Post-operative Patient Portal Messaging is Associated With Return to the Emergency Department After Lumbar Spine Surgery.

STUDY DESIGN: Retrospective study. OBJECTIVE: To explore the association between patients undergoing lumbar spine surgery who message their care team via an electronic patient portal (EPP) post-operatively and emergency department (ED) visits within 90 days of surgery. SUMMARY OF BACKGROUND DATA: Secure patient messaging through electronic patient portals has grown over recent years. Despite its frequent utilization by patients to engage with their care team, its association with clinical outcomes remains unknown in spine surgery. METHODS: This study was approved by our Institutional Review Board. Inclusion criteria were adults who underwent single-stage lumbar spine surgery between January 2016-June 2023. Patients with incomplete information, multi-stage surgeries, and those who died within 90 days of surgery were excluded. Patient sociodemographic, surgical, hospital readmission, and patient-provider engagement data were collected. RESULTS: A total of 13,135 patients were included. A total of 1,711 patients (13%) had a post-operative ED visit, and 4,791 patients (36%) used the patient portal to send a message after surgery. Sending a post-operative patient message after undergoing lumbar spine surgery was associated with an increased likelihood of having an ED visit that does not lead to readmission (1.29 (1.10-1.53), P = 0.002). Patients with high school degrees were more likely to have an ED visit without readmission (1.33 (1.08-1.65), P = 0.008). CONCLUSION: Patients at a higher risk of presenting to the ED post-operatively should be identified and may benefit from additional counseling and access to the care team virtually to limit unnecessary healthcare utilization. Focusing on patients who reach out via EPP messaging post-operatively may be a good target patient group to address first. Future research is needed to investigate the possible health literacy and other socioeconomic barriers affecting these patients so that appropriate, more cost-effective resources can be utilized to avoid clinically unnecessary and costly ED visits.

Assessing the variation and drivers of cost in 1-level lumbar fusion: a time-driven activity-based costing analysis.

BACKGROUND CONTEXT: As value-based health care arrangements gain traction in spine care, understanding the true cost of care becomes critical. Historically, inaccurate cost proxies have been used, including negotiated reimbursement rates or list prices. However, time-driven activity-based costing (TDABC) allows for a more accurate cost assessment, including a better understanding of the primary drivers of cost in 1-level lumbar fusion. PURPOSE: To determine the variation of total hospital cost, differences in characteristics between high-cost and non-high-cost patients, and to identify the primary drivers of total hospital cost in a sample of patients undergoing 1-level lumbar fusion. STUDY DESIGN/SETTING: Retrospective, multicenter (one academic medical center, one community-based hospital), observational study. PATIENT SAMPLE: A total of 383 patients undergoing elective 1-level lumbar fusion for degenerative spine conditions between November 2, 2021 and December 2, 2022. OUTCOME MEASURES: Total hospital cost of care (normalized); preoperative, intraoperative, and postoperative cost of care (normalized); ratio of most to least expensive 1-level lumbar fusion. METHODS: Patients undergoing a 1-level lumbar fusion between November 2, 2021 and December 2, 2022 were identified at two hospitals (one quaternary referral academic medical center and one community-based hospital) within our health system. TDABC was used to calculate total hospital cost, which was also broken up into: pre-, intra-, and postoperative timeframes. Operating surgeon and patient characteristics were also collected and compared between high- and non-high-cost patients. The correlation of surgical time and cost was determined. Multivariable linear regression was used to determine factors associated with total hospital cost. RESULTS: The most expensive 1-level lumbar fusion was 6.8x more expensive than the least expensive 1-level lumbar fusion, with the intraoperative period accounting for 88% of total cost. On average. the implant cost accounted for 30% of the total, but across the patient sample, the implant cost accounted for a range of 6% to 44% of the total cost. High-cost patients were younger (55 years [SD: 13 years] vs.63 years [SD: 13 years], p=.0002), more likely to have commercial health insurance (24 out of 38 (63%) vs. 181 out of 345 (52%), p=.003). There was a poor correlation between time of surgery (i.e., incision to close) and total overall cost (ρ: .26, p<.0001). Increase age (RC: -0.003 [95% CI: -0.006 to -0.000007], p=.049) was associated with decreased cost. Surgery by certain surgeons was associated with decreased total cost when accounting for other factors (p<.05). CONCLUSIONS: A large variation exists in the total hospital cost for patients undergoing 1-level lumbar fusion, which is primarily driven by surgeon-level decisions and preferences (e.g., implant and technology use). Also, being a "fast" surgeon intraoperatively does not mean your total cost is meaningfully lower. As efforts continue to optimize patient value through ensuring appropriate clinical outcomes while also reducing cost, spine surgeons must use this knowledge to lead, or at least be active participants in, any discussions that could impact patient care.

Inpatient opioid use varies by construct length among laminoplasty versus laminectomy and fusion patients.

Background: Laminoplasty (LP) and laminectomy and fusion (LF) are utilized to achieve decompression in patients with symptomatic degenerative cervical myelopathy (DCM). Comparative analyses aimed at determining outcomes and clarifying indications between these procedures represent an area of active research. Accordingly, we sought to compare inpatient opioid use between LP and LF patients and to determine if opioid use correlated with length of stay. Methods: Sociodemographic information, surgical and hospitalization data, and medication administration records were abstracted for patients >18 years of age who underwent LP or LF for DCM in the Mass General Brigham (MGB) health system between 2017 and 2019. Specifically, morphine milligram equivalents (MME) of oral and parenteral pain medication given after arrival in the recovery area until discharge from the hospital were collected. Categorical variables were analyzed using chi-squared analysis or Fisher exact test when appropriate. Continuous variables were compared using Independent samples t tests and Mann-Whitney U tests. Results: One hundred eight patients underwent LF, while 138 patients underwent LP. Total inpatient opioid use was significantly higher in the LF group (312 vs. 260 MME, p=.03); this difference was primarily driven by higher postoperative day 0 pain medication requirements. Furthermore, more LF patients required high dose (>80 MME/day) regimens. While length of stay was significantly different between groups, with LF patients staying approximately 1 additional day, postoperative day 0 MME was not a significant predictor of this difference. When operative levels including C2, T1, and T2 were excluded, the differences in total opioid use and average length of stay lost significance. Conclusions: Inpatient opioid use and length of stay were significantly greater in LF patients compared to LP patients; however, when constructs including C2, T1, T2 were excluded from analysis, these differences lost significance. Such findings highlight the impact of operative extent between these procedures. Future studies incorporating patient reported outcomes and evaluating long-term pain needs will provide a more complete understanding of postoperative outcomes between these 2 procedures.

Does Nasal Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevent Deep Surgical Site Infections for Elective Cervical Spinal Fusion?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery. SUMMARY OF BACKGROUND DATA: Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. MATERIALS AND METHODS: Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates. RESULTS: This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA. CONCLUSIONS: There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.

Magnetic Resonance Imaging Is Inadequate to Assess Cervical Sagittal Alignment Parameters.

STUDY DESIGN: Retrospective radiographic study. OBJECTIVE: To evaluate cervical sagittal alignment measurement reliability and correlation between upright radiographs and magnetic resonance imaging (MRI). SUMMARY OF BACKGROUND DATA: Cervical sagittal alignment (CSA) helps determine the surgical technique employed to treat cervical spondylotic myelopathy. Traditionally, upright lateral radiographs are used to measure CSA, but obtaining adequate imaging can be challenging. Utilizing MRI to evaluate sagittal parameters has been explored; however, the impact of positional change on these parameters has not been determined. METHODS: One hundred seventeen adult patients were identified who underwent laminoplasty or laminectomy and fusion for cervical spondylotic myelopathy from 2017 to 2019. Two clinicians independently measured the C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and the T1 tilt. Interobserver and intraobserver reliability were assessed by intraclass correlation coefficient. RESULTS: Intraobserver and interobserver reliabilities were highly correlated, with correlations greater than 0.85 across all permutations; intraclass correlation coefficients were highest with MRI measurements. The C2-C7 sagittal angle was highly correlated between x-ray and MRI at 0.76 with no significant difference ( P =0.46). There was a weaker correlation with regard to C2-C7 SVA (0.48) and T1 tilt (0.62) with significant differences observed in the mean values between the 2 modalities ( P <0.01). CONCLUSIONS: The C2-C7 sagittal angle is highly correlated and not significantly different between upright x-ray and supine MRIs. However, cervical SVA and T1 tilt change with patient position. Since MRI does not accurately reflect the CSA in the upright position, upright lateral radiographs should be obtained to assess global sagittal alignment when planning a posterior-based cervical procedure.

Surgical Intervention is Associated With Improvements in the ASIA Impairment Scale in Gunshot-induced Spinal Injuries of the Thoracic and Lumbar Spine.

STUDY DESIGN: Retrospective cohort study of patients from the National Spinal Cord Injury Statistical Center (NSCISC). OBJECTIVE: The aim was to compare the outcomes of patients with gunshot-induced spinal injuries (GSIs) treated operatively and nonoperatively. SUMMARY OF BACKGROUND DATA: The treatment of neurological deficits associated with gunshot wounds to the spine has been controversial. Treatment has varied widely, ranging from nonoperative to aggressive surgery. METHODS: Patient demographics, clinical information, and outcomes were extracted. Surgical intervention was defined as a "laminectomy, neural canal restoration, open reduction, spinal fusion, or internal fixation of the spine." The primary outcome was the American Spinal Injury Association (ASIA) Impairment Scale. Statistical comparisons of baseline demographics and neurological outcomes between operative and nonoperative cohorts were performed. RESULTS: In total, 961 patients with GSI and at least 1-year follow-up were identified from 1975 to 2015. The majority of patients were Black/African American (55.6%), male (89.7%), and 15-29 years old (73.8%). Of those treated surgically (19.7% of all patients), 34.2% had improvement in their ASIA Impairment Scale score at 1 year, compared with 20.6% treated nonoperatively. Overall, surgery was associated with a 2.0 [95% confidence interval (CI): 1.4-2.8] times greater likelihood of ASIA Impairment Scale improvement at 1 year. Specifically, benefit was seen in thoracic (odds ratio: 2.5; 95% CI: 1.4-4.6) and lumbar injuries (odds ratio: 1.7; 95% CI: 1.1-3.1), but not cervical injuries. CONCLUSIONS: While surgical indications are always determined on an individualized basis, in our review of GSIs, surgical intervention was associated with a greater likelihood of neurological recovery. Specifically, patients with thoracic and lumbar GSIs had a 2.5 and 1.7-times greater likelihood of improvement in their ASIA Impairment Scale score 1 year after injury, respectively, if they underwent surgical intervention.

Selecting the Next Class: The "Virtual Orthopaedic Rotation".

INTRODUCTION: When the COVID-19 pandemic forced the cancellation of visiting subinternships, we pivoted to create a virtual orthopaedic rotation (VOR). The purpose of this study was to assess the effect of the VOR on the residency selection process and determine the role of such a rotation in the future. METHODS: A committee was convened to create a VOR to replace visiting orthopaedic rotations for medical students who are interested in pursuing a career in orthopaedic surgery. The VOR was reviewed and sanctioned by our medical school, but no academic credit was granted. We conducted three 3-week VOR sessions. During each session, virtual rotators participated in regularly scheduled educational conferences and attended an invitation-only daily conference in the evenings that was designed for a medical student audience. In addition, students were paired with faculty and resident mentors in a structured mentorship program. Students' orthopaedic knowledge was assessed using prerotation and postrotation tests. RESULTS: From July to September 2020, 61 students from 37 distinct medical schools participated in the VOR. Notable improvements were observed in prerotation and postrotation orthopaedic knowledge test scores. In postrotation surveys, both students and faculty expressed high satisfaction with the curriculum but less certainty about how well they got to know each other. In the subsequent residency application cycle, 27.9% of the students who participated in the VOR were selected to interview, compared with 8.7% of the total application pool. DISCUSSION: The VOR was a valuable substitute for in-person clinical rotations during the COVID-19 pandemic. Although not likely to be a replacement for conventional away rotations, the VOR is a possible adjunct to in-person clinical rotations in the future.

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

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.

Caudal Lumbar Disc Herniations Are More Likely to Require Surgery for Symptom Resolution.

STUDY DESIGN: Retrospective study. OBJECTIVES: We examined the impact that location of a lumbar disc herniation has on the likelihood that a patient will require surgery after at least 6 weeks of nonoperative management. METHODS: Using ICD-10 codes M51.26 and M51.27, we identified patients at a single academic institution from 2015 to 2016 who received a diagnosis of primary lumbar radicular pain, had magnetic resonance imaging confirming a lumbar disc herniation, and underwent at least 6 weeks of nonoperative management. Patients experiencing symptoms suggesting cauda equina syndrome or progressive motor deficits were excluded. RESULTS: Five hundred patients met inclusion/exclusion criteria. Twenty-nine (5.8%) had L3-L4 herniations, 245 (49.0%) had L4-L5 herniations, and 226 (45.2%) had L5-S1 herniations. Overall, 451 (90.2%) patients did not undergo surgery within 1 year of diagnosis. Nonsurgical patients had an average herniation size occupying 31.2% of the canal, compared with 31.5% in patients who underwent surgery. While herniation size, age, sex, and race failed to demonstrate a statistical association with the likelihood for surgery, location of disc herniation demonstrated a strong association. L3-L4 and L4-L5 herniations had odds ratios of 0.19 and 0.45, respectively, relative to L5-S1 herniations (P = .0047). Patients were more than twice as likely to require a surgery on an L5-S1 herniation in comparison with an L4-L5 herniation (P < .05). L3-L4 herniations rarely required surgery. CONCLUSIONS: Patients with caudal lumbar disc herniations were more likely to require surgery after at least 6 weeks of conservative management than those with disc herniations in the mid-lumbar spine.

Laminoplasty-an underutilized procedure for cervical spondylotic myelopathy.

BACKGROUND CONTENT: Cervical laminoplasty (LP) and laminectomy and fusion (LF) are commonly used surgical techniques for cervical spondylotic myelopathy (CSM). Several recent studies have demonstrated superior perioperative metrics and decreased overall costs with LP, yet LF is performed far more often in the United States. PURPOSE: To determine the percentage of patients with CSM who are radiographically candidates for LP. STUDY DESIGN: Retrospective comparative cohort study. PATIENT SAMPLE: Patients >18 years old who underwent LF or LP for CSM at 2 large academic institutions from 2017 to 2019. OUTCOME MEASURES: Candidacy for LP based on radiographic criteria. METHODS: Radiographs were assessed by 2 spine surgeons not involved in the care of the patients to determine the C2-C7 Cobb angle and the presence and extent of cervical instability. Patients with kyphosis >13°, > 3.5 mm of listhesis on static imaging, or > 2.5 mm of motion on flexion-extension or standing-supine films were not considered candidates for LP. Intraclass coefficient (ICC) was calculated to assess the interobserver reliability of angular measurements and the presence of instability. The percentage of patients for whom LP was contraindicated was calculated. RESULTS: One hundred eight patients underwent LF while 142 underwent LP. Of the 108 patients who underwent LF, 79.6% were radiographically deemed candidates for LP, as were all 142 patients who underwent LP. The ICC for C2-C7 alignment was 0.90; there was 97% agreement with respect to the presence of instability. CONCLUSIONS: In 250 patients with CSM, 228 (91.2%) were radiographically candidates for LP. These data suggest that LP may be an underutilized procedure for the treatment for CSM.

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

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.

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

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.

Does Size Matter? An Analysis of the Effect of Lumbar Disc Herniation Size on the Success of Nonoperative Treatment.

STUDY DESIGN: Retrospective study. OBJECTIVE: In this study, we examined whether the size of a lumbar disc herniation (LDH) is predictive of the need for surgical intervention within 2 years after obtaining an initial magnetic resonance imaging (MRI) scan. We hypothesized that a fragment that occupied a larger percentage of the spinal canal would not predict which patients failed conservative management. METHODS: Using the ICD-10 code M51.26, we identified patients at a single academic institution, across the 2-year period from 2015 to 2016, who received a diagnosis of primary lumbar radicular pain, had MRI showing a disc herniation, and underwent at least 6 weeks of nonoperative management. Patients experiencing symptoms suggesting cauda equina syndrome and those with progressive motor neurological deficits were excluded from analysis, as were patients exhibiting "hard" disc herniations. Within the axial view of an MRI, the following measurements were made on AGFA-IMPACS for a given disc herniation: the length of both the canal and the herniated disc along the anterior-posterior axis, the average width of the disc within the canal; the total canal area, and the area of the disc herniation. Data analysis was conducted in SPSS and a 2-tailed reliability analysis using Cronbach's alpha as a measure of reliability was obtained. RESULTS: A total of 368 patients met the inclusion and exclusion criteria for this study. Of these, 14 (3.8%) had L3-L4 herniations, 185 had L4-L5 herniations (50.3%), and 169 had L5-S1 herniations (45.9%). Overall, 336 (91.3%) patients did not undergo surgery within 1 year of the LDH diagnosis. Patients who did not receive surgery had an average herniation size that occupied 31.2% of the canal, whereas patients who received surgery had disc herniations that occupied 31.5% of the canal on average. A Cronbach's alpha of .992 was observed overall across interobserver measurements. After controlling for age, race, gender, and location of herniation through a logistic regression, it was found that the size of the herniation and the percentage of the canal that was occupied had no predictive value with regard to failure of conservative management, generating an odds ratio for surgery of 1.00. CONCLUSIONS: The percentage of the spinal canal occupied by a herniated disc does not predict which patients will fail nonoperative treatment and require surgery within 2 years after undergoing a lumbar spine MRI scan.

Laminoplasty versus laminectomy and fusion for cervical spondylotic myelopathy: a cost analysis.

BACKGROUND CONTEXT: Laminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered. PURPOSE: We aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM. STUDY DESIGN: Retrospective comparative study. PATIENT SAMPLE: Adult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded. OUTCOME MEASURES: The primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs. METHODS: Patient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material - both implant and non-implant - cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables. RESULTS: Two hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF. CONCLUSIONS: This study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM.

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

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.

Disk Area Is a More Reliable Measurement Than Anteroposterior Length in the Assessment of Lumbar Disk Herniations: A Validation Study.

STUDY DESIGN: Retrospective study. OBJECTIVE: The goal of this study is to identify and validate the reliability and accuracy of 2 methods used to assess lumbar disk herniations (LDHs): anteroposterior length and cross-sectional area. BACKGROUND: Many clinicians characterize LDHs through the measurement of the anteroposterior length in the axial plane. Radiologists, on the other hand, have utilized software to measure the disk and canal areas to define the injury. In this study, the authors consider the reliability and accuracy of anteroposterior length in comparison with the area. METHODS: Using International Classification of Diseases, 10th Revision (ICD-10) code M51.26, patients at a single academic medical center who received a diagnosis of primary lumbar radicular pain with subsequent magnetic resonance imaging documentation of a single-level disk herniation in 2015 and 2016 were identified. AGFA-IMPACS software was utilized to make the following measurements: anterior-posterior canal length; anterior-posterior disk length; mid-canal width; mid-disk width; total canal area; total disk area. Data analysis was conducted in SPSS and a 2-tailed reliability analysis using Cronbach alpha as a measure of reliability was obtained. RESULTS: A total of 408 patients met the inclusion and exclusion criteria for this study. Sixteen (3.9%) had L3-L4 herniation, 208 had L4-L5 herniation (51.0%), and 184 had L5-S1 herniation (47.5%). The least reliable interobserver metrics, with respective Cronbach alpha values of 0.381 and 0.659, were the linear measurements of mid-disk width and anterior-posterior canal length. Area measurements of the disk and canal areas generated Cronbach alpha values of 0.707 and 0.863. Intraobserver Cronbach alpha values for all measurements, including all areas and lengths, met or exceeded 0.982. CONCLUSIONS: The cross-sectional area provides a more reliable measurement modality for diskLDHs in comparison to linear measurements. Unlike anteroposterior length, cross-sectional area incorporates the shape of a herniation or canal in its measurement. Thus, it is superior in its characterization LDH particularly in light of its stronger reproducibility. LEVEL OF EVIDENCE: Level III-retrospective study.

Predicting prolonged opioid prescriptions in opioid-naïve lumbar spine surgery patients.

IMPORTANCE: Preoperative determination of the potential for postoperative opioid dependence in previously naïve patients undergoing elective spine surgery may facilitate targeted interventions. OBJECTIVE: The purpose of this study was to develop supervised machine learning algorithms for preoperative prediction of prolonged opioid prescription use in opioid-naïve patients following lumbar spine surgery. DESIGN: Retrospective review of clinical registry data. Variables considered for prediction included demographics, insurance status, preoperative medications, surgical factors, laboratory values, comorbidities, and neighborhood characteristics. Five supervised machine learning algorithms were developed and assessed by discrimination, calibration, Brier score, and decision curve analysis. SETTING: One healthcare entity (two academic medical centers, three community hospitals), 2000 to 2018. PARTICIPANTS: Opioid-naïve patients undergoing decompression and/or fusion for lumbar disk herniation, stenosis, and spondylolisthesis. MAIN OUTCOME: Sustained prescription opioid use exceeding 90 days after surgery. RESULTS: Overall, of 8,435 patients included, 359 (4.3%) were found to have prolonged postoperative opioid prescriptions. The elastic-net penalized logistic regression achieved the best performance in the independent testing set not used for algorithm development with c-statistic=0.70, calibration intercept=0.06, calibration slope=1.02, and Brier score=0.039. The five most important factors for prolonged opioid prescriptions were use of instrumented spinal fusion, preoperative benzodiazepine use, preoperative antidepressant use, preoperative gabapentin use, and uninsured status. Individual patient-level explanations were provided for the algorithm predictions and the algorithms were incorporated into an open access digital application available here: https://sorg-apps.shinyapps.io/lumbaropioidnaive/. CONCLUSION AND RELEVANCE: The clinician decision aid developed in this study may be helpful to preoperatively risk-stratify opioid-naïve patients undergoing lumbar spine surgery. The tool demonstrates moderate discriminative capacity for identifying those at greatest risk of prolonged prescription opioid use. External validation is required to further support the potential utility of this tool in practice.

DEXA sensitivity analysis in patients with adult spinal deformity.

BACKGROUND: Adult spinal deformity (ASD) is a debilitating condition that commonly requires surgical intervention. However, ASD patients may also present with osteoporosis, predisposing them to surgical complications and failure of instrumentation. As a result, proper detection of low bone mineral density (BMD) is critical in order to ensure proper patient care. Typically dual-energy x-ray absorptiometry (DEXA) scans are performed on the hip and spine. Unfortunately, in ASD patients, the latter is often inaccurate PURPOSE: In this study, we consider the value of obtaining a forearm DEXA scan in addition to a hip scan in patients suffering from ASD and osteoporosis in order to accurately detect low BMD. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Patient data between 2016 and 2018 from a single academic medical center was utilized. Two hundred eighty-six patients met the initial search criteria. OUTCOME MEASURES: No outcomes measures related to self-reporting, physiology, or functionality were evaluated in this study. Primary outcome measures analyzed included T-scores across various anatomic locations and diagnoses relating to low bone density (ie, osteopenia and osteoporosis). METHODS: This retrospective study examines patients that underwent DEXA studies between 2016 and 2018 and were previously diagnosed with both osteoporosis and adult spinal deformity. For each patient, age, gender, body mass index, and smoking history were noted, as well as whether there was long-term prednisone use. T-scores from both the forearm and hip were recorded and analyzed. Diagnoses from hip DEXA scans were compared with those obtained from forearm scans to identify which region was more sensitive in detecting low BMD. From this data, the frequency of a missed diagnosis, due to reliance on hip or spine T-scores for detection of low BMD, was extrapolated. No external funding source was received in support of this study. RESULTS: Two hundred eighty-six patients matched the initial search criteria. Only 68% had one T-score value. However, 24.8% of patients had data for both the hip and forearm, whereas 7.1% had data for the forearm, hip, and spine. Among the 85 patients with more than one anatomical site of study, the forearm was more sensitive than the hip in its ability to detect osteopenia or osteoporosis 41.2% of the time. A two-tailed t test showed no statistically significant difference between hip T-scores and forearm T-scores. However, for more than 17% of patients, the forearm allowed clinicians to detect osteoporosis or osteopenia in a setting where using only the hip data would have missed such a diagnosis. CONCLUSIONS: Clinicians need to ensure they survey at least two locations when conducting DEXA studies before precluding a diagnosis of osteopenia or osteoporosis. All ASD patients being evaluated for low bone density should receive DEXA scans that survey at least the hip and the forearm. Misdiagnoses can be costly in the setting of ASD. They occur frequently when only a single hip scan is relied upon to assess BMD.

Natural language processing for automated detection of incidental durotomy.

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.

The Economic Burden of Residency Interviews on Applicants.

Background: The residency match is increasingly competitive. The interview is an essential component, yet little has been documented about the costs applicants incur during the interview process and it is unclear how they manage these expenses. Objective: The purpose of this study was to define the economic burden of residency interviews for United States (U.S.) allopathic students participating in the 2016 Main Residency Match. We hypothesized that the financial burden of residency interviews varies based on specialty and plays a role in the applicant's ability to participate in all desired interviews. Methods: A 26 question electronic survey was developed following pilot study of applicants to a single residency program. Following validation, the survey was distributed to administrative officials at all U.S. allopathic medical schools for circulation to senior students. Results were pooled for statistical analysis. Results: We received responses from 759 U.S. allopathic seniors. A single interview most commonly costs $250 - $499. Most applicants incurred substantial interview related costs. Sixtyfour percent of respondents spent at least $2,500, while 13% spent $7,500 or more. Specialty competitiveness was predictive of higher interview costs. Seventy-one percent of respondents borrowed money to fund interview costs, and 41% declined interviews for financial reasons. Conclusions: Senior medical students incur substantial costs to participate in residency interviews, often adding to already burdensome educational debt. We encourage residency programs, especially those in competitive specialty fields, to pursue cost reduction strategies. Additionally, medical schools should provide financial counseling to allow students to anticipate interview costs.