Spontaneous Spinal Hematoma in Patients Using Antiplatelets and Anticoagulants: A Systematic Review.

BACKGROUND: Spontaneous spinal hematoma (SSH) is a debilitating complication in patients taking either antiplatelet (AP) or anticoagulation (AC) medications. SSH is rare and, therefore, a systematic review is warranted to re-examine and outline trends, clinical characteristics, and outcomes associated with SSH formation. METHODS: PubMed, EMBASE, Scopus, and Web-of-Science were searched. Studies reporting clinical data of patients with SSH using AC medications were included. In addition, clinical studies meeting our a priori inclusion criteria limited to SSH were further defined in quality through risk bias assessment. RESULTS: We included 10 studies with 259 patients' pooled data post-screening 3083 abstracts. Within the cohort (n = 259), the prevalence of idiopathic, nontraumatic SSH with concomitant treatment with AC medications was greater 191 (73.75%) compared with AP treatment (27%). The lumbar spine was the most common site of hematoma (41.70%), followed by the cervical (22.01%) and thoracic (8.49%) spine. Most patients had surgical intervention (70.27%), and 29.73% had conservative management. The pooled data suggest that immediate diagnosis and intervention are the best prognostic factors in clinical outcomes. American Spinal Injury Association grading at initial symptom onset and post-treatment showed the greatest efficacy in symptomatic relief (87.64%) and return of motor and sensory symptoms (39.19%). CONCLUSIONS: Our review suggested that AC medications were related to SSH in most patients (74%), followed by APs (27%) and combined ACs + APs (1.9%). We recommend prompt intervention, a high suspicion for patients with neurologic deficits and diagnostic imaging before intervention to determine a case-specific treatment plan.

Cannabis Use Disorder Trends and Health Care Utilization After Cervical and Lumbar Spine Fusions.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To identify differences in complication rates after cervical and lumbar fusion over the first postoperative year between those with and without cannabis use disorder (CUD) and to assess how CUD affects opioid prescription patterns. SUMMARY OF BACKGROUND DATA: Cannabis is legal for medical purposes in 36 states and for recreational use in 18 states. Cannabis has multisystem effects and may contribute to transient vasoconstrictive, prothrombotic, and inflammatory effects. METHODS: The IBM MarketScan Database (2009-2019) was used to identify patients who underwent cervical or lumbar fusions, with or without CUD. Exact match hospitalization and postdischarge outcomes were analyzed at index, six, and 12 months. RESULTS: Of 72,024 cervical fusion (2.0% with CUD) and 105,612 lumbar fusion patients (1.5% with CUD), individuals with CUD were more likely to be young males with higher Elixhauser index. The cervical CUD group had increased neurological complications (3% vs. 2%) and sepsis (1% vs. 0%) during the index hospitalization and neurological (7% vs. 5%) and wound complications (5% vs. 3%) at 12 months. The lumbar CUD group had increased wound (8% vs. 5%) and myocardial infarction (MI) (2% vs. 1%) complications at six months and at 12 months. For those with cervical myelopathy, increased risk of pulmonary complications was observed with CUD at index hospitalization and 12-month follow-up. For those with lumbar stenosis, cardiac complications and MI were associated with CUD at index hospitalization and 12 months. CUD was associated with opiate use disorder, decreasing postoperatively. CONCLUSIONS: No differences in reoperation rates were observed for CUD groups undergoing cervical or lumbar fusion. CUD was associated with an increased risk of stroke for the cervical fusion cohort and cardiac (including MI) and pulmonary complications for lumbar fusion at index hospitalization and six and 12 months postoperatively. Opiate use disorder and decreased opiate dependence after surgery also correlated with CUD.

Opioid Dependence and Associated Health Care Utilization and Cost in Traumatic Spinal Cord Injury Population: Analysis Using Marketscan Database.

Background: Postinjury pain is a well-known debilitating complication of spinal cord injury (SCI), often resulting in long-term, high-dose opioid use with the potential for dependence. There is a gap in knowledge about the risk of opioid dependence and the associated health care utilization and cost in SCI. Objectives: To evaluate the association of SCI with postinjury opioid use and dependence and evaluate the effect of this opioid dependence on postinjury health care utilization. Methods: Using the MarketScan Database, health care utilization claims data were queried to extract 7187 adults with traumatic SCI from 2000 to 2019. Factors associated with post-SCI opioid use and dependence, postinjury health care utilization, and payments were analyzed with generalized linear regression models. Results: After SCI, individuals were more likely to become opioid users or transition from nondependent to dependent users (negative change: 31%) than become nonusers or transition from dependent to nondependent users (positive change: 14%, p < .0001). Individuals who were opioid-dependent users pre-SCI had more than 30 times greater odds of becoming dependent after versus not (OR 34; 95% CI, 26-43). Dependent users after injury (regardless of prior use status) had 2 times higher utilization payments and 1.2 to 6 times more health care utilization than nonusers. Conclusion: Opioid use and dependence were associated with high health care utilization and cost after SCI. Pre-SCI opioid users were more likely to remain users post-SCI and were heavier consumers of health care. Pre- and postopioid use history should be considered for treatment decision-making in all individuals with SCI.

Health Care Utilization and Associated Economic Burden of Postoperative Surgical Site Infection after Spinal Surgery with Follow-Up of 24 Months.

BACKGROUND: Surgical site infection (SSI) may lead to vertebral osteomyelitis, diskitis, paraspinal musculoskeletal infection, and abscess, and remains a significant concern in postoperative management of spinal surgery. SSI is associated with greater postoperative morbidity and increased health care payments. METHODS: We conducted a retrospective analysis using MarketScan to identify health care utilization payments and risk factors associated with SSI that occurs postoperatively. Known patient- or procedure-related risk factors were searched across those receiving spine surgery who developed postoperative infection. RESULTS: A total of 33,061 patients who developed infection after spinal surgery were identified in Marketscan. Overall payments at 6 months, including index hospitalization for those with infection, were $53,573 and $46,985 for the cohort with no infection. At 24 months, the infection group had overall payments of $83,280 and $66,221 for no infection. Risk factors with largest effect size most likely to contribute to infection versus no infection were depression (4.6%), diabetes (3.7), anemia (3.3%), two or more levels (2.8%), tobacco use (2.2%), trauma (2.1%), neoplasm (1.8%), congestive heart failure (1.3%), instrumentation (1.1%), renal failure (0.9%), intravenous drug use (0.8%), and malnutrition (0.5%). CONCLUSIONS: SSIs were associated with significant health care utilization payments at 24 months of follow-up. The following clinical and procedural risk factors appear to be predictive of postoperative SSI: depression, diabetes, anemia, two or more levels, tobacco use, trauma, neoplasm, congestive heart failure, instrumentation, renal failure, intravenous drug use, and malnutrition. Interpretation of modifiable and nonmodifiable risk factors for infection informs surgeons of expected postoperative course and preoperative risk for this most common and deleterious postoperative complication to spinal surgery.

Machine learning in clinical diagnosis, prognostication, and management of acute traumatic spinal cord injury (SCI): A systematic review.

Background: Machine learning has been applied to improve diagnosis and prognostication of acute traumatic spinal cord injury. We investigate potential for clinical integration of machine learning in this patient population to navigate variability in injury and recovery. Materials and methods: We performed a systematic review using PRISMA guidelines through PubMed database to identify studies that use machine learning algorithms for clinical application toward improvements in diagnosis, management, and predictive modeling. Results: Of the 132 records identified, a total of 13 articles met inclusion criteria and were included in final analysis. Of the 13 articles, 5 focused on diagnostic accuracy and 8 were related to prognostication or management of traumatic spinal cord injury. Across studies, 1983 patients with spinal cord injury were evaluated with most classifying as ASIA C or D. Retrospective designs were used in 10 of 13 studies and 3 were prospective. Studies focused on MRI evaluation and segmentation for diagnostic accuracy and prognostication, investigation of mean arterial pressure in acute care and intraoperative settings, prediction of ambulatory and functional ability, chronic complication prevention, and psychological quality of life assessments. Decision tree, random forests (RF), support vector machines (SVM), hierarchical cluster tree analysis (HCTA), artificial neural networks (ANN), convolutional neural networks (CNN) machine learning subtypes were used. Conclusions: Machine learning represents a platform technology with clinical application in traumatic spinal cord injury diagnosis, prognostication, management, rehabilitation, and risk prevention of chronic complications and mental illness. SVM models showed improved accuracy when compared to other ML subtypes surveyed. Inherent variability across patients with SCI offers unique opportunity for ML and personalized medicine to drive desired outcomes and assess risks in this patient population.

Transplantation of human neural progenitor cells secreting GDNF into the spinal cord of patients with ALS: a phase 1/2a trial.

Amyotrophic lateral sclerosis (ALS) involves progressive motor neuron loss, leading to paralysis and death typically within 3-5 years of diagnosis. Dysfunctional astrocytes may contribute to disease and glial cell line-derived neurotrophic factor (GDNF) can be protective. Here we show that human neural progenitor cells transduced with GDNF (CNS10-NPC-GDNF) differentiated to astrocytes protected spinal motor neurons and were safe in animal models. CNS10-NPC-GDNF were transplanted unilaterally into the lumbar spinal cord of 18 ALS participants in a phase 1/2a study (NCT02943850). The primary endpoint of safety at 1 year was met, with no negative effect of the transplant on motor function in the treated leg compared with the untreated leg. Tissue analysis of 13 participants who died of disease progression showed graft survival and GDNF production. Benign neuromas near delivery sites were common incidental findings at post-mortem. This study shows that one administration of engineered neural progenitors can provide new support cells and GDNF delivery to the ALS patient spinal cord for up to 42 months post-transplantation.

Trends and Long-term Health Care Utilization of Computer-assisted Neuronavigation in Spine Fusions: An Exact Matched Analysis of National Administrative Database.

BACKGROUND: Computer-assisted neuronavigation (CAN) during spine fusions has increasingly been utilized in the United States. The aim of this study was to analyze the trends, health care utilization, and clinical outcomes associated with CAN use. METHODS: The MarketScan database was queried using the ICD-9/10 and CPT 4th edition, from 2003 to 2019. We included patients aged ≥18 years with at least 2 years of follow-up. Outcomes were repeat/new fusions, length of stay (LOS), discharge disposition, hospital re-admissions, outpatient services, and medication refills for up to 24 months. RESULTS: Of 183,620 patients who underwent spine fusions, 5046 (2.75%) were identified to have CAN utilized. CAN is increasingly being utilized for spine fusions since 2010, reaching 10.76% of all fusions in 2017, compared to 0.38% in 2010. CAN had no impact on LOS, home discharge, or complications at index hospitalization and 30-days post discharge. CAN was associated with lower rates of repeat fusions at 6 months (1% vs. 2%) and 24 months (5% vs. 6%), P < 0.05. Patients who underwent CAN had lower payments at 6 months ($5186 vs. $5527, P = 0.0159), 12 months ($10,267 v.s $11,262, P = 0.0207), and 24 months ($21,453 vs. $24,355, P = 0.0021). CONCLUSIONS: CAN is increasing being used for spine fusions primarily for thoracolumbar procedures. No difference in complications, discharge disposition, and LOS were noted across the cohorts at index hospitalization, with higher index payments with CAN use. CAN was associated with lower rates of repeat fusions and corresponding health care utilization for up to 24 months.

Extensive spontaneous cervical epidural hematoma due to oral anticoagulant (dabigatran) successfully treated with reversal agent idarucizumab alone.

Background: Dabigatran is an anticoagulant (novel oral anticoagulant) that is a direct thrombin inhibitor and only recently has a reversal agent, idarucizumab, been made available (2015). Case Description: An 86-year-old male taking dabigatran for atrial fibrillation, acutely presented with the spontaneous onset of neck pain and quadriparesis. When the MRI demonstrated a C2-T2 spinal epidural hematoma, the patient was given the reversal agent idarucizumab. Due to his attendant major comorbidities, he was managed nonoperatively. Over the next 7 days, the patient's neurological deficits resolved, and within 2 weeks, he had regained normal neurological function. Conclusion: In this case, a C2-T2 epidural cervical hematoma attributed to dabigatran that was responsible for an acute, spontaneous quadriparesis was successfully treated with the reversal agent idarucizumab without surgical intervention being warranted.

The Phenotypes of Anxiety and Depression: Analysis of Combined Comorbidity and Treatment in Patients Undergoing Spinal Fusion.

BACKGROUND: Anxiety and depression are associated with suboptimal outcomes, higher complications, and cost of care after elective spine surgery. The effect of combined anxiety-depression and preoperative antidepressant treatment in spinal fusion patients is not known. OBJECTIVE: To study the burden of combined anxiety-depression and its impact on healthcare utilization and costs in patients undergoing spinal fusion and to study the prevalence and impact of antidepressant treatment preoperatively. METHODS: This is a retrospective cohort study from the IBM MarketScan Research Database (2000-2018). Patients were studied in 7 different "phenotypes" of anxiety and depression based on combination of diagnoses and treatment. Outcome measures included healthcare utilization and costs from 1 year preoperatively to 2 years postoperatively. Bivariate and multivariable analyses have been reported. RESULTS: We studied 75 087 patients with a median age of 57 years. Patients with combined anxiety-depression were associated with higher preoperative and postoperative healthcare utilization and costs, as compared with anxiety or depression alone. The presence of depression in patients with and without anxiety disorder was a risk factor for postoperative opioid use and 2-year reoperation rates, as compared with anxiety alone. Patients with anxiety and/or depression on antidepressants are associated with significantly higher healthcare costs and opioid use. The adjusted 2-year reoperation rate was not significantly different between treated and untreated cohorts. CONCLUSION: Spine surgeons should use appropriate measures/questionnaires to screen depressed patients for anxiety and vice versa because the presence of both adds significant risk of higher healthcare utilization and costs over patients with 1 diagnosis, especially anxiety alone.

Simulated Bundled Payments for 4 Common Surgical Approaches to Treat Degenerative Cervical Myelopathy: A Consideration to Break the Clinical Equipoise.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to compare 90-day and 2-year reimbursements for ≥2-level anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior laminectomy and fusion (LF) and laminoplasty (LP) done for degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: In DCM pathologies where there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes over posterior approaches. In the era of value and bundled payments initiatives, cost profile of various approaches will form an important consideration for decision making. MATERIALS AND METHODS: IBM MarketScan Research Database (2005-2018) was used to study beneficiaries (30-75 y) who underwent surgery (mACDF, ACCF, LF, LP) for DCM. Index hospital stay (operating room, surgeon, hospital services) and postdischarge inpatient, outpatient and prescription medication payments have been used to simulate 90-day and 2-year bundled payment amounts, along with their distribution for each procedure. RESULTS: A total of 10,834 patients with median age of 54 years were included. The median 90-day payment was $46,094 (interquartile range: $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital was 62.4% (operating room: 46.6) and surgeon payments were 17.5% of the average 90-day bundle. There was significant difference in the index, 90-day and 2-year reimbursements and their distribution among procedures. CONCLUSION: In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate, and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value as it is on an average 70% less expensive than LF over 90 days.

Simulated bundled payments for four common surgical approaches to treat degenerative cervical myelopathy: a consideration to break the clinical equipoise.

OBJECTIVE: In degenerative cervical myelopathy (DCM) pathologies in which there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes compared with posterior approaches. In this era of value and bundled payment initiatives, the cost profiles of various surgical approaches will form an important consideration in decision-making. The objective of this study was to compare 90-day and 2-year reimbursements for ≥ 2-level (multilevel) anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior cervical laminectomy and fusion (LF), and cervical laminoplasty (LP) performed for DCM. METHODS: The IBM MarketScan research database (2005-2018) was used to study beneficiaries 30-75 years old who underwent surgery using four approaches (mACDF, ACCF, LF, or LP) for DCM. Demographics, index surgery length of stay (LOS), complications, and discharge disposition were compared. Index admission (surgeon, hospital services, operating room) and postdischarge inpatient (readmission, revision surgery, inpatient rehabilitation), outpatient (imaging, emergency department, office visits, physical therapy), and medication-related payments were described. Ninety-day and 2-year bundled payment amounts were simulated for each procedure. All payments are reported as medians and interquartile ranges (IQRs; Q1-Q3) and were adjusted to 2018 US dollars. RESULTS: A total of 10,834 patients, with a median age of 54 years, were included. The median 90-day payment was $46,094 (IQR $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital payment was 62.4% (surgery/operating room 46.6%) and surgeon payments were 17.5% of the average 90-day bundle. There were significant differences in the index, 90-day, and 2-year reimbursements and their distribution among procedures. CONCLUSIONS: In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value because it is 70% less expensive on average than LF over 90 days.

Machine Learning in Neuro-Oncology, Epilepsy, Alzheimer's Disease, and Schizophrenia.

Applications of machine learning (ML) in translational medicine include therapeutic drug creation, diagnostic development, surgical planning, outcome prediction, and intraoperative assistance. Opportunities in the neurosciences are rich given advancement in our understanding of the brain, expanding indications for intervention, and diagnostic challenges often characterized by multiple clinical and environmental factors. We present a review of ML in neuro-oncology, epilepsy, Alzheimer's disease, and schizophrenia to highlight recent progression in these field, optimizing machine learning capabilities in their current forms. Supervised learning models appear to be the most commonly incorporated algorithm models for machine learning across the reviewed neuroscience disciplines with primary aim of diagnosis. Accuracy ranges are high from 63% to 99% across all algorithms investigated. Machine learning contributions to neurosurgery, neurology, psychiatry, and the clinical and basic science neurosciences may enhance current medical best practices while also broadening our understanding of dynamic neural networks and the brain.

Impact of age on mortality and complications in patients with Ankylosing Spondylitis spine fractures.

OBJECTIVE: The aim of this retrospective cohort study was to study the impact of age on in-hospital complications and mortality following surgery for Ankylosing Spondylitis (AS) associated spine fractures. METHODS: We extracted data from the Nationwide Inpatient Sample (NIS) database (1998-2018) using ICD-9/10 codes. Patients with a primary diagnosis of AS associated spine fractures who underwent fusion surgery were included. Complications and in-hospital mortality were analyzed. RESULTS: A total cohort of 8526 patients was identified. Overall, the median age of the cohort was 69 years. AS associated fractures were equally distributed among cervical and thoracolumbar regions. Overall, complications were noted in 48% of patients and pulmonary complications were the most common (32%) followed by renal (13%) and infection (12%). Complications were seen in 57.3% of patients ≥ 70 years of age compared to 38.4% of patients < 70 years of age (p < .0001). Also, 9.9 % of patients ≥ 70 years of age had in-hospital mortality compared to 3.1 % of patients < 70 years of age (p < .0001). Based on surgical approaches, elderly patients (≥70 years) who underwent anterior, posterior, and anterior + posterior approaches had 19.8%, 7.4% and 16.4% in-hospital mortality compared to 5.3%, 2.2% and 7.4% respectively for patients < 70 years. CONCLUSIONS: Elderly patients (≥70 years of age) were 3.2 times more likely to have in-hospital mortality and higher complications compared to younger patients (57% vs. 38%). Cervical compared to thoracolumbar fractures and anterior compared to posterior surgical approaches were associated with higher complications and in-hospital mortality.

Recombinant Human Bone Morphogenetic Protein-2 Use in Adult Spinal Deformity Surgery: Comparative Analysis and Healthcare Utilization at 24 Months' Follow-up.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used to achieve fusion in adult spinal deformity (ASD) surgery. Our aim was to investigate the long-term impact of rhBMP-2 use for clinical outcomes and health care utilization in this patient population. METHODS: We conducted an analysis using MarketScan to identify health resource utilization of rhBMP-2 use for ASD after surgical intervention compared to fusion without rhBMP-2 at 24 months' follow-up. Outcomes assessed included length of stay, complications, pseudoarthrosis, reoperation, outpatient services, and health care payments. RESULTS: Of 7115 patients who underwent surgery for ASD, 854 received rhBMP-2 and 6261 were operated upon without use of rhBMP-2. One month after discharge, the rhBMP-2 cohort had a nonsignificant trend in fewer complications (15.38%) than those who did not receive rhBMP-2 (18.07%), P = .0558. At 12 months, pseudoarthrosis was reported in 2.8% of cases with no BMP and 01.14% of cases with BMP, P = .0048. Average payments at 12 months were $120 138 for the rhBMP-2 group and $118 373 for the no rhBMP-2 group, P = .8228. At 24 months, payments were $141 664 for the rhBMP-2 group and $144 179 for the group that did not receive rhBMP-2, P = .5946. CONCLUSIONS: In ASD surgery, use of rhBMP-2 was not associated with increased complications or reoperations at index hospitalization and 1-month follow-up. Overall payments, including index hospitalization, readmissions, reoperations, and outpatient services were not different compared to those without the use of rhBMP-2 at 12 months and 24 months after discharge.

Augmented Reality in Spinal Surgery: Highlights From Augmented Reality Lectures at the Emerging Technologies Annual Meetings.

Introduction Augmented reality (AR) is an advanced technology and emerging field that has been adopted into spine surgery to enhance care and outcomes. AR superimposes a three-dimensional computer-generated image over the normal anatomy of interest in order to facilitate visualization of deep structures without the ability to directly see them. Objective To summarize the latest literature and highlight AR from the annual "Spinal Navigation, Emerging Technologies and Systems Integration" meeting lectures presented by the Seattle Science Foundation (SSF) on the development and use of augmented reality in spinal surgery.  Methods  We performed a comprehensive literature review from 2016 to 2020 on PubMed to correlate with lectures given at the annual "Emerging Technologies" conferences. After the exclusion of papers that concerned non-spine surgery specialties, a total of 54 papers concerning AR in spinal applications were found. The articles were then categorized by content and focus. Results The 54 papers were divided into six major focused topics: training, proof of concept, feasibility and usability, clinical evaluation, state of technology, and nonsurgical applications. The greatest number of papers were published during 2020. Each paper discussed varied topics such as patient rehabilitation, proof of concept, workflow, applications in neurological and orthopedic spine surgery, and outcomes data. Conclusions The recent literature and SSF lectures on AR provide a solid base and demonstrate the emergence of an advanced technology that offers a platform for an advantageous technique that is superior, in that it allows the operating surgeon to focus directly on the patient rather than a guidance screen.

Epidural hematoma in patients with ankylosing spondylitis requiring surgical stabilization: a single-institution retrospective review with literature analysis.

OBJECTIVE: Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the sacroiliac joints and axial spine that is closely linked with human leukocyte antigen-B27. There appears to be an increased frequency of associated epidural hematomas in spine fractures in patients with AS. The objective was to review the incidence within the literature and a single-institution experience of the occurrence of epidural hematoma in the context of patients with AS requiring spine surgery. METHODS: Deep 6 AI software was used to search the entire database of patients at a single level I trauma center (since the advent of the institution's modern electronic health record system) to look at all patients with AS who underwent spinal surgery and who had a diagnosis of epidural hematoma. Additionally, a systemic literature review was performed of all papers evaluating the incidence of epidural hematoma in patients with spine fractures. RESULTS: A single-institution, retrospective review of records from 2009 to 2020 yielded a total of 164 patients with AS who underwent spine surgery. Of those patients, 17 (10.4%) had epidural hematomas on imaging, with the majority requiring surgical decompression. These spine fractures occurred close to the cervicothoracic or thoracolumbar junction. The patients ranged in age from 51 to 88 years, and there were 14 males and 3 females in the cohort. Eight patients were administered an antiplatelet and/or anticoagulant agent, and the rest were not. All patients required surgical stabilization, with 64.7% of patients also requiring decompressive laminectomies for evacuation of the hematoma and spinal cord decompression. Only 1 death was reported in the series. There was a tendency toward neurological improvement after surgical intervention. CONCLUSIONS: AS has been a well-described pathologic process that leads to an increased risk of three-column injury in spine fracture, with an increased incidence of symptomatic epidural hematoma compared with patients without AS. Early recognition of this entity is important to ensure that appropriate surgical management includes addressing compression of the neural elements in addition to surgical stabilization.

Impact of preoperative treatment of osteoporosis on re-operations, complications and health care utilization in patients undergoing thoraco-lumbar spine fusions. A 5-year national database analysis.

OBJECTIVE: Identify the impact of preoperative treatment of Osteoporosis (OP) on reoperation rates, complications and healthcare utilization following thoraco-lumbar (TL) spine fusions. MATERIALS AND METHODS: We used ICD9/10 and CPT codes to extract data from MarketScan (2000-2018). Patients were divided into two groups based on preoperative treatment of OP within one year prior to the index spinal fusion: medication (m-OP) cohort and non-medication (nm-OP) cohort. Outcomes (re-operation rates, re-admission, complications, healthcare utilization) were analyzed at 1-, 12-, 24- and 60-months. RESULTS: Of 3606 patients, 65% (n = 2330) of patients did not receive OP medications (nm-OP). At index hospitalization, there were no difference in LOS (median nm-OP: 3 days vs. m-OP:4 days), discharge to home (nm-OP 80% vs. m-OP 75%) and complications (nm-OP 13% vs. m-OP 12%). Reoperation rates were not different among the cohorts at 1- (nm-OP 5.7% vs. m-OP 4.2%), 2- (nm-OP 9.4% vs. m-OP 7.8) and 5 years (nm-OP 16.9% vs. m-OP 14.8%). Patients in m-OP cohort incurred higher overall median payments at 1 year ($17,866 vs. $ 16,010), 2 years ($38,634 vs. $34,454) and 5 years ($94,797 vs. $91,072) compared to nm-OP cohort. CONCLUSION: Preoperative treatment of OP had no impact on complications, LOS, discharge disposition following TL fusions at index hospitalization. Similarly, no impact of preoperative treatment was noted in terms of reoperation rates at 12-, 24- and 60 months following the index spine fusion. Patients who received preoperative treatment for OP incurred higher health care utilization at 12-, 24- and 60 months following surgery.

Spine Surgery in the Octogenarian Population: A Comparison of Demographics, Surgical Approach, and Healthcare Utilization With the PearlDiver Database.

Background With the recent advances in technology and healthcare, increasing numbers of individuals over the age of 80 will require surgical intervention for spinal pathology. Given the risk of increased complications in the elderly, a limited number of spinal surgeries are performed on octogenarians every year. This makes it difficult to generalize the trends and outcomes of these surgeries to a greater population. This study attempts to understand the trends in the safety profile and healthcare utilization across the United States for octogenarians undergoing spinal fusion and/or decompression surgery for spinal stenosis and/or degenerative disease using the PearlDiver database. Methodology Patients who underwent fusion and/or decompression for stenosis and/or degenerative diseases were extracted using International Classification of Disease ninth and tenth revisions (ICD-9 prior to October 2015, ICD-10 after) from 2007 to 2016 in the PearlDiver database. Three comparative groups were considered: (1) primary fusion without concurrent decompression, (2) primary decompression with concurrent fusion, and (3) fusion with concurrent decompression. Outcomes of interest were patient characteristics, demographics, length of stay, surgery hospitalization payments, and discharge disposition. These outcomes were compared to patients over the age of 20 who also underwent spinal surgery. Results A total of 9,715 patients who underwent spinal surgery were identified in the search. Of the 9,139 patients, 503 were octogenarians and 73 were nonagenarians. Octogenarians and nonagenarians diagnosed with spinal stenosis were more likely to undergo decompression alone rather than fusion or both fusion and decompression (21 for both fusion and decompression; p < 0.0001). Patients diagnosed with both spinal stenosis and degeneration were more likely to undergo both fusion and decompression than fusion or decompression alone (239 for both, 208 for decompression alone, and 23 for fusion alone; p < 0.0001). No statistically significant difference was found in the percentage of patients discharged home following either fusion or decompression or both surgeries (p = 0.0737). The mean length of stay for patients in the 20-79-year age group was 2.79 days, whereas for the octogenarian and nonagenarian cohort it was 3.85 days. The index hospitalization pay for patients in the 20-79-year age group was $19,220, whereas for the octogenarians and nonagenarians cohort it was $15,091. Conclusions Patients over the age of 80 were more likely to undergo either a fusion procedure or a decompression procedure alone rather than both unless they were diagnosed with spinal degeneration. The PearlDiver database analysis indicates that the length of stay for octogenarians and nonagenarians is longer than that for patients in the 20-79-year age group, and that younger patients are more likely to be discharged earlier than patients over the age of 80. Moreover, we observed that the index hospitalization pay was higher for patients over the age of 20 than for octogenarians and nonagenarians in all cases except for a fusion procedure.