Social Media Posts Pertaining to Anterior Cervical Discectomy and Fusion (ACDF) Surgery: A Cross-sectional Analysis of Patient and Surgeon Perceptions.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To analyze publicly available content on a major social media outlet related to anterior cervical discectomy and fusion (ACDF) surgery based on perspective, location, timing, content, tone, and patient satisfaction. SUMMARY OF BACKGROUND DATA: Social media offers a powerful platform for sharing the patient experience with the public through an unfiltered perspective. Social media content may influence future perceptions around surgical care and postings around ACDF have not been previously reported. METHODS: A query of content from a major social media outlet was performed for the study period January 1, 2018, to January 1, 2020, and returned 6500 publicly available posts. Content was identified by the hashtags "#acdf" or "#acdfsurgery." Content was ranked by number of "likes." Of the 1500 most popular posts, 1136 related to ACDF surgery and were included. Post content was characterized and classified. RESULTS: Patients created 85% of ACDF-related content and spine surgeons created 11.8%. Most posts portrayed the patient experience in the postoperative period and depicted patients performing activities of daily living, participating in sports, or completing work activities (54.4%). The connotation of posts was deemed to be positive in 79.2% of cases. In regard to their care or state of health as it related to ACDF surgery, 59.8% of patients expressed satisfaction, whereas 14.1% expressed dissatisfaction. Female patients were >4 times as likely to express dissatisfaction (odds ratio=4.16, P =<0.0001), with their clinical course compared with their male counterparts. CONCLUSIONS: Patients were the source of most posts on a major social media outlet that pertained to ACDF surgery with a majority reporting positive tone and satisfaction. These mechanisms of communication offer surgeons unique insights into patient experience and may provide an opportunity for surgeons to assess patient feedback, influence patient perceptions, and enhance delivery of cervical spine care.

Determining the Impact of the COVID-19 Pandemic on Hand Surgery Fellowship Education.

The purpose of this study is to report the impact of COVID-19 on hand surgery fellow learning and preparedness for practice. A multi-dimensional questionnaire was distributed to current hand fellows and fellowship directors across the United States. Survey questions included fellowship location, institutional response, impact on practice, education and job search. Thirty-two hand surgery fellows and 14 fellowship directors completed the survey. Of fellows, 59% reported a greater than 75% decrease in case volume. Mean hours worked per week per fellow decreased by 52%. All fellowship directors and 94% of fellows did not expect COVID-19 to impact their ability to graduate, and nearly all fellows felt prepared to start practice after fellowship training. However, many fellows expressed concern about job opportunities. The work hours and exposure of hand surgery fellows to elective surgical cases have been adversely impacted by COVID-19. Nevertheless, current hand fellows feel prepared to enter practice. (Journal of Surgical Orthopaedic Advances 31(1):048-052, 2022).

Spine Surgery and COVID-19: The Influence of Practice Type on Preparedness, Response, and Economic Impact.

STUDY DESIGN: Cross-sectional observational cohort study. OBJECTIVE: To investigate preparation, response, and economic impact of COVID-19 on private, public, academic, and privademic spine surgeons. METHODS: AO Spine COVID-19 and Spine Surgeon Global Impact Survey includes domains on surgeon demographics, location of practice, type of practice, COVID-19 perceptions, institutional preparedness and response, personal and practice impact, and future perceptions. The survey was distributed by AO Spine via email to members (n = 3805). Univariate and multivariate analyses were performed to identify differences between practice settings. RESULTS: A total of 902 surgeons completed the survey. In all, 45.4% of respondents worked in an academic setting, 22.9% in privademics, 16.1% in private practice, and 15.6% in public hospitals. Academic practice setting was independently associated with performing elective and emergent spine surgeries at the time of survey distribution. A majority of surgeons reported a >75% decrease in case volume. Private practice and privademic surgeons reported losing income at a higher rate compared with academic or public surgeons. Practice setting was associated with personal protective equipment availability and economic issues as a source of stress. CONCLUSIONS: The current study indicates that practice setting affected both preparedness and response to COVID-19. Surgeons in private and privademic practices reported increased worry about the economic implications of the current crisis compared with surgeons in academic and public hospitals. COVID-19 decreased overall clinical productivity, revenue, and income. Government response to the current pandemic and preparation for future pandemics needs to be adaptable to surgeons in all practice settings.

Preoperative PROMIS Scores Predict Postoperative Outcomes in Lumbar Spine Surgery Patients.

STUDY DESIGN: Retrospective case series. OBJECTIVE: Our objective was to examine the ability of preoperative Patient-reported Outcomes Measurement Information System (PROMIS) scores to predict postoperative achievement of a minimum clinically important difference (MCID) in outcome scores following lumbar spine surgery. SUMMARY OF BACKGROUND DATA: PROMIS is a computer adaptive testing system that has been validated in spine surgery patients. PROMIS allows for more efficient and personalized data collection compared to legacy assessment tools. METHODS: A total of 138 patients who underwent lumbar spine surgery at a single institution completed PROMIS Physical Function (PF) and Pain Interference (PI) scores preoperatively and at 3, 12, and 24 months postoperatively. Univariate and multivariate analyses of PROMIS scores and clinical factors were performed. Receiver-operating characteristic curves were calculated to determine the ability of preoperative scores to predict postoperative achievement of an MCID of 8. PF and PI t score MCID achievement threshold values with 90% specificity were calculated. RESULTS: Preoperative PROMIS PF and PI scores were significantly correlated to achievement of postoperative MCID after multivariate analysis. Patients with worse preoperative scores were more likely to achieve MCID. Preoperative PF and PI scores showed strong predictive value in determining ability to achieve postoperative MCID with respective area under the curve of 0.85 and 0.82. A preoperative PF threshold T-score of 31.6 had a 64% chance of achieving postoperative MCID, while a preoperative PI threshold t score of 67.8 had an 86% chance of achieving postoperative MCID. CONCLUSION: Preoperative PROMIS PF and PI scores predicted improvement in postoperative PROMIS scores in lumbar spine surgery patients as worse preoperative scores correlated to improved PROMIS scores postoperatively. The calculated threshold t scores showed the ability to predict improvement in postoperative PROMIS scores. Preoperative PROMIS data may be useful in surgical decision-making and improved patient education regarding postoperative outcomes.Level of Evidence: 4.

Narrative review of intraoperative image guidance for transforaminal lumbar interbody fusion.

Recent advancements in imaging technology have changed the landscape of transforaminal lumbar interbody fusion (TLIF) with the objective of improving safety and efficacy for the patient and surgical team. Spine surgery, and specifically TLIFs, involve challenging anatomy and command precise surgical accuracy, creating an essential role for intraoperative imaging, navigation, and robotics. Traditionally, surgeons have relied upon fluoroscopy for pedicle screw and interbody placement. More recently, intraoperative 3-dimensional navigation (ION) has risen in popularity in TLIF surgery. This technology utilizes intra-operative advanced imaging, such as computed tomography (CT) and 3D-fluroscopy, to accurately track instruments and implants in relation to the patient's anatomy. ION has demonstrated improved accuracy of pedicle screw placement, decreased operating room times, and lower radiation exposure to the surgeon and staff. However, conventional fluoroscopy, 3D fluoroscopy, intraoperative CT, image-guided navigation, and robot-assisted surgery all have a role in TLIF surgery. Numerous studies have been published regarding the benefits and pitfalls of these intraoperative tools in spine surgery, but there is a relative lack of research regarding some of the newer technologies surrounding TLIF. As future studies are published, and technology continues to evolve, surgeons must stay abreast of novel techniques to maximize patient safety and outcomes. Over the coming decade, we can expect intraoperative navigation and robotics to play a more significant role in spine surgery.

COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study.

PURPOSE: The COVID-19 pandemic forced many surgeons to adopt "virtual medicine" practices, defined as telehealth services for patient care and online platforms for continuing medical education. The purpose of this study was to assess spine surgeon reliance on virtual medicine during the pandemic and to discuss the future of virtual medicine in spine surgery. METHODS: A comprehensive survey addressing demographic data and virtual medicine practices was distributed to spine surgeons worldwide between March 27, 2020, and April 4, 2020. RESULTS: 902 spine surgeons representing seven global regions responded. 35.6% of surgeons were identified as "high telehealth users," conducting more than half of clinic visits virtually. Predictors of high telehealth utilization included working in an academic practice (OR = 1.68, p = 0.0015) and practicing in Europe/North America (OR 3.42, p < 0.0001). 80.1% of all surgeons were interested in online education. Dedicating more than 25% of one's practice to teaching (OR = 1.89, p = 0.037) predicted increased interest in online education. 26.2% of respondents were identified as "virtual medicine surgeons," defined as surgeons with both high telehealth usage and increased interest in online education. Living in Europe/North America and practicing in an academic practice increased odds of being a virtual medicine surgeon by 2.28 (p = 0.002) and 1.15 (p = 0.0082), respectively. 93.8% of surgeons reported interest in a centralized platform facilitating surgeon-to-surgeon communication. CONCLUSION: COVID-19 has changed spine surgery by triggering rapid adoption of virtual medicine practices. The demonstrated global interest in virtual medicine suggests that it may become part of the "new normal" for surgeons in the post-pandemic era.

Impact of Preoperative Opioid Use on Postoperative Patient-reported Outcomes in Lumbar Spine Surgery Patients.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: Investigate the impact of preoperative opioid use on postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores in patients undergoing elective spine surgery. BACKGROUND DATA: The PROMIS has demonstrated reliability and validity in conditions such as lumbar stenosis, disc herniation, and cervical spondylosis. Although previous studies have identified the negative impact of preoperative opioid use on legacy patient-reported outcome measures following lumbar spine surgery, no study to date has utilized PROMIS computer adaptive tests. METHODS: Consecutive patients who underwent lumbar spine surgery at a single institution between 2014 and 2016 completed PROMIS PF and PI scores at baseline preoperatively and at 3, 12, and 24 months postoperatively. Preoperative opioid use was defined as >1 month before surgery. Univariate and linear mixed model multivariate analysis was performed to evaluate for correlation of preoperative opioid use, as well as patient risk factors, with postoperative PROMIS PI and PF scores at each time point. RESULTS: Ninety-one patients met inclusion criteria with PROMIS scores at every time point. A total of 36 (39.6%) patients self-reported taking opioids at the time of surgery. Mean duration of opioid use among opioid users was 6.5±7.4 months. Patients taking preoperative opioids had significantly less improvement at all time points out to 24 months. At 24 months, patients in the nonopioid group had mean PI improvement of -13.0±14.2 versus -4.9±15.4 in the opioid group (P=0.014). The mean postoperative improvement in the opioid group did not achieve minimally clinically important difference (MCID) of 8 at any time point. CONCLUSIONS: Patients who do not use opioids preoperatively show significant postsurgical improvement in PI scores compared with patients who use preoperative opioids. Mean improvement in PROMIS PI scores failed to meet an MCID of 8 in opioid users, whereas mean improvement exceeded this MCID in opioid naive patients. The results of this study help elucidate the deleterious impact of opioids, allowing surgeons to better set patient expectations. LEVEL OF EVIDENCE: Level III.

Characterizing the host response to rhPDGF-BB in a rat spinal arthrodesis model.

BACKGROUND: Due to the constraints surrounding autograft bone, surgeons have turned to osteoinductive agents to augment spinal fusion. Reports of complications and questionable efficacy slowed the adoption of these alternatives. Recombinant human platelet-derived growth factor B homodimer (rhPDGF-BB) has been Food and Drug Administration (FDA)-approved (Augment) to promote fusion in other areas of orthopedics, but its characterization in spine fusion has not yet been tested. The purpose of this study is to characterize the host response to PDGF-BB in vivo. METHODS: Eighty female Fischer rats underwent L4-5 posterolateral fusion using one of four implant types: (a) iliac crest syngeneic allograft harvested from syngeneic donors, (b) ß-TCP/bovine collagen matrix (ß-TCP/Col) with sodium acetate buffer, (c) ß-TCP/Col with 0.3 mg/mL "low dose," or (d) ß-TCP/Col with 3.0 mg/mL "high dose" of rhPDGF-BB. Animals underwent magnetic resonance imaging (MRI) and serum cytokine quantification at 4, 7, 10, and 21 days, postoperatively. Tissues were processed for immunofluorescence staining for Ki67 and von Willebrand factor (vWF) to assess neovascularization. RESULTS: MRI demonstrated no differences in fluid accumulation among the four treatment groups at any of the time points. Serum cytokine analysis showed no clinically significant differences between treatment groups in 20 of the 27 cytokines. Inflammatory cytokines IFN-γ, IL-1ß, IL-18, MCP-1, MIP-1α, TNF-α were not induced by rhPDGF-BB. Histology showed no differences in cell infiltration, and Ki67 and vWF immunofluorescence staining was similar among groups. CONCLUSIONS: rhPDGF-BB delivered with a ß-TCP/Col matrix exerts no exaggerated systemic or local host inflammatory response when compared to iliac crest syngeneic allograft bone or the control carrier. rhPDGF-BB mixed with a ß-TCP/Col matrix could be a viable and safe biologic alternative to syngeneic allograft in spine fusion. Further studies need to be performed to evaluate efficacy in this setting.

Assessing the Early Impact of the COVID-19 Pandemic on Spine Surgery Fellowship Education.

STUDY DESIGN: This was a cross-sectional study. OBJECTIVE: The objective of this study is to report the impact of COVID-19 on spine surgery fellow education and readiness for practice. SUMMARY OF BACKGROUND DATA: COVID-19 has emerged as one of the most devastating global health crises of our time. To minimize transmission risk and to ensure availability of health resources, many hospitals have cancelled elective surgeries. There may be unintended consequences of this decision on the education and preparedness of current surgical trainees. MATERIALS AND METHODS: A multidimensional survey was created and distributed to all current AO Spine fellows and fellowship directors across the United States and Canada. RESULTS: Forty-five spine surgery fellows and 25 fellowship directors completed the survey. 62.2% of fellows reported >50% decrease in overall case volume since cancellation of elective surgeries. Mean hours worked per week decreased by 56.2%. Fellows reported completing a mean of 188.4±64.8 cases before the COVID-19 crisis and 84.1% expect at least an 11%-25% reduction in case volume compared with previous spine fellows. In all, 95.5% of fellows did not expect COVID-19 to impact their ability to complete fellowship. Only 2 directors were concerned about their fellows successfully completing fellowship; however, 32% of directors reported hearing concerns regarding preparedness from their fellows and 25% of fellows were concerned about job opportunities. CONCLUSIONS: COVID-19 has universally impacted work hours and case volume for spine surgery fellows set to complete fellowship in the middle of 2020. Nevertheless, spine surgery fellows generally feel ready to enter practice and are supported by the confidence of their fellowship directors. The survey highlights a number of opportunities for improvement and innovation in the future training of spine surgeons. LEVEL OF EVIDENCE: Level III.

Correction to: Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

Unfortunately, the 13th author name has been incorrectly published in the original publication. The complete correct name is given below.

Strategies to Achieve Spinal Fusion in Multilevel Anterior Cervical Spine Surgery: An Overview.

BACKGROUND: Anterior cervical fusion offers surgeons a safe and reliable surgical option for single-level and multilevel pathology; however, multilevel fusions pose a higher risk of complications than single-level fusions, including possible pseudoarthrosis, adjacent segment disease, sagittal imbalance, and construct subsidence. Various techniques can be used to mitigate risk in multilevel anterior cervical fusion. QUESTIONS/PURPOSES: We reviewed the literature to determine the best surgical strategies in multilevel anterior cervical fusion. METHODS: We searched the PubMed database for articles published from January 1980 through July 2019. Two authors identified relevant articles and then manually screened them for others to include in this review. RESULTS: We initially identified 1936 articles and included 48 in our review. We found that clinical outcomes of multilevel anterior cervical fusion can be optimized through the use of biologics and graft selection, the evaluation of pre-existing deformity, the assessment of comorbidities, and the selection of fusion levels. Meticulous surgical technique in conjunction with modern surgical tools, such as instrumentation and biologics, allow surgeons to address complex cervical problems while limiting morbidity and enhancing clinical outcomes. CONCLUSIONS: Multilevel anterior cervical fusions offer a relatively safe and reliable treatment option for both single-level and multilevel pathology.

Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

PURPOSE: Spine surgeons around the world have been universally impacted by COVID-19. The current study addressed whether prior experience with disease epidemics among the spine surgeon community had an impact on preparedness and response toward COVID-19. METHODS: A 73-item survey was distributed to spine surgeons worldwide via AO Spine. Questions focused on: demographics, COVID-19 preparedness, response, and impact. Respondents with and without prior epidemic experience (e.g., SARS, H1NI, MERS) were assessed on preparedness and response via univariate and multivariate modeling. Results of the survey were compared against the Global Health Security Index. RESULTS: Totally, 902 surgeons from 7 global regions completed the survey. 24.2% of respondents had prior experience with global health crises. Only 49.6% reported adequate access to personal protective equipment. There were no differences in preparedness reported by respondents with prior epidemic exposure. Government and hospital responses were fairly consistent around the world. Prior epidemic experience did not impact the presence of preparedness guidelines. There were subtle differences in sources of stress, coping strategies, performance of elective surgeries, and impact on income driven by prior epidemic exposure. 94.7% expressed a need for formal, international guidelines to help mitigate the impact of the current and future pandemics. CONCLUSIONS: This is the first study to note that prior experience with infectious disease crises did not appear to help spine surgeons prepare for the current COVID-19 pandemic. Based on survey results, the GHSI was not an effective measure of COVID-19 preparedness. Formal international guidelines for crisis preparedness are needed to mitigate future pandemics.

Disparities in Hip Arthroplasty Outcomes: Results of a Statewide Hospital Registry From 2016 to 2018.

BACKGROUND: In November 2019, Centers for Medicare and Medicaid Services announced total hip arthroplasty (THA) will be removed from the inpatient-only list. This may lead to avoidance of patients who have prolonged hospitalizations and discharge to skilled nursing facilities or push providers to unsafely push patients to outpatient surgery centers. Disparities in hip arthroplasty may worsen as patients are "risk stratified" preoperatively to minimize cost outliers. We aimed to evaluate which patient characteristics are associated with extended length of stay (eLOS)-greater than 2 days-and nonhome discharge in patients undergoing hip arthroplasty. METHODS: The Illinois COMPdata administrative database was queried for THA admissions from January 2016 to June 2018. Variables included age, sex, race and ethnicity, median household income, Illinois region, insurance status, principal diagnosis, Charlson comorbidity index, obesity, discharge disposition, and LOS. Hospital characteristics included bundled payment participation and arthroplasty volume. Using multiple Poisson regression, we examined the association between these factors and the likelihood of nonhome discharge and eLOS. RESULTS: There were 41,832 THA admissions from January 2016 to June 2018. A total of 36% had LOS greater than 2 midnights and 25.3% of patients had nonhome discharges. Female patients, non-Hispanic black patients, patients older than 75, obese patients, Medicaid or uninsured status, Charlson comorbidity index > 3, and hip arthroplasty for fracture were associated with increased risk of eLOS and/or nonhome discharge (P < .05). CONCLUSION: With the Centers for Medicare and Medicaid Services emphasis on cost containment, patients at risk of extended stay or nonhome discharge may be deemed "high risk" and have difficulty accessing arthroplasty care. These are potentially vulnerable groups during the transition to the bundled payment model.

Burden of Sciatica on US Medicare Recipients.

OBJECTIVE: This study evaluates the disease burden of sciatica on the US Medicare cohort. BACKGROUND DATA: Sciatica is a common disability that has important physical, mental, and economic effects. The Medicare Health Outcomes Survey (HOS) is a demographic and outcomes survey used to monitor the performance of Medicare Advantage health plans in the United States. The HOS includes data on demographics, chronic medical conditions, and patient-reported outcomes. METHODS: Medicare HOS data for cohorts from 2007 to 2013 were obtained. Patients were placed into two categories based on the survey results: with or without a history of sciatica. Baseline demographics, chronic medical conditions, and physical health symptoms were aggregated. In addition, average VR-12 physical component summary and mental component summary scores were calculated for each group at baseline and at 2-year follow-up. A Fisher exact test was used to assess significance for categorical variables, and a t-test was used for continuous variables. VR-12 changes as small as 1 to 2 units have been found to be clinically and socially relevant. RESULTS: The baseline cohort data of 1,000,952 patients yielded 250,869 patients (25%) who reported the diagnosis of sciatica, compared with 750,083 patients (75%) without sciatica. Patients with a history of sciatica tended to be younger, less educated, and notably with more medical comorbidities. Physical component summary outcomes were approximately 8 units lower in the sciatica group at baseline and 7 units lower at 2-year follow-up. Mental component summary outcomes were 6 units lower in the sciatica group at baseline and 5 units lower at 2-year follow-up. CONCLUSION: A large percentage of the US Medicare cohort suffers from symptomatic sciatica. Our study identified a 25% prevalence in the Medicare cohort. In addition, sciatica is associated with an increased incidence of comorbid medical conditions and poor health-related quality of life. LEVEL OF EVIDENCE: Level III STUDY DESIGN:: Observational-Cohort Study.

Which Postoperative Day After Total Joint Arthroplasty Are Catastrophic Events Most Likely to Occur?

BACKGROUND: Despite lacking granularity, large database registries can help provide important information on rare outcomes following total joint arthroplasty (TJA). In an era of short stay and outpatient arthroplasty, an awareness of the timeframe for most common catastrophic complications can help providers maintain an appropriate degree of suspicion for these significant events. METHODS: Patients undergoing primary TJA between 2011 and 2016 were identified in the National Surgical Quality Improvement Program and queried for 4 adverse postoperative outcomes: pulmonary embolism (PE), myocardial infarction or cardiac arrest, cerebrovascular accident, and death. The timing of postoperative events was compared, and also their association with medical comorbidities and timing in inpatient vs outpatient arthroplasty. RESULTS: A total of 341,601 patients met inclusion criteria. Of them, 1631 (0.48%) patients sustained a postoperative PE, 1033 (0.3%) patients had a cardiac event, 304 patients had a cerebrovascular accident (0.09%), and 608 (0.18%) patients expired. Greater than 60% of all these complications occurred between postoperative days 0 and 5, including 65% of PE. On postoperative day 0, a catastrophic event is 13 times more likely to be a cardiac event (80.7%) compared to a PE (6%). However, by postoperative day 1, a cardiac event (41.2%) is only 1.03 times more likely than a PE (40%) and by postoperative day 2, a PE (62%) is twice as likely as a cardiac event (30%). CONCLUSION: Risk assessment for catastrophic event and timeliness of occurrence may guide providers to recommend enhanced observation for specific patients undergoing TJA.

Aryl Hydrocarbon Receptor Antagonists Mitigate the Effects of Dioxin on Critical Cellular Functions in Differentiating Human Osteoblast-Like Cells.

The inhibition of bone healing in humans is a well-established effect associated with cigarette smoking, but the underlying mechanisms are still unclear. Recent work using animal cell lines have implicated the aryl hydrocarbon receptor (AhR) as a mediator of the anti-osteogenic effects of cigarette smoke, but the complexity of cigarette smoke mixtures makes understanding the mechanisms of action a major challenge. 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD, dioxin) is a high-affinity AhR ligand that is frequently used to investigate biological processes impacted by AhR activation. Since there are dozens of AhR ligands present in cigarette smoke, we utilized dioxin as a prototype ligand to activate the receptor and explore its effects on pro-osteogenic biomarkers and other factors critical to osteogenesis using a human osteoblast-like cell line. We also explored the capacity for AhR antagonists to protect against dioxin action in this context. We found dioxin to inhibit osteogenic differentiation, whereas co-treatment with various AhR antagonists protected against dioxin action. Dioxin also negatively impacted cell adhesion with a corresponding reduction in the expression of integrin and cadherin proteins, which are known to be involved in this process. Similarly, the dioxin-mediated inhibition of cell migration correlated with reduced expression of the chemokine receptor CXCR4 and its ligand, CXCL12, and co-treatment with antagonists restored migratory capacity. Our results suggest that AhR activation may play a role in the bone regenerative response in humans exposed to AhR activators, such as those present in cigarette smoke. Given the similarity of our results using a human cell line to previous work done in murine cells, animal models may yield data relevant to the human setting. In addition, the AhR may represent a potential therapeutic target for orthopedic patients who smoke cigarettes, or those who are exposed to secondhand smoke or other environmental sources of aryl hydrocarbons.

Can Surgeon Demographic Factors Predict Postoperative Complication Rates After Elective Spinal Fusion?

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine whether surgeon demographic factors influence postoperative complication rates after elective spine fusion procedures. BACKGROUND: Surgeon demographic factors have been shown to impact decision making in the management of degenerative disease of the lumbar spine. Complication rates are frequently reported outcome measurements used to evaluate surgical treatments, quality-of-care, and determine health care reimbursements. However, there are few studies investigating the association between surgeon demographic factors and complication outcomes after elective spine fusions. METHODS: A database of US spine surgeons with corresponding postoperative complications data after elective spine fusions was compiled utilizing public data provided by the Centers for Medicare and Medicaid Services (2011-2013) and ProPublica Surgeon Scorecard (2009-2013). Demographic data for each surgeon was collected and consisted of: surgical specialty (orthopedic vs. neurosurgery), years in practice, practice setting (private vs. academic), type of medical degree (MD vs. DO), medical school location (United States vs. foreign), sex, and geographic region of practice. General linear mixed models using a Beta distribution with a logit link and pairwise comparison with post hoc Tukey-Kramer were used to assess the relationship between surgeon demographics and complication rates. RESULTS: 2110 US-practicing spine surgeons who performed spine fusions on 125,787 Medicare patients from 2011 to 2013 met inclusion criteria for this study. None of the surgeon demographic factors analyzed were found to significantly affect overall complication rates in lumbar (posterior approach) or cervical spine fusion. CONCLUSIONS: Publicly available complication rates for individual spine surgeons are being utilized by hospital systems and patients to assess aptitude and gauge expectations. The increasing demand for transparency will likely lead to emphasis of these statistics to improve outcomes. We conclude that none of the surgeon demographic factors analyzed in this study are associated with differences in overall complications rates in patients undergoing elective spine fusion as published by the ProPublica Surgeon Scorecard. LEVEL OF EVIDENCE: Level 3.

Factors Associated With Financial Relationships Between Spine Surgeons and Industry: An Analysis of the Open Payments Database.

STUDY DESIGN: A retrospective review of Centers for Medicare and Medicaid Services Database. OBJECTIVE: Utilizing Open Payments data, we aimed to determine the prevalence of industry payments to orthopedic and neurospine surgeons, report the magnitude of those relationships, and help outline the surgeon demographic factors associated with industry relationships. SUMMARY OF BACKGROUND DATA: Previous Open Payments data revealed that orthopedic surgeons receive the highest value of industry payments. No study has investigated the financial relationship between spine surgeons and industry using the most recent release of Open Payments data. METHODS: A database of 5898 spine surgeons in the United States was derived from the Open Payments website. Demographic data were collected, including the type of residency training, years of experience, practice setting, type of medical degree, place of training, gender, and region of practice. Multivariate generalized linear mixed models were utilized to determine the relationship between demographics and industry payments. RESULTS: A total of 5898 spine surgeons met inclusion criteria. About 91.6% of surgeons reported at least one financial relationship with industry. The median total value of payments was $994.07. Surgeons receiving over $1,000,000 from industry during the reporting period represented 6.6% of the database and accounted for 83.5% of the total value exchanged. Orthopedic training (P < 0.001), academic practice setting (P < 0.0001), male gender (P < 0.0001), and West or South region of practice (P < 0.0001) were associated with industry payments. Linear regression analysis revealed a strong inverse relationship between years of experience and number of payments from industry (r = -0.967, P < 0.0001). CONCLUSION: Financial relationships between spine surgeons and industry are highly prevalent. Surgeon demographics have a significant association with industry-surgeon financial relationships. Our reported value of payments did not include ownership or research payments and thus likely underestimates the magnitude of these financial relationships. LEVEL OF EVIDENCE: 3.

Do Demographic Factors of Spine Surgeons Affect the Rate at Which Spinal Fusion Is Performed on Patients?

STUDY DESIGN: Retrospective study. OBJECTIVE: The purpose of this study was to evaluate associations between spine surgeon demographics and the rate at which elective spine fusion is performed. SUMMARY OF BACKGROUND DATA: Rapidly increasing rates of elective spinal fusion in the United States have given rise to important questions about what factors may drive spine surgeon decision making. METHODS: Publicly available spine surgeon practice pattern data from Centers for Medicare and Medicaid Services were reviewed retrospectively. Fusion rate was defined as the number of fusion procedures performed on Medicare beneficiaries by a surgeon per total number of unique Medicare beneficiaries seen. Inclusion criteria were neurological or orthopedic spine surgeons who performed 11 or more separate spine fusion procedures on Medicare patients between 2011 and 2013 as defined by this database. Demographic information was collected from public record. The increased probability of a surgeon performing spine fusion was assessed using a relative risk (RR) and corresponding 95% confidence interval (CI). RESULTS: A total of 3979 spine surgeons who practice in the United States and performed spine fusion on 171,676 Medicare patients from 2011 to 2013 met the inclusion criteria. The average rate of spine fusion for surgeons in this database was 7.5%. Surgeons with higher fusion rates practiced in an academic versus private setting (RR = 1.44, 95% CI [1.35-1.53]; P < 0.0001), were more likely neurological versus orthopedic surgeons (RR = 1.10, 95% CI [1.05-1.15]; P < 0.0001), and practiced in the West versus Midwest, South, and Northeast region of the United States (RR = 1.20, 95% CI [1.14-1.27]; P < 0.0001). Number of years in practice was significantly associated negatively with fusion rate (P < 0.0001). CONCLUSION: Significant variation in the rate of spine fusion based on practice type, training, region, and experience suggests poor consensus on indications for this procedure. Knowledge of these relationships may help identify underlying reasons for variations in surgical care and improve surgical outcomes. LEVEL OF EVIDENCE: 3.

Sport and Sex-Specific Reporting Trends in the Epidemiology of Concussions Sustained by High School Athletes.

BACKGROUND: Approximately 300,000 U.S. adolescents sustain concussions annually while participating in organized athletics. This study aimed to track sex and sport-specific trends among high school sports-related concussions over time, to identify whether a particular sport predisposes athletes to a higher risk, and to assess whether traumatic brain injury law enactments have been successful in improving recognition. METHODS: Injury data for academic years 2005 to 2014 were collected from annual reports generated by High School RIO (Reporting Information Online). The relative proportions of total estimated concussions to total estimated injuries were compared using an injury proportion ratio. The concussion rate was defined as the number of concussions per 10,000 athlete exposures (1 athlete participating in 1 practice or competition), with rates compared using a rate ratio. To evaluate the impact of legislation on sports-related concussions in this population, trends in concussion rates and proportions were analyzed before enactment (academic years 2005-2009) and after enactment (academic years 2010-2014). RESULTS: Between 2005-2006 and 2014-2015, a significant increase (p < 0.0001) in the overall number of concussions for all sports combined, the overall concussion rate (rate ratio, 2.30 [95% confidence interval, 2.04 to 2.59]), and the overall proportion of concussions (injury proportion ratio, 2.68 [95% confidence interval, 2.66 to 2.70]) was seen. Based on the injury proportion ratio, during the 2014-2015 academic year, concussions were more common in girls' soccer than in any other sport (p < 0.0001). CONCLUSIONS: Because of potentially devastating consequences, concussion prevention and recognition measures continue to be emphasized in high school contact sports. The data in our study suggest that significant increases in the overall rate and proportion of reported concussions during the past decade could have been affected by traumatic brain injury legislation. To our knowledge, this is the first study to show that girls' soccer players may have an even greater risk of sustaining a concussion than all other sports. CLINICAL RELEVANCE: Sports-related concussions in adolescent athletes can have devastating consequences, and we now know that female athletes, especially girls' soccer players, may be at an even greater risk for sustaining this injury than all other athletes. Knowledge of the trends identified by this study may help lead to policy and prevention measures that can accommodate each sport effectively and potentially halt these trends.