NASS 2019 Highest-Rated Abstracts
Best Paper authors will preview some of the takeaways from the highest-rated abstracts. The following Questions and Answers highlight the Best Papers to be presented on Wednesday, Thursday and Friday morning, September 25-27.
Wednesday Best Papers
Prioritization of Realignment Associated with Superior Clinical Outcomes for Surgical Cervical Deformity Patients—Presenting author: Peter Passias, MD
  1. What question is your research attempting to answer?
    Does prioritizing certain cervical alignment parameters to a minimal degree of correction contribute to optimal quality of life in surgical cervical deformity patients?

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Through the combination of regional cervical radiographic factors, we found that prioritizing the lordosis of the cervical spine (through C2-C7 and C2-T2), followed by occipitocervical incorporation (C2 slope) global assessment (cSVA, C2-T3 SVA, TS-CL), and horizontal improvement (MGS) was associated with the greatest NDI improvement. This proposed prioritization involves the innate interdependence of the spine: cervical lordosis depending on both thoracic kyphosis and lumbar lordosis. With the distinct diagnosis of cervical deformity, cervical lordosis adaptation is due to the cervical spinal segment changes relative to the global spine to attempt to maintain the head over the pelvis and horizontal gaze. Addressing the intertwined cervical parameters in a specific order to a certain degree of correction can contribute to improved patient-reported neck disability.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    A standardized classification system of cervical deformity severity is in its preliminary stages. The most well-known classification was created by Ames and the International Spine Study Group, but it has yet to be formally validated with connection to HRQL outcomes. Also, little is known regarding the order of addressing correction of certain cervical alignment parameters for peak improvement in postoperative patient-reported outcomes. It is exciting that we were able to prioritize parameters to be corrected, not just for a postoperative radiographic alignment improvement, but taking into account what really matters, the patient’s perceived outcomes (through the use of NDI).

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    By establishing an order of targeting alignment parameters and their projected minimal corrective degree in surgical cervical deformity patients, operative decision making will benefit and inherently improve HRQL outcome management.

  5. Is follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Future studies should investigate the proposed prioritization and minimal thresholds of correction on a prospective trial with a larger, homogenous population of patients undergoing cervical deformity corrective surgery.

Anterior Cervical Discectomy and Fusions (ACDFs) at Physician-Owned Hospitals – Is it Time to Reconsider the Sanctions of the Affordable Care Act (ACA)?—Presenting author: Azeem Malik, MBBS
  1. What question is your research attempting to answer?
    The current study utilizes a national Medicare dataset to assess whether elective 1- to 3-level anterior cervical discectomy and fusions (ACDFs) performed at physician-owned hospitals are safe and cost- efficacious as compared to non-physician-owned hospitals.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    The results of the study suggest that elective 1- to 3-level ACDFs at physician-owned hospitals have significant cost savings (over $1,900/case), while having lower odds of experiencing 90-day medical complications and readmissions. The findings call into the need for revaluation/reconsideration of the ACA’s restriction on the expansion of these physician-owned hospitals.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    The Patient Protection and Affordable Care Act (ACA) of 2010 placed a moratorium on the introduction/creation of physician-owned facilities/hospitals. Health policy-makers believe that due to stake ownerships in profitability, physicians working in these hospitals have a financial disincentive toward driving up costs of care through unnecessary health care resource utilization. Furthermore, these hospitals also are criticized for creating barriers to access-of-care by “cherry-picking” healthier patients, and referring complex cases to other tertiary centers. With the demand of spine care growing across the United States, our findings question the concerns of health policy-makers regarding the safety and cost-efficacy of physician-owned facilities.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    The findings of this research support the reintroduction of physician-owned facilities in the current value-driven and cost-conscious health care market.

  5. Is follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Future research should focus on how the presence of a physician-owned facility in a health care referral region (HRR) may influence referral patterns and patient case-mix at nearby safety-net hospitals.

Posterior Cervical Fusion for Fracture vs Degenerative Cervical Spine Disease - Implications for a Bundled Payment Model—Presenting author: Azeem Malik, MBBS
  1. What question is your research attempting to answer?
    The current study aimed to investigate whether 30-day outcomes (complications and readmissions) and resource utilization differ between posterior cervical fusions (PCFs) performed for a fracture, versus those performed for degenerative cervical spine pathology.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Patients undergoing PCFs for fracture have significantly higher rates of postoperative adverse events and greater resource utilization as compared to individuals undergoing elective PCF for degenerative spine pathology.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement (BCPI) revolve around the use of Diagnosis Related Groups (DRGs) to categorize patients for reimbursement purposes. Though a posterior cervical fusion (PCF) performed for a fracture may have a different postoperative course of care as compared to a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate payments based on the indication/cause of surgery. The study calls into question the need of risk adjustment of bundled prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Ensuring appropriate risk-adjustment of prices will ensure bundled prices are equitable and fair for hospitals and providers who routinely take care of fracture patients.

  5. Is follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Further study using cost data is required to better understand the financial ramifications of our findings.
Reliability of the Neck Disability Index (NDI) and Japanese Orthopedic Association (JOA) Questionnaires in Adult Cervical Radiculopathy and Myelopathy Patients when Administered by Telephone or via Online Format—Presenting author: Gaurang Gupte, BS
  1. What question is your research attempting to answer?
    Is administration of the Neck Disability Index (NDI) and the Japanese Orthopedic Association (JOA) Cervical Myelopathy Questionnaire for cervical myelopathy and/or radiculopathy patients over phone and email a valid method?

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Administration of the NDI and JOA over phone and email is valid and can reduce non-response rates. Follow-up phone reminders can increase the response rate for administration of these patient-reported outcomes over email.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    We obtained a higher email response rate than previous studies utilizing email questionnaires for orthopedic patients. We attribute this to repeated reminder phone calls to patients requesting completion of the email questionnaires.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Electronic administration of the NDI and JOA can reduce loss to follow-up in long-term cervical spine studies and thus enable faster study completion with greater accuracy. It potentially enables new opportunities to assess patient populations less likely to follow up, such as trauma patients who have been understudied due to dependence on in-office assessments.

  5. Is follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    The methodology we have developed can be used by other spine specialists to drastically ease the burden of patient reported questionnaire data collection for their respective cervical spine research and clinical needs.
The Impact of Surgical Decompression on Neck Pain Outcomes in Patients with Degenerative Cervical Myelopathy: Results from the Multicenter Prospective AOSpine Studies—Presenting author: Michel Schneider, MD
  1. What question is your research attempting to answer?
    We addressed the following questions in this study: (1) What is the impact of operative intervention on neck pain at 12 and 24 months after surgery? (2) Does preoperative functional impairment affect the neck pain response to operative intervention? (3) Does surgical approach influence the neck pain outcome?

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    First, our results demonstrate a significant improvement of neck pain after the operative intervention. The overall neck disability index (NDI) changed significantly between preoperatively to the 6-, 12- and 24-month follow-up period (p<0.0001). Furthermore, all changes were noted to be above the minimum clinically important difference (MCID) of 7.5 points. The neck pain NDI subscore also improved significantly from preoperatively to all follow-up’s (p<0.0001).

    Second, the neck pain intensity did not differ in patients with different functional impairment pre- and postoperatively. Specifically, 78.4% (n=134) of patients with mild DCM reported pain preoperatively. Neck pain in this functional impairment category did decrease to 52.9% (n=174) at the 24 months follow-up. A similar improvement of neck pain was observed for patients categorized as moderate DCM. They indicated neck pain in 81.2% (n=212) initially, and in 51.7% (n=60) at 24-months. Patients with severe DCM presented with neck pain before the surgical treatment in 77.6%, (n=180) and reported pain in 48.1% (n=25) at 24-months follow-up.

    Third, neck pain improvement was independent of the surgical approach. Patients reported no neck pain in 33% after an anterior approach (AA), in 35% after a posterior approach (PA), in 32% after a posterior approach with instrumentation (PI), and in 29% after a combined anterior-posterior approach at six months from surgery.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    The improvement of neck pain in patients with DCM after operative intervention is remarkable and somehow surprising. Even after the significant improvement during the first six months postoperatively, neck pain decreased even more during the following 18 months. Specifically, more than 30% of individuals were free of neck pain six months postoperatively, almost 40% at 12 months and nearly 50% of patients 24 months after surgery. From a clinical point of view, patients were previously counseled to expect a halt of further deterioration of the neurological symptoms of DCM, and to expect some improvement in neurological function following surgery. However, patients are usually advised not to expect an improvement in neck pain after surgery.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    This new evidence has shown that patients undergoing surgery for DCM have a reduction in their neck pain. It will therefore help us counsel DCM patients of the additional benefits they should expect from their operative intervention.

  5. Is follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    The impact of neck pain on quality-of-life in patients with DCM has not been addressed in larger studies so far. Therefore, our next research project will focus on this topic. Our preliminary analysis shows significant quality-of-life differences in patients with and without neck pain after a surgical intervention.
Reduction in Mortality in Pediatric Patients Undergoing Surgery for Nonidiopathic Scoliosis by Implementing a Multidisciplinary Screening Process—Presenting author: Lorenzo Deveza, MD, PhD
  1. What question is your research attempting to answer?
    This is a research project to assess whether implementing a multidisciplinary safety protocol for complex pediatric spinal surgery leads to a decrease in complications. The multidisciplinary protocol is a 5-step process which involves spine surgeons, cardiologists, pulmonologists, general surgeons, anesthesiologists, dietitians and critical care medicine specialists to review pediatric nonidiopathic scoliosis cases to determine whether surgery could proceed. It was developed after a series of serious complications occurred at one pediatric institution. This protocol has been in place now for about five years. Given the length of time that the protocol has now been in place, it is timely to assess whether it has made a difference.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    The key finding in this study is that there was a reduction in mortality at 1 year after implementing the multidisciplinary safety protocol, while other minor complications remained similar. The main difference in patient characteristics that proceeded to surgery after implementing the conference was an increase in body mass index, suggesting patients deemed safe for surgery had better nutrition. The clinical significance of this is that the implementation of a multidisciplinary conference to screen pediatric patients prior to complex spinal surgery may reduce serious postoperative complications.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?) The study results are exciting because they demonstrate that implementing a multidisciplinary safety protocol for complex pediatric spinal surgery may help to reduce serious postoperative complications. In our study, we find that it helped to reduce mortality. Similar protocols are now in place at other institutions and reports have demonstrated benefits with surgical site infections. The current study adds to these findings and also shows benefits with a more severe surgical complication.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    This research applies to all surgical centers treating pediatric complex spinal deformity by providing evidence of the benefits to implementing a multidisciplinary spinal safety protocol.

  5. Is follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Within our own cohort, several important studies may help illuminate why certain patients performed better after implementing the multidisciplinary safety protocol. Furthermore, it is adds to the current literature in supporting the implementation of a multidisciplinary safety protocol.
Effect of Topical Steroid on Swallowing following ACDF: Results of a Prospective Randomized Double Blind Control Trial—Presenting author: TBA
Although we do not have Q&A from these authors, we can provide these excerpts from their abstract:

  • PURPOSE: To determine if the application of local intraoperative corticosteroids (LIC) during multi-levels ACDF surgery impacts early post-operative dysphagia severity.

  • STUDY DESIGN/SETTING:
    Double blinded randomized clinical trial – early post-operative results.

  • PATIENT SAMPLE:
    106 adult patients undergoing primary multi-level ACDF (2-4 levels) at a single institution.

  • METHODS:
    Patients who sustained a multilevel ACDF were enrolled and randomized in a double blinded fashion. Arm S (Steroid) received 1ml (40mg) of methylprednisolone delivered with an absorbable hemostatic matrix (vehicle) to the retro-esophageal space prior to closure. The control arm (C) only received the vehicle prior to closure. Dysphagia specific instruments (EAT-10 and the SWAL-QOL) were collected preoperatively, and at day-1 (POD1), day-2 (POD2), and 1 month (M1) postoperatively. Potential randomization biases were assessed by comparing the preoperative characteristics and surgical treatment of the 2 arms. A Friedman test was used to investigate change over time in PRO; a Mann-Whitney U test was performed to compare the median PRO scores (S vs C) at each time points.

  • CONCLUSIONS:
    Both arms demonstrated similar preoperative characteristics and underwent similar surgical procedures. Our study demonstrated the benefit of local intraoperative corticosteroids (LICs) with this delivery method to prophylactically reduce dysphagia following ACDFs. Early postop results were superior for treatment group, especially postop days 2, and maintained at 1 month.
Thursday Best Papers
Impact of Preoperative Chronic Opioid Therapy on Long-term Outcomes, Re-operations, Complications and Resource Utilization after Lumbar Arthrodesis—Presenting author: Andrew Pugely, MD, MBA
  1. What question is your research attempting to answer?
    The United States (US) is in the midst of an opioid epidemic. Despite the utility of opioid medications in controlling acute postoperative pain, news claiming thousands of lives lost or destroyed due to opioid abuse is dismal. Recent clinical trials have questioned the benefit-risk ratio of chronic opioid therapy (COT) in musculoskeletal disorders. In lieu of these emerging evidence-based findings, our team attempted to investigate the association of using preoperative COT on mid-term (90-day) to long-term (1-year; 2-year) outcomes following lumbar fusion, a routinely performed spine surgical procedure that involves fusing the lower back. We utilized a commercial payer (Humana, Inc.) database that permitted longitudinal tracking and pharmacological claims assessment to assess the association of being on COT with reoperation rates, postop complications and resource utilization (emergency department visits, steroid injections, postop opioid requirements).

    Eligible patients undergoing lumbar spinal fusion were categorized based on their preoperative opioid usage, allowing comprehensive assessment of outcome measures at predefined follow-up endpoints across opioid users (determined as having an opioid prescription within three months prior to surgery) versus opioid-naïve users (no history of prescription filling). We hypothesized that insights from a national cohort can confer generalizability in understanding risk of chronic preoperative opioid use with outcomes, aid in the formulation of practice recommendations and provide impetus to the development of standardized preoperative opioid weaning protocols.

  2. Please summarize your key findings and comment on the clinical significance (if applicable).
    The study noted that nearly six out of the 10 patients (≈57%) scheduled for primary lower back fusion surgery are on prescription opioids, preoperatively (3-month prior to their surgery). This reflects a dismally high proportion of patients requiring opioid medications for achieving adequate pain control prior to surgery. Ironically, patients who are on preoperative COT are also likely to be on opioids after spine surgery. Using robust observational techniques, our study quantified that patients on preoperative COT are 395% [OR:4.95, p<0.001] 535% [OR:6.35, p<0.001] and 603% [OR:7.03, p<0.001] more likely to be on postoperative opioid prescriptions at 90 days, 1 year and 2 years after spine surgery, respectively, when compared to opioid-naïve patients (no pre-op opioid).

    Taking a deeper dive into our findings, the risk-adjusted probability of being on opioid prescriptions after lower back fusion for 95% of patients who were on preoperative COT will range from 363%-429% at 3 months, and significantly increase further to 488%-589% at 1 year and 545%-667% at 2 years. The atypical postoperative opioid requirement in patients with COT undermines the role of lumbar surgery on spine correction and subsequent pain control. These findings rationally reflect the gaps in our current understanding on the causal association of using pre-op COT with postoperative pain control requirements and inferior outcomes. Resource utilization, as assessed by several surrogate measures, was also relatively higher in patients with COT. Despite risk-adjustment, the study elucidated that patients on COT are likely to incur 18% higher visits to the ED, 44% higher requirements for epidural steroid injections, and nearly 15% higher likelihood of developing infections or thromboembolic episode at 90 days following surgery. Likewise, the 1-year and 2-year reoperation risks after lumbar fusion in patients on COT are estimated at 30% and 25% higher compared to opioid-naïve patients.

    The relatively higher risk-adjusted estimates for ED visits (+27%) and steroid/facet-joint injections (+40%) at 1 year notes the lower postop nociceptive threshold for patients chronically sensitized on opioids. The atypical postop opioid requirements in conjunction with higher association for using alternative strategies (steroid/facet-joint injections) for pain mitigation warrants a root-causal analysis and intervention strategies aimed at weaning these patients preoperatively using multidisciplinary approaches. Going forward, an interplay of behavioral interventions, patient-specific requirement patterns, and the comprehension of neural-circuitry linked to the addiction-reward pathway using advanced neuroimaging modalities would help deliver optimized care to patients on COT.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    Contemporary to the burgeoning opioid popularity in the early 1990s, several factors led to the current national crises on opioids. The notion of “pain as the fifth vital sign” led to overwhelming proportions of providers prescribing opioids for ensuring “pain-free” patients. The advocacy from pharmaceutical companies for the safety and low risk of future abuse was one aspect of this multifactorial crisis. With an exponential rise in opioid medications prescribed, concerns relating to its misuse/abuse have led to a consortium of federal, state and private partnership to curb and regulate prescribing practices. Despite these national and regional measures, the opioid crises seen in spine surgical patients are dismal. Approximately six out of 10 patients undergoing a lower back intervention are on COT at least three months prior to their surgery. This represents the tip of an iceberg it is plausible for more patients to be on opioids if the preoperative cutoff is raised beyond the 3-month mark that was utilized in the current study. Going with the previously floated notion on the advantages of pain mitigation with opioids, the study debunks the utility of using COT considering the long-term implications on surgical outcomes. Interestingly, it was more surprising that patients on pre-op COT are likely to remain on these medications despite palliative/corrective spine surgery. The most interesting aspect of our finding is that if pre-op opioids and spine surgery provide relief to patients on COT, the need for atypical postoperative opioid requirements in these patients unarguably reflects a missing link that needs addressed for an opioid-free post-op environment.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    The current research quantifies the risk-adjusted impact of preoperative opioid use on outcomes, resource utilization, postoperative opioid use and re-do operations. The study highlights the consequence of prolonged opioid treatments to extend beyond the quality realm. Higher rates of adverse events in patients on COT will certainly cause higher postop resource utilization/costs as noted in our findings. Increased ED visits, additional pain mitigation alternatives (injections) and reoperation rates will significantly impact economics of spine care, which may contribute to rising insurance premiums. As financial bundles are developed for spine care, effectively managing complications will increase value delivery and protect payments. Recent data have linked perioperative opioid use to be as a major driver for increasing overall costs of spine surgery. When correlating the financial implications associated with inferior outcomes and higher resource utilization in patients on COT, it is imperative to stepwise wean these patients off opioids preoperatively. Postoperatively, pain mitigation measures should include a mix of non-opioid analgesics, behavioral interventions and understanding patient specific needs.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Despite the obvious merit of our study, the current investigation has limitations that need overall understanding to build upon future research and collaborations for combating the opioid epidemic. Foremost, the investigation was modeled on a retrospective (observational) design. Although the association of preoperative COT was evaluated comprehensively, the study cannot decipher in-depth causality for the postoperative observations reported in the study. For causal analysis, a prospective cohort design would be more appropriate.

    The study findings do not segregate based on the underlying spine pathology (degenerative, deformity, trauma, etc), level of surgery (single vs multilevel), radiographic metrics, severity or functional measures that may influence outcomes. Behavioral patterns and quantification of preoperative/postop opioid dosages could not be accounted for, based on the nature/design of the secondary data source (Humana, Inc) used for our investigation. The realm of research scope expands several horizons. The study findings urge for prospective trials assessing the utility of preoperative weaning from opioids prior to spine surgery and evaluating outcomes across those weaned versus those not weaned. At the University of Iowa, our research team works closely with allied health care providers including behavioral therapists, pharmacists, occupational/physical therapists and a team of research scientists in designing a multidisciplinary opioid weaning protocol for patients undergoing lumbar surgery. The efficacy of our opioid weaning protocol will be tested in a pilot, 3-arm randomized controlled trial (RCT) and is funded partly by the Lumbar Spine Research Society (LSRS). The trial envisages to level I recommendations and the utility of pre-op weaning on long-term outcomes in patients undergoing spine surgery.
Chiropractors treating patients with acute lower back pain in a spine treatment pathway model: A five-year prospective cohort study—Presenting author: Paul Bishop, DC, MD, PhD
  1. What question is your research attempting to answer?
    The role of chiropractors in the new Canadian Primary Care Network Healthcare Model.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Ninety-seven percent of eligible patients with acute lower back pain agreed to participate in a primary care spine treatment pathway model that included a standardized chiropractic treatment protocol. Pre- and post-treatment pain scores (VAS) and disability scores (RDQ) improved significantly in 72% of the patients in the study. Patient satisfaction was greater than 90%.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    A standardized chiropractic assessment and treatment protocol is a viable component of the new Canadian Primary Care Network Spine Patient Treatment Pathway model.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Including the standardized chiropractic assessment and treatment protocol in the Canadian Primary Care Network Healthcare Model has the potential to improve patient access to care (ie, shorter wait times), clinical outcomes, reduction in opioid use, reduction in ER visits and inappropriate MRI requests and overall cost effectiveness.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    A follow-up research study is now evaluating the value of this model in improving patient access to care (ie, shorten wait times), clinical outcome, reduction in opioid use, reduction in ER visits and inappropriate MRI requests, and overall cost effectiveness.
Common Psychiatric Conditions and Anterior Cervical Discectomy and Fusion: an Assessment of Postoperative Outcomes, 2-Year Costs, and Postoperative Opioid Utilization—Presenting author: Andrew Harris, BS
  1. What question is your research attempting to answer?
    We are attempting to determine if patients with anxiety and/or depression are at risk for specific adverse outcomes following inpatient anterior cervical discectomy and fusion (ACDF).

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Our key findings are that after adjusting for differences in age, sex and medical comorbidities, patients with either depression or anxiety have increased odds of chronic opioid use following ACDF, higher rates of revision surgery, and increased 1- and 2-year total postoperative health care payments. Depression is also independently associated with increased odds of all-cause hospital readmission at 30 and 90 days, and decreased odds discharge following inpatient surgery (meaning discharge to rehabilitation facilities, etc).

    These findings are clinically significant because they help us understand the potentially increased resource utilization, risk of prolonged opioid use, and cost associated with treating patients with the common psychiatric conditions of anxiety and depression. As a result, health care providers may increasingly focus on interventions such as opioid medication counseling and discharge planning with these patients prior to ACDF surgery in attempt to reduce the risk of adverse postoperative outcomes.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    Previous studies examining the association between psychiatric conditions and perioperative outcomes following ACDF have shown mixed results. Our study harnesses the power of a large sample size using private insurance claims data in order to study this issue on a national scale. The consistency and strength of our outcomes demonstrates that the association between depression and anxiety and risk of adverse outcomes following cervical spine surgery should not be ignored.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?
    We want to emphasize that our study is not suggesting that diagnoses of depression/anxiety should prevent patients from undergoing cervical spine surgery when indicated. Our results are simply describing a relationship upon which future studies may build upon, and seek to find ways to reduce the disparity in adverse outcomes.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    There are still several important questions that are unclear, and would be appropriate for future research studies. Because we only identified if patients had a diagnosis of depression or anxiety within the six months preceding surgery, we were unable to determine the severity of the condition or duration of illness. Thus, it is still unclear if there is a relationship between the severity of depression/anxiety and risk of adverse outcomes. In addition, it is also unclear if treating these psychiatric conditions prior to surgery results in a decrease in adverse outcomes.

    Future studies should focus on studying interventions that may reduce the disparity in postoperative adverse outcomes among patients with depression/anxiety following ACDF versus patients without diagnoses of these psychiatric conditions.
Opioid Utilization in Adult Idiopathic Scoliosis after Multilevel Deformity Correction: Postoperative Trends and Factors Associated with Long-Term Use—Presenting author: Piyush Kalakoti, MD
  • Q&A unavailable at time of publication.

Prospective Randomized Controlled Trial of Implant Density in AIS: Results of the Minimize Implants Maximize Outcomes Study—Presenting author: David Polly, MD
  • Q&A unavailable at time of publication.

Which MRI findings are associated with long-term disability in low back pain patients?—Presenting author: Peter Udby, MD, DC
  1. What question is your research attempting to answer?
    We want to know if MRI findings are associated with increased disability at long-term follow-up to help us understand if the disc degeneration, Modic changes and facet joint degeneration visualized on a MRI of a low back pain patient can predict future disability.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Contrary to our hypothesis, none of the degenerative MRI changes at baseline were associated with a worse outcome at 13-year follow-up. Baseline Modic changes were associated with statistically significant less long-term disability. Weekly physical activity at leisure was not surprisingly associated with less disability. The clinical significance is relevant since LBP patients with MC previously have been treated both with long courses (100 days) of antibiotics and in many cases spinal fusion. If MC transgress over time and symptoms improve without treatment, unnecessary treatment, associated complications and costs can all be reduced, and patient care will be improved.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    Degenerative changes were very common on MRIs of LBP patients, with more than half of all patients having at least one lumbar level with disc degeneration and more than 80% having degenerative facet joint changes on at least one level. However, the presence of these changes does not have a prognostic value on long-term disability. The results indicate that we might need to rethink our thoughts on degenerative MRI changes and their long-term impact on back pain and disability.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    With this new information, we can reduce unnecessary treatment, iatrogenic complications and health care expenses. Also, we can help guide patients with LBP and give them valuable information regarding the future and their prognosis.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Long-term follow-up MRI series would be interesting to evaluate the progression and transgression of the degenerative imaging findings. Also, this valuable evidence can help guide future research into other relevant pain generators of the spine. As back pain is the number one cause of global disability, we must continue to develop our understanding, through research like this, in order to break the pandemic curse of back pain.
Friday Best Papers
Outcomes of Decompression without Fusion in Patients with Lumbar Spinal Stenosis with Back Pain—Presenting author: Leah Carreon, MD, MSc
  1. What question is your research attempting to answer?
    Does simple discectomy without fusion in patients with lumbar disc herniation and substantial back pain improve the back pain in these patients?

  2. Please summarize your key findings and comment on the clinical significance (if applicable)…
    Simple discectomy in patients with lumbar disc herniation and substantial back pain leads to improved outcomes even without a fusion.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    The results show that fusion is not necessary to treat the back pain associated with lumbar disc herniation.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Patients with lumbar disc herniation can be counseled that discectomy alone can lead to improved outcomes.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Long-term follow-up to identify patients who did not improve and required fusion would be interesting. Identifying risk factors that led to the need for fusion would be important as well.
Ambulatory Status after Surgical and Nonsurgical Treatment for Spinal Metastasis—Presenting author: Andrew Schoenfeld, MD, MSc
  1. What question is your research attempting to answer? ?
    We evaluated the effects of operative and nonoperative management on maintenance of ambulatory function and survival for patients treated for spinal metastases who were independent ambulators at the time they presented for treatment. This is a select and highly functional group but could potentially also be the cohort most likely to benefit from surgery.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)...
    Propensity matching was used to yield an analytic sample in which operatively and nonoperatively treated patients were similar with respect to key baseline clinical features. We found that patients treated operatively were less likely to lose ambulatory function six months after presentation than those managed nonoperatively.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    This is among the first research of its kind to demonstrate a clear advantage for surgical intervention in a cohort of patients who were highly functional at the time of initial presentation for treatment for spinal metastases.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    For patients with spinal metastases, our data can be incorporated into discussions about the treatments that align best with patients' preferences regarding surgical risk, mortality and ambulatory status. Patients who are amenable to surgery and who are independently functional at the time of presentation may stand to benefit substantively from a treatment approach that incorporates surgery.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    There is follow-up work envisioned--including a prospective observational study to more completely validate the initial findings.
Impact of Previous Lumbar Spine Surgery on Outcome of Lumbar Total Disc Replacement: Analysis of Prospective 5-Year Follow-Up Study Data—Presenting author: Rick Guyer, MD
  • Q&A unavailable at time of publication.

Randomized, Prospective Clinical Trial to Evaluate Efficacy and Safety in Lumbar Fusion Surgery of Implantation of Autologous Bone Marrow Mesenchymal Cells Expanded Ex Vivo and Combined with Allogeneic Bone Tissue, Compared with Autologous Iliac Crest Graft, Part I: Radiological Findings—Presenting author: Pilar González-Tartière, MSc
  1. What question is your research attempting to answer?
    We wanted to assess if XCEL-MT-OSTEO-ALPHA (scaffold of heterologous human cancellous bone tissue seeded with autologous bone marrow mesenchymal cells expanded “ex vivo”) is a safe product and whether the lumbar fusion achieved is equal to or better than what you get with autologous iliac crest graft.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)…
    XCEL-MT-OSTEO-ALPHA is a safe and feasible product (no serious adverse reactions were associated) not only in lumbar spinal surgery, but also in hip osteonecrosis and pseudarhtosis.

    Radiological fusion rates in the area in which the product was applied were significantly higher than those obtained with autologous iliac crest graft at all X-ray controls and CT at six months. Fusion at one-year follow-up CT was equal or better, without being statistically significant.

    XCEL-MT-OSTEO-ALPHA can be an alternative to iliac crest graft in patients for whom it is not possible to obtain autologous iliac crest graft, or in which a great volume of graft is needed, or in those who need an early fusion.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    We found a safe and feasible alternative to autologous iliac crest graft, considered the gold standard in lumbar fusion. XCEL-MT-OSTEO-ALPHA is, compared to iliac crest graft, a more biologic treatment option and an autologous cellular source.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    XCEL-MT-OSTEO-ALPHA could be a suitable treatment option for patients with previous spinal surgeries in whom bone fusion was not achieved or in patients in whom it is not possible to obtain autologous iliac crest graft.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Previous studies have proven the safety of this product in other pathologies (hip osteonecrosis, large bones pseudarthrosis). There is an ongoing follow-up CT study of the patients included in this clinical trial. We believe a new clinical trial with patients with pseudarthrosis after spinal fusion is needed to test the product in more complex pathologies.
Evaluation of Health Related Quality of Life Improvement in Patients Undergoing Spine vs Adult Reconstructive Surgery—Presenting author: Aaron Buckland, MD
  • Q&A unavailable at time of publication.

Are Current DRG-Based Bundled Payment Models for Lumbar Fusions Risk-Adjusting Adequately? An Analysis of Medicare Beneficiariesy—Presenting author: Azeem Malik, MBBS
  1. What question is your research attempting to answer?
    Current bundled-payment models of care, such as the CMS Bundled-Payment for Care Improvement (BPCI), rely on the use of Diagnosis-Related Groups (DRG) to trigger episodes of care and define payments. The current study evaluates whether the use of DRGs to identify payments in bundled models of care is justified.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)…
    Under the proposed DRG-based bundled payment model, providers would be reimbursed the same amount for lumbar fusions regardless of the surgical approach (posterior vs anterior), the extent of fusion (1-3 levels vs >3 levels), use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs degenerative pathology), despite each of these factors having different resource utilization and associated costs.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    When defining and developing future bundled payments for spinal fusions, health policy makers should strive to account for the individual patient-level, state-level and procedure-level variations seen within DRGs to prevent the creation of a financial disincentive in taking care of sicker patients and/or performing more extensive complex spinal fusions.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Our study highlights discrepancies in the current bundled-payment system that may impede access to care for sick/complex patients.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    As providers, we need to advocate for better bundled-payment policies for spinal fusions to prevent the creation of financial disincentives.
Intravenous and Oral Tranexamic Acid are Equivalent at Reducing Blood Loss in Thoracolumbar Spinal Fusion: A Prospective Randomized Trial, Phase 2—Presenting author: Mohsin S. Fidai, MD
  1. What question is your research attempting to answer?
    Elective thoracolumbar spinal fusion surgery is associated with significant perioperative blood loss frequently requiring blood transfusion. Clinically, tranexamic acid (TXA) has been shown to reduce perioperative blood loss, as well as the risk of blood transfusion after spinal fusions. TXA can be administered intravenously (IV), topically and orally. Although IV TXA is effective in reducing blood loss, it is costly. The objective of this prospective randomized study was to compare the efficacy of IV and oral routes of TXA on perioperative blood loss and allogeneic blood transfusion rates in adult patients undergoing posterior thoracolumbar instrumented fusion surgery.

  2. Please summarize your key findings and comment on the clinical significance (if applicable)…
    We found no difference in the efficacy between the two routes of administration in both the primary outcome of hemoglobin drop and secondary outcomes. Oral TXA appears to be as safe as IV TXA in regard to postoperative thromboembolic events and infections.

  3. What is surprising/exciting/different about your research results? (For example, do they affirm or debunk any existing spine treatment or diagnosis?)
    In the setting of spine thoracolumbar fusions, oral TXA produced an equivalent reduction in hemoglobin and blood loss compared with its intravenous counterpart. Given the equivalent clinical outcomes, potential cost savings, and the ease of drug administration, oral TXA is a superior alternative to intravenous TXA.

  4. How can this research ultimately apply to or benefit spine patients? (Will it make diagnosis/treatment/payment any easier/less expensive/better in the future?)
    Given the ever changing landscape of medical reimbursement, cost-effective health care practice is beneficial to patients, providers, the health care system and society at large. The use of TXA in orthopedic surgery has become a routine practice because it has been shown to be safe, clinically beneficial and cost-effective. Allogeneic blood transfusions carry the risk of transfusion reactions, disease transmission and increased hospital costs.

  5. Is there follow-up research or work needed that can help shine additional light on this topic? Or, now that spine specialists know this, what should they do about it?
    Oral TXA is less expensive and easier to administer than IV TXA; switching to oral can lead to greater cost savings. In our institution, the oral TXA dosage cost $14 compared with $53 for the generic IV formulation alone (not including the cost of pharmacy preparation). As the American population continues to age, the number of spinal fusion surgeries performed in the United States will likely continue to increase from the current annual rate of about 500,000. Consequently, transitioning to oral TXA has potential to yield cost savings of at least $20 million per year for the health care system.