Orthopedic Spine Surgeons Research Articles

Pelvic index: A new pelvic parameter for assessing sagittal spinal alignment

The incidence of correctional surgery for adult spinal deformity (ASD) has increased significantly over the past 2 decades. Pelvic incidence, an angular measurement, is the gold standard pelvic parameter and is used to classify spinal shapes into Roussouly types. Current literature states that restoration of the spine to its original Roussouly classification optimizes outcomes. We propose a new pelvic parameter, pelvic index, as a length measurement to complement pelvic incidence in more accurately characterizing Roussouly types. This study is a retrospective evaluation of sagittal spinal radiographs of 208 patients who were assessed by a single fellowship trained orthopedic spine surgeon between January and December 2020. Measurements included pelvic incidence, sacroacetabular distance, and L5 vertebral height. Pelvic index was calculated as the ratio of sacroacetabular distance to L5 height. Each spine was also classified into one of the Roussouly types: 1, 2, 3 anteverted pelvis (AP), 3, or 4. The 2 pelvic parameters were compared between groups to assess their ability to differentiate between Roussouly types. Of the 208 patients included, 103 (49.5%) were female and 105 (50.5%) were male. The mean pelvic incidence was 54.9 ± 12.3° and the mean pelvic index was 3.99 ± 0.38. The difference in mean pelvic index was statistically significant between types 1 and 2 (0.15; p=.046) and between types 1 and 3 AP (0.19; p=.029). It was not statistically significant between types 3 and 4 (0.05; p=.251). However, in terms of pelvic incidence, the mean difference was statistically significant only between types 3 and 4 (10.4; p<.001). Pelvic index is the ratio of the sacroacetabular distance to the height of the L5 vertebra. In conjunction with pelvic incidence, pelvic index can help to distinguish between Roussouly types 1 and 2 and between types 1 and 3 AP, the low-pelvic incidence types.

The Sanders Classification and Obesity: Do Obese Kids With AIS Present With More Advanced Skeletal Maturity?

Obese and overweight (OOW) patients with adolescent idiopathic scoliosis (AIS) have been shown to initially present with a more advanced Risser score compared to normal weight (NW) patients. The Sanders Maturity Scale (SMS) is now more commonly used by surgeons to assist with treatment decisions because it more reliably predicts skeletal maturity. However, the relationship between SMS and obesity has not been described. We hypothesize that in patients with AIS, OOW patients will have a higher SMS score on initial presentation when compared to NW patients. Billing data from 2 different institutions were used to identify patients with AIS presenting to a pediatric orthopaedic spine surgeon for an initial visit between July 2012 and March 2020. We excluded those without height/weight data, spine radiographs, or left-hand radiographs for measuring SMS stage. Body mass index-for-age percentiles were calculated and used to group patients into NW (<85th percentile) or OOW (85th percentile and above) per Centers for Disease Control guidelines. After collecting preliminary data, a power analysis was performed using average SMS scores between NW and OOW patients with an alpha of 0.5, determining a needed sample size of approximately 300 male and 300 female subjects. Five hundred ninety patients (296 female, 294 male) were identified. The SMS stage at presentation was significantly greater in OOW compared to NW patients for both females (5.9±1.8 vs. 5.2±1.7; P =0.003) and males (4.9±1.9 vs. 4.1±1.8; P =0.002). The major curve magnitude for OOW females was significantly different from NW females (36±16 degrees vs. 30±16 degrees; P =0.004). The major curve magnitude was not different for OOW and NW males ( P =0.3). At initial presentation, OOW patients present at a greater skeletal maturity as measured by the SMS compared with NW patients. OOW female patients present with a greater major curve magnitudes than NW female patients. These results highlight negative implications of the pediatric obesity epidemic as it relates to the AIS population. These findings can be used to counsel families and provide anticipatory guidance for the AIS treatment plan. Level III-cross-sectional study.

Coronavirus Disease 2019 Shutdown Did Not Affect Mental Health Scores in Lumbar Decompression Patients in a Large Metropolitan Region.

Retrospective study. To evaluate the effect of the coronavirus disease 2019 (COVID-19) shutdown in a large metropolitan area on mental health scores of spine patients undergoing lumbar decompression in the preoperative and early postoperative phases. Global mental health has been demonstrated to be negatively affected by COVID-19 shutdowns. Preoperative mental health affects outcomes in spine patients, and the effect of COVID-19 shutdowns on mental health in this population is unclear. Patients were retrospectively identified from a single orthopedic spine surgeon registry. Patients were divided into 2 cohorts, separated by the date of surgery on or after March 20, 2020, the date of local shutdown due to COVID-19. After division, patients were propensity score matched for age, sex, ethnicity, common comorbidities, body mass index, preoperative visual analog scale back and leg pain scores, and preoperative Oswestry Disability Index. Perioperative characteristics were observed and recorded. Mental health scores, 12-item Short Form Mental Component Score, and 9-item Patient Health Questionnaire 9 were collected preoperatively, at 6 weeks, and at 12 weeks and compared between cohorts through Student t tests. Three hundred thirty-four patients were identified, with 184 patients remaining after propensity score matching. Of the remaining 184 patients, 119 patients were identified as having surgery within the 2 years before the shutdown ("Pre-Shutdown"), whereas 65 patients had surgery within the 2 years after shutdown ("Post-Shutdown"). There were no significant differences between Pre-Shutdown and Post-Shutdown cohorts with regard to either Short Form Mental Component Score or Patient Health Questionnaire-9 at any time period evaluated ( P > 0.050, all). The COVID-19 shutdown in a large metropolitan area did not affect preoperative or early postoperative mental health in patients undergoing lumbar decompression. However, each cohort was matched for preoperative pain and disability scores, which may have adversely been affected by the shutdown.

The Surgical Outcomes of Pedicle Subtraction Osteotomy per Different First Assistant: Retrospective Analysis of 312 Cases.

Pedicle subtraction osteotomies (PSOs) are complex spinal deformity surgeries that are associated with high complication rates. They are typically done by an experienced spine surgeon with another attending, resident, or physician assistant serving as the first assistant. The purpose of this study was to determine whether selecting a surgical team for single-level PSO based on case difficulty and fusion length could equalize intraoperative and perioperative outcomes among three groups: dual-attending (DA), attending and orthopaedic resident (RS), and attending and physician assistant (PA). This study was a retrospective cohort analysis of 312 patients undergoing single-level thoracic or lumbar PSO from January 2007 to December 2020 by a fellowship-trained orthopaedic spine surgeon. Demographic, intraoperative, and perioperative data within 30 days and 2 years of the index procedure were analyzed. Patient demographics did not markedly differ between surgical groups. The mean cohort age was 64.5 years with BMI 31.9 kg/m 2 . Patients with the DA approach had a significantly longer surgical time (DA = 412 min vs. resident = 372 min vs. physician assistant = 323 min; P < 0.001). Patients within the DA group experienced a significantly lower rate of infection (DA = 2.1% [3/140] vs. RS = 7.9% [9/114] vs. PA = 1.7% [1/58], P = 0.043), surgical complication rate (DA = 26% [37/140] vs. RS = 41% [47/114] vs. PA = 33% [19/58], P < 0 .001), and readmission rate (DA = 6.4% [9/140] vs. RS = 12.3% [14/114] vs. PA = 19% [11/58] P = 0.030) within 30 days of surgery. No notable differences were observed among groups in 2-year complication, infection, readmission, or revision surgery rates. These study results support the DA surgeon approach. Resident involvement, even in less complex cases, can still negatively affect perioperative outcomes. Additional selection criteria development is needed.

Surgeon Experience Matters: An Exact Matched Analysis of TLIF Outcomes Demonstrates No Difference in Surgical Outcomes Between Experienced Neurosurgeons and Orthopedic Surgeons.

Retrospective cohort study. To compare surgical and medical complications profile between neurosurgeons and orthopedic surgeons after transforaminal lumbar interbody fusion (TLIF) procedures. Studies comparing the impact of spine surgeon specialty (neurosurgery vs. orthopedic spine) on TLIF outcomes have been inconclusive and failed to control for operative learning curves and surgical maturity. Orthopedic spine surgeons perform fewer spine procedures in residency, although these differences may be attenuated by mandatory fellowship before starting practice. Any observed differences are likely attenuated with increasing surgeon experience. Using an all-payer claims database, PearlDiver Mariner, 120 million patient records were analyzed between 2010 and 2022, to identify individuals with lumbar stenosis or spondylolisthesis who underwent index one- to three-level TLIF procedures. International Classification of Diseases-Ninth Edition (ICD-9), International Classification of Diseases-10th Edition (ICD-10) and Current Procedural Terminology (CPT) codes were used to query the database. Only Neurosurgeons and Orthopedic spine surgeons who had performed at least 250 procedures were included in the study. Patients undergoing surgery for tumor, trauma, or infection were excluded. 1:1 exact matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with all-cause surgical or medical complications in a linear regression model. 1:1 exact matching created two equal groups of 18,195 patients without baseline differences who underwent TLIF procedures by neurosurgeons or orthopedic surgeons. There was no difference in all-cause surgical complications between neurosurgeons and orthopedic spine surgeons (relative risk=1.008, 95% CI: 0.850-1.195, P =0.965). All-cause medical complication rate was higher in the neurosurgery cohort (relative risk=1.144, 95% CI: 1.042-1.258, P =0.005). The results of this study suggest that after accounting for surgical maturity, neurosurgeons and orthopedic spine surgeons have similar surgical outcomes. However, neurosurgeons have higher all-cause medical complication rates compared with orthopedic spine surgeons. Further research is warranted to validate this relationship in other spine procedures and for other outcomes.

Geographic Distribution in Training and Practice of Academic Neurological and Orthopedic Spine Surgeons in the United States

Cross-sectional study. This study aimed to stratify the geographic distribution of academic spine surgeons in the United States, analyzing how this distribution highlights differences in academic, demographic, professional metrics, and gaps in access to spine care. Spine surgeons were identified using American Association of Neurological Surgeons and American Academy of Orthopedic Surgeons databases, categorizing into geographic regions of training and practice. Departmental websites, National Institutes of Health (NIH) RePort Expenditures and Results, Google Patent, and NIH icite databases were queried for demographic and professional metrics. Academic spine surgeons (347 neurological; 314 orthopedic) are predominantly male (95%) and few have patents (23%) or NIH funding (4%). Regionally, the Northeast has the highest proportion per capita (3.28 surgeons per million), but California is the state with the highest proportion (13%). The Northeast has the greatest regional retention post-residency at 74%, followed by the Midwest (59%). The West and South are more associated with additional degrees. Neurosurgery-trained surgeons hold more additional degrees (17%) than orthopedic surgeons (8%), whereas more orthopedic surgeons hold leadership positions (34%) than neurosurgeons (20%). Academic spine surgeons are found at the highest proportion in the Northeast and California; the Northeast has the greatest regional retention. Spine neurosurgeons have more additional degrees, whereas spine orthopedic surgeons have more leadership positions. These results are relevant to training programs looking to correct geographic disparities, surgeons in search of training programs, or students in pursuit of spine surgery.

Current Trends in Recombinant Human Bone Morphogenetic Protein 2 (rhBMP2) Usage for Spinal Fusion Surgery.

(1) Background: Since first approved by the FDA, on-label and off-label usage of recombinant human bone morphogenetic protein 2 (rhBMP2) for spinal fusion surgeries has become widespread. While many studies have investigated the safety and efficacy of its use, as well as its economic impact, few have looked at the current trends in its on- and off-label use. The goal of this study is to evaluate the current trends of on- and off-label rhBMP2 use for spinal fusion surgery. (2) Methods: A deidentified survey was created and electronically distributed to members of two international spine societies. Surgeons were asked to report their demographic information, surgical experience, and current usage of rhBMP2. They were then presented with five spinal fusion procedures and asked to report if they use rhBMP2 for these indications in their current practice. Responses were stratified between rhBMP2 users vs. non-users and on-label vs. off-label use. Data were analyzed using chi-square with Fisher's exact test for categorical data. (3) Results: A total of 146 respondents completed the survey with a response rate of 20.5%. There was no difference in overall rhBMP2 usage based on specialty, experience, or number of cases per year. Fellowship-trained surgeons and those who practice in the United States were more likely to use rhBMP2. Surgeons who were trained in the Southeast and Midwest regions reported the highest usage rates. rhBMP2 use was more common among fellowship-trained and US surgeons for ALIFs; non-US surgeons for multilevel anterior cervical discectomy and fusions; and fellowship-trained and orthopedic spine surgeons for lateral lumbar interbody fusions. Non-US surgeons were more likely to use rhBMP2 for off-label indications compared to surgeons from the US. (4) Conclusions: While various demographics of surgeons report different rates of rhBMP2 use, off-label use remains relatively commonplace amongst practicing spine surgeons.

Neck Disability Index as a Prognostic Factor for Outcomes Following Cervical Disc Replacement.

Retrospective review. We aim to elucidate the potential relationship between neck disability index (NDI) and outcomes following cervical disk replacement (CDR). The use of preoperative disability scores as predictors of outcomes following spine surgery has previously been studied, yet no literature has been published regarding its use in CDR. A retrospective database of a single orthopedic spine surgeon was searched for single-level CDR patients with preoperative NDI scores, excluding those with trauma, infection, or malignancy. Patients were separated into 2 cohorts by NDI score: Mild-Moderately Disabled (MD) (NDI<50) and Severely Disabled (NDI≥50). Patient-reported outcome measures were collected and compared within and between groups up to 1 year postoperatively and included Patient-reported Outcome Measurement Information System Physical Function, 12-Item Short Form (SF-12) Physical Component Score and Mental Component Score, visual analog scale (VAS) neck and arm pain, and NDI. MCID achievement rates were compared between the groups. All PROM scores significantly improved for both cohorts at one or more postoperative time points compared with preoperative baseline ( P ≤0.049, all), with the exception of SF-12 Mental Component Score, which only significantly improved in the MD cohort at 2 postoperative points ( P ≤0.007, both). Between groups, the MD cohort reported significantly superior scores at one or more time points for all studied patient-reported outcome measures ( P ≤0.047, all). MCID achievement rate did not significantly vary for any outcome at any time between cohorts. Regardless of preoperative disability, both groups reported improvement in physical function, pain, and disability scores following CDR. While not finding significance, patients with severe disability preoperatively consistently demonstrated higher minimal clinically important difference achievement in NDI. These data do not promote the use of NDI as a prognostic factor for outcomes following CDR. Further study with larger patient populations may be useful to clarify this potential relationship.

Predictors of Academic Productivity Among Spine Surgeons.

The relationship between research productivity in training and future productivity as an attending spine surgeon is not well-established in the literature nor has the effect of geographic location of training institutions on future academic success been investigated. The aim of our study was to (1) summarize characteristics of academically productive spine surgeons, (2) assess predictors of long-term academic productivity, and (3) establish the effect of geographic location on long-term academic productivity. A query was conducted of the 2021 to 2022 North American Spine Society Spine Fellowship Directory of all orthopaedic and neurosurgical spine fellowship selection committee members for each institution participating in the spine fellowship match. The attending publication rate and h- index were determined. A multivariate linear regression model was developed. P value was set to <0.05. We identified 310 orthopaedic and neurosurgical spine surgeons, representing 76 fellowship programs. Multivariate linear regression analysis identified that the publications during residency ( P < 0.001) and during fellowship ( P < 0.001) were significant predictors of an increased publication rate as an attending surgeon. By contrast, the preresidency publication rate ( P = 0.729) was not significantly predictive of the attending publication rate. Multivariate analysis of h- index found that residency publication rate had a positive correlation ( P = 0.031) compared with preresidency ( P = 0.579) or fellowship ( P = 0.257) rates. Attendings who had attended residency in the Northeast and currently practicing in the Northeast had a higher publication rate ( P < 0.001 and P = 0.004, respectively). A higher number of publications in residency and fellowship were markedly predictive of an increased publication rate as an attending spine surgeon. By contrast, preresidency publications may not be indicative of future academic productivity as an attending. Location may also contribute to attending publication rate and favor those who undergo residency training and ultimately practice in the Northeast.

Spine Surgical Subspecialty and Its Effect on Patient Outcomes: A Systematic Review and Meta-Analysis.

Systematic review and meta-analysis. To perform a systematic review and meta-analysis to identify if intraoperative or postoperative differences in outcomes exist between orthopedic and neurological spine surgeons. Spine surgeons may become board certified through orthopedic surgery or neurosurgical residency training, and recent literature has compared surgical outcomes between surgeons based on residency training background with conflicting results. Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a search of PubMed and Scopus databases was conducted and included articles comparing outcomes between orthopedic spine surgeons and neurosurgeons. The Newcastle-Ottawa scale was used to determine the quality of studies. Forest plots were generated using mean differences (MD) for continuous variables and odds ratios (OR) for binomial variables, and 95% CI was reported. Of 615 search term results, 16 studies were identified for inclusion. Evaluation of the studies found no differences in readmission rates [OR, ref: orthopedics: 0.99 (95% CI: 0.901, 1.09); I2 = 80%], overall complication rates [OR, ref: orthopedics: 1.03 (95% CI: 0.97, 1.10); I2 = 70%], reoperation rates [OR, ref: orthopedics: 0.91 (95% CI: 0.82, 1.00); I2 = 86%], or overall length of hospital stay between orthopedic spine surgeons and neurosurgeons [MD: -0.19 days (95% CI: -0.38, 0.00); I2 = 98%]. However, neurosurgeons ordered a significantly lower rate of postoperative blood transfusions [OR, ref: orthopedics: 0.49 (95% CI: 0.41, 0.57); I2 = 75%] while orthopedic spine surgeons had shorter operative times [MD: 14.28 minutes, (95% CI: 8.07, 20.49), I2 = 97%]. Although there is significant data heterogeneity, our meta-analysis found that neurosurgeons and orthopedic spine surgeons have similar readmission, complication, and reoperation rates regardless of the type of spine surgery performed.

Comparison of MRI and bolster hyperextension radiography in determining the flexibility of thoracic curves in Scheuermann kyphosis: a retrospective cross-sectional study

Background: The flexibility of the thoracic curve is important for the preoperative planning for patients with Scheuermann kyphosis (SK), and a lateral bolster hyperextension radiograph (HE) is the standard available method for this purpose. In this study, the authors aimed to evaluate how the flexibility of the thoracic curve in classic SK patients correlates between supine MRI and HE radiography. Methods: In a retrospective cross-sectional study, 38 SK patients who underwent surgical correction were included. Cobb angles were measured on three different images: lateral standing radiographs (EOS), lateral supine bolster HE radiography, and T2-weighted sagittal MRI. The mean differences between the Cobb angles measured on standing radiographs (EOS) and supine modalities (HE and MRI) was considered as the flexibility of the thoracic curve. Measurements were done two times by two orthopaedic spine surgeons, and acceptable intraobserver and interobserver reliability was observed using an intraclass correlation coefficient test. Results: The study population included 23 (60.5%) male patients and 15 (39.5%) female patients with a mean age of 23.4±8.8 yr (range 13 to 48). The mean flexibility of the thoracic curve was 31±10.9 degrees (40.5%) on supine MRIs and 36.1±11.5 degrees (47.25%) on bolster HE radiographs. A significant correlation was observed between the mean flexibility of the thoracic curve on MRI and HE radiographs (r=0.601, P&lt;0.001). Conclusions: Supine MRI can be regarded as a promising alternative to bolster HE radiography in determining the flexibility of thoracic curves in patients with classic SK. Level of Evidence: Level III

Effect of surgical experience and spine subspecialty on the reliability of the AO Spine Upper Cervical Injury Classification System.

The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5-10 years, 10-20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery). A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson's chi-square or Fisher's exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5-10 years: 0.69 vs 10-20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5-10 years: 0.62 vs 10-20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5-10 years: 0.61 vs 10-20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36). The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system.

Optimizing outcomes and experience for patients traveling abroad for spine surgery: A survey of neurosurgeons and orthopedic spine surgeons in Saudi Arabia

Background: It is widely accepted that patients with complex medical diagnoses and those with the means will travel for specialized medical care abroad. For various reasons, patients from the Gulf countries, including the Kingdom of Saudi Arabia (KSA), have comprised a significant proportion of patients traveling abroad for care. Rarely, however, have local physicians and surgeons been involved at the granular level in these decisions. This study aims to better understand the opinions, insights, and suggestions of local spine surgeons in KSA on the outbound surgical services provided to their patients.&#x0D; Materials and Methods: A cross-sectional study was conducted from April 11 to April 27, 2022. An electronic Qualtrics online survey with 12 items was sent to all spine surgeons from KSA, identified by the local neurosurgery, orthopedics, and spine societies.&#x0D; Results: A total of 110 participants were identified with 86 responses. The patient’s perception of the local system, the complexity of the case, and the opportunity for tourism, in that order, were selected as the main reasons for patients traveling abroad. The top three destinations for spine surgery were Germany (31%), the USA (23%), and Egypt (16%). Hospital and surgeon’s reputations were chosen as the most likely factors for patients to select their destination. The quality of care received abroad was considered fair (49%) or good (31%), while the communication between stakeholders and the patient was considered poor by 72% and 52% of the respondents, respectively.&#x0D; Conclusion: This study highlights the need to engage local physicians in the conversation involving destination services. While most Saudi surgeons surveyed consider the care abroad acceptable for their patients, the vast majority have identified a gap in communication among treating physicians, local physicians, and patients. Many have also suggested a need for better education and awareness locally to improve the perception of the local capabilities.

Utility of Spine Surgery Fellowship Training for Orthopaedic Surgeons in the United States.

Orthopaedic spine surgeons gain surgical experience through cases conducted during residency and fellowship training. This study elucidates the incremental benefit in spine surgery volume from orthopaedic spine surgery fellowship training. This was a retrospective national cohort study of orthopaedic surgery residents and orthopaedic spine surgery fellows graduating from US Accreditation Council for Graduate Medical Education-accredited training programs during the 2017 to 2020 academic years. Comparisons in spine surgery case volume were made with parametric tests. One hundred fourteen spine surgery fellows and 3,000 orthopaedic surgery residents were included. There was a 3.5-fold increase in total spine surgery cases conducted during fellowship versus residency (314 ± 129 vs. 89 ± 61, P < 0.001). Spine surgery fellows one standard deviation more than the mean reported 443 total spine cases. The largest differences between fellows and residents were Decompression (104 ± 48 vs. 28 ± 23, P < 0.001), Posterior Arthrodesis (94 ± 46 vs. 21 ± 18, P < 0.001), Anterior Arthrodesis (64 ± 31 vs. 13 ± 13, P < 0.001), and Instrumentation (43 ± 25 vs. 22 ± 12, P < 0.001). Spine surgery fellowship training affords orthopaedic surgeons the opportunity to increase spine surgery case volume by over threefold. The greatest increases in case volume were reported for Decompression, Posterior Arthrodesis, Anterior Arthrodesis, and Instrumentation.

Surgeon Learning Curve and Clinical Outcomes of Minimally Invasive Anterior Lumbar Interbody Fusion With Posterior Percutaneous Instrumentation.

This study reports the learning phase of the minimally invasive anterior lumbar interbody fusion (mini-ALIF) approach with a vascular and orthopaedic spine surgeon team. Adult patients who underwent primary mini-ALIF at the lowest two segments of the lumbar spine (i.e., L4/5, L5/S1) between January 2010 and December 2018 were analyzed. One hundred twenty-seven patients were included. There was no notable change in total surgical time over the study period. Estimated blood loss markedly decreased until stabilizing at case 30 and slowly declined thereafter. The mean estimated blood loss was 184 mL for L5/S1, 232 mL for L4/L5, and 458 mL for two-level mini-ALIF. There were 20 vascular issues requiring primary repair or packing. Vascular issues declined over time, with a rate of 32% in the first 25 cases and 0% in the last 25. The postoperative complication rate was highest in the first 25 cases (7 of 21 total complications). The odds ratio of vascular injury with body mass index (BMI) > 35 was 4.09 (1.4 to 11.7 confidence interval, P ≤ 0.008). Total surgical time and postoperative complications increased with increasing BMI. Performance of the mini-ALIF approach is associated with a learning curve of 25 to 30 cases before complications begin to decline. BMI > 35 is associated with increased surgical time and complications.

Predictive Analysis of Healthcare Resource Utilization after Elective Spine Surgery.

The management of degenerative spine pathology continues to be a significant source of costs to the US healthcare system. Besides surgery, utilization of healthcare resources after spine surgery drives costs. The responsibility of managing costs is gradually shifting to patients and providers. Patient-centered predictors of healthcare utilization after elective spine surgery may identify targets for cost reduction and value creation. Therefore, our study aims to quantify patterns of healthcare utilization and identify risk factors that predict high healthcare utilization after elective spine surgery. A total of 623 patients who underwent elective spine surgery at a tertiary academic medical center by one of three fellowship-trained orthopedic spine surgeons between 2013 and 2018 were identified in this retrospective cohort study. Healthcare utilization was quantified including advanced spine imaging, emergency and urgent care visits, hospital readmission, reoperation, PT/OT referrals, opioid prescriptions, epidural steroid injections, and pain management referrals. Patient variables, namely, the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification system, were assessed as potential predictors for healthcare utilization. Among all patients, a wide range of health utilization was identified. Age, body mass index, Charlson Comorbidity Index, and American Society of Anesthesiology class were identified as positive predictors of postoperative healthcare utilization including emergency department visits, spine imaging studies, opioid and nerve blocker prescriptions, inpatient rehabilitation, any referrals, and pain management referrals. Markers of patient health-such as CCI and ASA class-may be used to predict healthcare utilization following elective spine surgery. Identifying at-risk patients and addressing these challenges prior to surgery is an important step to deliver efficient postoperative care. 3.

Early outcomes following elective laminoplasty: A comparison of surgical specialties using the National surgical Quality Improvement Program (NSQIP) database

Study designRetrospective cohort study. ObjectiveThe objective of this study was to compare early outcomes in patients following cervical laminoplasty based upon surgeons’ specialty and compare preoperative comorbidities and operative characteristics. Summary of background dataCervical laminoplasty is a common procedure in patients presenting with cervical myelopathy secondary to spinal stenosis. Given this, it is routinely performed by both neurosurgeons and orthopedic spine surgeons. Surgeons’ training in different specialties could play a role in patients’ related outcomes when performing the same procedure. MethodsA retrospective review was conducted using the National Surgical Quality Improvement Program (NSQIP) database of all patients undergoing elective cervical laminoplasty identified by CPT code 63,050 and 63051. Preoperative demographics and comorbidities were evaluated. Following this, operative characteristics and complication rates were compared. Propensity score matching was used to adjust confound variables for the rate of complications. ResultsA total of 2708 cases were analyzed from the NSQIP database that met the inclusion criteria. Of these, there were 1143 cases in the orthopedic surgery cohort and 1565 cases in the neurosurgery cohort. Neurosurgery patients have a higher rate of preoperative dyspnea, hypertension, ASA class of 3 or more, and lower rates of clean wound class. Orthopedic surgery patients were more likely to have a longer operation time, while neurosurgery patients demonstrated a longer length of stay. Following propensity matching for comorbidities, neurological surgery patients were more likely to have unplanned readmissions, wound dehiscence, and pulmonary emboli (p < 0.05). ConclusionsIn conclusion, cervical laminoplasty is a safe and effective procedure when conducted by both orthopedic spine surgeons and neurosurgeons. In our series, neurosurgical patients were more likely to have higher rates of preoperative comorbidities and higher complication rates.

Assessing the Current State of Twitter Usage by Spine Surgeons in the United States

Background Twitter, one of the most widely used social media platforms, allows users to post short statements, media, and weblinks available for viewing and interaction. This study sought to characterize the way in which spine surgeons leverage Twitter as a professional tool and additionally, the extent to which the platform may be currently under-utilized. Methods A list of neurosurgical and orthopaedic spine surgeons was randomized and the first 500 individuals from each group were searched for on Twitter. For surgeons without accounts, it was recorded if they were mentioned in others’ tweets. Independent T-tests were performed for comparing quantitative variables between the two groups (tweets, number of followers, etc.) as well as comparing age with presence of account. Results Of all spine surgeons, 17% had accounts, 49% had no account but were mentioned, and 34% had no account but were not mentioned. There were no differences in twitter usage between genders, geographic region, nor neurosurgical and orthopaedic spine surgeons. The average age of those with and without an account was 51 and 55, respectively (p=.0004). While 22% of surgeons aged 50 and younger had accounts, only 14% of surgeons over 50 had accounts (p=.003). Conclusions In addition to younger surgeons being more likely to have an account, this study found a large discordance between the proportion of spine surgeons who actively engage on Twitter and those that are discussed on the platform by others.

A radiographic analysis of common 3D print materials and assessment of their fidelity within vertebral models

Introduction: The objective of this investigation is to examine a wide array of commonly accessible 3D print filaments and assess their radiographic fidelity in vertebral models.Material and methods: Solid cylinders were 3D printed on an Ultimaker S5 (Ultimaker B.V., Utrecht, Netherlands) in 12 commonly accessible filaments: ABS (Acrylonitrile butadiene styrene), PLA (Polylactic acid), Tough PLA, PP (Poly propylene), Carbon Fiber ABS, Wood fill, PETG (Polyethylene terephthalate glycol), Nylon, PC (Polycarbonate), Bronze fill, TPU 95A (Thermoplastic polyurethane), and CPE (Chlorinated polyethylene). Cylinders were imaged in a CT phantom with anatomic standards. Next, 11 identical L4 human vertebral models were 3D printed in the same materials (omission of TPU 95A). AP and lateral fluoroscopic images were taken of each of the vertebrae and sent to board-certified/board-eligible neurosurgeons, neuroradiologists, and orthopedic spine surgeons for evaluation.Results: CT imaging of the materials yielded a range of Hounsfield values from –120.6 HU (PP) to 167.76 HU (PETG). The polled experts rated CF ABS as the highest fidelity model (mean 4.069) and Bronze fill as lowest (mean 2.000). All simulated vertebrae in this study ranked higher than Bronze fill (p<0.05). Notably, CF ABS (p=0.0029), ABS (p=0.0075), and CPE (p=0.0182) ranked significantly higher than Tough PLA.Discussion: It was determined that CT values of examined filaments were not comparable to cortical bone standard but similar to other bone standards. Our results suggest that apart from Bronze fill, educators can create high fidelity fluoroscopic models with print materials such as ABS, CF ABS, and CPE.

Differences in the Practice of Traumatic Spinal Cord Injury Management Among Spine Surgeons in Saudi Arabia.

This study aims to explore the ease of adopting clinical practice guidelines (CPGs) in managing traumatic spinal cord injury (TSCI) among spine surgeons, with particular focus on the use of steroids, high-dependency unit, early spinal cord decompression, and maintaining a target mean arterial blood pressure (MAP). We conducted a cross-sectional study among the practicing spinal surgeons in Saudi Arabia and included surgeons from neurosurgical and orthopedic backgrounds. The study period was from April to June 2020. The respondents provided sociodemographic data, training background, years of experience, and their clinical practices in managing TSCI via a survey tool constructed based on a literature review. The data were analyzed to evaluate the association between a surgeon's demographics and clinical practices. Ninety-eight spinal surgeons responded, comprising 40% of the practicing spine surgeon population in Saudi Arabia. The only area where the neurosurgical spine and orthopedic spine surgeons' practices differed significantly was maintaining MAP within a target range. Other differences between practices were not statistically significant. The authors also found a significant correlation between the surgeon's school of training and their experience concerning steroids administration. On the other hand, the surgeon experience and volume of treated TSCI cases correlated significantly with admission to a high-dependency unit. The adoption of CPGs remains a challenge to many spinal surgeons. Neurosurgeons are more into keeping the MAP at certain target, whereas the school of training and surgeon experience were the largest determinants of the surgeon's practice in managing TSCI in Saudi Arabia. As the variability in managment among spine surgeons remains a challenge, international and national spine societies are expected to build clinical practice guidelines from the limited existing literature.