Exploring the Pathophysiology of Delirium: An Overview of Biomarker Studies, Animal Models, and Tissue-Engineered Models.

Delirium is an acute brain disorder associated with disorganized thinking, difficulty focusing, and confusion that commonly follows major surgery, severe infection, and illness. Older patients are at high risk for developing delirium during hospitalization, which may contribute to increased morbidity, longer hospitalization, and increased risk of institutionalization following discharge. The pathophysiology underlying delirium remains poorly studied. This review delves into the findings from biomarker studies and animal models, and highlights the potential for tissue-engineered models of the brain in studying this condition. The aim is to bring together the existing knowledge in the field and provide insight into the future direction of delirium research.

Association Between Intravenous to Oral Opioid Transition Time and Length of Hospital Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

BACKGROUND: Transitioning from intravenous (IV) to oral opioids after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is necessary during the postoperative course. However, few studies have assessed the effects of longer transition times on hospital length of stay (LOS). This study investigated the impact of longer IV to oral opioid transition times on LOS after PSF for AIS. METHODS: The medical records of 129 adolescents (10-18 years old) with AIS undergoing multilevel PSF at a major academic institution from 2013 to 2020 were reviewed. Patients were categorized by IV to oral opioid transition time: normal (≤2 days) vs prolonged (≥3 days). Patient demographics, comorbidities, deformity characteristics, intraoperative variables, postoperative complications, and LOS were assessed. Multivariate analyses were used to determine odds ratios for risk-adjusted extended LOS. RESULTS: Of the 129 study patients, 29.5% (n = 38) had prolonged IV to oral transitions. Demographics and comorbidities were similar between the cohorts. The major curve degree (P = 0.762) and median (interquartile range) levels fused (P = 0.447) were similar between cohorts, but procedure time was significantly longer in the prolonged cohort (normal: 6.6 ± 1.2 hours vs prolonged: 7.2 ± 1.3 hours, P = 0.009). Postoperative complication rates were similar between the cohorts. Patients with prolonged transitions had significantly longer LOS (normal: 4.6 ± 1.3 days vs prolonged: 5.1 ± 0.8 days, P < 0.001) but similar discharge disposition (P = 0.722) and 30-day readmission rates (P > 0.99). On univariate analysis, transition time was significantly associated with extended LOS (OR: 2.0, 95% CI [0.9, 4.6], P = 0.014), but this assocation was not significant on multivariate analysis (adjusted OR: 2.1, 95% CI [1.3, 4.8], P = 0.062). CONCLUSIONS: Longer postoperative IV to oral opioid transitions after PSF for AIS may have implications for hospital LOS.

Second Primary Malignancies of the Bones and Joints: More Common than Expected in Osteosarcoma Patients.

BACKGROUND: Osteosarcoma is the most common primary bone tumor in children, adolescents, and young adults. Second primary malignancies (SPMs) are a potential serious long-term event that can occur in osteosarcoma survivors. METHODS: The National Cancer Institute's Surveillance, Epidemiology, and End Results 18 database was queried for all osteosarcoma cases from 2000 through 2015. Standardized incidence ratio (SIR) and absolute excess risk (AER) of SPM per 10,000 persons (AER) relative to representative population-level data were calculated across for various anatomic locations. RESULTS: In total, 3438 patients with osteosarcoma were identified. Of these patients, 79 (2.3%) developed SPMs, with an SIR of 2.84 (95% confidence interval [CI] 2.35 to 3.39, P < 0.0001) and an AER of 44.96. The most common SPMs were tumors of the bones or joints (SIR 73.07, CI, 38.90 to 124.94, P < 0.0001, AER 7.48), tumors of soft tissues including the heart (SIR 15.19, CI, 5.58 to 33.07, P < 0.0001, AER 3.27), and leukemia (SIR 22.28, CI, 15.03 to 31.80, P < 0.0001, AER 16.74). CONCLUSION: The overall incidence of SPMs in osteosarcoma survivors was significantly higher than would otherwise be expected for this population. Considering the occurrence and targeting surveillance for SPM in the osteosarcoma patient population is warranted.

Impact of Racial Disparities on All-Cause Mortality in Patients With Tumors of the Spinal Cord or Spinal Meninges: A Propensity-Score Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The influence that race has on mortality rates in patients with spinal cord tumors is relatively unknown. The aim of this study was to investigate the influence of race on the outcomes of patients with primary malignant or nonmalignant tumors of the spinal cord or spinal meninges. METHODS: The Surveillance, Epidemiology, and End Results (SEER) Registry was used to identify all patients with a code for primary malignant or nonmalignant tumor of the spinal cord (C72.0) or spinal meninges (C70.1) from 1973 through 2016. Racial groups (African-American/Black vs. White) were balanced using propensity-score (PS) matching using a non-parsimonious 1:1 nearest neighbor matching algorithm. Overall survival (OS) estimates were obtained using the Kaplan-Meier method and compared across non-PS-matched and PS-matched groups using log-rank tests. Associations of survival with clinical variables was assessed using doubly robust Cox proportional-hazards (CPH) regression analysis. RESULTS: There were a total of 7,498 patients identified with 648 (6.8%) being African American. African-American patients with primary intradural spine tumors were more likely to die of all causes than were White patients in both the non-PS-matched [HR: 1.26, 95% CI: (1.04, 1.51), P = 0.01] and PS-matched cohorts [HR: 1.64, 95% CI: (1.28, 2.11), P < 0.0001]. On multivariate CPH regression analysis age at diagnosis [HR: 1.03, 95% CI: (1.02, 1.05), P < 0.0001], race [HR: 1.82, 95% CI: (1.22, 2.74), P = 0.004), and receipt of RT [HR: 2.62, 95% CI: (1.56, 4.37), P = 0.0002) were all significantly associated with all-cause mortality, when controlling for other demographic, tumor, and treatment variables. CONCLUSIONS: Our study provides population-based estimates of the prognosis for patients with primary malignant or nonmalignant tumors of the spinal cord or spinal meninges and suggests that race may impact all-cause mortality.

Association of inpatient opioid consumption on postoperative outcomes after open posterior spinal fusion for adult spine deformity.

INTRODUCTION: Opioids are the most commonly used analgesic in the postoperative setting. However, few studies have analyzed the impact of high inpatient opioid use on outcomes following surgery, with no current studies assessing its effect on patients undergoing spinal fusion for an adult spinal deformity (ASD). Thus, the aim of this study was to investigate risk factors for high inpatient opioid use, as well as to determine the impact of high opioid use on outcomes such as adverse events (AEs), hospital length of stay (LOS), cost of hospital admission, discharge disposition, and readmission rates in patients undergoing spinal fusion for ASD. METHODS: A retrospective cohort study was performed using the Premier healthcare database from the years 2016 and 2017. All adult patients > 40 years old who underwent thoracic or thoracolumbar fusion for ASD were identified using the ICD-10-CM diagnostic and procedural coding system. Patients were then categorized into three cohorts based on inpatient opioid use: Low MME (morphine milligram equivalents), Medium MME, and High MME. Patient demographics, comorbidities, treating hospital characteristics, intraoperative variables, postoperative AEs, LOS, discharge disposition, and total cost of hospital admission were assessed in the analysis. Multivariate regression analysis was done to determine independent predictors of high inpatient MME, prolonged LOS, and increased hospital cost. RESULTS: Of 1673 patients included, 417 (24.9%) were classified as Low MME, 840 (50.2%) as Medium MME, and 416 (24.9%) as High MME. Age significantly decreased with increasing MME (Low: 71.0% 65 + years vs Medium: 62.0% 65 + years vs High: 47.4% 65 + years, p < 0.001), while the proportions of patients presenting with three or more comorbidities were similar across the cohorts (Low: 20.1% with 3 + comorbidities vs Medium: 18.0% with 3 + comorbidities vs High: 24.3% with 3 + comorbidities, p = 0.070). With respect to postoperative outcomes, the proportion of patients who experienced any AE (Low: 60.2% vs Medium: 68.8% vs High: 70.9%, p = 0.002), extended LOS (Low: 6.7% vs Medium: 20.7% vs High: 45.4%, p < 0.001), or non-routine discharge (Low: 66.6% vs Medium: 73.5% vs High: 80.1%, p = 0.003) each increased along with total MME. In addition, rates of 30-day readmission were greatest among the High MME cohort (Low: 8.4% vs Medium: 7.9% vs High: 12.5%, p = 0.022). On multivariate analysis, medium and high MME were associated with prolonged LOS [Medium: OR 4.41, CI (2.90, 6.97); High: OR 13.99, CI (8.99, 22.51), p < 0.001] and increased hospital cost [Medium: OR 1.69, CI (1.21, 2.39), p = 0.002; High: OR 1.66, CI (1.12, 2.46), p = 0.011]. Preadmission long-term opioid use [OR 1.71, CI (1.07, 2.7), p = 0.022], a prior opioid-related disorder [OR 11.32, CI (5.92, 23.49), p < 0.001], and chronic pulmonary disease [OR 1.39, CI (1.06, 1.82), p = 0.018] were each associated with a high inpatient MME on multivariate analysis. CONCLUSION: Our study demonstrated that increasing inpatient MME consumption was associated with extended LOS and increased hospital cost in patients undergoing spinal fusion for ASD. Further studies identifying risk factors for increased MME consumption may provide better risk stratification for postoperative opioid use and healthcare resource utilization.

The Impact of Image Processing Algorithms on Optical Coherence Tomography Angiography Metrics and Study Conclusions in Diabetic Retinopathy.

Purpose: The purpose of this study was to evaluate the impact of image processing on quantitative metrics in optical coherence tomography angiography (OCTA) images and study conclusions in patients with diabetes. Methods: This was a single center, retrospective cross-sectional study. OCTA imaging with the Cirrus HD-OCT 5000 AngioPlex of patients with diabetes was performed. The 8 × 8 mm superficial slab images underwent 4 different preprocessing methods (none, background subtraction [BGS], foveal avascular zone brightness adjustment, and contrast limited adaptive histogram equalization [CLAHE]) followed by 4 different binarization algorithms (global Huang, global Otsu, local Niblack, and local Phansalkar) in ImageJ. Vessel density (VD), skeletonized VD (SVD), and fractal dimension (FD) were calculated. Mixed-effect multivariate linear regressions were performed. Results: Two hundred eleven scans from 104 patients were included. Of these scans, 67 (31.8%) had no diabetic retinopathy (DR), 99 (46.9%) had nonproliferative DR (NPDR), and 45 (21.3%) had proliferative DR (PDR). Forty-eight of 211 (22.7%) scans had diabetic macular edema (DME). The image processing method used significantly impacted values of VD, SVD, and FD (all P -values < 0.001). On multivariate analysis, the image processing method changed the clinical variables significantly associated with VD, SVD, and FD. However, BGS and CLAHE yielded more consistent significant covariates across multiple binarization algorithms. Conclusions: The image processing method can impact the conclusions of any given study analyzing quantitative OCTA metrics. Thus, caution is urged in the interpretation of such studies. Background subtraction or CLAHE may play a role in the standardization of image processing. Translational Relevance: This work proposes strategies to achieve robust and consistent analysis of OCTA imaging, which is especially important for clinical trials.

Impact of Frailty on Morbidity and Mortality in Adult Patients Undergoing Surgical Evacuation of Acute Traumatic Subdural Hematoma.

OBJECTIVE: To determine whether baseline frailty is an independent predictor of extended hospital length of stay (LOS), nonroutine discharge, and in-hospital mortality after evacuation of an acute traumatic subdural hematoma (SDH). METHODS: A retrospective cohort study was performed. All adult patients who underwent surgery for an acute traumatic SDH were identified using the National Trauma Database from the year 2017. Patients were categorized into 3 cohorts based on the criteria of the 5-item modified frailty index (mFI-5): mFI = 0, mFI = 1, or mFI = 2+. A multivariate logistic regression analysis was used to identify independent predictors of extended LOS, nonroutine discharge, and in-hospital mortality. RESULTS: Of the 2620 patients identified, 41.7% were classified as mFI = 0, 32.7% as mFI = 1, and 25.6% as mFI = 2+. Rates of extended LOS and in-hospital mortality did differ significantly between the cohorts, with the mFI = 0 cohort most often experiencing a prolonged LOS (mFI = 0: 29.41% vs. mFI = 1: 19.45% vs. mFI = 2+: 19.73%, P < 0.001) and in-hospital mortality (mFI = 0: 24.66% vs. mFI = 1: 18.11% vs. mFI = 2+: 21.58%, P = 0.002). On multivariate regression analysis, when compared with mFI = 0, mFI = 2+ (odds ratio 1.4, P = 0.03) predicted extended LOS and nonroutine discharge (odds ratio 1.61, P = 0.001). CONCLUSIONS: Our study demonstrates that baseline frailty may be an independent predictor of extended LOS and nonroutine discharge, but not in-hospital mortality, in patients undergoing evacuation for an acute traumatic SDH. Further investigations are warranted as they may guide treatment plans and reduce health care expenditures for frail patients with SDH.

Jump in Elective Total Hip and Knee Arthroplasty Numbers at Age 65 Years: Evidence for Moral Hazard?

INTRODUCTION: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are outstanding options for many older patients at the discretion of the patient and the surgeon. As patients turn 65 years, greater than 98% of the US population becomes eligible for Medicare, and this represents a time of changing healthcare coverage for many. METHODS: Patients undergoing elective TKA and THA were abstracted from the 2012 to 2018 National Surgical Quality Improvement Program database. Incidences of TKA and THA (combined and separate) were plotted and assessed by age. To assess factors associated with who "delayed" surgery until 65 years, demographic and preoperative characteristics, and postoperative adverse events were compared for the 2 years above and the 2 years below the 65-year-old mark with multivariate analysis. Significance was set at P < 0.05. RESULTS: In total, 515,139 TKA and THA patients were identified (62.04% TKA and 37.95% THA). When the number of procedures was plotted by age, a discontinuity in the bell-shaped curve was noted at age 65 years. Highlighting this finding, the changes in percent population between 63 and 64 years was -1.52%, between 64 and 65 years was +15.36%, and between 65 and 66 years was -2.32%. Relative to those who were 63 and 64 years (n = 36,511), those who were 65 and 66 years (n = 41,671) were more likely to be female, be non-Hispanic White, have a lower body mass index, and have a lower functional status but were not different in the preoperative American Society of Anesthesiologists class. CONCLUSION: In this large national sample, there was a clear step increase in undergoing TKA or THA once patients reached the age of 65 years (Medicare eligibility). This discontinuity in the bell-shaped curve may be evidence for a moral hazard in healthcare markets. Although factors in decision-making were not assessed, there were demographic factors associated with this step finding.

Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis.

BACKGROUND: As health care expenditures continue to increase, standardizing health care delivery across geographic regions has been identified as a method to reduce costs. However, few studies have demonstrated how the practice of elective spine surgery varies by geographic location. The aim of this study was to assess the geographic variations in management, complications, and total cost of elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). METHODS: The National Inpatient Sample database (2016-2017) was queried using the ICD-10-CM procedural and diagnostic coding systems to identify all adult (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF. Patients were divided into regional cohorts as defined by the U.S. Census Bureau: Northeast, Midwest, South, and West. Weighted patient demographics, Elixhauser comorbidities, perioperative complications, length of stay (LOS), discharge disposition, and total cost of admission were assessed. RESULTS: A total of 17,385 adult patients were identified. While the age (p=0.116) and proportion of female patients (p=0.447) were similar among the cohorts, race (p<0.001) and healthcare coverage (p<0.001) varied significantly. The Northeast had the largest proportion of patients in the 76-100th household income quartile (Northeast: 32.1%; Midwest: 16.9%; South: 15.7%; West: 27.5%, p<0.001). Complication rates were similar between regional cohorts (Northeast: 10.1%; Midwest: 12.2%; South: 10.3%; West: 11.9%, p=0.503), as was LOS (Northeast: 2.2±2.4 days; Midwest: 2.1±2.4 days; South: 2.0±2.5 days; West: 2.1±2.4 days, p=0.678). The West incurred the greatest mean total cost of admission (Northeast: $19,167±10,267; Midwest: $18,903±9,114; South: $18,566±10,152; West: $24,322±15,126, p<0.001). The Northeast had the lowest proportion of patients with a routine discharge (Northeast: 72.0%; Midwest: 84.8%; South: 82.3%; West: 83.3%, p<0.001). The odds ratio for Western hospital region was 3.46 [95% CI: (2.41, 4.96), p<0.001] compared to the Northeast for increased cost. CONCLUSION: Our study suggests that regional variations exist in elective ACDF for CSM, including patient demographics, hospital costs, and nonroutine discharges, while complication rates and LOS were similar between regions.

Large Hyphema following Femtosecond Laser-assisted Cataract Surgery (FLACS) and Trabectome Resulting in Endocapsular Hematoma.

Aim: To report a large hyphema following femtosecond laser-assisted cataract surgery (FLACS) and trabectome resulting in endocapsular hematoma. Background: Hyphema has previously been described following trabectome, however, no cases have been reported following FLACS or FLACS combined with microinvasive glaucoma surgery (MIGS). We report a case of a large hyphema following FLACS combined with MIGS that resulted in an endocapsular hematoma. Case description: A 63-year-old myopic female with exfoliation glaucoma underwent FLACS with a trifocal intraocular lens implant and Trabectome in the right eye. Significant intraoperative bleeding ensued following the trabectome and was treated with viscoelastic tamponade, anterior chamber (AC) washout, and cautery. The patient developed a large hyphema with intraocular pressure (IOP) rise that was treated with multiple AC taps, paracentesis, and eye drops. The hyphema took approximately 1 month to completely clear, leaving an endocapsular hematoma. This was treated successfully with Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser posterior capsulotomy. Conclusion: Hyphema may occur with angle-based MIGS in combination with FLACS and may cause endocapsular hematoma. An increase in episcleral venous pressure during the docking and suction phase of the laser may predispose to bleeding. Endocapsular hematoma is an uncommon finding after cataract surgery and may be treated with Nd:YAG posterior capsulotomy. How to cite this article: Chang EL, Apostolopoulos N, Mir TA, et al. Large Hyphema following Femtosecond Laser-assisted Cataract Surgery (FLACS) and Trabectome Resulting in Endocapsular Hematoma. J Curr Glaucoma Pract 2022;16(3):195-198.

Ramifications of Postoperative Dysphagia on Health Care Resource Utilization Following Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: The aim of this study was to investigate patient risk factors and health care resource utilization associated with postoperative dysphagia following elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: There is a paucity of data on factors predisposing patients to dysphagia and the burden this complication has on health care resource utilization following ACDF. METHODS: A retrospective cohort study was performed using the Nationwide Inpatient Sample (NIS) database from 2016 to 2017. All adult (above 18 y old) patients undergoing ACDF for cervical spondylotic myelopathy were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then categorized by whether they had a recorded postoperative dysphagia or no dysphagia. Weighted patient demographics, comorbidities, perioperative complications, length of hospital stay (LOS), discharge disposition, and total cost of admission were assessed. A multivariate stepwise logistic regression was used to determine both the odds ratio for risk-adjusted postoperative dysphagia as well as extended LOS. RESULTS: A total of 17,385 patients were identified, of which 1400 (8.1%) experienced postoperative dysphagia. Compared with the No-Dysphagia cohort, the Dysphagia cohort had a greater proportion of patients experiencing a complication (P=0.004), including 1 complication (No-Dysphagia: 2.9% vs. Dysphagia: 6.8%), and >1 complication (No-Dysphagia: 0.3% vs. Dysphagia: 0.4%). The Dysphagia cohort experienced significantly longer hospital stays (No-Dysphagia: 1.9±2.1 d vs. Dysphagia: 4.2±4.3 d, P<0.001), higher total cost of admission (No-Dysphagia: $19,441±10,495 vs. Dysphagia: $25,529±18,641, P<0.001), and increased rates of nonroutine discharge (No-Dysphagia: 16.5% vs. Dysphagia: 34.3%, P<0.001). Postoperative dysphagia was found to be a significant independent risk factor for extended LOS on multivariate analysis, with an odds ratio of 5.37 (95% confidence interval: 4.09, 7.05, P<0.001). CONCLUSION: Patients experiencing postoperative dysphagia were found to have significantly longer hospital LOS, higher total cost of admission, and increased nonroutine discharge when compared with the patients who did not. LEVEL OF EVIDENCE: Level III.

Impact of race on outcomes and healthcare utilization following spinal fusion for adolescent idiopathic scoliosis.

OBJECTIVES: Racial disparities in spine surgery have been shown to impact surgical management and postoperative complications. However, for adolescent patients with idiopathic scoliosis (AIS) treated by posterior spinal fusion (PSF), the influence of race on postoperative outcomes remains unclear. The aim of the study was to investigate the differences in baseline patient demographics, inpatient management, and postoperative complications for adolescents with AIS undergoing elective, posterior spinal surgery (≥ 4 levels). PATIENTS AND METHODS: The Kids' Inpatient Database year 2012 was queried. Adolescent patients (age 10-17 years old) with AIS undergoing elective, PSF (≥ 4 levels) were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Patients were divided into 4 cohorts: Black, White, Hispanic, and Other. Patient demographics, comorbidities, complications, length of hospital stay (LOS), discharge disposition and total cost were recorded. The primary outcome was the rate of intraoperative and postoperative complications and resource utilization after elective PSF intervention. RESULTS: Patient demographics significantly differed between the four cohorts. While age was similar (p = 0.288), the White cohort had a greater proportion of female patients (White: 79.0%; Black: 72.1%; Hispanic: 78.2%; Other: 75.9%, p = 0.006), and the Black cohort had the largest proportion of patients in the 0-25th income quartile (White: 16.1%; Black: 43.3%; Hispanic: 28.0%; Other: 15.3%, p < 0.001). There were significant differences in hospital region (p < 0.001) and bed size (p < 0.001) between the cohorts, with more Hispanic adolescents being treated in the West (White: 21.9%; Black: 8.9%; Hispanic: 40.3%; Other: 29.3%) at small hospitals (White: 14.0%; Black: 13.9%; Hispanic: 16.2%; Other: 7.1%). Baseline comorbidities were similar between the cohorts. The use of blood transfusions was significantly greater in the Black cohort compared to the other racial groups (White: 16.7%; Black: 25.0%; Hispanic: 24.5%; Other: 22.7%, p < 0.001). The number of vertebral levels involved differed significantly between the cohorts (p < 0.001), with the majority of patients having 9-levels or greater involved (White: 80.9%; Black: 81.7%; Hispanic: 84.3%; Other: 67.3%). The rate of complications encountered during admission was greatest in the Other cohort (White: 21.9%; Black: 23.6%; Hispanic: 22.2%; Other: 34.9%, p < 0.001). While LOS was similar between the cohorts (p = 0.702), median total cost of admission was highest for Hispanic patients (White: $49,340 [37,908-65,078]; Black: $47,787 [37,718-64,670]; Hispanic: $54,718 [40,689-69,266]; Other: $54,110 [41,292-71,540], p < 0.001). CONCLUSIONS: Our study suggests that race may not have a significant impact on surgical outcomes after elective posterior spine surgery for adolescent idiopathic scoliosis. Further studies are necessary to corroborate our findings.

Tinnitus as a presenting symptom of neurosarcoidosis with ocular involvement.

A 48-year-old woman with untreated hypothyroidism initially presented with tinnitus and hearing loss, followed by blurred vision and eye pain months later. Ophthalmic evaluation revealed no optic disc oedema. Visual field defects in both eyes suggested retrobulbar optic neuropathy. MRI of the brain and orbits demonstrated enhancement of both optic nerve sheaths and diffuse pachymeningeal enhancement. Audiologic evaluation revealed hearing loss in both ears, and frequent square wave jerks were seen on videonystagmography. Fine needle aspiration from one pulmonary lymph node showed non-necrotising granulomatous inflammation, confirming the diagnosis of neurosarcoidosis. The visual fields improved significantly on prednisone, and she is maintained on prednisone, infliximab and methotrexate. Though common, multiple cranial neuropathies in neurosarcoidosis are poorly represented in the literature. Clinicians should be aware of the symptoms that may herald a diagnosis of neurosarcoidosis, so that treatment may be implemented sooner, and further cranial neuropathies may be prevented.

Modified-frailty index does not independently predict complications, hospital length of stay or 30-day readmission rates following posterior lumbar decompression and fusion for spondylolisthesis.

BACKGROUND CONTEXT: Frailty has been associated with inferior surgical outcomes in various fields of spinal surgery. With increasing healthcare costs, hospital length of stay (LOS) and unplanned readmissions have emerged as clinical proxies reflecting overall value of care. However, there is a paucity of data assessing the impact that baseline frailty has on quality of care in patients with spondylolisthesis. PURPOSE: The aim of this study was to investigate the impact that frailty has on LOS, complication rate, and unplanned readmission after posterior lumbar spinal fusion for spondylolisthesis. STUDY DESIGN: A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016. PATIENT SAMPLE: All adult (≥18 years old) patients who underwent lumbar spinal decompression and fusion for spondylolisthesis were identified using ICD-9-CM diagnosis and procedural coding systems. We calculated the modified frailty index (mFI) for each patient using 5 dichotomous comorbidities - diabetes mellitus, congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, and dependent functional status. Each comorbidity is assigned 1 point and the points are summed to give a score between 0 and 5. As in previous literature, we defined a score of 0 as "not frail", 1 as "mild" frailty, and 2 or greater as "moderate to severe" frailty. OUTCOME MEASURES: Patient demographics, comorbidities, complications, LOS, readmission, and reoperation were assessed. METHODS: A multivariate logistic regression analysis was used to identify independent predictors of adverse events (AEs), extended LOS, complications, and unplanned readmission. RESULTS: There were a total of 5,296 patients identified, of which 2,030 (38.3%) were mFI=0, 2,319 (43.8%) patients mFI=1, and 947 (17.9%) were mFI ≥2. The mFI≥2 cohort was older (p≤.001) and had a greater average BMI (p≤.001). The mFI≥2 cohort had a slightly longer hospital stay (3.7 ± 2.3 days vs. mFI=1: 3.5 ± 2.8 days and mFI=0: 3.2 ± 2.1 days,p≤.001). Both surgical AEs and medical AEs were significantly greater in the mFI≥2 cohort than the other cohorts, (2.6% vs. mFI=1: 1.8% and mFI=0: 1.2%,p=.022) and (6.3% vs. mFI=1: 4.8% and mFI=0: 2.6%,p≤.001), respectively. While there was no significant difference in reoperation rates, the mFI≥2 cohort had greater unplanned 30-day readmission rates (8;4% vs. mFI=5.6: 4.8% and mFI=0: 3.4%,p≤.001). However, on multivariate regression analysis, mFI≥2 was not a significant independent predictor of LOS (p=.285), complications (p=.667), or 30-day unplanned readmission (p=.378). CONCLUSIONS: Our study indicates that frailty, as measured by the mFI, does not significantly predict LOS, 30-day adverse events, or 30-day unplanned readmission in patients undergoing lumbar spinal decompression and fusion for spondylolisthesis. Further work is needed to better define variable inputs that make up frailty to optimize surgical outcome prediction tools that impact the value of care.

Race Is an Independent Predictor for Nonroutine Discharges After Spine Surgery for Spinal Intradural/Cord Tumors.

OBJECTIVE: The aim of this study was to determine if race was an independent predictor of extended length of stay (LOS), nonroutine discharge, and increased health care costs after surgery for spinal intradural/cord tumors. METHODS: A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult (>18 years old) inpatients who underwent surgical intervention for a benign or malignant spinal intradural/cord tumor were identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedural coding systems. Patients were then categorized based on race: White, African American (AA), Hispanic, and other. Postoperative complications, LOS, discharge disposition, and total cost of hospitalization were assessed. A backward stepwise multivariable logistic regression analysis was used to identify independent predictors of extended LOS and nonroutine discharge disposition. RESULTS: Of 3595 patients identified, there were 2620 (72.9%) whites (W), 310 (8.6%) AAs/blacks, 275 (7.6%) Hispanic (H), and 390 (10.8%) other (O). Postoperative complication rates were similar among the cohorts (P = 0.887). AAs had longer mean (W, 5.4 ± 4.2 days vs. AA, 8.9 ± 9.5 days vs. H, 5.9 ± 3.9 days vs. O, 6.1 ± 3.9 days; P = 0.014) length of hospitalizations than the other cohorts. The overall incidence of nonroutine discharge was 55% (n = 1979), with AA race having the highest rate of nonroutine discharges (W, 53.8% vs. AA, 74.2% vs. H, 45.5% vs. O, 43.6%; P = 0.016). On multivariate regression analysis, AA race was the only significant racial independent predictor of nonroutine discharge disposition (odds ratio, 3.32; confidence interval, 1.67-6.60; P < 0.001), but not extended LOS (P = 0.209). CONCLUSIONS: Our study indicates that AA race is an independent predictor of nonroutine discharge disposition in patients undergoing surgical intervention for a spinal intradural/cord tumor.

Cost and Health Care Resource Utilization Differences After Spine Surgery for Bony Spine versus Primary Intradural Spine Tumors.

OBJECTIVE: The aim of this study was to compare complication rates, length of stay (LOS), and hospital costs after spine surgery for bony spine tumors and intradural spinal neoplasms. METHODS: A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult inpatients who underwent surgical intervention for a primary intradural spinal tumor or primary/metastatic bony spine tumor were identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis/procedural coding systems. Patient demographics, comorbidities, intraoperative variables, complications, LOS, discharge disposition, and total cost of hospitalization were assessed. Backward stepwise multivariable logistic regression analyses were used to identify independent predictors of perioperative complication, extended LOS (≥75th percentile), and increased cost (≥75th percentile). RESULTS: A total of 9855 adult patients were included in the study; 3850 (39.1%) were identified as having a primary intradural spinal tumor and 6005 (60.9%) had a primary or metastatic bony spine tumor. Those treated for bony tumors had more comorbidities (≥3, 67.8% vs. 29.2%) and more commonly experienced ≥1 complications (29.9% vs. 7.9%). Multivariate analyses also showed those in the bony spine cohort had a higher odds of experiencing ≥1 complications (odds ratio [OR], 4.26; 95% confidence interval [CI], 3.04-5.97; P < 0.001), extended LOS (OR, 2.44; 95% CI, 1.75-3.38; P < 0.001), and increased cost (OR, 5.32; 95% CI, 3.67-7.71; P < 0.001). CONCLUSIONS: Relative to patients being treated for primary intradural tumors, those undergoing spine surgery for bony spine tumors experience significantly higher risk for perioperative complications, extended LOS, and increased cost of hospital admission. Further identification of patient and treatment characteristics that may optimize management of spine oncology may reduce adverse outcomes, improve patient care, and reduce health care resources.

The Effects of Pulmonary Risk Factors on Hospital Resource Use After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis Correction.

OBJECTIVE: The aim of this study was to determine the impact of preoperative pulmonary risk factors (PRFS) on surgical outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients with AIS undergoing PSF were identified. Patients were then categorized by whether they had recorded baseline PRF or no-PRF. Patient demographics, comorbidities, intraoperative variables, complications, length of stay, discharge disposition, and readmission rate were assessed. RESULTS: A total of 4929 patients were identified, of whom 280 (5.7%) had baseline PRF. Compared with the no-PRF cohort, the PRF cohort had higher rates of complications (PRF, 4.3% vs. no-PRF, 2.2%; P = 0.03) and longer hospital stays (PRF, 4.6 ± 4.3 days vs. no-PRF, 3.8 ± 2.3 days; P < 0.001), yet, discharge disposition was similar between cohorts (P = 0.70). Rates of 30-day unplanned readmission were significantly higher in the PRF cohort (PRF, 6.3% vs. no-PRF, 2.7%; P = 0.009), yet, days to readmission (P = 0.76) and rates of 30-day reoperation (P = 0.16) were similar between cohorts. On multivariate analysis, PRF was found to be a significant independent risk factor for longer hospital stays (risk ratio, 0.74; 95% confidence interval, 0.44-1.04; P < 0.001) but not postoperative complication or 30-day unplanned readmission. CONCLUSIONS: Our study showed that PRF may be a risk factor for slightly longer hospital stays without higher rates of complication or unplanned readmission for patients with AIS undergoing PSF and thus should not preclude surgical management.

Clinical and economic burden of neurofibromatosis type 2 in the United States.

OBJECTIVES: We aimed to investigate the prevalence and cost-associated risk factors for hospital stays for Neurofibromatosis Type 2 (NF2) patients in the past decade. PATIENTS AND METHODS: A multi-year cross-sectional study was performed using the National Inpatient Sample. Patients with a diagnosis code of NF2 according to the International Classification of Diseases, 9th Revision, Clinical Modification coding system were queried from 2006-2014. Sampling discharge weights were used to calculate trend estimates for national demographics, hospital characteristics, comorbidities, and surgical interventions. Regression analysis was performed to determine significant independent associations between comorbidities and admission cost. RESULTS: From 2006-2014, there were 5,078 discharges for patients diagnosed with NF2. Patient demographics, comorbidities, and procedures performed were overall consistent over time. The most common admission diagnoses were hearing loss (28.2 %), acoustic schwannoma (14.3 %), cranial meningioma (11.8 %) and epilepsy (10.8 %). The most common procedures performed were craniotomy and meningioma resection (10.2 %) and acoustic neuroma open resection (7.9 %). The median inflation-adjusted cost of admission did not change over time, with an admission cost value of $12,387 [6,042 - 26,051]. On regression analysis, obstructive hydrocephalus, craniotomy and meningioma resection, acoustic neuroma open resection, and spine tumor resection were all independent predictors of increased cost. CONCLUSION: The care for NF2 patients continues to evolve over time. We report the prevalence of patient demographics, comorbidities, and treatments in the NF2 inpatient population. Further studies are warranted to better understand the risk factors for higher costs, so that patients with NF2 may continue to receive life-long quality care in a cost-effective manner.

Patient Risk Factors Associated With 30- and 90-Day Readmission After Cervical Discectomy: A Nationwide Readmission Database Study.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: The aim of this study was to assess the patient-level risk factors associated with 30- and 90-day unplanned readmissions following elective anterior cervical decompression and fusion (ACDF) or cervical disk arthroplasty (CDA). SUMMARY OF BACKGROUND DATA: For cervical disk pathology, both ACDF and CDA are increasingly performed nationwide. However, relatively little is known about the adverse complications and rates of readmission for ACDF and CDA. METHODS: A retrospective cohort study was performed using the Nationwide Readmission Database from the years 2013 to 2015. All patients undergoing either CDA or ACDF were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and to identify 30- and 31-90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R). RESULTS: There were a total of 13,093 index admissions with 856 (6.5%) readmissions [30-R: n=532 (4.0%); 90-R: n=324 (2.5%)]. Both overall length of stay and total cost were greater in the 30-R cohort compared with 90-R and Non-R cohorts. The most prevalent 30- and 90-day complications seen among the readmitted cohorts were infection, genitourinary complication, and device complication. On multivariate regression analysis, age, Medicaid status, medium and large hospital bed size, deficiency anemia, and any complication during index admission were independently associated with increased 30-day readmission. Whereas age, large hospital bed size, coagulopathy, and any complication during the initial hospitalization were independently associated with increased 90-day readmission. CONCLUSION: Our nationwide study identifies the 30- and 90-day readmission rates and several patient-related risk factors associated with unplanned readmission after common anterior cervical spine procedures. LEVEL OF EVIDENCE: Level III.

Does neurofibromatosis 1 status impact outcomes for pediatric/young adults undergoing spinal fusion?

BACKGROUND: Although spinal deformities are common in patients with neurofibromatosis type 1 (NF1), there is a paucity of data as to how this impacts outcomes of spinal fusion surgery in pediatric/young adult patients. METHODS: Using the Nationwide Inpatient Sample (2005-2014) for all patients undergoing spinal fusion ≤26 years of age, we compared the following factors: demographics, comorbidities, and perioperative variables (e.g., between NF1 vs. non-NF1, and between NF1 and propensity score (PS)-matched non- NF1 spinal fusion patients) using univariate hypothesis tests and multivariate regression analyses. Our main interest focused on length of stay, complication rates, adverse postoperative events, and incidence of nonroutine discharges. RESULTS: In this study, 238 (0.92%) NF1 spine patients were compared to 25,558 (99.08%) non-NF1 spine patients. NF1 fusion patients were younger, included fewer females, and were more likely to be on Medicaid. Perioperatively, NF1 patients underwent more anterior approaches, had more vertebrae fused, required more transfusions, had a longer length of stay (LOS), and were less likely to be discharged home. However, after PS- matching, all differences between NF1 and non-NF1 groups disappeared were similar (P > 0.05). In PS-matched multivariate analyses, NF1-status was not a significant independent predictor of length of stay or nonroutine discharge disposition. CONCLUSION: NF1-status was, therefore, not an independent predictor of complications, adverse postoperative events, longer LOS, or nonroutine hospital discharge in this cohort analysis. Further prospective studies are necessary to understand how outcomes in patients with NF1 compare to non-NF1 pediatric and young adult patients.