Surg Am 2021 Feb;103(3):219-226

Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, New York, NY.

Background: Surgical site infections are common and costly complications after spine surgery. Prophylactic antibiotics are the standard of care; however, the appropriate duration of antibiotics has yet to be adequately addressed. We sought to determine whether the duration of antibiotic administration (preoperatively only versus preoperatively and for 24 hours postoperatively) impacts postoperative infection rates.

Methods: All patients undergoing inpatient spinal procedures at a single institution from 2011 to 2018 were evaluated for inclusion. A minimum of 1 year of follow-up was used to adequately capture postoperative infections. The 1:1 nearest-neighbor propensity score matching technique was used between patients who did and did not receive postoperative antibiotics, and multivariable logistic regression analysis was conducted to control for confounding.

Results: A total of 4,454 patients were evaluated and, of those, 2,672 (60%) received 24 hours of postoperative antibiotics and 1,782 (40%) received no postoperative antibiotics. After propensity-matched analysis, there was no difference between patients who received postoperative antibiotics and those who did not in terms of the infection rate (1.8% compared with 1.5%). No significant decrease in the odds of postoperative infection was noted in association with the use of postoperative antibiotics (odds ratio = 1.17; 95% confidence interval, 0.620 to 2.23; p = 0.628). Additionally, there was no observed increase in the risk of Clostridium difficile infection or in the short-term rate of infection with multidrug-resistant organisms.

Conclusions: There was no difference in the rate of surgical site infections between patients who received 24 hours of postoperative antibiotics and those who did not. Additionally, we found no observable risks, such as more antibiotic-resistant infections and C. difficile infections, with prolonged antibiotic use.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.00934DOI Listing
February 2021

Lewinnek Safe Zone References are Frequently Misquoted.

Arthroplast Today 2020 Dec 26;6(4):945-953. Epub 2020 Nov 26.

Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA.

Background: Optimal acetabular component orientation in total hip arthroplasty (THA) is a necessity in achieving a stable implant. Although there has been considerable debate in the literature concerning the safe zone, to date, there has not been any review to determine if these references are consistent with the definition applied by Lewinnek et al. in 1978. Therefore, this article aims to examine the available literature in the PubMed database to determine how often a correct reference to the safe zone as defined by Lewinnek was applied to discussions regarding THA.

Methods: A search for literature in the PubMed database was performed for articles from 1978 to 2019. Search criteria included terms 'Lewinnek,' 'safe zone,' and 'total hip arthroplasty.' Exclusions included abstract-only articles, non-English articles, articles unrelated to THA, and those lacking full content.

Results: A review of literature yielded 147 articles for inclusion. Overall, only 11% (17) cited the Lewinnek article correctly. Forty-five percent (66) of articles referenced measurements in the supine position, 18% (26) referenced other positions, and 37% (55) did not specify. Nineteen percent (28) reported measurements of the acetabular cup orthogonal to the anterior pelvic plane, while 73% (108) did not, and 7% (11) did not specify. Twenty-three percent (34) measured from computed tomography scans instead of other methods.

Conclusions: In the discussion of the safe zone regarding THA, only 11% of articles listed are consistent with the definition established by Lewinnek. This warrants further investigation into a consistent application of the term and its implications for THA implant stability and dislocation rates.
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http://dx.doi.org/10.1016/j.artd.2020.09.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7701843PMC
December 2020

Single position circumferential fusion improves operative efficiency, reduces complications and length of stay compared with traditional circumferential fusion.

Spine J 2021 May 13;21(5):810-820. Epub 2020 Nov 13.

Atlantic Neurosurgical and Spine Specialists, Wilmington, 2208 S 17th St, NC 28401, USA.

Background Context: Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) with percutaneous posterior screw fixation are two techniques used to address degenerative lumbar pathologies. Traditionally, these anterior-posterior (AP) surgeries involve repositioning the patient from the supine or lateral decubitus position to prone for posterior fixation. To reduce operative time (OpTime) and subsequent complications of prolonged anesthesia, single-position lumbar surgery (SPLS) is a novel, minimally invasive alternative performed entirely from the lateral decubitus position.

Purpose: Assess the perioperative safety and efficacy of single position AP lumbar fusion surgery (SPLS).

Study Design: Multicenter retrospective cohort study.

Patient Sample: Three hundred and ninety patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group.

Outcome Measures: Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence, pelvic tilt, and segmental LL.

Methods: Patients undergoing primary ALIF and/or LLIF surgery with bilateral percutaneous pedicle screw fixation between L2-S1 were included over a 4-year period. Patients were classified as either traditional repositioned "Flip" surgery or SPLS. Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, EBL, LOS, perioperative complications. Radiographic analysis included LL, pelvic incidence, pelvic tilt, and segmental LL. All measures were compared using independent samples t-tests and chi-squared analyses as appropriate with significance set at p < .05. Propensity matching was completed where demographic differences were found.

Results: Three hundred and ninety patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group. Age, gender, BMI, and CCI were similar between groups. Levels fused (1.47 SPLS vs 1.52 Flip, p = .468) and percent cases including L5-S1 (31% SPLS, 35% Flip, p = .405) were similar between cohorts. SPLS significantly reduced OpTime (103 min vs 306 min, p < .001), EBL (97 vs 313 mL, p < .001), LOS (1.71 vs 4.12 days, p < .001), and fluoroscopy radiation dosage (32 vs 88 mGy, p < .001) compared to Flip. Perioperative complications were similar between cohorts with the exception of postoperative ileus, which was significantly lower in the SPLS group (0% vs 5%, p < .001). There was no significant difference in wound, vascular injury, neurological complications, or Venous Thrombotic Event. There was no significant difference found in 90-day return to operating room (OR).

Conclusions: SPLS improves operative efficiency in addition to reducing blood loss, LOS and ileus in this large cohort study, while maintaining safety.
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http://dx.doi.org/10.1016/j.spinee.2020.11.002DOI Listing
May 2021

A cost utility analysis of treating different adult spinal deformity frailty states.

J Clin Neurosci 2020 Oct 27;80:223-228. Epub 2020 Aug 27.

Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA. Electronic address:

The aim of this study was to investigate the cost utility of treating non-frail versus frail or severely frail adult spinal deformity (ASD) patients. 79 surgical ASD patients >18 years with available frailty and ODI data at baseline and 2-years post-surgery (2Y) were included. Utility data was calculated using the ODI converted to the SF-6D. QALYs utilized a 3% discount rate to account for decline to life expectancy (LE). Costs were calculated using the PearlDiver database. ICER was compared between non-operative (non-op.) and operative (op.) NF and F/SF patients at 2Y and LE. When compared to non-operative ASD, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2Y, and $68,311.35 vs. $47,764.61 for NF and F/SF at LE. Frail and severely frail patients had lower cost per QALY compared to not frail patients at 2Y and life expectancy, and had lower ICER values when compared to a non-operative cohort of ASD patients. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. Furthermore, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow up times, these findings support the cost effectiveness of ASD surgery at all frailty states.
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http://dx.doi.org/10.1016/j.jocn.2020.07.047DOI Listing
October 2020

A cost benefit analysis of increasing surgical technology in lumbar spine fusion.

Spine J 2021 Feb 15;21(2):193-201. Epub 2020 Oct 15.

Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.

Background Context: Numerous advances have been made in the field of spine fusion, such as minimally invasive (MIS) or robotic-assisted spine surgery. However, it is unknown how these advances have impacted the cost of care.

Purpose: Compare the economic outcomes of lumbar spine fusion between open, MIS, and robot-assisted surgery patients.

Study Design/setting: Retrospective review of a single center spine surgery database.

Patient Sample: Three hundred sixty propensity matched patients.

Outcome Measures: Costs, EuroQol-5D (EQ5D), cost per quality adjusted life years (QALY).

Methods: Inclusion criteria: surgical patients >18 years undergoing lumbar fusion surgery. Patients were categorized into 3 groups based on procedure type: open, MIS, or robotic. Open patients undergoing poster spinal fusion were considered as the control group. MIS patients included those undergoing transforaminal or lateral lumbar interbody fusion with percutaneous screws. Robotic patients were those undergoing robot-assisted fusion. Propensity score matching was performed between all groups for the number of levels fused. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims for ICD-9 codes. For robotic cases, costs were reflective of operational fees and initial purchase cost. Complications and comorbidities and major complications and comorbidities were assessed according to CMS.gov manual definitions. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs per QALY were calculated for both 1 year and life expectancy, assuming no loss of benefit. A 10,000 trial Monte Carlo simulation with probabilistic sensitivity analysis (PSA) assessed our model parameters and costs.

Results: Three hundred sixty propensity matched patients (120 open, 120 MIS, 120 robotic) met inclusion criteria. Descriptive statistics for the cohort were: age 58.8±13.5, 50% women, BMI 29.4±6.3, operative time 294.4±119.0, LOS 4.56±3.31 days, estimated blood loss 515.9±670.0 cc, and 2.3±2.2 average levels fused. Rates of post-op complications were significantly higher in robotic cases versus open and MIS (43% vs. 21% and 22% for open and MIS, p<.05). However, revision rates were comparable between all groups (3% open, 3% MIS, 5% robotic, p>.05). After factoring in complications, revisions, and purchasing and operating fees, the costs of robotic cases was significantly higher than both open and MIS surgery ($60,047.01 vs. $42,538.98 open and $41,471.21 MIS). In a subanalysis of 42 patients with baseline (BL) and 1Y EQ5D data, the cost per QALY at 1Y for open, MIS, and robot-assisted cases was $296,624.48, $115,911.69, and $592,734.30. If utility gained was sustained to life expectancy, the cost per QALY was $14,905.75, $5,824.71, $29,785.64 for open, MIS, and robot-assisted cases. Results of the PSA were consistent with MIS surgery having the most incremental cost effectiveness when compared to open and robotic surgery.

Conclusions: Numerous advances have been made in the field of spine surgery, however, there has been limited discussion of the effect these advances have on economic outcomes. When matched for levels fused, robot-assisted surgery patients had significantly higher rates of complications and 30% higher costs of surgery compared to minimally invasive and open spine surgery patients. While 1 year economic outcomes were not optimal for robotic surgery cases, the projected costs per QALYs at life expectancy were well below established acceptable thresholds. The above findings may be reflective of an educational learning curve and emerging surgical technologies undergoing progressive refinement.
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http://dx.doi.org/10.1016/j.spinee.2020.10.012DOI Listing
February 2021

Biologics and Minimally Invasive Approach to TLIFs: What Is the Risk of Radiculitis?

Int J Spine Surg 2020 Oct 12;14(5):804-810. Epub 2020 Oct 12.

Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York.

Background: Bone morphogenetic protein (BMP) and allograft containing mesenchymal stem cells (live cell) are popular biologic substitutes for iliac crest autograft used in transforaminal lumbar interbody fusion (TLIF). Use of these agents in the pathogenesis of postoperative radiculitis remains controversial. Recent studies have independently linked minimally invasive (MIS) TLIF with increased radiculitis risk compared to open TLIF. The purpose of this study was to assess the rate of postoperative radiculitis in open and MIS TLIF patients along with its relationship to concurrent biologic adjuvant use.

Methods: Patients ≥18 years undergoing single-level TLIF from June 2012 to December 2018 with minimum 1-year follow-up were included. Outcome measures were rate of radiculitis, intra- and postoperative complications, revision surgery; length of stay (LOS), and estimated blood loss (EBL).

Results: There were 397 patients: 223 with open TLIFs, 174 with MIS TLIFs. One hundred and fifty-nine surgeries used bone morphogenetic protein (BMP), 26 live cell, 212 neither. Open TLIF: higher mean EBL, LOS, and Charlson Comorbidity Index (CCI) than MIS. Postoperative radiculitis in 37 patients (9.32% overall): 16 cases MIS BMP (15.69% of their cohort), 6 MIS without BMP (8.33%), 5 open BMP (8.77%), 10 open without BMP (6.02%). MIS TLIF versus open TLIF: no differences in 1-year reoperation rates, infection/wound complication, pseudarthrosis, or postoperative complication rate. BMP versus non-BMP: no differences in reoperation rates, infection/wound complication, pseudarthrosis, or postoperative complication rate. Multivariate logistic regression found that neither BMP ( = .109) nor MIS ( = .314) was an independent predictor for postoperative radiculitis when controlled for age, gender, body mass index, and CCI. Using paired open and MIS groups (N = 168 each) with propensity score matching, these variables were still not independently associated with radiculitis ( = .174 BMP, = .398 MIS). However, the combination of MIS with BMP was associated with increased radiculitis risk in both the entire patient cohort (odds ratio [OR]: 2.259 [1.117-4.569], = .023, N = 397) and PSM cohorts (OR: 2.196 [1.045-4.616], = .038, N = 336) compared to other combinations of surgical approach and biologic use.

Conclusion: Neither the MIS approach nor BMP use is an independent risk factor for post-TLIF radiculitis. However, risk of radiculitis significantly increases when they are used in tandem. This should be considered when selecting biological adjuvants for MIS TLIF.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/7114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671460PMC
October 2020

Obesity Alters Spinopelvic Alignment Changes From Standing to Relaxed Sitting: the Influence of the Soft-tissue Envelope.

Arthroplast Today 2020 Sep 21;6(3):590-595.e1. Epub 2020 May 21.

Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.

Background: Changes in spinopelvic and lower extremity alignment between standing and relaxed sitting have important clinical implications with regard to stability of total hip arthroplasty. This study aimed to analyze the effect of body mass index (BMI) on lumbopelvic alignment and motion at the hip joint.

Methods: A retrospective review of patients who underwent full-body stereoradiographs in standing and relaxed sitting for total hip arthroplasty planning was conducted. Spinopelvic parameters measured included spinopelvic tilt (SPT), pelvic incidence (PI), lumbar lordosis (LL), PI minus LL (PI-LL), proximal femoral shaft angle (PFSA), and standing-to-sitting hip range of motion. Propensity score matching controlled for age, gender, PI, and hip ostoarthritis grade. Patients were stratified into normal (NORMAL; BMI, 18.5-24.9), overweight (OW; 25.0-29.9), and obese (OB; 30.0-34.9) groups. Alignment parameters were compared using one-way analysis of variance.

Results: There were 84 patients in each group after propensity score matching. Standing alignment between BMI groups was similar for all parameters ( > .05) except for PFSA ( < .001). Significant differences were noted for sitting alignment between patients who are NORMAL, OW, and OB in: SPT ( = .007), PI-LL ( = .018), and LL ( = .029). PFSA between groups was not significantly different ( > .05). Significant differences were found for sitting-to-standing alignment across groups in PFSA change ( < .001), SPT change ( = .006), PI-LL change ( = .005), LL change ( = .037), and hip flexion ( < .001).

Conclusions: Significant differences in sitting and standing-to-sitting change in lumbopelvic alignment based on BMI suggest obese patients recruit more posterior spinopelvic tilt when sitting to compensate for soft-tissue impingement that occurs anterior to the hip joint and limiting hip flexion.
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http://dx.doi.org/10.1016/j.artd.2020.02.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502584PMC
September 2020

Sports-related Cervical Spine Fracture and Spinal Cord Injury: A Review of Nationwide Pediatric Trends.

Spine (Phila Pa 1976) 2021 Jan;46(1):22-28

Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY.

Study Design: Retrospective cohort study.

Objective: Assess trends in sports-related cervical spine trauma using a pediatric inpatient database.

Summary Of Background Data: Injuries sustained from sports participation may include cervical spine trauma such as fractures and spinal cord injury (SCI). Large database studies analyzing sports-related cervical trauma in the pediatric population are currently lacking.

Methods: The Kid Inpatient Database was queried for patients with external causes of injury secondary to sports-related activities from 2003 to 2012. Patients were further grouped for cervical spine injury (CSI) type, including C1-4 and C5-7 fracture with/without spinal cord injury (SCI), dislocation, and SCI without radiographic abnormality (SCIWORA). Patients were grouped by age into children (4-9), pre-adolescents (Pre, 10-13), and adolescents (14-17). Kruskall-Wallis tests with post-hoc Mann-Whitney U's identified differences in CSI type across age groups and sport type. Logistic regression found predictors of TBI and specific cervical injuries.

Results: A total of 38,539 patients were identified (12.76 years, 24.5% F). Adolescents had the highest rate of sports injuries per year (P < 0.001). Adolescents had the highest rate of any type of CSI, including C1-4 and C5-7 fracture with and without SCI, dislocation, and SCIWORA (all P < 0.001). Adolescence increased odds for C1-4 fracture w/o SCI 3.18×, C1-4 fx w/ SCI by 7.57×, C5-7 fx w/o SCI 4.11×, C5-7 w/SCI 3.63×, cervical dislocation 1.7×, and cervical SCIWORA 2.75×, all P < 0.05. Football injuries rose from 5.83% in 2009 to 9.14% in 2012 (P < 0.001), and were associated with more SCIWORA (1.6% vs. 1.0%, P = 0.012), and football injuries increased odds of SCI by 1.56×. Concurrent TBI was highest in adolescents at 58.4% (pre: 26.6%, child: 4.9%, P < 0.001), and SCIWORA was a significant predictor for concurrent TBI across all sports (odds ratio: 2.35 [1.77-3.11], P < 0.001).

Conclusion: Adolescent athletes had the highest rates of upper/lower cervical fracture, dislocation, and SCIWORA. Adolescence and SCIWORA were significant predictors of concurrent TBI across sports. The increased prevalence of CSI with age sheds light on the growing concern for youth sports played at a competitive level, and supports recently updated regulations aimed at decreasing youth athletic injuries.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003718DOI Listing
January 2021

Expandable cages increase the risk of intraoperative subsidence but do not improve perioperative outcomes in single level transforaminal lumbar interbody fusion.

Spine J 2021 Jan 3;21(1):37-44. Epub 2020 Sep 3.

Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA. Electronic address:

Background Context: Expandable cages (EXP) are being more frequently utilized in transforaminal lumbar interbody fusions (TLIF). EXP were designed to reduce complications related to neurological retraction, enable better lordosis restoration, and improve ease of insertion, particularly in the advent of minimally invasive surgical (MIS) techniques, however they are exponentially more expensive than the nonexpandable (NE) alternative.

Purpose: To investigate the clinical results of expandable cages in single level TLIF.

Study Design/setting: Retrospective review at a single institution.

Patient Sample: Two hundred and fifty-two single level TLIFs from 2012 to 2018 were included.

Outcome Measures: Clinical characteristics, perioperative and neurologic complication rates, and radiographic measures.

Methods: Patients ≥18 years of age who underwent single level TLIF with minimum 1 year follow-up were included.

Outcome Measures: clinical characteristics, perioperative and neurologic complications. Radiographic analysis included pelvic incidence-lumbar lordosis (PI-LL) mismatch, segmental lumbar lordosis (LL) mismatch, disc height restoration, and subsidence ≥2 mm. Statistical analysis included independent t tests and chi-square analysis. For nonparametric variables, Mann-Whitney U test and Spearman partial correlation were utilized. Multivariate regression was performed to assess relationships between surgical variables and recorded outcomes. For univariate analysis significance was set at p<.05. Due to the multiple comparisons being made, significance for regressions was set at p<.025 utilizing Bonferroni correction.

Results: Two hundred and fifty-two TLIFs between 2012 and 2018 were included, with 152 NE (54.6% female, mean age 59.28±14.19, mean body mass index (BMI) 28.65±5.38, mean Charlson Comorbidity Index (CCI) 2.20±1.89) and 100 EXP (48% female, mean age 58.81±11.70, mean BMI 28.68±6.06, mean CCI 1.99±1.66) with no significant differences in demographics. Patients instrumented with EXP cages had a shorter length of stay (3.11±2.06 days EXP vs. 4.01±2.64 days NE; Z=-4.189, p<.001) and a lower estimated blood loss (201.31±189.41 mL EXP vs. 377.82±364.06 mL NE; Z=-6.449, p<.001). There were significantly more MIS-TLIF cases and bone morphogenic protein (BMP) use in the EXP group (88% MIS, p<.001 and 60% BMP, p<.001) as illustrated in Table 1. There were no significant differences between the EXP and NE groups in rates of radiculitis and neuropraxia. In multivariate regression analysis, EXP were not associated with a difference in perioperative outcomes or complications. Radiographic analyses demonstrated that the EXP group had a lower PI-LL mismatch than the NE cage group at baseline (3.75±13.81° EXP vs. 12.75±15.81° NE; p=.001) and at 1 year follow-up (3.81±12.84° EXP vs. 8.23±12.73° NE; p=.046), but change in regional and segmental alignment was not significantly different between groups. Multivariate regression demonstrated that EXP use was a risk factor for intraoperative subsidence (2.729[1.185-6.281]; p=.018).

Conclusions: Once technique was controlled for, TLIFs utilizing EXP do not have significantly improved neurologic or radiographic outcomes compared with NE. EXP increase risk of intraoperative subsidence. These results question the value of the EXP given the higher cost.
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http://dx.doi.org/10.1016/j.spinee.2020.08.019DOI Listing
January 2021

Radiation Exposure in Posterior Lumbar Fusion: A Comparison of CT Image-Guided Navigation, Robotic Assistance, and Intraoperative Fluoroscopy.

Global Spine J 2021 May 27;11(4):450-457. Epub 2020 Feb 27.

12297NYU Langone Orthopedic Hospital, New York, NY, USA.

Study Design: Retrospective clinical review.

Objective: To assess the use of intraoperative computed tomography (CT) image-guided navigation (IGN) and robotic assistance in posterior lumbar surgery and their relationship with patient radiation exposure and perioperative outcomes.

Methods: Patients ≥18 years old undergoing 1- to 2-level transforaminal lateral interbody fusion in 12-month period were included. Chart review was performed for pre- and intraoperative data on radiation dose and perioperative outcomes. All radiation doses are quantified in milliGrays (mGy). Univariate analysis and multivariate logistic regression analysis were utilized for categorical variables. One-way analysis of variance with post hoc Tukey test was used for continuous variables.

Results: A total of 165 patients were assessed: 12 IGN, 62 robotic, 56 open, 35 fluoroscopically guided minimally invasive surgery (MIS). There was a lower proportion of women in open and MIS groups ( = .010). There were more younger patients in the MIS group ( < .001). MIS group had the lowest mean posterior levels fused ( = .015). Total-procedure radiation, total-procedure radiation/level fused, and intraoperative radiation was the lowest in the open group and highest in the MIS group compared with IGN and robotic groups (all < .001). Higher proportion of robotic and lower proportion of MIS patients had preoperative CT ( < .001). Estimated blood loss ( = .002) and hospital length of stay ( = .039) were lowest in the MIS group. Highest operative time was observed for IGN patients ( < .001). No differences were observed in body mass index, Charlson Comorbidity Index, and postoperative complications ( = .313, .051, and .644, respectively).

Conclusion: IGN and robotic assistance in posterior lumbar fusion were associated with higher intraoperative and total-procedure radiation exposure than open cases without IGN/robotics, but significantly less than MIS without IGN/robotics, without differences in perioperative outcomes. Fluoro-MIS procedures reported highest radiation exposure to patient, and of equal concern is that the proportion of total radiation dose also applied to the surgeon and operating room staff in fluoro-MIS group is higher than in IGN/robotics and open groups.
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http://dx.doi.org/10.1177/2192568220908242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8119907PMC
May 2021

Age and Gender Confound PROMIS Scores in Spine Patients With Back and Neck Pain.

Global Spine J 2021 Apr 13;11(3):299-304. Epub 2020 Feb 13.

25061NYU Langone Health, New York, NY, USA.

Study Design: This was a single-center retrospective review.

Objectives: To explore how age and gender affect PROMIS scores compared with traditional health-related quality of life (HRQL) in spine patients.

Methods: Patients presenting with a primary complaint of back pain (BP) or neck pain (NP) were included. Legacy HRQLs were Oswestry Disability Index (ODI), Neck Disability Index (NDI), and Visual Analogue Scale (VAS). PROMIS Physical Function (PF), Pain Intensity (Int), and Pain Interference (Inf) were also administered to patients in a clinical setting. Patients were grouped by chief complaint, age (18-44, 45-64, 65+ years) and gender. Two parallel analyses were conducted to identify the effects of age and gender on patient-reported outcomes. Age groups were compared after propensity-score matching by VAS-pain and gender. Separately, genders were compared after propensity-score matching by age and VAS-pain.

Results: A total of 484 BP and 128 NP patients were matched into gender cohorts (n = 201 in each BP group, 46 in each NP group). Among BP patients, female patients demonstrated worse disability by ODI (44.15 vs 38.45, = .005); PROMIS-PF did not differ by gender. Among NP patients, neither legacy HRQLs nor PROMIS differed by gender when controlling for NP and age. BP and NP patients were matched into age cohorts (n = 135 in each BP group and n = 14 in each BP group). Among BP patients, ANOVA revealed differences between groups when controlling for BP and gender: ODI ( < .001), PROMIS-PF ( = .018), PROMIS-Int ( < .001) PROMIS-Inf ( < .001). Among NP patients, matched age groups differed significantly in terms of NDI ( = .032) and PROMIS-PF ( = .022) but not PROMIS-Int or PROMIS-Inf.

Conclusions: Age and gender confound traditional HRQLs as well as PROMIS domains. However, PROMIS offers age and gender-specific scores, which traditional HRQLs lack.
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http://dx.doi.org/10.1177/2192568220903030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013951PMC
April 2021

Applying the hip-spine relationship in total hip arthroplasty.

Hip Int 2021 Mar 12;31(2):144-153. Epub 2020 Aug 12.

Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA.

Total hip arthroplasty dislocations that occur inside Lewinnek's anatomical safe zone represent a need to better understand the hip-spine relationship. Unfortunately, the use of obtuse and redundant terminology to describe the hip-spine relationship has made it a relatively inaccessible topic in orthopaedics. However, with a few basic definitions and principles, the hip-spine relationship can be simplified and understood to prevent unnecessary dislocations following total hip arthroplasty.In the following text, we use common language to define a normal and abnormal hip-spine relationship, present an algorithm for recognising and treating a high-risk hip-spine patient, and discuss several common, high-risk hip-spine pathologies to apply these concepts. Simply, high-risk hip-spine patients often require subtle adjustments to acetabular anteversion based on radiographic evaluations and should also be considered for a high-offset stem, dual-mobility articulation, or large femoral head for additional protection against instability and dislocation.
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http://dx.doi.org/10.1177/1120700020949837DOI Listing
March 2021

Complication Risk in Primary and Revision Minimally Invasive Lumbar Interbody Fusion: A Comparable Alternative to Conventional Open Techniques?

Global Spine J 2020 Aug 5;10(5):619-626. Epub 2019 Aug 5.

NYU Langone Orthopedic Hospital, New York, NY, USA.

Study Design: Retrospective cohort study of prospective patients undergoing minimally invasive lumbar fusion at a single academic institution.

Objective: To assess differences in perioperative outcomes between primary and revision MIS (minimally invasive surgical) lumbar interbody fusion patients and compare with those undergoing corresponding open procedures.

Methods: Patients ≥18 years old undergoing lumbar interbody fusion were grouped by surgical technique: MIS or open. Patients within each group were propensity score matched for comorbidities and levels fused. Patient demographics, surgical factors, and perioperative complication incidences were compared between primary and revision cases using means comparison tests, as appropriate.

Results: Of the 214 lumbar interbody fusion patients included after propensity score matching, 44 (21%) cases were MIS, and 170 (79%) were open. For MIS patients, there were no significant differences between primary and revision cases in estimated blood loss (EBL; 344 vs 299 cm, = .682); however, primary cases had longer operative times (301 vs 246 minutes, = .029). There were no differences in length of stay (LOS), intensive care unit LOS, readmission, and intraoperative or postoperative complications (all > .05). For open patients, there were no differences between primary and revision cases in EBL ( > .05), although revisions had longer operative times (331 vs 278 minutes, = .018) and more postoperative complications (61.7% vs 23.8%, < .001). MIS revision procedures were shorter than open revisions (182 vs 213 minutes, = .197) with significantly less EBL (294 vs 965 cm, < .001), shorter inpatient and intensive care unit LOS, and fewer postoperative complications (all < .05).

Conclusions: Clinical outcomes of revision MIS lumbar interbody fusion were similar to those of primary surgery. Additionally, MIS techniques were associated with less EBL, shorter LOS, and fewer perioperative complications than corresponding open revisions.
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http://dx.doi.org/10.1177/2192568219867289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359676PMC
August 2020

The Relationship Between 3-dimensional Spinal Alignment, Thoracic Volume, and Pulmonary Function in Surgical Correction of Adolescent Idiopathic Scoliosis: A 5-year Follow-up Study.

Spine (Phila Pa 1976) 2020 Jul;45(14):983-992

Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA.

Study Design: Retrospective review of a prospective multicenter database.

Objective: The aim of this study was to study the effects of thoracic kyphosis (TK) restoration in adolescent idiopathic scoliosis (AIS) Type 1 and 2 curves on postoperative thoracic volume (TV) and pulmonary function.

Summary Of Background Data: Surgical correction of AIS is advocated to preserve or improve pulmonary function, prevent progressive deformity and pain, and improve self-appearance. Restoration of sagittal and 3D alignment, particularly TK, has become increasingly emphasized in efforts to improve pulmonary function, TVs, sagittal balance, and prevent adjacent-segment degeneration and deformity.

Methods: AIS patients 10 to 21years undergoing surgical correction of Lenke Type 1 and 2 curves with baseline, 1-erect-postoperative, and 5-year (5Y) postoperative visits including stereoradiographic assessment and pulmonary function tests (PFTs) were included. 3D-radiographic analysis was performed to assess spinal-alignment, chest-wall, and rib-cage dimensions at each time point. Outcome variables were analyzed between time points with one-way analysis of variance and between variables with linear regression analysis.

Results: Thirty-nine patients (37 females, 14.4 ± 2.2 years) were included. 3D-spinal-alignment analyses demonstrated significant reduction in preoperative to first-erect thoracic and lumbar Cobb-angles, an increase in TK:T2-12 (19.67°-39.69°) and TK:T5-12 (9.47°-28.05°), and reduction in apical vertebral rotation (AVR) (P < 0.001 for all). Spinal-alignment remained stable from 1-erect to 5Y. 3D rib-cage analysis demonstrated small reductions in baseline to first-erect depth (145-139 mm), width (235-232 mm), and increase in height (219-230 mm, P < 0.01), but no significant change in volume (5161-5222 cm,P = 0.184). From 1-erect to 5Y, significant increases in depth, width, height, and volume (all P < 0.001) occurred. PFTs showed preoperative to 5Y improvement in first second of Forced Expiratory Volume (FEV1) (2.74-2.98 L, P = 0.005) and forced vital capacity (FVC) (3.23-3.47 L, P = 0.008); however, total lung capacity (TLC) did not change (P = 0.517). Percent-predicted TLC decreased (Pre: 101.3% to 5Y: 89.3%, P < 0.001); however, percent-predicted forced expiratory volume and FVC did not (P = 0.112 and P = 0.068).

Conclusion: Although TK increases, coronal-Cobb and AVR decrease postoperatively; these do not directly influence TV, which increases from 1-erect to 5Y due to growth, corresponding with increases in FEV1 and FVC at 5Y; however, surgical restoration of kyphosis does not directly improve pulmonary function.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003472DOI Listing
July 2020

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Spine Versus Adult Reconstructive Surgery.

Spine (Phila Pa 1976) 2020 Sep;45(18):E1179-E1184

Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, Manhattan, NY.

Study Design: Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients.

Objective: The aim of this study was to compare baseline and postoperative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery.

Summary Of Background Data: Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the health-related quality of life across different disease states.

Methods: Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery [THA, TKA]) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL), and 6-month PROMIS scores of physical function, pain interference, and pain intensity were determined. Paired t tests compared differences in CCI, BL, 6 months, and change in PROMIS scores for spine and adult reconstruction procedures.

Results: A total of 304 spine surgery patients (age = 58.1 ± 15.6; 42.9% female) and 347 adult reconstruction patients (age = 62.9 ± 11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to physical function ([21.0, 22.2, 9.07, 12.6, 10.4] vs. [35.8, 35.0], respectively, P < 0.01), pain interference ([80.1, 74.1, 89.6, 92.5, 90.6] vs. [64.0, 63.9], respectively, P < 0.01), and pain intensity ([53.0, 53.1, 58.3, 58.5, 56.1] vs. [53.4, 53.8], respectively, P < 0.01). At 6 months, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of physical function ([+8.7, +22.2, +9.7, +12.9, +12.1] vs. [+5.3, +3.9], respectively, P < 0.01) and pain interference scores ([-15.4,-28.1, -14.7, -13.1, -12.3] vs. [-8.3, -6.0], respectively, P < 0.01).

Conclusion: Spinal surgery patients had lower BL and 6-month PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients.

Level Of Evidence: 3.
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September 2020

Mandibular slope: a reproducible and simple measure of horizontal gaze.

Spine Deform 2020 10 3;8(5):893-899. Epub 2020 Jun 3.

Icahn School of Medicine, Mount Sinai Hospital, 5 E 98th St., 4th Floor, New York, NY, USA.

Study Design: This study is a single-center retrospective radiographic review.

Objectives: The objective of this study is to evaluate a novel measurement parameter, mandibular slope (MS), as a measure of horizontal gaze.

Introduction: Assessment of sagittal spinal alignment is essential in the evaluation of spinal deformity patients. Ability to achieve a horizontal gaze, a parameter of sagittal alignment, is needed for the performance of daily activities. Standard measures of horizontal gaze, including the gold-standard chin-brow to vertical angle (CBVA) and the surrogate measures McGregor's line (McGS) and Chamberlain's line (CS), require high-quality imaging, precise head positioning, and reliance on difficult to view visual landmarks. A novel measurement parameter, MS, utilizing the caudal margin of the mandible on standard lateral spine radiographs is proposed.

Methods: 90 radiographs from spine deformity patients with or without spinal implants from a single center were evaluated. Three spine surgery fellows independently measured CBVA, McGS, CS, and MS at two timepoints at least one week apart to assess accuracy and reliability. MS was measured as the angle created by the inferior edge of the mandibular body and the horizontal. Formulas for calculating CBVA based on the above parameters were derived and compared to the actual CBVA.

Results: Mean age was 49.7 years, 76 females and 14 males. CBVA correlated with CS, McGS, and MS, r = 0.85, 0.81, and 0.80, respectively (p < 0.001). Standard error between real CBVA and calculated CBVA using CS (0.4 ± 4.79) and McGS (0.4 ± 3.9) was higher than that calculated using MS (- 0.2 ± 4.3). ICC demonstrated the highest inter-observer reliability with MS (0.999). MS had the highest intra-observer reliabilities 0.975, 0.981, and 0.988 (p < 0.001); CS and McGS also demonstrated high intra-observer reliability.

Conclusions: MS is a promising measure of horizontal gaze that correlates highly with CBVA, has excellent intra- and inter-observer reliability with CBVA, and is easily measured using standard lateral spine radiographs.
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http://dx.doi.org/10.1007/s43390-020-00137-xDOI Listing
October 2020

ODI Cannot Account for All Variation in PROMIS Scores in Patients With Thoracolumbar Disorders.

Global Spine J 2020 Jun 9;10(4):399-405. Epub 2019 Jun 9.

NYU Langone Orthopedic Hospital, Manhattan, NY, USA.

Study Design: Retrospective review of single institution.

Objective: To assess the relationship between Patient-Reported Outcomes Measurement Information System (PROMIS) and Oswestry Disability Index (ODI) scores in thoracolumbar patients.

Methods: Included: Patients ≥18 years with a thoracolumbar spine condition (spinal stenosis, disc herniation, low back pain, disc degeneration, spondylolysis). Bivariate correlations assessed the linear relationships between ODI and PROMIS (Physical Function, Pain Intensity, and Pain Interference). Correlation cutoffs assessed patients with high and low correlation between ODI and PROMIS. Linear regression predicted the relationship of ODI to PROMIS.

Results: A total of 206 patients (age 53.7 ± 16.6 years, 49.5% female) were included. ODI correlated with PROMIS Physical Function ( = -0.763, < .001), Pain Interference ( = 0.800, < .001), and Pain Intensity ( = 0.706, < .001). ODI strongly predicted PROMIS for Physical Function ( = 0.58, < .001), Pain Intensity ( = 0.50, < .001), and Pain Interference ( = 0.64, < .001); however, there is variability in PROMIS that ODI cannot account for. ODI questions about sitting and sleeping were weakly correlated across the 3 PROMIS domains. Linear regression showed overall ODI score as accounting for 58.3% ( = 0.583) of the variance in PROMIS Physical Function, 63.9% ( = 0.639) of the variance in Pain Interference score, and 49.9% ( = 0.499) of the variance in Pain Intensity score.

Conclusions: There is a large amount of variability with PROMIS that cannot be accounted for with ODI. ODI questions regarding walking, social life, and lifting ability correlate strongly with PROMIS while sitting, standing, and sleeping do not. These results reinforce the utility of PROMIS as a valid assessment for low back disability, while indicating the need for further evaluation of the factors responsible for variation between PROMIS and ODI.
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http://dx.doi.org/10.1177/2192568219851478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222681PMC
June 2020

Can Flexed-Seated and Single-Leg Standing Radiographs Be Useful in Preoperative Evaluation of Lumbar Mobility in Total Hip Arthroplasty?

J Arthroplasty 2020 08 27;35(8):2124-2130. Epub 2020 Mar 27.

Division of Spine Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York.

Background: The purpose of this study is to determine whether simulated radiographs in the "flexed-seated" or "step-up" positions better demonstrate a patient's range of spinopelvic motion between standing and sitting positions than relaxed sitting and standing radiographs.

Methods: An institutional review board approved cohort of 43 patients with hip osteoarthritis whom underwent full body sitting-standing radiographs from August 2016 to December 2017 at a single institution was reviewed. Subjects underwent single-leg step-up standing and flexed-seated radiographs, and relaxed standing and sitting radiographs. Sacral slope, spinopelvic tilt (SPT), and lumbar lordosis were measured in all radiographs. Alignment parameters were compared between both sets of imaging, and the change in SPT between the imaging modalities was plotted and stratified by pre-existing lumbar pathology.

Results: There were significant differences between the relaxed standing and step-up radiographs and the relaxed and flexed-seated radiographs for sacral slope, SPT, and lumbar lordosis (P < .002 for all), with the exception of SPT in the relaxed and step-up standing postures (P = .110). When transitioning from the standing to sitting position, the mean changes in SPT differed significantly between both sets of radiographs. Most importantly, when plotting changes in SPT between flexed and relaxed sitting postures, patients with fusions and flatback deformity trended toward greater anterior pelvic tilting, a position of greater risk of posterior dislocation.

Conclusion: Flexed sitting and single-leg standing imaging may emphasize the compensatory mechanisms of patients with concomitant hip and spine pathology more than relaxed imaging using our measurements. Our method may provide insight into high dislocation risk patients compared to the previously published hip measurement method.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.arth.2020.03.035DOI Listing
August 2020

Stiffness After Total Knee Arthroplasty: Is It a Result of Spinal Deformity?

J Arthroplasty 2020 06 19;35(6S):S330-S335. Epub 2020 Feb 19.

Hospital for Special Surgery, Adult Reconstruction and Joint Replacement Service, New York, NY.

Background: There are no studies to date analyzing the effect of spinal malalignment on outcomes of total knee arthroplasty (TKA). Knee flexion is a well-described lower extremity compensatory mechanism for maintaining sagittal balance with increasing spinal deformity. The purpose of this study was to determine whether a subset of patients with poor range of motion (ROM) after TKA have unrecognized spinal deformity, predisposing them to knee flexion contractures and stiffness.

Methods: We retrospectively evaluated a consecutive series of patients who underwent manipulation under anesthesia (MUA) for poor ROM after TKA. Using standing full-length biplanar images, knee alignment and spinopelvic parameters were measured. Patients were stratified by pelvic incidence minus lumbar lordosis as a measure of spinal sagittal alignment with a mismatch of ≥10° defined as abnormal, and we calculated the incidence of sagittal spinal deformity.

Results: Average ROM before MUA was extension 3° and flexion 83°. About 62% of patients had a pelvic incidence minus lumbar lordosis mismatch of ≥10°. In the spinal deformity group, post-MUA ROM was improved for flexion only, whereas both flexion and extension were improved in the nondeformity group.

Conclusion: Compensatory knee flexion because of sagittal spinal deformity may predispose to poor ROM after TKA. Patients with clinical suspicion should be worked up preoperatively and counseled accordingly.
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http://dx.doi.org/10.1016/j.arth.2020.02.031DOI Listing
June 2020

PROMIS is superior to established outcome measures in capturing disability resulting from sagittal malalignment in patients with back pain.

Spine Deform 2020 06 9;8(3):499-505. Epub 2020 Mar 9.

Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Health, 305 East 15th St., New York, NY, 10003, USA.

Introduction: Patient reported outcomes measurement information system (PROMIS) is a quality of life metric that has gained increased popularity due to computer adaptive testing. Previous studies have shown that PROMIS correlates with Oswestry Disability Index (ODI) in patients with back pain and takes significantly less time to complete. However, the ability of PROMIS to capture disability from spinal malalignment relative to established metrics is unknown. The aim of the present study is to validate the correlation between ODI and PROMIS in patients with back pain, analyze correlations of PROMIS and legacy metrics to sagittal alignment, and identify major drivers of PROMIS scores and ODI in patients with back pain.

Methods: A retrospective review was conducted of a prospectively collected outcome measures database (PROMIS, ODI, VAS Back, VAS Leg, VAS Neck, and VAS Arm) of spine patients > 18 years. Inclusion criteria for the present study was a chief complaint of back pain and full length weight bearing X-rays within 30 days of health related quality of life (HRQL) completion. Demographic information, radiographic alignment, psychiatric diagnoses, and comorbidities were recorded. PROMIS metrics were correlated to legacy metrics (ODI and VAS). Next, outcome metrics were correlated with sagittal alignment variables T1 Pelvic Angle (TPA), SVA, PT, and PI-LL. Patients were grouped based on the presence of spinal deformity (defined radiographically as any one of SVA > 4 cm, PI-LL > 10°, PT > 20°) and mean HRQL scores were investigated for the adult spinal deformity (ASD) and non-ASD groups. Finally, drivers of PROMIS PF scores and ODI scores were determined using multiple stepwise regression.

Results: 150 patients met inclusion criteria including 60 patients with ASD and 90 patients without. For the whole cohort, PROMIS PF correlated with ODI (r = - 0.651, p < 0.001), VAS Back (r = - 0.260, p = 0.014) and Charleson Comorbidity Index (r = - 0.336, p < 0.001). PROMIS PF had higher correlations than ODI for each sagittal alignment parameter tested, including TPA, SVA, PT, and PI-LL. When patients with ASD were compared to non-ASD patients, the PROMIS score was different between the groups but the ODI and VAS scores were not. Finally, stepwise linear regression showed that SVA, PI-LL, and VAS Leg were significant drivers of PROMIS PF (r = 0.406, p < 0.001). VAS Leg and VAS Back were significant contributors to ODI (r = 0.376, p < 0.001).

Conclusions: In a cohort of 150 patients with back pain, PROMIS correlated strongly with legacy outcome metrics, including VAS and ODI. PROMIS PF correlated more strongly with sagittal malalignment than ODI. Additionally, patients with spinal deformity had significantly worse PROMIS PF scores but similar ODI scores as patients without ASD. Finally, sagittal alignment was found to be a significant driver of PROMIS PF scores but not ODI scores. PROMIS PF should be utilized as a disability assessment tool in patients with spinal deformity due to ease of use, strong correlations with legacy metrics, and ability to capture disability resulting from sagittal alignment.
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http://dx.doi.org/10.1007/s43390-020-00068-7DOI Listing
June 2020

Predictors of long-term opioid dependence in transforaminal lumbar interbody fusion with a focus on pre-operative opioid usage.

Eur Spine J 2020 06 24;29(6):1311-1317. Epub 2020 Feb 24.

NYU School of Medicine, NYU Langone Medical Center and Hospital for Joint Diseases, NYU Langone Orthopedic Hospital, 306 East 15th Street, New York, NY, 10003, USA.

Purpose: Predictors of long-term opioid usage in TLIF patients have not been previously explored in the literature. We examined the effect of pre-operative narcotic use in addition to other predictors of the pattern and duration of post-operative narcotic usage.

Methods: We conducted a retrospective cohort study at a single academic institution of patients undergoing a one- or two-level primary TLIF between 2014 and 2017. Total oral morphine milligram equivalents (MMEs) for inpatient use were calculated and used as the common unit of comparison.

Results: A multivariate binary logistic regression (R = 0.547, specificity 95%, sensitivity 58%) demonstrated that a psychiatric or chronic pain diagnosis (OR 3.95, p = 0.013, 95% CI 1.34-11.6), pre-operative opioid use (OR 8.65, p < 0.001, 95% CI 2.59-29.0), ASA class (OR 2.95, p = 0.025, 95% CI 1.14-7.63), and inpatient total MME (1.002, p < 0.001, 95% CI 1.001-1.003) were positive predictors of prolonged opioid use at 6-month follow-up, while inpatient muscle relaxant use (OR 0.327, p = 0.049, 95% CI 0.108-0.994) decreased the probability of prolonged opioid use. Patients in the pre-operative opioid use group had a significantly higher rate of opioid usage at 6 weeks (79% vs. 46%, p < 0.001), 3 months (51% vs. 14%, p < 0.001), and 6 months (40% vs. 5%, p < 0.001).

Conclusions: Pre-operative opioid usage is associated with higher total inpatient opioid use and a significantly higher risk of long-term opiate usage at 6 months. Approximately 40% of pre-operative narcotic users will continue to consume narcotics at 6-month follow-up, compared with 5% of narcotic-naïve patients. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-020-06345-3DOI Listing
June 2020

Response to Letter to the Editor on "Prevalence of Sagittal Spinal Deformity Among Patients Undergoing Total Hip Arthroplasty".

J Arthroplasty 2020 05 31;35(5):1449. Epub 2020 Jan 31.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.

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http://dx.doi.org/10.1016/j.arth.2020.01.067DOI Listing
May 2020