Simulation-based trial of surgical-crisis checklists.

BACKGROUND: Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events. METHODS: Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. RESULTS: A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used. CONCLUSIONS: In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

Cost-effectiveness of lumbar discectomy and single-level fusion for spondylolisthesis: experience with the NeuroPoint-SD registry.

OBJECT: There is significant practice variation and uncertainty as to the value of surgical treatments for lumbar spine disorders. The authors' aim was to establish a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures by using prospectively collected outcomes. METHODS: An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level fusion for spondylolisthesis or single-level lumbar discectomy were included. The 36-Item Short Form Health Survey (SF-36) and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: lumbar disc (125 patients) and lumbar listhesis (35 patients). The quality-adjusted life year (QALY) data were calculated using 6-dimension utility index scores. Direct costs and complication costs were estimated using Medicare reimbursement values from 2011, and indirect costs were estimated using the human capital approach with the 2011 US national wage index. Total costs equaled $14,980 for lumbar discectomy and $43,852 for surgery for lumbar spondylolisthesis. RESULTS: There were 198 patients enrolled over 1 year. The mean age was 46 years (49% female) for lumbar discectomy (n = 148) and 58.1 years (60% female) for lumbar spondylolisthesis (n = 50). Ten patients with disc herniation (6.8%) and 1 with listhesis (2%) required repeat operation at 1 year. The overall 1-year follow-up rate was 88%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, visual analog scale, and SF-36 scores (p = 0.0002), which persisted at the 1-year evaluation (p < 0.0001). By 1 year, more than 80% of patients in each cohort who were working preoperatively had returned to work. Lumbar discectomy was associated with a gain of 0.225 QALYs over the 1-year study period ($66,578/QALY gained). Lumbar spinal fusion for Grade I listhesis was associated with a gain of 0.195 QALYs over the 1-year study period ($224,420/QALY gained). CONCLUSIONS: This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. These data are useful for demonstrating return to work and cost-effectiveness following surgical treatment of single-level lumbar disc herniation or spondylolisthesis. One-year cost per QALY was obtained, and this cost per QALY is expected to improve further by 2 years. This work sets the stage for real-world analysis of the value of health interventions.

Is there a difference in range of motion, neck pain, and outcomes in patients with ossification of posterior longitudinal ligament versus those with cervical spondylosis, treated with plated laminoplasty?

OBJECT: There are little data on the effects of plated, or plate-only, open-door laminoplasty on cervical range of motion (ROM), neck pain, and clinical outcomes. The purpose of this study was to compare ROM after a plated laminoplasty in patients with ossification of posterior longitudinal ligament (OPLL) versus those with cervical spondylotic myelopathy (CSM) and to correlate ROM with postoperative neck pain and neurological outcomes. METHODS: The authors retrospectively compared patients with a diagnosis of cervical stenosis due to either OPLL or CSM who had been treated with plated laminoplasty in the period from 2007 to 2012 at the University of California, San Francisco. Clinical outcomes were measured using the modified Japanese Orthopaedic Association (mJOA) scale and neck visual analog scale (VAS). Radiographic outcomes included assessment of changes in the C2-7 Cobb angle at flexion and extension, ROM at C2-7, and ROM of proximal and distal segments adjacent to the plated lamina. RESULTS: Sixty patients (40 men and 20 women) with an average age of 63.1 ± 10.9 years were included in the study. Forty-one patients had degenerative CSM and 19 patients had OPLL. The mean follow-up period was 20.9 ± 13.1 months. The mean mJOA score significantly improved in both the CSM and the OPLL groups (12.8 to 14.5, p < 0.01; and 13.2 to 14.2, respectively; p = 0.04). In the CSM group, the mean VAS neck score significantly improved from 4.2 to 2.6 after surgery (p = 0.01), but this improvement did not reach the minimum clinically important difference (MCID). Neither was there significant improvement in the VAS neck score in the OPLL group (3.6 to 3.1, p = 0.17). In the CSM group, ROM at C2-7 significantly decreased from 32.7° before surgery to 24.4° after surgery (p < 0.01). In the OPLL group, ROM at C2-7 significantly decreased from 34.4° to 20.8° (p < 0.01). In the CSM group, the change in the VAS neck score significantly correlated with the change in the flexion angle (r = - 0.31) and the extension angle (r = - 0.37); however, it did not correlate with the change in ROM at C2-7 (r = - 0.1). In the OPLL group, the change in the VAS neck score did not correlate with the change in the flexion angle (r = 0.03), the extension angle (r = - 0.17), or the ROM at C2-7 (r = - 0.28). The OPLL group had a significantly greater loss of ROM after surgery than did the CSM group (p = 0.04). There was no significant correlation between the change in ROM and the mJOA score in either group. CONCLUSIONS: Plated laminoplasty in patients with either OPLL or CSM decreases cervical ROM, especially in the extension angle. Among patients who have undergone laminoplasty, those with OPLL lose more ROM than do those with CSM. No correlation was observed between neck pain and ROM in either group. Neither group had a change in neck pain that reached the MCID following laminoplasty. Both groups improved in neurological function and outcomes.

Intraoperative neuromonitoring with MEPs and prediction of postoperative neurological deficits in patients undergoing surgery for cervical and cervicothoracic myelopathy.

OBJECT: The use of intraoperative neurophysiological monitoring (IONM) in surgical decompression surgery for myelopathy may assist the surgeon in taking corrective measures to reduce or prevent permanent neurological deficits. We evaluated the efficacy of IONM in cervical and cervicothoracic spondylotic myelopathy (CSM) cases. METHODS: The authors retrospectively reviewed 140 cases involving patients who underwent surgery for CSM utilizing IONM during 2011 at the University of California, San Francisco. Data on preoperative clinical variables, intraoperative changes in transcranial motor evoked potentials (MEPs), and postoperative new neurological deficits were collected. Associations between categorical variables were analyzed with the Fisher exact test. RESULTS: Of the 140 patients, 16 (11%) had significant intraoperative decreases in MEPs. In 8 of these cases, the MEP signal did not return to baseline values by the end of the operation. There were 8 (6%) postoperative deficits, of which 6 were C-5 palsies and 2 were paraparesis. Six of the patients with postoperative deficits had demonstrated persistent MEP signal change on IONM. There was a significant association between persistent MEP changes and postoperative deficits (p < 0.001). The sensitivity of intraoperative MEP monitoring was 75%, the specificity 98%, the positive predictive value 75%, and the negative predictive value 98%. Due to higher rates of false negatives, the sensitivity decreased to 60% in the subgroup of patients with vascular disease comorbidity. The sensitivity increased to 100% in elderly patients and in patients with preoperative motor deficits. The sensitivity and positive predictive value of deltoid and biceps MEP changes in predicting C-5 palsy were 67% and 67%, respectively. CONCLUSIONS: The authors found a correlation between decreased intraoperative MEPs and postoperative new neurological deficits in patients with CSM. Sensitivity varies based on patient comorbidities, age, and preoperative neurological function. Monitoring of MEPs is a useful adjunct for CSM cases, and the authors have developed a checklist to standardize their responses to intraoperative MEP changes.

The design, development, and implementation of a checklist for intraoperative neuromonitoring changes.

OBJECT: The purpose of this study was to provide an evidence-based algorithm for the design, development, and implementation of a new checklist for the response to an intraoperative neuromonitoring alert during spine surgery. METHODS: The aviation and surgical literature was surveyed for evidence of successful checklist design, development, and implementation. The limitations of checklists and the barriers to their implementation were reviewed. Based on this review, an algorithm for neurosurgical checklist creation and implementation was developed. Using this algorithm, a multidisciplinary team surveyed the literature for the best practices for how to respond to an intraoperative neuromonitoring alert. All stakeholders then reviewed the evidence and came to consensus regarding items for inclusion in the checklist. RESULTS: A checklist for responding to an intraoperative neuromonitoring alert was devised. It highlights the specific roles of the anesthesiologist, surgeon, and neuromonitoring personnel and encourages communication between teams. It focuses on the items critical for identifying and correcting reversible causes of neuromonitoring alerts. Following initial design, the checklist draft was reviewed and amended with stakeholder input. The checklist was then evaluated in a small-scale trial and revised based on usability and feasibility. CONCLUSIONS: The authors have developed an evidence-based algorithm for the design, development, and implementation of checklists in neurosurgery and have used this algorithm to devise a checklist for responding to intraoperative neuromonitoring alerts in spine surgery.

Patterns in neurosurgical adverse events: endovascular neurosurgery.

As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in endovascular neurosurgery concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. Based on a review of the literature, thromboembolic events appeared to be the most common adverse events in endovascular neurosurgery, with a reported incidence ranging from 2% to 61% depending on aneurysm rupture status and mode of detection of the event. Intraprocedural and periprocedural prevention and rescue regimens are advocated to minimize this risk; however, evidence on the optimal use of anticoagulant and antithrombotic agents is limited. Furthermore, it is unknown what proportion of eligible patients receive any prophylactic treatment. Groin-site hematoma is the most common access-related complication. Data from the cardiac literature indicate an overall incidence of 9% to 32%, but data specific to neuroendovascular therapy are scant. Manual compression, compression adjuncts, and closure devices are used with varying rates of success, but no standardized protocols have been tested on a broad scale. Contrast-induced nephropathy is one of the more common causes of hospital-acquired renal insufficiency, with an incidence of 30% in high-risk patients after contrast administration. Evidence from medical fields supports the use of various preventive strategies. Intraprocedural vessel rupture is infrequent, with the reported incidence ranging from 1% to 9%, but it is potentially devastating. Improvements in device technology combined with proper endovascular technique play an important role in reducing this risk. Occasionally, anatomical or technical difficulties preclude treatment of the lesion of interest. Reports of such occurrences are scant, but existing series suggest an incidence of 4% to 6%. Management strategies for radiation-induced effects are also discussed. The incidence rates are unknown, but protective techniques have been demonstrated. Many of these complications have strategies that appear effective in reducing their risk of occurrence, but development and evaluation of systematic guidelines and protocols have been widely lacking. Furthermore, there has been little monitoring of levels of adherence to potentially effective practices. Protocols and monitoring programs to support integrated implementation may be broadly effective.

Patterns in neurosurgical adverse events: intracranial neoplasm surgery.

OBJECT: Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to measuring and improving outcomes. As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in cranial tumor resection concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. METHODS: The authors performed a PubMed search using search terms "intracranial neoplasm," "cerebral tumor," "cerebral meningioma," "glioma," and "complications" or "adverse events." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to maximize the range of rates of occurrence for the reported adverse events. RESULTS: Review of the tumor neurosurgery literature showed that documented overall complication rates ranged from 9% to 40%, with overall mortality rates of 1.5%-16%. There was a wide range of types of adverse events overall. Deep venous thromboembolism (DVT) was the most common adverse event, with a reported incidence of 3%-26%. The presence of new or worsened neurological deficit was the second most common adverse event found in this review, with reported rates ranging from 0% for the series of meningioma cases with the lowest reported rate to 20% as the highest reported rate for treatment of eloquent glioma. Benign tumor recurrence was found to be a commonly reported adverse event following surgery for intracranial neoplasms. Rates varied depending on tumor type, tumor location, patient demographics, surgical technique, the surgeon's level of experience, degree of specialization, and changes in technology, but these effects remain unmeasured. The incidence on our review ranged from 2% for convexity meningiomas to 36% for basal meningiomas. Other relatively common complications were dural closure-related complications (1%-24%), postoperative peritumoral edema (2%-10%), early postoperative seizure (1%-12%), medical complications (6%-7%), wound infection (0%-4%), surgery-related hematoma (1%-2%), and wrong-site surgery. Strategies to minimize risk of these events were evaluated. Prophylactic techniques for DVT have been widely demonstrated and confirmed, but adherence remains unstudied. The use of image guidance, intraoperative functional mapping, and real-time intraoperative MRI guidance can allow surgeons to maximize resection while preserving neurological function. Whether the extent of resection significantly correlates with improved overall outcomes remains controversial. DISCUSSION: A significant proportion of adverse events in intracranial neoplasm surgery may be avoidable by use of practices to encourage use of standardized protocols for DVT, seizure, and infection prophylaxis; intraoperative navigation among other steps; improved teamwork and communication; and concentrated volume and specialization. Systematic efforts to bundle such strategies may significantly improve patient outcomes.

Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery.

OBJECT: As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality. METHODS: The authors performed a PubMed search using search terms "cerebral shunt," "cerebrospinal fluid shunt," "CSF shunt," "ventriculoperitoneal shunt," "cerebral shunt AND complications," "cerebrospinal fluid shunt AND complications," "CSF shunt AND complications," and "ventriculoperitoneal shunt AND complications." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported. RESULTS: In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36-0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half. Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation. CONCLUSIONS: Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes.

Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery.

OBJECT: As part of a project to devise evidence-based safety interventions for specialty surgery, we sought to review current evidence concerning the frequency of adverse events in open cerebrovascular neurosurgery and the state of knowledge regarding methods for their reduction. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. METHODS: The authors performed a PubMed search using search terms "cerebral aneurysm", "cerebral arteriovenous malformation", "intracerebral hemorrhage", "intracranial hemorrhage", "subarachnoid hemorrhage", and "complications" or "adverse events." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the reported adverse events. RESULTS: The review revealed hemorrhage-related hyperglycemia (incidence rates ranging from 27% to 71%) and cerebral salt-wasting syndromes (34%-57%) to be the most common perioperative adverse events related to subarachnoid hemorrhage (SAH). Next in terms of frequency was new cerebral infarction associated with SAH, with a rate estimated at 40%. Many techniques are advocated for use during surgery to minimize risk of this development, including intraoperative neurophysiological monitoring, but are not universally used due to surgeon preference and variable availability of appropriate staffing and equipment. The comparative effectiveness of using or omitting monitoring technologies has not been evaluated. The incidence of perioperative seizure related to vascular neurosurgery is unknown, but reported seizure rates from observational studies range from 4% to 42%. There are no standard guidelines for the use of seizure prophylaxis in these patients, and there remains a need for prospective studies to support such guidelines. Intraoperative rupture occurs at a rate of 7% to 35% and depends on aneurysm location and morphology, history of rupture, surgical technique, and surgeon experience. Preventive strategies include temporary vascular clipping. Technical adverse events directly involving application of the aneurysm clip include incomplete aneurysm obliteration and parent vessel occlusion. The rates of these events range from 5% to 18% for incomplete obliteration and 3% to 12% for major vessel occlusion. Intraoperative angiography is widely used to confirm clip placement; adjuncts include indocyanine green video angiography and microvascular Doppler ultrasonography. Use of these technologies varies by institution. DISCUSSION: A significant proportion of these complications may be avoidable through development and testing of standardized protocols to incorporate monitoring technologies and specific technical practices, teamwork and communication, and concentrated volume and specialization. Collaborative monitoring and evaluation of such protocols are likely necessary for the advancement of open cerebrovascular neurosurgical quality.

Adverse events in neurosurgery and their relationship to quality improvement.

Adverse events are common in neurosurgery. Their reporting is inconsistent and widely variable due to nonuniform definitions, data collection mechanisms, and retrospective data collection. Historically, neurosurgery has lagged behind general and cardiac surgical fields in the creation of multi-institutional prospective databases allowing for benchmarking and accurate adverse event/outcomes measurement, the bedrock of evidence used to guide quality improvement initiatives. The National Neurosurgery Quality and Outcomes Database has begun to address this issue by collecting prospective, multi-institutional outcomes data in neurosurgical patients. Once reliable outcomes exist, various targeted quality improvement strategies may be used to reduce adverse events and improve outcomes.

A controlled anterior sequential interbody dilation technique for correction of cervical kyphosis.

OBJECT: Cervical kyphosis can lead to spinal instability, spinal cord injury, and disability. The correction of cervical kyphosis is technically challenging, especially in severe cases. The authors describe the anterior sequential interbody dilation technique for the treatment of cervical kyphosis and evaluate perioperative outcomes, degree of correction, and long-term follow-up outcomes associated with the technique. METHODS: In the period from 2006 to 2011, a consecutive cohort of adults with cervical kyphosis (Cobb angles ≥ 0°) underwent sequential interbody dilation, a technique entailing incrementally increased interbody distraction with the sequential placement of larger spacers (at least 1 mm) in the discectomy and/or corpectomy spaces. The authors retrospectively reviewed these patients, and primary outcomes of interest included kyphosis correction, blood loss, hospital stay, complications, Nurick grade, pain, reoperation, and pseudarthrosis. A subgroup analysis among patients with preoperative kyphosis of 0°-9° (mild), 10°-19° (moderate), and ≥ 20° (severe) was performed. RESULTS: One hundred patients were included in the study: 74 with mild preoperative cervical kyphosis, 19 with moderate, and 7 with severe. The mean patient age was 53.1 years, and 54.0% of the patients were male. Mean estimated blood loss was 305.6 ml, and the mean length of hospital stay was 5.2 days. The overall complication rate was 9.0%, and there were no deaths. Sixteen percent of patients underwent supplemental posterior fusion. There was significant correction in cervical alignment (p < 0.001), and the mean overall kyphosis correction was 12.4°. Patients with severe preoperative kyphosis gained a correction of 24.7°, those with moderate kyphosis gained 17.8°, and those with mild kyphosis gained 10.1°. A mean correction of 32.0° was obtained if 5 levels were addressed. The mean follow-up was 26.8 months. The reoperation rate was 4.7%. At follow-up, there was significant improvement in visual analog scale neck pain (p = 0.020) and Nurick grade (p = 0.037). The pseudarthrosis rate was 6.3%. CONCLUSIONS: Sequential interbody dilation is a feasible and effective method of correcting cervical kyphosis. Complications and reoperation rates are low. Similar benefits are seen among all severities of kyphosis, and greater correction can be achieved in more severe cases.

The effects of smoking on perioperative outcomes and pseudarthrosis following anterior cervical corpectomy: Clinical article.

OBJECT: Smoking is one of the leading causes of preventable morbidity and death in the U.S. and has been associated with perioperative complications. In this study, the authors examined the effects of smoking on perioperative outcomes and pseudarthrosis rates following anterior cervical corpectomy. METHODS: All adult patients from 2006 to 2011 who underwent anterior cervical corpectomy were identified. Patients were categorized into 3 groups: patients who never smoked (nonsmokers), patients who quit for at least 1 year (quitters), and patients who continue to smoke (current smokers). Demographic, medical, and surgical covariates were collected. Multivariate analysis was used to define the relationship between smoking and blood loss, 30-day complications, length of hospital stay, and pseudarthrosis. RESULTS: A total of 160 patients were included in the study. Of the 160 patients, 49.4% were nonsmokers, 25.6% were quitters, and 25.0% were current smokers. The overall 30-day complication rate was 20.0%, and pseudarthrosis occurred in 7.6% of patients. Mean blood loss was 368.3 ml and mean length of stay was 6.5 days. Current smoking status was significantly associated with higher complication rates (p < 0.001) and longer lengths of stay (p < 0.001); current smoking status remained an independent risk factor for both outcomes after multivariate logistic regression analysis. The complications that were experienced in current smokers were mostly infections (76.5%), and this proportion was significantly greater than in nonsmokers and quitters (p = 0.013). Current smoking status was also an independent risk factor for pseudarthrosis at 1-year follow-up (p = 0.012). CONCLUSIONS: Smoking is independently associated with higher perioperative complications (especially infectious complications), longer lengths of stay, and higher rates of pseudarthrosis in patients undergoing anterior cervical corpectomy.

The role of decision analytic modeling in the health economic assessment of spinal intervention.

STUDY DESIGN: Narrative review. OBJECTIVE: To review the common tenets, strengths, and weaknesses of decision modeling for health economic assessment and to review the use of decision modeling in the spine literature to date. SUMMARY OF BACKGROUND DATA: For the majority of spinal interventions, well-designed prospective, randomized, pragmatic cost-effectiveness studies that address the specific decision-in-need are lacking. Decision analytic modeling allows for the estimation of cost-effectiveness based on data available to date. Given the rising demands for proven value in spine care, the use of decision analytic modeling is rapidly increasing by clinicians and policy makers. METHODS: This narrative review discusses the general components of decision analytic models, how decision analytic models are populated and the trade-offs entailed, makes recommendations for how users of spine intervention decision models might go about appraising the models, and presents an overview of published spine economic models. RESULTS: A proper, integrated, clinical, and economic critical appraisal is necessary in the evaluation of the strength of evidence provided by a modeling evaluation. As is the case with clinical research, all options for collecting health economic or value data are not without their limitations and flaws. There is substantial heterogeneity across the 20 spine intervention health economic modeling studies summarized with respect to study design, models used, reporting, and general quality. There is sparse evidence for populating spine intervention models. Results mostly showed that interventions were cost-effective based on $100,000/quality-adjusted life-year threshold. Spine care providers, as partners with their health economic colleagues, have unique clinical expertise and perspectives that are critical to interpret the strengths and weaknesses of health economic models. CONCLUSION: Health economic models must be critically appraised for both clinical validity and economic quality before altering health care policy, payment strategies, or patient care decisions. LEVEL OF EVIDENCE: 4.

Validation of the surgical Apgar score in a neurosurgical patient population.

OBJECT: The surgical Apgar score (SAS) reliably predicts postoperative death and complications and has been validated in a large cohort of general and vascular surgery patients. However, there has been limited study of the utility of the score in the neurosurgical population. The authors tested the hypothesis that the SAS would predict postoperative complications and length of stay after neurosurgical procedures. METHODS: A cohort of 918 intracranial and spine surgery patients treated over a 3-year period were retrospectively evaluated. The 10-point SAS was calculated and postoperative 30-day mortality and complications rates, intensive care unit (ICU) stay, and hospital stay were assessed by 2 independent raters. Univariate analysis and multivariate logistic regression were performed. RESULTS: There were 145 patients (15.8%) with at least 1 complication and 24 patients (2.6%) who died within 30 days of surgery. Surgical Apgar scores were significantly associated with the likelihood of postoperative complications (p < 0.001) and death (p = 0.002); scores varied inversely with postoperative complication and mortality risk in a multivariate analysis. Low SASs also predicted prolonged ICU and hospital stay. Patients with scores of 0-2 stayed a mean of 18.9 days (p < 0.001) and patients with scores of 3-4 stayed an average of 14.3 days (p < 0.001) compared with 4.1 days in patients with scores of 9-10. CONCLUSIONS: The application of the surgical Apgar score to a neurosurgical cohort predicted 30-day postoperative mortality and complication rates as well as extended ICU and hospital stay. This readily calculated score may help neurosurgical teams efficiently direct postoperative care to those at highest risk of death and complications.

The role of minimally invasive techniques in the treatment of adult spinal deformity.

Many surgeons use minimally invasive surgery (MIS) approaches for treatment of patients with adult degenerative spinal deformity. The feasibility and efficacy of these techniques in the treatment of certain subtypes of degenerative deformities have been reported. In this article, several MIS techniques are discussed and an established 6-level treatment algorithm (MiSLAT) is presented, to help guide spinal surgeons in the use of MIS techniques for the treatment of patients with degenerative deformity. MIS treatment of MiSLAT level I to IV deformities is recommended, whereas level V and VI deformities require more traditional open approaches for adequate deformity correction.

Outcomes after surgery for spinal metastatic leiomyosarcoma.

OBJECT: Leiomyosarcoma is a smooth-muscle sarcoma that rarely metastasizes to the spine. Its clinical course is variable, although patients with metastatic leiomyosarcoma can experience prolonged survival as compared with patients with more aggressive metastatic tumors. The authors report their single-institution experience in the surgical treatment of patients with leiomyosarcoma metastatic to the spine. METHODS: A retrospective review of the electronic medical records was performed to obtain details on clinical management and outcomes for patients who had undergone surgical intervention for metastatic leiomyosarcoma of the spine. The few articles available in the current literature on this topic were also analyzed. RESULTS: Eight patients with metastatic leiomyosarcoma of the spine underwent surgical management between 2005 and 2011. Six patients (75%) had improvement in their Nurick grade. Patients who had presented with pain as a primary symptom experienced significant relief. Five patients (63%) had lesion recurrence, and 4 underwent repeat surgery at a mean of 10.2 months after their initial surgery. The mean duration of survival was 11.7 months (range 3.3-23.0 months). CONCLUSIONS: Leiomyosarcoma rarely metastasizes to the spine. However, surgical intervention can relieve pain and improve neurological function. Given the potential for prolonged survival, aggressive management should be considered in well-selected patients.

Preoperative hyperglycemia and complication risk following neurosurgical intervention: A study of 918 consecutive cases.

BACKGROUND: Little is known about the relation between preoperative glycemic state and neurosurgical outcomes. Improved understanding of this relationship may identify patients at increased risk of complicated recovery and guide postoperative treatment strategies. METHODS: Data were collected about 918 consecutive craniotomy or spine-related neurosurgical cases at the University of Michigan Hospitals. Univariate statistics, bivariate chi-square tests, and analysis of variance were used to assess relations between preoperative blood glucose, demographics, medical comorbidities, systemic glucocorticoid use, and postoperative complication risk and postoperative hospital and intensive care unit (ICU) stay. We fit a multivariable logistic regression model of 30-day complication risk by preoperative blood glucose adjusted for potential confounders, and used analysis of covariance to assess the relation between preoperative blood glucose and hospital, as well as ICU stay, adjusted for potential confounders. RESULTS: Among all patients, 56.1% had peri-operative blood glucose levels below 100 mg/dl. 20.7% had levels from 100 to 120 mg/dl, 16.3% had levels from 121 to 160 mg/dl, and 6.9% had levels greater than 160 mg/dl. In multivariable regression models, blood glucose greater than 120 mg/dl was associated with increased risk of postoperative complications at all levels. Analysis of covariance showed that preoperative blood glucose above 120 mg/dl was associated with both increased length of ICU stay and length of hospital stay. CONCLUSIONS: Our findings suggest that even mild preoperative hyperglycemia is a predictor of postoperative complication risk, and prolonged hospital and ICU stay following neurosurgical intervention. Tight glycemic control may be in order when attempting to reduce risk of complications and limit postoperative recovery time.

Sex disparities in postoperative outcomes after neurosurgical intervention: findings from the UMEND project.

BACKGROUND: Little is known about the relationship between sex and the risk of complications after neurosurgical intervention. Improved understanding of this relationship may assist clinicians in advising patients of the risks and benefits of neurosurgical intervention and managing their patients after surgery. OBJECTIVE: To determine the independent relationship between sex and morbidity after neurosurgical intervention. METHODS: Data were collected for 918 neurosurgical cases at the University of Michigan Hospitals. Bivariate χ(2) tests and analysis of variance were used to assess relationships between sex, demographics, case type, medical comorbidities, postoperative complication risk, and postoperative hospital and intensive care unit stay. We fit a multivariable logistic regression model of 30-day complication risk by sex adjusted for potential confounders and used multifactor analysis of variance to assess the relationship between sex and hospital as well as intensive care unit stay, adjusted for potential confounders. RESULTS: The percentages of patients experiencing complications within 30 days of surgery were 20.3% for male and 11.3% for female patients. In multivariable regression models, male sex predicted postoperative complications compared with female sex (odds ratio: 2.0, 95% confidence interval: 1.4-3.0). By multifactor analysis of variance, male sex was associated with longer hospital stay (P < .01), but was not associated with neurosurgical intensive care unit stay. CONCLUSION: Our findings suggest male sex is an independent predictor of postoperative complication risk and increased hospital stay after neurosurgical intervention. This finding may be used clinically to help identify those patients at increased risk of a complicated recovery. Future research might consider mechanisms relating sex and postoperative outcomes.

Cigarette smoking: a risk factor for postoperative morbidity and 1-year mortality following craniotomy for tumor resection.

OBJECT: Identifying risk factors for surgical morbidity and mortality might improve the safety and efficacy of neurosurgical intervention. Cigarette smoking is a relatively common practice and is associated with several adverse health outcomes. The authors examined the relationship between smoking and intraoperative blood loss, postoperative outcomes, and survival following craniotomy for tumor resection. METHODS: A consecutive population of patients undergoing craniotomy for tumor resection between 2006 and 2009 was identified. Using multivariable models and Cox proportional hazard regression analysis, the authors assessed the relation between smoking and operative outcomes including blood loss, complication rates, hospital length of stay, 30-day mortality, and 1-year survival among patients who underwent craniotomy for tumor resection. RESULTS: A total of 453 patients were included in this study: 237 patients never smoked, 54 quit smoking for at least 1 year, and 162 were current smokers. Current smoking status was an independent risk factor for higher intraoperative blood loss, complication risk, and lower 1-year survival following intervention relative to patients who never smoked. Patients who quit smoking had significantly higher mean blood loss, but did not carry a higher risk for other outcomes such as postoperative complications and 1-year mortality compared with patients who never smoked. CONCLUSIONS: Current cigarette smoking is associated with poor surgical outcome and lower 1-year survival after undergoing craniotomy for tumor resection. However, quitting smoking and implementing strict smoking cessation programs may help mitigate these risks. Future research might investigate mechanisms underlying these associations.

Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older than 80 years.

OBJECT: Advances in the management of trauma-induced intracranial hematomas and hemorrhage (epidural, subdural, and intraparenchymal hemorrhage) have improved survival in these conditions over the last several decades. However, there is a paucity of research investigating the relation between patient age and outcomes of surgical treatment for these conditions. In this study, the authors examined the relation between patient age over 80 years and postoperative outcomes following closed head injury and craniotomy for intracranial hemorrhage. METHODS: A consecutive population of patients undergoing emergent craniotomy for evacuation of intracranial hematoma following closed head trauma between 2006 and 2009 was identified. Using multivariable logistic regression models, the authors assessed the relation between age (> 80 vs ≤ 80 years) and postoperative complications, intensive care unit stay, hospital stay, morbidity, and mortality. RESULTS: Of 103 patients, 27 were older than 80 years and 76 patients were 80 years of age or younger. Older age was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI 1.29-25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13-9.74). However, there were no statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status. CONCLUSIONS: The findings suggest that in comparison with younger patients, patients over 80 years of age may be similarly able to return to preinjury functional baselines but may require increased postoperative medical attention in the forms of rehabilitation and longer hospital stays. Prospective studies concerned with the relation between older age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhage are needed. Nonetheless, the findings of this study may allow for more informed decisions with respect to the care of elderly patients with intracranial hemorrhage.