Spinal Fusion Surgery In Patients Research Articles

Differences of Spinopelvic Parameters Before and After Posterior Spinal Fusion in Lumbosacral Spinal Stenosis Patients at H. Adam Malik Hospital Medan

Fusion and instrumentation during decompression surgery are suggested to reduce pain and overcome instability. However, spinal fusion also has some consequences as fusion changes the normal biomechanics of the spine and reduces spinal mobility. Evaluation of spinopelvic balance after posterior spinal fusion has not been widely studied. Therefore, the purpose of this study was to assess spinopelvic balance in adult patients who had been diagnosed with lumbosacral spinal stenosis and received spinal fusion procedures.This analytical study, using a pre-test and post-test design, was conducted from August to September 2022. The study population was patients with more than 40 years old who had been diagnosed with lumbosacral spinal stenosis and underwent spinal fusion at H. Adam Malik Hospital Medan in 2017-2021. Inclusion criteria were patients who had a lumbosacral x-ray before surgery, < 6 months after surgery, and > 6 months after surgery, and the lumbosacral x-ray is visible until the hip joint, and those lumbosacral spinal stenosis underwent spinal fusion. Exclusion criteria were incomplete data and implant failure after spinal fusion. The dependent t test or Mann-U-Whitney test was used to assess the statistical analysis.There were 22 samples included in this study. A total of 22 patients, The age ranged from 50-68 years old, with mean age of 59.48 ± 9.08 years old. There were more female samples (68.2%) than males (31.8%). Pelvic tilt mean angle were 19.140 ± 22.280 vs 17.68 ± 8.020 vs 14.270 ± 5.340. Sacral slope mean angle were 43.230 ± 20.220 vs 17.680 ± 8.020 vs 14.270 ± 5.340. Pelvic incidence mean angle were 57.680 ± 11.560 vs 55.590 ± 12.280 vs 52.640 ± 10.050. Lumbar lordosis mean angle were 43.910 ± 13.020 vs 41.550 ± 12.770 vs 41.18 ± 13.120. Pelvic incidence lumbar lordosis mismatch mean angle were 14.860 ± 10.260 vs 14.500 ± 10.790 vs 11.230 ± 8.550. The analysis showed changes in angles among the three groups in all evaluated spinopelvic parameters, but not statistically significant (p>0.05). Previous research. indicated that spinopelvic examinations such as lumbar lordosis, pelvic incidence, and pelvic tilt were highly correlated with sagittal balance, where pelvic incidence was a particularly important key parameter. In this study, spinopelvic parameters in three groups were examined, compared and evaluated at three different times, yielding no significant differences. The pelvic incidence lumbar lordosis mismatch is an important parameter to examine. However, the results of this study did not show any significant differences among the values before and after posterior spinal fusion surgery. There was no significant differences in spinopelvic parameters before posterior spinal fusion, < 6 months, and > 6 months after posterior spinal fusion surgery in patients with lumbosacral spinal stenosis.

Analysis of intervertebral disc CCR6 and IL-6 gene levels with short-term postoperative low back pain after spinal fusion in lumbar degenerative disease.

Previous studies have reported that specific pro-inflammatory cytokines or chemokines are more highly expressed in painful than in nonpainful intervertebral discs (IVDs). However, few studies have investigated their correlation with postsurgical outcomes or the relationship between postoperative pain and inflammatory cytokines in IVDs. Thus, the present study examined the correlation among the gene expression levels of pro-inflammatory cytokines and chemokines in IVD tissues removed during surgery and low back pain (LBP), leg pain (LP), and leg numbness (LN) at one year after spinal fusion surgery in patients with a lumbar degenerative disease (LDD). Chemokine and cytokine gene expression levels were measured in IVD samples from 48 patients with LDD. The associations between chemokine and cytokine gene expression levels and pain intensity (numeric rating scale [NRS]) were also analyzed. A correlation analysis was performed between gene expression in each IVD and preoperative and postoperative pain intensity. In the preoperative analysis, CCR6 was associated with NRSLBP (r = -0.291, P = 0.045). Postoperative pain analysis revealed correlations between postoperative NRSLBP and CCR6 (r = -0.328, P = 0.023) and between postoperative NRSLBP and IL-6 (r = -0.382, P = 0.007). Furthermore, patients with high postoperative LBP intensity (NRSLBP ≥ 7) also had high LBP intensity (NRSLBP ≥ 6) before surgery, and a correlation was observed (r = 0.418, P = 0.003). None of the gene mRNAs correlated with NRSLP or NRSLN, respectively. CCR6 and IL-6 gene expression in the IVD was associated with postoperative LBP intensity and may indicate a need for postoperative pain management.

Surgical site infection in pediatric spinal fusion surgery revisited: Outcome and risk factors after preventive bundle implementation

BackgroundSurgical site infections (SSI) contribute to significant morbidity, mortality, length of stay, and financial burden. We sought to evaluate the incidence and risk factors of surgical site infection following pediatric spinal fusion surgery in patients for whom standard perioperative antibiotic prophylaxis and preventive strategies have been implemented. MethodsWe conducted a retrospective study of children aged <18 years who underwent spinal fusion surgery from January 2017 to November 2021 at a quaternary academic pediatric medical center. Univariable analysis was used to evaluate associations between potential risk factors and SSI. ResultsOf 1111 patients, 752 (67.6%) were female; median age was 14.2 years. SSI occurred in 14 patients (1.3%). Infections were superficial incisional (n = 2; 14.3%), deep incisional (n = 9; 64.3%), and organ/space (n = 3; 21.4%). Median time to SSI was 14 days (range, 8 to 45 days). Staphylococcus aureus and Escherichia coli were the most frequently-isolated bacteria. Potential risk factors for SSIs included low body weight (Odds ratio (OR) 0.96, 95% confidence interval (CI) 0.93–0.99, p = 0.026), ASA classification of ≥3 (OR 24.53, 95%CI 3.20–188.22, p = 0.002), neuromuscular scoliosis (OR 3.83, 95%CI 3.82–78.32, p<0.001), prolonged operative time (OR 1.56, 95%CI 1.28–1.92, p<0.001), prolonged anesthetic time (OR 1.65, 95%CI 1.35–2.00, p<0.001), administration of prophylactic antibiotic ≥60 min before skin incision (OR 11.52, 95%CI 2.34–56.60, p = 0.003), and use of povidone-iodine alone for skin preparation (OR 5.97, 95%CI 1.27–28.06, p = 0.024). ConclusionIn the context of a robust bundle for SSI prevention; low body weight, ASA classification of ≥3, neuromuscular scoliosis, prolonged operative and anesthetic times, administration of prophylactic antibiotic >60 min before skin incision, and use of povidone-iodine alone for skin preparation increased the risk of SSI. Administration of prophylactic antibiotic within 60 min of skin incision, strict adherence to high-risk preventive protocol, and use of CHG-alcohol could potentially reduce the rate of SSI.

Surgical Outcomes and Fusion Rate Following Spinal Fusion in Patients with Chronic Kidney Disease: Impact of Kidney Function

To evaluate surgical outcomes and fusion rate following spinal fusion surgery in patients with chronic kidney disease and assess the impact of kidney function. From March 2017 to February 2021, 54 consecutive adult patients with chronic kidney disease who underwent spinal fusion surgery were enrolled. According to the glomerular filtration rate (GFR) categories, 35 and 19 patients were classified into the non-end-stage renal disease (ESRD) group (GFR categories 3a-4; eGFR, 15-59mL/min/1.73m2) and ESRD group (GFR category 5; eGFR, <15mL/min/1.73m2), respectively. Baseline characteristics did not differ between the groups. The lumbar and thoracolumbar spines were the most operated. The mean number of fused vertebrae (4.9±2.3 vs. 4.1±2.0, P=0.122), operative time (228.4±129.6min vs. 160.5±87.5min, P=0.113), and surgical bleeding (743.1±630.5mL vs. 539.5±384.4mL, P=0.354) did not differ between the groups. However, occurrence rates of medical complications (25.7% vs. 52.6%, P=0.048) and 3-month readmission (8.6% vs. 35.3%, P=0.045) were significantly different between the groups. While the 3-month mortality (10.5% vs. 2.9%, P=0.28) and pseudarthrosis rates (35.3% vs. 9.1%, P=0.047) were higher in the ESRD group, the difference was not statistically significant for the former entity. Surgeons should consider the possibility of high morbidity and pseudarthrosis associated with spine surgeries when operating on patients with ESRD.

Long-term Radiological and Clinical Outcome after Lumbar Spinal Fusion Surgery in Patients with Degenerative Spondylolisthesis: A Prospective 6-Year Follow-up Study.

ObjectiveTo assess which radiological alignment parameters are associated with a satisfactory long‐term clinical outcome after performing lumbar spinal fusion for treating degenerative spondylolisthesis.MethodsThis single‐center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient‐reported outcome using four different questionnaires (COMI, EQ‐5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low‐grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females).ResultsThe data of 17 patients after mono‐ or bisegmental lumbar fusion surgery to treat low‐grade lumbar spondylolisthesis and with a follow‐up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m2 and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8–21). The long‐term clinical outcome correlated significantly with the change of the pelvic tilt (r s = −0.515, P < 0.05) and the sagittal rotation (r s = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (r s = 0.637, P < 0.01) and the pelvic incidence (r s = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (r s = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires.ConclusionsThe surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long‐term clinical outcome after lumbar interbody fusion surgery.

Reconstruction surgery combined with impaction allogenic bone graft reinforcing endplate using fibula for Pseudarthrosis after spinal fusion surgery in patients with osteoporosis

Reconstruction surgery combined with impaction allogenic bone graft reinforcing endplate using fibula for Pseudarthrosis after spinal fusion surgery in patients with osteoporosis

Surgical Outcome of Spinal Fusion for Osteogenesis Imperfecta With Scoliosis: Is the Hybrid System With Pedicle Screws Applicable to Weak, Tiny, and Fragile Vertebrae?

Corrective surgery for spinal deformity associated with osteogenesis imperfecta (OI) is challenging due to the severe and rigid deformity combined with extreme bone fragility. However, surgical outcomes still remain unclear. In addition, the applicability of pedicle screws (PSs) to the tiny and fragile vertebrae in patients with OI is poorly understood. This study evaluated the surgical outcome, and the accuracy and safety of PS placement in patients with OI. Twenty-five patients with OI were included in this study. Mean age was 21.0±9.3 (10 to 49) years. Mean follow-up was 5.8±2.0 years. The Sillence classification showed 16 patients had the mildest type I, 1 patient had moderate type IV, and 8 patients had the most severe type III. Fifteen patients underwent anterior release followed by posterior fusion, and 10 patients underwent only posterior fusion. The accuracy of PS placement was evaluated with postoperative computed tomography. Scoliosis was corrected from 95.6 to 65.8 degrees after surgery (correction rate 32.5%) and 68.1 degrees at final follow-up (both, P<0.01). Space available for the lung was improved from 76.3% to 84.9% (P<0.05). No implant dislodgement occurred after surgery. A total of 290 screws were placed, of which 213 screws (73.4%) were placed completely. However, 30 screws (10.3%) penetrated >2 mm. In particular, rates of >2 mm penetration was much higher in type III than type I and IV (27.8% vs. 3.0%; P<0.01). Complications related to spinal surgery included 2 transient neurological disturbances. PSs were applicable to spinal fusion surgery in patients with OI. However special care should be taken in placing PSs because of the weakness of the pedicle cortex, which was easily penetrated especially in Sillence type III. Level IV.

The Effect of Older Age on the Perioperative Outcomes of Spinal Fusion Surgery in Patients With Lumbar Degenerative Disc Disease With Spondylolisthesis: A Propensity Score-Matched Analysis.

Degenerative spondylolisthesis (DS) is often treated with lumbar spinal fusion (LSF). However, there is concern that the morbidity of LSF may be prohibitively high in older adults. To evaluate the impact of advanced age on the safety of LSF for DS. Patients who underwent LSF for DS were retrospectively identified from National Surgical Quality Improvement Program datasets for 2011 to 2015 using Current Procedural Terminology codes. Data on demographic characteristics, comorbidities, surgical factors, and 30-d morbidity and mortality were collected. Propensity score matching (nearest neighbor) was performed with age (<70 vs ≥70 yr) as the dependent variable and sex, type of fusion procedure, number of levels fused, diabetes, smoking, hypertension, and chronic steroid use as covariates. Outcomes were compared between age <70 and ≥70 groups. The study cohort consisted of 2238 patients (n=1119, age <70; n=1119, age ≥70). The 2 age groups were balanced for key covariates including sex, race, diabetes, hypertension, CHF, smoking, chronic steroid use, type of fusion, and number of levels. Rates of all complications were similar between younger and older age groups, except urinary tract infection, which was more frequent among the ≥70 age group (OR 2.32, P=.009). Further, patients in the older age group were more likely to be discharged to a rehabilitation (OR 2.94, P<.001) or skilled care (OR 3.66, P<.001) facility, rather than directly home (OR 0.25, P<.001). LSF may be performed safely in older adults with DS. Our results suggest older age alone should not exclude a patient from undergoing lumbar fusion for DS.

Increased rates of spinal fusion surgery in patients with hereditary hemochromatosis: a five-year propensity matched cohort analysis.

Spinal arthropathy is associated with hereditary hemochromatosis and has been linked to calcium pyrophosphate dehydrate crystal deposition (CPPD) which resembles ankylosing spondylitis on radiograph, yet lacks clinical findings of inflammatory spinal arthritis. The aim of our study was to assess the use of spinal surgery and its outcomes in the US inpatient population with hereditary hemochromatosis from 2012 to 2016 by using the US Nationwide Inpatient Sample (NIS) database. The observational retrospective cohort study uses the NIS 2012 to 2016. All patients with hereditary hemochromatosis were included using International Classification of Diseases 9th and 10th revisions, Clinical Modification codes. The cohort was stratified according to having undergone spinal surgery and substratified by the type of surgery. The primary outcome was determining the use of spinal surgery in patients with hereditary hemochromatosis. Secondary outcomes were determining length of hospital stay and total hospital charges and costs. A total of 39 780 patients with hereditary hemochromatosis were identified and propensity matched to nonhereditary hemochromatosis controls. The mean patient age was 61 years, and 65% were females. For the primary outcome patients with hereditary hemochromatosis underwent significantly more spinal fusion surgery compared to patients without hereditary hemochromatosis odds of 2.13 (P = 0.05). While there was no difference in mean LOS, or costs, patients with hereditary hemochromatosis had higher hospital charges. Hereditary hemochromatosis is associated with higher odds of spinal fusion. It is a major complication not improved by phlebotomy, and there are currently no therapies to prevent this joint disease.

Extensive Spinal Fusion Surgery in Patients With Parkinson Disease or Atypical Parkinsonism: Time Course of Clinical Outcomes in 5 Years Progress Report.

A retrospective case series. To clarify the mid-term results of extensive spinal fusion surgery in patients with Parkinson disease (PD) or atypical Parkinsonism, especially with respect to their activities of daily living (ADL) over time SUMMARY OF BACKGROUND DATA.: Postural disorders associated with PD lead to spinal imbalance and deformity, resulting in significant disabilities. Clinical outcomes of extensive fusion surgeries in patients with PD over a medium-term follow-up period are currently unknown. Patients with PD who underwent extensive fusion surgery more than 5 years prior were included. The patients' backgrounds, surgical and radiographic parameters, perioperative and mechanical complications, and indoor ADL over time were assessed. To assess the activities of severely disabled patients, indoor ADL was classified into four stages: independent; or cane, walker, and wheelchair use. Twenty-two patients (mean age, 70.6 yrs) were included. The mean blood loss, duration of surgery, and fusion levels were 2039 mL, 424 minutes, and 11.9 levels, respectively. Sagittal vertical axis improved from 220 mm preoperatively to 95 mm postoperatively. Perioperative complications were observed in 17 cases (77%). Before surgery, 1, 5, 12, and four cases were independent in ADL, T-cane, walker, and wheelchair use, respectively, which improved to seven, four, six, and four, respectively in 1 year. Revision surgeries were performed in eight patients (36%) within 3 years of surgery. In the 3 to 5 years after the surgery, the ADL of nine patients worsened due to deterioration of PD. Fifteen cases were followed up over 5 years, at which one, two, four, and seven cases were independent in ADL, cane, walker, and wheelchair use, respectively. Surgical intervention in PD patients with spinal deformities leads to good short-term outcomes; however, the patients' conditions deteriorated because of complications within 3 years and worsening of PD over 3 years after the surgery. 4.

P104. A 2-year cost analysis of maximum nonoperative treatments in patients with symptomatic lumbar stenosis or spondylolisthesis that ultimately required surgery

BACKGROUND CONTEXT A variety of nonoperative therapies are attempted for pain management in patients with symptomatic lumbar stenosis or spondylolisthesis prior to surgery. The costs and utilization of maximal nonoperative therapy (MNT) remains unknown. PURPOSE The purpose of this study is to characterize the utilization and costs of MNTs within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1, 2, or 3-level lumbar decompression and fusion procedures between 2007 and 2016 within a large insurance database were included. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. OUTCOME MEASURES The primary outcome was the utilization of MNTs within 2 years prior to index surgery. METHODS Research records were searchable by International Classification of Diseases (ICD) diagnosis and procedure codes, Current Procedural Terminology (CPT) codes, and generic drug codes specific to Humana. “Utilization” of MNTs was characterized by cost billed to the patient, prescriptions written and number of units billed. RESULTS A total of 27,877 out of 3,423,114 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion; 17.6% of patients were smokers, 35.1% of patients had type II DM, and 24.8% were obese (BMI > 30 kg/m2). Patient maximal nonoperative therapy (MNT) utilization was as follows: 11,383 (40.8%) used NSAIDs, 19,770 (70.9%) used opioids, 12,414(44.5%) used muscle relaxants, 14,422 (51.7%) received LESI, 11,156 (40.0%) attended PT/OT, 4,005 (14.4%) presented to the ED, and 4,042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28,241,320. LESI comprised the largest portion of the total cost of MNT ($15,296,941, 54.2%), followed by opioids ($3,702,463, 13.1%) and NSAIDs ($3,058,335, 10.8%). At the patient level, on average $1,013.07 was spent on nonoperative treatments prior to index lumbar surgery. CONCLUSIONS Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio (ICER) for MNT could be highly unfavorable. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. A variety of nonoperative therapies are attempted for pain management in patients with symptomatic lumbar stenosis or spondylolisthesis prior to surgery. The costs and utilization of maximal nonoperative therapy (MNT) remains unknown. The purpose of this study is to characterize the utilization and costs of MNTs within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. Retrospective cohort study. Patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1, 2, or 3-level lumbar decompression and fusion procedures between 2007 and 2016 within a large insurance database were included. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. The primary outcome was the utilization of MNTs within 2 years prior to index surgery. Research records were searchable by International Classification of Diseases (ICD) diagnosis and procedure codes, Current Procedural Terminology (CPT) codes, and generic drug codes specific to Humana. “Utilization” of MNTs was characterized by cost billed to the patient, prescriptions written and number of units billed. A total of 27,877 out of 3,423,114 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion; 17.6% of patients were smokers, 35.1% of patients had type II DM, and 24.8% were obese (BMI > 30 kg/m2). Patient maximal nonoperative therapy (MNT) utilization was as follows: 11,383 (40.8%) used NSAIDs, 19,770 (70.9%) used opioids, 12,414(44.5%) used muscle relaxants, 14,422 (51.7%) received LESI, 11,156 (40.0%) attended PT/OT, 4,005 (14.4%) presented to the ED, and 4,042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28,241,320. LESI comprised the largest portion of the total cost of MNT ($15,296,941, 54.2%), followed by opioids ($3,702,463, 13.1%) and NSAIDs ($3,058,335, 10.8%). At the patient level, on average $1,013.07 was spent on nonoperative treatments prior to index lumbar surgery. Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio (ICER) for MNT could be highly unfavorable.

P40. Teriparatide treatment improves bone quality in the vertebral body out of proportion to the pedicles and lamina of the lumbosacral spine as measured by Hounsfield units

BACKGROUND CONTEXT Teriparatide treatment has been used to improve bone quality when considering spinal fusion surgery in patients with osteoporosis. This treatment has been shown to improve Hounsfield units (HU), a standardized measurement for radio density that can be obtained on CT scans, in lumbar vertebral bodies but its effect on other anatomic structures within the lumbosacral spine is unknown. STUDY DESIGN/SETTING Retrospective chart review. METHODS A retrospective chart review was performed from 1997 to 2018 across all campuses at our institution. We identified patients who had been treated with at least 6 months of Teriparatide with a lumbar or abdominal CT scan before and after therapy. HU were measured in the pedicles, lamina, and vertebral bodies from L1-S2. RESULTS Fifty-two patients (46 women, six men) were identified for analysis with an average age of 67 years who underwent an average of 20.9±6.5 months of Teriparatide therapy. Mean (± standard deviation) HU improvement in the vertebral bodies throughout the lumbosacral spine (L1-S2) was from 110±49 to 134±58 (p-value 0.029, 95% CI 2-44), a 22% improvement. HU in the pedicles increased from 222±98 to 255±102 (p-value 0.095, 95% CI -5 to 72), a 15% improvement. The lamina improved from 535±197 to 563±165 (p-value 0.44, 95% CI -43 to 98), a 5% improvement. CONCLUSIONS Teriparatide treatment improved bone quality as measured by Hounsfield units in the vertebral body, out of proportion to the improvement observed in the pedicles and lamina from L1-S2. This may indicate that improved screw fixation following Teriparatide therapy may be largely due to fixation within the vertebral body, but further biomechanical studies are warranted. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

P39. Teriparatide treatment improves bone quality in the lumbar spine out of proportion to DEXA changes

BACKGROUND CONTEXT Teriparatide has been used to improve bone quality when considering spinal fusion surgery in patients with osteoporosis. Hounsfield units (HU), a standardized measurement for radiodensity, can be obtained on routine computed tomography (CT) scans, while dual energy X-ray absorptiometry (DEXA) is the common test for bone density. PURPOSE To compare changes in bone quality in the lumbar spine between Hounsfield unit measurements and dual energy X-ray absorptiometry (DEXA) following teriparatide treatment. STUDY DESIGN/SETTING Retrospective Chart Review. METHODS A retrospective chart review was performed from 1997 to 2018 across all campuses at our institution. We identified patients who had been treated with at least 6 months of teriparatide with a CT scan and DEXA scan before and after therapy. HU were measured from L1-L4 with three measurements per vertebral body. RESULTS Fifty-two patients (46 women, six men) were identified for analysis with an average age of 67 years who underwent an average of 20.9±6.5 months of teriparatide therapy. Mean (± standard deviation) HU improvement throughout the lumbar spine (L1-L4) was from 109.8±53 to 133.9±61 with a p-value of 0.039 and a 95% CI from 1.2 to 46.1. Each individual lumbar level also had an average improvement in HU but only L1 was statistically significant (L1 improved from 112.4 to 139.2 with a p-value of 0.013). Based on DEXA results, lumbar spine t-scores improved from -2.4±1.5 to -1.7±1.5 with a p-value of 0.03. Average femoral t-scores improved from -2.5±1.1 to -2.3±1.0 with a p-value of 0.31. CONCLUSIONS Teriparatide treatment improved BMD based on HU and DEXA in the lumbar spine, without a change in femoral BMD. The 22% improvement in HU surpassed the changes seen on DEXA. These results supports some surgeons’ subjective sense that intraoperative bone quality following teriparatide treatment is better than indicated by DEXA results. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

Sa1603 – Increased Rates of Spinal Fusion Surgery in Patients with Hereditary Hemochromatosis: A Five-Year Propensity Matched Cohort Analysis

Sa1603 – Increased Rates of Spinal Fusion Surgery in Patients with Hereditary Hemochromatosis: A Five-Year Propensity Matched Cohort Analysis

Long-Term Costs of Maximum Nonoperative Treatments in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis that Ultimately Required Surgery: A 5-Year Cost Analysis.

Retrospective cohort study. The purpose of this study is to characterize the utilization and costs of MNTs prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. The costs and utilization of long-term maximal nonoperative therapy (MNT) can be substantial, and in the current era of bundled payments, the duration of conservative therapy trials should be reassessed. A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Only patients with lumbar stenosis or spondylolisthesis and those continuously active within the insurance system for at least 5 years prior to the index operation were eligible. A total of 4133 out of 497,822 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion. 20.8% of patients were smokers, 44.5% had type II DM, and 38.2% were obese (body mass index [BMI] >30 kg/m). Patient MNT utilization was as follows: 66.7% used nonsteroidal anti-inflammatory drugs (NSAIDs), 84.4% used opioids, 58.6% used muscle relaxants, 65.5% received lumbar epidural steroid injections (LESI), 66.6% attended 21.1% presented to the emergency department (ED), and 24.9% received chiropractor treatments. The total direct cost associated with all MNT prior to index spinal fusion was $9,000,968; LESI comprised the largest portion of the total cost of MNT ($4,094,646, 45.5%), followed by NSAIDS ($1,624,217, 18.0%) and opioid costs ($1,279,219, 14.2%). At the patient level, when normalized per patient utilizing therapy, an average $4010 was spent on nonoperative treatments prior to index lumbar surgery. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost-effectiveness ratio (ICER) for MNTs could be highly unfavorable. 3.

A 2-Year Cost Analysis of Maximum Nonoperative Treatments in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis That Ultimately Required Surgery.

Study Design:Retrospective cohort study.Objectives:The purpose of this study is to characterize the utilization and costs of maximal nonoperative therapies (MNTs) within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis.Methods:A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1-, 2-, or 3-level lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. The utilization of MNTs within 2 years prior to index surgery was assessed by cost billed to the patient, prescriptions written, and number of units billed.Results:A total of 27 877 out of 3 423 114 (0.8%) eligible patients underwent posterior lumbar instrumented fusion. Patient MNT utilization was as follows: 11 383 (40.8%) used nonsteroidal anti-inflammatory drugs (NSAIDs), 19 770 (70.9%) used opioids, 12 414 (44.5%) used muscle relaxants, 14 422 (51.7%) received lumbar epidural steroid injection (LESI), 11 156 (40.0%) attended physical therapy/occupational therapy, 4005 (14.4%) presented to the emergency department, and 4042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28 241 320 ($1013.07 per/patient). LESI comprised the largest portion of the total cost of MNT ($15 296 941, 54.2%), followed by opioids ($3 702 463, 13.1%) and NSAIDs ($3 058 335, 10.8%).Conclusions:Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio for MNT could be highly unfavorable.

Gender Differences in Use of Prolonged Nonoperative Therapies Before Index Lumbar Surgery

The purpose of the present study was to assess for gender-based differences in the usage and cost of maximal nonoperative therapy before spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures from 2007 to 2016. This database consists of 20.9 million covered lives and includes private or commercially insured and Medicare Advantage beneficiaries. Only patients continuously active within the Humana insurance system for ≥5 years before the index operation were eligible. Usage was characterized by the cost billed to the patient, prescriptions written, and number of units billed. A total of 4133 patients (58.5% women) underwent 1-, 2-, or 3-level posterior lumbar instrumented fusion. A significantly greater percentage of female patients used nonsteroidal anti-inflammatory drugs (P<0.0001), lumbar epidural steroid injections (P=0.0044), physical and/or occupational therapy (P<0.0001), and muscle relaxants (P < 0.0001). The total direct cost associated with all maximal nonoperative therapy before index spinal fusion was $9,000,968, with men spending $3,451,479 ($2011.35 per patient) and women spending $5,549,489 ($2296.02 per patient). When considering the quantity of units billed, women used 61.5% of the medical therapy units disbursed despite constituting 58.5% of the cohort. When normalized by the number of pills billed per patient using therapy, female patients used more nonsteroidal anti-inflammatory drugs, opioids, and muscle relaxants. These results suggest that gender differences exist in the use of nonoperative therapies for symptomatic lumbar stenosis or spondylolisthesis before fusion surgery.

Complications and Mortality After Lumbar Spinal Fusion in Elderly Patients With Late Stage Renal Disease.

Retrospective database review. To assess complication and mortality rates after lumbar spinal fusion surgery in patients with late stage renal disease. Lumbar spinal fusion surgeries are common in elderly patients who are well-known to have increased comorbidity burden. Elderly patients with severe chronic kidney disease (CKD) represent a population with poorly understood mortality and complication rates after spine surgery. Medicare data from the PearlDiver Database (2005-2012) was queried for patients who underwent primary 1-2 level posterolateral lumbar spine fusion surgeries. This cohort was divided into two study groups: a cohort with a preexisting diagnosis of late stage renal disease (N = 1654) and a control cohort of all other patients (N = 242,085). The control group was matched to the renal disease cohort by age, sex, and comorbidities. Moreover, 90-day complication rates and 90-day and 1-year mortality were assessed. The renal disease cohort had increased rates of all medical complications (21.3 vs. 14.2%; odds ratio, OR, 1.64; 95% confidence intervals, CI, 1.44 -1.85; P < 0.0001). Increased rates of infection (4.4 vs. 1.8%; OR 2.43; 95% CI 1.87 - 3.16; P < 0.0001) and procedure-day blood transfusions (20.7 vs. 14.7%; OR 1.51; 95% CI 1.33 - 1.72; P < 0.0001) were also observed in the renal disease cohort. Both 90-day (1.1 vs. 0.2%; OR 5.05; 95% CI 2.90-8.77; P < 0.0001) and 1-year mortality (1.9 vs. 0.7%; OR 2.77; 95% CI 1.87-4.11; P < 0.0001) were significantly higher in the renal disease group compared with the control group. Elderly patients with late-stage renal disease treated with 1-2 level posterolateral lumbar fusion have 1.6 times increased odds of experiencing a major medical complication within 3 months of surgery and 2.8 times increased odds of 1-year mortality when compared with matched controls. 3.

P38 - Complications and Mortality after Lumbar Spinal Fusion in Elderly Patients with Late Stage Renal Disease

STUDY DESIGN Retrospective database review. OBJECTIVE To assess complication and mortality rates after lumbar spinal fusion surgery in patients with late stage renal disease. SUMMARY OF BACKGROUND DATA Lumbar spinal fusion surgeries are common in elderly patients who are well-known to have increased comorbidity burden. Elderly patients with severe chronic kidney disease (CKD) represent a population with poorly understood mortality and complication rates after spine surgery. METHODS Medicare data from the PearlDiver Database (2005-2012) was queried for patients who underwent primary 1-2 level posterolateral lumbar spine fusion surgeries. This cohort was divided into two study groups: a cohort with a preexisting diagnosis of late stage renal disease (N = 1654) and a control cohort of all other patients (N = 242,085). The control group was matched to the renal disease cohort by age, sex, and comorbidities. Moreover, 90-day complication rates and 90-day and 1-year mortality were assessed. RESULTS The renal disease cohort had increased rates of all medical complications (21.3 vs. 14.2%; odds ratio, OR, 1.64; 95% confidence intervals, CI, 1.44 -1.85; P < 0.0001). Increased rates of infection (4.4 vs. 1.8%; OR 2.43; 95% CI 1.87 - 3.16; P < 0.0001) and procedure-day blood transfusions (20.7 vs. 14.7%; OR 1.51; 95% CI 1.33 - 1.72; P < 0.0001) were also observed in the renal disease cohort. Both 90-day (1.1 vs. 0.2%; OR 5.05; 95% CI 2.90-8.77; P < 0.0001) and 1-year mortality (1.9 vs. 0.7%; OR 2.77; 95% CI 1.87-4.11; P < 0.0001) were significantly higher in the renal disease group compared with the control group. CONCLUSION Elderly patients with late-stage renal disease treated with 1-2 level posterolateral lumbar fusion have 1.6 times increased odds of experiencing a major medical complication within 3 months of surgery and 2.8 times increased odds of 1-year mortality when compared with matched controls. LEVEL OF EVIDENCE 3.

Quality of life and disability: can they be improved by active postoperative rehabilitation after spinal fusion surgery in patients with spondylolisthesis? A randomised controlled trial with 12-month follow-up.

The aim of the study was to investigate the effectiveness of the postoperative 12-month exercise program compared to usual care on disability and health-related quality of life (HRQoL) in patients after lumbar spine fusion surgery (LSF). Altogether, 98 patients with isthmic (31) or degenerative (67) spondylolisthesis were randomised to exercise therapy group (EG) (n=48) or usual care group (UCG) (n=50) 3months after LSF. EG patients had home-based progressive strength and aerobic training program for 12months. UCG patients received only oral and written instructions of exercises. Oswestry Disability Index (ODI) and HRQoL (RAND-36) were evaluated at the time of randomization, at the end of the intervention and 1year after intervention. The mean ODI score decreased from 24 (12) to 18 (14) in the EG and from 18 (12) to 13 (11) in the UCG during intervention (between-groups p=0.69). At 1-year follow-up, 25% of the EG and 28% of the UCG had an ODI score ≥20. No between-group differences in HRQoL change were found at any time point. The mean (95% CI) physical functioning dimension of the HRQoL improved by 10.0 (4.6-15.3) in the EG and by 7.8 (2.5-13.0) in the UCG. In addition, the role physical score improved by 20.0 (7.7-32.3) in the EG and by 16.4 (4.4-28.4) in the UCG during the intervention. The exercise intervention did not have an impact on disability or HRQoL beyond the improvement achieved by usual care. However, disability remained at least moderate in considerable proportion of patients.