Adjunctive Use of Bone Growth Stimulation Increases Cervical Spine Fusion Rates in Patients at Risk for Pseudarthrosis.

STUDY DESIGN: A prospective multicenter clinical trial (NCT03177473) was conducted with a retrospective cohort used as a control arm. OBJECTIVE: The purpose of this study was to evaluate cervical spine fusion rates in subjects with risk factors for pseudarthrosis who received pulsed electromagnetic field (PEMF) treatment. SUMMARY OF BACKGROUND DATA: Certain risk factors predispose patients to pseudarthrosis, which is associated with prolonged pain, reduced function, and decreased quality of life. METHODS: Subjects in the PEMF group were treated with PEMF for 6 months postoperatively. The primary outcome measure was fusion status at the 12-month follow-up period. Fusion status was determined using anterior/posterior, lateral, and flexion/extension radiographs and computed tomography (without contrast). RESULTS: A total of 213 patients were evaluated (PEMF, n=160; Control, n=53). At baseline, the PEMF group had a higher percentage of subjects who used nicotine ( P =0.01), had osteoporosis ( P <0.05), multi-level disease ( P <0.0001), and were >65 years of age ( P =0.01). The PEMF group showed over two-fold higher percentage of subjects that had ≥3 risk factors (n=92/160, 57.5%) compared with the control group (n=14/53, 26.4%). At the 12-month follow-up, the PEMF group demonstrated significantly higher fusion rates compared with the control (90.0% vs. 60.4%, P <0.05). A statistically significant improvement in fusion rate was observed in PEMF subjects with multi-level surgery ( P <0.0001) and high BMI (>30 kg/m 2 ; P =0.0021) when compared with the control group. No significant safety concerns were observed. CONCLUSIONS: Adjunctive use of PEMF stimulation provides significant improvements in cervical spine fusion rates in subjects having risk factors for pseudarthrosis. When compared with control subjects that did not use PEMF stimulation, treated subjects showed improved fusion outcomes despite being older, having more risk factors for pseudarthrosis, and undergoing more complex surgeries.

The impact of anxiety and depression on lumbar spine surgical outcomes: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: The presence of depression and anxiety has been associated with negative outcomes in spine surgery patients. While it seems evident that a history of depression or anxiety can negatively influence outcome, the exact additive effect of both has not been extensively studied in a multicenter trial. The purpose of this study was to investigate the relationship between a patient's history of anxiety and depression and their patient-reported outcomes (PROs) after lumbar surgery. METHODS: Patients in the Michigan Spine Surgery Improvement Collaborative registry undergoing lumbar spine surgery between July 2016 and December 2021 were grouped into four cohorts: those with a history of anxiety only, those with a history of depression only, those with both, and those with neither. Primary outcomes were achieving the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System Physical Function 4-item Short Form (PROMIS PF), EQ-5D, and numeric rating scale (NRS) back pain and leg pain, and North American Spine Society patient satisfaction. Secondary outcomes included surgical site infection, hospital readmission, and return to the operating room. Multivariate Poisson generalized estimating equation models were used to report incidence rate ratios (IRRs) from patient baseline variables. RESULTS: Of the 45,565 patients identified, 3941 reported a history of anxiety, 5017 reported a history of depression, 9570 reported both, and 27,037 reported neither. Compared with those who reported having neither, patients with both anxiety and depression had lower patient satisfaction at 90 days (p = 0.002) and 1 year (p = 0.021); PROMIS PF MCID at 90 days (p < 0.001), 1 year (p < 0.001), and 2 years (p = 0.006); EQ-5D MCID at 90 days (p < 0.001), 1 year (p < 0.001), and 2 years (p < 0.001); NRS back pain MCID at 90 days (p < 0.001) and 1 year (p < 0.001); and NRS leg pain MCID at 90 days (p < 0.001), 1 year (p = 0.024), and 2 years (p = 0.027). Patients with anxiety only (p < 0.001), depression only (p < 0.001), or both (p < 0.001) were more likely to be readmitted within 90 days. Additionally, patients with anxiety only (p = 0.015) and both anxiety and depression (p = 0.015) had higher rates of surgical site infection. Patients with anxiety only (p = 0.006) and depression only (p = 0.021) also had higher rates of return to the operating room. CONCLUSIONS: The authors observed an association between a history of anxiety and depression and negative outcome after lumbar spine surgery. In addition, they found an additive effect of a history of both anxiety and depression with an increased risk of negative outcome when compared with either anxiety or depression alone.

Risk factors of emergency department visits following elective cervical and lumbar surgical procedures: a multi-institution analysis from the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVE: Emergency department visits 90 days after elective spinal surgery are relatively common, with rates ranging from 9% to 29%. Emergency visits are very costly, so their reduction is of importance. This study's objective was to evaluate the reasons for emergency department visits and determine potentially modifiable risk factors. METHODS: This study retrospectively reviewed data queried from the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry from July 2020 to November 2021. MSSIC is a multicenter (28-hospital) registry of patients undergoing cervical and lumbar degenerative spinal surgery. Adult patients treated for elective cervical and/or lumbar spine surgery for degenerative pathology (spondylosis, intervertebral disc disease, low-grade spondylolisthesis) were included. Emergency department visits within 90 days of surgery (outcome measure) were analyzed utilizing univariate and multivariate regression analyses. RESULTS: Of 16,224 patients, 2024 (12.5%) presented to the emergency department during the study period, most commonly for pain related to spinal surgery (31.5%), abdominal problems (15.8%), and pain unrelated to the spinal surgery (12.8%). On multivariate analysis, age (per 5-year increase) (relative risk [RR] 0.94, 95% CI 0.92-0.95), college education (RR 0.82, 95% CI 0.69-0.96), private insurance (RR 0.79, 95% CI 0.70-0.89), and preoperative ambulation status (RR 0.88, 95% CI 0.79-0.97) were associated with decreased emergency visits. Conversely, Black race (RR 1.30, 95% CI 1.13-1.51), current diabetes (RR 1.13, 95% CI 1.01-1.26), history of deep venous thromboembolism (RR 1.28, 95% CI 1.16-1.43), history of depression (RR 1.13, 95% CI 1.03-1.25), history of anxiety (RR 1.32, 95% CI 1.19-1.46), history of osteoporosis (RR 1.21, 95% CI 1.09-1.34), history of chronic obstructive pulmonary disease (RR 1.19, 95% CI 1.06-1.34), American Society of Anesthesiologists class > II (RR 1.18, 95% CI 1.08-1.29), and length of stay > 3 days (RR 1.29, 95% CI 1.16-1.44) were associated with increased emergency visits. CONCLUSIONS: The most common reasons for emergency department visits were surgical pain, abdominal dysfunction, and pain unrelated to index spinal surgery. Increased focus on postoperative pain management and bowel regimen can potentially reduce emergency visits. The risks of diabetes, history of osteoporosis, depression, and anxiety are areas for additional preoperative screening.

Do Patients Accurately Recall Pain Levels Following Sacroiliac Joint Steroid Injection? A Cohort Study of Recall Bias in Patient-reported Outcomes.

BACKGROUND: Sacroiliac joint (SIJ) injections are crucial in the diagnostic toolkit for evaluating SIJ pathology. Recall bias is an important component in patient-reported outcomes that has not been well studied in SIJ injection. OBJECTIVE: The purpose of this study was to characterize the accuracy, direction, and magnitude of pain level recall bias following SIJ steroid injection and study the factors that affect patient recollection. STUDY DESIGN: Prospective cohort study. SETTING: Level 1 academic medical center. METHODS: Using standardized questionnaires, baseline Numeric Rating Scale (NRS-11) scores were recorded for patients undergoing SIJ steroid injections at preinjection, at 4 hours postinjection, and at 24 hours postinjection. At a minimum of 2 weeks postinjection, patients were asked to recall their preinjection, 4-hour, and 24-hour postinjection NRS-11 scores. Actual and recalled NRS-11 scores were compared using paired t tests for each time interval. Multivariable linear regression was used to identify factors that correlated with consistent recall. RESULTS: Sixty patients with a mean age of 66 years (65% women) were included. Compared to their preinjection pain score, patients showed considerable improvement at both 4 hours (mean difference [MD] = 3.28; 95% CI, 2.68 - 3.89), and 24 hours (MD = 3.23; 95% CI, 2.44 - 4.03) postinjection. Patient recollection of preinjection symptoms was more severe than actual (MD = 0.65; 95% CI, 0.31 - 0.99). Patient recollection of symptoms was also more severe than actual at 4 hours (MD = 0.50; 95% CI .04 - 1.04) as well as at 24 hours postinjection (MD = 0.80; 95% CI, 0.16 - 1.44). The magnitude of recall bias was mild and did not exceed the minimal clinically important difference. There was a moderate correlation between actual and recalled pain levels when comparing preinjection with the 4-hour postinjection NRS-11 score (correlation coefficient [r] =0.64; P < 0.001) and moderate correlation when comparing preinjection with the 24-hour postinjection NRS-11 score (r = 0.62; P < 0.001). Linear regression models showed that at preinjection, patients with a lower body mass index and the presence of coexisting psychiatric diagnoses were better at recalling their pain (P < 0.05). Patients with a higher body mass index also experienced less pain relief when comparing preinjection with the 4-hour postinjection NRS-11 score (P < 0.05). LIMITATIONS: Recall pain scores were obtained via telephone surveys, which can lead to interview bias. One patient died, and 3 were lost to follow-up. We did not control for patient use of adjunctive pain relief modalities, which may modulate the overall response to injection. SIJ injections can also be diagnostic, so some patients may not have shared the same indication for injection or pain-generating diagnosis. CONCLUSIONS: Patients had favorable pain level responses to their SIJ steroid injection for both actual and recall surveys. Although patients demonstrated poor recall of absolute pain scores at preinjection, 4-hour postinjection, and 24-hour postinjection, they demonstrated robust recall of their net pain score improvement at both 4- and 24-hours postinjection. These findings suggest that there is utility in using patient recollection to describe the magnitude of pain relief following treatment for sacroiliac joint dysfunction.

Does Tighter Glycemic Control Beyond Hemoglobin A1c of 8% Improve Outcome for Lumbar Spine Surgery? A MSSIC Study.

BACKGROUND AND OBJECTIVES: Diabetes mellitus is associated with increased risk of postoperative adverse outcomes. Previous studies have emphasized the role of glycemic control in postoperative complications. This study aims to ascertain whether controlling hemoglobin A1c (HbA1c) lower than 8% preoperatively results in meaningful risk reduction or improved outcomes. METHODS: We used patient-level data from the Michigan Spine Surgery Improvement Collaborative registry, focusing on patients who underwent elective lumbar spine surgery between 2018 and 2021. The primary outcomes were length of stay and the occurrence of postoperative adverse events. Secondary outcomes included patient satisfaction, achievement of a minimum clinically important difference (MCID) of Patient-Reported Outcomes Measurement Information System-Physical Function, the EuroQol-5D and NRS of leg and back pain, and return to work. RESULTS: A total of 11 348 patients were included in this analysis. Patients with HbA1c above the thresholds before surgery had significantly higher risks of urinary retention for all 3 possible threshold values (incidence rate ratio [IRR] = 1.30, P = .015; IRR = 1.35, P = .001; IRR = 1.25, P = .011 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively). They also had longer hospital stay (IRR = 1.04, P = .002; IRR = 1.03, P = .001; IRR = 1.03, P < .001 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively) and had higher risks of developing any complication with HbA1c cutoff of 7.5% (IRR = 1.09, P = .010) and 7% (IRR = 1.12, P = .001). Diabetics with preoperative HbA1c above all 3 thresholds were less likely to achieve Patient-Reported Outcomes Measurement Information System MCID at the 90-day follow-up (IRR = .81, P < .001; IRR = .86, P < .001; IRR = .90, P = .007 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively) and less likely to achieve EuroQol-5D MCID at the 2-year follow-up (IRR = .87, P = .027; IRR = .84, P = .005 for the HbA1c cutoffs of 7.5% and 7%, respectively). CONCLUSION: Our study suggests that reducing HbA1c below 8% may have diminishing returns regarding reducing complications after spine surgery.

Intraoperative and Postoperative Management of Incidental Durotomies During Open Degenerative Lumbar Spine Surgery: A Systematic Review.

SUMMARY OF BACKGROUND DATA: Incidental durotomy is a common intraoperative complication of lumbar spine surgery. Intra and postoperative protocols in the management of this common complication vary considerably, with no consensus in the literature. OBJECTIVE: To systematically review (1) lumbar dural repair techniques for open degenerative procedures; (2) review described postoperative protocols after lumbar dural repairs. STUDY DESIGN: Systematic review. MATERIALS AND METHODS: A systematic review of the literature was performed for all articles published from inception until September 2022 using Pubmed, EMBASE, Medline, and Cochrane databases to identify articles assessing the management of durotomy in open surgery for degenerative diseases of the lumbar spine. Two independent reviewers assessed the articles for inclusion criteria, and disagreements were resolved by consensus. Outcomes included persistent leaks, return to the operating room, recurrent symptoms, medical complications, or patient satisfaction. RESULTS: A total of 10,227 articles were initially screened. After inclusion criteria were applied, 9 studies were included (n=1270 patients) for final review. Repair techniques included; no primary repair, suture repair in running or interrupted manner with or without adjunctive sealants, sealants alone, or patch repair with muscle, fat, epidural blood patch, or synthetic graft. Postoperative protocols included the placement of a subfascial drain with varying durations of bed rest. Notable findings included no benefit of prolonged bedrest compared with early ambulation ( P =0.4), reduced cerebrospinal fluid leakage with fat graft compared with muscle grafts ( P <0.001), and decreased rates of revision surgery in studies that used subfascial drains (1.7%-2.2% vs 4.34%-6.66%). CONCLUSIONS: Significant variability in intraoperative durotomy repair techniques and postoperative protocols exists. Primary repair with fat graft augmentation seems to have the highest success rate. Postoperatively, the use of a subfascial drain with early ambulation reduces the risk of pseudomenignocele formation, medical complications, and return to the operating room. Further research should focus on prospective studies with the goal to standardize repair techniques and postoperative protocols.

Risk factors for not reaching minimal clinically important difference at 90 days and 1 year after elective lumbar spine surgery: a cohort study.

OBJECTIVE: Patient-perceived functional improvement is a core metric in lumbar surgery for degenerative disease. It is important to identify both modifiable and nonmodifiable risk factors that can be evaluated and possibly optimized prior to elective surgery. This case-control study was designed to study risk factors for not achieving the minimal clinically important difference (MCID) in Patient-Reported Outcomes Measurement Information System Function 4-item Short Form (PROMIS PF) score. METHODS: The authors queried the Michigan Spine Surgery Improvement Collaborative database to identify patients who underwent elective lumbar surgical procedures with PROMIS PF scores. Cases were divided into two cohorts based on whether patients achieved MCID at 90 days and 1 year after surgery. Patient characteristics and operative details were analyzed as potential risk factors. RESULTS: The authors captured 10,922 patients for 90-day follow-up and 4453 patients (40.8%) did not reach MCID. At the 1-year follow-up period, 7780 patients were identified and 2941 patients (37.8%) did not achieve MCID. The significant demographic characteristic-adjusted relative risks (RRs) for both groups (RR 90 day, RR 1 year) included the following: symptom duration > 1 year (1.34, 1.41); previous spine surgery (1.25, 1.30); African American descent (1.25, 1.20); chronic opiate use (1.23, 1.25); and less than high school education (1.20, 1.34). Independent ambulatory status (0.83, 0.88) and private insurance (0.91, 0.85) were associated with higher likelihood of reaching MCID at 90 days and 1 year, respectively. CONCLUSIONS: Several key unique demographic risk factors were identified in this cohort study that precluded optimal postoperative functional outcomes after elective lumbar spine surgery. With this information, appropriate preoperative counseling can be administered to assist in shaping patient expectations.

Cervical disc arthroplasty versus anterior cervical discectomy and fusion: an analysis of the Michigan Spine Surgery Improvement Collaborative Database.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are established surgical options for the treatment of cervical radiculopathy, myelopathy, and cervical degenerative disc disease. However, current literature does not demonstrate a clear superiority between ACDF and CDA. PURPOSE: To investigate procedural and patient-reported outcomes of ACDF and CDA among patients included in the Michigan Spine Surgery Improvement Collaborative (MSSIC) database. DESIGN: Retrospective study of prospectively collected outcomes registry data. PATIENT SAMPLE: Individuals within the MSSIC database presenting with radiculopathy, myelopathy, or cervical spondylosis refractory to typical conservative care undergoing primary ACDF or CDA from January 4, 2016, to November 5, 2021. OUTCOME MEASURES: Perioperative measures (including surgery length, length of stay, return to OR, any complications), patient-reported functional outcomes at 2-year follow-up (including return to work, patient satisfaction, PROMIS, EQ-5D, mJOA). METHODS: Patients undergoing ACDF were matched 4:1 with those undergoing CDA; propensity analysis performed on operative levels (1- and 2- level procedures), presenting condition, demographics, and comorbidities. Initial comparisons performed with univariate testing and multivariate analysis performed with Poisson generalized estimating equation models clustering on hospital. RESULTS: A total of 2,208 patients with ACDF and 552 patients with CDA were included. Baseline demographics were similar, with younger patients undergoing CDA (45.6 vs 48.6 years; p<.001). Myelopathy was more frequent in ACDF patients (30% vs 25%; p=.015). CDA was more frequently planned as an outpatient procedure. Length of stay was increased in ACDF (1.3 vs 1.0 days; p<.001). Functional outcomes were similar, with comparable proportions of patients meeting minimal clinically important difference thresholds in neck pain, arm pain, PROMIS, EQ-5D, and mJOA score. After multivariate regression, no significant differences were seen in surgical or functional outcomes. CONCLUSIONS: This study demonstrates similar outcomes for those undergoing ACDF and CDA at 2 years. Previous meta-analyses of CDA clinical trial data adhere to strict inclusion and exclusion criteria required by clinical studies; this registry data provides "real world" clinical outcomes reflecting current practices for ACDF and CDA patient selection.

Operative Technique for Sacral Insufficiency Fractures Causing Spinopelvic Dissociation: A Case Report.

CASE: We present a case of a 54-year-old man with atraumatic, U-type sacral insufficiency and L5 compression fractures leading to spinopelvic dissociation, inability to ambulate, and bowel/bladder compromise. The patient underwent L3-4 percutaneous pedicle screw fixation with bilateral iliac bolts and percutaneous iliosacral screw fixation. Postoperatively, the patient had return of bowel/bladder function and independent ambulation at 2.5 years. CONCLUSION: Atraumatic spinopelvic dissociation is an underappreciated pathology in older patients. Here, we describe the result of our preferred treatment strategy, triangular osteosynthesis, to preserve function and independence. Despite optimal, prompt treatment, these injuries pose a difficult rehabilitation process for patients.

The Duration of Symptoms Influences Outcomes After Lumbar Microdiscectomies: A Michigan Spine Surgery Improvement Collaborative.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: We investigate whether duration of symptoms a patient experiences prior to lumbar microdiscectomy affects pain, lifestyle, and return to work metrics after surgery. METHODS: A retrospective review of patients with a diagnosis of lumbar radiculopathy undergoing microdiscectomy was conducted using a statewide registry. Patients were grouped based on self-reported duration of symptoms prior to surgical intervention (Group 1: symptoms less than 3 months; Group 2: symptoms between 3 months and 1 year; and Group 3: symptoms greater than 1 year). Radicular pain scores, PROMIS PF Physical Function measure (PROMIS PF), EQ-5D scores, and return to work rates at 90 days, 1 year, and 2 years after surgery were compared using univariate and multivariate analysis. RESULTS: There were 2408 patients who underwent microdiscectomy for lumbar disc herniation for radiculopathy with 532, 910, and 955 in Groups 1, 2, and 3, respectively. Postoperative leg pain was lower for Group 1 at 90 days, 1 year, and 2 years compared to Groups 2 and 3 (P < .05). Postoperative PROMIS PF and EQ-5D scores were higher for Group 1 at 90 days, 1 year, and 2 years compared to Groups 2 and 3 (P < .05). CONCLUSION: Patients with prolonged symptoms prior to surgical intervention experience smaller improvements in postoperative leg pain, PROMIS PF, and EQ-5D than those who undergo surgery earlier. Patients undergoing surgery within 3 months of symptom onset have the highest rates of return to work at 1 year after surgery.

Pulsed Electromagnetic Field Stimulation in Lumbar Spine Fusion for Patients With Risk Factors for Pseudarthrosis.

BACKGROUND: Lumbar spinal fusion surgeries are increasing steadily due to an aging and ever-growing population. Patients undergoing lumbar spinal fusion surgery may present with risk factors that contribute to complications, pseudarthrosis, prolonged pain, and reduced quality of life. Pulsed electromagnetic field (PEMF) stimulation represents an adjunct noninvasive treatment intervention that has been shown to improve successful fusion and patient outcomes following spinal surgery. METHODS: A prospective, multicenter study investigated PEMF as an adjunct therapy to lumbar spinal fusion procedures in patients at risk for pseudarthrosis. Patients with at least 1 of the following risk factors were enrolled: prior failed fusion, multilevel fusion, nicotine use, osteoporosis, or diabetes. Fusion status was determined by radiographic imaging, and patient-reported outcomes were also evaluated. RESULTS: A total of 142 patients were included in the analysis. Fusion status was assessed at 12 months follow-up where 88.0% (n = 125/142) of patients demonstrated successful fusion. Fusion success for patients with 1, 2+, or 3+ risk factors was 88.5%, 87.5%, and 82.3%, respectively. Significant improvements in patient-reported outcomes using the Short Form 36, EuroQol 5 Dimension (EQ-5D) survey, Oswestry Disability Index, and visual analog scale for back and leg pain were also observed compared with baseline scores (P < 0.001). A favorable safety profile was observed. PEMF treatment showed a positive benefit-risk profile throughout the 6-month required use period. CONCLUSIONS: The addition of PEMF as an adjunct treatment in patients undergoing lumbar spinal surgery provided a high rate of successful fusion with significant improvements in pain, function, and quality of life, despite having risk factors for pseudarthrosis. CLINICAL RELEVANCE: PEMF represents a useful tool for adjunct treatment in patients who have undergone lumbar spinal surgery. Treatment with PEMF may result in improved fusion and patient-reported outcomes, regardless of risk factors. TRIAL REGISTRATION: NCT03176303.

Multilevel Cervical Disk Arthroplasty: Moving Beyond Two Levels.

Cervical disk arthroplasty (CDA) is well-studied for 1-level and 2-level cervical pathology. There is an increasing trend towards its utilization for greater than 2-level disease as an alternative to the gold standard, anterior cervical discectomy and fusion (ACDF). The number of high-level, prospective studies or randomized trials regarding multilevel CDA is limited but continues to grow as the procedure gains popularity. In appropriately indicated patients with multilevel disease caused by disk herniations or spondylosis without extensive facet arthropathy, CDA shows promising results. Multilevel CDA should be avoided in patients with prior spinal trauma, significant degenerative spondylolisthesis with translation, arthrodesis without mobility, severely incompetent facet joints, ossification of the posterior longitudinal ligament, or kyphotic deformity. With overall similar risk profiles to ACDF but lower theoretical rates of pseudarthrosis and adjacent segment disease, multilevel CDA has been shown to preserve, or perhaps even increase, preoperative cervical range of motion. There are negligible differences in postoperative neck and arm pain, VAS scores, modified Japanese Orthopaedic Association scores, and Neck Disability Index scores when comparing multilevel CDA and ACDF. Despite current indications for multilevel CDA largely being based on single and 2-level data, careful patient selection is critical. Expansion of indications can be expected as literature continues to emerge regarding outcomes and complications in multilevel CDA, as well as with improvements in prosthesis design.

Patient satisfaction with follow-up after spinal fusion.

Background: Postoperative follow-up visits (PFUs) allow providers to track patient recovery but can be costly to patients. With the advent of the novel coronavirus pandemic, virtual/phone visits have been utilized as an alternative to in-person PFUs. Patients were surveyed to elucidate patient satisfaction with postoperative care in the setting of increased virtual follow-up visits. A prospective survey with retrospective cohort analysis of chart data was conducted to better understand the factors influencing patient satisfaction related to their PFUs after spine fusion with the goal of improving the value of postoperative care. Methods: Adult patients at least 1 year postoperative from cervical or lumbar fusion surgery completed a telephone survey related to their postoperative clinic experience. Medical record data including complications, number of visits and length of follow-up, and presence of phone/virtual visits were abstracted and analyzed. Results: Fifty patients (54% female) were included. Univariate analysis demonstrated no association between satisfaction and patient demographics, rates of complication, mean length or number of PFUs, or incidence of phone/virtual visits. Patients "very satisfied" with their clinic experience were more likely to be "very satisfied" with their outcome (P<0.01), and to feel their concerns were "very well addressed" (P<0.01). Multivariate analysis additionally demonstrated that satisfaction was positively associated with how well patient concerns were addressed (P<0.01) and the incidence of virtual/phone visits (P=0.01), and negatively associated with age (P=0.01) and level of education (P=0.01). Conclusions: After spinal fusion, patient satisfaction is positively related to virtual/phone visits and to how well their concerns are addressed. As long as patient concerns remain adequately addressed, surgeons can eliminate excess PFUs which are not clinically beneficial without adversely impacting patients' postoperative experience.

Clinical outcomes after bracing for vertebral compression fractures: a systematic review and meta-analysis of randomized trials.

Background: Vertebral compression fractures are common and result in significant pain and loss of function. Treatment strategy, however, remains controversial. We conducted a meta-analysis of randomized trials to elucidate the impact of bracing on these injuries. Methods: A comprehensive literature review utilizing Embase, OVID MEDLINE, and the Cochrane Library was performed to identify randomized trials evaluating brace therapy for adult patients with thoracic and lumbar compression fractures. Two independent reviewers assessed the eligibility of studies and risk of bias. The primary assessed outcome was pain after injury. Secondary outcomes were function, quality of life, opioid use, and kyphotic progression [anterior vertebral body compression percentage (AVBCP)]. Continuous variables were analyzed using mean differences and standardized mean differences, and dichotomous variables were analyzed using odds ratios in random-effects models. GRADE criteria were applied. Results: Of 1,502 articles, a total of 3 studies with 447 patients (96% female) were included. Fifty-four patients were managed without a brace, and 393 with a brace (195 rigid, 198 soft). At 3 to 6 months post-injury, rigid bracing resulted in significantly less pain compared to no brace (SMD =-1.32, 95% CI: -1.89 to -0.76, P<0.05, I2=41%), though this diminished at long-term follow-up of 48 weeks. Radiographic kyphosis, opioid use, function, or quality of life were not significantly different at any timepoint. Conclusions: Moderate quality evidence demonstrates rigid bracing of vertebral compression fractures may decrease pain up to 6 months post-injury, though there is no difference in radiographic parameters, opioid use, function, or quality of life at short- or long-term follow-up. No difference was found between rigid and soft bracing; therefore, soft bracing may be an adequate alternative.

Association of prolonged symptom duration with poor outcomes in lumbar spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: There is a scarcity of large multicenter data on how preoperative lumbar symptom duration relates to postoperative patient-reported outcomes (PROs). The objective of this study was to determine the effect of preoperative and baseline symptom duration on PROs at 90 days, 1 year, and 2 years after lumbar spine surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations between January 1, 2017, to December 31, 2021, with a follow-up of 2 years. Patients were stratified into three subgroups based on symptom duration: < 3 months, 3 months to < 1 year, and ≥ 1 year. The primary outcomes were reaching the minimal clinically important difference (MCID) for the PROs (i.e., leg pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), EQ-5D, North American Spine Society satisfaction, and return to work). The EQ-5D score was also analyzed as a continuous variable to calculate quality-adjusted life years. Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios, with the < 3-month cohort used as the reference. RESULTS: There were 37,223 patients (4670 with < 3-month duration, 9356 with 3-month to < 1-year duration, and 23,197 with ≥ 1-year duration) available for analysis. Compared with patients with a symptom duration of < 1 year, patients with a symptom duration of ≥ 1 year were significantly less likely to achieve an MCID in PROMIS PF, EQ-5D, back pain relief, and leg pain relief at 90 days, 1 year, and 2 years postoperatively. Similar trends were observed for patient satisfaction and return to work. With the EQ-5D score as a continuous variable, a symptom duration of ≥ 1 year was associated with 0.04, 0.05, and 0.03 (p < 0.001) decreases in EQ-5D score at 90 days, 1 year, and 2 years after surgery, respectively. CONCLUSIONS: A symptom duration of ≥ 1 year was associated with poorer outcomes on several outcome metrics. This suggests that timely referral and surgery for degenerative lumbar pathology may optimize patient outcome.

Do Patients Accurately Recall Their Preoperative Symptoms After Elective Orthopedic Procedures?

Patient-reported outcome measures are a frequent tool used to assess orthopedic surgical outcomes. However, recall bias is a potential limitation of these tools when used retrospectively, as they rely on patients to accurately recall their preoperative symptoms. A database search of Cochrane Library, PubMed, Medline Ovid, and Scopus until May 2021 was completed in duplicate by two reviewers. Studies considered eligible for inclusion were those which reported on patient recall bias associated with orthopedic surgery. The primary outcome of interest investigated was the accuracy of patient recollection of preoperative health status. Any factors that were identified as affecting patient recall were secondary outcomes of interest. Of the 4,065 studies initially screened, 20 studies with 3,454 patients were included in the final analysis. Overall, there were 2,371 (69%) knee and hip patients, 422 (12%) shoulder patients, 370 (11%) spine patients, 208 (6%) other upper extremity patients, and 83 (2%) foot and ankle patients. Out of the eight studies that evaluated patient recall within three months postoperatively, seven studies concluded that patient recall is accurate. Out of the 13 studies that evaluated patient recall beyond three months postoperatively, nine studies concluded that patient recall is inaccurate. The accuracy of patient recall of preoperative symptoms after elective orthopedic procedures is not reliable beyond three months postoperatively.

Investigating the Association of Patient Body Mass Index With Posterior Subcutaneous Fat Thickness in the Cervical Spine: A Retrospective Radiographic Study.

INTRODUCTION: Although BMI is often used as a surrogate for posterior cervical subcutaneous fat thickness (SFT), the association of BMI with cervical SFT is unknown. We performed a retrospective radiographic study to analyze the relationship between BMI and cervical SFT. METHODS: This was a retrospective cohort study of patients with cervical CT scans. SFT was assessed by measuring the distance (mm) from the spinous processes of C2-C7 to the skin edge. Pearson correlations and linear regression were used to analyze the relationship between BMI and SFT. One-way ANOVA was used to analyze differences in C2-C7 distances while stratifying by BMI. RESULTS: A total of 96 patients were included. BMI had a moderate correlation with average C2-C7 (r=0.546, p < 0.05) SFT, and a weak to moderate correlation with each individual C2-C7 distance. The strongest correlation was at the C7 level (r= 0.583, p < 0.05). These analyses remained significant controlling for potential confounders of patient age, sex, and diabetes. No difference was found in the average C2-C7 distance in patients with BMIs of 25-30 compared to those with BMIs of 30-40 (p=0.996), whereas in patients with BMI <25 and BMI >40, differences were significant (p < 0.05). CONCLUSIONS: BMI is not strongly correlated with SFT in the cervical spine. Although BMI less than 25 or greater than 40 is correlated with respectively decreased or increased cervical SFT, BMI of 25-40 is not correlated with cervical SFT. This is clinically important information for surgeons counseling patients on perioperative risk before undergoing cervical spine procedures, namely infection. Further research delineating the relationship between posterior SFT and surgical site infection in the cervical spine is warranted.

The Potential Negative Effects of Smoking on Cervical and Lumbar Surgery Beyond Pseudarthrosis: A Michigan Spine Surgery Improvement Collaborative Study.

OBJECTIVE: To review the Michigan Spine Surgery Improvement Collaborative registry to investigate the long-term associations between current smoking status and outcomes after elective cervical and lumbar spine surgery. METHODS: Using the Michigan Spine Surgery Improvement Collaborative, we captured all cases from January 1, 2017, to November 21, 2020, with outcomes data available; 19,251 lumbar cases and 7936 cervical cases were included. Multivariate regression analyses were performed to assess the relationship of smoking with the clinical outcomes. RESULTS: Current smoking status was associated with lower urinary retention and satisfaction for patients after lumbar surgery and was associated with less likelihood of achieving minimal clinically important difference in primary outcome measures including Patient-Reported Outcomes Measurement Information System, back pain, leg pain, and EuroQol-5D at 90 days and 1 year after surgery. Current smokers were also less likely to return to work at 90 days and 1 year after surgery. Among patients who underwent cervical surgery, current smokers were less likely to have urinary retention and dysphagia postoperatively. They were less likely to be satisfied with the surgery outcome at 1 year. Current smoking was associated with lower likelihood of achieving minimal clinically important difference in Patient-Reported Outcomes Measurement Information System, neck pain, arm pain, and EuroQol-5D at various time points. There was no difference in return-to-work status. CONCLUSIONS: Our analysis suggests that smoking is negatively associated with functional improvement, patient satisfaction, and return-to-work after elective spine surgery.

Robot-assisted versus conventional percutaneous sacroiliac screw fixation for posterior pelvic ring injuries: a systematic review and meta-analysis.

PURPOSE: Robot-assisted pelvic screw fixation is a new technology with promising benefits on intraoperative outcomes for patients with posterior pelvic ring injuries. We aim to compare robot-assisted pelvic screw fixation to the traditional fluoroscopy-assisted technique with regards to intraoperative and postoperative outcomes. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used along with a search of electronic information to identify all studies comparing the outcomes of robot-assisted versus conventional screw fixation in patients with posterior pelvic ring injuries. Primary outcomes included operative duration (minutes), intraoperative bleeding (mL), fluoroscopy exposure and intraoperative drilling frequency. Secondary outcome measures included Majeed score, healing time (minutes) and rate (%), postoperative complications, screw positioning, incision length (cm) and guide wire insertion times (minutes). The random effects model was used for analysis. RESULTS: Four observational studies including a total of 294 patients were identified. There was a significant difference between robot-assisted and conventional groups in terms of operative duration (MD = - 24.66, p < 0.05), intraoperative bleeding (MD = - 10.37, P < 0.05), fluoroscopy exposure (MD = - 2.15, P < 0.05) and intraoperative drilling frequency (MD = - 2.42, P = < 0.05). For secondary outcomes, no significant difference was seen in Majeed score, healing time and rate and postoperative complications. The robot-assisted group had better screw positioning, smaller incision length, and shorter anaesthesia and guide wire insertion times. CONCLUSIONS: Robot-assisted fixation has superior intraoperative outcomes compared to conventional fixation. Further studies are needed to look at postoperative outcomes as there is no significant difference in postoperative prognosis between the techniques.

The Utility of Postoperative Bracing on Radiographic and Clinical Outcomes Following Cervical Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVES: To determine the radiographic and clinical utility of postoperative orthoses following cervical spine surgery. METHODS: We performed a search of the PubMed, Cochrane Library, Medline Ovid, and SCOPUS databases from inception until November 2021. Eligible studies included outcomes of postoperative bracing vs no bracing following cervical spine surgery. The primary outcome of interest was fusion rates after cervical surgery in braced vs unbraced patients. Secondary outcomes included patient reported outcomes and complication rates. RESULTS: A total of 3232 titles were initially screened. After inclusion criteria were applied, 7 studies (550 patients) were included, which compared results of braced vs unbraced patients after cervical spine surgery. These studies showed acceptable reliability for inclusion based on the Methodical Index for Non-Randomized studies and Critical Appraisal Skills Programme assessment tools. There were no significant differences in fusion rates or complications between braced vs unbraced patients identified in any study. Patient reported pain and quality of life measures between braced and unbraced groups varied amongst studies, without any clear overall advantages favoring either method. CONCLUSIONS: This systematic review found that external bracing, though widely used following cervical spine surgery, may not offer any advantages in patient-reported outcomes, as compared to not bracing. In regard to the effect of bracing on fusion rates, no strong consensus can be made as the methods of fusion assessment in the included studies were heterogenous and suboptimal. Future high-quality studies using recommended methods of fusion assessment are needed to adequately address this important question.