P21. Inpatient outcomes after elective lumbar spinal fusion for patients with human immunodeficiency virus in the absence of acquired immunodeficiency syndrome

To our knowledge, no prior study has evaluated outcomes after elective lumbar spinal surgery in human immunodeficiency virus (HIV) patients without acquired immunodeficiency syndrome (AIDS). This review investigated the impact of HIV-positive status (without AIDS) on outcomes after elective lumbar fusion for degenerative disc disease (DDD). Adult patients registered in the Nationwide Inpatient Sample (2002-2011) undergoing elective lumbar fusion for DDD were extracted. The patient sample included 612,000 individual patient hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. The following outcome measures were recorded: wound complications, infection rate, cardiac, respiratory, neurologic, gastrointestinal complications, thromboembolic events and death. This cohort included 612,000 hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. HIV-positive patients were compared with HIV-negative patients undergoing lumbar fusion surgery and complications/adverse outcomes were recorded. This cohort included 612,000 hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. Compared with HIV-negative patients undergoing lumbar fusion, HIV-positive patients were younger (47 vs 55 years), male (61% vs 42%), largely insured by Medicare (30% vs 5%), and had higher rates of chronic obstructive pulmonary disease (23.7% vs 14.6%) (all P < 0.001) but had lower rates of obesity, hypertension and diabetes (all P < 0.001). Multivariable models demonstrated HIV positivity to be associated with higher odds for an adverse event (odds ratio [OR], 1.92; P < 0.001), in-hospital mortality (OR, 39.91; P < 0.001), wound complications (OR, 2.60; P = 0.004), respiratory (OR, 5.43; P < 0.001) and neurologic (OR, 1.96; P = 0.039) complications, and higher costs (7.1% higher; P = 0.011) compared with non-HIV patients. There were no differences in thromboembolic events, cardiac or gastrointestinal complications, discharge disposition, or length of stay. Even in this selected cohort of well-controlled HIV patients, there were high complications, with concerning rates of death and respiratory complications. These data shed new light on elective spine surgery in HIV patients and may influence the treatment algorithm of surgeons who are familiar with older studies. This abstract does not discuss or include any applicable devices or drugs

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P149. HIV in the absence of AIDS and in-patient outcomes following elective lumbar spinal fusion

Advancements in human immunodeficiency virus (HIV) detection and treatment have prolonged the life expectancy of those infected with HIV. No prior study has evaluated elective lumbar spinal surgery in HIV patients or in those HIV patients whom have yet to developed autoimmune deficiency syndrome (AIDS). The purpose of our study was to evaluate the effects of HIV-positive status in the absence of AIDS on demographics and rates of adverse events in patients undergoing elective lumbar fusion for degenerative disc disease. This study was based on the hypothesis was that in-hospital outcomes between asymptomatic HIV-positive and unaffected patients would be similar Adult patients (>18 years) registered in the NIS that underwent an elective lumbar arthrodesis for degenerative disc disease were included. Patients were subsequently categorized into HIV-positive status and HIV-negative status patients. To determine the true effect of atymptomatic HIV, patients with manifestations of AIDS and other immune compromise were excluded. Primary outcome measures were in-patient mortality, discharge disposition, short-term complications, length of hospital stay (LOS) and costs. Clinical data on those who underwent lumbar spine fusion surgery for degenerative disc disease were collected from the 2002–2011 NIS. Fusions for trauma, cancer and infections, amongst others, were excluded to primarily select for elective procedures. Those with clinical manifestations of AIDS were also excluded. In-hospital outcomes were compared between asymptomatic HIV-positive patients versus uninfected patients and analyzed in a multivariable binary logistic regression model. The HIV-positive group had more males (61.2% vs. 42.0%, p<.001), was younger (47.01+9.13years vs. 54.91+13.98years, p<.001), had higher rates of pre-existing COPD (23.7% vs. 14.6%, p<.001), yet had lower rates of obesity, hypertension and diabetes (p<.001). This cohort was characterized by a higher rate of any adverse postoperative event 14.2% versus 10.5% (p=.016), with significantly higher odds of adverse events (OR: 1.96), mortality (OR: 40.27), wound complications (OR: 2.60), respiratory complications (OR: 5.46) and neurologic complications (OR:1.98) (p<.005). Our study was purposely limited to elective lumbar spine surgery in patients with “controlled HIV.” Contrary to current literature showing very high rates of complications, our selected cohort had considerably fewer complications than prior studies, with the concerning exception being death. This data sheds new light on elective spine surgery in HIV patients and may influence the treatment algorithm of surgeons who are familiar with the older manuscripts

Bone Graft Options in Spinal Fusion: A Review of Current Options and the Use of Mesenchymal Cellular Bone Matrices.

BACKGROUND: Spinal fusion is the mainstay treatment for various spinal conditions ranging from lumbar and cervical stenosis to degenerative spondylolisthesis as well as extensive deformity corrections. A new emerging category of allograft is cellular bone matrices (CBMs), which take allogeneic mesenchymal stem cells and incorporate them into an osteoconductive and osteoinductive matrix. This study reviewed the current spinal fusion options and new emerging treatment options. METHODS: Articles were searched using PubMed. The search included English publications since January 1, 2014, using the search terms cellular bone matrix, mesenchymal stem cells spinal fusion, spinal arthrodesis AND mesenchymal stem cells, and spine fusion AND cellular bone matrix. RESULTS: Spinal fusion is accomplished through the use of allografts, autografts, and bone graft substitutes in combination or alone. An emerging category of allograft is CBMs, in which an osteoconductive and osteoinductive matrix is filled with mesenchymal stem cells. Studies demonstrate that CBMs have achieved equivalent or better fusion rates compared with traditional options for anterior cervical discectomy and fusions and posterolateral lumbar fusions; however, the studies have been retrospective and lacking control groups and therefore not ideal. CONCLUSIONS: Many treatment options have been successfully used in spinal fusion. Newer allografts such as CBMs have shown promising results in both animal and clinical studies. Further research is needed to determine the therapeutic dose of mesenchymal stem cells delivered within CBMs

An Investigation of a Novel Dural Repair Device for Intraoperative Incidental Durotomy Repair.

Incidental durotomies, or dural tears, can be very difficult and time consuming to repair properly when they are encountered in confined spaces. A novel dural repair device was developed to address these situations. In this paper, the novel device was assessed against the use of traditional tools and techniques for dural repairs in two independent studies using an intricate clinical simulation model. The aim was to examine the results of the two assessments and link the outcomes to the clinical use of the novel device in the operating room. The novel device outperformed conventional techniques as measured by dural repair time, CSF leak pressure and nerve root avoidance in the simulation. The results were generally replicable clinically, however, numerous additional clinical scenarios were also encountered that the simulation model was unable to capture due to various inherent limitations. The simulation model design, potential contributors to watertightness, clinical experiences, and limitation are discussed

Machete injuries to the upper extremity

We intend to describe and analyze the spectrum of upper extremity injuries that arises from both accidental and intentional machete injuries with a focus on associated complications and comorbidities. This review is the first from a United States institution, and the only from a designated level 1 trauma center. A retrospective review of machete related upper extremity injuries admitted to a level 1 trauma center from 2008 to 2016. The following data was collected on admitted patients: demographics, mechanism of injury, surgical management, and complications. We assessed the data with Pearson Chi square analysis. This cohort consisted of 48 patients (mean = 42 ± 13 years old); the majority were men (96%) involved in an assault (81%). These patients had a high rate of documented psychiatric history, substance and tobacco abuse, and being underinsured. Patient follow-up was extremely variable: 75% of patients presented for follow-up care (mean = 149 ± 344 days; range 8-1846 days). 44% had complications (i.e., infection, tendon rupture, nerve palsy). We identified no associations when examining follow-up rates or complication rates regarding patient comorbidities, insurance status, mechanism of injury, or the need for a nerve, artery, or tendon repair. Patients with current tobacco use did have an increased risk for infection. The majority (52%) of injuries occurred on the ulnar side of the forearm and to the non-dominant extremity (66%). Patients assaulted by machetes are significantly more likely to have a history of psychiatric illness, substance abuse, tobacco use, and are more likely to be underinsured compared to those with accidental machete injuries. While machete injuries may be uncommon in most areas of the United States, physicians should give special attention to the patient comorbidities as many of these patients have complex medical and social issues which could complicate attempts of appropriate treatment. IV; Prognostic Study

Fish-Mouth Thoracic Fracture Fixation with Minimally Invasive Percutaneous Reduction: A Technical Note

Surgical stabilization of thoracic spine fractures is recommended for unstable patterns, yet much debate exists regarding the best approach for reduction. The aim of this article was to report the outcome of a novel method for stabilization of a fish-mouth thoracic spine fracture. A retrospective patient chart review was conducted. Data collected included blood loss, operative time, length of stay, perioperative complications, neurologic deficits, and secondary procedures. The patient underwent percutaneous reduction of a hyperextension injury to the thoracic spine. Sufficient reduction was achieved through a percutaneous approach, followed by sequential distraction of 1 rod with sequential locking of the contralateral rod to maintain deformity correction. Electrophysiologic monitoring was used during the procedure. Sufficient fracture reduction was achieved and evaluated on postoperative computed tomography. Operative time was 145 minutes, and estimated blood loss was 120 mL. There were no cerebrospinal fluid leaks, iatrogenic neurologic deficits, implant failures, other systemic events or revisions during the 8-month follow-up. This article describes the feasibility of using a novel model for reduction and stabilization of fish-mouth thoracic spine fracture with minimal soft tissue violation

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P154. Fibromyalgia as a predictor of increased postoperative complications, readmission rates and hospital costs in patients undergoing posterior lumbar spine fusion

Fibromyalgia is associated with poor outcomes in patients undergoing various orthopedic procedures. No prior study has evaluated if this cohort has worse outcomes following spine surgery. The purpose of this study is to identify 90-day postoperative complications in patients with a history of fibromyalgia undergoing one- to two- level spine fusion. Retrospective database review. The Pearl Diver database (Pearl Diver Technologies, West Conshohocken, PA, USA) identified all patients undergoing one- to two- level spine from 2005 to 2014, from the Medicare provider. All patients with a history of fibromyalgia were also identified. Our consisted of two groups: patients with and without a history of fibromyalgia undergoing primary one- to two- level spine fusion. A total of 90-day medical complications were assessed including length of stay, readmission rates, and total cost of care. All patients in the database undergoing primary one- to two- level spine fusion were identified, in addition to all patients with a history of fibromyalgia 90days prior to their index procedure and having a diagnosis on the same day. This cohort served as our study group. Patients without a diagnosis of fibromyalgia undergoing one- to two- level spine fusion served as our control group. Patients from both cohorts were randomly matched based on age, gender, and comorbidities. Both groups were longitudinally followed for 90days to assess medical complications, readmission rates and total cost of care. Fibromyalgia patients had a greater total odds of postoperative complications within the first 90 days (OR: 2.05, p<.001). Day of surgery cost was also higher in patients with fibromyalgia ($95,036.93vs.$94,825.06, P=.021) Patients with fibromyalgia are at greater odds for postoperative complications 90days following surgery. Additionally, fibromyalgia patients are more likely to be readmitted to the hospital within the first 90days. Due to the complications caused by fibromyalgia, patients with this condition undergoing one- to two- level spine fusion incur a greater total cost of care on the day of the surgery and 90days after

The most influential publications in cervical myelopathy

Management of cervical myelopathy (CM) has continued to evolve through a better understanding of the long-term outcomes of this diagnosis as well as improved diagnostic guidelines. More recent literature continues to expand the field, but certain publications can be distinguished from others due to their lasting impact. Using the Clarivate Analytics Web of Science, search phrases were used to identify publications pertaining to CM. The fifty most cited articles were isolated. The frequency of citations, year of publication, country of origin, journal of publication, level of evidence (LOE), article type, as well as contributing authors and institutions were recorded. We also highlighted the five most cited articles (per year) from the past 10 years. Publications included ranged from 1952–2011, with the plurality of articles published during 2000–2009 (n=21; 42%). The most cited paper was Hillibrand’s 1999 reporting of adjacent segment disease rates following cervical fusions, followed by Hirabayashi’s 1983 review of his cervical laminoplasty outcomes. The third most cited was Brain’s 1952 review of the manifestations of cervical spondylosis. Spine contributed the most publications (n=26; 52%). A LOE of III was the most common (n=30; 60%). Clinical outcome articles were the most frequent type (n=28; 56%). Osaka University (Japan) and Kazou Yonenobu had the most contributions. Ames or Fehlings were the first or last author in each of the five most influential articles from the past 10 years. This bibliometric citation analysis identifies the most influential articles regarding CM. There are few publications with a high LOE, and more high powered studies are needed. Knowledge of these “classic” publications allows for a better overall understanding of the diagnosis, treatment, and future direction of research of CM

Availability and Variability of Consumer Prices for Lumbar Discectomy Across US Hospitals in 2018

Objective To determine the availability and variability of consumer pricing data for an elective lumbar discectomy in the USA. Methods Hospital representatives were contacted via telephone, hospital websites, and state price-transparency websites. A total of 153 hospitals were contacted via telephone calls under the guise of a patient requesting a self-pay price for elective lumbar discectomy. The same hospitals were then researched for price comparison between those requested by phone and those listed on hospital websites after installment of the price transparency law by the Centers of Medicare and Medicaid Services (CMS) on 1 January 2019. Complete and partial prices were recorded for both datasets when available. Hospitals were grouped based on profit status, teaching status, and geographical region. Statistical analysis compared rates of price availability and mean prices between hospital groups and between datasets. Results Thirty-four (23.0%) of 148 hospitals included in the final analysis were able to provide complete price information via telephone. An additional 70 (47.3%) were able to provide a partial price. A total of four (2.7%) institutions provided a complete price and an additional 65 (43.9%) provided a partial price via website. The mean complete price for microdiscectomy when provided was $27,342.36 (n = 34). When compared to government and non-profit hospitals combined, private hospitals had significantly lower partial-prices. Conclusion A patient seeking to undergo a common surgical procedure in the USA will likely be met with difficulty and few options if motivated by price. A high degree of variability exists among US hospitals in 2018 with regards to availability and comprehensiveness of pricing information