Laser interstitial thermal therapy for deep-seated perivascular brain tumors is not associated with distal ischemia.

PURPOSE: Laser interstitial thermal therapy (LITT) is a minimally invasive cytoreductive treatment option for brain tumors with a risk of vascular injury from catheter placement or thermal energy. This may be of concern with deep-seated tumors that have surrounding end-artery perforators and critical microvasculature. The purpose of this study was to assess the risk of distal ischemia following LITT for deep-seated perivascular brain tumors. METHODS: A retrospective review of a multi-institution database was used to identify patients who underwent LITT between 2013 and 2022 for tumors located within the insula, thalamus, basal ganglia, and anterior perforated substance. Demographic, clinical and volumetric tumor characteristics were collected. The primary outcome was radiographic evidence of distal ischemia on post-ablation magnetic resonance imaging (MRI). RESULTS: 61 LITT ablations for deep-seated perivascular brain tumors were performed. Of the tumors treated, 24 (39%) were low-grade gliomas, 32 (52%) were high-grade gliomas, and 5 (8%) were metastatic. The principal location included 31 (51%) insular, 14 (23%) thalamic, 13 (21%) basal ganglia, and 3 (5%) anterior perforated substance tumors. The average tumor size was 19.6 cm3 with a mean ablation volume of 11.1 cm3. The median extent of ablation was 92% (IQR 30%, 100%). Two patients developed symptomatic intracerebral hemorrhage after LITT. No patient had radiographic evidence of distal ischemia on post-operative diffusion weighted imaging. CONCLUSION: We demonstrate that LITT for deep-seated perivascular brain tumors has minimal ischemic risks and is a feasible cytoreductive treatment option for otherwise difficult to access intracranial tumors.

Association of prolonged symptom duration with poor outcomes in lumbar spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: There is a scarcity of large multicenter data on how preoperative lumbar symptom duration relates to postoperative patient-reported outcomes (PROs). The objective of this study was to determine the effect of preoperative and baseline symptom duration on PROs at 90 days, 1 year, and 2 years after lumbar spine surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations between January 1, 2017, to December 31, 2021, with a follow-up of 2 years. Patients were stratified into three subgroups based on symptom duration: < 3 months, 3 months to < 1 year, and ≥ 1 year. The primary outcomes were reaching the minimal clinically important difference (MCID) for the PROs (i.e., leg pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), EQ-5D, North American Spine Society satisfaction, and return to work). The EQ-5D score was also analyzed as a continuous variable to calculate quality-adjusted life years. Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios, with the < 3-month cohort used as the reference. RESULTS: There were 37,223 patients (4670 with < 3-month duration, 9356 with 3-month to < 1-year duration, and 23,197 with ≥ 1-year duration) available for analysis. Compared with patients with a symptom duration of < 1 year, patients with a symptom duration of ≥ 1 year were significantly less likely to achieve an MCID in PROMIS PF, EQ-5D, back pain relief, and leg pain relief at 90 days, 1 year, and 2 years postoperatively. Similar trends were observed for patient satisfaction and return to work. With the EQ-5D score as a continuous variable, a symptom duration of ≥ 1 year was associated with 0.04, 0.05, and 0.03 (p < 0.001) decreases in EQ-5D score at 90 days, 1 year, and 2 years after surgery, respectively. CONCLUSIONS: A symptom duration of ≥ 1 year was associated with poorer outcomes on several outcome metrics. This suggests that timely referral and surgery for degenerative lumbar pathology may optimize patient outcome.

Health Care Disparity in Pain.

Disparity in the treatment of chronic pain has become increasingly pertinent in health care, given the large burden of disease and its economic costs to society. That disease burden is disproportionally carried by minorities and those of lower socioeconomic status for a host of historical and systemic reasons. Only by understanding the cause of such disparities, collecting accurate and thorough data that illuminate all contributing factors, and diversifying the health care workforce, can we achieve more equitable treatment and reduce the burden of chronic pain.

Cost Analysis of Inpatient Rehabilitation after Spinal Injury: A Retrospective Cohort Analysis.

Objective The lifetime direct and indirect costs of spinal injury and spinal cord injury (SCI) increase as the severity of injury worsens. Despite the potential for substantial improvement in function with acute rehabilitation, the factors affecting its cost have not yet been evaluated. We used a proprietary hospital database to evaluate the direct costs of rehabilitation after spine injury. Methods A single-center, retrospective cohort cost analysis of patients with acute, traumatic spine injury treated at a tertiary facility from 2011 to 2017 was performed. Results In the 190 patients (mean age 46.1 ± 18.6 years, 76.3% males) identified, American Spinal Injury Association impairment scores on admission were 32.1% A, 14.7% B, 14.7% C, 33.2% D, and 1.1% E. Surgical treatment was performed in 179 (94.2%) cases. Most injuries were in the cervical spine (53.2%). A mean improvement of Functional Impairment Score of 30.7 ± 16.2 was seen after acute rehabilitation. Costs for care comprised facility (86.5%), pharmacy (9.2%), supplies (2.0%), laboratory (1.5%), and imaging (0.8%) categories. Injury level, injury severity, and prior inpatient surgical treatment did not affect the cost of rehabilitation. Higher injury severity (p = 0.0001, one-way ANOVA) and spinal level of injury (p = 0.001, one-way ANOVA) were associated with higher length of rehabilitation stay in univariate analysis. However, length of rehabilitation stay was the strongest independent predictor of higher-than-median cost (risk ratio = 1.56, 95% CI 1.21-2.0, p = 0.001) after adjusting for other factors. Conclusions Spine injury has a high upfront cost of care, with greater need for rehabilitation substantially affecting cost. Improving the efficacy of rehabilitation to reduce length of stay may be effective in reducing cost.

Analysis of Treatment Cost Variation Among Multiple Neurosurgical Procedures Using the Value-Driven Outcomes Database.

BACKGROUND: Health care costs comprise a substantial portion of total national expenditure. Although interest in cost-effectiveness analysis in neurosurgery has increased, there has been little cross-comparison of neurosurgical procedures. The aim of this study was to compare costs across elective neurosurgical procedures to understand whether drivers of cost differ. METHODS: The Value Driven Outcomes database was used to evaluate treatment costs for resection of vestibular schwannoma, intracranial meningioma, gliomas, and pituitary adenoma; anterior cervical discectomy and fusion and lumbar spinal fusion; and aneurysm treatment. RESULTS: A total of 1997 patients (mean age 54.6 ± 14.5 years; 45.2% male) were evaluated. The mean length of stay (LOS) was 4.0 ± 4.4 days. For cases involving hardware implantation, including spine fusion or aneurysm treatment, supplies and implants (49.1%) accounted for the largest fraction of costs followed by facility costs (37.9%). For cases that did not involve hardware, including tumor cases, facility costs (63.9%) were the largest fraction, followed by supplies and implants (16.2%). Aneurysm treatment and lumbar fusion were 1.5-3 times more costly than cranial tumor resection and anterior cervical discectomy and fusion per patient. Multivariate linear regression demonstrated that LOS (ß = 0.7, P = 0.0001) and patient treatment type (ß = 0.2, P = 0.0001) had the greatest effect on costs. LOS correlated with cost differently depending on case type; its effect was largest for patients with meningioma and smallest for patients with vestibular schwannoma. Costs across time increased similarly for all case types. CONCLUSIONS: Costs for neurosurgical procedures vary widely depending on treatment type and correlated directly with LOS. Strategies to reduce cost may require different approaches depending on procedure type.

Evaluating the Landscape of Clinical Research in Neurosurgery.

BACKGROUND: Many clinical trials and observational research never reach publication in peer-reviewed journals. Unpublished research results, including neutral study findings, hinder generation of new research questions, utilize healthcare resources without benefit, and may place patients at risk without benefit. OBJECTIVE: To examine the publication of neurosurgery trials listed in ClinicalTrials.gov. METHODS: Clinical neurosurgery research was identified by searching the registry and categorized by study type. Associated publications were identified on Pubmed.gov. RESULTS: Among the 709 studies identified, spine (292, 41.2%) studies were most common, followed by tumor and cranial (each 114, 16.1%). Funding was predominantly private (482, 68.0%), followed by industry (135, 19.0%) and National Institutes of Health (9, 1.3%). A lower proportion of published studies (vs unpublished) received private funding in functional (33.3 vs 65.3%) and tumor (80.0 vs 68.7%). Only 104/464 (22.4%) studies had an associated publication. The mean time from listed study completion to first publication was 31.0 ± 27.5 mo. Most published studies had significant study differences between treatment arms (n = 72, 69.2%); studies with neutral findings were less likely to be published (n = 13, 12.5%). Surgical discipline (P = .1), funding source (P = .8), patient age (P = .4), planned enrollment (P = .1), phase of trial (P = .3), and study type (P = .2) did not affect publication rates. However, the interaction between study category and funding source significantly affected publication rate (P = .04, generalized linear model, R2 = 0.05). Publication timing (1-way analysis of variance, P = .5) and frequency (chi-square, P = .2) did not differ among disciplines. CONCLUSION: Clinical trials and observational research in neurosurgery are often not published promptly, especially if results were nonsignificant or the trial had private funding.

Analysis of Anterior Cervical Discectomy and Fusion Healthcare Costs via the Value-Driven Outcomes Tool.

BACKGROUND: Examining the costs of single- and multilevel anterior cervical discectomy and fusion (ACDF) is important for the identification of cost drivers and potentially reducing patient costs. A novel tool at our institution provides direct costs for the identification of potential drivers. OBJECTIVE: To assess perioperative healthcare costs for patients undergoing an ACDF. METHODS: Patients who underwent an elective ACDF between July 2011 and January 2017 were identified retrospectively. Factors adding to total cost were placed into subcategories to identify the most significant contributors, and potential drivers of total cost were evaluated using a multivariable linear regression model. RESULTS: A total of 465 patients (mean, age 53 ± 12 yr, 54% male) met the inclusion criteria for this study. The distribution of total cost was broken down into supplies/implants (39%), facility utilization (37%), physician fees (14%), pharmacy (7%), imaging (2%), and laboratory studies (1%). A multivariable linear regression analysis showed that total cost was significantly affected by the number of levels operated on, operating room time, and length of stay. Costs also showed a narrow distribution with few outliers and did not vary significantly over time. CONCLUSION: These results suggest that facility utilization and supplies/implants are the predominant cost contributors, accounting for 76% of the total cost of ACDF procedures. Efforts at lowering costs within these categories should make the most impact on providing more cost-effective care.

Involvement of adenosine monophosphate activated kinase in interleukin-6 regulation of steroidogenic acute regulatory protein and cholesterol side chain cleavage enzyme in the bovine zona fasciculata and zona reticularis.

In bovine adrenal zona fasciculata (ZF) and NCI-H295R cells, interleukin-6 (IL-6) increases cortisol release, increases expression of steroidogenic acute regulatory protein (StAR), cholesterol side chain cleavage enzyme (P450scc), and steroidogenic factor 1 (SF-1) (increases steroidogenic proteins), and decreases the expression of adrenal hypoplasia congenita-like protein (DAX-1) (inhibits steroidogenic proteins). In contrast, IL-6 decreases bovine adrenal zona reticularis (ZR) androgen release, StAR, P450scc, and SF-1 expression, and increases DAX-1 expression. Adenosine monophosphate (AMP) activated kinase (AMPK) regulates steroidogenesis, but its role in IL-6 regulation of adrenal steroidogenesis is unknown. In the present study, an AMPK activator (AICAR) increased (P < 0.01) NCI-H295R StAR promoter activity, StAR and P450scc expression, and the phosphorylation of AMPK (PAMPK) and acetyl-CoA carboxylase (PACC) (indexes of AMPK activity). In ZR (decreased StAR, P450scc, SF-1, increased DAX-1) (P < 0.01) and ZF tissues (increased StAR, P450scc, SF-1, decreased DAX-1) (P < 0.01), AICAR modified StAR, P450scc, SF-1 and DAX-1 mRNAs/proteins similar to the effects of IL-6. The activity (increased PAMPK and PACC) (P < 0.01) of AMPK in the ZF and ZR was increased by AICAR and IL-6. In support of an AMPK role in IL-6 ZF and ZR effects, the AMPK inhibitor compound C blocked (P < 0.01) the effects of IL-6 on the expression of StAR, P450scc, SF-1, and DAX-1. Therefore, IL-6 modification of the expression of StAR and P450scc in the ZF and ZR may involve activation of AMPK and these changes may be related to changes in the expression of SF-1 and DAX-1.