Utility of Risk Analysis Index for Assessing Morbidity in Patients Undergoing Posterior Spinal Fusion for Adult Spinal Deformity.

BACKGROUND: This study investigates the predictive values of the Risk Analysis Index (RAI), the modified 5-item Frailty Index (mFI-5), and advanced age for predicting 30-day extended length of stay (LOS), 30-day complications and readmissions in patients undergoing posterior spinal fusion (PSF) for adult spinal deformity (ASD). METHODS: A retrospective cohort study was performed using the 2012-2021 ACS NSQIP database. Adults undergoing posterior spinal fusion for ASD were identified using CPT and ICD codes. Using receiver operating characteristic (ROC) and multivariable analyses, we compared the discriminative thresholds and independent associations of RAI, mFI-5, and greater patient age for extended LOS, 30-day complications and readmissions. RESULTS: In this cohort of 3,814 patients, RAI identified 90.7% as Robust, 6.0% as Normal, and 3.3% as Frail/Very Frail, while mFI-5 classified 47.1% as Robust, 37.5% as Normal, and 15.3% as Frail/Very Frail. Multivariate analysis revealed both RAI and mFI-5 as significant predictors of extended LOS for Normal (RAI: p<0.001; mFI-5: p=0.012) and Frail/Very Frail patients (RAI: p<0.001; mFI-5: p=0.002). Additionally, RAI was a significant predictor of 30-day complication risk for Normal patients (p=0.005). Furthermore, mFI-5 was a significant predictor of 30-day readmission among Frail/Very Frail patients (p=0.002). CONCLUSION: This study highlights the utility of RAI and mFI-5 in predicting extended LOS patients undergoing PSF for ASD. RAI was found to be superior to mFI-5 for predicting 30-day readmissions, while mF-5 was greater for 30-day complications. These findings highlight the importance of incorporating frailty assessments into preoperative surgical planning.

Assessing a revised-risk analysis index for morbidity and mortality after spine surgery for metastatic spinal tumors.

BACKGROUND: Risk Analysis Index (RAI) has been increasingly used to assess surgical frailty in various procedures, but its effectiveness in predicting mortality or in-patient hospital outcomes for spine surgery in metastatic disease remains unclear. The aim of this study was to compare the predictive values of the revised RAI (RAI-rev), the modified frailty index-5 (mFI-5), and advanced age for extended length of stay, 30-day readmission, complications, and mortality among patients undergoing spine surgery for metastatic spinal tumors. METHODS: A retrospective cohort study was performed using the 2012-2022 ACS NSQIP database to identify adult patients who underwent spinal surgery for metastatic spinal pathologies. Using receiver operating characteristic (ROC) and multivariable analyses, we compared the discriminative thresholds and independent associations of RAI-rev, mFI-5, and greater patient age with extended length of stay (LOS), 30-day complications, hospital readmission, and mortality. RESULTS: A total of 1,796 patients were identified, of which 1,116 (62.1%) were male and 1,008 (70.7%) were non-Hispanic White. RAI-rev identified 1,291 (71.9%) frail and 208 (11.6%) very frail patients, while mFI-5 identified 272 (15.1%) frail and 49 (2.7%) very frail patients. In the ROC analysis for extended LOS, both RAI-rev and mFI-5 showed modest predictive capabilities with area under the curve (AUC) values of 0.5477 and 0.5329, respectively, and no significant difference in their predictive abilities (p = 0.446). When compared to age, RAI-rev demonstrated superior prediction (p = 0.015). With respect to predicting 30-day readmission, no significant difference was observed between RAI-rev and mFI-5 (AUC 0.5394 l respectively, p = 0.354). However, RAI-rev outperformed age (p = 0.001). When assessing the risk of 30-day complications, RAI-rev significantly outperformed mFI-5 (AUC: 0.6016 and 0.5542 respectively, p = 0.022) but not age. Notably, RAI-rev demonstrated superior ability for predicting 30-day mortality compared to mFI-5 and age (AUC: 0.6541, 0.5652, and 0.5515 respectively, p < 0.001). Multivariate analysis revealed RAI-rev as a significant predictor of extended LOS [aOR: 1.96, 95% CI: 1.13-3.38, p = 0.016] and 30-day mortality [aOR: 5.27, 95% CI: 1.73-16.06, p = 0.003] for very frail patients. Similarly, the RAI-rev significantly predicted 30-day complications for frail [aOR: 2.63, 95% CI: 1.21-5.72, p = 0.015] and very frail [aOR: 3.69, 95% CI: 1.60-8.51, p = 0.002] patients. However, the RAI did not significantly predict 30-day readmission [Very Frail aOR: 1.52, 95% CI: 0.75-3.07, p = 0.245; Frail aOR: 1.46, 95% CI: 0.79-2.68, p = 0.225]. CONCLUSION: Our study demonstrates the utility of RAI-rev in predicting morbidity and mortality in patients undergoing spine surgery for metastatic spinal pathologies. Particularly, the superiority that RAI-rev has in predicting 30-day mortality may have significant implications in multidisciplinary decision making.

High inpatient-opioid consumption predicts extended length of hospital stay in patients undergoing spinal fusion for adolescent idiopathic scoliosis.

OBJECTIVES: Opioids are common medications used following spine surgery. However, few studies have assessed the impact of increased inpatient-opioid consumption on outcomes following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to determine the impact of increased inpatient-opioid consumption on hospital length of stay (LOS) following PSF for AIS. METHODS: A retrospective cohort study was performed using the Premier Healthcare Database (2016-2017). Adolescent patients (11-17 years old) who underwent PSF for AIS, identified using ICD-10-CM coding, were stratified by inpatient MME (morphine milligram equivalent) consumption into Low (< 25th percentile for the cohort), Medium (25-75th percentile), and High (> 75th percentile) cohorts. Demographics, comorbidities, intraoperative procedures, perioperative adverse events (AEs), length of hospital stay (LOS), non-routine discharge rates, cost of admission, and 30-day readmission rates were assessed. A logistic multivariate regression analysis was performed to determine the association between inpatient MME consumption and extended LOS. RESULTS: Of the 1042 study patients, 260 (24.9%) had Low-MME consumption, 523 (50.2%) had Medium-MME consumption, and 259 (24.9%) had High-MME consumption. A greater proportion of patients in the High cohort identified as non-Hispanic white (Low: 46.5% vs Medium: 61.4% vs High: 65.3%, p < 0.001), while the proportion of patients reporting any comorbidity did not vary across the cohorts (p = 0.940). The number of post-operative AEs experienced also did not vary across the cohorts (p = 0.629). A greater proportion of patients in the High cohort had an extended LOS (Low: 6.5% vs Medium: 8.6% vs High: 19.7%, p < 0.001), while a greater proportion of patients in the Low cohort had an increased cost of admission (Low: 33.1% vs Medium: 20.3% vs High: 26.6%, p < 0.001). The High cohort had increased 30-day readmission rates relative to the Low and Medium cohorts (Low: 0.8% vs Medium: 0.2% vs High: 1.5%, p = 0.049). Non-routine discharge rates did not vary among the cohorts (p = 0.441). On multivariate analysis, High-MME consumption was significantly associated with extended LOS, while Medium-MME consumption was not [Medium: aOR: 1.48, CI (0.83, 2.74), p = 0.193; High: aOR: 4.43, CI (2.47, 8.31), p < 0.001]. CONCLUSIONS: Our study showed that high post-operative-MME consumption was significantly associated with extended LOS in patients undergoing PSF for AIS. In light of these findings, changes to existing protocols that decrease the reliance on opioids for post-operative analgesia are merited to improve patient outcomes and reduce health-care expenditures.

Implications of surgical infection on surgical and hospital outcomes after spine surgery: A NSQIP study of 410,930 patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Surgical infections are unfortunately a fairly common occurrence in spine surgery, with rates reported as high as 16 %. However, there is a relative paucity of studies that look to understand how surgical infections may impact outcome variables. The aim of this study was to assess the impact of surgical infection on other perioperative complications, extended hospital length of stay (LOS), discharge disposition, and unplanned readmission following spine surgery. METHODS: A retrospective cohort study was performed using the 2016-2022 ACS NSQIP database. Adults receiving spine surgery for trauma, degenerative disease, and tumors were identified using CPT and ICD-9/10 codes. Patients were divided into two cohorts: surgical infection (superficial surgical site infection, deep surgical site infection, organ space surgical site infection, or wound dehiscence) and no surgical infection (those who did not experience any infection). Patient demographics, comorbidities, intraoperative variables, postoperative adverse events (AEs), and healthcare resource utilization were assessed. Multivariate logistic regression analysis was utilized to identify predictors of AEs, extended hospital length of stay, non-routine discharge, and unplanned readmission. RESULTS: In our cohort of 410,930 patients, 7854 (2.2 %) were found to have experienced a surgical infection. Regarding preoperative variables, a greater proportion of the surgical infection cohort was a female (p < 0.001) and had a higher mean BMI (p < 0.001), greater frailty and ASA scores (p < 0.001), and higher rates of all presenting comorbidities included in the study. Rates of AEs (p < 0.001), unplanned readmission (p < 0.001), reoperation (p < 0.001), non-home discharge (p < 0.001), and 30-day mortality were all greater in the surgical infection group when compared to the group without surgical infection. On multivariate analysis, surgical infection was found to be an independent predictor of experiencing postoperative complications [aOR: 6.15, 95 % CI: (5.72, 6.60), p < 0.001], prolonged LOS [2.71, 95 % CI: (2.54, 2.89), p < 0.001], non-routine discharge [aOR: 1.74, 95 % CI: (1.61, 1.88), p < 0.001], and unplanned readmission [aOR: 22.57, 95 % CI: (21.06, 24.19), p < 0.001]. CONCLUSIONS: Our study found that surgical infection increases the risk of complications, extended LOS, non-routine discharge, and unplanned readmission. Such findings warrant further studies that aim to validate these results and identify risk factors for surgical infections.

Regional variations in morbidity and mortality among neonates with intraventricular hemorrhage: a national database analysis.

BACKGROUND: Intraventricular hemorrhage (IVH) often affects newborns of low gestational age and low birth weight, requires critical care for neonates, and is linked to long-term neurodevelopmental outcomes. Assessing regional differences in the U.S. in care for neonatal IVH and subsequent outcomes can shed light on ways to mitigate socioeconomic disparities. METHODS: Using the 2016-2019 National Inpatient Sample (NIS), patients with a primary diagnosis of IVH were identified using ICD-10-CM codes. A retrospective cohort study was conducted with patients stratified by hospital region. Demographics, comorbidities, presentation, intraoperative variables, and inpatient outcomes were assessed. Multivariate logistic regression analyses were used to identify the impact of insurance status on extended LOS (defined as > 75th percentile of LOS), exorbitant cost (defined as > 75th percentile of cost), and mortality. RESULTS: Included in this study were 1630 newborns with IVH. A larger portion of patients in the South and Midwest were Black, compared to the Northeast and West (Northeast: 12.2% vs Midwest: 30.2% vs South: 22.8% vs West: 5.8%, p < 0.001), while a greater percentage of patients in the West and South were Hispanic (Northeast: 7.3% vs Midwest: 9.5% vs South: 22.8% vs West: 36.2%, p < 0.001). LOS was similar among all regions. Factors associated with prolonged LOS included hydrocephalus and CSF diversions. Median total cost of admission was highest in the West, while the South was associated with decreased odds of exorbitant cost. LOS was associated with exorbitant cost, and large bed-volume hospital, VLBW, and permanent CSF shunt were associated with mortality. CONCLUSIONS: Demographic variables, but not presenting or intraoperative variables, differed among regions, pointing to possible geographic health disparities. The West had the highest total cost of admission, while the South was associated with reduced odds of exorbitant admission costs.

Impact of Depression on Postoperative Medical and Surgical Outcomes in Spine Surgeries: A Systematic Review and Meta-Analysis.

Introduction: The relationship between psychiatric disorders, including depression, and invasive interventions has been a topic of debate in recent literature. While these conditions can impact the quality of life and subjective perceptions of surgical outcomes, the literature lacks consensus regarding the association between depression and objective perioperative medical and surgical complications, especially in the neurosurgical domain. Methods: MEDLINE (PubMed), EMBASE, PsycINFO, and the Cochrane Library were queried in a comprehensive manner from inception until 10 November 2023, with no language restrictions, for citations investigating the association between depression and length of hospitalization, medical and surgical complications, and objective postoperative outcomes including readmission, reoperation, and non-routine discharge in patients undergoing spine surgery. Results: A total of 26 articles were considered in this systematic review. Upon pooled analysis of the primary outcome, statistically significantly higher rates were observed for several complications, including delirium (OR:1.92), deep vein thrombosis (OR:3.72), fever (OR:6.34), hematoma formation (OR:4.7), hypotension (OR:4.32), pulmonary embolism (OR:3.79), neurological injury (OR:6.02), surgical site infection (OR:1.36), urinary retention (OR:4.63), and urinary tract infection (OR:1.72). While readmission (OR:1.35) and reoperation (OR:2.22) rates, as well as non-routine discharge (OR:1.72) rates, were significantly higher in depressed patients, hospitalization length was comparable to non-depressed controls. Conclusions: The results of this review emphasize the significant increase in complications and suboptimal outcomes noted in patients with depression undergoing spinal surgery. Although a direct causal relationship may not be established, addressing psychiatric aspects in patient care is crucial for providing comprehensive medical attention.

Insurance Disparities in Patient Outcomes and Healthcare Resource Utilization Following Neonatal Intraventricular Hemorrhage.

BACKGROUND: Within the field of pediatric neurosurgery, insurance status has been shown to be associated with surgical delay, longer time to referral, and longer hospitalization in epilepsy treatment, myelomeningocele repair, and spasticity surgery.1,2 The aim of this study was to investigate the association of insurance status with inpatient adverse events (AEs), length of stay (LOS), and costs for newborns diagnosed with intraventricular hemorrhage (IVH). METHODS: A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. Patients with a primary diagnosis of intraventricular hemorrhage were identified using ICD-10-CM diagnostic and procedural codes. Patients were categorized based on insurance status: Medicaid or Private Insurance (PI). Multivariate logistic regression analyses were used to identify the impact of insurance status on extended LOS (defined as >75th percentile of LOS) and exorbitant cost (defined as >75th percentile of cost). RESULTS: Demographics differed significantly between groups, with the majority of newborns in the PI cohort being White (Medicaid: 35.8% vs. PI: 60.3%, P < 0.001) and the majority of Medicaid patients being in the 0-25th quartile of household income (Medicaid: 40.9% vs. PI: 12.9%, P < 0.001). While insurance status was not independently associated with increased odds of extended LOS or exorbitant cost, Medicaid patients had a greater mean LOS and total cost of admission than PI patients. CONCLUSIONS: Demographic characteristics, mean LOS, and mean total cost differed significantly between Medicaid and PI patients, indicating potential disparities based on insurance status. However, insurance status was not independently associated with increased healthcare utilization, necessitating further research in this area of study.

Sociodemographic Disparities and Postoperative Outcomes Following Cranial Vault Remodeling for Craniosynostosis: Analysis of the 2012 to 2021 NSQIP-Pediatric Database.

OBJECTIVE: The objective of this study was to assess whether race and ethnicity are independent predictors of inferior postoperative clinical outcomes, including increased complication rates, extended length of stay (LOS), and unplanned 30-day readmission following cranial vault repair for craniosynostosis. METHODS: A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database. Pediatric patients under 2 years of age undergoing cranial vault repair for craniosynostosis between 2012 and 2021 were identified using the International Classification of Diseases-9/10 and Current Procedural Terminology codes. Patients were dichotomized into 4 cohorts: non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and other. Only patients with available race and ethnicity data were included in this study. Patient demographics, comorbidities, surgical variables, postoperative adverse events, and hospital resource utilization were assessed. Multivariate logistic regression analysis was used to assess the impact of race on complications, extended LOS, and unplanned readmissions. RESULTS: In our cohort of 7764 patients, 72.80% were NHW, 8.44% were NHB, 15.10% were Hispanic, and 3.67% were categorized as "other." Age was significantly different between the 4 cohorts ( P <0.001); NHB patients were the oldest, with an average age of 327.69±174.57 days old. Non-Hispanic White experienced the least adverse events while NHB experienced the most ( P =0.01). Total operative time and hospital LOS were shorter for NHW patients ( P <0.001 and P <0.001, respectively). Rates of unplanned 30-day readmission, unplanned reoperation, and 30-day mortality did not differ significantly between the 4 cohorts. On multivariate analysis, race was found to be an independent predictor of extended LOS [NHB: adjusted odds ratio: 1.30 (1.04-1.62), P=0.021; other: 2.28 (1.69-3.04), P =0.005], but not of complications or readmission. CONCLUSIONS: Our study demonstrates that racial and ethnic disparities exist among patients undergoing cranial vault reconstruction for craniosynostosis. These disparities, in part, may be due to delayed age of presentation among non-Hispanic, non-White patients. Further investigations to elucidate the underlying causes of these disparities are necessary to address gaps in access to care and provide equitable health care to at-risk populations.

Efficacy and utility of antifibrinolytics in pediatric spine surgery: a systematic review and network meta-analysis.

Antifibrinolytics have gained increasing attention in minimizing blood loss and mitigating the risks associated with massive transfusions, including infection and coagulopathy in pediatric patients undergoing spine surgery. Nevertheless, the selection of optimal agent is still a matter of debate. We aim to review the utility of these agents and compare the efficacy of antifibrinolytics in pediatric and adolescent spine surgeries. A comprehensive search was performed in Scopus, Web of Science, and MEDLINE databases for relevant works. Studies providing quantitative data on predefined outcomes were included. Primary outcome was perioperative bleeding between the groups. Secondary outcomes included transfusion volume, rate of complications, and operation time. Twenty-eight studies were included in the meta-analysis incorporating 2553 patients. The use of Tranexamic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 88%), Aprotinin (RoM: 0.54, 95%CI: [0.46-0.64], p < 0.001, I2 = 0%), and Epsilon-aminocaproic acid (RoM: 0.71, 95%CI: [0.62-0.81], p < 0.001, I2 = 60%) led to a 29%, 46%, and 29% reduction in perioperative blood loss, respectively. Network meta-analysis revealed higher probability of efficacy with Tranexamic acid compared to Epsilon-aminocaproic acid (P score: 0.924 vs. 0.571). The rate of complications was not statistically different between each two antifibrinolytic agent or antifibrinolytics compared to placebo or standard of care. Our network meta-analysis suggests a superior efficacy of all antifibrinolytics compared to standard of care/placebo in reducing blood loss and transfusion rate. Further adequately-powered randomized clinical trials are recommended to reach definite conclusion on comparative performance of these agents and to also provide robust objective assessments and standardized outcome data and safety profile on antifibrinolytics in pediatric and adolescent pediatric surgeries.

Isolated unilateral alar ligamentous injury: illustrative cases.

BACKGROUND: Isolated unilateral alar ligament injury (IUALI) is a rare and likely underreported occurrence after upper cervical trauma, with only 16 cases documented in the literature to date. Patients generally present with neck pain, and definitive diagnosis is typically made by magnetic resonance imaging (MRI). Unfortunately, likely due in part to its rarity, there are no formal guidelines for the treatment of an IUALI. Furthermore, there is a limited understanding of the long-term consequences associated with its inadequate treatment. OBSERVATIONS: Here, the authors report on three pediatric patients, each found to have an IUALI after significant trauma. All patients presented with neck tenderness, and two of the three had associated pain-limited range of neck motion. Imaging revealed either a laterally deviated odontoid process on cervical radiographs and/or MRI evidence of ligamentous strain or discontinuity. Each patient was placed in a hard cervical collar for 1 to 2 months with excellent resolution of symptoms. A comprehensive review of the literature showed that all patients with IUALI who had undergone external immobilization with either rigid cervical collar or halo fixation had favorable outcomes at follow-up. LESSONS: For patients with IUALI, a moderate course of nonsurgical management with rigid external immobilization appears to be an adequate first-line treatment.

Impact of a quality improvement initiative and monthly multidisciplinary meetings on outcomes after posterior spinal fusion for adolescent idiopathic scoliosis.

INTRODUCTION: Several studies have demonstrated the benefits of enhanced recovery after surgery (ERAS) protocols for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumented fusion (PSIF). However, there are relatively few studies investigating the effect of regular multidisciplinary team meetings on level selection, surgical performance parameters, and patient outcomes after PSIF for AIS. The aim of this study was to assess changes in intra- and postoperative outcomes following multidisciplinary team meeting implementation for patients undergoing PSIF for AIS. METHODS: The medical records of 96 adolescents (10 to 18 years old) diagnosed with AIS and undergoing PSIF at a major academic institution from 2017 to 2022 were retrospectively reviewed. A quality improvement (QI) initiative was implemented in February 2020, including institution of monthly multidisciplinary conferences focusing on preoperative indications, level selection, postoperative review of surgical performance parameters for previous cases, and discussion and optimization of postoperative ambulation and pain control protocols. Patients were placed into "Pre-QI" (treated pre-February 2020) and "Post-QI" (treated post-February 2020) cohorts. Patient demographics, comorbidities, deformity characteristics, intraoperative variables, ambulation status, postoperative complications, length of stay (LOS), and unplanned readmission rates were assessed. RESULTS: Of the 96 study patients, 44 (45.8%) were in the Pre-QI cohort, and 52 (54.2%) were in the Post-QI cohort. Mean major curve was not significantly different between the two cohorts (Pre-QI: 58.0 ± 7.3° vs Post-QI: 57.9 ± 14.5°, p = 0.169). The Pre-QI cohort had a greater mean minor curve degree (Pre-QI: 42.7 ± 11.8° vs Post-QI: 36.8 ± 12.4, p = 0.008). The Pre-QI cohort had significantly greater mean spinal levels fused (Pre-QI: 11.7 ± 1.7 vs Post-QI: 10.4 ± 2.6, p = 0.009), significantly greater mean estimated blood loss (Pre-QI: 1063.6 ± 631.5 ml vs. Post-QI: 415.8 ± 189.9 ml, p < 0.001), significantly greater mean operative time normalized to levels fused (Pre-QI: 0.6 ± 0.1 h/level fused vs Post-QI: 0.4 ± 0.1 h/level fused, p < 0.001), and a significantly greater proportion of patients with intraoperative drain placement (Pre-QI: 93.2% vs Post-QI: 5.8%, p < 0.001). The Post-QI cohort had significantly shorter time to postoperative ambulation (Pre-QI: 2.1 ± 0.9 days vs Post-QI: 1.3 ± 0.5 days, p < 0.001). A significantly greater proportion of patients in the Pre-QI cohort developed any postoperative complication (Pre-QI: 72.7% vs Post-QI: 34.6%, p < 0.001), and mean LOS was significantly greater among Pre-QI patients (Pre-QI: 4.5 ± 1.1 days vs Post-QI: 3.2 ± 0.8 days, p < 0.001). Discharge disposition (p = 0.758) and 30-day unplanned readmissions (p = 0.207) were similar between the cohorts. CONCLUSIONS: Our findings suggest that monthly multidisciplinary pediatric spine team meetings may improve patient care. Further studies exploring the incorporation of QI implementation with frequent multidisciplinary team meetings into existing ERAS protocols are merited.

Reduced racial disparities among newborns with intraventricular hemorrhage.

INTRODUCTION: Intraventricular hemorrhage (IVH) can ensue permanent neurologic dysfunction, morbidity, and mortality. While previous reports have identified disparities based on patient gender or weight, no prior study has assessed how race may influence in neonatal or infantile IVH patients. The aim of this study was to investigate the impact of race on adverse event (AE) rates, length of stay (LOS), and total cost of admission among newborns with IVH. METHODS: Using the 2016-2019 National Inpatient Sample database, newborns diagnosed with IVH were identified using ICD-10-CM codes. Patients were stratified based on race. Patient characteristics and inpatient outcomes were assessed. Multivariate logistic regression analyses were used to identify the impact of race on extended LOS and exorbitant cost. RESULTS: Of 1435 patients, 650 were White (45.3%), 270 African American (AA) (18.8%), 300 Hispanic (20.9%), and 215 Other (15.0%). A higher percentage of AA and Other patients than Hispanic and White patients were < 28 days old (p = 0.008). Each of the cohorts had largely similar presenting comorbidities and symptoms, although AA patients did have significantly higher rates of NEC (p < 0.001). There were no observed differences in rates of AEs, rates of mortality, mean LOS, or mean total cost of admission. Similarly, on multivariate analysis, no race was identified as a significant independent predictor of extended LOS or exorbitant cost. CONCLUSIONS: Our study found that in newborns with IVH, race is not associated with proxies of poor healthcare outcomes like prolonged LOS or excessive cost. Further studies are needed to validate these findings.

Variations in the genomic profiles and clinical behavior of meningioma by racial and ethnic group.

OBJECTIVE: The influence of socioeconomic factors on racial disparities among patients with sporadic meningiomas is well established, yet other potential causative factors warrant further exploration. The authors of this study aimed to determine whether there is significant variation in the genomic profile of meningiomas among patients of different races and ethnicities and its correlation with clinical outcomes. METHODS: The demographic, genomic, and clinical data of patients aged 18 years and older who had undergone surgery for sporadic meningioma between September 2008 and November 2021 were analyzed. Statistical analyses were performed to detect differences across all racial/ethnic groups, as were direct comparisons between Black and non-Black groups plus Hispanic and non-Hispanic groups. RESULTS: This study included 460 patients with intracranial meningioma. Hispanic patients were significantly younger at surgery (53.9 vs 60.2 years, p = 0.0006) and more likely to show symptoms. Black patients had a higher incidence of anterior skull base tumors (OR 3.2, 95% CI 1.7-6.3, p = 0.0008) and somatic hedgehog mutations (OR 5.3, 95% CI 1.6-16.6, p = 0.003). Hispanics were less likely to exhibit the aggressive genomic characteristic of chromosome 1p deletion (OR 0.28, 95% CI 0.07-1.2, p = 0.06) and displayed higher rates of TRAF7 somatic driver mutations (OR 2.96 95% CI 1.1-7.8, p = 0.036). Black patients had higher rates of recurrence (OR 2.6, 95% CI 1.3-5.2, p = 0.009) and shorter progression-free survival (PFS; HR 2.9, 95% CI 1.6-5.4, p = 0.002) despite extents of resection (EORs) similar to those of non-Black patients (p = 0.745). No significant differences in overall survival were observed among groups. CONCLUSIONS: Despite similar EORs, Black patients had worse clinical outcomes following meningioma resection, characterized by a higher prevalence of somatic hedgehog mutations, increased recurrence rates, and shorter PFS. Meanwhile, Hispanic patients had less aggressive meningiomas, a predisposition for TRAF7 mutations, and no difference in PFS. These findings could inform the care and treatment strategies for meningiomas, and they establish the foundation for future studies focusing on the genomic origins of these observed differences.

Association of Malnutrition with Surgical and Hospital Outcomes after Spine Surgery for Spinal Metastases: A National Surgical Quality Improvement Program Study of 1613 Patients.

Background: Malnutrition is a common condition that may exacerbate many medical and surgical pathologies. However, few have studied the impact of malnutrition on surgical outcomes for patients undergoing surgery for metastatic disease of the spine. This study aims to evaluate the impact of malnutrition on perioperative complications and healthcare resource utilization following surgical treatment of spinal metastases. Methods: We conducted a retrospective cohort study using the 2011-2019 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients with spinal metastases who underwent laminectomy, corpectomy, or posterior fusion for extradural spinal metastases were identified using the CPT, ICD-9-CM, and ICD-10-CM codes. The study population was divided into two cohorts: Nourished (preoperative serum albumin values ≥ 3.5 g/dL) and Malnourished (preoperative serum albumin values < 3.5 g/dL). We assessed patient demographics, comorbidities, intraoperative variables, postoperative adverse events (AEs), hospital LOS, discharge disposition, readmission, and reoperation. Multivariate logistic regression analyses were performed to identify the factors associated with a prolonged length of stay (LOS), AEs, non-routine discharge (NRD), and unplanned readmission. Results: Of the 1613 patients identified, 26.0% were Malnourished. Compared to Nourished patients, Malnourished patients were significantly more likely to be African American and have a lower BMI, but the age and sex were similar between the cohorts. The baseline comorbidity burden was significantly higher in the Malnourished cohort compared to the Nourished cohort. Compared to Nourished patients, Malnourished patients experienced significantly higher rates of one or more AEs (Nourished: 19.8% vs. Malnourished: 27.6%, p = 0.004) and serious AEs (Nourished: 15.2% vs. Malnourished: 22.6%, p < 0.001). Upon multivariate regression analysis, malnutrition was found to be an independent and associated with an extended LOS [aRR: 3.49, CI (1.97, 5.02), p < 0.001], NRD [saturated aOR: 1.76, CI (1.34, 2.32), p < 0.001], and unplanned readmission [saturated aOR: 1.42, CI (1.04, 1.95), p = 0.028]. Conclusions: Our study suggests that malnutrition increases the risk of postoperative complication, prolonged hospitalizations, non-routine discharges, and unplanned hospital readmissions. Further studies are necessary to identify the protocols that pre- and postoperatively optimize malnourished patients undergoing spinal surgery for metastatic spinal disease.

Decompression Alone Versus Interspinous/Interlaminar Device Placement for Degenerative Lumbar Pathologies: Systematic Review and Meta-Analysis.

INTRODUCTION: Interspinous devices (ISDs) and interlaminar devices (ILDs) are marketed as alternatives to conventional surgery for degenerative lumbar conditions; comparisons with decompression alone are limited. The present study reviews the extant literature comparing the cost and effectiveness of ISDs/ILDs with decompression alone. METHODS: Articles comparing decompression alone with ISD/ILD were identified; outcomes of interest included general and disease-specific patient-reported outcomes, perioperative complications, and total treatment costs. Outcomes were analyzed at <6 weeks, 3 months, 6 months, 1 year, 2 years, and last follow-up. Analyses were performed using random effects modeling. RESULTS: Twenty-nine studies were included in the final analysis. ILD/ISD showed greater leg pain improvement at 3 months (mean difference, -1.43; 95% confidence interval, [-1.78, -1.07]; P < 0.001), 6 months (-0.89; [-1.55, -0.24]; P = 0.008), and 12 months (-0.97; [-1.25, -0.68]; P < 0.001), but not 2 years (P = 0.22) or last follow-up (P = 0.09). Back pain improvement was better after ISD/ILD only at 1 year (-0.87; [-1.62, -0.13]; P = 0.02). Short-Form 36 physical component scores or Zurich Claudication Questionnaire (ZCQ) symptom severity scores did not differ between the groups. ZCQ physical function scores improved more after decompression alone at 6 months (0.35; [0.07, 0.63]; P = 0.01) and 12 months (0.23; [0.00, 0.46]; P = 0.05). Oswestry Disability Index and EuroQoL 5 dimensions scores favored ILD/ISD at all time points except 6 months (P = 0.07). Reoperations (odds ratio, 1.75; [1.23, 2.48]; P = 0.002) and total care costs (standardized mean difference, 1.19; [0.62, 1.77]; P < 0.001) were higher in the ILD/ISD group; complications did not differ significantly between the groups (P = 0.41). CONCLUSIONS: Patient-reported outcomes are similar after decompression alone and ILD/ISD; the observed differences do not reach accepted minimum clinically important difference thresholds. ISD/ILDs have higher associated costs and reoperation rates, suggesting current evidence does not support ILD/ISDs as a cost-effective alternative to decompression alone.

Influence of affective disorders on outcomes after suboccipital decompression for adult Chiari I malformation.

INTRODUCTION: Affective disorders (AD) have been shown to influence patient outcomes and healthcare resource utilization across several pathologies, though this relationship has not been described in patients with Chiari I malformations (CM-I). The aim of this study was to determine the impact of comorbid AD on postoperative events and healthcare resource utilization in adults following suboccipital decompression for CM-I. METHODS: A retrospective study was performed using the 2016-2019 National Inpatient Sample database. Adults who underwent suboccipital decompression for CM-I were identified using ICD-10-CM codes. Patients were stratified into two cohorts, those with AD and those without (No AD). Patient demographics, comorbidities, operative characteristics, perioperative adverse events (AEs), and healthcare resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of prolonged length of stay (LOS), exorbitant admission costs, and non-routine discharge (NRD). RESULTS: A total of 3985 patients were identified, of which 2780 (69.8%) were in the No AD cohort and 1205 (30.2%) were in the AD cohort. Patient demographics were similar, except for a greater proportion of Female patients than the No AD cohort (p = 0.004). Prevalence of some comorbidities varied between cohorts, including obesity (p = 0.030), ADHD (p < 0.001), GERD (p < 0.001), smoking (p < 0.001), and chronic pulmonary disease (p < 0.001). The AD cohort had a greater proportion of patients with 1-2 (p < 0.001) or ≥ 3 comorbidities (p < 0.001) compared to the No AD cohort. A greater proportion of patients in the AD cohort presented with headache compared to the No AD cohort (p = 0.003). Incidence of syringomyelia was greater in the No AD cohort (p = 0.002). A greater proportion of patients in the No AD cohort underwent duraplasty only (without cervical laminectomy) compared to the AD cohort (p = 0.021). Healthcare resource utilization was similar between cohorts, with no significant differences in mean LOS (No AD: 3.78 ± 3.51 days vs. 3.68 ± 2.71 days, p = 0.659), NRD (No AD: 3.8% vs. AD: 5.4%, p = 0.260), or mean admission costs (No AD: $20,254 ± 14,023 vs. AD: $29,897 ± 22,586, p = 0.284). On multivariate analysis, AD was not independently associated with extended LOS [OR (95%CI): 1.09 (0.72-1.65), p = 0.669], increased hospital costs [OR (95%CI): 0.98 (0.63-1.52), p = 0.930], or NRD [OR (95%CI): 1.39 (0.65-2.96), p = 0.302]. CONCLUSION: Our study suggests that the presence of an AD may not have as much of an impact on postoperative events and healthcare resource utilization in adult patients undergoing Chiari decompression. Additional studies may be warranted to identify other potential implications that AD may have in other aspects of healthcare in this patient population.

Racial disparities in the management and outcomes of primary osseous neoplasms of the spine: a SEER analysis.

PURPOSE: Primary osseous neoplasms of the spine, including Ewing's sarcoma, osteosarcoma, chondrosarcoma, and chordoma, are rare tumors with significant morbidity and mortality. The present study aims to identify the prevalence and impact of racial disparities on management and outcomes of patients with these malignancies. METHODS: The 2000 to 2020 Surveillance, Epidemiology, and End Results (SEER) Registry, a cancer registry, was retrospectively reviewed to identify patients with Ewing's sarcoma, osteosarcoma, chondrosarcoma, or chordoma of the vertebral column or sacrum/pelvis. Study patients were divided into race-based cohorts: White, Black, Hispanic, and Other. Demographics, tumor characteristics, treatment variables, and mortality were assessed. RESULTS: 2,415 patients were identified, of which 69.8% were White, 5.8% Black, 16.1% Hispanic, and 8.4% classified as "Other". Tumor type varied significantly between cohorts, with osteosarcoma affecting a greater proportion of Black patients compared to the others (p < 0.001). A lower proportion of Black and Other race patients received surgery compared to White and Hispanic patients (p < 0.001). Utilization of chemotherapy was highest in the Hispanic cohort (p < 0.001), though use of radiotherapy was similar across cohorts (p = 0.123). Five-year survival (p < 0.001) and median survival were greatest in White patients (p < 0.001). Compared to non-Hispanic Whites, Hispanic (p < 0.001) and "Other" patients (p < 0.001) were associated with reduced survival. CONCLUSION: Race may be associated with tumor characteristics at diagnosis (including subtype, size, and site), treatment utilization, and mortality, with non-White patients having lower survival compared to White patients. Further studies are necessary to identify underlying causes of these disparities and solutions for eliminating them.

Treatment of intramedullary spinal cord tumors: a modified Delphi technique of the North American Spine Society Section of Spine Oncology.

OBJECTIVE: Intramedullary spinal cord tumors (IMSCTs) are rare tumors with heterogeneous presentations and natural histories that complicate their management. Standardized guidelines are lacking on when to surgically intervene and the appropriate aggressiveness of resection, especially given the risk of new neurological deficits following resection of infiltrative tumors. Here, the authors present the results of a modified Delphi method using input from surgeons experienced with IMSCT removal to construct a framework for the operative management of IMSCTs based on the clinical, radiographic, and tumor-specific characteristics. METHODS: A modified Delphi technique was conducted using a group of 14 neurosurgeons experienced in IMSCT resection. Three rounds of written correspondence, surveys, and videoconferencing were carried out. Participants were queried about clinical and radiographic criteria used to determine operative candidacy and guide decision-making. Members then completed a final survey indicating their choice of observation or surgery, choice of resection strategy, and decision to perform duraplasty, in response to a set of patient- and tumor-specific characteristics. Consensus was defined as ≥ 80% agreement, while responses with 70%-79% agreement were defined as agreement. RESULTS: Thirty-six total characteristics were assessed. There was consensus favoring surgical intervention for patients with new-onset myelopathy (86% agreement), chronic myelopathy (86%), or progression from mild to disabling numbness (86%), but disagreement for patients with mild numbness or chronic paraplegia. Age was not a determinant of operative candidacy except among frail patients, who were deemed more suitable for observation (93%). Well-circumscribed (93%) or posteriorly located tumors reaching the surface (86%) were consensus surgical lesions, and participants agreed that the presence of syringomyelia (71%) and peritumoral T2 signal change (79%) were favorable indications for surgery. There was consensus that complete loss of transcranial motor evoked potentials with a 50% decrease in the D-wave amplitude should halt further resection (93%). Preoperative symptoms seldom influenced choice of resection strategy, while a distinct cleavage plane (100%) or visible tumor-cord margins (100%) strongly favored gross-total resection. CONCLUSIONS: The authors present a modified Delphi technique highlighting areas of consensus and agreement regarding surgical management of IMSCTs. Although not intended as a substitute for individual clinical decision-making, the results can help guide care of these patients. Additionally, areas of controversy meriting further investigation are highlighted.

Academic career progression in AANS/CNS Spine Section award recipients.

OBJECTIVE: The American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Spine Section awards highlight outstanding abstracts submitted to the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves by trainees interested in spine surgery, although the academic trajectory of awardees has not been studied. The aim of this study was to assess the academic career progression of prior recipients of the Journalistic and Academic Neurosurgical Excellence (JANE), Mayfield, and Kuntz research awards. METHODS: Prior JANE, Mayfield, and Kuntz award recipients were identified using awardee records accrued between 1984 and February 2022. Awardee sex, country of residence, specialty, subspecialty focus, and current academic appointment status (if applicable) were searched online. Awardee h-indices and number of peer-reviewed publications were assessed via Google Scholar profiles (or Scopus if unavailable) and PubMed, respectively. Receipt of federal research funding as principal investigator (PI) was determined using the websites of the National Institutes of Health, the National Science Foundation, and the Department of Defense Congressionally Directed Medical Research Programs. The abstract-to-publication rate was assessed. RESULTS: A total of 7 JANE awards, 57 Mayfield awards, and 149 Kuntz awards were identified. Of the JANE awardees, all recipients were male. Of the 4 unique JANE awardees who completed training, 2 (50.0%) held academic appointments at the time of the study. All of the JANE abstracts were published in peer-reviewed journals. The mean h-index of all JANE awardees was 28 and the mean number of publications was 126. None of the awardees have received federal research funding. Of the Mayfield awards, 98.2% were awarded to males. Of the 43 unique Mayfield awardees who completed training, 20 (46.5%) held faculty appointments at academic medical centers. All of the Mayfield abstracts since 2011 were published in peer-reviewed journals. The mean h-index of all Mayfield awardees was 26 and the mean number of publications was 82. Five Mayfield awardees received National Institutes of Health funding as PI, and 7 awardees received Department of Defense funding as PI. Of the Kuntz awards, 95.3% were awarded to males. Most awards were given to current residents and fellows (46.3%). Of the 55 unique Kuntz awardees who completed training, 31 (56.4%) held faculty appointments at academic medical centers. The abstract-to-publication rate of the total Kuntz abstracts was 70.5%. The mean h-index of all Kuntz awardees was 15 and the mean number of publications was 58. Five Kuntz awardees (3.4%) received federal research funding as PI. CONCLUSIONS: Many recipients of the JANE, Mayfield, and Kuntz Joint Spine Section awards have successfully translated award abstracts into peer-reviewed publications. Furthermore, approximately one-third of the awardees are active in academic neurosurgery, with some having secured federal research funding.

Implications of Frailty on Postoperative Health Care Resource Utilization in Ankylosing Spondylitis Patients Undergoing Spine Surgery for Spinal Fractures.

OBJECTIVE: The rise of spinal surgery for ankylosing spondylitis (AS) necessitates balancing health care costs with quality patient care. Frailty has been independently associated with adverse outcomes and increased costs. This study investigates whether frailty is an independent predictor of poor outcomes after elective surgery for AS. METHODS: Using the National Inpatient Sample (NIS) database, a retrospective study was conducted on adult patients with AS who underwent posterior spinal fusion for fracture between 2016 and 2019. Each patient was assigned a modified frailty index (mFI) score and categorized as prefrail (mFI = 0 or 1), moderately frail (mFI = 2), and highly frail (mFI≥3). Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay, non-routine discharge (NRD), and exorbitant admission costs. RESULTS: Of the 1910 patients, 35.3% were prefrail, 31.2% moderately frail, and 33.5% highly frail. Age was significantly different across groups (P < 0.001), and frailty was associated with increased comorbidities (P < 0.001). Mean length of stay (P = 0.007), NRD rate (P < 0.001), and mean cost of admission (P = 0.002) all significantly increased with increasing frailty. However, frailty was not an independent predictor of extended hospital stay, NRD, or higher costs on multivariate analysis. Instead, predictors included multiple adverse events, number of comorbidities, and race. CONCLUSIONS: While frailty in patients with AS is associated with older age, greater comorbidities, and increased adverse events, it was not an independent predictor of extended hospital stay, NRD, or higher hospital costs. Further research is required to understand the full impact of frailty on surgical outcomes and develop effective interventions.