Alexander R Vaccaro’s research while affiliated with Rothman Institute and other places

Study Design Retrospective cohort. Objective To assess the relationship between long-term gabapentinoid use and outcomes after lumbar fusion. Summary of Background Data Gabapentinoids, which include gabapentin and pregabalin, are commonly prescribed for radiculopathic pain. Basic science research has indicated that gabapentinoids may be detrimental to bone health/healing and clinical works has shown that initiating gabapentinoids at the time of spine surgery may decrease postoperative opioid requirements and increase risks of adverse outcomes. Despite these findings, no literature exists examining the impact of chronic gabapentinoid prescriptions on outcomes after lumbar fusion. Methods Adult patients who underwent elective one/two-level lumbar fusion (2017-2022) were identified via Structured Query Language search. Patient demographic/surgical characteristics, surgical outcomes, patient-reported outcome measures (PROMs), and preoperative gabapentinoid use were collected. Perioperative opioid data were collected utilizing the Pennsylvania Prescription Drug Monitoring Program. Appropriate statistical analyses were conducted with alpha set at 0.05. Results Amongst 461 included patients, 47 (10.2%) and 61 (13.2%) were chronically prescribed pregabalin and gabapentin, respectively. All groups were similar in terms of demographics, and surgical type/complexity. There were no differences in surgical outcomes, including two-year revision rate. Patients taking pregabalin consumed more total MMEs compared to gabapentin (132±344 vs. 104±351, P =0.022) and non-gabapentinoid patients (132±344 vs. 90.3±267, P =0.007). However, preoperative total MMEs were similar 60 days prior to surgery. Bivariate analysis demonstrated postoperative differences in back pain improvement at six-months ( P =0.025) between groups, however pairwise comparison did not show significance. Similarly, multivariate analysis did not show gabapentinoid usage as independently predictive of back pain scores. All other PROM comparisons were similar between groups. Conclusion Despite compelling basic science literature suggesting gabapentinoid exposure hindering bone health and healing capacity, the current investigation did not find an increase in surgical revision or other adverse outcomes, including opioid use and PROMs, associated with chronic preoperative gabapentinoid use.

Background The increasing prevalence of obesity has raised concerns about its impact on surgical outcomes and healthcare costs. This study evaluates the influence of Body Mass Index (BMI) on intraoperative costs and operative times during open Transforaminal Lumbar Interbody Fusion (TLIF) procedures using a Time-Driven Activity-Based Costing (TDABC) approach. Methods A retrospective analysis was conducted on 279 patients who underwent TLIF between 2019 and 2022. Patients were categorized into 5 BMI cohorts: healthy weight (BMI 18.5–24.99), overweight (BMI 25.0–29.99), Class I obese (BMI 30.0–34.99), Class II obese (BMI 35.0–39.99), and Class III obese (BMI >40). Intraoperative costs were calculated using TDABC methodology, with costs segmented into supply and personnel expenses. Operative times were measured in 3 phases: surgery time (incision to closure), OR time (patient entering to leaving), and turnover time. Multivariable regression models assessed the relationship between BMI and various intraoperative time and cost metrics, adjusting for potential confounders. Results BMI was significantly associated with increased operative times and personnel costs. Each unit increase in BMI corresponded to an additional 1.90 minutes in the operating room (p = .01) and a $25.72 increase in personnel costs (p = .008). However, no significant association was found between BMI and total or supply costs. Regression analyses indicated that obese patients did not significantly differ from healthy weight patients in terms of total intraoperative costs. Conclusions Higher BMI is associated with increased operative times and personnel costs in TLIF procedures, though it does not significantly impact total intraoperative costs when controlling for confounders. These findings suggest that BMI may not need to be a significant deterrent in patient selection for TLIF under bundled payment models.

Study Design Retrospective cohort study. Objective To determine hospital length of stay (LOS) and long-term opioid consumption among patients who received inpatient multimodal analgesia following lumbar spine surgery, as opposed to those who received opioids alone. Summary of Background Data Opioids have long been the historical choice for managing postoperative pain. The use of multimodal analgesia has become more commonplace in recent years as it is thought to achieve similar levels of pain control while simultaneously diminishing opioid consumption and decreasing LOS. Materials and Methods Patients who underwent 1 or 2-level lumbar fusion from 2018 to 2019 were included. Patients who received opioids on an as-needed basis were propensity-matched to a cohort who received multimodal analgesia based on demographics, surgical approach, and levels fused. LOS was collected for each patient. One year preoperative to 2 postoperative opioid use was obtained from the Pennsylvania Prescription Drug Monitoring Program and included total prescriptions and total morphine milligram equivalents (MMEs). A subanalysis was also performed comparing preoperative, perioperative, and postoperative tramadol consumption during this time frame. Results A total of 69 patients received an opioid-only pain regimen, while 207 patients received multimodal analgesia. Patients receiving a multimodal pain regimen consumed a higher daily tramadol MME but a comparable total in-hospital MME to patients in the opioid-only cohort. No statistically significant differences existed between cohorts with regards to LOS, preoperative, perioperative, and postoperative opioid consumption, though multimodal patients consumed more tramadol from 0 to 30 days postoperatively. Conclusions Patients who received a multimodal pain regimen consumed comparable quantities of opioids to those who received opioids alone and did not have a longer LOS following 1 and 2-level lumbar fusion.

Background Anterior cervical discectomy and fusion (ACDF) is a common surgery for patients with degenerative cervical disease and current interbody spacers utilized vary based on material composition, structure, and angle of lordosis. Currently, there is a lack of literature comparing subsidence rates or long-term radiographic outcomes with hyperlordotic and standard lordotic spacers. This study compares long-term radiographic outcomes, subsidence rate, and rate of fusion in patients who underwent ACDF with hyperlordotic or standard interbody placement. Materials and Methods Patients who underwent 1–3-level ACDF with either a standard lordosis or hyperlordotic interbody were included. Standard radiographs were evaluated for C2–7 lordosis (CL), sagittal vertical axis, C2 slope (C2S), T1 slope (T1S), subsidence rate, and fusion. Results Forty-five patients underwent ACDF with hyperlordotic interbody placement and after a 1:1 propensity match with standard lordotic patients, 90 patients were included. 1-year postoperative radiographs demonstrated the hyperlordotic cohort achieved higher CL (15.3° ± 10.6° vs. 9.58° ± 8.88°; P = 0.007). The change in CL (8.42° ± 9.42° vs. 0.94° ± 8.67°; P < 0.001), change in C2S (−4.02° ± 6.68° vs. −1.11° ± 5.42°; P = 0.026), and change in T1S (3.49° ± 7.30° vs. 0.04° ± 6.86°, P = 0.008) between pre- and postoperative imaging were larger in the hyperlordotic cohort. There was no difference in overall subsidence ( P = 0.183) and rate of fusion ( P = 0.353) between the cohorts. Conclusion Hyperlordotic spacer placement in ACDF can provide increased CL compared to standard lordosis spacers, which can be considered for patients requiring restoration or maintenance of CL following ACDF.

Study Design Retrospective cohort study. Objective To compare peri- and postoperative infection rates among patients with mild to moderate penicillin allergies who receive cefazolin vs vancomycin as prophylaxis for lumbar fusion. Additionally, we sought to determine if patients receiving cefazolin exhibited any clinical symptoms suggestive of drug-induced hypersensitivity reactions, and to compare those rates to patients who received vancomycin. Summary of Background Data Cefazolin has been historically linked to hypersensitivity reactions in penicillin-allergic patients due to cross-reactivity. As a result, vancomycin is often given to these patients instead. To our knowledge, no studies have directly compared these two antibiotics in penicillin-allergic patients undergoing lumbar fusion. Methods Patients with mild to moderate documented penicillin allergies who underwent lumbar fusion from 2017-2022 and received prophylactic cefazolin or vancomycin were studied. Demographic, surgical information, and hospital length of stay (LOS) were recorded. We identified drug sensitivity reactions, in hospital infections, 90-day readmissions related to infectious etiologies and need for irrigation and debridement (I&D) to treat a surgical site infection. Results 222 patients received cefazolin, while 180 received vancomycin. Patients receiving vancomycin had more medical comorbidities, while patients receiving cefazolin had slightly more levels fused. No significant differences existed between cohorts in postoperative infection rate. One patient given cefazolin developed a mild drug-induced skin reaction that was treated with topical steroids. No significant differences existed between cohorts in 90-day readmissions or need for I&D surgery. On bivariate analysis, patients given cefazolin had a longer LOS but this was attributed to confounding variables on multivariate analysis. Conclusions Cefazolin and vancomycin are comparable at preventing postoperative infections among patients with mild to moderate documented reactions to penicillin. Our findings also suggest that penicillin-allergic patients are not at higher risk of developing drug-related hypersensitivity reactions in response to cefazolin exposure when compared to those who received vancomycin.