Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review.

OBJECTIVE: The objective of this study was to investigate the perioperative management and outcomes of patients with a prior history of successful transplantation undergoing spine surgery. METHODS: We searched Medline, Embase, and Cochrane Central Register of Controlled Trials for matching reports in July 2021. We included case reports, cohort studies, and retrospective analyses, including terms for various transplant types and an exhaustive list of key words for various forms of spine surgery. RESULTS: We included 45 studies consisting of 34 case reports (published 1982-2021), 3 cohort analyses (published 2005-2006), and 8 retrospective analyses (published 2006-2020). The total number of patients included in the case reports, cohort studies, and retrospective analysis was 35, 48, and 9695, respectively. The mean 1-year mortality rate from retrospective analyses was 4.6% ± 1.93%, while the prevalence of perioperative complications was 24%. Cohort studies demonstrated an 8.5% ± 12.03% 30-day readmission rate. The most common procedure performed was laminectomy (38.9%) among the case reports. Mortality after spine surgery was noted for 4 of 35 case report patients (11.4%). CONCLUSIONS: This is the first systematic scoping review examining the population of transplant patients with subsequent unrelated spine surgery. There is significant heterogeneity in the outcomes of post-transplant spine surgery patients. Given the inherent complexity of managing this group and elevated mortality and complications compared to the general spine surgery population, further investigation into their clinical care is warranted.

Effects of repetitive head trauma on symptomatology of subsequent sport-related concussion.

OBJECTIVE: Adolescent participation in athletics continues to grow, leading to an increasing incidence of sports-related concussion (SRC). The current literature suggests that a greater number of prior concussions positively correlates with a greater number of total symptoms, but the specific concussion-related symptoms are not as well defined. The current study investigated the effects of prior recurrent head injury on the symptom profiles of student-athletes after another suspected concussion. METHODS: A multicenter database consisting of 25,815 Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) results was filtered for student-athletes aged 12-22 years old who competed in 21 different sports. Patients were separated into 2 cohorts: athletes reporting a single prior concussion (SRC1) and athletes reporting 2 or more prior concussions (SRC2+). Comparisons were assessed for differences in 22 symptoms and 4 symptom clusters at baseline, first postinjury test (PI1), and second postinjury test (PI2) by using univariate and multivariate analyses. RESULTS: No differences were seen between SRC1 (n = 2253) and SRC2+ (n = 976) at baseline. At PI1, the SRC2+ group (n = 286) had lower severity of headaches (p = 0.04) but increased nervousness (p = 0.042), irritability (p = 0.028), sadness (p = 0.028), visual problems (p = 0.04), and neuropsychiatric symptoms (p = 0.009) compared with SRC1 (n = 529). Multivariate analysis revealed decreased headache severity with increased prior concussion (ß = -0.27,95% CI -0.45 to -0.09, p = 0.003). Multivariate analysis at PI2 demonstrated the SRC2+ cohort (n = 130) had increased cognitive (ß = 1.22, 95% CI 0.27-2.18, p = 0.012), sleep (ß = 0.63, 95% CI 0.17-1.08, p = 0.007), and neuropsychiatric (ß = 0.67,95% CI 0.14-1.2,0.014) symptoms compared with SRC1 (n = 292). CONCLUSIONS: At longitudinal follow-up, patients with a history of recurrent concussions reported greater symptom burden in cognitive, sleep, and neuropsychiatric symptom clusters but not migraine symptoms. This is an important distinction because migraine symptoms are often more easily distinguishable to patients, parents, and physicians. Careful assessment of specific symptoms should be considered in patients with a history of recurrent head injury prior to return to play.

Novel Grading Scales for Static and Flexion-Extension Magnetic Resonance Imaging in Patients with Cervical Spondylotic Myelopathy.

BACKGROUND: Flexion-extension magnetic resonance imaging (MRI) has potential to identify cervical pathology not detectable on conventional static MRI. Our study evaluated standard quantitative and novel subjective grading scales for assessing the severity of cervical spondylotic myelopathy in dynamic sagittal MRI as well as in static axial and sagittal images. METHODS: Forty-five patients underwent both conventional and flexion-extension MRI prior to anterior cervical discectomy and fusion from C4 through C7. In addition to measuring Cobb angles and cervical canal diameter, grading scales were developed for assessment of vertebral body translation, loss of disc height, change in disc contour, deformation of cord contour, and cord edema. Data were collected at all levels from C2-C3 through C7-T1. Variations in measurements between cervical levels and from flexion through neutral to extension were assessed using Mann-Whitney, Kruskal-Wallis, and two-way ANOVA tests. RESULTS: Cervical canal diameter, vertebral translation, and posterior disc opening changed significantly from flexion to neutral to extension positions (P < 0.01). When comparing operative versus nonoperative cervical levels, significant differences were found when measuring sagittal cervical canal dimensions, vertebral translation, and posterior disc opening (P < 0.01). Degenerative loss of disc height, disc dehydration, deformation of ventral cord contour, and cord edema were all significantly increased at operative levels versus nonoperative levels (P < 0.01). CONCLUSIONS: Flexion-extension MRI demonstrated significant changes not available from conventional MRI. Subjective scales for assessing degenerative changes were significantly more severe at levels with operative cervical spondylotic myelopathy. The utility of these scales for planning surgical intervention at specific and adjacent levels is currently under investigation.

Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review Protocol.

Spine surgery patients with a history of organ transplantation are a complex population due to their unique anesthetic considerations, immunologic profiles, drug interactions, and potential organ dysfunction. It is common for these patients to develop neck/back pain and pathology that warrants surgical intervention. However, there is a relative dearth of literature examining their outcomes and clinical considerations. The purpose of this protocol is to investigate their clinical outcomes following spine surgery and medical management. We perform a systematic literature search using PRISMA-ScR guidelines to include case reports, cohort studies, and retrospective analyses. The search terms include kidney, liver, heart, pancreas, lung, and bone marrow for transplants of interest and contain an extensive list of terms covering spine surgery. The search is conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials. A thorough examination of titles and abstracts is performed followed by data extraction. The data points include patient demographics, past medical history, spine procedural information, and clinical outcomes. This systematic review will aid clinicians in identifying demographics, medical management, and clinical outcomes for spine surgery patients with a previous organ transplant. These findings will highlight the gaps in the knowledge of this complex population and stimulate further research.

Subspecialty and Training Preferences for U.S. Neurosurgery Faculty with International Training.

BACKGROUND: Academic neurosurgeons with international medical training play a large role in the U.S. neurosurgical workforce. We aimed to compare U.S.-trained neurosurgeons with internationally trained neurosurgeons to reveal differences in subspecialty preferences and training opportunities abroad. METHODS: We identified 1671 neurosurgeons from 115 Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgical residency programs. Data on demographics, institution characteristics, and chosen subspecialty were collected, and faculty were divided based on location of training. Univariate analysis and multivariable logistic regression compared faculty characteristics between training locations. RESULTS: Compared with the U.S. medical school + U.S. residency group, the international medical graduate + U.S. residency group was more likely to subspecialize in oncology/skull base and vascular neurosurgery and complete a fellowship in the United States or internationally (P < 0.05). The international medical graduate + international residency group was more likely to subspecialize in oncology/skull base neurosurgery, more likely to complete an international fellowship, and less likely to practice general neurosurgery (P < 0.05). Neurosurgeons in pediatrics, radiosurgery, and vascular subspecialties were more likely to receive fellowship training in any location (P < 0.05). Additionally, functional neurosurgeons were more likely to complete fellowships internationally, spinal neurosurgeons were less likely to pursue international fellowships, and peripheral nerve neurosurgeons were more likely to have dual fellowship training in both the United States and abroad (P < 0.05). CONCLUSIONS: International medical training affected subspecialty choice and fellowship training. Internationally trained neurosurgeons more often specialized in oncology and vascular neurosurgery. Functional neurosurgeons were more likely to complete international fellowships, spine neurosurgeons were less likely to complete international fellowships, and peripheral nerve neurosurgeons more often had both U.S. and international fellowships.

Academic Productivity of United States Neurosurgeons Trained Abroad.

BACKGROUND: Previous research in neurosurgery has examined academic productivity for U.S. medical graduates and residents. However, associations between scholarly output and international medical education, residency training, and fellowship training are scarcely documented. METHODS: We identified 1671 U.S. academic neurosurgeons in 2020 using publicly available data along with their countries of medical school, residency, and fellowship training. Using Scopus, h-index, number of publications, and number of times publications were cited were compiled. Demographic, subspeciality, and academic productivity variables were compared between training locations using univariate analysis and multivariable linear regression. RESULTS: Of the current neurosurgery faculty workforce, 16% completed at least 1 component of their training abroad. Canada was the most represented international country in the cohort. Academic productivity for neurosurgeons with international medical school and/or international residency did not significantly differ from that of neurosurgeons trained in the United States. Neurosurgeons with ≥1 U.S. fellowships or ≥1 international fellowships did not have higher academic productivity than neurosurgeons without a fellowship. However, dual fellowship training in both domestic and international programs was associated with higher mean h-index (ß = 6.00, 95% confidence interval 1.01 to 10.98, P = 0.02), higher citations (ß = 2092.0, 95% confidence interval 460.1 to 3724.0, P = 0.01), and a trend toward higher publications (ß = 36.82, 95% confidence interval -0.21 to 73.85, P = 0.051). CONCLUSIONS: Neurosurgeon scholarly output was not significantly affected by international training in medical school or residency. Dual fellowship training in both a domestic and an international program was associated with higher academic productivity.

Surgical Start Time Is Not Predictive of Microdiscectomy Outcomes.

STUDY DESIGN: Retrospective analysis of clinical data from a single institution. OBJECTIVE: The objective of this study was to assess the time of surgery as a possible predictor for outcomes, length of stay, and cost following microdiscectomy. SUMMARY OF BACKGROUND DATA: The volume of microdiscectomy procedures has increased year over year, heightening interest in surgical outcomes. Previous investigations have demonstrated an association between time of procedures and clinical outcomes in various surgeries, however, no study has evaluated its influence on microdiscectomy. METHODS: Demographic and outcome variables were collected from all patients that underwent a nonemergent microdiscectomy between 2008 and 2016. Patients were divided into 2 cohorts: those receiving surgery before 2 pm were assigned to the early group and those with procedures beginning after 2 pm were assigned to the late group. Outcomes and patient-level characteristics were compared using bivariate, multivariable logistic, and linear regression models. Adjusted length of stay and cost were coprimary outcomes. Secondary outcomes included operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates. RESULTS: Of the 1261 consecutive patients who met the inclusion criteria, 792 were assigned to the late group and 469 were assigned to the early group. There were no significant differences in demographics or baseline characteristics between the 2 cohorts. In the unadjusted analysis, mean length of stay was 1.80 (SD=1.82) days for the early group and 2.00 (SD=1.70) days for the late group (P=0.054). Mean direct cost for the early cohort was $5088 (SD=$4212) and $4986 (SD=$2988) for the late cohort (P=0.65). There was no difference in adjusted length of stay or direct cost. No statistically significant differences were found in operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates between the 2 cohorts. CONCLUSION: The study findings suggest that early compared with late surgery is not significantly predictive of surgical outcomes following microdiscectomy.

Afternoon Surgical Start Time Is Associated with Higher Cost and Longer Length of Stay in Posterior Lumbar Fusion.

BACKGROUND: Existing research about surgical start time is equivocal about associations between outcomes and late start times, and there is only one published report investigating start time in spine surgery. Therefore, the objective of this study was to assess associations between surgical start time, length of stay (LOS), and cost in lumbar spine surgery. METHODS: Patients at a single institution undergoing posterior lumbar fusion (PLF) were grouped based on whether they received their surgery before or after 2 pm, with those receiving their surgery between 12 am and 6 am and receiving surgery for tumors, trauma, or infections being excluded. These 2 groups were then compared on the basis of demographics and outcomes with cost and LOS as the coprimary outcomes. RESULTS: A total of 2977 patients underwent PLF during the study period. There were minimal differences in preoperative characteristics of the cohorts. The patients who underwent PLF starting after 2 pm had longer LOS (0.45 days; 95% confidence interval [CI], 0.18-0.72; P = 0.001) and higher costs ($1343; 95% CI, $339-$2348; P = 0.009) than cases starting before 2 pm The late surgical start cohort also had higher rates of nonhome discharge (29.73% vs. 23.17%, P = 0.0004), and 30-day (4.36% vs. 2.5%, P = 0.01) and 90-day emergency department visits (5.72% vs. 2.94%, P = 0.0005). CONCLUSIONS: Late surgical start time is associated with longer LOS and higher cost in patients undergoing PLF.

Utility of the Hospital Frailty Risk Score for Predicting Adverse Outcomes in Degenerative Spine Surgery Cohorts.

BACKGROUND: As spine surgery becomes increasingly common in the elderly, frailty has been used to risk stratify these patients. The Hospital Frailty Risk Score (HFRS) is a novel method of assessing frailty using International Classification of Diseases, Tenth Revision (ICD-10) codes. However, HFRS utility has not been evaluated in spinal surgery. OBJECTIVE: To assess the accuracy of HFRS in predicting adverse outcomes of surgical spine patients. METHODS: Patients undergoing elective spine surgery at a single institution from 2008 to 2016 were reviewed, and those undergoing surgery for tumors, traumas, and infections were excluded. The HFRS was calculated for each patient, and rates of adverse events were calculated for low, medium, and high frailty cohorts. Predictive ability of the HFRS in a model containing other relevant variables for various outcomes was also calculated. RESULTS: Intensive care unit (ICU) stays were more prevalent in high HFRS patients (66%) than medium (31%) or low (7%) HFRS patients. Similar results were found for nonhome discharges and 30-d readmission rates. Logistic regressions showed HFRS improved the accuracy of predicting ICU stays (area under the curve [AUC] = 0.87), nonhome discharges (AUC = 0.84), and total complications (AUC = 0.84). HFRS was less effective at improving predictions of 30-d readmission rates (AUC = 0.65) and emergency department visits (AUC = 0.60). CONCLUSION: HFRS is a better predictor of length of stay (LOS), ICU stays, and nonhome discharges than readmission and may improve on modified frailty index in predicting LOS. Since ICU stays and nonhome discharges are the main drivers of cost variability in spine surgery, HFRS may be a valuable tool for cost prediction in this specialty.

Adjacent Segment Reoperation and Other Perioperative Outcomes in Patients Who Underwent Anterior Lumbar Interbody Fusions at One and Two Levels.

OBJECTIVE: This is the first large retrospective analysis of patients undergoing anterior lumbar interbody fusion (ALIF) with concern for clinical determinants leading to reoperation for adjacent segment disease (ASD). The objective of this study is to examine the specific perioperative and clinical determinants that affect need for adjacent segment reoperation in patients who underwent 1-level and 2-level ALIF procedures for degenerative disc disorders. METHODS: All cases at our institution between 2008 and 2016 involving an ALIF performed for degenerative disc disorders at 1 or 2 levels were examined. A total of 404 ALIF cases, of which 268 were single-level (66.33%) and 136 were 2-level procedures (33.67%), were included. Adjacent segment reoperation was the primary outcome. Secondary outcomes included increased blood loss, extended surgery duration, greater nonhome discharge, extended hospitalization, and higher total direct costs. Univariate and multivariate logistic regression assessed how number of levels fused related to perioperative outcomes. RESULTS: The patient cohorts shared similar demographic characteristics and showed expected differences in certain intraoperative outcomes. After controlling for preoperative and intraoperative variables, multivariate regression showed that patients who underwent 2-level ALIFs experienced increased odds of adjacent segment reoperation (P = 0.0424) but no other adverse clinical outcomes. CONCLUSIONS: Our findings support a biomechanical hypothesis of ASD onset after fusion, suggesting that the risk of ASD after ALIF lies primarily in the number of levels fused rather than any demographic or intraoperative variables.

Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke.

Background and Purpose- The emergency management of stroke is complex and highly time-sensitive. Recent landmark trials demonstrating the strong benefit of thrombectomy have led to rapid change in stroke management. This article reviews a large number of medical malpractice lawsuits related to the emergency management of stroke to characterize factors involved in these lawsuits. Methods- Three large legal databases were used to search for jury verdicts and settlements in cases related to the acute care of stroke patients in the United States. Search terms included "stroke" and "medical malpractice." Cases were screened to include only cases in which the allegation involved negligence in the acute care of a patient suffering a stroke. Results- We found 246 medical malpractice cases related to the acute management of ischemic stroke and 26 related to intracranial hemorrhage. Seventy-one cases specifically alleged a failure to treat with tPA (tissue-type plasminogen activator) and 7 cases alleged a failure to treat, or to timely treat, with thrombectomy. Overall there were 151 cases (56%) which ended with no payout, 74 cases (27%) were settled out of court, and 47 cases (17%) went to court and resulted in a verdict for the plaintiff. The average payout in settlements was $1 802 693, and the average payout in plaintiff verdicts was $9 705 099. Conclusions- Malpractice litigation is a risk in acute stroke care and can lead to significant financial consequences. The majority of malpractice lawsuits related to the emergency management of stroke allege a failure to diagnose and failure to treat. Allegations of a failure to treat acute ischemic stroke with tPA were frequently found and are common in lawsuits. Allegations of a failure to treat a large vessel occlusion with thrombectomy were less frequently found. Given recent changes in practice guidelines and the demonstrated strong treatment effect of thrombectomy, it is likely that such litigation will increase in the coming years.