Spine Surgery Research Research Articles

Appropriateness and Quality of Composite Endpoint Use and Reporting in Spine Surgery: A Systematic Review.

A composite endpoint (CEP) is a measure comprising 2 or more separate component outcomes. The use of these constructs is increasing. We sought to conduct a systematic review on the usage, quality of reporting, and appropriate use of CEPs in spine surgery research. A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Articles reporting randomized controlled trials of a spine surgery intervention using a CEP as a primary outcome were included. We assessed the quality of CEP reporting, appropriateness of CEP use, and correspondence between CEP treatment effect and component outcome treatment effect in the included trials. Of 2,321 initial titles, 43 citations were included for analysis, which reported on 20 unique trials. All trials reported the CEP construct well. In 85% of trials, the CEP design was driven by US Food and Drug Administration guidance. In the majority of trials, the reporting of CEP results did not adhere to published recommendations: 43% of tests that reported statistically significant results on component outcomes were not statistically significant when adjusted for multiple testing. 67% of trials did not meet appropriateness criteria for CEP use. In addition, CEP treatment effect tended to be 6% higher than the median treatment effect for component outcomes. Given that CEP analysis was not appropriate for the majority of spine surgery trials and the inherent challenges in the reporting and interpretation of CEP analysis, CEP use should not be mandated by regulatory bodies in spine surgery trials. Level I. See Instructions for Authors for a complete description of levels of evidence.

Assessing the potential role of ChatGPT in spine surgery research.

Since its release in November 2022, Chat Generative Pre-Trained Transformer 3.5 (ChatGPT), a complex machine learning model, has garnered more than 100 million users worldwide. The aim of this study is to determine how well ChatGPT can generate novel systematic review ideas on topics within spine surgery. ChatGPT was instructed to give ten novel systematic review ideas for five popular topics in spine surgery literature: microdiscectomy, laminectomy, spinal fusion, kyphoplasty and disc replacement. A comprehensive literature search was conducted in PubMed, CINAHL, EMBASE and Cochrane. The number of nonsystematic review articles and number of systematic review papers that had been published on each ChatGPT-generated idea were recorded. Overall, ChatGPT had a 68% accuracy rate in creating novel systematic review ideas. More specifically, the accuracy rates were 80%, 80%, 40%, 70% and 70% for microdiscectomy, laminectomy, spinal fusion, kyphoplasty and disc replacement, respectively. However, there was a 32% rate of ChatGPT generating ideas for which there were 0 nonsystematic review articles published. There was a 71.4%, 50%, 22.2%, 50%, 62.5% and 51.2% success rate of generating novel systematic review ideas, for which there were also nonsystematic reviews published, for microdiscectomy, laminectomy, spinal fusion, kyphoplasty, disc replacement and overall, respectively. ChatGPT generated novel systematic review ideas at an overall rate of 68%. ChatGPT can help identify knowledge gaps in spine research that warrant further investigation, when used under supervision of an experienced spine specialist. This technology can be erroneous and lacks intrinsic logic; so, it should never be used in isolation. Not applicable.

Definition of malnutrition from routinely-collected data for orthopedic surgery research: the global leadership initiative on malnutrition (GLIM) tool and others.

The correct identification of malnourished patients in the context of hip, knee, or spine surgery research would enhance the quality of analytical studies investigating the prediction potential of preoperative nutritional disorders on postoperative recovery. However, accurate malnutrition screening and diagnostic assessment rely on parameters that were not routinely collected in routine practice until a few years ago. The authors of this article present substitute literature-based equations that can be built up using historical routinely collected data to classify patients that had been at risk of malnutrition or malnourished. For what concerns the risk screening, several methods are available to identify patients at risk of over- or undernutrition, encompassing the BWd (body weight difference from the ideal weight), GNRI (geriatric nutritional risk index), INA (instant nutritional assessment), LxA (combination of lymphocyte count and albumin), PMA (protein malnutrition with acute inflammation), PMAC (protein malnutrition with acute and chronic inflammation), IDM (iron deficit malnutrition), and VBD (vitamin B deficit malnutrition). Conversely, the GLIM (global leadership initiative on malnutrition) criteria can be used to assess malnutrition and diagnose subclasses of undernutrition. Rational use of these tools can facilitate the conduction of efficient prospective studies in the future, as well as bespoke retrospective cohort studies and database research.

Three decades of spine surgery research evolution in Saudi Arabia: A bibliometric analysis

Background: Over recent decades, there has been a constant increase in the numbers and quality of spine surgery research. We herein plan to analyze the evolution of spine surgery-related publications from Saudi Arabia for three decades.
 Materials and Methods: A systematic review of the literature with predefined inclusion criteria was carried out, utilizing multiple significant databases (PubMed, Google Scholar, and Embase). Multiple search terms were used to retrieve related articles. Numerous variables were collected and analyzed, such as articles’ level of evidence, citation numbers, study design, and author-related information. For comparison, the study period was divided into three time frames: 1990–2000, 2001–2010, and 2011–2022.
 Results: Out of 2969 articles, only 254 met the inclusion criteria of the current study. During the period 2011–2022, an increase of 41% was observed in the number of publications. The highest number of publications was in 2020 (n = 36, 14.2%). Level IV comprised the highest percentage (n = 130, 51%). High-quality articles (Levels I and II) had increased (11%) from 2011 to 2022. The most commonly utilized study design was case reports (44%). Seven randomized controlled trials were identified during the study period. Most of the included articles were from Riyadh province (65%). Research interest revolved around general spine care, trauma, and oncology in 2011–2022.
 Conclusion: This is the first study to quantitatively analyze spine surgery-related research in Saudi Arabia. However, there has been significant development in several publications in the last decade, but the quality still needs to be improved. Therefore, we should aim to produce higher-quality studies to meet the country’s 2030 vision goals to be one of the leading nations in spine surgery practice.

A twitter analysis of patient and family experience in pediatric spine surgery.

There is little data on patient and caregiver perceptions of spine surgery in children and youth. This study aims to characterize the personal experiences of patients, caregivers, and family members surrounding pediatric spine surgery through a qualitative and quantitative social media analysis. The Twitter application programming interface was searched for keywords related to pediatric spine surgery from inception to March 2022. Relevant tweets and accounts were extracted and subsequently classified using thematic labels. Tweet metadata was collected to measure user engagement via multivariable regression. Sentiment analysis using Natural Language Processing was performed on all tweets with a focus on tweets discussing the personal experiences of patients and caregivers. 2424 tweets from 1847 individual accounts were retrieved for analysis. Patients and caregivers represented 1459 (79.0%) of all accounts. Posts discussed the personal experiences of patients and caregivers in 83.5% of tweets. Pediatric spine surgery research was discussed in few posts (n=90, 3.7%). Within the personal experience category, 975 (48.17%) tweets were positive, 516 (25.49%) were negative, and 533 (26.34%) were neutral. Presence of a tag (beta: -6.1, 95% CI -9.7 to -2.5) and baseline follower count (beta<0.001, 95% CI <0.001 to <0.001) significantly affected tweet engagement negatively and positively, respectively. Patients and caregivers actively discuss topics related to pediatric spine surgery on Twitter. Posts discussing personal experience are most prevalent, while posts on research are scarce, unlike previous social media studies. Pediatric spine surgeons can leverage this dialogue to better understand the worries and needs of patients and their families.

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.

Current and future applications of mobile health technology for evaluating spine surgery patients: a review.

Mobile health (mHealth) technology has assumed a pervasive role in healthcare and society. By capturing real-time features related to spine health, mHealth assessments have the potential to transform multiple aspects of spine care. Yet mHealth applications may not be familiar to many spine surgeons and other spine clinicians. Consequently, the objective of this narrative review is to provide an overview of the technology, analytical considerations, and applications of mHealth tools for evaluating spine surgery patients. Reflecting their near-ubiquitous role in society, smartphones are the most commonly available form of mHealth technology and can provide measures related to activity, sleep, and even social interaction. By comparison, wearable devices can provide more detailed mobility and physiological measures, although capabilities vary substantially by device. To date, mHealth evaluations in spine surgery patients have focused on the use of activity measures, particularly step counts, in an attempt to objectively quantify spine health. However, the correlation between step counts and patient-reported disease severity is inconsistent, and further work is needed to define the mobility metrics most relevant to spine surgery patients. mHealth assessments may also support a variety of other applications that have been studied less frequently, including those that prevent postoperative complications, predict surgical outcomes, and serve as motivational aids to patients. These areas represent key opportunities for future investigations. To maximize the potential of mHealth evaluations, several barriers must be overcome, including technical challenges, privacy and regulatory concerns, and questions related to reimbursement. Despite those obstacles, mHealth technology has the potential to transform many aspects of spine surgery research and practice, and its applications will only continue to grow in the years ahead.

Spine Surgery Research: The Top Researchers and the Most Popular Topics

Spine Surgery Research: The Top Researchers and the Most Popular Topics

Leveraging Artificial Intelligence and Synthetic Data Derivatives for Spine Surgery Research.

Retrospective cohort study. Leveraging electronic health records (EHRs) for spine surgery research is impeded by concerns regarding patient privacy and data ownership. Synthetic data derivatives may help overcome these limitations. This study's objective was to validate the use of synthetic data for spine surgery research. Data came from the EHR from 15 hospitals. Patients that underwent anterior cervical or posterior lumbar fusion (2010-2020) were included. Real data were obtained from the EHR. Synthetic data was generated to simulate the properties of the real data, without maintaining a one-to-one correspondence with real patients. Within each cohort, ability to predict 30-day readmissions and 30-day complications was evaluated using logistic regression and extreme gradient boosting machines (XGBoost). We identified 9,072 real and 9,088 synthetic cervical fusion patients. Descriptive characteristics were nearly identical between the 2 datasets. When predicting readmission, models built using real and synthetic data both had c-statistics of .69-.71 using logistic regression and XGBoost. Among 12,111 real and 12,126 synthetic lumbar fusion patients, descriptive characteristics were nearly the same for most variables. Using logistic regression and XGBoost to predict readmission, discrimination was similar with models built using real and synthetic data (c-statistics .66-.69). When predicting complications, models derived using real and synthetic data showed similar discrimination in both cohorts. Despite some differences, the most influential predictors were similar in the real and synthetic datasets. Synthetic data replicate most descriptive and predictive properties of real data, and therefore may expand EHR research in spine surgery.

A seat at the table: an invitation to the SRS podium via the study group.

The SRS annual meeting (SRS-AM) represents the pinnacle of research in the field of spinal deformity. Spine surgery research was historically based on single-surgeon experience, but an increasing number of abstracts presented at SRS-AM are conducted by multicenter study groups, which may have improved the quality of literature available to surgeons. We sought to determine the proportion of SRS-AM podium presentations (PP) resulting from study groups over a 15-year period. 1874 PP from the 2005-2019 SRS-AM were reviewed to determine if they resulted from a study group or multicenter collaboration. Abstracts were also classified as pediatric- or adult-focused. Pearson correlations were calculated to analyze changes in the proportion of study group or multicenter PP. The number of SRS PP increased from 102 to 171 from 2005 to 2019. 381 (20.3%) PP were identified as a study group product, while 536 (28.6%) resulted from multicenter collaboration. The proportion of study group PP increased by 0.9% annually from 8.8 to 26.9% (r2 = 0.44, p = 0.007), while multicenter PP increased by 1.2% annually from 11.8 to 40.9% (r2 = 0.51, p = 0.003). A greater proportion of study group PP were level of evidence I or II studies compared to those not resulting from the work of study groups (53.8 vs 19.3%, p < 0.001). SRS-AM PP resulting from research study groups and multicenter collaborations increased over threefold from 2005 to 2019. Spine surgeons are taking a more proactive approach to produce more generalizable research with higher level of evidence through multicenter study groups, allowing them to make more informed decisions to ultimately improve surgical outcomes for patients. V.

The 100 Most-Cited Publications in Endoscopic Spine Surgery Research.

Study Design:A bibliometric review of the literature.Objective:Our objective was to identify and analyze the 100 most-cited publications in the field of endoscopic spine surgery (ESS).Methods:In order to determine the top cited 100 articles, a 3-step approach was employed. First, the 100 most-cited ESS studies were identified using the key phrase “endoscopic spine surgery.” Then, 8 keywords were identified from the 100 studies of step 1 were used to conduct a second round searching in all databases of the Web of Science. Finally, when the results of the first and second steps were overlapped, duplicated studies were removed. The 100 top-cited articles were used for further analysis.Results:The citation number of the top 100 most-cited articles ranged from 44 to 236 with a mean value of 84.4. The most productive periods were from 2001 to 2010. The majority of publications came from Spine and Neurosurgery, where Spine holds the largest number of 35 articles, followed by Neurosurgery with 13 articles. Overall, 10 countries contributed to the 100 articles, with the most productive country being the United States, followed by Germany and Korea.Conclusion:This bibliometric study is meant to produce a list of intellectual milestones in the field of ESS. This article’s identification of the most influential articles in the field of ESS gives us a unique and comprehensive insight into the development of ESS in the past several decades.

Critically Low Confidence in the Results Produced by Spine Surgery Systematic Reviews: An AMSTAR-2 Evaluation From 4 Spine Journals.

Study Design:A systematic cross-sectional survey of systematic reviews (SRs).Objective:To evaluate the methodological quality of spine surgery SRs published in 2018 using the updated AMSTAR 2 critical appraisal instrument.Methods:We identified the PubMed indexed journals devoted to spine surgery research in 2018. All SRs of spine surgical interventions from those journals were critically appraised for quality independently by 2 reviewers using the AMSTAR 2 instrument. We calculated the percentage of SRs achieving a positive response for each AMSTAR 2 domain item and assessed the levels of confidence in the results of each SR.Results:We identified 28 SRs from 4 journals that met our criteria for inclusion. Only 49.5% of the AMSTAR 2 domain items satisfied the AMSTAR 2 criteria. Critical domain items were satisfied less often (39.1%) compared with noncritical domain items (57.3%). Domain items most poorly reported include accounting for individual study risk of bias when interpreting results (14%), list and justification of excluded articles (18%), and an a priori establishment of methods prior to the review or registered protocol (18%). The overall confidence in the results was rated “low” in 2 SRs and “critically low” in 26.Conclusions:The credibility of a SR and its value to clinicians and policy makers are dependent on its methodological quality. This appraisal found significant methodological limitations in several critical domains, such that the confidence in the findings of these reviews is “critically low.”

Clinical outcomes research in spine surgery: what are appropriate follow-up times?

In BriefThe time course required for the patient-reported outcomes of pain, physical function, and mental health to reach a recovery plateau after elective lumbar spine surgery was assessed utilizing a prospectively maintained multicenter registry. The work is important as it demonstrates that specific health dimensions follow different recovery plateaus and it provides evidence that a 2-year postoperative follow-up is not required to accurately assess the treatment effect of established surgeries for lumbar spinal pathologies.

Friday, September 28, 2018 10:45 AM–12:00 PM abstracts: how should we measure our success: 184. Clinical outcomes research in spine surgery: What are appropriate follow-up times?

BACKGROUND CONTEXT There has been a generic dictum in spine and musculoskeletal clinical research that 2 years follow-up is necessary for patient reported outcomes (PRO); however, the rationale for this duration is not evidence based. PURPOSE The purpose of this study is to determine the PRO follow-up time necessary to ensure that the effectiveness of a lumbar surgical intervention is adequately captured. STUDY DESIGN/SETTING Using PROs from the Canadian Spine Outcomes and Research Network (CSORN) prospective database the time-course to recovery plateau after lumbar spine surgery was assessed. PATIENT SAMPLE The time-course to recovery plateau after lumbar spine surgery was assessed for lumbar disc herniation, degenerative spondylolisthesis, and spinal stenosis in 1,200 patients. OUTCOME MEASURES ODI, Visual Analogue Scale (VAS) leg and back pain, and Short form (SF-12) mental and physical component summary (MCS/PCS) scores. METHODS Analysis of multicenter prospective clinical spine registry.One-way ANOVAs with post-hoc testing were used to compare the following standardized PROs at baseline, three, twelve, and twenty-four months postoperatively: RESULTS There were significant differences determined by one-way ANOVAs for all spine pathologies and specific PROs (p CONCLUSIONS Individual PROs after surgery for lumbar spine pathologies follow specific time-courses to plateaued recovery indicating a 2-year follow-up may not be required for all outcomes to be accurately assessed. Ultimately the clinical research question should dictate follow-up time and the outcome measure utilized, however there is now evidence to guide the specific duration of follow-up for each PRO.

Incidence of early postoperative complications requiring surgical revision for recurrent lumbar disc herniation after spinal surgery: a retrospective observational study of 9,310 patients from the German Spine Register

BackgroundThe recurrence rate in lumbar disc herniations (LDH) has been reported between 5 and 25%. There are only few data about this phenomenon that occurs within days of the initial operation. We analyse early recurrent LDH by analysis of data from the German Spine register.MethodsData from patients undergoing disc herniation surgery in the lumbar region were extracted from the German Spine Registry between 1st January 2012 and 31st December 2016. Patients with early recurrent LDH within days of initial surgery were separately analysed.ResultsA total of 9310 surgeries for LDH were documented in the German Spine Register. From these patients 115 (1.2%) presented an early recurrent disc surgeries within days of the initial surgery. The mean age was 70 ± 2.50 years. Most affected segment was L4/5 (47 cases, 41%), followed by L3/4 (45 cases, 39%). The most of our patients showed a normal or overweight Body Mass Index. Surgery for early recurrent LDH was associated with a high rate of incidental durotomies (20 cases, 17.6%). In 3 cases (2.6%) therapy with a lumbar drain was necessary.ConclusionsThe rate of early recurrent LDH within days of surgery is 1.2%. Age seems to be an important factor in early recurrent LDH while obesity does not. The data of the German Spine Register seems to have a reliable data collection system that can perform multicentre data analysis. The databases from this Register could be used in the future for various purposes, such as the evaluation of multicentre surgical techniques, results in patients with various surgical procedures and basic research in spine surgery.

Assessing the evolution and level of evidence of spine surgery research in Saudi Arabia

Objectives: To measure the impact of Saudi publications on global spine surgery literature, to evaluate the quality of these papers by measuring the level of evidence (LOE) and then to compare it with similar international studies done on the topic of spine surgery. Materials and Methods: The study design was a systematic review, where a systemic online search using PubMed, Google Scholar and Embase was carried out using search terms related to spine surgery. The impact of each article was measured by the citation number and was reviewed by Oxford Centre for Evidence-Based Medicine LOE scale. Results: We identified 128 articles that met the inclusion criteria, of which 58% were Level IV studies. The most common study design was case reports (45%). We compared our study with the similar or different methodology of international studies for spine surgery research. Conclusion: This first study, for the analysis of spine surgery literature in Saudi Arabia, shows that Saudi publications in spine surgery have little impact on the global spine surgery research. The LOE was low and that there is insignificant change throughout 25 years. A national multicentre or international collaborative research is recommended to produce high LOE research.

National Database Research in Spine Surgery: Limitations in the Current Literature.

Many of the studies in the spine surgical literature using national databases have been directed at examining adverse events, readmission rates, cost, and risk factors for poorer outcomes. Although such studies allow for assessment of large cohorts taken from multiple institutions, they are limited by data collection methods, short-term follow-up, and minimal assessment of functional outcomes. Furthermore, few studies are directed at producing actionable practice changes to improve patient care. Recent work aimed at producing databases with more relevance to spine surgery represent exciting developments to the rapidly growing field of health outcomes research.

Quality of Spine Surgery Research from the Arab Countries: A Systematic Review and Bibliometric Analysis.

Purpose. The purpose of our study is to evaluate the level of evidence (LOE) of spine surgery publications in the Arab countries and compare it with standard international literature in spine surgery and to determine the stand of the Arab nations academic production with that of the global one. Methods. An online search using “PubMed” and “Google Scholar” was carried out, using search terms related to spine surgery such as “Spine surgery,” “Scoliosis,” “Herniated disc.” Each article was reviewed and graded by two reviewers using Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence scale. Results. We have identified 434 articles that met the inclusion criteria; 56% were level IV studies. The most common study design was case reports (42%). The number of Arab countries with publications in spine surgery was 18 countries. The country with the highest rate of publications was Egypt (26%). The quantity of the published studies increased from 151 in (2000–2008) to 283 in (2009–2015). There is statistical significance between high and low LOE articles (p = 0.0007). Conclusion. We have observed that LOE has not changed significantly over the period of 15 years and that much of the publications are of a low LOE (levels III and IV). We, herein, emphasize the need for spine surgeons in the Arab countries to conduct studies of higher LOE.

Database Research in Spine Surgery.

With the introduction of several publicly available national databases to study surgical outcomes, the use of such databases for spine surgery research has increased dramatically. These databases allow researchers to retrospectively examine data from a large sample of patients. This rise in the use of national databases to study surgical outcomes parallels an increasing reliance by administrators, payers, and third-party graders to evaluate surgical quality with the use of large administrative databases. A good understanding of the most commonly utilized databases for spine surgery is important for critical assessment of this growing body of literature.

Results of Database Studies in Spine Surgery Can Be Influenced by Missing Data.

National databases are increasingly being used for research in spine surgery; however, one limitation of such databases that has received sparse mention is the frequency of missing data. Studies using these databases often do not emphasize the percentage of missing data for each variable used and do not specify how patients with missing data are incorporated into analyses. This study uses the American College of Surgeons National SurgicalQuality Improvement Program (ACS-NSQIP) database to examine whether different treatments of missing data can influence the results of spine studies. (1) What is the frequency of missing data fields for demographics, medical comorbidities, preoperative laboratory values, operating room times, and length of stay recorded in ACS-NSQIP? (2) Using three common approaches to handling missing data, how frequently do those approaches agree in terms of finding particular variables to be associated with adverse events? (3) Do different approaches to handling missing data influence the outcomes and effect sizes of an analysis testing for an association with these variables with occurrence of adverse events? Patients who underwent spine surgery between 2005 and 2013 were identified from the ACS-NSQIP database. A total of 88,471 patients undergoing spine surgery were identified. The most common procedures were anterior cervical discectomy and fusion, lumbar decompression, and lumbar fusion. Demographics, comorbidities, and perioperative laboratory values were tabulated for each patient, and the percent of missing data was noted for each variable. These variables were tested for an association with "any adverse event" using three separate multivariate regressions that used the most common treatments for missing data. In the first regression, patients with any missing data were excluded. In the second regression, missing data were treated as a negative or "reference" value; for continuous variables, the mean of each variable's reference range was computed and imputed. In the third regression, any variables with >10% rate of missing data were removed from the regression; among variables with ≤10% missing data, individual cases with missing values were excluded. The results of these regressions were compared to determine how the different treatments of missing data could affect the results of spine studies using the ACS-NSQIP database. Of the 88,471 patients, as many as 4441 (5%) had missing elements among demographic data, 69,184 (72%) among comorbidities, 70,892 (80%) among preoperative laboratory values, and 56,551 (64%) among operating room times. Considering the three different treatments of missing data, we found different risk factors for adverse events. Of 44 risk factors found to be associated with adverse events in any analysis, only 15 (34%) of these risk factors were common among the three regressions. The second treatment of missing data (assuming "normal" value) found the most risk factors (40) to be associated with any adverse event, whereas the first treatment (deleting patients with missing data) found the fewest associations at 20. Among the risk factors associated with any adverse event, the 10 with the greatest effect size (odds ratio) by each regression were ranked. Of the 15 variables in the top 10 for any regression, six of these were common among all three lists. Differing treatments of missing data can influence the results of spine studies using the ACS-NSQIP. The current study highlights the importance of considering how such missing data are handled. Until there are better guidelines on the best approaches to handle missing data, investigators should report how missing data were handled to increase the quality and transparency of orthopaedic database research. Readers of large database studies should note whether handling of missing data was addressed and consider potential bias with high rates or unspecified or weak methods for handling missing data.