Study Design. Retrospective cohort. Objective. We evaluate the correlation of the Patient-Reported Outcomes Measurement Information System for physical function (PROMIS-PF) with legacy patient-reported outcome measures (PROMs) in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) up to 2 years postoperatively. Summary of Background Data. PROMIS-PF has not been validated past 6 months following MIS TLIF. Methods. A surgical registry was retrospectively reviewed for eligible MIS TLIFs between May 2015 and September 2017. Inclusion criteria were primary, one- or two-level MIS TLIFs for degenerative spinal pathology. Patients without preoperative or 2-year follow up PROMIS-PF surveys were excluded. Demographic, perioperative, and PROMs including Visual Analog Scale (VAS) back, VAS leg, Oswestry Disability Index (ODI), 12-Item Short Form (SF-12) physical component summary (PCS) scores, and PROMIS-PF at preoperative and postoperative timepoint (e.g., 6 weeks, 12 weeks, 6 months, 1 year, and 2 years). A paired t test evaluated PROM improvement from baseline. The relationship of PROMIS-PF with VAS back, VAS leg, SF-12 PCS, and ODI was evaluated with a Pearson correlation coefficient. Results. The 68-subject cohort was 41.2% female, with an average age of 52.9 years; 44.1% were obese, and the majority underwent one-level fusions (95.6%). Pain (VAS back, VAS leg) and disability metrics (ODI) demonstrated significant improvement at all timepoints following MIS TLIF when compared to baseline (all P < 0.001). Physical function (SF-12 PCS, PROMIS-PF) demonstrated significant postoperative improvement at 12 weeks, 6 months, 1 year, and 2 years (all P < 0.001). All evaluated timepoints, with the exception of preoperative VAS back scores, revealed strong PROMIS-PF correlations with VAS back, VAS leg, ODI, and SF-12 PCS. Conclusion. PROMIS-PF demonstrated a strong correlation with pain (VAS back, VAS leg), disability (ODI) and physical function (SF-12) at all postoperative follow-ups through 2 years. Our study provides longitudinal evidence for utilizing PROMIS-PF as a valid physical function measure among patients undergoing MIS TLIF. Level of Evidence: 4.

Background: The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol.Methods: Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics.Results: Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures.Conclusions: The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain.Level of Evidence: 4. Clinical Relevance: The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

Study Design. Literature review. Objective. To discern which social media outlets contribute most to spine surgery literature dissemination and to investigate how popular articles compare to articles with most citations. Summary of Background Data. Scientific literature is increasingly disseminated through social media. The Altmetric Attention Score (AAS) is defined as an automated, weighted score calculation from counts of all online attention received by various research outputs. Increasing AAS values indicate more online attention. For example, the overall top 100 Altmetric spine surgery peer-reviewed articles since 2010 had an AAS range from 78 to 1537. Among all spine surgery literature reviewed since 2010, the mean AAS was 5.3 with a median of 1.0. Methods. We performed an Altmetric database search of nine spine surgery journals from January 2010 to October 2019. Mean AAS was summarized alongside metrics including citation count and impact factor. We assessed correlations between AAS and online sources, readers, and citations. Journals were grouped by impact factor, and analysis-of-variance compared mean AAS. The 100 highest AAS articles were compared to the most cited. Results. 13,601 articles were included. The mean AAS was 5.3, with Twitter contributing the most. The three highest associations were news (P < 0.001), Twitter (P < 0.001), and Facebook (P < 0.001). There was no significant association between impact factor and AAS. Compared with the most cited articles, the top 100 AAS articles had significantly more article types, more prospective studies, fewer retrospective studies, fewer reviews, and fewer systematic reviews (P < 0.001 for all). Spine contributed the most articles in both top 100 sets. Conclusion. Our evaluation revealed Twitter, newsfeeds, and Facebook were the most significant social media outlets. Compared to articles with the most citations, the most popular articles are prospective and encompass broader study designs. Social media plays an integral role in dissemination, both within spine literature and the public sphere. Level of Evidence: 3

The number of citations a publication receives has been regarded as one measure of its importance and clinical impact. However, studies have yet to investigate which characteristics are predictors of citation rates within the spine subspecialty literature. To explore this topic, all articles published in 2010 in Spine and from 2010 to 2011 in The Spine Journal and the Journal of Neurosurgery: Spine were reviewed. The Web of Science search engine was used to determine the number of times each article was cited in the 5 years following its publication. Sample characteristics were collected and were compared with a χ2 test for differences Multivariate logistic regression was utilized to determine if collected study characteristics were associated with achievement of citation frequency higher than the median for the entire study sample. Among the 927 articles analyzed, the 5-year citation number ranged from 0 to 125, with a median of 8 (interquartile range: 4–16). Upon multivariate analysis, the following were identified as predictors of citation number higher than the median: North American origin (P=0.014), sample size >30 (P<0.001), study topic (P<0.050), and publication in the Journal of Neurosurgery: Spine (P<0.001). Practitioners and research personnel can use these findings to help elucidate which factors might affect the potential impact and overall reach of their work in the spine literature.

Study Design: This is a retrospective study. Objective: The objective of this study was to determine if there is an association between preoperative depression, as quantified by Patient Health Questionnaire-9 (PHQ-9), and postoperative improvement in pain and disability after anterior cervical discectomy and fusion (ACDF). Summary of Background Data: Few studies have quantified depression symptoms in the preoperative period using PHQ-9 and have tracked patient-reported outcomes (PROs) following ACDF. Methods: Patients undergoing ACDF were retrospectively reviewed and stratified by their preoperative PHQ-9 score. PROs, including Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck and arm pain, and 12-Item Short Form (SF-12) Physical Component Score (PCS), were measured preoperatively and at 6-week, 3-month, 6-month, and 1-year postoperatively. PRO scores were analyzed amongst PHQ-9 cohorts using multiple linear regression. Achievement of minimum clinically important difference (MCID) was compared using χ2 analysis. Results: Higher PHQ-9 scores were associated with increased preoperative NDI, VAS neck, and VAS arm scores and significantly lower SF-12 PCS scores preoperatively. Cohorts experienced similar VAS pain scores up to 1-year following surgery, except for VAS neck pain at 3 months when patients with greater depression symptoms had more pain. High PHQ-9 patients had higher NDI values at 6 weeks and 3-month marks but had similar NDI scores at 6 months and 1-year. Similarly, SF-12 PCS scores were lower for patients with a higher PHQ-9 score at 3 and 6 months, however, both groups had similar scores at 1-year follow-up. A greater percentage of the high PHQ-9 cohort achieved MCID for NDI, however, there were no differences in MCID achievement for VAS neck, VAS arm, or SF-12 PCS. Conclusions: Patients with worse preoperative mental health reported significantly greater preoperative disability and pain. However, both cohorts demonstrated similar clinical recovery at the 1-year follow-up. These findings suggest patients with worse preoperative mental health can expect significant improvements in PROs following surgery.

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Study Design: This was a retrospective cohort study. Objective: The purpose of this study is to examine whether the time duration from symptom onset to operative treatment is associated with postoperative clinical improvement after anterior cervical discectomy and fusion (ACDF). Summary of Background Data: There is a paucity of literature regarding the influence of preoperative symptom duration on patient-reported outcomes (PROs) following ACDF. Methods: Patients who underwent primary, single-level ACDF were retrospectively reviewed and stratified according to preoperative symptom duration (<12 and ≥12 mo). Demographic and perioperative characteristics were compared using χ2 analysis and linear regression. Subgroup mean scores were compared and achievement of minimal clinically important difference (MCID) was assessed for the Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck pain, VAS arm pain, and 12-Item Short-Form Physical Component Score. Results: A total of 109 patients underwent primary, single-level ACDF: 68 had duration of symptoms (DOS) <12 months and 41 had a DOS ≥12 months. When comparing DOS subgroup preoperative PROs, there was no preoperative difference in NDI, VAS arm or neck pain, and 12-Item Short-Form Physical Component Score. In the postoperative period, there were no significant differences in the improvement of PROs throughout the 12-month timepoint. A significantly larger proportion of the <12 months DOS cohort achieved NDI MCID at the 3-month (66.1% vs. 43.8%, P=0.039) and 6-month (76.8% vs. 53.6%, P=0.030) postoperative period. Conclusions: Among the patient subgroups with <12 and ≥12 months DOS, there were no statistically significant differences observed in any of the measured PRO means at any timepoint. When assessing MCID, however, patients with shorter DOS (<12 mo) were observed to attain NDI MCID at the 3- and 6-month timepoints more often than patients with DOS ≥12 months. Our findings suggest that delayed surgical intervention may impair functional recovery to MCID in patients with degenerative cervical disease.

In this review, we discuss the demonstrated value of vitamin D in bone maintenance, fracture resistance, spinal health, and spine surgery outcomes. Despite this, the effect of vitamin D levels in spine surgery has not been well described. Through this review of literature, several conclusions were drawn. First, despite the fact that a high number of spine surgery patients are vitamin D deficient, screening is not commonly performed. Second, adequate vitamin D levels will not be achieved in a majority of these patients without supplementation. Last, inadequate vitamin D levels may increase the risk of pseudarthrosis. Given these findings, we suggest that many patients undergoing spinal surgery could be treated with vitamin D supplementation prior to surgery without the need for confirmatory testing for vitamin D deficiency. This is a more cost-effective method than screening all patients. However, future randomized trials and cost-effectiveness analyses are needed to determine the ultimate effects of vitamin D supplementation on clinical morbidity and surgical outcomes.