Chordoma incidence, treatment, and survival in the 21st century: a population-based Ontario cohort study.

OBJECTIVE: This study estimates the incidence, treatment patterns, and overall survival for patients with chordoma treated in Ontario. METHODS: A 17-year (2003-2019) population-based cohort study was conducted, including all patients in the Ontario Cancer Registry with histologically proven chordoma. Primary outcomes of interest were age-standardized annual incidence, overall survival, and rates of radiation therapy, chemotherapy, and open resection. RESULTS: A total of 208 patients were diagnosed with chordoma over the study period: 97 patients with skull base chordoma, 37 with mobile spine chordoma, and 65 with sacropelvic chordoma. A total of 133 patients were treated with either open or endoscopic surgery, of whom 99 were also treated with some form of radiation therapy. Across the 17-year study period, the average annual age-standardized incidence was 12.04 cases per 10 million (95% CI 9.31-14.78 cases per 10 million). There was no significant change in the annual incidence rate over the study period (average annual percent change 2.27, 95% CI -1.74 to 6.44; p = 0.25). The odds of receiving radiation therapy or chemotherapy significantly increased by 8% per year (95% CI 1%-16% per year, p = 0.036) over the study period. The odds of receiving open resection significantly decreased by 14% per year (95% CI 8%-20% per year, p < 0.001). The odds of receiving endoscopic surgery among patients with skull base chordoma increased by 38% per year (95% CI 22%-60% per year, p < 0.001), while the odds of patients receiving biopsy alone did not change significantly over the study period (p = 0.684). After diagnosis of chordoma, the 5-, 10-, and 15-year overall survival probabilities were 0.74 (95% CI 0.69-0.81), 0.58 (95% CI 0.51-0.67), and 0.48 (95% CI 0.40 to 0.59), respectively. There was no significant association between hazard of death and year of diagnosis (p = 0.126) or anatomical location (p = 0.712, skull base vs mobile spine chordoma; p = 0.518 skull base vs sacropelvic chordoma). CONCLUSIONS: Chordoma is a rare disease with no significant change in the average annual incidence rate between 2003 to 2019. During this time, treatment with less invasive modalities increased, particularly for skull base chordoma. Overall survival exceeds 10 years for many patients, with no change in the hazard of death across the study period.

Who Gets Better After Surgery for Degenerative Cervical Myelopathy? A Responder Analysis from the Multicenter Canadian Spine Outcomes and Research Network.

BACKGROUND CONTEXT: Degenerative cervical myelopathy (DCM) is the most common cause of acquired non-traumatic spinal cord injury worldwide. Surgery is a common treatment for DCM; however, outcomes often vary across patients. PURPOSE: To inform preoperative education and counseling, we performed a responder analysis to identify factors associated with treatment response. STUDY DESIGN/SETTING: An observational cohort study was conducted utilizing prospectively collected data from the Canadian Spine Outcomes Research Network (CSORN) registry collected between 2015-2022. PATIENT SAMPLE: We included all surgically treated DCM patients with complete 12-month follow-up and patient-reported outcomes (PROs) available at 1-year. OUTCOME MEASURES: Treatment response was measured using the minimal clinically important difference (MCID) in PROs including the Neck Disability Index (NDI) and EuroQol-5D (EQ-5D) at 12 months post-surgery. METHODS: A Least Absolute Shrinkage and Selection Operator (LASSO) machine learning model was used to identify significant associations between 14 pre-operative patient factors and likelihood of treatment response measured by achievement of the MCID in NDI, and EQ-5D. Variable importance was measured using standardized coefficients. To test robustness of findings we trained a separate XGBOOST model, with variable importance measured using SHAP values. RESULTS: Among the 554 DCM patients included, 229 (41.3%) and 330 (59.6%) patients responded to treatment by meeting or surpassing MCID thresholds for NDI and EQ-5D at 1-year, respectively. LASSO regression for likelihood of treatment response measured through NDI found the variable importance rank order to be baseline NDI (OR 1.06 per 1 point increase; 95% CI 1.04 - 1.07), then symptom duration (OR 0.65; 95% CI 0.44-0.97). For EQ-5D, the variable importance rank order was baseline EQ-5D (OR 0.16 per 0.1-point increase; 95% CI 0.03 - 0.78), living independently (OR 2.17; 95% CI 1.22 - 3.85), symptom duration (OR 0.62; 95% CI 0.40 - 0.97), then number of levels affected (OR 0.80 per additional level; 95% CI 0.67 - 0.96). A separate XGBoost model of treatment response measured through NDI, corroborated findings that patients with higher baseline NDI, and shorter symptom duration were more likely to respond to treatment, and additionally found older patients, and those with kyphosis on baseline upright x-ray were less likely to respond. Similarly, an XGBoost model for treatment response measured through EQ-5D corroborated findings that patients with higher baseline EQ-5D, shorter symptom duration, living independently, with fewer affected levels were more likely to respond to treatment, and additionally found older patients were less likely to respond. CONCLUSIONS: Our findings suggest patients with shorter symptom duration, higher baseline patient NDI, lower EQ-5D, younger age, living independently, without kyphosis on pre-operative x-ray, and fewer affected levels are more likely to respond to treatment. Timing of surgery with respect to patient symptoms is underscored as a crucial and modifiable patient factor associated with improved surgical outcomes in DCM.

Unemployment and Personal Income Loss After Traumatic Brain Injury.

Importance: Employment and personal income loss after traumatic brain injury is a major source of postinjury stress and a barrier to societal reintegration. The magnitude of labor market ramifications following traumatic brain injury remains largely unknown. Objectives: To quantify the 3-year postinjury labor market consequences following traumatic brain injury in Canada. To also estimate the incurred national labor market cost over the study period. Design, Setting, and Participants: This retrospective quasi-experimental, pan-Canadian observational cohort study used linked administrative health and federal taxation data obtained between 2007 and 2017. Mixed-effects difference-in-difference regressions were constructed to estimate the annualized magnitude of the personal income and employment loss during each of the 3 years following injury, respectively, relative to preinjury baseline. Participants included tax-filing adult (19 to 61 years old) traumatic brain injury survivors. Exposure: Traumatic brain injury. Main Outcome Measures: Coprimary outcomes were personal income loss and the proportion of newly unemployed individuals per annum. Secondary objectives were to quantify income and employment loss within mild, moderate, and severe traumatic brain injury subgroups. Results: A total of 18 050 patients with traumatic brain injury between 2007 and 2017 were identified (mean age, 38.0 [SD, 12.4] years; 13 360 male [74.0%]), each of whom was followed up with for 3 consecutive fiscal years. Mean income was CAD $42 600 (US $31 083) in the fiscal year prior to injury and 82% were employed at time of injury. The adjusted mean loss of personal income was CAD $7635 (US $5650) in the first year after injury (Y+1) and CAD $5000 (US $3700) in the third year after injury (Y+3) relative to uninjured controls. In each of the 3 postinjury years, 7.8% individuals were newly unemployed compared with the preinjury baseline. The adjusted average personal income loss for mild, moderate, and severe traumatic brain injury subgroups were CAD $3354 (US $2482), CAD $6750 (US $4995), and CAD $17 375 (US $12 859), respectively, at Y+3; the proportion of unemployed individuals increased by 5.8%, 9.2%, and 20% across the same groups at Y+3 after injury relative to preinjury baseline. The estimated total reduction in personal income aggregated over the 3 postinjury years for the affected participants was CAD $588 million (US $435 million). Conclusions and Relevance: This work represents national cohort data quantifying the labor market implications of traumatic brain injury. These results may be used to inform economic evaluations and social service resource allocation.

Days at Home After Traumatic Brain Injury: Moving Beyond Mortality to Evaluate Patient-Centered Outcomes Using Population Health Data.

BACKGROUND AND OBJECTIVES: Administrative data are invaluable for assessing outcomes at the population level. However, there are few validated patient-centered outcome measures that capture morbidity following traumatic brain injury (TBI) using these data. We sought to characterize and validate days at home (DAH) as a measure to quantify population-level outcomes after moderate to severe TBI. We additionally assessed the earliest feasible outcome assessment period for patients with TBI using this outcome measure. METHODS: This multicenter retrospective cohort study used linked health administrative data sources to identify adults with moderate to severe TBI presenting to trauma centers in Ontario, Canada, between 2009 and 2021. DAH at 180 days (DAH180 days) reflects the total number of days spent alive and at home excluding the days spent institutionalized across care settings. Construct validity was determined using hierarchical quantile regression to assess the associations between clinical and injury covariates with DAH180 days. Predictive validity was assessed using Spearman rank correlation. We estimated minimally important difference (MID) in DAH180 days to aid with outcome measure interpretability. RESULTS: There were 6,340 patients who met inclusion criteria. Median DAH180 days was 70 days (interquartile range 0-144). Mortality occurred in 2,162 (34.1%) patients within 90 days following injury. Patients in the lower DAH180 days group were more commonly older (absolute standardized difference [ASD] = 0.68) with higher preinjury health resource utilization (ASD = 0.36) and greater injury severity (ASD = 0.81). Increased baseline health resource utilization (-10.1 days, 95% CI -17.4 to -2.8, p = 0.0041), older age (-4.6 days, 95% CI -5.7 to -3.4, p < 0.001), higher cranial injury severity (-84.6 days, 95% CI -98.3 to -71.0, p < 0.001), and major extracranial injuries (-14.2 days, 95% CI -19.5 to -8.93, p < 0.001) were significantly associated with fewer DAH180 days. DAH180 days was positively correlated with DAH at up to 3 years (r = 0.91, 95% CI 0.90-0.92) and negatively correlated with direct health care expenditure (rs = -0.89, 95% CI -0.88 to -0.90). The average MID estimated from anchor-based and distribution-based methods was 18 days. DISCUSSION: We validate DAH180 days as a potentially useful outcome measure with construct, predictive, and face validity in a population with moderate to severe TBI. Given the intensity of acute care requirements for patients with TBI, our work highlights DAH180 days as a feasible and sufficiently responsive outcome measure.

Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury.

Importance: Identifying disparities in health outcomes related to modifiable patient factors can improve patient care. Objective: To compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance. Design, Setting, and Participants: This retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024. Exposure: Uninsured or public insurance compared with private insurance. Main Outcomes and Measures: Coprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients. Results: The study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses. Conclusions and Relevance: Health insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.

Influence of health insurance on withdrawal of life sustaining treatment for patients with isolated traumatic brain injury: a retrospective multi-center observational cohort study.

BACKGROUND: Healthcare inequities for patients with traumatic brain injury (TBI) represent a major priority area for trauma quality improvement. We hypothesized a relationship between health insurance status and timing of withdrawal of life sustaining treatment (WLST) for adults with severe TBI. METHODS: This multicenter retrospective observational cohort study utilized data collected between 2017 and 2020. We identified adult (age ≥ 16) patients with isolated severe TBI admitted participating Trauma Quality Improvement Program centers. We determined the relationship between insurance status (public, private, and uninsured) and the timing of WLST using a competing risk survival analysis framework adjusting for baseline, clinical, injury and trauma center characteristics. Multivariable cause-specific Cox regressions were used to compute adjusted hazard ratios (HR) reflecting timing of WLST, accounting for mortality events. We also quantified the between-center residual variability in WLST using the median odds ratio (MOR) and measured insurance status association with access to rehabilitation at discharge. RESULTS: We identified 42,111 adults with isolated severe TBI treated across 509 trauma centers across North America. There were 10,771 (25.6%) WLST events in the cohort and a higher unadjusted incidence of WLST events was evident in public insurance patients compared to private or uninsured groups. After adjustment, WLST occurred earlier for publicly insured (HR 1.07, 95% CI 1.02-1.12) and uninsured patients (HR 1.29, 95% CI 1.18-1.41) compared to privately insured patients. Access to rehabilitation was lower for both publicly insured and uninsured patients compared to patients with private insurance. Accounting for case-mix, the MOR was 1.49 (95% CI 1.43-1.55), reflecting significant residual between-center variation in WLST decision-making. CONCLUSIONS: Our findings highlight the presence of disparate WLST practices independently associated with health insurance status. Additionally, these results emphasize between-center variability in WLST, persisting despite adjustments for measurable patient and trauma center characteristics.

Contemporary trends in the incidence and timing of spinal metastases: A population-based study.

Background: Spinal metastases are a significant complication of advanced cancer. In this study, we assess temporal trends in the incidence and timing of spinal metastases and examine underlying patient demographics and primary cancer associations. Methods: In this population-based retrospective cohort study, health data from 2007 to 2019 in Ontario, Canada were analyzed (n = 37, 375 patients identified with spine metastases). Primary outcomes were annual incidence of spinal metastasis, and time to metastasis after primary diagnosis. Results: The age-standardized incidence of spinal metastases increased from 229 to 302 cases per million over the 13-year study period. The average annual percent change (AAPC) in incidence was 2.2% (95% CI: 1.4% to 3.0%) with patients aged ≥85 years demonstrating the largest increase (AAPC 5.2%; 95% CI: 2.3% to 8.3%). Lung cancer had the greatest annual incidence, while prostate cancer had the greatest increase in annual incidence (AAPC 6.5; 95% CI: 4.1% to 9.0%). Lung cancer patients were found to have the highest risk of spine metastasis with 10.3% (95% CI: 10.1% to 10.5%) of patients being diagnosed at 10 years. Gastrointestinal cancer patients were found to have the lowest risk of spine metastasis with 1.0% (95% CI: 0.9% to 1.0%) of patients being diagnosed at 10 years. Conclusions: The incidence of spinal metastases has increased in recent years, particularly among older patients. The incidence and timing vary substantially among different primary cancer types. These findings contribute to the understanding of disease trends and emphasize a growing population of patients who require subspecialty care.

Quantifying the Association Between Surgical Spine Approach and Tracheostomy Timing After Traumatic Cervical Spinal Cord Injury.

BACKGROUND AND OBJECTIVES: Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI. METHODS: This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation. RESULTS: The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest. CONCLUSION: Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach.

Stereotactic Body Radiation Therapy for Sacral Metastases: Deviation From Recommended Target Volume Delineation Increases the Risk of Local Failure.

PURPOSE: Although spine stereotactic body radiation therapy (SBRT) is considered a standard of care in the mobile spine, mature evidence reporting outcomes specific to sacral metastases is lacking. Furthermore, there is a need to validate the existing sacral SBRT international consensus contouring guidelines to define the optimal contouring approach. We report mature rates of local failure (LF), adverse events, and the effect of contouring deviations in the largest experience to date specific to sacrum SBRT. METHODS AND MATERIALS: Consecutive patients who underwent sacral SBRT from 2010 to 2021 were retrospectively reviewed. The primary endpoint was magnetic resonance imaging-based LF with a focus on adherence to target volume contouring recommendations. Secondary endpoints included vertebral compression fracture and neural toxicity. RESULTS: Of the 215 sacrum segments treated in 112 patients, most received 30 Gy/4 fractions (51%), 24 Gy/2 fractions (31%), or 30 Gy/5 fractions (10%). Sixteen percent of segments were nonadherent to the consensus guideline with a more restricted target volume (undercontoured). The median follow-up was 21.4 months (range, 1.5-116.9 months). The cumulative incidence of LF at 1 and 2 years was 18.4% and 23.1%, respectively. In those with guideline adherent versus nonadherent contours, the LF rate at 1 year was 15.1% versus 31.4% and at 2 years 18.8% versus 40.0% (hazard ratio [HR], 2.5; 95% CI, 1.4-4.6; P = .003), respectively. On multivariable analysis, guideline nonadherence (HR, 2.4; 95% CI, 1.3-4.7; P = .008), radioresistant histology (HR, 2.4; 95% CI, 1.4-4.1; P < .001), and extraosseous extension (HR, 2.5; 95% CI, 1.3-4.7; P = .005) predicted for an increased risk of LF. The cumulative incidence of vertebral compression fracture was 7.1% at 1 year and 12.3% at 2 years. Seven patients (6.3%) developed peripheral nerve toxicity, of whom 4 had been previously radiated. CONCLUSIONS: Sacral SBRT is associated with high efficacy rates and an acceptable toxicity profile. Adhering to consensus guidelines for target volume delineation is recommended to reduce the risk of LF.

Vision Transformer-based Decision Support for Neurosurgical Intervention in Acute Traumatic Brain Injury: Automated Surgical Intervention Support Tool.

Purpose To develop an automated triage tool to predict neurosurgical intervention for patients with traumatic brain injury (TBI). Materials and Methods A provincial trauma registry was reviewed to retrospectively identify patients with TBI from 2005 to 2022 treated at a specialized Canadian trauma center. Model training, validation, and testing were performed using head CT scans with binary reference standard patient-level labels corresponding to whether the patient received neurosurgical intervention. Performance and accuracy of the model, the Automated Surgical Intervention Support Tool for TBI (ASIST-TBI), were also assessed using a held-out consecutive test set of all patients with TBI presenting to the center between March 2021 and September 2022. Results Head CT scans from 2806 patients with TBI (mean age, 57 years ± 22 [SD]; 1955 [70%] men) were acquired between 2005 and 2021 and used for training, validation, and testing. Consecutive scans from an additional 612 patients (mean age, 61 years ± 22; 443 [72%] men) were used to assess the performance of ASIST-TBI. There was accurate prediction of neurosurgical intervention with an area under the receiver operating characteristic curve (AUC) of 0.92 (95% CI: 0.88, 0.94), accuracy of 87% (491 of 562), sensitivity of 87% (196 of 225), and specificity of 88% (295 of 337) on the test dataset. Performance on the held-out test dataset remained robust with an AUC of 0.89 (95% CI: 0.85, 0.91), accuracy of 84% (517 of 612), sensitivity of 85% (199 of 235), and specificity of 84% (318 of 377). Conclusion A novel deep learning model was developed that could accurately predict the requirement for neurosurgical intervention using acute TBI CT scans. Keywords: CT, Brain/Brain Stem, Surgery, Trauma, Prognosis, Classification, Application Domain, Traumatic Brain Injury, Triage, Machine Learning, Decision Support Supplemental material is available for this article. © RSNA, 2024 See also commentary by Haller in this issue.

Admitting Hospital Influences on Withdrawal of Life-Sustaining Treatment Decision for Patients With Severe Traumatic Brain Injury.

BACKGROUND AND OBJECTIVES: Withdrawal of life-sustaining treatment (WLST) in severe traumatic brain injury (TBI) is complex, with a paucity of standardized guidelines. We aimed to assess the variability in WLST practices between trauma centers in North America. METHODS: This retrospective study used data from trauma centers through the American College of Surgeons Trauma Quality Improvement Program between 2017 and 2020. We included adult patients (>16 years) with severe TBI and a documented decision for WLST. We constructed a series of hierarchical logistic regression models to adjust for patient, injury, and hospital attributes influencing WLST; residual between-center variability was characterized using the median odds ratio. The impact of disparate WLST practices was further assessed by ranking centers by their conditional random intercept and assessing mortality, length of stay, and WLST between quartiles. RESULTS: We identified a total of 85 511 subjects with severe TBI treated across 510 trauma centers, of whom 20 300 (24%) had WLST. Patient-level factors associated with increased likelihood of WLST were advanced age, White race, self-pay, or Medicare insurance status (compared with private insurance). Black race was associated with reduced tendency for WLST. Treatment in nonprofit centers and higher-severity intracranial and extracranial injuries, midline shift, and pupil asymmetry also increased the likelihood for WLST. After adjustment for patient and hospital attributes, the median odds ratio was 1.45 (1.41-1.49 95% CI), suggesting residual variation in WLST between centers. When centers were grouped into quartiles by their propensity for WLST, there was increased adjusted mortality and shorter length of stay in fourth compared with first quartile centers. CONCLUSION: We highlighted the presence of contextual phenomena associated with disparate WLST practice patterns between trauma centers after adjustment for case-mix and hospital attributes. These findings highlight a need for standardized WLST guidelines to improve equity of care provision for patients with severe TBI.

Development of the cervical myelopathy severity index: a new patient reported outcome measure to quantify impairments and functional limitations.

BACKGROUND CONTEXT: Existing degenerative cervical myelopathy (DCM) severity scales have significant shortcomings, creating a strong impetus for the development of a practical measurement tool with sound psychometric properties. PURPOSE: This work reports the item generation and reduction of the Cervical Myelopathy Severity Index (CMSI), a new DCM patient-reported outcome measure of symptoms and functional limitations. DESIGN: Prospective observational study. PATIENT SAMPLE: Adult DCM patients belonging to one of three distinct treatment groups: (1) observation cohort, (2) preoperative surgical cohort, (3) 6 to 12 months postoperative cohort. OUTCOME MEASURES: Patient-reported outcome measure of symptoms and functional limitations. METHODS: Item generation was performed using semi-structured patient focus groups emphasizing symptoms experienced and functional limitations. Readability was assessed through think-aloud patient interviews. Item reduction involved surveys of DCM patients with a spectrum of disease severity and board-certified spine surgeons experienced in the treatment of DCM. A priori criteria for item removal included: patient median importance/severity <2 (of 4), 30% or more no severity (response of zero), item severity correlations ≤ 0.80 (Spearman), item severity reliability (weighted kappa <0.60) based on a 2-week interval and clinician median importance <2 with retention of items with very high clinical importance. RESULTS: There were 42 items generated from a combination of specialist input and patient focus groups. Items captured sensorimotor symptoms and limitations related to upper and lower extremities as well as sphincter dysfunction. Ninety-eight patients (43, 30, 25 observation, pre- and postsurgery respectively) and 51 surgeons completed the assessment. Twenty-three items remained after application of median importance and severity thresholds and weighted kappa cutoffs. After elimination of highly correlated (>0.80) items and combining two similar items, the final CMSI questionnaire list included 14 items. CONCLUSIONS: The CMSI is a new DCM patient-reported clinical measurement tool developed using patient and clinician input to inform item generation and reduction. Future work will evaluate the reliability, validity, and responsiveness of the CMSI in relation to existing myelopathy measurement indices.

Early surgery compared to nonoperative management for mild degenerative cervical myelopathy: a cost-utility analysis.

BACKGROUND CONTEXT: Degenerative cervical myelopathy (DCM) is a form of acquired spinal cord compression and contributes to reduced quality of life secondary to neurological dysfunction and pain. There remains uncertainty regarding optimal management for individuals with mild myelopathy. Specifically, owing to lacking long-term natural history studies in this population, we do not know whether these individuals should be treated with initial surgery or observation. PURPOSE: We sought to perform a cost-utility analysis to examine early surgery for mild degenerative cervical myelopathy from the healthcare payer perspective. STUDY DESIGN/SETTING: We utilized data from the prospective observational cohorts included in the Cervical Spondylotic Myelopathy AO Spine International and North America studies to determine health related quality of life estimates and clinical myelopathy outcomes. PATIENT SAMPLE: We recruited all patients that underwent surgery for DCM enrolled in the Cervical Spondylotic Myelopathy AO Spine International and North America studies between December 2005 and January 2011. OUTCOME MEASURES: Clinical assessment measures were obtained using the Modified Japanese Orthopedic Association scale and health-related quality of life measures were obtained using the Short Form-6D utility score at baseline (preoperative), 6 months, 12 months and 24 months postsurgery. Cost measures inflated to January 2015 values were obtained using pooled estimates from the hospital payer perspective for surgical patients. METHODS: We employed a Markov state transition model with Monte Carlo microsimulation using a lifetime horizon to obtain an incremental cost utility ratio associated with early surgery for mild myelopathy. Parameter uncertainty was assessed through deterministic means using one-way and two-way sensitivity analyses and probabilistically using parameter estimate distributions with microsimulation (10,000 trials). Costs and utilities were discounted at 3% per annum. RESULTS: Initial surgery for mild degenerative cervical myelopathy was associated with an incremental lifetime increase of 1.26 quality-adjusted life years (QALY) compared to observation. The associated cost incurred to the healthcare payer over a lifetime horizon was $12,894.56, resulting in a lifetime incremental cost-utility ratio of $10,250.71/QALY. Utilizing a willingness to pay threshold in keeping with the World Health Organization definition of "very cost-effective" ($54,000 CDN), the probabilistic sensitivity analysis demonstrated that 100% of cases were cost-effective. CONCLUSIONS: Surgery compared to initial observation for mild degenerative cervical myelopathy was cost-effective from the Canadian healthcare payer perspective and was associated with lifetime gains in health-related quality of life.

Withdrawal of Life-Sustaining Treatment for Pediatric Patients With Severe Traumatic Brain Injury.

Importance: The decision to withdraw life-sustaining treatment for pediatric patients with severe traumatic brain injury (TBI) is challenging for clinicians and families with limited evidence quantifying existing practices. Given the lack of standardized clinical guidelines, variable practice patterns across trauma centers seem likely. Objective: To evaluate the factors influencing decisions to withdraw life-sustaining treatment across North American trauma centers for pediatric patients with severe TBI and to quantify any existing between-center variability in withdrawal of life-sustaining treatment practices. Design, Setting, and Participants: This retrospective cohort study used data collected from 515 trauma centers through the American College of Surgeons Trauma Quality Improvement Program between 2017 and 2020. Pediatric patients younger than 19 years with severe TBI and a documented decision for withdrawal of life-sustaining treatment were included. Data were analyzed from January to May 2023. Main Outcomes and Measures: A random intercept multilevel logistic regression model was used to quantify patient, injury, and hospital characteristics associated with the decision to withdraw life-sustaining treatment; the median odds ratio was used to characterize residual between-center variability. Centers were ranked by their conditional random intercepts and quartile-specific adjusted mortalities were computed. Results: A total of 9803 children (mean [SD] age, 12.6 [5.7]; 2920 [29.8%] female) with severe TBI were identified, 1003 of whom (10.2%) had a documented decision to withdraw life-sustaining treatment. Patient-level factors associated with an increase in likelihood of withdrawal of life-sustaining treatment were young age (younger than 3 years), higher severity intracranial and extracranial injuries, and mechanism of injury related to firearms. Following adjustment for patient and hospital attributes, the median odds ratio was 1.54 (95% CI, 1.46-1.62), suggesting residual variation in withdrawal of life-sustaining treatment between centers. When centers were grouped into quartiles by their propensity for withdrawal of life-sustaining treatment, adjusted mortality was higher for fourth-quartile compared to first-quartile centers (odds ratio, 1.66; 95% CI, 1.45-1.88). Conclusions and Relevance: Several patient and injury factors were associated with withdrawal of life-sustaining treatment decision-making for pediatric patients with severe TBI in this study. Variation in withdrawal of life-sustaining treatment practices between trauma centers was observed after adjustment for case mix; this variation was associated with differences in risk-adjusted mortality rates. Taken together, these findings highlight the presence of inconsistent approaches to withdrawal of life-sustaining treatment in children, which speaks to the need for guidelines to address this significant practice pattern variation.

Pathophysiology and surgical decision-making in central cord syndrome and degenerative cervical myelopathy: correcting the somatotopic fallacy.

Our understanding of Central Cord Syndrome (CCS), a form of incomplete spinal cord injury characterized by disproportionate upper extremity weakness, is evolving. Recent advances challenge the traditional somatotopic model of corticospinal tract organization within the spinal cord, suggesting that CCS is likely a diffuse injury rather than focal lesion. Diagnostic criteria for CCS lack consensus, and varied definitions impact patient identification and treatment. Evidence has mounted for early surgery for CCS, although significant variability persists in surgical timing preferences among practitioners. A demographic shift toward an aging population has increased the overlap between CCS and Degenerative Cervical Myelopathy (DCM). Understanding this intersection is crucial for comprehensive patient care. Assessment tools, including quantitative measures and objective evaluations, aid in distinguishing CCS from DCM. The treatment landscape for CCS in the context of pre-existing DCM is complex, requiring careful consideration of pre-existing neurologic injury, patient factors, and injury factors. This review synthesizes emerging evidence, outlines current guidelines in diagnosis and management, and emphasizes the need for ongoing research to refine our understanding and treatment strategies for this evolving patient population.

Factors influencing withdrawal of life-supporting treatment in cervical spinal cord injury: a large multicenter observational cohort study.

BACKGROUND: Traumatic spinal cord injury (SCI) leads to profound neurologic sequelae, and the provision of life-supporting treatment serves great importance among this patient population. The decision for withdrawal of life-supporting treatment (WLST) in complete traumatic SCI is complex with the lack of guidelines and limited understanding of practice patterns. We aimed to evaluate the individual and contextual factors associated with the decision for WLST and assess between-center differences in practice patterns across North American trauma centers for patients with complete cervical SCI. METHODS: This retrospective multicenter observational cohort study utilized data derived from the American College of Surgeons Trauma Quality Improvement Program database between 2017 and 2020. The study included adult patients (> 16 years) with complete cervical SCI. We constructed a multilevel mixed effect logistic regression model to adjust for patient, injury and hospital factors influencing WLST. Factors associated with WLST were estimated through odds ratios with 95% confidence intervals. Hospital variability was characterized using the median odds ratio. Unexplained residual variability was assessed through the proportional change in variation between models. RESULTS: We identified 5070 patients with complete cervical SCI treated across 477 hospitals, of which 960 (18.9%) had WLST. Patient-level factors associated with significantly increased likelihood of WLST were advanced age, male sex, white race, prior dementia, low presenting Glasgow Coma Scale score, having a pre-hospital cardiac arrest, SCI level of C3 or above, and concurrent severe injury to the head or thorax. Patient-level factors associated with significantly decreased likelihood of WLST included being racially Black or Asian. There was significant variability across hospitals in the likelihood for WLST while accounting for case-mix, hospital size, and teaching status (MOR 1.51 95% CI 1.22-1.75). CONCLUSIONS: A notable proportion of patients with complete cervical SCI undergo WLST during their in-hospital admission. We have highlighted several factors associated with this decision and identified considerable variability between hospitals. Further work to standardize WLST guidelines may improve equity of care provided to this patient population.

Risk factors associated with in-hospital adverse events: a multicenter observational cohort study of 1853 pediatric patients with traumatic spinal cord injury.

OBJECTIVE: In this study, the authors aimed to quantify the frequency of in-hospital major adverse events (AEs) in a multicenter cohort of pediatric patients with spinal cord injury (SCI) managed at North American trauma centers. They also sought to identify patient and injury factors associated with the occurrence of major and immobility-related AEs. METHODS: Data derived from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) were used to identify a cohort of pediatric patients (age < 19 years) with traumatic SCI. The authors identified individuals with major and immobility-related AEs following injury. They used mixed-effects multivariable logistic regression to identify clinical variables associated with AEs after injury. This analytical approach allowed them to account for similarities in care delivery between patients managed in the same trauma settings during the study period while also adjusting for patient-level confounders. The adjusted impact of AEs on in-hospital mortality and length of stay (LOS) were also assessed through further multivariable regression analysis. Additional subgroup analyses were performed to reduce bias associated with competing risks and explore the age-specific risk factor associations with AEs. RESULTS: A total of 1853 pediatric patients who sustained either cervical or thoracic SCI were managed at ACS TQIP trauma centers between 2017 and 2020. The most frequently encountered AE types were pressure ulcer, unplanned intubation, cardiac arrest requiring cardiopulmonary resuscitation, and ventilator-associated pneumonia. The crude rate of major in-hospital and immobility-related AEs significantly differed between subgroups, with higher proportions of AEs in complete injuries compared with incomplete injuries. The adjusted risk for major AE following injury was significantly elevated for cervical complete SCI, patients with severe concomitant abdominal injuries, and for those presenting with depressed Glasgow Coma Scale scores less than 13. These same risk factors were associated with major AEs in children older than 8 years but were not significant for younger children (age ≤ 8 years). Complication occurrence was not associated with difference in risk-adjusted mortality (OR 0.72, 95% CI 0.45-1.14), but did increase LOS by 2.2 days (95% CI 1.4-2.7 days). CONCLUSIONS: The authors outlined the prevalence of in-hospital AEs in a large multicenter cohort of North American pediatric SCI patients. Important risk factors predisposing this population to AEs include cervical complete injuries, simultaneous abdominal trauma, and Glasgow Coma Scale scores < 13 at presentation. Postinjury complications impacted health resource utilization by increased LOS but did not affect postinjury mortality. These findings have important implications for pediatric SCI providers and future care quality benchmarking.

Association between Trauma Center Type and Mortality for Injured Children with Severe Traumatic Brain Injury.

BACKGROUND: There is conflicting evidence regarding the relationship between trauma center type and mortality for children with traumatic brain injuries. Identification of mortality differences following brain injury across differing trauma center types may result in actionable quality improvement initiatives to standardize care for these children. METHODS: We utilized Trauma Quality Improvement Program data from 2017-2020 to identify children with severe traumatic brain injury managed at level I and II state- or American College of Surgeon-verified trauma centers. We used a random intercept multilevel logistic regression model to assess the relationship between exposure (trauma center type either adult, pediatric or mixed) and outcome (in-hospital mortality). Several secondary analyses were performed to assess the influence of trauma center volume, age strata and traumatic brain injury heterogeneity. RESULTS: There were 10,105 patients identified across 512 trauma centers. Crude mortality was 25.2%, 36.2% and 28.9% for pediatric, adult, and mixed trauma centers respectively. After adjustment for confounders, odds of mortality were higher for children managed at adult trauma centers (OR 1.67; 95% CI: 1.30 - 2.13) compared to pediatric trauma centers. Male sex, self-pay insurance status, and interfacility transfers, motor vehicle, pedestrian/ cyclist and firearm injury mechanisms, presence of concomitant abdomen, lower extremity, or chest injuries, midline shift >5 mm within 24 hours, presence of age-adjusted hypotension and either pupil asymmetry or non-reactivity were all associated with a greater odds of death. Adjustment for trauma volume and subgroup analysis using a homogenous traumatic brain injury subgroup did not change the demonstrated associations. CONCLUSIONS: Our results suggest mortality was higher at adult trauma centers compared to mixed and pediatric trauma centers for children with traumatic brain injuries. Importantly, there exists the potential for unmeasured confounding. We aim for these findings to direct continuing quality improvement initiatives to improve outcomes for brain injured children. LEVEL OF EVIDENCE: III; Type of study: Prognostic/ epidemiological.

"Instant 3D" Angiography: Novel Technique for Rapid Conversion of 2D Angiograms into 3D Stereoscopic Videos.

BACKGROUND: Rotational angiography, often referred to as a "spin", is typically presented in 2D. Since rotational angiograms are composed of images acquired from multiple angles, we took advantage of this property to develop a method for converting any rotational angiogram into a 3 dimensional (3D) video. METHODS: Our aim was to develop a low cost and easily distributable solution without requiring additional hardware or altering acquisition techniques. Six previously acquired rotational angiograms from our institution were imported using custom-written code and exported as anaglyph (red-cyan) videos. RESULTS: The resulting 3D videos convey anatomical depth that is not apparent from viewing the 2D images alone. Processing time was 1.3 ± 0.6 s (mean ± SD) per angiogram. The only associated cost was $10 for red-cyan 3D glasses. Using our software, any rotational angiogram with at least 0.3 frames per degree of rotation can be converted into 3D. CONCLUSIONS: Our solution is an inexpensive and rapid method for generating stereoscopic videos from existing angiograms. It does not require any additional hardware and is readily deployable in low-resource settings. Because the videos are in anaglyph format, they are viewable on any 2 dimensional (2D) display in the interventional suite or operating room, on a mobile device, or at home.

Assessment of the incremental prognostic value from the modified frailty index-5 in complete traumatic cervical spinal cord injury.

Frailty, as measured by the modified frailty index-5 (mFI-5), and older age are associated with increased mortality in the setting of spinal cord injury (SCI). However, there is limited evidence demonstrating an incremental prognostic value derived from patient mFI-5. We conducted a retrospective cohort study to evaluate in-hospital mortality among adult complete cervical SCI patients at participating centers of the Trauma Quality Improvement Program from 2010 to 2018. Logistic regression was used to model in-hospital mortality, and the area under the receiver operating characteristic curve (AUROC) of regression models with age, mFI-5, or age with mFI-5 was used to compare the prognostic value of each model. 4733 patients were eligible. We found that both age (80 y versus 60 y: OR 3.59 95% CI [2.82 4.56], P < 0.001) and mFI-5 (score ≥ 2 versus < 2: OR 1.53 95% CI [1.19 1.97], P < 0.001) had statistically significant associations with in-hospital mortality. There was no significant difference in the AUROC of a model including age and mFI-5 when compared to a model including age without mFI-5 (95% CI Δ AUROC [- 8.72 × 10-4 0.82], P = 0.199). Both models were superior to a model including mFI-5 without age (95% CI Δ AUROC [0.06 0.09], P < 0.001). Our findings suggest that mFI-5 provides minimal incremental prognostic value over age with respect to in-hospital mortality for patients complete cervical SCI.