Novel psychiatric disorders following mild traumatic brain injury: a retrospective multivariable analysis with screening recommendations.

OBJECTIVE: Concussions are a form of mild traumatic brain injury (mTBI) that most commonly occur after blunt trauma to the head and may result in temporary loss of consciousness. These patients are typically comanaged by neurocritical care specialists, neurologists, and neurosurgeons depending on the severity of disease. The purpose of this study was twofold: 1) evaluate how patient demographic characteristics impact the development of novel psychiatric disorders (NPDs) after mTBI; and 2) develop screening recommendations to identify patients with NPDs. METHODS: The authors used data from the 2010-2019 National Readmissions Database of the Healthcare Cost and Utilization Project. Patients who were readmitted for mTBI within a year of their first admission between 2010 and 2019 were identified (n = 206,070). The association between patient demographic characteristics and the emergence of NPDs after mTBI was examined using multivariable binomial regression analysis. Density plots were used to examine diagnostic patterns for NPDs. RESULTS: The mean ± SD age of all patients was 50.9 ± 26.2 years, and 43.9% of patients were female. Overall, an additional 818 (0.40%) patients were reported to have novel suicidal ideation (SI), 3866 (1.9%) novel depression, 3449 (1.7%) novel anxiety, and 88 (0.043%) novel homicidal ideation (HI) after mTBI. Younger age (OR 0.9775, 95% CI 0.9705-0.9848, p < 0.0001) and reduced Charlson Comorbidity Index (CCI) score (OR 0.9155, 95% CI 0.8539-0.9774, p = 0.010) may predict novel SI, and female sex (OR 0.7464, 95% CI 0.6026-0.9214, p = 0.0069) may be inversely related to novel SI after mTBI. Also, multivariable analysis found that female sex (OR 1.1774, 95% CI 1.0654-1.3016, p = 0.0014) and Medicare/Medicaid insurance type (OR 0.9381, 95% CI 0.8983-0.9797, p = 0.0039) may predict novel anxiety after mTBI. Similarly, younger age (OR 0.9956, 95% CI 0.9923-0.9989, p = 0.0096), higher CCI score (OR 1.0363, 95% CI 1.0099-1.0629, p = 0.0062), and Medicare/Medicaid insurance type (OR 0.9386, 95% CI 0.8998-0.9789, p = 0.0032) may predict novel depression. Lastly, female sex (OR 0.3271, 95% CI 0.1467-0.6567, p = 0.0031) and increased median income (OR 0.8829, 95% CI 0.7930-0.9944, p = 0.049) were inversely proportional to novel HI after mTBI. The median time to diagnosis of NPD was 69.5 days for depression, 66.5 days for anxiety, 70.0 days for SI, and 66.5 days for HI. CONCLUSIONS: Numerous patient demographic factors are significant predictors of the development of NPDs after mTBI and concussion. Screening for NPDs within 3 weeks and 3 months after mTBI may identify most patients at risk for developing novel postconcussive psychiatric conditions, including anxiety, depression, HI, and SI. Further studies are warranted to understand how patient demographic characteristics should dictate medical management and screening after mTBI and concussion.

The impact of frailty on postoperative complications in geriatric patients undergoing multi-level lumbar fusion surgery.

STUDY DESIGN: Retrospective Cohort Study. PURPOSE: This study evaluates the impact of patient frailty status on postoperative complications in those undergoing multi-level lumbar fusion surgery. METHODS: The Nationwide Readmission Database (NRD) was retrospectively queried between 2016 and 2017 for patients receiving multi-level lumbar fusion surgery. Demographics, frailty status, and relevant complications were queried at index admission and readmission intervals. Primary outcome measures included perioperative complications and 30-, 90-, and 180-day complication and readmission rates. Perioperative complications of interest were infection, urinary tract infection (UTI), and posthemorrhagic anemia. Secondary outcome measures included inpatient length of stay (LOS), adjusted all-payer costs, and discharge disposition. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail patients with similar diagnoses and procedures. Subgroup analysis of minimally invasive surgery (MIS) versus open surgery within frail and non-frail cohorts was conducted to evaluate differences in surgical and medical complication rates. The analysis used nonparametric Mann-Whitney U testing and odds ratios. RESULTS: Frail patients encountered higher rates perioperative complications including posthemorrhagic anemia (OR: 1.73, 95%CI 1.50-2.00, p < 0.0001), infection (OR: 2.94, 95%CI 2.04-4.36, p < 0.0001), UTI (OR: 2.57, 95%CI 2.04-3.26, p < 0.0001), and higher rates of non-routine discharge (OR: 2.07, 95%CI 1.80-2.38, p < 0.0001). Frail patients had significantly greater LOS and total all-payer inpatient costs compared to non-frail patients (p < 0.0001). Frailty was associated with significantly higher rates of 90- (OR: 1.43, 95%CI 1.18-1.74, p = 0.0003) and 180-day (OR: 1.28, 95%CI 1.03-1.60, p = 0.02) readmissions along with higher rates of wound dehiscence (OR: 2.21, 95%CI 1.17-4.44, p = 0.02) at 90 days. Subgroup analysis revealed that frail patients were at significantly higher risk for surgical complications with open surgery (16%) compared to MIS (0%, p < 0.0001). No significant differences were found between surgical approaches with respect to medical complications in both cohorts, nor surgical complications in non-frail patients. CONCLUSIONS: Frailty was associated with higher odds of all perioperative complications, LOS, and all-payer costs following multi-level lumbar fusion. Frail patients had significantly higher rates of 90 and 180-day readmission and higher rates of wound disruption at 90-days. On subgroup analysis, MIS was associated with significantly reduced rates of surgical complications specifically in frail patients. Our results suggest frailty status to be an important predictor of perioperative complications and long-term readmissions in geriatric patients receiving multi-level lumbar fusions. Frail patients should undergo surgery utilizing minimally invasive techniques to minimize risk of surgical complications. Future studies should explore the utility of implementing frailty in risk stratification assessments for patients undergoing spine surgery.

Identifying risks factors in thoracolumbar anterior fusion surgery through predictive analytics in a nationally representative inpatient sample.

PURPOSE: Anterior thoracolumbar (TL) surgical approaches provide more direct trajectories compared to posterior approaches. Proper patient selection is key in identifying populations that may benefit from anterior TL fusion. Here, we utilize predictive analytics to identify risk factors in anterior TL fusion in patients with trauma and deformity. METHODS: In this retrospective cohort study of patients receiving anterior TL fusion (between and including T12/L1), population-based regression models were developed to identify risk factors using the National Readmission Database 2016-2017. Readmissions were analyzed at 30- and 90-day intervals. Risk factors included hypertension, obesity, malnutrition, smoking, alcohol use, long-term opioid use, and frailty. Multivariate regression models were developed to determine the influence of each risk factor on complication rates. RESULTS: A total of 265 and 375 patients were identified for the scoliosis and burst fracture cohorts, respectively. In patients with scoliosis, alcohol use was found to increase the length of stay (LOS) (p = 0.00061) and all-payer inpatient cost following surgery (p = 0.014), and frailty was found to increase the inpatient LOS (p = 0.0045). In patients with burst fractures, malnutrition was found to increase the LOS (p < 0.0001) and all-payer cost (p < 0.0001), obesity was found to increase the all-payer cost (p = 0.012), and frailty was found to increase the all-payer cost (p = 0.031) and LOS (p < 0.0001). DISCUSSION: Patient-specific risk factors in anterior TL fusion surgery significantly influence complication rates. An understanding of relevant risk factors before surgery may facilitate preoperative patient selection and postoperative patient triage and risk categorization.

Impact of diagnosis and type of sacroiliac joint fusion on postoperative complications.

PURPOSE: Two main surgical approaches are available for fusing the sacroiliac joint (SIJ): an open or minimally invasive (MIS) approach. The purpose of this study was to analyze the associated total hospital charges and postoperative complications of the MIS and open approach. METHODS: Using the 2016 and 2017 National Readmission Database, we conducted a retrospective cohort analysis of 2521 patients who received a SIJ fusion with an open (N = 1990) or MIS (N = 531) approach for diagnosed sacrum pain, sacroiliitis, sacral instability, or spondylosis. Each cohort was analyzed for postoperative complications. RESULTS: We identified 604 patients diagnosed with sacrum pain, 1142 with sacroiliitis, 315 with spondylosis, and 288 with sacral instability. Patients who received the open approach for sacrum pain had significantly higher rates of novel post-procedural pain (p = 0.045) and novel lumbar pathology (p = 0.015) within 30 days. On 30-day follow-up, patients with sacroiliitis treated with open SIJ fusion had significantly higher rates of novel postprocedural pain compared to those treated with MIS fusion (p = 0.045). Patients who received the open approach for spondylosis resulted in significantly higher rates of non-elective readmission within 30 days compared to the MIS approach (p < 0.0001). In addition, the open technique for spondylosis resulted in significantly higher rates of non-elective readmissions for infection within 30 days (p = 0.014). On 30-day follow-up, patients with sacral instability treated with open SIJ fusion had significantly higher rates of UTI (p = 0.045). CONCLUSION: Our study suggests that there exist unique postoperative complications that arise after SIJ fusion specific to preoperative diagnosis and surgical approach.

The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery.

PURPOSE: This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery. METHODS: The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios. RESULTS: Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals. CONCLUSIONS: Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.

Cemented Vs Cementless Femoral Fixation for Total Hip Arthroplasty After Displaced Femoral Neck Fracture: A Nationwide Analysis of Short-Term Complications and Readmission Rates.

BACKGROUND: Active patients with displaced femoral neck fractures are often treated with total hip arthroplasty (THA). However, optimal femoral fixation in these patients is controversial. The purpose of this study was to compare early complication and readmission rates in patients with hip fracture treated with THA receiving cemented vs cementless femoral fixation. METHODS: The National Readmissions Database was queried to identify patients undergoing primary THA for femoral neck fracture from 2016 to 2017. Postoperative complications and unplanned readmissions at 30, 90, and 180 days were compared between patients treated with cemented and cementless THA. Univariate and multivariate analyses were performed to compare differences between groups and account for confounding variables. RESULTS: Of 17,491 patients identified, 4427 (25.3%) received cemented femoral fixation and 13,064 (74.7%) cementless. The cemented group was significantly older (77.2 vs 71.1, P < .001), had more comorbidities (Charlson comorbidity index: 4.44 vs 3.92, P < .001), and had a greater proportion of women (70.5% vs 65.2%, P < .001) compared with the cementless group. On multivariate analysis, cemented fixation was associated with reduced rates of periprosthetic fracture (odds ratio: 0.052, 95% confidence interval: 0.003-0.247, P = .004) at 30 days but similar readmission rates at 30, 90, and 180 days (odds ratio range: 1.012-1.114, P > .05) postoperatively compared with cementless fixation. Cemented fixation was associated with greater odds of medical complications at 180 days postoperatively (odds ratio:: 1.393, 95% confidence interval: 1.042-1.862, P = .025). CONCLUSION: Cemented femoral fixation was associated with a lower short-term incidence of periprosthetic fractures, higher incidence of medical complications, and equivalent unplanned readmission rates within 180 days postoperatively compared with cementless fixation in patients undergoing THA for femoral neck fracture. LEVEL OF EVIDENCE: Level III.

The role of frailty in geriatric cranial neurosurgery for primary central nervous system neoplasms.

OBJECTIVE: Frailty is a clinical state of increased vulnerability due to age-associated decline and has been well established as a perioperative risk factor. Geriatric patients have a higher risk of frailty, higher incidence of brain cancer, and increased postoperative complication rates compared to nongeriatric patients. Yet, literature describing the effects of frailty on short- and long-term complications in geriatric patients is limited. In this study, the authors evaluate the effects of frailty in geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm. METHODS: The authors conducted a retrospective cohort study of geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm between 2010 and 2017 by using the Nationwide Readmission Database. Demographics and frailty were queried at primary admission, and readmissions were analyzed at 30-, 90-, and 180-day intervals. Complications of interest included infection, anemia, infarction, kidney injury, CSF leak, urinary tract infection, and mortality. Nearest-neighbor propensity score matching for demographics was implemented to identify nonfrail control patients with similar diagnoses and procedures. The analysis used Welch two-sample t-tests for continuous variables and chi-square test with odds ratios. RESULTS: A total of 6713 frail patients and 6629 nonfrail patients were identified at primary admission. At primary admission, frail geriatric patients undergoing cranial neurosurgery had increased odds of developing acute posthemorrhagic anemia (OR 1.56, 95% CI 1.23-1.98; p = 0.00020); acute infection (OR 3.16, 95% CI 1.70-6.36; p = 0.00022); acute kidney injury (OR 1.32, 95% CI 1.07-1.62; p = 0.0088); urinary tract infection prior to discharge (OR 1.97, 95% CI 1.71-2.29; p < 0.0001); acute postoperative cerebral infarction (OR 1.57, 95% CI 1.17-2.11; p = 0.0026); and mortality (OR 1.64, 95% CI 1.22-2.24; p = 0.0012) compared to nonfrail geriatric patients receiving the same procedure. In addition, frail patients had a significantly increased inpatient length of stay (p < 0.0001) and all-payer hospital cost (p < 0.0001) compared to nonfrail patients at the time of primary admission. However, no significant difference was found between frail and nonfrail patients with regard to rates of infection, thromboembolism, CSF leak, dural tear, cerebral infarction, acute kidney injury, and mortality at all readmission time points. CONCLUSIONS: Frailty may significantly increase the risks of short-term acute complications in geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm. Long-term analysis revealed no significant difference in complications between frail and nonfrail patients. Further research is warranted to understand the effects and timeline of frailty in geriatric patients.

Does state malpractice environment affect outcomes following spinal fusions? A robust statistical and machine learning analysis of 549,775 discharges following spinal fusion surgery in the United States.

OBJECTIVE: Spine surgery is especially susceptible to malpractice claims. Critics of the US medical liability system argue that it drives up costs, whereas proponents argue it deters negligence. Here, the authors study the relationship between malpractice claim density and outcomes. METHODS: The following methods were used: 1) the National Practitioner Data Bank was used to determine the number of malpractice claims per 100 physicians, by state, between 2005 and 2010; 2) the Nationwide Inpatient Sample was queried for spinal fusion patients; and 3) the Area Resource File was queried to determine the density of physicians, by state. States were categorized into 4 quartiles regarding the frequency of malpractice claims per 100 physicians. To evaluate the association between malpractice claims and death, discharge disposition, length of stay (LOS), and total costs, an inverse-probability-weighted regression-adjustment estimator was used. The authors controlled for patient and hospital characteristics. Covariates were used to train machine learning models to predict death, discharge disposition not to home, LOS, and total costs. RESULTS: Overall, 549,775 discharges following spinal fusions were identified, with 495,640 yielding state-level information about medical malpractice claim frequency per 100 physicians. Of these, 124,425 (25.1%), 132,613 (26.8%), 130,929 (26.4%), and 107,673 (21.7%) were from the lowest, second-lowest, second-highest, and highest quartile states, respectively, for malpractice claims per 100 physicians. Compared to the states with the fewest claims (lowest quartile), surgeries in states with the most claims (highest quartile) showed a statistically significantly higher odds of a nonhome discharge (OR 1.169, 95% CI 1.139-1.200), longer LOS (mean difference 0.304, 95% CI 0.256-0.352), and higher total charges (mean difference [log scale] 0.288, 95% CI 0.281-0.295) with no significant associations for mortality. For the machine learning models-which included medical malpractice claim density as a covariate-the areas under the curve for death and discharge disposition were 0.94 and 0.87, and the R2 values for LOS and total charge were 0.55 and 0.60, respectively. CONCLUSIONS: Spinal fusion procedures from states with a higher frequency of malpractice claims were associated with an increased odds of nonhome discharge, longer LOS, and higher total charges. This suggests that medicolegal climate may potentially alter practice patterns for a given spine surgeon and may have important implications for medical liability reform. Machine learning models that included medical malpractice claim density as a feature were satisfactory in prediction and may be helpful for patients, surgeons, hospitals, and payers.

Post-Operative Complications Associated with Long-Term NSAID or Long-Term Opioid Use Prior to Lumbar Spinal Fusion Surgery.

OBJECTIVE: Lower back pain (LBP) has been implicated as a significant cause of chronic pain in the United States, often requiring analgesic use. In this study, we investigate the trends in long-term preoperative NSAID (LTN) and Opioid (LTO) use in patients with low back pain in the United States, and the resultant postoperative complications following lumbar fusion. METHODS: In this retrospective cohort study of patients with lumbar pathologies, multivariate population-based regression models were developed using the 2010-2017 National Readmission Database. Short-term complications (30-, 90-day) and long-term complications (180-, 300-day) were analyzed at readmission. RESULTS: Of patients diagnosed with LBP (N = 1427,190) we found a rise in LTO users and a fall in LTN users following 2015. We identified 654,264 individuals who received a lumbar spine fusion, of which 22,975 were LTN users and 11,213 were LTO users. LTO users had significantly higher total inpatient charges (p-value<0.0001) and LOS (p-value<0.0001), while LTN users had lower rates of acute infection (OR: 0.993, 95% CI: 0.987-0.999, p = 0.017) and acute posthemorrhagic anemia (OR: 0.957, 95% CI: 0.935-0.979, p < 0.001) at primary admission. Readmission analysis showed that LTN use had significantly lower odds of readmission compared to LTO use at all time points (p < 0.01 for all). LTN use had significantly higher odds of hardware failure (OR: 1.134, 95% CI: 1.039-1.237, p = 0.005) within 300-days of receiving a lumbar fusion. CONCLUSIONS: LTO users had significantly higher readmission rates compared to LTN. In addition, we found that LTN use was associated with significantly higher odds of hardware failure at long-term follow-up in patients receiving lumbar fusion surgery.

The Effect of Modifiable Risk Factors on Postoperative Complications in Lumbar Spine Fusions.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The impact of modifiable risk factors (MRFs) on complications, costs, and readmission rates at 30, 90, and 180-days following lumbar spine fusion. METHODS: Patients with lumbar spine fusions within the 2016-2017 Nationwide Readmissions Database (NRD). Patients were stratified by the following MRFs: Alcohol use, tobacco/nicotine use, nutritional malnourishment, dyslipidemia, and primary hypertension. Differences in complications, non-elective readmission rates, costs, and length of stay were compared between MRFs and the non-MRF group. Statistical analysis was conducted using Tukey multiple comparisons of means, 1-way ANOVA, Wald testing, unpaired Welch 2-sample t-tests, multivariate analysis, and predictive modeling. RESULTS: The final analysis included 297,579 lumbar fusion patients. At 30 and 90 days, patients with nutritional malnutrition, dyslipidemia, and primary hypertension had significantly greater readmission rates than patients without MRFs (all P<0.01). At 180-days, all MRFs had significantly greater readmission rates than the non-MRF group (all P<0.001). Dyslipidemia demonstrated significantly greater rates of myocardial infarction at 90 days compared to all groups (all P<0.02). Nutritional malnutrition was associated with a significantly greater mortality rate than primary hypertension, non-MRF, and tobacco/nicotine use at 90 days (P<0.001) and only tobacco/nicotine use at 180 days (P=0.007). Predictive modeling showed increases of 0.77%, 1.70%, and 2.44% risk of readmission at 30, 90, and 180-days respectively per additional MRF (all P<0.001). CONCLUSIONS: These findings highlight the negative impact each MRF has on patients following lumbar spinal fusion. Further longitudinal research is necessary to comprehensively characterize the effects of various MRFs on spine surgery outcomes.

Cemented versus Cementless Femoral Fixation for Elective Primary Total Hip Arthroplasty: A Nationwide Analysis of Short-Term Complication and Readmission Rates.

Cementless fixation during total hip arthroplasty (THA) is the predominant mode of fixation utilized for both acetabular and femoral components during elective primary THAs performed in the United States. This study aims to compare early complication and readmission rates between primary THA patients receiving cemented versus cementless femoral fixation. The 2016-2017 National Readmissions Database was queried to identify patients undergoing elective primary THA. Postoperative complication and readmission rates at 30, 90, and 180 days were compared between cemented and cementless cohorts. Univariate analysis was conducted to compare differences between cohorts. Multivariate analysis was performed to account for confounding variables. Of 447,902 patients, 35,226 (7.9%) received cemented femoral fixation, while 412,676 (92.1%) did not. The cemented group was older (70.0 vs. 64.8, p < 0.001), more female (65.0% vs. 54.3%, p < 0.001), and more comorbid (CCI 3.65 vs. 3.22, p < 0.001) compared to the cementless group. On univariate analysis, the cemented cohort had decreased odds of periprosthetic fracture at 30 days postoperatively (OR: 0.556, 95%-CI 0.424-0.729, p < 0.0001), but higher odds of hip dislocation, periprosthetic joint infection, aseptic loosening, wound dehiscence, readmission, medical complications, and death at all timepoints. On multivariate analysis, the cemented fixation cohort demonstrated reduced odds of periprosthetic fracture at all postoperative timepoints: 30 (OR: 0.350, 95%-CI 0.233-0.506, p < 0.0001), 90 (OR: 0.544, 95%-CI 0.400-0.725, p < 0.0001), and 180 days (OR: 0.573, 95%-CI 0.396-0.803, p = 0.002). Cemented femoral fixation was associated with significantly fewer short-term periprosthetic fractures, but more unplanned readmissions, deaths, and postoperative complications compared to cementless femoral fixation in patients undergoing elective THA.

Postoperative Complication and Reoperation Rates Following Resection of Soft Tissue vs. Bone Malignancies Based on Anatomic Location in the Inpatient Setting.

Introduction: Surgical excisions of upper and lower extremity malignancies are increasing annually, due in part to the rising incidence of sarcomas. The purpose of this study is to compare readmissions, reoperation rate, and complications following surgical excision of soft/connective tissue vs bone malignancies of the upper and lower extremities. Methods: The Nationwide Readmissions Database (NRD) was queried from 2016-2017 to conduct a retrospective analysis of 16,435 patients diagnosed with malignant neoplasms of the long bone (ULLB, n = 1,433) and soft tissue (ULST, n = 2,049) of the upper limb and malignant neoplasms of the long bone (LLLB, n = 5,422) and soft tissue (LLST, n = 7,531) of the lower limb. Patients who underwent surgical excision of their neoplasms were included. Binomial multivariate logistic regression was used to compare complications, nonelective readmission rates, and reoperation rates between the two groups at 30 and 90 days. Results: Average age of the ULST group was 61.88, with 36% female. Average age of the ULLB group was 44.97, with 41.90% female. Average age of the LLST group was 60.96, with 46.90% female. Average age of the LLLB group was 43.09, with 42.60% female. The ULST group had lower odds of readmission within 30 days (p=0.263), which became significant within 90 days of surgery (p=0.045). The LLST group had significantly higher odds of infection, reoperation within 30 to 90 days of the index surgery compared to the LLLB group (p < 0.0001). The LLST group had significantly lower odds of readmission within 30 (p=0.04) and 90 days (p=0.015) of the index surgery. Conclusion: Patients in the ULST group had significantly lower odds of 90-day readmission compared to the ULLB group. There were also significantly lower odds of 30- and 90-day readmission in the LLST group compared to the LLLB group. However, the LLST group had significantly higher odds of infection and reoperation within 30 and 90 days compared to the LLLB group.

Stroke management and outcomes in low-income and lower-middle-income countries: a meta-analysis of 8535 patients.

OBJECTIVE: Strokes affect almost 13 million new people each year, and whereas the outcomes of stroke have improved over the past several decades in high-income countries, the same cannot be seen in low-income and lower-middle-income countries. This is the first study to identify the availability of diagnostic tools along with the rates of stroke mortality and other poststroke complications in low-income and lower-middle-income countries. METHODS: A review of the literature was completed with a search of the MEDLINE, Embase, and Scopus databases, with adherence to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they reported any outcomes of stroke in low-income and lower-middle-income countries as designated by the World Bank classification. A meta-analysis calculating pooled prevalence rates of diagnostic characteristics and stroke outcomes was completed for all endpoint variables. RESULTS: A total of 19 studies were included, of which 6 came from Ethiopia, 3 from Zambia, and 2 each from Tanzania and Iran. Single studies from Zimbabwe, Botswana, Senegal, Cameroon, Uganda, and Sierra Leone were included. A total of 5265 (61.7%) patients had an ischemic stroke, 2124 (24.9%) had hemorrhagic stroke, with the remaining 1146 (13.4%) having an unknown type. Among 6 studies the pooled percentage of patients presenting to hospital within 1 day was 48.37% (95% CI 38.59%-58.27%; I2 = 97.0%, p < 0.01). The pooled in-hospital mortality rate was 19.81% (95% CI 15.26%-25.31%; I2 = 91%, p < 0.01), but was higher in a hemorrhagic subgroup (27.07% [95% CI 22.52%-32.15%; I2 = 54%, p = 0.05]) when compared to an ischemic group (13.16% [95% CI 8.60%-19.62%; I2 = 87%, p < 0.01]). The 30-day pooled mortality rate was 23.24% (95% CI 14.17%-35.70%; I2 = 93%, p < 0.01). At 30 days, the functional independence (modified Rankin Scale score 0-2) pooled rate was 13.10% (95% CI 7.50%-21.89%; I2 = 82%, p < 0.01). CONCLUSIONS: A severe healthcare disparity is present in low-income and lower-middle-income countries, where there is delayed diagnosis of strokes and increased rates of poor clinical outcomes for these patients.

Is the Centers for Medicare and Medicaid Services Hierarchical Condition Category Risk Adjustment Model Satisfactory for Quantifying Risk After Spine Surgery?

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) coding is a risk adjustment model that allows for the estimation of risk-and cost-associated with health care provision. Current models may not include key factors that fully delineate the risk associated with spine surgery. OBJECTIVE: To augment CMS HCC risk adjustment methodology with socioeconomic data to improve its predictive capabilities for spine surgery. METHODS: The National Inpatient Sample was queried for spinal fusion, and the data was merged with county-level coverage and socioeconomic status variables obtained from the Brookings Institute. We predicted outcomes (death, nonroutine discharge, length of stay [LOS], total charges, and perioperative complication) with pairs of hierarchical, mixed effects logistic regression models-one using CMS HCC score alone and another augmenting CMS HCC scores with demographic and socioeconomic status variables. Models were compared using receiver operating characteristic curves. Variable importance was assessed in conjunction with Wald testing for model optimization. RESULTS: We analyzed 653 815 patients. Expanded models outperformed models using CMS HCC score alone for mortality, nonroutine discharge, LOS, total charges, and complications. For expanded models, variable importance analyses demonstrated that CMS HCC score was of chief importance for models of mortality, LOS, total charges, and complications. For the model of nonroutine discharge, age was the most important variable. For the model of total charges, unemployment rate was nearly as important as CMS HCC score. CONCLUSION: The addition of key demographic and socioeconomic characteristics substantially improves the CMS HCC risk-adjustment models when modeling spinal fusion outcomes. This finding may have important implications for payers, hospitals, and policymakers.

Demographic-Dependent Risk of Developing Severe Novel Psychiatric Disorders after Concussion.

Current guidelines for patients experiencing a concussion or mild traumatic brain injury (mTBI) often focus on conservative care and observation. However, mTBI may increase the risk of severe novel psychiatric disorders (NPDs) within 180 days, and long-term management of mTBI should include psychiatric evaluation in patient populations. Retrospective cohort analysis was conducted using 8 years of the Nationwide Readmission Database. All individuals who were admitted for concussion and were readmitted within 180 days were queried. This cohort was then subdivided based on age, sex, and whether they experienced loss of consciousness (LOC) to control for demographic-dependent confounding. A binary decision tree provided recommendations for patients who may be at risk of developing severe NPDs. Analysis included 12,080 patients who experienced concussion. Males and females with LOC had higher rates of depression in all age quartiles within 180 days (p < 0.05). Young females with LOC had increased rates of suicidal ideation (p < 0.01), and those >25 years of age had increased rates of anxiety (p < 0.005). Adult males with LOC had increased rates of suicidal ideation (p < 0.002) and males >75 years of age had increased rates of anxiety at readmission (p < 0.05). Males without LOC had increased rates of depression (p < 0.005), with men in the second quartile also at higher risk of developing anxiety (p < 0.05). Females without LOC showed the fewest number of NPDs at readmission. Concussion may be associated with increased rates of NPDs in the first 6 months following discharge. We use these data to develop recommendations for psychiatric screening of patients with mTBI.

Influence of patient-specific factors when comparing multifidus fat infiltration between chronic low back pain patients and asymptomatic controls.

Introduction: Many studies have attempted to link multifidus (MF) fat infiltration with muscle quality and chronic low back pain (cLBP), but there is no consensus on these relationships. Methods: In this cross-sectional cohort study, 39 cLBP patients and 18 asymptomatic controls were included. The MF muscle was manually segmented at each lumbar disc level and fat fraction (FF) measurements were taken from the corresponding advanced imaging water-fat images. We assessed the distribution patterns of MF fat from L1L2 to L5S1 and compared these patterns between groups. The sample was stratified by age, sex, body mass index (BMI), subject-reported pain intensity (VAS), and subject-reported low back pain disability (oswestry disability index, ODI). Results: Older patients had significantly different MF FF distribution patterns compared to older controls (p < 0.0001). Male patients had 34.8% higher mean lumbar spine MF FF compared to male controls (p = 0.0006), significantly different MF FF distribution patterns (p = 0.028), 53.7% higher mean MF FF measurements at L2L3 (p = 0.037), and 50.6% higher mean MF FF measurements at L3L4 (p = 0.041). Low BMI patients had 29.7% higher mean lumbar spine MF FF compared to low BMI controls (p = 0.0077). High BMI patients only had 4% higher mean lumbar spine MF FF compared to high BMI controls (p = 0.7933). However, high BMI patients had significantly different MF FF distribution patterns compared to high BMI controls (p = 0.0324). Low VAS patients did not significantly differ from the control cohort for any of our outcomes of interest; however, high VAS patients had 24.3% higher mean lumbar spine MF FF values (p = 0.0011), significantly different MF FF distribution patterns (p < 0.0001), 34.7% higher mean MF FF at L2L3 (p = 0.040), and 34.6% higher mean MF FF at L3L4 (p = 0.040) compared to the control cohort. Similar trends were observed for ODI. Conclusions: This study suggests that when the presence of paraspinal muscle fat infiltration is not characteristic of an individual's age, sex, and BMI, it may be associated with lower back pain.

The Impact of Osteobiologic Subtype Selection on Perioperative Complications and Hospital-Reported Charges in Single- and Multi-Level Lumbar Spinal Fusion.

BACKGROUND: Over the last several decades, various osteobiologics including allograft, synthetics, and growth factors have been used for lumbar spinal fusion surgery. However, the data on these osteobiologic products remain controversial with conflicting evidence in the literature. This study evaluates the influence of osteobiologic type selection on perioperative complications and hospital-reported charges in single-level and multilevel lumbar fusion. METHODS: Using the 2016 and 2017 Nationwide Readmission Database, we conducted a retrospective cohort analysis of 125,143 patients who received lumbar fusion with either autologous tissue substitute, nonautologous tissue substitute, or synthetic substitute. This cohort was split into single-level and multilevel fusion procedures, and one-to-one age and sex propensity score matching was implemented. This resulted in cohorts each consisting of 1967 patients for single-level fusion, and cohorts each consisting of 1657 patients for multilevel fusion. Statistical analysis included one-way analysis of variance and Tukey multiple comparisons of means. RESULTS: Autologous single-level fusion resulted in significantly more postoperative pain at 30-, 90-, and 180-day follow-up compared to fusion with nonautologous graft (P < .05). Multilevel fusion with autologous graft had higher rates of acute postsurgical anemia compared with synthetic (P = .021) and nonautologous (P = .016) alternatives, and less postsurgical infection when compared with nonautologous fusion (P = .0020). In addition, procedures using autologous osteobiologics were associated with significantly more neurological complications at 30 days (P = .049) and 90 days (P = .048) for multi-level fusion and at 30 days (P = .044) for single-level fusion compared with the nonautologous group. Lastly, for both cohorts, the total accrued inpatient hospital charges during admission for patients receiving nonautologous grafts were the most expensive and those for patients receiving autologous grafts were the least expensive. CONCLUSION: Significant differences were found between the groups with respect to rates of complications, including infection, postoperative pain, and neurologic injury. Furthermore, the hospital-reported charges of each procedure varied significantly. As the field of biologics continues to expand, it is important to continually evaluate the safety, efficacy, and cost-effectiveness of these novel materials and techniques. LEVEL OF EVIDENCE: 3 CLINICAL RELEVANCE: With increased utilization of osteobiologics and spinal fusion being a common procedure, longitudinal data on readmissions, and post-operative complications are critical in guiding evidence-based practice.

The Influence of Body Mass Index in Obese and Morbidly Obese Patients on Complications and 30- and 90-day Readmissions Following Lumbar Spine Fusion.

STUDY DESIGN: Retrospective cohort study using the 2013-2017 National Readmission Database. OBJECTIVE: The aim of this study was to quantify the influence of body mass index (BMI) on complication and readmission rates following lumbar spine fusion. SUMMARY OF BACKGROUND DATA: Compared to controls, patients with BMI ≥35 had greater odds of readmission, infection, and wound complications following lumbar spine fusion. METHODS: Patients who underwent elective lumbar spine fusion within the population-based sample were considered for inclusion. Exclusion criteria included nonelective lumbar spine fusions, malnourished, anorexic, or underweight patients, and surgical indications of trauma or neoplasm. Patients were grouped by BMI: 18.5 to 29.9 (controls), 30 to 34.9 (obesity I), 35 to 39.9 (obesity II), and ≥40 (obesity III). Multivariate regression was performed to analyze differences in complications and readmissions between groups. Predictive modeling was conducted to estimate the impact of BMI on 30- and 90-day infection, wound complication, and readmissions rates. RESULTS: A total of 86,697 patients were included for analysis, with an average age of 58.9 years and 58.9% being female. The obesity II group had significantly higher odds of infection (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.28-2.62, P = 0.001), wound dehiscence (OR: 3.08, 95% CI: 1.70-6.18, P = 0.0006), and 30-day readmission (OR: 1.32, 95% CI: 1.11-1.58, P = 0.002), whereas the obesity III group had significantly higher odds of acute renal failure (OR: 2.14, 95% CI: 1.20-4.06, P = 0.014), infection (OR: 2.43, 95% CI: 1.72-3.48, P < 0.0001), wound dehiscence (OR: 3.76, 95% CI: 2.08-7.51, P < 0.0001), 30-day readmission (OR: 1.62, 95% CI: 1.36-1.93, P < 0.0001), and 90-day readmission (OR: 1.53, 95% CI: 1.31-1.79, P < 0.0001) compared with controls. Predictive modeling showed cumulative increases of 6.44% in infection, 3.69% in wound dehiscence, and 1.35% in readmission within 90-days for each successive BMI cohort. CONCLUSION: Progressively higher risks for infection, wound complications, and hospital readmission were found with each progressive BMI level.Level of Evidence: 3.

Propensity-matched Analysis of 1062 Patients Following Minimally Invasive Versus Open Sacroiliac Joint Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The aim of this study was to compare the hospital charges and postoperative complications of minimally invasive surgery (MIS) and open approaches to sacroiliac joint (SIJ) fusion. SUMMARY OF BACKGROUND DATA: The data source utilized in this study is the Healthcare Cost and Utilization Project National Readmission Database (NRD) from 2016 and 2017. The NRD is a yearly nationally representative inpatient database from the Agency for Healthcare Research and Quality with information regarding patient demographics, diagnoses, procedures, and readmissions. MATERIALS AND METHODS: The 2016-2017 NRD was used to identify 2521 patients receiving SIJ fusion with open (n=1990) or MIS approaches (n=531) for diagnosed sacrum pain, sacroiliitis, sacral instability, or spondylosis after excluding for those who received prior SIJ fusion, those diagnosed with neoplasms or trauma of the pelvis or sacrum, and nonelective procedures. We then one-to-one propensity-matched the open (n=531) to the MIS approach (n=531) for age, sex, and Charlson Comorbidity Index. Statistical analysis was performed to compare total hospital charges, immediate surgical complications, nonelective readmission rate, and 30-, 90-, and 180-day postoperative complications between the 2 approaches. RESULTS: The mean total hospital charge was the only significant difference between 2 group. Open SIJ fusion had significantly higher charge compared with the MIS approach (open $101,061.90±$81,136.67; MIS $83,594.78±$49,086.00, P<0.0001). The open approach was associated with nonsignificant higher rates of novel lumbar pathology at 30-, 90-, and 180-day readmissions and revision surgeries at 30 and 180 days. MIS approach had higher rates nervous system complications at 30-, 90-, and 180-day readmission, as well as infection and urinary tract infection within 30 days, none being significant. Novel postprocedural pain was similar between the 2 groups at 90 and 180 days. CONCLUSIONS: The current study found that open SIJ fusion was associated with significantly higher hospital charges. Although no significant differences in postoperative complications were found, there were several notable trends specific to each surgical approach.

Complication Trends and Costs of Surgical Management in 11,086 Osteoporotic Patients Receiving Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to compare different aspects of fusion surgery in patients with osteoporosis with regard to graft subtype and surgical approach. SUMMARY OF BACKGROUND DATA: Osteoporosis and chronic lower back pain are common in elderly populations and significantly increase the risk of compression fractures within the spine. METHODS: Using the 2016-2017 National Readmission Database we identified 11,086 osteoporotic patients who received lumbar fusion using ICD-10 coding. Information regarding biologic graft type and surgical approach was collected. Patients were stratified by number of levels fused. Perioperative complications were collected at 30-, 90-, and 180-day follow-up intervals. Statistical analysis included univariate testing and multivariate regression modeling, controlling for patient demographics and comorbidities. RESULTS: Patients receiving single-level fusion with autologous grafts had higher rates of hardware failure (P = 0.00014) at 30-day follow-up and 90-day follow-up (P < 0.0001) and higher rates of lumbar vertebral fractures at 90-day follow-up (P = 0.045) compared to those treated with nonautologous grafts. Patients receiving lumbar fusion with anterior and posterior approaches had no difference in readmission or infection rates, but the anterior approach was associated with a higher cost. CONCLUSION: In this study, osteoporotic patients treated with autologous grafts had higher rates of complications compared to those treated with nonautologous grafts. Anterior and posterior approaches had similar complication rates; however, the anterior approach was associated with a higher total cost.Level of Evidence: 4.