Orthopedic Spine Surgeons Research Articles

Intraoperative Neuromonitoring Use Patterns in Degenerative, Nondeformity Cervical Spine Surgery: A Survey of the Cervical Spine Research Society.

A cross-sectional survey study. To determine the neuromonitoring (NM) usage patterns among cervical spine surgeons when performing degenerative, nondeformity cervical spine surgery. Intraoperative NM is frequently used in spine surgery. Although there is literature to support the use of NM in deformity surgery, its utility in degenerative cervical spine surgery remains unclear. A survey was distributed to members of the Cervical Spine Research Society to assess practice patterns of NM use during degenerative cervical spine surgery. The survey consisted of 17 multiple choice questions. The first 3 questions focus on practice experience. The remaining 14 questions pertain to NM practice patterns in the setting of radiculopathy and myelopathy. Significantly more surgeons routinely (>75% of the time) used NM for myelopathy versus radiculopathy (64% vs. 38%, P<0.001). Private practitioners were overall more likely to use NM than academicians (55% vs. 28%, P=0.007 for radiculopathy; 75% vs. 57%, P=0.09 for myelopathy). No significant difference in NM usage was found comparing neurosurgeons and orthopedic spine surgeons. The most commonly cited primary reasons for NM usage were prevention of positioning/hypotension-related neurological complications, and medicolegal protection. Routine NM use during degenerative cervical surgery is significantly more common in myelopathy and is thought to be of more value than in radiculopathy. However, the most common reasons for usage were to provide medicolegal cover and to mitigate neurological complications related to positioning/hypotension, rather than to protect against direct surgical events. These findings contrast the prevailing notion that NM is beneficial in reducing complications related to events occurring in the surgical site when performing spinal deformity correction. We believe that these data provide an important baseline for informing best practice guidelines and further study regarding appropriate NM use for degenerative, nondeformity, cervical spine surgery.

101. Prospective evaluation of degenerative cervical myelopathy in asymptomatic patients over 60 years

BACKGROUND CONTEXT Degenerative cervical myelopathy (DCM) is caused by narrowing of the cervical spinal canal resulting in compression of the spinal cord. The diagnosis of DCM is confirmed by history, physical exam findings, and advanced imaging showing cord compression. Radcliff et al reported the incidence of undiagnosed DCM in hip fracture patients (18%) and elective hip replacement patients (0%) based on history, modified Japanese Orthopedic Association (mJOA) score, and physical exam. Other investigators have studied the specificity and sensitivity of physical exam findings for diagnosing DCM and found it to be imperfect, with 21% of patients diagnosed with DCM lacking obvious clinical signs. PURPOSE The purpose of this study was to determine the prevalence of undiagnosed DCM in patients over 60 years by combining history, physical exam, and MRI. STUDY DESIGN/SETTING Prospective case series. PATIENT SAMPLE Patients aged 60 years or older without history or current symptoms of DCM. OUTCOME MEASURES Central canal stenosis as measured by MRI, myelopathic symptoms on neurologic exam, and patient-reported outcomes (mJOA and neck disability index [NDI]). METHODS Patients 60 years and older were prospectively enrolled from primary care practices. Patients were excluded if they had a history of debilitating neck pain, inability to have a cervical MRI, neurologic disease, cognitive impairment, or prior cervical spine surgery. A cervical MRI was performed using a 3.0 Tesla imaging system and a cervical coil. NDI and mJOA scores were collected for all patients, as well as a thorough history and physical exam. MRI results were reviewed independently by an orthopedic spine surgeon and neuroradiologist. Central cervical canal stenosis was graded 0-3, with 0 indicating no canal stenosis and 3 indicating spinal cord compression with myelomalacia. Patients were diagnosed with DCM if they had myelopathic history (mJOA RESULTS Eighty patients were included in the study: 39 Males (48.8%) and 41 Females (51.2%). The average age was 68.6 years-old (range 60–90 years). The mean NDI was 2.5%, range 0-24%. The mean mJOA score for the cohort was 17.5 (range 14-18). Two patients (3.8%) had an mJOA score of 16. Two (2.5%) patients had myelomalacia on MRI but were asymptomatic. CONCLUSIONS In our study, the prevalence of cervical spinal cord compression in patients 60 years and older with minimal neck pain was found by MRI to be 37.5%. Among these patients, one was diagnosed with DCM, while two others had myelomalacia with a normal physical exam. Our data support the work of other researchers and show that patients may have MRI findings of myelomalacia but remain asymptomatic. This study confirms a small but important prevalence of spinal stenosis and spinal cord compression in patients over 60 who have minimal or no symptoms. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

150. Outpatient vs inpatient anterior lumbar surgery: a multisite, comparative analysis of patient safety measures

BACKGROUND CONTEXT The frequency and complexity of spinal surgery performed in an outpatient setting has been steadily increasing in the past decade. However, data on the safety and efficacy of most spinal procedures adapted to the outpatient setting is lacking. The few studies that have reviewed specific outpatient procedures have mostly focused on anterior cervical surgery, and have drawn conflicting conclusions. To our knowledge, there is no published literature on the feasibility, safety and effectiveness of anterior lumbar surgery (fusions and disc replacements) in an outpatient setting. PURPOSE The purpose of this study is to evaluate the safety and efficacy of outpatient anterior lumbar procedures compared to procedures done at an inpatient setting in a matched cohort of patients. STUDY DESIGN/SETTING This study is a retrospective matched cohort study of patients who underwent an anterior lumbar interbody fusion (ALIF) or a lumbar artificial disc replacement (LADR) at an inpatient facility, compared to a free-standing ambulatory surgery center. PATIENT SAMPLE Consecutive adult patients of several orthopedic and neurosurgical spine surgeons, who underwent elective stand-alone ALIF or LADR or a hybrid of fusion and disc replacement, at either an inpatient tertiary care facility or an outpatient surgical center were studied. A minimum of 90-day follow-up was required. OUTCOME MEASURES Reoperation rates, readmission rates, 90-day complication rates, and length-of-stay data were collected and compared between the two groups. Complications that were specifically assessed included neurological injury, durotomy, vascular injuries, bowel injuries, postoperative ileus, epidural or retroperitoneal hematomas, postoperative urinary retention, urinary tract infections, deep vein thrombosis (DVT), pulmonary embolism (PE), cardio-pulmonary complications, intractable pain, surgical site infection, and death. METHODS Medical records of 231 consecutive patients who underwent ALIF or LADR procedures between 2016-2019 were reviewed. The inpatient and outpatient cohorts were matched with regards to age, sex, body mass index (BMI), and medical comorbidities. Length of stay, complication data, reoperations, and readmissions were recorded and compared between the groups. RESULTS A total of 124 (54%) inpatient and 107 (46%) outpatient patients were reviewed for this study. The two groups had similar baseline characteristics. While there was a trend toward fewer complications, reoperations and readmission for the outpatient cohort, the differences were not statistically significant. The overall 90-day complication rate was 5.6% for the inpatient cohort, and 0.9% for the outpatient cohort. Of the patients in the inpatient cohort, 3.2% were re-admitted within 90 days, compared to 1.9% of those in the outpatient cohort. Reoperation rate was 1.6% for the inpatient cohort. No patient from the outpatient cohort required reoperation. The average hospital stay was 56.9 hours, compared to 5.2 hours at the ambulatory surgery center. CONCLUSIONS There were no statistically significant differences between the 90-day complication and reoperation rates between anterior lumbar procedures performed in an inpatient vs outpatient setting in a matched cohort of patients. Furthermore, the overall 90-day readmission rates were lower for outpatients than for inpatients. Our results support the conclusion that anterior lumbar procedures including 1- and 2-level ALIF and LADR procedures can be performed safely in an outpatient setting. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

P61. A significant number of elective spine surgery plans are altered by a weekly indications conference with high surgeon compliance

BACKGROUND CONTEXT Rates and costs of elective spine surgery have skyrocketed in recent years, yet many patients continue to experience poor outcomes. Furthermore, no standardized appropriateness criteria exist for spinal procedures. Identifying methods for pairing the proper patient with the optimal intervention is of the utmost importance. Prior studies have evaluated the utility of multidisciplinary of spine conferences for patient management, but none have evaluated the impact of a multidisciplinary surgical indications conference (MSIC) on surgical planning and decision making. PURPOSE To characterize the impact a weekly MSIC has on surgical planning and the compliance rates of surgeons with a MSIC's decisions. STUDY DESIGN/SETTING Retrospective observational study. PATIENT SAMPLE There were 100 consecutive patients presented at a weekly MSIC. OUTCOME MEASURES Rates of surgical planning alterations. Compliance rates with the MSIC's decisions 30-day postoperative complication and readmission rates for patients undergoing surgery after review at a MSIC. METHODS We reviewed consecutive cases at our institution's weekly MSIC from September-December 2019 where three neurosurgical and three orthopedic spine surgeons discuss each upcoming surgery. Every elective surgery at the institution was presented and each surgeon voiced their opinion before a group consensus decision was made on how to proceed. Patient demographics, comorbidities, surgeon specific information, the proposed surgery, invasiveness rating, group consensus for each surgery, surgeon compliance with the group consensus, and 30-day complication and readmission data were collected. Descriptive statistics were performed for the group's decision to accept or alter a proposed surgery. A binomial test was utilized to determine if the proportion of altered surgical plans significantly differed from zero. Univariate analysis was performed using chi-squared tests and Fisher's exact test for categorical variables and t-tests and Wilcoxon rank-sum test for continuous variables to compare differences between surgical cases approved without changes and those that the group altered. RESULTS We reviewed 100 consecutive patients scheduled for elective spine surgery at our indications conference during the study period. The group determined that surgical plans should be altered in 19 cases (19%), with three of these cases being postponed or cancelled, which was statistically significant utilizing a binomial test (p CONCLUSIONS MSICs can lead to surgical planning alterations in a significant number of cases. This may result in better selection of surgical candidates and procedures for particular patients, leading to better outcomes and providing greater value to patients. Surgeon compliance with the MSIC's decisions was high, suggesting surgeons are willing to adhere to a MSIC's advice. Although long-term patient outcomes remain to be evaluated, this care model will likely play an integral role in optimizing the care spine surgeons provide patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

187. Compared to gold standard bone SPECT/CT showed superior accuracy in detecting pseudarthrosis

BACKGROUND CONTEXT Pseudarthrosis remains the primary cause of persistent pain postoperatively after spinal fusion surgery, leading to failed back surgery syndrome. The utility of the integrated single-photon emission computed tomography and computed tomography (SPECT/CT) in a bone scan as a problem-solving tool in evaluating patients with suspected pseudarthrosis, hardware failure and adjacent level disease has been previously reported. A number of studies have been done showing its benefits and limitations when compared to other imaging techniques. Direct comparison against the gold standard of surgical pseudarthrosis confirmation is limited. PURPOSE The purpose of this study is to evaluate the diagnostic accuracy of SPECT/CT, computed tomography (CT) and magnetic resonance imaging (MRI) scans in preoperatively identifying pseudarthrosis with verification by intraoperative findings. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE Patients undergoing revision spinal surgery. OUTCOME MEASURES Imaging comparison to gold standard. METHODS After obtaining IRB approval, a retrospective study of patients who underwent revision spinal fusion was completed. The surgeries were performed by a single orthopedic spine surgeon over a 12-month period. Patients included in the study had SPECT/CT imaging done prior to surgery, and had either MRI or CT scan or both. All available preoperative imaging results (SPECT/CT, CT and MRI) and operative reports were collected, verified and compared. Estimates of sensitivity, specificity, likelihood ratios (LRs), positive predictive value (PPV) and negative predictive value (NPV) were all calculated to evaluate the diagnostic accuracy. RESULTS A total of 60 surgical patients (62% female, mean age 58 years), including 19 cervical fusion (32%), five thoracolumbar fusion (8%) and 36 lumbar fusion (60%), were included in this series. Prior to spinal surgery, average time to imaging of 60 patients who underwent SPECT/CT, 31 patients who underwent CT, and 33 patients who underwent MRI was around 5 months, respectively. Results of diagnostic accuracy show that when compared to lower sensitivity studies like CT (11%) and MRI (6%), SPECT/CT sensitivity was high at 91% (95% CI 75-98%) leading a significant negative likelihood ratio at -LR 0.1 (95% CI 0.04-0.36) and a PPV of 83% (95% CI 70-91%); specificity was moderate at 79% (95% CI 59-92%) with a moderate positive likelihood ratio of +LR 4 (95% CI 2-9) and a NPV of 88% (95% CI 71-96%). CONCLUSIONS SPECT/CT scan was found to demonstrate excellent criterion validity to rule-out a diagnosis of pseudarthrosis when a negative result was observed; however, further validation is warranted. DISCUSSION Pseudarthrosis can be challenging to diagnose as it can also occur with other postoperative complications such as adjacent level disease and/or hardware failure, SPECT/CT scan should be integrated into routine clinical practice as a diagnostic tool in patients with persistent postoperative pain. A negative SPECT-CT virtually rules out pseudarthrosis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

P42. When does MRI change management of pediatric back pain? A predictive scoring system

BACKGROUND CONTEXT The prevalence of back pain in the pediatric population is increasing and represents a global burden. Workup and management of back pain in this population presents a clinical challenge. Although many cases are self-limited, failure to diagnose a pathology that requires clinical intervention can carry severe repercussions. Oftentimes the challenge facing spine specialists with this population is determining when to order advanced imaging, such as magnetic resonance imaging (MRI). MRI carries a high cost to the patient and health care system, and may even require procedural sedation in the pediatric population. Understanding when an MRI will help guide clinical management may help improve the quality and timeliness of care, while also reducing costs. PURPOSE The aim of this study was to develop a predictive scoring system based on pediatric patient factors to help determine when an MRI will change clinical management. STUDY DESIGN/SETTING This study is a retrospective cohort analysis from a single orthopedic surgery practice, composed of orthopedic spine surgeons and pediatric orthopedic surgeons. PATIENT SAMPLE Consecutive pediatric patients (less than 21 years old) who presented to clinic with a chief complaint of back pain between 2010 and 2018. OUTCOME MEASURES The primary outcome measured was whether or not an MRI directly contributed to a change in clinical management of the patient. Examples of a change in management include changing the duration or type of conservative care, indicating a patient for surgery, contraindicating a patient for surgery, or reveal findings that require additional advanced imaging. METHODS Demographic factors analyzed included age, sex, body mass index (BMI), and comorbid conditions. Presentation variables analyzed included the duration of symptoms, primary location of pain (cervical, thoracic, or lumbar), the presence of arm or leg pain, nocturnal symptoms, weight loss, fevers or chills, history of trauma, sudden onset of pain, and whether or not the injury was sports related. If a patient had advanced imaging, such as MRI, a physician reviewer determined whether or not the imaging resulted in a change of management based on comprehensive chart review. A predictive model of factors that influence whether MRI results in a change in imaging was then generated using cross-validation LASSO logistic regression analysis. RESULTS A total of 729 patients were included, with a mean age of 15.1 years (range: 3 to 20 years). Of these, 344 (47.2%) had an MRI. On bivariate analysis, the presence of leg pain (p CONCLUSIONS A predictive model was generated to help determine when ordering an MRI may result in a change in clinical management for workup of back pain in the pediatric population. The main factors included a neuro deficit, nocturnal symptoms, sudden onset, leg pain, lumbar pain, and age. Spine specialists can use these findings to better determine if and when an MRI might be appropriate. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

244. Relationship between 25-hydroxy vitamin D level and surgical site infection in spine surgery

BACKGROUND CONTEXT Surgical site infection (SSI) creates a significant burden on the patient and the health care system. Preoperative medical optimization, antibiotics have been incorporated in standard practice reduce perioperative complications, and many others are currently under investigation. In animal models, 25-hydroxy vitamin D level has been shown to have antimicrobial and wound healing effects. Preoperative levels have been shown to correlate with SSI in thoracic and bariatric surgeries. However, to date it has not been evaluated in spine patients. PURPOSE To investigate whether low vitamin D status is associated with increased risk of developing post-operative infections in spine surgeries. STUDY DESIGN/SETTING Retrospective PATIENT SAMPLE Patients undergoing thoracolumbar spine surgery between November 2012 and March 2019 performed by one fellowship-trained orthopedic spine surgeon at a single academic center. OUTCOME MEASURES The outcome variable was SSI undergoing surgical intervention. METHODS We identified all patients within the stated sample and enrolled only patients with preop vitamin D levels. SSI, age, BMI, season of surgery, race, type of surgery, diagnosis, ASA, smoking status were extracted. The key independent variable was Vit D level (classified as 60 ng/mL= Potentially Harmful). Bivariate analysis with chi-square and t-tests were used to compare characteristics between the non-SSI and SSI cohorts undergoing spine surgery. Multivariable logistic regression analyses were used to determine associations between vitamin D levels and SSIs after controlling for relevant confounders such as BMI, type of surgery, diagnosis, comorbidities. RESULTS A total of 545 patients met our inclusion criteria, 9 (1.7%) of which acquired an SSI. The mean 25-Hydroxy vitamin D was 31.6 ± 13.6 ng/dL in non-SSI group, and 35.7 ± 20.2 ng/dL in SSI group (p-value 0.17). The mean age was 56 ± 15.6 years in the non-SSI group and 64 ± 7.5 years in the SSI group (p- value 0.045). 21.7% of non-SSI patients had moderate risk of vitamin D deficiency, 27.9% had low risk of deficiency, 46.8% had adequate levels and 3.6% had potentially harmful levels. 33.3% of non-SSI patients had moderate risk of Vitamin D deficiency, 11.1% had low risk of deficiency, 33.3% had adequate levels and 22.2% had potentially harmful levels (p-value 0.02). On bivariate analysis, the percentage of patients with potentially harmful levels of Vitamin D in the SSI group was higher than in the non-SSI group (22.2% and 3.6% respectively, p-value 0.02). On multivariable analysis, patients with adequate vitamin D level had lower odds of SSI as compared to vitamin D deficient patients (OR 0.11, CI 0.01-0.98, p-value 0.048). Though not statistically significant, patients with potentially harmful vitamin D level were at higher odds of SSI (OR 1.41, CI 0.11-17.34, p-value 0.79). CONCLUSIONS Our analysis showed that patients with adequate levels of vitamin D has lower risk of SSIs as compared to vitamin D deficient patients after controlling for relevant confounders. Optimizing preop vitamin D levels could potentially reduce the incidence of SSI in spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Radiographic Analysis Comparison of Cervical Alignment After Variable Level of Anterior Cervical Discectomy and Fusion (ACDF)

Background: To compare the radiographic cervical lordosis alignment between pre-operative and post-operative surgery after variable level of anterior cervical discectomy and fusion (ACDF) .In the current review, the standard surgical treatment of cervical spondylotic myelopathy is ACDF the restoration and maintenance of cervical lordosis alignment is an important clinical parameter after single level or multilevel anterior cervical discectomy and fusion. The increase or decrease cervical lordosis alignment is affected by the sagittal vertical axis and balance. Methods: This study was performed a retrospective radiographic analysis of 147 patients who underwent single to multilevel ACDF (Total N= 147; 1-level (N=36), 2-level (N=60), 3-level (N=42) and 4-level (N=9)) by orthopedic spine surgeons and neurosurgeons between 2016 and 2018. The authors measured the cervical lordosis alignment of the cervical spine using the Cobb method (Inferior endplate of C2 to inferior endplate of C7) at pre-operative and post-operative surgery. Radiographs were measured by three orthopedic doctor viewers. Statistical analysis were performed using R software. Results: The radiographic analysis comparison of cervical alignment after ACDF was showed the results that cervical lordosis alignment had no significantly change of decreased cervical lordosis alignment at pre-op mean 14.88°(± 8.66) and initial post-op mean 13.01°(±7.65) in all level of ACDF. Conclusions: The radiographic analysis of variable level anterior cervical discectomy and fusion in single to multilevel (1-level, 2-level, 3-level and 4-level) has no significantly change in cervical lordosis alignment after initial postop surgery.

Letter: Maintaining Neurosurgical Resident Education and Safety During the COVID-19 Pandemic.

Letter: Maintaining Neurosurgical Resident Education and Safety During the COVID-19 Pandemic.

PEDICLE MORPHOLOGY IN SCOLIOSIS: CLASSIFICATION AGREEMENT FOR PRE-OPERATIVE EVALUATION

ABSTRACT Objectives Although Watanabe morphological classification is well known, there is no consensus of its use among spine surgeons. We propose an analysis of the Watanabe classification by three observers, one senior and two recently graduated orthopedic spine surgeons, and its applicability in pre-operative evaluation. Methods An intraobserver and interobserver analysis of the classifications of 937 thoracic pedicles among 55 scoliosis patients treated surgically in two institutions. The average age at time of surgery was 16.3 years (10- 50 years). The etiologies of the scoliosis were: idiopathic (n= 47), congenital (n=4), syndromic (n= 3) and neuromuscular (n=1). The mean Cobb angle was 67 degrees (41- 120º). The evaluation of the thoracic pedicle was performed using pre-operative CT images. Results A total of 937 pedicles were classified by three observers with percentages of 47.5% type A, 28.6% type B, 17.1% type C and 6.9% type D for the total pedicles, convex and concave. Intraobserver agreement was fair to almost perfect (kappa 0.34 to 0.92) and interobserver agreement was fair to moderate (kappa 0.33 to 0.59) with statistical significance of p&lt;0.001. Conclusion Watanabe classification remains a good method for predicting intraoperative difficulties, and has better agreement as the surgeon becomes more experienced. Level of evidence II; Prognostic Studies.

The short-term impact of COVID-19 pandemic on spine surgeons: a cross-sectional global study.

PurposeThe outbreak of COVID-19 erupted in December 2019 in Wuhan, China. In a few weeks, it progressed rapidly into a global pandemic which resulted in an overwhelming burden on health care systems, medical resources and staff. Spine surgeons as health care providers are no exception. In this study, we try to highlight the impact of the crisis on spine surgeons in terms of knowledge, attitude, practice and socioeconomic burden. MethodsThis was global, multicentric cross-sectional study on 781 spine surgeons that utilized an Internet-based validated questionnaire to evaluate knowledge about COVID-19, availability of personal protective equipment, future perceptions, effect of this crisis on practice and psychological distress. Univariate and multivariate ordinal logistic regression analyses were used to evaluate the predictors for the degree of COVID-19 effect on practice. ResultsOverall, 20.2%, 52% and 27.8% of the participants were affected minimally, intermediately and hugely by COVID-19, respectively. Older ages (β = 0.33, 95% CI 0.11–0.56), orthopedic spine surgeons (β = 0.30, 95% CI 0.01–0.61) and those who work in the private sector (β = 0.05, 95% CI 0.19–0.61) were the most affected by COVID-19. Those who work in university hospitals (β = − 0.36, 95% CI 0.00 to − 0.71) were affected the least. The availability of N95 masks (47%) and disposable eye protectors or face shields (39.4%) was significantly associated with lower psychological stress (p = 0.01). Only 6.9%, 3.7% and 5% had mild, moderate and severe mental distress, respectively. ConclusionWhile it is important to recognize the short-term impact of COVID-19 pandemic on the practice of spine surgery, predicting where we will be standing in 6–12 months remains difficult and unknown. The COVID-19 crisis will probably have an unexpected long-term impact on lives and economies.

Industry Payments to Orthopedic Spine Surgeons Reported by the Open Payments Database: 2014-2017.

This was a retrospective study of publicly available data. The objective of this study was to characterize and assess trends in Open Payments Database (OPD) industry payments reported to orthopedic spine surgeons from 2014 to 2017. There have been a lack of studies characterizing OPD industry payments to orthopedic spine surgeons over the 4 full years of data available. General industry payments made to orthopedic spine surgeons from 2014 to 2017 were characterized by year with analysis of: number of compensated surgeons, median payment per surgeon, top strata of compensated surgeons, and subtype (ie, food/beverage). Research and Ownership Payments were characterized by median payment per surgeon. Mann-Whitney U tests were used to compare payments. For General Payments, the number of compensated orthopedic spine surgeons increased from 1539 in 2014 to 1673 in 2017. Later year median General Payments per surgeon were compared with the 2014 median ($1051): 2015 ($1070: P=0.375), 2016 ($1263: P=0.012), and 2017 ($978: P=0.561). In 2014, the top 10% of compensated orthopedic spine surgeons received 89% of the total General compensation to orthopedic spine surgeons, top 5% received 79%, and the top 1% received 55%. The median General Payment for these 3 top strata remained similar over the 4 years evaluated (P>0.05). For subtype analyses, the median aggregate General Payment for "education" increased (P=0.002) across the years. Finally, it was determined that the median payment per surgeon for Research and Ownership Payment categories remained stable across the time period (P>0.05). Many expected industry payments to surgeons to decrease under public scrutiny of the OPD, but the present study showed no net change in median payment (General, Research, and Ownership) over the years studied. In the age of greater transparency, these findings shed insight into the orthopedic spine surgeon-industry relationship. Level III.

Liaison Treatment for Metastatic Spinal Tumors.

Introduction The cancer board system employed at many hospitals and treatment centers involves multidisciplinary healthcare teams, including physicians, and the timing of treatment generally follows that of a consultation model. Thus, it is difficult to detect spinal metastases using the current implementation of the cancer board system, which can lead to delays in treatment. A new multidisciplinary treatment strategy for patients with metastatic spinal tumors was designed, and 745 patients were treated based on this strategy. Methods In the first 5 years using the liaison treatment approach, 745 patients were diagnosed with metastatic spinal tumor. Tumors were discovered before a skeletal-related event (SRE) in 704 patients and after an SRE in 41 patients. We conducted our analysis in two patient groups: those with and without an SRE at the time of treatment initiation. Results In most patients, the average spinal instability neoplastic score was 5.2, which indicates that we were able to detect the spinal tumor before a significant breakdown of the spinal support system. Ninety-five percent of patients were classified according to the Frankel grade classification during their initial diagnosis, and many patients initially underwent treatment before the onset of paralysis. Of patients with an SRE, 33% were Frankel grade E, indicating that approximately half were paralyzed at initial diagnosis. The median survival duration was prolonged by approximately 9 months in patients without an SRE compared with those with an SRE. Conclusions Orthopedic spine surgeons are responsible for maintaining activities of daily living, improving quality of life, and prolonging life expectancy in patients with metastatic spinal tumors. The results of this study revealed that the liaison treatment system for metastatic spinal tumors has made it possible to successfully prevent SREs without neurological deficits and to prolong survival.

Intraoperative real-time stress in degenerative lumbar spine surgery: simultaneous analysis of electroencephalography signals and heart rate variability: a pilot study

BACKGROUND CONTEXTInterest in intraoperative stress has increased due to its potentially detrimental impact on surgical performance and burnout among spine surgeons. PURPOSEThe purpose of this study was to analyze intraoperative stress in real time in terms of electroencephalography signals and heart rate variability using a wearable device during spine surgery. STUDY DESIGNProspective observational study. PATIENT SAMPLEFive orthopedic spine surgeons with experience ranging from 1 to 30 years were included. OUTCOME MEASURESThe outcome measures included stress levels among the spine surgeons and differences in stress parameters between novice and expert surgeons and between assistants and operators. METHODSFrom June 2018 to November 2018, 179 consecutive records of intraoperative stress measures, including intraoperative electroencephalography signals and heart rate variability, comprising beats per minute (BPM) and low frequency/high frequency ratio, for the orthopedic spine surgeons were prospectively gathered, compared, and analyzed. RESULTSAmong all measures, sensory-motor rhythm (SMR) waves, gamma waves, and BPM differed significantly during surgery (analysis of variance; p=.040, .013, .002, respectively). Surgery duration and intraoperative bleeding were positively correlated with stress parameters, including gamma waves and tension. For operators, surgeon experience was negatively correlated with concentration, tension, and SMR, gamma, M-beta, and H-beta waves (Pearson correlation, p<.05). However, for assistants, surgeon experience was positively correlated with concentration, tension, BPM, and SMR, M-beta, H-beta, and gamma waves. Bleeding amounts were correlated positively with gamma waves and tension for both operators and assistants (Pearson correlation, p<.05). Stress among operators was higher than that among assistants in terms of low frequency/high frequency ratio. CONCLUSIONSOperators and surgeons with low experience exhibited higher stress levels during surgery, which should be addressed when scheduling elective surgery to ensure optimal conditions among spine surgeons.

Quality improvement in post-operative opioid and benzodiazepine regimen in adolescent patients after posterior spinal fusion.

Prospective, quality-improvement. To evaluate pain management following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and Scheuermann's Kyphosis (SK) determine the optimal opioid and benzodiazepine prescription amounts, and implement a multimodal post-operative pain regimen. The incidence of prescription opioid abuse is increasing in the United States. Orthopedic spine surgeons often prescribe large quantities of opioids post-operatively for pain control. Previous efforts on pain control have focused on in-patient post-operative regimens after PSF. Between 2/1/17 and 5/30/18 patients with AIS or SK were sent home with pain diaries after discharge to document daily narcotic, benzodiazepine, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and gabapentin use following PSF. Diaries were collected at the 4week post-operative visit. Data from two cohorts were reviewed: pre-intervention and post-intervention. Our prescription intervention went into effect 9/1/17. Twenty-four (30%) patients returned pain diaries. The pre-intervention cohort consisted of 12 patients (7 female; 5 males; 14.9years (range 12-19)). Patients were prescribed on average 80 × 5mg tabs (26-140) of oxycodone but used on average 45 tabs (12-129) over an average of 17.5days (9-33). They were prescribed an average of 30 × 2mg tabs (0-150) of diazepam, used on average 4.8 (0-105) tabs over 12.5 (5-25) days. The post-intervention cohort consists of 12 patients (9 female; 3 male; 14.8years (12-19)). They were prescribed on average 50 × 5mg tabs (35-80) of oxycodone, used 20.5 (0-39.5) tabs over 8.5days (3-16). They were prescribed on average 18 × 2mg tabs of diazepam (0-43), used 5.4 tabs (0-19) over 10days (5-14). This analysis has directly impacted clinical practice. Prescribed opioid and benzodiazepine doses have been decreased by over 50%, and more resources are being directed towards determining the disparity between the amount of medications prescribed and consumed in our post-operative patients.

Evaluating Single-Surgeon Bias Toward Recommending Corrective Procedures for Cervical Spondylotic Myelopathy Based on Demographic Factors and Comorbidities in a 484-Patient Cohort.

Study Design:Retrospective case series.Objectives:An increasing focus has been placed on removing implicit (unconscious) bias from the surgical selection process. In spine surgery, there is the potential for implicit bias to affect the decision to either operate on a patient or not, given lack of definitive surgical indications for many elective procedures. The objective of this study was to analyze the surgical decision making of a single spine surgeon in an effort to understand surgical decision-making trends based on certain demographic factors.Methods:This was a retrospective study of 484 patients who had undergone a corrective procedure for cervical myelopathy by an orthopedic spine surgeon at our institution. The preoperative modified Japanese Orthopaedic Association score served as the metric of severity of disease for cervical myelopathy. The factors that have been associated with implicit bias that were evaluated were smoking status, narcotic use status, gender, body mass index, and age.Results:Multivariate linear regression analysis showed that even after controlling for comorbidities and confounders, the only variable which predicted likelihood to operate on a patient of a milder symptomology was age (odds ratio [OR] = −0.138; (confidence interval [CI] = −0.034 to −0.006). The other factors (smoking status, narcotic use status, gender, and body mass index) were not associated with surgical decision making.Conclusions:Our study demonstrates absence of association between commonly studied areas of implicit bias and the decision to operate on a patient with milder symptomology at initial presentation of cervical spondylotic myelopathy.

How engaged interdependence impacts operating room management metrics

ObjectiveIn this retrospective case study, we examine the impact of an operational coaching-based initiative, Engaged Interdependence, on operating room efficiency. DesignEngaged Interdependence is a professional development model that allows surgeons to expand their technical and managerial skills. Engaged Interdependence is composed of three parts and includes 6–8 h of direct operating room surgeon-to-surgeon observation or assistance once every other month, one-hour group discussions every month and 4–6 h of independent reading every month. Surgeon RM began coaching surgeon DL on 2/1/2017. We collected 12 months before and after the start data, splitting the data into a Before and an On/After groups for statistical and graphical comparison. All operating room management data were collected using WiseOR® and OR efficiency was assessed using four metrics: OR workload (patient time in room plus turnover time), operating time, over-utilized (OU) time, and under-utilized (UU) time. OR workload and operating time were analyzed using a Wilcoxon rank sum test, while OU and UU time were analyzed using a two-tailed t-test. SettingSmall, academic medical center. ParticipantA single orthopedic spine surgeon. ResultsOR workload hours significantly decreased for four of five most common procedures: Procedure 1 “Laminectomy, Part Facetectomy, Foraminotomy, Herniated Disc Lumbar” (Before Mean [M] ± Standard Deviation [SD]=2.09±0.42 h, After M = 1.95±0.42; p = 0.077); Procedure 2 “Laminectomy with Facetectomy + Foraminotomy, Lumbar” (Before M = 2.95±0.77 h, After M = 2.41±0.55; p = 0.022); Procedure 3 “Posterior Non-Segmental Instrumentation” (Before M = 4.11±0.66, After M = 3.52±0.76; p = 0.014); Procedure 4 “Laminectomy, Facetectomy + Foraminotomy Additional Segment” (Before M = 4.05±0.94, After M = 2.80±0.32; p = 0.0018); and Procedure 5 “Posterior Segmental Instrumentation- 3–6 Vertical Segments” (Before M = 6.40±0.83, After M = 4.62±1.1; p = 0.0065).Operating time hours significantly decreased for all five procedures: Procedure 1 (Before M = 1.34±0.38, After M = 1.17±0.32, p = 0.026), Procedure 2 (Before M = 2.15±0.71, After M = 1.61±0.54, p = 0.0058), Procedure 3 (Before M = 3.18±0.67, After M = 2.70±0.63, p = 0.032), Procedure 4 (Before M = 2.92±0.69, After M = 2.09±0.29, p = 0.014), and Procedure 5 (Before M = 5.43±0.83, After M = 3.58±1.0, p = 0.0032).OU time minutes significantly decreased (Before M = 20.5 ± 34.8, After M = 10.1 ± 22.8, p = 0.014), while UU time remained unchanged (Before M = 16.2 ± 22.3, After M = 23.4 ± 28.7, p = 0.063). ConclusionEngaged Interdependence represents a potential high-value intervention that can improve operating room efficiency. Although operational coaching is a subjective process, perioperative health care systems may generate a return on investment by fostering operational and organizational decision-making skills.

Ian McKim Thompson: an iconoclastic leader who helped to change the BMA

Although Ian McKim Thompson was born in Knutsford, Cheshire, he always identified with Birmingham and the West Midlands. His father was a bank manager and his mother a medical graduate...

Changes in Pediatric Spine Surgery Patterns Over the Last 10 Years Among ABOS Part II Candidates.

A retrospective review of prospectively collected data. Our purpose was to evaluate the volume of pediatric spine cases being done by surgeons applying for American Board of Orthopaedic Surgeons (ABOS) certification. Pediatric orthopedic surgery has become increasingly subspecialized over the past decade. Data were reviewed from the ABOS for surgeons undergoing part II of ABOS certification between 2004 and 2014. Applicants were divided into pediatric orthopedic surgeons and spine surgeons based on their self-declared subspecialty for the ABOS Part II examination. A total of 102,424 cases were reviewed to identify spine cases performed on patients <18 years old. Between 2004 and 2014, the total number of ABOS part II pediatric candidates increased significantly, from a low of 15 to a high of 44 (r = 0.68, P = 0.001). During this time frame, there has been no significant increase in the total number of pediatric spine cases reported (r = 0.09, P = 0.19). In 2004, 46.5% (33/71) of the pediatric spine cases were done by spine surgeons, which decreased to 17.3% (28/162) in 2014. Conversely in 2004, 53.5% (38/71) of pediatric spine cases were done by pediatric orthopedists, which increased to 82.7% (134/162) in 2014. The number of pediatric candidates performing pediatric spine cases decreased 35% from 2004 to 2014, but the percentage performing >20 spine cases during their candidate year has increased from 0% to 7% (r = 0.31, P = 0.04). The share of pediatric spine surgeries performed by pediatric candidates has increased from 54% in 2004 to 83%, with a corresponding fall in the share surgeries performed by spine candidates (47% to >17%). The percentage of pediatric candidates performing more than 20 spine cases/year increased from 0% to 7%, reflecting a trend of spine subspecialization within pediatric surgery. 3.

63. Orthopedic vs neurosurgery: understanding 90-day complications and costs in patients undergoing elective 1- to 2-level posterior lumbar fusions by different specialties

BACKGROUND CONTEXT Spine surgery is routinely performed by either orthopedic or neurological spine surgeons. Controversy still exists as to whether a provider's specialty (orthopedic vs neurosurgery) influences outcomes. PURPOSE With present evidence limited to inpatient-only and 30-day outcomes, the current study aims to understand differences in 90-day complication rates and health care resource utilization/costs between orthopedic and neurosurgical spine surgeons performing elective 1- to 2-level posterior lumbar fusions. STUDY DESIGN/SETTING Retrospective review of insurance claims from the Humana Commercial Database. PATIENT SAMPLE The 2007-2015Q2 Humana Commercial Database was queried using Current Procedural Terminology codes (22612, 22614, 22630, 22632, 22633 and 22634) to identify patients undergoing 1-to-2 level posterior lumbar fusions with active enrollment up to 90-days post-procedure. Patients undergoing fusion due to trauma, deformity and/or malignancy were excluded to capture a relevant study population of patients with degenerative lumbar pathology. OUTCOME MEASURES The 90-day complications included wound, pulmonary, cardiac, thromboembolic, sepsis, pneumonia, urinary tract infections, renal, dural tears and mechanical complications. Additional outcomes included emergency department (ED) visits, revision surgeries and readmissions within 90 days. The surgical and 90-day resource utilization costs for the two groups were compared, by studying average reimbursements for acute-care (index hospitalization, surgeon and anesthesia) and postacute care categories (office visits, nursing care, home health services, physical therapy, emergency department visits and readmissions). METHODS All 90-day complications and costs were compared using multivariable logistic and linear regression techniques while controlling for baseline differences in age, gender, race, region, Elixhauser Co-morbidity Index (ECI) and type of plan/benefit. RESULTS A total of 10,509 patients (5,523 = orthopedic, 4,986 = neurosurgery) underwent an elective 1- to 2- level posterior lumbar fusion during the time period. With the exception of a significantly lower odds of wound complications (OR 0.81) and a higher odds of dural tears (OR 1.29) in elective posterior lumbar fusions performed by orthopedic surgeons, no statistically strong differences were seen in 90-day complication rates between the two groups. Total 90-day costs were also similar between orthopedic and neurosurgeons, with the only exception being that surgeon reimbursement was lower for orthopedic surgery vs neurosurgery ($1,202 vs $1,372; p CONCLUSIONS A provider's specialty does not largely influence 90-day surgical safety outcomes and costs. The results of the study promote the formation and acceptance of dual training pathways for entry into the realm of spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.