Publications by authors named "Jeffrey L Gum"

77 Publications

Costs associated with potentially unnecessary post-operative healthcare encounters after lumbar spine surgery.

Spine J 2021 Sep 3. Epub 2021 Sep 3.

Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, Kentucky 40202.

Background Context: Excessive use of post-operative imaging after lumbar surgery has been documented, becoming a target for cutting costs. This must be balanced with the patient's need for information and allay their post-operative concerns.

Purpose: To determine the incidence and associated costs of patient interactions with the healthcare system, outside the standard follow up routine, in the first post-operative year.

Study Design: Retrospective longitudinal cohort PATIENT SAMPLE: Consecutive series of 200 patients who underwent lumbar fusions from 2018-2019 from a multi-surgeon single tertiary spine center.

Outcome Measures: All healthcare encounters: phone calls, office and emergency department visits, and additional testing METHODS: A consecutive series of 200 patients who underwent lumbar fusions from 2018-2019 were identified. All non-routine healthcare encounters: phone calls, office and emergency department visits, and additional testing were collected. Direct costs for all healthcare services were determined using the Medicare Allowable rates. Indirect costs were determined using local, median income, length of office visits, and distance from the clinic to the patient's home.

Results: Of 200 patients, 14 with thoracic fusion were excluded. The mean age of the 186 included patients was 58.26 years and 85 (46%) were male. Forty-seven percent (87/186) had only routine post-operative visits and 24 had revision surgery. Seventy-five patients made a total of 102 phone calls, 55 office visits, leading to 38 diagnostic studies none of which led to an additional intervention. Using Medicare Allowable rates, the mean direct cost was $776 per patient and the using a median income of $16/hour the mean indirect cost was $124 per patient. There were no differences in the baseline characteristics among the patients who only had routine post-op encounters, had non-routine encounters or had a repeat surgery.

Conclusion: Forty percent of the patients undergoing lumbar surgery had a healthcare encounter outside their routine follow up that did not result in additional intervention after their index operation. These potentially unnecessary encounters create additional cost and inconvenience to both the patient and healthcare system. Providing patient reassurance is important and providers should identify ways to reduce associated costs through patient education, virtual visits, or new technologies to monitor patient's post- operative progress.
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http://dx.doi.org/10.1016/j.spinee.2021.08.009DOI Listing
September 2021

Reaching the medicare allowable threshold in adult spinal deformity surgery: multicenter cost analysis comparing actual direct hospital costs versus what the government will pay.

Spine Deform 2021 Sep 1. Epub 2021 Sep 1.

Presbyterian/St. Luke's Medical Center, Rocky Mountain Hospital for Children, Denver, CO, USA.

Study Design: Retrospective multicenter cost analysis.

Objective: To (1) determine if index episode of care (iEOC) costs of Adult Spinal Deformity (ASD) surgeries are below the Medicare Allowable (MA) threshold, and (2) identify variables that can predict iEOC cases that are below MA. Previous studies have suggested that actual direct hospital cost of Adult Spinal Deformity (ASD) surgery is higher than Medicare Allowable (MA) rates, which has become the benchmark reimbursement target for hospital accounting systems.

Methods: From a prospective, multicenter ASD surgical database, patients undergoing long instrumented fusions (> 5 level) with cost data were identified. iEOC cost was calculated utilizing actual direct hospital cost. MA rates were calculated using hospital specific, year-appropriate CMS Inpatient Pricer Payment System. Recursive partitioning identified potentially modifiable variables that can predict iEOC cost < MA.

Results: Administrative direct cost data from 210 patients were obtained from 4 of 11 centers. Ninety-five (45%) patients had iEOC cost < MA. There was significant variation across the four centers in both iEOC cost ($56,788-$78,878, p < 0.0001) and reimbursement ($40,623-$91,351, p < 0.0001) across deformity-specific DRGs (453,454,456,457). Academic centers were more likely to have iEOC costs < MA (67.2% vs 8.9%, p < 0.0001). Recursive partitioning (r = 0.309) identified rhBMP-2 use of < 24 mg, sagittal plane deformity, a combined anterior/posterior approach, and an SF36-MCS < 39 as predictive for iEOC cost < MA. Performing an anterior/posterior approach reimburses between 14.7% and 121.1% more (2.2-fold) than posterior-only approach. This change in DRG allows iEOC cost to be more likely below the MA threshold.

Conclusion: There is significant institutional (private vs academic) variation in ASD reimbursement. BMP use, deformity type, approach, and baseline mental health impact ASD surgery cost being below Medicare reimbursement. ASD surgeries with anterior/posterior approaches are in DRGs that can potentially reimburse 2.2-fold the posterior-only surgery, making it more likely to fall below the MA threshold.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-021-00405-4DOI Listing
September 2021

Global coronal decompensation and adult spinal deformity surgery: comparison of upper-thoracic versus lower-thoracic proximal fixation for long fusions.

J Neurosurg Spine 2021 Aug 27:1-13. Epub 2021 Aug 27.

18Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.

Objective: Deterioration of global coronal alignment (GCA) may be associated with worse outcomes after adult spinal deformity (ASD) surgery. The impact of fusion length and upper instrumented vertebra (UIV) selection on patients with this complication is unclear. The authors' objective was to compare outcomes between long sacropelvic fusion with upper-thoracic (UT) UIV and those with lower-thoracic (LT) UIV in patients with worsening GCA ≥ 1 cm.

Methods: This was a retrospective analysis of a prospective multicenter database of consecutive ASD patients. Index operations involved instrumented fusion from sacropelvis to thoracic spine. Global coronal deterioration was defined as worsening GCA ≥ 1 cm from preoperation to 2-year follow-up.

Results: Of 875 potentially eligible patients, 560 (64%) had complete 2-year follow-up data, of which 144 (25.7%) demonstrated worse GCA at 2-year postoperative follow-up (35.4% of UT patients vs 64.6% of LT patients). At baseline, UT patients were younger (61.6 ± 9.9 vs 64.5 ± 8.6 years, p = 0.008), a greater percentage of UT patients had osteoporosis (35.3% vs 16.1%, p = 0.009), and UT patients had worse scoliosis (51.9° ± 22.5° vs 32.5° ± 16.3°, p < 0.001). Index operations were comparable, except UT patients had longer fusions (16.4 ± 0.9 vs 9.7 ± 1.2 levels, p < 0.001) and operative duration (8.6 ± 3.2 vs 7.6 ± 3.0 hours, p = 0.023). At 2-year follow-up, global coronal deterioration averaged 2.7 ± 1.4 cm (1.9 to 4.6 cm, p < 0.001), scoliosis improved (39.3° ± 20.8° to 18.0° ± 14.8°, p < 0.001), and sagittal spinopelvic alignment improved significantly in all patients. UT patients maintained smaller positive C7 sagittal vertical axis (2.7 ± 5.7 vs 4.7 ± 5.7 cm, p = 0.014). Postoperative 2-year health-related quality of life (HRQL) significantly improved from baseline for all patients. HRQL comparisons demonstrated that UT patients had worse Scoliosis Research Society-22r (SRS-22r) Activity (3.2 ± 1.0 vs 3.6 ± 0.8, p = 0.040) and SRS-22r Satisfaction (3.9 ± 1.1 vs 4.3 ± 0.8, p = 0.021) scores. Also, fewer UT patients improved by ≥ 1 minimal clinically important difference in numerical rating scale scores for leg pain (41.3% vs 62.7%, p = 0.020). Comparable percentages of UT and LT patients had complications (208 total, including 53 reoperations, 77 major complications, and 78 minor complications), but the percentage of reoperated patients was higher among UT patients (35.3% vs 18.3%, p = 0.023). UT patients had higher reoperation rates of rod fracture (13.7% vs 2.2%, p = 0.006) and pseudarthrosis (7.8% vs 1.1%, p = 0.006) but not proximal junctional kyphosis (9.8% vs 8.6%, p = 0.810).

Conclusions: In ASD patients with worse 2-year GCA after long sacropelvic fusion, UT UIV was associated with worse 2-year HRQL compared with LT UIV. This may suggest that residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusion to the proximal thoracic spine. These results may inform operative planning and improve patient counseling.
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http://dx.doi.org/10.3171/2021.2.SPINE201938DOI Listing
August 2021

Multicenter assessment of outcomes and complications associated with transforaminal versus anterior lumbar interbody fusion for fractional curve correction.

J Neurosurg Spine 2021 Aug 20:1-14. Epub 2021 Aug 20.

18Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.

Objective: Few studies have compared fractional curve correction after long fusion between transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) for adult symptomatic thoracolumbar/lumbar scoliosis (ASLS). The objective of this study was to compare fractional correction, health-related quality of life (HRQL), and complications associated with L4-S1 TLIF versus those of ALIF as an operative treatment of ASLS.

Methods: The authors retrospectively analyzed a prospective multicenter adult spinal deformity database. Inclusion required a fractional curve ≥ 10°, a thoracolumbar/lumbar curve ≥ 30°, index TLIF or ALIF performed at L4-5 and/or L5-S1, and a minimum 2-year follow-up. TLIF and ALIF patients were propensity matched according to the number and type of interbody fusion at L4-S1.

Results: Of 135 potentially eligible consecutive patients, 106 (78.5%) achieved the minimum 2-year follow-up (mean ± SD age 60.6 ± 9.3 years, 85% women, 44.3% underwent TLIF, and 55.7% underwent ALIF). Index operations had mean ± SD 12.2 ± 3.6 posterior levels, 86.6% of patients underwent iliac fixation, 67.0% underwent TLIF/ALIF at L4-5, and 84.0% underwent TLIF/ALIF at L5-S1. Compared with TLIF patients, ALIF patients had greater cage height (10.9 ± 2.1 mm for TLIF patients vs 14.5 ± 3.0 mm for ALIF patients, p = 0.001) and lordosis (6.3° ± 1.6° for TLIF patients vs 17.0° ± 9.9° for ALIF patients, p = 0.001) and longer operative duration (6.7 ± 1.5 hours for TLIF patients vs 8.9 ± 2.5 hours for ALIF patients, p < 0.001). In all patients, final alignment improved significantly in terms of the fractional curve (20.2° ± 7.0° to 6.9° ± 5.2°), maximum coronal Cobb angle (55.0° ± 14.8° to 23.9° ± 14.3°), C7 sagittal vertical axis (5.1 ± 6.2 cm to 2.3 ± 5.4 cm), pelvic tilt (24.6° ± 8.1° to 22.7° ± 9.5°), and lumbar lordosis (32.3° ± 18.8° to 51.4° ± 14.1°) (all p < 0.05). Matched analysis demonstrated comparable fractional correction (-13.6° ± 6.7° for TLIF patients vs -13.6° ± 8.1° for ALIF patients, p = 0.982). In all patients, final HRQL improved significantly in terms of Oswestry Disability Index (ODI) score (42.4 ± 16.3 to 24.2 ± 19.9), physical component summary (PCS) score of the 36-item Short-Form Health Survey (32.6 ± 9.3 to 41.3 ± 11.7), and Scoliosis Research Society-22r score (2.9 ± 0.6 to 3.7 ± 0.7) (all p < 0.05). Matched analysis demonstrated worse ODI (30.9 ± 21.1 for TLIF patients vs 17.9 ± 17.1 for ALIF patients, p = 0.017) and PCS (38.3 ± 12.0 for TLIF patients vs 45.3 ± 10.1 for ALIF patients, p = 0.020) scores for TLIF patients at the last follow-up (despite no differences in these parameters at baseline). The rates of total complications were similar (76.6% for TLIF patients vs 71.2% for ALIF patients, p = 0.530), but significantly more TLIF patients had rod fracture (28.6% of TLIF patients vs 7.1% of ALIF patients, p = 0.036). Multiple regression analysis demonstrated that a 1-mm increase in L4-5 TLIF cage height led to a 2.2° reduction in L4 coronal tilt (p = 0.011), and a 1° increase in L5-S1 ALIF cage lordosis led to a 0.4° increase in L5-S1 segmental lordosis (p = 0.045).

Conclusions: Operative treatment of ASLS with L4-S1 TLIF versus ALIF demonstrated comparable mean fractional curve correction (66.7% vs 64.8%), despite use of significantly larger, more lordotic ALIF cages. TLIF cage height had a significant impact on leveling L4 coronal tilt, whereas ALIF cage lordosis had a significant impact on restoration of lumbosacral lordosis. The advantages of TLIF may include reduced operative duration and hospitalization; however, associated HRQL was inferior and more rod fractures were detected in the TLIF patients included in this study.
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http://dx.doi.org/10.3171/2020.11.SPINE201915DOI Listing
August 2021

Examination of Adult Spinal Deformity Patients Undergoing Surgery with Implanted Spinal Cord Stimulators and Intrathecal Pumps.

Spine (Phila Pa 1976) 2021 Jul 23. Epub 2021 Jul 23.

Department of Orthopaedics, Warren Alpert Medical School, Brown University, Providence, RI Warren Alpert Medical School, Brown University, Providence, RI Brown University, Providence, RI Hospital for Special Surgery, New York, NY University of Pittsburgh Medical Center, Pittsburgh, PA Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY University of Virginia Health System, Charlottesville, VA Duke University, Durham, NC Washington University, St. Louis, MO University of California-Davis, Sacramento, CA Norton Leatherman Spine Center, Louisville, KY Scripp's Clinic, La Jolla, CA Johns Hopkins University, Baltimore, MD University of Calgary Spine Program, University of Calgary, Alberta Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX University of Kansas Hospital, Kansas City, KS Denver International Spine Center, Denver, CO University of California-San Francisco, CA Swedish Neuroscience Institute, Seattle, WA.

Study Design: Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients.

Objective: We hypothesized that patients undergoing ASD surgery with and without previous SCS/ITP would exhibit increased complication rates but comparable improvement in HRQOL.

Summary Of Background Data: ASD patients sometimes seek pain management with spinal cord stimulators (SCS) or intrathecal medication pumps (ITP) prior to spinal deformity correction. Few studies have examined outcomes in this patient population.

Methods: Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Pre-operative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, ODI, SF-36 MCS, and SRS-22r. Propensity score matching was utilized.

Results: In total, out of 1,034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intra-operatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (p > 0.2), with similarly non-significant differences for intraoperative and infection complications (all p > 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 versus 47.6, p = 0.0057) and at 2-year follow-up (44.4 versus 27.7, p = 0.0295). The magnitude of improvement, however, did not significantly differ (p = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (p > 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching MCID in ODI (47.6% versus 60.9%, p = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (p < 0.05).

Conclusions: ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and post-operative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004176DOI Listing
July 2021

Dual pitch screw design provides equivalent fixation to upsized screw diameter in revision pedicle screw instrumentation: a cadaveric biomechanical study.

Spine J 2021 Jul 15. Epub 2021 Jul 15.

Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY, USA; Department of Orthopaedic Surgery, University of Louisville School of Medicine, 550 S. Jackson Street, 1st Floor ACB, Louisville, KY, USA.

Background Context: There are situations that require the replacement of pedicle screws. They are often exchanged when loose or broken or to accommodate a different sized rod or pedicle screw system. Traditionally, pedicle screws are replaced by up-sizing the core diameter until an interference fit is obtained. However, this method carries a risk of pedicle screw breach.

Purpose: To determine if dual pitch screws, with cancellous pitch in the vertebral body and cortical pitch throughout the pedicle, allows for in-line screw revision without upsizing screw diameter.

Study Design: Cadaveric biomechanical Study PATIENT SAMPLE: Not applicable OUTCOME MEASURES: Not applicable METHODS: Pedicle screws were tested in the lumbar vertebrae from eleven cadavers. Standard pitch 5.5 mm screws were inserted and loaded using a "break-in" protocol. Screws were removed and replaced with one of four screw types: 5.5 mm Standard Pitch, 5.5 mm Dual Pitch, 6.0 mm Standard Pitch, or 6.0 mm Dual Pitch. Failure testing was done using a stepwise increasing cyclic loading protocol for 100 cycles at each increasing load level. The loading consisted of a combined axial and bending load simulating the load seen by the most inferior screw.

Results: Failure was consistent, with the tip of the screw displacing inferiorly into the vertebral body while simultaneously pulling out. Failure strength was lowest in the 5.5mm Standard (135.8±29.4N) followed by 6.0mm Standard (141.8±38.6N), 5.5mm Dual (158.1±53.8N), and 6.0mm Dual (173.6±52.1N, p=.023). There was no difference in the failure strength between the 5.5mm Dual and 6.0mm Standard. Lumbar level (p=.701) and donor spine (p=.062) were not associated with failure strength.

Conclusions: After pedicle screw removal, screws with a larger core diameter or with a dual pitch have similar failure strengths. Dual pitch screws may allow for in-line revision of screws without upsizing screw diameter, minimizing the risk of pedicle breach or fracture.

Clinical Significance: Dual pitch screws, with cancellous pitch in the vertebral body and cortical pitch through the pedicle, allows for in-line revision of pedicle screws without upsizing screw diameter; reducing the risk of pedicle breach or fracture when exchanging screws.
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http://dx.doi.org/10.1016/j.spinee.2021.07.010DOI Listing
July 2021

Defining a Surgical Invasiveness Threshold for Increased Risk of a Major Complication Following Adult Spinal Deformity Surgery.

Spine (Phila Pa 1976) 2021 Jul;46(14):931-938

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

Study Design: Retrospective review.

Objectives: The aim of this study was to define a surgical invasiveness threshold that predicts major complications after adult spinal deformity (ASD) surgery; use this threshold to categorize patients into quartiles by invasiveness; and determine the odds of major complications by quartile.

Summary Of Background Data: Understanding the relationship between surgical invasiveness and major complications is important for estimating the likelihood of major complications after ASD surgery.

Methods: Using a multicenter database, we identified 574 ASD patients (more than 5 levels fused; mean age, 60 ± 15 years) with minimum 2-year follow-up. Invasiveness was calculated as the ASD Surgical and Radiographic (ASD-SR) score. Youden index was used to identify the invasiveness score cut-off associated with optimal sensitivity and specificity for predicting major complications. Resulting high- and low-invasiveness groups were divided in half to create quartiles. Odds of developing a major complication were analyzed for each quartile using logistic regression (alpha = 0.05).

Results: The ASD-SR cutoff score that maximally predicted major complications was 90 points. ASD-SR quartiles were 0 to 65 (Q1), 66 to 89 (Q2), 90 to 119 (Q3), and ≥120 (Q4). Risk of a major complication was 17% in Q1, 21% in Q2, 35% in Q3, and 33% in Q4 (P < 0.001). Comparisons of adjacent quartiles showed an increase in the odds of a major complication from Q2 to Q3 (odds ratio [OR] 1.8; 95% confidence interval [CI]: 1.0-3.0), but not from Q1 to Q2 or from Q3 to Q4. Patients with ASD-SR scores ≥90 were 1.9 times as likely to have a major complication than patients with scores <90 (OR 1.9, 95% CI 1.3-2.9). Mean ASD-SR scores above and below 90 points were 121 ± 25 and 63 ± 17, respectively.

Conclusion: The odds of major complications after ASD surgery are significantly greater when the procedure has an ASD-SR score ≥90. ASD-SR score can be used to counsel patients regarding these increased odds.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003949DOI Listing
July 2021

Combination of Side-Bending and Traction Radiographs Do Not Influence Selection of Fusion Levels Compared to Either One Alone in Adolescent Idiopathic Scoliosis.

Global Spine J 2021 May 12:21925682211015193. Epub 2021 May 12.

Norton Leatherman Spine Center, Louisville, KY, USA.

Study Design: A retrospective study.

Objectives: Curve flexibility in patients with adolescent idiopathic scoliosis (AIS) can be evaluated using different techniques. This study aimed to determine whether the combination of side-bending (SB) and traction (TX) radiographs influences preoperative planning for AIS than either radiograph alone.

Methods: Thirty-two spine surgeons were asked to review 30 AIS Lenke type 1 cases and select an upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) for the posterior spinal instrumentation of each case. Each rater reviewed the cases 3 times in each round. The raters were provided with the full-length posteroanterior (PA) and lateral standing and SB radiographs for round 1; PA, lateral, and TX radiographs for round 2; and PA, lateral, SB, and TX radiographs for round 3. Intra- and inter-rater reliabilities were evaluated using Kappa statistics.

Results: The intra-rater reliability for UIV and LIV was 0.657 and 0.612 between rounds 1 and 2, 0.634 and 0.692 between rounds 1 and 3, and 0.659 and 0.638 between rounds 2 and 3, respectively, which indicated substantial agreement between rounds. The inter-rater kappa reliabilities for UIV and LIV selection were 0.103 and 0.412 for round 1, 0.121 and 0.380 for round 2, and 0.125 and 0.368 for round 3, indicating slight to moderate agreement between raters.

Conclusions: Whether raters used either SB or TX radiography, or both in addition to PA and lateral standing radiographs, did not influence the decision making for UIV or LIV of AIS Lenke type 1 surgery.
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http://dx.doi.org/10.1177/21925682211015193DOI Listing
May 2021

Artificial intelligence clustering of adult spinal deformity sagittal plane morphology predicts surgical characteristics, alignment, and outcomes.

Eur Spine J 2021 08 15;30(8):2157-2166. Epub 2021 Apr 15.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Alpert Medical School, Providence, Rhode Island, 1 Kettle Point Avenue, East Providence, RI, 02914, USA.

Purpose: AI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics-this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology.

Methods: This was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map-a form of artificial neural network frequently employed in unsupervised classification tasks-was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared.

Results: Qualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not.

Conclusions: This study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity.

Level Of Evidence Iv: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.
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http://dx.doi.org/10.1007/s00586-021-06799-zDOI Listing
August 2021

Drivers of in-hospital opioid consumption in patients undergoing lumbar fusion surgery.

J Spine Surg 2021 Mar;7(1):19-25

Norton Leatherman Spine Center, Louisville, KY, USA.

Background: With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions.

Methods: This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use.

Results: A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type.

Conclusions: Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.
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http://dx.doi.org/10.21037/jss-20-626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8024760PMC
March 2021

Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption.

J Spine Surg 2020 Dec;6(4):681-687

Norton Leatherman Spine Center, Louisville, KY, USA.

Background: The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF).

Methods: This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs).

Results: In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs.

Conclusions: The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%.
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http://dx.doi.org/10.21037/jss-20-629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797802PMC
December 2020

Cannabinoids and orthopedic surgery: a systematic review of therapeutic studies.

J Orthop Surg Res 2021 Jan 14;16(1):57. Epub 2021 Jan 14.

Norton Leatherman Spine Center, 210 E Gray Street, Suite 900, Louisville, KY, USA.

Background: Recent work has shed light on the potential benefits of cannabinoids for multimodal pain control following orthopedic procedures. The objective of this review was to summarize the available evidence of analgesic and opioid-sparing effects cannabinoids have in orthopedic surgery and identify adverse events associated with their use.

Methods: A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines including PubMed, EMBASE, MEDLINE, PsycINFO, and Google Scholar was performed to include all primary, therapeutic studies published on the use of cannabis, and cannabis-derived products in orthopedic surgery.

Results: The literature review returned 4292 citations. Thirteen publications were found to meet inclusion criteria. Four randomized controlled trials were evaluated while the remaining studies were of quasi-experimental design.

Conclusion: Research on cannabinoids in orthopedic surgery is mostly of a quasi-experimental nature and is mainly derived from studies where orthopedics was not the primary focus. The overall results demonstrate potential usefulness of cannabinoids as adjunctive analgesics and in mitigating opioid use. However, the current evidence is far from convincing. There is a need to produce rigorous evidence with well-designed randomized controlled trials specific to orthopedic surgery to further establish these effects.
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http://dx.doi.org/10.1186/s13018-021-02205-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7809869PMC
January 2021

Improvement in SRS-22R Self-Image Correlate Most with Patient Satisfaction after 3-Column Osteotomy.

Spine (Phila Pa 1976) 2021 Jun;46(12):822-827

Presbyterian/St. Luke's Medical Center, Rocky Mountain Hospital for Children, Denver, CO.

Study Design: Longitudinal cohort.

Objectives: The aim of this study was to examine the relationship between patient satisfaction, patient-reported outcome measures (PROMs) and radiographic parameters in adult spine deformity (ASD) patients undergoing three-column osteotomies (3CO).

Summary Of Background Data: Identifying factors that influence patient satisfaction in ASD is important. Evidence suggests Scoliosis Research Society-22R (SRS-22R) Self-Image domain correlates with patient satisfaction in patients with ASD.

Methods: This is a retrospective review of ASD patients enrolled in a prospective, multicenter database undergoing a 3CO with complete SRS-22R pre-op and minimum 2-years postop. Spearman correlations were used to evaluate associations between the 2-year SRS Satisfaction score and changes in SRS-22R domain scores, Oswestry Disability Index (ODI), and radiographic parameters.

Results: Of 135 patients eligible for 2-year follow-up, 98 patients (73%) had complete pre- and 2-year postop data. The cohort was mostly female (69%) with mean BMI of 29.7 kg/m2 and age of 61.0 years. Mean levels fused was 12.9 with estimated blood loss of 2695 cc and OR time of 407 minutes; 27% were revision surgeries. There was a statistically significant improvement between pre- and 2-year post-op PROMs and all radiographic parameters except Coronal Vertical Axis. The majority of patients had an SRS Satisfaction score of ≥3.0 (90%) or ≥4.0 (68%), consistent with a moderate ceiling effect. Correlations of patient satisfaction was significant for Pain (0.43, P < 0.001), Activity (0.39, P < 0.001), Mental (0.38, P = 0.001) Self-Image (0.52, P < 0.001). ODI and Short-Form-36 Physical component summary had a moderate correlation as well, with mental component summary being weak. There was no statistically significant correlation between any radiographic or operative parameters and patient satisfaction.

Conclusion: There was statistically significant improvement in all PROMs and radiographic parameters, except coronal vertical axis at 2 years in ASD patients undergoing 3CO. Improvement in SRS Self-Image domain has the strongest correlation with patient satisfaction.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003897DOI Listing
June 2021

Multicenter assessment of surgical outcomes in adult spinal deformity patients with severe global coronal malalignment: determination of target coronal realignment threshold.

J Neurosurg Spine 2020 Dec 4:1-14. Epub 2020 Dec 4.

18Department of Neurological Surgery, University of California, San Francisco, California.

Objective: The impact of global coronal malalignment (GCM; C7 plumb line-midsacral offset) on adult spinal deformity (ASD) treatment outcomes is unclear. Here, the authors' primary objective was to assess surgical outcomes and complications in patients with severe GCM, with a secondary aim of investigating potential surgical target coronal thresholds for optimal outcomes.

Methods: This is a retrospective analysis of a prospective multicenter database. Operative patients with severe GCM (≥ 1 SD above the mean) and a minimum 2-year follow-up were identified. Demographic, surgical, radiographic, health-related quality of life (HRQOL), and complications data were analyzed.

Results: Of 691 potentially eligible operative patients (mean GCM 4 ± 3 cm), 80 met the criteria for severe GCM ≥ 7 cm. Of these, 62 (78%; mean age 63.7 ± 10.7 years, 81% women) had a minimum 2-year follow-up (mean follow-up 3.3 ± 1.1 years). The mean ASD-Frailty Index was 3.9 ± 1.5 (frail), 50% had undergone prior fusion, and 81% had concurrent severe sagittal spinopelvic deformity with GCM and C7-S1 sagittal vertical axis (SVA) positively correlated (r = 0.313, p = 0.015). Surgical characteristics included posterior-only (58%) versus anterior-posterior (42%) approach, mean fusion of 13.2 ± 3.8 levels, iliac fixation (90%), 3-column osteotomy (36%), operative duration of 8.3 ± 3.0 hours, and estimated blood loss of 2.3 ± 1.7 L. Final alignment and HRQOL significantly improved (p < 0.01): GCM, 11 to 4 cm; maximum coronal Cobb angle, 43° to 20°; SVA, 13 to 4 cm; pelvic tilt, 29° to 23°; pelvic incidence-lumbar lordosis mismatch, 31° to 5°; Oswestry Disability Index, 51 to 37; physical component summary of SF-36 (PCS), 29 to 37; 22-Item Scoliosis Research Society Patient Questionnaire (SRS-22r) Total, 2.6 to 3.5; and numeric rating scale score for back and leg pain, 7 to 4 and 5 to 3, respectively. Residual GCM ≥ 3 cm was associated with worse SRS-22r Appearance (p = 0.04) and SRS-22r Satisfaction (p = 0.02). The minimal clinically important difference and/or substantial clinical benefit (MCID/SCB) was met in 43%-83% (highest for SRS-22r Appearance [MCID 83%] and PCS [SCB 53%]). The severity of baseline GCM (≥ 2 SD above the mean) significantly impacted postoperative SRS-22r Satisfaction and MCID/SCB improvement for PCS. No significant partial correlations were demonstrated between GCM or SVA correction and HRQOL improvement. There were 89 total complications (34 minor and 55 major), 45 (73%) patients with ≥ 1 complication (most commonly rod fracture [19%] and proximal junctional kyphosis [PJK; 18%]), and 34 reoperations in 22 (35%) patients (most commonly for rod fracture and PJK).

Conclusions: Study results demonstrated that ASD surgery in patients with substantial GCM was associated with significant radiographic and HRQOL improvement despite high complication rates. MCID improvement was highest for SRS-22r Appearance/Self-Image. A residual GCM ≥ 3 cm was associated with a worse outcome, suggesting a potential coronal realignment target threshold to assist surgical planning.
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http://dx.doi.org/10.3171/2020.7.SPINE20606DOI Listing
December 2020

Practical answers to frequently asked questions for shared decision-making in adult spinal deformity surgery.

J Neurosurg Spine 2020 Oct 16:1-10. Epub 2020 Oct 16.

1Norton Leatherman Spine Center, Louisville, Kentucky.

Objective: The shared decision-making (SDM) process provides an opportunity to answer frequently asked questions (FAQs). The authors aimed to present a concise list of answers to FAQs to aid in SDM for adult spinal deformity (ASD) surgery.

Methods: From a prospective, multicenter ASD database, patients enrolled between 2008 and 2016 who underwent fusions of 5 or more levels with a minimum 2-year follow-up were included. All deformity types were included to provide general applicability. The authors compiled a list of FAQs from patients undergoing ASD surgery and used a retrospective analysis to provide answers. All responses are reported as either the means or the proportions reaching the minimal clinically important difference at the 2-year follow-up interval.

Results: Of 689 patients with ASD who were eligible for 2-year follow-up, 521 (76%) had health-related quality-of-life scores available at the time of that follow-up. The mean age at the initial surgery was 58.2 years, and 78% of patients were female. The majority (73%) underwent surgery with a posterior-only approach. The mean number of fused levels was 12.2. Revision surgery accounted for 48% of patients. The authors answered 12 FAQs as follows:1. Will my pain improve? Back and leg pain will both be reduced by approximately 50%.2. Will my activity level improve? Approximately 65% of patients feel improvement in their activity level.3. Will I feel better about myself? More than 70% of patients feel improvement in their appearance.4. Is there a chance I will get worse? 4.1% feel worse at 2 years postoperatively.5. What is the likelihood I will have a complication? 67.8% will have a major or minor complication, with 47.8% having a major complication.6. Will I need another surgery? 25.0% will have a reoperation within 2 years.7. Will I regret having surgery? 6.5% would not choose the same treatment.8. Will I get a blood transfusion? 73.7% require a blood transfusion.9. How long will I stay in the hospital? You need to stay 8.1 days on average.10. Will I have to go to the ICU? 76.0% will have to go to the ICU.11. Will I be able to return to work? More than 70% will be working at 1 year postoperatively.12. Will I be taller after surgery? You will be 1.1 cm taller on average.

Conclusions: The above list provides concise, practical answers to FAQs encountered in the SDM process while counseling patients for ASD surgery.
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http://dx.doi.org/10.3171/2020.6.SPINE20363DOI Listing
October 2020

State-of-the-art: outcome assessment in adult spinal deformity.

Spine Deform 2021 Jan 9;9(1):1-11. Epub 2020 Oct 9.

Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY, 40202, USA.

Adult spinal deformity (ASD) is a diagnosis that encompasses heterogeneous disorders with an increasing prevalence. This increasing prevalence may be due to greater patient longevity or greater awareness of available treatments. Outcome assessment in ASD has evolved over the last 3 decades from physician-based assessments to a patient-centered perception of improvement. Outcome assessment that is reliable, accurate and responsive to change is especially important in ASD, as surgical treatment is known to carry a high cost and complication rate Glassman (Spine Deform 3:199-203, 2015); Glassman (Spine (Phila Pa 1976) 32: 2764-2770, 2007); Smith (J Neurosurg Spine 25:1-14, 2016). In an era of value-based care, diagnosis associated with such heterogeneity and high cost must provide sound evidence to support the cost versus outcome ratio. Numerous general health and disease specific patient-reported outcome measures (PROMs) have been utilized in ASD. We discuss these instruments in detail in the following state-of-the-art review.
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http://dx.doi.org/10.1007/s43390-020-00220-3DOI Listing
January 2021

Economic analysis of 90-day return to the emergency room and readmission after elective lumbar spine surgery: a single-center analysis of 5444 patients.

J Neurosurg Spine 2020 Oct 2:1-7. Epub 2020 Oct 2.

Objective: In the future, payers may not cover unplanned 90-day emergency room (ER) visits or readmissions after elective lumbar spine surgery. Prior studies using large administrative databases lack granularity and/or use a proxy for actual cost. The purpose of this study was to identify risk factors and subsequent costs associated with 90-day ER visits and readmissions after elective lumbar spine surgery.

Methods: A prospective, multisurgeon, single-center electronic medical record was queried for elective lumbar spine fusion surgeries from 2013 to 2017. Predictive models were created for 90-day ER visits and readmissions.

Results: Of 5444 patients, 729 (13%) returned to the ER, most often for pain (n = 213, 29%). Predictors of an ER visit were prior ER visit (OR 2.5), underserved zip code (OR 1.4), and number of chronic medical conditions (OR 1.4). In total, 421 (8%) patients were readmitted, most frequently for wound infection (n = 123, 2%), exacerbation of chronic obstructive pulmonary disease (n = 24, 0.4%), and sepsis (n = 23, 0.4%). Predictors for readmission were prior ER visit (OR 1.96), multiple chronic conditions (OR 1.69), obesity (nonobese, OR 0.49), race (African American, OR 1.43), admission status (ER admission, OR 2.29), and elevated hemoglobin A1c (OR 1.80). The mean direct hospital cost for an ER visit was $1971, with 75% of visits costing less than $1890, and the average readmission cost was $7347, with 75% of readmissions costing less than $8820. Over the 5-year study period, the cost to the institution for 90-day return ER visits was $5.1 million.

Conclusions: Risk factors for 90-day ER visit and readmission after elective lumbar spine surgery include medical comorbidities and socioeconomic factors. Proper patient counseling, appropriate postoperative pain management, and optimization of modifiable risk factors prior to surgery are areas to focus future efforts to lower 90-day ER visits and readmissions and reduce healthcare costs.
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http://dx.doi.org/10.3171/2020.6.SPINE191477DOI Listing
October 2020

Robotic-assisted cortical bone trajectory (CBT) screws using the Mazor X Stealth Edition (MXSE) system: workflow and technical tips for safe and efficient use.

J Robot Surg 2021 Feb 28;15(1):13-23. Epub 2020 Sep 28.

Department of Spine Surgery, Norton Leatherman Spine Center, 210 E. Gray St. Suite 900, Louisville, KY, 40202, USA.

Robotic-assisted spine surgery has a number of potential advantages, including more precise pre-operative planning, a high degree of accuracy in screw placement, and significantly reduced radiation exposure to the surgical team. While the current primary goal of these systems is to improve the safety of spine surgery by increasing screw accuracy, there are a number of technical errors that may increase the risk of screw malposition. Given the learning curve associated with this technology, it is important for the surgeon to have a thorough understanding of all required steps. In this article, we will demonstrate the setup and workflow of a combined navigation and robotic spine surgery platform using the Mazor X Stealth Edition (MXSE) system to place cortical-based trajectory (CBT) screws, including a review of all technical tips and pearls to efficiently perform this procedure with minimal risk of screw malposition. In this article, we will review surgical planning, operating room setup, robotic arm mounting, registration, and CBT screw placement using the MXSE system.
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http://dx.doi.org/10.1007/s11701-020-01147-7DOI Listing
February 2021

Health-related quality-of-life improvement with lumbar fusion in patients with lower-extremity arthritis.

J Neurosurg Spine 2020 Sep 4:1-6. Epub 2020 Sep 4.

Objective: Lumbar fusion can lead to significant improvements in patient-reported outcomes (PROs) in patients with degenerative conditions. It is unknown whether the presence of hip or knee arthritis confounds the responses of patients to low-back-specific PROs. This study examined PROs with lumbar fusion in patients with concomitant lower-extremity arthritis. The purpose of the current study was to examine whether patients with significant lower-extremity arthritis who undergo lumbar fusion achieve similar improvements in low-back-specific PROs compared to patients without lower-extremity arthritis.

Methods: Patients were identified from a prospectively enrolled multicenter registry of patients undergoing lumbar fusion surgery for degenerative conditions. Two hundred thirty patients identified with lumbar fusion and who also had concomitant lower-extremity arthritis were propensity matched to 233 patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists grade, number of levels fused, and surgical approach. One-year improvement in PROs, numeric rating scales (0-10) for back and leg pain, and the Oswestry Disability Index and EuroQol-5D scores were compared for patients with and without lower-extremity arthritis.

Results: Baseline demographics and preoperative outcome measures did not differ between the two propensity-matched groups with 110 cases each. Patients with concomitant lower-extremity arthritis achieved similar improvement in health-related quality-of-life measures to patients without lower-extremity arthritis, with no significant differences between the groups (p > 0.10).

Conclusions: The presence of lower-extremity arthritis does not adversely affect the results of lumbar fusion in properly selected patients. Patients with lower-extremity arthritis who undergo lumbar fusion can achieve meaningful improvement in PROs similar to patients without arthritis.
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http://dx.doi.org/10.3171/2020.6.SPINE20759DOI Listing
September 2020

Drivers for nonhome discharge in a consecutive series of 1502 patients undergoing 1- or 2-level lumbar fusion.

J Neurosurg Spine 2020 Jul 31:1-6. Epub 2020 Jul 31.

Objective: Unexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion.

Methods: The electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors.

Results: A total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001).

Conclusions: Increased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.
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http://dx.doi.org/10.3171/2020.5.SPINE20410DOI Listing
July 2020

Prospective multicenter assessment of complication rates associated with adult cervical deformity surgery in 133 patients with minimum 1-year follow-up.

J Neurosurg Spine 2020 Jun 19:1-13. Epub 2020 Jun 19.

17Department of Neurological Surgery, University of California, San Francisco, California.

Objective: Although surgical treatment can provide significant improvement of symptomatic adult cervical spine deformity (ACSD), few reports have focused on the associated complications. The objective of this study was to assess complication rates at a minimum 1-year follow-up based on a prospective multicenter series of ACSD patients treated surgically.

Methods: A prospective multicenter database of consecutive operative ACSD patients was reviewed for perioperative (< 30 days), early (30-90 days), and delayed (> 90 days) complications with a minimum 1-year follow-up. Enrollment required at least 1 of the following: cervical kyphosis > 10°, cervical scoliosis > 10°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°.

Results: Of 167 patients, 133 (80%, mean age 62 years, 62% women) had a minimum 1-year follow-up (mean 1.8 years). The most common diagnoses were degenerative (45%) and iatrogenic (17%) kyphosis. Almost 40% of patients were active or past smokers, 17% had osteoporosis, and 84% had at least 1 comorbidity. The mean baseline Neck Disability Index and modified Japanese Orthopaedic Association scores were 47 and 13.6, respectively. Surgical approaches were anterior-only (18%), posterior-only (47%), and combined (35%). A total of 132 complications were reported (54 minor and 78 major), and 74 (56%) patients had at least 1 complication. The most common complications included dysphagia (11%), distal junctional kyphosis (9%), respiratory failure (6%), deep wound infection (6%), new nerve root motor deficit (5%), and new sensory deficit (5%). A total of 4 deaths occurred that were potentially related to surgery, 2 prior to 1-year follow-up (1 cardiopulmonary and 1 due to obstructive sleep apnea and narcotic use) and 2 beyond 1-year follow-up (both cardiopulmonary and associated with revision procedures). Twenty-six reoperations were performed in 23 (17%) patients, with the most common indications of deep wound infection (n = 8), DJK (n = 7), and neurological deficit (n = 6). Although anterior-only procedures had a trend toward lower overall (42%) and major (21%) complications, rates were not significantly different from posterior-only (57% and 33%, respectively) or combined (61% and 37%, respectively) approaches (p = 0.29 and p = 0.38, respectively).

Conclusions: This report provides benchmark rates for ACSD surgery complications at a minimum 1-year (mean 1.8 years) follow-up. The marked health and functional impact of ACSD, the frail population it affects, and the high rates of surgical complications necessitate a careful risk-benefit assessment when contemplating surgery. Collectively, these findings provide benchmarks for complication rates and may prove useful for patient counseling and efforts to improve the safety of care.
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http://dx.doi.org/10.3171/2020.4.SPINE20213DOI Listing
June 2020

Establishing the minimum clinically important difference in Neck Disability Index and modified Japanese Orthopaedic Association scores for adult cervical deformity.

J Neurosurg Spine 2020 May 29:1-5. Epub 2020 May 29.

3Department of Neurological Surgery, University of California, San Francisco, California.

Objective: It is being increasingly recognized that adult cervical deformity (ACD) is correlated with significant pain, myelopathy, and disability, and that patients who undergo deformity correction gain significant benefit. However, there are no defined thresholds of minimum clinically important difference (MCID) in Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scores.

Methods: Patients of interest were consecutive patients with ACD who underwent cervical deformity correction. ACD was defined as C2-7 sagittal Cobb angle ≥ 10° (kyphosis), C2-7 coronal Cobb angle ≥ 10° (cervical scoliosis), C2-7 sagittal vertical axis ≥ 4 cm, and/or chin-brow vertical angle ≥ 25°. Data were obtained from a consecutive cohort of patients from a multiinstitutional prospective database maintained across 13 sites. Distribution-based MCID, anchor-based MCID, and minimally detectable measurement difference (MDMD) were calculated.

Results: A total of 73 patients met inclusion criteria and had sufficient 1-year follow-up. In the cohort, 42 patients (57.5%) were female. The mean age at the time of surgery was 62.23 years, and average body mass index was 29.28. The mean preoperative NDI was 46.49 and mJOA was 13.17. There was significant improvement in NDI at 1 year (46.49 vs 37.04; p = 0.0001). There was no significant difference in preoperative and 1-year mJOA (13.17 vs 13.7; p = 0.12). Using multiple techniques to yield MCID thresholds specific to the ACD population, the authors obtained values of 5.42 to 7.48 for the NDI, and 1.00 to 1.39 for the mJOA. The MDMD was 6.4 for the NDI, and 1.8 for the mJOA. Therefore, based on their results, the authors recommend using an MCID threshold of 1.8 for the mJOA, and 7.0 for the NDI in patients with ACD.

Conclusions: The ACD-specific MCID thresholds for NDI and mJOA are similar to the reported MCID following surgery for degenerative cervical disease. Additional studies are needed to verify these findings. Nonetheless, the findings here will be useful for future studies evaluating the success of surgery for patients with ACD undergoing deformity correction.
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http://dx.doi.org/10.3171/2020.3.SPINE191232DOI Listing
May 2020

Cost-effectiveness of surgical treatment of adult spinal deformity: comparison of posterior-only versus anteroposterior approach.

Spine J 2020 09 12;20(9):1464-1470. Epub 2020 Apr 12.

Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40204, USA.

Background Context: Considerable debate exists regarding the optimal surgical approach for adult spinal deformity (ASD). It remains unclear which approach, posterior-only or combined anterior-posterior (AP), is more cost-effective. Our goal is to determine the 2-year cost per quality-adjusted life year (QALY) for each approach.

Purpose: To compare the 2-year cost-effectiveness of surgical treatment for ASD between the posterior-only approach and combined AP approach.

Study Design: Retrospective economic analysis of a prospective, multicenter database PATIENT SAMPLE: From a prospective, multicenter surgical database of ASD, patients undergoing five or more level fusions through a posterior-only or AP approach were identified and compared.

Methods: QALYs gained were determined using baseline, 1-year, and 2-year postoperative Short Form 6D. Cost was calculated from actual, direct hospital costs including any subsequent readmission or revision. Cost-effectiveness was determined using cost/QALY gained.

Results: The AP approach showed significantly higher index cost than the posterior-only approach ($84,329 vs. $64,281). This margin decreased at 2-year follow-up with total costs of $89,824 and $73,904, respectively. QALYs gained at 2 years were similar with 0.21 and 0.17 in the posterior-only and the AP approaches, respectively. The cost/QALY at 2 years after surgery was significantly higher in the AP approach ($525,080) than in the posterior-only approach ($351,086).

Conclusions: We assessed 2-year cost-effectiveness for the surgical treatment through posterior-only and AP approaches. The posterior-only approach is less expensive both for the index surgery and at 2-year follow-up. The QALY gained at 2-years was similar between the two approaches. Thus, posterior-only approach was more cost-effective than the AP approach under our study parameters. However, both approaches were not cost-effective at 2-year follow-up.
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http://dx.doi.org/10.1016/j.spinee.2020.03.018DOI Listing
September 2020

Cost-Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery.

Spine (Phila Pa 1976) 2020 Jul;45(14):1009-1015

Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX.

Study Design: Economic modeling of data from a multicenter, prospective registry.

Objective: The aim of this study was to analyze the cost utility of recombinant human bone morphogenetic protein-2 (BMP) in adult spinal deformity (ASD) surgery.

Summary Of Background Data: ASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis.

Methods: Of 522 ASD patients with fusion of five or more spinal levels, 367 (70%) had at least 2-year follow-up. Total direct cost was calculated by adding direct costs of the index surgery and any subsequent reoperations or readmissions. Cumulative quality-adjusted life years (QALYs) gained were calculated from the change in preoperative to final follow-up SF-6D health utility score. A decision-analysis model comparing BMP versus no-BMP was developed with pseudarthrosis as the primary outcome. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates (Alpha = 0.05).

Results: BMP was used in the index surgery for 267 patients (73%). The mean (±standard deviation) direct cost of BMP for the index surgery was $14,000 ± $6400. Forty patients (11%) underwent revision surgery for symptomatic pseudarthrosis (BMP group, 8.6%; no-BMP group, 17%; P = 0.022). The mean 2-year direct cost was significantly higher for patients with pseudarthrosis ($138,000 ± $17,000) than for patients without pseudarthrosis ($61,000 ± $25,000) (P < 0.001). Simulation analysis revealed that BMP was associated with positive incremental utility in 67% of patients and considered favorable at a willingness-to-pay threshold of $150,000/QALY in >52% of patients.

Conclusion: BMP use was associated with reduction in revisions for symptomatic pseudarthrosis in ASD surgery. Cost-utility analysis suggests that BMP use may be favored in ASD surgery; however, this determination requires further research.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003442DOI Listing
July 2020

Group-based Trajectory Modeling: A Novel Approach to Classifying Discriminative Functional Status Following Adult Spinal Deformity Surgery: Study of a 3-year Follow-up Group.

Spine (Phila Pa 1976) 2020 Jul;45(13):903-910

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

Study Design: Retrospective review of prospectively collected database.

Objective: To delineate and visualize trajectories of the functional status in surgically-treated adult spinal deformity (ASD) patients.

Summary Of Background Data: Classifying long-term recovery following ASD surgery is not well defined.

Methods: One thousand one hundred seventy-one surgically-treated patients with a minimum of 3-year follow-up were included. The group-based trajectory modeling (GBTM) was used to identify distinct trajectories of functional status over time, measured by Oswestry Disability Index (ODI). Patient profiles were then compared according to the observed functional patterns.

Results: The GBTM identified four distinct functional patterns. The first group (10.0%) started with minimal disability (ODI: 15 ± 10) and ended up almost disability-free (low-low). The fourth group (21.5%) began with high ODI (66 ± 11) and improvement was minimal (high-high). Groups two (40.1%) and three (28.4%) had moderate disability (ODI: 39 ± 11 vs. 49 ± 11, P < 0.001) before surgery. Following surgery, marked improvement was seen in group two (median-low), but deterioration/no change was observed in group three (median-high). The low-low group primarily included adult idiopathic scoliosis, while the high-high group had the oldest and the most severe patients as compared with the rest of the groups. A subgroup analysis was performed between groups two and three with propensity score matching on age, body mass index, baseline physical component score (PCS), and severity of deformity. Notably, the baseline mental status of the median-high group was significantly worse than that of the median-low group, though the differences in demographics, surgery, and deformity no longer existed.

Conclusions: Patients with moderate-to-low disability are more likely to obtain better functional postoperative outcomes. Earlier surgical interventions should be considered to prevent progression of deformity, and to optimize favorable outcomes. Greatest improvement appears to occur in moderately disabled patients with good mental health. GBTM permits classification into distinct groups, which can help in surgical decision making and setting expectations regarding recovery.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003419DOI Listing
July 2020

The Berg balance scale for assessing dynamic stability and balance in the adult spinal deformity (ASD) population.

J Spine Surg 2019 Dec;5(4):451-456

Norton Leatherman Spine Center, Louisville, KY, USA.

Background: Adult spinal deformity (ASD) is a prevalent condition in individuals over the age of 65; leading to impaired standing balance and abnormal gait patterns. This functional impairment may be due to the fixed sagittal or coronal malalignment; associated spinal stenosis or deconditioning. The Berg balance scale (BBS) was developed to measure balance by assessing the performance of functional tasks. The purpose of this study is to determine if BBS is a useful metric for evaluating functional status in ASD patients.

Methods: ASD patients who required fusion from the thoracic spine to the pelvis from 2014 to 2016 were enrolled and asked to complete the BBS prior to and six months after surgery. BBS were obtained by a certified physical therapist. Standard demographic; radiographic and surgical data were collected. The Oswestry disability index (ODI), EuroQOL-5D and numeric rating scales (0 to 10) for back and leg pain were assessed at baseline and post-intervention.

Results: Of 21 patients enrolled; 19 completed pre- and post-surgery BBS. The mean age was 59.8±13.3 years with 14 females. There was a statistically significant improvement in all outcome scores and radiographic parameters after surgery; but no difference in BBS. Only one patient had a BBS score low enough to be considered a medium fall risk. There was no difference in the pre-op BBS scores in the four patients that had revision surgery compared to those that did not.

Conclusions: In this small pilot study; BBS did not appear to be associated with measures of clinical and radiographic improvement in ASD patients. The test was also potentially problematic in that it has a ceiling effect and required significant time with a trained physical therapist for administration. Continued effort to identify a viable measure of balance dysfunction in ASD patients is warranted.
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http://dx.doi.org/10.21037/jss.2019.09.15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989922PMC
December 2019

Accuracy of cortical bone trajectory screw placement in midline lumbar fusion (MIDLF) with intraoperative cone beam navigation.

J Spine Surg 2019 Dec;5(4):443-450

Norton Leatherman Spine Center, Louisville, KY, USA.

Background: Cortical bone trajectory (CBT) screws have been recently described as a method of lumbosacral fixation. These screws are typically inserted under fluoroscopic guidance with a medial-to-lateral trajectory in the axial plane and a caudal-to-cephalad trajectory in the sagittal plane. In an effort to reduce surgeon radiation exposure and improve accuracy, CBT screws may be inserted under navigation with intraoperative cone beam computed tomography (CT). However, the accuracy of CBT screw placement under intraoperative navigation has yet to be assessed in the literature. The purpose of the study was to evaluate the accuracy of CBT screw placement using intraoperative cone beam CT navigation.

Methods: One hundred and thirty-four consecutive patients who underwent CBT fixation with 618 screws under intraoperative navigation were analyzed from May 2016 through May 2018. Screws were placed by one of three senior spine surgeons using the Medtronic O-Arm Stealth Navigation. Screw position and accuracy were assessed on intraoperative and postoperative CT scans using 2D and 3D reconstructions with VitreaCore software.

Results: The majority of surgeries were primary cases (73.1%). The mean age at the time of surgery was 61.5±10.0 years and the majority of patients were female (61.2%). Most patients underwent surgery for a diagnosis of degenerative spondylolisthesis (47.8%) followed by mechanical collapse with foraminal stenosis (22.4%). Ten violations of the vertebral cortex were noted with an average breach distance of 1.0±0.7 mm. Three breaches were lateral (0.5%) and seven were medial (1.1%). The overall navigated screw accuracy rate was 98.3%. The accuracy to within 1 mm of error was 99.2%. There were no intra-operative neurologic, vascular, or visceral complications related to the placement of the CBT screws.

Conclusions: CBT screw fixation under an intraoperative cone beam CT navigated insertion technique is safe and reliable. Despite five breaches greater than 1mm, there were no complications related to the placement of the CBT screws in this series.
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http://dx.doi.org/10.21037/jss.2019.09.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989933PMC
December 2019

Index episode-of-care propensity-matched comparison of transforaminal lumbar interbody fusion (TLIF) techniques: open traditional TLIF versus midline lumbar interbody fusion (MIDLIF) versus robot-assisted MIDLIF.

J Neurosurg Spine 2020 Jan 24:1-7. Epub 2020 Jan 24.

Objective: Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF.

Methods: A retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed.

Results: Of 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors' first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF.

Conclusions: Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors' first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.
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http://dx.doi.org/10.3171/2019.9.SPINE1932DOI Listing
January 2020

Job Selection After Orthopedic Surgery Training: Why Are Our Trainees Failing to Select the Right Job?

Cureus 2019 Aug 31;11(8):e5539. Epub 2019 Aug 31.

Research, Norton Healthcare, Norton Leatherman Spine Center, Louisville, USA.

A survey was administered to a random sampling of the American Academy of Orthopaedic Surgeons (AAOS) members to determine the rate at which recently trained orthopedic surgeons switch their first job and to identify factors affecting the job selection process. There were 351 (21%) respondents. Respondents considered practice location (41%), practice type (28%), and family proximity (23%) as most important while research opportunity (54%) and signing bonus (33%) were considered least important in their first job. Half of the respondents (51%) left their first job before the completion of their fifth year; most left for financial reasons (34%) or because the practice was not as advertised (31%). Many (53%) stated they had minimal training in selecting their first job and most (88%) felt inadequately prepared for the business side of orthopedics. Further studies are needed to evaluate the high rate of initial post-training job attrition to decrease the personal and societal costs of this phenomenon.
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http://dx.doi.org/10.7759/cureus.5539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819073PMC
August 2019

Minimally-Invasive midline posterior interbody fusion with cortical bone trajectory screws compares favorably to traditional open transforaminal interbody fusion.

Heliyon 2019 Sep 11;5(9):e02423. Epub 2019 Sep 11.

Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY, 40202, United States.

Objective: Posterior interbody fusion is commonly performed for degenerative lumbar conditions. A minimally invasive technique of midline exposure limited only to the facets and fixation with laterally directed cortical bone trajectory (CBT) screws was introduced with the intent of decreasing surgical morbidity. The purpose of this study was to determine if posterior interbody fusion with this limited midline exposure will have less blood loss and shorter operative times (i.e., can be considered minimally invasive) compared to traditional open transforaminal interbody fusion.

Methods: A consecutive single-surgeon series of patients who underwent posterior interbody fusion with either a navigated, midline only exposure (MidLIF) or full, traditional open, exposure of the transverse processes with a posterolateral fusion (open TLIF) were identified. Demographic, peri-operative data, patient reported outcomes (PROs), and reoperation/readmission rates were collected and compared.

Results: There were 29 cases in the MidLIF and 27 in the open TLIF group. Both groups were similar with respect to surgical indications, age, BMI, gender, ASA grade and operative level. The MidLIF group had significantly lower estimated blood loss (266 vs. 446 cc, p = 0.003), shorter operative time (170 vs. 210 minutes, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.016) compared to the open TLIF group. A sub-analysis of single-level cases showed similar findings with significantly lower estimated blood loss (247 vs. 411 cc, p = 0.10), shorter operative time (159 vs. 199 min, p = 0.003), and shorter length of hospital stay (2.9 vs. 3.7 days, p = 0.023) in the MidLIF group. Patient reported outcomes at 6 weeks, 3 months, 6 months, 12 months and 24 months post-operative favored MidLIF with significantly greater ODI improvements at both 6 weeks and 12 months; and lower ODI and back pain at both 12 months and 24 months.

Conclusions: MidLIF had lower blood loss and shorter operative time compared to the traditional open TLIF technique. These differences compare well to reported values in the literature for tubular minimally-invasive TLIF. Patient reported outcomes from 6 weeks to 24 months post-operative, hospital length of stay, and reoperation/readmission rates all favored MidLIF compared to traditional open TLIF.
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http://dx.doi.org/10.1016/j.heliyon.2019.e02423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6744604PMC
September 2019
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