Study Design. Retrospective cohort. Objective. To compare robotics and navigation for minimally invasive elective lumbar fusion in terms of radiation exposure and time demand. Summary of Background Data. Although various studies have been conducted to demonstrate the benefits of both navigation and robotics over fluoroscopy in terms of radiation exposure, literature is lacking in studies comparing robotics versus navigation. Materials and Methods. Patients who underwent elective one-level or two-level minimally invasive transforaminal lumbar interbody fusion (TLIF) by a single surgeon using navigation (Stryker SpineMask) or robotics (ExcelsiusGPS) were included (navigation 2017–2019, robotics 2019–2021, resulting in prospective cohorts of consecutive patients for each modality). All surgeries had the intraoperative computed tomography workflow. The two cohorts were compared for radiation exposure [fluoroscopy time and radiation dose: image capture, surgical procedure, and overall) and time demand (time for setup and image capture, operative time, and total operating room (OR) time]. Results. A total of 244 patients (robotics 111, navigation 133) were included. The two cohorts were similar in terms of baseline demographics, primary/revision surgeries, and fusion levels. For one-level TLIF, total fluoroscopy time, total radiation dose, and % of radiation for surgical procedure were significantly less with robotics compared with navigation (20 vs. 25 s, P<0.001; 38 vs. 42 mGy, P=0.05; 58% vs. 65%, P=0.021). Although time for setup and image capture was significantly less with robotics (22 vs. 25 min, P<0.001) and operative time was significantly greater with robotics (103 vs. 93 min, P<0.001), there was no significant difference in the total OR time (145 vs. 141 min, P=0.25). Similar findings were seen for two-level TLIF as well. Conclusion. Robotics for minimally invasive TLIF, compared with navigation, leads to a significant reduction in radiation exposure both to the surgeon and patient, with no significant difference in the total OR time.

Study Design. Retrospective review of prospectively collected data. Objective. To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF). Summary of Background Data. Assessing postoperative inefficiencies is vital to increase the feasibility of ALF. Materials and Methods. Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge. Results. Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS. Conclusions. Unavailability of PT, surgery after 1 pm, orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge. Level of Evidence. 4.

Study Design. Retrospective review of prospectively collected data. Objective. To determine the Oswestry Disability Index (ODI) cutoff for achieving Patient Acceptable Symptom State (PASS) at one year following minimally invasive lumbar spine surgery. Summary of Background Data. An absolute score denoting PASS, rather than a change score denoting minimal clinically important difference (MCID), might be a better metric to assess clinical outcomes. Materials and Methods. Patients who underwent primary minimally invasive transforaminal lumbar interbody fusion or decompression were included. The outcome measure was ODI. The anchor question was the Global Rating Change. "Compared with preoperative, you feel (1) much better, (2) slightly better, (3) same, (4) slightly worse, or (5) much worse." For analysis, it was collapsed to a dichotomous outcome variable (acceptable = response of 1 or 2, unacceptable = response of 3, 4, or 5). Proportion of patients achieving PASS and the ODI cutoff using receiver operating characteristic curve analyses were assessed for the overall cohort as well as subgroups based on age, sex, type of surgery, and preoperative ODI. Differences between the PASS and MCID metrics were analyzed. Results. A total of 137 patients were included. In all, 87% of patients achieved PASS. Patients less than or equal to 65 years and those undergoing fusion were more likely to achieve PASS. The receiver operating characteristic curve analysis revealed an ODI cutoff of 25.2 to achieve PASS (area under the curve. 0.872, sensitivity: 82%, specificity: 83%). The subgroup analyses based on age, sex, and preoperative ODI revealed area under the curve > 0.8 and ODI threshold values consistent between 25.2 and 25.5 (except 28.4 in patients with preoperative ODI > 40). PASS was found to have significantly higher sensitivity compared with MCID (82% vs. 69%, P = 0.01). Conclusions. Patients with ODI <25 are expected to achieve PASS, irrespective of age, sex, and preoperative disability. PASS was found to have significantly higher sensitivity than MCID.

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OBJECTIVE The objective of this study was to assess the outcomes of minimally invasive lumbar decompression in patients ≥ 80 years of age and compare them with those of younger age groups. METHODS This was a retrospective cohort study. Patients who underwent primary unilateral laminotomy for bilateral decompression (ULBD) (any number of levels) and had a minimum of 1 year of follow-up were included and divided into three groups by age: < 60 years, 60–79 years, and ≥ 80 years. The outcome measures were 1) patient-reported outcome measures (PROMs) (visual analog scale [VAS] back and leg, Oswestry Disability Index [ODI], 12-Item Short-Form Health Survey [SF-12] Physical Component Summary [PCS] and Mental Component Summary [MCS] scores, and Patient-Reported Outcomes Measurement Information System Physical Function [PROMIS PF]); 2) percentage of patients achieving the minimal clinically important difference (MCID) and the time taken to do so; and 3) complications and reoperations. Two postoperative time points were defined: early (< 6 months) and late (≥ 6 months). RESULTS A total of 345 patients (< 60 years: n = 94; 60–79 years: n = 208; ≥ 80 years: n = 43) were included in this study. The groups had significantly different average BMIs (least in patients aged ≥ 80 years), age-adjusted Charlson Comorbidity Indices (greatest in the ≥ 80-year age group), and operative times (greatest in 60- to 79-year age group). There was no difference in sex, number of operated levels, and estimated blood loss between groups. Compared with the preoperative values, the < 60-year and 60- to 79-year age groups showed a significant improvement in most PROMs at both the early and late time points. In contrast, the ≥ 80-year age group only showed significant improvement in PROMs at the late time point. Although there were significant differences between the groups in the magnitude of improvement (least improvement in ≥ 80-year age group) at the early time point in VAS back and leg, ODI, and SF-12 MCS, no significant difference was seen at the late time point except in ODI (least improvement in ≥ 80-year group). The overall MCID achievement rate decreased, moving from the < 60-year age group toward the ≥ 80-year age group at both the early (64% vs 51% vs 41% ) and late (72% vs 58% vs 52%) time points. The average time needed to achieve the MCID in pain and disability increased, moving from the < 60-year age group toward the ≥ 80-year age group (2 vs 3 vs 4 months). There was no significant difference seen between the groups in terms of complications and reoperations except in immediate postoperative complications (5.3% vs 4.8% vs 14%). CONCLUSIONS Although in this study minimally invasive decompression led to less and slower improvement in patients ≥ 80 years of age compared with their younger counterparts, there was significant improvement compared with the preoperative baseline.

Study Design. A Retrospective cohort study. Objective. To (1) assess whether diagnoses and surgical plans established during a new patient telemedicine visit changed following an in-person evaluation and (2) determine any differences in perioperative outcomes between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery. Summary of Background Data. Data on capability of telemedicine to deliver high-quality preoperative assessment without a traditional in-person interaction and physical examination is lacking. Materials and Methods. Records of patients who had a new patient telemedicine visit and indicated for surgery with documented specific diagnosis as well as surgical plans from a spine department at an urban tertiary center from April 2020 to April 2021 were reviewed. For a subset of patients that had a follow-up in-person evaluation before surgery, these diagnoses and plans were compared. Perioperative outcomes were compared between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery. Results. A total of 166 patients were included. Of these, 101 patients (61%) only had a new patient telemedicine visit before surgery while 65 (39%) had a telemedicine visit followed by an inperson evaluation. There were no differences in the rate of case cancellations before surgery and patient-reported outcome measures between these two groups (P > 0.05). Of 65 patients who had both a telemedicine followed by an in-person visit, the diagnosis was unchanged for 61 patients (94%) and the surgical plan did not change for 52 patients (80%). The main reason for surgical plan change was due to updated findings on new imaging, 10 patients, (77%). Conclusions. The current study suggests that telemedicine evaluations can provide an effective means of preoperative assessment for spine patients.

Study Design. Single-center, multisurgeon, retrospective review. Objective. To evaluate the timing of return to commonly performed activities following minimally invasive spine surgery. Identify preoperative factors associated with these outcomes. Summary of Background Data. Studies have reported return to activities with open techniques, but the precise timing of when patients return to these activities after minimally invasive surgery remains uncertain. Materials and Methods. Patients who underwent either minimally invasive lumbar laminectomy (MI-L) or minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) were included. Patient-reported outcome measures, return to drive, return to work, and discontinuation of opioids data were reviewed. Regression was conducted to identify factors associated with return to driving by 15 days, return to work by 30 days, and for discontinuing opioids by 15 days. A composite group analysis was also performed for patients who returned to all three activities by 30 days. Results. In total, 123 MI-L patients and 107 MI-TLIF patients were included. Overall, 88.8% of MI-L patients and 96.4% of MI-TLIF patients returned to driving in 11 and 18.5 days, respectively. In all, 91.9% of MI-L patients and 85.7% of MI-TLIF patients returned to work in 14 and 25 days. In all, 88.7% of MI-L patients and 92.6% of MI-TLIF patients discontinued opioids in a median of seven and 11 days. Overall, 96.2% of MI-L patients and 100% of MI-TLIF patients returned to all three activities, with a median of 27 and 31 days, respectively. Male sex [odds ratio (OR)=3.57] and preoperative 12-Item Short Form Physical Component Score (OR=1.08) are associated with return to driving by 15 days. Male sex (OR=3.23) and preoperative 12-Item Short Form Physical Component Score (OR=1.07) are associated with return to work by 30 days. Preoperative Visual Analog Scale back was associated with decreased odds of discontinuing opioids by 15 days (OR=0.84). Conclusion. Most patients return to activity following MI-L and MI-TLIF. These findings serve as an important compass for preoperative counseling.

Study Design. Retrospective review of prospectively collected data. Objective. To determine the Neck Disability Index (NDI) cut-off for achieving patient acceptable symptom state (PASS) at six months following degenerative cervical spine surgery. Summary of Background Data. An absolute score denoting PASS might be a better marker to assess clinical outcomes than a change score denoting minimal clinically important difference. Materials and Methods. Patients who underwent primary anterior cervical decompression and fusion, cervical disk replacement, or laminectomy were included. The outcome measure was NDI. The anchor used to assess PASS achievement at six months was the response on the Global Rating Change: "Compared with preoperative, you feel (1) much better, (2) slightly better, (3) same, (4) slightly worse, or (5) much worse." It was converted to a dichotomous outcome variable (acceptable = response of 1 or 2, unacceptable = response of 3, 4, or 5) for analyses. The overall cohort and subgroups based on age (65 yr and below, above 65 yr), sex, myelopathy, and preoperative NDI ( ≤ 40, > 40) were analyzed for the proportion of patients achieving PASS and the NDI cut-off using receiver operator curve. Results. Seventy-five patients (42 anterior cervical decompression and fusion, 23 cervical disc replacement, 10 laminectomy) were included. 79% of patients achieved PASS. Males, patients with age 65 years and below, preoperative NDI ≤ 40, and absence of myelopathy were more likely to achieve PASS.The receiver operator curve analysis revealed an Oswestry Disability Index cut-off of 21 to achieve PASS (area under the curve, AUC: 0.829, sensitivity: 81%, specificity: 80%). The subgroup analyses based on age, sex, myelopathy, and preoperative NDI revealed AUCs > 0.7 and NDI threshold values consistent between 17 and 23. Conclusions. With an AUC of 0.829, NDI showed an excellent discriminative ability. Patients with NDI ≤ 21 are expected to achieve PASS following degenerative cervical spine surgery.