Virtual Reality-Enabled Resident Education of Lateral-Access Spine Surgery.

OBJECTIVE: Lateral-access spine surgery has many benefits, but adoption has been limited by a steep learning curve. Virtual reality (VR) is gaining popularity and lends itself as a useful tool in enhancing neurosurgical resident education. We thus sought to assess whether VR-based simulation could enhance the training of neurosurgery residents in lateral spine surgery. METHODS: Neurosurgery residents completed a VR-based lateral spine module on lateral patient positioning and performing lateral lumbar interbody fusion using the PrecisionOS VR system on the Meta Quest 2 headset. Simulation occurred 1×/week every other week for a total of 3 simulations over 6 weeks. Pre- and postintervention surveys as well as intrasimulation performance metrics were assessed over time. RESULTS: The majority of resident participants showed improvement in performance scores, including an automated PrecisionOS precision score, number of radiographs used within the simulation, and time to completion. All participants showed improvement in comfort with anatomic landmarks for lateral access surgery, confidence performing lateral surgery without direct supervision, and assessing fluoroscopy in spine surgery for hardware placement and image interpretation. Participant perception on the utility of VR as an educational tool also improved. CONCLUSIONS: VR-based simulation enhanced neurosurgical residents' ability to understand lateral access surgery. Immersive surgical simulation resulted in improved resident confidence with surgical technique and workflow, perceived improvement in anatomical knowledge, and simulation performance scores. Trainee perceptions on virtual simulation and training as a curriculum supplement also improved following completion of VR training.

Comparative analysis of perioperative characteristics and early outcomes in transforaminal endoscopic lumbar diskectomy: general anesthesia versus conscious sedation.

PURPOSE: To better understand how anesthesia type impacts patient selection and recovery in TELD, we conducted a multicenter prospective study which evaluates the differences in perioperative characteristics and outcomes between patients who underwent TELD with either general anesthesia (GA) or conscious sedation (CS). METHODS: We prospectively collected data from all TELD performed by five neurosurgeons at five different medical centers between February and October of 2022. The study population was dichotomized by anesthesia scheme, creating CS and GA cohorts. This study's primary outcomes were the Oswetry Disability Index (ODI) and the Visual Analog Scale (VAS) for back and leg pain, assessed preoperatively and at 2-week follow-up. RESULTS: A total of 52 patients underwent TELD for symptomatic lumbar disk herniation. Twenty-three patients received conscious sedation with local anesthesia, and 29 patients were operated on under general anesthesia. Patients who received CS were significantly older (60.0 vs. 46.7, p < 0.001) and had lower BMI (28.2 vs. 33.4, p = 0.005) than patients under GA. No intraoperative or anesthetic complications occurred in the CS and GA cohorts. Improvement at 2-week follow-up in ODI, VAS-back, and VAS-leg was greater in patients receiving CS relative to patients under GA, but these differences were not statistically significant. CONCLUSION: In our multicenter prospective analysis of 52 patients undergoing TELD, we found that patients receiving CS were significantly older and had significantly lower BMI compared to patients under GA. On subgroup analysis, no statistically significant differences were found in the improvement of PROMs between patients in the CS and GA group.

Incidence and management of dural tears in full-endoscopic unilateral laminotomies for bilateral lumbar decompression.

PURPOSE: To report incidence of dural lacerations in lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) and to describe patient outcomes following a novel full-endoscopic bimanual durotomy repair. METHODS: Retrospective review of prospectively collected database including 5.5 years of single surgeon experience with LE-ULBD. Patients with no durotomy were compared with patients who experienced intraoperative durotomy, including demographics, ASA score, prior surgery, number of levels treated, procedure time, hospital length of stay (LOS), visual analogue scale, perioperative complications, revision surgeries, use of analgesics, and Oswestry Disability Index (ODI). RESULTS: In total, 13/174 patients (7.5%) undergoing LE-ULBD experienced intraoperative durotomy. No significant differences in demographic, clinical or operative variables were identified between the 2 groups. Sustaining a durotomy increased LOS (p = 0.0019); no differences in perioperative complications or rate of revision surgery were identified. There was no difference in minimally clinically important difference for ODI between groups (65.6% for no durotomy versus 55.6% for durotomy, p = 0.54). CONCLUSION: In this cohort, sustaining a durotomy increased LOS but, with accompanying intraoperative repair, did not significantly affect rate of complications, revision surgery or functional outcomes. Our method of bimanual endoscopic dural repair provides an effective approach for repair of dural lacerations in interlaminar ULBD cases.

Full-endoscopic trans-pars interarticularis approach for far lateral lumbar discectomy.

PURPOSE: Surgical management of far lateral disc herniations remains challenging. Current transforaminal full-endoscopic approaches require non-visualized docking in the Kambin's triangle and have been associated with significant risk of inadvertent nerve injury. We develop a full-endoscopic approach based on reliable bony landmarks allowing for visualization of the exiting nerve root prior to the far lateral discectomy. METHODS: The surgical details of a full-endoscopic trans-pars interarticularis approach for far lateral discectomy are described. These descriptions include high quality intraoperative images and important surgical pearls. A small patient cohort is presented to demonstrate feasibility and safety of the procedure. RESULTS: We demonstrate the feasibility of this approach in 14 patients with a mean age of 59.5 ± 14.7 years. At a mean follow up of 21.9 ± 6.8 months, improvement of the visual analogue scale (VAS) for leg pain was 4.3 ± 1.0 resulting in minimally clinically important difference in 78.6% of the patients. The mean improvement in VAS for the back pain was 2.6 ± 0.8 and for Oswestry disability index (ODI) was 20.6 ± 5.3. Nuances of the trans-pars surgical techniques are presented in a patient with a right-sided L4-5 far lateral disc herniation. Preoperative imaging studies, steps of the surgical progression, and intraoperative views are described in detail. CONCLUSION: Using the pars interarticularis as the bony target area allows for safe visualized access to the extraforaminal compartment of the exiting nerve root. This novel surgical technique has the potential benefit of decreasing inadvertent neural injury and subsequent postoperative dysesthesias.

Full-endoscopic technique mitigates obesity-related perioperative morbidity of minimally invasive lumbar decompression.

PURPOSE: Obesity is associated with increased surgical complexity and postoperative complications in spine surgery. Minimally invasive procedures have been shown to lessen some of the increased risk in obese patients. This study investigated whether utilization of a working channel endoscope can further mitigate obesity-associated challenges in spinal surgery. METHODS: A retrospective review of a single-surgeon database was conducted for all adult patients undergoing full-endoscopic unilateral laminotomies for bilateral decompression between November 2015 and March 2021. Data collected included body mass index, in operating room preparation time, procedure time, length of hospital stay, use of analgesics, complications, and quality of life measured by Oswestry Disability Index. RESULTS: Our cohort included 174 patients. Of these, 74 (42.5%) were obese. The average age was 63.6 years. In-operating room preparation time was 70.0 ± 1.7 min for obese patients and 64.4 ± 1.5 min for non-obese patients (p = 0.02). There was no difference in operative time, durotomy rates or other perioperative complications between obese and non-obese patients. Hospital length of stay trended toward longer in the obese group, but did not reach significance. A greater percentage of obese patients were still using both narcotic and non-narcotic pain medications 2 weeks after surgery. There was no significant difference in functional outcomes between groups. CONCLUSION: Full-endoscopic unilateral laminotomies for bilateral decompression are safe and effective in both non-obese and obese patients. The use of an endoscope can partially mitigate obesity-related morbidity in lumbar decompression. However, obesity is significantly related to increased postoperative analgesic use.

Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis.

BACKGROUND CONTEXT: Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence. PURPOSE: The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database. DESIGN: This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases. PATIENT SAMPLE: A total of 1277 noninstrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients. OUTCOME MEASURES: The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake. METHODS: All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching. RESULTS: In the nonpropensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS. CONCLUSIONS: FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

Bone metastasis from glioblastoma: a systematic review.

INTRODUCTION: Glioblastoma (GBM) is a devastating disease with poor overall survival. Despite the common occurrence of GBM among primary brain tumors, metastatic disease is rare. Our goal was to perform a systematic literature review on GBM with osseous metastases and understand the rate of metastasis to the vertebral column as compared to the remainder of the skeleton, and how this histology would fit into our current paradigm of treatment for bone metastases. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant literature search was performed using the PubMed database from 1952 to 2021. Search terms included "GBM", "glioblastoma", "high-grade glioma", "bone metastasis", and "bone metastases". RESULTS: Of 659 studies initially identified, 67 articles were included in the current review. From these 67 articles, a total of 92 distinct patient case presentations of metastatic glioblastoma to bone were identified. Of these cases, 58 (63%) involved the vertebral column while the remainder involved lesions within the skull, sternum, rib cage, and appendicular skeleton. CONCLUSION: Metastatic dissemination of GBM to bone occurs. While the true incidence is unknown, workup for metastatic disease, especially involving the spinal column, is warranted in symptomatic patients. Lastly, management of patients with GBM vertebral column metastases can follow the International Spine Oncology Consortium two-step multidisciplinary algorithm for the management of spinal metastases.

Optimal timing of referral for nerve transfer surgery for postoperative C5 palsy.

OBJECTIVE: Cervical nerve 5 palsy can occur following surgery for cervical spine pathology. The prognosis of C5 palsy is generally favorable, and most patients recover useful function. However, some patients do not recover useful strength. Nerve transfers are a potential effective treatment of postoperative severe C5 palsy. This study aimed to further delineate the natural history of recovery from postoperative C5 palsy, determine whether lack of recovery at specific time points predicts poor recovery prognosis, and thereby determine a reasonable time point for referral to a complex peripheral nerve specialist. METHODS: The authors conducted a retrospective review of 72 patients who underwent surgery for cervical spondylosis and stenosis complicated by C5 palsy. Medical Research Council (MRC) motor strength grades were recorded preoperatively; immediately postoperatively; at discharge; and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Univariate and multivariate logistic regression models were used to identify demographic and clinical risk factors associated with recovery of useful strength after severe C5 palsy. RESULTS: The mean patient age was 62.5 years, and 36.1% of patients were female. Thirty patients (41.7%) experienced severe C5 palsy with less than antigravity strength (MRC grade 2 or less) at discharge. Twenty-one (70%) of these patients recovered useful strength (MRC grade 3 or greater) at 12 months postoperatively, and 9 patients (30%) did not recover useful strength at 12 months. Of those patients with persistent severe C5 palsy at 3 months postoperatively, 50% recovered useful strength at 12 months. Of those patients with persistent severe C5 palsy at 6 months postoperatively, 25% recovered useful strength at 12 months. No patient with MRC grade 0 or 1 strength at 6 months postoperatively recovered useful strength. A history of diabetes was associated with the occurrence of severe C5 palsy. On multivariate analysis, female sex was associated with recovery of useful strength. CONCLUSIONS: Most patients with severe C5 palsy recover useful strength in their C5 myotome within 12 months of onset. However, at 3 months postoperatively, patients with persistent severe C5 palsy had only a 50% chance of recovering useful strength by 12 months. Lack of recovery of useful strength at 3 months postoperatively is a reasonable time point for referral to a complex peripheral nerve center to establish care and to determine candidacy for nerve transfer surgery if severe C5 palsy persists.

Pre- and intraoperative thoracic spine localization techniques: a systematic review.

OBJECTIVE: In the era of modern medicine with an armamentarium full of state-of-the art technologies at our disposal, the incidence of wrong-level spinal surgery remains problematic. In particular, the thoracic spine presents a challenge for accurate localization due partly to body habitus, anatomical variations, and radiographic artifact from the ribs and scapula. The present review aims to assess and describe thoracic spine localization techniques. METHODS: The authors performed a literature search using the PubMed database from 1990 to 2020, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 27 articles were included in this qualitative review. RESULTS: A number of pre- and intraoperative strategies have been devised and employed to facilitate correct-level localization. Some of the more well-described approaches include fiducial metallic markers (screw or gold), metallic coils, polymethylmethacrylate, methylene blue, marking wire, use of intraoperative neuronavigation, intraoperative localization techniques (including using a needle, temperature probe, fluoroscopy, MRI, and ultrasonography), and skin marking. CONCLUSIONS: While a number of techniques exist to accurately localize lesions in the thoracic spine, each has its advantages and disadvantages. Ultimately, the localization technique deployed by the spine surgeon will be patient-specific but often based on surgeon preference.

Navigation and Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion: Technique, Feasibility, Safety, and Case Series.

BACKGROUND: Single-position prone lateral interbody fusion is a recently introduced technical modification of the minimally invasive retroperitoneal transpsoas approach for lateral lumbar interbody fusion (LLIF). Several technical descriptions of single-position prone LLIF have been published with traditional fluoroscopy for guidance. However, there has been no investigation of either three-dimensional computed tomography-based navigation for prone LLIF or integration with robotic assistance platforms with the prone lateral technique. This study evaluated the feasibility and safety of spinal navigation and robotic assistance for single-position prone LLIF. METHODS: Retrospective review of medical records and a prospectively acquired database for a single center was performed to examine immediate and 30-day clinical and radiographic outcomes for consecutive patients undergoing single-position prone LLIF with spinal navigation and/or robotic assistance. RESULTS: Nine patients were treated, 4 women and 5 men. Mean age was 65.4 years (range, 46-75 years), and body mass index was 30.2 kg/m2 (range, 24-38 kg/m2). The most common surgical indication was adjacent segment disease (44.4%), followed by pseudarthrosis (22.2%), spondylolisthesis (11.1%), degenerative disc disease (11.1%), and recurrent stenosis (11.1%). Postoperative approach-related complications included pain-limited bilateral hip flexor weakness (4/5) and pain-limited left knee extension weakness (4/5) in 1 patient (11.1%) and right lateral thigh numbness and dysesthesia in 1 patient (11.1%). All cages were placed within quarters 2-3, signifying the middle portion of the disc space. There were no instances of misguidance by navigation. CONCLUSIONS: Integration of spinal navigation and robotic assistance appears feasible, accurate, and safe as an alternative to fluoroscopic guidance for single-position LLIF.

Magnetic resonance imaging of human neural stem cells in rodent and primate brain.

Stem cell transplantation therapies are currently under investigation for central nervous system disorders. Although preclinical models show benefit, clinical translation is somewhat limited by the absence of reliable noninvasive methods to confirm targeting and monitor transplanted cells in vivo. Here, we assess a novel magnetic resonance imaging (MRI) contrast agent derived from magnetotactic bacteria, magneto-endosymbionts (MEs), as a translatable methodology for in vivo tracking of stem cells after intracranial transplantation. We show that ME labeling provides robust MRI contrast without impairment of cell viability or other important therapeutic features. Labeled cells were visualized immediately post-transplantation and over time by serial MRI in nonhuman primate and mouse brain. Postmortem tissue analysis confirmed on-target grft location, and linear correlations were observed between MRI signal, cell engraftment, and tissue ME levels, suggesting that MEs may be useful for determining graft survival or rejection. Overall, these findings indicate that MEs are an effective tool for in vivo tracking and monitoring of cell transplantation therapies with potential relevance to many cellular therapy applications.

Impact of Michigan's new opioid prescribing laws on spine surgery patients: analysis of the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVE: In 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery. METHODS: Patient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated. RESULTS: Patients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323). CONCLUSIONS: There was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

The impact of age on approach-related complications with navigated lateral lumbar interbody fusion.

OBJECTIVE: Age is known to be a risk factor for increased complications due to surgery. However, elderly patients can gain significant quality-of-life benefits from surgery. Lateral lumbar interbody fusion (LLIF) is a minimally invasive procedure that is commonly used to treat degenerative spine disease. Recently, 3D navigation has been applied to LLIF. The purpose of this study was to determine whether there is an increased complication risk in the elderly with navigated LLIF. METHODS: Patients who underwent 3D-navigated LLIF for degenerative disease from 2014 to 2019 were included in the analysis. Patients were divided into elderly and nonelderly groups, with those 65 years and older categorized as elderly. Ninety-day medical and surgical complications were recorded. Patient and surgical characteristics were compared between groups, and multivariate regression analysis was used to determine independent risk factors for complication. RESULTS: Of the 115 patients included, 56 were elderly and 59 were nonelderly. There were 15 complications (25.4%) in the nonelderly group and 10 (17.9%) in the elderly group, which was not significantly different (p = 0.44). On multivariable analysis, age was not a risk factor for complication (p = 0.52). However, multiple-level LLIF was associated with an increased risk of approach-related complication (OR 3.58, p = 0.02). CONCLUSIONS: Elderly patients do not appear to experience higher rates of approach-related complications compared with nonelderly patients undergoing 3D navigated LLIF. Rather, multilevel surgery is a predictor for approach-related complication.

The feasibility of computer-assisted 3D navigation in multiple-level lateral lumbar interbody fusion in combination with posterior instrumentation for adult spinal deformity.

OBJECTIVE: The lateral lumbar interbody fusion (LLIF) technique is used to treat many common spinal degenerative pathologies including kyphoscoliosis. The use of spinal navigation for LLIF has not been broadly adopted, especially in adult spinal deformity. The purpose of this study was to evaluate the feasibility as well as the intraoperative and navigation-related complications of computer-assisted 3D navigation (CaN) during multiple-level LLIF for spinal deformity. METHODS: Retrospective analysis of clinical and operative characteristics was performed for all patients > 18 years of age who underwent multiple-level CaN LLIF combined with posterior instrumentation for adult spinal deformity at the University of Michigan between 2014 and 2020. Intraoperative CaN-related complications, LLIF approach-related postoperative complications, and medical postoperative complications were assessed. RESULTS: Fifty-nine patients were identified. The mean age was 66.3 years (range 42-83 years) and body mass index was 27.6 kg/m2 (range 18-43 kg/m2). The average coronal Cobb angle was 26.8° (range 3.6°-67.0°) and sagittal vertical axis was 6.3 cm (range -2.3 to 14.7 cm). The average number of LLIF and posterior instrumentation levels were 2.97 cages (range 2-5 cages) and 5.78 levels (range 3-14 levels), respectively. A total of 6 intraoperative complications related to the LLIF stage occurred in 5 patients. Three of these were CaN-related and occurred in 2 patients (3.4%), including 1 misplaced lateral interbody cage (0.6% of 175 total lateral cages placed) requiring intraoperative revision. No patient required a return to the operating room for a misplaced interbody cage. A total of 12 intraoperative complications related to the posterior stage occurred in 11 patients, with 5 being CaN-related and occurring in 4 patients (6.8%). Univariate and multivariate analyses revealed no statistically significant risk factors for intraoperative and CaN-related complications. Transient hip weakness and numbness were found to be in 20.3% and 22.0% of patients, respectively. At the 1-month follow-up, weakness was observed in 3.4% and numbness in 11.9% of patients. CONCLUSIONS: Use of CaN in multiple-level LLIF in the treatment of adult spinal deformity appears to be a safe and effective technique. The incidence of approach-related complications with CaN was 3.4% and cage placement accuracy was high.

Effect of Fenestrated Pedicle Screws with Cement Augmentation in Osteoporotic Patients Undergoing Spinal Fusion.

OBJECTIVE: Osteoporosis is a well-known risk factor for instrumentation failure and subsequent pseudoarthrosis after spinal fusion. In the present systematic review, we analyzed the biomechanical properties, clinical efficacy, and complications of cement augmentation via fenestrated pedicle screws in spinal fusion. METHODS: We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reports appearing in the PubMed database up to March 31, 2020 were queried using the key words "cement," "pedicle screw," and "osteoporosis." We excluded non-English language studies, studies reported before 2000, studies that had involved use of cement without fenestrated pedicle screws, nonhuman studies, technical reports, and individual case reports. RESULTS: Twenty-five studies met the inclusion criteria. Eleven studies had tested the biomechanics of cement-augmented fenestrated pedicle screws. The magnitude of improvement achieved by cement augmentation of pedicle screws increased with the degree of osteoporosis. The cement-augmented fenestrated pedicle screw was superior biomechanically to the alternative "solid-fill" technique. Fourteen studies had evaluated complications. Cement extravasation with fenestrated screw usage was highly variable, ranging from 0% to 79.7%. However, cement extravasation was largely asymptomatic. Thirteen studies had assessed the outcomes. The use of cement-augmented fenestrated pedicles decreased screw pull out and improved fusion rates; however, the clinical outcomes were similar to those with traditional pedicle screw placement. CONCLUSIONS: The use of cement-augmented fenestrated pedicle screws can be an effective strategy for achieving improved pedicle screw fixation in patients with osteoporosis. A potential risk is cement extravasation; however, this complication will typically be asymptomatic. Larger comparative studies are needed to better delineate the clinical efficacy.

Correlation Between the Oswestry Disability Index and the North American Spine Surgery Patient Satisfaction Index.

BACKGROUND: The Oswestry Disability Index (ODI) is a widely used patient-reported outcome instrument in lumbar spine surgery, but its relationship to the increasingly scrutinized but still heterogeneous patient satisfaction metrics has not been well described. One popular metric is the North American Spine Society (NASS) patient satisfaction index. This study aimed to determine whether change in ODI predicts patient satisfaction. METHODS: Adult patients at a neurosurgery spine clinic completed the ODI and NASS questionnaires at various times in their care between September 2014 and November 2018. Scores were retrospectively analyzed using ordinal logistic regression. RESULTS: One thousand thirty-seven patients were identified (mean age 59.3 ± 14.7 years, 54.2% male). At 3, 12, and 24 months postoperatively, 684 (84.5%), 400 (83.3%), and 215 (80.9%) patients, respectively, expressed satisfaction (NASS score 1 or 2). Mean ± standard deviation improvements in ODI at 3, 12, and 24 months postoperatively were 16.8 ± 17.5 (n = 675), 18.4 ± 17.5 (n = 396), and 19.7 ± 17.7 (n = 213). For every unit improvement in ODI, the odds of selecting the next most satisfied NASS score at 3, 12, and 24 months postoperatively increased by 6.8% (95% confidence interval [CI] 5.6%-8.1%), 5.8% (95% CI 4.4%-7.1%), and 6.0% (95% CI 4.2%-7.9%), respectively. Every 10-unit improvement increased the odds, respectively, by 93.8% (95% CI 73.2%-117.0%), 75.0% (95% CI 53.8%-99.1%), and 79.4% (95% CI 50.3%-114.1%). CONCLUSIONS: Improvements in ODI are predictive of increased patient satisfaction as defined by the NASS index. A 10-point improvement in ODI nearly doubled the odds of increased satisfaction 3 months postoperatively.

Predictors of surgical treatment in children with tethered fibrofatty filum terminale.

OBJECTIVE: Thickened or fatty filum terminale is an occult lesion that can cause tethered cord syndrome requiring surgical untethering. This study's objectives were to estimate the incidence of tethered fibrofatty filum terminale (TFFT) in a large insured pediatric population, identify predictors of surgery among those TFFT patients, and assess a diagnostic algorithm. METHODS: TFFT was defined according to the ICD-9-CM code for cord tethering (742.59), after excluding codes for diastematomyelia, lipomyelomeningocele, terminal myelocystocele, meningocele, and myelomeningocele. Utilizing the Optum Insight database for 2001-2014, the authors identified pediatric patients (< 21 years) in the US who were diagnosed with a tethered cord and estimated the TFFT incidence rates in that source population and the surgical untethering probability among TFFT patients over the 14-year period. Logistic regression was used to estimate the effects (adjusted OR and 95% CI) of age at diagnosis, sex, Charlson Comorbidity Index (CCI) score, diagnosis of Chiari malformation type I, diagnosis of syrinx, and the probability of surgery by US census region. Lastly, to evaluate their algorithm for identifying TFFT from ICD-9 codes, the authors estimated its positive predictive value (PPV) among 50 children who were diagnosed at their institution and met the ICD-9-CM criteria. RESULTS: There were 3218 diagnoses of TFFT, with 482 of these pediatric patients undergoing tethered cord release during the study period. The estimated incidence rate was 12.0 per 100,000/year (95% CI 11.6-12.4 per 100,000/year). The incidence rate was slightly higher in females than in males (12.7 vs 11.4 per 100,000/year). The probability of surgery in the total pediatric TFFT population was 15.0% (95% CI 13.8%-16.2%) and was greater in children with a syrinx (OR 2.2, 95% CI 1.6-3.0), children 7-11 years of age at diagnosis versus < 1 year (OR 1.5, 95% CI 1.1-2.0), CCI score ≥ 3 versus 0 (OR 2.3, 95% CI 1.4-3.8), and residents of the Western vs Northeastern US (OR 2.3, 95% CI 1.6-3.5). In the authors' own institution's database, the PPV of TFFT was 35/50 (70.0%, 95% CI 57.3%-82.7%) for identifying tethered cord due to fibrofatty filum terminale among childhood positives. CONCLUSIONS: Patients with comorbidities or an associated syrinx showed a higher risk of untethering procedures for TFFT. Also, surgery was appreciably more frequent in the Western US. These findings signify the need for a collaborative prospective cohort study of long-term outcomes for TFFT patients with and without surgery to determine which patients should have surgery.