North American Spine Society Research Articles

What's New in Spine Surgery.

What's New in Spine Surgery.

Readability of Online Spine Patient Education Resources

We assessed the readability of spine-related patient education materials on professional society websites to determine whether this had improved since last studied. We also compared the readability of these materials to a more patient-centered source, such as WebMD. Patient education pages from the American Association of Neurologic Surgeons (AANS), North American Spine Society (NASS), and spine-related pages from the American Academy of Orthopaedic Surgeons (AAOS), and WebMD were reviewed. Readability was evaluated using the Flesch Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) formulas. The mean FKGL and FRE scores of the societies were compared using one-way analysis of variance. The rate of a reading level at or below an eighth grade level was compared using the χ2 test. We analyzed a total of 156 sites. The mean FKGL score for the professional society sites was 11.4. The mean FRE score for the professional societies was 45.8, with 14.4% written at or below an eighth grade reading level. We found a significant difference in the FKGL scores and materials at or below the eighth grade level between the AAOS and AANS and AAOS and NASS. The mean FKGL and FRE scores for WebMD were 7.57 and 68.1, respectively, with a significant difference compared with the scores for the AAOS, NASS, and AANS. In addition, 80% of the WebMD materials had been written at or below the eighth grade reading level. A significant difference compared with the AANS and NASS (P < 0.0001) but not for the AAOS (P= 0.059). The average readability of spine-related topics exceeded the eighth grade reading level. The AAOS resources had better readability compared with the NASS and AANS. We found no improvement in readability since last studied. The readability of professional societies' materials was significantly worse than those from WebMD.

Someone needs to claim it: second notice

Twelve years ago, I published a letter to the editor of The Spine Journal titled “Someone Needs to Claim It” [1]. That letter was a plea to the North American Spine Society (NASS) to claim the dysfunctional sacroiliac joint (SIJ) as its own. It was a plea to begin the task of educating spine surgeons about the diagnosis and treatment of the dysfunctional SIJ and to promote nonproprietary research on what was a very poorly understood pain generator. At that time, it was the surgeons who lacked the knowledge as the nonsurgical clinicians and pain doctors seemed to have a clear understanding of the disabling pain the dysfunctional SIJ could cause and were treating it with an array of conservative and semi-invasive techniques [2].

Attitudes and trends in the use of radiolucent spinal implants: A survey of the North American Spine Society section of spinal oncology

BackgroundIn spinal oncology, titanium implants pose several challenges including artifact on advanced imaging and therapeutic radiation perturbation. To mitigate these effects, there has been increased interest in radiolucent carbon fiber (CF) and CF-reinforced polyetheretherketone (CFR-PEEK) implants as an alternative for spinal reconstruction. This study surveyed the members of the North American Spine Society (NASS) section of Spinal Oncology to query their perspectives regarding the clinical utility, current practice patterns, and recommended future directions of radiolucent spinal implants. MethodsIn February 2021, an anonymous survey was administered to the physicians of the NASS section of Spinal Oncology. Participation in the survey was optional. The survey contained 38 items including demographic questions as well as multiple-choice, yes/no questions, Likert rating scales, and short free-text responses pertaining to the “clinical concept”, “efficacy”, “problems/complications”, “practice pattern”, and “future directions” of radiolucent spinal implants. ResultsFifteen responses were received (71.4% response rate). Six of the participants (40%) were neurosurgeons, eight (53.3%) were orthopedic surgeons, and one was a spinal radiation oncologist. Overall, there were mixed opinions among the specialists. While several believed that radiolucent spinal implants provide substantial benefits for the detection of disease recurrence and radiation therapy options, others remained less convinced. Ongoing concerns included high costs, low availability, limited cervical and percutaneous options, and suboptimal screw and rod designs. As such, participants estimated that they currently utilize these implants for 27.3% of anterior and 14.7% of all posterior reconstructions after tumor resection. ConclusionA survey of the NASS section of Spinal Oncology found a lack of consensus with regards to the imaging and radiation benefits, and several ongoing concerns about currently available options. Therefore, routine utilization of these implants for anterior and posterior spinal reconstructions remains low. Future investigations are warranted to practically validate these devices’ theoretical risks and benefits.

Does reduction of the Meyerding grade correlate with outcomes in patients undergoing decompression and fusion for grade I degenerative lumbar spondylolisthesis?

Reduction of Meyerding grade is often performed during fusion for spondylolisthesis. Although radiographic appearance may improve, correlation with patient-reported outcomes (PROs) is rarely reported. In this study, the authors' aim was to assess the impact of spondylolisthesis reduction on 24-month PRO measures after decompression and fusion surgery for Meyerding grade I degenerative lumbar spondylolisthesis. The Quality Outcomes Database (QOD) was queried for patients undergoing posterior lumbar fusion for spondylolisthesis with a minimum 24-month follow-up, and quantitative correlation between Meyerding slippage reduction and PROs was performed. Baseline and 24-month PROs, including the Oswestry Disability Index (ODI), EQ-5D, Numeric Rating Scale (NRS)-back pain (NRS-BP), NRS-leg pain (NRS-LP), and satisfaction (North American Spine Society patient satisfaction questionnaire) scores were noted. Multivariable regression models were fitted for 24-month PROs and complications after adjusting for an array of preoperative and surgical variables. Data were analyzed for magnitude of slippage reduction and correlated with PROs. Patients were divided into two groups: < 3 mm reduction and ≥ 3 mm reduction. Of 608 patients from 12 participating sites, 206 patients with complete data were identified in the QOD and included in this study. Baseline patient demographics, comorbidities, and clinical characteristics were similarly distributed between the cohorts except for depression, listhesis magnitude, and the proportion with dynamic listhesis (which were accounted for in the multivariable analysis). One hundred four (50.5%) patients underwent lumbar decompression and fusion with slippage reduction ≥ 3 mm (mean 5.19, range 3 to 11), and 102 (49.5%) patients underwent lumbar decompression and fusion with slippage reduction < 3 mm (mean 0.41, range 2 to -2). Patients in both groups (slippage reduction ≥ 3 mm, and slippage reduction < 3 mm) reported significant improvement in all primary patient reported outcomes (all p < 0.001). There was no significant difference with regard to the PROs between patients with or without intraoperative reduction of listhesis on univariate and multivariable analyses (ODI, EQ-5D, NRS-BP, NRS-LP, or satisfaction). There was no significant difference in complications between cohorts. Significant improvement was found in terms of all PROs in patients undergoing decompression and fusion for lumbar spondylolisthesis. There was no correlation with clinical outcomes and magnitude of Meyerding slippage reduction.

The role of gender in academic productivity, impact, and leadership among academic spine surgeons

BACKGROUND/CONTEXTWomen represent a small minority of practicing orthopedic surgeons and neurosurgeons, with spine surgery having a disproportionately low representation relative to other subspecialties. Previous efforts have attempted to characterize gender patterns in authorship amongst select spine journals. However, no study to our knowledge has done a comprehensive assessment of the influence of gender on academic productivity, impact, and leadership amongst academic spine faculty. PURPOSETo evaluate the impact of gender on academic productivity, promotion to leadership positions, and career advancement among academic spine faculty in the United States. STUDY DESIGNCross-sectional study. PATIENT SAMPLEAcademic spine faculty associated with orthopedic residency, North American Spine Society spine fellowship programs, and American Association of Neurological Surgeons spine fellowship programs. OUTCOME MEASURESAcademic productivity as measured by publications counts, h-index, authorship ranking as well as academic rank and leadership roles METHODSWe identified all spine faculty across orthopedic residency, orthopedic spine fellowship, and neurosurgical spine fellowship programs in the United States, and abstracted academic performance characteristics, cumulative h-index, and complete publication records for each individual faculty member. Proportions of men and women by specialty, academic rank, and leadership were compared with Fisher's exact testing, and comparison of mean h-index and publication counts compared with Wilcoxon rank-sum testing. Adjusted analyses on publication count and h-index were achieved with poisson regression analysis with gender as the primary predictor adjusting for specialty, degrees, academic rank, and seniority based on time since fellowship completion. RESULTSThe representation of women among spine faculty associated with orthopedic residency and North American Spine Society spine fellowship programs was 5.6%. On average, women had 40% fewer total publications (p=.025), h-indices approximately 5 units lower than men (p=.006), 40% fewer total high-impact publications (p=.030), half the senior author publications (p=.005), and half the high-impact senior author publications (p=.007) compared to men. After adjusting for seniority and academic rank, the number of publications in high impact journals no longer differed between men and women, although differences persisted for total publication count and the h-index. Men were significantly more likely to occupy higher academic ranks, with 25.6% of men and 9.5% of women holding the rank of full professor (p=.031), although there was no significant difference in the rate of appointment to leadership positions. Similar findings were encountered among American Association of Neurological Surgeons spine fellowship faculty. CONCLUSIONSThe present study details the low rate of women in academic spine surgery. Furthermore, gender disparities exist in publication volume, impact, and h-indices. A much lower proportion of women hold higher-ranking academic positions compared to men, though appointment to leadership positions was similar between genders. Differences in seniority and publication metrics may in part be due to the relatively younger cohort of women faculty. These findings underscore the need for active investment in diversity and pipeline efforts that facilitate recruitment and support academic productivity of women in spine surgery.

Non-specific low back pain: interpretation of North American Spine Society (NASS) guidelines for evidence-based medicine

Low back pain is a common disease. In 2020, the North American Spine Society (NASS) formulated an evidence-based clinical guideline for the diagnosis and treatment of non-specific low back pain. The guidelines mainly addressed five aspects of non-specific low back pain: diagnosis, imaging examination, conservative treatment, interventional treatment, and surgical treatment. Based on an in-depth understanding of the guidelines, this article gives a brief explanation of the diagnosis and treatment of non-specific low back pain, so as to provide references for clinicians.

Clinical outcomes in revision lumbar spine fusions: an observational cohort study.

The authors compared primary lumbar spine fusions with revision fusions by using patient Oswestry Disability Index (ODI) scores to evaluate the impact of the North American Spine Society (NASS) evidence-based medicine (EBM) lumbar fusion indications on patient-reported outcome measures of revision surgeries. This study was a retrospective analysis of a prospective observational cohort of patients who underwent elective lumbar fusion between January 2018 and December 2019 at a single quaternary spine surgery service and had a minimum of 6 months of follow-up. A prospective quality improvement database was constructed that included the data from all elective lumbar spine surgeries, which were categorized prospectively as primary or revision surgeries and EBM-concordant or EBM-discordant revision surgeries based on the NASS coverage EBM policy. In total, 309 patients who met the inclusion criteria were included in the study. The ODIs of all groups (primary, revision, revision EBM concordant, and revision EBM discordant) were statistically compared. Differences in frequencies between cohorts were evaluated using chi-square and Fisher's exact tests. The unpaired 2-tailed Student t-test and the Mann-Whitney U-test for nonparametric data were used to compare continuous variables. Logistic regression was performed to determine the associations between independent variables (surgery status and NASS criteria indications) and functional outcomes. Primary lumbar fusions were significantly associated with improved functional outcomes compared with revisions, as evidenced by ODI scores (OR 1.85, 95% CI 1.16-2.95 to achieve a minimal clinically important difference, p = 0.01). The percentage of patients whose functional status had declined at the 6-month postoperative evaluation was significantly higher in patients who had undergone a revision surgery than in those who underwent a primary surgery (23% vs 12.3%, respectively). An increase in ODI score, indicating worse clinical outcome after surgery, was greater in patients who underwent revision procedures (OR 2.14, 95% CI 1.17-3.91, p = 0.0014). Patients who underwent EBM-concordant revision surgery had significantly improved mean ODI scores compared with those who underwent EBM-discordant revision surgery (7.02 ± 5.57 vs -4.6 ± 6.54, p < 0.01). The results of this prospective quality improvement program investigation illustrate that outcomes of primary lumbar fusions were superior to outcomes of revisions. However, revision procedures that met EBM guidelines were associated with greater improvements in ODI scores, which indicates that the use of defined EBM guideline criteria for reoperation can improve clinical outcomes of revision lumbar fusions.

Smoking Is Associated With Lower Satisfaction in Nondiabetic Patients Undergoing Minimally Invasive Single-level Transforaminal Lumbar Interbody Fusion.

This was a retrospective review of prospectively collected registry data. The objective of this study was to investigate the effect of smoking on 2 years postoperative functional outcomes, satisfaction, and radiologic fusion in nondiabetic patients undergoing minimally invasive transforaminal lumbar interbody fusion (TLIF) for degenerative spine conditions. There is conflicting data on the effect of smoking on long-term functional outcomes following lumbar fusion. Moreover, there remains a paucity of literature on the influence of smoking within the field of minimally invasive spine surgery. Prospectively collected registry data of nondiabetic patients who underwent primary single-level minimally invasive TLIF in a single institution was reviewed. Patients were stratified based on smoking history. All patients were assessed preoperatively and postoperatively using the Numerical Pain Rating Scale for back pain and leg pain, Oswestry Disability Index, Short-Form 36 Physical and Mental Component Scores. Satisfaction was assessed using the North American Spine Society questionnaire. Radiographic fusion rates were compared. In total, 187 patients were included, of which 162 were nonsmokers, and 25 had a positive smoking history. In our multivariate analysis, smoking history was insignificant in predicting for minimal clinically important difference attainment rates in Physical Component Score and fusion grading outcomes. However, in terms of satisfaction score, positive smoking history remained a significant predictor (odds ratio=4.7, 95% confidence interval: 1.10-20.09, P=0.036). Nondiabetic patients with a positive smoking history had lower satisfaction scores but comparable functional outcomes and radiologic fusion 2 years after single-level TLIF. Thorough preoperative counseling and smoking cessation advice may help to improve patient satisfaction following minimally invasive spine surgery. Level III-nonrandomized cohort study.

Disparities in outcomes after spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

Most studies on racial disparities in spine surgery lack data granularity to control for both comorbidities and self-assessment metrics. Analyses from large, multicenter surgical registries can provide an enhanced platform for understanding different factors that influence outcome. In this study, the authors aimed to determine the effects of race on outcomes after lumbar surgery, using patient-reported outcomes (PROs) in 3 areas: the North American Spine Society patient satisfaction index, the minimal clinically important difference (MCID) on the Oswestry Disability Index (ODI) for low-back pain, and return to work. The Michigan Spine Surgery Improvement Collaborative was queried for all elective lumbar operations. Patient race/ethnicity was categorized as Caucasian, African American, and "other." Measures of association between race and PROs were calculated with generalized estimating equations (GEEs) to report adjusted risk ratios. The African American cohort consisted of a greater proportion of women with the highest comorbidity burden. Among the 7980 and 4222 patients followed up at 1 and 2 years postoperatively, respectively, African American patients experienced the lowest rates of satisfaction, MCID on ODI, and return to work. Following a GEE, African American race decreased the probability of satisfaction at both 1 and 2 years postoperatively. Race did not affect return to work or achieving MCID on the ODI. The variable of greatest association with all 3 PROs at both follow-up times was postoperative depression. While a complex myriad of socioeconomic factors interplay between race and surgical success, the authors identified modifiable risk factors, specifically depression, that may improve PROs among African American patients after elective lumbar spine surgery.

The impact of pathoanatomical diagnosis on elective spine surgery patient expectations: a Canadian Spine Outcomes and Research Network study.

Patients undergoing spine surgery generally have high expectations for improvement postoperatively. Little is known about how these expectations are affected by the diagnosis. The purpose of this study was to examine whether preoperative expectations differ based on diagnostic pathoanatomical patterns in elective spine surgery patients. Patients with common degenerative cervical/lumbar pathology (lumbar/cervical stenosis, lumbar spondylolisthesis, and cervical/lumbar disc herniation) who had given their consent for surgery were analyzed using the Canadian Spine Outcomes and Research Network (CSORN). Patients reported the changes they expected to experience postoperatively in relation to 7 separate items using a modified version of the North American Spine Society spine questionnaire. Patients were also asked about the most important item that would make them consider the surgery a success. Sociodemographic, lifestyle, and clinical variables were also collected. There were 3868 eligible patients identified within the network for analysis. Patients with lumbar disc herniation had higher expectations for relief of leg pain compared with stenosis and lumbar degenerative spondylolisthesis cohorts within the univariate analysis. Cervical stenosis (myelopathy) patients were more likely to rank general physical capacity as their most important expectation from spine surgery. The multinomial regression analysis showed that cervical myelopathy patients have lower expectations for relief of arm or neck pain from surgery (OR 0.54, 0.34-0.88; p < 0.05). Patient factors, including age, symptoms (pain, disability, depression), work status, and lifestyle factors, were significantly associated with expectation, whereas the diagnoses were not. Patients with degenerative spinal conditions consenting for spine surgery have high expectations for improvement in all realms of their daily lives. With the exception of patients with cervical myelopathy, patient symptoms rather than diagnoses had a more substantial impact on the dimensions in which patients expected to improve or their most important expected change. Determination of patient expectation should be individualized and not biased by pathoanatomical diagnosis.

Readability of the Most Commonly Accessed Online Patient Education Materials Pertaining to Surgical Treatments of the Spine

The American Medical Association and National Institutes of Health have recommended that patient education materials should be written at the sixth-grade reading level to maximize patient comprehension. The objective of the present study was to evaluate the readability of Internet information for the 9 most common spinal surgeries. We reviewed 90 online patient educational materials regarding the 9 most common spinal surgeries as reported by the North American Spine Society. A Google search was performed on March 23, 2019 for each surgery, and the top 10 most visited websites for each surgery were assessed for reading level using the Flesch-Kincaid formula. Using the Flesch-Kincaid formula, the average grade reading level of the 90 websites included was 12.82, with a reading ease of 37.04 ("difficult college"). Only 6 websites relayed information to patients at or below the national average of an eighth-grade reading level. The websites for bone morphogenic protein had the highest average grade reading level at 15.88 ± 2.6. Lumbar microscopic discectomy had the lowest average grade reading level at 10.37 ± 2.89. All surgical options discussed had an average readability above the recommended sixth-grade reading level. The most accessed online materials for common spinal surgeries, not only exceeded the readability limits recommended by both the American Medical Association and the National Institutes of Health, but they also exceeded the average reading ability of most adults in the United States. Patients, therefore, might not fully comprehend the information from commonly accessed websites regarding surgical spine treatment options.

English

BACKGROUND Epidural steroid injections (ESIs) have been widely used for over 50 years in the treatment of back pain with or without radiculopathy. In this study, we intended to evaluate the effect of single caudal epidural steroid injection (CESI) in patients suffering from chronic lumbago-sciatica syndrome, resistant to conservative medical therapy. METHODS This was a retrospective study. CESI was performed on thirty-four patients suffering from chronic lumbago-sciatica syndrome, from April 2019 to March 2020. Single injection of caudal epidural steroid (40 mg Triamcinolone Acetonide) diluted with 10 ml. of sterile water was given guided by anatomic landmark, confirmed by “Whoosh” test and radiologically with dye. Patients were followed for 12 weeks using Numeric Rating Scale (NRS) for pain, Oswestry disability index (ODI) and North American spine society patient satisfaction index (NASS). Values were recorded before the injection and after the injection at 1 week, 3 week, 6 week and 12 week during follow-up. RESULTS Significant improvement in patient’s status was observed after CESI, as measured with NRS, ODI and NASS at one, three, six and twelve weeks as compared to pre injection (zero week) but no significant difference was observed at successive follow ups at first to third and third to six weeks. There was significant reversal of NRS and ODI Score from 6 week to 12 week follow-up. Sixty seven percent of patients were satisfied at the end of the follow-up and mild side-effects were reported in a few patients. CONCLUSIONS CESI is a safe, simple and cost-effective intervention procedure for the treatment of chronic lumbago-sciatica syndrome. It provides rapid pain relief and physical function improvement of the patient starting within a week. KEYWORDS Injections, Epidural, Sciatica, Low Back Pain

The content and accessibility of spine surgery fellowship websites and the North American Spine Surgery (NASS) fellowship directory

BACKGROUND CONTEXTThe North American Spine Society (NASS) spine fellowship directory is an established resource that provides applicants with access to important information about different fellowship programs. Additionally, some programs have created websites to provide information about their fellowship program. There has been limited research on the amount and breadth of information provided by these different resources. PURPOSETo assess and compare the scope of information provided by the North American Spine Society (NASS) fellowship directory and individual fellowship program websites. STUDY DESIGN/SETTINGWeb Content Accessibility Study. PATIENT SAMPLEThere were no patient data used in this study. All reported data were accessed from public websites and the NASS fellowship directory (August 2022 fellowships). OUTCOME MEASURESOutcome measures were reported as the presence or lack thereof of 22 topics pertaining to the specifics of each individual spine fellowship program on both the NASS fellowship directory and individual fellowship program websites. METHODSThe NASS fellowship directory (August 2022 fellowships) and individual program websites were evaluated by two independent reviewers. Program websites were identified via Google search with a systematic protocol. Within each platform, the availability of various data were recorded. Twenty-four different data points were assessed for each program and were categorized into four main categories—general program information, fellow profiles, clinical roles, and nonclinical roles of the fellow. Chi-squared tests were used to compare differences in the availability of specific data provided by the NASS fellowship directory and individual program websites. RESULTSSeventy-four fellowship programs were identified. The NASS fellowship directory was more likely to provide information about the application process, a description of the program, fellow salary, faculty members, case descriptions, and research requirements (p<.05). The program websites were more likely to provide information about current and previous fellows—including a list of current fellow(s), their education/training, and a list of the previous fellows and their job choice (p<.05). Program websites were also more likely to discuss rotation schedules, clinic expectations, research opportunities, journal club, institutional meetings, sponsored national meetings, and current/previous research (p<.05). However, certain information, including specific clinical responsibilities (eg, rotation schedule, call expectations, clinic expectations) and the profiles of current and previous fellows, were not well represented on either platform. CONCLUSIONSThere were significant differences in the type of information provided by the NASS fellowship directory and program websites. Furthermore, there were key pieces of information that were not well represented on either platform.

Management of degenerative spondylolisthesis: development of appropriate use criteria

Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. A Modified Delphi process was used. The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

The Severity of Preoperative HbA1c and Predicting Postoperative Complications in Spine Surgery

Background: Diabetes mellitus (DM) is associated with higher perioperative complications. Hemoglobin A1c (HbA1c) has not routinely utilized in preoperative assessment for spine surgeries. Methods: In this single institution prospective study, HbA1c testing was included in preoperative laboratory examination of spinal surgeries from 2016 through 2018. HbA1c levels were categorized using guidelines of the American Diabetes Association as normal (HbA1c 6.5%). HbA1c > 8% was separated as poorly controlled DM for analysis. Perioperative complications and comorbidity data were collected to assess for associations with DM using logistic regression models. Odds ratios (ORs) and 95% Confidence Intervals were determined. Results: 440 patients (238 male, mean age 56.43 + 13.28, mean BMI 30.80 + 6.65.) met the study’s criteria. HbA1c was 8.0 in 23 (5.22%). Bivariate logistic modeling showed that patients with poorly controlled DM demonstrated a higher risk of complications (OR = 2.92) than the diabetes patients (OR = 2.13). Malignancy (OR= 2.62), and hypertension (OR 1.86) were also significant risk factors for complications. However, smoking (OR = 0.83) was not significant. Poorly controlled DM remained associated with complications in multivariable logistic regression modeling (OR=2.72). Conclusions: Poorly control DM defined by preoperative HbA1c was significantly associated with postoperative complications. Smoking, however, was not significant. Preoperative HbA1c can be used to assess risk of post-operative spine surgery complications. Funding Statement: North American Spine Society research grant award of 2016 Declaration of Interests: Dr. Tanaka reports grants from NASS, during the conduct of the study; all other authors have nothing to declare. Ethics Approval Statement: The Institutional Review Board at the University of Missouri Health Care (IRB # 2005429) approved this prospective cohort study.

Perioperative antibiotic prophylaxis in spinal surgery.

Study design: Complete audit cycle. Introduction: To highlight the unjustified overuse of perioperative antibiotics in clean non-instrumented lumbar spinal surgeries. To convince orthopedic surgeons in a methodological way of local field comparison between common practice on the use of perioperative antibiotics prophylaxis (PAP) in clean non-instrumented lumbar spinal surgeries and the ideal practice according to “The guidelines published by North American Spine Society (NASS)”. Methods: A complete audit cycle had been done. One hundred and eight patients underwent clean non-instrumented lumbar spinal surgeries in a tertiary spine center, during the period from the 1st of April to the 31st of June 2017 (primary audit period) and during the period from the 8th of May to the 21st of November 2018 (re-audit period). Group I: audit group (n = 54) was given the usual regimen (IV first-generation cephalosporin for 1–6 days, followed by oral antibiotics, till the removal of stitches) and Group II: re-audit group (n = 54) received only the IV antibiotics for one day). The study protocol was approved by our institution’s Ethical Committee (17100582). Results: This study showed a wide gap between international standards and local prescribing practices and calls for multiple interventions to improve our practice. Out of the 108 patients, only one case (1.85%) developed surgical site infection (SSI) in the audit group (Group I). The difference in infection rates between the two groups was statistically insignificant. Conclusion: A single-day postoperative dose of antibiotics effectively prevents postoperative wound infection following non-instrumented lumbar spinal surgery and is not associated with a higher infection rate.

"July Effect" Revisited: July Surgeries at Residency Training Programs are Associated with Equivalent Long-term Clinical Outcomes Following Lumbar Spondylolisthesis Surgery.

Retrospective analysis of a prospective registry. We utilized the Quality Outcomes Database (QOD) registry to investigate the "July Effect" at QOD spondylolisthesis module sites with residency trainees. There is a paucity of investigation on the long-term outcomes following surgeries involving new trainees utilizing high-quality, prospectively collected data. This was an analysis of 608 patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Surgeries were classified as occurring in July or not in July (non-July). Outcomes collected included estimated blood loss, length of stay, operative time, discharge disposition, complications, reoperation and readmission rates, and patient-reported outcomes (Oswestry Disability Index [ODI], Numeric Rating Scale [NRS] Back Pain, NRS Leg Pain, EuroQol-5D [EQ-5D] and the North American Spine Society [NASS] Satisfaction Questionnaire). Propensity score-matched analyses were utilized to compare postoperative outcomes and complication rates between the July and non-July groups. Three hundred seventy-one surgeries occurred at centers with a residency training program with 21 (5.7%) taking place in July. In propensity score-matched analyses, July surgeries were associated with longer operative times ( average treatment effect = 22.4 minutes longer, 95% confidence interval 0.9-449.0, P = 0.041). Otherwise, July surgeries were not associated with significantly different outcomes for the remaining perioperative parameters (estimated blood loss, length of stay, discharge disposition, postoperative complications), overall reoperation rates, 3-month readmission rates, and 24-month ODI, NRS back pain, NRS leg pain, EQ-5D, and NASS satisfaction score (P > 0.05, all comparisons). Although July surgeries were associated with longer operative times, there were no associations with other clinical outcomes compared to non-July surgeries following lumbar spondylolisthesis surgery. These findings may be due to the increased attending supervision and intraoperative education during the beginning of the academic year. There is no evidence that the influx of new trainees in July significantly affects long-term patient-centered outcomes.Level of Evidence: 3.

Mental Health Associated With Postoperative Satisfaction in Lumbar Degenerative Surgery Patients.

Retrospective review of prospectively collected data. To assess the association between preoperative and postoperative mental health status with postoperative satisfaction in lumbar degenerative surgery patients. Poor preoperative mental health has been shown to negatively affect postoperative satisfaction among spine surgery patients, but there is limited evidence on the impact of postoperative mental health on satisfaction. Adult patients undergoing surgery for lumbar degenerative conditions at a single institution were included. Mental health was assessed preoperatively and 12 months postoperatively using Patient-Reported Outcomes Measurement Information System Depression and Anxiety scores. Satisfaction was assessed 12 months postoperatively using North American Spine Society Patient Satisfaction Index. The authors evaluated associations between mental health and satisfaction with univariate and multivariable logistic regression to adjust for confounders. Preoperative depression/anxiety level was corrected for postoperative depression/anxiety level, and vice versa. Statistical significance was assessed at α=0.05. A total of 183 patients (47% male individuals; avg. age, 62 y) were included. Depression was present in 27% preoperatively and 29% postoperatively, and anxiety in 50% preoperatively and 31% postoperatively. Ninteen percent reported postoperative dissatisfaction using the North American Spine Society Patient Satisfaction Index. Univariate analysis identified race, family income, relationship status, current smoking status, change in pain interference, and change in physical function as potential confounders. In adjusted analysis, odds of dissatisfaction were increased in those with mild postoperative depression (adjusted odds ratio=6.1; 95% confidence interval, 1.2-32; P=0.03) and moderate or severe postoperative depression (adjusted odds ratio=7.5; 95% confidence interval, 1.3-52; P=0.03). Preoperative and postoperative anxiety and preoperative depression were not associated with postoperative satisfaction. Following lumbar degenerative surgery, patients with postoperative depression, irrespective of preoperative depression status, have significantly higher odds of dissatisfaction. These results emphasize the importance of postoperative screening and treatment of depression in spine patients with dissatisfaction. Level III-nonrandomized cohort study.

Predictors of the Best Outcomes Following Minimally Invasive Surgery for Grade 1 Degenerative Lumbar Spondylolisthesis.

The factors driving the best outcomes following minimally invasive surgery (MIS) for grade 1 degenerative lumbar spondylolisthesis are not clearly elucidated. To investigate the factors that drive the best 24-mo patient-reported outcomes (PRO) following MIS surgery for grade 1 degenerative lumbar spondylolisthesis. A total of 259 patients from the Quality Outcomes Database lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis with MIS techniques (188 fusions, 72.6%). Twenty-four-month follow-up PROs were collected and included the Oswestry disability index (ODI) change (ie, 24-mo minus baseline value), numeric rating scale (NRS) back pain change, NRS leg pain change, EuroQoL-5D (EQ-5D) questionnaire change, and North American Spine Society (NASS) satisfaction questionnaire. Multivariable models were constructed to identify predictors of PRO change. The mean age was 64.2±11.5 yr and consisted of 148 (57.1%) women and 111 (42.9%) men. In multivariable analyses, employment was associated with superior postoperative ODI change (β-7.8; 95% CI [-12.9 to -2.6]; P=.003), NRS back pain change (β -1.2; 95% CI [-2.1 to -0.4]; P=.004), EQ-5D change (β 0.1; 95% CI [0.01-0.1]; P=.03), and NASS satisfaction (OR=3.7; 95% CI [1.7-8.3]; P<.001). Increasing age was associated with superior NRS leg pain change (β -0.1; 95% CI [-0.1 to -0.01]; P=.03) and NASS satisfaction (OR=1.05; 95% CI [1.01-1.09]; P=.02). Fusion surgeries were associated with superior ODI change (β -6.7; 95% CI [-12.7 to -0.7]; P=.03), NRS back pain change (β -1.1; 95% CI [-2.1 to -0.2]; P=.02), and NASS satisfaction (OR=3.6; 95% CI [1.6-8.3]; P=.002). Preoperative employment and surgeries, including a fusion, were predictors of superior outcomes across the domains of disease-specific disability, back pain, leg pain, quality of life, and patient satisfaction. Increasing age was predictive of superior outcomes for leg pain improvement and satisfaction.