Publications by authors named "James D Kang"

173 Publications

Improving Arthroplasty Efficiency and Quality Through Concentrating Service Volume by Complexity: Surviving the Medicare Policy Changes.

J Arthroplasty 2021 Apr 20. Epub 2021 Apr 20.

Department of Orthopaedic Surgery, Brigham and Women's Health, Boston, MA.

We have an academic medical center (AMC), an associated community-based hospital (CBH) and several ambulatory care centers which are being prepared to provide same day discharge (SDD) total joint arthroplasty (TJA) and unicompartmental knee arthroplasty (UKA). The near-capacity AMC cared for medically and technically complicated TJA patients. The CBH wanted to increase volume, improve margins, and become a center of excellence with an efficient hospital outpatient department and SDD TJA experience.

Methods: We transitioned primary, uncomplicated TJA, UKA, and minimally invasive TJA to the CBH. Revision surgeries, patients with extensive comorbidities, and complex primaries were performed at the AMC. Protocols were developed to facilitate SDD UKA and total hip arthroplasty (THA) as well as rapid recovery protocols for total knee arthroplasty (TKA) at both hospitals. A protocol-based system was put in place to make both hospitals ready for the removal of TKA from the Inpatient-Only list to avoid Quality Improvement Organization and possible resultant Recovery Audit Contractor audits if referred after implementation.

Results: The CBH volume increased 36.7% (+239). AMC volume slightly decreased (-0.46%, -5) resulting in an increase in margin contribution for the system. CBH quality metrics (surgical site infections, length of stay, readmissions, and mortality) were improved. Surgeon satisfaction improved as their volume, efficiency, quality metrics, and finances were enhanced. Although CBH per case revenue was 80.3% and 74.4% of the AMC for THA and TKA, net margins were 3.6% and 18.8% higher for THA and TKA, respectively. Increased efficiency, lower hospital cost, and higher volume at the CBH allowed for an increase in revenue despite lower reimbursement per case.

Conclusion: This strategy will help hospital systems improve net margins while improving patient care despite lower net revenue per TJA episode. These strategies will become increasingly important going forward with the transition of higher numbers of TJA patients to outpatient which will be subjected to further decreases in net revenue per patient.
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http://dx.doi.org/10.1016/j.arth.2021.04.005DOI Listing
April 2021

Trends and Complications in Spinopelvic Fixation for Deformity for Spinal Surgeons in Early Independent Practice.

Clin Spine Surg 2021 Mar 29. Epub 2021 Mar 29.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Retrospective case series study.

Objective: Evaluate trends and complications following posterior spinal instrumented fusion for deformity with/without pelvic fixation using the American Board of Orthopaedic Surgery Part II Oral Examination Candidate Case List data from 2008 to 2017.

Summary Of Background Data: Complication rates for cases with pelvic fixation are widely reported in spine deformity literature but are typically derived from practices of senior surgeons. As surgical experience and clinical volume are shown to decrease complication rates, spine surgeons newly in practice may have higher risks of such events.

Materials And Methods: Surgical cases submitted by candidates taking the American Board of Orthopaedic Surgery Part II Oral Examination between 2008 and 2017 with a self-designated sub-specialty of spine surgery were retrospectively reviewed. Mortality, readmission/reoperation data, and complications as reported by candidates were tracked over time. Bivariate testing and multivariable Poisson analyses, respectively, were used to assess complication rates and time-related trends.

Results: A total of 37,539 cases were submitted between 2008 and 2017. Four hundred sixty-one cases (1.2%) were for deformity; of these, 60 cases included pelvic fixation (13% of deformity cases). For all deformity cases, we noted medical, surgical, and overall complication rates to be 17%, 22.3%, and 31.5%. Multivariable analyses demonstrated no difference in surgical/overall complication rates between spinopelvic and nonspinopelvic instrumented groups, but showed a consistently low number of cases using spinopelvic fixation over time.

Conclusions: Newly practicing spinal surgeons consistently performed low numbers of deformity cases with relatively high complication rates which remained stable over time.
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http://dx.doi.org/10.1097/BSD.0000000000001163DOI Listing
March 2021

Correction to: ISSLS prize in basic science 2021: a novel inducible system to regulate transgene expression of TIMP1.

Eur Spine J 2021 Mar 7. Epub 2021 Mar 7.

Ferguson Laboratory for Orthopaedic and Spine Research, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.

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http://dx.doi.org/10.1007/s00586-021-06783-7DOI Listing
March 2021

ISSLS prize in basic science 2021: a novel inducible system to regulate transgene expression of TIMP1.

Eur Spine J 2021 Feb 1. Epub 2021 Feb 1.

Ferguson Laboratory for Orthopaedic and Spine Research, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.

Purpose: Inflammatory and oxidative stress upregulates matrix metalloproteinase (MMP) activity, leading to intervertebral disc degeneration (IDD). Gene therapy using human tissue inhibitor of metalloproteinase 1 (hTIMP1) has effectively treated IDD in animal models. However, persistent unregulated transgene expression may have negative side effects. We developed a recombinant adeno-associated viral (AAV) gene vector, AAV-NFκB-hTIMP1, that only expresses the hTIMP1 transgene under conditions of stress.

Methods: Rabbit disc cells were transfected or transduced with AAV-CMV-hTIMP1, which constitutively expresses hTIMP1, or AAV-NFκB-hTIMP1. Disc cells were selectively treated with IL-1β. NFκB activation was verified by nuclear translocation. hTIMP1 mRNA and protein expression were measured by RT-PCR and ELISA, respectively. MMP activity was measured by following cleavage of a fluorogenic substrate.

Results: IL-1β stimulation activated NFκB demonstrating that IL-1β was a surrogate for inflammatory stress. Stimulating AAV-NFκB-hTIMP1 cells with IL-1β increased hTIMP1 expression compared to unstimulated cells. AAV-CMV-hTIMP1 cells demonstrated high levels of hTIMP1 expression regardless of IL-1β stimulation. hTIMP1 expression was comparable between IL-1β stimulated AAV-NFκB-hTIMP1 cells and AAV-CMV-hTIMP1 cells. MMP activity was decreased in AAV-NFκB-hTIMP1 cells compared to baseline levels or cells exposed to IL-1β.

Conclusion: AAV-NFκB-hTIMP1 is a novel inducible transgene delivery system. NFκB regulatory elements ensure that hTIMP1 expression occurs only with inflammation, which is central to IDD development. Unlike previous inducible systems, the AAV-NFκB-hTIMP1 construct is dependent on endogenous factors, which minimizes potential side effects caused by constitutive transgene overexpression. It also prevents the unnecessary production of transgene products in cells that do not require therapy.
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http://dx.doi.org/10.1007/s00586-021-06728-0DOI Listing
February 2021

Conditioned open-label placebo for opioid reduction after spine surgery: a randomized controlled trial.

Pain 2021 Jan 11. Epub 2021 Jan 11.

Departments of Anesthesiology, Perioperative, and Pain Medicine and Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States Program in Placebo Studies and Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.

Abstract: Placebo effects have traditionally involved concealment or deception. However, recent evidence suggests that placebo effects can also be elicited when prescribed transparently as "open-label placebos" (OLPs), and that the pairing of an unconditioned stimulus (eg, opioid analgesic) with a conditioned stimulus (eg, placebo pill) can lead to the conditioned stimulus alone reducing pain. In this randomized control trial, we investigated whether combining conditioning with an OLP (COLP) in the immediate postoperative period could reduce daily opioid use and postsurgical pain among patients recovering from spine surgery. Patients were randomized to COLP or treatment as usual, with both groups receiving unrestricted access to a typical opioid-based postoperative analgesic regimen. The generalized estimating equations method was used to assess the treatment effect of COLP on daily opioid consumption and pain during postoperative period from postoperative day (POD) 1 to POD 17. Patients in the COLP group consumed approximately 30% less daily morphine milligram equivalents compared with patients in the treatment as usual group during POD 1 to 17 (-14.5 daily morphine milligram equivalents; 95% CI: [-26.8, -2.2]). Daily worst pain scores were also lower in the COLP group (-1.0 point on the 10-point scale; 95% CI: [-2.0, -0.1]), although a significant difference was not detected in average daily pain between the groups (-0.8 point; 95% CI: [-1.7, 0.2]). These findings suggest that COLP may serve as a potential adjuvant analgesic therapy to decrease opioid consumption in the early postoperative period, without increasing pain.
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http://dx.doi.org/10.1097/j.pain.0000000000002185DOI Listing
January 2021

Orthopaedic Manifestations of Amyloidosis.

J Am Acad Orthop Surg 2021 May;29(10):e488-e496

From the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Zhang, Makhni, Kang, and Blazar), and the Harvard Medical School, Boston, MA (Zhang, Makhni, Kang, and Blazar).

Amyloidosis is a disorder of misfolded proteins in human tissues, which can result in morbid cardiac and neurological disease. Historically, the utility of tissue biopsy during orthopaedic procedures to detect amyloidosis has been limited because no disease-modifying therapies were available; however, new drug therapies have recently emerged for the treatment of amyloidosis. Although these novel pharmaceuticals show promise for slowing disease progression, they are primarily effective in the early stages of amyloidosis, underscoring the importance of early diagnosis. Common orthopaedic manifestations of amyloidosis include carpal tunnel syndrome, trigger finger, spontaneous distal biceps tendon rupture, rotator cuff disease, and lumbar spinal stenosis. Carpal tunnel syndrome is frequently the earliest manifestation of amyloidosis, on average preceding a formal diagnosis of amyloidosis by over four years. By recognizing the constellation of musculoskeletal symptoms in the patient with amyloidosis, orthopaedic surgeons can play an active role in patient referral, early detection of systemic disease, and prompt initiation of disease-modifying treatment. There may be a role for selective biopsy for amyloid deposition in at-risk patients during routine orthopaedic procedures.
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http://dx.doi.org/10.5435/JAAOS-D-20-01146DOI Listing
May 2021

National utilization and inpatient safety measures of lumbar spinal fusion methods by race/ethnicity.

Spine J 2020 Nov 20. Epub 2020 Nov 20.

Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA; Division of General Medicine, Massachusetts General Hospital, 50 Staniford St, 9th floor, Boston, MA 02114 USA.

Background Context: Degenerative lumbar conditions are prevalent, disabling, and frequently managed with decompression and fusion. Black patients have lower spinal fusion rates than White patients.

Purpose: Determine whether specific lumbar fusion procedure utilization differs by race/ethnicity and whether length of stay (LOS) or inpatient complications differ by race/ethnicity after accounting for procedure performed.

Study Design: Large database retrospective cohort study PATIENT SAMPLE: Lumbar fusion recipients at least age 50 in the 2016 National Inpatient Sample with diagnoses of degenerative lumbar conditions.

Outcome Measures: Type of fusion procedure used and inpatient safety measures including LOS, prolonged LOS, inpatient medical and surgical complications, mortality, and cost.

Methods: We examined the association between race/ethnicity and the safety measures above. Covariates included several patient and hospital factors. We used multiple linear or logistic regression to determine the association between race and fusion type (PLF, P/TLIF, ALIF, PLF + P/TLIF, and PLF + ALIF [anterior-posterior fusion]) and to determine whether race was associated independently with inpatient safety measures, after adjustment for patient and hospital factors.

Results: Fusion method use did not differ among racial/ethnic groups, except for somewhat lower anterior-posterior fusion utilization in Black patients compared to White patients (crude odds ratio [OR]: 0.81 [0.67-0.97]). Inpatient safety measures differed by race/ethnicity for rates of prolonged LOS (Blacks 18.1%, Hispanics 14.5%, and Whites 11.7%), medical complications (Blacks 9.9%, Hispanics 8.7%, and Whites 7.7%), and surgical complications (Blacks 5.2%, Hispanics 6.9%, and Whites 5.4%). Differences persisted after adjustment for procedure type as well as patient and hospital factors. Blacks and Hispanics had higher risk for prolonged LOS compared to Whites (adjusted OR Blacks 1.39 [95% confidence interval {CI} 1.22-1.59]; Hispanics 1.24 [95% CI 1.02-1.52]). Blacks had higher risk for inpatient medical complications compared to Whites (adjusted OR 1.24 [95% CI 1.05-1.48]), and Hispanics had higher risk for inpatient surgical complications compared to Whites (adjusted OR 1.34 [95% CI 1.06-1.68]).

Conclusions: Fusion method use was generally similar between racial/ethnic groups. Inpatient safety measures, adjusted for procedure type, patient and hospital factors, were worse for Blacks and Hispanics.
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http://dx.doi.org/10.1016/j.spinee.2020.11.003DOI Listing
November 2020

Development of prediction models for clinically meaningful improvement in PROMIS scores after lumbar decompression.

Spine J 2021 Mar 31;21(3):397-404. Epub 2020 Oct 31.

Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA. Electronic address:

Background: The ability to preoperatively predict which patients will achieve a minimal clinically important difference (MCID) after lumbar spine decompression surgery can help determine the appropriateness and timing of surgery. Patient-Reported Outcome Measurement Information System (PROMIS) scores are an increasingly popular outcome instrument.

Purpose: The purpose of this study was to develop algorithms predictive of achieving MCID after primary lumbar decompression surgery.

Patient Sample: This was a retrospective study at two academic medical centers and three community medical centers including adult patients 18 years or older undergoing one or two level posterior decompression for lumbar disc herniation or lumbar spinal stenosis between January 1, 2016 and April 1, 2019.

Outcome Measures: The primary outcome, MCID, was defined using distribution-based methods as one half the standard deviation of postoperative patient-reported outcomes (PROMIS physical function, pain interference, pain intensity).

Methods: Five machine learning algorithms were developed to predict MCID on these surveys and assessed by discrimination, calibration, Brier score, and decision curve analysis. The final model was incorporated into an open access digital application.

Results: Overall, 906 patients completed at least one PROMs survey in the 90 days before surgery and at least one PROMs survey in the year after surgery. Attainment of MCID during the study period by PROMIS instrument was 74.3% for physical function, 75.8% for pain interference, and 79.2% for pain intensity. Factors identified for preoperative prediction of MCID attainment on these outcomes included preoperative PROs, percent unemployment in neighborhood of residence, comorbidities, body mass index, private insurance, preoperative opioid use, surgery for disc herniation, and federal poverty level in neighborhood of residence. The discrimination (c-statistic) of the final algorithms for these outcomes was 0.79 for physical function, 0.74 for pain interference, and 0.69 for pain intensity with good calibration. The open access digital application for these algorithms can be found here: https://sorg-apps.shinyapps.io/promis_pld_mcid/ CONCLUSION: Lower preoperative PROMIS scores, fewer comorbidities, and certain sociodemographic factors increase the likelihood of achieving MCID for PROMIS after lumbar spine decompression.
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http://dx.doi.org/10.1016/j.spinee.2020.10.026DOI Listing
March 2021

Surgeon-level variance in achieving clinical improvement after lumbar decompression: the importance of adequate risk adjustment.

Spine J 2021 Mar 9;21(3):405-410. Epub 2020 Oct 9.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA. Electronic address:

Background Context: Patient-Reported Outcome Measurement Information System (PROMIS) scores are increasingly utilized in clinical care. However, it is unclear if PROMIS can discriminate surgeon performance on an individual level.

Purpose: The purpose of this study was to examine surgeon-level variance in rates of achieving minimal clinically important difference (MCID) after lumbar decompression.

Patient Sample: This is a prospective, observational cohort study performed across a healthcare enterprise (two academic medical centers and three community centers). Patients 18 years or older undergoing one- to two-level primary decompression for lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) were included.

Outcome Measures: The primary outcome was achievement of MCID, using a distribution-based method, on paired PROMIS physical function scores.

Methods: Descriptive statistics were generated to examine the baseline characteristics of the study cohort. Bivariate analyses were used to examine the impact of surgeon-level variance on rates of MCID. Multivariable analyses were used to examine the risk-adjusted impact of surgeon-level variance on rates of MCID.

Results: Overall, 636 patients treated by nine surgeons were included. The median patient age was 58 [interquartile range (IQR): 46-70] and 62.3% (n=396) were female. Among all patients, 56.9% (n=362) underwent surgery for LDH. The overall rate of achieving MCID was 75.8% (n=482). Of the surgeons, the median years in practice were 12 (range 4-31) and 55.6% (n=5) were in academic practice settings. On bivariate analysis, patients treated by one of the surgeons had lower rates of achieving MICD (odds ratio=0.37, 95% confidence interval: 0.15-0.91, p=.03). However, on multivariable analysis adjusting for operative indication (LDH vs. LSS), body mass index, number of comorbidities, percent unemployment in patient zip code, and preoperative PROMIS physical function scores, all surgeons were equally likely to obtain MCID.

Conclusions: In this cohort, variance in PROMIS scores after primary lumbar decompression is influenced by patient-related factors and not by individual surgeon. Adequate risk adjustment is needed if ascertaining clinical improvement on an individual surgeon basis.

Level Of Evidence: 2.
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http://dx.doi.org/10.1016/j.spinee.2020.10.005DOI Listing
March 2021

Complication Events After Spinal Surgery Performed by American Board of Orthopaedic Surgery (ABOS) Part II Candidates (2008-2017).

Spine (Phila Pa 1976) 2021 Jan;46(2):101-106

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Retrospective cohort study.

Objective: To evaluate complications following spine surgery using American Board of Orthopaedic Surgeons (ABOS) Part II examination data from 2008 to 2017.

Summary Of Background Data: Recent research has demonstrated the importance of surgical experience and clinical volume in minimizing complications after spine surgery. This may be challenging for orthopedic spine surgeons who are just starting their practice.

Methods: We performed a retrospective review of surgical cases submitted to the ABOS by candidates taking the Part II Spine examination between 2008 and 2017. Complications, including peri-operative mortality as reported by candidates to the ABOS, were tracked over time. Complications were classified as surgical or medical using a predefined algorithm. Multivariable Poisson regression analyses adjusting for confounders were used to assess rates of complications and mortality over time. All analyses controlled for biologic sex, age, surgical diagnosis, and surgical location.

Results: A total of 37,539 spine surgical patients were analyzed, with an average of 3754 cases performed each year. Following adjusted Poisson analysis, we determined that cases in 2017 had an increased likelihood of complications when compared to those treated in 2008 (IRR 1.20; 95% CI 1.09, 1.32). Similar findings were encountered for surgical complications (IRR 1.20; 95% CI 1.07, 1.34). In contrast, spine surgical cases reported to the ABOS in 2017 had a 55% lower likelihood of mortality when compared to procedures performed in 2008 (IRR 0.45; 95% CI 0.24, 0.84; P = 0.01).

Conclusions: Our analysis of ABOS Part II candidates demonstrates that reported complication rates may be increasing while mortality is decreasing. The etiologies behind these findings are likely multifactorial. Encouragingly, we believe that observed reductions in mortality suggest overall improvements in patient safety following spine surgery. At a minimum, our data provide benchmarks through which spine surgeons, hospitals, and residency or fellowship programs can evaluate performance.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003741DOI Listing
January 2021

In vitro nucleus pulposus tissue model with physicochemical stresses.

JOR Spine 2020 Sep 1;3(3):e1105. Epub 2020 Jul 1.

Department of Orthopaedic Surgery Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA.

Intervertebral discs (IVDs) are exposed to changes in physicochemical stresses including hydrostatic and osmotic pressure via diurnal spinal motion. Homeostasis, degeneration, and regeneration in IVDs have been studied using in vitro, ex vivo, and animal models. However, incubation of nucleus pulposus (NP) cells in medium has limited capability to reproduce anabolic turnover and regeneration under physicochemical stresses. We developed a novel pressure/perfusion cell culture system and a semipermeable membrane pouch device for enclosing isolated NP cells for in vitro incubation under physicochemical stresses. We assessed the performance of this system to identify an appropriate stress loading regimen to promote gene expression and consistent accumulation of extracellular matrices by bovine caudal NP cells. Cyclic hydrostatic pressure (HP) for 4 days followed by constant HP for 3 days in high osmolality (HO; 450 mOsm/kg HO) showed a trend towards upregulated aggrecan expression and dense accumulation of keratan sulfate without gaps by the NP cells. Furthermore, a repetitive regimen of cyclic HP for 2 days followed by constant HP for 1 day in HO (repeated twice) significantly upregulated gene expression of aggrecan ( < .05) compared to no pressure and suppressed matrix metalloproteinase-13 expression ( < .05) at 6 days. Our culture system and pouches will be useful to reproduce physicochemical stresses in NP cells for simulating anabolic, catabolic, and homeostatic turnover under diurnal spinal motion.
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http://dx.doi.org/10.1002/jsp2.1105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524234PMC
September 2020

Trends in Spinal Surgery Performed by American Board of Orthopaedic Surgery Part II Candidates (2008 to 2017).

J Am Acad Orthop Surg 2020 Sep 17. Epub 2020 Sep 17.

From the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Introduction: The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination is typically taken two calendar years after fellowship completion. Despite previous studies using ABOS Part II Oral Examination data in other subspecialties, types of cases performed by spine surgeons in initial independent practice have not been well-studied. Such data may help trainees anticipate case composition observed in early practice and allow spine fellowship programs to understand emerging trends.

Methods: We retrospectively reviewed surgical cases submitted to the ABOS by candidates taking the Part II Oral Examination between 2008 and 2017 whose designated subspecialty was spine. A hierarchical, restrictive algorithm was used to determine procedures based on candidate-reported International Classification of Diseases 9th/10th Revision and Current Procedural Terminology codes. Adjusted multivariable Poisson regression analyses were used to assess changes in procedure incidence rates over time.

Results: We identified 37,539 cases, averaging 3,754 cases/yr, and an average of 49 cases per candidate per 6-month collection period. The most common procedures were lumbar diskectomy (22% of all procedures), posterolateral spinal fusion (PSF) (19%), and anterior cervical diskectomy and fusion (ACDF) (17%). Rates of ACDF and cervical disk arthroplasty significantly increased over time (incidence rate ratios of 1.41 and 23.3 times higher, respectively, at the end of the study period), whereas rates of cervical foraminotomy, lumbar diskectomy, PSF, and structural autograft use decreased (incidence rate ratios of 0.35, 0.84, 0.55, and 0.30). Rates of anterior lumbar interbody fusion/lateral lumbar interbody fusion and transforaminal lumbar interbody fusion did not significantly change over the study period.

Discussion: Recent spine fellowship graduates are performing more cervical disk arthroplasties and ACDFs while decreasingly using structural autograft as well as performing fewer PSFs and lumbar diskectomies. Techniques such as anterior lumbar interbody fusion/lateral lumbar interbody fusions and transforaminal lumbar interbody fusions have not changed significantly over the last decade.

Level Of Evidence: Level IV (retrospective case series study).
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http://dx.doi.org/10.5435/JAAOS-D-20-00437DOI Listing
September 2020

Brief Preoperative Screening for Frailty and Cognitive Impairment Predicts Delirium after Spine Surgery.

Anesthesiology 2020 12;133(6):1184-1191

Background: Frailty and cognitive impairment are associated with postoperative delirium, but are rarely assessed preoperatively. The study was designed to test the hypothesis that preoperative screening for frailty or cognitive impairment identifies patients at risk for postoperative delirium (primary outcome).

Methods: In this prospective cohort study, the authors administered frailty and cognitive screening instruments to 229 patients greater than or equal to 70 yr old presenting for elective spine surgery. Screening for frailty (five-item FRAIL scale [measuring fatigue, resistance, ambulation, illness, and weight loss]) and cognition (Mini-Cog, Animal Verbal Fluency) were performed at the time of the preoperative evaluation. Demographic data, perioperative variables, and postoperative outcomes were gathered. Delirium was the primary outcome detected by either the Confusion Assessment Method, assessed daily from postoperative day 1 to 3 or until discharge, if patient was discharged sooner, or comprehensive chart review. Secondary outcomes were all other-cause complications, discharge not to home, and hospital length of stay.

Results: The cohort was 75 [73 to 79 yr] years of age, 124 of 219 (57%) were male. Many scored positive for prefrailty (117 of 218; 54%), frailty (53 of 218; 24%), and cognitive impairment (50 to 82 of 219; 23 to 37%). Fifty-five patients (25%) developed delirium postoperatively. On multivariable analysis, frailty (scores 3 to 5 [odds ratio, 6.6; 95% CI, 1.96 to 21.9; P = 0.002]) versus robust (score 0) on the FRAIL scale, lower animal fluency scores (odds ratio, 1.08; 95% CI, 1.01 to 1.51; P = 0.036) for each point decrease in the number of animals named, and more invasive surgical procedures (odds ratio, 2.69; 95% CI, 1.31 to 5.50; P = 0.007) versus less invasive procedures were associated with postoperative delirium.

Conclusions: Screening for frailty and cognitive impairment preoperatively using the FRAIL scale and the Animal Verbal Fluency test in older elective spine surgery patients identifies those at high risk for the development of postoperative delirium.

Editor’s Perspective:
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http://dx.doi.org/10.1097/ALN.0000000000003523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657972PMC
December 2020

Transforming the Orthopaedic Patient Experience Through Telemedicine.

J Patient Exp 2020 Jun 27;7(3):302-304. Epub 2020 May 27.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1177/2374373520929449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410140PMC
June 2020

Post-operative hyperglycemia and its association with surgical site infection after instrumented spinal fusion.

Clin Neurol Neurosurg 2020 Oct 20;197:106100. Epub 2020 Jul 20.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States. Electronic address:

Objective: To evaluate the correlation between postoperative hyperglycemia and surgical site infection among patients who underwent primary instrumented spinal fusion surgery.

Patients And Methods: We collected data on all eligible patients treated at our institution over the course of 2005-2017. We defined serum hyperglycemia using a primary threshold of serum glucose ≥140 mg/dL and used ≥115 mg/dL as a secondary test. We used logistic regression techniques to evaluate unadjusted results for serum hyperglycemia on revision surgeries for infection, followed by sequential adjustment for sociodemographic and procedural characteristics.

Results: We included 3664 patients. Surgical site infections occurred in 4%. Post-operative hyperglycemia was significantly associated with a higher rate of revision surgery for infection (p = 0.02). Following adjusted analysis, hyperglycemia remained a statistically significant predictor for revision surgery due to infection (OR 2.19; 95 % CI 1.13, 4.25). Similar results were evident when using the lower threshold of ≥115 mg/dL (OR 2.36; 95 % CI 1.06, 5.23).

Conclusions: This study highlights the importance of measuring serum glucose after spinal fusion and the need for heightened surveillance and/or treatment in those who exhibit postoperative hyperglycemia. In this context, it could be advantageous to use a lower threshold for hyperglycemia (115 mg/dL) in order to trigger interventions for glycemic control.
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http://dx.doi.org/10.1016/j.clineuro.2020.106100DOI Listing
October 2020

The Prognostic Value of Laboratory Markers and Ambulatory Function at Presentation for Post-Treatment Morbidity and Mortality Following Epidural Abscess.

Spine (Phila Pa 1976) 2020 Aug;45(15):E959-E966

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Retrospective cohort study.

Objective: To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess.

Summary Of Background Data: Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored.

Methods: We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet-lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement.

Results: We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43).

Conclusion: We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003454DOI Listing
August 2020

Attenuation of ataxia telangiectasia mutated signalling mitigates age-associated intervertebral disc degeneration.

Aging Cell 2020 07 21;19(7):e13162. Epub 2020 Jun 21.

Ferguson Laboratory for Orthopedic and Spine Research, Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.

Previously, we reported that persistent DNA damage accelerates ageing of the spine, but the mechanisms behind this process are not well understood. Ataxia telangiectasia mutated (ATM) is a protein kinase involved in the DNA damage response, which controls cell fate, including cell death. To test the role of ATM in the human intervertebral disc, we exposed human nucleus pulposus (hNP) cells directly to the DNA damaging agent cisplatin. Cisplatin-treated hNP cells exhibited rapid phosphorylation of ATM and subsequent increased NF-κB activation, aggrecanolysis, decreased total proteoglycan production and increased expression of markers of senescence, including p21, γH AX and SA-ß-gal. Treating cisplatin-exposed hNP cells with an ATM-specific inhibitor negated these effects. In addition, genetic reduction of ATM reduced disc cellular senescence and matrix proteoglycan loss in the progeroid Ercc1 mouse model of accelerated ageing. These findings suggest that activation of ATM signalling under persistent genotoxic stress promotes disc cellular senescence and matrix homeostatic perturbation. Thus, the ATM signalling pathway represents a therapeutic target to delay the progression of age-associated spine pathologies.
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http://dx.doi.org/10.1111/acel.13162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406969PMC
July 2020

The American Board of Orthopaedic Surgery Response to COVID-19.

J Am Acad Orthop Surg 2020 Jun;28(11):e465-e468

From the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Wright), Department of Orthopaedic Surgery, Penn State Hershey Medical Center, Hershey, PA (Dr. Armstrong), Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee/Campbell Clinic, Memphis, TN (Dr. Azar), Department of Orthopaedic Surgery and Rehabilitation, Stritch School of Medicine, Loyola University-Chicago, Maywood, IL (Dr. Bednar), Orthopaedic Surgery, University of Michigan, Ann Arbor, MI (Dr. Carpenter), Public Member, Cedar Rapids, IA (Mr. Evans), Orthopaedic Surgery, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA (Dr. Flynn), Department of Orthopaedic Surgery, University of Nebraska, Omaha, NE (Dr. Garvin), Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL (Dr. Jacobs), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Kang), Resurgens Orthopaedics, Atlanta, GA (Dr. Lundy), Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN (Dr. Mencio), Department of Orthopedic Surgery and Neurosurgery, Mayo Clinic, Jacksonville, FL (Dr. Murray), Hospital of the University of Pennsylvania, Philadelphia, PA (Dr. Nelson), Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Evanston, IL (Dr. Peabody), Department of Orthopaedic Surgery, Prisma Health-Upstate, Greenville, SC (Dr. Porter), Orthopaedics, Emory University, Atlanta, GA (Dr. Roberson), Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT (Dr. Saltzman), Orthopaedic Surgery and Rehabilitation, Penn State Health System, State College, PA (Dr. Sebastianelli), University of Washington, Harborview Medical Center, Seattle, WA (Dr. Taitsman), Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Van Heest), and American Board of Orthopaedic Surgery, Chapel Hill, NC (Dr. Martin), and Wake Forest School of Medicine, Winston-Salem, NC (Dr. Martin).

The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.
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http://dx.doi.org/10.5435/JAAOS-D-20-00392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195847PMC
June 2020

Development of machine learning and natural language processing algorithms for preoperative prediction and automated identification of intraoperative vascular injury in anterior lumbar spine surgery.

Spine J 2020 Apr 12. Epub 2020 Apr 12.

Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA. Electronic address:

Background: Intraoperative vascular injury (VI) may be an unavoidable complication of anterior lumbar spine surgery; however, vascular injury has implications for quality and safety reporting as this intraoperative complication may result in serious bleeding, thrombosis, and postoperative stricture.

Purpose: The purpose of this study was to (1) develop machine learning algorithms for preoperative prediction of VI and (2) develop natural language processing (NLP) algorithms for automated surveillance of intraoperative VI from free-text operative notes.

Patient Sample: Adult patients, 18 years or age or older, undergoing anterior lumbar spine surgery at two academic and three community medical centers were included in this analysis.

Outcome Measures: The primary outcome was unintended VI during anterior lumbar spine surgery.

Methods: Manual review of free-text operative notes was used to identify patients who had unintended VI. The available population was split into training and testing cohorts. Five machine learning algorithms were developed for preoperative prediction of VI. An NLP algorithm was trained for automated detection of intraoperative VI from free-text operative notes. Performance of the NLP algorithm was compared to current procedural terminology and international classification of diseases codes.

Results: In all, 1035 patients underwent anterior lumbar spine surgery and the rate of intraoperative VI was 7.2% (n=75). Variables used for preoperative prediction of VI were age, male sex, body mass index, diabetes, L4-L5 exposure, and surgery for infection (discitis, osteomyelitis). The best performing machine learning algorithm achieved c-statistic of 0.73 for preoperative prediction of VI (https://sorg-apps.shinyapps.io/lumbar_vascular_injury/). For automated detection of intraoperative VI from free-text notes, the NLP algorithm achieved c-statistic of 0.92. The NLP algorithm identified 18 of the 21 patients (sensitivity 0.86) who had a VI whereas current procedural terminologyand international classification of diseases codes identified 6 of the 21 (sensitivity 0.29) patients. At this threshold, the NLP algorithm had a specificity of 0.93, negative predictive value of 0.99, positive predictive value of 0.51, and F1-score of 0.64.

Conclusion: Relying on administrative procedural and diagnosis codes may underestimate the rate of unintended intraoperative VI in anterior lumbar spine surgery. External and prospective validation of the algorithms presented here may improve quality and safety reporting.
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http://dx.doi.org/10.1016/j.spinee.2020.04.001DOI Listing
April 2020

Commentary on "Gene Therapy Approach for Intervertebral Disc Degeneration: An Update".

Authors:
James D Kang

Neurospine 2020 Mar 31;17(1):15-16. Epub 2020 Mar 31.

Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.

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http://dx.doi.org/10.14245/ns.2040092.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136106PMC
March 2020

Incidental Durotomy Is Associated With Increased Risk of Delirium in Patients Aged 65 and Older.

Spine (Phila Pa 1976) 2020 Sep;45(17):1215-1220

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Retrospective cohort study.

Objective: To evaluate the impact of incidental durotomy during spine surgery on the development of delirium in patients aged 65 and older.

Summary Of Background Data: Delirium after spine surgery has been shown to increase the risk of adverse events, including morbidity and readmissions. Durotomy has previously been postulated to influence the risk of delirium, but this has not been explored in patients 65 and older, the demographic at greatest risk of developing delirium.

Methods: We obtained clinical data on 766 patients, including 182 with incidental durotomy, from the Partners healthcare registry (2012-2019). Patients had their medical records abstracted and age, biologic sex, body mass index, smoking status, preoperative diagnosis, use of a fusion-based procedure, and number of comorbidities were recorded. Our primary outcome was the development of delirium. Our primary predictor was incidental durotomy. We used logistic regression techniques to adjust for sociodemographic and clinical confounders. We performed propensity score matching as a sensitivity test. We hypothesized that elderly patients would be at increased risk of delirium following durotomy.

Results: Delirium was identified in 142 patients (19%). Among patients with an incidental durotomy, 26% were diagnosed with delirium. The incidence of delirium was 16% in the control group. Following adjusted analysis, the likelihood of delirium was significantly greater in patients with a durotomy (odds ratio [OR] 1.91; 95% confidence interval [CI] 1.27, 2.88). After propensity score matching, durotomy remained significantly associated with delirium in multivariable adjusted analyses (OR 1.90; 95% CI 1.07, 3.39).

Conclusion: This investigation is among the first to specifically evaluate an association between durotomy and delirium in elderly patients undergoing spine surgery. The increased association between durotomy and delirium in this cohort should prompt increased surveillance and interventions designed to minimize the potential for cognitive deterioration or impairment during postoperative management of a durotomy.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003493DOI Listing
September 2020

Decision Making for Treatment of Persistent Sciatica.

N Engl J Med 2020 03;382(12):1161-1162

From the Department of Orthopedic Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston.

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http://dx.doi.org/10.1056/NEJMe2000711DOI Listing
March 2020

Can natural language processing provide accurate, automated reporting of wound infection requiring reoperation after lumbar discectomy?

Spine J 2020 10 4;20(10):1602-1609. Epub 2020 Mar 4.

Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA. Electronic address:

Background: Surgical site infections are a major driver of morbidity and increased costs in the postoperative period after spine surgery. Current tools for surveillance of these adverse events rely on prospective clinical tracking, manual retrospective chart review, or administrative procedural and diagnosis codes.

Purpose: The purpose of this study was to develop natural language processing (NLP) algorithms for automated reporting of postoperative wound infection requiring reoperation after lumbar discectomy.

Patient Sample: Adult patients undergoing discectomy at two academic and three community medical centers between January 1, 2000 and July 31, 2019 for lumbar disc herniation.

Outcome Measures: Reoperation for wound infection within 90 days after surgery METHODS: Free-text notes of patients who underwent surgery from January 1, 2000 to December 31, 2015 were used for algorithm training. Free-text notes of patients who underwent surgery after January 1, 2016 were used for algorithm testing. Manual chart review was used to label which patients had reoperation for wound infection. An extreme gradient-boosting NLP algorithm was developed to detect reoperation for postoperative wound infection.

Results: Overall, 5,860 patients were included in this study and 62 (1.1%) had a reoperation for wound infection. In patients who underwent surgery after January 1, 2016 (n=1,377), the NLP algorithm detected 15 of the 16 patients (sensitivity=0.94) who had reoperation for infection. In comparison, current procedural terminology and international classification of disease codes detected 12 of these 16 patients (sensitivity=0.75). At a threshold of 0.05, the NLP algorithm had positive predictive value of 0.83 and F1-score of 0.88.

Conclusion: Temporal validation of the algorithm developed in this study demonstrates a proof-of-concept application of NLP for automated reporting of adverse events after spine surgery. Adapting this methodology for other procedures and outcomes in spine and orthopedics has the potential to dramatically improve and automatize quality and safety reporting.
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http://dx.doi.org/10.1016/j.spinee.2020.02.021DOI Listing
October 2020

Prospective validation of a clinical prediction score for survival in patients with spinal metastases: the New England Spinal Metastasis Score.

Spine J 2021 Jan 19;21(1):28-36. Epub 2020 Feb 19.

Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02214, USA.

Background Context: The New England Spinal Metastasis Score (NESMS) was proposed as an intuitive and accessible prognostic tool for predicting survival in patients with spinal metastases. We designed an appropriately powered, prospective, longitudinal investigation to validate the NESMS.

Purpose: To prospectively validate the NESMS.

Study Design: Prospective longitudinal observational cohort study.

Patient Sample: Patients, aged 18 and older, presenting for treatment with spinal metastatic disease.

Outcome Measures: One-year mortality (primary); 6-month mortality and mortality at any time point following enrollment (secondary).

Methods: The date of enrollment was set as time zero for all patients. The NESMS was assigned based on data collected at the time of enrollment. Patients were prospectively followed to one of two predetermined end-points: death, or survival at 365 days following enrollment. Survival was visually assessed with Kaplan-Meier curves and then analyzed using multivariable logistic regression, followed by Bayesian regression to assess for robustness of point estimates and 95% confidence intervals (CI).

Results: This study included 180 patients enrolled between 2017 and 2018. Mortality within 1-year occurred in 56% of the cohort. Using NESMS 3 as the referent, those with a score of 2 had significantly greater odds of mortality (odds ratio 7.04; 95% CI 2.47, 20.08), as did those with a score of 1 (odds ratio 31.30; 95% CI 8.82, 111.04). A NESMS score of 0 was associated with perfect prediction, as 100% of individuals with this score were deceased at 1-year. Similar determinations were encountered for mortality at 6-months and overall.

Conclusions: This study validates the NESMS and demonstrates its utility in prognosticating survival for patients with spinal metastatic disease, irrespective of selected treatment strategy. This is the first study to prospectively validate a prognostic utility for patients with spinal metastases. The NESMS can be directly applied to patient care, hospital-based practice and health-care policy.
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http://dx.doi.org/10.1016/j.spinee.2020.02.009DOI Listing
January 2021

Natural language processing for automated detection of incidental durotomy.

Spine J 2020 05 23;20(5):695-700. Epub 2019 Dec 23.

Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA. Electronic address:

Background: Incidental durotomy is a common intraoperative complication during spine surgery with potential implications for postoperative recovery, patient-reported outcomes, length of stay, and costs. To our knowledge, there are no processes available for automated surveillance of incidental durotomy.

Purpose: The purpose of this study was to develop natural language processing (NLP) algorithms for automated detection of incidental durotomies in free-text operative notes of patients undergoing lumbar spine surgery.

Patient Sample: Adult patients 18 years or older undergoing lumbar spine surgery between January 1, 2000 and June 31, 2018 at two academic and three community medical centers.

Outcome Measures: The primary outcome was defined as intraoperative durotomy recorded in free-text operative notes.

Methods: An 80:20 stratified split was undertaken to create training and testing populations. An extreme gradient-boosting NLP algorithm was developed to detect incidental durotomy. Discrimination was assessed via area under receiver-operating curve (AUC-ROC), precision-recall curve, and Brier score. Performance of this algorithm was compared with current procedural terminology (CPT) and international classification of diseases (ICD) codes for durotomy.

Results: Overall, 1,000 patients were included in the study and 93 (9.3%) had a recorded incidental durotomy in the free-text operative report. In the independent testing set (n=200) not used for model development, the NLP algorithm achieved AUC-ROC of 0.99 for detection of durotomy. In comparison, the CPT/ICD codes had AUC-ROC of 0.64. In the testing set, the NLP algorithm detected 16 of 18 patients with incidental durotomy (sensitivity 0.89) whereas the CPT and ICD codes detected 5 of 18 (sensitivity 0.28). At a threshold of 0.05, the NLP algorithm had specificity of 0.99, positive predictive value of 0.89, and negative predictive value of 0.99.

Conclusions: Internal validation of the NLP algorithm developed in this study indicates promising results for future NLP applications in spine surgery. Pending external validation, the NLP algorithm developed in this study may be used by entities including national spine registries or hospital quality and safety departments to automate tracking of incidental durotomies.
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http://dx.doi.org/10.1016/j.spinee.2019.12.006DOI Listing
May 2020

Design of the prospective observational study of spinal metastasis treatment (POST).

Spine J 2020 04 8;20(4):572-579. Epub 2019 Nov 8.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.

Background Context: There are several prognostic scores available that intend to inform decision-making for patients with spinal metastases. Many of these have not been found to reliably predict survival across the continuum of care. Recently, our group developed the New England Spinal Metastasis Score (NESMS). While the NESMS demonstrated many of the necessary attributes of a useful prediction tool, it has yet to be validated prospectively.

Purpose: To describe the prospective observational study of spinal metastasis treatment (POST). This investigation examined the performance of the NESMS, compared its predictive capacity with other scoring systems and determined its ability to identify patients who benefit the most from surgery.

Study Design: Prospective observational study at two medical centers.

Patient Sample: Patients age 18 and older with spinal metastases involving the spine.

Outcome Measures: Survival, post-treatment morbidity and health-related quality of life outcomes.

Methods: The POST study assessed patients at baseline and at 1-month, 3-month, 6-month, and 12-month time-points. During the baseline assessment patient demographics, past medical history and assessment of co-morbidities, surgical history, primary tumor histology, and ambulatory status were recorded along with the designated treatment strategy (eg, operative or nonoperative). The NESMS and other predictive scores for each patient were calculated based on baseline data. Study-specific surveys administered at all time-points consisted of the EuroQuol 5-Dimension and Short-Form (SF)-12, Visual Analog Scale (VAS) for pain, and PROMIS assessment of global health.

Results: Two hundred patients were enrolled in POST from 2017 to 2019. Patients were followed to one of the two predetermined study end-points (ie, mortality, or completion of the 12-month follow-up). Survival was considered the principle dependent variable. Post-treatment morbidity and health-related quality of life outcomes were considered secondarily. Analyses, by aim, relied on Cox proportional hazards regression, repeated measures logistic regression, propensity score matching and multivariable logistic regression.

Conclusion: The POST's findings are anticipated to provide evidence regarding the prognostic capabilities of the NESMS as well as that of other popular grading schemes for survival, post-treatment complications and physical as well as mental function.
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http://dx.doi.org/10.1016/j.spinee.2019.10.021DOI Listing
April 2020

Non-operative management of spinal metastases: A prognostic model for failure.

Clin Neurol Neurosurg 2020 01 4;188:105574. Epub 2019 Nov 4.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.

Objectives: To describe patient-specific characteristics associated with non-operative failure leading to surgery.

Patients And Methods: We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications.

Results: We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004).

Conclusion: We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.
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http://dx.doi.org/10.1016/j.clineuro.2019.105574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6949394PMC
January 2020

Normal intervertebral segment rotation of the subaxial cervical spine: An study of dynamic neck motions.

J Orthop Translat 2019 Jul 21;18:32-39. Epub 2019 Jan 21.

Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.

Background: Accurate knowledge of the intervertebral center of rotation (COR) and its corresponding range of motion (ROM) can help understand development of cervical pathology and guide surgical treatment.

Methods: Ten asymptomatic subjects were imaged using MRI and dual fluoroscopic imaging techniques during dynamic extension-flexion-extension (EFE) and axial left-right-left (LRL) rotation. The intervertebral segment CORs and ROMs were measured from C34 to C67, as the correlations between two variables were analyzed as well.

Results: During the EFE motion, the CORs were located at 32.4 ± 20.6%, -2.4 ± 11.7%, 21.8 ± 12.5% and 32.3 ± 25.5% posteriorly, and the corresponding ROMs were 13.8 ± 4.3°, 15.1 ± 5.1°, 14.4 ± 7.0° and 9.2 ± 4.3° from C34 to C67. The ROM of C67 was significantly smaller than other segments. The ROMs were not shown to significantly correlate to COR locations ( = -0.243,  = 0.132). During the LRL rotation cycle, the average CORs were at 85.6 ± 18.2%, 32.3 ± 25.3%, 15.7 ± 12.3% and 82.4 ± 31.3% posteriorly, and the corresponding ROMs were 3.5 ± 1.7°, 6.9 ± 3.8°, 9.6 ± 4.1° and 2.6 ± 2.5° from C34 to C67. The ROMs of C34 and C67 was significantly smaller than those of C45 and C56. A more posterior COR was associated with a less ROM during the neck rotation ( = -0.583,  < 0.001). The ROMs during EFE were significantly larger than those during LRL in each intervertebral level.

Conclusion: The CORs and ROMs of the subaxial cervical intervertebral segments were segment level- and neck motion-dependent during the neck motions.

The Translational Potential Of This Article: Our study indicates that the subaxial cervical intervertebral CORs and ROMs were segment level- and neck motion-dependent. This may help to improve the artificial disc design as well as surgical technique by which the neck functional motion is restored following the cervical arthroplasty.
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http://dx.doi.org/10.1016/j.jot.2018.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6718920PMC
July 2019

Discogenic Back Pain: Literature Review of Definition, Diagnosis, and Treatment.

JBMR Plus 2019 May 4;3(5):e10180. Epub 2019 Mar 4.

Leni & Peter W. May Department of Orthopaedics Icahn School of Medicine at Mount Sinai New York NY USA.

Discogenic back pain is multifactorial; hence, physicians often struggle to identify the underlying source of the pain. As a result, discogenic back pain is often hard to treat-even more so when clinical treatment strategies are of questionable efficacy. Based on a broad literature review, our aim was to define discogenic back pain into a series of more specific and interacting pathologies, and to highlight the need to develop novel approaches and treatment strategies for this challenging and unmet clinical need. Discogenic pain involves degenerative changes of the intervertebral disc, including structural defects that result in biomechanical instability and inflammation. These degenerative changes in intervertebral discs closely intersect with the peripheral and central nervous systems to cause nerve sensitization and ingrowth; eventually central sensitization results in a chronic pain condition. Existing imaging modalities are nonspecific to pain symptoms, whereas discography methods that are more specific have known comorbidities based on intervertebral disc puncture and injection. As a result, alternative noninvasive and specific diagnostic methods are needed to better diagnose and identify specific conditions and sources of pain that can be more directly treated. Currently, there are many treatments/interventions for discogenic back pain. Nevertheless, many surgical approaches for discogenic pain have limited efficacy, thus accentuating the need for the development of novel treatments. Regenerative therapies, such as biologics, cell-based therapy, intervertebral disc repair, and gene-based therapy, offer the most promise and have many advantages over current therapies. © 2019 The Authors. Published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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http://dx.doi.org/10.1002/jbm4.10180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524679PMC
May 2019