Tumor-Related and Patient-Related Variables Affecting Length of Hospital Stay Following Vestibular Schwannoma Microsurgery.

OBJECTIVE: Review a single institution's vestibular schwannoma (VS) microsurgery experience to determine (1) correlations between demographics, comorbidities, and/or surgical approach on hospital length of stay (LOS) and discharge disposition and (2) trends in surgical approach over time. METHODS: Retrospective case series from a multidisciplinary skull base program at a tertiary care, academic hospital. All adult (>18 years) patients undergoing primary microsurgery for VS between 2008 and 2018 were included. RESULTS: A total of 147 subjects were identified. Surgical approach was split between middle fossa (MF) (16%), retrosigmoid (RS) (35%), and translabyrinthine (TL) (49%) craniotomies. For the 8% of patients had other than routine (OTR) discharge. Mean LOS was significantly longer for patients undergoing RS than either MF or TL. Brainstem compression by the tumor was associated with longer LOS as were diagnoses of chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD). For all discharges, the 40 to 50- and 50 to 60-year-old subgroups had significantly shorter LOS than the 70-years-and-older patients. For the 92% of patients routinely discharged, there was a significantly shorter LOS in the 40 to 50-year-olds compared to the 70-years-and-older patients. There was a significant shift in surgical approach from RS to TL over the study period. CONCLUSION: Over 90% of VS microsurgery patients were routinely discharged with a median hospital LOS of 3.2 days, both of which are consistent with published data. There is an inverse relationship between age and LOS with patients older than 70 years having significantly longer LOS. Brainstem compression, COPD, PVD, and the RS approach negatively affect LOS. LEVEL OF EVIDENCE: 4.

Helping spine surgeons detect pre-surgical psychological distress in complex spine patients: an observational pilot study.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: Analysis of a standardized, pre-surgical psychological evaluation program for complex spine surgery. Adult spinal deformity (ASD) patients have a high rate of comorbid mental health conditions. Although there is a body of literature demonstrating the impact of psychological factors, including anxiety and depression, on spine surgery outcome, it is estimated that spine surgeons utilize a psychological assessment only about one third of the time prior to a patient's spine surgery. At this time, there is not a widely reported pre-surgical psychological evaluation program for ASD patients. METHODS: 129 consecutive complex spine surgery candidates receiving a pre-surgical psychological evaluation were analyzed between January 1st 2014 and December 31st 2018. Based on the available literature and professional experience in our facility, a color code for patients was developed from Green (low psychological or psychosocial co-morbidity) to Red (high psychological or psychosocial co-morbidity). Univariate analysis was used to evaluate between color grades and demographics, mental health disorders and outcomes. RESULTS: 83% of complex spine patients had at least one psychological disorder or psychosocial barrier. Only 17% had a combination of realistic expectations for surgery, a good support plan, and were without a history of mental illness. The pre-surgical psychological color criteria were validated in showing higher rates of major depression, anxiety disorder, and bipolar disorder in moderate to severe color grades (p < .001) in addition to higher PHQ-9 and GAD-7 scores (p < .001). Patients having a more severe color grade had lower rates of a discharge home and were taking higher morphine equivalent dosages (MEDs) at their six-month follow-up, though both did not reach statistical significance (p = .07 and p = .08; respectively). CONCLUSION: A comprehensive pre-surgical psychological evaluation may be beneficial to risk stratify and counsel patients being evaluated for surgical reconstruction of adult spinal deformities. LEVEL OF EVIDENCE: 3.

Use of Opioids and Other Analgesics Before and After Primary Surgery for Adult Spinal Deformity: A 10-Year Nationwide Study.

OBJECTIVE: To report the 1-year pre and postoperative analgesic use in patients undergoing primary surgery for adult spinal deformity (ASD) and assess risk factors for chronic postoperative opioid use. METHODS: Patients > 18 years undergoing primary instrumented surgery for ASD in Denmark between 2006 and 2016 were identified in the Danish National Patient Registry. Information on analgesic use were obtained from the Danish National Health Service Prescription Database. Use of analgesics was calculated one year before and after surgery for each patient, per quarter (-Q4 to -Q1 before and Q1 to Q4 after). Users were defined as patient with one or more prescriptions in the given quarter. RESULTS: We identified 892 patients. Preoperatively, 28% (n = 246) of patients were opioid users in -Q4 and 33% (n = 295) in -Q1. Postoperatively, 85% (n = 756) of patients were opioid users in Q1 and 31% (n = 280) in Q4. Proportions of users of other analgesics (paracetamol, antidepressants, and anticonvulsants) were stable before and after surgery. Use of nonsteroidal anti-inflammatory drug decreased postoperatively by 40% (-Q1 vs. Q4). 26% of patients had chronic preoperative opioid use (one or more prescriptions in each -Q2 and -Q1) and 24% had chronic postoperative use (prescription each of Q1-Q4). Multivariate logistic regression analysis showed age increment per 10 years and preoperative chronic opioid use as risk factors for chronic postoperative opioid use. CONCLUSION: One year after ASD surgery, opioid use was not reduced compared to preoperative usage.

Characterizing the Risk of Long-Term Opioid Utilization in Patients Undergoing Lumbar Spine Surgery.

STUDY DESIGN: Single-institution retrospective cohort study. OBJECTIVE: To determine whether prescribing practices at discharge are associated with opioid dependence (OD) in patients undergoing discectomy or laminectomy procedures for degenerative indications. SUMMARY OF BACKGROUND DATA: Long-term opioid use in spine surgery is associated with higher healthcare utilization and worse postoperative outcomes. The impact of prescribing practices at discharge within this surgical population is poorly understood. METHODS: A query of an administrative database was conducted to identify all patients undergoing discectomy or laminectomy procedures at our high-volume tertiary referral center between 2007 and 2016. For patients included in the analysis, opioid prescription data on admission and discharge were manually abstracted from the electronic health record, including opioid type, frequency, route, and dose, and then converted to daily morphine equivalent dose (MED) values. We defined OD as a consecutive narcotic prescription lasting for at least 90 days within the first 12 months after the index surgical procedure. RESULTS: Of the 819 total patients, 499 (60.9%) patients had an active opioid prescription before surgery. Postoperatively, 813 (99.3%) received at least one narcotic prescription within 30 days of index surgery, and 162 (19.8%) continued with sustained opioid use in the 12 months after surgery. In adjusted analysis, patients with OD had a higher incidence of preoperative depression (P = 0.012) and preoperative opioid use (P < 0.001), as well as a higher frequency of preoperative benzodiazepine prescriptions (P = 0.009), and discharge MED value exceeding 120 mg/day (P = 0.013). Postoperative OD was observed in 7.5% of previously opioid-naïve patients. CONCLUSION: This is the first study to test for an association between MED values prescribed at discharge and sustained opioid use after lumbar spine surgery. In addition to previously reported risk factors, discharge prescription dose exceeding 120 mg/day is independently associated with OD after spine surgery. LEVEL OF EVIDENCE: 3.

Investigating Risk Factors and Predicting Complications in Deep Brain Stimulation Surgery with Machine Learning Algorithms.

BACKGROUND: Deep brain stimulation (DBS) surgery is an option for patients experiencing medically resistant neurologic symptoms. DBS complications are rare; finding significant predictors requires a large number of surgeries. Machine learning algorithms may be used to effectively predict these outcomes. The aims of this study were to 1) investigate preoperative clinical risk factors and 2) build machine learning models to predict adverse outcomes. METHODS: This multicenter registry collected clinical and demographic characteristics of patients undergoing DBS surgery (n = 501) and tabulated occurrence of complications. Logistic regression was used to evaluate risk factors. Supervised learning algorithms were trained and validated on 70% and 30%, respectively, of both oversampled and original registry data. Performance was evaluated using area under the receiver operating characteristics curve (AUC), sensitivity, specificity, and accuracy. RESULTS: Logistic regression showed that the risk of complication was related to the operating institution in which the surgery was performed (odds ratio [OR] = 0.44, confidence interval [CI] = 0.25-0.78), body mass index (OR = 0.94, CI = 0.89-0.99), and diabetes (OR = 2.33, CI = 1.18-4.60). Patients with diabetes were almost 3× more likely to return to the operating room (OR = 2.78, CI = 1.31-5.88). Patients with a history of smoking were 4× more likely to experience postoperative infection (OR = 4.20, CI = 1.21-14.61). Supervised learning algorithms demonstrated high discrimination performance when predicting any complication (AUC = 0.86), a complication within 12 months (AUC = 0.91), return to the operating room (AUC = 0.88), and infection (AUC = 0.97). Age, body mass index, procedure side, gender, and a diagnosis of Parkinson disease were influential features. CONCLUSIONS: Multiple significant complication risk factors were identified, and supervised learning algorithms effectively predicted adverse outcomes in DBS surgery.

Implementation of an Opioid Reduction Protocol for Simple Outpatient Neurosurgical Procedures: A Single-Center Experience.

STUDY DESIGN: Quality improvement with before and after evaluation of the intervention. OBJECTIVE: To evaluate postoperative opioid utilization at a high-volume tertiary referral center following implementation of an opioid reduction protocol for simple outpatient neurosurgical procedures. SUMMARY OF BACKGROUND DATA: The opioid epidemic has been well-publicized both in the scientific and lay press over the last few years. As a response to this crisis many state-wide and national medical groups have sought to develop opioid prescribing guidelines for both acute and chronic pain states. Some guidelines have studied opioid prescribing in orthopedic procedures but have primarily limited their recommendations to simple outpatient orthopedic joint procedures. Although, it is not clear that these opioid prescribing reductions are directly translatable to neurosurgical procedures. METHODS: We implemented an opioid reduction protocol geared towards the postoperative management for simple outpatient neurosurgical procedures and measured the effect on number of pills and total morphine equivalent dose (MED) prescribed, postoperative readmissions, refill requests, and conversion to long-term opiate use. RESULTS: Our study population was 246 patients, with 109 patients in the pre-intervention (PRE) group and 137 patients in the post-intervention (POST) group. The vast majority of patients in both groups were discharged with an opioid prescription (93% PRE, 91% POST, P = 0.87). The POST group had significantly lower total discharge opioid medication quantity (52 tabs PRE, 27 tabs POST, P < 0.001), discharge day MED (51.3 PRE, 45.3 POST, P = 0.01), and total discharge MED (287 PRE, 149 POST, P < 0.001). CONCLUSION: A standardized discharge protocol for postoperative neurosurgery can lead to significant reductions in opioid discharge quantity without compromising patient safety or increasing the utilization of hospital resources through readmissions, refill requests, or clinic phone calls. This study provides an example of a feasible and effective discharge prescription regimen that may be generalizable to some of the most common outpatient neurosurgical procedures. LEVEL OF EVIDENCE: 3.

Pre-operative smoking history increases risk of infection in deep brain stimulation surgery.

Although general risk of deep brain stimulation (DBS) therapy has been previously described, application of risk prediction at the individual patient level is still largely at the discretion of a treating physician or a multidisciplinary team. To explore associations between potentially modifiable patient characteristics and common adverse events following DBS surgery, we retrospectively reviewed consecutive adult patients who had undergone new DBS electrode placement surgeries at two high-volume tertiary referral centers between October 1997 and May 2018. Among 501 patients included in the analysis (mean age (SD), 64.6 (10.4) years), 165 (32.9%) were female, 67 (13.4%) had diabetes, 231 (46.1%) had hypertension, 25 (5.0%) were smokers, 27 (5.4%) developed an infection, 15 (3.0%) had intracranial or intraventricular hemorrhage, and 53 (10.6%) had an unplanned return to the operating room. Patients who developed a surgical site infection were more likely to report history of smoking before DBS surgery (16% vs 5%, p = 0.04). There was a trend for patients with hypertension to be at risk for intracranial hemorrhage (p = 0.11). In conclusion, this multicenter study demonstrated an association between preoperative smoking and increased risk of infection following new DBS implantation surgery. Counseling about this risk should be considered in preoperative evaluation of patients who are considering undergoing a DBS procedure.

Altered Neuroinflammation and Behavior after Traumatic Brain Injury in a Mouse Model of Alzheimer's Disease.

Traumatic brain injury (TBI) has acute and chronic sequelae, including an increased risk for the development of Alzheimer's disease (AD). TBI-associated neuroinflammation is characterized by activation of brain-resident microglia and infiltration of monocytes; however, recent studies have implicated beta-amyloid as a major manipulator of the inflammatory response. To examine neuroinflammation after TBI and development of AD-like features, these studies examined the effects of TBI in the presence and absence of beta-amyloid. The R1.40 mouse model of cerebral amyloidosis was used, with a focus on time points well before robust AD pathologies. Unexpectedly, in R1.40 mice, the acute neuroinflammatory response to TBI was strikingly muted, with reduced numbers of CNS myeloid cells acquiring a macrophage phenotype and decreased expression of inflammatory cytokines. At chronic time points, macrophage activation substantially declined in non-Tg TBI mice; however, it was relatively unchanged in R1.40 TBI mice. The persistent inflammatory response coincided with significant tissue loss between 3 and 120 days post-injury in R1.40 TBI mice, which was not observed in non-Tg TBI mice. Surprisingly, inflammatory cytokine expression was enhanced in R1.40 mice compared with non-Tg mice, regardless of injury group. Although R1.40 TBI mice demonstrated task-specific deficits in cognition, overall functional recovery was similar to non-Tg TBI mice. These findings suggest that accumulating beta-amyloid leads to an altered post-injury macrophage response at acute and chronic time points. Together, these studies emphasize the role of post-injury neuroinflammation in regulating long-term sequelae after TBI and also support recent studies implicating beta-amyloid as an immunomodulator.