Performing Spine Surgery Research Articles

Women in spine surgery: can we change the society?

Although the number of educated women and physicians, and especially neurosurgeons, is increasing worldwide, the educational opportunities, careers, and beliefs concerning female neurosurgeon's status and abilities are undermined. To date, reported studies have focused on the conditions of the work environment, work-life balance, and the academic career of female neurosurgeons. In this study, we aimed to report the patients' viewpoint and how they choose spine physicians. We conducted an international survey based on 19 questions in four languages (Bulgarian, Greek, English, and German). The responses of 413 individuals, unrelated to the medical field (sex, 315 female and 115 male individuals; one individual did not answer the question regarding the gender), were obtained. Except for the question regarding the patient's preference for the physician sex, the survey aimed to examine the factors that might be contributing to this choice, including education, age, heard/read recommendations/advertisements, knowledge regarding the work of the neurosurgeons/orthopedists, and their difference regarding spine surgery. The majority of the participants responded that they prefer male surgeons to treat their spine. The results showed a significant correlation between the choice of a male spine surgeon and heard/read advertisements/recommendations and knowledge regarding the work of the neurosurgeon. Despite the fact that education was not related to physician selection, it was an indirect factor that led to the final choice. Women in surgery, mainly in neurosurgery, are being treated by society in an unequal way. Female surgeons are still discriminated because of their gender. The most patients prefer female physicians to talk to, but still believe that they are incapable to perform spine surgery. We cannot stop this until we change our mindset and perception of reality.

Machine Learning Models for Predicting Disability and Pain Following Lumbar Disc Herniation Surgery

Lumber disc herniation surgery can reduce pain and disability. However, a sizable minority of individuals experience minimal benefit, necessitating the development of accurate prediction models. To develop and validate prediction models for disability and pain 12 months after lumbar disc herniation surgery. A prospective, multicenter, registry-based prognostic study was conducted on a cohort of individuals undergoing lumbar disc herniation surgery from January 1, 2007, to May 31, 2021. Patients in the Norwegian Registry for Spine Surgery from all public and private hospitals in Norway performing spine surgery were included. Data analysis was performed from January to June 2023. Microdiscectomy or open discectomy. Treatment success at 12 months, defined as improvement in Oswestry Disability Index (ODI) of 22 points or more; Numeric Rating Scale (NRS) back pain improvement of 2 or more points, and NRS leg pain improvement of 4 or more points. Machine learning models were trained for model development and internal-external cross-validation applied over geographic regions to validate the models. Model performance was assessed through discrimination (C statistic) and calibration (slope and intercept). Analysis included 22 707 surgical cases (21 161 patients) (ODI model) (mean [SD] age, 47.0 [14.0] years; 12 952 [57.0%] males). Treatment nonsuccess was experienced by 33% (ODI), 27% (NRS back pain), and 31% (NRS leg pain) of the patients. In internal-external cross-validation, the selected machine learning models showed consistent discrimination and calibration across all 5 regions. The C statistic ranged from 0.81 to 0.84 (pooled random-effects meta-analysis estimate, 0.82; 95% CI, 0.81-0.84) for the ODI model. Calibration slopes (point estimates, 0.94-1.03; pooled estimate, 0.99; 95% CI, 0.93-1.06) and calibration intercepts (point estimates, -0.05 to 0.11; pooled estimate, 0.01; 95% CI, -0.07 to 0.10) were also consistent across regions. For NRS back pain, the C statistic ranged from 0.75 to 0.80 (pooled estimate, 0.77; 95% CI, 0.75-0.79); for NRS leg pain, the C statistic ranged from 0.74 to 0.77 (pooled estimate, 0.75; 95% CI, 0.74-0.76). Only minor heterogeneity was found in calibration slopes and intercepts. The findings of this study suggest that the models developed can inform patients and clinicians about individual prognosis and aid in surgical decision-making.

PROPOSE. Development and validation of a prediction model for shared decision making for patients with lumbar spinal stenosis

BackgroundDecompression for lumbar spinal stenosis (LSS) is the most frequently performed spine surgery in Denmark. According to the Danish spine registry DaneSpine, at 1 year after surgery, about 75% of patients experiences considerable pain relief and around 66% improvement in quality of life. However, 25% do not improve very much. We have developed a predictive decision support tool, PROPOSE. It is intended to be used in the clinical conversation between healthcare providers and LSS patients as a shared decision-making aid presenting pros and cons of surgical intervention. This study presents the development and evaluation of PROPOSE in a clinical setting. MethodsFor model development, 6.357 LSS patients enrolled in DaneSpine were identified. For model validation, predictor response and predicted outcome was collected via PROPOSE from 228 patients. Observed outcome at 1 year was retrieved from DaneSpine. All participants were treated at 3 Danish spine centers. The outcome measures presented are improvement in walking distance, the Oswestry Disability Index, EQ-5D-3L and leg/back pain on the Visual Analog Scale. Outcome variables were dichotomized into success (1) and failure (0). With the exception of walking distance, a success was defined as reaching minimal clinically important difference at 1-year follow-up. Models were trained using Multivariate Adaptive Regression Splines. Performance was assessed by inspecting confusion matrix, ROC curves and comparing GCV (generalized cross-validation) errors. Final performance of the models was evaluated on independent test data. ResultsThe walking distance model demonstrated excellent performance with an AUC of 0.88 and a Brier score of 0.14. The VAS leg pain model had the lowest discriminatory performance with an AUC of 0.67 and a Brier score of 0.22. ConclusionsPROPOSE works in a real-world clinical setting as a proof of concept and demonstrates acceptable performance. It may have the potential of aiding shared decision making.

Neurosurgery compared to orthopedic spine consultation: A single level I trauma center experience

IntroductionBoth Orthopedic Surgery (OS) and Neurosurgery (NS) perform spine surgery in the setting of trauma. However, it is unknown whether outcomes differ between these specialties. This study compares management and outcomes for vertebral fractures between NS and OS, hypothesizing similar operation rate, length of stay (LOS), and readmission. Research questionDo outcomes differ between NS and OS in the management of vertebral fractures following trauma? MethodsA retrospective single-center study was conducted on adult patients with cervical, thoracic, lumbar, and sacral fractures treated at a single trauma center, where no standardized pathway exists across NS and OS. Patients were compared for injury profile, diagnostic imaging, and operative techniques as well as LOS, mortality, and complications. ResultsA total of 630 vertebral fracture patients (OS:350 (55.6%); NS:280 (44.4%)) were included. NS utilized magnetic resonance imaging (MRI) more commonly (36.4% vs. 22.6%, p < 0.001). NS patients more often underwent operation (13.2% vs. 7.4%, p = 0.016) despite similar fracture number and severity (p > 0.05). Post-operative complications, LOS, and readmission rates were similar between cohorts (p > 0.05). Discussion and conclusionDespite similar injury profiles, NS had higher rates of MRI usage and operative interventions in the context of traumatic spine fractures. Despite differences in management, major clinical outcomes were similar between NS and OS. However, we do call for further standardization of evaluation and treatment of patients based on established algorithms from such as the AOSpine Thoracolumbar Spine Injury Classification System (ATLICS).

Instrumented lumbar fusion in patients over 75 years of age: is it worthwhile?-a comparative study of the improvement in quality of life between elderly and young patients.

Surgical treatment of degenerative lumbar disease in the elderly is controversial. Elderly patients have an increased risk for medical and surgical complications commensurate with their comorbidities, and concerns over complications have led to frequent cases of insufficient decompression to avoid the need for instrumentation. The purpose of this study was to evaluate clinical outcome between older and younger patients undergoing lumbar instrumented arthrodesis. This is a retrospective, comparative study of prospectively collected outcomes. One hundred and fifty-four patients underwent 1- or 2-level posterolateral lumbar fusion. Patients were divided into two groups. Group 1: 87 patients ≤65 years of age who underwent decompression and posterolateral instrumented fusion; Group 2: 67 patients ≥75 years of age who underwent the same procedures with polymethylmethacrylate (PMMA) pedicle-screw augmentation. Mean follow-up 27.47 months (range, 76-24 months). Mean age was 49.1 years old (range, 24-65) for the younger group and 77.8 (range, 75-86) in the elderly group. Patients ≥75 years of age showed higher preoperative comorbidity (American Society of Anesthesiology, ASA: 1.7 vs. 2.4), and ≥2 systemic diseases with greater frequency (12.5% vs. 44.7%). No significant differences were found between the two groups in terms of postoperative complications, fusion, or revision rate. During follow-up, adjacent disc disease and adjacent fracture occurred significantly more in Group 2 (P<0.05). At the end of follow-up, there were no significant differences between the two groups in any of the clinical and health-related quality of life scores or satisfaction with treatment received. Osteoporosis represents a major consideration before performing spine surgery. Despite an obvious increased risk of complications in elderly patients, PMMA-augmented fenestrated pedicle screw instrumentation in spine fusion represents a safe and effective surgical treatment option to elderly patients with poor bone quality. Age itself should not be considered a contraindication in otherwise appropriately selected patients.

Is outpatient spine surgery associated with new, persistent opioid use in opioid-naïve patients? A retrospective national claims database analysis

BACKGROUND CONTEXTAlthough spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting. PURPOSETo assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures. STUDY DESIGNRetrospective analysis using national administrative claims database. PATIENT SAMPLEA total of 390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery. OUTCOME MEASURESPatients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users. METHODSWe utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors. RESULTSA total of 19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval {CI}: 0.69, 0.73], p < .001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < .001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < .001) were lower in the outpatient cohort compared to the inpatient. CONCLUSIONOur results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification. LEVEL OF EVIDENCELevel III Prognostic Study. MINI ABSTRACTWe utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.

How Much Experience is Required to Acquire the Skills to Independently Perform Spine Surgery? What Milestones are Needed for Successful Surgery?

To assess the number of surgeries needed to acquire the necessary skills to perform spine surgery independently. A questionnaire on 12 different spinal procedures was sent to orthopedic surgeons affiliated with the spine teams of orthopedic departments at either the Akita University or Sapporo Medical University. Participants were asked to identify whether they (A) could independently perform each procedure, (B) could perform each procedure with the assistance of a senior doctor, or (C) were unable to perform each procedure. Those whose response was (A) were asked how many surgeries were required to acquire the necessary skills. Those who responded to (B) or (C) were asked how many surgeries they believed were required to acquire the skills necessary to operate independently. Participants also responded to 10 questions on surgical training techniques and rated the usefulness of each method. A total of 55 spine surgeons responded to the questionnaire. Group A required significantly fewer surgeries in the following categories to become independent than required Group C: upper cervical spine surgery (7.3/19.3), anterior cervical decompression/fusion (6.7/28.8), posterior cervical decompression/fusion (9.5/27.3), lumbar discectomy (12.6/26.7), endoscopic lumbar discectomy (10.2/24.2), spinal tumor resection (6.5/37.2), and spinal kyphosis surgery (10.3/32.3). Over 80% of participants responded that the following were effective methods: "surgeries where a senior doctor is the main surgeon, and the respondent is the assistant and observer"; "surgeries where the respondent is the main surgeon, and a senior doctor is an assistant"; "self-study using surgery manuals, articles, and textbooks"; and "training through video surgery sessions". Surgeons who do not perform specific procedures independently require more surgical experience than those who operate independently. Our results may help develop more efficient training methods for spine surgeons.

Surgical classification using natural language processing of informed consent forms in spine surgery.

In clinical spine surgery research, manually reviewing surgical forms to categorize patients by their surgical characteristics is a crucial yet time-consuming task. Natural language processing (NLP) is a machine learning tool used to adaptively parse and categorize important features from text. These systems function by training on a large, labeled data set in which feature importance is learned prior to encountering a previously unseen data set. The authors aimed to design an NLP classifier for surgical information that can review consent forms and automatically classify patients by the surgical procedure performed. Thirteen thousand two hundred sixty-eight patients who underwent 15,227 surgeries from January 1, 2012, to December 31, 2022, at a single institution were initially considered for inclusion. From these surgeries, 12,239 consent forms were classified based on the Current Procedural Terminology (CPT) code, categorizing them into 7 of the most frequently performed spine surgeries at this institution. This labeled data set was split 80%/20% into train and test subsets, respectively. The NLP classifier was then trained and the results demonstrated its performance on the test data set using CPT codes to determine accuracy. This NLP surgical classifier had an overall weighted accuracy rate of 91% for sorting consents into correct surgical categories. Anterior cervical discectomy and fusion had the highest positive predictive value (PPV; 96.8%), whereas lumbar microdiscectomy had the lowest PPV in the testing data (85.0%). Sensitivity was highest for lumbar laminectomy and fusion (96.7%) and lowest for the least common operation, cervical posterior foraminotomy (58.3%). Negative predictive value and specificity were > 95% for all surgical categories. Utilizing NLP for text classification drastically improves the efficiency of classifying surgical procedures for research purposes. The ability to quickly classify surgical data can be significantly beneficial to institutions without a large database or substantial data review capabilities, as well as for trainees to track surgical experience, or practicing surgeons to evaluate and analyze their surgical volume. Additionally, the capability to quickly and accurately recognize the type of surgery will facilitate the extraction of new insights from the correlations between surgical interventions and patient outcomes. As the database of surgical information grows from this institution and others in spine surgery, the accuracy, usability, and applications of this model will continue to increase.

Longitudinal Assessment of Modern Spine Surgery Training: 10-Year Follow-up of a Nationwide Survey of Residency and Spine Fellowship Program Directors.

This study is a cross-sectional survey distributed to all PDs of ORTH and NSGY residencies and spine fellowships in the United States. Participants were queried regarding characteristics of their program, ideal characteristics of residency training, and opinions regarding the current training environment. χ2 tests were used to compare answers over the years. In total, 241 PDs completed the survey. From 2013 to 2023, NSGY increased the proportion of residents with >300 spine cases (86%-100%) while ORTH remained with >90% of residents with < 225 cases (p < 0.05). A greater number of NSGY PDs encouraged spine fellowship even for community spine surgery practice (0% in 2013 vs. 14% in 2023, p < 0.05), which continued to be significantly different from ORTH PDs (∼88% agreed, p > 0.05). 100% of NSGY PDs remained confident in their residents performing spine surgery, whereas ORTH confidence significantly decreased from 43% in 2013 to 25% in 2023 (p < 0.05). For spinal deformity, orthopaedic PDs (92%), NSGY PDs (96%), and fellowship directors (95%), all agreed that a spine fellowship should be pursued (p = 0.99). In both 2013 and 2023, approximately 44% were satisfied with the spine training model in the United States. In 2013, 24% of all PDs believed we should have a dedicated spine residency, which increased to 39% in 2023 (fellowship: 57%, ORTH: 38%, NSGY: 21%) (p < 0.05). Spine surgery training continues to evolve, yet ORTH and neurological surgery training remains significantly different in case volumes and educational strengths. In both 2013 and 2023, less than 50% of PDs were satisfied with the current spine surgery training model, and a growing minority believe that spine surgery should have its own residency training pathway. IV.

Over 20 years of declining Medicare reimbursement for spine surgeons: a temporal and geographic analysis from 2000 to 2021.

Procedural reimbursement for spine surgery has changed drastically over the past 20 years. A comprehensive understanding of these trends is important as major changes in reimbursement models of spine surgery continue to evolve within various spine specialties as well as broader national healthcare policy. In this study the authors evaluated the monetary trends in Medicare reimbursement rates for the 15 most common spinal surgery procedures from 2000 to 2021. The National Surgery Quality Improvement Project database (2019) was queried to determine the 15 most commonly performed spine surgery procedures. The Current Procedural Terminology (CPT) codes for each of these procedures were obtained from the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services, and comprehensive reimbursement data for each code were extracted. Changes in Medicare reimbursement rates were calculated and averaged for each procedure as both raw percent changes and percent changes adjusted for inflation to 2021 US dollars (USD) based on the consumer price index (CPI). The adjusted R2 value, the compound annual growth rate (CAGR), and both the average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all included procedures. After adjustment for inflation, average reimbursement for all procedures decreased by 33.8% from 2000 to 2021. The greatest mean decrease was seen in anterior cervical arthrodesis (-38.7%), while the smallest mean decrease was in vertebral body excision (-17.1%). From 2000 to 2021, the adjusted reimbursement rate for all included procedures decreased by an average of 1.9% each year, with an average R2 value of 0.69. This is the first study to evaluate monetary trends in Medicare reimbursement for spine surgery procedures. After adjusting for inflation, Medicare reimbursement for the 15 most commonly performed spine procedures has steadily decreased from 2000 to 2021. Increased awareness of these trends and the forces driving them will be critical in the coming years as negotiations regarding reimbursement models continue to unfold. Greater understanding of spine surgery reimbursement among policy makers, hospitals, and surgeons will be important to ensure continued access to quality surgical spine care in the United States.

Adequacy of spine surgery fellowship training in Turkey: Results of a survey.

The aim of this study was to determine the adequacy of spine surgery fellowship training (SSFT) in Turkey and what is needed for further development by interviewing current fellows. Forty male orthopaedics and traumatology or neurosurgery specialists who had completed SSFT in three different spine centers in Turkey between 2010 and 2018 were asked to complete a survey with 29 questions about SSFT in Turkey. Thirty specialists responded, and the collected data were analyzed. Twenty-seven (90%) participants were orthopaedic and traumatology specialists and three (10%) were neurosurgery specialists, with a mean age of 39 (range = 35-53) years. Most participants received their residency training in the provinces where their fellowship training took place (11 (37%) in İstanbul and 7 (23%) in Ankara). The mean duration between residency training and the start of SSFT was 4 (range = 0-14) years, and the mean SSFT duration was 8 (range = 1-18) months. Seventy percent of participants had participated in spine surgery cases during their residency. Twenty-three (77%) participants reported that spine surgery training in their hospital during their residency was inadequate. Seventeen (57%) participants felt that they could not independently perform spine surgery cases before SSFT. All three centers (100%) participating in the study that offered SSFT were non-public institutions such as private hospitals and private university hospitals of medicine managed by a dedicated mentor with personal commitment, without any accreditation for SSFT. While 25 (83%) participants indicated that they felt competent enough to perform a standard spinal deformity surgery case independently at the end of SSFT, 5 (17%) indicated the opposite. This proportion, which was 43% at the end of residency, increased to 83% after SSFT. The results of this study have demonstrated the importance of SSFT in spine surgery as a specialty with a potentially high risk of complications that require prolonged case observation, challenging work-up, and adequate equipment. In this regard, there is a need for regulations on accreditation in government health facilities that provide ideal conditions. We propose to offer SSFT to all surgeons interested in spine surgery in Turkey by conducting further studies supported by an optimal health sector that ensures the appropriate requirements, in accordance with the declaration of TOTEK (The Turkish Orthopaedics and Traumatology Education Council), training workshops, and an accredited master's degree program in spine surgery or subspecialty.

Virtual Reality Simulator for Training on Surgery Ergonomics Skills

This work focuses on ergonomics skills based on Virtual Reality (VR) training simulator for spine surgery. The proposed system used the Head Mounted Display (HMD) device for monitoring and data collection. The aim of the project was to provide a training approach for residents that would enable them to acquire the proper ergonomic skills needed while performing spine surgery. A VR training simulator has been designed and implemented to measure two ergonomic skills required that need to be maintained during any surgery. The two components were neck’s angle and table’s height. The experiments showed that the users are usually focused on their work and tend to pay less attention to their body’s position and movements. This can result in a wrong ergonomics setup, which leads to musculoskeletal pain. Thus, the users (residents) need to be trained to have good ergonomics positions. The proposed system measured this using a specific metric that collected head positions, angles, elbow height, and other parameters. The designed model was a VR simulator for neurosurgical education in particular; however, it might be good for some other similar surgeries. The study concluded that incorporating simulations into residents’ training and simulated surgeries can strengthen the surgeons’ skills and outcomes. As a result, both residents and expert surgeons can benefit from the use of the developed model.

ESTIMATED EXPOSURE OF SPINE SURGEONS TO RADIATION

ABSTRACT Objective To estimate the amount of radiation received and accumulated in the bodies of two surgeons, one being the responsible surgeon and the other the assistant, performing spine surgery procedures over a period of 25 years. Methods Seventy-two spinal surgeries were performed during a seven-month period and the radiation loads were measured in both surgeons. The measurement of radiation was captured in fluoroscopy in anteroposterior and lateral incidences. The surgeon and the assistant used two dosimeters, one in the cervical region protecting the thyroid and the other on the lead apron in the genital region. The radioactive loads were measured in millisieverts and the accumulated charges were recorded monthly in both regions of the body in the two surgeons for seven months and the means for the work periods (1, 5, 10, 15, 20 and 25 years) were estimated. Results It was observed that in the surgeon the average accumulated radiation loads were 131.9% and 176.92% higher than those of the assistant in the cervical and genital regions, respectively. Conclusion While the use of X-rays is indispensable in routine orthopedic surgery, we have to consider the development of techniques of protection, rigor and discipline in the use of safety materials for surgeons. Preventive exposure reduction measures such as using thyroid protection equipment and turning the head away from the patient during fluoroscopy, among others, should be mandatory to promote less radiation exposure. Level of evidence II; Comparative prospective study.

Artificial intelligence for adult spinal deformity: current state and future directions

As we experience a technological revolution unlike any other time in history, spinal surgery as a discipline is poised to undergo a dramatic transformation. As enormous amounts of data become digitized and more readily available, medical professionals approach a critical juncture with respect to how advanced computational techniques may be incorporated into clinical practices. Within neurosurgery, spinal disorders in particular, represent a complex and heterogeneous disease entity that can vary dramatically in its clinical presentation and how it may impact patients’ lives. The spectrum of pathologies is extremely diverse, including many different etiologies such as trauma, oncology, spinal deformity, infection, inflammatory conditions, and degenerative disease among others. The decision to perform spine surgery, especially complex spine surgery, involves several nuances due to the interplay of biomechanical forces, bony composition, neurologic deficits, and the patient's desired goals. Adult spinal deformity as an example is one of the most complex, given its involvement of not only the spine, but rather the entirety of the skeleton in order to appreciate radiographic completeness. With the vast array of variables contributing to spinal disorders, treatment algorithms can vary significantly, and it is very difficult for surgeons to predict how patients will respond to surgery. As such, it will become imperative for spine surgeons to utilize the burgeoning availability of advanced computational tools to process unprecedented amounts of data and provide novel insights into spinal disease. These tools range from predictive models built using machine learning algorithms, to deep learning methods for imaging analysis, to natural language processing that can mine text from electronic medical records or transcribed patient visits – all to better treat the intricacies of spinal disorders. The adoption of such techniques will empower patients and propel spine surgeons into the era of personalized medicine, by allowing clinical plans to be tailored to address individual patients’ needs. This paper, which exists in the context of a larger body of literatutre, provides a comprehensive review of the current state and future of artificial intelligence and machine learning with a particular emphasis on Adult spinal deformity surgery.

Cost effectiveness of outpatient lumbar discectomy

BackgroundMicrodiscectomy is the most commonly performed spine surgery and the first transitioning for outpatient settings. However, this transition was never studied, in what comes to cost-utility assessment. Accordingly, this economic study aims to access the cost-effectiveness of outpatient lumbar microdiscectomy when compared with the inpatient procedure.MethodsThis is a cost utility study, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy Quality-adjusted life-years were calculated from Oswestry Disability Index values (ODI). ODI was prospectively assessed in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. A probabilistic sensitivity analysis was performed and incremental cost-effectiveness ratio (ICER) calculated.ResultsOutpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135,753 to €345,755/QALY, higher than the predefined threshold of €60,000/QALY gained. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group.ConclusionThis is the first economic study on cost-effectiveness of outpatient lumbar microdiscectomy, showing a significant reduction in costs, with a similar clinical outcome, proving it cost-effective.

Intraoperative Spinal Cord Monitoring: Focusing on the Basic Knowledge of Orthopedic Spine Surgeon and Neurosurgeon as Members of a Team Performing Spine Surgery under Neuromonitoring.

An intraoperative functional spinal cord monitoring system is a technology used by spine and spinal cord surgeons to perform a safe surgery and to gain further surgical proficiency. However, no existing clinical neurophysiological method used in the operating room can monitor all complex spinal cord functions. Therefore, by observing the activities of certain neural action potentials transferred via limited neural tissues, surgeons need to deductively estimate the function of the whole spinal cord. Thus, as the number of spinal cord functions that need to be observed increases, spinal cord monitoring can be more reliable. However, in some situations, critical decision-making is affected by the limited capability of these methods. Nevertheless, good teamwork enables sharing of seamless information within the team composed of a surgeon, anesthesiologist, monitoring technician and nurses greatly contributes to making quick and accurate decisions. The surgeon, who is the person in charge of the team, should communicate with multidisciplinary team members using common technical terms. For this reason, spine and spinal cord surgeons must have appropriate knowledge of the methods currently used, especially of their utility and limitations. To date, at least six electrophysiological methods are available for clinical utilization: three are used to monitor sensory-related tracts, and three are used to monitor motor-related spinal cord functions. If surgeons perform electrode setting, utilizing their expertise, then the range of available methods is broadened, and more meticulous intraoperative functional spinal cord monitoring can be carried out. Furthermore, if the team members share information effectively by utilizing a clinically feasible judicious checklist or tools, then spinal cord monitoring will be more reliable.

Addressing Coronavirus Disease 2019 in Spine Surgery: A Rapid National Consensus Using the Delphi Method via Teleconference.

The magnitude and potential duration of the current coronavirus disease 2019 (COVID-19) pandemic is something that most doctors currently in practice have yet to experience. While considerable information regarding COVID-19 is being published every day, it is challenging to filter out the most relevant or appropriate information for our individual practice. The Spine Society of Singapore convened via a teleconference on April 24, 2020 to collaborate on a national level and share collective wisdom in order to tackle the ongoing crisis. In the teleconference, 13 spine surgeons from across various hospitals in Singapore constituted the panel of experts. The following topics were discussed: repurposing of surgeons, continuity of spine services, introduction of telemedicine, triaging of spinal surgeries, preoperative testing, new challenges in performing spine surgery, and preparing for the post-pandemic era. While some issues required only the sharing of best practices, the Delphi panel method was adopted to form a consensus on others. Existing spine specific triage guidelines were debated and a locally accepted set of guidelines was established. Although preoperative testing is currently not performed routinely, the panel voted in favor of its implementation because they concluded that it is vital to protect themselves, their colleagues, and their patients. Solutions to operating room specific concerns were also discussed. This article reflects the opinions and insights shared during this meeting and reviews the evidence relevant to the issues that were raised. The rapid consensus reached during the teleconference has enabled us to be concerted, and thus stronger, in our national efforts to provide the best standard of care via our spine services in these challenging times. We believe that this article will provide some guidance for addressing COVID-19 in spine surgery and encourage other national/regional societies to conduct similar discussions that would help their navigation of this pandemic.

Utility of Preoperative Laboratory Testing in Assessing Risk of Adverse Outcomes After Anterior Cervical Discectomy and Fusion: Insights from National Surgical Registry

Preoperative laboratory tests are varied in their administration among physicians, and previous studies have published conflicting reports on their utility. Anterior cervical discectomy and fusion (ACDF) is a commonly performed spine surgery, and patients often undergo preoperative testing. We sought to assess the relationship between preoperative laboratory values and risk for adverse postoperative outcomes after ACDF. The American College of Surgeons-National Surgical Quality Improvement Program was queried from 2012 to 2017 to identify patients undergoing elective ACDF. Multivariable logistic regression was performed to assess the association between abnormal laboratory test values and adverse 30-day outcomes. Relative predictor importance was determined using an importance metric defined as Wald χ2 penalized by degrees of freedom. A total of 47,111 patients were included. On multivariable analysis, high creatinine (P= 0.030), anemia (P < 0.001), hyponatremia (P= 0.034), and leukocytosis (P<0.001) were found to be significantly associated with any 30-day complications. Anemia (P < 0.001), hypernatremia (P= 0.028), hyponatremia (P= 0.016), and leukocytosis (P<0.001) were found to be significantly associated with serious 30-day complications. High creatinine (P= 0.027), anemia (P < 0.001), hyponatremia (P= 0.047), and leukocytosis (P= 0.004) were found to be significantly associated with 30-day unplanned readmissions. High blood urea nitrogen (P= 0.007), high creatinine (P= 0.028), anemia (P<0.001), low platelet count (P < 0.001), hyponatremia (P<0.001), and leukocytosis (P < 0.001) were found to be significantly associated with nonhome discharge. Predictor importance analysis revealed that abnormal preoperative laboratory values were important determinants in predicting these 30-day outcomes. Our analyses indicate that abnormal preoperative laboratory values are associated with increased risk for adverse outcomes after elective ACDF and can be used in predictive analyses of outcomes.

Utilization and Outcomes for Spine Surgery in the United States and Canada.

A retrospective cohort study. The aim of this study was to examine variation in spine surgery utilization between the province of Ontario and state of New York among all patients and pre-specified patient subgroups. Spine surgery is common and costly. Within-country variation in utilization is well studied, but there has been little exploration of variation in spine surgery utilization between countries. We used population-level administrative data from Ontario (years 2011-2015) and New York (2011-2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery using relevant procedure codes. Patients were stratified according to age and surgical urgency (elective vs. emergent). We calculated standardized utilization rates (procedures per-10,000 population per year) for each jurisdiction. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared utilization rates of spinal decompression and fusion surgery in Ontario and New York among all patients and after stratifying by surgical urgency and patient age. Patients in Ontario were older than patients in New York for both decompression (mean age 58.8 vs. 51.3 years; P < 0.001) and fusion (58.1 vs. 54.9; P < 0.001). A smaller percentage of hospitals in Ontario than New York performed decompression (26.1% vs. 54.9%; P < 0.001) or fusion (15.2% vs. 56.7%; P < 0.001). Overall, utilization of spine surgery (decompression plus fusion) in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 16.5 per-10,000 per-year (P < 0.001). Ontario-New York differences in utilization were smaller for emergent cases (2.0 per 10,000 in Ontario vs. 2.5 in New York; P < 0.001), but larger for elective cases (4.6 vs. 13.9; P < 0.001). The lower utilization in Ontario was particularly large among younger patients (age <60 years). We found significantly lower utilization of spine surgery in Ontario than in New York. These differences should inform policy reforms in both jurisdictions. 3.

CATASTROPHIC AIRWAY COMPLICATIONS STATUS POST ANTERIOR CERVICAL DISCECTOMY AND FUSION

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Anterior cervical discectomy and fusion is a commonly performed spine surgery and considered a relatively safe procedure. It usually carries a small risk of postoperative complications, however, airway compromise after cervical spine surgery can be catastrophic and one that all providers should be aware of. Here we present a case of catastrophic airway complication status post anterior cervical discectomy and fusion. CASE PRESENTATION: We present a 75 year-old female with long history of C2 fracture with anterior displacement secondary to fall with intermittent left arm numbness and weakness who presented for a scheduled C3/4/5 Anterior Cervical Discectomy and Fusion. Patient had a prolonged surgical fixation resulting in prolonged duration of time in the prone position. The patient had significant facial and upper airway swelling and was therefore not extubated postop due to the concerns of the above mentioned swelling. The following morning, the swelling improved and the patient was extubated with no complications. Postop day 2, the patient developed stridor which did not respond to dexamethasone or racemic epinephrine. The neck swelling quickly worsened and fiberoptic intubation was planned. The patient was found to have an edematous larynx with difficulty passing the endotracheal tube through the vocal cords. The patient was noted to desaturate and subsequently became pulseless; CPR was initiated. Emergent crychothyroidotomy which was successfully performed however patient's end tidal and oxygen saturations remained flat. Bedside echo showed no cardiac activity and the patient unfortunately did not obtain ROSC. DISCUSSION: Anterior cervical discectomy and fusion is considered a relatively safe procedure, but can be related to catastrophic complications. Airway compromise requiring reintubation are rare, but have never been quantified. Potential causes of airway obstruction include pharyngeal edema, hematoma, cerebrospinal fluid leak and angioedema. Risk factors for airway complication include prolonged anesthetic time, extensive cervical dissections above C4 and estimated blood loss greater than 300 mL. The average time to respiratory insufficiency in these patients is 23 hours after surgery. Therefore, we suggest that intensive observation of respiratory function should be monitored for at least 48 hours following an anterior cervical discectomy and fusion procedure. CONCLUSIONS: This case shows that airway complications following anterior cervical discectomy and fusion can be catastrophic. This is a complication that all Pulmonary Critical Care physicians should be aware of. The above mentioned risk factors should be checked and intense observation of respiratory function should be monitored for at least 48 hours after surgery. Reference #1: Lim, S., Kesavabhotla, K., Cybulski, G. R., Dahdaleh, N. S., & Smith, Z. A. (2017). Predictors for Airway Complications Following Single- and Multilevel Anterior Cervical Discectomy and Fusion. Spine, 42(6), 379-384. Reference #2: Sagi, H. C., Beutler, W., Carroll, E., & Connolly, P. J. (2002). Airway Complications Associated With Surgery on the Anterior Cervical Spine. Spine, 27(9), 949-953 DISCLOSURES: No relevant relationships by Armand Golchin, source=Web Response No relevant relationships by William McGee, source=Web Response No relevant relationships by Mitchell Onwochei-Ashei, source=Web Response No relevant relationships by Quazi Kamran Uddin, source=Web Response