Study design. Retrospective Objective: Evaluate correlations between preoperative expectations for pain improvement and 12-month functional outcomes and satisfaction following 1-2 level primary anterior cervical surgery. Summary of background data: Limited data exists evaluating correlations between patients’ preoperative expectations for pain relief and subsequent functional and satisfaction outcomes following primary anterior cervical surgery. Understanding correlations between expectations and outcomes may help identify patients most likely to benefit from surgery. Methods: Patients who underwent 1-2 level primary ACDF or CDA for degenerative disease between 2016-2021 were included. All patients had 12-month NDI data. Preoperative expectations for pain relief were collected at the initial clinic visit using 5-point Likert scales. Preoperative and 12-month postoperative satisfaction were recorded using 7-point Likert scales. Covariates including age, gender, procedure type, smoking status, opioid use, worker’s compensation/litigation, BMI, and indication (radiculopathy versus myelopathy). Linear regression models were constructed to assess 12-month NDI change score versus pain relief expectations. Additional regression models assessed expectations versus achievement of MCID at 3- and 12-months and satisfaction at 12-months. Results: 198 ACDF (56.1% female, median age 57) and 52 CDR patients (55.8% female, median age 51) were included. Regression models found no significant correlations between pain relief expectations and degree of NDI score improvement at the 12-month postoperative timepoint or MCID achievement at the 3- and 12-month postoperative timepoints. There was no association between preoperative expectations and 12-month satisfaction. However, greater preoperative dissatisfaction was significantly associated with greater 12-month improvement in NDI score. Conclusion: Preoperative pain relief expectations were not associated with functional outcomes or satisfaction following 1-2 level primary ACDF or CDR at 12-month follow-up. Patients’ dissatisfaction with their preoperative spinal condition was significantly associated with greater 12-month NDI improvement. Assessing preoperative satisfaction may help identify those most likely to benefit from surgery.

Study DesignRetrospective study.ObjectivesThe current study compares the ability of the modified Frailty Index (mFI), the American Society of Anesthesiologists (ASA) classification, the modified Charleston Comorbidity Index (mCCI), the American College of Surgeons Surgical Risk Calculator (SRC), and the Fusion Risk Score (FRS) to predict perioperative outcomes.MethodsComorbidity indices were calculated for patients undergoing elective thoracic and lumbar spinal fusion at a single institution and assessed for their discriminative ability in predicting the desired outcomes using an area under the curve (AUC) analysis.Results393 patients met the inclusion and exclusion criteria. Patients being treated for adult spinal deformity (ASD) had the highest rate of complications (44.4%). The FRS had acceptable discrimination (AUC >0.7) and the highest ability among the methods studied to predict any adverse effects, new neurological deficit, return to OR within 90 days, and surgical site infection. It had good discrimination ability (AUC >0.8) predicting durotomy, respiratory failure (RF) requiring intubation, hemodynamic instability, and sepsis. The SRC had acceptable discrimination and highest ability to predict deep venous thrombosis (DVT). The mCCI had excellent and the highest ability to predict acute renal failure (ARF). For the other outcomes, the indices had either poor predictive ability (AUC 0.6-0.7) or no discriminative ability (AUC <0.6).ConclusionsThe FRS had a better ability than the ASA, mCCI, mFI, and SRC to predict the most perioperative adverse events and reoperation. Further study is needed to develop preoperative indices with better predictive ability of postoperative outcomes.

STUDY DESIGN:Retrospective review of prospectively collected data. OBJECTIVE:The current study evaluates whether the addition of the Vertebral Bone Quality (VBQ) score to the Fusion Risk Score (FRS) improves its ability to predict perioperative outcomes. SUMMARY OF BACKGROUND DATA:The FRS was developed to assess preoperative risk in patients undergoing thoracic and lumbar fusions. It includes patient-derived and surgical variables, but it does not include one that directly accounts for bone health. The VBQ score allows assessment of bone quality and has been shown to correlate to DEXA-measured bone mineral density (BMD) scores. METHODS:The VBQ score was weighted based on a regression model and then added to the FRS (FRS/VBQ). The ability of the two scores to predict the outcomes was then assessed using the area under the curve (AUC). PATIENT SAMPLE:Patients undergoing elective thoracic and lumbar spinal fusion from January 2019 to June 2020 were included. OUTCOME MEASURES:The study evaluated various perioperative adverse outcomes, including major and minor adverse events, discharge other than home, extended length of stay, 90-day emergency department visits, 90-day readmission, and 90-day and 2-year reoperation rates. RESULTS:A total of 353 met the inclusion and exclusion criteria. The FRS/VBQ demonstrated improved predictive ability compared with the FRS alone when evaluating 90-day reoperation. Both scores showed fair predictive ability for any adverse event, major adverse events, minor adverse events, and 2-year reoperation rates, with AUCs ranging from 0.700 to 0.737. Both had poor predictive ability for the other outcomes. CONCLUSIONS:Adding VBQ to the FRS significantly enhances its predictive accuracy for reoperation rate. This updated risk score provides a more comprehensive understanding of a patient's preoperative risk profile, aiding both patients and physicians in assessing surgical risks and optimizing outcomes through preoperative risk stratification. LEVEL OF EVIDENCE:3.

BACKGROUND CONTEXT The Fusion Risk Score (FRS) was developed to assess the risk of developing complications after spinal surgery. It includes patient-derived and surgical variables, but it does not include one that directly accounts for bone health. The Vertebral Bone Quality (VBQ) score is an MRI based technique that allows assessment of bone quality and has been shown to correlate to DEXA-measured bone mineral density (BMD) scores and quantitative computed tomography. PURPOSE The current study evaluates whether the addition of the VBQ to the FRS improves its ability to predict 90-day postoperative complications and reoperation in patients undergoing fusion procedures. STUDY DESIGN/SETTING A retrospective review of prospectively collected data was performed. PATIENT SAMPLE Patients undergoing elective thoracic and lumbar spinal fusion at a single institution from January 2019 to June 2020 were identified. Exclusion criteria included age under 18 years, less than 2-year followup, concomitant cervical spine procedures, no preoperative T1-weighted lumbar MRI, previous lumbar fusion including more than two lumbar vertebrae, and surgeries performed for trauma, neoplasm, or infection. OUTCOME MEASURES Perioperative adverse outcome variables evaluated included major adverse events (AE) (ie, cardiac arrest, death, deep vein thrombosis, myocardial infarction, postoperative intubation, pulmonary embolism, return to the operating room, sepsis, and stroke), minor AE (ie, hypotension requiring intervention, acute kidney injury, respiratory failure, cardiac arrythmia, pneumonia, surgical site infection, urinary tract infection, clostridium difficile colitis, superficial surgical site infection, and surgical wound dehiscence), any AE, discharge to higher-level of care, extended length of stay (ELOS), 90-day emergency department (ED) visits, 90-day readmission, 90-day reoperation, and 2-year reoperation. METHODS The contribution of the VBQ score was weighted according to the odds ratio (OR) in a regression model and then added to the FRS (FRS/VBQ). The ability of the FRS and the FRS/VBQ to predict the predetermined outcomes was then assessed by using the area under the curve (AUC) from a receiver operating characteristics (ROC) curve analysis and 95% confidence intervals (95% CI). RESULTS Of 421 patients initially identified, 353 met the inclusion and exclusion criteria. The FRS/VBQ had good predictive ability when assessing 90-day reoperation (AUC 0.808) while the FRS had fair predictive ability (AUC 0.783). The FRS/VBQ and the FRS had fair predictive ability when evaluating occurrence of any adverse effect (AUC 0.717 and 0.720), major adverse events (AUC 0.737 and 0.728), minor adverse events (AUC 0.729 and 0.734), and 2-year reoperation rates (AUC 0.723 and 0.700). Both scores had poor predictive ability when evaluating 90-day readmission (AUC 0.689 and 0.679), discharge to a higher level of care (AUC 0.649 and 0.658), and 90-day ED visits (AUC 0.603 and 0.595). CONCLUSIONS Adding evaluation of bone health as assessed with the VBQ to the FRS improves its ability to accurately predict postoperative complications and reoperation. This updated risk score allows for an improved understanding of a patient's preoperative risk. Utilizing preoperative risk stratification will continue to help patients and physicians understand the risks of surgery and help to optimize outcomes. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs. The Fusion Risk Score (FRS) was developed to assess the risk of developing complications after spinal surgery. It includes patient-derived and surgical variables, but it does not include one that directly accounts for bone health. The Vertebral Bone Quality (VBQ) score is an MRI based technique that allows assessment of bone quality and has been shown to correlate to DEXA-measured bone mineral density (BMD) scores and quantitative computed tomography. The current study evaluates whether the addition of the VBQ to the FRS improves its ability to predict 90-day postoperative complications and reoperation in patients undergoing fusion procedures. A retrospective review of prospectively collected data was performed. Patients undergoing elective thoracic and lumbar spinal fusion at a single institution from January 2019 to June 2020 were identified. Exclusion criteria included age under 18 years, less than 2-year followup, concomitant cervical spine procedures, no preoperative T1-weighted lumbar MRI, previous lumbar fusion including more than two lumbar vertebrae, and surgeries performed for trauma, neoplasm, or infection. Perioperative adverse outcome variables evaluated included major adverse events (AE) (ie, cardiac arrest, death, deep vein thrombosis, myocardial infarction, postoperative intubation, pulmonary embolism, return to the operating room, sepsis, and stroke), minor AE (ie, hypotension requiring intervention, acute kidney injury, respiratory failure, cardiac arrythmia, pneumonia, surgical site infection, urinary tract infection, clostridium difficile colitis, superficial surgical site infection, and surgical wound dehiscence), any AE, discharge to higher-level of care, extended length of stay (ELOS), 90-day emergency department (ED) visits, 90-day readmission, 90-day reoperation, and 2-year reoperation. The contribution of the VBQ score was weighted according to the odds ratio (OR) in a regression model and then added to the FRS (FRS/VBQ). The ability of the FRS and the FRS/VBQ to predict the predetermined outcomes was then assessed by using the area under the curve (AUC) from a receiver operating characteristics (ROC) curve analysis and 95% confidence intervals (95% CI). Of 421 patients initially identified, 353 met the inclusion and exclusion criteria. The FRS/VBQ had good predictive ability when assessing 90-day reoperation (AUC 0.808) while the FRS had fair predictive ability (AUC 0.783). The FRS/VBQ and the FRS had fair predictive ability when evaluating occurrence of any adverse effect (AUC 0.717 and 0.720), major adverse events (AUC 0.737 and 0.728), minor adverse events (AUC 0.729 and 0.734), and 2-year reoperation rates (AUC 0.723 and 0.700). Both scores had poor predictive ability when evaluating 90-day readmission (AUC 0.689 and 0.679), discharge to a higher level of care (AUC 0.649 and 0.658), and 90-day ED visits (AUC 0.603 and 0.595). Adding evaluation of bone health as assessed with the VBQ to the FRS improves its ability to accurately predict postoperative complications and reoperation. This updated risk score allows for an improved understanding of a patient's preoperative risk. Utilizing preoperative risk stratification will continue to help patients and physicians understand the risks of surgery and help to optimize outcomes.

Background: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are attractive targets for transition to the outpatient setting. We assessed the prevalence of rapid responses and major complications in the inpatient setting following 1 or 2-level ACDFs and CDAs. We evaluated factors that may place patients at greater risk for a rapid response or a postoperative complication. Methods: This was an institutional review board-approved, retrospective cohort study of adults undergoing 1 or 2-level ACDF or CDA at 1 hospital over a 2-year period (2018 and 2019). Data on patient demographic characteristics, surgical procedures, and comorbidities were collected. Rapid response events were identified by hospital floor staff and involved acute changes in a patient’s clinical condition. Complications were events that were life-threatening, required an intervention, or led to delayed hospital discharge. Results: In this study, 1,040 patients were included: 888 underwent ACDF and 152 underwent CDA. Thirty-six patients (3.5%) experienced a rapid response event; 22% occurred >24 hours after extubation. Patients having a rapid response event had a significantly higher risk of developing a complication (risk ratio, 10; p < 0.01) and had a significantly longer hospital stay. Twenty-four patients (2.3%) experienced acute complications; 71% occurred >6 hours after extubation. Patients with a complication were older and more likely to be current or former smokers, have chronic obstructive pulmonary disease, have asthma, and have an American Society of Anesthesiologists (ASA) score of >2. The length of the surgical procedure was significantly longer in patients who developed a complication. All patients who developed dysphagia had a surgical procedure involving C4-C5 or more cephalad. Patients with a rapid response event or complication were more commonly undergoing revision surgical procedures. Conclusions: Rapid response and complications are uncommon following 1 or 2-level ACDFs or CDAs but portend a longer hospital stay and increased morbidity. Revision surgical procedures place patients at higher risk for rapid responses and complications. Additionally, older patients, patients with chronic obstructive pulmonary disease or asthma, patients who are current or former smokers, and patients who have an ASA score of ≥3 are at increased risk for postoperative complications. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BackgroundPolyetheretherketone (PEEK) and machined allograft interbody spacers are among devices used as fusion adjuncts in anterior cervical discectomy and fusion (ACDF). Most results are good to excellent but some patients develop pseudarthrosis. We compared the reoperation rates for pseudarthrosis following 1- or 2-level ACDF with PEEK or allograft cages.MethodsThis was a retrospective cohort study. We reviewed patients who underwent 1- or 2-level ACDF. The rate of subsequent surgery for pseudarthrosis was calculated for cases confirmed by computerized tomography. Patient-reported outcomes were collected at post-index surgery follow-up and post-revision ACDF follow-up. Radiographic parameters were assessed at a minimum of 1-year post-op on all patients.ResultsTwo hundred and nine patients were included: 167 received allograft and 42 received PEEK. Subsidence was demonstrated in 31% of allograft and 29% of PEEK patients. There were no significant differences in clinical outcomes between allograft and PEEK groups. Clinical outcomes were not adversely affected by subsidence. Reoperation for pseudarthrosis was performed in 8% of allograft patients and 14% of PEEK patients (not statistically different). Improvement in patient-reported outcome was significantly better for patients without symptomatic post-operative pseudarthrosis.ConclusionsBoth allograft and PEEK spacers are acceptable options for ACDF surgery. Similar clinical outcomes and rates of radiographic subsidence were found. Subsidence was not a factor in clinical outcomes. Reoperation for pseudarthrosis was associated with poor outcomes. A higher incidence of revision for symptomatic pseudarthrosis occurred in the PEEK group, but this was not statistically significant.

STUDY DESIGN:This is a retrospective cohort study.OBJECTIVE:To compare posterolateral versus transforaminal interbody fusion (PLF vs. PLF+TLIF) of the L4/5 segment regarding rates of subsequent surgery, clinical and radiographic parameters, and patient satisfaction.SUMMARY OF BACKGROUND DATA:Surgical treatment of lumbar stenosis, decompression with or without fusion, is an efficacious treatment in select patients. Reoperation is thought to be a problem after lumbar fusion. Despite multiple studies, the fusion method that minimizes the need for subsequent surgery has yet to be determined.MATERIALS AND METHODS:A retrospective cohort study was conducted on 89 patients who had an isolated L4/5 decompression and fusion, from January 2006 to 2012. All patients had stenosis and degenerative spondylolisthesis at the L4/5 level. All surgeries were performed at a single center, using either PLF (31 patients) or PLF+TLIF (58 patients) techniques. Preoperative and postoperative patient-reported outcome measures (Oswestry disability index, visual analog scale back pain, visual analog scale leg pain) and radiographic parameters (L4/5 lordosis and overall lumbar lordosis) were measured. Patient satisfaction was acquired via a questionnaire. Chart reviews and patient questionnaires were used to determine the incidence of subsequent lumbar surgery over a minimum follow-up of 5 years.RESULTS:At an average of 8.7 years follow-up, 2 of 31 patients in the PLF group had subsequent lumbar surgery, compared with 16 of 58 patients in the PLF+TLIF group (6% vs. 28%; P=0.02). There were no significant differences between groups with respect to sex, age, body mass index, tobacco, perioperative measures, patient-reported outcomes, or radiographic parameters (P>0.05).CONCLUSIONS:Both PLF and PLF+TLIF are effective fusion methods for L4/5 stenosis and spondylolisthesis. In this study, patients treated with PLF were less likely to undergo a subsequent lumbar surgery. More research is needed to determine which factors influence whether PLF or PLF+TLIF should be used in these patients.LEVEL OF EVIDENCE:Level III.