Predicting 30-day mortality after surgery for metastatic disease of the spine: the H2-FAILS score.

PURPOSE: Scoring systems for metastatic spine disease focus on predicting long- to medium-term mortality or a combination of perioperative morbidity and mortality. However, accurate prediction of perioperative mortality alone may be the most important factor when considering surgical intervention. We aimed to develop and evaluate a new tool, the H2-FAILS score, to predict 30-day mortality after surgery for metastatic spine disease. METHODS: Using the National Surgical Quality Improvement Program database, we identified 1195 adults who underwent surgery for metastatic spine disease from 2010 to 2018. Incidence of 30-day mortality was 8.7% (n = 104). Independent predictors of 30-day mortality were used to derive the H2-FAILS score. H2-FAILS is an acronym for: Heart failure (2 points), Functional dependence, Albumin deficiency, International normalized ratio elevation, Leukocytosis, and Smoking (1 point each). Discrimination was assessed using area under the receiver operating characteristic curve (AUC). The H2-FAILS score was compared with the American Society of Anesthesiologists Physical Status Classification (ASA Class), the 5-item modified Frailty Index (mFI-5), and the New England Spinal Metastasis Score (NESMS). Internal validation was performed using bootstrapping. Alpha = 0.05. RESULTS: Predicted 30-day mortality was 1.8% for an H2-FAILS score of 0 and 78% for a score of 6. AUC of the H2-FAILS was 0.77 (95% confidence interval: 0.72-0.81), which was higher than the mFI-5 (AUC 0.58, p < 0.001), ASA Class (AUC 0.63, p < 0.001), and NESMS (AUC 0.70, p = 0.004). Internal validation showed an optimism-corrected AUC of 0.76. CONCLUSIONS: The H2-FAILS score accurately predicts 30-day mortality after surgery for spinal metastasis. LEVEL OF EVIDENCE: Prognostic level III.

A Nationwide, Systematic, and Comprehensive Assessment of Surgical Capacity in Lebanon: Results of the Surgical Capacity in Areas With Refugees (SCAR) Study.

OBJECTIVE: We sought to perform a systematic, comprehensive, and nationwide cross-sectional analysis of surgical capacity in Lebanon. BACKGROUND: Providing surgical care in refugee areas is increasingly recognized as a global health priority. The surgical capacity of Lebanon where at least 1 in 6 inhabitants is currently a refugee remains unknown. METHODS: The Surgical Capacity in Areas with Refugees cross-sectional study included 3 steps: (1) geographically mapping all hospitals providing surgical care in Lebanon, (2) systematically assessing each hospital's surgical capacity, and (3) identifying surgical care gaps/disparities. First, a list of hospitals in Lebanon and their locations was generated combining data from the Lebanese Ministry of Health and Syndicate of Hospitals. Specialty, rehabilitation, and maternity facilities were excluded. Second, the validated 5 domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool was administered in each hospital through a face-to-face or phone interview. Hospitals' PIPES indices were computed; data were aggregated and analyzed for geographic and private/public disparities. RESULTS: A total of 129 hospitals were geographically mapped; 20% were public. The PIPES tool was administered in all hospitals (100%). The mean PIPES index was 10.98 (Personnel = 14.91, Infrastructure = 15.36, Procedures = 37.47, Equipment = 21.63, Supplies = 24.78). The number of hospital beds, operating rooms, surgeons, and anesthesiologists per 100,000 people were 217, 8, 16, and 9, respectively. Deficiencies in infrastructure were significant, whereby 62%, 36%, 16%, and 5% of hospitals lack incinerators, pretested blood, intensive care units, and computed tomography, respectively. Continuous external electricity was lacking in 16 hospitals (12%). Compared to private hospitals, public hospitals had a lower PIPES index (10.48 vs 11.1, P = 0.022), including lower Personnel and Infrastructure scores (12.31 vs 15.57, P = 0.03; 14.04 vs 15.7, P = 0.003, respectively). Geographically, the administrative governorates with highest refugee concentrations had the lowest PIPES indices. CONCLUSIONS: Evaluating surgical capacity in Lebanon reveals significant deficiencies, most pronounced in public hospitals in which refugee care is provided and in areas with the highest refugee concentration.

Refugee Access to Surgical Care in Lebanon: A Post Hoc Analysis of the SCAR Study.

BACKGROUND: Lebanon hosts an estimated one million Syrian refugees registered with the United Nations High Commissioner for Refugees (UNHCR). The UNHCR contracts with select Lebanese hospitals to provide affordable primary and emergency care to refugees. We aimed to assess the surgical capabilities of UNHCR-affiliated hospitals in Lebanon. METHODS: Cross-sectional data from the Surgical Capacity in Areas with Refugees study were combined with hospital affiliation data obtained from the UNHCR. The Surgical Capacity in Areas with Refugees study evaluated surgical capacity in Lebanon by mapping all acute care hospitals and administering the five domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool to each hospital. Mean PIPES indices and mean numbers of hospital beds, surgeons, and anesthesiologists were compared between UNHCR-affiliated and nonaffiliated hospitals. Geographically, the distribution of UNHCR-affiliated hospitals was cross-referenced with refugee population distributions. RESULTS: One hundred and twenty nine hospitals were included, 35 (27.1%) of which were affiliated with the UNHCR. The PIPES tool was administered across all hospitals. Mean PIPES indices and mean number of hospital beds, general surgeons, and anesthesiologists were similar between UNHCR-affiliated and nonaffiliated hospitals. Geographical mapping of hospitals and refugee populations across Lebanon revealed a disparity in the Northeastern region of the country: that region had the highest number of refugees but lacked sufficient UNHCR coverage. CONCLUSIONS: Hospitals covered by the UNHCR performed similarly to nonaffiliated hospitals with respect to all aspects of the PIPES surgical capacity tool. However, there is a concerning geographic mismatch between UNHCR coverage and refugee density, specifically in the governorates of Akkar, Bekaa, and Baalbek-Hermel.

Minimally invasive transforaminal lumbar interbody fusion with expandable versus static interbody devices: radiographic assessment of sagittal segmental and pelvic parameters.

OBJECTIVE Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has been adopted as an alternative technique to hasten recovery and minimize postoperative morbidity. Advances in instrumentation technologies and operative techniques have evolved to maximize patient outcomes as well as radiographic results. The development of expandable interbody devices allows a surgeon to perform MIS-TLIF with minimal tissue disruption. However, sagittal segmental and pelvic radiographic outcomes after MIS-TLIF with expandable interbody devices are not well characterized. The object of this study is to evaluate the radiographic sagittal lumbar segmental and pelvic parameter outcomes of MIS-TLIF performed using an expandable interbody device. METHODS A retrospective review of MIS-TLIFs performed between 2014 and 2016 at a high-volume center was performed. Radiographic measurements were performed on lateral radiographs before and after MIS-TLIF with static or expandable interbody devices. Radiographic measurements included disc height, foraminal height, fused disc angle, lumbar lordosis, pelvic incidence, sacral slope, and pelvic tilt. Mismatch between pelvic incidence and lumbar lordosis were calculated for each radiograph. RESULTS A total of 48 MIS-TLIFs were performed, predominantly at the L4-5 level, in 44 patients. MIS-TLIF with an expandable interbody device led to a greater and more sustained increase in disc height when compared with static interbody devices. Foraminal height increased after MIS-TLIF with expandable but not with static interbody devices. MIS-TLIF with expandable interbody devices increased index-level segmental lordosis more than with static interbody devices. The increase in segmental lordosis was sustained in the patients with expandable interbody devices but not in patients with static interbody devices. For patients with a collapsed disc space, MIS-TLIF with an expandable interbody device provided superior and longer-lasting increases in disc height, foraminal height, and index-level segmental lordosis than in comparison with patients with static interbody devices. Using an expandable interbody device improved the Oswestry Disability Index scores more than using a static interbody device, and both disc height and segmental lordosis were correlated with improved clinical outcome. Lumbar MIS-TLIF with expandable or static interbody devices had no effect on overall lumbar lordosis, pelvic parameters, or pelvic incidence-lumbar lordosis mismatch. CONCLUSIONS Performing MIS-TLIF with an expandable interbody device led to a greater and longer-lasting restoration of disc height, foraminal height, and index-level segmental lordosis than MIS-TLIF with a static interbody device, especially for patients with a collapsed disc space. However, neither technique had any effect on radiographic pelvic parameters.

Initial institutional experience using a robotic arm-enabled 4K 3D exoscope in neurosurgical operations.

The extracorporeal telescope (exoscope) presents a novel digital camera system as a versatile alternative to traditional optical microscopy for microsurgery and minimally invasive neurosurgical operations. Recent innovations in exoscope technology offer 4K-definition multiscreen outputs, pneumatic robot arms, 3-dimensional depth perception, and greater illumination, focus, and magnification powers for enhanced intraoperative visualization. The authors present their initial institutional experience using a robotic arm-enabled 4K 3D exoscope in a variety of cranial and spinal neurosurgical operations, namely Chiari decompression, microvascular decompression for trigeminal neuralgia, anterior cervical discectomy, and lumbar decompressions. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23150.

Resection of an incidentally discovered spinal arachnoid web: illustrative case.

BACKGROUND: Spinal arachnoid webs (SAWs) are rare pathologies of the spinal meninges often associated with syringomyelia and the radiographic "scalpel sign." Patients can experience pain, numbness, gait disturbances, or no symptoms at all. They are typically diagnosed via magnetic resonance imaging and treated with laminectomy and excision. OBSERVATIONS: A 61-year-old male presented after a mechanical fall and had an incidentally discovered SAW on imaging. He was initially asymptomatic and was therefore conservatively managed. Several years later, however, the patient experienced new-onset back pain, paresthesia, and balance problems, with interval imaging demonstrating worsening of the edema surrounding his SAW. The patient subsequently underwent resection of the SAW, which led to significant resolution of his symptoms. LESSONS: An SAW can be asymptomatic or can manifest with a wide variety of symptoms. When this condition is incidentally discovered in asymptomatic patients, neurosurgeons should guide these patients to follow-up urgently if they develop any neurological symptoms. At that time, further imaging can be performed to determine if surgical treatment is indicated. Although SAW is rare, clinicians should be aware of the signs and symptoms, because prompt surgical intervention can significantly improve neurological symptoms.

Exoscope Use in Spine Surgery: A Systematic Review of Applications, Benefits, and Limitations.

BACKGROUND: Exoscopes were recently developed as an alternative to the operative microscope (OM) and endoscope for intraoperative visualization during neurosurgery. Prior reviews studying mixed cranial and spinal surgical cohorts reported advantages with exoscope use, including improved ergonomics and teaching. In recent years, there has been an increase in exoscope research, with no updated systematic review focused exclusively on the benefits and limitations of exoscope use in spine surgery. Thus, we sought to systematically synthesize the literature related to exoscope-assisted spine surgery. METHODS: A literature search was conducted using the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to identify relevant studies reported between 2010 and September 2023. Data, such as the exoscope model used, procedure types performed, and user observations, were then collected. RESULTS: A total of 31 studies met our inclusion criteria, including 481 patients with spine pathologies who underwent a surgical procedure using 1 of 9 exoscope models. The lumbar region was the most frequently operated area (n = 234; 48.6%), and discectomies comprised the most overall procedures (n = 273; 56.8%). All patients benefited clinically. The reported advantages of exoscopes compared with OMs or endoscopes were improved focal distance, surgeon posture, trainee education, compactness, and assistant participation. Other aspects such as stereopsis, illumination, and cost had various observations. CONCLUSIONS: Exoscopes have advantages compared with OMs or endoscopes during spine surgery. The user learning curve is minimal, and no negative patient outcomes have been reported. However, some aspects of exoscope use necessitate longer term prospective research before exoscopes can be considered a standard tool in the armamentarium of intraoperative visualization strategies.

Impact of Upper Limb Motor Recovery on Functional Independence After Traumatic Low Cervical Spinal Cord Injury.

Cervical spinal cord injury (SCI) causes devastating loss of upper limb function and independence. Restoration of upper limb function can have a profound impact on independence and quality of life. In low-cervical SCI (level C5-C8), upper limb function can be restored via reinnervation strategies such as nerve transfer surgery. The translation of recovered upper limb motor function into functional independence in activities of daily living (ADLs), however, remains unknown in low cervical SCI (i.e., tetraplegia). The objective of this study was to evaluate the association of patterns in upper limb motor recovery with functional independence in ADLs. This will then inform prioritization of reinnervation strategies focused to maximize function in patients with tetraplegia. This retrospective study performed a secondary analysis of patients with low cervical (C5-C8) enrolled in the SCI Model Systems (SCIMS) database. Baseline neurological examinations and their association with functional independence in major ADLs-i.e., eating, bladder management, and transfers (bed/wheelchair/chair)-were evaluated. Motor functional recovery was defined as achieving motor strength, in modified research council (MRC) grade, of ≥ 3 /5 at one year from ≤ 2/5 at baseline. The association of motor function recovery with functional independence at one-year follow-up was compared in patients with recovered elbow flexion (C5), wrist extension (C6), elbow extension (C7), and finger flexion (C8). A multi-variable logistic regression analysis, adjusting for known factors influencing recovery after SCI, was performed to evaluate the impact of motor function at one year on a composite outcome of functional independence in major ADLs. Composite outcome was defined as functional independence measure score of 6 or higher (complete independence) in at least two domains among eating, bladder management, and transfers. Between 1992 and 2016, 1090 patients with low cervical SCI and complete neurological/functional measures were included. At baseline, 67% of patients had complete SCI and 33% had incomplete SCI. The majority of patients were dependent in eating, bladder management, and transfers. At one-year follow-up, the largest proportion of patients who recovered motor function in finger flexion (C8) and elbow extension (C7) gained independence in eating, bladder management, and transfers. In multi-variable analysis, patients who had recovered finger flexion (C8) or elbow extension (C7) had higher odds of gaining independence in a composite of major ADLs (odds ratio [OR] = 3.13 and OR = 2.87, respectively, p < 0.001). Age 60 years (OR = 0.44, p = 0.01), and complete SCI (OR = 0.43, p = 0.002) were associated with reduced odds of gaining independence in ADLs. After cervical SCI, finger flexion (C8) and elbow extension (C7) recovery translate into greater independence in eating, bladder management, and transfers. These results can be used to design individualized reinnervation plans to reanimate upper limb function and maximize independence in patients with low cervical SCI.

Is dorsal root entry zone lesioning effective and safe for managing continuous versus paroxysmal pains post-brachial plexus avulsion?

OBJECTIVE: Patients with brachial plexus avulsion (BPA) experience chronic deafferentation pain characterized by two patterns: continuous background pain and electrical shooting paroxysmal attacks. The authors' aim was to report the effectiveness and safety of dorsal root entry zone (DREZ) lesioning in relieving the two forms of pain over short and long periods. METHODS: All patients who underwent DREZ lesioning performed by the senior author for medically refractory BPA-related pain between July 1, 2016, and June 30, 2020, in Johns Hopkins Hospital were followed up. The intensity levels for continuous and paroxysmal pains were evaluated using the numeric rating scale (NRS) preoperatively and at 4 time points postsurgery, including the day of discharge, with a mean hospital stay of 5.6 ± 1.8 days; first postoperative clinic visit (33.0 ± 15.7 days); short-term follow-up (4.0 ± 1.4 months); and long-term follow-up (3.1 ± 1.3 years). The percent of pain relief according to the NRS was categorized into excellent (≥ 75%), fair (25%-74%), and poor (< 25%). RESULTS: A total of 19 patients were included, with 4 (21.1%) lost to long-term follow-up. The mean age was 52.7 ± 13.6 years; 16 (84.2%) were men, and 10 (52.6%) had left-sided injuries. A motor vehicle accident was the most common etiology of BPA (n = 16, 84.2%). Preoperatively, all patients had motor deficits, and 8 (42.1%) experienced somatosensory deficits. The greatest pain relief was observed at the first postoperative and short-term follow-up visits, with the lowest proportions of patients having continuous pain (26.3% and 23.5%, respectively) and paroxysmal pain (5.3% and 5.9%, respectively). Also, the highest reductions in mean NRS scores were observed for first postoperative and short-term follow-up visits (continuous 1.1 ± 2.1 and 1.1 ± 2.3; paroxysms 0.4 ± 1.4 and 0.5 ± 1.7, respectively) compared to the preoperative symptomatology (continuous 6.7 ± 3.0; paroxysms 7.9 ± 4.3) (p < 0.001). Most patients had excellent relief of continuous pain (82.4% and 81.3%) and of paroxysms (90.9% and 90.0%) at the first postoperative visit and short-term follow-up visit, respectively. The pain relief benefits had diminished by 3 years after surgery but remained significantly better than in the preoperative assessment. At the last evaluation, the proportion of patients achieving excellent relief of paroxysmal pain (66.7%) was double that for continuous pain (35.7%) (p < 0.001). New sensory phenomena were observed among 10 patients (52.6%), and 1 patient developed a motor deficit. CONCLUSIONS: DREZ lesioning is an effective and safe option for relieving BPA-associated pain, with good long-term outcomes and better benefits for paroxysmal pain than for the continuous pain component.

Predictors of Postoperative Segmental and Overall Lumbar Lordosis in Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Consecutive Case Series.

STUDY DESIGN: Retrospective Case-Series. OBJECTIVES: Due to heterogeneity in previous studies, the effect of MI-TLIF on postoperative segmental lordosis (SL) and lumbar lordosis (LL) remains unclear. Therefore, we aim to identify radiographic factors associated with lordosis after surgery in a homogenous series of MI-TLIF patients. METHODS: A single-center retrospective review identified consecutive patients who underwent single-level MI-TLIF for grade 1 degenerative spondylolisthesis from 2015-2020. All surgeries underwent unilateral facetectomies and a contralateral facet release with expandable interbody cages. PROs included the ODI and NRS-BP for low-back pain. Radiographic measures included SL, disc height, percent spondylolisthesis, cage positioning, LL, PI-LL mismatch, sacral-slope, and pelvic-tilt. Surgeries were considered "lordosing" if the change in postoperative SL was ≥ +4° and "kyphosing" if ≤ -4°. Predictors of change in SL/LL were evaluated using Pearson's correlation and multivariable regression. RESULTS: A total of 73 patients with an average follow-up of 22.5 (range 12-61) months were included. Patients experienced significant improvements in ODI (29% ± 22% improvement, P < .001) and NRS-BP (3.3 ± 3 point improvement, P < .001). There was a significant increase in mean SL (Δ3.43° ± 4.37°, P < .001) while LL (Δ0.17° ± 6.98°, P > .05) remained stable. Thirty-eight (52%) patients experienced lordosing MI-TLIFs, compared to 4 (5%) kyphosing and 31 (43%) neutral MI-TLIFs. A lower preoperative SL and more anterior cage placement were associated with the greatest improvement in SL (ß = -.45° P = .001, ß = 15.06° P < .001, respectively). CONCLUSIONS: In our series, the majority of patients experienced lordosing or neutral MI-TLIFs (n = 69, 95%). Preoperative radiographic alignment and anterior cage placement were significantly associated with target SL following MI-TLIF.

Association Between Neighborhood-Level Socioeconomic Disadvantage and Patient-Reported Outcomes in Lumbar Spine Surgery.

BACKGROUND: Despite an increased understanding of the impact of socioeconomic status on neurosurgical outcomes, the impact of neighborhood-level social determinants on lumbar spine surgery patient-reported outcomes remains unknown. OBJECTIVE: To evaluate the impact of geographic social deprivation on physical and mental health of lumbar surgery patients. METHODS: A single-center retrospective cohort study analyzing patients undergoing lumbar surgery for degenerative disease from 2015 to 2018 was performed. Surgeries were categorized as decompression only or decompression with fusion. The area deprivation index was used to define social deprivation. Study outcomes included preoperative and change in Patient-Reported Outcomes Measurement (PROMIS) physical function (PF), pain interference (PI), depression, and anxiety (mean follow-up: 43.3 weeks). Multivariable imputation was performed for missing data. One-way analysis of variance and multivariable linear regression were used to evaluate the association between area deprivation index and PROMIS scores. RESULTS: In our cohort of 2010 patients, those with the greatest social deprivation had significantly worse mean preoperative PROMIS scores compared with the least-deprived cohort (mean difference [95% CI]-PF: -2.5 [-3.7 to -1.4]; PI: 3.0 [2.0-4.1]; depression: 5.5 [3.4-7.5]; anxiety: 6.0 [3.8-8.2], all P < .001), without significant differences in change in these domains at latest follow-up (PF: +0.5 [-1.2 to 2.2]; PI: -0.2 [-1.7 to 2.1]; depression: -2 [-4.0 to 0.1]; anxiety: -2.6 [-4.9 to 0.4], all P > .05). CONCLUSION: Lumbar spine surgery patients with greater social deprivation present with worse preoperative physical and mental health but experience comparable benefit from surgery than patients with less deprivation, emphasizing the need to further understand social and health factors that may affect both disease severity and access to care.

Assessing the Accuracy of Spinal Instrumentation Using Augmented Reality (AR): A Systematic Review of the Literature and Meta-Analysis.

Technological advancements, particularly in the realm of augmented reality (AR), may facilitate more accurate and precise pedicle screw placement. AR integrates virtual data into the operator's real-world view, allowing for the visualization of patient-specific anatomy and navigated trajectories. We aimed to conduct a meta-analysis of the accuracy of pedicle screw placement using AR-based systems. A systematic review of the literature and meta-analysis was performed using the PubMed/MEDLINE database, including studies reporting the accuracy of pedicle screw placement using AR. In total, 8 studies with 163 patients and 1259 screws were included in the analysis. XVision (XVS) was the most commonly used AR system (595 screws) followed by the Allura AR surgical navigation system (ARSN) (462 screws). The overall accuracy was calculated as 97.2% (95% CI 96.2-98.1% p < 0.001). Subgroup analysis revealed that there was no statistically significant difference in the accuracy rates achieved by XVS and Allura ARSN (p = 0.092). AR enables reliable, accurate placement of spinal instrumentation. Future research efforts should focus on comparative studies, cost effectiveness, operative time, and radiation exposure.

Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review.

BACKGROUND: Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI. OBJECTIVE: To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS: A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis. RESULTS: After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review. CONCLUSIONS: Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.

Contemporary Trends in Minimally Invasive Sacroiliac Joint Fusion Utilization in the Medicare Population by Specialty.

BACKGROUND AND OBJECTIVES: Sacroiliac (SI) joint dysfunction constitutes a leading cause of pain and disability. Although surgical arthrodesis is traditionally performed under open approaches, the past decade has seen a rise in minimally invasive surgical (MIS) techniques and new federally approved devices for MIS approaches. In addition to neurosurgeons and orthopedic surgeons, proceduralists from nonsurgical specialties are performing MIS procedures for SI pathology. Here, we analyze trends in SI joint fusions performed by different provider groups, along with trends in the charges billed and reimbursement provided by Medicare. METHODS: We review yearly Physician/Supplier Procedure Summary data from 2015 to 2020 from the Centers for Medicare and Medicaid Services for all SI joint fusions. Patients were stratified as undergoing MIS or open procedures. Utilization was adjusted per million Medicare beneficiaries and weighted averages for charges and reimbursements were calculated, controlling for inflation. Reimbursement-to-charge (RCR) ratios were calculated, reflecting the proportion of provider billed amounts reimbursed by Medicare. RESULTS: A total of 12 978 SI joint fusion procedures were performed, with the majority (76.5%) being MIS procedures. Most MIS procedures were performed by nonsurgical specialists (52.1%) while most open fusions were performed by spine surgeons (71%). Rapid growth in MIS procedures was noted for all specialty categories, along with an increased number of procedures offered in the outpatient setting and ambulatory surgical centers. The overall RCR increased over time and was ultimately similar between spine surgeons (RCR = 0.26) and nonsurgeon specialists (RCR = 0.27) performing MIS procedures. CONCLUSION: Substantial growth in MIS procedures for SI pathology has occurred in recent years in the Medicare population. This growth can largely be attributed to adoption by nonsurgical specialists, whose reimbursement and RCR increased for MIS procedures. Future studies are warranted to better understand the impact of these trends on patient outcomes and costs.

Clinically meaningful improvement in disabilities of arm, shoulder, and hand (DASH) following cervical spine surgery.

BACKGROUND CONTEXT: Patients with cervical spine disease suffer from upper limb disability. At present, no clinical benchmarks exist for clinically meaningful change in the upper limb function following cervical spine surgery. PURPOSE: Primary: to establish clinically meaningful metrics; the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) of upper limb functional improvement in patients following cervical spine surgery. Secondary: to identify the prognostic factors of MCID and SCB of upper limb function following cervical spine surgery. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients ≥18 years of age who underwent cervical spine surgery from 2012 to 2016. OUTCOME MEASURES: Patient-reported outcomes: Neck disability index (NDI) and Disabilities of Arm, Shoulder, and Hand (DASH). METHODS: MCID was defined as minimal improvement and SCB as substantial improvement in the DASH score at last follow-up. The anchor-based methods (ROC analyses) defined optimal MCID and SCB thresholds with area under curve (AUC) in discriminating improved vs. non-improved patients. The MCID was also calculated by distribution-based methods: half standard-deviation (0.5-SD) and standard error of the mean (SEM) method. A multivariable logistic regression evaluated the impact of baseline factors in achieving the MCID and SCB in DASH following cervical spine surgery. RESULTS: Between 2012 and 2016, 1,046 patients with average age of 57±11.3 years, 53% males, underwent cervical spine surgery. Using the ROC analysis, the threshold for MCID was -8 points with AUC of 0.73 (95% CI: 0.67-0.79) and the SCB was -18 points with AUC of 0.88 (95% confidence interval [CI]: 0.85-0.91). The MCID was -11 points by 0.5-SD and -12 points by SEM-method. On multivariable analysis, patients with myelopathy had lower odds of achieving MCID and SCB, whereas older patients and those with ≥6 months duration of symptoms had lower odds of achieving DASH MCID and SCB respectively. CONCLUSIONS: In patients undergoing cervical spine surgery, MCID of -8 points and SCB of -18 points in DASH improvement may be considered clinically significant. These metrics may enable evaluation of minimal and substantial improvement in the upper extremity function following cervical spine surgery.

Association of upper-limb neurological recovery with functional outcomes in high cervical spinal cord injury.

OBJECTIVE: High cervical spinal cord injury (SCI) results in complete loss of upper-limb function, resulting in debilitating tetraplegia and permanent disability. Spontaneous motor recovery occurs to varying degrees in some patients, particularly in the 1st year postinjury. However, the impact of this upper-limb motor recovery on long-term functional outcomes remains unknown. The objective of this study was to characterize the impact of upper-limb motor recovery on the degree of long-term functional outcomes in order to inform priorities for research interventions that restore upper-limb function in patients with high cervical SCI. METHODS: A prospective cohort of high cervical SCI (C1-4) patients with American Spinal Injury Association Impairment Scale (AIS) grade A-D injury and enrolled in the Spinal Cord Injury Model Systems Database was included. Baseline neurological examinations and functional independence measures (FIMs) in feeding, bladder management, and transfers (bed/wheelchair/chair) were evaluated. Independence was defined as score ≥ 4 in each of the FIM domains at 1-year follow-up. At 1-year follow-up, functional independence was compared among patients who gained recovery (motor grade ≥ 3) in elbow flexors (C5), wrist extensors (C6), elbow extensors (C7), and finger flexors (C8). Multivariable logistic regression evaluated the impact of motor recovery on functional independence in feeding, bladder management, and transfers. RESULTS: Between 1992 and 2016, 405 high cervical SCI patients were included. At baseline, 97% of patients had impaired upper-limb function with total dependence in eating, bladder management, and transfers. At 1 year of follow-up, the largest proportion of patients who gained independence in eating, bladder management, and transfers had recovery in finger flexion (C8) and wrist extension (C6). Elbow flexion (C5) recovery had the lowest translation to functional independence. Patients who achieved elbow extension (C7) were able to transfer independently. On multivariable analysis, patients who gained elbow extension (C7) and finger flexion (C8) were 11 times more likely to gain functional independence (OR 11, 95% CI 2.8-47, p < 0.001) and patients who gained wrist extension (C6) were 7 times more likely to gain functional independence (OR 7.1, 95% CI 1.2-56, p = 0.04). Older age (≥ 60 years) and motor complete SCI (AIS grade A-B) reduced the likelihood of gaining independence. CONCLUSIONS: After high cervical SCI, patients who gained elbow extension (C7) and finger flexion (C8) had significantly greater independence in feeding, bladder management, and transfers than those with recovery in elbow flexion (C5) and wrist extension (C6). Recovery of elbow extension (C7) also increased the capability for independent transfers. This information can be used to set patient expectations and prioritize interventions that restore these upper-limb functions in patients with high cervical SCI.

Dorsal Root Entry Zone Lesioning for the Treatment of Pain After Brachial Plexus Avulsion Injury: 2-Dimensional Operative Video and Technical Report.

BACKGROUND: Neuropathic pain after nerve root or plexus avulsion injury is disabling and often refractory to medical therapy. Dorsal root entry zone (DREZ) lesioning is a neurosurgical procedure that disrupts the pathological generation and transmission of nociceptive signaling through the selective lesioning of culprit neurons within the dorsal horn of the spinal cord. OBJECTIVE: To present a case report and describe the operative technique for cervical spinal cord DREZ lesioning using radiofrequency thermocoagulation. METHODS: We present the case of a 29-year-old man who experienced a traumatic right-sided brachial plexus avulsion injury. The patient experienced severe neuropathic pain in his distal right upper extremity. He underwent cervical spinal DREZ lesioning. Postoperatively, he reported immediate and total pain relief that was sustained on follow-up at 3 months. We describe the operative technique for DREZ lesioning, including preoperative considerations, patient position, incision, approach, exposure, microsurgical dissection, DREZ lesioning, fixation, and closure. RESULTS: The goal of DREZ lesioning is the selective destruction of nociceptive fibers within the lateral bundle of the dorsal rootlet and superficial layers of the dorsal horn gray matter, while preserving the medial inhibitory fibers. DREZ lesioning targets the putative pain generator and ascending pain pathways that mediate the characteristic neuropathic pain after avulsion injury. Neurological complications include worsening pain or motor and sensory deficits of the ipsilateral lower extremity. CONCLUSION: DREZ lesioning provides an effective and durable treatment for neuropathic pain after nerve root or plexus avulsion injury.

Etiologies and Outcomes of Spinal Epidural Lipomatosis: Systematic Review of the Literature and Meta-Analysis of Reported Cases.

STUDY DESIGN: This was a systematic review of the literature. OBJECTIVE: The aim was to examine the contemporary demographics, etiological factors, treatment options and outcomes of spinal epidural lipomatosis (SEL) in adults. SUMMARY OF BACKGROUND DATA: SEL is primarily seen in obese patients as well as those on steroid therapy. Much regarding the etiology and treatment outcomes of SEL is unknown. METHODS: We reviewed Ovid MEDLINE, PubMed, SCOPUS, and Google Scholars databases from 1990 through August 2020 to identify cases of SEL. Data collected included patient characteristics, disease associations, level of pathology, treatment, and clinical outcomes. RESULTS: Ninety articles (145 individual cases) were included in the analysis. The median age was 54 years and 79% were males. Obesity-associated SEL constituted the largest proportion (52%) of our cohort. 22% of SEL cases were related to steroid use, while 26% cases were considered to be idiopathic. Lumbosacral SEL was the most frequently reported level of disease (68.9%), followed by the thoracic level (26.2%). The mean age of cases who underwent surgical intervention was 55 years, as compared with 48 years in those who received conservative management ( P =0.03). 95% of patients reported some degree of symptomatic improvement regardless of the treatment modality. Logistic regression suggested a possible superior outcome associated with those undergoing surgical treatment. CONCLUSION: In contrast to historical comparisons, contemporary articles support that obesity has become the major contributing factor for SEL. Logistic regression of the existing cases suggests that there may be a role for surgical intervention in select patients.

Optimizing nerve transfer surgery in tetraplegia: clinical decision making based on innervation patterns in spinal cord injury.

OBJECTIVE: Nerve transfers are increasingly being utilized in the treatment of chronic tetraplegia, with increasing literature describing significant improvements in sensorimotor function up to years after injury. However, despite technical advances, clinical outcomes remain heterogenous. Preoperative electrodiagnostic testing is the most direct measure of nerve health and may provide prognostic information that can optimize preoperative patient selection. The objective of this study in patients with spinal cord injury (SCI) was to determine various zones of injury (ZOIs) via electrodiagnostic assessment (EDX) to predict motor outcomes after nerve transfers in tetraplegia. METHODS: This retrospective review of prospectively collected data included all patients with tetraplegia from cervical SCI who underwent nerve transfer at the authors' institution between 2013 and 2020. Preoperative demographic data, results of EDX, operative details, and postoperative motor outcomes were extracted. EDX was standardized into grades that describe donor and recipient nerves. Five zones of SCI were defined. Motor outcomes were then compared based on various zones of innervation. RESULTS: Nineteen tetraplegic patients were identified who underwent 52 nerve transfers targeting hand function, and 75% of these nerve transfers were performed more than 1 year postinjury, with a median interval to surgery following SCI of 24 (range 8-142) months. Normal recipient compound muscle action potential and isolated upper motor neuron injury on electromyography (EMG) were associated with greater motor recovery. When nerve transfers were stratified based on donor EMG, greater motor gains were associated with normal than with abnormal donor EMG motor unit recruitment patterns. When nerve transfers were separated based on donor and recipient nerves, normal flexor donors were more crucial than normal extensor donors in powering their respective flexor recipients. CONCLUSIONS: This study elucidates the relationship of the preoperative innervation zones in SCI patients to final motor outcomes. EDX studies can be used to tailor surgical therapies for nerve transfers in patients with tetraplegia. The authors propose an algorithm for optimizing nerve transfer strategies in tetraplegia, whereby understanding the ZOI and grade of the donor/recipient nerve is critical to predicting motor outcomes.

Timing of Revascularization in Ischemic Moyamoya Disease: Association of Early Versus Delayed Surgery with Perioperative and Long-Term Outcomes.

OBJECTIVE: Patients with nmoyamoya disease (MMD) who present primarily with ischemic stroke are known to have greater rates of perioperative strokes as compared with those who present with nonstroke symptoms. The optimal timing for revascularization for these patients remains unclear. METHODS: From 1994 to 2015, 91 patients with MMD presented with signs and symptoms of an acute ischemic stroke with diffusion restriction correlate on magnetic resonance imaging, and these patients were subdivided into those who underwent early revascularization (<90 days from last stroke), versus those who underwent delayed revascularization (≥90 days after last stroke), based on evidence that most neurological recovery after stroke occurs during the first three months. Perioperative and long-term outcomes were compared between the 2 surgical cohorts. RESULTS: In total, 27 patients underwent early revascularization, and 64 patients underwent delayed revascularization. Patients who underwent early revascularization had a statistically greater rate of perioperative stroke (P = 0.04) and perioperative mortality (P = 0.03), and overall complication rate (P = 0.049). At last follow-up of 5.2 ± 4.3 years, patients who underwent delayed revascularization had a lower mortality rate (P = 0.01) and a lower overall postoperative stroke incidence (P = 0.002). As a function of time, patients with MMD undergoing delayed revascularization had a statistically higher length of stroke-free survival (P = 0.005). CONCLUSIONS: Patients with MMD who present with ischemic stroke are more likely to have perioperative strokes, overall perioperative complications, worse long-term mortality rates, and lower rates of stroke-free survival if revascularization surgery occurred within 90 days of last stroke.