A current review of spinal meningiomas: epidemiology, clinical presentation and management.

PURPOSE: To provide an up-to-date review of the epidemiology, histopathology, molecular biology, and etiology of spinal meningiomas, as well as discuss the clinical presentation, clinical evaluation, and most recent treatment recommendations for these lesions. METHODS: PubMed and Google Scholar search was performed for studies related to meningiomas of the spine. The terms "meningioma," "spinal meningioma," "spine meningioma," "meningioma of the spine," "benign spinal tumors," and "benign spine tumors," were used to identify relevant studies. All studies, including primary data papers, meta-analyses, systematic reviews, general reviews, case reports, and clinical trials were considered for review. RESULTS: Eighty-four studies were identified in the review. There were 22 studies discussing adverse postoperative outcomes, 21 studies discussing tumor genetics, 19 studies discussing epidemiology and current literature, 9 studies discussing radiation modalities and impact on subsequent tumor development, 5 studies on characteristic imaging findings, 5 studies discussing hormone use/receptor status on tumor development, 2 discussing operative techniques and 1 discussing tumor identification. CONCLUSION: Investigations into spinal meningiomas generally lag behind that of intracranial meningiomas. Recent advancements in the molecular profiling of spinal meningiomas has expanded our understanding of these tumors, increasing our appreciation for their heterogeneity. Continued investigation into the defining characteristics of different spinal meningiomas will aid in treatment planning and prognostication.

Spondyloepimetaphyseal dysplasia Pakistani type: expansion of the phenotype.

Spondyloepimetaphyseal dysplasia (SEMD), Pakistani type, is a skeletal dysplasia characterized by platyspondyly, delayed epiphyseal ossification, mild metaphyseal abnormalities, short stature, and short and bowed legs, and is caused by mutations in PAPSS2. In a single Turkish patient also hyperandrogenism was reported. We describe five patients from a Turkish family with SEMD Pakistani type with homozygosity for a nonsense mutation (p.R329X) leading to a stop codon in PAPSS2. Plasma levels of dehydroepiandrosterone (DHEA) and androstenedione were normal, but DHEA sulfate levels were low in four of the patients. Two patients and a mother had history of pubertal hyperandrogenism. Testosterone level was mildly elevated in one of the female patients, and insulin resistance was not detected in any of the patients. The patients also had precocious costal calcification, small iliac bones, short femoral necks, coxa vara, short halluces and fused vertebral bodies, none of which has been reported previously in this entity.

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.

Hospital Frailty Risk Score and Healthcare Resource Utilization After Surgery for Primary Spinal Intradural/Cord Tumors.

OBJECTIVE: The Hospital Frailty Risk Score (HFRS) is a metric that measures frailty among patients in large national datasets using ICD-10 codes. While other metrics have been utilized to demonstrate the association between frailty and poor outcomes in spine oncology, none have examined the HFRS. The aim of this study was to investigate the impact of frailty using the HFRS on complications, length of stay, cost of admission, and discharge disposition in patients undergoing surgery for primary tumors of the spinal cord and meninges. METHODS: A retrospective cohort study was performed using the Nationwide Inpatient Sample database from 2016 to 2018. Adult patients undergoing surgery for primary tumors of the spinal cord and meninges were identified using ICD-10-CM codes. Patients were categorized into 2 cohorts based on HFRS score: Non-Frail (HFRS<5) and Frail (HFRS≥5). Patient characteristics, treatment, perioperative complications, LOS, discharge disposition, and cost of admission were assessed. RESULTS: Of the 5955 patients identified, 1260 (21.2%) were Frail. On average, the Frail cohort was nearly 8 years older (P < .001) and experienced more postoperative complications (P = .001). The Frail cohort experienced longer LOS (P < .001), a higher rate of non-routine discharge (P = .001), and a greater mean cost of admission (P < .001). Frailty was found to be an independent predictor of extended LOS (P < .001) and non-routine discharge (P < .001). CONCLUSION: Our study is the first to use the HFRS to assess the impact of frailty on patients with primary spinal tumors. We found that frailty was associated with prolonged LOS, non-routine discharge, and increased hospital costs.

Impact of Affective Disorders on Inpatient Opioid Consumption and Hospital Outcomes Following Open Posterior Spinal Fusion for Adult Spine Deformity.

OBJECTIVE: Affective disorders (ADs) are common and have a profound impact on surgical recovery, though few have studied the impact of ADs on inpatient narcotic consumption. The aim of this study was to assess the impact of ADs on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity. METHODS: A retrospective cohort study was performed using the 2016-2017 Premier Healthcare Database. Adults who underwent adult spinal deformity surgery were identified using International Classification of Disease, Tenth Revision, codes. Patients were grouped based on comorbid diagnosis of an AD. Demographics, comorbidities, intraoperative variables, complications, length of stay, admission costs, and nonroutine discharge rates were assessed. Increased inpatient opioid use was categorized by morphine milligram equivalents consumption greater than the 75th percentile. Multivariate regression analysis was used to identify predictors of increased healthcare recourse utilization. RESULTS: Of the 1831 study patients, 674 (36.8%) had an AD. A smaller proportion of patients in the AD cohort were 65+ years of age (P = 0.001), while a greater proportion of patients in the AD cohort identified as non-Hispanic White (P < 0.001). A greater proportion of patients in the AD cohort had increased morphine milligram equivalents consumption (P < 0.001). The AD cohort also had a longer mean length of stay (P < 0.001). A greater proportion of patients in the AD cohort had nonroutine discharges (P = 0.039) and unplanned 30-day readmission (P = 0.041). On multivariate analysis, AD was significantly associated with increased cost (odds ratio: 1.61, P < 0.001) and nonroutine discharge (odds ratio: 1.36, P = 0.035). CONCLUSIONS: ADs may be associated with increased inpatient opioid consumption and healthcare resource utilization.

Leveraging HFRS to assess how frailty affects healthcare resource utilization after elective ACDF for CSM.

BACKGROUND CONTEXT: Frailty is a common comorbidity associated with worsening outcomes in various medical and surgical fields. The Hospital Frailty Risk Score (HFRS) is a recently developed tool which assesses frailty using 109 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) comorbidity codes to assess severity of frailty. However, there is a paucity of studies utilizing the HFRS with patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). PURPOSE: The aim of this study was to investigate the impact of HFRS on health care resource utilization following ACDF for CSM. STUDY DESIGN: A retrospective cohort study was performed using the Nationwide Inpatient Sample (NIS) database from 2016-2019. PATIENT SAMPLE: All adult (≥18 years old) patients undergoing primary, ACDF for CSM were identified using the ICD-10 CM codes. OUTCOME MEASURES: Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total admission costs were assessed. METHODS: The 109 ICD-10 codes with pre-assigned values from 0.1 to 7.1 pertaining to frailty were queried in each patient, with a cumulative HFRS ≥5 indicating a frail patient. Patients were then categorized as either Low HFRS (HFRS<5) or Moderate to High HFRS (HFRS≥5). A multivariate stepwise logistic regression was used to determine the odds ratio for risk-adjusted extended LOS, non-routine discharge disposition, and increased hospital cost. RESULTS: A total of 29,305 patients were identified, of which 3,135 (10.7%) had a Moderate to High HFRS. Patients with a Moderate to High HFRS had higher rates of 1 or more postoperative complications (Low HFRS: 9.5% vs. Moderate-High HFRS: 38.6%, p≤.001), significantly longer hospital stays (Low HFRS: 1.8±1.7 days vs. Moderate-High HFRS: 4.4 ± 6.0, p≤.001), higher rates of non-routine discharge (Low HFRS: 5.8% vs. Moderate-High HFRS: 28.2%, p≤.001), and increased total cost of admission (Low HFRS: $19,691±9,740 vs. Moderate-High HFRS: $26,935±22,824, p≤.001) than patients in the Low HFRS cohort. On multivariate analysis, Moderate to High HFRS was found to be a significant independent predictor for extended LOS [OR: 3.19, 95% CI: (2.60, 3.91), p≤.001] and non-routine discharge disposition [OR: 3.88, 95% CI: (3.05, 4.95), p≤.001] but not increased cost [OR: 1.10, 95% CI: (0.87, 1.40), p=.418]. CONCLUSIONS: Our study suggests that patients with a higher HFRS have increased total hospital costs, a longer LOS, higher complication rates, and more frequent nonroutine discharge compared with patients with a low HFRS following elective ACDF for CSM. Although frail patients should not be precluded from surgical management of cervical spine pathology, these findings highlight the need for peri-operative protocols to medically optimize patients to improve health care quality and decrease costs.

Differences in Health Care Resource Utilization After Surgery for Metastatic Spinal Column Tumors in Patients with a Concurrent Affective Disorder in the United States.

BACKGROUND: Affective disorders, such as depression and anxiety, are exceedingly common among patients with metastatic cancer. The aim of this study was to investigate the relationship between affective disorders and health care resource utilization in patients undergoing surgery for a spinal column metastasis. METHODS: A retrospective cohort study was performed using the 2016-2018 National Inpatient Sample database. All adult patients (≥18 years) undergoing surgery for a metastatic spinal tumor were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification coding systems. Patients were categorized into 2 cohorts: no affective disorder (No-AD) and affective disorder (AD). Patient demographics, comorbidities, hospital characteristics, intraoperative variables, postoperative adverse events (AEs), length of stay (LOS), discharge disposition, and total cost of hospital admission were assessed. A multivariate logistic regression analysis was used to identify independent predictors of increased cost, nonroutine discharge, and prolonged LOS. RESULTS: Of the 8360 patients identified, 1710 (20.5%) had a diagnosis of AD. Although no difference was observed in the rates of postoperative AEs between the cohorts (P = 0.912), the AD cohort had a significantly longer mean LOS (No-AD, 10.1 ± 8.3 days vs. AD, 11.6 ± 9.8 days; P = 0.012) and greater total cost (No-AD, $53,165 ± 35,512 vs. AD, $59,282 ± 36,917; P = 0.011). No significant differences in nonroutine discharge were observed between the cohorts (P = 0.265). On multivariate regression analysis, having an affective disorder was a significant predictor of increased costs (odds ratio, 1.45; confidence interval, 1.03-2.05; P = 0.034) and nonroutine discharge (odds ratio, 1.40; confidence interval, 1.06-1.85; P = 0.017), but not prolonged LOS (P = 0.067). CONCLUSIONS: Our study found that affective disorders were significantly associated with greater hospital expenditures and nonroutine discharge, but not prolonged LOS, for patients undergoing surgery for spinal metastases.

Assessment of Frailty Indices and Charlson Comorbidity Index for Predicting Adverse Outcomes in Patients Undergoing Surgery for Spine Metastases: A National Database Analysis.

OBJECTIVE: The aim of this study was to assess the predictive ability of Metastatic Spinal Tumor Frailty Index (MSTFI) and the Modified 5-Item Frailty Index (mFI-5) on adverse outcomes, compared with the known Charlson Comorbidity Index (CCI). METHODS: A retrospective cohort study was performed using National Surgical Quality Improvement Program database from 2011 to 2019. All adult patients undergoing various procedures for extradural spinal metastases were identified. Patients were stratified into frail and nonfrail cohorts based on CCI, mFI-5, and MSTFI scores. A multivariate logistic regression analysis was used to identify independent predictors of prolonged length of stay, nonroutine discharge, adverse events, and unplanned readmission. RESULTS: Of the 1613 patients included in this study, 21.4% had a CCI >0, 56.6% had an mFI-5 >0, and 76.7% of patients had an MSTFI >0. On multivariate analysis, all 3 indices were found to be predictive of nonroutine discharge (CCI: adjusted odds ratio [aOR], 1.41 vs. mFI-5: aOR, 1.37 vs. MSTFI: aOR, 1.5) and adverse events (CCI: aOR, 1.53 vs. mFI-5: aOR, 1.23 vs. MSTFI: aOR, 1.43). High CCI (adjusted relative risk, 1.67) and MSTFI (adjusted relative risk, 1.14), but not mFI-5, were also associated with a prolonged length of stay, whereas MSTFI was found to be the only significant predictor of unplanned readmission (aOR, 1.22). CONCLUSIONS: Our study suggests that MSTFI frailty index may be more sensitive than both CCI and mFI-5 in identifying adverse outcomes after spine surgery for metastases.

Octogenarians Are Independently Associated With Extended LOS and Non-Routine Discharge After Elective ACDF for CSM.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to determine the impact age has on LOS and discharge disposition following elective ACDF for cervical spondylotic myelopathy (CSM). METHODS: A retrospective cohort study was performed using the National Inpatient Sample (NIS) database from 2016 and 2017. All adult patients >50 years old undergoing ACDF for CSM were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then stratified by age: 50 to 64 years-old, 65 to 79 years-old, and greater than or equal to 80 years-old. Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total cost of admission were assessed. RESULTS: A total of 14 865 patients were identified. Compared to the 50-64 and 65-79 year-old cohorts, the 80+ years cohort had a significantly higher rate of postoperative complication (50-64 yo:10.2% vs. 65-79 yo:12.6% vs. 80+ yo:18.9%, P = 0.048). The 80+ years cohort experienced significantly longer hospital stays (50-64 yo: 2.0 ± 2.4 days vs. 65-79 yo: 2.2 ± 2.8 days vs. 80+ yo: 2.3 ± 2.1 days, P = 0.028), higher proportion of patients with extended LOS (50-64 yo:18.3% vs. 65-79 yo:21.9% vs. 80+ yo:28.4%, P = 0.009), and increased rates of non-routine discharges (50-64 yo:15.1% vs. 65-79 yo:23.0% vs. 80+ yo:35.8%, P < 0.001). On multivariate analysis, age 80+ years was found to be a significant independent predictor of extended LOS [OR:1.97, 95% CI:(1.10,3.55), P = 0.023] and non-routine discharge [OR:2.46, 95% CI:(1.44,4.21), P = 0.001]. CONCLUSIONS: Our study demonstrates that octogenarian age status is a significant independent risk factor for extended LOS and non-routine discharge after elective ACDF for CSM.

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.

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.

Hospital Frailty Risk Score and healthcare resource utilization after surgery for metastatic spinal column tumors.

OBJECTIVE: The Hospital Frailty Risk Score (HFRS) was developed utilizing ICD-10 diagnostic codes to identify frailty and predict adverse outcomes in large national databases. While other studies have examined frailty in spine oncology, the HFRS has not been assessed in this patient population. The aim of this study was to examine the association of HFRS-defined frailty with complication rates, length of stay (LOS), total cost of hospital admission, and discharge disposition in patients undergoing spine surgery for metastatic spinal column tumors. METHODS: A retrospective cohort study was performed using the years 2016 to 2019 of the National Inpatient Sample (NIS) database. All adult patients (≥ 18 years old) undergoing surgical intervention for metastatic spinal column tumors were identified using the ICD-10-CM diagnostic codes and Procedural Coding System. Patients were categorized into the following three cohorts based on their HFRS: low frailty (HFRS < 5), intermediate frailty (HFRS 5-15), and high frailty (HFRS > 15). Patient demographics, comorbidities, treatment modality, perioperative complications, LOS, discharge disposition, and total cost of hospital admission were assessed. A multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, nonroutine discharge, and increased cost. RESULTS: Of the 11,480 patients identified, 7085 (61.7%) were found to have low frailty, 4160 (36.2%) had intermediate frailty, and 235 (2.0%) had high frailty according to HFRS criteria. On average, age increased along with progressively worsening frailty scores (p ≤ 0.001). The proportion of patients in each cohort who experienced ≥ 1 postoperative complication significantly increased along with increasing frailty (low frailty: 29.2%; intermediate frailty: 53.8%; high frailty: 76.6%; p < 0.001). In addition, the mean LOS (low frailty: 7.9 ± 5.0 days; intermediate frailty: 14.4 ± 13.4 days; high frailty: 24.1 ± 18.6 days; p < 0.001), rate of nonroutine discharge (low frailty: 40.4%; intermediate frailty: 60.6%; high frailty: 70.2%; p < 0.001), and mean total cost of hospital admission (low frailty: $48,603 ± $29,979; intermediate frailty: $65,271 ± $43,110; high frailty: $96,116 ± $60,815; p < 0.001) each increased along with progressing frailty. On multivariate regression analysis, intermediate and high frailty were each found to be significant predictors of both prolonged LOS (intermediate: OR 3.75 [95% CI 2.96-4.75], p < 0.001; high: OR 7.33 [95% CI 3.47-15.51]; p < 0.001) and nonroutine discharge (intermediate: OR 2.05 [95% CI 1.68-2.51], p < 0.001; high: OR 5.06 [95% CI 1.93-13.30], p = 0.001). CONCLUSIONS: This study is the first to use the HFRS to assess the impact of frailty on perioperative outcomes in patients with metastatic bony spinal tumors. Among patients with metastatic bony spinal tumors, frailty assessed using the HFRS was associated with longer hospitalizations, more nonroutine discharges, and higher total hospital costs.

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.

Clinical Outcomes between Stand-Alone Zero-Profile Spacers and Cervical Plate with Cage Fixation for Anterior Cervical Discectomy and Fusion: A Retrospective Analysis of 166 Patients.

Stand-alone (SA) zero-profile implants are an alternative to cervical plating (CP) in anterior cervical discectomy and fusion (ACDF). In this study, we investigate differences in surgical outcomes between SA and CP in ACDF. We conducted a retrospective analysis of 166 patients with myelopathy and/or radiculopathy who had ACDF with SA or CP from Jan 2013-Dec 2016. We measured surgical outcomes including Bazaz dysphagia score at 3 months, Nurick grade at last follow-up, and length of hospital stay. 166 patients (92F/74M) were reviewed. 92 presented with radiculopathy (55%), 37 with myelopathy (22%), and 37 with myeloradiculopathy (22%). The average operative time with CP was longer than SA (194 ± 69 vs. 126 ± 46 min) (p < 0.001), as was the average length of hospital stay (2.1 ± 2 vs. 1.5 ± 1 days) (p = 0.006). At 3 months, 82 patients (49.4%) had a follow-up for dysphagia, with 3 patients reporting mild dysphagia and none reporting moderate or severe dysphagia. Nurick grade at last follow-up for the myelopathy and myeloradiculopathy cohorts improved in 63 patients (85%). Prolonged length of stay was associated with reduced odds of having an optimal outcome by 0.50 (CI = 0.35-0.85, p = 0.003). Overall, we demonstrate that there is no significant difference in neurological outcome or rates of dysphagia between SA and CP, and that both lead to overall improvement of symptoms based on Nurick grading. However, we also show that the SA group has shorter length of hospital stay and operative time compared to CP.

Impact of Frailty on Morbidity and Mortality in Adult Patients Presenting with an Acute Traumatic Cervical Spinal Cord Injury.

OBJECTIVE: The aim of this study was to determine if baseline frailty was an independent predictor of adverse events (AEs) and in-hospital mortality in patients being treated for acute cervical spinal cord injury (SCI). METHODS: A retrospective cohort study was performed using the National Trauma Database (NTDB) from 2017. Adult patients (>18 years old) with acute cervical SCI were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification diagnostic and procedural coding systems. 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. Patient demographics, comorbidities, type of injury, diagnostic and treatment modality, AEs, and in-patient mortality were assessed. A multivariate logistic regression analysis was used to identify independent predictors of in-hospital AEs and mortality. RESULTS: Of 8986 patients identified, 4990 (55.5%) were classified as mFI = 0, 2328 (26%) as mFI = 1, and 1668 (18.5%) as mFI≥2. On average, the mFI≥2 cohort was 5 years older than the mFI = 1 cohort and 22 years older than the mFI = 0 cohort (P < 0.001). Most patients in each cohort sustained either complete SCI or central cord syndrome after a fall or transport accident (mFI = 0, 77.31% vs. mFI = 1, 89.5% vs. mFI≥2, 93.65%). With respect to in-hospital events, the proportion of patients who experienced any AE increased significantly along with frailty score (mFI = 0, 30.42% vs. mFI = 1, 31.74% vs. mFI≥2, 34.95%; P < 0.001). In-hospital mortality followed a similar trend, increasing with frailty score (mFI = 0, 10.53% vs. mFI = 1, 11.33% vs. mFI≥2, 16.23%; P < 0.001). On multivariate regression analysis, both mFI = 1 1.21 (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.05-1.4; P = 0.008) and mFI≥2 (OR, 1.23; 95% CI, 1.05-1.45; P = 0.012) predicted AEs, whereas only mFI≥2 was found to be a predictor for in-hospital mortality (OR, 1.45; 95% CI, 1.14-1.83; P = 0.002). CONCLUSIONS: Increasing frailty is associated with an increased risk of AEs and in-hospital mortality in patients undergoing treatment for cervical SCI.

Independent Association of Obesity and Nonroutine Discharge Disposition After Elective Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy.

OBJECTIVE: The prevalence of obesity continues to rise in the United States at a disparaging rate. Although previous studies have attempted to identify the influence obesity has on short-term outcomes following elective spine surgery, few studies have assessed the impact on discharge disposition following anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). The aim of this study was to determine whether obesity impacts the hospital management, cost, and discharge disposition after elective ACDF for adult CSM. METHODS: The National Inpatient Sample database was queried using the International Classification of Diseases, 10th revision, Clinical Modification, coding system to identify all (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF for the years 2016 and 2017. Discharge weights were used to estimate national demographics, Elixhauser comorbidities, complications, length of stay, total cost of admission, and discharge disposition. RESULTS: There were 17,385 patients included in the study, of whom 3035 (17.4%) had obesity (no obesity: 14,350; obesity: 3035). The cohort with obesity had a significantly greater proportion of patients with 3 or more comorbidities compared with the cohort with no obesity (no obesity: 28.1% vs. obesity: 43.5%, P < 0.001). The overall complication rates were greater in the cohort with obesity (no obesity: 10.3% vs. obesity: 14.3%, P = 0.003). On average, the cohort with obesity incurred a total cost of admission $1154 greater than the cost of the cohort with no obesity (no obesity: $19,732 ± 11,605 vs. obesity: $20,886 ± 10,883, P = 0.034) and a significantly greater proportion of nonroutine discharges (no obesity: 16.6% vs. obesity: 24.2%, P < 0.001). In multivariate regression analysis, obesity, age, race, health care coverage, hospital bed size, region, comorbidity, and complication rates all were independently associated with nonroutine discharge disposition. CONCLUSIONS: Our study demonstrates that obesity is an independent predictor for nonroutine discharge disposition following elective anterior cervical discectomy and fusion for cervical spondylotic myelopathy.

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.

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.

Patient- and hospital-related risk factors for non-routine discharge after lumbar decompression and fusion for spondylolisthesis.

OBJECTIVE: In various spinal surgeries, non-routine discharges have been associated with inferior outcomes. However, there exists a paucity of data regarding the relationship between non-routine discharge and quality of care among patients with spondylolisthesis. The aim of this study was to identify independent predictors for non-routine discharge following spinal decompression and fusion for lumbar spondylolisthesis. METHODS: A retrospective cohort study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016. Adult patients (≥18 years old) who underwent spinal decompression and fusion for lumbar spondylolisthesis were identified using ICD-9-CM diagnosis and CPT procedural coding systems. The study population was divided into two cohorts based on discharge disposition: routine (RD) and non-routine discharge (NRD). Patient demographics, comorbidities, adverse events, LOS, reoperation, and readmission were assessed. A multivariate logistic regression model was used to identify the independent predictors of non-home discharge and 30-day unplanned readmission. RESULTS: A total of 5252 patients were identified, of which 4316 (82.2%) had a RD and 936 (18.8%) had a NRD. The NRD cohort tended to be older (p < 0.001) and have a higher BMI (p < 0.001). Patients who experienced a NRD had a longer LOS (NRD: 4.7 ± 3.7 days vs RD: 3.1 ± 2.0 days, p < 0.001), a higher proportion of adverse events (p < 0.001), higher rates of reoperation (p = 0.005) and unplanned 30-day readmission rates (p < 0.001). On multivariate regression analysis, age [OR: 1.08, 95% CI (1.06-1.10), p < 0.001], female sex [OR: 2.01, 95% (1.51-2.69), p < 0.001], non-Hispanic Black race/ethnicity [OR: 2.10, 95% CI (1.36-3.24), p = 0.001], BMI [OR: 1.03, 95% CI (1.01-1.05), p = 0.007], dependent functional status [OR: 3.33, 95% CI (1.59 - 6.99), p = 0.001], malnourishment [OR: 2.14, 95% CI (1.27-3.62), p = 0.005], and LOS [OR: 1.26, 95% CI (1.18-1.33), p < 0.001] were all independent predictors for NRD. However, NRD did not independently predict an unplanned 30-day readmission on multivariate analysis. CONCLUSION: In our study we found that on univariate analysis NRD was associated with increased adverse events, length of stay and 30-day unplanned readmission. When controlling for patient- and hospital-related factors, we found that female sex, non-Hispanic Black race, BMI, dependent functional status, malnourishment and longer LOS were independently associated with NRD. However, NRD did not independently predict an unplanned 30-day readmission.

Thirty- and 90-day Readmissions After Spinal Surgery for Spine Metastases: A National Trend Analysis of 4423 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to investigate differences in 30- and 90-day readmissions for spine metastases treated with decompression and/or fusion spine surgery in a nationwide readmission database. SUMMARY OF BACKGROUND DATA: Patients with metastases to the spine represent a particularly vulnerable patient group that may encounter frequent readmissions. However, the 30- and 90-day rates for readmission following surgery for spine metastases have not been well described. METHODS: The Nationwide Readmission Database years 2013 to 2015 was queried. Patients were grouped by no readmission (non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). Weighted multivariate analysis assessed impact of treatment approach and clinical factors associated with 30- and 90-day readmissions. RESULTS: There were a total of 4423 patients with a diagnosis of spine metastases identified who underwent spine surgery, of which 1657 (37.5%) encountered either a 30-or 90-day unplanned readmission (30-R: n = 1068 [24-.1%]; 90-R: n = 589 [13.3%]; non-R: n = 2766). The most prevalent inpatient complications observed were postoperative infection (30-R: 16.3%, 90-R: 14.3%, non-R: 11.5%), acute post-hemorrhagic anemia (30-R: 13.4%, 90-R: 14.2%, non-R: 14.5%), and genitourinary complication (30-R: 5.7%, 90-R: 2.9%, non-R: 6.2%). The most prevalent 30-day and 90-day reasons for admission were sepsis (30-R: 10.2%, 90-R: 10.8%), postoperative infection (30-R: 13.7%, 90-R: 6.5%), and genitourinary complication (30-R: 3.9%, 90-R: 4.1%). On multivariate regression analysis, surgery type, age, hypertension, and renal failure were independently associated with 30-day readmission; rheumatoid arthritis/collagen vascular diseases, and coagulopathy were independently associated with 90-day readmission. CONCLUSION: In this study, we demonstrate several patient-level factors independently associated with unplanned hospital readmissions after surgical treatment intervention for spine metastases. Furthermore, we find that the most common reasons for readmission are sepsis, postoperative infection, and genitourinary complications.Level of Evidence: 3.