BACKGROUND CONTEXT Pseudarthrosis is a common indication for revision spine operations. Clinical presentations of pseudarthrosis are heterogeneous. While the majority of patients present with pain, many can be symptomatic. Etiologies of pseudarthrosis also vary from structural to biologic, including infection. PURPOSE To determine prevalence of subclinical infection and identify risk factors associated with positive intraoperative cultures in revisions for lumbar pseudarthrosis. STUDY DESIGN/SETTING Single-center retrospective cohort. PATIENT SAMPLE Adults who underwent revision posterior instrumented fusions for lumbar pseudarthrosis. OUTCOME MEASURES Intraoperative microbiological analysis. METHODS Retrospective review of adults who underwent revision posterior instrumented fusions for lumbar pseudarthrosis at a single institution. All patients had intraop cultures obtained regardless of clinical suspicion for infection. Patients with overt infection were excluded. Demographic, medical, and surgical data were analyzed for association with positive cultures and instrumentation failure. RESULTS Fifty-one patients (avg age 59.1±13.2 years, female-28, avg # prior operations 3.2±2.8) were included. Seventeen (33.3%) had at least 1 positive intraop culture, and 7 (13.7%) had ≥2 positive intraop cultures. Instrumentation failure was evident in 14 (27.5%) patients. Female gender was associated with decreased odds of having ≥2 positive intraop cultures (OR=0.10, p<0.05). While no other demographic, medical, or surgical characteristics were significantly associated with intraop cultures or instrumentation failure, odds of having 1 positive intraop culture were increased in patients with instrumentation failure (OR=1.77, p=0.38) and a major risk factor for infection (OR=2.55, p=0.20). The odds of having ≥2 positive intraop cultures were increased in patients with instrumentation failure (OR=4.53, p=0.07). CONCLUSIONS One third of patients undergoing revision for lumbar pseudarthrosis had subclinical infection (positive intraoperative culture). As such, intraoperative cultures should ideally be routinely obtained in the revision setting for lumbar pseudarthrosis and/or instrumentation failure regardless of clinical suspicion for infection. Further studies are necessary to identify risks of subclinical infection leading to pseudarthrosis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Pseudarthrosis is a common indication for revision spine operations. Clinical presentations of pseudarthrosis are heterogeneous. While the majority of patients present with pain, many can be symptomatic. Etiologies of pseudarthrosis also vary from structural to biologic, including infection. To determine prevalence of subclinical infection and identify risk factors associated with positive intraoperative cultures in revisions for lumbar pseudarthrosis. Single-center retrospective cohort. Adults who underwent revision posterior instrumented fusions for lumbar pseudarthrosis. Intraoperative microbiological analysis. Retrospective review of adults who underwent revision posterior instrumented fusions for lumbar pseudarthrosis at a single institution. All patients had intraop cultures obtained regardless of clinical suspicion for infection. Patients with overt infection were excluded. Demographic, medical, and surgical data were analyzed for association with positive cultures and instrumentation failure. Fifty-one patients (avg age 59.1±13.2 years, female-28, avg # prior operations 3.2±2.8) were included. Seventeen (33.3%) had at least 1 positive intraop culture, and 7 (13.7%) had ≥2 positive intraop cultures. Instrumentation failure was evident in 14 (27.5%) patients. Female gender was associated with decreased odds of having ≥2 positive intraop cultures (OR=0.10, p<0.05). While no other demographic, medical, or surgical characteristics were significantly associated with intraop cultures or instrumentation failure, odds of having 1 positive intraop culture were increased in patients with instrumentation failure (OR=1.77, p=0.38) and a major risk factor for infection (OR=2.55, p=0.20). The odds of having ≥2 positive intraop cultures were increased in patients with instrumentation failure (OR=4.53, p=0.07). One third of patients undergoing revision for lumbar pseudarthrosis had subclinical infection (positive intraoperative culture). As such, intraoperative cultures should ideally be routinely obtained in the revision setting for lumbar pseudarthrosis and/or instrumentation failure regardless of clinical suspicion for infection. Further studies are necessary to identify risks of subclinical infection leading to pseudarthrosis.

STUDY DESIGN:Cost analysis of a retrospectively identified cohort of patients who had undergone primary single-level lumbar fusion at a single institution's orthopedic or neurosurgery department. OBJECTIVE:The purpose of this article is to analyze the determinants of direct costs for single-level lumbar fusions and identify potential areas for cost reduction. METHODS:Adult patients who underwent primary single-level lumbar fusion from fiscal years 2008 to 2012 were identified via administrative and departmental databases and were eligible for inclusion. Patients were excluded if they underwent multiple surgeries, had previous surgery at the same anatomic region, underwent corpectomy, kyphectomy, disc replacement, surgery for tumor or infection, or had incomplete cost data. Demographic data, surgical data, and direct cost data in the categories of supplies, services, room and care, and pharmacy, was collected for each patient. RESULTS:The cohort included 532 patients. Direct costs ranged from $8286 to $73 727 (median = $21 781; mean = $22 890 ± $6323). Surgical approach was an important determinant of cost. The mean direct cost was highest for the circumferential approach and lowest for posterior instrumented spinal fusions without an interbody cage. The difference in mean direct cost between transforaminal lumbar interbody fusions, anterior lumbar interbody fusions, and lateral transpsoas fusions was not statistically significant. Surgical supplies accounted for 44% of direct costs. Spinal implants were the primary component of supply costs (84.9%). Services accounted for 38% of direct costs and were highly dependent on operative time. Comorbidities were an important contributor to variance in the cost of care as evidenced by high variance in pharmacy costs and length of stay related to their management. CONCLUSION:The costs of spinal surgeries are highly variable. Important cost drivers in our analysis included surgical approach, implants, operating room time, and length of hospital stay. Areas of high cost and high variance offer potential targets for cost savings and quality improvements.

STUDY DESIGN:Retrospective case series. OBJECTIVES:Both the rate and complexity of spine surgeries in elderly patients has increased. This study reports the outcomes of multilevel spine fusion in elderly patients and provides evidence on the appropriateness of complex surgery in elderly patients. METHODS:We identified 101 patients older than70 years who had ≥5 levels of fusion. Demographic, medical, and surgical data, and change between preoperative and >500 days postoperative health survey scores were collected. Health surveys were visual analogue scale (VAS), EuroQoL 5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), Scoliosis Research Society questionnaire (SRS-30), and Short Form health survey (SF-12) (physical composite score [PCS] and mental composite score [MCS]). Minimal clinically important differences (MCIDs) were defined for each survey. RESULTS:Complications included dural tears (19%), intensive care unit admission (48%), revision surgery within 2 to 5 years (24%), and death within 2 to 5 years (16%). The percentage of patients who reported an improvement in health-related quality of life (HRQOL) of at least an MCID was: VAS Back 69%; EQ-5D 41%; ODI 58%; SRS-30 45%; SF-12 PCS 44%; and SF-12 MCS 48%. Improvement after a primary surgery, as compared with a revision, was on average 13 points higher in ODI (P = .007). Patients who developed a surgical complication averaged an improvement 11 points lower on ODI (P = .042). Patients were more likely to find improvement in their health if they had a lower American Society of Anesthesiologists or Charlson Comorbidity Index score or a higher metabolic equivalent score. CONCLUSIONS:In multilevel surgery in patients older than 70 years, complications are common, and on average 77% of patients attain some improvement, with 51% reaching an MCID. Physiological status is a stronger predictor of outcomes than chronological age.

BACKGROUND CONTEXT: Medical expenditures for the diagnosis and treatment of spinal deformity are increasing more rapidly than other areas of health expenditures. Surgical management of spinal deformity is also characterized by significant variability in rates, costs and approaches to care. Such variability is clear evidence of the absence of an evidence-based approach to care. Areas of both high cost and high variability present potential targets for innovation, cost-saving and the promotion of consensus in clinical practice.

BACKGROUND CONTEXT: Measuring clinical outcomes after surgery for spinal disorders is important to guide an evidence-based approach to care. Loss of patients to follow-up is a significant limitation of many clinical outcome papers. There are several barriers that may prevent patients from following up after surgery including inconvenience, geographical distance, financial constraints, change in insurance coverage, or satisfaction with care. The purpose of this paper is to report the reasons that patients lost to follow-up did not follow-up, and the outcomes of care in these patients.