North American Spine Society

Total hip arthroplasty (THA) is a commonly performed procedure with wonderful outcomes, but perioperative adverse events, dislocations, and need for revision can arise. This study explores how a surgeon's subspecialty training-arthroplasty, trauma, or nonarthroplasty/nontrauma-correlates with postoperative outcomes after THA. Using the 2010 to 2022 M165Ortho PearlDiver Database, patients who underwent elective THA were identified. Patients were grouped based on the subspecialty training of the surgeon performing the procedure: arthroplasty, trauma, or nonarthroplasty/nontrauma. Multivariate analysis, adjusting for patient age, sex, and comorbidities, was used to compare 90-day adverse events and readmission rates between patient groups. Five-year dislocations and revisions were then assessed and compared with Kaplan-Meier analysis. Of 742,630 THAs identified, nonarthroplasty, nontrauma surgeons conducted 677,094 (91.1%), arthroplasty surgeons conducted 61,826 (8.3%), and trauma surgeons conducted 3,711 (0.5%). Compared with nonarthroplasty nontrauma surgeons, arthroplasty-trained surgeons had lower odds of any adverse events (odds ratio [OR], 0.80; P < 0.001), serious adverse events (OR, 0.83; P < 0.001), and minor adverse events (OR, 0.80; P < 0.001). Specific adverse events with lower odds in the arthroplasty group included pulmonary embolism, sepsis, surgical site infection, acute kidney injury, pneumonia, and urinary tract infections. Compared with nonarthroplasty nontrauma surgeons, trauma-trained surgeons only had higher odds of wound dehiscence (OR, 1.42; P = 0.001). The 5-year revision rates were lowest in the arthroplasty group (3.1%), followed by the nontrauma, nonarthroplasty group (3.5%; P < 0.001) and the trauma group (4.5%; P < 0.001). Similar patterns were observed in the 5-year hip dislocation rates. Subspecialty training in arthroplasty is associated with lower complication rates and better implant survival after THA. These findings suggest that arthroplasty training is associated with improved outcomes, potentially contributed to experience, volume, and/or care pathways.

Radiofrequency ablation (RFA) is an interventional procedure that has been used to treat chronic back pain for over 50 years; this unique case report demonstrates the effectiveness of pulsed radiofrequency ablation (PRFA) on the dorsal root ganglion (DRG) in the treatment of chronic radicular pain (Russo etal., 2021, J Pain Res, 14, 3897). The RFA provides pain relief by using thermal energy to disrupt peripheral nerves carrying nociceptive signals back to the central nervous system (Abd-Elsayed etal. 2020, Pain Ther, 9, 709). However, there is a lack of literature about the safety and efficacy of PRFA of the DRG.

Background:This study compared trends in use, predictive factors, and reimbursement of endoscopic carpal tunnel release (ECTR) withthose of open carpal tunnel release (OCTR) from 2010 to 2021 using a national administrative database.Methods:ECTR and OCTR patients were identified in the PearlDiver M151Ortho data set. Numeric and proportional utilization of these procedures was characterized for each year of study. Multivariate analysis was conducted to identify predictive factors for having ECTR performed. The average 90-day reimbursement of ECTR and OCTR was determined.Results:From 2010 through 2021, 441,023 ECTR and 1,767,820 OCTR procedures were identified. The proportional use of ECTR compared with OCTR rose from 2010 (15.7% of procedures) to 2021 (26.1%). Independent predictors of having ECTR performed rather than OCTR included geographic variation (compared with having surgery in the Midwest, Northeast odds ratio [OR], 1.53; West OR, 1.62; and South OR, 1.66), having Medicare or commercial insurance (compared with commercial, Medicare OR, 0.94, and Medicaid OR, 0.69), female sex, and fewer comorbidities. The average 90-day reimbursement for ECTR was $3,114.82, compared with $3,087.62 for OCTR.Discussion:As of 2021, over one-fourth of carpal tunnel releases are done endoscopically. Several factors independently predict whether patients receive ECTR or OCTR.

Retrospective cohort. To report normative measurements of L1 to S1 lumbar neuroforamina on plain film radiography (PFR), computed tomography (CT), and magnetic resonance imaging (MRI), accounting for patients' sex and ethnicity. The quantitative criteria fothe diagnosis of neuroforaminal stenosis remains unknown. Acquiring a thorough understanding of normative foraminal dimensions is a key step in formulating objective parameters for neuroforaminal stenosis. We measured 988 images from 494 patients between 18 and 35 years old without spinal pathology who received PFR, CT, or MRI within 1 year of each other. Neuroforaminal measurements were defined as the height, area, and sagittal and axial widths. Statistical analyses were performed to assess relationships among PFR, CT, and MRI-derived neuroforaminal measurements, as well as the influence of patients' sex and ethnicity. 330 PFR, 377 CT, and 281 MRI were measured. Of these, 213 PFR and CT, 117 PFR and MRI, and 164 MRI and CT intrapatient images were compared. Statistically significant differences were observed among PFR, CT, and MRI measurements across all levels L1 to S1. PFR measurements were larger compared with those derived from CT and MRI. Weak-to-moderate correlations were observed between PFR and CT, PFR and MRI, and CT and MRI, with the magnitude of correlation decreasing caudally from L1 to S1. Variations in neuroforaminal anatomy were observed based on sex and ethnicity. This study reports 25,951 measurements of normal L1 to S1 neuroforaminal anatomy assessed by PFR, CT, and MRI. The values reported in this study may be used as normative reference measurements of the lumbar neuroforamina. PFR measurements of the neuroforamina are larger compared with those derived from CT and MRI across all levels from L1 to S1. There is a poor correlation between PFR, CT, and MRI when measuring the lumbar neuroforamina. Differences in neuroforaminal anatomy are evident based on patients' sex and ethnicity.

A retrospective cohort review. To develop a scoring system for predicting increased risk of postoperative complications in adult spinal deformity (ASD) surgery based on baseline nutritional and metabolic factors. Endocrine and metabolic conditions have been shown to adversely influence patient outcomes and may increase the likelihood of postoperative complications. The impact of these conditions has not been effectively evaluated in patients undergoing ASD surgery. ASD patients 18 years or above with baseline and two-year data were included. An internally cross-validated weighted equation using preoperative laboratory and comorbidity data correlating to increased perioperative complications was developed via Poisson regression. Body mass index (BMI) categorization (normal, over/underweight, and obese) and diabetes classification (normal, prediabetic, and diabetic) were used per the Centers for Disease Control and Prevention and the American Diabetes Associates parameters. A novel ASD-specific nutritional and metabolic burden score (ASD-NMBS) was calculated via Beta-Sullivan adjustment, and Conditional Inference Tree determined the score threshold for experiencing ≥1 complication. Cohorts were stratified into low-risk and high-risk groups for comparison. Logistic regression assessed correlations between increasing burden score and complications. Two hundred one ASD patients were included (mean age: 58.60±15.4, sex: 48% female, BMI: 29.95±14.31, Charlson Comorbidity Index: 3.75±2.40). Significant factors were determined to be age (+1/yr), hypertension (+18), peripheral vascular disease (+37), smoking status (+21), anemia (+1), VitD hydroxyl (+1/ng/mL), BMI (+13/cat), and diabetes (+4/cat) (model: P <0.001, area under the curve: 92.9%). Conditional Inference Tree determined scores above 175 correlated with ≥1 post-op complication ( P <0.001). Furthermore, HIGH patients reported higher rates of postoperative cardiac complications ( P =0.045) and were more likely to require reoperation ( P =0.024) compared with low patients. The development of a validated novel nutritional and metabolic burden score (ASD-NMBS) demonstrated that patients with higher scores are at greater risk of increased postoperative complications and course. As such, surgeons should consider the reduction of nutritional and metabolic burden preoperatively to enhance outcomes and reduce complications in ASD patients.

Total knee arthroplasty (TKA) is a common orthopaedic procedure, after which many patients benefit from physical therapy (PT). However, such services may not be uniformly accessible and used. To that end, disparities in access to care such as PT after interventions may be a factor for those of varying race/ethnicities. TKAs were abstracted from the 2014 to 2016 Standard Analytic Files PearlDiver data set-a large national health administrative data set containing information on more than 60 million Medicare patients. Occurrences of home or outpatient PT within 90 days after TKA were identified. Patient demographic factors were extracted, including age, sex, Elixhauser Comorbidity Index, estimated average household income of patient based on zip code (low average household income [<75k/year] or high average household income [>75k/year]), and patient race/ethnicity (White, Hispanic, Asian, Native American, Black, or Other). Predictive factors for PT utilization were determined and compared with univariate and multivariate analyses. Of 23,953 TKA patients identified, PT within 90 days after TKA was used by 18,837 (78.8%). Patients self-identified as White (21,824 [91.1%]), Black (1,250 [5.2%]), Hispanic (268 [1.1%]), Asian (241 [1.0%]), Native American (90 [0.4%]), or "Other" (280 [1.2%]) and were of low household income (19,957 [83.3%]) or high household income (3,994 [16.7%]). When controlling for age, sex, and ECI, PT was less likely to be received by those of low household income (relative to high household income OR 0.79) or by those of defined race/ethnicity (relative to White or Black OR 0.81, Native American OR 0.58, Asian OR 0.50, or Hispanic OR 0.44) ( P < 0.05 for each). In a large Medicare data set, disparities in utilization of PT after TKA were identified based on patient's estimated household income and race/ethnicity. Identification of such factors may help facilitate the expansion of care to meet the needs of all groups adequately. Level III.

With the advent of bundled care payments for spine surgery, there is increasing scrutiny on the costs and resource utilization associated with surgical care. The purpose of this study was to compare (1) the total cost of the hospital episode of care and (2) discharge destination between White, Black, and Hispanic patients receiving elective anterior cervical decompression and fusion for degenerative cervical myelopathy (DCM) in Medicare patients. The 2019 Medicare Provider Analysis and Review Limited Data Set and the 2019 Impact File were used for this project. Multivariate models were created for total cost and discharge destination, controlling for confounders found on univariate analysis. We then performed a subanalysis for differences in specific cost-center charges. There were 11,506 White (85.4%), 1,707 Black (12.7%), and 261 Hispanic (1.9%) patients identified. There were 6,447 males (47.8%) and 7,027 females (52.2%). Most patients were between 65 to 74 years of age (n = 7,101, 52.7%). The mean cost of the hospital episode was $20,919 ± 11,848. Most patients were discharged home (n = 11,584, 86.0%). Race/ethnicity was independently associated with an increased cost of care (Black: $783, Hispanic: $1,566, P = 0.001) and an increased likelihood of nonhome discharge (Black: adjusted odds ratio: 1.990, P < 0.001, Hispanic: adjusted odds ratio: 1.822, P < 0.001) compared with White patients. Compared with White patients, Black patients were charged more for accommodations ($1808), less for supplies (-$1780), and less for operating room (-$1072), whereas Hispanic patients were charged more ($3556, $7923, and $5162, respectively, P < 0.05). Black and Hispanic race/ethnicity were found to be independently associated with an increased cost of care and risk for nonhome discharge after elective anterior cervical decompression and fusion for DCM compared with White patients. The largest drivers of this disparity appear to be accommodation, medical/surgical supply, and operating room-related charges. Further analysis of these racial disparities should be performed to improve value and equity of spine care for DCM.

Retrospective, observational. The aim of this study was to define the impact of preoperative chronic opioid therapy (COT) on outcomes following cervical spine fusions. Opioid therapy is a commonly practiced method to control acute postoperative pain. However, concerns exist relating to use of prescription opioids, including inherent risk of abuse, tolerance, and inferior outcomes following major surgery. A commercial dataset was queried from 2007 to 2015 for patients undergoing primary cervical spine arthrodesis [ICD-9 codes 81.01-81.03]. Primary outcome measures were 1-year and 2-year reoperation rates, emergency department (ED) visits, adverse events, and prolonged postoperative opioid use. Secondary outcomes included short-term outcomes including 90-day complications (cardiac, renal, neurologic, infectious, etc.). COT was defined as a history of opioid prescription filling within 3 months before surgery and was the primary exposure variable of interest. Generalized linear models investigated the association of preoperative COT on primary/secondary endpoints following risk-adjustment. Overall, 20,730 patients (51.3% female; 85.9% >50 years) underwent primary cervical spine arthrodesis. Of these, 10,539 (n = 50.8%) met criteria for COT. Postoperatively, 75.3% and 29.8% remained on opioids at 3 months and 1 year. Multivariable models identified an association between COT and an increased risk of 90-day ED visit [odds ratio (OR): 1.25; P < 0.001] and wound complications (OR: 1.24; P = 0.036). At 1 year, COT was strongly associated with reoperations (OR: 1.17; P = 0.043), ED visits (OR: 1.31; P < 0.001), and adverse events including wound complications (OR: 1.32; P < 0.001), infections (OR: 1.34; P = 0.042), constipation (OR: 1.11; P = 0.032), neurological complications (OR: 1.44; P = 0.01), acute renal failure (OR: 1.24; P = 0.004), and venous thromboembolism (OR: 1.20; P = 0.008). At 2 years, COT remained a significant risk factor for additional long-term negative outcomes such as reoperations, including adjacent segment disc disease (OR: 1.21; P = 0.005), ED visits (OR: 1.32; P < 0.001), and other adverse events. Preoperative COT was associated with prolonged postoperative narcotic use at 3 months (OR: 1.30; P < 0.001), 1 year (OR: 5.17; P < 0.001), and at 2 years (OR: 5.75; P < 0.001) after cervical arthrodesis. Preoperative COT is a modifiable risk factor that is strongly associated with prolonged postoperative opioid use. In addition, COT was associated with inferior short-term and long-term outcomes after cervical spine fusion. 3.