Publications by authors named "Gregory D Schroeder"

266 Publications

Global Validation of the AO Spine Upper Cervical Injury Classification.

Spine (Phila Pa 1976) 2022 Jul 25. Epub 2022 Jul 25.

Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Global Cross Sectional Survey.

Objective: To determine the classification accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on an international group of AO Spine members.

Summary Of Background Data: Previous upper cervical spine injury classifications have primarily been descriptive without incorporating a hierarchical injury progression within the classification system. Further, upper cervical spine injury classifications have focused on distinct anatomical segments within the upper cervical spine. The AO Spine Upper Cervical Injury Classification System incorporates all injuries of the upper cervical spine into a single classification system focused on a hierarchical progression from isolated bony injuries (type A) to fracture dislocations (type C).

Methods: A total of 275 AO Spine members participated in a validation aimed at classifying 25 upper cervical spine injuries via computed tomography (CT) scans according to the AO Spine Upper Cervical Classification System. The validation occurred on two separate occasions, three weeks apart. Descriptive statistics for percent agreement with the gold-standard were calculated and Pearson's chi square test evaluated significance between validation groups. Kappa coefficients (ƙ) determined the interobserver reliability and intraobserver reproducibility.

Results: The accuracy of AO Spine members to appropriately classify upper cervical spine injuries was 79.7% on assessment 1 (AS1) and 78.7% on assessment 2 (AS2). The overall intraobserver reproducibility was substantial (ƙ=0.70), while the overall interobserver reliability for AS1 and AS2 was substantial (ƙ=0.63 and ƙ=0.61, respectively). Injury location had higher interobserver reliability (AS1: ƙ = 0.85 and AS2: ƙ=0.83) than the injury type (AS1: ƙ=0.59 and AS2: 0.57) on both assessments.

Conclusion: The global validation of the AO Spine Upper Cervical Injury Classification System demonstrated substantial interobserver agreement and intraobserver reproducibility. These results support the universal applicability of the AO Spine Upper Cervical Injury Classification System.
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http://dx.doi.org/10.1097/BRS.0000000000004429DOI Listing
July 2022

A Short-Term Assessment of Lumbar Sagittal Alignment Parameters in Patients Undergoing Anterior Lumbar Interbody Fusion.

Spine (Phila Pa 1976) 2022 Jul 15. Epub 2022 Jul 15.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107.

Study Design: Retrospective cohort.

Objective: To determine if intraoperative on-table lumbar lordosis and segmental lordosis coincide with perioperative change in lordosis.

Summary Of Background Data: Improvements in sagittal alignment are believed to correlate with improvements in clinical outcomes. Thus, it is important to establish whether intraoperative radiographs predict postoperative improvements in lumbar lordosis or segmental lordosis.

Methods: Electronic medical records were reviewed for patients ≥18 years old who underwent single- and two-level anterior lumbar interbody fusion (ALIF) with posterior instrumentation between 2016 and 2020. Lumbar lordosis, segmental lordosis, and the lordosis distribution index (LDI) were compared between pre-, intra-, and post-operative radiographs using paired t-tests. A linear regression determined the effect of subsidence on segmental lordosis and lumbar lordosis.

Results: A total of 118 patients met inclusion criteria. Of those, 75 patients had one-level fusions and 43 had a two-level fusion. Lumbar lordosis significantly increased following on-table positioning (delta (Δ): 5.7°, P<0.001). However, lumbar lordosis significantly decreased between the intraoperative to postoperative radiographs at 2-6 weeks (Δ: -3.4°, P=0.001), while no change was identified between the intraoperative and >3 month postoperative radiographs (Δ: -1.6°, P=0.143). Segmental lordosis was found to significantly increase from the preoperative to intraoperative radiographs (Δ: 10.9°, P<0.001), but it subsequently decreased at the 2-6 week follow up (Δ: -2.7, P<0.001) and at the final follow up (Δ: -4.1, P<0.001). On linear regression, cage subsidence/allograft resorption was predictive of the Δ segmental lordosis (β=0.55; 95% CI, 0.16-0.94; P=0.006), but not lumbar lordosis (β=0.10; 95% CI, -0.44-0.65; P=0.708).

Conclusion: Early post-operative radiographs may not accurately reflect the improvement in lumbar lordosis seen on intraoperative radiographic imaging, but they are predictive of long-term lumbar sagittal alignment. Each millimeter of cage subsidence or allograft resorption reduces segmental lordosis by 0.55°, but subsidence does not significantly affect lumbar lordosis.

Levels Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000004430DOI Listing
July 2022

Does Post-Operative Spine Infection Bacterial Gram Type Affect Surgical Debridement or Antibiotic Duration?

Spine (Phila Pa 1976) 2022 Jul 15. Epub 2022 Jul 15.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107.

Study Design: Retrospective cohort study.

Objective: To evaluate differences in readmission rates, number of debridements, and length of antibiotic therapy when comparing bacterial gram type following lumbar spinal fusion infections.

Summary Of Background Data: Surgical site infections (SSIs) after spinal fusion serve as a significant source of patient morbidity. It remains to be elucidated how bacterial classification of the infecting organism affects the management of postoperative spinal SSI.

Methods: Patients who underwent spinal fusion with a subsequent diagnosis of SSI between 2013-2019 were retrospectively identified. Patients were grouped based on bacterial infection type (gram-positive, gram-negative, or mixed infections). Poisson's regressions analyzed the relationship between the type of bacterial infection and the number of incision and debridement (I&D) reoperations, and the duration of IV antibiotic therapy. Significance was set at P<0.05.

Results: Of 190 patients, 92 had gram-positive (G+) infections, 57 had gram-negative (G-) infections, and 33 had mixed (M) infections. There was no difference in 30- or 90-day readmissions for infection between groups (both P=0.051). Patients in the M group had longer durations of IV antibiotic treatment (G+: 46.4 vs G-: 41.0 vs M: 55.9 d, P=0.002). Regression analysis demonstrated mixed infections were 46% more likely to require a greater number of debridements (P=0.001) and 18% more likely to require an increased duration of IV antibiotic therapy (P<0.001), while gram-negative infections were 10% less likely to require an increased duration of IV antibiotic therapy (P<0.001) when compared to G- infections.

Conclusion: Spinal SSI due to a mixed bacterial gram type results in an increased number of debridements and a longer duration of IV antibiotics required to resolve the infection compared to gram-negative or gram-positive infections.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004405DOI Listing
July 2022

Depression Increases Posterior Cervical Decompression and Fusion Revision Rates and Diminishes Neck Disability Index Improvement.

Spine (Phila Pa 1976) 2022 Jul 14. Epub 2022 Jul 14.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107.

Study Design: Retrospective cohort.

Objective: To determine if depression and/or anxiety significantly affect patient-reported outcome measures (PROMs) after posterior cervical decompression and fusion (PCDF).

Summary Of Background Data: Mental health diagnoses are receiving increased recognition for their influence of outcomes after spine surgery. The magnitude that mental health disorders contribute to patient-reported outcomes following PCDF requires increased awareness and understanding.

Methods: A review of electronic medical records identified patients who underwent a PCDF at a single institution during the years 2013-2020. Patients were placed into either depression/anxiety or non-depression/anxiety group based on their medical history. A delta score (∆) was calculated for all PROMs by subtracting postoperative from preoperative scores. Chi-squared tests and t-tests were utilized to analyze categorical and continuous data, respectively. Regression analysis determined independent predictors of change in PROMs. Alpha was set at 0.05.

Results: A total of 195 patients met inclusion criteria, with 60 (30.8%) having a prior diagnosis of depression/anxiety. The depression/anxiety group was younger (58.8 vs. 63.0, P=0.012), predominantly female (53.3% vs. 31.9%, P=0.007), and more frequently required revision surgery (11.7% vs. 0.74%, P=0.001). Additionally, they had worse baseline mental component (MCS-12) (42.2 vs. 48.6, P<0.001), postoperative MCS-12 (46.5 vs. 52.9, P=0.002), postoperative neck disability index (NDI) (40.7 vs. 28.5, P=0.001), ∆NDI (-1.80 vs. -8.93, P=0.010), NDI minimum clinically important difference improvement (MCID) (15.0% vs. 29.6%, P=0.046), and postoperative Visual Analog Scale (VAS) Neck scores (3.63 vs. 2.48, P=0.018). Only the non-depression/anxiety group improved in MCS-12 (P=0.002) and NDI (P<0.001) postoperatively. Depression and/or anxiety was an independent predictor of decreased magnitude of NDI improvement on regression analysis (β=7.14, P=0.038).

Conclusion: Patients with history of depression or anxiety demonstrate less improvement in patient-reported outcomes and a higher revision rate after posterior cervical fusion, highlighting the importance of mental health on clinical outcomes after spine surgery.

Levels Of Evidence: 3 (treatment).
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http://dx.doi.org/10.1097/BRS.0000000000004371DOI Listing
July 2022

The Effect of Preoperative Marijuana Use on Surgical Outcomes, Patient-Reported Outcomes, and Opioid Consumption Following Lumbar Fusion.

Global Spine J 2022 Jul 18:21925682221116819. Epub 2022 Jul 18.

Department of Orthopaedic Surgery, 542915Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Study Design: Retrospective Cohort Study.

Objectives: To (1) investigate the effect of marijuana use on surgical outcomes following lumbar fusion, (2) determine how marijuana use affects patient-reported outcomes measures (PROMs), and (3) determine if marijuana use impacts the quantity of opioids prescribed.

Methods: Patients 18 years of age who underwent primary one- or two-level lumbar fusion with preoperative marijuana use at our institution were identified. A 3:1 propensity match incorporating patient demographics and procedure type was conducted to compare preoperative marijuana users to non-marijuana users. Patient demographics, surgical characteristics, surgical outcomes (90-day all-cause and 90-day surgical readmissions, reoperations, and revision surgeries), pre- and postoperative narcotic usage, and PROMs were compared between groups. Multivariate regression models were created to determine the effect of marijuana on surgical reoperations patient-reported outcomes (PROMs) 1-year postoperatively.

Results: Of the 259 included patients, 65 used marijuana preoperatively. Multivariate logistic regression analysis demonstrated that marijuana use (OR = 2.28, = .041) significantly increased the likelihood of having a spine reoperation. No other surgical outcome was found to be significantly different between groups. Multivariate linear regression analysis showed that marijuana use was not significantly associated with changes in 1-year postoperative PROMs (all, > .05). The quantity of pre- and postoperative opioids prescriptions was not significantly different between groups (all, > .05).

Conclusions: Preoperative marijuana use increased the likelihood of a spine reoperation for any indication following lumbar fusion, but it was not associated with 90-day all cause readmission, surgical readmission, the magnitude of improvement in PROMs, or differences in opioid consumption.

Level Of Evidence: III.
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http://dx.doi.org/10.1177/21925682221116819DOI Listing
July 2022

Does Age and Medicare Status Affect Clinical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion?

World Neurosurg 2022 Jul 14. Epub 2022 Jul 14.

Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia PA.

Objective: To determine if Medicare status and age affects clinical outcomes following anterior cervical discectomy and fusion (ACDF).

Methods: Patients who underwent ACDF between 2014 and 2020 with complete preoperative and one-year postoperative patient reported outcome measures (PROMs) were grouped based on Medicare status and age: no Medicare under 65 years (NM<65), Medicare under 65 years (M<65), no Medicare 65 years or older (NM≥65), and Medicare 65 years or older (M≥65). Multivariate regression for ΔPROMs (Δ: postoperative minus preoperative) controlled for confounding differences between groups. Significant was set at P<0.05.

Results: A total of 1,288 patients were included, with each group improving in visual analog score (VAS) Neck (all, p<0.001), VAS Arm (M<65: p=0.003; remaining groups: p<0.001), and neck disability index (NDI) (M<65: p=0.009; remaining groups: p<0.001) following surgery. Only M<65 did not significantly improve in physical component score (PCS-12) and modified Japanese Orthopaedic Association score (mJOA) (p=0.256 and p=0.092, respectively). When comparing patients under 65 years, non-Medicare patients had better preoperative PCS-12 (p<0.001), NDI (p<0.001), and mJOA (p<0.001), as well as better postoperative values for all PROMs (p<0.001), but there were no differences in ΔPROMs. Multivariate analysis identified M<65 to be an independent predictor of decreased improvement in ΔPCS-12 (β=-4.07, p=0.015), ΔVAS Neck (β=1.17, p=0.010), and ΔVAS Arm (β=1.15, p=0.025) compared to NM<65.

Conclusions: Regardless of age and Medicare status, all patients undergoing ACDF had significant clinical improvement postoperatively. However, Medicare patients under age 65 have a smaller magnitude of improvement in patient reported outcome measures.
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http://dx.doi.org/10.1016/j.wneu.2022.07.032DOI Listing
July 2022

The Effect of Tranexamic Acid on Operative and Post-Operative Blood Loss in Transforaminal Lumbar Interbody Fusions.

World Neurosurg 2022 Jul 12. Epub 2022 Jul 12.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107.

Study Design: Retrospective Cohort Study OBJECTIVE: The purpose of this study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF).

Summary Of Background Data: Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for one- to three-level TLIF patients.

Methods: All patients requiring one- to three-level TLIF who received a pre-operative loading dose of TXA were grouped and compared to patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with Chi-squared, Kruskal-Wallis, or Analysis of Variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss (TBL), drain output, and length of stay. Statistical significance was set at P <0.05.

Results: Patients who received pre-operative TXA had more comorbidities (p=0.006), longer surgery length (p<0.001), and longer length of stay (p=0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (p<0.001, p=0.001, p=0.007, p<0.001, respectively), but was not associated with a change in estimated blood loss (EBL), total blood loss (TBL), or length of stay (LOS).

Conclusion: The application of pre-operative TXA for patients undergoing one- to three-level TLIF reduced drain output in the first two postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.
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http://dx.doi.org/10.1016/j.wneu.2022.07.020DOI Listing
July 2022

Does change in focal lordosis after spinal fusion affect clinical outcomes in degenerative spondylolisthesis?

J Craniovertebr Junction Spine 2022 Apr-Jun;13(2):127-139. Epub 2022 Jun 13.

Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Study Design: Retrospective cohort study.

Objective: The objective of this study is to determine the effect of focal lordosis and global alignment and proportion (GAP) scores on patient reported outcome measures (PROMs) after posterior lumbar fusion for patients with 1- or 2-level lumbar degenerative spondylolisthesis (DS).

Summary Of Background Data: In patients with DS, improvements in spinopelvic parameters are believed to improve clinical outcomes. However, the effect of changing focal lordosis in patients with 1-or 2-level degenerative lumbar spondylolisthesis is unclear.

Materials And Methods: Postoperative spinopelvic parameters and perioperative focal lordosis changes were measured for 162 patients at a single academic center from January 2013 to December 2017. Patients were divided into three groups: >2° (lordotic group), between 2° and -2° (neutral group), and -2°° (kyphotic group). Patients were then reclassified based on GAP scores. Recovery ratios (RR) and the number of patients achieving the minimal clinically important difference (MCID) were calculated for PROMs. Standard descriptive statistics were reported for patient demographics and outcomes data. Multiple linear regression analysis controlled for confounders. Alpha was set at < 0.05.

Results: There was no significant association between change in focal lordosis and surgical complications including adjacent segment disease ( = 0.282), instrumentation failure ( = 0.196), pseudarthrosis ( = 0.623), or revision surgery ( = 0.424). In addition, the only PROM affected by change in focal lordosis was Mental Component Scores (ΔMCS-12) (lordotic = 2.5, neutral = 8.54, and kyphotic = 5.96, = 0.017) and RR for MCS-12 (lordotic = 0.02, neutral = 0.14, kyphotic 0.10, = 0.008). Linear regression analysis demonstrated focal lordosis was a predictor of decreased improvement in MCS-12 (β = -6.45 [-11.03- -1.83], = 0.007). GAP scores suggested patients who were correctly proportioned had worse MCID compared to moderately disproportioned and severely disproportioned patients ( = 0.024).

Conclusions: The change in focal lordosis not a significant predictor of change in PROMs for disability, pain, or physical function. Proportioned patients based on the GAP score had worse MCID for Oswestry Disability Index.

Level Of Evidence: III.
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http://dx.doi.org/10.4103/jcvjs.jcvjs_144_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9274667PMC
June 2022

Perioperative Chanage in Cervical Lordosis and Health-Related Quality-of-Life Outcomes.

Int J Spine Surg 2022 Jul 14. Epub 2022 Jul 14.

Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.

Background: Surgeons have scrutinized spinal alignment and its impact on improving clinical outcomes following anterior cervical discectomy and fusion (ACDF). The primary analysis of this study examines the relationship between change in perioperative cervical lordosis (CL) and health-related quality-of-life (HRQOL) outcomes after ACDF. Secondary analysis evaluates the effects of fusion construct length on outcomes in patients grouped by preoperative cervical alignment.

Methods: A retrospective cohort study was performed on an institutional database including patients who underwent 1- to 3-level ACDF. C2-C7 CL was measured preoperatively and at final follow-up. For primary analysis, patients were classified based on their perioperative cervical lordotic correction: (1) kyphotic, (2) maintained, and (3) restored. For secondary analysis, patients were categorized based on their preoperative C2-C7 CL: (1) kyphotic, (2) neutral, and (3) lordotic. Demographics and perioperative change in patient-reported outcome measures were compared between groups.

Results: A total of 308 patients were included. A significant difference was noted among maintained, restored, and kyphotic groups in terms of delta physical compositeshort form-12 score (ΔPCS-12) (9.0 vs 10.3 vs 1.5; = 0.04) and delta visual analog scale score (ΔVAS) for arm pain (-0.9 vs -3.8 vs -0.6; = 0.03). Regression analysis revealed significantly greater improvement of PCS-12 (β: 8.6; = 0.03) and VAS arm (β: -2.0; = 0.03) scores in restored patients compared with kyphotic patients. The length of fusion construct in patients grouped by preoperative cervical alignment had no significant impact on the clinical outcomes on regression analysis.

Conclusions: Significantly greater PCS-12 and VAS arm improvement were seen in patients whose cervical sagittal alignment was restored to neutral/lordotic compared with those who remained kyphotic. Multivariate analysis demonstrated no association between construct length and perioperative outcomes.

Clinical Relevance: The results of this study highlight the importance of sagittal alignment and restoration of CL after short-segment ACDF. Irrespective of preoperative sagittal alignment, the length of ACDF fusion construct does not have a significant impact on clinical outcomes.

Level Of Evidence: 3:
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http://dx.doi.org/10.14444/8325DOI Listing
July 2022

Clinical Outcomes at One-year Follow-up for Patients With Surgical Site Infection After Spinal Fusion.

Spine (Phila Pa 1976) 2022 Aug 29;47(15):1055-1061. Epub 2022 Jun 29.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA.

Study Design: Retrospective case-control study.

Objective: To compare health-related quality of life outcomes at one-year follow-up between patients who did and did not develop surgical site infection (SSI) after thoracolumbar spinal fusion.

Summary Of Background Data: SSI is among the most common healthcare-associated complications. As healthcare systems increasingly emphasize the value of delivered care, there is an increased need to understand the clinical impact of SSIs.

Materials And Methods: A retrospective 3:1 (control:SSI) propensity-matched case-control study was conducted for adult patients who underwent thoracolumbar fusion from March 2014 to January 2020 at a single academic institution. Exclusion criteria included less than 18 years of age, incomplete preoperative and one-year postoperative patient-reported outcome measures, and revision surgery. Continuous and categorical data were compared via independent t tests and χ 2 tests, respectively. Intragroup analysis was performed using paired t tests. Regression analysis for ∆ patient-reported outcome measures (postoperative minus preoperative scores) controlled for demographics. The α was set at 0.05.

Results: A total of 140 patients (105 control, 35 SSI) were included in final analysis. The infections group had a higher rate of readmission (100% vs. 0.95%, P <0.001) and revision surgery (28.6% vs. 12.4%, P =0.048). Both groups improved significantly in Physical Component Score (control: P =0.013, SSI: P =0.039), Oswestry Disability Index (control: P <0.001, SSI: P =0.001), Visual Analog Scale (VAS) Back (both, P <0.001), and VAS Leg (control: P <0.001, SSI: P =0.030). Only the control group improved in Mental Component Score ( P <0.001 vs. SSI: P =0.228), but history of a SSI did not affect one-year improvement in ∆MCS-12 ( P =0.455) on regression analysis. VAS Leg improved significantly less in the infection group (-1.87 vs. -3.59, P =0.039), which was not significant after regression analysis (β=1.75, P =0.050).

Conclusion: Development of SSI after thoracolumbar fusion resulted in increased revision rates but did not influence patient improvement in one-year pain, functional disability, or physical and mental health status.
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http://dx.doi.org/10.1097/BRS.0000000000004394DOI Listing
August 2022

Postoperative Opioid Use Following Single-Level Transforaminal Lumbar Interbody Fusion Compared with Posterolateral Lumbar Fusion.

World Neurosurg 2022 Jun 26. Epub 2022 Jun 26.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Objective: To compare postoperative opioid morphine milligram equivalents (MME) prescriptions for opioid-naïve patients undergoing single-level transforaminal lumbar interbody fusion (TLIF) versus posterolateral lumbar fusion (PLF) and total postoperative MME prescribed based on operative duration.

Methods: Patients undergoing single-level TLIF or PLF from September 2017 to June 2020 were identified from a single institution. Patients were first grouped based on procedure type (TLIF or PLF) and subsequently regrouped based on median operative duration. Statistical tests compared patient demographics and opioid prescription data between groups. Multivariate regressions were performed to control for demographics, operative time, and procedure type.

Results: Of 345 patients undergoing single-level PLF or TLIF, 174 (50.4%) were opioid-naïve; 101 opioid-naïve patients (58.0%) underwent PLF and 73 (42.0%) underwent TLIF. Patients undergoing TLIF received more opioid prescriptions (1.99 vs. 1.26, P < 0.001) and total MME (91.2 vs. 66.8, P = 0.002). After regrouping patients based on operative duration, independent of procedure type, there were no differences in postoperative opioid prescriptions, and Spearman rank correlation coefficient between total MME and operative duration was r = 0.014. Multivariate analysis identified TLIF as an independent predictor of increased postoperative opioid prescriptions (β = 0.64, P < 0.001), prescribers (β = 0.49, P = 0.003), and MME (β = 24.4, P = 0.030).

Conclusions: Opioid-naïve patients undergoing single-level TLIF receive a greater number of postoperative opioids than patients undergoing single-level PLF, and TLIF was an independent predictor of increased postoperative opioid prescribers, prescribers, and MME. There were no differences in postoperative opioid prescriptions when assessing patients based on operative duration.
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http://dx.doi.org/10.1016/j.wneu.2022.06.092DOI Listing
June 2022

Does Age Younger Than 65 Affect Clinical Outcomes in Medicare Patients Undergoing Lumbar Fusion?

Clin Spine Surg 2022 May 23. Epub 2022 May 23.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA.

Study Design: This was a retrospective cohort study.

Objective: To determine if age (younger than 65) and Medicare status affect patient outcomes following lumbar fusion.

Summary Of Background Data: Medicare is a common spine surgery insurance provider, but most qualifying patients are older than age 65. There is a paucity of literature investigating clinical outcomes for Medicare patients under the age of 65.

Materials And Methods: Patients 40 years and older who underwent lumbar fusion surgery between 2014 and 2019 were queried from electronic medical records. Patients with >2 levels fused, >3 levels decompressed, incomplete patient-reported outcome measures (PROMs), revision procedures, and tumor/infection diagnosis were excluded. Patients were placed into 4 groups based on Medicare status and age: no Medicare under 65 years (NM<65), no Medicare 65 years or older (NM≥65), yes Medicare under 65 (YM<65), and yes Medicare 65 years or older (YM≥65). T tests and χ2 tests analyzed univariate comparisons depending on continuous or categorical type. Multivariate regression for ∆PROMs controlled for confounders. Alpha was set at 0.05.

Results: Of the 1097 patients, 567 were NM<65 (51.7%), 133 were NM≥65 (12.1%), 42 were YM<65 (3.8%), and 355 were YM≥65 (32.4%). The YM<65 group had significantly worse preoperative Visual Analog Scale back (P=0.01) and preoperative and postoperative Oswestry Disability Index (ODI), Short-Form 12 Mental Component Score (MCS-12), and Physical Component Score (PCS-12). However, on regression analysis, there were no significant differences in ∆PROMs for YM <65 compared with YM≥65, and NM<65. NM<65 (compared with YM<65) was an independent predictor of decreased improvement in ∆ODI following surgery (β=12.61, P=0.007); however, overall the ODI was still lower in the NM<65 compared with the YM<65.

Conclusion: Medicare patients younger than 65 years undergoing lumbar fusion had significantly worse preoperative and postoperative PROMs. The perioperative improvement in outcomes was similar between groups with the exception of ∆ODI, which demonstrated greater improvement in Medicare patients younger than 65 compared with non-Medicare patients younger than 65.

Level Of Evidence: Level III (treatment).
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http://dx.doi.org/10.1097/BSD.0000000000001347DOI Listing
May 2022

Patients with Dual Shoulder-Spine Disease: Does Operative Order Affect Clinical Outcomes?

World Neurosurg 2022 Aug 10;164:e1269-e1280. Epub 2022 Jun 10.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Objective: 1) To analyze the effect of operative sequence (anterior cervical discectomy and fusion [ACDF] first or rotator cuff repair [RCR] first) on surgical outcomes after both procedures for patients with dual shoulder-spine injuries and 2) to determine how operative sequence affects patient-reported outcome measures (PROMs) after surgery.

Methods: Patients >18 years of age who underwent primary ACDF and primary RCR at our institution were retrospectively identified. Only patients with overlapping symptoms before the first procedure were included. Patients were divided into 2 cohorts (ACDF first or RCR first). Patient demographics, surgical characteristics, surgical outcomes, and PROMs were compared between groups. Multivariate linear regression models were developed to determine if operative order was predictive of improvements in PROM scores at the 1-year postoperative point after the second procedure. Alpha was set at P < 0.05.

Results: Of the 85 patients included, 44 patients (51.8%) underwent ACDF first, whereas 41 patients (48.2%) underwent RCR first. There were no significant differences in the rate of 90-day readmission, spine reoperations, and rotator cuff reoperations between groups (all, P > 0.05). Multivariate linear regression showed that undergoing an ACDF first was not a significant predictor of Δ Mental Component Score of the Short-Form 12 (β = -2.78; P = 0.626) and Δ Physical Component Score of the Short-Form 12 (β = 7.74; P = 0.077) at the 1-year postoperative point after the second procedure.

Conclusions: For patients with dual shoulder-spine injuries who are appropriate surgical candidates, undergoing ACDF first compared with RCR first does not result in significant differences in clinical surgical or patient-reported outcomes.
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http://dx.doi.org/10.1016/j.wneu.2022.06.006DOI Listing
August 2022

Cefazolin prophylaxis in spine surgery: patients are frequently underdosed and at increased risk for infection.

Spine J 2022 Jun 6. Epub 2022 Jun 6.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA.

Background Context: Perioperative antibiotics are critical in reducing the risk of postoperative spine infections. However, the efficacy and optimal weight-based prophylactic cefazolin dosing is unclear.

Purpose: To determine (1) if inadequate weight-based prophylactic dosing of cefazolin affects infection rates after spinal fusions, and (2) identify the optimal dosing of cefazolin.

Study Design/setting: Single center retrospective cohort PATIENT SAMPLE: Patients undergoing posterior cervical or lumbar spinal fusion between January 2000 and October 2020 OUTCOME MEASURES: Postoperative surgical site infection status METHODS: Patients were grouped based on our institutionally derived dosing adequacy standards, 1 g for <60 kg, 2 g for 60 to 120 kg, and 3 g for >120 kg. Univariate comparisons and multivariate regressions identified the effect of inadequate dosing on infection rate. Patients were subsequently regrouped into cefazolin dose (grams) administered and logistic regression and receiver operating characteristic curves were compiled to determine the probability of infection based on cefazolin dose and patient weight. Alpha was set at 0.05.

Results: A total of 2,643 patients met inclusion criteria and 95 infections (3.6%) were identified. The infection rate was higher in the inadequate dosing group (5.86% vs. 2.58%, p<.001). Adequate dosing was a predictor of decreased infections after lumbar fusion (OR: 0.43, p<.001), but not posterior cervical fusions (OR: 0.47, p=.065). Patients were subsequently regrouped into 1 g or 2 g of cefazolin administered resulting in a 5.01% and 2.77% infection rate, respectively (p=.005). The area under the curve (AUC) and 95% confidence interval for one (0.850 [0.777-0.924]) and two (0.575 [0.493-0.657]) g of cefazolin demonstrated lower infection rates for patients given 2 g cefazolin.

Conclusions: Patients receiving an inadequate weight-based dose of preoperative cefazolin had an increased risk of infection following spinal fusion surgery. Two grams prophylactic cefazolin significantly reduces the likelihood of infection.
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http://dx.doi.org/10.1016/j.spinee.2022.05.018DOI Listing
June 2022

The Effect of Anterior Cervical Discectomy and Fusion Procedure Duration on Patient-Reported Outcome Measures.

World Neurosurg 2022 Aug 11;164:e548-e556. Epub 2022 May 11.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Objective: To determine whether operative duration of anterior cervical discectomy and fusion (ACDF) significantly affects patient-reported outcome measures (PROMs) 90 days after surgery and at 1-year follow-up.

Methods: Patients who underwent primary 1-level to 4-level ACDF were retrospectively identified. Demographic data and PROMs were collected through chart review. Patients were split into short, medium, and long tertiles based on procedure duration. PROM surveys were administered preoperatively as baseline measurements, at initial follow-up (between 60 and 120 days postoperatively), and at 1 year postoperatively. Outcomes included Neck Disability Index, Short-Form 12 Physical Component Score (PCS-12), Short-Form 12 Mental Component Score, visual analog scale (VAS) neck score, and VAS arm score.

Results: Significant short-term improvements were found across all groups for all PROMs. All groups showed long-term improvements in Short-Form 12 Mental Component Score, PCS-12, Neck Disability Index, VAS neck score, and VAS arm score, with the exception of the medium-duration group in PCS-12 (P = 0.093). On multivariate analysis, short-duration procedures predicted better improvement in VAS neck score (β = -1.01; P = 0.012) and VAS arm score (β = -1.38; P = 0.002) compared with long-duration procedures, whereas medium-duration procedures resulted in better improvement in VAS arm score (β = -1.00; P = 0.011). Further, short and medium duration was a predictor of decreased length of hospital stay (β = -0.67, P = 0.001 and β = -0.59, P = 0.001, respectively) compared with long-duration procedures.

Conclusions: All groups improved after ACDF regardless of surgical duration. Further, surgical duration was not a predictor of differing improvement in physical function or disability.
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http://dx.doi.org/10.1016/j.wneu.2022.05.016DOI Listing
August 2022

What is the role of dynamic cervical spine radiographs in predicting pseudarthrosis revision following anterior cervical discectomy and fusion?

Spine J 2022 May 12. Epub 2022 May 12.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA.

Background Context: Postoperative dynamic radiographs are used to assess fusion status after anterior cervical discectomy and fusion (ACDF) with comparable accuracy to computed tomography (CT) scans.

Purpose: To (1) determine if dynamic radiographs accurately predict pseudarthrosis revision in a cohort of largely asymptomatic patients who underwent ACDF, (2) determine how adjacent segment motion is affected by fusion status, and (3) analyze how clinical outcomes differ between patients with symptomatic and asymptomatic pseudarthrosis.

Study Design: Retrospective cohort study.

Patient Sample: Patients ≥ 18 years who underwent primary one- to four-level ACDF at a single institution over a 10-year period.

Outcome Measures: Interspinous motion on preoperative and postoperative flexion-extension radiographs and preoperative and postoperative Visual Analogue Scale for Neck Pain (VAS Neck) and Arm Pain (VAS Arm), Neck Disability Index (NDI), Modified Japanese Orthopaedic Association scale (mJOA), Mental and Physical Component Scores of the Short-Form 12 (SF-12) Health Survey (MCS-12 and PCS-12) METHODS: The difference in spinous process motion between flexion and extension radiographs was used to determine motion at each level of the ACDF construct. Pseudarthrosis was defined as ≥ 1 mm spinous process motion on dynamic radiographs. A receiver operating characteristic (ROC) curve was generated to predict the probability of surgical revision for pseudarthrosis based on millimeters of interspinous motion at each instrumented level. Patient reported outcome measures (PROMs) were used to assess the effect of pseudarthrosis on clinical outcomes. Alpha was set at p<.05.

Results: A total of 597 patients met inclusion criteria including 1,203 ACDF levels. Of those, 215 patients (36.0%) were diagnosed with a pseudarthrosis on dynamic radiographs with 29 patients (4.9%) requiring pseudarthrosis revision. ROC analysis identified a "cutoff" value of 1.00 mm of interspinous process motion for generating an optimal area under the curve (AUC). The negative predictive value (NPV) was 99.6%, whereas the positive predictive value (PPV) was 13.7%. When analyzing adjacent segment motion, the Δ supra-adjacent interspinous process motion (ISM) was significantly lower for patients with a superior construct pseudarthrosis (-1.06 mm vs. 1.80 mm, p<.001), whereas the Δ infra-adjacent level ISM was significantly lower for patients with an inferior construct pseudarthrosis (-1.21 mm vs. 2.15 mm, p<.001). Patients with a pseudarthrosis not requiring revision had worse postoperative NDI (29.3 vs. 23.4, p=.027), VAS Neck (3.40 vs. 2.63, p=.012), and VAS Arm (3.09 vs. 1.85, p=.001) scores at 3 months, but not 1-year, compared with patients who were fused. Patients requiring pseudarthrosis revision had higher 1-year postoperative NDI (38.0 vs. 23.7, p=.047) and lower 1-year postoperative Δ VAS Arm (-0.22 vs. -2.97, p=.016) scores.

Conclusions: One-year postoperative dynamic radiographs have a greater than 99% negative predictive value for identifying patients requiring pseudarthrosis revision, but they have a low positive predictive value. Most patients with a pseudarthrosis remain asymptomatic with similar 1-year postoperative patient-reported outcomes compared with patients without a pseudarthrosis.
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http://dx.doi.org/10.1016/j.spinee.2022.04.020DOI Listing
May 2022

Development of Online Technique for International Validation of the AO Spine Subaxial Injury Classification System.

Global Spine J 2022 Apr 27:21925682221098967. Epub 2022 Apr 27.

387400Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Global cross-sectional survey.

Objective: To develop and refine the techniques for web-based international validation of fracture classification systems.

Methods: A live webinar was organized in 2018 for validation of the AO Spine Subaxial Injury Classification System, consisting of 35 unique computed tomography (CT) scans and key images with subaxial spine injuries. Interobserver reliability and intraobserver reproducibility was calculated for injury morphology, subtype, and facet injury according to the classification system. Based on the experiences from this webinar and incorporating rater feedback, adjustments were made in the organization and techniques used and in 2020 a repeat validation webinar was performed, evaluating images of 41 unique subaxial spine injuries.

Results: In the 2018 session, the AO Spine Subaxial Injury Classification System demonstrated fair interobserver reliability for fracture subtype (κ = 0.35) and moderate reliability for fracture morphology and facet injury (κ=0.45, 0.43, respectively). However, in 2020, the interobserver reliability for fracture morphology (κ = 0.87) and fracture subtype (κ = 0.80) was excellent, while facet injury was substantial (κ = 0.74). Intraobserver reproducibility for injury morphology (κ =0.49) and injury subtype/facet injury were moderate (κ = 0.42) in 2018. In 2020, fracture morphology and subtype reproducibility were excellent (κ =0.85, 0.88, respectively) while reproducibility for facet injuries was substantial (κ = 0.76).

Conclusion: With optimized webinar-based validation techniques, the AO Spine Subaxial Injury Classification System demonstrated vast improvements in intraobserver reproducibility and interobserver reliability. Stringent fracture classification methodology is integral in obtaining accurate classification results.
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http://dx.doi.org/10.1177/21925682221098967DOI Listing
April 2022

Effect of Fellow Involvement and Experience on Patient Outcomes in Spine Surgery.

J Am Acad Orthop Surg 2022 Apr 13. Epub 2022 Apr 13.

From the Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA.

Introduction: Investigations in spine surgery have demonstrated that trainee involvement correlates with increased surgical time, readmissions, and revision surgeries; however, the specific effects of spine fellow involvement remain unelucidated. This study aims to investigate the isolated effect of fellow involvement on surgical timing and patient-reported outcomes measures (PROMs) after spine surgery and evaluate how surgical outcomes differ by fellow experience.

Methods: All patients aged 18 years or older who underwent primary or revision decompression or fusion for degenerative diseases and/or spinal deformity between 2017 and 2019 at a single academic institution were retrospectively identified. Patient demographics, surgical factors, intraoperative timing, transfusion status, length of stay (LOS), readmissions, revision rate, and preoperative and postoperative PROMs were recorded. Surgeries were divided based on spine fellow participation status and occurrence in the start or end of fellowship training. Univariate and multivariate analyses compared outcomes across fellow involvement and fellow experience groups.

Results: A total of 1,108 patients were included. Age, preoperative diagnoses, number of fusion levels, and surgical approach differed markedly by fellow involvement. Fellow training experience groups differed by patient smoking status, preoperative diagnosis, and surgical approach. On univariate analysis, spine fellow involvement was associated with extended total theater time, induction start to cut time, cut to close time, and LOS. Increased spine fellow training was associated with reduced cut to close time and LOS. On regression, fellow involvement predicted cut to close extension while increased fellow training experience predicted reduction in cut to close time, both independent of surgical factors and assisting residents or physician assistants. Transfusions, readmissions, revision rate, and PROMs did not differ markedly by fellow involvement or experience.

Conclusion: Spine fellow participation predicted extended procedural duration. However, the presence of a spine fellow did not affect long-term postoperative outcomes. Furthermore, increased fellow training experience predicted decreased procedural time, underscoring a learning effect.

Availability Of Data And Material: The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Level Of Evidence: Level 3.
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http://dx.doi.org/10.5435/JAAOS-D-21-01019DOI Listing
April 2022

The impact of preoperative neurological symptom severity on postoperative outcomes in cervical spondylotic myelopathy.

J Craniovertebr Junction Spine 2022 Jan-Mar;13(1):94-100. Epub 2022 Mar 9.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Spine Service, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Study Design: The study design is a retrospective cohort study.

Objective: To compare patient-reported outcomes between patients with mild versus moderate-to-severe myelopathy following surgery for cervical spondylotic myelopathy (CSM).

Summary Of Background Data: Recent studies have demonstrated that decompression for CSM leads to improved quality of life when measured by patient-reported outcomes. However, it is unknown if preoperative myelopathy classification is predictive of superior postoperative improvements.

Materials And Methods: A retrospective review of patients treated surgically for CSM at a single institution from 2014 to 2015 was performed. Preoperative myelopathy severity was classified according to the modified Japanese Orthopaedic Association (mJOA) scale as either mild (≥15) or moderate-to-severe (<15). Other outcomes included neck disability index (NDI), 12-item short-form survey (SF-12), and visual analog scale (VAS) for arm and neck pain. Differences in outcomes were tested by linear mixed-effects models followed by pairwise comparisons using least square means. Multiple linear regression determined whether any baseline outcomes or demographics predicted postoperative mJOA.

Results: There were 67 patients with mild and 50 patients with moderate-to-severe myelopathy. Preoperatively, patients with moderate-to-severe myelopathy reported significantly worse outcomes compared to the mild group for NDI, Physical Component Score (PCS-12), and VAS arm ( = 0.031). While both groups experienced improvements in NDI, PCS-12, VAS Arm and Neck after surgery, only the moderate-to-severe patients achieved improved mJOA (+3.1 points, < 0.001). However, mJOA was significantly worse in the moderate-to-severe when compared to the mild group postoperatively (-1.2 points, = 0.017). Both younger age ( = 0.017, -coefficient = -0.05) and higher preoperative mJOA ( < 0.001, -coefficient = 0.37) predicted higher postoperative mJOA.

Conclusions: Although patients with moderate-to-severe myelopathy improved for all outcomes, they did not achieve normal absolute neurological function, indicating potential irreversible spinal cord changes. Early surgical intervention should be considered in patients with mild myelopathy if they seek to prevent progressive neurological decline over time.
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http://dx.doi.org/10.4103/jcvjs.jcvjs_165_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8978848PMC
March 2022

Adult Isthmic Spondylolisthesis: A Radiographic and Outcomes Analysis Comparing Circumferential Fusions Versus TLIF Procedures.

Clin Spine Surg 2022 Apr 7. Epub 2022 Apr 7.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital.

Study Design: This was a retrospective cohort study.

Objective: The objective of this study was to compare radiographic and patient-reported outcome measures (PROMs) between circumferential fusions and transforaminal lumbar interbody fusion (TLIF) for adult isthmic spondylolisthesis (IS).

Summary Of Background Data: Definitive management of adult IS typically requires decompression and fusion. Multiple fusion techniques have been described, but literature is sparse in identifying the optimal technique.

Methods: Patients with IS undergoing single-level or 2-level circumferential fusion or TLIF with a minimum 1-year follow-up were included. Patient demographics, surgical characteristics, and PROMs were extracted from patients' electronic medical records. Descriptive statistics and multivariate regression analysis compared outcomes with significance set atP-value <0.05.

Results: A total of 78 circumferential fusions (48 open decompression and fusions and 30 circumferential fusions utilizing posterior percutaneous instrumentation) and 50 TLIF procedures were included. Length of stay was significantly longer when comparing circumferential procedures (3.56±0.96 d) versus TLIFs (2.88±1.14 d) (P=0.002). The circumferential fusion group resulted in greater postoperative improvement in segmental lordosis [anterior/posterior (A/P): 6.45, TLIF: -1.99,P<0.001], posterior disk height (A/P: 12.6 mm, TLIF: 8.9 mm,P<0.001), and ∆disk height (A/P: 7.7 mm, TLIF: 3.6 mm,P<0.001). Both groups significantly improved in all PROMs (P<0.001). While the circumferential fusion group had a significantly higher rate of perioperative surgical complications (12.82% vs. 2.00%,P=0.049), there was no difference in the rate of 30-day readmissions (P=0.520) or revision surgeries between techniques (P=0.057).

Conclusions: Circumferential fusions are associated with improvements in radiographic outcomes compared with TLIFs, but this is at the expense of longer hospital length of stay and increased risk for perioperative complications. The surgical technique did not result in superior postoperative PROMs or differences in readmissions or revisions.
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http://dx.doi.org/10.1097/BSD.0000000000001336DOI Listing
April 2022

Does Interbody Cage Lordosis and Position Affect Radiographic Outcomes After Single-level Transforaminal Lumbar Interbody Fusion?

Clin Spine Surg 2022 Apr 5. Epub 2022 Apr 5.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA.

Study Design: This was a retrospective cohort study.

Objective: The objective of this study was to determine if the degree of interbody cage lordosis and cage positioning are associated with changes in postoperative sagittal alignment after single-level transforaminal lumbar interbody fusion (TLIF).

Summary Of Background Data: Ideal sagittal alignment and lumbopelvic alignment have been shown to correlate with postoperative clinical outcomes. TLIF is one technique that may improve these parameters, but whether the amount of cage lordosis improves either segmental or lumbar lordosis (LL) is unknown.

Methods: A retrospective review was performed on patients who underwent single-level TLIF with either a 5-degree or a 12-degree lordotic cage. LL, segmental lordosis (SL), disk height, center point ratio, cage position, and cage subsidence were evaluated. Correlation between center point ratio and change in lordosis was assessed using the Spearman correlation coefficient. Secondary analysis included multiple linear regression to determine independent predictors of change in SL.

Results: A total of 126 patients were included in the final analysis, with 51 patients receiving a 5-degree cage and 75 patients receiving a 12-degree cage. There were no differences in the postoperative minus preoperative LL (∆LL) (12-degree cage: -1.66 degrees vs. 5-degree cage: -2.88 degrees,P=0.528) or ∆SL (12-degree cage: -0.79 degrees vs. 5-degree cage: -1.68 degrees,P=0.513) at 1-month follow-up. Furthermore, no differences were found in ∆LL (12-degree cage: 2.40 degrees vs. 5-degree cage: 1.00 degrees,P=0.497) or ∆SL (12-degree cage: 1.24 degrees vs. 5-degree cage: 0.35 degrees,P=0.541) at final follow-up. Regression analysis failed to show demographic factors, cage positioning, or cage lordosis to be independent predictors of change in SL. No difference in subsidence was found between groups (12-degree cage: 25.5% vs. 5-degree cage: 32%,P=0.431).

Conclusion: Lordotic cage angle and cage positioning were not associated with perioperative changes in LL, SL, or cage subsidence after single-level TLIF.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001334DOI Listing
April 2022

Instrumentation Across the Cervicothoracic Junction Does Not Improve Patient-reported Outcomes in Multilevel Posterior Cervical Decompression and Fusion.

Clin Spine Surg 2022 Apr 5. Epub 2022 Apr 5.

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA.

Study Design: This was a retrospective cohort.

Objective: The objective of this study was to determine if instrumentation across the cervicothoracic junction (CTJ) in elective multilevel posterior cervical decompression and fusion (PCF) is associated with improved patient-reported outcome measures (PROMs).

Summary Of Background Data: Fusion across the CTJ may result in lower revision rates at the expense of prolonged operative duration. However, it is unclear whether constructs crossing the CTJ affect PROMs.

Materials And Methods: Standard Query Language (SQL) identified patients with PROMs who underwent elective multilevel PCF (≥3 levels) at our institution. Patients were grouped based on anatomic construct: crossing the CTJ (crossed) versus not crossing the CTJ (noncrossed). Subgroup analysis compared constructs stopping at C7 or T1. Independentttests and χ2tests were utilized for continuous and categorical data, respectively. Regression analysis controlled for baseline demographics. The α was set at 0.05.

Results: Of the 160 patients included, the crossed group (92, 57.5%) had significantly more levels fused (5.27 vs. 3.71,P<0.001), longer operative duration (196 vs. 161 min,P=0.003), greater estimated blood loss (242 vs. 160 mL,P=0.021), and a decreased revision rate (1.09% vs. 10.3%,P=0.011). Neither crossing the CTJ (vs. noncrossed) nor constructs spanning C3-T1 (vs. C3-C7) were independent predictors of ∆PROMs (change in preoperative minus postoperative patient-reported outcomes) on regression analysis. However, C3-C7 constructs had a greater revision rate than C3-T1 constructs (15.6% vs. 1.96%,P=0.030).

Conclusion: Crossing the CTJ in patients undergoing elective multilevel PCF was not an independent predictor of improvement in PROMs at 1 year, but they experienced lower revision rates.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001335DOI Listing
April 2022

Do Inflammatory Cytokines Affect Patient Outcomes After ACDF?

Clin Spine Surg 2022 05 30;35(4):137-143. Epub 2022 Mar 30.

Department of Orthopaedic Surgery, Rothman Institute.

Study Design: Prospective cohort study.

Objective: The aim was to determine the relationship between serum inflammatory mediators, preoperative cervical spine disease severity, and clinical outcomes after anterior cervical discectomy and fusion (ACDF).

Summary Of Background Data: Given the role of the inflammatory cascade in spinal degenerative disease, it has been hypothesized that inflammatory markers may serve as a predictor of patient outcomes after surgery.

Materials And Methods: All patients over age 18 who underwent ACDF for cervical spondylosis with associated radiculopathy and/or myelopathy between 2015 and 2017 from a single institution were prospectively recruited. Preoperative serum inflammatory markers including interleukin (IL)-6, IL-8, tumor necrosis factor-α, high-mobility group box-1 (HMGB1), and white blood cells were measured and correlated to patient demographics, surgical characteristics, duration of symptoms, previous opioid use, and preoperative and 1-year postoperative patient-reported outcomes measures (PROMs) including the neck disability index (NDI), visual analog scale neck pain, visual analog scale arm pain, and Physical and Mental Component Scores of the Short Form-12 (PCS and MCS, respectively) using spearman's rho coefficient.

Results: A total of 77 patients were enrolled with follow-up PROMs available for 62% (n=48) of patients at a minimum of 1-year after ACDF. The absolute concentrations of IL-6 and tumor necrosis factor-α were found to be weakly correlated with one another (ρ=0.479). Preoperative symptoms lasting <1-year were weakly correlated with elevation in HMGB1 (ρ=0.421). All other patient demographics exhibited negligible correlation with the preoperative inflammatory markers. Lower preoperative PCS (ρ=0.355) and higher preoperative NDI (ρ=0.336) were weakly correlated with elevated HMGB1. Lower MCS (ρ=0.395) and higher NDI (ρ=0.317) preoperatively were weakly correlated with elevated white blood cells. Postoperative improvement in MCS (ρ=0.306) and MCS recovery ratio (ρ=0.321) exhibited a weakly positive correlation with IL-6.

Conclusion: Preoperative cytokine levels demonstrated minimal correlation with preoperative symptoms or clinical improvement, suggesting that profiling of patient cytokines has limited utility in predicting outcomes after ACDF.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001318DOI Listing
May 2022

The Impact of Preoperative Symptom Duration on Patient Outcomes After Posterior Cervical Decompression and Fusion.

Global Spine J 2022 Mar 24:21925682221087735. Epub 2022 Mar 24.

Department of Orthopaedic Surgery, Rothman Institute, 12313Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Retrospective Cohort Study.

Objectives: To determine if decreased preoperative symptom duration is associated with greater clinical improvement in function and myelopathic symptoms after posterior cervical decompression and fusion (PCDF).

Methods: All patients over age 18 who underwent primary PCDF for cervical myelopathy or myeloradiculopathy at a single institution between 2014 and 2020 were retrospectively identified. Patient demographics, surgical characteristics, duration of symptoms, and preoperative and postoperative patient reported outcomes measures (PROMs) including modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), Visual Analogue Scale (VAS) Neck, VAS Arm, and SF-12 were collected. Univariate and multivariate analyses were performed to compare change in PROMs and minimum clinically important difference achievement (%MCID) between symptom duration groups (< 6 months, 6 months-2 years, > 2 years).

Results: Preoperative symptom duration groups differed significantly by sex and smoking status. Patients with < 6 months of preoperative symptoms improved significantly in all PROMs. Patients with 6 months-2 years of preoperative symptoms did not improve significantly in mJOA, Physical Component Scores (PCS), or NDI. Patients with > 2 years of symptoms failed to demonstrate significant improvement in mJOA, NDI, or Mental Component Scores (MCS). Univariate analysis demonstrated significantly decreased improvement in mJOA with longer symptom durations. Increased preoperative symptom duration trended toward decreased %MCID for mJOA and MCS. Regression analysis demonstrated that preoperative symptom duration of > 2 years relative to < 6 months predicted decreased improvement in mJOA and NDI and decreased MCID achievement for mJOA and MCS.

Conclusion: Increased duration of preoperative symptoms (> 2 years) before undergoing PCDF was associated with decreased postoperative improvement in myelopathic symptoms.
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March 2022

The Impact of Upper Cervical Spine Alignment on Patient-reported Outcome Measures in Anterior Cervical Decompression and Fusion.

Clin Spine Surg 2022 07 16;35(6):E539-E545. Epub 2022 Mar 16.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA.

Study Design: This was a retrospective cohort study.

Objective: To determine the extent to which the upper cervical spine compensates for malalignment in the subaxial cervical spine, and how changes in upper cervical spine sagittal alignment affect patient-reported outcomes.

Summary Of Background Data: Previous research has investigated the relationship between clinical outcomes and radiographic parameters in the subaxial cervical spine following anterior cervical discectomy and fusion (ACDF). However, limited research exists regarding the upper cervical spine (occiput to C2), which accounts for up to 40% of neck movement and has been hypothesized to compensate for subaxial dysfunction.

Materials And Methods: Patients undergoing ACDF for cervical radiculopathy and/or myelopathy at a single center with minimum 1-year follow-up were included. Radiographic parameters including cervical sagittal vertical axis, C0 angle, C1 inclination angle, C2 slope, Occiput-C1 angle (Oc-C1 degrees), Oc-C2 degrees, Oc-C7 degrees, C1-C2 degrees, C1-C7 degrees, and C2-C7 degrees cervical lordosis (CL) were recorded preoperatively and postoperatively. Delta (Δ) values were calculated by subtracting preoperative values from postoperative values. Correlation analysis as well as multiple linear regression analysis was used to determine relationships between radiographic and clinical outcomes. Alpha was set at 0.05.

Results: A total of 264 patients were included (mean follow-up 20 mo). C2 slope significantly decreased for patients after surgery (Δ=-0.8, P =0.02), as did parameters of regional cervical lordosis (Oc-C7 degrees, C1-C7 degrees, and C2-C7 degrees; P <0.001, <0.001, and 0.01, respectively). Weak to moderate associations were observed between postoperative CL and C1 inclination ( r =-0.24, P <0.001), Oc-C1 degrees ( r =0.59, P <0.001), and C1-C2 degrees ( r =-0.23, P <0.001). Increased preoperative C1-C2 degrees and Oc-C2 degrees inversely correlated with preoperative SF-12 Mental Composite Score (MCS-12) scores ( r =-0.16, P =0.01 and r =-0.13, P =0.04). Cervical sagittal vertical axis was found to have weak but significant associations with Short Form-12 (SF-12) Physical Composite Score (PCS-12) ( r =-0.13, P =0.03) and MCS-12 ( r =0.12, P =0.05).

Conclusion: No clinically significant relationship between upper cervical and subaxial cervical alignment was detected for patients undergoing ACDF for neurological symptoms. Upper cervical spine alignment was not found to be a significant predictor of patient-reported outcomes after ACDF.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001310DOI Listing
July 2022

How Do Patients With Predominant Neck Pain Improve After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

Int J Spine Surg 2022 Apr 10;16(2):240-246. Epub 2022 Mar 10.

Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA.

Background: The presence of predominant pain in the arm vs the neck as a predictor of postoperative outcomes after anterior cervical discectomy and fusion (ACDF) has been seldom reported; therefore, the purpose of this study was to determine whether patients with predominant neck pain improve after surgery compared to patients with predominant arm pain or those with mixed symptoms in patients undergoing ACDF for radiculopathy.

Methods: A retrospective cohort study was conducted on patients who underwent ACDF at a single center from 2016 to 2018. Patients were split into groups based on preoperative neck and arm pain scores: neck (N) pain dominant group (visual analog scale [VAS] neck ≥ VAS arm by 1.0 point); neutral group (VAS neck < VAS arm by 1.0 point); or arm (A) pain dominant group (VAS arm ≥ VAS neck by 1.0 point), using a threshold difference of 1.0 point. Subsequently, individuals were substratified into 2 groups based on the arm to neck pain ratio (ANR): non-arm pain dominant defined as ANR ≤1.0 and arm pain dominant (APD) defined as ANR >1.0. Patient-reported outcome measurements including Neck Disability Index (NDI), Physical Component Score-12, and Mental Component Score (MCS-12) were compared between groups.

Results: No significant differences between groups when stratifying patients using a threshold difference of 1.0 point. When stratifying patients using the ANR, those in the APD group had significantly higher postoperative MCS-12 ( = 0.008) and NDI ( = 0.011) scores. In addition, the APD group showed a greater magnitude of improvement for MCS-12 and NDI scores ( = 0.043 and = 0.038, respectively). Multiple linear regression showed that the A and the APD groups were both independent predictors of improvement in NDI.

Conclusion: Patients with dominant arm pain showed significantly greater improvement in terms of MCS-12 and NDI scores compared to patients with dominant neck pain.

Clinical Relevance: To compare the impact of ACDF on arm and neck pain in the context of cervical radiculopathy using patient-reported outcome measures as an objective measurement.

Level Of Evidence: 3:
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http://dx.doi.org/10.14444/8212DOI Listing
April 2022

What Is the Impact of Smoking on Patient-Reported Outcomes Following Posterior Cervical Decompression and Fusion?

World Neurosurg 2022 Jun 5;162:e319-e327. Epub 2022 Mar 5.

Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Objective: The purpose of this retrospective cohort study was to investigate the impact of smoking on patient-reported outcome measures (PROMs) following elective posterior cervical decompression and fusion (PCF).

Methods: Electronic medical records at a single institution were reviewed for patients undergoing elective PCF. Patients were grouped based on smoking history: current smokers, former smokers, and never smokers. A delta score (Δ) was calculated for all PROMs (postoperative minus preoperative scores). Continuous and categorical data were compared using analysis of variance or χ tests. Regression analysis controlled for demographics. Patients were then regrouped into current smokers and nonsmokers for reanalysis.

Results: A total of 195 patients were included, of whom 35 (22.1%) were current smokers, 51 (26.2%) were former smokers, and 101 (51.8%) were never smokers. Preoperative and postoperative Short-Form 12 Mental Component Score (MCS-12) were significantly lower in the current smoker group (preoperative: current 42.7, former 49.9, and never 46.6; P = 0.024; postoperative: current 44.6, former 53.7, and never 52.2; P = 0.003). Only never smokers improved in MCS-12 and Neck Disability Index following surgery. On regrouping, current smokers had significantly lower preoperative MCS-12 (42.7 vs. 47.7, P = 0.031), lower preoperative modified Japanese Orthopaedic Association (12.2 vs. 14.0, P = 0.039), greater preoperative visual analog scale Arm (6.39 vs. 4.94, P = 0.025), and lower postoperative MCS-12 (44.6 vs. 52.7, P = 0.001). Only the nonsmokers improved in MCS-12 and Neck Disability Index following surgery. On regression analysis, smoking was not an independent predictor of ΔPROMs.

Conclusions: Univariate analysis found that smokers have worse symptoms at baseline. However, smoking status was not an independent predictor of improvement in ΔPROMs following elective PCF.
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http://dx.doi.org/10.1016/j.wneu.2022.03.003DOI Listing
June 2022

Lumbo-sacral Junction Instability by Traumatic Sacral Fractures: Isler's Classification Revisited - A Narrative Review.

Global Spine J 2022 Feb 22:21925682221076414. Epub 2022 Feb 22.

Spine Surgery Group, 476660Cajuru University Hospital, curitiba, Brazil.

Study Design: Narrative review.

Objectives: Multiple classifications have been proposed for sacral fractures since the last century. While initial classifications focussed on vertical and transverse fractures, the recent fracture classifications encompass all injury patterns. In 1990, Isler classified unilateral vertical sacral fractures based on its potential influence on lumbo-sacral joint (LSJ) stability.

Methods: We re-visited the original description of Isler's classification of sacral fractures and subsequent studies that have cited it. We will further describe basic LSJ anatomy, evolution of sacral classification systems and the use of Isler's classification system as it relates to LSJ instability and chronic low back pain.

Results: Isler described a subset of unilateral vertical sacral fractures where the fracture line exited medial or through the L5-S1 facet joint, based on radiographic review of 193 sacral fractures (incidence -3.5%). He stated that such a fracture should be recognised as it can impede hemi-pelvis reduction and can result in late LSJ instability. The article has been cited in 106 studies and only a few studies have described the incidence of this variant. Nevertheless, the injury is considered as an indication for surgical fixation.

Conclusion: A review of various classifications indicates that sacral fractures have three important bio-mechanical implications, namely, pelvic ring continuity (vertical fractures), spino-pelvic alignment (high transverse fractures) and lumbo-sacral joint integrity (Isler's fractures). Though there is a universal recognition of Isler's fractures and its impact on LSJ integrity, there is a lack of clinical and bio-mechanical evidence regarding the concept of instability caused by a unilateral Isler fracture.
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http://dx.doi.org/10.1177/21925682221076414DOI Listing
February 2022

The impact of case order and intraoperative staff changes on spine surgical efficiency.

Spine J 2022 07 1;22(7):1089-1099. Epub 2022 Feb 1.

Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA.

Background Context: Despite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency.

Purpose: This study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases.

Study Design/ Setting: Retrospective cohort analysis PATIENT SAMPLE: All patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy.

Outcome Measures: Intraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions.

Methods: Surgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups.

Results: A total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time.

Conclusions: Intraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.
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http://dx.doi.org/10.1016/j.spinee.2022.01.015DOI Listing
July 2022

Does Cervical Spondylolisthesis Influence Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion Surgery?

Int J Spine Surg 2021 Dec;15(6):1161-1166

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, 925 Chestnut St., Philadelphia, PA, USA.

Background: No prior work has explored whether the presence of degenerative spondylolisthesis impacts patient-reported outcome measurements (PROMs) after an anterior cervical discectomy and fusion (ACDF); therefore, the goal of the current study was to determine whether the presence of a spondylolisthesis affects PROMs after an ACDF.

Methods: A retrospective cohort study was conducted on patients over the age of 18 who underwent a 1- or 2-level ACDF. All patients received preoperative standing lateral x-rays and were placed into 1 of 2 groups based on the presence of cervical spondylolisthesis from C2-T1: (1) no spondylolisthesis (NS) group or (2) spondylolisthesis (S) group. Preoperative, postoperative, and delta (postoperative minus preoperative) were recorded and compared between groups via univariate and multivariate analysis. Outcomes reported were the Physical Component Scores of the Short Form-12 (PCS-12), the Mental Component Scores of the Short Form-12 (MCS-12), the Neck Disability Index (NDI), and visual analog scale (VAS) Arm/Neck.

Results: A total of 202 patients were included in the final analysis with 154 in the NS group and 48 in the S group. Both patient cohorts reported significant postoperative improvement in PCS-12, NDI, and VAS Arm/Neck. When comparing outcome scores between groups, only MCS-12 delta scores were different between groups, with the S group exhibiting a greater mean delta score (8.3 vs 1.3, = 0.024) than the NS group after ACDF. Multiple linear regression analysis indicated having spondylolisthesis at baseline was a significant predictor of greater change in MCS-12 than the NS group (β = 4.841; 95% CI, 0.876, 8.805; = 0.017).

Conclusion: Both groups demonstrated significant postoperative improvement in PCS-12, NDI, or VAS Neck/Arm pain scores with no significant differences between groups. Patients with spondylolisthesis were found to have significantly greater improvement scores in MCS-12 scoring than those without spondylolisthesis after ACDF surgery.
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http://dx.doi.org/10.14444/8147DOI Listing
December 2021
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