Minimizing Blood Loss in Spine Surgery.

Study Design: Broad narrative review. Objective: To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. Methods: A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. Results: There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP)Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. Conclusion: As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period

The Distribution of Surface Soil Moisture over Space and Time in Eastern Taylor Valley, Antarctica

Available soil moisture is thought to be the limiting factor for most ecosystem processes in the cold polar desert of the McMurdo Dry Valleys (MDVs) of Antarctica. Previous studies have shown that microfauna throughout the MDVs are capable of biological activity when sufficient soil moisture is available (~2–10% gravimetric water content), but few studies have attempted to quantify the distribution, abundance, and frequency of soil moisture on scales beyond that of traditional field work or local field investigations. In this study, we present our work to quantify the soil moisture content of soils throughout the Fryxell basin using multispectral satellite remote sensing techniques. Our efforts demonstrate that ecologically relevant abundances of liquid water are common across the landscape throughout the austral summer. On average, the Fryxell basin of Taylor Valley is modeled as containing 1.5 ± 0.5% gravimetric water content (GWC) across its non-fluvial landscape with ~23% of the landscape experiencing an average GWC > 2% throughout the study period, which is the observed limit of soil nematode activity. These results indicate that liquid water in the soils of the MDVs may be more abundant than previously thought, and that the distribution and availability of liquid water is dependent on both soil properties and the distribution of water sources. These results can also help to identify ecological hotspots in the harsh polar Antarctic environment and serve as a baseline for detecting future changes in the soil hydrological regime

168 Decompression versus Fusion for Grade 1 Lumbar Spondylolisthesis A Multicenter Assessment of 12-Month Patient-Reported Outcomes Using the Quality Outcomes Database

Abstract INTRODUCTION The ideal treatment strategy for patients with degenerative lumbar spondylolisthesis remains a topic of debate. The authors compared patient-reported outcomes for patients undergoing 1- or 2-level decompression with those undergoing 1-level fusion for grade 1 lumbar spondylolisthesis. METHODS A retrospective analysis of prospectively collected Quality Outcomes Database (QoD) data was performed at 12 participating centers. Patients were included who underwent either 1- to 2-level lumbar decompression or 1-level lumbar fusion for a diagnosis of degenerative grade 1 spondylolisthesis between July 1, 2014 and June 30, 2016. A variety of demographic, comorbidity, and patient reported outcome measures were collected and analyzed. RESULTS A total of 599 patients met criteria for analysis, with 462 undergoing fusion and 137 undergoing decompression. On univariate analysis, older patients, patients with lower body mass index, men, Medicare enrollees, diabetics, patients without depression, patients with predominantly back pain, individuals with preoperative motor or ambulation deficits, patients with symptom duration less than 3 mo, patients with more formal education, and the unemployed were more likely to receive decompression compared to fusion (all P values < .05). Patients undergoing fusion had significantly higher intraoperative blood loss, surgical length, and length of stay compared to decompression (all P values < .001). At 12 mo postoperatively, patients undergoing fusion had greater improvements in Numerical Rating Scale (NRS) back pain (–4.1 ± 3.0 vs –2.7 ± 3.4, P = .007), Oswestry Disability Index (ODI, –26.3 ± 18.8 vs –18.5 ± 20.1, P = .001), and EQ5D (0.25 ± 0.2 vs 0.17 ± 0.2, P = .004) compared to decompression. In our multivariate regression models, fusion remained associated with greater 12-mo improvement in NRS back pain (P = .042) and ODI (P = .004) compared to decompression alone. CONCLUSION Based on data derived from a large, multi-institutional cohort of QoD patients, single-level fusion provides greater improvements in NRS back pain and ODI at 12 mo than 1- or 2-level decompression in patients with grade 1 degenerative spondylolisthesis

Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database

OBJECTIVE: Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry. METHODS: The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics. RESULTS: Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age >= 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald chi(2) = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance). CONCLUSIONS: The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy

Regional Variance in Disability and Quality-of-Life Outcomes After Surgery for Grade I Degenerative Lumbar Spondylolisthesis: A Quality Outcomes Database Analysis

Regional differences in outcomes after spine surgery are poorly understood. We assessed disability and quality-of-life outcomes by geographic region in the United States using the NeuroPoint Alliance Quality Outcomes Database. We queried the prospective Quality Outcomes Database patient registry to identify patients who underwent elective 1- or 2-level lumbar surgery for grade I degenerative spondylolisthesis from July 2014 through June 2016. Primary outcome measures included Oswestry Disability Index (ODI) and EuroQOL-5D (EQ-5D) reported at 24 months postoperatively. Differences in EQ-5D and ODI were compared across geographic regions of the United States (Northeast, Midwest, South, West). We identified 608 patients from 12 centers who underwent surgery. Of these, 517 (85.0%) had ODI data and 492 (80.9%) had EQ-5D data at 24 months. Southern states had the largest representation (304 patients; 5 centers), followed by Northeastern (114 patients; 3 centers), Midwestern (96 patients; 2 centers), and Western (94 patients; 2 centers) states. Baseline ODI scores were significantly different among regions, with the South having the greatest baseline disability burden (Northeast: 40.9 ± 16.9, South: 51.2 ± 15.8, Midwest: 40.9 ± 17.8, West: 45.0 ± 17.1, P < 0.001). The change in ODI at 24 months postoperatively was significantly different among regions, with the South showing the greatest ODI improvement (Northeast: −21.1 ± 18.2, South: −26.5 ± 20.2, Midwest: −18.2 ± 22.9, West: −21.7 ± 19.6, P < 0.001). All regions had ≥60% achievement of the minimum clinically important difference in ODI at 24 months postoperatively. No regional differences were observed for EQ-5D. Significant regional variation exists for disability outcomes, but not quality of life, at 24 months after spinal surgery for grade I degenerative spondylolisthesis

Outcomes and Complications With Age in Spondylolisthesis: An Evaluation of the Elderly From the Quality Outcomes Database

Prospective database analysis. To assess the effect of age on patient-reported outcomes (PROs) and complication rates after surgical treatment for spondylolisthesis SUMMARY OF BACKGROUND DATA.: Degenerative lumbar spondylolisthesis affects 3% to 20% of the population and up to 30% of the elderly. There is not yet consensus on whether age is a contraindication for surgical treatment of elderly patients. The Quality Outcomes Database lumbar registry was used to evaluate patients from 12 US academic and private centers who underwent surgical treatment for grade 1 lumbar spondylolisthesis between July 2014 and June 2016. A total of 608 patients who fit the inclusion criteria were categorized by age into the following groups: less than 60 (n = 239), 60 to 70 (n = 209), 71 to 80 (n = 128), and more than 80 (n = 32) years. Older patients showed lower mean body mass index (P 80-year-old patients; P = 0.002). There were no baseline differences in PROs (Oswestry Disability Index, EuroQol health survey [EQ-5D], Numeric Rating Scale for leg pain and back pain) among age categories. A significant improvement for all PROs was seen regardless of age (P < 0.05), and most patients met minimal clinically important differences (MCIDs) for improvement in postoperative PROs. No differences in hospital readmissions or reoperations were seen among age groups (P < 0.05). Multivariate analysis demonstrated that, after controlling other variables, a higher age did not decrease the odds of achieving MCID at 12 months for the PROs. Our results indicate that well-selected elderly patients undergoing surgical treatment of grade 1 spondylolisthesis can achieve meaningful outcomes. This modern, multicenter US study reflects the current use and limitations of spondylolisthesis treatment in the elderly, which may be informative to patients and providers. 4

Association of ≥ 12 months of delayed surgical treatment for cervical myelopathy with worsened postoperative outcomes: a multicenter analysis of the Quality Outcomes Database

Degenerative cervical myelopathy (DCM) results in significant morbidity. The duration of symptoms prior to surgical intervention may be associated with postoperative surgical outcomes and functional recovery. The authors' objective was to investigate whether delayed surgical treatment for DCM is associated with worsened postoperative outcomes. Data from 1036 patients across 14 surgical centers in the Quality Outcomes Database were analyzed. Baseline demographic characteristics and findings of preoperative and postoperative symptom evaluations, including duration of symptoms, were assessed. Postoperative functional outcomes were measured using the Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scale. Symptom duration was classified as either less than 12 months or 12 months or greater. Univariable and multivariable regression were used to evaluate for the associations between symptom duration and postoperative outcomes. In this study, 513 patients (49.5%) presented with symptom duration 0.05). Surgical intervention resulted in improved mJOA and NDI scores at 3 months, and this improvement was sustained in both patients with short and longer initial symptom duration. Patients with DCM can still undergo successful surgical management despite delayed presentation

Predictors of the Best Outcomes Following Minimally Invasive Surgery for Grade 1 Degenerative Lumbar Spondylolisthesis

The factors driving the best outcomes following minimally invasive surgery (MIS) for grade 1 degenerative lumbar spondylolisthesis are not clearly elucidated. To investigate the factors that drive the best 24-mo patient-reported outcomes (PRO) following MIS surgery for grade 1 degenerative lumbar spondylolisthesis. A total of 259 patients from the Quality Outcomes Database lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis with MIS techniques (188 fusions, 72.6%). Twenty-four-month follow-up PROs were collected and included the Oswestry disability index (ODI) change (ie, 24-mo minus baseline value), numeric rating scale (NRS) back pain change, NRS leg pain change, EuroQoL-5D (EQ-5D) questionnaire change, and North American Spine Society (NASS) satisfaction questionnaire. Multivariable models were constructed to identify predictors of PRO change. The mean age was 64.2 ± 11.5 yr and consisted of 148 (57.1%) women and 111 (42.9%) men. In multivariable analyses, employment was associated with superior postoperative ODI change (β-7.8; 95% CI [-12.9 to -2.6]; P = .003), NRS back pain change (β -1.2; 95% CI [-2.1 to -0.4]; P = .004), EQ-5D change (β 0.1; 95% CI [0.01-0.1]; P = .03), and NASS satisfaction (OR = 3.7; 95% CI [1.7-8.3]; P < .001). Increasing age was associated with superior NRS leg pain change (β -0.1; 95% CI [-0.1 to -0.01]; P = .03) and NASS satisfaction (OR = 1.05; 95% CI [1.01-1.09]; P = .02). Fusion surgeries were associated with superior ODI change (β -6.7; 95% CI [-12.7 to -0.7]; P = .03), NRS back pain change (β -1.1; 95% CI [-2.1 to -0.2]; P = .02), and NASS satisfaction (OR = 3.6; 95% CI [1.6-8.3]; P = .002). Preoperative employment and surgeries, including a fusion, were predictors of superior outcomes across the domains of disease-specific disability, back pain, leg pain, quality of life, and patient satisfaction. Increasing age was predictive of superior outcomes for leg pain improvement and satisfaction