Iliac Crest Bone Graft for Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Prospective Analysis of Inpatient Pain, Narcotics Consumption, and Costs

BACKGROUND CONTEXT Iliac crest bone grafting (ICBG) has been associated with enhanced fusion rates. However, concerns have been raised in regard to increased operative time and postoperative pain. The advantages of ICBG compared to other spinal fusion adjuncts have been debated. However, little is known regarding this technique in the setting of a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). STUDY DESIGN/SETTING Prospective cohort. PATIENT SAMPLE Ninety-eight patients who underwent a MIS TLIF procedure with ICBG or BMP-2, 49 in each cohort. OUTCOME MEASURES Inpatient narcotics consumption in oral morphine equivalents (OME), Visual Analog Scale (VAS) pain, and direct hospital costs. METHODS Prospective, consecutive analysis of patients undergoing primary, single-level MIS TLIF with ICBG were compared to a historical cohort of consecutive patients that received BMP-2. Operative characteristics were compared between groups using chi square analysis or independent t test for categorical and continuous variables, respectively. Postoperative inpatient pain was measured using the VAS, and inpatient narcotics consumption was quantified as OMEs for both groups. Outcomes were compared between groups using multivariate regression controlling for preoperative characteristics. Statistical significance was set at p\u3c.05. RESULTS A total of 98 patients were included in this analysis, 49 in each cohort. No significant differences were noted between cohorts except in regard to gender (more males in the BMP cohort, 67.35% vs. 46.94%, p=.041). There was a significant increase in operative time (14.53 minutes, p=.006) and estimated blood loss (16.64 mL, p=.014) in the ICBG cohort. No significant differences were identified for inpatient length of stay or VAS scores. Narcotics consumption was similar between groups on postoperative days 0 and 1. ICBG was associated with decreased total direct costs ($19,315 vs.$21,645, p\u3c.001) as compared to BMP-2. CONCLUSIONS Patients undergoing MIS TLIF who underwent ICBG experienced increases in operative time and estimated blood loss that were not clinically significant. Furthermore, iliac crest harvesting did not result in either an increase in acute pain or narcotics consumption. Further follow-up is necessary to determine the associated arthrodesis rates and long term outcomes between each cohort. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs

Swallowing Function Following Anterior Cervical Discectomy and Fusion With and Without Anterior Plating: A SWAL-QOL (Swallowing-Quality of Life) and Radiographic Assessment

Objective Anterior cervical plating in anterior cervical discectomy and fusion (ACDF) procedures are associated with improved outcomes compared to stand-alone cages. However, concerns exist regarding increased rates of postoperative dysphagia following an ACDF. This study aims to quantify the effect of anterior plating on swallowing-quality of life (SWAL-QOL) scores and radiographic swelling assessments following a primary, single-level ACDF. Methods Patients retrospectively reviewed. Patients grouped into those receiving a cage or anterior plate. SWAL-QOL scores were recorded preoperatively and 6 weeks and 12 weeks postoperatively. Lateral radiographs were used to create a swelling index with a ratio of the prevertebral swelling distance to the anterior-posterior diameter of each involved vertebral body. An air index was created using the same methodology. Statistical analysis was performed using chi-square analysis and independent t-tests for categorical and continuous variables. Results Sixty-eight primary, single-level ACDF patients were included. Forty-one (60.3%) received a stand-alone cage and 27 (39.7%) received a cage with anterior plating. No differences in demographics, comorbidities, operative time, estimated blood loss, or length of hospital stay were identified between Cage and Plate cohorts. Finally, no differences were observed in postoperative SWAL-QOL scores or swelling and air indices between groups. Conclusion The results demonstrate that patients undergoing a primary, single-level ACDF with or without anterior plating experience similar operative times and lengths of stay. Patients that receive a cage with anterior plating did not experience significant increases in dysphagia as measured by the SWAL-QOL questionnaire compared to patients that received a stand-alone cage. Furthermore, radiographic assessments of swelling are comparable

Impact of Iliac Crest Bone Grafting on Postoperative Outcomes and Complication Rates Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

Objective The relationship between bone graft technique and postoperative outcomes for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has not been well-defined. This study aims to determine the effect of iliac crest bone grafting (ICBG) on patient-reported outcomes (PROs) and complication rates following MIS TLIF. Methods Primary, single-level MIS TLIF patients were consecutively analyzed. Patients that prospectively received a percutaneous technique of ICBG were compared to patients that retrospectively received bone morphogenetic protein-2 (BMP-2). Complication rates were assessed perioperatively and up to 1 year postoperatively. Changes in Oswestry Disability Index (ODI), visual analogue scale (VAS) back, and VAS leg pain were compared. Rates of minimum clinically important difference (MCID) achievement at final follow-up for ODI, VAS back, and VAS leg scores were compared. Results One hundred forty-nine patients were included: 101 in the BMP-2 cohort and 48 in the ICBG cohort. The ICBG cohort demonstrated increases in intraoperative blood loss and shorter lengths of stay. ICBG patients also experienced longer operative times, though this did not reach statistical significance. No significant differences in complication or reoperation rates were identified. The ICBG cohort demonstrated greater improvements in VAS leg pain at 6-week and 12-week follow-up. No other significant differences in PROs or MCID achievement rates were identified. Conclusion Patients undergoing MIS TLIF with ICBG experienced clinically insignificant increases in intraoperative blood loss and did not experience increases in postoperative pain or disability. Complication and reoperation rates were similar between groups. These results suggest that ICBG is a safe option for MIS TLIF

Does the Day of the Week Affect Length of Stay and Hospital Charges Following Anterior Cervical Discectomy and Fusion?

Background To reduce the economic impact of excessive costs, risk factors for increased length of stay (LOS) must be identified. Previous literature has demonstrated that surgeries later in the week can affect the LOS and costs following joint arthroplasty. However, few investigations regarding the day of surgery have been performed in the spine literature. The present study attempts to identify the association between day of surgery on LOS and hospital charges following anterior cervical discectomy and fusion (ACDF) procedures. Methods A prospectively maintained surgical database of primary, level 1-2 ACDF patients between 2008 and 2015 was retrospectively reviewed. Patients were stratified by surgery day: early week (Tuesday) or late week (Friday) ACDF. Differences in patient demographics and preoperative characteristics were compared between cohorts using chi-square analysis or Student t test for categorical and continuous variables, respectively. Direct hospital costs were obtained using hospital charges for each procedure and subsequent care prior to discharge. Associations between date of surgery and costs were assessed using multivariate linear regression controlled for. Results Two hundred and ninety-five patients were included in the analysis. One hundred and fifty-three patients underwent early week ACDF, and 142 underwent late week ACDF. Surgery day cohorts reported similar baseline characteristics. There were no differences in operative characteristics or hospital LOS between cohorts. Additionally, no differences in total or subcategorical hospital costs were identified between surgery day cohorts. Conclusions Patients undergoing ACDF later in the week exhibit similar LOS and hospital costs compared to those undergoing ACDF early in the week. These results suggest that outpatient procedures with short postoperative stays are likely not affected by the changes in hospital work efficiency that occur during the transition to the weekend. As such, hospitals should not restrict outpatient procedures to specific days of the week. Level of Evidence 3

Comparison of Postoperative Outcomes between Primary MIS TLIF and MIS TLIF as a Revision Procedure to Primary Decompression

Study design: Retrospective cohort. Objective: To compare postoperative improvements in surgical and patient-reported outcomes (PROs) between patients undergoing minimally invasive laminectomy and minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) as a primary procedure to patients undergoing MIS laminectomy and TLIF as a revision to primary lumbar decompression (LD). Summary of background data: MIS TLIF and LD have demonstrated to be effective surgical options for lumbar degenerative disease. However, some patients undergoing LD experience recurrent symptoms and eventually require a revision decompression with fusion. Methods: A prospectively maintained surgical database of patients who underwent a primary or revision one-level MIS TLIF for degenerative spinal pathology between 2014 and 2016 was reviewed. Consecutive patients undergoing primary MIS TLIF and revision lumbar discectomy and/or laminectomy were matched in a one-to-one fashion to primary MIS TLIF patients who had not undergone a previous LD by age and preoperative diagnosis. Differences in patient demographic, comorbidity, and perioperative characteristics between procedure groups were assessed using Pearson chi-squared analysis and Student t test for categorical and continuous variables, respectively. Improvements in PROs from preoperative values were compared between primary and revision cohorts using Student t tests. Pearson chi-squared analysis was used to compare rates of minimum clinically important difference achievement between procedure groups. Statistical significant was set at P \u3c 0.05. Results: A total of 52 patients were included in this analysis. Twenty-six underwent primary MIS laminectomy and TLIF and 26 underwent MIS TLIF with a revision decompression. No differences in baseline or perioperative variables were observed. Revision and primary MIS TLIF patients experienced similar improvements in PROs at all postoperative time points. Conclusion: The results of the present study demonstrate patients undergoing primary MIS TLIF with LD as a revision to a primary decompression experienced similar postoperative improvements in PROs as compared to primary MIS TLIF patients. This indicates a primary decompression does not compromise clinical outcomes in patients undergoing MIS TLIF. As such, patients should not be precluded from undergoing MIS TLIF based on the history of a previous LD. Level of evidence: 3

Sex Differences for Anterior Cervical Fusion: Complications and Length of Stay

Study design: Retrospective cohort. Objective: To assess differences in baseline characteristics between sexes of patients undergoing anterior cervical discectomy and fusion (ACDF) and risk factors for adverse outcomes according to sex. Summary of background data: ACDF is a common treatment for cervical spine disease. To reduce the rate of complications, risk factors associated with adverse events have been identified. However, few studies have examined the risk for inferior outcomes or complications after ACDF by sex. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent ACDF from 2005 through 2014. Data collected included demographics, comorbidities, operative characteristics, and postoperative adverse events. Demographic and comorbidity variables were compared between men and women using chi-squared analysis. Perioperative outcomes were compared between groups using multivariate linear regression or Poisson regression with robust error variance controlling for preoperative characteristics. Results: In the 20,383 patients who met inclusion criteria, the male cohort was slightly older, less likely to be normal weight or morbidly obese, and had a higher incidence of diabetes and hypertension (P \u3c 0.001 for each). Male sex was associated with a greater risk of any adverse event (relative risk = 1.2; P = 0.043), as well as any severe adverse event (relative risk = 1.4; P = 0.001). Moreover, male sex exhibited longer operative times compared to the female group (127 vs. 117 min; β = 10; P \u3c 0.001). Conclusion: The results of the current study suggest male sex is associated with an increased risk of adverse events following ACDF. Male sex has previously been demonstrated to correlate with medical comorbidities, which may be partly responsible for the increased morbidity. Because of the contrasting evidence throughout the literature, further studies are required to better elucidate this effect