Optimal Dosing of Levetiracetam for Seizure Prophylaxis in Critically Ill Patients: A Prospective Observational Study.

OBJECTIVES: Critically ill patients eliminate levetiracetam (LEV) more rapidly than healthy controls, yet low doses are commonly used for seizure prophylaxis in the ICU setting. We compared the rates of achievement of target serum levels and new onset seizure (clinical and/or electrographic) among patients who received low (500 mg bid) versus high (750-1,000 mg bid) dose LEV. DESIGN: Prospective, observational study. SETTING: Tertiary care, academic center. PATIENTS: We included patients who received prophylactic LEV following traumatic brain injury, intracerebral hemorrhage, spontaneous subarachnoid hemorrhage, or supratentorial neurosurgery between 2019 and 2021. Patients with a history of seizure, antiseizure medication use, or renal failure requiring dialysis were excluded. INTERVENTIONS: None. MEASUREMENTS: LEV levels were obtained at steady state. The impact of low-dose versus high-dose LEV on the primary outcome of target LEV levels (12-46 µg/mL), and the secondary outcome of clinical and/or electrographic seizure, were assessed using multivariable logistic regression analyses adjusting for age, LEV loading dose, BMI, primary diagnosis and creatinine clearance (CrCl). MAIN RESULTS: Of the 205 subjects included in analyses, n = 106 (52%) received LEV 500 mg bid (median 13 mg/kg/d), and n = 99 (48%) received LEV 750-1,000 mg bid (median 25 mg/kg/d). Overall, 111 of 205 patients (54%) achieved target levels: 48 (45%) from the low-dose group versus 63 (64%) from the high-dose group (odds ratio [OR] 2.1; 95% CI, 1.1-3.7; p = 0.009). In multivariable analyses, high-dose LEV predicted target levels (adjusted OR [aOR] 2.23; 95% CI, 1.16-4.27; p = 0.016), and was associated with lower seizure odds (aOR 0.32; 95% CI, 0.13-0.82; p = 0.018) after adjusting for age, loading dose, BMI, diagnosis, and CrCl. CONCLUSIONS: Underdosing of LEV was common, with only 54% of patients achieving target serum levels. Higher doses (750-1,000 mg bid) were more than twice as likely to lead to optimal drug levels and reduced the odds of seizure by 68% compared with low-dose regimens (500 mg bid).

Poor Accuracy of Manually Derived Head Computed Tomography Parameters in Predicting Intracranial Hypertension After Nontraumatic Intracranial Hemorrhage.

BACKGROUND: The utility of head computed tomography (CT) in predicting elevated intracranial pressure (ICP) is known to be limited in traumatic brain injury; however, few data exist in patients with spontaneous intracranial hemorrhage. METHODS: We conducted a retrospective review of prospectively collected data in patients with nontraumatic intracranial hemorrhage (subarachnoid hemorrhage [SAH] or intraparenchymal hemorrhage [IPH]) who underwent external ventricular drain (EVD) placement. Head CT scans performed immediately prior to EVD placement were quantitatively reviewed for features suggestive of elevated ICP, including temporal horn diameter, bicaudate index, basal cistern effacement, midline shift, and global cerebral edema. The modified Fisher score (mFS), intraventricular hemorrhage score, and IPH volume were also measured, as applicable. We calculated the accuracy, positive predictive value (PPV), and negative predictive value (NPV) of these radiographic features for the coprimary outcomes of elevated ICP (> 20 mm Hg) at the time of EVD placement and at any time during the hospital stay. Multivariable backward stepwise logistic regression analysis was performed to identify significant radiographic factors associated with elevated ICP. RESULTS: Of 608 patients with intracranial hemorrhages enrolled during the study time frame, 243 (40%) received an EVD and 165 (n = 107 SAH, n = 58 IPH) had a preplacement head CT scan available for rating. Elevated opening pressure and elevated ICP during hospitalization were recorded in 48 of 152 (29%) and 103 of 165 (62%), respectively. The presence of ≥ 1 radiographic feature had only 32% accuracy for identifying elevated opening pressure (PPV 30%, NPV 58%, area under the curve [AUC] 0.537, 95% asymptotic confidence interval [CI] 0.436-0.637, P = 0.466) and 59% accuracy for predicting elevated ICP during hospitalization (PPV 63%, NPV 40%, AUC 0.514, 95% asymptotic CI 0.391-0.638, P = 0.820). There was no significant association between the number of radiographic features and ICP elevation. Head CT scans without any features suggestive of elevated ICP occurred in 25 of 165 (15%) patients. However, 10 of 25 (40%) of these patients had elevated opening pressure, and 15 of 25 (60%) had elevated ICP during their hospital stay. In multivariable models, mFS (adjusted odds ratio [aOR] 1.36, 95% CI 1.10-1.68) and global cerebral edema (aOR 2.93, 95% CI 1.27-6.75) were significantly associated with elevated ICP; however, their accuracies were only 69% and 60%, respectively. All other individual radiographic features had accuracies between 38 and 58% for identifying intracranial hypertension. CONCLUSIONS: More than 50% of patients with spontaneous intracranial hemorrhage without radiographic features suggestive of elevated ICP actually had ICP > 20 mm Hg during EVD placement or their hospital stay. Morphological head CT findings were only 32% and 59% accurate in identifying elevated opening pressure and ICP elevation during hospitalization, respectively.

Do Inflammatory Cytokines Affect Patient Outcomes After ACDF?

STUDY DESIGN: Prospective cohort study. OBJECTIVE: The aim was to determine the relationship between serum inflammatory mediators, preoperative cervical spine disease severity, and clinical outcomes after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Given the role of the inflammatory cascade in spinal degenerative disease, it has been hypothesized that inflammatory markers may serve as a predictor of patient outcomes after surgery. MATERIALS AND METHODS: All patients over age 18 who underwent ACDF for cervical spondylosis with associated radiculopathy and/or myelopathy between 2015 and 2017 from a single institution were prospectively recruited. Preoperative serum inflammatory markers including interleukin (IL)-6, IL-8, tumor necrosis factor-α, high-mobility group box-1 (HMGB1), and white blood cells were measured and correlated to patient demographics, surgical characteristics, duration of symptoms, previous opioid use, and preoperative and 1-year postoperative patient-reported outcomes measures (PROMs) including the neck disability index (NDI), visual analog scale neck pain, visual analog scale arm pain, and Physical and Mental Component Scores of the Short Form-12 (PCS and MCS, respectively) using spearman's rho coefficient. RESULTS: A total of 77 patients were enrolled with follow-up PROMs available for 62% (n=48) of patients at a minimum of 1-year after ACDF. The absolute concentrations of IL-6 and tumor necrosis factor-α were found to be weakly correlated with one another (ρ=0.479). Preoperative symptoms lasting <1-year were weakly correlated with elevation in HMGB1 (ρ=0.421). All other patient demographics exhibited negligible correlation with the preoperative inflammatory markers. Lower preoperative PCS (ρ=0.355) and higher preoperative NDI (ρ=0.336) were weakly correlated with elevated HMGB1. Lower MCS (ρ=0.395) and higher NDI (ρ=0.317) preoperatively were weakly correlated with elevated white blood cells. Postoperative improvement in MCS (ρ=0.306) and MCS recovery ratio (ρ=0.321) exhibited a weakly positive correlation with IL-6. CONCLUSION: Preoperative cytokine levels demonstrated minimal correlation with preoperative symptoms or clinical improvement, suggesting that profiling of patient cytokines has limited utility in predicting outcomes after ACDF. LEVEL OF EVIDENCE: Level III.

Levetiracetam for Seizure Prophylaxis in Neurocritical Care: A Systematic Review and Meta-analysis.

BACKGROUND: Levetiracetam is commonly used for seizure prophylaxis in patients with intracerebral hemorrhage (ICH), traumatic brain injury (TBI), supratentorial neurosurgery, and spontaneous subarachnoid hemorrhage (SAH). However, its efficacy, optimal dosing, and the adverse events associated with levetiracetam prophylaxis remain unclear. METHODS: A systematic search of PubMed, Embase, and Cochrane central register of controlled trials (CENTRAL) database was conducted from January 1, 2000, to October 30, 2020, including articles addressing treatment with levetiracetam for seizure prophylaxis after SAH, ICH, TBI, and supratentorial neurosurgery. Non-English, pediatric (aged < 18 years), preclinical, reviews, case reports, and articles that included patients with a preexisting seizure condition or epilepsy were excluded. The coprimary meta-analyses examined first seizure events in (1) levetiracetam versus no antiseizure medication and (2) levetiracetam versus other antiseizure medications in all ICH, TBI, SAH, and supratentorial neurosurgery populations. Secondary meta-analyses evaluated the same comparator groups in individual disease populations. Risk of bias in non-randomised studies - of interventions (ROBINS-I) and risk-of-bias tool for randomized trials (RoB-2) tools were used to assess risk of bias. RESULTS: A total of 30 studies (n = 6 randomized trials, n = 9 prospective studies, and n = 15 retrospective studies), including 7609 patients (n = 4737 with TBI, n = 701 with SAH, n = 261 with ICH, and n = 1910 with neurosurgical diseases) were included in analyses. Twenty-seven of 30 (90%) studies demonstrated moderate to severe risk of bias, and 11 of 30 (37%) studies used low-dosage levetiracetam (250-500 mg twice daily). In the primary meta-analyses, there were no differences in seizure events for levetiracetam prophylaxis (n = 906) versus no antiseizure medication (n = 2728; odds ratio [OR] 0.79, 95% confidence interval [CI] 0.53-1.16, P = 0.23, fixed-effect, I2 = 26%, P = 0.23 for heterogeneity) or levetiracetam (n = 1950) versus other antiseizure prophylaxis (n = 2289; OR 0.84, 95% CI 0.55-1.28, P = 0.41, random-effects, I2 = 49%, P = 0.005 for heterogeneity). Only patients with supratentorial neurosurgical diseases benefited from levetiracetam compared with other antiseizure medications (median 0.70 seizure events per-patient-year with levetiracetam versus 2.20 seizure events per-patient-year for other antiseizure medications, OR 0.34, 95% CI 0.20-0.58, P < 0.001, fixed-effects, I2 = 39%, P = 0.13 for heterogeneity). There were no significant differences in meta-analyses of patients with ICH, SAH, or TBI. Adverse events of any severity were reported in a median of 8% of patients given levetiracetam compared with 21% of patients in comparator groups. CONCLUSIONS: Based on the current moderately to seriously biased heterogeneous data, which frequently used low and possibly subtherapeutic doses of levetiracetam, our meta-analyses did not demonstrate significant reductions in seizure incidence and neither supports nor refutes the use of levetiracetam prophylaxis in TBI, SAH, or ICH. Levetiracetam may be preferred post supratentorial neurosurgery. More high-quality randomized trials of prophylactic levetiracetam are warranted.

Comparison Between Clinically Available Low-Intensity Pulsed Ultrasound (LIPUS) and a Novel Bimodal Acoustic Signal System for Accelerating Fracture Healing.

Low-intensity pulsed ultrasound (LIPUS) accelerates fracture healing by stimulating the production of bone callus and the mineralization process. This study compared a novel bimodal acoustic signal (BMAS) device for bone fracture healing to a clinical LIPUS system (EXOGEN; Bioventus, Durham, NC, USA). Thirty rabbits underwent a bilateral fibular osteotomy. Each rabbits' legs were randomized to receive 20-min treatment daily for 18 days with BMAS or LIPUS. The latter utilizes a longitudinal ultrasonic mode only, while the former employs ultrasound-induced shear stress to promote bone formation. Power Doppler imaging (PDI) was acquired days 0, 2, 4, 7, 11, 14, and 18 post-surgery to monitor treatment response and quantified off-line. X-rays were acquired to evaluate fractures on days 0, 14, 18, and 21. Seventeen rabbits completed the study and were euthanized day 21 post-surgery. The fibulae were analyzed to determine maximum torque, initial torsional stiffness, and angular displacement at failure. ANOVAs and paired t-tests were used to compare pair-wise outcome variables for the two treatment modes on a per rabbit basis. The BMAS system induced better fracture healing with greater stiffness (BMAS 0.21 ± 0.19 versus LIPUS 0.16 ± 0.19 [Formula: see text]cm/°, p = 0.050 ) and maximum torque (BMAS 7.84 ± 5.55 versus LIPUS 6.26 ± 3.46 [Formula: see text]cm, p = 0.022 ) than the LIPUS system. Quantitative PDI assessments showed a higher amount of vascularity with LIPUS than BMAS on days 4 and 18 ( ). In conclusion, the novel BMAS technique achieved better bone fracture healing response than the current Food and Drug Administration (FDA)-approved LIPUS system.

A prospective study of long-term outcomes among hospitalized COVID-19 patients with and without neurological complications.

BACKGROUND: Little is known regarding long-term outcomes of patients hospitalized with COVID-19. METHODS: We conducted a prospective study of 6-month outcomes of hospitalized COVID-19 patients. Patients with new neurological complications during hospitalization who survived were propensity score-matched to COVID-19 survivors without neurological complications hospitalized during the same period. The primary 6-month outcome was multivariable ordinal analysis of the modified Rankin Scale(mRS) comparing patients with or without neurological complications. Secondary outcomes included: activities of daily living (ADLs;Barthel Index), telephone Montreal Cognitive Assessment and Neuro-QoL batteries for anxiety, depression, fatigue and sleep. RESULTS: Of 606 COVID-19 patients with neurological complications, 395 survived hospitalization and were matched to 395 controls; N = 196 neurological patients and N = 186 controls completed follow-up. Overall, 346/382 (91%) patients had at least one abnormal outcome: 56% had limited ADLs, 50% impaired cognition, 47% could not return to work and 62% scored worse than average on ≥1 Neuro-QoL scale (worse anxiety 46%, sleep 38%, fatigue 36%, and depression 25%). In multivariable analysis, patients with neurological complications had worse 6-month mRS (median 4 vs. 3 among controls, adjusted OR 1.98, 95%CI 1.23-3.48, P = 0.02), worse ADLs (aOR 0.38, 95%CI 0.29-0.74, P = 0.01) and were less likely to return to work than controls (41% versus 64%, P = 0.04). Cognitive and Neuro-QOL metrics were similar between groups. CONCLUSIONS: Abnormalities in functional outcomes, ADLs, anxiety, depression and sleep occurred in over 90% of patients 6-months after hospitalization for COVID-19. In multivariable analysis, patients with neurological complications during index hospitalization had significantly worse 6-month functional outcomes than those without.

Toxic Metabolic Encephalopathy in Hospitalized Patients with COVID-19.

BACKGROUND: Toxic metabolic encephalopathy (TME) has been reported in 7-31% of hospitalized patients with coronavirus disease 2019 (COVID-19); however, some reports include sedation-related delirium and few data exist on the etiology of TME. We aimed to identify the prevalence, etiologies, and mortality rates associated with TME in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients. METHODS: We conducted a retrospective, multicenter, observational cohort study among patients with reverse transcriptase-polymerase chain reaction-confirmed SARS-CoV-2 infection hospitalized at four New York City hospitals in the same health network between March 1, 2020, and May 20, 2020. TME was diagnosed in patients with altered mental status off sedation or after an adequate sedation washout. Patients with structural brain disease, seizures, or primary neurological diagnoses were excluded. The coprimary outcomes were the prevalence of TME stratified by etiology and in-hospital mortality (excluding comfort care only patients) assessed by using a multivariable time-dependent Cox proportional hazards models with adjustment for age, race, sex, intubation, intensive care unit requirement, Sequential Organ Failure Assessment scores, hospital location, and date of admission. RESULTS: Among 4491 patients with COVID-19, 559 (12%) were diagnosed with TME, of whom 435 of 559 (78%) developed encephalopathy immediately prior to hospital admission. The most common etiologies were septic encephalopathy (n = 247 of 559 [62%]), hypoxic-ischemic encephalopathy (HIE) (n = 331 of 559 [59%]), and uremia (n = 156 of 559 [28%]). Multiple etiologies were present in 435 (78%) patients. Compared with those without TME (n = 3932), patients with TME were older (76 vs. 62 years), had dementia (27% vs. 3%) or psychiatric history (20% vs. 10%), were more often intubated (37% vs. 20%), had a longer hospital length of stay (7.9 vs. 6.0 days), and were less often discharged home (25% vs. 66% [all P < 0.001]). Excluding comfort care patients (n = 267 of 4491 [6%]) and after adjustment for confounders, TME remained associated with increased risk of in-hospital death (n = 128 of 425 [30%] patients with TME died, compared with n = 600 of 3799 [16%] patients without TME; adjusted hazard ratio [aHR] 1.24, 95% confidence interval [CI] 1.02-1.52, P = 0.031), and TME due to hypoxemia conferred the highest risk (n = 97 of 233 [42%] patients with HIE died, compared with n = 631 of 3991 [16%] patients without HIE; aHR 1.56, 95% CI 1.21-2.00, P = 0.001). CONCLUSIONS: TME occurred in one in eight hospitalized patients with COVID-19, was typically multifactorial, and was most often due to hypoxemia, sepsis, and uremia. After we adjustment for confounding factors, TME was associated with a 24% increased risk of in-hospital mortality.

A Novel Scoring System to Predict Length of Stay After Anterior Cervical Discectomy and Fusion.

INTRODUCTION: The movement toward reducing healthcare expenditures has led to an increased volume of outpatient anterior cervical diskectomy and fusions (ACDFs). Appropriateness for outpatient surgery can be gauged based on the duration of recovery each patient will likely need. METHODS: Patients undergoing 1- or 2-level ACDFs were retrospectively identified at a single Level I spine surgery referral institution. Length of stay (LOS) was categorized binarily as either less than two midnights or two or more midnights. The data were split into training (80%) and test (20%) sets. Two multivariate regressions and three machine learning models were developed to predict a probability of LOS ≥ 2 based on preoperative patient characteristics. Using each model, coefficients were computed for each risk factor based on the training data set and used to create a calculatable ACDF Predictive Scoring System (APSS). Performance of each APSS was then evaluated on a subsample of the data set withheld from training. Decision curve analysis was done to evaluate benefit across probability thresholds for the best performing model. RESULTS: In the final analysis, 1,516 patients had a LOS <2 and 643 had a LOS ≥2. Patient characteristics used for predictive modeling were American Society of Anesthesiologists score, age, body mass index, sex, procedure type, history of chronic pulmonary disease, depression, diabetes, hypertension, and hypothyroidism. The best performing APSS was modeled after a lasso regression. When applied to the withheld test data set, the APSS-lasso had an area under the curve from the receiver operating characteristic curve of 0.68, with a specificity of 0.78 and a sensitivity of 0.49. The calculated APSS scores ranged between 0 and 45 and corresponded to a probability of LOS ≥2 between 4% and 97%. CONCLUSION: Using classic statistics and machine learning, this scoring system provides a platform for stratifying patients undergoing ACDF into an inpatient or outpatient surgical setting.

Does Smoking Status Influence Health-Related Quality of Life Outcome Measures in Patients Undergoing ACDF?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: Whereas smoking has been shown to affect the fusion rates for patients undergoing an anterior cervical discectomy and fusion (ACDF), the relationship between smoking and health-related quality of life outcome measurements after an ACDF is less clear. The purpose of this study was to evaluate whether smoking negatively affects patient outcomes after an ACDF for cervical degenerative pathology. METHODS: Patients with tumor, trauma, infection, and previous cervical spine surgery and those with less than a year of follow-up were excluded. Smoking status was assessed by self-reported smoking history. Patient outcomes, including Neck Disability Index, Short Form 12 Mental Component Score, Short Form 12 Physical Component Score (PCS-12), Visual Analogue Scale (VAS) arm pain, VAS neck pain, and pseudarthrosis rates were evaluated. Outcomes were compared between smoking groups using multiple linear and logistic regression, controlling for age, sex, and body mass index (BMI), among other factors. A P value <.05 was considered significant. RESULTS: A total of 264 patients were included, with a mean follow-up of 19.8 months, age of 53.1 years, and BMI of 29.6 kg/m2. There were 43 current, 69 former, and 152 nonsmokers in the cohort. At baseline, nonsmokers had higher PCS-12 scores than current smokers (P = .010), lower VAS neck pain than current (P = .035) and former (P = .014) smokers, as well as lower VAS arm pain than former smokers (P = .006). Postoperatively, nonsmokers had higher PCS-12 scores than both current (P = .030) and former smokers (P = .035). Smoking status was not a significant predictor of change in patient outcome in multivariate analysis. CONCLUSIONS: Whereas nonsmokers had higher function and lower pain than former or current smokers preoperatively, smoking status overall was not found to be an independent predictor of outcome scores after ACDF. This supports the notion that smoking status alone should not deter patients from undergoing ACDF for cervical degenerative pathology.

Processing and Handling Cost of Single-use Versus Traditional Instrumentation for 1 Level Lumbar Fusions.

STUDY DESIGN: A single center, observational prospective clinical study. OBJECTIVE: The aim of this study was to compare the instrumentation-related cost and efficiency of single-use instrumentation versus traditional reusable instrument trays. SUMMARY OF BACKGROUND DATA: Single-use instrumentation provides the opportunity to reduce costs associated with cleaning and sterilizing instrumentation after surgery. Although previous studies have shown single-use instrumentation is effective in other orthopedic specialties, it is unclear if single-use instrumentation could provide economic advantages in spine surgery. MATERIALS AND METHODS: A total of 40 (20 reusable instrumentation and 20 single-use instrumentation) lumbar decompression (1-3 level) and fusion (1 level) spine surgeries were collected. Instrument handling, opening, setup, re-stocking, cleaning, sterilization, inspection, packaging, and storage were recorded by direct observation for both reusable and single-use instrumentation. The rate of infection was noted for each group. RESULTS: Mean time of handling instruments by the scrub nurse was 11.6 (±3.9) minutes for reusable instrumentation and 2.1 (±0.5) minutes for single-use instrumentation. Mean cost of handling reusable instruments was estimated to be $8.52 (±$2.96) per case, and the average cost to reprocess a single tray by Sterilization Processing Department (SPD) was $58. Thus, the median cost for sterilizing 2 reusable trays per case was $116, resulting in an average total Costresuable of $124.52 (±$2.96). Mean cost of handling single-use instrumentation was estimated to be $1.57 ($0.38) per case. CONCLUSION: Single-use instrumentation provided greater cost savings and reduced time from the opening of instrumentation to use in surgery when compared with reusable instrumentation.

A Prospective Study of Neurologic Disorders in Hospitalized Patients With COVID-19 in New York City.

OBJECTIVE: To determine the prevalence and associated mortality of well-defined neurologic diagnoses among patients with coronavirus disease 2019 (COVID-19), we prospectively followed hospitalized severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients and recorded new neurologic disorders and hospital outcomes. METHODS: We conducted a prospective, multicenter, observational study of consecutive hospitalized adults in the New York City metropolitan area with laboratory-confirmed SARS-CoV-2 infection. The prevalence of new neurologic disorders (as diagnosed by a neurologist) was recorded and in-hospital mortality and discharge disposition were compared between patients with COVID-19 with and without neurologic disorders. RESULTS: Of 4,491 patients with COVID-19 hospitalized during the study timeframe, 606 (13.5%) developed a new neurologic disorder in a median of 2 days from COVID-19 symptom onset. The most common diagnoses were toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%), and hypoxic/ischemic injury (1.4%). No patient had meningitis/encephalitis or myelopathy/myelitis referable to SARS-CoV-2 infection and 18/18 CSF specimens were reverse transcriptase PCR negative for SARS-CoV-2. Patients with neurologic disorders were more often older, male, white, hypertensive, diabetic, intubated, and had higher sequential organ failure assessment (SOFA) scores (all p < 0.05). After adjusting for age, sex, SOFA scores, intubation, history, medical complications, medications, and comfort care status, patients with COVID-19 with neurologic disorders had increased risk of in-hospital mortality (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.17-1.62, p < 0.001) and decreased likelihood of discharge home (HR 0.72, 95% CI 0.63-0.85, p < 0.001). CONCLUSIONS: Neurologic disorders were detected in 13.5% of patients with COVID-19 and were associated with increased risk of in-hospital mortality and decreased likelihood of discharge home. Many observed neurologic disorders may be sequelae of severe systemic illness.

Cost-effectiveness Applications of Patient-reported Outcome Measures (PROMs) in Spine Surgery.

Because of the rising health care costs in the United States, there has been a focus on value-based care and improving the cost-effectiveness of surgical procedures. Patient-reported outcome measures (PROMs) can not only give physicians and health care providers immediate feedback on the well-being of the patients but also be used to assess health and determine outcomes for surgical research purposes. Recently, PROMs have become a prominent tool to assess the cost-effectiveness of spine surgery by calculating the improvement in quality-adjusted life years (QALY). The cost of a procedure per QALY gained is an essential metric to determine cost-effectiveness in universal health care systems. Common patient-reported outcome questionnaires to calculate QALY include the EuroQol-5 dimensions, the SF-36, and the SF-12. On the basis of the health-related quality of life outcomes, the cost-effectiveness of various spine surgeries can be determined, such as cervical fusions, lumbar fusions, microdiscectomies. As the United States attempts to reduce costs and emphasize value-based care, PROMs may serve a critical role in spine surgery moving forward. In addition, PROM-driven QALYs may be used to analyze novel spine surgical techniques for value-based improvements.

Statistics for the Practicing Spine Surgeon: Fundamental Measurements.

There are vast numbers of evidenced-based clinical trials produced each year, making it increasingly difficult to stay up to date with new treatments and protocols designed to provide the most optimal patient care. A physician's ability to combine existing knowledge with new data is limited by a basic understanding of the background statistics used in these studies. Our goal is to not only define the basic statistics commonly used in clinical trials but to also ensure that practitioners are able to have a working understanding of these statistical measurements to effectively make the most informed and efficacious decisions regarding patient management. On the basis of the recent growth of empirical spine literature, it is becoming more important for spine surgeons to have the basic statistical background necessary to efficiently interpret new data, which may affect clinical decision making regarding patient care.

Propensity Score Matching: A Statistical Method.

Propensity score matching (PSM) is a commonly used statistical method in orthopedic surgery research that accomplishes the removal of confounding bias from observational cohorts where the benefit of randomization is not possible. An alternative to multiple regression analysis, PSM attempts to reduce the effects of confounders by matching already treated subjects with control subjects who exhibit a similar propensity for treatment based on preexisting covariates that influence treatment selection. It, therefore, establishes a new control group by discarding outlier control subjects. This new control group reduces the unwanted influences of covariates, allowing for proper measurement of the intended variable. An example from orthopedic spine literature is discussed to illustrate how PSM may be applied in practice. PSM is uniquely valuable in its utility and simplicity, but it is limited in that it requires the removal of data and works primarily on binary treatments. In addition to matching, the propensity score can be used for stratification, covariate adjustments, and inverse probability of treatment weighting, but these topics are outside the scope of this paper. Personnel in the orthopedic field would benefit from learning about the function and application of this method given its common use in the orthopedic literature.

Role of Imaging, Tissue Sampling, and Biomarkers for Diagnosis of SSI in Spine Surgery.

In July 2018, the Second International Consensus Meeting on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 15 focused on the use of imaging, tissue sampling, and biomarkers in spine surgery, for which this article provides the recommendations, voting results, and rationales.

The C2 "Parsicle" Screw: Introduction of a Novel Posterior Surgical Technique For Upper Cervical Fixation.

The instrumentation of C2 is technically challenging given the anatomic complexity of the upper cervical spine. Although the placement of C2 pedicle screws may be safer than transarticular screw placement, the inconsistent location of the transverse foramen and vertebral artery precludes placement of such screws in up to 26% of patients. In cases where vertebral artery anatomy prevents the safe placement of a pedicle screw, a pars screw is an excellent alternative. However, pars screws must stop short of the vertebral foramen, limiting the typical length of these screws to only 14-18 mm. The associated purchase and rigidity are compromised compared with the pedicle screw. A modified C2 fixation technique was developed by our group which we have named the C2 "parsicle" screw reflecting the hybrid nature of the screw incorporating aspects of pars and pedicle screw fixation.

Are Outcomes of Anterior Cervical Discectomy and Fusion Influenced by Presurgical Depression Symptoms on the Mental Component Score of the Short Form-12 Survey?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The purpose of this study was to investigate whether preoperative depressive symptoms, measured by mental component score of the Short Form-12 survey (MCS-12), influence patient-reported outcome measurements (PROMs) following an anterior cervical discectomy and fusion (ACDF) surgery for cervical degeneration. SUMMARY OF BACKGROUND DATA: There is a paucity of literature regarding preoperative depression and PROMs following ACDF surgery for cervical degenerative disease. METHODS: Patients who underwent an ACDF for degenerative cervical pathology were identified. A score of 45.6 on the MCS-12 was used as the threshold for depression symptoms, and patients were divided into two groups based on this value: depression (MCS-12 ≤45.6) and nondepression (MCS-12 >45.6) groups. Outcomes including Neck Disability Index (NDI), physical component score of the Short Form-12 survey (PCS-12), and Visual Analogue Scale Neck (VAS Neck), and Arm (VAS Arm) pain scores were evaluated using independent sample t test, recovery ratios, percentage of patients reaching the minimum clinically important difference, and multiple linear regression - controlling for factors such as age, sex, and BMI. RESULTS: The depression group was found to have significantly worse baseline pain and disability than the nondepression group in NDI (P < 0.001), VAS Neck pain (P < 0.001), and VAS Arm pain (P < 0.001) scores. Postoperatively, both groups improved to a similar amount with surgery based on the recovery ratio analysis. The depression group continued to have worse scores than the nondepression group in NDI (P = 0.010), PCS-12 (P = 0.026), and VAS Arm pain (P = 0.001) scores. Depression was not a significant predictor of change in any PROMs based on regression analysis. CONCLUSION: Patients who presented with preoperative depression reported more pain and disability symptoms preoperatively and postoperatively; however, both groups achieved similar degrees of improvement. LEVEL OF EVIDENCE: 3.

Consensus on Wound Care of SSI in Spine Surgery.

In July of 2018, the Second International Consensus Meeting on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 7 focused on wound care, for which this article provides the recommendations, voting results, and rationales.

Consensus on the Role of Antibiotic Use in SSI Following Spinal Surgery.

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 17 focused on the use of antibiotics in spine surgery, for which this article provides the recommendations, voting results, and rationales.