Adult versus adolescent idiopathic scoliosis surgery: a meta-analysis of clinical and radiographic outcomes.

INTRODUCTION: While the natural history of adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AdIS) is well documented in the literature, the impact of age on postoperative outcomes remains an active area of research. We performed a systematic review and meta-analysis to compare patients undergoing surgery for AIS and AdIS with respect to: (1) postoperative Cobb correction, (2) perioperative variables, and (3) postoperative complications. METHODS: A systematic literature search was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. INCLUSION CRITERIA: studies published between 2002 and 2022, retrospective, and comparing AIS vs. AdIS patients undergoing deformity surgery. The primary outcome was postoperative Cobb correction. Secondary outcomes included estimated blood loss (EBL), operative time, total instrumented levels, length of stay (LOS), and postoperative complications. Random-effects models were performed according to the method of DerSimonian and Laird. RESULTS: Of 190 identified articles, 14 fit the inclusion criteria. A total of 1788 patients were included, 1275(71.3%) with AIS, and 513(28.7%) with AdIS. There was a significant age difference between AIS and AdIS (15.3 vs. 36.7 years, mean difference (MD) = 21.3 years, 95%CI = 14.3-28.4,p < 0.001). Mean postoperative Cobb percentage correction was reported in 5 articles and was significantly higher in AIS (68.4%) vs. AdIS (61.4%) (MD = -7.2, 95%CI = -11.6,-2.7,p = 0.001). EBL was not significantly different between AIS and AdIS (695.6 mL vs 817.7 mL,p = 0.204). Furthermore, no difference was found in operative time (MD = 37.9 min,95%CI = -10.7;86.6,p = 0.127), total instrumented level (MD = 0.88,95%CI = -0.7,2.4,p = 0.273), and LOS (MD = 0.5, 95%CI = -0.2;1.2, p = 0.188). Four articles reported postoperative complications in AIS vs AdIS, with no difference in neurological deficit, instrumentation-related complications, and medical complications. CONCLUSION: AIS patients had better radiographic correction compared to AdIS. Though no difference was found in perioperative outcomes and complications, these findings emphasize the importance of counseling patients regarding the optimal timing of surgical correction.

Robot-Assisted Versus Laparoscopic Distal Pancreatectomy in Patients with Resectable Pancreatic Cancer: An International, Retrospective, Cohort Study.

BACKGROUND: Robot-assisted distal pancreatectomy (RDP) is increasingly used as an alternative to laparoscopic distal pancreatectomy (LDP) in patients with resectable pancreatic cancer but comparative multicenter studies confirming the safety and efficacy of RDP are lacking. METHODS: An international, multicenter, retrospective, cohort study, including consecutive patients undergoing RDP and LDP for resectable pancreatic cancer in 33 experienced centers from 11 countries (2010-2019). The primary outcome was R0-resection. Secondary outcomes included lymph node yield, major complications, conversion rate, and overall survival. RESULTS: In total, 542 patients after minimally invasive distal pancreatectomy were included: 103 RDP (19%) and 439 LDP (81%). The R0-resection rate was comparable (75.7% RDP vs. 69.3% LDP, p = 0.404). RDP was associated with longer operative time (290 vs. 240 min, p < 0.001), more vascular resections (7.6% vs. 2.7%, p = 0.030), lower conversion rate (4.9% vs. 17.3%, p = 0.001), more major complications (26.2% vs. 16.3%, p = 0.019), improved lymph node yield (18 vs. 16, p = 0.021), and longer hospital stay (10 vs. 8 days, p = 0.001). The 90-day mortality (1.9% vs. 0.7%, p = 0.268) and overall survival (median 28 vs. 31 months, p = 0.599) did not differ significantly between RDP and LDP, respectively. CONCLUSIONS: In selected patients with resectable pancreatic cancer, RDP and LDP provide a comparable R0-resection rate and overall survival in experienced centers. Although the lymph node yield and conversion rate appeared favorable after RDP, LDP was associated with shorter operating time, less major complications, and shorter hospital stay. The specific benefits associated with each approach should be confirmed by multicenter, randomized trials.

Lateral to Medial Joint Space Ratio is Predictive of Survivorship After Primary Hip Arthroscopy.

PURPOSE: To assess whether preoperative joint space measures would be predictive of survivorship in patients undergoing hip arthroscopy (HA) for femoroacetabular impingement (FAI). METHODS: Data on consecutive patients who underwent hip arthroscopy between February 2008 and February 2018 were retrospectively reviewed. To be eligible for final analysis, patients were required to have preoperative radiographs for joint space measurements and data indicating conversion to a total hip arthroplasty (THA), hip resurfacing, or neither; at a minimum of 2 years after primary hip arthroscopy. Survivorship following HA was defined as remaining conversion free and served as the primary outcome. A multivariate logistic regression analysis and receiver operator curve (ROC) were used to evaluate the correlation between joint space measurements and survivorship following HA. RESULTS: A total of 1,885 primary arthroscopy cases were included in this study. The multivariate regression analysis found preoperative lateral-to-medial joint space ratio (L/M ratio) to be the strongest predictive factor of survivorship after primary hip arthroscopy (OR = 2.084, CI95% = 1.239-3.503; P = .006). The ROC curve for the model demonstrated acceptable discrimination with an area under the curve (AUC) of 0.792. Patients with an L/M ratio ≥0.75 had a survivorship rate of 91.7% compared to a rate of 75% for patients with an L/M ratio <0.75 (OR: 3.68). CONCLUSIONS: This study found that, of the factors evaluated in this study, the most significant factor in predicting survivorship at 2 years after undergoing primary hip arthroscopy was a larger lateral-to-medial joint space ratio. This may suggest an initiation of primary arthritis at the edge-loading area of the lateral acetabulum. LEVEL OF EVIDENCE: III, retrospective comparative observation study.

The Inverse Relationship Between Labral Size and Acetabular Coverage: Does It Protect the Cartilage in the Dysplastic Hip?

PURPOSE: The aims of this study were to confirm the relationship between osseous coverage and labral size and to investigate the severity of intra-articular damage in borderline dysplastic hips in correlation to labral size. METHODS: Patients treated with primary hip arthroscopy for symptomatic labral tears between 2010 and 2018 were considered for this study. Patients were included if they had preoperative radiographic measures and intraoperative assessments of the labra and cartilage. The study group was divided into borderline dysplastic and nondysplastic groups via 3 measurements: lateral center edge angle (LCEA), acetabular index (Ax), and anterior center edge angle (ACEA). Undercoverage was defined as LCEA ≤ 25°, Ax ≥ 10°, and ACEA ≤ 20°. The labrum was measured in four quadrants: anterosuperior (AS), anteroinferior (AI), posterosuperior (PS), and posteroinferior (PI). Additionally, to assess cartilage damage in borderline dysplastic hips, hips with average labral size in the top quartile were compared to hips with average labral size in the bottom quartile. RESULTS: A total of 1765 hips (1589 patients) were included in the study. The mean LCEA, Ax, and ACEA between the borderline dysplastic and nondysplastic groups were significantly different (P < .001). According to the Ax classification, there was significant evidence that borderline dysplastic hips had larger labra (P < .05). Among the dysplastic group, there was significantly more cartilage damage according to the Outerbridge classifications along both the acetabulum and femoral head in hips with labra in the upper quartile (P =.011 and .005, respectively). CONCLUSION: An inverse relationship may exist between acetabular depth and labral size. Additionally, specifically in borderline dysplastic hips, a relatively large labrum correlates with worse intra-articular damage compared to borderline dysplastic hips with a relatively small labrum. Larger labral size may indicate a higher degree of instability in patients with borderline dysplasia. LEVEL OF EVIDENCE: Level III, case-control study.

Best Practice Guidelines for Propensity Score Methods in Medical Research: Consideration on Theory, Implementation, and Reporting. A Review.

Rigorous and reproducible methodology of controlling for bias is essential for high-quality, evidence-based studies. Propensity score matching (PSM) is a valuable way to control for bias and achieve pseudo-randomization in retrospective observation studies. The purpose of this review is to 1) provide a clear conceptual framework for PSM, 2) recommend how to best report its use in studies, and 3) offer some practical examples of implementation. First, this article covers the concepts behind PSM, discusses its pros and cons, and compares it with other methods of controlling for bias, namely, hard/exact matching and regression analysis. Second, recommendations are given for what to report in a manuscript when PSM is used. Finally, a worked example is provided, which can also serve as a template for the reader's own studies. A study's conclusions are only as strong as its methods. PSM is an invaluable tool for producing rigorous and reproducible results in observational studies. The goal of this article is to give practicing clinical physicians not only a better understanding of PSM and its implications but the ability to implement it for their own studies. STUDY DESIGN: Review.

The landscape of neuro-oncology in East Africa: a review of published records.

INTRODUCTION: Primary central nervous system (CNS) tumors represent an important and growing cause of worldwide morbidity and mortality. There are global variations in the reported case burden of CNS tumors, with high-income countries reporting a higher incidence of cases than low- and middle-income countries. Variations are attributed to differences in access to care, diagnostic capacity, risk exposure, and under-reporting in LMICs. This study aims to review existing literature on the distribution of primary CNS tumors and neuro-oncologic care, and the contribution of scientists and institutions to neuro-oncologic research across 18 East African countries over the last 5 decades. METHOD: A search was conducted using OVID Medline and PubMed databases to identify relevant East African neuro-oncologic studies published over the last 50 years. RESULTS: The authors reviewed 36 neuro-oncology articles published across 8 of 18 East African countries. Kenya represented the highest number of published articles; ten countries queried yielded zero publications. A total of 2006 cases from all age groups were represented in published literature consisting of a wide spectrum of CNS tumors. One-third of reported cases were pediatric. Meningioma formed the largest proportion (43.3%) followed by glioma (33.7%). Sixty-seven percent of publications gave an overview of clinical care received by patients with most patients not receiving comprehensive neuro-oncologic care. CONCLUSION: The modest collection of neuro-oncology publications from East Africa shows that the case diversity of primary CNS tumors in East Africa is comparable to the rest of the world. There is, however, poorer access to neurosurgical care and adjuvant therapy. Multidisciplinary efforts from clinicians, researchers, and healthcare agencies are needed to quantify and address the requisite neuro-oncology needs in this region.

Binary Tönnis classification: simplified modification demonstrates better inter- and intra-observer reliability as well as agreement in surgical management of hip pathology.

BACKGROUND: The traditional Tönnis Classification System has inherent drawbacks as it is vulnerable to the subjectivity of a four-grade system. A two-grade classification could potentially be more reliable. The purpose of this study is to (1) compare the inter-observer and intra-observer reliability of the traditional Tönnis Classification System and a simplified Binary Tönnis Classification System for hip osteoarthritis and to (2) evaluate the clinical applicability of both systems. Our hypothesis is that the proposed Binary Tönnis Classification System will have better reliability and agreement for surgical decision-making. METHODS: Forty consecutive patients were selected to participate in this study. Patients were included in this study if they were between 35 and 60 years old. Patients were excluded if they had prior hip surgeries or conditions. All radiographs were randomized and blinded by a non-observer. Five fellowship-trained hip surgeons from a single center, in a fully crossed design, analyzed and graded all the radiographs utilizing the traditional Tönnis Classification System and the proposed Binary Tönnis Classification System. Intra- and inter-observer reliability values for both the systems were calculated using the Cohen's κ coefficient. A multi-rater κ was calculated using the weighted Fleiss method. RESULTS: The study sample contained 40 anterosuperior hip radiographs. For the traditional Tönnis Classification System, the weighted κ showed a fair inter-observer reliability (κ = 0.474) and excellent intra-observer reliability (κ mean = 0.866). For the proposed Binary Tönnis Classification System, both inter-observer and intra-observer reliability demonstrated excellent values, (κ = 0.858 and 0.928, respectively). On average, the Binary Tönnis Classification System correctly captured 87% of cases. When the traditional Tönnis Classification System was dichotomized, the capture rate was 84%. CONCLUSION: A simplified binary Tönnis Classification System demonstrates better reliability and clinical implementation than the traditional Tönnis Classification System.

Can Radiographic Joint Space Accurately Predict Chondral Damage During Hip Arthroscopy? A Cross-Sectional Analysis.

PURPOSE: To examine how preoperative radiographic joint space correlated with intraoperative chondral damage as diagnosed during hip arthroscopy, in patients without radiographic evidence of osteoarthritis or joint space <2 mm. METHODS: Patients younger than the age of 50 years without previous hip conditions who underwent hip primary arthroscopy had their joint space and intraoperative chondral damage compared. A narrow joint space group was defined as those in the lowest decile of the average joint space. The demographics and presence of intra-articular findings of chondral damage were compared. In addition, receiver operator characteristic (ROC) curves were used to assess joint space as a predictor of intraarticular damage. RESULTS: There were 1892 in this analysis. The incidence of severe cartilage damage (Outerbridge III and IV) was not significantly different between the narrow and non-narrow groups. The ROC analysis for joint space at detecting chondral damage was poor. The ROC area under the curve for joint space detecting any chondral defect (acetabular or femoral head) was 0.536 (confidence interval 0.506-0.565), with low sensitivity (0.492), specificity (0.582), negative predictive value (0.720), and positive predictive value (0.340). Spearman correlation could not demonstrate a correlation between joint space and cartilage damage (⍴Acetabular = 0.10, ⍴Femoral Head = 0.04). Interestingly, a gradual widening was observed between the medial and lateral joint spaces, with more pronounced findings in hips without damage. CONCLUSIONS: The results of this study demonstrate that in patients with Tönnis 0 and 1, narrower joint space may be an anatomic variant and cannot predict actual intraoperative cartilage damage. However, if the lateral joint space has relative narrowing compared with the medial joint space, this may indicate acetabular cartilage damage. LEVEL OF EVIDENCE: III, retrospective diagnostic comparative study.

Can We Help Patients Forget Their Joint? Determining a Threshold for Successful Outcome for the Forgotten Joint Score.

BACKGROUND: Clinically important thresholds improve interpretability of patient-reported outcomes. A threshold for a successful outcome does not exist for the Forgotten Joint Score (FJS). The purpose of this study is to determine a threshold score for the FJS, 1 and 2 years after total hip arthroplasty (THA). METHODS: A retrospective analysis of 247 primary THA recipients between December 2012 and April 2017 was performed. A binary "successful treatment" was defined as achieving a composite criterion of pain, function, and satisfaction. Receiver operator characteristic analysis determined thresholds for successful outcome at 1 and 2 years postoperatively, subanalyzed by demographics. Results were validated by a 75th centile comparison. The ceiling effect of FJS was also assessed. RESULTS: The average FJS was 70.06 ± 29.39 and 75.05 ± 28.73 at 1 and 2 years, respectively (P < .001). The proportion of patients meeting the composite criteria for success was 66.8% at 1 year and 76.5% at 2 years (P = .017). The receiver operator characteristic analysis for FJS at 1 and 2 years yielded excellent accuracy as defined by area under the curve (0.91 and 0.92, respectively). The threshold values were 73.96 and 69.79 at the respective time points. A mild ceiling effect was found with 16% and 23% of cases achieving a score of 100 at 1 and 2 years, respectively. CONCLUSION: The FJS has excellent accuracy in demonstrating successful outcome following THA. The FJS threshold for success at 1 and 2 years postoperatively is 73.96 and 69.79, respectively. The higher rates of success at 2 years, along with a rise in the mean FJS, may indicate continued clinical improvement up to 2 years after THA.

Cannabidiol: A New Hope for Patients With Dravet or Lennox-Gastaut Syndromes.

OBJECTIVE: To review the efficacy, safety, pharmacology and pharmacokinetics of pure, plant-derived cannabidiol (CBD; Epidiolex) in the treatment of Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS). DATA SOURCES: Relevant information was identified through EMBASE and Ovid MEDLINE (1946 to October 2018). Product labeling and https://www.clinicaltrials.gov were also reviewed. STUDY SELECTION/DATA EXTRACTION: English language articles evaluating efficacy and safety in humans with treatment-resistant epilepsies were reviewed; additional pharmacology and pharmacokinetic studies in humans, animals, and in vitro were also included. DATA SYNTHESIS: Pure, plant-based CBD is a pharmaceutical grade extract that exhibits clinically significant antiseizure properties, with a hypothesized multimodal mechanism of action. In the GWPCARE trial series, CBD displayed superior efficacy in reducing key seizure frequencies (convulsive seizures in DS; drop seizures in LGS) by 17% to 23% compared with placebo as adjunctive therapy to standard antiepileptic drugs in patients 2 years of age and older. Common adverse effects were somnolence, diarrhea, and elevated hepatic transaminases. Noteworthy drug-drug interactions included clobazam, valproates, and significant inducers/inhibitors of CYP2C19 and 3A4 enzymes. Relevance to Patient Care and Clinical Practice: A discussion regarding CBD dosing, administration, adverse effects, monitoring parameters, and interactions is provided to guide clinicians. CBD offers patients with DS and LGS a new treatment option for refractory seizures. CONCLUSION: This is the first cannabis-derived medication with approval from the US Food and Drug Administration. This CBD formulation significantly reduces seizures as an adjunct to standard antiepileptic therapies in patients ≥2 years old with DS and LGS and is well tolerated.

Copper Deficiency Myelopathy Mimicking Cervical Spondylitic Myelopathy: A Systematic Review of the Literature with Case Report.

BACKGROUND AND CONTEXT: Copper deficiency myelopathy (CDM) is a rare disease that can present with spastic quadriparesis and sensory ataxia. As a result, it can precisely mimic cervical spondylitic myelopathy (CSM). Copper deficiency may be seen following gastric bypass surgery, malabsorption syndromes such as celiac disease, and with excessive exogenous zinc intake. We present a systematic review of the literature for CDM and an illustrative case . PURPOSE: Provide a systematic review of CDM to highlight the importance of recognizing the consideration of CDM in patients presenting to a spine surgeon with myelopathy that progress despite adequate surgical decompression, or myelopathy concomitant with cytopenia, thus requiring further workup. STUDY DESIGN/SETTING: Retrospective medical record review and systematic review of the literature PATIENT SAMPLE: PubMed and Ovid-Embase database search was conducted in July 2022 OUTCOME MEASURES: Self-reported measures include PRISMA flow diagram for retrospective review; Physiological measures include retrospective review of MRI imaging of cervical spine; alternate demographic and laboratory value data extracted via literature review METHODS: A PubMed and Ovid-Embase database search was conducted in July 2022 searching for "copper deficiency myelopathy [MeSH]" from 2000 to 2022 via PRISMA guidelines. Following title and abstract review, the following data was extracted from full text: age, sex, etiology, hematological values upon presentation (mean corpuscular volume, white blood count, platelet count, and hemoglobin level), metal serum studies (serum copper, ceruloplasmin, and zinc), 24-hour collection of copper and zinc, and distinct radiographic findings on MRI. RESULTS: A total of 116 studies were included in this review which contained 198 cases of copper deficiency myelopathy. The mean age was 53.57 ± 14.14 years, with the majority being females (63.8%). The most common etiology was prior gastric surgery (n=55, 36.2 %) followed by excessive zinc consumption from the use of zinc denture cream (n=39, 19.9%)The mean serum copper was 15.67 ± 17.84 (normal=80.0-155.0) mcg/dL and mean ceruloplasmin was 6.43 ± 5.25 (normal=16-45) mg/dL. In spite of appropriate treatment with copper supplementation, only 47 cases (24%) reported improvement in neurological status, and only 10 (5.1%) recovered to baseline. A hyperintense T2 signal abnormality resembling an inverted "v" in the dorsal columns was the most common radiographic abnormality. CONCLUSION: Pertinent risk factors for copper deficiency myelopathy include prior upper gastrointestinal surgery, zinc excess, and malabsorption. Characteristic laboratory and imaging findings include cytopenia, low serum copper and ceruloplasmin, and distinct inverted "v" T2 signal hyperintensity in the dorsal columns. The neurologic deterioration with copper deficiency will progress in spite of decompressive surgery, and can be devastating and irreversible even with copper supplementation, reinforcing the importance of early detection. We thus recommend patients with myelopathy presenting with a history of gastric bypass, malabsorption syndromes, excessive zinc exposure, cytopenia, or imaging resembling an inverted "v" shaped hyperintense T2 MRI signal in the dorsal columns, should first undergo blood tests for copper, ceruloplasmin, and B12 levels prior to surgical consideration.

Determining the Effect of Intraoperative TXA on Postoperative Blood Loss in ACDF.

STUDY DESIGN: Retrospective cohort study using prospectively collected data. OBJECTIVE: To determine the effectiveness of intraoperative tranexamic acid (TXA) in anterior cervical discectomy and fusion (ACDF) on postoperative blood loss. SUMMARY OF BACKGROUND DATA: TXA has been proven to be a safe and effective agent in reducing blood loss after cervical surgery; however, its efficacy when used intraoperatively for ACDF surgeries had yet to be researched. Currently, there are few studies examining the effects of intraoperative TXA in cervical spinal fusion, and none specifically examining TXA use in ACDF. METHODS: A tertiary medical center's prospectively collected spine registry was queried between 1/1/18 and 12/1/21 for all patients who underwent elective ACDF surgery and received a drain postoperatively. Patients were separated into 2 groups; those who had received intraoperative TXA and those who did not. Baseline demographic and operative variables were collected from the registry. The primary outcome was postoperative blood loss over a 24-hour period. Secondary outcomes included total drain output, intraoperative estimated blood loss, operative duration, drain duration, changes in preoperative to postoperative hemoglobin and hematocrit levels, and rate of transfusions, complications, revisions, and reoperations. Univariate and multivariate regression analyses were performed. RESULTS: Two hundred eighty-six patients were included. One hundred ninety patients underwent ACDF and did not receive intraoperative TXA, whereas 96 patients underwent ACDF and did receive TXA. There were no differences in any demographic or baseline variables. Multivariate analysis showed intraoperative TXA was associated with shorter drain duration (ß=-5.74, 95% CI: -10.9 to -0.53, P =0.031) and reduction in 24-hour drain output (ß=-12.2, 95% CI: -19.4 to -4.89, P =0.001) and total drain output (ß=-14.0, 95% CI: -22.9 to -5.05, P =0.002). CONCLUSIONS: TXA use during ACDF procedures leads to a decrease in perioperative blood loss and faster drain removal. TXA is an effective and safe agent for reducing perioperative blood loss in ACDF surgery. LEVEL OF EVIDENCE: III.

Comparison of Outcomes in Patients with Cervical Spine Metastasis After Different Surgical Approaches: A Single-Center Experience.

OBJECTIVE: In patients undergoing cervical spine surgery for metastatic spine disease, we sought to 1) compare perioperative and oncologic outcomes among 3 different operative approaches, 2) report fusion rates, and 3) compare different types of anterior vertebral body replacement. METHODS: A single-center retrospective cohort study of patients undergoing extradural cervical/cervicothoracic spine metastasis surgery between February 2010 and January 2021 was conducted. Operative approaches were anterior-alone, posterior-alone, or combined anterior-posterior, and the grafts/cages used in the anterior fusions were cortical allografts, static cages, or expandable cages. All cages were filled with autograft/allograft. Outcomes included perioperative/postoperative variables, along with fusion rates, functional status, local recurrence (LR), and overall survival (OS). RESULTS: Sixty-one patients underwent cervical spine surgery for metastatic disease, including 11 anterior (18.0%), 28 posterior (45.9%), and 22 combined (36.1%). New postoperative neurologic deficit was the highest in the anterior approach group (P = 0.038), and dysphagia was significantly higher in the combined approach group (P = 0.001). LR (P > 0.999), OS (P = 0.655), and time to both outcomes (log-rank test, OS, P = 0.051, LR, P = 0.187) were not significantly different. Of the 51 patients alive at 3 months, only 19 (37.2%) obtained imaging ≥3 months. Fusion was seen in 11/19 (57.8%) at a median of 8.3 months (interquartile range, 4.6-13.7). Among the anterior corpectomies, the following graft/cage was used: 6 allografts (54.5%), 4 static cages (36.3%), and 1 expandable cage (9.0%), with no difference found in outcomes among the 3 groups. CONCLUSIONS: The only discernible differences between operative approaches were that patients undergoing an anterior approach had higher rates of new postoperative neurologic deficit, and the combined approach group had higher rates of postoperative dysphagia.

Combined Anterior-Posterior vs. Posterior-Only Approach in Adult Spinal Deformity Surgery: Which Strategy Is Superior?

Introduction: Whether a combined anterior-posterior (AP) approach offers additional benefits over the posterior-only (P) approach in adult spinal deformity (ASD) surgery remains unknown. In a cohort of patients undergoing ASD surgery, we compared the combined AP vs. the P-only approach in: (1) preoperative/perioperative variables, (2) radiographic measurements, and (3) postoperative outcomes. Methods: A single-institution, retrospective cohort study was performed for patients undergoing ASD surgery from 2009 to 2021. Inclusion criteria were ≥5-level fusion, sagittal/coronal deformity, and 2-year follow-up. The primary exposure was the operative approach: a combined AP approach or P alone. Postoperative outcomes included mechanical complications, reoperation, and minimal clinically important difference (MCID), defined as 30% of patient-reported outcome measures (PROMs). Multivariable linear regression was controlled for age, BMI, and previous fusion. Results: Among 238 patients undergoing ASD surgery, 34 (14.3%) patients underwent the AP approach and 204 (85.7%) underwent the P-only approach. The AP group consisted mostly of anterior lumbar interbody fusion (ALIF) at L5/S1 (73.5%) and/or L4/L5 (38.0%). Preoperatively, the AP group had more previous fusions (64.7% vs. 28.9%, p < 0.001), higher pelvic tilt (PT) (29.6 ± 11.6° vs. 24.6 ± 11.4°, p = 0.037), higher T1 pelvic angle (T1PA) (31.8 ± 12.7° vs. 24.0 ± 13.9°, p = 0.003), less L1-S1 lordosis (-14.7 ± 28.4° vs. -24.3 ± 33.4°, p < 0.039), less L4-S1 lordosis (-25.4 ± 14.7° vs. 31.6 ± 15.5°, p = 0.042), and higher sagittal vertical axis (SVA) (102.6 ± 51.9 vs. 66.4 ± 71.2 mm, p = 0.005). Perioperatively, the AP approach had longer operative time (553.9 ± 177.4 vs. 397.4 ± 129.0 min, p < 0.001), more interbodies placed (100% vs. 17.6%, p < 0.001), and longer length of stay (8.4 ± 10.7 vs. 7.0 ± 9.6 days, p = 0.026). Radiographically, the AP group had more improvement in T1PA (13.4 ± 8.7° vs. 9.5 ± 8.6°, p = 0.005), L1-S1 lordosis (-14.3 ± 25.6° vs. -3.2 ± 20.2°, p < 0.001), L4-S1 lordosis (-4.7 ± 16.4° vs. 3.2 ± 13.7°, p = 0.008), and SVA (65.3 ± 44.8 vs. 44.8 ± 47.7 mm, p = 0.007). These outcomes remained statistically significant in the multivariable analysis controlling for age, BMI, and previous fusion. Postoperatively, no significant differences were found in mechanical complications, reoperations, or MCID of PROMs. Conclusions: Preoperatively, patients undergoing the combined anterior-posterior approach had higher PT, T1PA, and SVA and lower L1-S1 and L4-S1 lordosis than the posterior-only approach. Despite increased operative time and length of stay, the anterior-posterior approach provided greater sagittal correction without any difference in mechanical complications or PROMs.

Does Preoperative Bilsky Score Predict Outcome Following Surgical Resection of Primary Tumors of the Spine?

OBJECTIVE: In patients undergoing surgery for primary bone tumors of the spine, we sought to compare Bilsky score 0-1 versus 2-3 in: 1) preoperative presentation, 2) perioperative variables, and 3) long-term outcomes. METHODS: A single-center, retrospective cohort study was undertaken of patients undergoing surgery for extradural, primary bone tumors of the spine between January 2010 and January 2021. The primary exposure variable was Bilsky score, dichotomized as 0-1 versus 2-3. Survival analysis was performed to assess local recurrence (LR) and overall survival (OS). RESULTS: Of 38 patients undergoing resection of primary spinal tumors, 19 (50.0%) patients presented with Bilsky 0-1 and 19 (50.0%) Bilsky 2-3 grades. The most common diagnosis was chondrosarcoma (33.3%), followed by chordoma (16.7%). There were 15 (62.5%) malignant tumors. Preoperatively, there was no significant difference in demographics, Karnofsky Performance Scale (KPS) (P > 0.999), or motor deficit (P > 0.999). Perioperatively, no difference was found in operative time (P = 0.954), blood loss (P = 0.416), length of stay (P = 0.641), neurologic deficit (P > 0.999), or discharge disposition (P = 0.256). No difference was found in Enneking resection status (69.2% vs. 54.5%, P = 0.675). Long-term, no differences were found regarding reoperation (P = 0.327), neurologic deficit (P > 0.999), postoperative KPS (P = 0.605) and modified McCormick Scale (MMS) (P = 0.870). No difference was observed in KPS (P = 0.418) and MMS (P = 0.870) at last follow-up. However, patients with Bilsky 2-3 had shorter time to LR (1715.0 vs. 513.0 ± 633.4 days, log-rank; P = 0.002) and shorter OS (2025.0 ± 1165.3 vs. 794.0 ± 952.6 days, log-rank; P = 0.002). CONCLUSIONS: Bilsky 2-3 lesions were associated with shorter time to LR and shorter OS. Patients harboring primary spinal tumors with higher grade Bilsky score appear to be at a higher risk for worse outcomes.

Impact of occupational characteristics on return to work for employed patients after elective cervical spine surgery.

OBJECTIVE: In a cohort of employed patients undergoing elective cervical spine surgery with an uncomplicated postoperative course, the authors sought to determine the demographic, functional, and occupational characteristics associated with return to work (RTW) following surgery. METHODS: A retrospective cohort study of prospectively collected data was undertaken of patients undergoing elective cervical spine surgery for degenerative disease in the Quality Outcomes Database. Study inclusion criteria were: 1) employed prior to surgery and planned to RTW, 2) no unplanned readmissions, 3) achieved 30% improvement on the Neck Disability Index (NDI), and 4) were satisfied with the surgical outcome at 3 or 12 months postoperatively. A multivariable Cox regression model was built using demographic, functional, operative, and occupational characteristic to predict time to RTW. RESULTS: Of 5110 included patients, 4788 (93.7%) returned to work within 12 months, with a median time of 35 (IQR 19-60) days. Patients who did RTW were significantly younger (51.3 ± 9.4 vs 55.8 ± 9.6 years, p < 0.001), more often underwent an anterior approach (85.8% vs 80.7%, p = 0.009), were significantly more privately insured (82.1% vs 64.0%, p < 0.001), and were less likely to have workers' disability insurance (6.7% vs 14.6%, p < 0.001) compared with patients who did not RTW. On multivariable Cox regression, demographic factors associated with a longer RTW were older age (hazard ratio [HR] 0.99, 95% CI 0.99-1.00, p < 0.001) and Black race (HR 0.71, 95% CI 0.62-0.81, p < 0.001). Male sex was associated with a shorter RTW time (HR 1.19, 95% CI 1.11-1.26, p < 0.001). Regarding baseline functional status, worse preoperative NDI (HR 0.99, 95% CI 0.99-0.99, p < 0.001) was associated with a longer RTW, whereas the absence of myelopathy was associated with a shorter RTW (HR 1.17, 95% CI 1.09-1.25, p < 0.001). Having a sedentary (HR 1.81, 95% CI 1.65-1.99, p < 0.001), light-intensity (HR 1.60, 95% CI 1.45-1.76, p < 0.001), and medium-intensity (HR 1.11, 95% CI 1.01-1.22, p = 0.037) occupation was associated with a shorter RTW time compared with a heavy-intensity occupation at any time point. Heavy-intensity occupations were independently the strongest predictor of longer RTW. Similar predictors of shorter RTW were found in a subanalysis of occupation intensity and among operative approaches used. CONCLUSIONS: Among patients undergoing elective degenerative cervical spine surgery who had favorable surgical outcomes and planned to RTW before surgery, 94% had a successful RTW. Age was the strongest predictor of lower odds of RTW. Regarding time to RTW, having a sedentary, light-intensity, or medium-intensity occupation was associated with a shorter RTW time compared with a heavy-intensity occupation. These findings highlight the importance of considering the demographic and occupational characteristics when predicting postoperative RTW in patients with satisfactory surgical outcomes.

Electrode position and cognitive outcome following deep brain stimulation surgery.

OBJECTIVE: Subthalamic nucleus (STN) and globus pallidus internus (GPI) deep brain stimulation (DBS) effectively treat motor symptoms in Parkinson's disease (PD) but may be associated with cognitive and psychiatric changes in some patients. Evaluation of changes in cognitive and psychiatric symptoms following DBS is complicated by changes in these symptoms that occur as part of the natural disease course. The aim of this study was to evaluate whether electrode position was associated with changes in neurocognitive symptoms in patients who underwent STN and GPI DBS. METHODS: A single-institution retrospective cohort study was conducted on patients with PD who underwent DBS from 2008 to 2019. Cognitive and psychiatric outcomes included Beck Depression Inventory II (BDI-II) score, presence of impulsive-compulsive behavior (ICB), Mini-Mental State Examination (MMSE) score, and overall cognitive status grade determined by comprehensive neuropsychology testing (normal, mild impairment, moderate impairment, and dementia). Pre- and postoperative comparisons were performed using a Wilcoxon signed-rank test or paired t-test. Patients with and without cognitive decline were compared using a Mann-Whitney U-test or unpaired t-test. A chi-square test was used for categorical comparisons. RESULTS: One hundred thirty patients were included (mean age 62.5 ± 7.9 years). At a mean postoperative follow-up from DBS of 13.0 ± 12.7 (range 6-66) months, there was an improvement in ICB (26.3% preoperatively vs 15.0% postoperatively, p = 0.017), but a decline in MMSE score (28.6 ± 1.6 vs 27.6 ± 2.0, p < 0.001) and overall cognitive status (normal: 66.2% vs 39.2%; mild: 12.3% vs 17.7%; moderate: 21.5% vs 33.1%; dementia: 0.0% vs 10.0%; p < 0.001). Patients undergoing STN DBS had a worse decline in overall cognitive status than patients who underwent GPI DBS (p = 0.006). Postoperative cognitive decline was associated with a more medial electrode position only for patients who underwent STN DBS. CONCLUSIONS: Cognitive change was observed in some patients with PD who underwent both GPI and STN DBS, likely due partly to underlying disease progression. Compared with GPI DBS, STN DBS was associated with a greater likelihood of cognitive decline. In STN but not GPI DBS, cognitive decline was associated with medialized electrode position, suggesting modulation of nonmotor STN divisions may contribute to cognitive changes following STN DBS.