Study Design: Retrospective radiologic analysis. Objective: The aim was to investigate if lateral flexion-extension radiographs identify additional cases of degenerative cervical spondylolisthesis (DCS) that would be missed by obtaining solely neutral upright radiographs, and determine the reliability of magnetic resonance imaging (MRI) in diagnosis. Summary of Background Data: DCS and instability can be a cause of neck pain, radiculopathy, and even myelopathy. Standard anteroposterior and lateral radiographs and MRI of the cervical spine will identify most cervical spine pathology, but spondylolisthesis and instability are dynamic issues. Standard imaging may also miss DCS in some cases. Methods: We compared the number of patients who demonstrated cervical spondylolisthesis on lateral neutral and flexion-extension radiographs in addition to MRI. We used established criteria to define instability as ≥2 mm of listhesis on neutral imaging, and ≥1 mm of motion between flexion-extension radiographs. Results: A total of 111 patients (555 cervical levels) were analyzed. In all, 41 patients (36.9%) demonstrated cervical spondylolisthesis on neutral and/or flexion-extension radiographs. Of the 77 levels of spondylolisthesis, 17 (22.1%) were missed on neutral radiographs (P,0.05). Twenty levels (26.0%) were missed when flexion-extension radiographs were used alone (P=0.02). Twenty-nine levels (37.7%) of DCS identified on radiograph were missed by MRI (P=0.004). Conclusions: Lateral flexion-extension views can be useful in the diagnosis of DCS. These views provide value by identifying a significant cohort of patients that would be undiagnosed based on neutral radiographs alone. Moreover, MRI missed 38% of DCS cases identified by radiographs. Therefore, lateral radiographs can be a useful adjunct to neutral radiographs and MRI when instability is suspected or if these imaging modalities are unable to identify the source of a patient’s neck or arm pain.

Background: Endoscopic spine surgery has recently grown in popularity due to the potential benefits of reduced pain and faster recovery time as compared to open surgery. Biportal spinal endoscopy has been successfully applied to lumbar disc herniations and lumbar spinal stenosis. Obesity is associated with increased risk of complications in spine surgery. Few prior studies have investigated the impact of obesity and associated medical comorbidities with biportal spinal endoscopy. Methods: This study was a prospectively collected, retrospectively analyzed comparative cohort design. Patients were divided into cohorts of normal body weight (Bone Mass Index (BMI)18.0–24.9), overweight (BMI 25.0–29.9) and obese (BMI > 30.0) as defined by the World Health Organization (WHO). Patients underwent biportal spinal endoscopy by a single surgeon at a single institution for treatment of lumbar disc herniations and lumbar spinal stenosis. Demographic data, surgical complications, and patient-reported outcomes were analyzed. Statistics were calculated amongst treatment groups using analysis of variance and chi square where appropriate. Statistical significance was determined as p < 0.05. Results: Eighty-four patients were followed. 26 (30.1%) were normal BMI, 35 (41.7%) were overweight and 23 (27.4%) were obese. Patients with increasing BMI had correspondingly greater American Society of Anesthesiologist (ASA) scores. There were no significant differences in VAS Back, VAS Leg, and ODI scores, or postoperative complications among the cohorts. There were no cases of surgical site infections in the cohort. All cohorts demonstrated significant improvement up to 1 year postoperatively. Conclusions: This study demonstrates that obesity is not a risk factor for increased perioperative complications with biportal spinal endoscopy and has similar clinical outcomes and safety profile as compared to patients with normal BMI. Biportal spinal endoscopy is a promising alternative to traditional techniques to treat common lumbar pathology.

Background: We analyzed the role of hypoalbuminemia, dialysis, and other risk factors that increase morbidity/ mortality following surgery for primary pyogenic spinal infections (PSIs). The American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) that included 627 patients was utilized as our database. Methods: Primary spinal surgery for spondylodiscitis was evaluated in a ACS-NSQIP database involving 627 patients between 2010 and 2019. Outcome assessment included evaluation of 30-day postoperative morbidity, and mortality rates. Results: Within 30 postoperative days, complications occurred in 14.6% (92/627) of patients; 59 (9.4%) required readmission, and 39 (6.2%) required additional surgery. The most common complications were: wound infections, pneumonia, septic shock, and death (1.8%). Hypoalbuminemia (i.e., significantly associated with unplanned readmission and reoperation), and dialysis were the two major risk factors contributing to increased perioperative morbidity and mortality. Conclusion: Among 627 ACS-NSQIP patients undergoing primary surgery for PSIs, hypoalbuminemia and dialysis were associated with higher risks of major perioperative morbidity (i.e., within 30 postoperative days – mostly readmissions and reoperations) and mortality.

Background: Preoperative optimization in patients undergoing posterior spinal fusion is essential to limit the number and severity of postoperative complications. Here, we, additionally, evaluated the impact of hypoalbuminemia on morbidity and mortality after posterior spinal fusion surgery. Methods: This retrospective analysis was performed using data from a prospective multicentric database (ACSNSQIP:2015–2020) regarding patients undergoing posterior spinal fusions. Factors studied included; baseline demographics and 30-day postoperative complications (i.e., reoperations, readmissions, and mortality rates). Results: There were 6805 patients who met the inclusion criteria. They averaged 62 years of age and had an average BMI of 30.2. Within the 30-day postoperative period, 634 (9.3%) sustained complications; 467 (6.9%) were readmitted, 263 (3.9%) required reoperations, and 37 (0.5%) expired. Although multiple preoperative risk factors were analyzed, hypoalbuminemia, severe hypoalbuminemia, and dialysis were the strongest independent risk factors associated with complications (i.e., reoperations, readmissions, and mortality). Conclusion: Hypoalbuminemia, severe hypoalbuminemia, and dialysis were significant predictors for morbidity and mortality after posterior spinal fusion surgery.

Background: Although posterior lumbar fusions (PLFs) have risen in popularity due to minimally invasive techniques and favorable outcomes, complications still arise. Studies show relatively constant rates of postoperative complications from 2006 to 2016, but there are limited studies evaluating outcomes after 2016. Consequently, we aim to investigate trends in postoperative complications for PLFs from 2009 to 2022. Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried for single-level PLFs between 2006 and 2022. Patients between 2006 and 2008 were excluded due to limited sample size. Inclusion criteria included >18 years old and Current Procedural Terminology code 22612. Baseline demographics and comorbidities were recorded. Annual 30-day complication rates of wound infection, readmission, reoperation, length of stay, intraoperative blood transfusions (IBTs), and mortality were recorded. Analysis of variance and multivariable Poisson log-linear regression were performed to compare complication rates between years and outcomes between 2020–2022 and 2017–2019. Results: Wound infection rates declined from 3.7% in 2009 to 2.7% in 2019, with an increase to 3.0% by 2022 (P = 0.015). IBT decreased significantly, from 20.58% in 2010 to 9.40% in 2022 (P < 0.001). Sepsis rates fell from 2.15% in 2009 to 0.88% in 2022 (P = 0.017). The average length of stay decreased from 2009 to 2019 (P < 0.001). Wound infection (P = 0.006) and pneumonia (P = 0.039) rates significantly increased between 2020 and 2022. Conclusion: Rates of older age, diabetes, and hypertension increased among PLF patients between 2009 and 2022, while most complication rates remained constant. Rates of wound infection, IBT, sepsis, and average length of stay have improved since 2009 despite an increase in wound infection and pneumonia from 2020 to 2022.

Background: The costs of cervical spine surgery have steadily increased. We performed a 5-year propensity scoring-matched analysis of 276 patients undergoing anterior versus posterior cervical surgery at one institution. Methods: We performed propensity score matching on financial data from 276 patients undergoing 1–3 level anterior versus posterior cervical fusions for degenerative disease (2015–2019). Results: We found no significant difference between anterior versus posterior approaches for hospital costs ($42,529.63 vs. $45,110.52), net revenue ($40,877.25 vs. $34,036.01), or contribution margins ($14,230.19 vs. $6,312.54). Multivariate regression analysis showed variables significantly associated with the lower contribution margins included age (β = −392.3) and length of stay (LOS; β = −1151). Removing age/LOS from the analysis, contribution margins were significantly higher for the anterior versus posterior approach ($17,824.16 vs. $6,312.54, P = 0.01). Conclusion: Anterior cervical surgery produced higher contribution margins compared to posterior approaches, most likely because posterior surgery was typically performed in older patients requiring longer LOS.