Factors Related to Clinical Performance in Spine Surgery Fellowship: Can We Predict Success.

INTRODUCTION: The factors most important in the spine fellowship match may not ultimately correlate with quality of performance during fellowship. This study examined the spine fellow applicant metrics correlated with high application rank compared with the metrics associated with the strongest clinical performance during fellowship. METHODS: Spine fellow applications at three academic institutions were retrieved from the San Francisco Match database (first available to 2021) and deidentified for application review. Application metrics pertaining to research, academics, education, extracurriculars, leadership, examinations, career interests, and letter of recommendations were extracted. Attending spine surgeons involved in spine fellow selection at their institutions were sent a survey to rank (1) fellow applicants based on their perceived candidacy and (2) the strength of performance of their previous fellows. Pearson correlation assessed the associations of application metrics with theoretical fellow rank and actual performance. RESULTS: A total of 37 spine fellow applications were included (Institution A: 15, Institution B: 12, Institution C: 10), rated by 14 spine surgeons (Institution A: 6, Institution B: 4, Institution C: 4). Theoretical fellow rank demonstrated a moderate positive association with overall research, residency program rank, recommendation writer H-index, US Medical Licensing Examination (USMLE) scores, and journal reviewer positions. Actual fellow performance demonstrated a moderate positive association with residency program rank, recommendation writer H-index, USMLE scores, and journal reviewer positions. Linear regressions identified journal reviewer positions (ß = 1.73, P = 0.002), Step 1 (ß = 0.09, P = 0.010) and Step 3 (ß = 0.10, P = 0.002) scores, recommendation writer H-index (ß = 0.06, P = 0.029, and ß = 0.07, P = 0.006), and overall research (ß = 0.01, P = 0.005) as predictors of theoretical rank. Recommendation writer H-index (ß = 0.21, P = 0.030) and Alpha Omega Alpha achievement (ß = 6.88, P = 0.021) predicted actual performance. CONCLUSION: Residency program reputation, USMLE scores, and a recommendation from an established spine surgeon were important in application review and performance during fellowship. Research productivity, although important during application review, was not predictive of fellow performance. LEVEL OF EVIDENCE: III. STUDY DESIGN: Cohort Study.

Preoperative Fluoroscopically Guided Regional Erector Spinae Plane Blocks Reduce Opioid Use, Increase Mobilization, and Reduce Length of Stay Following Lumbar Spine Fusion.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the effectiveness of erector spinae plane (ESP) blocks at improving perioperative pain control and function following lumbar spine fusions. METHODS: A retrospective analysis was performed on patients undergoing < 3 level posterolateral lumbar fusions. Data was stratified into a control group and a block group. We collected postop MED (morphine equivalent dosages), physical therapy ambulation, and length of stay. PROMIS pain interference (PI) and physical function (PF) scores, ODI, and VAS were collected preop and at the first postop visit. Chi-square and student's t-test (P = .05) were used for analysis. We also validated a novel fluoroscopic technique for ESP block delivery. RESULTS: There were 37 in the block group and 39 in the control group. There was no difference in preoperative opioid use (P = .22). On postop day 1, MED was reduced in the block group (32 vs 51, P < .05), and more patients in the block group did not utilize any opioids (22% vs 5%, P < .05). The block group ambulated further on postop day 1 (312 ft vs 204 ft, P < .05), and had reduced length of stay (2.4 vs 3.2 days, P < .05). The block group showed better PROMIS PI scores postoperatively (58 vs 63, P < .05). The novel delivery technique was validated and successful in targeting the correct level and plane. CONCLUSIONS: ESP blocks significantly reduced postop opioid use following lumbar fusion. Block patients ambulated further with PT, had reduced length of stay, and had improved PROMIS PI postoperatively. Validation of the block demonstrated the effectiveness of a novel fluoroscopic delivery technique. ESP blocks represent an underutilized method of reducing opioid consumption, improving postoperative mobilization and reducing length of stay following lumbar spine fusion.

Risk Factors for Postoperative Ileus in Patients Undergoing Spine Surgery.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Postoperative ileus (POI) is a common complication following elective spinal surgeries. The aim of this study was to determine the incidence of POI and identify demographic and surgical risk factors for developing POI after elective instrumented fusion of the thoracolumbar spine. METHODS: The University of Utah Institutional Review Board (IRB) approved this retrospective study. The study does not require informed consent given the data reviewed was deidentified and collected in accordance with the institution's standard of care. A designated IRB committee determined that study is exempt under exemption category 7. IRB approval number 00069703. Patients undergoing instrumented thoracolumbar fusion for one or more levels were retrospectively identified from an internal spine surgery database. Cases performed for trauma, infection, or tumors were excluded. Demographics, medical comorbidities, surgical variables, and opioid medication administration (morphine milligram equivalents, MME) were abstracted from the electronic medical record. Univariate analysis was used to identify variables associated with POI. These variables were then tested for independent association with POI using multivariate logistic regression. RESULTS: 418 patients were included in the current study. The incidence of POI was 9.3% in this cohort. There was no significant relationship between development of POI and patient age, gender, BMI, diabetes mellitus, thyroid dysfunction, lung disease, CKD, GERD, smoking status, alcohol abuse, anemia, or prior abdominal surgery. Univariate analysis demonstrated significant association between POI and fusion ≥7 levels compared to fusions of fewer levels (P = .001), as well as intraoperative sufentanil compared to other opioids (35.9% vs 20.1%, P = .02). POI was not significantly associated with total intraoperative MME, approach, use of interbody cage, or osteotomy. Multivariate logistic regression confirmed total 24-hour postoperative MME as an independent risk factor for POI (OR 1.004, P = .04), however, intraoperative sufentanil administration was not an independent risk factor for POI when controlling for other variables. CONCLUSIONS: This retrospective cohort study demonstrates that greater postoperative MME is an independent risk factor for POI after thoracolumbar spine fusion when accounting for demographic, medical, and surgical variables with multiple logistic regression. Prospective studies are warranted to evaluate clinical measures to decrease the risk of POI among patients undergoing instrumented thoracolumbar spinal fusions.

What Does Your PROMIS Score Mean? Improving the Utility of Patient-Reported Outcomes at the Point of Care.

STUDY DESIGN: Prospective cohort. OBJECTIVES: Patient-Reported Outcome Measurement Information System (PROMIS) has been validated for lumbar spine. Use of patient-reported outcome (PRO) measures can improve clinical decision making and health literacy at the point of care. Use of PROMIS, however, has been limited in part because clinicians and patients lack plain language understanding of the meaning of scores and it remains unclear how best to use them at the point of care. The purpose was to develop plain language descriptions to apply to PROMIS Physical Function (PF) and Pain Interference (PI) scores and to assess patient understanding and preferences in presentation of their individualized PRO information. METHODS: Retrospective analysis of prospectively collected PROMIS PF v1.2 and PI v1.1 for patients presenting to a tertiary spine center for back/lower extremity complaints was performed. Patients with missing scores, standard error >0.32, and assessments with <4 or >12 questions were excluded. Scores were categorized into score groups, specifically PROMIS PF groups were: <18, 20 ± 2, 25 ± 2, 30 ± 2, 35 ± 2, 40 ± 2, 45 ± 2, 50 ± 2, 55 ± 2, 60 ± 2, and >62; and PROMIS PI groups were: <48, 50 ± 2, 55 ± 2, 60 ± 2, 65 ± 2, 70 ± 2, 75 ± 2, 80 ± 2, and >82. Representative questions and answers from the PROMIS PI and PROMIS PF were selected for each score group, where questions with <25 assessments or representing <15% of assessments were excluded. Two fellowship-trained spine surgeons further trimmed the questions to create a streamlined clinical tool using a consensus process. Plain language descriptions for PROMIS PF were then used in a prospective assessment of 100 consecutive patients. Patient preference for consuming the score data was recorded and analyzed. RESULTS: In total, 12 712 assessments/5524 unique patients were included for PF and 14 823 assessments/6582 unique patients for PI. More than 90% of assessments were completed in 4 questions. The number of assessments and patients per scoring group were normally distributed. The mean PF score was 37.2 ± 8.2 and the mean PI was 63.3 ± 7.4. Plain language descriptions and compact clinical tool was were generated. Prospectively 100 consecutive patients were surveyed for their preference in receiving their T-score versus plain language description versus graphical presentation. A total of 78% of patients found receiving personalized PRO data helpful, while only 1% found this specifically not helpful. Overall, 80% of patients found either graphical or plain language more helpful than T-score alone, and half of these preferred plain language and graphical descriptions together. In total, 89% of patients found the plain language descriptions to be accurate. CONCLUSIONS: Patients at the point of care are interested in receiving the results of their PRO measures. Plain language descriptions of PROMIS scores enhance patient understanding of PROMIS numerical scores. Patients preferred plain language and/or graphical representation rather than a numerical score alone. While PROs are commonly used for assessing outcomes in research, use at point of care is a growing interest and this study clarifies how they might be utilized in physician-patient communication.

Response to the Coronavirus Disease 2019 Pandemic by the Spine Division at a Level-I Academic Referral Center.

Coronavirus disease 2019 (COVID-19) is a ubiquitous health concern and a global pandemic. In an effort to slow the disease spread and protect valuable healthcare resources, cessation of nonessential surgery, including many orthopaedic procedures, has become commonplace. This crisis has created a unique situation in the care of spine patients as we must balance the urgency of patient evaluation, surgical intervention, and continued training against the risk of disease exposure and resource management. The spine division of an orthopaedic surgery department has taken an active role in enacting protocol changes in anticipation of COVID-19. In the initial 4 weeks of the COVID-19 pandemic the spine division went from an average of 60.4 cases to 10 cases during the same timeframe. Clinic visits decreased from 417.4 to 322 with new patient visits decreasing from 28% to 20%. Three hundred eighteen of the 322 (98.7%) clinic visits were performed via telehealth. Although these changes have been forced upon us by necessity, we feel that our division and department will emerge in a more responsive, agile, and stronger state. As we look to the coming months and beyond, it will be important to continue to adapt to the changing landscape during unprecedented times.

Hangman's Fracture.

STUDY DESIGN: Review article. OBJECTIVE: A review and update of the treatment of Hangman's fractures including the indications for both nonoperative and operative treatment of typical and atypical fractures. SUMMARY OF BACKGROUND DATA: Hangman's fractures are the second most common fracture pattern of the C2 vertebrae following odontoid fractures. Many of the stable extension type I and II fractures can be treated with external immobilization, whereas the predominant flexion type IIa and III fractures require surgical stabilization. METHODS: A review of the literature. RESULTS: The clinical and radiographic outcomes of the treatment of Hangman's fractures lend a good overall prognosis when the correct diagnosis is made. The nonoperative treatment of stable type I and II fractures with external immobilization leads to excellent long-term outcomes as does the operative treatment of the unstable type IIa and III fractures. CONCLUSIONS: Hangman's fractures can be classified as stable (type I and most II) or unstable (type IIa and III) and the optimal treatment depends upon this distinction. Stable injuries do well with rigid immobilization and rarely require operative intervention. In contrast, unstable injuries do poorly if treated nonoperatively but do well with surgical intervention. When treating atypical Hangman's variants, great vigilance and close clinical observation is paramount if nonoperative treatment is indicated given the potential for neurological compression in this fracture pattern. Properly identifying and treating these injuries represents an opportunity for the spine surgeon to optimize patient outcomes.

The Impact of Preoperative Mindfulness-Based Stress Reduction on Postoperative Outcomes in Lumbar Spine Degenerative Disease: 3-Month and 12-Month Results of a Pilot Study.

BACKGROUND: We previously reported inpatient and 30-day postoperative patient-reported outcomes (PROs) of a controlled, noncrossover pilot study using preoperative mindfulness-based stress reduction (MBSR) training for lumbar spine surgery. Our goal here was to assess 3-month and 12-month postoperative PROs of preoperative MBSR in lumbar spine surgery for degenerative disease. METHODS: Intervention group participants were prospectively enrolled in a preoperative online MBSR course. A comparison standard care only group was one-to-one matched retrospectively by age, sex, surgery type, and prescription opioid use. Three-month and 12-month postoperative PROs for pain, disability, quality of life, and opioid use were compared within and between groups. Regression models were used to assess whether MBSR use predicted outcomes. RESULTS: Twenty-four participants were included in each group. At 3 months, follow-up was 87.5% and 95.8% in the comparison and intervention groups, respectively. In the intervention group, mean Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) was significantly higher, whereas mean Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) and Oswestry Disability Index were significantly lower. The change from baseline in mean PROMIS-PF and PROMIS-PI was significantly greater than in the comparison group. At 12 months, follow-up was 58.3% and 83.3% in the comparison and intervention groups, respectively. In the intervention group, mean PROMIS-PI was significantly lower and change in mean PROMIS-PI from baseline was significantly greater. MBSR use was a significant predictor of change in PROMIS-PF at 3 months and in PROMIS-PI at 12 months. No adverse events were reported. CONCLUSIONS: Three-month and 12-month results suggest that preoperative MBSR may have pain control benefits in lumbar spine surgery.

The impact of the lordosis distribution index on failure after surgical treatment of adult spinal deformity.

BACKGROUND CONTEXT: Proximal junctional failure (PFJ) is a common and dreaded complication of adult spinal deformity. Previous research has identified parameters associated with the development of PJF and the search for radiographic and clinical variables continues in an effort to decrease the incidence of PFJ. The lordosis distribution index (LDI) is a parameter not based on pelvic incidence. Ideal values for LDI have been established in prior literature with demonstrated association with PJF. PURPOSE: The purpose of this study is compare PJF and mechanical failure rates between patients with ideal and nonideal LDI cohort. STUDY DESIGN: This is a retrospective, single-center case-controlled study. PATIENT SAMPLE: Adult patients who underwent surgical treatment for spinal deformity as defined by the SRS-Schwab criteria between 2001 and 2016 were included. Furthermore, fusion constructs spanned at least four vertebral segments with the upper instrumented vertebra (UIV) T9 or caudal. Patients who were under the age of 18, those with radiographic data less than 1 year, and those with neoplastic or trauma etiologies were excluded. Prior thoracolumbar spine surgery was not an exclusion criterion. OUTCOME MEASURES: The outcome measures were physiologic in nature: The primary outcome was defined as PFJ. The International Spine Study Group (ISSG) definition for PJF was used, which includes postoperative fracture of the UIV or UIV+1, instrumentation failure at UIV, PJA increase greater than 15° from preoperative baseline or extension of the construct needed within 6 months. Secondary outcomes included extension of the construct after 6 months or revision due to instrumentation failure, pseudarthrosis or distal junctional failure. METHODS: A portion of this project was funded through National Institute of Health Grant 5UL1TR001067-05. The authors have no conflict of interest related to this study. The records of patients meeting the inclusion criteria were reviewed. Clinical and radiographic data were extracted and analyzed. Univariate cox proportional hazard models were used to identify factors associated with mechanical failure and included in a multivariate Cox proportional hazards model. RESULTS: There were 187 patients that met the inclusion criteria. Univariate analysis demonstrated the number of levels fused, instrumentation to the sacrum or pelvis, PI-LL difference between pre- and postoperative states, T1-SPI, T9-SPI, and postoperative LDI (treated as a continuous variable). When LDI was treated as a categorical variable using an LDI cutoff of less than 0.5 for hypolordotic, 0.5 to 0.8 for aligned and greater than 0.8 for hyperlordotic, there was no difference in failure rates between the two groups. CONCLUSIONS: Lumbar lordosis is an important parameter in adult deformity. However, the LDI is an imperfect variable and previously developed categories did not show differences in failure rates in this cohort.

The Impact of Preoperative Mindfulness-Based Stress Reduction on Postoperative Patient-Reported Pain, Disability, Quality of Life, and Prescription Opioid Use in Lumbar Spine Degenerative Disease: A Pilot Study.

BACKGROUND: Prescription opioid medications negatively affect postoperative outcomes after lumbar spine surgery. Furthermore, opioid-related overdose death rates in the United States increased by 200% between 2000 and 2014. Thus, alternatives are imperative. Mindfulness-based stress reduction (MBSR), a mind-body therapy, has been associated with improved activity and mood in opioid-using patients with chronic pain. This study assessed whether preoperative MBSR is an effective adjunct to standard postoperative care in adult patients undergoing lumbar spine surgery for degenerative disease. METHODS: The intervention group underwent a preoperative online MBSR course. The comparison group was matched retrospectively in a 1:1 ratio by age, sex, type of surgery, and preoperative opioid use. Prescription opioid use during hospital admission and at 30 days postoperatively were compared with preoperative use. Thirty-day postoperative patient-reported outcomes for pain, disability, and quality of life were compared with preoperative patient-reported outcomes. Dose-response effect of mindfulness courses was assessed using Mindful Attention Awareness Scale scores. RESULTS: In this pilot study, 24 participants were included in each group. Most intervention patients (70.83%) completed 1 session, and the mean Mindful Attention Awareness Scale score was 4.28 ± 0.71 during hospital admission. At 30 days, mean visual analog scale back pain score was lower in the intervention group (P = 0.004) but other patient-reported outcomes did not differ. CONCLUSIONS: During hospital admission, no significant dose-response effect of mindfulness techniques was found. At 30 days postoperatively, MBSR use was associated with less back pain. Further research is needed to assess the effectiveness of preoperative MBSR on postoperative outcomes in lumbar spine surgery for degenerative disease.

Perioperative Effects Associated With the Surgical Treatment of Degenerative Spondylolisthesis: Interbody Versus No Interbody.

STUDY DESIGN: This is a retrospective analysis. OBJECTIVE: The purpose of this study was to compare the clinical, radiographic, and perioperative complication profiles of performing an interbody and posterior arthrodesis (CAGE) versus posterolateral lumbar fusion (PLF) alone in patients undergoing surgery for degenerative spondylolisthesis (DS). SUMMARY OF BACKGROUND DATA: DS is a common disorder that, failing nonoperative treatment, may be managed with surgical decompression and concomitant posterior arthrodesis. At present, the risk/benefit ratio of including an additional interbody arthrodesis has not been clearly delineated in the literature. MATERIALS AND METHODS: We reviewed 174 consecutive patients (118 female and 56 male) diagnosed with single-level DS that met the inclusion/exclusion criteria, from January 1, 2000 to August 1, 2011. Clinical outcomes, fusion rates, radiographic outcomes, and complication profiles were recorded. RESULTS: We identified 174 patients who received a single-level lumbar interbody fusion with posterolateral fusion (CAGE, n=89) or posterolateral fusion alone (PLF, n=85). No difference in patient-reported outcomes or fusion rate was detected between the 2 groups. We did identify better segmental lordosis increase (4.9±3.2 vs. 0.9±1.9 degrees; P=0.001) and interdiscal height change (2.1±2.4 vs. 0.6±1.6 mm) in the CAGE group. Operative time, 199.8±36.6 versus 142.6±28.5 minutes (P<0.001); blood loss, 355±216.4 versus 269±28.5 mL (P<0.001); and postoperative radiculitis, 28.9% versus 7.0% (P=0.003) were worse in the CAGE group compared with the PLF group. CONCLUSIONS: The ideal surgical approach when treating patients with DS remains in question. This study suggests, when comparing PLF with or without additional interbody fusion, that the lack of clinical or fusion-related benefit may not justify the higher risk profile including longer surgery, higher blood loss, and increased risk of postoperative radiculitis. Long-term prospective studies are required to further clarify these findings. LEVEL OF EVIDENCE: Level III.

Surgical Site Infections in Spine Surgery: Preoperative Prevention Strategies to Minimize Risk.

STUDY DESIGN: Literature review. OBJECTIVES: A review of the literature identifying preoperative risk factors for developing surgical site infections after spine surgery and discussion of the preventive strategies to minimize risks. METHODS: A review of the literature and synthesis of the data to provide an updated review on the preoperative management of surgical site infection. RESULTS: Preoperative prevention strategies of reducing surgical site infections in spine surgery remains a challenging problem. Careful mitigation of modifiable patient comorbidities, blood glucose control, smoking, obesity, and screening for pathologic microorganisms is paramount to reduce this risk. Individualized antibiotic regimens, skin preparation, and hand hygiene also play a critical role in surgical site infection prevention. CONCLUSIONS: This review of the literature discusses the preoperative preventive strategies and risk management techniques of surgical site infections in spine surgery. Significant decreases in surgical site infections after spine surgery have been noted over the past decade due to increased awareness and implementation of the prevention strategies described in this article. However, it is important to recognize that prevention of surgical site infection requires a system-wide approach that includes the hospital system, the surgeon, and the patient. Continued efforts should focus on system-wide implementation programs including careful patient selection, individualized antibiotic treatment algorithms, identification of pathologic organisms, and preoperative decolonization programs to further prevent surgical site infections and optimize patient outcomes.

Failure of facet replacement system with metal-on-metal bearing surface and subsequent discovery of cobalt allergy: report of 2 cases.

The aim of this study was to report on 2 patients in whom metal-on-metal (MOM) facet replacements failed, with subsequent positive findings on allergy testing. Motion-preserving devices have been used with limited success when instrumentation is indicated in the mobile spine. MOM-bearing surfaces in orthopedics were developed to increase implant longevity, yet have been associated with numerous adverse outcomes, including local tissue reactions, pseudotumors, metallosis, and the need for revision surgery. Five patients with spinal stenosis and low-grade spondylolisthesis were randomized to undergo facet replacement surgery with the ACADIA facet replacement system at the authors' institution. Two patients experienced a return of neurological symptoms after a pain-free interval (< 2 years) with development of local tissue reaction and positive findings on allergy testing to cobalt, the metal in the MOM-bearing surface. Both patients underwent successful removal of the implant and revision to titanium posterior spinal fusion and interbody fusion without further complication. Motion-preserving devices have been designed and trialed for specific indications in the mobile spine. Given the adverse results from MOM devices in hip arthroplasty and now the early reports with MOM facet replacements, caution is warranted when moving forward with any MOM joint-bearing surface. Both patients presented here had an unusual tissue reaction locally and subsequent positive allergy testing results to cobalt. These 2 patients appear to have developed a delayed hypersensitivity reaction to the metal, likely from fine debris at the MOM interface.

Prevention of Surgical Site Infection in Spine Surgery.

BACKGROUND: Spine surgery is complicated by an incidence of 1% to 9% of surgical site infection (SSI). The most common organisms are gram-positive bacteria and are endogenous, that is are brought to the hospital by the patient. Efforts to improve safety have been focused on reducing SSI using a bundle approach. The bundle approach applies many quality improvement efforts and has been shown to reduce SSI in other surgical procedures. OBJECTIVE: To provide a narrative review of practical solutions to reduce SSI in spine surgery. METHODS: Literature review and synthesis to identify methods that can be used to prevent SSI. RESULTS: SSI prevention starts with proper patient selection and optimization of medical conditions, particularly reducing smoking and glycemic control. Screening for staphylococcus organisms and subsequent decolonization is a promising method to reduce endogenous bacterial burden. Preoperative warming of patients and timely administration of antibiotics are critical to prevent SSI. Skin preparation using chlorhexidine and alcohol solutions are recommended. Meticulous surgical technique and maintenance of sterile techniques should always be performed. Postoperatively, traditional methods of tissue oxygenation and glycemic control remain essential. Newer wound care methods such as silver impregnation dressing and wound-assisted vacuum dressing are encouraging but need further investigation. CONCLUSION: Significant reduction of SSIs is possible, but requires a systems approach involving all stakeholders. There are many simple and low-cost components that can be adjusted to reduce SSIs. Systematic efforts including understanding of pathophysiology, prevention strategies, and system-wide quality improvement programs demonstrate significant reduction of SSI.

Fenestrated Screws Augmented With PMMA Increase the Pullout Strength of Sacral Pedicle Screws.

STUDY DESIGN: Biomechanics. OBJECTIVE: The objective of this study was to compare the fixation in osteoporotic specimens of a bicortical sacral pedicle screw to the following constructs: a unicortical solid screw augmented with polymethylmethacrylate (PMMA) (TRACT), a unicortical fenestrated screw augmented with PMMA (FEN), and a bicortical screw/sacral alar screw combination (PED/ALA). SUMMARY OF BACKGROUND DATA: Rigid posterior sacral fixation of osteoporotic spines is problematic due to poor bone quality. Options to improve fixation include bicortical or tricortical screw trajectory, addition of S2 alar screws, or PMMA augmentation. MATERIALS AND METHODS: Eleven osteoporotic cadaveric sacra were potted in 2-part filler compound. As a baseline fixation method, a 6.5-mm bicortical pedicle screw was placed into 1 pedicle of each sacra. The contralateral side was randomly assigned to receive a unicortical fenestrated 6.5-mm pedicle screw augmented with PMMA, a unicortical solid 6.5-mm pedicle screw augmented with PMMA, or a bicortical pedicle screw/alar screw construct. Pedicle screws were failed in cantilever pullout using a materials testing machine. Data were normalized into a test index by taking the ratio of the test screw pullout strength to the intraspecimen bicortical control screw pullout strength. RESULTS: The fixation strengths as expressed by the test index of the TRACT, FEN, and PED/ALA groups were 101%, 157%, and 167%, respectively. Although there was no statistical difference detected between the FEN and PED/ALA groups, the TRACT group had a trend toward lower pullout strength than the FEN (P=0.06) or PED/ALA (0.06) groups. Although underpowered, this study did not detect biomechanical inferiority for any of the 3 test configurations when compared with standard bicortical S1 screws. CONCLUSIONS: The data indicate that the fixation strength of a fenestrated, PMMA-augmented construct or a combined S1 pedicle/S2 alar screw construct may be better than either standard bicortical or unicortical PMMA screw-tract augmented screws.

Oswestry Disability Index: a psychometric analysis with 1,610 patients.

BACKGROUND: One-fourth of the adult US population has or will experience back pain and has undergone one of a myriad of treatments. Understanding the outcomes of these many treatments from pharmacologic to surgical, from manipulation to modality, allows for a better understanding and value-driven decision making. Patient-reported outcome measures are the current standard and include general and disease-specific measures. The Oswestry Disability Index (ODI) is the most commonly used disease-specific patient-reported outcome tool to measure functional disability related to back pain. Few studies have evaluated its psychometric properties in a large patient sample using a modern tool such as the Rasch analysis model. This study aims to identify the benefits and deficiencies of the ODI as an outcome tool for assessing patients with back pain. PURPOSE: This study aimed to investigate the psychometric properties, performance, and applicability of the ODI in patients with back pain who visited a university-based outpatient clinic. STUDY DESIGN: This study used a secondary analysis-assessment of diagnostic tool on consecutive patients. PATIENT SAMPLE: The sample comprised 1,610 patients visiting an academic spine center. OUTCOME MEASURES: The ODI was the outcome measure. METHODS: Detailed Rasch analysis of the ODI was performed. Standard descriptive statistics were also assessed. RESULTS: The ODI performed well overall. It demonstrated suboptimal unidimensionality (ie, unexplained variance after accounting for the first dimension) of 8.3%. Person reliability was good, at 0.85, and item reliability was excellent, at 1.00. The overall item fit for the ODI was good with an outfit mean square of 1.02. The ODI had a floor effect of 29.9% and ceiling effect of 3.9%. The raw score to measure correlation of the ODI was excellent, at 0.944. CONCLUSIONS: The ODI performed relatively well overall, with some problematic findings. It had good person and item reliability, although it did not demonstrate strong evidence of unidimensionality. The ODI has moderately poor coverage, with a very large floor effect and small ceiling effect, which could present a challenge in interpreting results of scores at the end of the spectrum.

Patient Satisfaction is Not Associated With Self-reported Disability in a Spine Patient Population.

STUDY DESIGN: This is a retrospective review. OBJECTIVE: To evaluate the relationship between patient functional status and self-assessment of disability as measured by 3 commonly used clinical assessment instruments-the Oswestry Disability Index (ODI), the Neck Disability Index (NDI), and the EuroQol (EQ)-5D and patient satisfaction scores in a spine surgery clinic population. SUMMARY OF BACKGROUND DATA: Patient satisfaction surveys, which measure the "patient experience of care" are becoming an increasingly important measure of the quality of medical care. Despite the widespread use of patient satisfaction surveys, little is known about the relationship between patient satisfaction and patient functional status or self-assessed level of disability. MATERIALS AND METHODS: We retrospectively reviewed records of 231 consecutive patients presenting to a single academic spine surgery center between February 2011 and October 2013 who completed both a patient satisfaction survey as well as one or more patient-reported outcome questionnaires (NDI, ODI, and/or EQ-5D) for a single clinical encounter. Statistical analysis was performed to determine if an association exists between the overall patient satisfaction score and each patient-reported outcome score. RESULTS: Spearman correlation coefficients demonstrated no correlation between any patient-reported outcome score and the patient satisfaction score [NDI=-0.113 (-0.409 to 0.207) P=0.489] [ODI=-0.008 (-0.149 to 0.133) P=0.912] [EQ-5D=0.011 (-0.119 to 0.140) P=0.872] for a single clinical encounter. CONCLUSIONS: These results provide evidence against an association between patient-reported functional status or self-assessed level of disability and patient satisfaction in a spine patient population.

PROMIS PF CAT Outperforms the ODI and SF-36 Physical Function Domain in Spine Patients.

STUDY DESIGN: The Oswestry Disability Index v2.0 (ODI), SF36 Physical Function Domain (SF-36 PFD), and PROMIS Physical Function CAT v1.2 (PF CAT) questionnaires were prospectively collected from 1607 patients complaining of back or leg pain, visiting a university-based spine clinic. All questionnaires were collected electronically, using a tablet computer. OBJECTIVE: The aim of this study was to compare the psychometric properties of the PROMIS PF CAT with the ODI and SF36 Physical Function Domain in the same patient population. SUMMARY OF BACKGROUND DATA: Evidence-based decision-making is improved by using high-quality patient-reported outcomes measures. Prior studies have revealed the shortcomings of the ODI and SF36, commonly used in spine patients. The PROMIS Network has developed measures with excellent psychometric properties. The Physical Function domain, delivered by Computerized Adaptive Testing (PF CAT), performs well in the spine patient population, though to-date direct comparisons with common measures have not been performed. METHODS: Standard Rasch analysis was performed to directly compare the psychometrics of the PF CAT, ODI, and SF36 PFD. Spearman correlations were computed to examine the correlations of the three instruments. Time required for administration was also recorded. RESULTS: One thousand six hundred seven patients were administered all assessments. The time required to answer all items in the PF CAT, ODI, and SF-36 PFD was 44, 169, and 99 seconds. The ceiling and floor effects were excellent for the PF CAT (0.81%, 3.86%), while the ceiling effects were marginal and floor effects quite poor for the ODI (6.91% and 44.24%) and SF-36 PFD (5.97% and 23.65%). All instruments significantly correlated with each other. CONCLUSION: The PROMIS PF CAT outperforms the ODI and SF-36 PFD in the spine patient population and is highly correlated. It has better coverage, while taking less time to administer with fewer questions to answer. LEVEL OF EVIDENCE: 2.

Perioperative Complications of Pedicle Subtraction Osteotomy.

Study Design Retrospective case series. Objective To describe the perioperative complications (0 to 90 days) associated with pedicle subtraction osteotomies (PSOs) performed at a tertiary spine center by two experienced spine surgeons who recently adopted the technique. Methods We reviewed all 65 patients (47 women and 18 men; mean age 60 years, range 24 to 80) who underwent a PSO at our institution. Descriptive data and analysis of complications were limited to the perioperative time (within 90 days of surgery). Data analyzed included operative time, length of stay (LOS), estimated blood loss (EBL), blood products, comorbidities, neurologic complications, and medical complications. Complications were rated as major and minor. Radiographic data was also analyzed. Results Ten patients (15.4%) had a major complication, and 15 (23%) had a minor complication. There were three perioperative deaths. The most common major complication was neurologic deficit (6.2%, 4/65), three with a permanent foot drop, and one with paraplegia secondary to postoperative hematoma. There were no differences between patients with and without a major complication in regard to age, gender, comorbidities, operative time, number of levels fused, and EBL (p > 0.05). Patients with a major complication had a longer intensive care unit stay (p = 0.04). There was no difference in the rate of major complications between the initial and later cases performed. Conclusion The major complication rate for pedicle subtraction osteotomy was 15% and the minor complication rate was 23%. The most common major complication was neurologic deficit in 6.2%. The complication rate did not change with increased surgeon experience.

Fixed-Angle, Posteriorly Connected Anterior Cage Reconstruction Improves Stiffness and Decreases Cancellous Subsidence in a Spondylectomy Model.

STUDY DESIGN: An idealized biomechanical model. OBJECTIVE: The aim of this study was to evaluate the biomechanical properties of a construct designed to minimize intervertebral cage subsidence and maximize stiffness. SUMMARY OF BACKGROUND DATA: Reconstruction after vertebral resection typically involves posterior segmental fixation and anterior interbody support. However, poor bone density, adjuvant radiation, or the oncologic need for endplate resection make interbody device subsidence and resultant instrumentation failure a significant concern. METHODS: An idealized thoracolumbar spondylectomy reconstruction model was constructed using titanium segmental instrumentation and Delrin plastic. In vivo mechanical stress was simulated on a custom multi-axis spine simulator. Rigid body position in space was measured using an optical motion-capture system. Cancellous subsidence was modeled using a 1 cm thick wafer of number 3 closed-cell Sawbones foam at one endplate. Ten foam specimens were tested in a control state consisting of posterior segmental fixation with a free interbody cage. Ten additional foam specimens were tested in the test state, with the Delrin interbody cage "connected" to the posterior rods using two additional pedicle screws placed into the cage. Foam indentation was quantified using a precision digital surface-mapping device, and subsidence volume calculated using geometric integration. RESULTS: The control group exhibited significantly greater foam indentation after cycling, with a mean subsidence volume of 1906 mm [95% confidence interval (95% CI) 1810-2001] than the connected cage group subsidence volume of 977 mm (95% CI 928-1026 mm; P < 0.001]. Construct stiffness was greater in the connected cage group (3.1 Nm/degree, 95% CI 3.1-3.2) than in the control group (2.3 Nm/degree, 95% CI 2.2-2.4; P < 0.001). CONCLUSION: In an idealized spondylectomy model, connecting the anterior column cage to the posterior instrumentation using additional pedicle screws results in a construct that is nearly 40% stiffer and exhibits 50% less cancellous subsidence compared with a traditional unconnected cage. LEVEL OF EVIDENCE: N/A.

Excision of the Posterior Longitudinal Ligament During Anterior Cervical Corpectomy: A Biomechanical Study.

STUDY DESIGN: An in vitro biomechanical study of the cervical spine. OBJECTIVE: To evaluate the biomechanical significance of the posterior longitudinal ligament (PLL) after anterior cervical corpectomy and reconstruction with a strut graft and anterior plate. SUMMARY OF BACKGROUND DATA: Routine excision of the PLL during anterior cervical corpectomy is controversial. Many surgeons believe that maintaining the PLL after cervical corpectomy adds stability to the reconstruction, whereas others believe it can be excised without sequelae. There are no biomechanical studies to our knowledge evaluating the biomechanical significance of excising the PLL during corpectomy and whether this affects the stability of a reconstruction consisting of a strut graft and anterior plate. The purpose of this study was to evaluate the biomechanical effects of PLL excision during a complete anterior cervical corpectomy reconstructed with a strut graft and anterior plate. METHODS: Seven human cadaveric fresh-frozen cervical spines C2-T1 were tested for range of motion before surgery and reconstruction. A complete C6 corpectomy was performed and an interbody strut spacer with load cell was placed along with an anterior plate. Range of motion was measured with ±2.5 Nm of torque in flexion-extension, lateral bending, and axial rotation. Load-sharing data were recorded with incremental axial loads. The PLL was excised and range of motion and load-sharing testing was repeated. RESULTS: There were no significant differences in range of motion or load sharing with an anterior corpectomy and reconstruction after PLL excision. CONCLUSIONS: Excision of the PLL during anterior cervical corpectomy reconstructed with a strut graft and anterior plate does not significantly affect the construct stability or load sharing of the graft.