Temporal trends in neurosurgical volume and length of stay in a public healthcare system: A decade in review with a focus on the COVID-19 pandemic.

Background: Over the past decade, neurosurgical interventions have experienced changes in operative frequency and postoperative length of stay (LOS), with the recent COVID-19 pandemic significantly impacting these metrics. Evaluating these trends in a tertiary National Health Service center provides insights into the impact of surgical practices and health policy on LOS and is essential for optimizing healthcare management decisions. Methods: This was a single tertiary center retrospective case series analysis of neurosurgical procedures from 2012 to 2022. Factors including procedure type, admission urgency, and LOS were extracted from a prospectively maintained database. Six subspecialties were analyzed: Spine, Neuro-oncology, Skull base (SB), Functional, Cerebrospinal fluid (CSF), and Peripheral nerve (PN). Mann-Kendall temporal trend test and exploratory data analysis were performed. Results: 19,237 elective and day case operations were analyzed. Of the 6 sub-specialties, spine, neuro-oncology, SB, and CSF procedures all showed a significant trend toward decreasing frequency. A shift toward day case over elective procedures was evident, especially in spine (P < 0.001), SB (tau = 0.733, P = 0.0042), functional (tau = 0.156, P = 0.0016), and PN surgeries (P < 0.005). Over the last decade, decreasing LOS was observed for neuro-oncology (tau = -0.648, P = 0.0077), SB (tau = -0.382, P = 0.012), and functional operations, a trend which remained consistent during the COVID-19 pandemic (P = 0.01). Spine remained constant across the decade while PN demonstrated a trend toward increasing LOS. Conclusion: Most subspecialties demonstrate a decreasing LOS coupled with a shift toward day case procedures, potentially attributable to improvements in surgical techniques, less invasive approaches, and increased pressure on beds. Setting up extra dedicated day case theaters could help deal with the backlog of procedures, particularly with regard to the impact of COVID-19.

Determining the risk of spinal pathology progression in neurofibromatosis type 1 patients - a national tertiary neurofibromatosis type 1 centre study.

BACKGROUND: Neurofibromatosis type 1 (NF1) gives rise to a variety of spinal pathologies that include dural ectasia (DE), vertebral malalignments (VMA), spinal deformities (SD), syrinx, meningoceles, spinal nerve root tumours (SNRT), and spinal plexiform tumours (SPT). The relationship between these and the progression of these pathologies has not been explored before in detail and this paper aims to address this. METHODS: Data was retrospectively collected from adult NF1 multi-disciplinary team meetings from 2016 to 2022 involving a total of 593 patients with 20 distinct predictor variables. Data were analyzed utilizing; Chi-Square tests, binary logistic regression, and Kaplan-Meier analysis. RESULTS: SNRT (19.9%), SD (18.6%), and (17.7%) of VMA had the highest rates of progression. SD was significantly associated (p < 0.02) with the presence and progression of all spinal pathologies except for SPT. Statistically significant predictors of SD progression included the presence of DVA, VMA, syrinx, meningocele, and SNRT. Kaplan-Meier analysis revealed no statistically significant difference between the times to progression for SD (85 days), SNRT (1196 days), and VMA (2243 days). CONCLUSION: This paper explores for the first time in detail, the progression of various spinal pathologies in NF1. The presence and progression of SD is a key factor that correlated with the progression of different spinal pathologies. Early identification of SD may help support clinical decision-making and guide radiological follow-up protocols and treatment.

Predicting neurosurgical referral outcomes in patients with chronic subdural hematomas using machine learning algorithms - A multi-center feasibility study.

Background: Chronic subdural hematoma (CSDH) incidence and referral rates to neurosurgery are increasing. Accurate and automated evidence-based referral decision-support tools that can triage referrals are required. Our objective was to explore the feasibility of machine learning (ML) algorithms in predicting the outcome of a CSDH referral made to neurosurgery and to examine their reliability on external validation. Methods: Multicenter retrospective case series conducted from 2015 to 2020, analyzing all CSDH patient referrals at two neurosurgical centers in the United Kingdom. 10 independent predictor variables were analyzed to predict the binary outcome of either accepting (for surgical treatment) or rejecting the CSDH referral with the aim of conservative management. 5 ML algorithms were developed and externally tested to determine the most reliable model for deployment. Results: 1500 referrals in the internal cohort were analyzed, with 70% being rejected referrals. On a holdout set of 450 patients, the artificial neural network demonstrated an accuracy of 96.222% (94.444-97.778), an area under the receiver operating curve (AUC) of 0.951 (0.927-0.973) and a brier score loss of 0.037 (0.022-0.056). On a 1713 external validation patient cohort, the model demonstrated an AUC of 0.896 (0.878-0.912) and an accuracy of 92.294% (90.952-93.520). This model is publicly deployed: https://medmlanalytics.com/neural-analysis-model/. Conclusion: ML models can accurately predict referral outcomes and can potentially be used in clinical practice as CSDH referral decision making support tools. The growing demand in healthcare, combined with increasing digitization of health records raises the opportunity for ML algorithms to be used for decision making in complex clinical scenarios.

The Fate of Nonoperative Management in Patients with Lytic Spondylolisthesis.

BACKGROUND: There is a lack of consensus within the current literature about the role of nonoperative management in lytic spondylolisthesis. Our objective was to assess the fate that nonoperative management plays in patients diagnosed with lytic spondylolisthesis. METHODS: Data were collected between May 2015 and February 2020 from 41 patients who were initially referred specifically for instrumented lumbar fixation but were instead planned for nonoperative management as they opted to avoid surgery. Magnetic resonance imaging (MRI) scans were used to determine spondylolisthesis grade, type of deformity, and radiologic features. Patient notes were reviewed to establish management plans. Furthermore, patients were also contacted via telephone to assess their symptoms and disease progression. RESULTS: Twenty-six of the 41 patients had lytic spondylolisthesis (63.4%). Of these patients, the male-to-female ratio was 10:16. The median age was 60 (range: 22-76) years. A total of 12 patients were managed nonoperatively for 5 years or longer, with 2 patients showing progression from grade I to II. CONCLUSION: Nonoperative management of lytic spondylolisthesis is a reasonable option in a selected cohort of patients. The longer in duration patients are managed conservatively, the less likely they are to require a surgical intervention. Even severe radiologic foraminal stenosis without radicular pain does not seem to push patients toward surgery. Management decisions must be made on an individual basis. These data can give some reassurance to patients who wish to consider nonoperative management and help guide clinicians.

Wrong site spine surgery in the U.K.: a review of current practice.

Wrong site spine surgery is a rare but serious complication. The scale of the problem in the U.K. and the current practice of spine surgeons in localising the level whilst performing routine spine surgery is unknown. As these events are rare and their nature very disparate, it is necessary to identify whether there are any common themes to be able to take effective steps to mitigate this risk. A review was undertaken of the wrong site spine surgery incidents submitted to StEIS (Strategic Executive Information System), the system used to report and monitor the progress of Serious Incident investigations across the NHS. Subsequently a survey of the Society of British Neurosurgeons was undertaken to answer some of the questions which arose from this review. Up to half of spine surgeons surveyed by the SBNS admit to having performed wrong site spine surgery. 40 percent of wrong site surgery reported to NHSE was at the L4/5 level. What exactly constitutes wrong level spine surgery is not universally accepted by spine surgeons. The critical factors in causing wrong site spine surgery in the U.K. are explored. It is hoped that the results from this study would improve training, lead to better policies and support investment in trying to reduce this complication.

Development and Validation of the Chronic Subdural HematOma Referral oUtcome Prediction Using Statistics (CHORUS) Score: A Retrospective Study at a National Tertiary Center.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurosurgical condition with an increasing rate of patient referrals. CSDH referral decision-making is a subjective clinical process, and our aim was to develop a simple scoring system capable of acting as a decision support tool aiding referral triage. METHODS: A single tertiary center retrospective case series analysis of all CSDH patient referrals from 2015 to 2020 was conducted. Ten independent variables used in the referral process were analyzed to predict the binary outcome of either accepting or rejecting the CSDH referral. Following feature selection analysis, a multivariable scoring system was developed and evaluated. RESULTS: 1500 patient referrals were included. Stepwise multivariable logistic and least absolute shrinkage and selection operator regression identified age <85 years, the presence of headaches, dementia, motor weakness, radiological midline shift, a reasonable premorbid quality of life, and a large sized hematoma to be statistically significant predictors of CSDH referral acceptance (P <0.04). These variables derived a scoring system ranging from -9 to 6 with an optimal cut-off for referral acceptance at any score >1 (P <0.0001). This scoring system demonstrated optimal calibration (brier score loss = 0.0552), with a score >1 predicting referral acceptance with an area under the curve of 0.899 (0.876-0.922), a sensitivity of 83.838% (76.587-91.089), and a specificity of 96.000% (94.080-97.920). CONCLUSIONS: Certain patient specific clinical and radiological characteristics can predict the acceptance or rejection of a CSDH referral. Considering the precision of this scoring system, it has the potential for effectively triaging CSDH referrals.

A Review of Spinal Lesions in Neurofibromatosis Type 1 in a Large Neurofibromatosis Type 1 Center.

BACKGROUND: Spinal lesions are a known manifestation of neurofibromatosis type 1 (NF1). The aim of this retrospective review was to analyze and report the prevalence of spinal lesions on imaging in a large NF1 center. METHODS: The data were collected from a period of 62 months from a cohort of 514 patients. Data were collected from multidisciplinary team meeting reports that included radiologic reports of each patient investigating 20 distinct variables. The prevalence of each of these lesions was calculated, and any statistically significant associations were investigated using the χ2 test. RESULTS: Four-hundred forty-seven patients had classic NF1, and 67 patients had spinal NF1. Many of the patients had spinal abnormalities; 25.7% of these patients were found to have dural ectasia, whereas 44.9% of patients had a spinal deformity. A statistically significant association between dural ectasia and spinal neurofibromatosis was established (P < 0.05). An additional statically significant association was established between dural ectasia and spinal deformity (P < 0.00001). The patients with spinal nerve root tumors were identified, and it was found that 49.8% of patients possessed these tumors, whereas 56.3% of these tumors were intraspinal tumors. The most common region affected was the cervical spine, and the most common spinal level was C2. CONCLUSIONS: This high prevalence of spinal tumours in mobile areas of the spine is possibly the result of a combination of genetic predisposition and repeated microtraumas resulting in tumor formation. This is the largest reported study of spinal lesions in NF1 based on imaging and offers insights into the etiology and relationships between lesions.

Natural language processing for the automated detection of intra-operative elements in lumbar spine surgery.

Background: The aim of this study was to develop natural language processing (NLP) algorithms to conduct automated identification of incidental durotomy, wound drains, and the use of sutures or skin clips for wound closure, in free text operative notes of patients following lumbar surgery. Methods: A single-centre retrospective case series analysis was conducted between January 2015 and June 2022, analysing operative notes of patients aged >18 years who underwent a primary lumbar discectomy and/or decompression at any lumbar level. Extreme gradient-boosting NLP algorithms were developed and assessed on five performance metrics: accuracy, area under receiver-operating curve (AUC), positive predictive value (PPV), specificity, and Brier score. Results: A total of 942 patients were used in the training set and 235 patients, in the testing set. The average age of the cohort was 53.900 ± 16.153 years, with a female predominance of 616 patients (52.3%). The models achieved an aggregate accuracy of >91%, a specificity of >91%, a PPV of >84%, an AUC of >0.933, and a Brier score loss of ≤0.082. The decision curve analysis also revealed that these NLP algorithms possessed great clinical net benefit at all possible threshold probabilities. Global and local model interpretation analyses further highlighted relevant clinically useful features (words) important in classifying the presence of each entity appropriately. Conclusions: These NLP algorithms can help monitor surgical performance and complications in an automated fashion by identifying and classifying the presence of various intra-operative elements in lumbar spine surgery.

Outcomes and efficiency of managing patients admitted for surgery for spinal metastases.

Background: This study evaluated the current pathways for dealing with patients admitted for surgery to address spinal metastases. Methods: In this retrospective analysis (2016-2021), the following variables were studied admission, demographics, length of stay, critical care admission, hospital costs, primary cancer, and average survival. Results: There were 306 patients admitted from 2016 to 2021; 66 were planned admissions, 203 were emergency admissions, and 37 were day case admission. Patients averaged 65.4 years old. About 75% (203) were emergently admitted, while 25% (66) had planned elective admissions. Their respective lengths of stay were 16.5 versus 5.74 days. Interestingly, nearly half of the emergency admissions (46.3%) did not have surgery during that admission. The most common level for metastatic disease was the thoracic spine in both groups (53% in the elective vs. 62% emergency groups). The most common primary lesions included lung, breast, and prostate in both groups. The average survival in the emergency admission group was 9.1 months and the planned admission group was 13.07 months. Notably, the costs of emergent care were much higher than planned admissions. Conclusion: The pathway for spinal metastases is unique in that though there is a pathway for late-stage disease, there is not one for early disease. As a result, the majority of patients admitted for surgery for spinal metastases come in as an emergency rather than as a planned admission. Yet, close to half do not end up having surgery during that emergency admission to the spinal center. The cost of emergency care is significantly higher versus planned elective care for spinal metastatic disease. A service transformation is suggested to combat these problems with a pathway for managing all spinal metastases, rather than just metastatic spinal cord compression.

A case of a giant thoracic schwannoma.

Background: Giant solitary schwannomas are rare, benign, and typically slow-growing tumors reaching up to 20 cm in size. Case Description: A 43-year-old male presented with shortness of breath and chest pain. The thoracic MRI showed a giant mass 15 cm in diameter filling the left chest cavity. The lesion was resected utilizing intrathoracic approach and required a multilevel approach. Vertebrectomy with instrumented fusion was performed. The pathological diagnosis was benign schwannoma without nuclear atypia. Postoperatively, the patient fully recovered without sequelae. Conclusion: A 43-year-old male presented with a 15 cm diameter chest mass that proved to be a schwannoma that was resected without long-term sequelae.

A postoperative complication of lumbar discectomy: A discal/annular cyst.

Background: A postoperative discal/annular cyst following lumbar discectomy may reproduce the symptoms/signs of a recurrent lumbar disc herniation (i.e., back pain and radiculopathy). Case Description: A 21-year-old rugby player developed leg pain after an uncomplicated lumbar microdiscectomy. The repeat lumbar magnetic resonance imaging confirmed a postoperative lumbar annular/ discal cyst, for which he underwent repeat surgery. The diagnosis was further confirmed histopathologically at surgery. Conclusion: Although rare, postoperative discal/annular cysts may be potential causes of recurrent postoperative pain and lumbar radiculopathy mimicking recurrent disc herniations.

Recommencement of anticoagulation/antiplatelet therapy following non-operative management of a Chronic Subdural Hematoma - Is there an optimal time frame?

BACKGROUND: There is no consensus among clinicians regarding recommencement of antithrombotic agents following conservative management of a Chronic Subdural Hematoma (cSDH). Thus, the primary objective of this study was to determine the most commonly recommended interval and whether the data reveal a general consensus that should be adopted. METHODS: A retrospective analysis of Salford Royal Foundation Trust's Neurosurgical referral database for patients referred with a cSDH between March 2017 and March 2020 was carried out. Patients were sorted by whether they were on blood-thinning medications. RESULTS: Over the 3-year period, there were a total of 1220 referral and 1099 patients. 502 (41.14%) of these referrals and 479 (43.59%) patients were on one more blood thinning agent. Of these patients 221 (46.13%) conservative management, there was a clear male predominance (M: F ≈ 2.5:1) in this cohort. 2 weeks was the most commonly advised time-frame (n = 76, 36.36%) to withhold. Of the 234 referrals, there were 13 (5.88%) re-referrals in total. Crucially, there was no significant difference in reaccumulation rates between patients asked to withhold their blood thinners for 2 weeks versus those asked to stop for longer than 2 weeks (P = 0.57). CONCLUSION: For the majority of bleeds, there is no clear benefit from asking patients to withhold their anticoagulant/antiplatelet for longer than 2 weeks. In cases, where it is deemed appropriate to stop for longer than 2 weeks, clear instructions should be provided and documented along with reasons behind the decision.

Neurosurgery activity levels in the United Kingdom and republic of Ireland during the first wave of the covid-19 pandemic - a retrospective cross-sectional cohort study.

The impact of Covid-19 on surgical patients worldwide has been substantial. In the United Kingdom (UK) and the Republic of Ireland (RoI), the first wave of the pandemic occurred in March 2020. The aims of this study were to: (1) evaluate the volume of neurosurgical operative activity levels, Covid-19 infection rate and mortality rate in April 2020 with a retrospective cross-sectional cohort study conducted across 16 UK and RoI neurosurgical centres, and (2) compare patient outcomes in a single institution in April-June 2020 with a comparative cohort in 2019. Across the UK and RoI, 818 patients were included. There were 594 emergency and 224 elective operations. The incidence rate of Covid-19 infection was 2.6% (21/818). The overall mortality rate in patients with a Covid-19 infection was 28.6% (6/21). In the single centre cohort analysis, an overall reduction in neurosurgical operative activity by 65% was observed between 2020 (n = 304) and 2019 (n = 868). The current and future impact on UK neurosurgical operative activity has implications for service delivery and neurosurgical training.

The impact of COVID-19 on neurosurgical head trauma referrals and admission at a tertiary neurosurgical centre.

BACKGROUND: COVID-19 has greatly impacted surgical specialities throughout the globe leading to a decrease in hospital admissions and referrals. Neurosurgery has seen a great decline in cases including head trauma leading to a negative impact on the development of neurosurgical trainees. The main objective of this study is to the identify changes in neurosurgical referrals, admissions and management during the COVID-19 pandemic. We also aim to assess how current practise could be adapted to help manage future pandemic peaks. METHODS: Data was collected for the first 31 days of lockdown during 2020 (23rd March - 22nd April) and compared to the same time period in the years 2016-2019. We assessed the number of referrals, admissions and clinical information of patients during this period with a key emphasis on head trauma. RESULTS: Neurosurgical head injury referrals and admissions reduced by 57.5% and 48.3% respectively during the first 31 days of lockdown when compared to the mean figures for the same period in the previous 4 years. This was also seen with head trauma with a 21.9% decline in referrals and 39.1% reduction in admissions for the period of interest. A significant decrease in length of stay (P < 0.001) was seen between 2020 and the years 2017-19. CONCLUSION: The impact of COVID-19 makes it imperative that we plan for future pandemics to lessen the impact on neurosurgery. Special considerations need to be taken so that trainees are sufficiently prepared for completion of training whilst still priotising patient safety and providing high quality care.

Spinal cord compression from hypertrophic nerve roots in chronic inflammatory demyelinating polyradiculoneuropathy - A case report.

BACKGROUND: Spinal cord compression secondary to nerve root hypertrophy is often attributed to hereditary neuropathies. However, to avoid misdiagnosis, rare immune-mediated neuropathy such as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) should not be overlooked. This report presents a case of multilevel nerve root hypertrophy leading to significant cord compression from CIDP. CASE DESCRIPTION: We report a 56-year-old gentleman with type two diabetes mellitus who presented with subacute cervical cord syndrome following a fall. Mixed upper and lower motor neuron features were noted on examination. Magnetic resonance imaging showed significant pan-spinal proximal nerve root hypertrophy, compressing the cervical spinal cord. Initial radiological opinion raised the possibility of neurofibromatosis type 1 (NF-1), but neurophysiology revealed both axonal and demyelinating changes that were etiologically non-specific. C6 root and sural nerve biopsies taken at cervical decompression displayed striking features suggestive for CIDP. Although NF-1 is the most observed condition associated with root hypertrophy, other important and potentially treatable differentials need to be entertained. CONCLUSION: While rare, CIDP can cause significant spinal cord compression. Furthermore, clinical manifestations of CIDP can mimic those of inherited peripheral neuropathies. Neurologists and neurosurgeons should be aware of this condition to optimize subsequent therapeutic decision-making.

Considerations in revising occipitocervical fixation for dysphagia.

BACKGROUND: Dysphagia after occipitocervical fixation (OCF) is a complex phenomenon and revision surgery in this context involves difficult decision-making. The pathogenesis is explored and surgical strategies discussed. A surgical strategy that has not been described before in the management of this condition, is discussed with two illustrative cases. METHODS: Two cases are presented where dysphagia occurred after OCF for C1/C2 instability. The preoperative imaging was not available to determine whether the optimal craniocervical angle had been achieved. Both had revision surgery with removal of the cranial fixation and fusion to the atlas instead. One of the cases had the revision surgery more than 10 years after the original OCF. RESULTS: The dysphagia recovered after the revision surgery in both cases. The patients gained weight and reported more satisfaction with their posture and head movements compared to before the revision surgery. There was no head ptosis and instead, patients reported better forward gaze and head position. CONCLUSION: In cases of C1/C2 instability, it is preferable to perform C1/C2 fusion rather than OCF. If performing an OCF, care must be taken to fix the head at the same O-C2 angle as preoperative. When an OCF done for C1 C2 instability ends up causing dysphagia, it is feasible and effective to shorten the rostral construct by removing the cranial fixation and fusing to C1 instead.

Spinal cord herniation following multilevel anterior cervical discectomy and fusion: A case report and literature review.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal operations. Spinal cord herniation following these procedures is rare, more typically being described as occurring posteriorly rather than following anterior corpectomy and fusion (e.g., reported in four corpectomy cases). Here, we describe a case in which spinal cord herniation was attributed to a three-level ACDF. CASE DESCRIPTION: A 31-year-old male initially presented with a 1 year's duration of increasing myelopathy attributed to MR documented three-level disc disease (C4-C7). He successfully underwent a three-level ACDF without complications/durotomy. One year later, he again presented, with myelopathy (i.e., recurrent neck pain and stiffness) newly attributed to MR documented anterolateral C4-C5 cord herniation. As he declined further surgery, he was treated medically (e.g., utilizing analgesia and physiotherapy) and was no worse 6 months later. CONCLUSION: The occurrence of spinal cord herniation through a prior ACDF defect must be considered when patients present with recurrent myelopathy following previous ACDF surgery.

Foramen magnum osteochondroma causing myelopathy in a patient with hereditary multiple exostoses.

BACKGROUND: Osteochondromas are commonly occurring benign bone tumors which may be either a solitary lesion or occur due to association with hereditary multiple exostoses (HMEs). There have been several reported cases of spinal osteochondromas, but intracranial lesions are rare. CASE DESCRIPTION: A 51-year-old male with a history of multiple osteochondromas presented with myelopathy. He had an exostosis arising from the foramen magnum causing compression of the cervical spinal cord that was successfully removed. Genetic testing revealed that he had HMEs. CONCLUSION: Osteochondromas of the skull are extremely rare. However, parts of the foramen magnum ossify in cartilage and can give rise to an osteochondroma. Here, we present a patient with HMEs who developed cervical myelopathy due to an osteochondroma arising from the foramen magnum. Due to the cartilaginous ossification of the foramen magnum, clinicians should be aware that osteochondromas can occur in this location and potentially give rise to cervical myelopathy.

A novel gold marker to aid intraoperative localisation during spinal surgery!

Methods of pre-operative level marking for spinal surgery include fiducial implants, coil implants, spinal needle implant, methylene blue and cement injection. We describe a novel gold marker used for preoperative spinal marking and report our experience.The notes and scans of patients who had gold marker for preoperative spinal marking over the period from June 2016 to November 2018 were analysed.20 patients had preoperative spinal marking using the gold marker. The accuracy was 100% and there were no complications. Compared to injecting cement, we save over £700 per patient!

The association of spinal deformity with dural ectasia in neurofibromatosis type 1.

Objective: To establish the prevalence of dural ectasia in patients with complex neurofibromatosis type-1 (NF-1) and its association with spinal deformities that manifest alongside.Methods: Analysis of the neuroradiological notes from 24 months of multidisciplinary team meetings for patients with complex NF-1 (equating to 378 patients). Review of the MRI scans of all patients with dural ectasia with each scan graded using a novel grading system.Results: A total of 38 of the 378 patients were found to have dural ectasia (10.05%). The median age of these 38 patients was 36 years ranging from 18 to 64. The male: female ratio was 16:22. In all, 90.9% of patients with a 'major' form of dural ectasia had a concurrent spinal deformity present compared to 18.18% of patients with a minor form.Conclusions: The more severe the dural ectasia, the greater the likelihood a concurrent deformity with NF-1. The vertebral bodies and pedicles are more commonly involved than the posterior elements.