The Impact of Cognitive Impairment on Postoperative Complications After Spinal Surgery: A Matched Analysis.

OBJECTIVE: The coprevalence of age-related comorbidities such as cognitive impairment and spinal disorders is increasing. No studies to date have assessed the postoperative spine surgery outcomes of patients with mild cognitive impairment (MCI) or severe cognitive impairment (dementia) compared with those without preexisting cognitive impairment. METHODS: Using all-payer claims database, 235,123 persons undergoing either cervical or lumbar spine procedures between January 2010 and October 2020 were identified. Exact 1:1:1 matching based on baseline patient demographics and comorbidities was used to create a dementia group, MCI group, and control group without MCI/dementia (n = 3636). The primary outcome was the rate of any 30-day major postoperative complications. Secondary outcomes included the rates of revision surgery, readmission rates within 30 days, and health care costs within 1 year postoperatively. RESULTS: Compared with the control group, patients with dementia had an 8-fold and 5.4-fold increase in all-cause 30-day complications after undergoing cervical and lumbar spine procedures, respectively. Similarly, patients with MCI had a 3.1-fold and 2.2-fold increase in all-cause 30-day complications, respectively. Patients with either MCI or dementia had increased rates of pneumonia and urinary tract infection after either spine procedure compared with control (P < 0.01). Odds of revision surgery were increased in the lumbar surgery cohort for dementia (3.43; 95% confidence interval, 1.69-6.95) and for MCI (2.41; 95% confidence interval, 1.14-5.05). CONCLUSIONS: This is the first study to characterize the postoperative complications profile of patients with preexisting dementia or MCI undergoing cervical and lumbar spine surgery. Both dementia and MCI are associated with increased postoperative complications within 30 days.

The impact of smoking and smoking cessation interventions on outcomes following single-level anterior cervical discectomy and fusion procedures.

BACKGROUND: While several studies explore the impact of smoking tobacco on spinal fusion outcomes, there is a paucity of literature on the influence of modern smoking cessation therapies on such outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF). OBJECTIVE: Our study explores the outcomes of single-level ACDF surgery in nonsmokers, active smokers, and smokers undergoing cessation therapy. METHODS: MARINER30, an all-payer claims database, was utilized to identify patients undergoing single-level ACDF between 2010 and 2019. The primary outcomes were the rates of composite surgical complications, dysphagia, hematoma, symptomatic pseudarthrosis, instrumentation removal, need for revision surgery, and all-cause readmission rates within 30 and 90-days. RESULTS: The matched population consisted of 5769 patients undergoing single-level ACDF with 1923 (33.33%) in each of the following groups: (1) nonsmokers; (2) active smokers; and (3) patients undergoing smoking cessation therapy. Nonsmokers had significantly lower rates of composite surgical complications (3.74% vs 13.05% vs 15.08%), revision surgery (4.06% vs 20.07% vs 22.88%), instrumentation removal (0.83% vs. 2.08% vs. 2.76%), and dysphagia (0.36% vs 0.99% vs 0.62%) when compared to patients in the active smoking and smoking cessation groups, respectively. CONCLUSION: Patients using smoking cessation therapy were more likely to develop postoperative dysphagia and undergo revision surgery when compared to their actively smoking counterparts. While surgeons routinely recommend smoking cessation prior to surgery, the effects of smoking cessation therapies on surgical outcomes are not well characterized.

The Impact of Smoking Cessation Therapy on Lumbar Fusion Outcomes.

OBJECTIVE: While there are several reports on the impact of smoking tobacco on spinal fusion outcomes, there is minimal literature on the influence of modern smoking cessation therapies on such outcomes. Our study explores the outcomes of single-level lumbar fusion surgery in active smokers and in smokers undergoing recent cessation therapy. METHODS: MARINER30, an all-payer claims database, was utilized to identify patients undergoing single-level lumbar fusions between 2010 and 2019. The primary outcomes were the rates of any complication, symptomatic pseudarthrosis, need for revision surgery, and all-cause readmission within 30 and 90 days. RESULTS: The exact matched population analyzed in this study contained 31,935 patients undergoing single-level lumbar fusion with 10,645 (33%) in each of the following groups: (1) active smokers; (2) patients on smoking cessation therapy; and (3) those without any smoking history. Patients undergoing smoking cessation therapy have reduced odds of developing any complication following surgery (odds ratio 0.86, 95% confidence interval 0.80-0.93) when compared with actively smoking patients. Nonsmokers and patients on cessation therapy had a significantly lower rate of any complication compared with the smoking group (9.5% vs. 17% vs. 19%, respectively). CONCLUSIONS: When compared with active smoking, preoperative smoking cessation therapy within 90 days of surgery decreases the likelihood of all-cause postoperative complications. However, there were no between-group differences in the likelihood of pseudarthrosis, revision surgery, or readmission within 90 days.

Trends in Racial and Ethnic Representation Among Neurosurgery Applicants and Residents: A Comparative Analysis of Procedural Specialties.

BACKGROUND: Diversity, equity, and inclusion within the healthcare workforce are conducive to providing culturally competent care. However, few existing studies have assessed the level of racial and ethnic diversity among resident physicians and residency applicants. Our objective was to provide a comparative analysis of the trends in racial and ethnic representation within different subspecialties in medicine. METHODS: Using data from the American Association of Medical Colleges and the Journal of the American Medical Association, we evaluated the racial and ethnic identification of residency applicants and current residents in 9 procedural-focused specialties from 2005 to 2019 and performed a descriptive analysis to compare the different levels of racial and ethnic diversity in these specialties. RESULTS: Among the specialties analyzed during the study period, neurosurgery had the greatest magnitude of differences between Black/African-American residency applicants and current residents. The percentage of Black/African-American applicants was 92% greater than that of Black/African-American residents (10% of applicants vs. 5.2% of residents). In contrast, the percentage of White neurosurgery residents was 17.6% greater than that of White neurosurgery applicants (53.9% of applicants vs. 63.4% of residents). Similar trends were noted in all the specialties evaluated. Obstetrics and gynecology demonstrated the least disparity between Black/African-American applicants and residents (13.7% of applicants vs. 10.2% of residents; 35.4% difference). Hispanic and Asian representation varied widely between specialties. CONCLUSIONS: Among the surveyed specialties, neurosurgery demonstrated the greatest disparity between the percentage of Black/African-American residency applicants and current residents. To further drive progress in this domain, we advocate for a series of initiatives designed to increase underrepresented minority participation in neurosurgery practice and scholarship.

Patient and Spine Surgeon Perceptions on Shared Decision-Making in the Treatment of Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity.

STUDY DESIGN: Retrospective. OBJECTIVE: To understand patients' and spine surgeons' perspectives about decision-making around surgery for adult spinal deformity. SUMMARY OF BACKGROUND DATA: Surgery for correction of adult spinal deformity is often beneficial; however, in over 20% of older adults (≥ 65 yrs of age), outcomes from surgery are less desirable. MATERIALS AND METHODS: We conducted semistructured, in-depth interviews with six patients and five spine surgeons. Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes. RESULTS: Patients themes: 1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; 2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; 3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and 4) patients felt that pain management was the most difficult part of recovery from surgery. Surgeons themes: 1) surgeons varied substantially in their interpretations of shared decision-making; 2) surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; 3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and 4) surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration. CONCLUSION: Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery. These findings highlight the need for improved understanding of both sides of shared decision-making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness. LEVEL OF EVIDENCE: 3.

The influence of social determinants of health on single-level anterior cervical discectomy and fusion outcomes.

OBJECTIVE: Methods of reducing complications in individuals electing to undergo anterior cervical discectomy and fusion (ACDF) rely upon understanding at-risk patient populations, among other factors. This study aims to investigate the interplay between social determinants of health (SDOH) and postoperative complication rates, length of stay, revision surgery, and rates of postoperative readmission at 30 and 90 days in individuals electing to have single-level ACDF. METHODS: Using MARINER30, a database that contains claims information from all payers, patients were identified who underwent single-level ACDF between 2010 and 2019. Identification of patients experiencing disparities in 1 of 6 categories of SDOH was completed using ICD-9 and ICD-10 (International Classifications of Diseases, Ninth and Tenth Revisions) codes. The population was propensity matched into 2 cohorts based on comorbidity status: those with SDOH versus those without. RESULTS: A total of 10,030 patients were analyzed; there were 5015 (50.0%) in each cohort. The rates of any postoperative complication (12.0% vs 4.6%, p < 0.001); pseudarthrosis (3.4% vs 2.6%, p = 0.017); instrumentation removal (1.8% vs 1.2%, p = 0.033); length of stay (2.54 ± 5.9 days vs 2.08 ± 5.07 days, p < 0.001 [mean ± SD]); and revision surgery (9.7% vs 4.2%, p < 0.001) were higher in the SDOH group compared to patients without SDOH, respectively. Patients with any SDOH had higher odds of perioperative complications (OR 2.8, 95% CI 2.43-3.33), pseudarthrosis (OR 1.3, 95% CI 1.06-1.68), revision surgery (OR 2.4, 95% CI 2.04-2.85), and instrumentation removal (OR 1.4, 95% CI 1.04-2.00). CONCLUSIONS: In patients who underwent single-level ACDF, there is an association between SDOH and higher complication rates, longer stay, increased need for instrumentation removal, and likelihood of revision surgery.

Decisional Regret Among Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity: A Single Institutional Study.

STUDY DESIGN: Retrospective. OBJECTIVE: To investigate the prevalence of decisional regret among older adults undergoing surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Among older adults (≥65 years old), ASD is a leading cause of disability, with a population prevalence of 60% to 70%. While surgery is beneficial and results in functional improvement, in over 20% of older adults outcomes from surgery are less desirable. METHODS: Older adults with ASD who underwent spinal surgery at a quaternary medical center from January 1, 2016 to March 1, 2019, were enrolled in this study. Patients were categorized into medium/high or low-decisional regret cohorts based on their responses to the Ottawa decision regret questionnaire. Decisional regret assessments were completed 24 months after surgery. The primary outcome measure was prevalence of decisional regret after surgery. Factors associated with high decisional regret were analyzed by multivariate logistic regression. RESULTS: A total of 155 patients (mean age, 69.5 yrs) met the study inclusion criteria. Overall, 80% agreed that having surgery was the right decision for them, and 77% would make the same choice in future. A total of 21% regretted the choice that they made, and 21% responded that surgery caused them harm. Comparing patient cohorts reporting medium/high- versus low-decisional regret, there were no differences in baseline demographics, comorbidities, invasiveness of surgery, length of stay, discharge disposition, or extent of functional improvement 12-months after surgery. After adjusting for sex, American Society of Anesthesiologists score, invasiveness of surgery, and presence of a postoperative complication, older adults with preoperative depression had a 4.0 fold increased odds of high-decisional regret (P  = 0.04). Change in health related quality of life measures were similar between all groups at 12-months after surgery. CONCLUSION: While the majority of older adults were appropriately counseled and satisfied with their decision, one-in-five older adults regret their decision to undergo surgery. Preoperative depression was associated with medium/high decisional regret on multivariate analysis.Level of Evidence: 4.

The Financial Impact of the COVID-19 Pandemic on Neurosurgery Practice in Spring 2020.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has changed health care delivery across the United States. Few analyses have specifically looked at quantifying the financial impact of the pandemic on practicing neurosurgeons. A survey analysis was performed to address this need. METHODS: A 19-question survey was distributed to practicing neurosurgeons in the United States and its territories. The questions evaluated respondents' assessments of changes in patient and procedural volume, salary and benefits, practice expenses, staffing, applications for government assistance, and stroke management. Responses were stratified by geographic region. RESULTS: The response rate was 5.1% (267/5224). Most respondents from each region noted a >50% decrease in clinic volume. Respondents from the Northeast observed a 76% decrease in procedure volume, which was significantly greater than that of other regions (P = 0.003). Northeast respondents were also significantly more likely to have been reassigned to nonneurosurgical clinical duties during the pandemic (P < 0.001). Most respondents also noted decreased salary and benefits but experienced no changes in overall practice expenses. Most respondents did not experience significant reductions in nursing or midlevel staffing. These trends were not significantly different between regions. CONCLUSIONS: The COVID-19 pandemic has led to decreases in patient and procedural volume and physician compensation despite stable practice expenses. Significantly more respondents in the Northeast region noted decreases in procedural volume and reassignment to nonneurosurgical COVID-related medical duties. Future analysis is necessary as the pandemic evolves and the long-term clinical and economic implications become clear.

Comparison of Postoperative Opioid Utilization in an ACDF Cohort: Narcotic Naive Patients Versus Preoperative Opioid Users.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To compare the postoperative opioid utilization rates and costs after anterior cervical discectomy and fusion (ACDF) procedures between groups of patients who were preoperative opioid users versus opioid naive. SUMMARY OF BACKGROUND DATA: Opioid medications are frequently prescribed after ACDF procedures. Given the current opioid epidemic, there is increased emphasis on early identification of patients at risk for prolonged postoperative opioid use. METHODS: Records from patients diagnosed with cervical stenosis who underwent a ≤3-level index ACDF surgery between 2007 and 2017 were collected from a large insurance database. International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and generic drug codes were used to search clinical records. Two cohorts were established: a group of patients who utilized opioids preoperatively and a group of patients who were opioid naive at the time of surgery. The 1-year utilization and costs of postoperative therapies were documented for each group. RESULTS: The preoperative opioid use cohort contained 4485 patients (61.6%), whereas the opioid-naive cohort included 2799 patients (38.4%). Postoperatively, 86.6% of the preoperative opioid use group continued to use opioids, whereas 59.0% of the opioid-naive group began using opioids. Patients who utilized opioids preoperatively were 4.48 times more likely (95% confidence interval, 3.99-5.02, P<0.001) to use opioids postoperatively and 4.30 times more likely (95% confidence interval, 3.10-5.94, P<0.001) to become opioid dependent compared with opioid-naive patients. In addition, after normalization, patients in the preoperative opioid use group utilized 3.7 times more opioid units/patient and billed for 5.3 times more dollars/patient than opioid-naive patients. CONCLUSIONS: In patients with cervical stenosis who undergo an ACDF procedure, the postoperative utilization and costs of opioids seem to be substantially higher in patients with preoperative opioid use compared with opioid-naive patients. Efforts should be made to avoid opioid use as a component of conservative management before surgery. LEVEL OF EVIDENCE: Level III.

Sex Differences in Postoperative Complications and Functional Status After Deformity Correction Surgery: Do Men Fare Better Than Women?

OBJECTIVE: We investigated whether a sex-related difference exists in the postoperative complication risk and health-related quality of life measures after surgery for adult spinal deformity. METHODS: We performed a retrospective study of 156 adult patients with a diagnosis of adult spinal deformity who had undergone spinal surgery. The primary outcome variables included the postoperative complication rates and changes in the health-related quality of life measures. Adjusted odds ratios were estimated by multivariate logistic regression with the inclusion of covariate terms for sex, smoking, preoperative optimization, American Society of Anesthesiologists grade, depression, osteoporosis, invasiveness of surgery (number of vertebral levels fused), and baseline functional disability. RESULTS: At presentation, the women were more likely to be smokers (74 women [71.15%]; 23 men [42.31%]; P = 0.01) and to have a greater prevalence of depression (36 women [34.62%]; 10 men [19.23%]; P = 0.06). The women had also presented with more severe baseline pain (visual analog scale for back pain score, 7.24 vs. 6.00 [P = 0.02]; visual analog scale for leg pain score, 5.87 vs. 5.59 [P = 0.07]) and worse functional disability (patient-reported outcomes measurement information system score, 6.82 vs. 5.65 [P = 0.01]; Oswestry disability index, 45.42 vs. 37.07 [P = 0.01]). However, postoperatively, the women experienced greater improvement in pain and disability compared with the men. The unadjusted odds of a postoperative complication was greater for the women (odds ratio, 1.14; 95% confidence interval, 0.55-2.33). On multivariate logistic regression analysis, the association between sex and postoperative complications was attenuated after controlling for other baseline variables. CONCLUSIONS: In the present study, after adjustment for important baseline prognostic factors, no differences were found in the postoperative complication rates or extent of functional improvement when stratified by sex. Both sexes responded equally well to corrective surgery for symptomatic adult spinal deformity.

An Assessment of Nonoperative Management Strategies in a Herniated Lumbar Disc Population: Successes Versus Failures.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the utilization of conservative treatments in patients with lumbar intervertebral disc herniations who were successfully managed nonoperatively versus patients who failed conservative therapies and elected to undergo surgery (microdiscectomy). METHODS: Clinical records from adult patients with an initial herniated lumbar disc between 2007 and 2017 were selected from a large insurance database. Patients were divided into 2 cohorts: patients treated successfully with nonoperative therapies and patients that failed conservative management and opted for microdiscectomy surgery. Nonoperative treatments utilized by the 2 groups were collected over a 2-year surveillance window. "Utilization" was defined by cost billed to patients, prescriptions written, and number of units disbursed. RESULTS: A total of 277 941 patients with lumbar intervertebral disc herniations were included. Of these, 269 713 (97.0%) were successfully managed with nonoperative treatments, while 8228 (3.0%) failed maximal nonoperative therapy (MNT) and underwent a lumbar microdiscectomy. MNT failures occurred more frequently in males (3.7%), and patients with a history of lumbar epidural steroid injections (4.5%) or preoperative opioid use (3.6%). In a logistic multivariate regression analysis, male sex and utilization of opioids were independent predictors of conservative management failure. Furthermore, a cost analysis indicated that patients who failed nonoperative treatments billed for nearly double ($1718/patient) compared to patients who were successfully treated ($906/patient). CONCLUSION: Our results suggest that the majority of patients are successfully managed nonoperatively. However, in the subset of patients that fail conservative management, male sex and prior opioid use appear to be independent predictors of treatment failure.

Regional differences in prolonged non-operative therapy utilization prior to primary ACDF surgery.

There is a paucity of data characterizing regional variations in the utilization and costs of conservative management in patients suffering from cervical stenosis prior to anterior cervical discectomy and fusion (ACDF) surgery. An understating of these regional trends becomes critical as outcomes-based reimbursement strategies become standard. The objective of this investigation was to evaluate for regional differences in the utilization and overall costs of maximal non-operative therapy (MNT) prior to ACDF surgery. Medical records from patients with symptomatic cervical stenosis undergoing a ≤3-level index ACDF procedure between 2007 and 2016 were accessed from a large insurance database. Geographic regions (Midwest, Northeast, South, and West) reflected U.S. Census Bureau definitions. MNT utilization within 2-years prior to ACDF surgery was analyzed. An index ACDF surgery was performed in 15,825 patients. Patient regional breakdown was as follows: South (67.6% of patients), Midwest (21.8% of patients), West (8.9% of patients), Northeast (1.6% of patients). Regional variations were identified in the number of patients utilizing NSAIDs (p < 0.001), opioids (p < 0.001), muscle relaxants (p < 0.001), cervical epidural steroid injections (p = 0.001), physical therapy/occupational therapy treatments (p < 0.001), and chiropractor visits (p < 0.001). The West (64.5%) and South (63.5%) had the greatest proportion of patients utilizing narcotics. When normalized by the number of opioid using-patients however, the Northeast (691.4 pills/patient) and South (674.4 pills/patient) billed for the most opioid pills. The total direct cost associated with all MNT prior to index ACDF was $17,255,828. The Midwest ($1,277.72 per patient) and South ($1,047.86 per patient) had the greatest average dollars billed.

A comparison of prolonged nonoperative management strategies in cervical stenosis patients: Successes versus failures.

A paucity of evidence exists regarding the optimal composition of conservative therapies to best treat patients diagnosed with cervical stenosis prior to consideration of surgery. The purpose of this study was to compare the nonoperative therapy utilization strategies in cervical stenosis patients successfully managed with conservative treatments versus those that failed medical management and opted for an anterior cervical discectomy and fusion (ACDF) surgery. Medical records from adult patients with a diagnosis of cervical stenosis from 2007 to 2017 were collected retrospectively from a large insurance database. Patients were divided into two cohorts: patients treated successfully with nonoperative therapies and patients that failed conservative management and opted for ACDF surgery. Nonoperative therapies utilized by the two cohorts were collected over a 2-year surveillance window. A total of 90,037 adult patients with cervical stenosis comprised the base population. There were 83,384 patients (92.6%) successfully treated with nonoperative therapies alone, while 6,653 patients (7.4%) ultimately failed conservative management and received an ACDF. Failure rates of non-operative therapies were higher in smokers (11.2%), patients receiving cervical epidural steroid injections (11.2%), and male patients (8.1%). A greater percentage of patients who failed conservative management utilized opioid medications (p < 0.001), muscle relaxants (p < 0.001), and CESIs (p < 0.001). The costs of treating patients that failed conservative management was double the amount of the successfully treated group (failed cohort: $1,215.73 per patient; successful cohort: $659.58 per patient). A logistic regression analysis demonstrated that male patients, smokers, opioid utilization, and obesity were independent predictors of conservative treatment failure.

Association of osteopenia and osteoporosis with higher rates of pseudarthrosis and revision surgery in adult patients undergoing single-level lumbar fusion.

OBJECTIVE: Patients with osteopenia or osteoporosis who require surgery for symptomatic degenerative spondylolisthesis may have higher rates of postoperative pseudarthrosis and need for revision surgery than patients with normal bone mineral densities (BMDs). To this end, the authors compared rates of postoperative pseudarthrosis and need for revision surgery following single-level lumbar fusion in patients with normal BMD with those in patients with osteopenia or osteoporosis. The secondary outcome was to investigate the effects of pretreatment with medications that prevent bone loss (e.g., teriparatide, bisphosphonates, and denosumab) on these adverse outcomes in this patient cohort. METHODS: Patients undergoing single-level lumbar fusion between 2007 and 2017 were identified. Based on 1:1 propensity matching for baseline demographic characteristics and comorbidities, 3 patient groups were created: osteopenia (n = 1723, 33.3%), osteoporosis (n = 1723, 33.3%), and normal BMD (n = 1723, 33.3%). The rates of postoperative pseudarthrosis and revision surgery were compared between groups. RESULTS: The matched populations analyzed in this study included a total of 5169 patients in 3 groups balanced at baseline, with equal numbers (n = 1723, 33.3%) in each group: patients with a history of osteopenia, those with a history of osteoporosis, and a control group of patients with no history of osteopenia or osteoporosis and with normal BMD. A total of 597 complications were recorded within a 2-year follow-up period, with pseudarthrosis (n = 321, 6.2%) being slightly more common than revision surgery (n = 276, 5.3%). The odds of pseudarthrosis and revision surgery in patients with osteopenia were almost 2-fold (OR 1.7, 95% CI 1.26-2.30) and 3-fold (OR 2.73, 95% CI 1.89-3.94) higher, respectively, than those in patients in the control group. Similarly, the odds of pseudarthrosis and revision surgery in patients with osteoporosis were almost 2-fold (OR 1.92, 95% CI 1.43-2.59) and > 3-fold (OR 3.25, 95% CI 2.27-4.65) higher, respectively, than those in patients in the control group. Pretreatment with medications to prevent bone loss prior to surgery was associated with lower pseudarthrosis and revision surgery rates, although the differences did not reach statistical significance. CONCLUSIONS: Postoperative pseudarthrosis and revision surgery rates following single-level lumbar spinal fusion are significantly higher in patients with osteopenia and osteoporosis than in patients with normal BMD. Pretreatment with medications to prevent bone loss prior to surgery decreased these complication rates, although the observed differences did not reach statistical significance.