To examine implementation approaches and effectiveness of preoperative cognitive behavioral therapy (CBT) on patient-reported outcomes following lumbar fusion. We systematically searched PubMed/Medline, Cochrane Database of Systematic Reviews, and Epistemonikos (inception to December 15, 2024) for studies investigating preoperative CBT in patients scheduled for lumbar fusion. Primary and secondary outcomes were postoperative disability (Oswestry Disability Index, ODI) and health-related quality of life (EQ-5D), respectively, at 3 and 6 months. Meta-analysis employed Inverse Variance Random Effects Standardized Mean Difference models to compare the change from baseline. From a total of 182 studies, three RCTs comprising 307 patients (mean age: 50 years; 58

Background: Timely treatment is critical for patients with bone and soft tissue tumors, but access to care may not be equitable across all populations. While treatment delays have been well studied in other cancers, disparities in time to treatment remain underexplored in orthopaedic oncology. This study aimed to determine whether racial or ethnic disparities exist in the timing of surgery, chemotherapy, or radiation for patients with sarcoma or metastatic bone disease. Methods: A retrospective cohort study was conducted using the TriNetX US Collaborative Network, a multi-institutional electronic health record database. Adult patients undergoing biopsy and subsequently diagnosed with bone sarcoma, soft tissue sarcoma, or metastatic bone disease were identified. Time to treatment was defined as the number of days between biopsy and the first recorded surgery, chemotherapy, or radiation. Patients were stratified by race and ethnicity, and statistical comparisons were performed using Mann-Whitney U tests and t-tests. Results: A total of 63,087 patients met inclusion criteria (55,697 with metastatic bone disease/bone sarcoma and 7390 with soft tissue sarcoma). In the metastatic/bone sarcoma cohort, Hispanic patients had shorter mean time to resection (58 ± 94 vs. 82 ± 239 days, p = 0.008) and fixation (35 ± 142 vs. 72 ± 315 days, p < 0.001) compared to non-Hispanic patients, although median times did not differ significantly. Among black patients, time to fixation was shorter than in White patients (mean 22 ± 103 vs. 114 ± 468 days, p < 0.001; median 0 days in both groups), while delays were observed in time to radiation (median 13 vs. 7 days; mean 85 ± 284 vs. 43 ± 203 days, p < 0.001). In the soft tissue sarcoma cohort, Black patients experienced longer mean times to resection (142 ± 293 vs. 79 ± 216 days) and radiation (141 ± 514 vs. 96 ± 364 days), though comparisons were limited by sample size. Conclusions: This large, multi-institutional study demonstrates that disparities in orthopaedic oncology differ by treatment modality and clinical context. Shorter wait times to surgery among Hispanic and Black patients in metastatic disease likely reflect more advanced disease presentation and barriers to early access, whereas delays in resection and radiation highlight inequities in accessing non-emergent, coordinated oncologic care. Reporting both means and medians provides a more complex understanding of treatment delays and underscores the need for interventions that expand early access to orthopaedic oncologists and ensure timely, equitable care.

Background/Objectives: Adult spinal deformity (ASD) management often requires pelvic fixation, with S2 alar-iliac (S2AI) screws emerging as an alternative to traditional iliac screws. Despite multiple meta-analyses comparing these techniques, the methodological quality of these syntheses and technical heterogeneity across primary studies significantly impact their conclusions and subsequent clinical decision-making. This systematic review evaluates the evidence quality of meta-analyses comparing S2AI with traditional iliac screws for ASD management, focusing on methodological rigor, primary study overlap, and clinical heterogeneity. Methods: PubMed, Cochrane, and Epistemonikos were searched for meta-analyses comparing S2AI with iliac screws for patients with ASD. The Quality of Reporting of Meta-analyses (QUOROM) checklist and the revised Assessment of Multiple Systematic Reviews (AMSTAR 2) tool were adopted to assess the methodological quality. Primary study overlap was evaluated using the Corrected Covered Area (CCA) method. Clinical heterogeneity was assessed by examining characteristics of studies included in ≥67% of meta-analyses. Results: From a total of 29 publications, six meta-analyses met the inclusion criteria (4807 patients; mean age: 59 years; 33% female). All included meta-analyses exhibited critically low methodological quality per AMSTAR-2, with common flaws including failure to provide lists of excluded studies and lack of a priori protocols. Very high primary study overlap was observed (CCA: 31%), with only 11% (2 of 19) primary studies included in all meta-analyses, whereas 42% (8 of 19) primary studies were included by only a single meta-analysis. Substantial clinical heterogeneity existed regarding patient characteristics, surgical techniques, and outcome definitions. Conclusions: This systematic review of meta-analyses identified critically low methodological quality, high primary study overlap, and substantial clinical heterogeneity in the existing evidence comparing pelvic fixation techniques for ASD. While published meta-analyses generally favor S2AI screws, these significant limitations prevent drawing definitive conclusions about superiority. Future research should prioritize high-quality prospective studies with standardized reporting to generate more reliable evidence for improving surgical outcomes in ASD management.

Background:The number of patients undergoing single- and multilevel lumbar fusion continues to rise. Although prior studies suggest that radiographic factors and preoperative patient-reported outcomes may predict surgical results, evidence regarding the predictive value of patient demographics on perioperative and postoperative outcomes remains limited. Using cluster analysis to define distinct demographic-based patient phenotypes, this study examines how patient demographics influence surgical outcomes in a disadvantaged, inner-city population. Methods:This is a retrospective, single-center cohort study including 459 patients who underwent a 1-3 level lumbar fusion between 2022 and 2024. The primary outcome was revision surgery at maximum follow-up. A 2-step cluster analysis was performed using SPSS 30 (IBM). Comparisons were performed between clusters using Chi-squared test for categorical variables and a one-way ANOVA with Tukey's posttest for continuous variables. Intra-cluster analysis was run using multivariate regression. p < .05 was considered significant. Results:A total of 459 patients underwent 1-3 level lumbar fusion (mean age 62.1 ± 10.9 years; 69.0% female; mean body mass index (BMI) 31.3 ± 5.6), with 92.4% identifying as non-white and 29.3% as non-English speaking. Mean operative time was 286 minutes, blood loss 206 mL, and hospital stay 4.7 days. Within 90 days, 19.2% visited the ER, 10.2% were readmitted, and 4.1% returned to the operating room (OR); 5.5% of patients ultimately required revision fusions, and 12.1% remained on chronic opioids at final follow-up. Cluster analysis identified 3 patient subgroups differing significantly by age, language, race, insurance, substance use, psychiatric medication, and prior laminectomy (all p < .001). Cluster 1 (younger, psychiatric/substance use) had higher revision rates (9.1% vs. 2.0-3.1%, p = .01). Conclusions:Distinct patient groups show differing lumbar fusion risks; younger patients with psychiatric and substance-use factors face higher revision rates and potentially worse recovery.

Introduction: Postoperative white blood cell (WBC) count and neutrophil-to-lymphocyte ratio (NLR) are routinely available after lumbar fusion, but early elevations may reflect surgical stress. We evaluated associations of postoperative day (POD) 1 and POD3 WBC/NLR with 90 d surgical wound infection (SWI) after elective short-segment lumbar fusion. Methods: This retrospective cohort included adults undergoing elective one- to three-level lumbar fusion from 2022 to 2024 at one academic center. SWI was a pragmatic electronic-health-record-based endpoint encompassing clinically documented wound-related events, not a uniformly culture-confirmed deep, implant-associated, or surveillance-defined infection. Complete-case univariable and parsimoniously adjusted logistic regressions examined WBC/NLR associations with SWI. Results: Among 380 outcome-eligible patients, 18 (4.7 %) developed SWI. POD1 analyses included 368 patients (18 events), POD3 analyses 336 (17 events), and paired analyses 327 (17 events). After adjustment for body mass index and operative duration, POD1 associations were attenuated; POD3 WBC (odds ratio 1.17, 95 % confidence interval 1.00-1.37; p = 0.049 ) and NLR (odds ratio 1.12, 95 % confidence interval 1.01-1.23; p = 0.026 ) remained associated with SWI. However, these associations weakened after adjustment for corresponding POD1 values. Absolute and percentage POD1-to-POD3 changes were not significantly associated with SWI. Conclusions: POD1 WBC/NLR elevations were associated with patient and operative context. POD3 values showed exploratory associations with SWI after limited adjustment but did not establish diagnostic thresholds, clinical utility, or a validated prediction model.

Background: Chordoma is a rare bone cancer with limited treatment options. Clinical trials are crucial for developing effective therapies, but their success depends on including diverse patient populations. The objective of this study was to systematically evaluate the reporting of racial, ethnic, and socioeconomic diversity in United States clinical trials exploring treatment for chordoma. Methods: A literature search was conducted through PubMed/Medline, Cochrane, Epistemonikos, and ClinicalTrials.gov databases for published US chordoma trials up until 19 August 2024. The data collected included trial characteristics and racial and ethnic data, as well as socioeconomic indicators when available. Methodological Index for Non-Randomized Studies (MINORS) and Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB2) analyses were adopted to assess the methodological quality. The N-1 Chi-squared (χ2) test was implemented to compare the reported racial and ethnic data with the most recent US Census Bureau data. Results: Five trials involving 111 patients (median age: 63 years; 34% female) were included. Four studies (80%) were single-arm non-randomized studies with one study (25%) having a high methodological quality and three (75%) having a moderate quality based on the MINORS analysis. Most patients (91%, n = 82) were White/Caucasian, representing a proportion which was significantly higher than the reported 75% in the US population (p = 0.0005). Black/African American patients (2%, n = 2) were significantly underrepresented compared to the 14% in the US population (p = 0.0015). Regarding ethnicity, Hispanic/Latino patients (7%, n = 6) were significantly underrepresented compared to the 20% in the US population (p = 0.0021). No measures of socioeconomic status were reported. Conclusions: This systematic review highlighted the need for improved racial and ethnic diversity in chordoma trials and the better reporting of socioeconomic data. The underrepresentation of minority groups may obscure potential disparities in disease incidence, treatment access, and clinical outcomes.

Patient-specific technologies within the field of adult spinal deformity (ASD) aid surgeons in pre-surgical planning, accurately help identify anatomical landmarks, and can project optimal post-surgical sagittal alignment. This narrative review aims to discuss the current uses of patient-specific technologies in ASD and identify new innovations that may very soon be integrated into patient care. Pre-operatively, machine learning or artificial intelligence helps surgeons to simulate post-operative alignment and provide information for the 3D-printing of pre-contoured rods and patient-specific cages. Intraoperatively, robotic surgery and intraoperative guides allow for more accurate positioning of implants. Implant materials are being developed to allow for better osseointegration and patient outcome monitoring. Despite the significant promise of these technologies, work still needs to be performed to ensure their accuracy, safety, and cost efficacy.

To develop an algorithmic approach for predicting surgical site infections (SSIs) in patients undergoing lumbar laminectomy and discectomy for adult degenerative spinal disease (DSD) by incorporating ensembled stacking into state-of-the-art (SOTA) automated machine learning (aML). The study utilized a comprehensive dataset from a prospective multicenter surveillance study on SSIs following lumbar laminectomy and discectomy to manage adult DSD. The Google Colab environment was adopted to load the dataset using Python programming language. Nine algorithms, including eXtreme Gradient Boosting (XGBoost), Light Gradient Boosting Machine (LGBM), Neural Network (NN), Categorical Boosting (CatBoost), and Random Forest (RF), were adopted with hyperparameter tuning using the current SOTA for aML. Ensembling of the developed algorithmic models was carried out, followed by stacking and ensembled stacking. Five-fold stratified, shuffled cross-validation was implemented. The macro-weighted average Area Under the Receiver Operating Curve (mWA-AUROC) analysis was used to evaluate the discriminating classification ability of the developed models along with other evaluation metrics. A stacked ensemble algorithmic model, comprising a stacked XGBoost model and an ensemble of XGBoost, NN, CatBoost, LGBM, and RF algorithmic models, achieved an mWA-AUROC of 0.994, an accuracy of 98.7

Accurate prediction of financial metrics in spine surgery is crucial as healthcare transitions to value-based care. While bundled payment models have succeeded in other orthopedic procedures, the heterogeneity of spinal surgery complicates their adoption. We develop the first preoperative risk-stratified multimodal machine learning model that integrates structured clinical data and unstructured surgeon notes using natural language processing to predict financial parameters. The model achieved ROC-AUC values of 0.845 and 0.883 for outlier total and variable costs, respectively, reflecting good-to-excellent performance. Among 1898 spinal surgery patients, 209 (11.0%) were identified as financial outliers, contributing to $12.8 million in losses, while the remaining cases yielded $1.8 million in profits. Financial outliers exhibited higher ICU admissions, 90-day reoperations, and longer LOS (all P < 0.001). We propose a patient-specific payment plan by quantifying predicted risk, enabling fair payment adjustments for high-risk spinal surgery patients. Institutions treating higher-risk patients face a greater financial burden in a flat bundled payment structure, emphasizing the need for individualized, risk-based models to improve payment equity and align resource allocation with patient complexity.

Background: Tranexamic acid (TXA) has shown efficacy in reducing blood loss in various surgical specialties without increasing thromboembolic risks, but its role in metastatic spinal tumor surgery (MSTS) remains unclear. This systematic review synthesized evidence on the safety and efficacy of TXA in MSTS. Methods: PubMed, Cochrane, and Epistemonikos were searched from inception to February 1, 2025 for studies reporting on TXA use in MSTS. Study quality was assessed using the Methodological index for non-randomized studies (MINORS) tool for non-randomized studies and the the Revised Cochrane risk-of-bias tool for randomized trials (RoB2) for randomized controlled trial (RCT). The impact of TXA on perioperative complications, blood loss, transfusion requirements, and operating time were evaluated. Meta-analysis feasibility was explored based on methodological and patient population uniformity. Results: Out of a total of nine studies, 6 studies reporting on 566 patients (mean age 59 years; 45% female) met the inclusion criteria. The 5 nonrandomized studies exhibited moderate methodological quality on MINORS analysis, while the RCT demonstrated low risk of bias on RoB2 analysis. A meta-analysis was precluded due to high participant and protocol heterogeneity. TXA was not associated with increased perioperative complications, including thromboembolic events. Blood loss impact varied, with 2 studies reporting contrasting results and others finding no significant effect. Transfusion requirements showed inconsistent results across studies. TXA consistently showed no impact on operative time. Conclusion: There is limited evidence to draw definitive conclusions regarding the safety and efficacy of TXA in metastatic spine tumor surgery. The best available evidence suggests that the complication rate is not higher in cases involving TXA use. The benefit in decreasing blood loss was variable. High-quality research is imperative to clarify the role of TXA in this complex patient population, as well as for the establishment of refined treatment protocols.

BACKGROUND CONTEXT:Machine learning (ML) algorithms can utilize the large amount of tabular data in electronic health records (EHRs) to predict perioperative safety indicators. Integrating unstructured free-text inputs via natural language processing (NLP) may further enhance predictive accuracy. PURPOSE:To design and validate a preoperative multimodal ML architecture that integrates structured EHR data (patient demographics, comorbidities, and clinical covariates) with unstructured free-text inputs (past medical and surgical history, medications, and problem lists) via NLP. The multimodal models aim to improve the prediction of perioperative safety indicators compared to baseline ML models that only use structured tabular EHR data. STUDY DESIGN:Retrospective cohort study. PATIENT SAMPLE:A total of 1,898 patients were admitted for elective or emergency spine surgery at four separate large urban academic spine centers during a 5-year period from 2018 to 2023. OUTCOME MEASURES:Numerical outputs between 0 and 1 corresponding to the likelihood of (I) extended length of stay (LOS), (II) 90-day reoperation, and (III) perioperative intensive care unit (ICU) admission. METHODS:We predicted the following safety indicators (I) extended length of stay (LOS), (II) 90-day reoperation, and (III) perioperative intensive care unit (ICU) admission. The quanteda package for NLP within the R environment was utilized to preprocess free-text EHR inputs. The refined text was tokenized and transformed into numerical vectors using a bag-of-words approach and integrated with the tabular EHR data to create a document-feature matrix. Two extreme gradient boosted (XGBoost) ML models were trained: a base model utilizing only structured tabular EHR data and a combined multimodal model that leveraged both combined structured tabular EHR data with numerical vectors derived from free-text NLP inputs. Hyperparameter tuning was performed via grid search, and the models were validated using 10-fold cross validation with an 80:20 training/testing split. Word clouds were generated for the free-text data and explainable artificial intelligence (XAI) techniques were employed for feature importance. Metrics calculated for model performance included Area Under the Receiving-Operating Characteristic Curve (AUC-ROC), Brier score, Calibration slope, Calibration Intercept, Precision, Recall and F1-Score. RESULTS:A total of 1,898 patients (60.7% female) were extracted from January 2018 to September 2023, with a median age of 60.0 (IQR: 52.0-68.0) and median body mass index (BMI) of 30.3 kgm2 (IQR: 26.3-34.6). Extended LOS was defined as ≥ 14.4 days, constituting 10.1% of all individuals. The median LOS for the entire cohort was 4.0 days (IQR: 2.0-7.0), while the 90-day reoperation rate was 10.54%, and the ICU admission rate was 7.74%. The preoperative tabular EHR models predicted perioperative safety indicators with AUC ranging from 0.770 to 0.779, Brier scores ranging from 0.074 to 0.099, and calibration slopes ranging from 2.279 to 2.418. Precision and recall for this model ranged from 0.918 to 0.973 and 0.988 to 0.994, respectively, resulting in F1-scores between 0.954 and 0.973. The combined multimodal models predicted perioperative safety indicators with AUC ranging from 0.827 to 0.903, Brier scores ranging from 0.056 to 0.083, and calibration slopes ranging from 0.755 to 1.217. The multimodal models achieved precision ranging from 0.909 to 0.933 and recall ranging from 0.979 to 0.994, leading to F1-scores between 0.943 and 0.962. Important tabular predictors included patient age, BMI, hemoglobin level, white blood cell count, platelet count, and a combined anterior/posterior spinal fusion approach. Important free-text inputs included vertebral osteomyelitis, radiculopathy, myelopathy, and spinal metastasis. CONCLUSIONS:The multimodal NLP model exhibited superior performance in all outcome measures when compared to the baseline tabular model. Future work includes incorporating additional model dimensions, such as the history of present illness, physical exam, and spinal imaging, and clinically implementing the models into our informed consent and preoperative optimization pathway.

INTRODUCTION:Standard spine surgery machine learning (ML) models often rely on structured clinical data, overlooking nuanced free text, such as preoperative surgical notes. The aims of this work were to develop a multimodal ML model combining structured electronic health record (EHR) data with natural language-processed unstructured clinical narratives. METHODS:After testing against Convolutional Neural Network, Support Vector Machine, LightGBM, and Random Forest algorithms, the XGBoost algorithm was selected for model development. Three models were developed: (1) a structured EHR-based ML model; (2) an NLP-based model using preoperative notes; (3) a combined multimodal model. Perioperative outcomes included extended length of stay (≥8.0 days) and nonhome discharge. Preprocessing included tokenization, stemming, and bag-of-words vectorization. Hyperparameters were tuned through grid search and 10-fold cross-validation. Key performance metrics included area-under-the-receiver-operating characteristic curve, Brier score, calibration slope and intercept, precision, recall, and F1 score. RESULTS:A total of 486 patients (58.8% female, n = 281) were included, with a median age of 61.0 years (interquartile range: 52.0 to 68.0 years) and median body mass index of 29.4 kg/m 2 (interquartile range: 25.1 to 34.5 kg/m 2 ). For extended length of stay, the multimodal model excelled (ROC-AUC: 0.908, Brier: 0.114, F1: 0.896), followed by the NLP-only model (ROC-AUC: 0.868, Brier: 0.132, F1: 0.877), and the XGBoost-only model (ROC-AUC: 0.736, Brier: 0.201, F1: 0.815). For nonhome discharge, the multimodal model led (ROC-AUC: 0.920, Brier: 0.105, F1: 0.907), compared with the NLP-only model (ROC-AUC: 0.892, Brier: 0.102, F1: 0.916) and XGBoost-only model (ROC-AUC: 0.771, Brier: 0.144, F1: 0.893). Explainable AI revealed that body mass index, age, Medicare insurance, Charlson comorbidity index, Medicaid status, Hispanic ethnicity, fusion history, and thoracolumbar and cervical levels of surgery were the most important model features. CONCLUSION:Incorporating unstructured surgeon notes into ML models markedly enhanced the prediction of perioperative outcomes in spinal surgery, suggesting that free-text notes may provide greater predictive utility than standard EHR variables. LEVEL OF EVIDENCE:III.

Identify characteristics predictive of CPPD in the lumbar spine and evaluate the impact of CPPD on perioperative adverse events. A cohort of patients who underwent open lumbar decompressions for spinal stenosis at a single academic tertiary referral center from 1/1/2001 to 1/31/2021 with pathology-proven pseudogout were compared with an age, sex and BMI propensity-matched non-CPPD cohort. The primary outcome was incidental durotomy. Secondary outcomes were 90-day reoperations and all-cause readmissions, chronic pain utilization and motor deficits. Independent associations between patient factors, operative characteristics and CPPD with adverse events were identified using step-wise multivariate logistic regressions. A total of 139 patients diagnosed with CPPD based on operative pathology (mean age 68.4 ± 10.7 years, 49.6% female, mean BMI 28.9 ± 6.1) were compared with a matched cohort of 133 patients. Active smoking (OR 3.1, 95% CI 1.3 to 7.6) and a prior epidural steroid injection (OR 2.5, 95% CI 1.4 to 4.3) were independently associated with lumbar CPPD. CPPD was associated with an increased likelihood of durotomy (OR 2.2, 95% CI 1.1 to 4.5). CPPD was more prevalent in active smokers and those who received an epidural steroid injection. Durotomies were more common in patients with CPPD.

Background:While glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have demonstrated benefits in reducing complications following total knee and hip arthroplasty, their effects in spinal surgery remain unclear. Prior studies have reported mixed results across select spinal fusion procedures, and the impact of GLP-1 RAs on perioperative outcomes has not been well-defined. This study evaluates the association between preoperative GLP-1 RA use and key perioperative outcomes in spinal surgery. Methods:We conducted a retrospective, propensity score-matched analysis of adult patients (≥18 years) undergoing spinal decompression and/or fusion at an urban academic spine service over the past 5 years. Patients prescribed a GLP-1 RA preoperatively comprised the exposure cohort. A 1:4 nearest-neighbor propensity score matching algorithm was then used to identify comparable controls without GLP-1 RA use, based on age, sex, body mass index (BMI), primary procedure code, comorbidities (diabetes, hypertension, hyperlipidemia, heart disease, smoking status, kidney disease, and anxiety), and the use of prevalent diabetic medications (insulin, metformin, sulfonylureas, and SGLT-2 inhibitors). Primary outcomes included length of stay (LOS), operating room (OPR) time, 90-day reoperation, 90-day readmission, and nonroutine discharge. Binary outcomes were assessed using multivariate logistic regression, while the Mann-Whitney U test was used for continuous variables. Results:The final matched cohort included 1385 patients (GLP-1 RA: n = 277; control: n = 1,108), with anterior cervical discectomy and fusion being the most common procedure (n = 333, 24%). The GLP-1 RA cohort was predominantly female (n = 172, 62.1%), with a mean age of 61.4 years and mean BMI of 33.8 kg/m². Both cohorts exhibited high rates of comorbidities, including diabetes and hypertension. GLP-1 RA use was associated with a significant reduction in median postoperative LOS (3 days vs. 4 days; p = 0.036), particularly among patients undergoing lumbar fusion. No significant differences were observed in OPR time, 90-day reoperation, 90-day readmission, or nonroutine discharge rates. Conclusions:Preoperative GLP-1 RA use was associated with a statistically significant reduction in postoperative LOS among patients undergoing spinal decompression and/or fusion. Further prospective, multi-institutional studies are warranted to validate these findings and to determine whether this reduction translates into clinically and financially meaningful benefits, including improved long-term outcomes.

Study Design Retrospective cohort study. Objective Determine if the use of a Wilson kyphosis frame during single level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) at L4-5 or L5-S1 impacts postoperative lumbar lordosis. Methods A retrospective analysis of patients who underwent a single level MIS TLIF at L4-5 and L5-S1 from 1/1/2016 to 1/1/2021 was performed. Patient demographics were collected, and radiographic measurements preoperatively and 6 months postoperatively were performed. Our primary outcome was “delta lumbar lordosis” (delta LL), or the difference between pre-operative and 6 month postoperative lumbar lordosis. Statistical analysis was performed using step-wise multivariate linear regressions. Results A total of 180 patients were included. Mean age was 58.5 ± 11.8 years and 48.3% were female. Mean BMI was 28.6 ± 5.6. Wilson positioning frames were used in 96/180 (53.3%) procedures. Use of a Wilson Frame was independently predictive of 2.5° reduced delta LL (Coeff −2.5, 95% CI -4.1 to −0.9). However, use of a Wilson frame was not found to be independently associated with postoperative mismatch between pelvic incidence and lumbar lordosis. Conclusions Use of a Wilson kyphosis frame during single level MIS TLIF at L4-5 and L5-S1 resulted in a loss of 2.5° of lordosis compared with those patients who had a MIS TLIF without a Wilson frame. The clinical impact of this loss over long-term follow-up will be the subject of future studies.

Introduction Hypoalbuminemia is associated with poor outcomes in cancer patients, but its role in spinal metastases remains unclear. Research question This study aimed to identify albumin cutoff values defining hypoalbuminemia and describe the association between serum albumin and outcomes in patients with spinal metastases. Material and methods A narrative review of articles up to December 2022 was conducted using PubMed/Medline, EMBASE, and Web of Science databases. Variables extracted included study design, patient characteristics, serum albumin levels, treatments, and levels of evidence. Outcomes included survival/mortality, complications, ambulatory status, readmission, length of stay, discharge disposition, and blood loss. Results Thirty-eight studies comprising 21,401 patients were analyzed. Most studies (92%) were Level of Evidence III. Albumin was evaluated as a continuous variable in 18% of studies and as a dichotomous variable in 76%, with 3.5 g/dL being the most common threshold for hypoalbuminemia. Primary outcomes evaluated were survival/mortality (71% of studies), complications (34%), and reoperation/readmission (11%). Of studies examining the association between hypoalbuminemia and survival/mortality, 74% found a significant association. An association between albumin levels and complications was found in 54% of relevant studies. Discussion and conclusion The findings of this study suggest that a threshold of 3.5 g/dL seems most appropriate to define hypoalbuminemia in patients with spinal metastases. However, evidence also supports a level-dependent effect. The most consistent significant association was between low albumin and survival at both fixed and continuous time points. There is less evidence to support an association between hypoalbuminemia and other endpoints such as perioperative complications.

ObjectivesStand-alone (SA) and anterior cage-and-plate (ACP) have been studied in anterior cervical discectomy and fusion (ACDF). However, fusion assessment methods vary and existing studies are not propensitymatched and often lack patient-reported outcomes (PROMs). We compare fusion rates between propensity-matched single- and multi-level SA versus ACP using a method validated by intraoperative motion testing during revision surgery. We also compare sagittal alignment, perioperative outcomes, and PROMs.MethodsPatients >18 years who underwent primary ACDF were included. 2:1 propensity score matching was performed. Fusions were assessed using 1 year computer tomography and flexion/extension radiographs via validated fusion assessment methods. ALOD was assessed at least 6-months postoperatively. Sagittal alignment was assessed at preoperative, short-term postoperative (2-6 weeks), and long-term postoperative (6 months or more) time points. PROMs, operative time, blood loss, dysphagia, and complications were analyzed.Results153 patients (51 SA) were included after matching. There were no differences in fusion rates overall (P = .662), or by number of surgical levels. There were no differences in ALOD at upper or lower levels, nor was there a difference in ALOD grade. Regarding segmental lordosis, overall lordosis, T1 slope, TS-CL, and PROMs (NDI, SF-12 PCS, VAS neck and arm), there were no differences at preoperative or any postoperative time point. Operative time and blood loss were greater in the ACP cohort, with no differences in complications or postoperative dysphagia.ConclusionsFusion rates, PROMs, radiographic outcomes, complications, and dysphagia rates were all comparable following single and multi-level ACDF between SA and ACP.