Preoperative cerebral angiography nearly doubles the rate of diffusion-weighted imaging lesion detection following minimally invasive surgery for intracerebral hemorrhage.

BACKGROUND: Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH. METHODS: Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIs were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. RESULTS: DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02). CONCLUSIONS: In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH.

Comparative Analysis of Early Outcomes and Complications of PSO Among Neurosurgeons and Orthopedic Surgeons.

STUDY DESIGN: Retrospective comparative cohort study using the National Surgical Quality Improvement Program. OBJECTIVE: The aim of this study was to evaluate trends in the annual number of PSOs performed, describe the patient populations associated with each cohort, and compare outcomes between specialties.Summary of Background Data:Pedicle subtraction osteotomies (PSO) are complex and advanced spine deformity surgical procedures performed by neurosurgeons and orthopedic surgeons. Though both sets of surgeons can be equally qualified and credentialed to perform a PSO, it is possible that differences in training and exposure could translate into differences in patient management and outcomes. METHODS: Patients that underwent lumbar PSO from 2005 to 2014 in the American College of Surgeons-National Surgical Quality Improvement Program registry were identified. Relevant demographic, preoperative comorbidity, and postoperative 30-day complications were queried and analyzed. The data was divided into 2 cohorts consisting of those patients who were treated by neurosurgeons versus orthopedic surgeons. Additional data from the Scoliosis Research Society Morbidity and Mortality database was queried and analyzed for comparison. RESULTS: Demographic and comorbidity factors were similar between the neurosurgery and orthopedic surgery cohorts, except there were higher rates of hypertension among orthopedic surgeon-performed PSOs (65.66% vs. 48.67%, P =0.004). Except for 2012, in every year queried, orthopedic surgeons reported more PSOs than neurosurgeons. In patients who underwent lumbar fusion surgery, there was a higher rate of PSOs if the surgery was performed by an orthopedic surgeon (OR 1.7824, 95% CI: 1.4017-2.2665). The incidence of deep vein thrombosis after PSOs was higher for neurosurgery compared with orthopedic surgery (8.85% vs. 1.20%, P =0.004). However, besides deep vein thrombosis, there were no salient differences in surgical complication rates between neurosurgeon-performed PSOs and orthopedic surgeon-performed PSOs. CONCLUSIONS: The number of PSO procedures performed by neurosurgeons and orthopedic surgeons has increased annually. Differences in outcomes between neurosurgeons and orthopedic surgeons suggest an opportunity for wider assessment and alignment of adult spinal deformity surgery exposure and training across specialties.

Cervical fusion for adult patients with atlantoaxial rotatory subluxation.

Background: Atlantoaxial rotatory subluxation (AARS) is a rare injury of the C1/C2 junction. It is often associated with trauma in adults. Treatment may depend on the duration of symptoms and clinical presentation, but there is no consensus regarding the ideal management of these injuries. Our objective is to ascertain the prevalence of neurological deficit, complications, and outcomes of patients diagnosed with AARS undergoing cervical fusion (CF) versus those treated without CF. Methods: The 2016-2019 National Inpatient Sample (NIS) was queried using International Classification of Diseases, 10th revision (ICD-10) for adult patients with C1/C2 subluxation. Patients undergoing CF were defined through ICD-10 procedure codes. Baseline health and acute illness severity was calculated using the 11-point modified frailty index (mFI-11). Presenting characteristics, treatment complications, and outcomes were evaluated of CF vs. non-CF patients. Results: Of 990 adult patients with AARS, 720 were treated without CF and 270 were treated with CF. CF patients were more often myelopathic. Patients that had undergone CF treatment were negatively associated with having had extensive trauma. Patients undergoing CF experienced significantly longer length of stay (LOS), increased healthcare resource utilization, and decreased inpatient mortality. Sepsis had a negative association with patients that underwent CF treatment while pneumonia had a positive association. Conclusions: Adult patients undergoing CF for AARS demonstrated an increase in healthcare resource utilization but also a significant decrease in mortality. Extent of acute injury appears to have a strong influence on decision making for CF. Further study of decision making for treatment of this rare injury in adults is warranted.

MIS-TLIF Procedure is Improving With Experience: Systematic Review of the Learning Curve Over the Last Decade.

STUDY DESIGN: This was a systematic review. OBJECTIVE: This review evaluates the minimally invasive transforaminal lumbar interbody fusions (MIS-TLIF) learning curve in the literature and compares outcomes during and after completing the curve. SUMMARY OF BACKGROUND DATA: MIS-TLIF are performed for various spine conditions. Proponents cite improved clinical outcomes while critics highlight the steep learning curve to attain proficiency. METHODS: Literature searches on Medline and Embase utilized relevant subject headings and keywords. Manuscripts reporting learning curve statistics were included. Monotonic trends of operative duration were assessed with Mann-Kendall nonparametric testing. RESULTS: Nine studies met inclusion criteria. Number of patients ranged from 26 to 150 (average 83.2, median of 86). Commonly reported metrics included number of procedures to complete the curve, operative duration, blood loss, ambulation time, length of stay, complication rate, follow-up visual analogue scale (VAS) for back and leg pain, and fusion rate. Various methods were employed to determine number of cases to complete the curve, all involving operative duration. Number of cases ranged from 14 to 44. A significant negative trend for operative duration of cases during the learning curve (τ=-0.733, P =0.039) was found over the years that studies were published. Initial complication rates varied from 6.8% to 23.8%. Initial VAS-back and VAS-leg ranged from 0.8 to 2.9 and 0.5 to 2.3, respectively. While definitions of "good" fusion varied, fusion rates meeting Bridwell grade I or II during the learning curve ranged from 84.0% to 95.2%. CONCLUSIONS: Surgeons in their learning curve have become faster at the MIS-TLIF procedure. Clinical outcomes including postoperative pain and fusion rates showed satisfactory results, but surgeons learning the procedure should take measures to minimize complications in early cases, such as utilizing novel navigation technology or supervision from more experienced surgeons. Learning curve research methodology could benefit from standardization.

Intraoperative Navigation in Spine Surgery: Effects on Complications and Reoperations.

INTRODUCTION: Intraoperative navigation during spine surgery improves pedicle screw placement accuracy. However, limited studies have correlated the use of navigation with clinical factors, including operative time and safety. In the present study, we compared the complications and reoperations between surgeries with and without navigation. METHODS: The National Surgical Quality Improvement Project database was queried for posterior cervical and lumbar fusions and deformity surgeries from 2011 to 2018 and divided by navigation use. Patients aged >89 years, patients with deformity aged <25 years, and patients undergoing surgery for tumors, fractures, infections, or nonelective indications were excluded. The demographics and perioperative factors were compared via univariate analysis. The outcomes were compared using multivariable logistic regression adjusting for age, sex, body mass index, American Society of Anesthesiologists class, surgical region, and multiple treatment levels. The outcomes were also compared stratifying by revision status. RESULTS: Navigation surgery patients had had higher American Society of Anesthesiologists class (P < 0.0001), more multiple level surgeries (P < 0.0001), and longer operative times (P < 0.0001). The adjusted analysis revealed that navigated lumbar surgery had lower odds of complications (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.77-0.90; P < 0.0001), blood transfusion (OR, 0.79; 95% CI, 0.72-0.87; P < 0.0001), and wound debridement and/or drainage (OR, 0.66; 95% CI, 0.44-0.97; P = 0.04) compared with non-navigated lumbar surgery. Navigated cervical fusions had increased odds of transfusions (OR, 1.53; 95% CI, 1.06-2.23; P = 0.02). Navigated primary fusion had decreased odds of complications (OR, 0.91; 95% CI, 0.85-0.98; P = 0.01). However, no differences were found in revisions (OR, 0.89; 95% CI, 0.69-1.14; P = 0.34). CONCLUSIONS: Navigated surgery patients experienced longer operations owing to a combination of the time required for navigation, more multilevel procedures, and a larger comorbidity burden, without differences in the incidence of infection. Fewer complications and wound washouts were required for navigated lumbar surgery owing to a greater proportion percentage of minimally invasive cases. The combined use of navigation and minimally invasive surgery might benefit patients with the proper indications.

Clinical Trials in Spinal Tumors: A Two-Decade Review.

OBJECTIVE: Clinical trials are essential for assessing the advancements in spine tumor therapeutics. The purpose of the present study was to characterize the trends in clinical trials for primary and metastatic tumor treatment during the past 2 decades. METHODS: The ClinicalTrials.gov database was queried using the search term "spine" for all interventional studies from 1999 to 2020 with the categories of "cancer," "neoplasm," "tumor," and/or "metastasis." The tumor type, phase data, enrollment numbers, and home institution country were recorded. The sponsor was categorized as an academic institution, industry, government, or other and the intervention type as procedure, drug, device, radiation therapy, or other. The frequency of each category and the cumulative frequency during the 20-year period were calculated. RESULTS: A total of 106 registered trials for spine tumors were listed. All, except for 2, that had begun before 2008 had been completed. An enrollment of 51-100 participants (29.8%) was the most common, and most were phase II studies (54.4%). Most of the studies had examined metastatic tumors (58.5%), and the number of new trials annually had increased 3.4-fold from 2009 to 2020. Most of the studies had been conducted in the United States (56.4%). The most common intervention strategy was radiation therapy (32.1%), although from 2010 to 2020, procedural studies had become the most frequent (2.4/year). Most of the studies had been sponsored by academic institutions (63.2%), which during the 20-year period had sponsored 3.2-fold more studies compared with the industry partners. CONCLUSIONS: The number of clinical trials for spine tumor therapies has rapidly increased during the past 15 years, owing to studies at U.S. academic medical institutions investigating radiosurgery for the treatment of metastases. Targeted therapies for tumor subtypes and sequelae have updated international best practices.

The Impact of American Society of Anesthesiologists Status on Cost of Care and Length of Stay Following Posterior Cervical Decompression and Fusion.

BACKGROUND: Increased posterior cervical decompression and fusion (PCDF) procedures over the past decade have raised the prospect of bundled payment plans. The American Society of Anesthesiologists (ASA) Physical Status Classification system may enable accurate estimation of health care costs, length of stay (LOS), and other postoperative outcomes in patients undergoing PCDF. METHODS: Low (I and II) versus high (III and IV) ASA class was used to evaluate 971 patients who underwent PCDF between 2008 and 2016 at a single institution. Demographics were compared using univariate analysis. Cost of care, LOS, and postoperative complications were compared using multivariable logistic and linear regression, controlling for sex, age, length of surgery, and number of segments fused. RESULTS: The high ASA class cohort was older (mean age 62 years vs. 55 years, P < 0.0001) and had higher Elixhauser comorbidity index scores (P < 0.0001). ASA class was independently associated with longer LOS (2.1 days, 95% confidence interval [CI] 1.3-2.9, P < 0.0001) and higher cost ($2936, 95% CI $1457-$4415, P < 0.0001). Patients with high ASA class were more likely to have a nonhome discharge (3.9, 95% CI 2.8-5.6, P < 0.0001), delayed extubation (3.2, 95% CI 1.4-7.3, P = 0.006), intensive care unit stay (2.4, 95% CI 1.5 3.7, P = 0.0001), in-hospital complications (1.5, 95% CI 1.0-2.2, P = 0.03), and 30-day (3.2, 95% CI 1.5-6.8, P = 0.003) and 90-day (3.2, 95% CI 1.8-5.7, P = 0.0001) readmission. CONCLUSIONS: High ASA class is strongly associated with increased costs, LOS, and adverse outcomes following PCDF and could be useful for preoperative prediction of these outcomes.

Comparison of Cost and Perioperative Outcome Profiles for Primary and Revision Posterior Cervical Fusion Procedures.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To compare perioperative outcomes and hospitalization costs between patients undergoing primary or revision posterior cervical discectomy and fusion (PCDF). SUMMARY OF BACKGROUND DATA: While prior studies found differences in outcomes between primary and revision anterior cervical discectomy and fusion (ACDF), risk, and outcome profiles for posterior cervical revision procedures have not yet been elucidated. METHODS: Institutional records were queried for cases involving isolated PCDF procedures to evaluate preoperative characteristics and outcomes for patients undergoing primary versus revision PCDF between 2008 and 2016. The primary outcome was perioperative complications, while perioperative and resource utilization measures such as hospitalization length, required stay in the intensive care unit (ICU), direct hospitalization costs, and 30-day emergency department (ED) admissions were explored as secondary outcomes. RESULTS: One thousand one hundred twenty four patients underwent PCDF, with 218 (19.4%) undergoing a revision procedure. Patients undergoing revision procedures were younger (53.0 vs. 60.5 yrs), but had higher Elixhauser scores compared with the non-revision cohort. Revision cases tended to involve fewer spinal segments (3.6 vs. 4.1 segments) and shorter surgical durations (179.3 vs. 206.3 min), without significant differences in estimated blood loss. There were no significant differences in the overall complication rates (P = 0.20), however, the primary cohort had greater rates of required ICU stays (P = 0.0005) and non-home discharges (P = 0.0003). The revision cohort did experience significantly increased odds of 30-day ED admission (P = 0.04) and had higher direct hospitalization (P = 0.03) and surgical (P < 0.0001) costs. CONCLUSION: Complication rates, including incidental durotomy, were similar between primary and revision PCDF cohorts. Although prior surgery status did not predict complication risk, comorbidity burden did. Nevertheless, patients undergoing revision procedures had decreased risk of required ICU stay but greater risk of 30-day ED admission and higher direct hospitalization and surgical costs.Level of Evidence: 3.

Comparison of Anterior and Posterior Surgical Approaches for Treatment of Thoracic Myelopathy.

OBJECTIVE: To study a large multi-institutional sample of patients undergoing anterior versus posterior approaches for surgical decompression of thoracic myelopathy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent decompression for thoracic myelopathy between 2007 and 2015 via anterior or posterior approaches. Patients were excluded if they were undergoing surgery for tumors to isolate a degenerative cohort. Demographics, patient comorbidities, operative details, and postoperative complications were compared between the 2 cohorts. RESULTS: Although there were no differences in age (P = 0.06), sex (P = 0.72), or American Society of Anesthesiologists class (P = 0.59), there were higher rates of steroid use (P = 0.01) and hematologic disorders that predispose to bleeding (P = 0.04) at baseline in the posterior approach cohort. The posterior approach patients had longer operative times (P = 0.03), but there were no differences in length of stay (P = 0.64). Although there were no significant differences in the rates of major organ system complications or return to the operating room (P = 0.52), the posterior approach cohort displayed a trend toward increased severe adverse complications (29.8% vs. 17.6%, P = 0.28) compared with the anterior approach cohort. CONCLUSION: Although the anterior approach to surgical decompression of thoracic myelopathy demonstrated a lower complication rate, this result did not reach statistical significance. The anterior approach was associated with significantly shorter mean operative time, but otherwise there were no significant differences in operative or postoperative outcomes. These findings may support the favorability of the anterior approach but warrant further investigation in a larger study.

The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified. METHODS: Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type. RESULTS: Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906-$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9-6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37-8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00-24.02, P < 0.0001). CONCLUSION: Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.Level of Evidence: 3.

Giant chondrosarcoma of the falx in an adolescent: A case report.

BACKGROUND: Intracranial chondrosarcomas are slowly growing malignant cartilaginous tumors that are especially rare in adolescents. CASE DESCRIPTION: A 19-year-old woman with no medical history presented with symptoms of intermittent facial twitching and progressive generalized weakness for 6 months. The patient's physical examination was unremarkable. Imaging revealed a large bifrontal mass arising from the falx cerebri, with significant compression of both cerebral hemispheres and downward displacement of the corpus callosum. The patient underwent a bifrontal craniotomy for gross total resection of tumor. Neuropathologic examination revealed a bland cartilaginous lesion most consistent with low-grade chondrosarcoma. Her postoperative course was uneventful, and she was discharged to home on postoperative day 3. CONCLUSION: This is an unusual case of an extra-axial, non-skull base, low-grade chondrosarcoma presenting as facial spasm in an adolescent patient.

Comparison of Surgical Outcomes of Microdiskectomy Procedures by Patient Admission Status.

OBJECTIVE: We sought to compare the cost and in-hospital outcomes following lumbar microdiskectomy procedures by admission type. METHODS: Patients undergoing lumbar microdiskectomy at a single institution from 2008 to 2016 following an elective admission (EL) were compared against those who were admitted from the emergency department (ED) or from elsewhere within or outside the hospital system (TR) for their perioperative outcomes and cost. Multivariable modeling controlled for age, sex, self-reported race, Elixhauser comorbidity score, payer type, number of segments, and procedure length. RESULTS: Of the 1249 patients included in this study, 1116 (89.4%) were admitted electively while 123 (9.8%) were admitted from the ED and 10 (0.8%) were transferred from other hospitals. EL patients had significantly lower comorbidity burdens (P < 0.0001). Univariate and multivariable analyses revealed that transfer admission patients experienced significantly longer hospitalizations (ED: +1.7 days; P < 0.0001; TR: +5.3 days; P < 0.0001) and higher direct costs (ED: $1889; P < 0.0001; TR: $7001; P < 0.0001) compared with EL patients. Despite these risks, ED and TR patients only had increased odds of nonhome discharge compared with EL patients (ED: 3.4; P = 0.002; TR: 7.9; P = 0.02). CONCLUSIONS: Patients admitted as transfers and from the ED had significantly increased hospitalization lengths of stay and direct costs compared with electively admitted patients.

Third Ventricle Cavernous Malformation and Obstructive Hydrocephalus Thought to Be a Colloid Cyst.

BACKGROUND: Third ventricle cavernous malformations (CMs) associated with ventriculomegaly and obstructive hydrocephalus are quite rare in patients. Preoperative surgical planning can be challenging due to the lesion's non-specific appearance on CT and magnetic resonance imaging that can mimic other intraventricular pathologies, such as a colloid cyst. Management of these lesions can be varied in the setting of obstructive hydrocephalus. CASE DESCRIPTION: The patient is a 78-year-old woman who first presented to her primary care provider with balance difficulties and inability to ambulate on her own. She also had bladder incontinence and progressive, severe headaches. Imaging of the brain demonstrated entrapment of the right lateral ventricle and obstructive hydrocephalus due to a lesion in the third ventricle obstructing the right foramen of Monro, thought to be a colloid cyst. A right frontal neuroendoscopic approach with direct visualization, however, confirmed a third ventricle CM. A septal pellucidum fenestration was performed to restore cerebrospinal fluid communication and no resection of the lesion was performed. The patient recovered well after the operation and at clinical follow-up reported no headaches and was walking well without a walker and with no neurological deficits. CONCLUSIONS: A third ventricle CM was discovered after a neuroendoscopic approach for resection of a presumed colloid cyst in a patient with obstructive hydrocephalus. A neuroendoscopic septostomy was performed to treat the obstructive hydrocephalus and no resection was attempted. The patient suffered no complications and is at her neurologic baseline with no deficits.

Utilization of the American Society of Anesthesiologists (ASA) classification system in evaluating outcomes and costs following deformity spine procedures.

PURPOSE: Adult spinal deformity (ASD) has increased prevalence in aging populations. Due to the high cost of surgery, studies have evaluated risk factors that predict readmissions and poor outcomes. The American Society of Anesthesiologists (ASA) classification system has been applied to patients with ASD to assess preoperative health and assess the correlation between ASA class and postoperative complications. This study evaluates the relationship between ASA and complications, length of stay (LOS), and direct costs following spine deformity surgery. METHODS: Patients undergoing spine deformity surgery at a single institution from 2008-2016 were included and stratified based upon ASA status. Primary outcomes included patient demographics, adjusted LOS, and cost of care. Secondary measures compared between cohorts included adverse events, non-home discharge, and readmission rates. RESULTS: 442 patients with ASD were included in this study. Higher ASA class was correlated with greater Elixhauser Comorbidity Index (ECI) scores (p < 0.0001) and older age (p < 0.0001). Univariate analysis showed longer LOS (p < 0.0001) and greater direct costs in patients with higher ASA class (p < 0.0001). Patients in ASA Class III or IV had the greatest incidence of ICU stay when compared to patients without systemic disease (p < 0.0001). Upon multivariable regression analysis, high ASA class was associated with higher rates of non-home discharge (OR 5.0, 95% CI 3.1-8.1). Direct costs were greater for higher ASA class (regression estimate = + $9,666, p = 0.002). CONCLUSION: This study demonstrates that ASA class is correlated with a more complicated postoperative hospital course, greater rates of non-home discharge, total direct costs in spine deformity patients.

Surgery for spinal deformity: non-elective admission status is associated with higher cost of care and longer length of stay.

INTRODUCTION: Surgery is commonly indicated for adult spinal deformity. Annual rates and costs of spinal deformity surgery have both increased over the past two decades. However, the impact of non-elective status on total cost of hospitalization and patient outcomes has not been quantified. OBJECTIVE: To evaluate the impact of admission status on patient outcomes and healthcare costs in spinal deformity surgery. METHODS: All patients who underwent spinal deformity surgery at a single institution between 2008 and 2016 were grouped by admission status: elective, emergency (ED), or transferred. Demographics were compared by univariate analysis. Cost of care and length of stay (LOS) were compared between admission statuses using multivariable linear regression with elective admissions as reference. Multivariate logistic regression was utilized to assess in-hospital complications, discharge destination, and readmission rates. RESULTS: There were 427 spinal deformity surgeries included in this study. Compared to elective patients, ED patients had higher Elixhauser Comorbidity Index scores (p < 0.0001), longer LOS (+ 10.9 days, 97.5% CI 6.1-15.6 days, p < 0.0001), and higher costs (+ $20,076, 97.5% CI $9,073-$31,080, p = 0.0008). Transferred patients had significantly higher Elixhauser scores (p = 0.0002), longer LOS (+ 8.8 days, 97.5% CI 3.0-14.7 days, p < 0.0001), and higher rates of non-home discharge (OR = 15.8, 97.5% CI 2.3-110.0, p = 0.001). CONCLUSION: Patients admitted from the ED undergoing spinal deformity surgery had significantly higher cost of care and longer LOS compared to elective patients. Transferred patients had significantly longer LOS and a higher rate of non-home discharge compared to elective patients.

Nonhome Discharge as an Independent Risk Factor for Adverse Events and Readmission in Patients Undergoing Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: A retrospective study of a prospectively collected cohort. OBJECTIVE: To characterize a cohort of patients who underwent anterior cervical discectomy and fusion (ACDF) and examine whether nonhome discharge (NHD) is associated with postdischarge adverse events (AEs) and readmission. SUMMARY OF THE BACKGROUND DATA: Predictors of NHD have been elucidated in the spine surgery literature, and NHD has been tied to poor outcomes in the joint arthroplasty literature, but no such analysis exists for patients undergoing ACDF. MATERIALS AND METHODS: All patients who underwent ACDF from 2012 to 2015 in the National Surgical Quality Improvement Program were identified. Those who underwent concomitant posterior cervical operations were excluded. Patients who were discharged to home were compared with those discharged to nonhome destinations on the basis of demographics and outcomes. Multivariable models were created to assess whether NHD was an independent risk factor for postdischarge AEs and readmission. RESULTS: NHD patients were significantly older (63.96 vs. 53.57 y; P<0.0001), more functionally dependent (13.87% vs. 1.09%; P<0.0001), more likely to have body mass index >40 (9.38% vs. 7.51%; P=0.004), and more likely to have ASA Class >2 (77.89% vs. 39.57%; P<0.0001). Patients who underwent NHD were significantly more likely to suffer severe AEs (14.44% vs. 0.93%; P<0.0001), minor AEs (7.22% vs. 0.24%; P<0.0001), and infectious complications (3.58% vs. 0.13%; P<0.0001) before discharge. When examining AEs after discharge, patients who underwent NHD were more likely to suffer severe AEs (6.37% vs. 1.34%; P<0.0001), minor AEs (4.09% vs. 0.74%; P<0.0001), death (1.25% vs. 0.07%; P<0.0001), and unplanned readmission (10.12% vs. 3.06%; P<0.0001). In adjusted analysis, NHD was found to independently predict severe AEs after discharge (odds ratio, 2.40; 95% confidence interval, 1.87-3.07; P<0.0001) and readmission (odds ratio, 1.77; 95% confidence interval, 1.46-2.14; P<0.0001). CONCLUSIONS: NHD patients were significantly sicker than those discharged home. In addition, NHD is associated with higher rates of postdischarge complications.

Persistent symptoms after endovenous thermal ablation may suggest proximal venous outflow obstruction.

OBJECTIVE: Proximal venous outflow obstruction (PVOO) in the iliac veins and superficial venous disease are inter-related in ways not fully understood. We observed among our patients undergoing vein stent placement for PVOO a significant number having had prior endovenous thermal ablations (EVTA) in their history. This study was undertaken to better characterize these patients and develop an algorithm in their management. METHODS: In a combined retrospective and prospective data registry of 682 patients who underwent vein stent placement for chronic PVOO at a single institution from March 2013 to November 2017, 100 limbs of 99 patients (14.5% of all patients) had a history of EVTA or other superficial venous procedures before their vein stenting. Limbs with dilated truncal veins on ultrasound examination or limbs that underwent poststent EVTA or superficial venous procedures were excluded. The mean age of these 99 patients was 60.2 years (range, 28-88 years; standard deviation, 13.855). Fifty-one percent of the patients were male. The most common presenting symptom of the patient cohort was edema (n = 59), followed by venous-related skin changes (n = 22). RESULTS: Bilateral stents were performed in 58%, with a mean number of 2.06 stents per patient. EVTA was the primary superficial vein procedure in 97%. Bilateral EVTA were performed in 53% and unilateral EVTA in 47%. The mean time between the first EVTA to vein stenting was 1202.7 days. Patients were followed at 30 days, 90 days, 6 months, 1 year, and >1 year. The outcome for each patient at each postoperative visit was compared with preoperative parameters (subject's assessment, physical examination, and provider assessment) and was scored as follows: -1 (worse than preoperative), 0 (no change), +1 (mildly improved), +2 (significantly improved), or +3 (completely recovered). The mean outcome score at 30 days was 1.63 (84 patients), 2.05 at 90 days (62 patients), 2.09 at 6 months (74 patients), 1.93 at 1 year (54 patients), and 1.97 at >1 year (39 patients). CONCLUSIONS: Approximately 15% of patients undergoing vein stent placement for chronic PVOO have an antecedent history of superficial venous disease and EVTA. PVOO should be considered and the patient evaluated accordingly if symptoms persisted or recurred after EVTA. Vein stent placement among these patients with PVOO will result in further symptomatic relief, but complete symptomatic relief is not observed in everyone. The algorithm for the management of these patients warrants further investigation.

Virchow's triad in "silent" deep vein thrombosis.

OBJECTIVE: While determining the incidence of chronic deep vein thrombosis (DVT) and the hypercoagulation profiles of patients who underwent venous stenting for symptomatic venous insufficiency, we assessed the significance of Virchow's triad in the setting of proximal venous outflow obstruction and DVT. METHODS: Within our registry of 500 patients who underwent venous stenting for proximal venous outflow obstruction between 2013 and 2016, we selected the first 152 consecutive patients who had routine hypercoagulation profile testing performed preoperatively. Statistical analysis was performed using independent t-tests, χ2 tests, and multiple logistic regressions. RESULTS: By history or intraoperative chronic postphlebitic changes (CPPCs), 77 patients (50.7%) were positive for remote DVT; 51 (33.6%) had intraoperative findings of CPPCs without a history of DVT, 20 (13.2%) had intraoperative CPPCs with a history of DVT, and 6 (3.9%) had a history of DVT without intraoperative findings. The χ2 tests were significant for increased findings of CPPCs among patients with a history of DVT (81% vs 38%; P < .01). The χ2 tests were also significant for increased rates of intraoperative findings of CPPCs in patients with one or more positive hypercoagulation markers (67% vs 42%; P < .01). The most significant predictor for findings of CPPCs or DVT history was the presence of at least one hypercoagulation marker (n = 148; odds ratio, 2.41; P = .022). CONCLUSIONS: Remote history of DVT and intraoperative findings of CPPCs were prevalent. CPPC findings were found in many patients with no history of DVT. Hypercoagulation markers conferred significant predictive value for DVT. This information may influence our understanding of Virchow's triad and DVT etiology.

Pharmacologic Stress Gastropathy Prophylaxis May Not Be Necessary in At-Risk Surgical Trauma ICU Patients Tolerating Enteral Nutrition.

OBJECTIVE: Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis. DESIGN: A retrospective cohort study of records from 2008 to 2013. SETTING: Adult patients in a single-center STICU were included. PATIENTS: Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention. INTERVENTION: Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US$121/patient stay were realized. CONCLUSION: Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.