A Conceptual Model for Spine Surgery Recovery: A Qualitative Study of Patients' Expectations, Experiences, and Satisfaction.

STUDY DESIGN: Qualitative interview study. OBJECTIVE: The aim was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo lumbar spine surgery and what factors influence patient satisfaction. SUMMARY OF BACKGROUND DATA: Quantitative studies have assessed patients' expectations for lumbar spine surgery outcomes, with greater expectation fulfillment leading to higher satisfaction. However, there is limited literature using qualitative methods to understand the patient perspective from the decision to undergo lumbar spine surgery through long-term recovery. MATERIALS AND METHODS: Semistructured phone interviews were conducted with 20 participants (nine females, mean age ±SD=61.2±11.1 yr) and three focus groups with 12 participants (nine females, mean age ±SD=62.0±10.9 yr). Sessions were audio recorded and transcribed. Two independent researchers coded the transcripts using a hierarchical coding system. Major themes were identified and a conceptual model was developed. RESULTS: A total of 1355 coded quotes were analyzed. The decision to have lumbar spine surgery was influenced by chronic pain impact on daily function, pain coping, and patient expectations. Results demonstrated that fulfilled expectations and setting realistic expectations are key factors for patient satisfaction after surgery, while less known constructs of accepting limitations, adjusting expectations, and optimism were found by many patients to be essential for a successful recovery. Emotional factors of fear, anxiety, and depression were important aspects of presurgical and postsurgical experiences. CONCLUSION: Our Spine Surgery Recovery conceptual model provides guidance for future research and clinical practice to optimize treatment and improve overall patient satisfaction. Recommendations based on this model include the assessment of patient expectations and mental well-being throughout postoperative recovery as well as preoperatively to help set realistic expectations and improve satisfaction. Educational, acceptance-based or positive psychological interventions may be potentially beneficial for addressing key factors identified in this model.

Selective effects of a brain tumor on the metric representation of the hand: a pre- versus post-surgery comparison.

Body representation disorders are complex, varied, striking, and very disabling in most cases. Deficits of body representation have been described after lesions to multimodal and sensorimotor cortical areas. A few studies have reported the effects of tumors on the representation of the body, but little is known about the changes after tumor resection. Moreover, the impact of brain lesions on the hand size representation has been investigated in few clinical cases. Hands are of special importance, as no other body part has the ability for movement and interaction with the environment that the hands have, and we use them for a multitude of daily activities. Studies with clinical population can add further knowledge into the way hands are represented. Here, we report a single case study of a patient (AM) who was an expert bodybuilder and underwent a surgery to remove a glioblastoma in the left posterior prefrontal and precentral cortex at the level of the hand's motor region. Pre- (20 days) and post- (4 months) surgery assessment did not show any motor or cognitive impairments. A hand localization task was used, before and after surgery (12 months), to measure possible changes of the metric representation of his right hand. Results showed a post-surgery modulation of the typically distorted hand representation, with an overall accuracy improvement, especially on width dimension. These findings support the direct involvement of sensorimotor areas in the implicit representation of the body size and its relevance on defining specific size representation dimensions.

Factors impacting surgical decision making between prenatal and postnatal repair for myelomeningocele.

OBJECTIVES: To determine factors influencing patients to choose prenatal or postnatal repair of their child's myelomeningocele (MMC) when both treatment options are offered. METHODS: We distributed a retrospective survey via email and social media to parents of children with MMC who were offered both prenatal and postnatal surgery as intervention options. RESULTS: A total of 127 surveys met all inclusion criteria. The majority of responders considered partner's opinion (85%), maternal risks of prenatal surgery (71%), and risk for preterm labor (76%) as influencers. Financially, the costs of childcare (39.4% postnatal, 13.8% prenatal, p = 0.002), relocation (57.6% postnatal, 36.2% prenatal, p = 0.019), and travel (51.5% postnatal, 33% prenatal, p = 0.033) were more influential for the postnatal group while insurance coverage (36.4% postnatal, 68.1% prenatal, p = 0.003) was more influential to the prenatal group. Of the medical factors, the consideration of maternal risk for transfusion was different between surgical groups (39.4% postnatal, 18.1% prenatal, p = 0.015). The open responses suggest that both surgical groups found the quality of life for the baby to be significant to their decision-making. CONCLUSIONS: These findings should guide providers to tailor counseling to patient's needs. Comprehensive counseling should include information on financial resources, referral to financial counselors, and psychosocial support services.

Postoperative Delirium in Patients After Brain Tumor Surgery.

BACKGROUND: Postoperative delirium is a common surgical complication that can be associated with poorer outcome. Many patients with brain tumors experience delirium after surgery. We hypothesize that patients who experience delirium after resection of a brain tumor will have worse outcomes post surgery in terms of mortality, disposition, and length of stay compared with those without postoperative delirium. We also examine differences between nurse and physician diagnoses of delirium. METHODS: Data from patients undergoing brain tumor resection at University of Missouri Hospital were retrospectively collected. Delirium was defined using Diagnostic and Statistical Manual-5 criteria. Patients with delirium were compared with patients without delirium using chi-squared test, Cohen Kappa value, and binomial proportion analysis at 95% confidence intervals or P < 0.05. RESULTS: Of 500 patients having brain tumor resections, 93 (18.6%) were diagnosed with postoperative delirium. Patients with delirium had higher 30-day mortality (9.78% vs. 1.48%; P < 0.0001), required restraints more often (42.39% vs. 5.91%, P < 0.0001), had longer hospital length of stay (14.3 vs. 6.3 days; P < 0.0001), and increased skilled nursing facility disposition (57.3% vs. 26.11%; P < 0.0001) than patients without delirium. Diagnosis of delirium between nursing staff and clinicians moderately correlated (Kappa 0.5677 ± 0.0536). CONCLUSIONS: Delirium, a common postoperative complication after brain tumor surgery, is associated with longer length of stay, increased disposition to skilled nursing facility, and increased 30-day mortality. These findings reinforce the importance of early recognition, diagnosis, and treatment of postoperative delirium in brain tumor resection patients.

Memory outcomes of temporal lobe surgery in adults aged over 45 years.

OBJECTIVE: It is assumed that temporal lobe resection in older people is associated with worse seizure outcomes and potential postsurgical memory decline. We studied postsurgical memory development and surgical efficacy in patients over 45 years of age compared with younger patients. METHODS: We studied 88 patients (51 male and 37 female) after temporal lobe surgery, which involved hippocampal resection. The patients were evaluated before surgery and in the first (72 patients) and/or third (57 patients) postsurgical year. The Wechsler Memory Scale III test was performed to evaluate the MQ postsurgical development. Engel's classification was used to evaluate the postsurgical seizure outcome. RESULTS: The presurgical MQ (median 88) in ≥45 years age group was significantly lower than in both younger groups (median MQ = 100 for ≤30 years age group, p = 0.002; median MQ = 107 for 31-44 years age group, p = 0.002). Three years after the surgery, the MQ decreased significantly in ≤30 years age group (p = 0.012), while only non-significant MQ decline was observed in both older groups. We found no significant impact of age on the surgical outcome. CONCLUSION: Higher age at the time of surgery does not significantly increase the risk for postsurgical memory decline; however, older patients are more likely to have lowered presurgical MQ. We did not find significant differences in the impact of surgery on seizure outcome among the age groups. Epilepsy surgery appears to be a safe and effective method in the age over 45 years even though an earlier surgery should be preferred.

Outcomes and Quality-of-Life Measures after Endoscopic Endonasal Resection of Kadish Stage C Olfactory Neuroblastomas.

OBJECTIVE: The endoscopic endonasal approach (EEA) has been applied in the treatment of olfactory neuroblastoma (ONB). However, there is a lack of research examining the impact of EEA on locally advanced ONB. This study assessed the outcomes of EEA in patients with locally advanced ONB and its impact on the quality of life (QOL). METHODS: We retrospectively reviewed patients with Kadish stage C ONB who underwent EEA between December 2004 and October 2019 and assessed demographic data, histopathologic grade, the extent of resection, postoperative complications, and outcomes. Preoperative and postoperative QOL was assessed using the Sino-Nasal Outcome Test. RESULTS: Twenty-six patients (18 men, 8 women; aged 26-79 years) were enrolled, with 12 cases of Hyams grade II and III and 1 case of grade I and IV each. In total, 25 patients received radiotherapy and 16 patients received chemotherapy, of whom 11 received preoperative neoadjuvant chemotherapy. Postoperative nasal bleeding was observed in 2 patients. The follow-up ranged from 8 to 124 months (median, 42.3 months). The 1-year and 5-year overall survival were 96.2% and 84.8%, respectively. The 1-year and 5-year disease-free survival were 76.9% each. The analysis of the postoperative Sino-Nasal Outcome Test scores showed significant improvement in certain psychological and sleep-associated domains, compared with the preoperative scores. CONCLUSIONS: Our results showed that pure EEA followed by radiotherapy offered excellent outcomes in the management of selected patients with locally advanced ONB. The postoperative QOL was significantly improved. More research is required on neoadjuvant chemotherapy to establish its role.

Clinical Uncertainty and Equipoise in the Management of Recurrent Glioblastoma.

BACKGROUND: A significant proportion of glioblastoma (GBM) patients are considered for repeat resection, but evidence regarding best management remains elusive. Our aim was to measure the degree of clinical uncertainty regarding reoperation for patients with recurrent GBM. METHODS: We first performed a systematic review of agreement studies examining the question of repeat resection for recurrent GBM. An electronic portfolio of 37 pathologically confirmed recurrent GBM patients including pertinent magnetic resonance images and clinical information was assembled. To measure clinical uncertainty, 26 neurosurgeons from various countries, training backgrounds, and years' experience were asked to select best management (repeat surgery, other nonsurgical management, or conservative), confidence in recommended management, and whether they would include the patient in a randomized trial comparing surgery with nonsurgical options. Agreement was evaluated using κ statistics. RESULTS: The literature review did not reveal previous agreement studies examining the question. In our study, agreement regarding best management of recurrent GBM was slight, even when management options were dichotomized (repeat surgery vs. other options; κ=0.198 [95% confidence interval: 0.133-0.276]). Country of practice, years' experience, and training background did not change results. Disagreement and clinical uncertainty were more pronounced within clinicians with (κ=0.167 [0.055-0.314]) than clinicians without neuro-oncology fellowship training (κ=0.601 [0.556-0.646]). A majority (51%) of responders were willing to include the patient in a randomized trial comparing repeat surgery with nonsurgical alternatives in 26/37 (69%) of cases. CONCLUSION: There is sufficient uncertainty and equipoise regarding the question of reoperation for patients with recurrent glioblastoma to support the need for a randomized controlled trial.

How Do Pediatric Neurosurgeons Make Intraoperative Decisions?

OBJECTIVE: The purpose of this research was to explore the processes by which pediatric neurosurgeons make intraoperative decisions when they encounter something unexpected or uncertain while they are operating. METHODS: The study used the grounded theory method of data collection and analysis. Twenty-six pediatric neurosurgeons (PNs) from 12 countries were interviewed about the process by which they make intraoperative decisions. Data were analyzed line by line, and constant comparison was used to examine relationships within and across codes and categories. RESULTS: PNs described a complex process that existed along a spectrum in making intraoperative decisions. Three types of response processes emerged from the analysis: 1) internal processing, with the themes of getting oneself under control and performing control for the surgical team; 2) action processes that included the themes of stabilizing the patient, responding intuitively/automatically when making decisions, and shifting surgical strategies; and 3) analytical processing that involved assessing the situation, consulting with colleagues and the family of the patient when making intraoperative decisions. CONCLUSIONS: The findings from this study contribute novel information on PNs' intraoperative decision making processes and can be used to train resident neurosurgeons about the various components involved in these processes. This research suggests that new models of decision making are needed within the medical and neurosurgical context and inspire a new set of questions about the process by which surgeons make life and death decisions in the operating room.

Stigmatizing Diagnoses in Neurosurgery: A Narrative Review.

Stigma is defined as a social process resulting in labeling, stereotyping, and separation that cause status loss, disapproval, rejection, exclusion, and discrimination of the labeled individuals. Stigma can be experienced by individuals or groups, can be real or perceived, and can include a wide array of characteristics (e.g., race/ethnicity, gender, and health conditions). It is well documented that stigma for health conditions is a barrier to treatment and leads to worse outcomes for vulnerable people. The purpose of this study is to examine the increasingly mature field of stigma theory and research, and how this relates to the practice of neurosurgery. This review provides an overview of stigma and its application in a neurosurgical setting, including diagnoses treated by neurosurgeons as well as diagnoses with impact on neurosurgical outcomes. Examples of stigmatizing diagnoses of relevance to neurosurgical practice include epilepsy, pain, smoking, obesity, and substance use disorder. This information is useful for the practicing neurosurgeon to understand the origins and higher-order effects of societal perceptions surrounding certain diagnoses, and the subsequent effects on health that those perceptions can create on a systemic level.

Does a Multidisciplinary Triage Pathway Facilitate Better Outcomes After Spine Surgery?

STUDY DESIGN: Single-center prospective non-randomized matched cohort comparison. OBJECTIVE: To compare elective lumbar spine surgery outcomes for cases triaged through a multidisciplinary spine pathway versus conventional referral processes. SUMMARY OF BACKGROUND DATA: Many health care systems have facilitated low back pain (LBP) guidelines into primary care practice by creating local or regional "pathways" with the goal of enhanced quality of care, improved patient satisfaction and optimal resource utilization, particularly for imaging and surgery. Few comparative outcomes exist for LBP pathways, particularly for surgical outcomes. METHODS: One-hundred-fifty patients (SSP group n = 75; conventional group n = 75) undergoing elective lumbar surgery for degenerative conditions between 2011 and 2016 were analyzed with 1-year follow-up. Patient self-reported outcomes included the Oswestry disability index (ODI), visual analogue pain scores (VAS) for back and leg, and EuroQol Group 5-Dimension self-report (EQ-5D). We also assessed baseline clinical features, indications for surgery, therapies received prior to surgery, type of surgery, wait times, and overall patient satisfaction. RESULTS: The groups had equivalent baseline demographics, body mass index, Saskatchewan Spine Pathway (SSP) classification of pain pattern, pain scores, functional scores, quality of life scores, indication for surgery, and type of surgery (instrumented or non-instrumented). There was no difference with respect to wait times to see the surgeon or for surgery. Wait time for magnetic resonance imaging (MRI) was significantly shorter for the SSP group (16.8 vs. 63.0 days, P < 0.001). Patients triaged through the SSP were significantly more likely to utilize multiple nonoperative treatment strategies prior to seeing the surgeon (P < 0.04). Patient satisfaction was significantly higher for SSP patients prior to surgical assessment (P = 0.03) but did not differ between groups after surgery. CONCLUSION: The SSP facilitates significantly shorter wait times for MRI and promotes nonoperative treatment strategies. Preoperative patient satisfaction is significantly higher among SSP patients, but there were no significant differences in surgical outcomes.Level of Evidence: 3.

Pre-treatment expectations of patients with spinal metastases: what do we know and what can we learn from other disciplines? A systematic review of qualitative studies.

BACKGROUND: Little is known about treatment expectations of patients with spinal metastases undergoing radiotherapy and/or surgery. Assuming that patients with spinal metastases share characteristics with patients who had spinal surgery for non-cancer related conditions and with advanced cancer patients, we performed a systematic review to summarize the literature on patient expectations regarding treatment outcomes of spinal surgery and advanced cancer care. METHODS: A comprehensive search was performed in MEDLINE, EMBASE and PsycINFO for studies between 2000 and sep-2019. Studies including adult patients (> 18 years), undergoing spinal surgery or receiving advanced cancer care, investigating patients' pre-treatment expectations regarding treatment outcomes were included. Two independent reviewers screened titles, abstracts and full-texts, extracted data and assessed methodological quality. RESULTS: The search identified 7343 articles, of which 92 were selected for full-text review. For this review, 31 articles were included. Patients undergoing spinal surgery had overly optimistic expectations regarding pain and symptom relief, they underestimated the probability of functional disability, and overestimated the probability of (complete) recovery and return to work. Studies highlighted that patients feel not adequately prepared for surgery in terms of post-treatment expectations. Similarly, advanced cancer patients receiving palliative treatment often had overly optimistic expectations regarding their survival probability and cure rates. CONCLUSIONS: Patients tend to have overly optimistic expectations regarding pain and symptom relief, recovery and prognosis following spinal surgery or advanced cancer care. Pretreatment consultation about the expected pain and symptom relief, recovery and prognosis may improve understanding of prognosis, and promote and manage expectations, which, in turn, may lead to better perceived outcomes. TRIAL REGISTRATION: PROSPERO registration number: CRD42020145151 .

Effectiveness of the Chiari Health Index for Pediatrics instrument in measuring postoperative health-related quality of life in pediatric patients with Chiari malformation type I.

OBJECTIVE: The authors' previously published work validated the Chiari Health Index for Pediatrics (CHIP), a new instrument for measuring health-related quality of life (HRQOL) for pediatric Chiari malformation type I (CM-I) patients. In this study, the authors further evaluated the CHIP to assess HRQOL changes over time and correlate changes in HRQOL to changes in symptomatology and radiological factors in CM-I patients who undergo surgical intervention. Strong HRQOL evaluation instruments are currently lacking for pediatric CM-I patients, creating the need for a standardized HRQOL instrument for this patient population. This study serves as the first analysis of the CHIP instrument's effectiveness in measuring short-term HRQOL changes in pediatric CM-I patients and can be a useful tool in future CM-I HRQOL studies. METHODS: The authors evaluated prospectively collected CHIP scores and clinical factors of surgical intervention in patients younger than 18 years. To be included, patients completed a baseline CHIP captured during the preoperative visit, and at least 1 follow-up CHIP administered postoperatively. CHIP has 2 domains (physical and psychosocial) comprising 4 components, the 3 physical components of pain frequency, pain severity, and nonpain symptoms, and a single psychosocial component. Each CHIP category is scored on a scale, with 0 indicating absent and 1 indicating present, with higher scores indicating better HRQOL. Wilcoxon paired tests, Spearman correlations, and linear regression models were used to evaluate and correlate HRQOL, symptomatology, and radiographic factors. RESULTS: Sixty-three patients made up the analysis cohort (92% Caucasian, 52% female, mean age 11.8 years, average follow-up time 15.4 months). Dural augmentation was performed in 92% of patients. Of the 63 patients, 48 reported preoperative symptoms and 42 had a preoperative syrinx. From baseline, overall CHIP scores significantly improved over time (from 0.71 to 0.78, p < 0.001). Significant improvement in CHIP scores was seen in patients presenting at baseline with neck/back pain (p = 0.015) and headaches (p < 0.001) and in patients with extremity numbness trending at p = 0.064. Patients with syringomyelia were found to have improvement in CHIP scores over time (0.75 to 0.82, p < 0.001), as well as significant improvement in all 4 components. Additionally, improved CHIP scores were found to be significantly associated with age in patients with cervical (p = 0.009) or thoracic (p = 0.011) syrinxes. CONCLUSIONS: The study data show that the CHIP is an effective instrument for measuring HRQOL over time. Additionally, the CHIP was found to be significantly correlated to changes in symptomatology, a finding indicating that this instrument is a clinically valuable tool for the management of CM-I.

Anxiety in neurosurgical patients undergoing nonurgent surgery during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic has forced many countries into lockdown and has led to the postponement of nonurgent neurosurgical procedures. Although stress has been investigated during this pandemic, there are no reports on anxiety in neurosurgical patients undergoing nonurgent surgical procedures. METHODS: Neurosurgical patients admitted to hospitals in eastern Lombardy for nonurgent surgery after the lockdown prospectively completed a pre- and postoperative structured questionnaire. Recorded data included demographics, pathology, time on surgical waiting list, anxiety related to COVID-19, primary pathology and surgery, safety perception during hospital admission before and after surgery, and surgical outcomes. Anxiety was measured with the State-Trait Anxiety Inventory. Descriptive statistics were computed on the different variables and data were stratified according to pathology (oncological vs nononcological). Three different models were used to investigate which variables had the greatest impact on anxiety, oncological patients, and safety perception, respectively. Because the variables (Xs) were of a different nature (qualitative and quantitative), mostly asymmetrical, and related to outcome (Y) by nonlinear relationships, a machine learning approach composed of three steps (1, random forest growing; 2, relative variable importance measure; and 3, partial dependence plots) was chosen. RESULTS: One hundred twenty-three patients from 10 different hospitals were included in the study. None of the patients developed COVID-19 after surgery. State and trait anxiety were reported by 30.3% and 18.9% of patients, respectively. Higher values of state anxiety were documented in oncological compared to nononcological patients (46.7% vs 25%; p = 0.055). Anxiety was strongly associated with worry about primary pathology, surgery, disease worsening, and with stress during waiting time, as expected. Worry about positivity to SARS-CoV-2, however, was the strongest factor associated with anxiety, even though none of the patients were infected. Neuro-oncological disease was associated with state anxiety and with worry about surgery and COVID-19. Increased bed distance and availability of hand sanitizer were associated with a feeling of safety. CONCLUSIONS: These data underline the importance of psychological support, especially for neuro-oncological patients, during a pandemic.

Ambulatory neurosurgery in the COVID-19 era: patient and provider satisfaction with telemedicine.

OBJECTIVE: Telemedicine has rapidly expanded in the recent years as technologies have afforded healthcare practitioners the ability to diagnose and treat patients remotely. Due to the COVID-19 pandemic, nonessential clinical visits were greatly limited, and much of the outpatient neurosurgical practice at the authors' institution was shifted quickly to telehealth. Although there are prior data suggesting that the use of telemedicine is satisfactory in other surgical fields, data in neurosurgery are limited. This study aimed to investigate both patient and provider satisfaction with telemedicine and its strengths and limitations in outpatient neurosurgery visits. METHODS: This quality improvement study was designed to analyze provider and patient satisfaction with telemedicine consultations in an outpatient neurosurgery clinic setting at a tertiary care, large-volume, academic center. The authors designed an 11-question survey for neurosurgical providers and a 13-question survey for patients using both closed 5-point Likert scale responses and multiple choice responses. The questionnaires were administered to patients and providers during the period when the clinic restricted in-person visits. At the conclusion of the study, the overall data were analyzed qualitatively and quantitatively. RESULTS: During the study period, 607 surveys were sent out to patients seen by telehealth at the authors' academic center, and 122 responses were received. For the provider survey, 85 surveys were sent out to providers at the authors' center and other academic centers, and 40 surveys were received. Ninety-two percent of patients agreed or strongly agreed that they were satisfied with that particular telehealth visit. Eighty-eight percent of patients agreed that their telehealth visit was more convenient for them than an in-person visit, but only 36% of patients stated they would like their future visits to be telehealth. Sixty-three percent of providers agreed that telehealth visits were more convenient for them than in-person visits, and 85% of responding providers stated that they wished to incorporate telehealth into their future practice. CONCLUSIONS: Although the authors' transition to telehealth was both rapid and unexpected, most providers and patients reported positive experiences with their telemedicine visits and found telemedicine to be an effective form of ambulatory neurosurgical care. Not all patients preferred telemedicine visits over in-person visits, but the high satisfaction with telemedicine by both providers and patients is promising to the future expansion of telehealth in ambulatory neurosurgery.

Variations in attitudes towards stereotactic biopsy of adult diffuse midline glioma patients: a survey of members of the AANS/CNS Tumor Section.

PURPOSE: Diffuse midline gliomas are rare midline CNS malignancies that primarily affect children but can also affect adults. While radiation is standard treatment, prognosis remains fatal. Furthermore, due to its sensitive anatomic location, many physicians have been reluctant to perform biopsies without potential for improved prognosis. However, recent advancements in molecular-targeted therapeutics have encouraged greater tissue sampling. While the literature reflects this progress, the landscape of how clinicians actually manage these patients remains unclear. Our goal was to assess the attitudes of current practicing neurosurgical oncologists towards management of adult diffuse midline gliomas, reasons behind their practices, and factors that might influence these practices. METHODS: We created and distributed a survey with 16 multiple choice and open-ended questions to members of the Tumor Section of the Congress of Neurological Surgeons. RESULTS: A total of 81 physicians responded to the survey. Although time since training and volume of glioma patients did not significantly affect the decision to consider clinical trials or to offer biopsy, those that operated on fewer gliomas (< 25/year) were more likely to cite surgical morbidity as the primary reason not to biopsy these midline locations. Further, surgeons with access to more advanced molecular testing were significantly more likely to consider clinical trial eligibility when offering biopsies. CONCLUSION: Factors that affect the management of diffuse midline gliomas and the role of biopsy are relatively uniform across the field, however, there were a few notable differences that reflect the changes within the neuro-oncology field in response to clinical trials.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Spine Versus Adult Reconstructive Surgery.

STUDY DESIGN: Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients. OBJECTIVE: The aim of this study was to compare baseline and postoperative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery. SUMMARY OF BACKGROUND DATA: Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the health-related quality of life across different disease states. METHODS: Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery [THA, TKA]) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL), and 6-month PROMIS scores of physical function, pain interference, and pain intensity were determined. Paired t tests compared differences in CCI, BL, 6 months, and change in PROMIS scores for spine and adult reconstruction procedures. RESULTS: A total of 304 spine surgery patients (age = 58.1 ±â€Š15.6; 42.9% female) and 347 adult reconstruction patients (age = 62.9 ±â€Š11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to physical function ([21.0, 22.2, 9.07, 12.6, 10.4] vs. [35.8, 35.0], respectively, P < 0.01), pain interference ([80.1, 74.1, 89.6, 92.5, 90.6] vs. [64.0, 63.9], respectively, P < 0.01), and pain intensity ([53.0, 53.1, 58.3, 58.5, 56.1] vs. [53.4, 53.8], respectively, P < 0.01). At 6 months, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of physical function ([+8.7, +22.2, +9.7, +12.9, +12.1] vs. [+5.3, +3.9], respectively, P < 0.01) and pain interference scores ([-15.4,-28.1, -14.7, -13.1, -12.3] vs. [-8.3, -6.0], respectively, P < 0.01). CONCLUSION: Spinal surgery patients had lower BL and 6-month PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients. LEVEL OF EVIDENCE: 3.

Surgical decision making in the setting of severe traumatic brain injury: A survey of neurosurgeons.

BACKGROUND: Surgical decision-making in severe traumatic brain injury (TBI) is complex. Neurosurgeons weigh risks and benefits of interventions that have the potential to both maximize the chance of recovery and prolong suffering. Inaccurate prognostication can lead to over- or under-estimation of outcomes and influence treatment recommendations. OBJECTIVE: To evaluate the impact of evidence-based risk estimates on neurosurgeon treatment recommendations and prognostic beliefs in severe TBI. METHODS: In a survey-based randomized experiment, a total of 139 neurosurgeons were presented with two hypothetical patient with severe TBI and subdural hematoma; the intervention group received additional evidence-based risk estimates for each patient. The main outcome was neurosurgeon treatment recommendation of non-surgical management. Secondary outcomes included prediction of functional recovery at six months. RESULTS: In the first patient scenario, 22% of neurosurgeons recommended non-surgical management and provision of evidence-based risk estimates increased the propensity to recommend non-surgical treatment (odds ratio [OR]: 2.81, 95% CI: 1.21-6.98; p = 0.02). Neurosurgeon prognostic beliefs of 6-month functional recovery were variable in both control (median 20%, IQR: 10%-40%) and intervention (30% IQR: 10%-50%) groups and neurosurgeons were less likely to recommend non-surgical management when they believed prognosis was favorable (odds ratio [OR] per percentage point increase in 6-month functional recovery: 0.97, 95% confidence interval [CI]: 0.95-0.99). The results for the second patient scenario were qualitatively similar. CONCLUSIONS: Our findings show that the provision of evidence-based risk predictions can influence neurosurgeon treatment recommendations and prognostication, but the effect is modest and there remains large variability in neurosurgeon prognostication.

Lower Satisfaction After Adult Spinal Deformity Surgery in Japan Than in the United States Despite Similar SRS-22 Pain and Function Scores: A Propensity-Score Matched Analysis.

STUDY DESIGN: A multicenter retrospective case series. OBJECTIVE: The purpose of this study was to compare the clinical outcomes of a surgical treatment for adult spinal deformity (ASD) in the United States (US) with those in Japan (JP) in a matched cohort. SUMMARY OF BACKGROUND DATA: Surgical outcomes of thoracic-lumbar-sacral (TLS) spinal fusions in adult spinal deformity ASD patients who live in Asian countries are poorly understood. METHODS: A total of 300 surgically treated ASDs of age more than 50 years with the lowest instrumented vertebra at the pelvis and a minimum follow-up of 2 years (2y) were consecutively included. Patients were propensity-score matched for age, sex, levels fused, and 2y postop sagittal spinal alignment. Demographic, surgical, and radiographic parameters were compared between the US and JP groups. RESULTS: A total of 186 patients were matched by propensity score and were almost identical within these parameters: age (US vs. JP: 66 ±â€Š8 vs. 65 ±â€Š7 yr), sex (females: 90% vs. 89%), levels fused (10 ±â€Š3 vs. 10 ±â€Š2), 2y C7 sagittal vertical axis (C7SVA) (5 ±â€Š5 vs. 5 ±â€Š4 cm), 2y Pelvic incidence minus lumbar lordosis (9 ±â€Š15° vs. 9 ±â€Š15°), and 2y pelvic tilt (PT) (25 ±â€Š10° vs. 24 ±â€Š10°). Oswestry Disability Index (ODI) scores and Scoliosis Research Society patient questionnaire ((SRS-22) function and pain scores were similar at 2y between the US and JP groups (ODI: 27 ±â€Š19% vs. 28 ±â€Š14%, P = 0.72; SRS-22 function: 3.6 ±â€Š0.9 vs. 3.6 ±â€Š0.7, P = 0.54; SRS-22 pain: 3.6 ±â€Š1.0 vs. 3.8 ±â€Š0.8, P = 0.11). However, significantly lower satisfaction was observed in JP than in the US (SRS-22 satisfaction: 4.3 ±â€Š0.9 vs. 4.0 ±â€Š0.8, P < 0.01). CONCLUSION: Surgical treatment for ASD was similarly effective in patients in the US and in JP. However, satisfaction scores were lower in JP compared with the US. Differences in lifestyle and cultural expectations may impact patient satisfaction following ASD surgery. LEVEL OF EVIDENCE: 3.

The Presence and Persistence of Unrealistic Expectations in Patients Undergoing Nerve Surgery.

BACKGROUND: Unrealistic expectations of the outcomes of peripheral nerve surgery reduce patient satisfaction. Most clinicians can recall patients with unrealistic expectations despite verbal preoperative education. OBJECTIVE: To assess patients' baseline level of understanding regarding nerve surgery and appropriate expectations. Additionally, we tested the effect of a written, preoperative educational handout on the patients' retention of knowledge. METHODS: This cross-sectional survey recruited patients scheduled to undergo peripheral nerve surgery at a single institution in 2016 to 2017. During the preoperative visit, a specialized nurse practitioner reviewed perioperative protocols, risks and benefits of the surgery, and postoperative care. Patients immediately completed a survey to assess their preoperative understanding of the verbally reviewed information. During the same visit, an additional written handout was given to patients in a randomized fashion. At their first postoperative visit, all patients completed the survey again. RESULTS: A total of 60 patients (mean age 52 yr) were enrolled of which 62% were male. Immediately following verbal instruction, 31% of patients had erroneous (unrealistic) expectations regarding pain, 30% had erroneous expectations regarding postoperative motor outcome, and 41% had erroneous expectations regarding the timing of postoperative recovery. There was no significant difference between patients who received the written handout vs those who did not, on retesting in the postoperative period. CONCLUSION: Patients undergoing peripheral nerve procedures demonstrated a high baseline level of unrealistic expectations despite standard in-person verbal counseling by specialty providers. A written handout did not have clear benefit in the retention of preoperative surgical teaching. Further investigation into more effective preoperative patient counseling is needed.