Dual- Versus Single-Plate Fixation of Clavicle Fractures: Understanding the Rationale Behind both Approaches.

Clavicle fractures are a common injury resulting from a high-energy force, such as a fall onto the shoulder, motor vehicle accident, or sporting activity. Although some clavicle fractures may be treated nonoperatively, operative treatment results in higher union rates and faster return to activity. Here we discuss the operative treatment options for plating of clavicle fractures; specifically, a single plate placed either superiorly or anteriorly or two plates placed orthogonally. Because both techniques provide adequate stability, fracture and patient characteristics should guide the surgical decision making regarding single versus dual plating of clavicle fractures.

Preventing Tommy John Surgery: The Identification of Trends in Pitch Selection, Velocity, and Spin Rate Before Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction is a common surgery among Major League Baseball (MLB) pitchers that results in a significant number of missed games. Little has been reported regarding game-by-game trends that can identify those on the verge of becoming injured. PURPOSE: To determine if there is a patterned change in MLB pitchers' pitch selection, velocity, or spin rate in games leading up to Tommy John surgery that may predict subsequent UCL surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of MLB pitchers who underwent primary UCL reconstruction between 2009 and 2019 was performed. Pitch characteristics were evaluated on a game-by-game basis for the 15 games leading up to surgery. A Mann-Kendall trend test was used to identify trends in pitch selection, velocity, and spin rate for multiple pitch types. A Kendall τb correlation coefficient was identified, with values closer to 1 or -1 signifying a stronger monotonic trend. RESULTS: A total of 223 MLB pitchers underwent UCL reconstruction in the time period. In the 15 games leading up to surgery, decreases in pitch velocity for 4-seam fastballs (τb = -0.657; P < .001), 2-seam fastballs (τb = -0.429; P = .029), and sliders (τb = -0.524; P = .008) were significantly associated with game number closer to injury. There was a significant positive association in the spin rate for cutters (τb = 0.410; P = .038) and a significant negative association in spin rate for 4-seam fastballs over the course of these 15 games (τb = -0.581; P = .003). In addition, there was a significant positive association in the percentage of curveballs thrown (τb = 0.486; P = .013). CONCLUSION: The study results suggest that there is a patterned change in certain pitch statistics in MLB pitchers in the games leading up to Tommy John surgery. Although the absolute change from game to game may be small, it may be possible for these trends to be monitored before a player becomes injured, thus reducing the significant burden Tommy John surgery places on these athletes.

Is There an Association Between Authors' Conflicts of Interest and Outcomes in Clinical Studies Involving Autologous Chondrocyte Implantation?

BACKGROUND: Autologous chondrocyte implantation (ACI) is an increasingly popular technique for the treatment of articular cartilage defects. Because several companies have financial interests in ACI, it is important to consider possible conflicts of interest when evaluating studies reporting outcomes of ACI. PURPOSE: To determine whether there is an association between authors' financial conflicts of interest and the outcomes of ACI studies. STUDY DESIGN: Cross-sectional study. METHODS: A search of PubMed and MEDLINE databases for "autologous chondrocyte implantation" was performed. Clinical studies published after 2012 through May 15, 2019, and in English were included. Studies were determined to have financial conflicts of interest if any contributing author had relevant conflicts, either self-reported in the published study's disclosures section or reported online in the American Academy of Orthopaedic Surgeons Disclosure database or the Centers for Medicare & Medicaid Services Open Payments database. The outcomes of each study were rated as favorable, equivocal, or unfavorable based on predefined criteria and then tested for association with conflicts of interest through use of the Fisher exact test. RESULTS: A total of 79 studies met the inclusion criteria. Nearly all studies were of level 3 or 4 evidence. Conflicts of interest were established in 51.90% of studies (n = 41). Conflicts that were not self-reported by the authors were discovered in 18% of studies. The level of evidence was not associated with conflict of interest. No statistically significant difference was found in the rate of favorable outcomes between studies with conflicts (92.68%) and those with no conflicts (81.58%) (P = .126). Publications by US authors were more likely to have financial conflicts of interest (P = .003). CONCLUSION: Favorable results were reported in a majority of studies involving ACI. No statistical association was found between the frequency of favorable outcomes and the presence of financial conflicts of interest, country of authorship, or level of evidence. There was a trend toward more favorable outcomes in studies with conflicts of interest. Additionally, nearly 20% of publications had possible conflicts found online that were not self-reported. It is critical for orthopaedic surgeons to judiciously evaluate published studies and consider financial conflicts of interest before performing ACI techniques on patients.

Improvements in Back and Leg Pain Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Improvement in patient-reported outcomes after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is poorly defined. As such, the purpose of this study was to quantify improvements in Visual Analogue Scale back and leg pain, Oswestry Disability Index (ODI), and Short Form-12 (SF-12) Mental and Physical Composite scores following MIS-TLIF. METHODS: A surgical registry of patients who underwent primary 1-level MIS-TLIF during 2014-2015 was reviewed. Comparisons of Visual Analogue Scale back and leg pain, ODI, and Short Form-12 Mental and Physical Composite scores were performed using paired t tests from preoperative to each postoperative time point. Analysis of variance was used to estimate the degree of improvement in back and leg pain over the first postoperative year. Subgroup analysis was performed for patients presenting with predominant back (pBP) or leg (pLP) pain. Multivariate linear regression was performed to compare patient-reported outcome scores by subgroup. RESULTS: A total of 106 patients were identified. Visual Analogue Scale back and leg scores, and ODI improved from preoperative scores at all postoperative time points (P < .05 for each). Patients with pBP (n = 68) and patients with pLP (n = 38) reported reductions in both back and leg pain over the first postoperative year (P < .05 for each). In the pBP cohort, patients experienced significant reductions in ODI after the first 6 postoperative weeks (P < .05 for each). In the pLP cohort, patients experienced significant reductions in ODI throughout the first postoperative year (P < .05 for each). Patients with pLP and pBP experienced similar reductions in back pain, whereas patients with pLP experienced significantly greater reductions in leg pain at all postoperative time points (P < .05 for each). CONCLUSIONS: The current study suggests patients experience significant improvements in back and leg pain following MIS-TLIF regardless of predominant symptom. CLINICAL RELEVANCE: These results can assist surgeons when counseling their patients on the magnitude of symptom improvement they may experience following MIS-TLIF.

A Review of Vitamin D in Spinal Surgery: Deficiency Screening, Treatment, and Outcomes.

In this review, we discuss the demonstrated value of vitamin D in bone maintenance, fracture resistance, spinal health, and spine surgery outcomes. Despite this, the effect of vitamin D levels in spine surgery has not been well described. Through this review of literature, several conclusions were drawn. First, despite the fact that a high number of spine surgery patients are vitamin D deficient, screening is not commonly performed. Second, adequate vitamin D levels will not be achieved in a majority of these patients without supplementation. Last, inadequate vitamin D levels may increase the risk of pseudarthrosis. Given these findings, we suggest that many patients undergoing spinal surgery could be treated with vitamin D supplementation prior to surgery without the need for confirmatory testing for vitamin D deficiency. This is a more cost-effective method than screening all patients. However, future randomized trials and cost-effectiveness analyses are needed to determine the ultimate effects of vitamin D supplementation on clinical morbidity and surgical outcomes.

Etiology-Based Classification of Adjacent Segment Disease Following Lumbar Spine Fusion.

BACKGROUND: Adjacent segment disease (ASDz) is a potential complication following lumbar spinal fusion. A common nomenclature based on etiology and ASDz type does not exist and is needed to assist with clinical prognostication, decision making, and management. QUESTIONS/PURPOSES: The objective of this study was to develop an etiology-based classification system for ASDz following lumbar fusion. METHODS: We conducted a retrospective chart review of 65 consecutive patients who had undergone both a lumbar fusion performed by a single surgeon and a subsequent procedure for ASDz. We established an etiology-based classification system for lumbar ASDz with the following six categories: "degenerative" (degenerative disc disease or spondylosis), "neurologic" (disc herniation, stenosis), "instability" (spondylolisthesis, rotatory subluxation), "deformity" (scoliosis, kyphosis), "complex" (fracture, infection), or "combined." Based on this scheme, we determined the rate of ASDz in each etiologic category. RESULTS: Of the 65 patients, 27 (41.5%) underwent surgery for neurogenic claudication or radiculopathy for adjacent-level stenosis or disc herniation and were classified as "neurologic." Ten patients (15.4%) had progressive degenerative disc pathology at the adjacent level and were classified as "degenerative." Ten patients (15.4%) had spondylolisthesis or instability and were classified as "instability," and three patients (4.6%) required revision surgery for adjacent-level kyphosis or scoliosis and were classified as "deformity." Fifteen patients (23.1%) had multiple diagnoses that included a combination of categories and were classified as "combined." CONCLUSION: This is the first study to propose an etiology-based classification scheme of ASDz following lumbar spine fusion. This simple classification system may allow for the grouping and standardization of patients with similar pathologies and thus for more specific pre-operative diagnoses, personalized treatments, and improved outcome analyses.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Grade I Versus Grade II Isthmic Spondylolisthesis.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is often used to treat low-grade isthmic spondylolisthesis (IS). No studies have compared surgical outcomes for grade I and II IS following MIS-TLIF. Therefore, the objective of the current study was to compare outcomes between patients with grade I and II IS following MIS-TLIF. METHODS: A retrospective cohort analysis was performed on a prospectively maintained database of patients who underwent a primary 1-level MIS-TLIF for treatment of IS between 2007 and 2015. Grade I patients underwent a unilateral tubular approach with a single interbody cage and bilateral pedicle screw instrumentation. Grade II patients underwent a bilateral tubular approach with bilateral interbody cage and pedicle screw placement. Baseline patient demographics and characteristics were compared using Student t test and χ2 analysis. Differences in peri- and postoperative outcomes were assessed using Poisson regression with robust error variance or linear regression adjusted for perioperative variables. RESULTS: A total of 58 patients with IS underwent MIS-TLIF; 21 (36.2%) were grade I and 37 (63.8%) were grade II. The grade I cohort was younger (42.2 versus 50.6 years, P = .029); no other differences in preoperative variables were observed. No significant differences in operative time, estimated blood loss, length of hospital stay, postoperative visual analogue scale scores, or complication and revision rates were demonstrated between cohorts. Arthrodesis rate was lower in the grade I cohort, though not statistically significant. CONCLUSIONS: Despite the grade I cohort being younger with less-severe diagnoses, the grade II cohort experienced similar outcomes. This finding may be due to the grade II cohort receiving bilateral cages, potentially providing a better fusion environment. CLINICAL RELEVANCE: These results suggest that MIS-TLIF provides sufficient stabilization and fusion for treatment of grade II IS despite increased vertebral body displacement. In addition, MIS-TLIF with bilateral approach and interbody cage placement should be examined for treatment of high-grade IS cases.

Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Isthmic Versus Degenerative Spondylolisthesis.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is a common surgical procedure for treatment of degenerative spondylolisthesis (DS) but remains controversial for treatment of isthmic spondylolisthesis (IS). Few studies have compared IS and DS outcomes after MIS TLIF. Therefore, the objective of the current study was to compare outcomes of patients with IS and DS after MIS TLIF. METHODS: A retrospective cohort analysis was performed on a prospectively maintained database of patients who underwent a primary, 1-level MIS TLIF for grade I or II IS or DS. Grade I and II DS and grade I IS patients were treated with MIS TLIF via a unilateral tubular approach, whereas the grade II IS patients were treated via a bilateral tubular approach. Differences in patient demographics and preoperative characteristics were assessed using independent sample t tests and χ2 tests. The type of spondylolisthesis and its effect on postoperative outcomes was analyzed using Poisson regression with robust error variance (binary outcomes) or linear regression (continuous outcomes) adjusted for preoperative characteristics. Subgroup analysis comparing grade I IS versus DS and grade II IS versus DS was performed. RESULTS: A total of 223 patients were included (IS: 62 [27.8%]; DS: 161 [72.2%]). IS patients were younger (P < .001), had a lower comorbidity burden (P < .001), and a greater incidence of grade II spondylolisthesis (P < .001) at L5-S1 (P < .001) than the DS cohort. Patients with IS experienced longer operative times (P < .001) and lower, but not statistically significant, arthrodesis rates compared to the DS cohort. No differences were observed in the remaining preoperative patient characteristics, perioperative or postoperative outcomes. CONCLUSIONS: Despite being younger and having a lower comorbidity burden than the DS cohort, similar outcomes were observed after MIS TLIF for IS patients. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: These results suggest MIS TLIF is an appropriate treatment option for IS patients despite the increased instability inherent with IS.

Preoperative Mental Health May Not Be Predictive of Improvements in Patient-Reported Outcomes Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Prior literature has associated poor preoperative mental health with inferior patient-reported outcomes (PROs) after spinal procedures. Therefore, the objective of this study was to test for association of preoperative Short Form 12 (SF-12) mental health composite score (MCS) with improvements in Oswestry Disability Index (ODI) and back and leg visual analogue scale (VAS) pain scores after a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). METHODS: A surgical database of patients who underwent a primary, 1 level MIS TLIF was reviewed. Preoperative SF-12 MCS was tested for association with preoperative ODI, back VAS, and leg VAS. Preoperative MCS was then tested for association with changes in ODI, back VAS, and leg VAS from preoperative to postoperative visits. These tests were conducted using multivariate regression controlling for baseline characteristics and the preoperative score of the PRO being assessed. RESULTS: A total of 113 patients were included in the analysis. At baseline, higher preoperative MCS was associated with lower preoperative ODI (coefficient: -0.58, P < .001), lower preoperative back VAS (-0.05, P = .003), and lower preoperative leg VAS (-0.06, P = .003). However, there was no association between preoperative MCS and improvement in PROs at any postoperative timepoint (P > .05). The percent of patients achieving a minimum clinically important difference in PROs at 6 months did not differ between the bottom and top MCS halves (P > .05). CONCLUSIONS: The results of this study suggest that better preoperative mental health is associated with lower perceived preoperative disability and decreased severity of back and leg pain. In contrast to other studies, the present study was unable to demonstrate that preoperative mental health is predictive of improvement in PROs at any postoperative timepoint after MIS TLIF. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: These results suggest that surgeons should exercise care in assuming that patients with poorer preoperative mental health are inferior surgical candidates.

Improvements in Back and Leg Pain After Minimally Invasive Lumbar Decompression.

BACKGROUND: Few studies have quantified clinical improvement following minimally invasive lumbar decompression based on predominant back pain or leg pain. PURPOSE: To quantify improvement in patient-reported outcomes following minimally invasive lumbar decompression and determine the degree of improvement in back pain, leg pain, and disability in patients who present with predominant back pain or predominant leg pain. METHODS: Patients who underwent primary, one-level minimally invasive lumbar decompression for degenerative pathology were retrospectively reviewed. Comparisons of visual analog scale (VAS) back and leg pain scores, Oswestry Disability Index (ODI) scores, and Short Form-12 (SF-12) mental and physical component scores from pre-operative to 6-week, 12-week, 6-month, and 1-year follow-up. Subgroup analyses were performed for patients with predominant back pain or predominant leg pain. RESULTS: A total of 102 patients were identified. Scores on VAS back and leg pain, ODI, and SF-12 physical component improved from pre-operative to all post-operative time points. After 1 year, patients reported a 2.8-point (47%) reduction in back pain and a 4-point (61.1%) reduction in leg pain scores; 52 patients with predominant back pain and 50 patients with predominant leg pain reported reductions in pain throughout the year following surgery. In both the back and leg pain cohorts, patients experienced reductions in ODI during the first 6 months and throughout 1-year follow-up, respectively. The majority of patients achieved minimum clinically important difference, regardless of predominant symptom. CONCLUSIONS: Patients reported improvements in back and leg pain following minimally invasive lumbar decompression regardless of predominant presenting symptom; however, patients with predominant leg pain may experience greater improvement than those with predominant back pain.

The identification of risk factors for increased postoperative pain following minimally invasive transforaminal lumbar interbody fusion.

PURPOSE: To evaluate specific demographic and perioperative variables associated with higher inpatient pain scores following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). METHODS: Patients who underwent a single-level, primary MIS TLIF were retrospectively reviewed. Perioperative outcomes were collected, and postoperative inpatient VAS pain scores were measured. Both bivariate and stepwise multivariate Poisson regressions with robust error variance were used to assess risk factors for average inpatient pain score ≥ 5.0. A final backward stepwise regression model was created using age, gender, smoking status, diabetes status, insurance status, BMI, comorbidity burden, pedicle screw laterality, operative time, and estimated blood loss. RESULTS: A total of 255 patients undergoing primary, single-level MIS TLIF were included. Age less than 50 years, workers' compensation insurance, preoperative VAS pain score ≥ 7, and operative duration ≥ 110 min were associated with greater postoperative pain. However, other variables such as gender, BMI, smoking status, comorbidity burden, diabetes status, and pedicle screw laterality were not associated with increased postoperative pain. CONCLUSION: The results of this study suggest that younger age, workers' compensation, elevated preoperative pain scores, and longer operative times are independently associated with greater inpatient pain following TLIF. Surgeons can use this information to better assess which patients may require additional pain control following TLIF. Patient expectations of postoperative outcomes in regard to pain and recovery may also be better managed. These slides can be retrieved under Electronic Supplementary Material. (paragraph). Then process the ppt slide as graphical image.

Rigid-Plating and Cortico-Cancellous Allograft Are Effective for 3-Level Anterior Cervical Discectomy and Fusion: Radiographic and Clinical Outcomes.

OBJECTIVE: To determine the risk factors associated with radiographic changes and clinical outcomes following 3-level anterior cervical discectomy and fusion (ACDF) using rigidplate constructs and cortico-cancellous allograft. ACDF has demonstrated efficacy for treatment of multilevel degenerative cervical conditions, but current data exists in small heterogeneous forms. METHODS: A retrospective review included 98 patients with primary 3-level ACDF surgery at one institution from 2008 to 2013 with minimum 1-year follow-up. Cervical sagittal vertical axis (SVA), segmental height, fusion, and lordosis radiographs were measured preoperatively and at 2 postoperative periods. RESULTS: Rates of asymptomatic pseudarthroses and total reoperations were 18% and 4%, respectively. Results demonstrated immediate improvements in cervical lordosis (5.5°, p < 0.01) and segmental height (5.0-mm increase, p < 0.01) with little changes in the cervical SVA (3.2-mm increase, p < 0.01). The segmental height decreased from immediate postoperative period to final follow-up (1.7-mm decrease, p < 0.01). Older age was protective against radiolucent lines (p < 0.05). Patient-reported outcomes significantly improved following surgery (p < 0.01). Current smoking status and diagnosis of diabetes mellitus had no impact on radiographic or clinical outcomes. Risk factors were not identified for the 5 reoperations (4%). CONCLUSION: Three-level ACDF with rigid-plating and cortico-cancellous allograft is an effective procedure for degenerative diseases of the cervical spine without the application of additional adjuncts or combined anteriorposterior cervical surgeries. Significant improvements in cervical lordosis, segmental height, and segmental alignment can be achieved with little change in cervical SVA and a low rate of reoperations over short-term follow-up. Similarly, patient-reported outcomes show significant improvements.

Improvements in Grip and Pinch Strength and Patient-reported Outcomes After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Prospective. OBJECTIVE: To evaluate improvements in grip and pinch strength in patients with or without myelopathy and determine patient factors that are predictive of continued postoperative grip strength weakness. SUMMARY OF BACKGROUND DATA: The degree to which cervical myelopathy can diminish upper extremity muscle strength has not been objectively characterized. Few studies have investigated the association between the expected improvements in patient-reported outcomes (PROs) and strength in grip and pinch after anterior cervical discectomy and fusion (ACDF). METHODS: Patients were asked to perform grip and pinch strength tests both preoperatively and at 6-month follow-up. Patients were also administered PRO surveys, which included Neck Disability Index, Short-Form-12 physical composite score and mental composite score, and Visual Analog Scale neck and arm pain scores. Receiver operating characteristic (ROC) curve analysis was used to determine optimum cutoff values of preoperative patient factors to predict postoperative dominant handgrip weakness after ACDF. RESULTS: Patients with radiculopathy demonstrated a significantly greater improvement in Visual Analog Scale arm pain compared with patients with myelopathy. The ROC curve analysis determined the optimum cutoff for preoperative dominant handgrip strength to be 22 kgf. This value demonstrated a sensitivity of 0.89 and a specificity of 0.62. The area under the ROC curve value was 0.71 (95% confidence interval, 0.55-0.88), indicating fair prognostic accuracy of the cutoff for postoperative dominant handgrip weakness. CONCLUSIONS: In this prospective, observational study, postoperative increase in grip and pinch strength demonstrated an association with improvement of pain and disability of the neck and overall quality of health regardless of the presence of cervical myelopathy. Preoperative grip strength weakness was found to be predictive of postoperative grip strength deficiency after ACDF. Our investigation suggests the recovery of hand function may be correlated with improvement of PROs after ACDF.

Postoperative satisfaction following lumbar spinal fusion surgery: patient expectation versus actuality.

OBJECTIVE: Due to the reported benefits associated with minimally invasive spine surgery (MIS), patients seeking out minimally invasive surgery may have higher expectations regarding their outcomes. In this study the authors aimed to assess the effects of preoperative expectations and postoperative outcome actuality, and the difference between the two, on postoperative satisfaction following MIS for lumbar fusion procedures. METHODS: Patients scheduled for either a 1- or 2-level lumbar fusion MIS were administered confidential surveys preoperatively and at 6 months postoperatively. The surveys administered preoperatively consisted of 2 parts: preoperative patient-reported outcomes (PROs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) back pain, and VAS leg pain, and expected postoperative PROs. The surveys administered 6 months postoperatively consisted of 2 parts: postoperative PROs and satisfaction. Preoperative symptoms, expected postoperative symptoms, and actual postoperative symptoms were compared using paired t-tests. Pearson correlation was used to compare the association between 1) postoperative change in PROs and satisfaction, 2) expectation and satisfaction, 3) expectation-actuality discrepancy and satisfaction, and 4) actuality and satisfaction. RESULTS: In total, 101 patients completed all surveys. Patients expected to improve in all PROs from baseline, except for ODI personal care, in which they expected to get worse after surgery. In actuality, patients improved in all PROs from baseline, except for ODI personal care, in which they did not demonstrate improvement or worsening. Patients did not surpass any expectations regarding PRO improvement. The association between patient satisfaction and postoperative change was strong for the VAS back pain score, while ODI and VAS leg pain scores showed moderate correlations. Preoperative expectation and postoperative satisfaction demonstrated weak to moderate correlations for all outcome measures. All 3 PROs demonstrated moderate correlation between patient satisfaction and the expectation-actuality discrepancy. All 3 PROs demonstrated strong correlations between satisfaction and actual postoperative outcomes, with ODI having the strongest correlation. CONCLUSIONS: In this observational study, the authors determined that the actual postoperative results following surgery were strongly correlated with patient satisfaction, while the patients' expectation, the expectation-actuality discrepancy, and the postoperative improvement did not demonstrate strong correlations for all patient-reported outcome measures utilized in this study. The investigation results suggest that the most important indicator of how satisfied patients feel following surgery may be the actual outcome itself, rather than the preoperative expectation or the degree to which the expected result was met.

Narcotic Consumption Following Minimally Invasive Lumbar Decompression: A Comparison Between Hospital and Ambulatory-Based Surgery Centers.

BACKGROUND: Several studies have compared outcomes between hospital-based centers (HBCs) and ambulatory surgery centers (ASCs) following minimally invasive lumbar decompression (MIS LD). However, the association between narcotic consumption and pain in the immediate postoperative period has not been well characterized. As such, this study aims to examine pain, narcotic consumption, and length of stay (LOS) among patients discharged on postoperative day 0 following a 1-level MIS LD between HBCs or ASCs. METHODS: Patients who underwent a primary, 1-level MIS LD were retrospectively reviewed and stratified by operative location. Differences between groups in patient demographics were assessed using independent-sample t tests for continuous variables and χ2 analysis for categoric variables. The operative location and its effect on perioperative characteristics, inpatient pain scores, and narcotics consumption were analyzed using multivariate linear regression adjusted for significant patient characteristics. RESULTS: There were 235 patients identified, of whom 90 and 145 underwent surgery at an HBC or ASC, respectively. The HBC cohort exhibited an increased comorbidity burden and had a greater percentage of privately insured patients. The HBC cohort recorded shorter operative time and greater total estimated blood loss. Patients in the HBC cohort experienced prolonged LOS, and consumed greater total oral morphine equivalents compared with the ASC cohort. No differences were observed in the remaining outcomes. CONCLUSIONS: The results of the current study suggest that patients who underwent MIS LD at an ASC received fewer narcotics than patients treated at an HBC, which may contribute to shortened LOS. Additionally, there was no difference in patient-reported pain between cohorts despite the differences in narcotic use. As such, postoperative narcotics administration varied, indicating HBC patients perhaps required more narcotic pain medications to achieve the same pain scores that were sufficient enough to allow patient discharge, thus prolonging LOS. LEVEL OF EVIDENCE: III.

Dysphagia Following Anterior Cervical Spine Surgery: Assessment Using an Abridged SWAL-QOL.

BACKGROUND: Study design: Retrospective cohort study. Objective: To determine which components of the swallowing disorders quality of life (SWAL-QOL) survey are most relevant to assess dysphagia following anterior cervical spine surgery (ACSS). Summary of background data: The SWAL-QOL survey is an instrument that has been applied to patients undergoing ACSS procedures as a means of objectifying swallow function. However, the SWAL-QOL is lengthy, cumbersome, and primarily used for otolaryngological procedures. METHODS: Patients undergoing ACSS procedures were administered the SWAL-QOL prior to surgery and at 6- and 12-week postoperative visits. The preoperative and postoperative SWAL-QOL scores were compared using paired t tests. Questions with statistically and clinically significant postoperative changes were used to create an abridged survey. RESULTS: Fifty patients completed surveys at all 3 encounters and were included in the analysis. The total scaled score at 6 weeks was significantly lower than the preoperative score (P = .003) but returned to near baseline scores by 12 weeks (P = .178). Five sections had significantly lower scores at both postoperative visits compared to their respective preoperative values. Additionally, 13 individual questions had significantly lower scores at both postoperative visits, while 8 had significantly lower scores at only 1 of the postoperative visits. Of these 21 questions demonstrating statistical significance, 16 also demonstrated a clinically significant decrease (>5.0%) from preoperative scores. These 16 questions were included in the abridged survey developed for use in ACSS patients. CONCLUSIONS: The results of this study suggest that several questions in the full SWAL-QOL questionnaire demonstrated minor or no changes at postoperative visits following ACSS. As a result, we propose a modified, 16-question SWAL-QOL survey including only questions that were both statistically and clinically significant. This truncated survey may be better suited for use in cervical spine patients.

Impact of the Number of Levels on Adverse Events and Length of Stay Following Posterior Lumbar Fusion Procedures.

STUDY DESIGN: Retrospective SUMMARY OF BACKGROUND DATA:: Little is known regarding the impact of the number of operative levels on the risk for adverse events following spinal procedures. OBJECTIVE: The objective of this study was to test for associations between the number of operative levels and occurrence of adverse events following posterior lumbar fusion (PLF). METHODS: Patients undergoing 1-, 2-, or 3-level PLFs were identified in the American College of Surgeons National Surgical Quality Improvement Program database. The number of operative levels was tested for association with occurrence of adverse events in the 30-days following the procedure using multivariate regression. Post hoc pairwise comparisons were made between 1- and 2-level and between 2- and 3-level procedures. Analyses were adjusted for differences in baseline characteristics. RESULTS: In total, 8162 underwent 1-level, 3,527 underwent 2-level, and 718 underwent 3-level procedures. Patients undergoing 2-level procedures had a higher rate of anemia requiring blood transfusion than 1-level procedures (23.4% vs. 8.6%; adjusted relative risk [RR]=2.5; P<0.001). Furthermore, patient undergoing 3-level procedures had a higher rate of anemia requiring blood transfusion than 2-level procedures (29.9% vs. 23.4%; adjusted RR=1.3; P<0.001). In addition, patients undergoing 3-level procedures had a longer length of stay than 2-level procedures (4.6 vs. 3.9 d; P<0.001) and 2-level procedures had a longer length of stay than 1-level procedures (3.9 vs. 3.5 d; P<0.001). CONCLUSIONS: Increasing the number of operative levels by one level has minimal impact on the rates of most short-term postoperative adverse events following PLF. This is true both for an increase from 1 to 2 levels and from 2 to 3 levels. While surgeons should consider that an increase in the number of operative levels may increase the risk for blood transfusion and will almost certainly prolong the hospital stay, they need not fear a major increase in the rates of postoperative adverse events.

Impact of local steroid application in a minimally invasive transforaminal lumbar interbody fusion: results of a prospective, randomized, single-blind trial.

OBJECTIVELocal epidural steroid application may be associated with decreased pain and narcotic use in the immediate postoperative period following lumbar discectomy. However, local steroid delivery following lumbar fusion procedures has not been well characterized. This study aims to characterize the effect of local intraoperative depomedrol application on perioperative and postoperative outcomes following a single-level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).METHODSA prospective, randomized, single-blinded study was performed. A priori power analysis determined that 86 patients were needed to detect a difference of 1 point in the visual analog scale (VAS) pain score between groups. Ninety-three patients were randomized into depomedrol (DEPO) and no depomedrol (NODEPO) cohorts. Prior to surgical closure, DEPO patients received 1 ml depomedrol (80 mg) applied directly to the surgical site by using a Gelfoam carrier. NODEPO patients received 1 ml saline on the same Gelfoam carrier. Perioperative outcomes including acute postoperative pain and narcotic use were assessed for the duration of inpatient stay. Patient-reported outcomes (PROs) questionnaires including VAS back and leg pain scores, and Oswestry Disability Index (ODI) were administered preoperatively and at 6-week, 12-week, and 6-month follow-up. Outcomes for DEPO and NODEPO cohorts were compared using linear regression controlled for sex.RESULTSOf the 93 patients, 45 (48.4%) were randomized to DEPO and 48 (51.6%) to NODEPO. A greater percentage of DEPO patients were female (53.3% vs 27.1%, p = 0.010). There were no other significant differences in patient baseline characteristics. Similarly, operating time, estimated blood loss, and length of inpatient stay did not differ between cohorts. Patients in the DEPO cohort consumed fewer hourly narcotics on postoperative day 0 (5.3 vs 6.3 oral morphine equivalents/hour, p = 0.034). However, no differences in acute postoperative pain or total narcotics consumption were observed between groups. Preoperative VAS leg scores were statistically different between cohorts (p = 0.027). However, preoperative ODI and VAS back scores did not differ between groups. Additionally, DEPO and NODEPO groups experienced similar improvements in PROs at all postoperative time points.CONCLUSIONSLocal depomedrol use did not lead to decreases in acute postoperative pain or narcotics consumption after MIS TLIF. Additionally, local depomedrol was not associated with postoperative improvements in PROs. The findings of this randomized trial suggest that surgical and clinical outcomes following MIS TLIF may not be impacted by intraoperative application of depomedrol.Clinical trial registration no.: NCT03308084 (clinicaltrials.gov).

A Comparison of Narcotic Consumption Between Hospital and Ambulatory-Based Surgery Centers Following Anterior Cervical Discectomy and Fusion.

BACKGROUND: Several studies have compared outcomes between hospital-based (HBCs) and ambulatory surgery centers (ASCs) following anterior cervical discectomy and fusion (ACDF). However, the association between narcotic consumption and pain in the early postoperative period has not been well characterized. As such, the purpose of this study is to compare pain, narcotic consumption, and length of stay (LOS) between HBC and ASC patients undergoing same-day-discharge following ACDF. METHODS: A surgical registry of patients who underwent a primary, 1- or 2-level ACDF during 2013-2015 was reviewed. Patients were stratified by operative location. Differences in demographics were assessed using independent-sample t tests and chi-square analysis. The presence of an association between operative location and outcomes was analyzed using Poisson regression with robust error variance or linear regression adjusted for preoperative characteristics. RESULTS: A total of 76 patients were identified, of which 42 and 34 underwent surgery at an HBC or ASC, respectively. The HBC cohort had greater total (P < .001) and hourly (P = .034) narcotic consumption and prolonged LOS (P < .001). Over 90% of ASC patients consumed less than or equal to the 30th percentile (32.0 mg) of oral morphine equivalents (OME), whereas over 57% of HBC patients consumed greater than 32.0 mg OME. The HBC cohort consumed greater average doses of fentanyl and oxycodone (P < .001 for each). CONCLUSIONS: This study demonstrates that patients undergoing same-day surgery for primary 1- or 2-level ACDF received more narcotics at HBCs compared to at ASCs. The increased narcotic consumption at HBCs may have resulted in longer LOS; however, this did not impact long-term pain, complications, or clinical outcomes. CLINICAL RELEVANCE: Patients scheduled to be discharged on postoperative day 0 following ACDF at HBCs may be able to receive fewer narcotics and be discharged sooner without compromising pain control or increasing their risk for complications.