Lumbar Spinal Fusion Research Articles

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

Retrospective review of a single institution cohort. 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. 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. 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. 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. 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.

Computer-assisted Navigation in Lumbar Spine Instrumented Fusions: Comparison of In-hospital and 30-Day Postoperative Complications With Nonnavigated Fusions in a National Database.

To compare in-hospital and 30-day postoperative complications for lumbar spine operations with and without use of computer-assisted navigation. Patients who underwent 1-level to 3-level lumbar spinal instrumentation and fusions 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Emergent procedures and patients aged younger than 18 years were excluded. Patients whose surgery involved the use of computer-assisted navigation were propensity score matched 1:4 based on preoperative demographics and comorbidities to operations without the use of navigation. Multivariate analysis was done to compare postoperative complications. In total, 8,500 patients (average age: 60.7 ± 12.9, male 3,866, female 4,634) were analyzed (1,700 navigation, 6,800 Non-Navigated). Operations with navigation had significantly fewer overall complications (24% vs. 27%, P = 0.008; odds ratio [OR] = 0.83; CI = 0.73 to 0.95), fewer minor complications (20% vs. 24%, P = 0.002; OR = 0.80; CI = 0.70 to 0.91), fewer blood transfusions (17% v. 20%, P = 0.013; OR = 0.82; CI = 0.71 to 0.95), more wound dehiscences (0.4% vs. 0.8%, P = 0.022; OR = 2.16; CI = 1.12,4.19), and shorter average lengths of hospital stays (4.8 ± 4.8 vs. 5.1 ± 5.8 days, P = 0.01). Operations with computer navigation had significantly longer average surgical times (247 ± 129 vs 221 ± 115 minutes, P < 0.001). No significant differences were observed in 30-day revision rates, readmissions, and mortality. Although use of computer-assisted navigation in short-segment lumbar spine fusions (1 to 3 levels) did not decrease revision rates for screw misplacement within 30 days postoperatively, it independently reduced the frequency of blood transfusions and minor complications and decreased hospital lengths of stay compared with operations without navigation. These benefits came at the expense of increased surgical times and wound dehiscences within 30 days postoperatively. Given the inherent limitations of large national databases, these results warrant confirmation through prospective, multicenter investigations.

Does the combination of intrathecal fentanyl and morphine improve clinical outcomes in patients undergoing lumbar fusions?

Intrathecal morphine (ITM) has been widely effective in improving postoperative outcomes in patients undergoing a multitude of surgeries, including lumbar spine fusion. A major limitation of ITM administration is the increase in the incidence of respiratory depression in a dose-dependent manner. One way to bypass this is to use a more potent opioid with a shorter half-life, such as fentanyl. This is a retrospective analysis of patients who underwent one- or two-level transforaminal lumbar interbody fusions. The patients received one of two interventions: 0.2mg intrathecal duramorph/morphine (ITM group; n=70), 0.2mg duramorph + 50 mcg fentanyl (ITM + fentanyl group; n=68) and the control group (n=102). Primary outcomes included postoperative pain (Visual Analog Scale) and opioid intake (MED - morphine equivalent dosage, mg) for postoperative days (POD) 1- 4. Secondary outcomes included opioid-related side effects. One-way analyses of variance and follow-up post-hoc Tukey's honest significant difference statistical tests were used to measure treatment effects. Significantly lower POD1 pain scores for both the ITM and ITM + fentanyl groups vs. control were detected, with no difference between the ITM vs. ITM + fentanyl groups. Similar results were found for POD1 MED intake. A multivariate regression analysis controlling for confounding variables did not attenuate the differences seen in POD1 pain scores while revealing that only the ITM + fentanyl predicted a decrease in POD1 MED intake. No differences were seen for postoperative opioid-related side effects. Our study provides support for supplementing a low dose of both intrathecal morphine and fentanyl to improve postoperative outcomes.

CLINICAL AND RADIOLOGICAL OUTCOMES IN PATIENTS TREATED WITH LUMBAR SPINE INSTRUMENTATION WITH PLF: A 5YR FOLLOW UP STUDY

Lumbar posterior instrumentation with fusion is a common surgical option for the Introduction: treatment of degenerative disc disease. The fusion options are PLF(Posterolateral Fusion) or Interbody fusion, which include several approaches, each having certain advantages and disadvantages over the other. Although there is clear superiority of interbody fusion over PLF, not every lumbar posterior instrumentation requires an interbody fusion. PLF has been used over several decades and it shows promising results. In this study we aim to demonstrate the clinical and radiological outcomes of lumbar spine fusion with PLF at 5 years follow up. A retrospective, cli Methods: nical and radiographic study was performed on 93 consecutive patients who underwent lumbar posterior instrumentation with PLF over a period of 2 years and followed up for 5 years. Radiographic and clinical functional outcomes were collected and compared at preoperative and at 5 years post operative time point. Parametric and nonparametric tests were used when appropriate with p value &lt; 0.05 being signicant 93 consecutive patients were evaluated with an average age of 44.6 ± 11.6 Results: years, and 57% were female. Mean Visual Analog Scale (VAS) for back pain decreased signicantly by a mean of 6.04 ± 1.5 points from preoperative to 5 years postoperative (p &lt; 0.001). Signicant fusion rates were achi Conclusion: eved and maintained at 5 years follow up after PLF. Clinically, the patients reported a signicant decrease in VAS scores. PLF achieves improvement in functional outcomes and is still an alternate procedure to interbody fusion

Significance of surgical first assistant expertise for surgical site infection prevention: Propensity score matching analysis.

Surgical site infection (SSI) is one of the most common postoperative complications in patients undergoing major operations, such as spinal fusion surgery, and a major contributor to patient morbidity and mortality. SSI is considered the most preventable type of infection; however, the risk of SSI is multifactorial. This study aimed to determine the extent to which the expertise of the surgical first assistant (SFA) affected SSI rates. We retrospectively reviewed 528 patients at a single institution who underwent lumbar spine fusion surgery via the posterior approach performed by a single surgeon between January 2012 and May 2020. The SFAs participating in the surgeries were classified into 2 groups: a certified neurosurgery specialist and relatively less experienced neurosurgery resident trainees. To reduce potential selection bias and confounding factors, propensity score matching was performed between the 2 groups. In 170 of the 528 lumbar spine fusion surgeries, the SFA was a certified neurosurgery specialist. In the other 358 surgeries, the SFA was a resident trainee. Seventeen patients met the SSI criteria. The SSI rate was significantly different between the 2 groups (0.6% (1 patient) and 4.5% (16 patients) in the certified specialist and resident trainee groups, respectively; P = .02). After propensity score matching, 170 paired patients were selected. After adjusting for confounding factors, SFAs that were certified neurosurgery specialists were associated with a lower likelihood of SSI (adjusted OR 0.09; 95% CI, 0.01 to 0.79; P = .029) than SFAs that were neurosurgery residents. A higher level of SFA expertise was significantly associated with a lower overall SSI rate in lumbar spine fusion surgeries. It is difficult to predict the incidence of SSI; however, this finding suggests the importance of SFA expertise in preventing SSI.

Letter to the Editor: Postoperative Sagittal Balance Has Only a Limited Role in the Development of Adjacent Segment Disease After Lumbar Spine Fusion for Degenerative Lumbar Spine Disorders A Subanalysis of the 10-Year Follow-up Study.

Sethy, Siddharth S. MBBS, MS (Orthopaedics); Goyal, Nikhil MBBS, MS (Orthopaedics); Kandwal, Pankaj MBBS, MS (Orthopaedics) Author Information

Reply to Letter to the Editor Regarding the Article "Postoperative Sagittal Balance has Only a Limited Role in the Development of Adjacent Segment Disease after Lumbar Spine Fusion for Degenerative Lumbar Spine Disorders: A Subanalysis of the 10-year Follow-up Study".

Toivonen, Leevi A. MD, PhDa; Mäntymäki, Heikki MD, PhDa; Häkkinen, Arja PhDb; Kautiainen, Hannu PhDc; Neva, Marko H. MD, PhDa Author Information

Placebo-controlled Trial of Oral Vitamin D and Alendronate Efficacy for Pain and Modic Changes in Lumbar Fusion Surgery

Background and Aim: Modic changes are alterations in the spine endplates and subchondral bone shock absorption, seen by magnetic resonance imaging (MRI). No studies have investigated the effect of vitamin D and alendronate as oral drugs on reducing and modifying Modic changes after degenerative spine fusion surgery. This study aimed to evaluate the efficacy of oral vitamin D and alendronate administration in patients with low back pain, and Modic changes undergoing lumbar fusion surgery. Methods and Materials/Patients: A total of 81 middle age women with a normal range of serum vitamin d were enrolled in three groups who underwent lumbar fusion surgery according to neurosurgical criteria. Group 1 (n=27) received additional oral alendronate, group 2 (n=27) received oral vitamin D for six months postoperatively, and group 3 (n=27) received no drug (except simple analgesics and antibiotics). The patients were followed up with a visual analog scale (VAS) and Oswestry disability index (ODI). MRI was done before and six months after surgery. Results: There was no significant difference between the three groups in VAS and ODI scores (P=0.416, P=0.601, respectively), but the mean VAS and ODI in all three groups decreased over six months, which was statistically significant (P&lt;0.001). Modic changes in all three groups changed significantly over 6 months (P&lt;0.01). In the vitamin D and alendronate groups, Modic type 3 increased significantly, but Modic type 2 and Modic type 1 decreased significantly in the vitamin d and no medication groups, respectively. Conclusion: Oral vitamin D administration has a desirable effect not only on clinical outcomes after lumbar spinal fusion surgery because of degenerative surgery but also on vertebral endplate Modic changes compared to oral bisphosphonate.

Creation of a Risk Calculator for Predicting New-Onset Cardiac Arrhythmias in Patients Undergoing Lumbar Fusion.

As an increasing number of lumbar fusion procedures are being conducted at specialty hospitals and surgery centers, appropriate patient selection and risk stratification is critical to minimizing patient transfers. Postoperative cardiac arrhythmia has been linked to worse patient outcomes and is a common cause of patient transfer. Therefore, we created a risk calculator to predict a patient's likelihood of developing a new-onset postoperative cardiac arrhythmia after lumbar spinal fusion, which may improve preoperative facility selection. A retrospective review was conducted of patients who undergoing lumbar fusion from 2017 to 2021 at a single academic center. Patients were excluded if they had any medical history of a cardiac arrhythmia. Multivariable regression was conducted to determine independent predictors of inpatient arrhythmias. The final regression was applied to a bootstrap to validate an arrhythmia prediction model. A risk calculator was created to determine a patient's risk of new-onset cardiac arrhythmia. A total of 1,622 patients were included, with 45 patients developing a new-onset postoperative arrhythmia. Age (OR = 1.05; 95% CI, 1.02 to 1.09; P = 0.003), history of beta-blocker use (OR = 2.01; 95% CI, 1.08 to 3.72; P = 0.027), and levels fused (OR = 1.59; 95% CI, 1.20 to 2.00; P = 0.001) were all independent predictors of having a new-onset inpatient arrhythmia. This multivariable regression produced an area under the curve of 0.742. The final regression was applied to a bootstrap prediction modeling technique to create a risk calculator including the male sex, age, body mass index, beta-blocker use, and levels fused (OR = 1.04, [CI = 1.03 to 1.06]) that produced an area under the curve of 0.733. A patient's likelihood of developing postoperative cardiac arrhythmias may be predicted by comorbid conditions and demographic factors including age, sex, body mass index, and beta-blocker use. Knowledge of these risk factors may improve appropriate selection of an outpatient surgical center or orthopaedic specialty hospital versus an inpatient hospital for lumbar fusions.

Put Down the Tin: Chewing Tobacco Use Is Associated With Worse Outcomes After Primary Lumbar Fusion.

Retrospective study. This study evaluated the impact of chewing tobacco on both medical and spine-related complication rates after spinal lumbar fusions in comparison to both a control cohort and a smoking cohort. Smoking is a prevalent modifiable risk factor that has been demonstrated to be associated with increased complications after lumbar fusion. Although smoking rates have decreased in the United States, chewing tobacco use has not similarly reduced. Despite chewing tobacco delivering up to 4 times the dose of smoking, the impact of chewing tobacco is incompletely understood. A retrospective cohort study was conducted using the PearlDiver database. Patients who underwent lumbar spine fusion and used chewing tobacco were matched with a control cohort and a smoking cohort. Medical complications within 90 days after primary lumbar fusion were evaluated, including deep venous thrombosis, acute kidney injury, pulmonary embolism, transfusion, acute myocardial infarction, and inpatient readmission. Spine-related complications were evaluated at 2 years postoperatively, including pseudoarthrosis, incision and drainage (I&D), instrument failure, revision, and infection. After primary lumbar fusion, the chewing tobacco cohort demonstrated significantly higher rates of pseudoarthrosis [odds ratio (OR): 1.41], revision (OR: 1.57), and any spine-related complication (OR: 1.32) compared with controls. The smoking cohort demonstrated significantly higher rates of pseudoarthrosis (OR: 1.88), I&D (OR: 1.27), instrument failure (OR: 1.39), revision (OR: 1.54), infection (OR: 1.34), and any spine-related complication (OR: 1.77) compared with controls. The chewing tobacco cohort demonstrated significantly lower rates of pseudoarthrosis (OR: 0.84), I&D (OR: 0.49), infection (OR: 0.70), and any spine-related complication (OR: 0.81) compared with the smoking cohort. This study demonstrated that chewing tobacco is associated with higher rates of both spine-related and medical complications after primary lumbar fusion. However, chewing tobacco use is associated with less risk of complications compared with smoking. Level III.

Postoperative Opioid Use Among Opioid-Naive Cannabis Users Following Single-Level Lumbar Fusions

As the literature grows on opioid use, the impact of simultaneous cannabis use has hitherto been mostly unexplored. In this study, we assessed the effects of cannabis use on postoperative opioid utilization in opioid-naive patients undergoing single level fusions of the lumbar spine. Using an all-payer claims database, the medical records of 91 million patients were analyzed to identify patients who had undergone single level lumbar fusions between January 2010 and October 2020. Rates of opioid utilization at 6months following index procedure (morphine milligram equivalents/day), the development of opioid use disorder (OUD), and the rates of opioid overuse were assessed. Following examination of 87,958 patient records, 454 patients were matched and distributed equally into cannabis user and noncannabis user cohorts. At 6months following index procedure, cannabis users were equal to nonusers in their rates of prescribed opioid utilization (49.78%, P > 0.99). Cannabis users used smaller daily dosages compared to nonusers (51.1±35.05 vs. 59.72±41, P= 0.003). On the other hand, the proportion of patients diagnosed with OUD was found to be significantly higher among patients using cannabis (18.94% vs. 3.96%, P < 0.0001). Compared to noncannabis users, opioid-naive patients who are cannabis users undergoing lumbar spinal fusions are at a higher risk of developing opioid dependence following surgery, despite having decreased daily dosages of opioids overall. Further studies should explore the factors associated with the development of OUD and the details of concurrent marijuana use to effectively treat pain while limiting the potential for abuse.

Accounting for age in prediction of discharge destination following elective lumbar fusion: a supervised machine learning approach

BACKGROUND CONTEXTThe number of elective spinal fusion procedures performed each year continues to grow, making risk factors for post-operative complications following this procedure increasingly clinically relevant. Nonhome discharge (NHD) is of particular interest due to its associations with increased costs of care and rates of complications. Notably, increased age has been found to influence rates of NHD. PURPOSETo identify aged-adjusted risk factors for nonhome discharge following elective lumbar fusion through the utilization of Machine Learning-generated predictions within stratified age groupings. STUDY DESIGNRetrospective Database Study. PATIENT SAMPLEThe American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database years 2008 to 2018. OUTCOME MEASURESPostoperative discharge destination. METHODSACS-NSQIP was queried to identify adult patients undergoing elective lumbar spinal fusion from 2008 to 2018. Patients were then stratified into the following age ranges: 30 to 44 years, 45 to 64 years, and ≥65 years. These groups were then analyzed by eight ML algorithms, each tasked with predicting post-operative discharge destination. RESULTSPrediction of NHD was performed with average AUCs of 0.591, 0.681, and 0.693 for those aged 30 to 44, 45 to 64, and ≥65 years respectively. In patients aged 30 to 44, operative time (p<.001), African American/Black race (p=.003), female sex (p=.002), ASA class three designation (p=.002), and preoperative hematocrit (p=.002) were predictive of NHD. In ages 45 to 64, predictive variables included operative time, age, preoperative hematocrit, ASA class two or class three designation, insulin-dependent diabetes, female sex, BMI, and African American/Black race all with p<.001. In patients ≥65 years, operative time, adult spinal deformity, BMI, insulin-dependent diabetes, female sex, ASA class four designation, inpatient status, age, African American/Black race, and preoperative hematocrit were predictive of NHD with p<.001. Several variables were distinguished as predictive for only one age group including ASA Class two designation in ages 45 to 64 and adult spinal deformity, ASA class four designation, and inpatient status for patients ≥65 years. CONCLUSIONSApplication of ML algorithms to the ACS-NSQIP dataset identified a number of highly predictive and age-adjusted variables for NHD. As age is a risk factor for NHD following spinal fusion, our findings may be useful in both guiding perioperative decision-making and recognizing unique predictors of NHD among specific age groups.

681 Postoperative Muscle Relaxant Use Associated With Increased Risk of Delirium Following Lumbar Spinal Fusion

INTRODUCTION: Muscle relaxants including cyclobenzaprine and baclofen are frequently utilized in pain management following spine surgery as part of enhanced recovery after surgery (ERAS) protocols. These medications are associated with anticholinergic and central nervous system side effects and are used with caution in outpatient treatment for those at high-risk of delirium, especially the elderly. Literature investigating their association with delirium in the postoperative setting has not been described. METHODS: Patients over age 65 undergoing elective posterior lumbar fusion between 2017 and 2021 at the senior author’s institution were retrospectively reviewed. Variables collected included patient demographics as well as whether subjects received postoperative administration of baclofen and/or cyclobenzaprine on postoperative day 1 as part of a multimodal analgesia regimen. Doubly-robust inverse probability weighting (IPW) with cox-regression was used to evaluate the incidence of postoperative delirium between groups. RESULTS: Five-hundred and thirty-one patients were included in the analysis. Incidence of delirium in those who received postoperative muscle relaxants was 17.6% (44/250) compared to 11.4% (32/281) in the control group who did not (p = 0.001). Doubly-robust IPW analysis found patients who received muscle relaxants were at a 2.07 (95% CI: 1.18-3.63) times increased risk of delirium compared to controls (p = 0.015). Postoperative time to delirium onset was similar between groups (3.0 vs 3.1 days; p = 0.916) while the average duration of delirium was significantly longer in those who received postoperative muscle relaxants (2.5 vs 1.6 days; p = 0.008). CONCLUSIONS: Postoperative muscle relaxant use was associated with a higher risk of delirium in elderly adults following lumbar spinal fusion. Although muscle relaxants may assist with postoperative pain control as part of ERAS protocols while minimizing opioid administration, their side effect profile should be considered in patients at high risk of postoperative delirium.

185 Cannabis Dependence and Health Care Utilization Following Cervical and Lumbar Spine Fusions: National Database Analysis

INTRODUCTION: Recent increases in cannabis use have been associated with broader legalization and social acceptance. Smoking tobacco leads to a higher incidence of pseudoarthrosis and complications following spinal fusion. However, little research has been done regarding the impact of cannabis on outcomes following spine fusions. METHODS: The IBM MarketScan Database (2009-2019) was used to identify patients who underwent single or multilevel cervical or lumbar fusions. Patients were categorized based on cannabis abuse disorder. Inpatient hospitalization outcomes (length of stay, discharge disposition, complications, payments), post-discharge outcomes (reoperation, readmission, outpatient services, medication refills, payments), and complications were analyzed at 6- and 12- months following index procedure. Exact match was used to control for unbalanced demographics. SAS 9.4 was used for data analysis. RESULTS: The exact match cohort had 2958 cervical fusion patients (1479 with a cannabis-related disorder) and 3204 lumbar fusion patients (1602 with a cannabis-related disorder). For cervical fusion, no significant difference between patients with and without cannabis-related disorder was found for most peri- and postoperative complications, overall complications, or discharge home. Users had significantly higher occurrence of sepsis (1.1% vs 0.3%, P = 0.0073) and significantly lower hospitalization payments ($18541 vs. $21137, P=0.0019). For lumbar fusion, no difference was found for overall complications or specific peri- and postoperative complications. Users had significantly lower hospitalization payments ($22612 vs. $29013, P = 0.0002). In both the cervical and lumbar groups, no differences were found in reoperation. Opioid use was lower for users directly post-operation, but higher 3-12 months post-operation. CONCLUSIONS: Cannabis dependence and abuse disorders are not associated with worsened perioperative outcomes in patients undergoing single or multilevel cervical or lumbar fusions.

667 Trends and Patterns of Robotic Assistance in Lumbar Fusion Surgery

INTRODUCTION: Robotic-assisted spine surgery is an emerging field that is growing in utilization. Intraoperative robotic surgical units cost upwards of $600,000 for medical facilities to purchase. Despite significant cost barriers, these devices are highly marketable for hospitals and physicians. METHODS: The Nationwide Inpatient Sample database from 2016 to 2019 was investigated. Inclusion criteria were patients ≥ 18-years-old who underwent elective lumbar spinal fusion surgery. Trends of robotic-assisted lumbar fusion were examined over time, as well as stratified based on patient and surgical characteristics. RESULTS: A total of 176,377 patients met the inclusion criteria. The overall rate of robotic-assisted lumbar fusion was 1.2% (2,131/174,246). Patients with private insurance were more likely to receive robotic-assisted lumbar fusion (40.3% vs. 37.5%; p &lt; 0.05). Stratifying by race, whites were more likely to receive robotic-assisted lumbar fusion (84.1% vs. 79.5%; p &lt; 0.05). Patients who underwent robotic-assisted lumbar fusion were significantly more likely to have a diagnosis of spondylolisthesis compared to those that underwent traditional lumbar fusion (25.9% vs. 22.0%; p &lt; 0.05). Patients with lumbar fusion done via the anterior approach were more likely to have robotic-assisted surgery compared to other approaches (25.2% vs. 21.3; p &lt; 0.05). Overall, there was a steady increase in its use over time, with patients who underwent lumbar fusion procedures four times more likely to receive robotic-assistance in 2019 compared to 2016 (OR: 4.0; 95% CI: 3.5-4.6; p &lt; 0.0001). Robotic-assisted lumbar fusion was associated with higher inpatient costs ($170,036.40 vs. $139,026.10; p &lt; 0.0001) despite having equivalent length of stay (3.31 ± 2.6 vs. 3.37 ± 2.6; p = 0.06). CONCLUSIONS: Robotic-assisted lumbar fusion is on the rise. Patients who had private insurance, were diagnosed with spondylolisthesis, and who had lumbar fusion via the anterior approach were more likely to undergo lumbar fusion using robotic-assistance.

Determination of Work Related to Endoscopic Decompression of Lumbar Spinal Stenosis.

Background: Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT®) code 62380. However, no work relative value units (wRVUs) are currently assigned to the procedure. A physician's payment needs to be updated to commensurate with the work involved in the modern version of the lumbar endoscopic decompression procedure with and without the use of any implants to stabilize the spine. In the United States, the American Medical Association (AMA) and its Specialty Society Relative Value Scale Update Committee (RUC) proposes to the Centers for Medicare and Medicaid Services (CMS) what wRVUs to assign for any endoscopic lumbar surgery codes. Methods: The authors conducted an independent survey between May and June 2022 which reached 210 spine surgeons using the TypeForm survey platform. The survey link was sent to them via email and social media. Surgeons were asked to assess the endoscopic procedure's technical and physical effort, risk, and overall intensity without focusing just on the time required to perform the surgery. Respondents were asked to compare the work involved in modern comprehensive endoscopic spine care with other commonly performed lumbar surgeries. For this purpose, respondents were provided with the verbatim descriptions of 12 other existing comparator CPT® codes and associated wRVUs of common spine surgeries, as well as a typical patient vignette describing an endoscopic lumbar decompression surgery scenario. Respondents were then asked to select the comparator CPT® code most reflective of the technical and physical effort, risk, intensity, and time spent on patient care during the pre-operative, peri- and intra-operative, and post-operative periods of a lumbar endoscopic surgery. Results: Of the 30 spine surgeons who completed the survey, 85.8%, 46.6%, and 14.3% valued the appropriate wRVU for the lumbar endoscopic decompression to be over 13, over 15, and over 20, respectively. Most surgeons (78.5%; <50th percentile) did not think they were adequately compensated. Regarding facility reimbursement, 77.3% of surgeons reported that their healthcare facility struggled to cover the cost with the received compensation. The majority (46.5%) said their facility received less than USD 2000, while another 10.7% reported less than USD 1500 and 17.9% reported less than USD 1000. The professional fee received by surgeons was <USD 1000 for 21.4%, <USD 2000 for 17.9%, and <USD 1500 for 10.7%, resulting in a fee less than USD 2000 for 50% of responding surgeons. Most responding surgeons (92.6%) recommended an endoscopic instrumentation carveout to pay for the added cost of the innovation. Discussion and Conclusions: The survey results indicate that most surgeons associate CPT® 62380 with the complexity and intensity of a laminectomy and interbody fusion preparation, considering the work in the epidural space using the contemporary outside-in and interlaminar technique and the work inside the interspace using the inside-out technique. Modern endoscopic spine surgery goes beyond the scope of a simple soft-tissue discectomy. The current iterations of the procedure must be considered to avoid undervaluing its complexity and intensity. Additional undervalued payment scenarios could be created if technological advances continue to replace traditional lumbar spinal fusion protocols with less burdensome, yet no less complex, endoscopic surgeries that necessitate a high surgeon effort in terms of time required to perform the operation and its intensity. These undervalued payment scenarios of physician practices, as well as the facility and malpractice expenses, should be further discussed to arrive at updated CPT® codes reflective of modern comprehensive endoscopic spine care.

Robotic assistance in lumbar fusion surgery: trends and patterns from 2016-2019.

Robotic-assisted spine surgery is an emerging field that is growing in utilization. Intraoperative robotic surgical units cost upwards of $600,000 for medical facilities to purchase. Despite significant cost barriers, these devices are highly marketable for hospitals and physicians. The Nationwide Inpatient Sample database from 2016 to 2019 was reviewed. Inclusion criteria were patients over 18years of age who underwent elective lumbar spinal fusion. Trends of robotic-assisted lumbar fusion were examined over time, as well as stratified based on patient and surgical characteristics. A total of176,377 patients met the inclusion criteria. The overall rate of robotic-assisted lumbar fusion was 1.2% (2,131/174,246). Patients with private insurance were more likely to receive robotic-assisted lumbar fusion (40.3% vs. 37.5%; p < 0.05). Stratifying by race, whites were more likely to receive robotic-assisted lumbar fusion (84.1% vs. 79.5%; p < 0.05). Patients who underwent robotic-assisted lumbar fusion were significantly more likely to have a diagnosis of spondylolisthesis compared to those that underwentnon-robotic-assisted lumbar fusion (25.9% vs. 22.0%; p < 0.05). Patients with lumbar fusion done via the anterior approach were more likely to have robotic-assisted surgery compared to other approaches (25.2% vs. 21.3; p < 0.05). Overall, there was a steady increase in its use over time, with patients who underwent lumbar fusion procedures four times more likely to receive robotic assistance in 2019 compared to 2016 (OR: 4.0; 95% CI: 3.5-4.6; p < 0.0001). Robotic-assisted lumbar fusion was associated with higher inpatient costs ($170,036.40 vs. $139,026.10; p < 0.0001) despite having equivalent length of stay (3.31 ± 2.6 vs.3.37 ± 2.6; p = 0.06). Robotic-assisted lumbar fusion is on the rise. Patients who had private insurance, were diagnosed with spondylolisthesis, and who had lumbar fusion via the anterior approach were more likely to undergo lumbar fusion using robotic assistance.

Trend of unplanned reoperation rates after lumbar degenerative surgery from 2011 to 2019: a large patient population study.

Unplanned reoperation is commonly performed due to postoperative complications. Previous studies have reported the incidence of unplanned reoperation following lumbar spinal surgery. But few study focused on the trend of reoperation rates, and the reasons of unplanned reoperation were not clear. In this study, we conducted a retrospective study to determine the trend of unplanned reoperation rates after degenerative lumbar spinal surgery from 2011 to 2019, and the reasons and risk factors of unplanned reoperation were also determined. Data of patients who were diagnosed with degenerative lumbar spinal disease and underwent posterior lumbar spinal fusion surgery in our institution from January 2011 to December 2019 were reviewed. Those who received unplanned reoperation during the primary admission were identified. The demographics, diagnosis, surgical segments and postoperative complications of these patients were recorded. The rates of unplanned reoperation from 2011 to 2019 were calculated, and the reasons of unplanned reoperation were statistically analysed. A total of 5289 patients were reviewed. Of them, 1.91% (n = 101) received unplanned reoperation during the primary admission. The unplanned reoperation rates of degenerative lumbar spinal surgery firstly increased from 2011 to 2014, with a peak rate in 2014 (2.53%). Then, the rates decreased from 2014 to 2019, with the lowest one in 2019 (1.46%). Patients with lumbar spinal stenosis have a higher rate of unplanned reoperation (2.67%) compared with those diagnosed as lumbar disc herniation (1.50%) and lumbar spondylolisthesis (2.04%) (P < 0.05). The main reasons for unplanned reoperation were wound infection (42.57%), followed by wound hematoma (23.76%). Patients who underwent 2-segment spinal surgery had a higher unplanned reoperation rate (3.79%) than those receiving other segments surgery (P < 0.001). And different spine surgeons had different reoperation rates. The rates of unplanned reoperation after lumbar degenerative surgery increased at first and then decreased during past 9 years. Wound infection was the major reason for unplanned reoperation. 2-segment surgery and surgeon's surgical skills were related to the reoperation rate.

12-Month clinical and radiographic outcomes of ViBone viable bone matrix in patients undergoing cervical and lumbar spinal fusion surgery

BackgroundTo investigate the clinical safety and efficacy of ViBone® Viable Bone Matrix (VBM), a next generation cellular bone matrix allograft that comprises all three essential bone-forming components: osteogenic, osteoinductive, and osteoconductive factors, and is optimized to enhance cell viability and bone formation.MethodsThis was a multi-center, prospective, post-market study evaluating the safety and efficacy of ViBone VBM in patients undergoing 1–3 level anterior cervical discectomy and fusion or lumbar interbody fusion surgery. Patients were evaluated at baseline, 6-month, and 12-month follow-up clinically and radiographically. Clinical assessment included Visual Analog Scale for pain (VAS-pain), the Neck Disability Index (NDI) for patients with cervical pathologies, and the Oswestry Disability Index (ODI) for patients with lumbar pathologies. Fusion success defined by an independent radiologist was determined radiographically by plain films.ResultsClinical outcomes evaluated with VAS-pain, NDI, and ODI scales were improved significantly at 6 and 12 months compared to baseline. All patients reached clinically significant improvements at 12 months. There were no adverse events or infections attributed to ViBone VBM. At 12 months, the fusion rate per patient was 88.1% in cervical and 97.6% in lumbar patients, while per-level fusion was 98.5% for cervical and 100% for lumbar segments.ConclusionsPatients undergoing cervical and lumbar spinal fusion implanted with ViBone VBM demonstrated favorable outcomes at 6 months and 12 months as measured by subjective clinical measures and radiographic fusion rates.Trial registration This study was registered as NCT03425682 on 1/29/2018.

Clinical outcome of Bioball universal adapter in revision hip arthroplasty

BackgroundRemoval of a well-fixed uncemented femoral component in revision hip arthroplasty is challenging. A modular head–neck adapter provides an option to optimise the femoral offset and anteversion, avoiding the need for femoral stem revision. AimTo present the clinical results following revision arthroplasty with the Bioball head-neck adapter in the elderly American Society of Anaesthesiologists (ASA) Grade II, III & IV patients. Materials and methodsA retrospective review of our database was performed, and all patients classed as ASA grades II, III, & IV treated with the Bioball Universal Adapter (BUA) for 10 years were included. The indication for revision, stem retention, type of adapter, and head size were identified. Patients were contacted by a research nurse to assess the Forgotten Joint Score (FJS), the Oxford Hip Score (OHS), and any symptoms of instability at a minimum of one year post revision surgery. ResultsOur study included 47 patients. 5 (10.6%) were ASA II, 19 (40.4%) were ASA III and 23 (49%) were ASA IV. The mean age was 74 years. The mean follow up was 52 months ± 28.4 SD. The median FJS was 86 ± 11.6 SD. The median OHS was 43 ± 6.2 SD. One patient (2.1%) developed recurrent dislocation following lumbar spinal fusion. None of the other patients experienced instability. The survival rate for the adapter was 98%. ConclusionThe BUA gives good clinical outcomes with very low post revision instability. It is a valuable option for the elderly because it avoids the morbidity and risks associated with the removal of a well-fixed femoral stem. Level of EvidenceLevel IV