Background:The prevalence of cervical spondylotic myelopathy (CSM) is increasing annually and represents a large burden of disability. Anterior cervical discectomy and fusion (ACDF), posterior cervical decompression (PCD), and PCD and fusion (PCDF) are commonly used surgical approaches to address this pathology. This single-institution retrospective cohort of ACDFs, PCDFs, and PCDs compares readmission rates and the incidence/indication for reoperation at 90-day, 1-year, and 2-year follow-up. Methods:Patients undergoing ACDF, PCD, or PCDF between 2013 and 2019 were identified using CPT codes. Charts were reviewed for demographics, surgical characteristics, and reoperations. Statistical analysis included t-tests for continuous variables and χ2 testing for categorical variables. Results:A total of 366 patients undergoing 175 ACDFs, 86 PCDFs, and 105 PCDs were included. Initial analysis of complications by surgical approach showed that the rate of reoperation was significantly higher in the PCDF group at 30-day and 1-year (P<0.001, P=0.003) with no difference at 2-year. Overall readmission rate over 1 year was 30.6%, and there was no significant difference between groups. Subsequent analyses demonstrated that patients undergoing PCDF or PCD had significantly higher Charleston Comorbidity Indices (CCI) than ACDF patients (P<0.001). Upon controlling for CCI in regression analyses, neither reoperation nor readmission rates varied significantly by surgical approach. Conclusions:In our cohort, we observe advantages and limitations for each surgical approach. On examination of patient factors, patients undergoing PCDF and PCD tended to have a higher burden of comorbidities compared to those treated via an anterior approach. Upon controlling for comorbidity index, the observed difference in reoperation rates was no longer apparent. Thus, patient comorbidities, rather than surgical approach, may be the major driver for postoperative complications for treatment of CSM.

BACKGROUND CONTEXT:Lumbar discectomy is the standard of care for symptomatic lumbar disc herniation (LDH). However, recurrent LDH (rLDH) necessitates reoperation in 3% to 18% of patients, posing a substantial challenge for both patient counseling and healthcare economics. While studies have focused on demographic and clinical risk factors, the contribution of preoperative radiographic parameters to recurrence risk remains poorly defined. PURPOSE:This study evaluated preoperative MRIs for patients undergoing one-level lumbar discectomy to determine combined clinical and radiographic factors associated with operative rLDH following a single-level discectomy. STUDY DESIGN:This retrospective cohort study included adult patients who underwent a primary, single-level lumbar microdiscectomy at a tertiary academic center. PATIENT SAMPLE:Adult patients undergoing index one-level lumbar discectomy were included. Patients were excluded for revision surgery, fusion, nondiscal pathology, or unavailable preoperative MRI. OUTCOME MEASURES:Patients were considered to have operative rLDH if they underwent repeat discectomy or discectomy and fusion at the index level within 3 years of their primary surgery. Potential variables included demographics, comorbidities, and radiographic parameters from preoperative MRI, including herniation morphology, disc degeneration (modified Pfirrmann grade), endplate changes (Modic), and facet arthropathy. METHODS:A multivariable Cox proportional hazards model was used on a matched cohort to identify independent variables associated with time to reoperation. Receiver operating characteristics curves and were developed based on mixed clinical and radiographic models. RESULTS:Two thousand six hundred eight patients underwent single level lumbar discectomy between 2013 and 2024, of whom 129 (4.9%) required reoperation for rLDH. The matched cohort included 250 patients, of whom 129 (51.6%) required reoperation for rLDH within 3 years. After multivariable adjustment, several factors were independently associated with recurrence risk. Significant radiographic factors included the presence of Modic changes (hazard ratio [HR], 1.86; 95% confidence interval [95% CI], 1.23-2.82; p=.003) and a higher facet degeneration index (HR, 1.43 per grade; 95% CI, 1.30-1.57; p<.001). Significant clinical variables included a higher Charlson comorbidity index (HR, 1.21 per point; 95% CI, 1.08-1.36; p=.002), younger age (HR, 0.98 per year; 95% CI, 0.96-1.00, p=.04), and male sex (HR, 1.58; 95% CI, 1.09-2.30; p=.02). Radiographic factors increased the AUC compared to clinical factors alone, particularly beyond 1 year. CONCLUSIONS:Higher systemic comorbidity burden, degenerative endplate changes, and worsened facet arthropathy are significantly associated with risk of operative rLDH and should be considered for patient counseling and surgical planning.

OBJECTIVE Surgical correction of adult spinal deformity (ASD) is associated with a high rate of hardware complication that can be challenging to predict. Hardware integrity and alignment after surgery are typically followed with standing radiography, where pedicle screw loosening may be incidentally identified but the clinical significance of which is often unclear. This study aimed to identify the incidence and implications of pedicle screw loosening at the upper instrumented vertebra (UIV) after surgical correction of ASD. METHODS A single-institution retrospective analysis was performed on a cohort of 217 patients who underwent long- segment fusion with pelvic fixation for correction of ASD between September 2013 and November 2021. Cases with a minimum 1-year follow-up were included. UIV pedicle screws were graded on radiographs for evidence of loosening with a 0- to 3-point scale: 0, no loosening; 1, lucency within screw threads; 2, lucency around screw threads; and 3, screw dislodgment/backout. Need for hardware revision surgery was assessed as the primary outcome. Patient-reported outcome measures (PROMIS and Oswestry Disability Index scores) were assessed as secondary outcomes among the patients with available scores. RESULTS Low-grade UIV screw loosening (grade 1) was identified in 37 patients (17.1%), and high-grade UIV loosening (grade 2 or 3) was identified in 23 patients (10.6%). Low-grade UIV loosening was not associated with eventual need for hardware revision (OR 0.52, 95% CI 0.17-1.61, p = 0.258); however, high-grade loosening was associated with increased odds of hardware revision (OR 5.17, 95% CI 1.74-15.36, p = 0.003), including specifically surgery for correction of proximal junctional kyphosis (OR 5.73, 95% CI 1.27-25.95, p = 0.024). Among patients with PROMIS T-scores, those requiring hardware revision reported worse Pain Interference (65.0 +/- 5.1 vs 59.6 +/- 7.7, p = 0.001) and Physical Function (33.3 +/- 5.6 vs 37.4 +/- 7.4; p = 0.011). Patients with high-grade UIV loosening reported higher Oswestry Disability Index scores than those without high-grade loosening (grade 0 or 1), although this failed to reach statistical significance (44.0 +/- 8.5 vs 33.7 +/- 18.5, p = 0.101). CONCLUSIONS Grade 1 UIV pedicle screw loosening may represent a benign incidental finding, whereas high-grade loosening is associated with significantly increased odds of hardware revision surgery. High-grade loosening may also be associated with worse patient-reported disability. The authors' findings suggest that while low-grade UIV loosening may often be managed expectantly, identification of high-grade UIV pedicle screw loosening on follow-up imaging warrants increased attention and continued surveillance.

OBJECTIVE:Intraoperative antifibrinolytic therapy with tranexamic acid (TXA) is a focus of interest for blood loss reduction in multilevel adult spinal deformity (ASD) correction surgery. There is considerable heterogeneity in the reported findings regarding the safety and efficacy of this therapy. In the present study, the authors aimed to rigorously investigate the safety and efficacy of TXA in multilevel ASD correction surgery and to explore secondary perioperative outcomes. METHODS:This retrospective cohort study used data from the authors' institutional spine deformity database, including records of surgeries performed between January 1, 2013, and December 13, 2021, with a minimum follow-up of 2 years. Adult patients undergoing elective thoracolumbosacral posterior spinal fusion involving 6 or more vertebrae were included. The primary outcome was the safety and efficacy of TXA, with secondary outcomes including postoperative complications and overall outcomes. Propensity-scored stabilized inverse probability of treatment weighting was used to adjust for confounding factors. Subsequent weighted analysis of the treatment effect was performed using regression models for hypothesis testing, with 95% confidence intervals calculated based on weighted means, variances, and standard errors. The p values of primary outcomes and subgroup analyses were adjusted for multiplicity testing with the Benjamini-Hochberg correction at a false discovery rate of 0.05. The conduct and reporting of this study were supported by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS:The study included 598 patients, with 257 receiving TXA and 341 controls. Weighted analysis revealed that TXA administration was associated with significant reductions in estimated blood loss (p = 0.007), percentage of estimated blood volume lost (p = 0.035), intraoperative total red blood cell transfusion volume (p = 0.035), and postoperative packed red blood cells transfusion volume (p = 0.035). No significant differences were observed in postoperative thromboembolic events (p = 0.397). CONCLUSIONS:TXA was significantly associated with reduced blood loss and transfusion requirements in multilevel ASD correction surgery without increasing the risk of thromboembolic complications.

Prescription opioids after surgery may pose a risk if left unused. However, prescribers rely on their best judgement in determining how much their patients need, often resulting in over-prescription of these medications. Opioid disposal is a strategy to reduce the risk of persistent use or misuse of opioids. At-home disposal kits allow patients to safely dispose of leftover opioids. In this study, we assess the impact of opioid disposal kits on disposal rates after orthopedic surgery. In a difference-in-differences study of 1,321 eligible patients, disposal kits were associated with a 10.6 percentage point increase (95% CI: -3.5% to 24.7%) in disposal rates as well as a 10.5 percentage point increase (95% CI: 0.2% to 20.9%) in the fraction of opioids disposed. We build on prior research and identify that providing surgery patients with an opioid disposal kit at the time of discharge increases their self-disposal rates.

Among all upper extremity nerves, the ulnar nerve is both the most commonly injured and notoriously difficult to regenerate. Despite this, ulnar nerve injuries remain understudied. Nonhuman primates (NHPs) offer an ideal model for the human upper extremity, but existing NHP nerve trauma literature is biased towards median and radial injury models. To address this, a nonhuman primate ulnar nerve injury model was developed and regeneration assessed following sural nerve autografting using electrophysiological and histological techniques. Unilateral 4 cm ulnar nerve injuries were created at the mid-forearm level, sural nerve autografts were sutured into resulting defects (n = 3), and animals were survived for 6 months. At the terminal time point, intraoperative electrophysiological testing, tissue harvest, and tissue processing were performed. Naïve nerves (n = 5) served as controls. Animals appeared clinically normal throughout the study period, other than an expected decrease in fine hand muscle function. After 6 months, histological and electrophysiological evidence suggested that axons crossed the graft and reached distal muscle targets. However, regenerating nerves exhibited a reduced motor nerve conduction velocity, reduced compound action muscle potential (CMAP) amplitude and area under the curve, increased latency, and increased duration versus naïve controls as expected. Histological analysis revealed reduced axon diameters, thinner myelin sheaths, and smaller muscle fiber cross-sectional areas as compared to controls. At 6 months post-injury, 4 cm ulnar defects bridged with sural autografts show signs of ongoing regeneration and nascent reinnervation. Specific electrophysiological and histological benchmarks for ulnar nerve recovery following clinically relevant autografting are presented.

OBJECTIVE:Core outcome sets (COSs) are needed to promote data consistency across studies as well as data synthesis and comparability. The goal of the current study was to utilize a modified Delphi process to develop a COS-sciatic injury and neuropathy evaluation (COS-SINE). METHODS:A five-stage approach was utilized to develop the COS-SINE: stage 1, consortium development; stage 2, literature review to identify potential outcome measures; stage 3, Delphi survey to develop consensus on outcomes for inclusion; stage 4, Delphi survey to develop definitions; and stage 5, consensus meeting to finalize the COS and definitions. The study followed the Core Outcome Set-STAndards for Development recommendations. RESULTS:The Core Outcomes in Nerve Surgery (COINS) Consortium comprised 23 participants, all neurological surgeons, representing 13 countries. Three participants were excluded on the basis of agreed upon participation rules. The final COS-SINE consisted of 36 data points/outcomes covering the domains of demographics, diagnostics, patient-reported outcomes, motor and sensory outcomes, and complications. Appropriate instruments, methods of testing, and definitions were set. The consensus minimum duration of follow-up was 24 months, with consensus optimal time points for assessment identified as preoperatively and 3, 6, 12, 24, and 36 months postoperatively. CONCLUSIONS:The COINS Consortium developed a consensus COS and provided definitions, methods of implementation, and time points for assessment. The COS-SINE should serve as a minimum set of data that should be collected in all future neurosurgical studies on sciatic nerve injury and neuropathy. Incorporation of this COS should help improve consistency in reporting and data synthesis and comparability and should minimize outcome-reporting bias.

Importance Prescribing more opioids than patients need following surgery is associated with long-term use, misuse, and diversion. Interventions are needed to increase adherence to procedure-specific guidelines while preserving the ability to manage pain. Objective To test whether providing clinicians monthly feedback with peer comparisons and patient-reported outcomes would increase adherence to postoperative opioid prescribing guidelines. Design, Setting, and Participants This stepped-wedge cluster randomized clinical trial was conducted at 6 surgical departments or divisions caring for patients undergoing 30 high-volume surgical procedures in a 5-hospital academic health system in Pennsylvania and New Jersey. Surgical clinicians (attending surgeons, advanced practice professionals, and resident physicians) with 5 or more opioid prescriptions per month for eligible procedures during a 3-month period at baseline were eligible for inclusion. Six clinician clusters were randomly assigned to the intervention in 3 steps offset by 2 months. Each step included a 9-month baseline, a 6-month intervention, and a 6-month follow-up. The first step of the intervention began on June 8, 2022. Follow-up concluded in October 2023, and data analysis was performed from November 2023 to April 2024. Intervention Clinicians were emailed a report on their most frequently performed procedures, which contained a figure of the following mean numbers: pills prescribed relative to guidelines, pills peer clinicians prescribed, and pills patients reported using after a procedure; an additional figure displayed patients' self-reported ability to manage pain. Monthly reports included prescribing trends, peer comparison feedback, and reminders about how many pills patients take and how well patients reported pain management with guideline-adherent prescriptions. Main Outcomes and Measures The primary outcome was the proportion of guideline-adherent opioid prescriptions; secondary outcomes included patient-reported ability to manage pain (measured on a 0 to 10 scale, with 0 being not at all able), pain score, pills prescribed, pills leftover, and refill rate. Results A total of 143 surgical clinicians treating 20 557 patients were included (10 069 at baseline, 5382 during the intervention, and 5106 at follow-up). Mean (SD) patient age was 57.0 (15.7) years, and 10 996 patients (53.5%) were female. The baseline guideline adherence rate was 57.2%. During the intervention, adherence increased to 71.8%, with an adjusted intervention effect of 5.3% (95% CI, 2.0%-8.7%). The impact of the intervention increased over time, and adherence remained above baseline at follow-up (74.4%). The largest change was noted for orthopedic procedures of knee, hip, and shoulder arthroplasty. Patient-reported pain and ability to manage pain were unchanged. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial, a feedback intervention using peer comparisons and patient-reported data increased opioid guideline adherence without compromising patients' ability to manage pain. Trial Registration ClinicalTrials.gov Identifier: NCT05358522

INTRODUCTION:Coagulopathy in the setting of traumatic brain injury (TBI) increases the risk of poor outcomes. Thromboelastography with platelet mapping (TEG-PM) provides a dynamic assessment of clotting parameters including adenosine diphosphate (ADP) inhibition and can guide antiplatelet reversal. METHODS:A cross-sectional study of a single Level I Trauma Center traumatic brain injury database from February 2015 to March 2024 was conducted to develop a prediction model of ADP inhibition. Included patients had evidence of traumatic intracranial hemorrhage on CT at the time of presentation and underwent TEG-PM testing. Patients with a history of antiplatelet or anticoagulant use were excluded. Significant ADP inhibition was defined as ≥ 60%. RESULTS:485 patients were included. Patients with significant ADP inhibition were younger and more likely to have a severe head injury (Glasgow Coma Scale 3-8). In a multivariate logistic regression model including age and head injury severity as independent variables, severe head injury significantly increased the likelihood of ADP inhibition (odds ratio 2.14, 95% confidence interval 1.28-3.58). CONCLUSION:The observation that severe head injury was significantly associated with ADP inhibition could help identify patients at risk for platelet dysfunction in settings without TEG-PM.

OBJECTIVE:Spine surgery prehabilitation programs aim to optimize patients' functional capacity prior to surgery. The impact of a multi-modal prehabilitation program incorporating physical exercises, home modifications, and preoperative education has not been investigated. This study investigates the impact of a multi-dimensional prehabilitation program within a comprehensive Enhanced Recovery After Surgery (ERAS) program on spine surgery outcomes. METHODS:A single-center retrospective cross-sectional study was conducted of patients undergoing elective spine surgery from 2021 to 2024. Patients who underwent prehabilitation were matched with patients who did not undergo prehabilitation based on age, sex, body mass index, co-morbid conditions, and surgery type. Outcomes examined included length of stay, discharge disposition, readmission, Emergency Department (ED) visits, and pre-and post-operative Patient-Reported Outcomes Measurement Information System-Depression (PROMIS-D), Pain Interference (PROMIS-PI) and PROMIS-Physical Function (PROMIS-PF) T-scores. Prehabilitation patients were surveyed on satisfaction and pain levels before and after surgery. RESULTS:The total sample included 105 prehabilitation and 105 standard-of-care patients. No significant differences were found regarding length of stay, discharge disposition, readmission rates, ED visit rates, PROMIS-D, PROMIS-PI, and PROMIS-PF T-scores. Compared to their baseline scores, prehabilitation patients reported greater preparedness after their procedure and reduced pain (p-value < 0.001); between-group comparisons were not possible due to lack of data available from the standard-of-care group CONCLUSION: While prehabilitation did not significantly impact postoperative outcomes compared to standard of care, prehabilitation did improve patients' feelings of preparedness and comfort for discharge within the prehabilitation group.

Peripheral nerve injury is a significant clinical challenge, often leading to permanent functional deficits. Standard interventions, such as autologous nerve grafts or distal nerve transfers, require sacrificing healthy nerve tissue and typically result in limited motor or sensory recovery. Nerve regeneration is complex and influenced by several factors: 1) the regenerative capacity of proximal neurons, 2) the ability of axons and support cells to bridge the injury, 3) the capacity of Schwann cells to maintain a supportive environment, and 4) the readiness of target muscles or sensory organs for reinnervation. Emerging bioengineering solutions, including biomaterials, drug delivery systems, fusogens, electrical stimulation devices, and tissue-engineered products, aim to address these challenges. Effective translation of these therapies requires a deep understanding of the physiology and pathology of nerve injury. This article proposes a comprehensive framework for developing restorative strategies that address all four major physiological responses in nerve repair. By implementing this framework, we envision a paradigm shift that could potentially enable full functional recovery for patients, where current approaches offer minimal hope.

Study Design: This is a retrospective cohort study. Objective: The primary objective was to determine the accuracy of the Risk Assessment and Prediction Tool (RAPT) score-based discharge disposition prediction among patients undergoing spine surgery within an Enha Recovery After Surgery (ERAS) program. The secondary objective was to determine if using RAPT to initiate preoperative referrals to home services expedited care. Summary of Background Data: The RAPT score has been applied to spine surgery patients but has not been validated among participants in an ERAS program. Methods: All patients undergoing elective spine surgery within an ERAS program over a 1-year period received a preoperative social work evaluation incorporating the generation of RAPT score. Patients predicted to be discharged home with services received a preoperative referral for home services. The predicted versus actual discharge destination was compared, and the association of preoperative home services referral with the timing of home services initiation was assessed. Results: Four hundred eight patients received a preoperative social work evaluation with RAPT score calculation. Two hundred seven (50.7%) patients had an accurately predicted postoperative discharge disposition based on RAPT score. Among the patients who received home services following discharge, the mean time to receipt of home services was shorter among patients who had a correct discharge disposition prediction compared with patients who had an incorrect prediction, but this difference was not statistically significant [31.3 (SD: 15.6) vs. 42.0 h (SD: 44.2), P =0.24]. Conclusions: This study supports the feasibility of integrating RAPT score calculation into a preoperative social work evaluation. However, the traditional tiers of RAPT scores had limited accuracy in predicting discharge disposition in this cohort of patients undergoing spine surgery within an ERAS program. Level of Evidence: Level III.

Evidence-based opioid prescribing guidelines have resulted in reductions in postoperative prescription size without offsetting increases in patient-initiated refills. While there is extensive literature detailing postoperative opioid usage and guideline implementation in other specialties, data for neurosurgical patients have been limited to date. We conducted a prospective study of postoperative opioid use and patient-reported outcomes for 1,215 elective spine and peripheral nerve neurosurgical cases between December 2018 and March 2022, with the implementation of prescribing guidelines in February 2021 at three hospital sites within an academic health system. Opioid prescribing guideline development was based on patient-reported opioid consumption behaviors monitored using an automated two-way text messaging platform. The aggregate response rate to the automated text-messaging system was 48.2% throughout the study period. Prior opioid use, median household income of patient ZIP code, and operative procedure were identified as significant independent estimators of likelihood to respond to opioid-use questions (p<0.05). There were significant reductions in the mean postsurgical opioid prescription for thoracolumbar laminectomies and fusions (p<0.001) after guideline implementation. There was no difference in mean cumulative postsurgical opioid consumption by operative procedure after guideline implementation. Prior opioid use (OR: 1.91, SD: 0.50, p<0.05) and mean pain score (OR: 1.16, SD: 0.06, p<0.01) were significant predictors of elevated opioid use. Pain scores did not significantly differ at postoperative Month 3 by operative procedure. Opioid prescribing guideline development for neurosurgical cases that is informed by patient-reported opioid behaviors may reduce opioid volume prescribed by operative procedure and the total volume of unused opioid medication retained by patients.

Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) remain difficult problems following correction of adult spinal deformity (ASD). The goal of this study was to perform a comprehensive evaluation of risk factors associated with PJK and PJF using advanced statistical methods through inverse probability weighting (IPW). Patients who presented to the authors' institution with symptomatic ASD from 2013 to 2021 and who underwent thoracolumbar fusion ending in the pelvis were included in the study. The primary outcomes were development of PJK and PJF following ASD correction. PJK was classified using Glattes' criteria. PJF was defined as a proximal junctional angle > 20° from preoperative measures or complications at the upper instrumented vertebra (UIV) including vertebral body fracture, instability, and/or hardware failure. Patient charts and images (radiography, CT, and MRI) were used to extract demographics, measures of sagittal and coronal balance on pre- and postoperative radiography, operative techniques, and bone health metrics. Propensity score generation with IPW was used to control for confounding variables. In total, 187 patients were included in the study with a median follow-up of 24.6 months. Sixty-nine patients (36.9%) developed PJK, while 26 (13.9%) developed PJF. Kaplan-Meier analysis showed that both PJK and PJF largely occurred within the 1st year of index ASD correction. IPW showed that patients who developed PJK had a larger correction in the sagittal plane including global lumbar lordosis (p < 0.001) and sagittal vertical axis (p = 0.020). PJF development was associated with factors at the UIV including low Hounsfield units (p = 0.026) and cranially directed screws at the UIV (p = 0.040). PJK and PJF remain challenging postoperative complications following correction of ASD. In this large retrospective study that utilized IPW analysis, the authors found factors unique to each outcome. These results suggest that increased correction in the sagittal plane is more commonly associated with PJK, while junctional factors including bone quality and cranially directed screws at the UIV are associated with PJF. These findings can inform pre- and intraoperative medical and surgical strategies to reduce the incidence of PJK and PJF following ASD correction.

Obesity's impact on postoperative complications and poor functional outcomes in spine surgery is well-documented. It affects both the technical difficulty of lumbar spine surgery and systemic health. The increased adipose tissue around the spine necessitates extensive soft tissue dissection. Minimally invasive endoscopic surgery may reduce these complications. This study investigates the effects of BMI on outcomes in endoscopic spine surgery, comparing clinical outcomes in patients with BMI > 30 vs. BMI < 30 undergoing endoscopic lumbar decompression surgery. We identified all individuals who underwent single-level lumbar nerve root decompression utilizing both endoscopic and open approaches at a multi-hospital academic center between 2019 and 2023. Comprehensive data on each patient was collected, including each patient’s demographics, length-of-stay (LOS), demographics, surgical time, operative time, Charlson comorbidity index (CCI), and patient-reported outcome measures (PROMs). Differences in outcome measures were adjusted for demographic variations and evaluated using Student’s t-tests. The study cohort comprised 110 patients: 39 non-obese and 71 obese. Non-obese patients showed significant improvement in PROMIS PF scores (3.39 vs. -1.5, p=0.047), but there were no statistically significant differences in PROMIS PI, PROMIS Depression, EQ5D, LOS, reoperation rates, CSF leaks, or nerve injury. No infections or wound complications occurred in either group. Our findings suggest that obesity does not negatively impact endoscopic nerve decompression outcomes for lumbar radiculopathy. In particular, improved patient-reported physical function among non-obese patients was the only noteworthy distinction between the two groups. Collectively, since there are minimal disparities in other metrics when comparing obese to non-obese patients, our results suggest that an endoscopic approach may mitigate the surgical risk that obesity portends. Future studies with larger cohorts will help further elucidate our finding.

OBJECTIVE:The Social Deprivation Index (SDI) measures area-level social disadvantage. SDI values range from 0 (no distress/prosperous) to 100 (highest distress). This study investigated the association between SDI and lumbar spine surgery outcomes. METHODS:A retrospective cross-sectional study was performed using electronic health record data from a multihospital academic health system from 2017 to 2024. Eligible patients included adults who underwent lumbar fusion or decompression alone. The primary exposure of interest was the binary SDI (low distress [SDI < 50] vs high distress [SDI ≥ 50 and ≤ 100]). SDI was associated with the patient's zip code of residence. The associations between SDI category and pain reduction, physical function improvement, length of stay, and 30-day readmission were examined. Both unadjusted and adjusted regression models were created. Adjusted models included the following covariates: age, comorbidities, race, insurance, and surgery type. Multiple imputation by chained equations was used to impute missing values. RESULTS:The total sample included 7598 patients with 5139 in the low-SDI group and 2459 in the high-SDI group. SDI category was not significantly associated with the likelihood of pain reduction or physical function improvement after surgery. In the adjusted model, residence in a high-SDI area was significantly associated with extended length of stay (OR 1.21, 95% CI 1.07-1.36, p = 0.002). In the unadjusted model, patients from high-SDI areas were significantly more likely to experience 30-day readmission (OR 1.35, 95% CI 1.07-1.71, p = 0.01). In the adjusted model, this association was no longer statistically significant (OR 1.00, 95% CI 0.74-1.36, p ≥ 0.99). CONCLUSIONS:Patients from high-SDI areas had similar pain and physical function outcomes compared to patients from low-SDI areas after lumbar spine surgery. High SDI was significantly associated with length of stay. This study highlights the need for interventions that address the unique needs of patients from low-resource settings to improve lumbar spine surgery outcomes.

OBJECTIVE:The aim of this study was to describe the effect of opioid prescribing guideline implementation for elective spine surgery cases on prescribing and consumption behaviors in a multisite academic hospital system. The effectiveness of an automated text messaging system as a tool to monitor postoperative opioid use and pain outcomes and inform guideline development and deployment is also evaluated. METHODS:The authors conducted a prospective study of postoperative opioid use behaviors and patient-reported outcomes for 2101 elective spine surgery cases between December 2018 and March 2022, prior to and following the implementation of opioid-prescribing guidelines in February 2021 at three urban hospital sites within a large academic health system. Opioid-prescribing guideline development was based on patient-reported opioid consumption behaviors monitored using a two-way text messaging platform in the perioperative and postoperative settings; its implementation involved standardized indication-specific discharge pain medication dosing. Opioid prescription and consumption trends were compared between pre-guideline and post-guideline implementation cases. RESULTS:The overall response rate to the automated text messaging system was 50.2% when evaluating all elective spine surgery cases. There were significant reductions in the mean postsurgical opioid prescription for thoracolumbar laminectomies and fusions (p < 0.001) after guideline implementation. There was no difference in mean cumulative postsurgical opioid consumption by operative procedure after guideline implementation. Prior opioid use (OR 1.81, 95% CI 1.05-3.03; p < 0.05) and the aggregate 12-week mean pain score (OR 1.20, 95% CI 1.07-1.35; p < 0.05) were significant predictors of elevated opioid use. CONCLUSIONS:Opioid-prescribing guideline development for elective spine surgery cases that is informed by patient-reported opioid behaviors using a text messaging platform might reduce opioid volume prescribed by the operative procedure.

INTRODUCTION: Endoscopic lumbar decompression is a common surgical intervention for radiculopathy, offering potential benefits over open decompression, such as shorter operative times and faster postoperative recovery. Both endoscopic and open approaches improve patient quality of life, but further studies are needed to fully understand the advantages of the increasingly used endoscopic method. METHODS: Patients at an academic medical center who underwent single-level lumbar nerve root decompression from 2019-2023 via the endoscopic approach were compared to those who underwent open decompression during the same period. Data extracted from electronic health records included demographics, Charlson comorbidity index (CCI), operative time, LOS, and patient-reported outcome measures (PROMs). Student’s t-tests were used to compare differences based on surgical technique. RESULTS: 2527 patients (mean age 60.4 ± 14.8y) underwent lumbar nerve root decompression with either endoscopic (n=112) or open (n=2415) approaches. Endoscopic cases had a significantly lower LOS (0.67 days, IQR: 0 to 1 day) than open cases (1.63 days, IQR: 0 to 2 days), with no significant differences in gender, race, BMI, age, and CCI (p=5.10*10^-8). Patients who underwent endoscopic decompression (-1.55, IQR: -5 to 0) experienced a similar postoperative decrease in pain on the VAS scale as those who had open surgeries (-2.11, IQR: -5 to 0), indicating non-superiority of open approaches compared to fully endoscopic approaches (p=0.083). CONCLUSIONS: Endoscopic lumbar decompression resulted in shorter hospital stays compared to open techniques, while showing non-inferior improvement in pain scores. The shorter LOS is likely due to reduced tissue trauma from smaller incisions and minimal muscle manipulation. Although pain scores were similar between both methods, the reduced LOS with endoscopic techniques may decrease immediate postoperative healthcare utilization.

Prescribing more opioids than patients need following surgery is associated with long-term use, misuse, and diversion. Interventions are needed to increase adherence to procedure-specific guidelines while preserving the ability to manage pain. To test whether providing clinicians monthly feedback with peer comparisons and patient-reported outcomes would increase adherence to postoperative opioid prescribing guidelines. This stepped-wedge cluster randomized clinical trial was conducted at 6 surgical departments or divisions caring for patients undergoing 30 high-volume surgical procedures in a 5-hospital academic health system in Pennsylvania and New Jersey. Surgical clinicians (attending surgeons, advanced practice professionals, and resident physicians) with 5 or more opioid prescriptions per month for eligible procedures during a 3-month period at baseline were eligible for inclusion. Six clinician clusters were randomly assigned to the intervention in 3 steps offset by 2 months. Each step included a 9-month baseline, a 6-month intervention, and a 6-month follow-up. The first step of the intervention began on June 8, 2022. Follow-up concluded in October 2023, and data analysis was performed from November 2023 to April 2024. Clinicians were emailed a report on their most frequently performed procedures, which contained a figure of the following mean numbers: pills prescribed relative to guidelines, pills peer clinicians prescribed, and pills patients reported using after a procedure; an additional figure displayed patients’ self-reported ability to manage pain. Monthly reports included prescribing trends, peer comparison feedback, and reminders about how many pills patients take and how well patients reported pain management with guideline-adherent prescriptions. The primary outcome was the proportion of guideline-adherent opioid prescriptions; secondary outcomes included patient-reported ability to manage pain (measured on a 0 to 10 scale, with 0 being not at all able), pain score, pills prescribed, pills leftover, and refill rate. A total of 143 surgical clinicians treating 20 557 patients were included (10 069 at baseline, 5382 during the intervention, and 5106 at follow-up). Mean (SD) patient age was 57.0 (15.7) years, and 10 996 patients (53.5%) were female. The baseline guideline adherence rate was 57.2%. During the intervention, adherence increased to 71.8%, with an adjusted intervention effect of 5.3% (95% CI, 2.0%-8.7%). The impact of the intervention increased over time, and adherence remained above baseline at follow-up (74.4%). The largest change was noted for orthopedic procedures of knee, hip, and shoulder arthroplasty. Patient-reported pain and ability to manage pain were unchanged. In this stepped-wedge cluster randomized clinical trial, a feedback intervention using peer comparisons and patient-reported data increased opioid guideline adherence without compromising patients’ ability to manage pain. ClinicalTrials.gov Identifier: NCT05358522