Social Vulnerability Index Provides Greater Granularity Compared to the Area Deprivation Index When Assessing Outcomes Following Elective Lumbar Fusion.

STUDY DESIGN: Retrospective review of a single institution cohort. OBJECTIVE: To determine whether Area Deprivation Index (ADI) or Social Vulnerability Index (SVI) is more suitable for evaluating minimum clinically important difference (MCID) achievement following elective lumbar fusion as captured by the Patient Reported Outcomes Measurement Information System (PROMIS). SUMMARY OF BACKGROUND DATA: A total of 182 patients who underwent elective one- to two-level posterior lumbar fusion between January 2015 and September 2021. METHODS: ADI and SVI values were calculated from patient-supplied addresses. Patients were grouped into quartiles based on values; higher quartiles represented greater disadvantage. MCID thresholds for Pain Interference (PI) and Physical Function (PF) were determined via a distribution-based method. Multivariable logistic regression was performed to identify factors impacting MCID attainment. Univariate logistic regression was performed to determine which themes comprising SVI values affected MCID achievement. Statistical significance was set at P<0.05. RESULTS: Multivariate logistic regression demonstrated that ADI and SVI quartile assignment significantly impacted achievement of MCID for PI (P=0.04 and P=0.01 respectively) and PF (P=0.03 and P=0.02 respectively). Specifically, assignment to the third ADI and SVI quartiles were significant for PI (OR: 0.39 and 0.23 respectively), and PF (OR: 0.24 and 0.22 respectively). Race was not a significant predictor of MCID for either PI or PF. Univariate logistic regression demonstrated that among SVI themes, the socioeconomic status theme significantly affected achievement of MCID for PI (P=0.01), while the housing type and transportation theme significantly affected achievement of MCID for PF (P=0.01). CONCLUSION: ADI and SVI quartile assignment were predictors of MCID achievement. While ADI and SVI may both identify patients at risk for adverse outcomes following lumbar fusion, SVI offers greater granularity in terms of isolating themes of disadvantage impacting MCID achievement.

Depression State Correlates with Functional Recovery Following Elective Lumbar Spine Fusion.

OBJECTIVE: To determine how depression state impacts postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores and achievement of minimum clinically important difference (MCID) following lumbar fusion. Depression has been shown to negatively impact outcomes following numerous orthopedic surgeries. Situational and major clinical depression can differentially affect postoperative outcomes. METHODS: Adult patients undergoing elective 1-3 level lumbar fusion were reviewed. Patients with a formal diagnosis of major depression were classified as "clinically depressed" whereas patients with at least "mild" PROMIS Depression scores in the absence of formal depression diagnosis were deemed "situationally depressed." analysis of variance testing was used to assess differences within and between groups. Multivariate regression was used to identify features associated with the achievement of MCID. RESULTS: Two hundred patients were included. The average age was 65.9 ± 12.2 years. 75 patients (37.5%) were nondepressed, 66 patients (33.0%) were clinically depressed, and 59 patients (29.5%) were situationally depressed. Situationally depressed patients had worse preoperative physical function (PF) and pain interference (PI) scores and were more likely to have severe symptoms (P = 0.001, P = 0.001). All groups improved significantly from preoperative baseline scores. All groups met MCID PF at different rates, with highest proportion of situationally depressed reaching this metric (P = 0.03). Rates of achieving MCID PI were not significantly different between groups (P = 0.47). Situational depression was predictive of achieving MCID PF (P = 0.002) but not MCID PI. CONCLUSIONS: Our study investigated the relationship between depression and postoperative PROMIS scores and identified situationally depressed patients as having the worst preoperative impairment. Despite this, the situationally depressed cohort had the highest likelihood of achieving MCID PF, suggestive of a bidirectional relationship between lumbar degenerative disease and subclinical, situational depression. These findings may help guide preoperative counseling on expectations, and patient selection.

Clinical Improvement After Lumbar Fusion: Using PROMIS to Assess Recovery Kinetics.

STUDY DESIGN: Retrospective review of a single institution cohort. OBJECTIVE: The goal of this study is to identify features that predict delayed achievement of minimum clinically important difference (MCID) following elective lumbar spine fusion using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. SUMMARY OF BACKGROUND DATA: Preoperative prediction of delayed recovery following lumbar spine fusion surgery is challenging. While many studies have examined factors impacting the achievement of MCID for patient-reported outcomes in similar cohorts, few studies have assessed predictors of early functional improvement. METHODS: We retrospectively reviewed patients undergoing elective one-level posterior lumbar fusion for degenerative pathology. Patients were subdivided into two groups based on achievement of MCID for each respective PROMIS domain either before six months ("early responders") or after six months ("late responders") following surgical intervention. Multivariable logistic regression analysis was used to determine features associated with odds of achieving distribution-based MCID before or after six months follow up. RESULTS: 147 patients were included. The average age was 64.3±13.0 years. At final follow-up, 57.1% of patients attained MCID for PI and 72.8% for PF. However, 42 patients (49.4%) reached MCID for PI by six months, compared to 44 patients (41.1%) for PF. Patients with severe symptoms had the highest probability of attaining MCID for PI (OR 10.3; P =0.001) and PF (OR 10.4; P =0.001) Preoperative PROMIS symptomology did not predict early achievement of MCID for PI or PF. Patients who received concomitant iliac crest autograft during their lumbar fusion had increased odds of achieving MCID for PI (OR 8.56; P =0.001) before six months. CONCLUSION: Our study demonstrated that the majority of patients achieved MCID following elective one-level lumbar spine fusion at long-term follow-up, although less than half achieved this clinical benchmark for each PROMIS metric by six months. We also found that preoperative impairment was not associated with when patients would achieve MCID. Further prospective investigations are warranted to characterize the trajectory of clinical improvement and identify the risk factors associated with poor outcomes more accurately.

Socioeconomic disadvantage is correlated with worse PROMIS outcomes following lumbar fusion.

BACKGROUND CONTEXT: Socioeconomic status (SES) has been associated with differential healthcare outcomes and may be proxied using the area-deprivation index (ADI). Few studies to date have investigated the role of ADI on patient-reported outcomes and clinically meaningful improvement following lumbar spine fusion surgery. PURPOSE: The purpose of this study is to investigate the role of SES on lumbar fusion outcomes using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. STUDY DESIGN/SETTING: Retrospective review of a single institution cohort. PATIENT SAMPLE: About 205 patients who underwent elective one-to-three level posterior lumbar spine fusion. OUTCOME MEASURES: Change in PROMIS scores and achievement of minimum clinically important difference (MCID). METHODS: Patients 18 years or older undergoing elective one-to-three level lumbar spine fusion secondary to spinal degeneration from January 2015 to September 2021 with minimum one year follow-up were reviewed. ADI was calculated using patient-supplied addresses and patients were grouped into quartiles. Higher ADI values represent worse deprivation. Minimum clinically important difference (MCID) thresholds were calculated using distribution-based methods. Analysis of variance testing was used to assess differences within and between the quartile cohorts. Multivariable regression was used to identify features associated with the achievement of MCID. RESULTS: About 205 patients met inclusion and exclusion criteria. The average age of our cohort was 66±12 years. The average time to final follow-up was 23±8 months (range 12-36 months). No differences were observed between preoperative baseline scores amongst the four quartiles. All ADI cohorts showed significant improvement for pain interference (PI) at final follow-up (p<.05), with patients who had the lowest socioeconomic status having the lowest absolute improvement from preoperative baseline physical function (PF) and PI (p=.01). Only those patients who were in the lowest socioeconomic quartile failed to significantly improve for PF at final follow-up (p=.19). There was a significant negative correlation between socioeconomic level and the absolute proportion of patients reaching MCID for PI (p=.04) and PF (p=.03). However, while ADI was a significant predictor of achieving MCID for PI (p=.02), it was nonsignificant for achieving MCID for PF. CONCLUSIONS: Our study investigated the influence of ADI on postoperative PROMIS scores and identified a negative correlation between ADI quartile and the proportion of patients reaching MCID. Patients in the worse ADI quartile had lower chances of reaching clinically meaningful improvement in PI. Policies focused on alleviating geographical deprivation may augment clinical outcomes following lumbar surgery.

Long-Term Health-Related Quality of Life After Harrington Instrumentation and Fusion for Adolescent Idiopathic Scoliosis: A Minimum 40-Year Follow-up.

BACKGROUND: Despite its importance for clinical decisions, the long-term consequences of posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), particularly in the lower lumbar spine, remain unclear. This study evaluates the long-term health-related quality of life and the need for a further surgical procedure in patients treated with Harrington instrumentation from 1961 to 1977 according to the lowest instrumented vertebra (LIV) and in comparison with age-matched norms. METHODS: A search was performed to identify and contact the 314 identified patients with AIS treated with PSIF by Dr. L.A. Goldstein. The assessment included identified subsequent spine surgery, the Oswestry Disability Index (ODI), Scoliosis Research Society-7 (SRS-7), EuroQol-5 Dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). The health-related quality of life was compared with U.S. norms and, within the cohort, was compared by patient factors, LIV, and subsequent spine surgery. RESULTS: In this study, 134 patients (42.7%) were identified; 24 (7.6%) had died, 81 (25.8%) consented to participate in the study, and 29 (9.2%) declined participation. The mean follow-up was 45.4 years (range, 40 to 56 years). There were 81 patients who completed the surveys, 77 patients who completed the SRS-7, 77 patients who completed the ODI, and 76 patients who completed the PROMIS-29 and EQ-5D. There were 12.8% of patients with LIV L3 or proximal and 36.4% with LIV L4 or distal who had an additional surgical procedure (odds ratio, 3.98). Comparing the ODI of patients who had undergone an additional surgical procedure with those who had not showed 42% and 73% minimal disability, 53% and 23% moderate disability, and 5% and 2% severe disability. Of the patients who had not undergone an additional surgical procedure, those with LIV L3 or proximal had mean scores of 14.12 points for the ODI and 23.3 points for the SRS-7 and those with LIV L4 or distal had mean scores of 17.9 points for the ODI and 22.7 points for the SRS-7; these differences were not significant. The mean PROMIS-29 and EQ-5D scores were not different from normal U.S. age-based means. CONCLUSIONS: Patients with AIS treated with PSIF at a mean 45-year follow-up and LIV L4 or distal had a higher rate of undergoing an additional surgical procedure than those with LIV L3 or proximal. Patients undergoing an additional surgical procedure had lower health-related quality of life than those who did not. Despite this, there was no difference in health-related quality of life for patients with LIV L4 or distal compared with patients with LIV L3 or proximal. This cohort of patients with AIS treated with PSIF demonstrates normal self-reported health-related quality of life compared with the age-matched general population. These long-term outcomes of PSIF for AIS are encouraging. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Traumatic Bilateral L3-4 Facet Dislocation With Open Decompression and Short Segment Fusion.

Traumatic lumbar facet dislocations are exceedingly rare, with reported cases primarily involving the lumbosacral junction. This injury arises from very high flexion distraction forces imparted on the lumbar spine. Herein we describe a bilateral L3-4 facet dislocation, a particularly rare injury pattern, using a short-segment posterior decompression and fusion followed by an interbody fusion through a lateral approach. Our case involves a 24-year-old man who presented to the emergency department after a high-speed, head-on motor vehicle collision. He was a restrained passenger with no prior significant medical history. He was found to have multisystem injuries, the most notable a L3-4 bilateral lumbar facet dislocation. The patient was neurologically intact upon his presentation but developed radiculopathy several hours into his hospital admission. He was treated operatively through a posterior decompression and instrumented short-segment fusion as well as a subsequent interbody fusion through a lateral approach at the same level. Pure lumbar spine facet dislocations outside the lumbosacral junction, especially bilateral dislocations, are exceedingly rare and often result in neurological deficits. A literature review reveals only a few cases outside of Asia, all of which were treated with decompression and either short- or long-segment fusion. No accepted treatment algorithm for this injury has been established. Open treatment is almost always indicated. Decompression and short-segment fusion is a valid treatment option, but patient and injury characteristics must be considered on an individualized basis.Level of Evidence: 5.

An Analysis of Patient and Fracture Characteristics and Clinical Outcomes in Patients With Hyperostotic Spine Fractures.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate outcomes and complications following operative and nonoperative management of hyperostotic spine fractures. METHODS: Patients presenting between 2008 and 2017 to a single level 1 trauma center with hyperostotic spine fractures had their information and fracture characteristics reviewed. Bivariate analyses were conducted to compare patients across a number of characteristics and outcomes. Multivariate logistic regression models for complication and mortality were done in a stepwise fashion. RESULTS: Sixty-five ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH) patients with a spine fracture met our inclusion criteria. DISH was slightly more prevalent (55% vs 45%). Overall delayed diagnosis, reoperation, mortality (at 1 year), and complication rates were high at 32%, 13%, 23%, and 57%, respectively. In multivariate logistic regression models, patients undergoing operative management had significantly increased odds of having a complication (odds ratio [OR] = 23.03, 95% confidence interval [CI] = 2.24-236.45, P = .008), while increasing age was associated with increased odds of death (OR = 1.18, 95% CI = 1.06-1.31, P = .003). CONCLUSIONS: Patients with AS or DISH who fracture their spine are at high risk of complication and death. However, neither operative nor nonoperative treatment increases the odds of mortality. This study helps add to a growing, but still limited, body of literature on the characteristics of patients with spine fractures in the setting of AS or DISH.

Evaluating Trends and Outcomes of Spinal Deformity Surgery in Cerebral Palsy Patients.

BACKGROUND: There is a paucity of literature examining surgical trends and outcomes in both child and adult cerebral palsy (CP) patients. We aimed to evaluate surgical trends, complications, length of stay, and charges for spinal deformity surgery in CP patients. METHODS: Using the Nationwide Inpatient Sample (NIS) from 2001 to 2013, patients with CP scoliosis who underwent spinal fusion surgery were identified. Patient characteristics and comorbidities were recorded. Trends in spinal fusion approaches were grouped as anterior (ASF), posterior (PSF), or combined anterior-posterior (ASF/PSF). Complication rates, length of stay, and charges for each approach were analyzed. Bivariate analyses using adjusted Wald tests and multivariate analyses using linear (logarithmic transformation) and logistic regressions were performed. RESULTS: Of the 5191 adult CP patients who underwent spinal fusion the majority underwent PSF (86.5%), followed by the ASF/PSF approach (9.3%). The rate of PSF for cerebral palsy patients with spinal deformity increased significantly per 1 million people in the US population (0.90 to 1.30; P = .048). Complication rate, hospital length of stay, and charges were higher for patients undergoing ASF/PSF (P < .05). The overall complication rate for all surgical approaches was 25.7%. Patient comorbidities and combined ASF/PSF increased the odds of complication. Combined ASF/PSF was also associated with an increased length of stay and charges. CONCLUSION: Combined ASF/PSF in patients with CP accounted for only 9.3% of surgical cases but was associated with the longest hospital stay, highest charges, and increased complications. Further scrutiny of the surgical indications and preoperative risk stratification should be undertaken to minimize complications, reduce length of stay, and decrease charges for CP patients undergoing spinal fusion. LEVEL OF EVIDENCE: IV.

Predictors of 30-Day Unplanned Readmissions, Complications, and Mortality Following Operative Management of C2 Fractures.

STUDY DESIGN: Retrospective database review. OBJECTIVES: To determine factors associated with unplanned readmission, complications, and mortality in patients undergoing operative management for C2 fractures. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS NSQIP) was queried between 2007 and 2014. Unplanned readmission, any complication, and mortality were the outcomes of interest. Bivariate statistics were calculated, and multivariate regression models were estimated. RESULTS: A total of 285 patients were enrolled. Readmission data was available for 199 patients and 11 patients (5.5% of 199 patients) had an unplanned readmission. Overall, 60 patients (21% of 285 patients) had at least 1 complication and 15 patients (5.3% of 285 patients) died. Five factors were associated with complications: transferred from another facility (odds ratio [OR] 3.00, 95% confidence interval [CI]1.51-5.98; P < .01); operative time ≥180 minutes (OR 2.43, 95% CI 1.11-5.36; P = .03); at least 1 patient comorbidity (OR 2.50, 95% CI 1.01-6.18; P < .05); American Society of Anesthesiologists (ASA) class 3 (OR 4.86, 95% CI 1.19-19.88; P = .03); and ASA class 4 (OR 7.24, 95% CI 1.66-31.66; P = .01). The only factor associated with unplanned readmission was having at least one postoperative complication (OR 7.10, 95% CI 1.04-48.59; P < .05), while patients who were partially or totally dependent from a functional standpoint were at increased odds of death (OR 3.98, 95% CI 1.12-14.08; P = .03). CONCLUSIONS: Patients with functional limitations have increased odds of death, while patients with postoperative complications have increased odds of unplanned readmission. Being transferred from an outside facility, having an operative time ≥180 minutes, having at least one comorbidity, and being classified as ASA class 3 or 4 increase patient odds of complication.

Trends in spinal deformity surgery in Marfan syndrome.

STUDY DESIGN: Analysis of a national database. OBJECTIVE: To analyze trends in fusion surgery for spinal deformity in Marfan syndrome (MFS) patients, compare patients with and without Marfan, and evaluate differences in surgical approaches. SUMMARY OF BACKGROUND DATA: National trends of fusion surgery for spinal deformities in MFS patients are not known. Given the rarity of MFS and the nuanced differences in the spinal deformity it causes, it is important to explore differences in fusion surgery between spinal deformity patients with and without MFS. METHODS: We identified 314 patients (1,410 weighted) with a diagnosis of MFS and spinal deformity who underwent spinal fusion between the years 2003 and 2014. Our primary outcome was national trends in the use of posterior (PSF), anterior-posterior (APSF), and anterior (ASF) spinal fusions. We also compared perioperative complications, mortality rate, length of stay, and hospital charges in a propensity score matched sample of spinal fusion patients with and without a diagnosis of MFS. RESULTS: The proportion of PSF surgeries increased significantly (p<.01) from 66.7% in 2003 to 92.0% in 2014. MFS patients were more likely to have higher neurologic (2.4% vs. 0.79%, p=.01) complications. There was a significant association between age and approach (p<.01). PSF had a mean age of 20.2, whereas APSF and ASF had mean ages of 27.1 and 35.2, respectively. Approximately 62% of cervical fusions used ASF. CONCLUSIONS: Our study provides findings from the largest sample analyzed to date and is the only thus far that investigates national trends. Our results are largely consistent with those of other works in that MFS patients undergoing spinal fusion surgery have higher neurologic complications. We also report that surgical treatment has shifted toward a posterior approach. Our findings can give surgeons a better understanding of the postoperative complications and changing national trends in spinal fusion surgery for patients with MFS.

National Trends and Complications in the Surgical Management of Ossification of the Posterior Longitudinal Ligament (OPLL).

STUDY DESIGN: A retrospective database analysis. OBJECTIVE: The aim of this study was to analyze US trends in surgical approaches for ossification of the posterior longitudinal ligament (OPLL); and to compare US patient and hospital characteristics, length of stay, total charges, and 30-day complications by surgical approach in OPLL management. SUMMARY OF BACKGROUND DATA: A robust literature on surgical management of OPLL in East Asian countries, where OPLL has a higher prevalence, exists. However, there is a paucity of literature evaluating the surgical management of OPLL in non-Asian countries. METHODS: Using the Nationwide Inpatient Sample (NIS), we identified surgically treated OPLL patients from 2003 to 2014. Data on patient characteristics, surgical approaches, complications, hospital characteristics, length of stay, and hospital charges were extracted and analyzed. Analysis of variance (ANOVA) and Chi-squared tests were used to assess variation across categorical variables. Linear regression was used to evaluate the trend of surgical management for OPLL over the study timeframe. RESULTS: Five thousand two hundred twelve patients fit our inclusion criteria. The overall complication rate was 21.5%, but the highest complication rate was for patients undergoing a combined anterior-posterior decompression/fusion (44.7%). Patients undergoing a combined anterior-posterior decompression/fusion had a longer length of stay and higher total charges (P < 0.01). Overall, surgical OPLL cases significantly increased from 2003 to 2014 (336-920; P < 0.01). CONCLUSION: To our knowledge, this is the largest study examining the surgical treatment of OPLL in a non-Asian country. OPLL surgical cases increased over the study timeframe and the overall surgical complication rate was 21.5%. The percentage of Asians or Pacific Islanders with OPLL undergoing surgical intervention was 10.8%, which is higher than the prevalence in the US population (4.9%). This suggests a potential genetic component to OPLL. Future work is warranted to determine how best to decrease the high complication rate. LEVEL OF EVIDENCE: 4.

An Evaluation of PROMIS in Patients With Primary or Metastatic Spine Tumors.

STUDY DESIGN: Retrospective evaluation of prospectively collected data. OBJECTIVE: In spine tumor patients: i) to assess the correlation of Patient-reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PI), and Depression scores with Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores; and ii) to assess ceiling and floor effects of PROMIS PF, PI, and Depression domains and the ODI/NDI. SUMMARY OF BACKGROUND DATA: There remains no widely used patient-reported outcome (PRO) instrument for spine tumor patients. PROMIS, a universal PRO tool, may add notable value to patient care. A paucity of work exists comparing PROMIS to legacy PRO tools in primary and metastatic spine tumor patients. METHODS: Patients confirmed to have a primary or metastatic spine tumor were asked to complete PROMIS PF, PI, and Depression domains and either an ODI or NDI questionnaire between May 2015 and December 2017. Pearson correlation coefficients (r) were calculated. Ceiling and floor effects were determined. P < 0.05 was significant. RESULTS: Eighty unique visits from 51 patients with spine tumors (44 metastatic/67 visits; 7 primary/13 visits) met our inclusion criteria. A strong correlation existed between PROMIS PI and the ODI/NDI in both primary and metastatic tumor patient subgroups (range, r = 0.75-0.86, P < 0.05). PROMIS PF and the ODI/NDI demonstrated a strong correlation among all patients (r = -0.75, P < 0.05) and in the metastatic disease subgroup (r = -0.78, P < 0.05). A strong correlation existed between PROMIS Depression and the ODI/NDI in the primary tumor subgroup (r = 0.79, P < 0.05). PROMIS Depression demonstrated the largest floor effect (13.6%); there were similar ceiling effects. CONCLUSION: PROMIS PF and PI domains correlate well with the ODI/NDI in spine tumor patients and have a similar ceiling effect but decreased floor effect. PROMIS Depression was not as well captured, except in the primary tumor subgroup. LEVEL OF EVIDENCE: 2.

Evaluating the Correlation and Performance of PROMIS to SRS Questionnaires in Adult and Pediatric Spinal Deformity Patients.

STUDY DESIGN: Retrospective cross-sectional cohort analysis. OBJECTIVES: 1) To assess the correlation of Patient-Reported Outcomes Management Information System (PROMIS) domains with SRS-22r/SRS-30 domains in all scoliosis patients; 2) to assess the correlation of PROMIS domains with SRS-30 domains in adult scoliosis patients; 3) to assess the correlation of PROMIS domains with SRS-22r/SRS-30 domains in pediatric scoliosis patients; and 4) to assess ceiling and floor effects of PROMIS and SRS-22r/SRS-30 domains. SUMMARY OF BACKGROUND DATA: Studies evaluating correlations between PROMIS and a number of legacy PRO tools have been conducted. To our knowledge, no literature exists examining the correlation of PROMIS and SRS questionnaires in adult and pediatric spinal deformity patients. METHODS: Outpatient visits from July 2015 to December 2017 with concurrent PROMIS and SRS questionnaires were analyzed. Pediatric patients completed the SRS-22r, whereas adults completed the SRS-30. PROMIS measured Physical Function/Mobility, Pain Interference, and Depression domains. Spearman correlation coefficients (ρ) were calculated. Ceiling and floor effects were calculated and compared. RESULTS: 227 (164 adult; 64 pediatric) patient visits representing 173 patients were included. Moderate to strong correlation existed between PROMIS Physical Function/Mobility and SRS Function/Activity (F/A) domains (ρ, range 0.59-0.84; p < .001). PROMIS Pain Interference and SRS Pain domains showed strong-moderate to strong correlation (ρ, range -0.68 to -0.83; p < .001). PROMIS Depression and SRS Mental Health (MH) domains demonstrated strong-moderate to strong correlation (ρ, range -0.67 to -0.80; p < .001). Ceiling and floor effects were all less in PROMIS domains (range, 0.44% to 0.88%) compared with SRS domains (range, 0.88% to 17.62%). CONCLUSIONS: PROMIS Physical Function/Mobility, Pain Interference, and Depression domains correlate well with SRS F/A, Pain, and MH. SRS SI/A and Satisfaction are not as well captured. PROMIS showed better ceiling and floor effects than SRS. LEVEL OF EVIDENCE: Level III.

Scholarly Success of Orthopaedic Surgeons Participating in the Clinician Scholar Career Development Program.

BACKGROUND: A concern exists about the decline in young orthopaedic surgeons pursuing careers as clinician-researchers. One program designed to address this concern is the American Academy of Orthopaedic Surgeons/Orthopaedic Research and Education Foundation/Orthopaedic Research Society (AAOS/OREF/ORS) Clinician Scholar Career Development Program (CSCDP). The aims of this study were to better understand the characteristics of CSCDP participants and how the experience effects involvement in career-impacting opportunities and scholarly activity. METHODS: This study was a retrospective analysis. CSCDP participants from 2003 to 2014 were recorded, and demographic information was collected. An Internet search was utilized to determine each surgeon's current practice environment. The National Institutes of Health (NIH) Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database was used to track NIH funding. The OREF and its web site were used to query OREF grant funding. American Orthopaedic Association (AOA) Traveling Fellowship awardees were recorded from the AOA web site. Specialty-specific traveling fellowship awardee information was collected via organization web sites, and direct-contact, scholarly activity, and impact were determined using the Scopus database Hirsch index (h-index). RESULTS: Two hundred and thirty-two individuals (229 confirmed current orthopaedic surgeons) participated in the CSCDP. Fifteen (6.6%), 41 (17.9%), 20 (8.7%), and 17 (7.4%) former CSCDP participants have been awarded NIH funding, OREF grant support, AOA Traveling Fellowships, and/or specialty-specific traveling fellowships, respectively. Those involved in any of the career-impactful opportunities post-CSCDP have had higher scholarly activity and impact compared with those who were not involved in the career-impactful opportunities (h-index: 15.9 [standard deviation (SD), 8.1] versus 10.0 [SD, 5.7], p < 0.0001). No scholarly activity and impact differences existed between orthopaedic subspecialties (p = 0.077). CONCLUSIONS: The CSCDP appears to play an important role in promoting clinician-researcher careers in orthopaedic surgery. CLINICAL RELEVANCE: The CSCDP must continue to adapt to the surrounding health-care landscape to achieve an even better success rate in creating clinician-researchers who will further advance musculoskeletal health and discovery for the betterment of the patients and the profession.

Comparison of adult spinal deformity patients with and without rheumatoid arthritis undergoing primary non-cervical spinal fusion surgery: a nationwide analysis of 52,818 patients.

BACKGROUND CONTEXT: Numerous studies have analyzed the impact of rheumatoid arthritis (RA) on the cervical spine and its related surgical interventions. However, there is a paucity of literature available conducting the same analyses in patients with non-cervical spine involvement. PURPOSE: The objective of this study was to compare patient characteristics, comorbidities, and complications in patients with and without RA undergoing primary non-cervical spinal fusions. STUDY DESIGN/SETTING: This is a retrospective national database review. PATIENT SAMPLE: A total of 52,818 patients with adult spinal deformity undergoing non-cervical spinal fusions (1,814 patients with RA and 51,004 patients without RA). OUTCOME MEASURES: The outcome measures in the study include patient characteristics, as well as complication and mortality rates. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample from 2003 to 2014, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes were used to identify patients aged ≥18 years old with and without RA undergoing primary non-cervical spinal fusions. Univariate analysis was used to determine patient characteristics, comorbidities, and complication values for each group. Bivariate analysis was used to compare the two groups. Significance was set at p<.05. RESULTS: Patients with RA were older (p<.001), were more likely to be women (p<.001), had increased rates of osteoporosis (p<.001), had a greater percentage of their surgeries reimbursed by Medicare (p<.001), and more often had weekend admissions (p=.014). There was no difference in all the other characteristics. Patients with RA had higher rates of iron deficiency anemia, congestive heart failure, chronic pulmonary disease, depression, and fluid and electrolyte disorders (all, p<.001). Patients without RA had higher rates of alcohol abuse (p=.027). There was no difference in all the other complications. There was no difference in mortality rate (p=.99). Total complications were greater in patients with RA (p<.001). Patients with RA had higher rates of infection (p=.032), implant-related complications (p=.010), incidental durotomies (p=.001), and urinary tract infections (p<.001). No difference existed among the other complications. CONCLUSIONS: Patients with RA have an increased number of comorbidities and complication rates compared with patients without RA. Such knowledge can help surgeons and patients with RA have beneficial preoperative discussions regarding outcomes.

Variability Over Time of Preoperative Sagittal Alignment Parameters: Radiographic and Clinical Considerations.

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate preoperative variability in radiographic sagittal parameters in adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: In ASD surgical planning, deformity magnitude is determined from preoperative radiographs. There are no studies evaluating the clinical relevance and timing to repeat radiographs during interval clinic visits and timing to repeat radiograph for preoperative planning. METHODS: A total of 139 patients with ASD with minimum two preoperative full-body spine x-rays were included. Cervical, thoracic, lumbar, pelvic, and hip/knee sagittal alignment parameters were analyzed using dedicated spine measurement software. Patients were grouped by time intervals between x-rays: A: 8 weeks or lesser, B: 10 to 20 weeks, and C: 21 weeks or more. Changes in sagittal parameters were correlated to age and deformity magnitude (T1 pelvic angle or pelvic tilt [PT] >20°). RESULTS: The cohort had mean age 59 years, mean body mass index 27, 30% men, 95 patients with no prior spine surgery, and 44 patients at minimum 9 months since prior spine surgery. There were 25 patients in group A, 38 in B, and 71 in C. All radiographic measures showed good time-based consistency at intervals less than 21 weeks (groups A and B). Group C had significant increases in PT (1.5°) and hip extension (2.1°) (P < 0.05). These changes were greater in group C patients with previous surgery (PT 3.7°; P < 0.006, hip extension 3.2°; P < 0.025). Greater interval changes in parameters were also associated with higher magnitudes of deformity and younger patient ages. CONCLUSION: All sagittal radiographic parameters were statistically consistent at intervals of less than 21 weeks. In patients with more than 21 weeks between interval x-rays, change in PT was greater than the standard error of measurement for patients with prior surgery or severe deformity. Consideration should be made to obtain new x-rays for patients with ASD when the interval between clinical visits exceeds 5 months. LEVEL OF EVIDENCE: 4.

Pelvic Fixation in Adult and Pediatric Spine Surgery: Historical Perspective, Indications, and Techniques: AAOS Exhibit Selection.

Achieving solid osseous fusion across the lumbosacral junction has historically been, and continues to be, a challenge in spine surgery. Robust pelvic fixation plays an integral role in achieving this goal. The goals of this review are to describe the history of and indications for spinopelvic fixation, examine conventional spinopelvic fixation techniques, and review the newer S2-alar-iliac technique and its outcomes in adult and pediatric patients with spinal deformity. Since the introduction of Harrington rods in the 1960s, spinal instrumentation has evolved substantially. Indications for spinopelvic fixation as a means to achieve lumbosacral arthrodesis include a long arthrodesis (five or more vertebral levels) or use of three-column osteotomies in the lower thoracic or lumbar spine, surgical treatment of high-grade spondylolisthesis, and correction of lumbar deformity and pelvic obliquity. A variety of techniques have been described over the years, including Galveston iliac rods, Jackson intrasacral rods, the Kostuik transiliac bar, iliac screws, and S2-alar-iliac screws. Modern iliac screws and S2-alar-iliac screws are associated with relatively low rates of pseudarthrosis. S2-alar-iliac screws have the advantages of less implant prominence and inline placement with proximal spinal anchors. Collectively, these techniques provide powerful methods for obtaining control of the pelvis in facilitating lumbosacral arthrodesis.

Intraoperative Cardiopulmonary Arrest in Children Undergoing Spinal Deformity Correction: Causes and Associated Factors.

STUDY DESIGN: Retrospective review. OBJECTIVE: To report the incidence of and risk factors for intraoperative cardiopulmonary arrest (ICA) in children undergoing spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Spinal deformities in children are associated with comorbidities that can pose substantial risks during surgery. METHODS: We reviewed records of patients who underwent surgery at two pediatric tertiary-care hospitals from 2004 through 2014. Fisher exact test and the Student t test were used to compare ICA and non-ICA groups by patient diagnosis, estimated blood loss, number of vertebral levels fused, and proportion of blood volume lost (significance, P < 0.05). We classified proximate causes of ICA based on hemoglobin, metabolic panel/electrolyte imbalance, electrocardiogram/echocardiography, and vital signs. RESULTS: ICA occurred in 11 of 2524 (0.4%) patients. Patients with neuromuscular disorders had a 3-fold higher risk of ICA compared with those without neuromuscular disorders. At the time of ICA, hemoglobin levels were 5  g/dL or less in four patients, potassium was higher than 5.5  mEq/L in six patients, and ionized calcium was less than or equal to 1  mmol/L in two patients. There were significant differences between the ICA and non-ICA groups in mean number of vertebral levels fused (15 vs. 12), patient weight (34 vs. 49  kg), estimated blood loss (2623 vs. 959  mL), and proportion of blood volume lost (1.03 vs. 0.33) (all P < 0.01). Suspected causes of ICA were cardiovascular causes (eight patients) and anaphylaxis, primary rhythm disturbance, and respiratory/airway cause (one patient each). The incidence of ICA for patients with idiopathic scoliosis was 0.13%. Ten of the 11 patients were successfully resuscitated, and one patient died. CONCLUSION: ICA occurs in approximately 0.4% of children undergoing spinal fusion surgery. Patients with neuromuscular disorders are at greater risk of ICA than those without these disorders. LEVEL OF EVIDENCE: 3.