Perioperative pain protocols following surgery for adolescent idiopathic scoliosis: a snapshot of current treatments utilized by attending orthopedic surgeons.

PURPOSE: Perioperative management after adolescent idiopathic scoliosis (AIS) surgery varies extensively between surgeons and institutions. We devised a questionnaire to assess surgeon baseline characteristics, practice settings, and pain regimens to assess what factors contribute to perioperative pain protocols. METHODS: A multiple-choice questionnaire including 130 independent variables regarding baseline characteristics, practice environments, and pain regimen protocols was distributed to elicit information among surgeons performing AIS fusion surgery. Pairwise bivariate analysis between practice location, length of practice, and practice environment vs. type of post-operative analgesia was completed using two-tailed Fisher's exact test. RESULTS: 85 respondents participated, all identified as practicing orthopedic surgeons. The largest group of respondents reported 20-40% of their total practice was dedicated to AIS (36%). Respondents were predominantly hospital-employed academic physicians (67%). The most common pain medication administered preoperatively was gabapentin (54%). Postoperative regimens were highly varied. Discharge pain regimens most commonly included short-acting opiates (89%), acetaminophen (86%), antispasmodics (59%), and NSAIDs (51%). Bivariate analysis revealed that fentanyl PCA was significantly associated with practice location (p < 0.05). Utilization of NSAIDs was significantly associated with length in training, with older physicians utilizing anti-inflammatories more regularly than younger physicians (p < 0.05). CONCLUSION: This study identifies common perioperative regimens utilized in AIS surgery. Of interest, younger surgeons are less likely to prescribe NSAIDs post-operatively than surgeons who have been in practice for longer periods of time, which may represent a bias against anti-inflammatory medications in younger surgeons.

Impact of Surgeon Case Volume on Outcomes After Reverse Total Shoulder Arthroplasty.

INTRODUCTION: Despite a rapid increase in utilization of reverse total shoulder arthroplasty (rTSA), volume-outcome studies focusing on surgeon volume are lacking. Surgeon-specific volume-outcome studies may inform policymakers and provide insight into learning curves and measures of efficiency with greater case volume. METHODS: This retrospective cohort study with longitudinal data included all rTSA cases as recorded in the Centers for Medicare & Medicaid Services Limited Data Set (2016 to 2018). The main effect was surgeon volume; this was categorized using two measures of surgeon volume: (1) rTSA case volume and (2) rTSA + TSA case volume. Volume cutoff values were calculated by applying a stratum-specific likelihood ratio analysis. RESULTS: Among 90,318 rTSA cases performed by 7,097 surgeons, we found a mean annual rTSA surgeon volume of 6 ± 10 and a mean rTSA + TSA volume of 9 ± 14. Regression models using surgeon-specific rTSA volume revealed that surgery from low (<29 cases) compared with medium (29 to 96 cases) rTSA-volume surgeons was associated with a significantly higher 90-day all-cause readmission (odds ratio [OR], 1.17; confidence interval [CI], 1.10 to 1.25; P < 0.0001), higher 90-day readmission rates because of an infection (OR, 1.46; CI, 1.16 to 1.83; P = 0.0013) or dislocation (OR, 1.43; CI, 1.19 to 1.72; P = 0.0001), increased 90-day postoperative cost (+11.3% CI, 4.2% to 19.0%; P = 0.0016), and a higher transfusion rate (OR, 2.06; CI, 1.70 to 2.50; P < 0.0001). Similar patterns existed when using categorizations based on rTSA + TSA case volume. CONCLUSION: Surgeon-specific volume-outcome relationships exist in this rTSA cohort, and we were able to identify thresholds that may identify low and medium/high volume surgeons. Observed volume-outcome relationships were independent of the definition of surgeon volume applied: either by focusing on the number of rTSAs performed per surgeon or anatomic TSAs performed. LEVEL OF EVIDENCE: III.

An 11-Year-Long Analysis of the Risks Associated With Age in Patients Undergoing Anterior Cervical Discectomy and Fusion in a Large, Urban Academic Hospital.

STUDY DESIGN: A retrospective database study of patients at an urban academic medical center undergoing an Anterior Cervical Discectomy and Fusion (ACDF) surgery between 2008 and 2019. OBJECTIVE: ACDF is one of the most common spinal procedures. Old age has been found to be a common risk factor for postoperative complications across a plethora of spine procedures. Little is known about how this risk changes among elderly cohorts such as the difference between elderly (60+) and octogenarian (80+) patients. This study seeks to analyze the disparate rates of complications following elective ACDF between patients aged 60-69 or 70-79 and 80+ at an urban academic medical center. METHODS: We identified patients who had undergone ACDF procedures using CPT codes 22,551, 22,552, and 22,554. Emergent procedures were excluded, and patients were subdivided on the basis of age. Then each cohort was propensity matched for univariate and univariate logistic regression analysis. RESULTS: The propensity matching resulted in 25 pairs in both the 70-79 and 80+ y.o. cohort comparison and 60-69 and 80+ y.o. cohort comparison. None of the cohorts differed significantly in demographic variables. Differences between elderly cohorts were less pronounced: the 80+ y.o. cohort experienced only significantly higher total direct cost (P = .03) compared to the 70-79 y.o. cohort and significantly longer operative time (P = .04) compared to the 60-69 y.o. cohort. CONCLUSIONS: Octogenarian patients do not face much riskier outcomes following elective ACDF procedures than do younger elderly patients. Age alone should not be used to screen patients for ACDF.

Decompression Alone in the Setting of Adult Degenerative Lumbar Scoliosis and Stenosis: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis.OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis (DLS) and stenosis is commonly performed, however, there is no summary of evidence for outcomes. METHODS: A systematic search of English language medical literature databases was performed for studies describing outcomes of decompression alone in DLS, defined as Cobb angle >10˚, and 2-year minimum follow-up. Three outcomes were examined: 1) Cobb angle progression, 2) reoperation rate, and 3) ODI and overall satisfaction. Data were pooled and weighted averages were calculated to summarize available evidence. RESULTS: Across 15 studies included in the final analysis, 586 patients were examined. Average preoperative and postoperative Cobb angles were 17.6˚ (Range: 12.7 - 25˚) and 18.0 (range 14.1 - 25˚), respectively. Average change in Cobb angle was an increase of 1.8˚. Overall rate of reoperation ranged from 3 to 33% with an average of 9.7%. Average ODI before surgery, after surgery, and change in scores were 56.4%, 27.2%, and an improvement of 29% respectively. Average from 8 studies that reported patient satisfaction was 71.2%. CONCLUSIONS: Current literature on decompression alone in the setting of DLS is sparse and is not high quality, limited to patients with small magnitude of lumbar coronal Cobb angle, and heterogenous in the type of procedure performed. Based on available evidence, select patients with DLS who undergo decompression alone had minimal progression of Cobb angle, relatively low reoperation rate, and favorable patient-reported outcomes.

Enhanced Recovery Components for Posterior Lumbar Spine Fusion: Harnessing National Data to Compare Protocols.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The aim of this study was to assess the most commonly used components of enhanced recovery after surgery (ERAS) combinations and their relative effectiveness. SUMMARY OF BACKGROUND DATA: Data is lacking on use and effectiveness of various ERAS combinations which are increasingly used in spine surgery. MATERIALS AND METHODS: Posterior lumbar fusion cases were extracted from the Premier Healthcare claims database (2006-2016). Seven commonly included components in spine ERAS protocols were identified: (1) multimodal analgesia, (2) tranexamic acid, (3) antiemetics on the day of surgery, (4) early physical therapy, (5) no urinary catheter, (6) no patient-controlled analgesia, and (7) no wound drains. Outcomes were: length of stay, "any complication," blood transfusion, and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes, separately for 2006-2012 and 2013-2016. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: Among 97,419 (74%; 2006-2012) and 34,932 (26%; 2013-2016) cases ERAS component variations decreased over time. The most commonly used combinations included multimodal analgesia, antiemetics, early physical therapy, avoidance of a urinary catheter, patient-controlled analgesia and drains (10% n=9401 and 19% n=6635 in 2006-2012 and 2013-2016, respectively), and did not include tranexamic acid. Multivariable models revealed minor differences between ERAS combinations in terms of length of stay and costs. The most pronounced beneficial effects in 2006-2012 were seen for the second most commonly (compared with less often) used ERAS combination(s) in terms of blood transfusion (OR: 0.65; CI: 0.59-0.71) and "any complication" (OR: 0.73; CI: 0.66-0.80), both P<0.05. In 2013-2016 the third most commonly used ERAS combination showed the strongest effect: blood transfusion OR: 0.63; CI: 0.50-0.78, P<0.05. CONCLUSIONS: ERAS component variations decreased over time; maximum benefits were particularly seen in terms of transfusion and complication risk reduction. These findings may inform future ERAS utilization and clinical trials comparing various ERAS protocols.

Risk Factors for 30- and 90-Day Readmission due to Intestinal Bowel Obstruction after Posterior Lumbar Fusion.

STUDY DESIGN: A retrospective analysis of data from the Healthcare Cost and Utilization Project Nationwide Readmissions Database (HCUP-NRD). PURPOSE: To identify the perioperative characteristics associated with 30-day and 90-day readmission due to intestinal bowel obstructions (IBOs) following posterior lumbar fusion (PLF) procedure. OVERVIEW OF LITERATURE: PLF procedures are used to repair spinal injuries and curvature deformities. IBO is a common surgical complication and its repair often necessitates surgery that increases the readmission rates and healthcare costs. Previous studies have identified the preoperative risk factors for 30-day readmissions in PLF; however, no study has specifically investigated IBO or identified risk factors for 90-day readmissions. METHODS: Data on demographic characteristics and medical comorbidities of patients who underwent PLF with subsequent readmission were obtained from the HCUP-NRD. The perioperative characteristics that were significantly different between patients readmitted with and without an active diagnosis of IBO were identified with bivariate analysis for both 30-day and 90-day readmissions. The significant characteristics were then included in a multivariate analysis to identify those that were independently associated with 30- day and 90-day readmissions. RESULTS: Drug abuse (odds ratio [OR], 4.00), uncomplicated diabetes (OR, 2.06), having Medicare insurance (OR, 1.65), age 55-64 years (OR, 2.42), age 65-79 years (OR, 2.77), and age >80 years (OR, 3.87) were significant risk factors for 30-day readmission attributable to IBO after a PLF procedure. CONCLUSIONS: Of the several preoperative risk factors identified for readmission with IBO after PLF surgery, drug abuse had the strongest association and was likely to be the most clinically relevant factor. Physicians and care teams should understand the risks of opioid-based pain management regimens, attempt to manage pain with a multimodal approach, and minimize the opioid use.

Anterior Reconstruction Techniques for Cervical Spine Deformity.

Cervical spine deformity is an uncommon yet severely debilitating condition marked by its heterogeneity. Anterior reconstruction techniques represent a familiar approach with a range of invasiveness and correction potential-including global or focal realignment in the sagittal and coronal planes. Meticulous preoperative planning is required to improve or prevent neurologic deterioration and obtain satisfactory global spinal harmony. The ability to perform anterior only reconstruction requires mobility of the opposite column to achieve correction, unless a combined approach is planned. Anterior cervical discectomy and fusion has limited focal correction, but when applied over multiple levels there is a cumulative effect with a correction of approximately 6° per level. Partial or complete corpectomy has the ability to correct sagittal deformity as well as decompress the spinal canal when there is anterior compression behind the vertebral body. If pathoanatomy permits, a hybrid discectomy-corpectomy construct is favored over multilevel corpectomies. The anterior cervical osteotomy with bilateral complete uncinectomy may be necessary for angular correction of fixed cervical kyphosis, and is particularly useful in the midcervical spine. A detailed understanding of the patient's local anatomy, careful attention to positioning, and avoiding long periods of retraction time will help prevent complications and iatrogenic injury.

Emerging Techniques in Diagnostic Imaging for Idiopathic Scoliosis in Children and Adolescents: A Review of the Literature.

Traditionally, full spine standing radiographs have been the reference standard for diagnostic imaging in adolescent idiopathic scoliosis (AIS). However, recent advances in diagnostic imaging have the potential to reduce radiation exposure and preserve the image quality and utility. Recent advances in diagnostic imaging for AIS include the EOS imaging system, the DIERS formetric scanner, and ultrasonography. Moderate to strong evidence is available to support the interobserver reliability and validity of each of these modalities, even compared with the reference standard imaging techniques. As such, these emerging techniques might prove beneficial in diagnosing and monitoring AIS and its progression, without high levels of continued radiation exposure. To understand the historical perspective and current state of advanced imaging techniques for AIS, a search of PubMed electronic database was conducted to identify studies that had examined these new techniques in the diagnosis of idiopathic scoliosis in children and adolescents.

Biomaterials in Spinal Implants: A Review.

The aim to find the perfect biomaterial for spinal implant has been the focus of spinal research since the 1800s. Spinal surgery and the devices used therein have undergone a constant evolution in order to meet the needs of surgeons who have continued to further understand the biomechanical principles of spinal stability and have improved as new technologies and materials are available for production use. The perfect biomaterial would be one that is biologically inert/compatible, has a Young's modulus similar to that of the bone where it is implanted, high tensile strength, stiffness, fatigue strength, and low artifacts on imaging. Today, the materials that have been most commonly used include stainless steel, titanium, cobalt chrome, nitinol (a nickel titanium alloy), tantalum, and polyetheretherketone in rods, screws, cages, and plates. Current advancements such as 3-dimensional printing, the ProDisc-L and ProDisc-C, the ApiFix, and the Mobi-C which all aim to improve range of motion, reduce pain, and improve patient satisfaction. Spine surgeons should remain vigilant regarding the current literature and technological advancements in spinal materials and procedures. The progression of spinal implant materials for cages, rods, screws, and plates with advantages and disadvantages for each material will be discussed.

Altering the natural history of rheumatoid arthritis: The role of immunotherapy and biologics in orthopaedic care.

Rheumatoid Arthritis (RA) is an idiopathic disease characterized by systemic inflammation, persistent synovitis, and the presence of autoantibodies. Because of the musculoskeletal deformity caused by RA, multiple orthopaedic procedures are regularly performed as part of the treatment. The changing rates of surgery and the rise in new efficacious medical therapy have improved the prognosis for patients with RA. This review will discuss the natural history of rheumatoid arthritis, common medications used to treat it, how disease progression has changed as a function of new biologic immunotherapy, and the role of orthopaedic intervention in this new landscape of advanced rheumatoid care.

Exercise as a Treatment for Schizophrenia: A Review.

Schizophrenia is a mental disorder that is characterized by progressive cognitive impairment in areas of attention, working memory, and executive functioning. Although no clear etiology of schizophrenia has been discovered, many factors have been identified that contribute to the development of the disease, such as neurotransmitter alterations, decreased synaptic plasticity, and diminished hippocampal volume. Historically, antipsychotic medications have targeted biochemical alterations in the brains of patients with schizophrenia but have been ineffective in alleviating cognitive and hippocampal deficits. Other modalities, such as exercise therapy, have been proposed as adjuvant or primary therapy options. Exercise therapy has been shown to improve positive and negative symptoms, quality of life, cognition, and hippocampal plasticity, and to increase hippocampal volume in the brains of patients with schizophrenia. This article will briefly review the clinical signs, symptoms and proposed etiologies of schizophrenia, and describe the current understanding of exercise programs as an effective treatment in patients with the disease.

Nonmaleficence in medical training: Balancing patient care and efficient education.

The principle of nonmaleficence requires that every medical action be weighed against all benefits, risks, and consequences, occasionally deeming no treatment to be the best treatment. In medical education, it also applies to performing tasks appropriate to an individual's level of competence and training. Students, residents, and attending physicians alike maintain a beneficence-based responsibility to patients, and attending physicians have a fiduciary responsibility to educate younger generations of doctors.

Risk Factors Associated with 30-Day Mortality After Open Reduction and Internal Fixation of Vertebral Fractures.

OBJECTIVE: Few studies have examined the outcomes of open reduction and internal fixation of vertebral fractures. The purpose of this study was to determine patient-related and surgery-related risk factors associated with 30-day postoperative mortality after open reduction and internal fixation (ORIF) of cervical, thoracic, and lumbar vertebral fractures. METHODS: This was a retrospective cohort study of data from the 2010-2014 ACS-NSQIP database. Adult patients who underwent ORIF of vertebral fractures in the cervical, thoracic, or lumbar spine were included. Patients were divided into 2 groups on the basis of the occurrence of 30-day postoperative mortality. A univariate analysis was performed to compare baseline patient characteristics, comorbidities, operative variables, and 30-day postoperative complications between the mortality and nonmortality groups. A subsequent multivariate regression analysis adjusting for patient and operative factors was then performed to identify independent risk factors for 30-day mortality. RESULTS: A total of 900 patients who underwent vertebral ORIF were included. The overall 30-day postoperative mortality rate was 1.56%. The mortality group had a higher incidence of pneumonia, pulmonary complications, cardiac complications, blood transfusion, sepsis, and prolonged hospitalization. Multivariate regression analysis identified pulmonary comorbidity and diabetes as independent predictors of 30-day mortality following ORIF of vertebral fractures. CONCLUSIONS: Pulmonary comorbidity and diabetes were found to be independent risk factors for 30-day mortality after ORIF of vertebral fractures. Recognizing these risk factors is important in preoperative risk stratification, perioperative care, and patient counseling.

Developmental dysplasia of the hip: a history of innovation.

Developmental dysplasia of the hip (DDH) is a relatively common malady that has profound consequences in the infant if left untreated. Effective and early treatment of DDH has been praised as one of the most successful ventures of modern pediatric orthopedics. Yet, before the modern management of DDH came into existence, there were extensive technological developments in the field of harnesses, casts, and traction methods. This paper aims to identify the centuries-old history of advancement in DDH treatment and the many important people involved. Their devices, thoughts, and ideas continue to have a profound impact on the current practice of orthopedic surgery.

The Science of Quality Improvement.

The manufacturing industry has supplied many quality-improvement methodologies that have been successfully utilized in health-care delivery, such as Plan-Do-Study-Act (PDSA) cycles, Total Quality Management, Six Sigma, and Lean. Many tools of quality improvement, such as PDSA cycles and DMAIC (Design-Measure-Analyze-Improve-Control) of the Six Sigma method, are similar to the scientific method that is familiar to clinicians. Correct identification of the sources and types of process variation within a system is paramount for process improvement. Reduction in process variation via standardization and reinforcement of process protocols leads to improved process outcomes. Quality-improvement projects should define a clear governance structure to maintain project timeliness and completion.

Crohn's disease in Caucasians and African Americans, as defined by clinical predictors and single nucleotide polymorphisms.

OBJECTIVES: To compare three aspects of Crohn's disease (CD) between African Americans and Caucasians: (1) demographic data and environmental factors affecting CD susceptibility, (2) disease presentation and clinical course, and (3) genetic susceptibility via the use of single nucleotide polymorphism (SNP) data for inflammatory bowel disease (IBD) susceptibility loci. METHODS: Clinical data and peripheral blood were obtained from 1032 patients (554 CD patients and 478 controls) derived from a clinically well-defined university-based medical and surgical digestive disease practice and included those who were diagnosed with IBD. Genomic DNA was extracted and polymerase chain reaction (PCR) amplification and genotyping were performed for 11 SNPs, including the NOD2, IL-23r, OCTN 1, and the IGR gene variants. RESULTS: A total of 554 patients with CD were included in this study: 53 African Americans (10%), 485 Caucasians (87%), and 15 of other races (3%). The strongest demographic predictor of CD in African American patients was a family history of IBD. Ileocolic disease (L3) was the most common site involved in both African Americans and Caucasians, while the penetrating phenotype (B3) was the most common CD disease behavior in both races. Genotype association analysis showed a significant association between 2 IL23r gene SNPs and CD susceptibility in African Americans (p = .016 and .028, respectively). CONCLUSION: We believe this study is the first to report on genotype-phenotype associations in African American CD patients and compare findings to Caucasian CD patients within the same geographic area. We found no association between NOD2 gene SNPs and CD susceptibility in African Americans patients (p > .05).