Pediatric Skull Fracture Characteristics Associated with the Development of Leptomeningeal Cysts in Young Children after Trauma: A Single Institution's Experience.

BACKGROUND: Currently, the pathogenesis of leptomeningeal cysts, also known as growing skull fractures, is still debated. The purpose of this study was to examine the specific skull fracture characteristics that are associated with the development of growing skull fractures and describe the authors' institutional experience managing this rare entity. METHODS: A retrospective cohort study was performed that included all patients younger than 5 years presenting to a single institution with skull fractures from 2003 to 2017. Patient demographics, cause of injury, skull fracture characteristics (e.g., amount of diastasis, linear versus comminuted fracture), concomitant neurologic injuries, and management outcomes were recorded. Potential factors contributing to the development of a growing skull fracture and neurologic injuries associated with growing skull fractures were evaluated using univariate logistic regression. RESULTS: A total of 905 patients met the authors' inclusion criteria. Of these, six (0.66 percent) were diagnosed with a growing skull fracture. Growing skull fractures were more likely to be comminuted (83.3 percent versus 40.7 percent; p = 0.082) and to present with diastasis on imaging (100 percent versus 26.1 percent; p < 0.001; mean amount of diastasis, 7.1 mm versus 3.1 mm; p < 0.001). Univariate logistic regression analysis confirmed the role of a comminuted fracture pattern (OR, 7.572) and the degree of diastasis (OR, 2.081 per mm diastasis) as significant risk factors for the development of growing skull fractures. CONCLUSIONS: The authors' analysis revealed that fracture comminution and diastasis width are associated with the development of growing skull fractures. The authors recommend dural integrity assessment, close follow-up, and early management in young children who present with these skull fracture characteristics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The impact of patient blood management on blood utilization and clinical outcomes in complex spine surgery.

BACKGROUND: Patient blood management (PBM) is especially applicable in major spine surgery, during which bleeding and transfusion are common. What remains unclear in this setting is the overall impact of bundled PBM measures on transfusion requirements and clinical outcomes. We compared these outcomes before and after implementing a PBM program. STUDY DESIGN AND METHODS: We conducted a retrospective review of 928 adult complex spine surgery patients performed by a single surgeon between January 2009 and June 2016. Although PBM measures were phased in over time, tranexamic acid (TXA) administration became standard protocol in July 2013, which defined our pre- and post-PBM periods. Transfusion rates for all blood components before and after PBM implementation were compared, as were morbid event rates and mortality. RESULTS: Baseline characteristics were similar before and after PBM. Before PBM, the mean number of units/patient decreased for red blood cells (RBCs; by 19.5%; p = 0.0057) and plasma (by 33%; p = 0.0008), but not for platelets (p = 0.15). After risk adjustment by multivariable analyses, the composite outcome of morbidity or mortality showed a nonsignificant trend toward improvement after PBM (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.39-1.01; p = 0.055), and the risk of thrombotic events was unchanged (OR, 1.12; 95% CI, 0.42-2.58; p = 0.80). CONCLUSION: In complex spine surgery, a multifaceted PBM program that includes TXA can be advantageous by reducing transfusion requirements without changing clinical outcomes.

Staff Perceptions of Chaplains in a Neurosciences Critical Care Unit.

Hospital chaplains often visit critically ill patients, but neurosciences critical care unit (NCCU) staff beliefs surrounding chaplains have not been characterized. In this study, we used Qualtrics® to survey 70 NCCU healthcare workers about their attitudes toward chaplains in the NCCU. Chaplains were seen positively by staff but were less likely to be viewed as part of the care team by staff with more than five years of NCCU experience. The results of this study will allow chaplaincy programs to target staff education efforts in order to enhance the care provided to patients in critical care settings.

Burnout and Resilience Among Neurosciences Critical Care Unit Staff.

BACKGROUND: Preventing burnout and promoting resiliency are important for health professionals' well-being and quality of patient care, as individuals with high levels of burnout are more likely to self-report suboptimal patient interactions. The purpose of this study was to characterize resiliency and burnout among health care professionals in the neurosciences critical care unit (NCCU) at a tertiary care center. METHODS: All NCCU clinical staff were invited to participate in a Qualtrics® electronic survey between November 2016 and August 2017. The survey assessed burnout using the abbreviated Maslach Burnout Inventory (aMBI) and resiliency using the ten-question Connor-Davidson Resilience Scale (CD-RISC 10). Higher scores on each aMBI subsection (range 0-18) indicate higher levels of each characteristic; larger resiliency scores (range 0-40) indicate higher resiliency. Categorical variables were compared using the Chi-square test and continuous variables using the Mann-Whitney U test or independent samples t test. RESULTS: A total of 65 participants (65/70, 93%) were included in the final analysis. Of respondents, 49 (75%) were nurses, 49 (75%) were female, and mean age was 34 years. Median emotional exhaustion, depersonalization, and personal accomplishment scores were as follows: 8 (IQR 6-11), 3 (IQR 0-6), and 15 (IQR 13-16). High emotional exhaustion scores and high depersonalization scores were reported in 45% (n = 29) and 28% (n = 18) of participants, respectively. Longer time working in the NCCU (1-5 years vs. less than 1 year) was independently associated with higher emotional exhaustion scores (p = 0.012). When compared to agnostic/atheist backgrounds, Catholicism was independently associated with higher personal accomplishment scores (p = 0.026). The median resiliency score was 31 (IQR 28-36). Older age was independently associated with higher resiliency scores (p = 0.044). CONCLUSIONS: This study is the first to characterize levels of burnout and resiliency among NCCU providers. A significant minority of participants reported high levels of emotional exhaustion and depersonalization, with those working longer in the NCCU more likely to experience emotional exhaustion. Efforts to improve the current work environments to optimally support the emotional needs of staff are needed to allow care providers to thrive and to promote longevity among NCCU providers.

Greater anemia tolerance among hospitalized females compared to males.

BACKGROUND: Although females have a lower baseline hemoglobin (Hb) compared to males, it is unknown whether females have a greater tolerance for anemia when hospitalized. We tested the hypothesis that females tolerate severe anemia better than males, with decreased inpatient mortality in this setting. STUDY DESIGN AND METHODS: We conducted a retrospective cohort study in 230,644 adult patients admitted to Johns Hopkins Hospital from January 2009 to June 2016. The relationships between nadir Hb and percentage change in Hb with inpatient mortality were assessed for nontransfused males and females. A multivariable logistic regression was used to determine risk-adjusted differences between males and females for the likelihood of inpatient mortality at nadir Hb levels of 5, 6, and 7 g/dL. RESULTS: Males had increased mortality when nadir Hb was 6.0 g/dL or less (p < 0.05), whereas females did not. The risk-adjusted likelihood for inpatient mortality was greater for males compared to females at a nadir Hb of 6 g/dL or less (odds ratio, 1.84; 95% confidence interval, 1.09-3.16) (p = 0.02), but this sex-related difference was not significant at a nadir Hb of 5 or 7 g/dL or less. Inpatient mortality increased significantly in both males and females when the percentage decrease in Hb was greater than 50% from baseline (p < 0.05). CONCLUSIONS: Compared to males, females tolerate a lower nadir Hb, but a similar percentage change in Hb, before an increase in inpatient mortality is recognized. The findings suggest that females may be "preconditioned" to tolerate anemia better than males.

What Do Plastic Surgery Patients Think of Financial Conflicts of Interest and the Sunshine Act?

BACKGROUND: The purpose of this study was to evaluate patients' views of conflicts of interest (COI) and their comprehension of recent legislation known as the Physician Payments Sunshine Act. This report constitutes the first evaluation of plastic surgery patients' views on COI and the government-mandated Sunshine Act. METHODS: This cross-sectional study invited patients at an academic, general plastic surgery outpatient clinic to complete an anonymous survey. The survey contained 25 questions that assessed respondents' perceptions of physician COI and awareness of the Sunshine Act. Analyses were performed to examine whether perspectives on COI and the Sunshine Act varied by level of education or age. RESULTS: A total of 361 individuals completed the survey (90% response rate). More than half of respondents with an opinion believed that COI would affect their physician's clinical decision-making (n = 152, 52.9%). Although almost three fourths (n = 196, 71.2%) believed that COI should be regulated and COI information reported to a government agency, the majority were not aware of the Sunshine Act before this survey (n = 277, 81.2%) and had never accessed the database (n = 327, 95.9%). More than half of patients (n = 161, 59.2%) stated that they would access a publicly available database with physicians' COI information. A larger proportion of older and educated patients believed that regulation of physicians' COI was important (P < 0.001). CONCLUSIONS: Awareness of and access to plastic surgeon COI information is low among plastic surgery patients. Older and more educated patients believed that transparency regarding COI is important with regard to their clinical care.

Defining Usage and Clinical Outcomes Following Perioperative Fresh Frozen Plasma and Platelet Administration in Spine Surgery Patients.

STUDY DESIGN: This was a retrospective study. OBJECTIVES: The main objectives of this study were to characterize the utilization of fresh frozen plasma (FFP) and platelets in spine surgery and the clinical outcomes following their administration. SUMMARY OF BACKGROUND DATA: Blood component transfusion is often a crucial therapy during spine surgery. Little is known about the association between transfusion with FFP and/or platelets and perioperative morbidity in patients undergoing spine surgery. MATERIALS AND METHODS: At a single large tertiary medical center, the surgical billing database was retrospectively queried for patients undergoing spinal surgery from 2008 to 2015. A univariate analysis compared patient characteristics for those who received FFP and/or platelets perioperatively and those who did not. To determine independent predictors of FFP and platelet administration and independent predictors of perioperative complications, both univariate and multivariate analyses were used. RESULTS: In total, 6931 patients met inclusion criteria. One thousand seven (14.5%) patients received perioperative FFP transfusion and 432 (6.2%) received platelets. In multivariate analysis, Charlson Comorbidity Index (CCI) ≥4, preoperative hemoglobin <12 g/dL, preoperative international normalized ratio (INR) ≥1.7, higher estimated blood loss, and receipt of packed red blood cell or platelet transfusion were associated with perioperative FFP administration (all P≤0.001). More than half of all patients received FFP with an INR trigger of <1.7. Those who received perioperative FFP were more likely to experience infection, increased length of stay, and ischemic, respiratory, thrombotic, and renal complications (all P<0.0001). Perioperative FFP [odds ratio (OR): 2.43], platelet transfusion (OR: 1.81), American Society of Anesthesiologists (ASA) grade 3 or 4 (OR: 1.84), CCI≥4 (OR: 1.75), and receipt of packed red blood cells (OR: 1.73) were independent predictors of experiencing any complication (all P≤0.008). CONCLUSIONS: The majority of patients were given FFP with a liberal INR trigger of >1.7. Perioperative FFP and platelet administration are independent predictors of perioperative complications following spine surgery.

Interventions to Prevent and Reduce Burnout Among Undergraduate and Graduate Medical Education Trainees: a Systematic Review.

OBJECTIVE: The authors conducted a systematic review of the published literature to identify interventions to prevent and/or reduce burnout among medical students and residents. METHODS: The authors searched 10 databases (from the start of each through September 21, 2016) using keywords related to burnout, medical education, and prevention. Teams of two authors independently reviewed the search results to select peer-reviewed, English language articles describing educational interventions to prevent and/or reduce burnout among medical students and/or residents that were evaluated using validated burnout measures. They assessed study quality using the Medical Education Research Study Quality Instrument and the Cochrane Risk of Bias Tool. RESULTS: Fourteen studies met inclusion criteria and all used the Maslach Burnout Inventory as at least one measure of burnout. Four were single group pre-post studies, 6 non-randomized two-group studies, and 4 randomized controlled trials. None of the studies were designed specifically to target burnout prevention. In 12 studies, residents were the targeted learners. Six of the 14 studies reported statistically significant changes in burnout scores: 5 reported improvement and 1 reported worsening of burnout. Of the 5 studies that reported statistically significant benefit, 1 studied a complementary and alternative medicine elective, 1 studied the Respiratory One Meditation method, and 3 studied duty hour changes. CONCLUSIONS: This review highlights the need for rigorously designed studies in burnout prevention and reduction among residents and especially medical students.

Comparison of PROMIS Anxiety and Depression, PHQ-8, and GAD-7 to screen for anxiety and depression among patients presenting for spine surgery.

OBJECTIVE: In this paper, the authors demonstrate to spine surgeons the prevalence and severity of anxiety and depression among patients presenting for surgery and explore the relationships between different legacy and Patient-Reported Outcomes Measurement Information System (PROMIS) screening measures. METHODS: A total of 512 adult spine surgery patients at a single institution completed the 7-item Generalized Anxiety Disorder questionnaire (GAD-7), 8-item Patient Health Questionnaire (PHQ-8) depression scale, and PROMIS Anxiety and Depression computer-adaptive tests (CATs) preoperatively. Correlation coefficients were calculated between PROMIS scores and GAD-7 and PHQ-8 scores. Published reference tables were used to determine the presence of anxiety or depression using GAD-7 and PHQ-8. Sensitivity and specificity of published guidance on the PROMIS Anxiety and Depression CATs were compared. Guidance from 3 sources was compared: published GAD-7 and PHQ-8 crosswalk tables, American Psychiatric Association scales, and expert clinical consensus. Receiver operator characteristic curves were used to determine data-driven cut-points for PROMIS Anxiety and Depression. Significance was accepted as p < 0.05. RESULTS: In 512 spine surgery patients, anxiety and depression were prevalent preoperatively (55% with any anxiety, 24% with generalized anxiety screen-positive; and 54% with any depression, 24% with probable major depression). Correlations were moderately strong between PROMIS Anxiety and GAD-7 scores (r = 0.72; p < 0.001) and between PROMIS Depression and PHQ-8 scores (r = 0.74; p < 0.001). The observed correlation of the PROMIS Depression score was greater with the PHQ-8 cognitive/affective score (r = 0.766) than with the somatic score (r = 0.601) (p < 0.001). PROMIS Anxiety and Depression CATs were able to detect the presence of generalized anxiety screen-positive (sensitivity, 86.0%; specificity, 81.6%) and of probable major depression (sensitivity, 82.3%; specificity, 81.4%). Receiver operating characteristic curve analysis demonstrated data-driven cut-points for these groups. CONCLUSIONS: PROMIS Anxiety and Depression CATs are reliable tools for identifying generalized anxiety screen-positive spine surgery patients and those with probable major depression.

Analysis of Cervical Spine Injuries in Elderly Patients from 2001 to 2010 Using a Nationwide Database: Increasing Incidence, Overall Mortality, and Inpatient Hospital Charges.

BACKGROUND: Cervical spine (C-spine) injuries cause significant morbidity and mortality among elderly patients. Although the population of older-adults ≥65 years in the United States is expanding, estimates of the burden and outcome of C-spine injury are lacking. METHODS: The Nationwide Inpatient Sample 2001-2010 was analyzed. International Classification of Diseases, Ninth Revision, Clinical Modification codes identified patients with isolated C-spine fractures (ICF) and C-spine fractures with spinal cord injury (CSCI). Annual admission and mortality rates were calculated using U.S. Census data. RESULTS: A total of 167,278 older adults were included. Median age was 81 years (interquartile range = 74-86). Most patients were female (54.9%), had Medicare coverage (77.6%), were treated in teaching hospitals (63.2%), and had falls as the leading injury mechanism (51.2%). ICF occurred in 91.3%, whereas CSCI occurred in 8.7% (P < 0.001). ICF was more common in ≥85-year-old patients and CSCI in 65- to 69-year-old patients (P < 0.001). The most common injured C-spine level in ICF was the C2 level (47.6%, P < 0.001) and in CSCI was C1-C4 level (4.5%, P < 0.001). Overall, 15.8% underwent C-spine surgery. Hospitalization rates increased from 26/100,000 in 2001 to 68/100,000 in 2010 (∼167% change, P < 0.001). Correspondingly, overall mortality increased from 3/100,000 in 2001 to 6/100,000 in 2010, P < 0.001. In-hospital mortality was 11.3%, was strongly associated with increasing age and CSCI (P < 0.001). CONCLUSIONS: In summary, C-spine fractures among U.S. older adults constitute a significant health care burden. ICFs occur commonly, C2-vertebra fractures are most frequent, whereas CSCIs are linked to increased hospital-resource use and worse outcomes. The incidence of C-spine fractures and mortality more than doubled over the past decade; however, proportional in-hospital mortality is decreasing.

Plastic Surgeons' Perceptions of Financial Conflicts of Interest and the Sunshine Act.

BACKGROUND: It is unknown whether recent legislation known as the Physician Payments Sunshine Act has affected plastic surgeons' views of conflicts of interest (COI). The purpose of this study was to evaluate plastic surgeons' beliefs about COI and their comprehension of the government-mandated Sunshine Act. METHODS: Plastic surgeon members of the American Society of Plastic Surgeons were invited to complete an electronic survey. The survey contained 27 questions that assessed respondents' past and future receipt of financial gifts from industry, awareness of the Sunshine Act, and beliefs surrounding the influence of COI on surgical practice. RESULTS: A total of 322 individuals completed the survey. A majority had previously accepted gifts from industry (n = 236; 75%) and would accept future gifts (n = 181; 58%). Most respondents believed that COI would affect their colleagues' medical practice (n = 190; 61%) but not their own (n = 165; 51%). A majority was aware of the Sunshine Act (n = 272; 89%) and supported data collection on surgeon COI (n = 224; 73%). A larger proportion of young surgeons believed patients would benefit from knowing their surgeon's COI (P = 0.0366). Surgeons who did not expect COI in the future believed financial COI could affect their own clinical practice (P = 0.0221). CONCLUSIONS: Most plastic surgeons have a history of accepting industry gifts but refute their influence on personal clinical practice. Surgeon age and anticipation of future COI affected beliefs about the benefits of COI disclosure to patients and the influence of COI on surgical practice.

The Accuracy of Conflict-of-Interest Disclosures Reported by Plastic Surgeons and Industry.

BACKGROUND: The purpose of this study was to analyze the frequency and nature of self-reported conflict-of-interest disclosures in the plastic surgery literature and to compare these findings to the Physician Payments Sunshine Act database. METHODS: All articles published from August of 2013 through December of 2013 in four major plastic surgery journals were analyzed. For every publication, the conflict-of-interest disclosure statement for each investigator was reviewed. These statements were then compared to transactions of value for each investigator as reported by biomedical companies in the Sunshine Act database. An analysis was performed to identify and characterize specific factors associated with conflict-of-interest disclosures. RESULTS: A total of 1002 independent investigators/authors were identified. Of these, 90 investigators (9 percent) self-reported a conflict of interest. In contrast, a total of 428 authors (42.7 percent) were found to have received transactions of value from a biomedical company according to the Sunshine Act database. Conversely, a total of 22 authors (2.2 percent) self-reported a conflict of interest but were not found to have received transactions of value in the Sunshine Act database. Our analysis found that (1) academic investigators, (2) transactions of value in excess of $500, and (3) publishing articles related to the sponsoring biomedical company were all statistically associated with reporting conflicts of interest (p < 0.0001). CONCLUSIONS: Discordance exists between investigator/authors self-reporting in scientific journals and the government-mandated reporting of conflicts of interest by industry. Factors associated with conflict-of-interest disclosure include academic status, transaction amount, and article content related to the sponsoring biomedical company.

Discriminant Ability, Concurrent Validity, and Responsiveness of PROMIS Health Domains Among Patients With Lumbar Degenerative Disease Undergoing Decompression With or Without Arthrodesis.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: The aim of this study was to investigate the ability of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains to discriminate between levels of disease severity and to determine the concurrent validity and responsiveness of PROMIS relative to "legacy" measures. SUMMARY OF BACKGROUND DATA: PROMIS may measure recovery after lumbar spine surgery. Concurrent validity and responsiveness have not been compared with legacy measures in this population. METHODS: We included 231 adults undergoing surgery for lumbar degenerative disease. Discriminant ability of PROMIS was estimated for adjacent categories of disease severity using the Oswestry Disability Index (ODI). Concurrent validity was determined through correlation between preoperative legacy measures and PROMIS. Responsiveness was estimated using distribution-based and anchor-based criteria (change from preoperatively to within 3 months postoperatively) anchored to treatment expectations (North American Spine Society Patient Satisfaction Index) to determine minimal important differences (MIDs). Significance was accepted at P < 0.05. RESULTS: PROMIS discriminated between disease severity levels, with mean differences between adjacent categories of 3 to 8 points. There were strong to very strong correlations between Patient Health Questionnaire-8, Generalized Anxiety Disorder-7, and PROMIS anxiety, depression, fatigue, and sleep disturbance; between ODI and PROMIS fatigue, pain, and physical function; between the 12-Item Short-Form Health Survey physical component and PROMIS pain and physical function; and between the Brief Pain Inventory (BPI) pain interference and PROMIS depression and pain. BPI back pain and leg pain intensity showed weak or no correlation with PROMIS. Distribution-based MIDs ranged from 3.0 to 3.5 points. After incorporating longitudinal anchor-based estimates, final PROMIS MID estimates were anxiety, -4.4; depression, -6.0; fatigue, -5.3; pain, -5.4; physical function, 5.2; satisfaction with participation in social roles, 6.0; and sleep disturbance, -6.5. CONCLUSION: PROMIS discriminated between disease severity levels, demonstrated good concurrent validity, and was responsive to changes after lumbar spine surgery. LEVEL OF EVIDENCE: 2.

Impact of frailty on complications in patients with thoracic and thoracolumbar spinal fracture.

OBJECTIVES: It is well-documented that geriatric patients are at risk for serious injuries after fracture due to pre-existing medical conditions, physical changes of aging, and medication effects. Frailty has been demonstrated to be a predictor of morbidity and mortality in inpatient head and neck surgery, and for surgical intervention for adult spinal deformity and degenerative spine disease. However, the impact of frailty on complications following thoracolumbar/thoracic fractures are unknown and has not been previously assessed in the literature, particularly in a nationwide setting. PATIENTS AND METHODS: This was a retrospective study of the prospectively-collected American College of Surgeons National Surgical Quality Improvement database for the years 2007 through 2012. Patients who underwent spinal decompression (+/- fusion) or an alternative intervention, defined as vertebroplasty or kyphoplasty (VP/KP) for thoracic or thoracolumbar fracture were identified. Frailty status was determined using a modified frailty index from the Canadian Study of Health and Aging Frailty Index, with frailty defined as a score = 0.27. 30-day morbidity and mortality were compared between frail and non-frail patients in each treatment group. RESULTS: A total of 303 patients were included in this study. Of these, 38% of patients had VP/KP and 62% underwent surgery. Within the VP/KP cohort, 26% were frail. The proportion of these patients who developed at least one complication was 3.3% versus 3.6% for non-frail patients (p = 1.0). The 30-day mortality for frail versus not frail patients in this cohort was 0% versus 2.4% (p = 1.0). Among the surgical group, 13% were frail. In contrast, the likelihood of complications was 33.3% among frail patients and 4.2% for non-frail patients (p < 0.001). Frail patients also had a 16.7% 30-day mortality rate as compared to 0.6% in the non-frail group (p = 0.001). When comparing the frail versus non-frail patients overall, frail patients had a complication rate of 16.7%, as opposed to 4.0% in non-frail patients. CONCLUSION: Frailty and surgical intervention are correlated with a higher 30-day complication rate in patients with thoracic and thoracolumbar fracture. This finding is an important consideration for surgical decision-making and patient counseling on treatment options.

External fixation and surgical fusion for pediatric cervical spine injuries: Short-term outcomes.

OBJECTIVE: To compare in-hospital complication rates in pediatric patients with atlantoaxial and subaxial injuries undergoing either external fixation or surgical fusion. PATIENTS AND METHODS: Baseline and outcome data were obtained from the 2002-2011 Nationwide Inpatient Sample (NIS) for patients under the age of 18 with a diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation. Patients who underwent external immobilization or internal fixation were included for analysis. Variables analyzed included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of at least one in-hospital complication. RESULTS: A total of 2878 pediatric patients with cervical spine injury were identified; 1462 patients (50.8%) with atlantoaxial (C1-2) injury and 1416 (49.2%) with subaxial (C3-7) injury. Among atlantoaxial injury patients, external fixation was associated with lower total charges ($73,786 vs. $98,158, p = .040) and a lower likelihood of developing at least one complication (1.9% vs. 6.8%, p = .029) compared to surgical fusion, and was a more common treatment for subluxation alone (16.4% vs. 2.6%, p < .001). Among subaxial injury patients, there were no significant differences in age (p = .262), length of stay (p = .196), occurrence of at least one complication (p = .334), or total charges (p = .142). Subaxial subluxation injuries alone were treated more often with surgical fusion (2.2% vs. 1.2%, p < .001). CONCLUSION: Optimal treatment of patients with cervical injury may vary by location of injury. Our findings warrant further investigation into the difference in clinical outcomes between surgical and non-surgical management of atlantoaxial and subaxial injury.

In-hospital medical complications after non-operative and operative treatment of thoracolumbar fractures in patients over 75 years of age.

Management of spine fractures among the elderly is complicated by preexisting comorbidities and increased risk of osseous nonunion. Whether operative treatment is superior for the management of thoracolumbar fractures in the aged is unknown. The purpose of this study was to investigate the rates of in-hospital medical complications after non-operative and operative treatment of thoracolumbar fractures in elderly patients. The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify patients over 75 years of age with a principal discharge diagnosis of thoracolumbar fracture without spinal cord injury. Three treatment groups were compared: non-operative treatment, operative treatment, and minimally-invasive vertebroplasty/kyphoplasty (VP/KP). A total of 59,565 patients were identified; 46,962 treated non-operatively, 1,487 treated operatively, and 11,116 treated with VP/KP. Operative patients had the longest length of hospital stay (P < 0.001) and the highest injury severity scores (P < 0.001). The percentage of patients who developed at least one complication was highest in the operative group (16.3%), versus 8.7% in the non-operative and 8.1% in the VP/KP group (P < 0.001). Even after controlling for potential confounders such as injury severity score, surgical patients had significantly higher odds of complication occurrence (P < 0.001). Adjusted charges were highest for operative patients ($123,777 ±â€¯135,997 vs. $27,116 ±â€¯32,694 [non-operative] and $42,326 ±â€¯31,984 [VP/KP]). Operative treatment for elderly patients has higher complication rates that need to be considered during preoperative patient counseling. Future research is necessary to elucidate the comparative rates of long-term complications and functional status outcomes for thoracolumbar fracture treatment among elderly patients.

Percentage change in hemoglobin level and morbidity in spine surgery patients.

OBJECTIVE The aim of this study was to characterize the association between percentage change in hemoglobin (ΔHb)-i.e., the difference between preoperative Hb and in-hospital nadir Hb concentration-and perioperative adverse events among spine surgery patients. METHODS Patients who underwent spine surgery at the authors' institution between December 4, 2008, and June 26, 2015, were eligible for this retrospective study. Patients who underwent the following procedures were included: atlantoaxial fusion, subaxial anterior cervical fusion, subaxial posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, excision of intervertebral disc, and excision of spinal cord lesion. Data on intraoperative transfusion were obtained from an automated, prospectively collected, anesthesia data management system. Data on postoperative hospital transfusions were obtained through an Internet-based intelligence portal. Percentage ΔHb was defined as: ([preoperative Hb - nadir Hb]/preoperative Hb) × 100. Clinical outcomes included in-hospital morbidity and length of stay associated with percentage ΔHb. RESULTS A total of 3949 patients who underwent spine surgery were identified. Of these, 1204 patients (30.5%) received at least 1 unit of packed red blood cells. The median nadir Hb level was 10.6 g/dl (interquartile range 8.7-12.4 g/dl), yielding a mean percentage ΔHb of 23.6% (SD 15.4%). Perioperative complications occurred in 234 patients (5.9%) and were more common in patients with a larger percentage ΔHb (p = 0.017). Hospital-related infection, which occurred in 60 patients (1.5%), was also more common in patients with greater percentage ΔHb (p = 0.001). CONCLUSIONS Percentage ΔHb is independently associated with a higher risk of developing any perioperative complication and hospital-related infection. The authors' results suggest that percentage ΔHb may be a useful measure for identifying patients at risk for adverse perioperative events.

Can Early Patient-reported Outcomes Be Used to Identify Patients at Risk for Poor 1-Year Health Outcomes After Lumbar Laminectomy With Arthrodesis?

STUDY DESIGN: Prospective cohort. OBJECTIVE: Determine A) between-patient variability in patient-reported outcomes (PROs) at four postoperative time points; B) within-patient correlation of 1-year PROs with PROs at three earlier time points; and C) ability of early PROs to predict 1-year PROs after lumbar laminectomy with arthrodesis. SUMMARY OF BACKGROUND DATA: It is unclear whether early PROs can help identify patients at risk for poor health outcomes. METHODS: Between 2015 and 2016, we assessed pre- and postoperative back pain, leg pain, disability, physical health, and mental health in 146 patients. We examined PRO variability between patients and correlations within patients during the first postoperative year. For early (≤3-mo) and 1-year PROs, we examined concordance between experiencing a minimal important difference (MID) early and at 1 year and odds of experiencing a 1-year MID given early absence of a MID. RESULTS: Postoperatively, we found increasing between-patient variability of PROs. For individual patients, we found moderate to strong between-assessment correlations (intraclass correlations) between repeated PROs (back pain, 0.47; leg pain, 0.51; disability, 0.47; physical health, 0.63; mental health, 0.53). Early MIDs were experienced for back pain (57%), leg pain (52%), physical health (38%), disability (34%), and mental health (16%). Concordance was moderate for leg pain (0.48), mental health (0.46), disability (0.38), back pain (0.36), and physical health (0.25). In patients without an early MID, odds of experiencing a MID at 1 year were low for physical health (odds ratio [OR] = 0.33), back pain (OR = 0.30), leg pain (OR = 0.14), and disability (OR = 0.11) but not mental health (OR = 0.50). CONCLUSION: Although postoperative recovery is variable, early PROs can identify patients at risk for poor 1-year outcomes and may help tailor care during the first year after lumbar laminectomy with arthrodesis. LEVEL OF EVIDENCE: 2.