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1.
J Neurosurg Spine ; : 1-9, 2021 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-33962388

RESUMO

OBJECTIVE: Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry. METHODS: The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics. RESULTS: Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance). CONCLUSIONS: The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.

2.
J Neurooncol ; 2021 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-33973145

RESUMO

PURPOSE: The majority of spinal meningiomas are grade I tumors, as defined by World Health Organization (WHO) classification making atypical (grade II) or anaplastic (grade III) tumors extremely rare lesions to encounter in clinical practice. Here, we present our institutional experience of management of grade II and III spinal meningiomas. METHODS: Following IRB approval, we queried all available institutional electronic medical records for patients undergoing surgical resection of pathology-proven spinal meningiomas, with further review of patients with grade II and III. Variables of interest included age, sex, histological type, tumor size, symptoms at baseline, treatment characteristics, symptom resolution at the last follow-up, recurrence, NF-2 status, concurrent intracranial meningioma, and mortality. Kaplan Meier curves were constructed to study time to progression/recurrence. RESULTS: A total of 188 patients undergoing surgical resection of spinal meningioma between 1988 and 2018 were identified. Among those, 172 (91.5%) patients had grade I meningioma and 16 (8.5%) patients had high grade meningiomas [grade II (15) and III (1)]. Over a median (IQR) follow-up of 8.0 years (5.1-13.0), mortality and recurrence rates were 18.8% (n = 3) and 47.1% (n = 8), respectively. In univariate analysis, adjuvant radiotherapy and thoracic segment involvement were associated with lower rates of recurrence while male sex was associated with a higher rate of recurrence. CONCLUSIONS: Results showed variations in clinical outcomes for patients with high grade spinal meningiomas, especially the recurrence. Adjuvant radiotherapy and thoracic segment involvement was associated with lower rates of recurrence while recurrence ocurred at a higher rate in males.

3.
J Neurooncol ; 2021 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-33811630

RESUMO

BACKGROUND: En bloc spondylectomy is the gold standard for surgical resection of sacral chordomas (CHO), but the effect of extent of resection on recurrence and survival in patients with CHO of the cervical spine remains elusive. METHODS: MEDLINE, Embase, Scopus, and Cochrane were systematically reviewed. Patients with cervical CHO treated at three tertiary-care academic institutions were reviewed for inclusion. We performed an individual participant data meta-analysis to assess the overall survival (OS) and progression free survival (PFS) after en bloc-gross total resection (GTR) and intralesional-GTR compared to subtotal resection (STR). We then performed an intention-to-treat analysis including all patients with attempted en bloc resection in the en bloc group, regardless of the surgical margins. RESULTS: There was a total of 13 series including 161 patients with cervical CHO, including our current series of 22 patients. GTR (en bloc-GTR + intralesional-GTR) was associated with a significant decrease in the risk of local progression (pooled hazard ratio (PHR) = 0.22; 95% CI 0.08-0.59; p = 0.003) and risk of death (PHR 0.31; 95%; CI 0.12-0.83; p = 0.020). A meta-regression analyses determined that intralesional-GTR improved PFS (PHR 0.35; 95% CI 0.16-0.76; p = 0.009) as well as OS (PHR 0.25; 95% CI 0.08-0.79; p = 0.019) when compared to STR. En bloc-GTR was associated with a significant reduction in the risk of local progression (PHR 0.06; 95% CI 0.01-0.77; p = 0.030), but not a decreased OS (PHR 0.50; 95% CI 0.19-1.27; p = 0.145). Our intention-to-treat analyses revealed a near significant improvement in OS for the en bloc group (PHR: 0.15; 95% CI 0.02-1.22; p = 0.054), and nearly identical improvement in PFS. Radiation data was not available for the studies included in the meta-analysis. CONCLUSION: This is the first and only meta-analysis of patients with cervical CHO. We found that both en bloc-GTR and intralesional-GTR resulted in improved local tumor control when compared to STR.

4.
J Neurointerv Surg ; 2021 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-33883210

RESUMO

BACKGROUND: CT-guided biopsy is a commonly used diagnostic procedure for spinal lesions. This meta-analysis aims to investigate its diagnostic performance and complications, as well as factors influencing outcomes. METHODS: A systematic review of the literature was performed to identify studies reporting outcomes of CT-guided biopsies for spinal lesions. Diagnostic yield (ie, the rate of procedures resulting in a specific pathological diagnosis) and diagnostic accuracy (ie, the rate of procedures resulting in the correct diagnosis) were the primary outcomes of interest. Complications following biopsy procedures were also included. RESULTS: Thirty-nine studies with 3917 patients undergoing 4181 procedures were included. Diagnostic yield per procedure was 91% (95% CI 88% to 94%) among 3598 procedures. The most common reason for non-diagnostic biopsies was inadequacy of sample. No difference in diagnostic yield between different locations and between lytic, sclerotic, and mixed lesions was found. Diagnostic yield did not differ between procedures using ≤13G and ≥14G needles. Diagnostic accuracy per procedure was 86% (95% CI 82% to 89%) among 3054 procedures. Diagnostic accuracy among 2426 procedures that yielded a diagnosis was 94% (95% CI 92% to 96%). Complication rate was 1% (95% CI 0.4% to 1.9%) among 3357 procedures. Transient pain and minor hematoma were the most common complications encountered. CONCLUSION: In our meta-analysis of 39 studies reporting diagnostic performance and complications of CT-guided biopsy, we found a diagnostic yield of 91% and diagnostic accuracy of 86% with a complication rate of 1%. Diagnostic yield did not differ between different locations, between lytic, sclerotic and mixed lesions, and between wide- and thin-bore needles.

5.
J Neurosurg Spine ; : 1-10, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33862593

RESUMO

OBJECTIVE: The ideal surgical management of grade I lumbar spondylolisthesis has not been determined despite extensive prior investigations. In this cohort study, the authors used data from the large, multicenter, prospectively collected Quality Outcomes Database to bridge the gap between the findings in previous randomized trials and those in a more heterogeneous population treated in a typical practice. The objective was to assess the difference in patient-reported outcomes among patients undergoing decompression alone or decompression plus fusion. METHODS: The primary outcome measure was change in 24-month Oswestry Disability Index (ODI) scores. The minimal clinically important difference (MCID) in ODI score change and 30% change in ODI score at 24 months were also evaluated. After adjusting for patient-specific and clinical factors, multivariable linear and logistic regressions were employed to evaluate the impact of fusion on outcomes. To account for differences in age, sex, body mass index, and baseline listhesis, a sensitivity analysis was performed using propensity score analysis to match patients undergoing decompression only with those undergoing decompression and fusion. RESULTS: In total, 608 patients who had grade I lumbar spondylolisthesis were identified (85.5% with at least 24 months of follow-up); 140 (23.0%) underwent decompression alone and 468 (77.0%) underwent decompression and fusion. The 24-month change in ODI score was significantly greater in the fusion plus decompression group than in the decompression-only group (-25.8 ± 20.0 vs -15.2 ± 19.8, p < 0.001). Fusion remained independently associated with 24-month ODI score change (B = -7.05, 95% CI -10.70 to -3.39, p ≤ 0.001) in multivariable regression analysis, as well as with achieving the MCID for the ODI score (OR 1.767, 95% CI 1.058-2.944, p = 0.029) and 30% change in ODI score (OR 2.371, 95% CI 1.286-4.371, p = 0.005). Propensity score analysis resulted in 94 patients in the decompression-only group matched 1 to 1 with 94 patients in the fusion group. The addition of fusion to decompression remained a significant predictor of 24-month change in the ODI score (B = 2.796, 95% CI 2.228-13.275, p = 0.006) and of achieving the 24-month MCID ODI score (OR 2.898, 95% CI 1.214-6.914, p = 0.016) and 24-month 30% change in ODI score (OR 2.300, 95% CI 1.014-5.216, p = 0.046). CONCLUSIONS: These results suggest that decompression plus fusion in patients with grade I lumbar spondylolisthesis may be associated with superior outcomes at 24 months compared with decompression alone, both in reduction of disability and in achieving clinically meaningful improvement. Longer-term follow-up is warranted to assess whether this effect is sustained.

6.
Artigo em Inglês | MEDLINE | ID: mdl-33713697

RESUMO

The increasing use of patient-reported outcome (PRO) measures is forcing clinicians and health care systems to decide which to select and how to incorporate them into their records and clinical workflows. This overview addresses three topics related to these concerns. First, a literature review summarizes key psychometric and practical factors (such as reliability, responsiveness, computer adaptive testing, and interpretability) in choosing PROs for clinical practice. Second, three clinical decision support (CDS) issues are highlighted: gathering PROs, electronic health record impact on providers, and incorporating PROs into CDS design and implementation. Lastly, the salience of cross-cutting domains as well as nine key pragmatic decisions are reviewed. Cross-cutting domains are those that are relevant across most medical and mental health conditions, such as the SPADE symptom pentad (sleep problems, pain, anxiety, depression, and low energy/fatigue) and physical functioning. The nine pragmatic decisions include: 1) generic vs. disease-specific scales; 2) single- vs. multi-domain scales; 3) universal scales vs. user-choice selection; 4) number of domains to measure; 5) prioritization of domains when multiple domains are assessed; 6) action thresholds; 7) clinical purpose (screening vs. monitoring); as well as the 8) frequency and 9) logistical aspects of PRO administration.

8.
J Neurosurg Spine ; : 1-9, 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33740766

RESUMO

OBJECTIVE: The development of new treatment approaches for degenerative lumbar spondylolisthesis (DLS) has introduced many questions about comparative effectiveness and long-term outcomes. Patient registries collect robust, longitudinal data that could be combined or aggregated to form a national and potentially international research data infrastructure to address these and other research questions. However, linking data across registries is challenging because registries typically define and capture different outcome measures. Variation in outcome measures occurs in clinical practice and other types of research studies as well, limiting the utility of existing data sources for addressing new research questions. The purpose of this project was to develop a minimum set of patient- and clinician-relevant standardized outcome measures that are feasible for collection in DLS registries and clinical practice. METHODS: Nineteen DLS registries, observational studies, and quality improvement efforts were invited to participate and submit outcome measures. A stakeholder panel was organized that included representatives from medical specialty societies, health systems, government agencies, payers, industries, health information technology organizations, and patient advocacy groups. The panel categorized the measures using the Agency for Healthcare Research and Quality's Outcome Measures Framework (OMF), identified a minimum set of outcome measures, and developed standardized definitions through a consensus-based process. RESULTS: The panel identified and harmonized 57 outcome measures into a minimum set of 10 core outcome measure areas and 6 supplemental outcome measure areas. The measures are organized into the OMF categories of survival, clinical response, events of interest, patient-reported outcomes, and resource utilization. CONCLUSIONS: This effort identified a minimum set of standardized measures that are relevant to patients and clinicians and appropriate for use in DLS registries, other research efforts, and clinical practice. Collection of these measures across registries and clinical practice is an important step for building research data infrastructure, creating learning healthcare systems, and improving patient management and outcomes in DLS.

9.
J Neurosurg Spine ; : 1-11, 2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33607612

RESUMO

OBJECTIVE: Surgical treatment for degenerative spondylolisthesis has been proven to be clinically challenging and cost-effective. However, there is a range of thresholds that surgeons utilize for incorporating fusion in addition to decompressive laminectomy in these cases. This study investigates these surgeon- and site-specific factors by using the Quality Outcomes Database (QOD). METHODS: The QOD was queried for all cases that had undergone surgery for grade 1 spondylolisthesis from database inception to February 2019. In addition to patient-specific covariates, surgeon-specific covariates included age, sex, race, years in practice (0-10, 11-20, 21-30, > 30 years), and fellowship training. Site-specific variables included hospital location (rural, suburban, urban), teaching versus nonteaching status, and hospital type (government, nonfederal; private, nonprofit; private, investor owned). Multivariable regression and predictor importance analyses were performed to identify predictors of the treatment performed (decompression alone vs decompression and fusion). The model was clustered by site to account for site-specific heterogeneity in treatment selection. RESULTS: A total of 12,322 cases were included with 1988 (16.1%) that had undergone decompression alone. On multivariable regression analysis clustered by site, adjusting for patient-level clinical covariates, no surgeon-specific factors were found to be significantly associated with the odds of selecting decompression alone as the surgery performed. However, sites located in suburban areas (OR 2.32, 95% CI 1.09-4.84, p = 0.03) were more likely to perform decompression alone (reference = urban). Sites located in rural areas had higher odds of performing decompression alone than hospitals located in urban areas, although the results were not statistically significant (OR 1.33, 95% CI 0.59-2.61, p = 0.49). Nonteaching status was independently associated with lower odds of performing decompression alone (OR 0.40, 95% CI 0.19-0.97, p = 0.04). Predictor importance analysis revealed that the most important determinants of treatment selection were dominant symptom (Wald χ2 = 34.7, accounting for 13.6% of total χ2) and concurrent diagnosis of disc herniation (Wald χ2 = 31.7, accounting for 12.4% of total χ2). Hospital teaching status was also found to be relatively important (Wald χ2 = 4.2, accounting for 1.6% of total χ2) but less important than other patient-level predictors. CONCLUSIONS: Nonteaching centers were more likely to perform decompressive laminectomy with supplemental fusion for spondylolisthesis. Suburban hospitals were more likely to perform decompression only. Surgeon characteristics were not found to influence treatment selection after adjustment for clinical covariates. Further large database registry experience from surgeons at high-volume academic centers at which surgically and medically complex patients are treated may provide additional insight into factors associated with treatment preference for degenerative spondylolisthesis.

10.
Clin Neurol Neurosurg ; 201: 106438, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33385933

RESUMO

BACKGROUND: Pain management following spine surgery remains a challenge. The significant use of opioids may lead to opioid-related adverse events. These complications can increase perioperative morbidity and rapidly expend health care resources by developing chronic pain. Although intraoperative pain control for surgery has been studied in the literature, a thorough assessment of the effect in spine surgery is rarely reported. The objective of the present study was to examine the outcomes of intraoperative intravenous lidocaine and intrawound or epidural bupivacaine use in spine surgery. METHODS: An electronic literature search was conducted for studies on the use of lidocaine and bupivacaine in spine surgery for all years available. Only articles in English language were included. Postoperative opioid consumption, VAS score, nausea/vomiting, and length of hospital stay comprised the outcomes of interest. Pooled descriptive statistics with Risk Ratios (RR), Mean Differences (MD) and 95 % confidence interval were used to synthesize the outcomes for each medication. RESULTS: A total of 10 studies (n = 579) were included in the analysis. Comparison of the opioid consumption revealed a significant mean difference between lidocaine and bupivacaine (MD: -12.25, and MD: -0.4, respectively, p = 0.01), favoring lidocaine. With regard to postoperative VAS, the pooled effect of both groups decreased postoperative pain (MD: -0.61 (95 % CI: -1.14, -0.08)), with a more significant effect in the lidocaine group (MD: -0.84, (95 % CI: -1.21, -0.48)). There was no significant effect in length of stay, and postoperative nausea/vomiting. CONCLUSIONS: The results of the present meta-analysis indicate that lidocaine and bupivacaine use may decrease postoperative pain and opioid consumption. Lidocaine had a stronger effect on the reduction of opioid consumption compared to bupivacaine.

11.
Clin Orthop Relat Res ; 479(4): 726-732, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33416225

RESUMO

BACKGROUND: Sarcopenia, defined as decreased skeletal mass, is an independent marker of frailty that is not accounted for by other risk-stratification methods. Recent studies have demonstrated a clear association between paraspinal sarcopenia and worse patient-reported outcomes and complications after spine surgery. Currently, sarcopenia is characterized according to either a quantitative assessment of the paraspinal cross-sectional area or a qualitative analysis of paraspinal fatty infiltration on MRI. No studies have investigated whether the cervical paraspinal cross-sectional area correlates with fatty infiltration of the cervical paraspinal muscles on advanced imaging. QUESTION/PURPOSE: Do patients undergoing anterior cervical discectomy and fusion (ACDF) with increasing paraspinal fatty degeneration on advanced imaging also demonstrate decreased cervical paraspinal cross-sectional area? METHODS: Between 2011 and 2017, 98 patients were prospectively enrolled in a database of patients undergoing one- to three-level ACDF for degenerative conditions at a single institution. To be eligible for this prospective study, patients were required to undergo an MRI before surgery, be older than 18 years, and have no previous history of cervical spine surgery. Two independent reviewers, both surgeons not involved in the patients' care and who were blinded to the clinical outcomes, retrospectively assessed the paraspinal cross-sectional area and Goutallier classification of the right-sided paraspinal muscle complex. We then compared the patients' Goutallier grades with their paraspinal cross-sectional area measurements. We identified 98 patients for inclusion. Using the Fuchs modification of the Goutallier classification, we classified the fatty degeneration of 41 patients as normal (Goutallier Grades 0 to 1), that of 47 patients as moderate (Grade 2), and that of 10 patients as severe (Grades 3 to 4). We used ANOVA to compare all means between groups. RESULTS: There was no difference in the mean paraspinal cross-sectional area of the obliquus capitus inferior (normal 295 ± 81 mm2; moderate 317 ± 104 mm2; severe 300 ± 79 mm2; p = 0.51), multifidus (normal 146 ± 59 mm2; moderate 170 ± 70 mm2; severe 192 ± 107 mm2; p = 0.11), or sternocleidomastoid (normal 483 ± 150 mm2; moderate 468 ± 149 mm2; severe 458 ± 183 mm2; p = 0.85) among patients with mild, moderate, and severe fatty infiltration based on Goutallier grading. There was a slightly greater longus colli cross-sectional area in the moderate and severe fatty infiltration groups (74 ± 22 mm2 and 66 ± 18 mm2, respectively) than in the normal group (63 ± 15 mm2; p = 0.03). CONCLUSION: Because our study demonstrates minimal association between paraspinal cross-sectional area and fatty infiltration of the cervical paraspinals, we recommend that physicians use the proven qualitative assessment of paraspinal fatty infiltration during preoperative evaluation of patients who are candidates for ACDF. Future studies investigating the relationship between cervical paraspinal cross-sectional area and patient-reported outcomes after ACDF are necessary to lend greater strength to this recommendation. LEVEL OF EVIDENCE: Level III, diagnostic study.

12.
World Neurosurg ; 149: 249-264.e1, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33516869

RESUMO

BACKGROUND: Expandable cages have been increasingly used in cervical and lumbar reconstructions; however, there is a paucity in the literature on how they compare with traditional nonexpandable cages in the cervical spine. We present a systematic review and meta-analysis, comparing the clinical and radiologic outcomes of expandable versus nonexpandable corpectomy cage use in the cervical spine. METHODS: A database search identified studies detailing the outcomes of expandable and nonexpandable titanium cage use in the cervical spine. These studies were screened using the PRISMA protocol. Fixed-effects and random-effects models were used with a 95% confidence interval. Two analyses were carried out for each outcome: one including all studies and the other including only studies reporting on exclusively 1-level and 2-level cases. RESULTS: Forty-one studies were included. The mean change in segmental lordosis was significantly greater in expandable cages (all, 6.72 vs. 3.69°, P < 0.001; 1-level and 2-level, 6.81° vs. 4.31°, P < 0.001). The mean change in cervical lordosis was also significantly greater in expandable cages (all, 5.71° vs. 3.11°, P = 0.027; 1-level and 2-level, 5.71° vs. 2.07°, P = 0.002). No significant difference was found between the complication rates (all, P = 0.43; 1-level and 2-level, P = 0.94); however, the proportion of revisions was significantly greater in expandable cages (all, 0.06 vs. 0.02, P = 0.03; 1-level and 2-level, 0.08 vs. 0.01, P = 0.017). CONCLUSIONS: The use of expandable cages may carry a modest improvement in radiologic outcomes compared with nonexpandable cages in the cervical spine; however, they may also lead to a higher rate of revisions based on our analyses.

13.
Mayo Clin Proc ; 96(5): 1193-1202, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33384145

RESUMO

OBJECTIVE: To highlight the early experience of implementing a robotic spine surgery program at a three-site medical center, evaluating the impact of increasing experience on the operative time and number of procedures performed. PATIENTS AND METHODS: A retrospective chart review of patients undergoing robotic screw placement between September 4, 2018, and October 16, 2019, was conducted. Baseline characteristics as well as intraoperative and post-operative outcomes were obtained. RESULTS: For a total of 77 patients, the mean age (SD) was 55.7 years (11.5) and 49.4% (n=38) were female. A total of 402 screws were placed (384 pedicle screws, 18 cortical screws) using robotic guidance with a median of two operative levels (interquartile range [IQR], 1 to 2). Median (IQR) estimated blood loss was 100 mL (50 to 200 mL) and the median (IQR) operative time was 224 minutes (193 to 307 minutes). With accrual of surgical experience, operative time declined significantly (R=-0.39; P<.001) whereas the number of procedures performed per week increased (R=0.30; P=.05) throughout the study period. Median (IQR) length of hospital stay following surgery was 2 days (IQR, 2 to 3 days). There were two screws requiring revision intraoperatively. No postoperative revisions were required, and no complications were encountered related to screw placement. CONCLUSION: Early experience at our institution using a spinal robot has demonstrated no requirement for postoperative screw revisions and no complications related to screw malposition. The increased operative times were reduced as the frequency of procedures increased. Moreover, procedural times diminished over a short period with a weekly increasing number of procedures.

14.
Global Spine J ; : 2192568220988270, 2021 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-33472412

RESUMO

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Studies investigating the impact of interbody subsidence in ACDF suggest a correlation between subsidence and worse radiographic and patient-reported outcomes. The purpose of this study was to assess whether allograft subsidence assessed on CT is associated with worse cervical alignment. METHODS: We performed a retrospective review of a prospective cohort of patients undergoing 1 to 3 level ACDF. Cervical alignment was assessed on standing radiographs performed preoperatively, less than 2 months postoperatively, and greater than 6 months postoperatively. Allograft subsidence was assessed on CT scan performed at least 6 months postoperatively. Patients with at least 1 level demonstrating greater than 4mm of cage subsidence were classified as severe subsidence. Student's t-test was used to compare all means between groups. RESULTS: We identified 66 patients for inclusion, including 56 patients with non-severe subsidence and 10 patients with severe subsidence. For the entire cohort, there was a significant increase in C2-7 Lordosis (p = 0.005) and Segmental Lordosis (p < 0.00 001) from preoperative to early postoperative. On comparison of severely and non-severely subsided levels, severely subsided levels demonstrated a significantly greater loss of segmental lordosis from early to mid-term follow-up than non-severely subsided levels (-4.89 versus -2.59 degrees, p < 0.0001), manifesting as a significantly lower segmental lordosis at >6 months postoperative (0.54 versus 3.82 degrees, p < 0.00 001). There were no significant differences in global cervical alignment parameters between patients with severe and non-severe subsidence. CONCLUSIONS: Severe subsidence is associated with a significant increase in loss of segmental lordosis, but has minimal effect on global cervical alignment parameters.

15.
J Neurooncol ; 152(2): 299-311, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33481148

RESUMO

INTRODUCTION: Stereotactic radiosurgery (SRS) has been increasingly employed to treat patients with intracranial metastasis, both as a salvage treatment after failed whole brain radiation therapy (WBRT) and as an initial treatment. "Several studies have shown that SRS may be as effective as WBRT with the added benefit of preserving neuro-cognition". However, some patients may have local failure following SRS for intracranial metastasis, defined as increase in total lesion volume by 25% after at least 3 months of follow up. METHODS: The SRS registry, established by the Neuro point alliance (NPA) under the auspices of the American Association of Neurological Surgeons (AANS), was queried for patients with intracranial metastasis receiving SRS at the participating sites. Demographic, clinical symptoms, tumor, and treatment characteristics as well as follow up status were summarized for the cohort. A multivariable explanatory cox- regression was performed to evaluate the impact of each of the factors on time to local failure.at last follow-up. RESULTS: A total of 441 patients with 1255 intracranial metastatic lesions undergoing SRS were identified. The most common primary cancer histology was non-small cell lung cancer (43.8%, n = 193). More than half of the cohort had more than 1 metastatic lesion (2-3 lesions: 29.5%, n = 130; more than 3 lesions: 25.2% (n = 111). The average duration of follow-up for the cohort was found to be 8.4 months (SD = 7.61). The mean clinical treatment volume (CTV), after adding together the volume of each lesion for each patient was 5.39 cc (SD = 7.6) at baseline. A total of 20.2% (n = 89) had local failure (increase in volume by > 25%) with a mean time to progression of 7.719 months (SD = 6.09). The progression free survival (PFS) for the cohort at 3, 6 and 12 months were found to be 94.9%, 84.3%, and 69.4%, respectively. On multivariable cox regression analysis, factors associated with increased hazard of local failure included male gender (HR 1.65, 95% CI 1.03-2.66, p = 0.037), chemotherapy at or before SRS (HR = 2.39, 95% CI 1.41-4.05, p = 0.001), WBRT at or before SRS (HR = 2.21, 95% CI 1.16- 4.22, p = 0.017), while surgical resection (HR 0.45, 95% CI 0.21-0. 97, p = 0.04) and immunotherapy (0.34, 95% CI 0.16-0.50, p = 0.014) were associated with lower hazard of local failure. CONCLUSION: Factors found to be predictive of local failure included higher RPA score and those receiving chemotherapy, while patients undergoing surgical resection and those with occipital lobe lesions were less likely to experience local failure. Our analyses not only corroborate those previously reported but also demonstrate the utility of a multi-institutional registry to advance real-world SRS research for patients with intracranial metastatic lesions.

16.
World Neurosurg ; 148: 118-126, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33516865

RESUMO

BACKGROUND: Intraoperative vascular injuries in the cervical spine are rare, but carry significant morbidity and mortality when they do occur. There is a need to better characterize the risk of vertebral artery injury (VAI) after posterior C1-C2 fusion. The aim of this study was to investigate the rate of VAI in patients undergoing posterior C1-C2 cervical fusion. METHODS: An electronic database search was performed to identify studies that reported rates of VAI following posterior cervical fusion at C1-C2 level. Patient-specific risk factors, surgical indication, surgical technique, and other data were collected for each study. Forest plots were created to outline the pooled ratios of VAI in the literature. RESULTS: Eleven studies with 773 patients were identified. Mean age of patients was 48.47 years (range, 6-78 years), and most patients were female (61.7%, n = 399). Trauma was the most frequent indication for surgery (18.8%, n = 146), followed by inflammatory processes affecting the vertebrae (13.2%, n = 102). The rate of VAI per patient was 2% (95% confidence interval = 1%-4%) among 773 patients, while injury rate per screw was 1% (95% confidence interval = 0%-2%) among 2238 screws placed. CONCLUSIONS: The rate of VAI after C1-C2 posterior cervical fusion was found to be 2% for each operated patient and 1% for each screw placed.

17.
Clin Neurol Neurosurg ; 201: 106429, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33360953

RESUMO

BACKGROUND: Elective lumbar fusion is a commonly employed procedure for degenerative lumbar spine disease. With healthcare costs rising reimbursement for procedures may be restricted by payers. Additionally, patients may undergo elective fusion once deductibles are covered, typically in the fourth quarter in a given year. The objective of this study was to analyze the trends in utilization for posterior lumbar fusion (PLF) earlier in the year (Q1-Q3) as compared to the end of the year(Q4). Variations in this proposed trend by insurance type were also studied as a primary outcome. METHODS: We queried the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) between January 1, 2012 and December 31, 2014 for patients diagnosed with lumbar disc degenerative disease (DDD). Outcomes of interest included utilization and frequency of PLF. RESULTS: 221,466 patients hospitalized with Lumbar DDD between 2012 and 2014 were identified. Of these, 67,343(30.4 %) underwent a PLF procedure. The likelihood of lumbar fusion in patients hospitalized with DDD was significantly higher in the 4th quarter, compared to 1st quarter (OR1.13, p < 0.001). Marginal effect analysis indicated that Medicare patients were 1.0 % more likely to undergo PLF in quarter 4 compared to quarters 1-3 (p = 0.003), while privately insured patients were 2.5 % more likely to undergo PLF in quarter 4 compared to quarters 1-3(p < 0.001). CONCLUSION: These results indicate that utilization of PLF is higher at the end of the year relative to the beginning, especially for patients with private insurance. This may be due to deductibles that have previously been paid off, lowering out-of-pocket expenses.

18.
Spine (Phila Pa 1976) ; 46(11): 717-725, 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-33337676

RESUMO

STUDY DESIGN: Retrospective analysis of prospectively collected registry data. OBJECTIVE: The aim of this study was to compare the performance of 30% reduction to established absolute point-change values for measures of disability and pain in patients undergoing elective cervical spine surgery. SUMMARY OF BACKGROUND DATA: Recent studies recommend using a proportional change from baseline instead of an absolute point-change value to define minimum clinically important difference (MCID). METHODS: Analyses included 13,179 patients who underwent cervical spine surgery for degenerative disease between April 2013 and February 2018. Participants completed a baseline and 12-month follow-up assessment that included questionnaires to assess disability (Neck Disability Index [NDI]), neck and arm pain (Numeric Rating Scale [NRS-NP/AP], and satisfaction [NASS scale]). Participants were classified as met or not met 30% reduction from baseline in each of the respective measures. The 30% reduction in scores at 12 months was compared to a wide range of established absolute point-change MCID values using receiver-operating characteristic curves, area under the receiver-operating characteristic curve (AUROC), and logistic regression analyses. These analyses were conducted for the entire patient cohort, as well as for subgroups based on baseline severity and surgical approach. RESULTS: Thirty percent reduction in NDI and NRS-NP/AP scores predicted satisfaction with more accuracy than absolute point-change values for the total population and ACDF and posterior fusion procedures (P < 0.05). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 16.8%) and bed-bound disability (ODI 81%-100%: 16.6%) categories. For pain, there was a 1.9% to 11% and 1.6% to 9.6% AUROC difference for no/mild neck and arm pain (NRS 0-4), respectively, in favor of a 30% reduction threshold. CONCLUSION: A 30% reduction from baseline is a valid method for determining MCID in disability and pain for patients undergoing cervical spine surgery.Level of Evidence: 3.

19.
World Neurosurg ; 147: e171-e188, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33359880

RESUMO

OBJECTIVE: In this study, we sought to characterize contemporary trends in cost and utilization of spinal cord stimulation (SCS). METHODS: The Healthcare Cost and Utilization Project-National Inpatient Sample was queried for inpatient admissions from 2008 to 2014 where SCS was performed. We then determined the rates and costs of SCS performed in this time frame to treat diagnoses that we classified as device-related complications, degenerative spine disease, pain syndromes, and neuropathies/neuritis/nerve lesions. Least-squares regression was performed to determine the yearly trends for each indication adjusted by the total number of yearly hospitalizations for that diagnosis. RESULTS: We identified a total of 6876 admissions in whom an SCS was performed. The overall rate of inpatient SCS procedures performed has decreased by 45% from 2008 to 2014 (14.0 to 7.7 procedures per 100,000 admissions). Adjusted analysis for yearly trends also demonstrated a declining trend for all indications; however, this was not found to be statistically significant, except for device-related complications (P = 0.004). The median inflation-adjusted cost of an admission where SCS was performed increased slightly by 7.4% from $26,200 (IQR: $16,700-$33,800) in 2008 to $28,100 (IQR: $19,600-$36,900) in 2014. Billed hospital charges demonstrated a significant increase with median inflation-adjusted admission charge of $66,068 in 2008 to $110,672 in 2014. CONCLUSIONS: Despite a declining contemporary trend in inpatient SCS, an increase was noted in admission costs and hospital charges. A significant declining trend was noted in revision SCS implantations due to device-related complications.

20.
World Neurosurg ; 2020 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-33276177

RESUMO

INTRODUCTION: Minimally invasive spine surgery (MIS) has been associated with lower complication rates and improved patient reported outcomes in recent studies. In this study, we aimed to investigate operative and postoperative outcomes associated with both surgical techniques in elderly patients. METHODS: Patients who are 65 years old or older underwent either minimally invasive or open surgery for lumbar degenerative conditions. Patients with non-degenerative etiology such as infection or trauma were excluded from the analysis. Patient characteristics such as demographics, associated comorbidities as well as perioperative and postoperative complications were collected. Outcomes of interest were operative time, estimated blood loss (EBL), length of stay (LOS), readmissions, reoperations, and any complications. RESULTS: A total of 107 elderly patients were identified for this study with a median age of 73.0 years. Demographics and comorbidities in both groups were similar in both groups. Univariate analysis yielded MIS group with significantly lower EBL (p<0.001), operative time (p<0.001) and length of stay (p<0.001). In multivariable analysis, EBL and LOS were found to be significantly lower in the MIS group (p=0.02 and 0.001, respectively). Rates of complications, readmissions (no readmissions in MIS group), reoperations, and pain improvement have also favored the MIS group and although they were not found to be significantly different among two groups on univariate and multivariable analysis, the results trended towards significance. CONCLUSION: These findings suggest that minimally invasive spine surgery in the elderly is safe and may pose lower risk of associated perioperative and post-operative complications with faster recovery time.

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