Predictors of Nonhome Discharge After Cervical Disc Replacement.

STUDY DESIGN: Retrospective review of a national database. OBJECTIVE: The aim of this study was to identify the factors that increase the risk of nonhome discharge after CDR. SUMMARY OF BACKGROUND DATA: As spine surgeons continue to balance increasing surgical volume, identifying variables associated with patient discharge destination can help expedite postoperative placement and reduce unnecessary length of stay. However, no prior study has identified the variables predictive of nonhome patient discharge after cervical disc replacement (CDR). METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent primary 1-level or 2-level CDR between 2011 and 2020. Multivariable Poisson regression with robust error variance was employed to identify the predictors for nonhome discharge destination following surgery. RESULTS: A total of 7276 patients were included in this study, of which 94 (1.3%) patients were discharged to a nonhome destination. Multivariable regression revealed older age (OR: 1.076, P<0.001), Hispanic ethnicity (OR: 4.222, P=0.001), BMI (OR: 1.062, P=0.001), ASA class ≥3 (OR: 2.562, P=0.002), length of hospital stay (OR: 1.289, P<0.001), and prolonged operation time (OR: 1.007, P<0.001) as predictors of nonhome discharge after CDR. Outpatient surgery setting was found to be protective against nonhome discharge after CDR (OR: 0.243, P<0.001). CONCLUSIONS: Age, Hispanic ethnicity, BMI, ASA class, prolonged hospital stay, and prolonged operation time are independent predictors of nonhome discharge after CDR. Outpatient surgery setting is protective against nonhome discharge. These findings can be utilized to preoperatively risk stratify expected discharge destination, anticipate patient discharge needs postoperatively, and expedite discharge in these patients to reduce health care costs associated with prolonged length of hospital stay. LEVEL OF EVIDENCE: IV.

Discrepancy between global- and disease-specific outcome measures following lumbar spine surgery.

OBJECTIVE: The aim of this study was to assess the correlation between patient-perceived changes in health and commonly utilized patient-reported outcome measures (PROMs) in lumbar spine surgery. METHODS: This was a retrospective review of prospectively collected data on consecutive patients who underwent lumbar microdiscectomy, lumbar decompression, or lumbar fusion at a single academic institution from 2017 to 2023. Correlation between the global rating of change (GRC) questionnaire, a 5-item Likert scale (much better, slightly better, about the same, slightly worse, and much worse), and PROMs (Oswestry Disability Index, visual analog scale for back and leg pain, 12-Item Short Form Health Survey Physical Component Summary and Mental Component Summary, and PROMIS physical function) was assessed using Spearman's rank correlation coefficients. RESULTS: A total of 1871 patients (397 microdiscectomies, 965 decompressions, and 509 fusions) were included. A majority of patients in each group rated their lumbar condition as much better at each postoperative time point compared with preoperatively and reported improved health status at each postoperative time point compared with the previous follow-up visit. Statistically significant but weak to moderate correlations were found between GRC and change in PROM scores from the preoperative time point. Correlation between GRC and change in PROM scores from the prior visit showed some statistically significant correlations, but the strengths ranged from very weak to weak. CONCLUSIONS: A majority of patients undergoing lumbar microdiscectomy, decompression, or fusion endorsed notable improvements in health status in the early postoperative period and continued to improve at late follow-up. However, commonly used PROMs demonstrated very weak to moderate correlations with patient-perceived changes in overall lumbar spine-related health status as determined by GRC. Therefore, currently used PROMs may not be as sensitive at detecting these changes or may not be adequately reflecting changes in health conditions that are meaningful to patients undergoing lumbar spine surgery.

Opening Side of Unilateral Open-Door Laminoplasty Does Not Impact Improvement in Arm Pain or Space Available for the Spinal Cord.

Background/Objectives: There exists limited data guiding open-door laminoplasty. The objective of this study is to determine if open-door laminoplasty affects radiographic decompression or arm pain outcomes. Methods: Adult patients who underwent unilateral open-door laminoplasty cervical myelopathy were included. The side opened was dependent on surgeon discretion. We recorded preoperative side of symptoms, side of radiographic compression, arm pain scores, and canal diameter. Patients with open-side ipsilateral or contralateral to dominant symptoms or compression were compared to determine any effect on arm pain outcomes or spinal canal diameter. If the symptoms were equal bilaterally, patients were neutral. Results: A total of 167 patients were included, with an average age of 64 ± 11 years and average follow-up time of 64.5 ± 72 weeks. The average preoperative arm pain visual analog score (VAS) was 2.13 ± 2.86, and the average arm VAS after 6 months was 1.52 ± 2.68. For dominant symptoms, the ipsilateral, contralateral, and neutral groups had a significant improvement in arm VAS at >6 months postoperatively. For dominant compression, the ipsilateral and contralateral groups had a significant improvement in both arm VASs and canal diameter at >6 months postoperatively. No differences were seen between groups for either. We observed a significant correlation between size of plate and change in canal diameter; however, no differences were noted for arm pain. Conclusions: Laminoplasty may be effective in addressing radicular arm pain by increasing the spinal canal's diameter and space available for the cord. The laterality of open-door laminoplasty did not affect arm pain improvement or canal expansion.

Isolated decompression for degenerative spondylolisthesis is less costly than fusion even with high revision rates.

BACKGROUND CONTEXT: Isolated decompression and decompression with instrumented fusion are accepted surgical treatments for lumbar spondylolisthesis. Although isolated decompression is a less costly solution with similar patient-reported outcomes, it is associated with higher rates of re-operation than primary fusion. PURPOSE: To determine the costs associated with primary decompression, primary fusion, and decompression and fusion for degenerative spondylolisthesis. We further sought to establish at what revision rate is primary decompression still a less costly surgical treatment for degenerative lumbar spondylolisthesis. STUDY DESIGN/SETTING: A retrospective database study of the Medicare Provider Analysis and Review (MEDPAR) limited data set. PATIENT SAMPLE: Patients who underwent single-level fusion or decompression for degenerative spondylolisthesis. OUTCOME MEASURES: Cost of surgical care. METHODS: All inpatient stays that underwent surgery for single-level lumbar/lumbosacral degenerative spondylolisthesis in the 2019 calendar year (n=6,653) were queried from the MEDPAR limited data set. Patients were stratified into three cohorts: primary decompression (n=300), primary fusion (n=5,757), and revision fusion (n=566). Univariate analysis was conducted to determine cost differences between these groups and results were confirmed with multivariable regression. An economic analysis was then done to determine at what revision rate would primary decompression still be a less costly treatment choice. RESULTS: on univariate analysis, the cost of primary single-level decompression for spondylolisthesis was $14,690±9,484, the cost of primary single-level fusion was $26,376±11,967, and revision fusion was $26,686±11,309 (p<0.001). on multivariate analysis, primary fusion was associated with an increased cost of $3,751, and revision fusion was associated with increased cost of $7,502 (95%ci: 2,990-4,512, p<0.001). economic analysis found that a revision rate less than or equal to 43.8% would still result in primary decompression being less costly for a practice than primary fusion for all patients. CONCLUSIONS: Isolated decompression for degenerative lumbar spondylolisthesis is a less costly treatment choice even with rates of revision fusion as high as 43.8%. This was true even with an assumed revision rate of 0% after primary fusion. This study solely looks at cost data, however, and many patients may still benefit from primary fusion when appropriately indicated.

Impact of age on comparative outcomes of decompression alone versus fusion for L4 degenerative spondylolisthesis.

PURPOSE: To compare the outcomes of decompression alone and fusion for L4-5 DLS in different age cohorts (< 70 years, ≥ 70 years). METHODS: This retrospective cohort study included patients who underwent minimally invasive decompression or fusion for L4-5 DLS and had a minimum of 1-year follow-up. Outcome measures were: (1) patient-reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale back and leg, VAS; 12-Item Short Form Survey Physical Component Score, SF-12 PCS), (2) minimal clinically important difference (MCID), (3) patient acceptable symptom state (PASS), (4) response on the global rating change (GRC) scale, and (5) complication rates. The decompression and fusion groups were compared for outcomes separately in the < 70-year and ≥ 70-year age cohorts. RESULTS: 233 patients were included, out of which 52% were < 70 years. Patients < 70 years showed non-significant improvement in SF-12 PCS and significantly lower MCID achievement rates for VAS back after decompression compared to fusion. Analysis of the ≥ 70-year age cohort showed no significant differences between the decompression and fusion groups in the improvement in PROMs, MCID/PASS achievement rates, and responses on GRC. Patients ≥ 70 years undergoing fusion had significantly higher in-hospital complication rates. When analyzed irrespective of the surgery type, both < 70-year and ≥ 70-year age cohorts showed significant improvement in PROMs with no significant difference. CONCLUSIONS: Patients < 70 years undergoing decompression alone did not show significant improvement in physical function and had significantly less MCID achievement rate for back pain compared to fusion. Patients ≥ 70 years showed no difference in outcomes between decompression alone and fusion.

Level-specific comparison of 3D navigated and robotic arm-guided screw placement: an accuracy assessment of 1210 pedicle screws in lumbar surgery.

BACKGROUND CONTEXT: Robotic spine surgery, utilizing 3D imaging and robotic arms, has been shown to improve the accuracy of pedicle screw placement compared to conventional methods, although its superiority remains under debate. There are few studies evaluating the accuracy of 3D navigated versus robotic-guided screw placement across lumbar levels, addressing anatomical challenges to refine surgical strategies and patient safety. PURPOSE: This study aims to investigate the pedicle screw placement accuracy between 3D navigation and robotic arm-guided systems across distinct lumbar levels. STUDY DESIGN: A retrospective review of a prospectively collected registry PATIENT SAMPLE: Patients undergoing fusion surgery with pedicle screw placement in the prone position, using either via 3D image navigation only or robotic arm guidance OUTCOME MEASURE: Radiographical screw accuracy was assessed by the postoperative computed tomography (CT) according to the Gertzbein-Robbins classification, particularly focused on accuracy at different lumbar levels. METHODS: Accuracy of screw placement in the 3D navigation (Nav group) and robotic arm guidance (Robo group) was compared using Chi-squared test/Fisher's exact test with effect size measured by Cramer's V, both overall and at each specific lumbosacral spinal level. RESULTS: A total of 321 patients were included (Nav, 157; Robo, 189) and evaluated 1210 screws (Nav, 651; Robo 559). The Robo group demonstrated significantly higher overall accuracy (98.6 vs. 93.9%; p<.001, V=0.25). This difference of no breach screw rate was signified the most at the L3 level (No breach screw: Robo 91.3 vs. 57.8%, p<.001, V=0.35) followed by L4 (89.6 vs. 64.7%, p<.001, V=0.28), and L5 (92.0 vs. 74.5%, p<.001, V=0.22). However, screw accuracy at S1 was not significant between the groups (81.1 vs. 72.0%, V=0.10). CONCLUSION: This study highlights the enhanced accuracy of robotic arm-guided systems compared to 3D navigation for pedicle screw placement in lumbar fusion surgeries, especially at the L3, L4, and L5 levels. However, at the S1 level, both systems exhibit similar effectiveness, underscoring the importance of understanding each system's specific advantages for optimization of surgical complications.

Morbidly Obese Patients Have Similar Clinical Outcomes and Recovery Kinetics After Minimally Invasive Decompression.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To study the impact of class 2/3 obesity (body mass index, BMI >35) on outcomes following minimally invasive decompression. SUMMARY OF BACKGROUND DATA: No previous study has analyzed the impact of class 2/3 obesity on outcomes following minimally invasive decompression. METHODS: Patients who underwent primary minimally invasive decompression were divided into 4 cohorts based on their BMI: normal (BMI 18.5 to <25), overweight (25 to <30), class 1 obesity (30 to <35), and class 2/3 obesity (BMI >35). Outcome measures were: 1) intraoperative variables: operative time, estimated blood loss (EBL); 2) patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS); 3) global rating change (GRC), minimal clinically important difference (MCID), and patient acceptable symptom state (PASS) achievement rates; 4) return to activities; and 5) complication and reoperation rates. RESULTS: 838 patients were included (226 normal, 357 overweight, 179 class 1 obesity, 76 class 2/3 obesity). Class 1 and 2/3 obesity groups had significantly greater operative times compared to the other groups. Class 2/3 obesity group had worse ODI, VAS back and SF-12 PCS preoperatively, worse ODI, VAS back, VAS leg and SF-12 PCS at <6 months, and worse ODI and SF-12 PCS at >6 months. However, they had significant improvement in all PROMs at both postoperative timepoints and the magnitude of improvement was similar to other groups. No significant differences were found in MCID and PASS achievement rates, likelihood of betterment on the GRC scale, return to activities, and complication/reoperation rates. CONCLUSIONS: Class 2/3 obese patients have worse PROMs pre- and post-operatively. However, they show similar improvement in PROMs, MCID and PASS achievement rates, likelihood of betterment, recovery kinetics, and complication/reoperation rates as other BMI groups following minimally invasive decompression.

Temporal Trends of Improvement After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To analyze temporal trends in improvement after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Although several studies have shown that patients improve significantly after MIS TLIF, evidence regarding the temporal trends in improvement is still largely lacking. METHODS: Patients who underwent primary single-level MIS TLIF for degenerative conditions of the lumbar spine and had a minimum of 2-year follow-up were included. Outcome measures were: 1) patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS); 2) global rating change (GRC); 3) minimal clinically important difference (MCID); and 4) return to activities. Timepoints analyzed were preoperative, 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years. Trends across these timepoints were plotted on graphs. RESULTS: 236 patients were included. VAS back and VAS leg were found to have statistically significant improvement compared to the previous timepoint up to 3 months after surgery. ODI and SF-12 PCS were found to have statistically significant improvement compared to the previous timepoint up to 6 months after surgery. Beyond these timepoints, there was no significant improvement in PROMs. 80% of patients reported feeling better compared to preoperative by 3 months. >50% of patients achieved MCID in all PROMs by 3 months. Most patients returned to driving, returned to work, and discontinued narcotics at an average of 21, 20, and 10 days, respectively. CONCLUSIONS: Patients are expected to improve up to 6 months after MIS TLIF. Back pain and leg pain improve up to 3 months and disability and physical function improve up to 6 months. Beyond these timepoints, the trends in improvement tend to reach a plateau. 80% of patients feel better compared to preoperative by 3 months after surgery.

Practical Answers to Frequently Asked Questions in Anterior Cervical Spine Surgery for Degenerative Conditions.

INTRODUCTION: Surgical counseling enables shared decision making and optimal outcomes by improving patients' understanding about their pathologies, surgical options, and expected outcomes. Here, we aimed to provide practical answers to frequently asked questions (FAQs) from patients undergoing an anterior cervical diskectomy and fusion (ACDF) or cervical disk replacement (CDR) for the treatment of degenerative conditions. METHODS: Patients who underwent primary one-level or two-level ACDF or CDR for the treatment of degenerative conditions with a minimum of 1-year follow-up were included. Data were used to answer 10 FAQs that were generated from author's experience of commonly asked questions in clinic before ACDF or CDR. RESULTS: A total of 395 patients (181 ACDF, 214 CDR) were included. (1, 2, and 3) Will my neck/arm pain and physical function improve? Patients report notable improvement in all patient-reported outcome measures. (4) Is there a chance I will get worse? 13% (ACDF) and 5% (CDR) reported worsening. (5) Will I receive a significant amount of radiation? Patients on average received a 3.7 (ACDF) and 5.5 mGy (CDR) dose during. (6) How long will I stay in the hospital? Most patients get discharged on postoperative day one. (7) What is the likelihood that I will have a complication? 13% (8% minor and 5% major) experienced in-hospital complications (ACDF) and 5% (all minor) did (CDR). (8) Will I need another surgery? 2.2% (ACDF) and 2.3% (CDR) of patients required a revision surgery. (9 & 10) When will I be able to return to work/driving? Most patients return to working (median of 16 [ACDF] and 14 days [CDR]) and driving (median of 16 [ACDF] and 12 days [CDR]). CONCLUSIONS: The answers to the FAQs can assist surgeons in evidence-based patient counseling.

Impact of Preoperative Symptom Duration on Patient-Reported Outcomes Following Cervical Disc Replacement for Cervical Radiculopathy.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the impact of preoperative symptom duration on postoperative functional outcomes following cervical disc replacement (CDR) for radiculopathy. SUMMARY OF BACKGROUND DATA: CDR has emerged as a reliable and efficacious treatment option for degenerative cervical spine pathologies. The relationship between preoperative symptom duration and outcomes following CDR is not well established. METHODS: Patients with radiculopathy without myelopathy who underwent primary 1- or 2-level CDRs were included and divided into shorter (<6 mo) and prolonged (≥6 mo) cohorts based on preoperative symptom duration. Patient-reported outcome measures (PROMs) included Neck Disability Index (NDI), Visual Analog Scale (VAS) Neck and Arm. Change in PROM scores and minimal clinically important difference (MCID) rates were calculated. Analyses were conducted on the early (within 3 mo) and late (6 mo-2 y) postoperative periods. RESULTS: A total of 201 patients (43.6±8.7 y, 33.3% female) were included. In both early and late postoperative periods, the shorter preoperative symptom duration cohort experienced significantly greater change from preoperative PROM scores compared to the prolonged symptom duration cohort for NDI, VAS-Neck, and VAS-Arm. The shorter symptom duration cohort achieved MCID in the early postoperative period at a significantly higher rate for NDI (78.9% vs. 54.9%, P=0.001), VAS-Neck (87.0% vs. 56.0%, P<0.001), and VAS-Arm (90.5% vs. 70.7%, P=0.002). Prolonged preoperative symptom duration (≥6 mo) was identified as an independent risk factor for failure to achieve MCID at the latest timepoint for NDI (OR: 2.9, 95% CI: 1.2-6.9, P=0.016), VAS-Neck (OR: 9.8, 95% CI: 3.7-26.0, P<0.001), and VAS-Arm (OR: 7.5, 95% CI: 2.5-22.5, P<0.001). CONCLUSIONS: Our study demonstrates improved patient-reported outcomes for those with shorter preoperative symptom duration undergoing CDR for radiculopathy, suggesting delayed surgical intervention may result in poorer outcomes and greater postoperative disability. LEVEL OF EVIDENCE: III.

Clinical and Radiological Predictors of Slower and Non-Improvement Following Surgical Treatment of L4-5 Degenerative Spondylolisthesis: Preliminary Results.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To identify the predictors of slower and non-improvement following surgical treatment of L4-5 degenerative lumbar spondylolisthesis (DLS). SUMMARY OF BACKGROUND DATA: There is limited evidence regarding clinical and radiological predictors of slower and non-improvement following surgery for L4-5 DLS. METHODS: Patients who underwent minimally invasive decompression or fusion for L4-5 DLS and had a minimum of 1-year follow-up were included. Outcome measures were: (1) minimal clinically important difference (MCID), (2) patient acceptable symptom state (PASS), and (3) global rating change (GRC). Clinical variables analyzed for predictors were age, gender, body mass index (BMI), surgery type, comorbidities, anxiety, depression, smoking, osteoporosis, and preoperative patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS). Radiological variables analyzed were slip percentage, translational and angular motion, facet diastasis/cyst/orientation, laterolisthesis, disc height, scoliosis, main and fractional curve Cobb angles, and spinopelvic parameters. RESULTS: 233 patients (37% decompression, 63% fusion) were included. At <3 months, high pelvic tilt (PT) (OR 0.92, P 0.02) and depression (OR 0.28, P 0.02) were predictors of MCID non-achievement and GRC non-betterment, respectively. Neither retained significance at >6 months and hence, were identified as predictors of slower improvement. At >6 months, low preoperative VAS leg (OR 1.26, P 0.01) and high facet orientation (OR 0.95, P 0.03) were predictors of MCID non-achievement, high L4-5 slip percentage (OR 0.86, P 0.03) and L5-S1 angular motion (OR 0.78, P 0.01) were predictors of GRC non-betterment, and high preoperative ODI (OR 0.96, P 0.04) was a predictor of PASS non-achievement. CONCLUSIONS: High PT and depression were predictors of slower improvement and low preoperative leg pain, high disability, high facet orientation, high slip percentage, and L5-S1 angular motion were predictors of non-improvement. However, these are preliminary findings and further studies with homogeneous cohorts are required to establish these findings.

Psoas Muscle Health is Correlated with Time to Achieve MCID in Patients with Predominant Axial Back Pain Following Decompression Surgery: Early Results.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the impact of psoas muscle health (cross-sectional area, CSA) on achieving minimal clinically important differences (MCID) in patient-reported outcome measures (PROMs) following laminectomy for patients with predominant back pain (PBP) and leg pain (PLP). SUMMARY OF BACKGROUND DATA: Psoas muscle health is linked to postoperative outcomes in decompression patients, with MRI-based grading of psoas CSA correlating with these outcomes. However, evidence on its impact on symptomatic recovery, measured by PROMs, is lacking. METHODS: 106 patients with PBP (VAS back >VAS leg) and 139 patients with PLP (VAS leg >VAS back) who underwent laminectomy from 2017-2021 were included. Axial T2 MRI images were analyzed for psoas CSA using a validated method. Based on the lowest-quartile normalized total psoas area (NTPA) thresholds, patients were divided into "Good" and "Poor" muscle health groups. The correlation analyses were performed between the psoas CSA and changes in PROMs. Kaplan-Meier survival analysis was conducted to determine the probability of achieving MCID as a function of time. RESULTS: Of 106 PBP patients, 83 (78.3%) had good muscle health, 23 (21.6%) had poor muscle health. Of 139 PLP patients, 54 (38.8%) had good muscle health, 85 (61.1%) had poor muscle health. In the PBP group, older age was associated with poor muscle health (69.70±9.26 vs. 59.92±15.01, P=0.0002). For both cohorts, there were no differences in the rate of MCID achievement for any PROMs between the good and poor muscle health groups. In the PBP group, Kaplan-Meier analysis showed patients with good psoas health achieved MCID-VAS back and Oswestry Disability Index (ODI) in median times of 14 and 42 days (P=0.045 and 0.015), respectively. CONCLUSION: Good psoas muscle health is linked to faster attainment of MCID, especially in patients with PBP compared to PLP after decompression surgery. LEVEL OF EVIDENCE: 3.

Chat Generative Pretraining Transformer Answers Patient-focused Questions in Cervical Spine Surgery.

STUDY DESIGN: Review of Chat Generative Pretraining Transformer (ChatGPT) outputs to select patient-focused questions. OBJECTIVE: We aimed to examine the quality of ChatGPT responses to cervical spine questions. BACKGROUND: Artificial intelligence and its utilization to improve patient experience across medicine is seeing remarkable growth. One such usage is patient education. For the first time on a large scale, patients can ask targeted questions and receive similarly targeted answers. Although patients may use these resources to assist in decision-making, there still exists little data regarding their accuracy, especially within orthopedic surgery and more specifically spine surgery. METHODS: We compiled 9 frequently asked questions cervical spine surgeons receive in the clinic to test ChatGPT's version 3.5 ability to answer a nuanced topic. Responses were reviewed by 2 independent reviewers on a Likert Scale for the accuracy of information presented (0-5 points), appropriateness in giving a specific answer (0-3 points), and readability for a layperson (0-2 points). Readability was assessed through the Flesh-Kincaid grade level analysis for the original prompt and for a second prompt asking for rephrasing at the sixth-grade reading level. RESULTS: On average, ChatGPT's responses scored a 7.1/10. Accuracy was rated on average a 4.1/5. Appropriateness was 1.8/3. Readability was a 1.2/2. Readability was determined to be at the 13.5 grade level originally and at the 11.2 grade level after prompting. CONCLUSIONS: ChatGPT has the capacity to be a powerful means for patients to gain important and specific information regarding their pathologies and surgical options. These responses are limited in their accuracy, and we, in addition, noted readability is not optimal for the average patient. Despite these limitations in ChatGPT's capability to answer these nuanced questions, the technology is impressive, and surgeons should be aware patients will likely increasingly rely on it.

Ninety Percent of Patients Are Satisfied With Their Decision to Undergo Spine Surgery for Degenerative Conditions.

STUDY DESIGN: Cross-sectional survey and retrospective review of prospectively collected data. OBJECTIVE: To explore how patients perceive their decision to pursue spine surgery for degenerative conditions and evaluate factors correlated with decisional regret. SUMMARY OF BACKGROUND DATA: Prior research shows that one-in-five older adults regret their decision to undergo spinal deformity surgery. However, no studies have investigated decisional regret in patients with degenerative conditions. METHODS: Patients who underwent cervical or lumbar spine surgery for degenerative conditions (decompression, fusion, or disk replacement) between April 2017 and December 2020 were included. The Ottawa Decisional Regret Questionnaire was implemented to assess prevalence of decisional regret. Questionnaire scores were used to categorize patients into low (<40) or medium/high (≥40) decisional regret cohorts. Patient-reported outcome measures (PROMs) included the Oswestry Disability Index, Patient-reported Outcomes Measurement Information System, Visual Analog Scale (VAS) Back/Leg/Arm, and Neck Disability Index at preoperative, early postoperative (<6 mo), and late postoperative (≥6 mo) timepoints. Differences in demographics, operative variables, and PROMs between low and medium/high decisional regret groups were evaluated. RESULTS: A total of 295 patients were included (mean follow-up: 18.2 mo). Overall, 92% of patients agreed that having surgery was the right decision, and 90% would make the same decision again. In contrast, 6% of patients regretted the decision to undergo surgery, and 7% noted that surgery caused them harm. In-hospital complications (P=0.02) and revision fusion (P=0.026) were significantly associated with higher regret. The medium/high decisional regret group also exhibited significantly worse PROMs at long-term follow-up for all metrics except VAS-Arm, and worse achievement of minimum clinically important difference for Oswestry Disability Index (P=0.007), Patient-Reported Outcomes Measurement Information System (P<0.0001), and VAS-Leg (P<0.0001). CONCLUSIONS: Higher decisional regret was encountered in the setting of need for revision fusion, increased in-hospital complications, and worse PROMs. However, 90% of patients overall were satisfied with their decision to undergo spine surgery for degenerative conditions. Current tools for assessing patient improvement postoperatively may not adequately capture the psychosocial values and patient expectations implicated in decisional regret.

Trends in Indications and Contraindications for Cervical Disk Arthroplasty from 2009 to 2019.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: Assess trends of indications and contraindications for the use of Cervical Disk Arthroplasty (CDA). SUMMARY OF BACKGROUND DATA: As spine surgeons become more familiar with CDA, there have been expansions in indications. METHODS: The Medicare Provider Analysis and Review Limited Data Sets for 2009, 2014, and 2019 were utilized. Patients undergoing elective CDA were included. Diagnosis for index surgery and "contraindications" as defined by original CDA Investigative Device Exemption (IDE) criteria were assessed. Variables were identified by the International Classification of Diseases (ICD)-9 or ICD-10 diagnosis and procedural codes. RESULTS: A total of 1067 elective CDA patients were included. There were 230 patients in 2009, 300 patients in 2014, and 537 patients in 2019. The proportion of patients aged >65 increased from 35% to 51% (P<0.001). Incidence of CDA for radiculopathy increased from 57% to 69% (P<0.001), myelopathy increased from 23% to 78% (P<0.001), and spondylosis without radiculopathy or myelopathy decreased from 19% to 3% (P<0.001). There were increased incidences of ankylosing spondylitis (0.4% to 2.8%, P=0.007), long-term steroid use (1% to 2%, P=0.039), morbid obesity (2% to 6%, P=0.019), and osteoporosis (1% to 5%, P=0.014). The incidence of hybrid CDA and anterior cervical discectomy and fusion (ACDF) decreased from 28% to 23% (P=0.007). CONCLUSION: From 2009 to 2019, the number of CDA performed in older patients increased. An increase in the use of CDA for the treatment of myelopathy and radiculopathy and a decrease in the treatment of isolated cervical spondylosis was observed. The proportion of CDA performed in patients with original IDE trial "contraindications" increased. Further research into the efficacy of CDA for patients with contraindications is warranted.

Predictors for Failure to Respond to Erector Spinae Plane Block Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To identify the risk factors associated with failure to respond to erector spinae plane (ESP) block following minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). SUMMARY OF BACKGROUND DATA: ESP block is an emerging opioid-sparing regional anesthetic that has been shown to reduce immediate postoperative pain and opioid demand following MI-TLIF-however, not all patients who receive ESP blocks perioperatively experience a reduction in immediate postoperative pain. METHODS: This was a retrospective review of consecutive patients undergoing 1-level MI-TLIF who received ESP blocks by a single anesthesiologist perioperatively at a single institution. ESP blocks were administered in the OR following induction. Failure to respond to ESP block was defined as patients with a first numerical rating scale (NRS) score post-surgery of >5.7 (mean immediate postoperative NRS score of control cohort undergoing MI TLIF without ESP block). Multivariable logistic regressions were performed to identify predictors for failure to respond to ESP block. RESULTS: A total of 134 patients were included (mean age 60.6 years, 43.3% females). The median and interquartile range (IQR) first pain score post-surgery was 2.5 (0.0-7.5). Forty-nine (36.6%) of patients failed to respond to ESP block. In the multivariable regression analysis, several independent predictors for failure to respond to ESP block following MI TLIF were identified: female sex (OR 2.33, 95% CI 1.04-5.98, P=0.040), preoperative opioid use (OR 2.75, 95% CI 1.03- 7.30, P=0.043), anxiety requiring medication (OR 3.83, 95% CI 1.27-11.49, P=0.017), and hyperlipidemia (OR 3.15, 95% CI 1.31-7.55, P=0.010). CONCLUSIONS: Our study identified several predictors for failure to respond to ESP block following MI TLIF including female sex, preoperative opioid pain medication use, anxiety, and hyperlipidemia. These findings may help inform the approach to counseling patients on perioperative outcomes and pain expectations following MI-TLIF with ESP block. LEVEL OF EVIDENCE: III.

Limited Improvement With Minimally Invasive Lumbar Decompression Alone for Degenerative Scoliosis With Cobb Angle Over 20°: The Impact of Decompression Location.

STUDY DESIGN: Retrospective review of a prospectively collected multisurgeon registry. OBJECTIVE: To evaluate the outcomes of minimally invasive (MI) decompression in patients with severe degenerative scoliosis (DS) and identify factors associated with poorer outcomes. SUMMARY OF BACKGROUND CONTEXT: MI decompression has gained widespread acceptance as a treatment option for patients with lumbar canal stenosis and DS. However, there is a lack of research regarding the clinical outcomes and the impact of MI decompression location in patients with severe DS exhibiting a Cobb angle exceeding 20°. MATERIALS AND METHODS: Patients who underwent MI decompression alone were included and categorized into the DS or control groups based on Cobb angle (>20°). Decompression location was labeled as "scoliosis-related" when the decompression levels were across or between end vertebrae and "outside" when the operative levels did not include the end vertebrae. The outcomes, including the Oswestry Disability Index (ODI), were compared between the propensity score-matched groups for improvement and minimal clinical importance difference (MCID) achievement at ≥1 year postoperatively. Multivariable regression analysis was conducted to identify factors contributing to the nonachievement of MCID in ODI of the DS group at the ≥1-year time point. RESULTS: A total of 253 patients (41 DS) were included in the study. Following matching for age, sex, osteoporosis status, psoas muscle area, and preoperative ODI, the DS groups exhibited a significantly lower rate of MCID achievement in ODI (DS: 45.5% vs. control 69.0%, P =0.047). The "scoliosis-related" decompression (odds ratio: 9.9, P =0.028) was an independent factor of nonachievement of MCID in ODI within the DS group. CONCLUSIONS: In patients with a Cobb angle >20°, lumbar decompression surgery, even in the MI approach, may result in limited improvement of disability and physical function. Caution should be exercised when determining a surgical plan, especially when decompression involves the level between or across the end vertebrae. LEVEL OF EVIDENCE: 3.

Impact of Metabolic Syndrome on Early Postoperative Outcomes After Cervical Disk Replacement: A Propensity-matched Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the demographics, perioperative variables, and complication rates following cervical disk replacement (CDR) among patients with and without metabolic syndrome (MetS). SUMMARY OF BACKGROUND DATA: The prevalence of MetS-involving concurrent obesity, insulin resistance, hypertension, and hyperlipidemia-has increased in the United States over the last 2 decades. Little is known about the impact of MetS on early postoperative outcomes and complications following CDR. METHODS: The 2005-2020 National Surgical Quality Improvement Program was queried for patients who underwent primary 1- or 2-level CDR. Patients with and without MetS were divided into 2 cohorts. MetS was defined, according to other National Surgical Quality Improvement Program studies, as concurrent diabetes mellitus, hypertension requiring medication, and body mass index ≥30 kg/m 2 . Rates of 30-day readmission, reoperation, complications, length of hospital stay, and discharge disposition were compared using χ 2 and Fisher exact tests. One to 2 propensity-matching was performed, matching for demographics, comorbidities, and number of operative levels. RESULTS: A total of 5395 patients were included for unmatched analysis. Two hundred thirty-six had MetS, and 5159 did not. The MetS cohort had greater rates of 30-day readmission (2.5% vs. 0.9%; P =0.023), morbidity (2.5% vs. 0.9%; P =0.032), nonhome discharges (3% vs. 0.6%; P =0.002), and longer hospital stays (1.35±4.04 vs. 1±1.48 days; P =0.029). After propensity-matching, 699 patients were included. All differences reported above lost significance ( P >0.05) except for 30-day morbidity (superficial wound infections), which remained higher for the MetS cohort (2.5% vs. 0.4%, P =0.02). CONCLUSIONS: We identified MetS as an independent predictor of 30-day morbidity in the form of superficial wound infections following single-level CDR. Although MetS patients experienced greater rates of 30-day readmission, nonhome discharge, and longer lengths of stay, MetS did not independently predict these outcomes after controlling for baseline differences in patient characteristics. LEVEL OF EVIDENCE: Level III.

Capacity for large language model chatbots to aid in orthopedic management, research, and patient queries.

Large language model (LLM) chatbots possess a remarkable capacity to synthesize complex information into concise, digestible summaries across a wide range of orthopedic subject matter. As LLM chatbots become widely available they will serve as a powerful, accessible resource that patients, clinicians, and researchers may reference to obtain information about orthopedic science and clinical management. Here, we examined the performance of three well-known and easily accessible chatbots-ChatGPT, Bard, and Bing AI-in responding to inquiries relating to clinical management and orthopedic concepts. Although all three chatbots were found to be capable of generating relevant responses, ChatGPT outperformed Bard and BingAI in each category due to its ability to provide accurate and complete responses to orthopedic queries. Despite their promising applications in clinical management, shortcomings observed included incomplete responses, lack of context, and outdated information. Nonetheless, the ability for these LLM chatbots to address these inquires has largely yet to be evaluated and will be critical for understanding the risks and opportunities of LLM chatbots in orthopedics.

The Impact of Posterior Intervertebral Osteophytes on Patient-Reported Outcome Measures After L5-S1 Anterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: (1) To develop a reliable grading system to assess the severity of posterior intervertebral osteophytes and (2) to investigate the impact of posterior intervertebral osteophytes on clinical outcomes after L5-S1 decompression and fusion through anterior lumbar interbody fusion (ALIF) and minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF). BACKGROUND: There is limited evidence regarding the clinical implications of posterior lumbar vertebral body osteophytes for ALIF and MIS-TLIF surgeries and there are no established grading systems that define the severity of these posterior lumbar intervertebral osteophytes. PATIENTS AND METHODS: A retrospective analysis of patients undergoing L5-S1 ALIF or MIS-TLIF was performed. Preoperative and postoperative patient-reported outcome measures of the Oswestry Disability Index (ODI) and leg Visual Analog Scale (VAS) at 2-week, 6-week, 12-week, and 6-month follow-up time points were assessed. Minimal clinically important difference (MCID) for ODI of 14.9 and VAS leg of 2.8 were utilized. Osteophyte grade was based on the ratio of osteophyte length to foraminal width. "High-grade" osteophytes were defined as a maximal osteophyte length >50% of the total foraminal width. RESULTS: A total of 70 consecutive patients (32 ALIF and 38 MIS-TLIF) were included in the study. There were no significant differences between the two cohorts in patient-reported outcome measures or achievement of MCID for Leg VAS or ODI preoperatively or at any follow-ups. On multivariate analysis, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with leg VAS or ODI scores at any follow-up time point. In addition, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with the achievement of MCID for leg VAS or ODI at 6 months. CONCLUSION: ALIF and MIS-TLIF are both valid options for treating degenerative spine conditions and lumbar radiculopathy, even in the presence of high-grade osteophytes that significantly occupy the intervertebral foramen. LEVEL OF EVIDENCE: 3.