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1.
Neurosurgery ; 2020 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-32409828

RESUMO

BACKGROUND: It remains unclear if minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is comparable to traditional, open TLIF because of the limitations of the prior small-sample-size, single-center studies reporting comparative effectiveness. OBJECTIVE: To compare MI-TLIF to traditional, open TLIF for grade 1 degenerative lumbar spondylolisthesis in the largest study to date by sample size. METHODS: We utilized the prospective Quality Outcomes Database registry and queried patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery with MI- or open TLIF methods. Outcomes were compared 24 mo postoperatively. RESULTS: A total of 297 patients were included: 72 (24.2%) MI-TLIF and 225 (75.8%) open TLIF. MI-TLIF surgeries had lower mean body mass indexes (29.5 ± 5.1 vs 31.3 ± 7.0, P = .0497) and more worker's compensation cases (11.1% vs 1.3%, P < .001) but were otherwise similar. MI-TLIF had less blood loss (108.8 ± 85.6 vs 299.6 ± 242.2 mL, P < .001), longer operations (228.2 ± 111.5 vs 189.6 ± 66.5 min, P < .001), and a higher return-to-work (RTW) rate (100% vs 80%, P = .02). Both cohorts improved significantly from baseline for 24-mo Oswestry Disability Index (ODI), Numeric Rating Scale back pain (NRS-BP), NRS leg pain (NRS-LP), and Euro-Qol-5 dimension (EQ-5D) (P > .001). In multivariable adjusted analyses, MI-TLIF was associated with lower ODI (ß = -4.7; 95% CI = -9.3 to -0.04; P = .048), higher EQ-5D (ß = 0.06; 95% CI = 0.01-0.11; P = .02), and higher satisfaction (odds ratio for North American Spine Society [NASS] 1/2 = 3.9; 95% CI = 1.4-14.3; P = .02). Though trends favoring MI-TLIF were evident for NRS-BP (P = .06), NRS-LP (P = .07), and reoperation rate (P = .13), these results did not reach statistical significance. CONCLUSION: For single-level grade 1 degenerative lumbar spondylolisthesis, MI-TLIF was associated with less disability, higher quality of life, and higher patient satisfaction compared with traditional, open TLIF. MI-TLIF was associated with higher rates of RTW, less blood loss, but longer operative times. Though we utilized multivariable adjusted analyses, these findings may be susceptible to selection bias.

2.
Clin Neurol Neurosurg ; 195: 105821, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32388145

RESUMO

Heterotopic Ossification (HO) refers to the formation of bone within soft tissue. Traumatic spinal cord injury (SCI) has been shown to be associated with development of HO. However, risk factors for HO following SCI are unknown. In light of this knowledge gap, we performed a systematic review and meta-analysis to summarize available evidence and elucidate risk factors associated with heterotopic ossification. An electronic literature search was conducted using five databases. Studies containing SCI patients, with a proportion diagnosed with HO, were included. Meta-analyses were performed to assess the association between following risk factors and development of HO: sex, type of injury, spasticity, pressure ulcer, injury level, urinary tract infection (UTI), deep vein thrombosis (DVT), number of smokers, and pneumonia. Nine studies with 2,115 patients were included. It was found that males (Odds Ratio [95% Confidence Interval]: 2.25 [1.61, 3.13]), smokers (2.88 [1.62, 5.11]), patients with complete injury (3.61 [2.29, 5.71]), pneumonia (2.86 [2.18, 3.75]), pressure ulcers (2.45 [1.89, 3.18]), UTI (3.84 [2.63, 5.62]) and spasticity (2.12 [1.67, 2.68]) had significantly higher odds of developing HO after spinal cord injury. In contrast, location of injury (Cervical vs. thoracic injury; (1.03 [0.72, 1.49]) and DVT (1.37 [0.91, 2.07]) were not associated with development of HO. Pooled results from existing literature on HO development show that several factors are significantly associated with development of HO. Given the complexity of SCI management, the results might have a positive impact on the clinical practice by leading to an effective screening aproach.

3.
J Neurosurg Spine ; : 1-11, 2020 May 08.
Artigo em Inglês | MEDLINE | ID: mdl-32384269

RESUMO

OBJECTIVE: Lumbar decompression without arthrodesis remains a potential treatment option for cases of low-grade spondylolisthesis (i.e., Meyerding grade I). Minimally invasive surgery (MIS) techniques have recently been increasingly used because of their touted benefits including lower operating time, blood loss, and length of stay. Herein, the authors analyzed patients enrolled in a national surgical registry and compared the baseline characteristics and postoperative clinical and patient-reported outcomes (PROs) between patients undergoing open versus MIS lumbar decompression. METHODS: The authors queried the Quality Outcomes Database for patients with grade I lumbar degenerative spondylolisthesis undergoing a surgical intervention between July 2014 and June 2016. Among more than 200 participating sites, the 12 with the highest enrollment of patients into the lumbar spine module came together to initiate a focused project to assess the impact of fusion on PROs in patients undergoing surgery for grade I lumbar spondylolisthesis. For the current study, only patients in this cohort from the 12 highest-enrolling sites who underwent a decompression alone were evaluated and classified as open or MIS (tubular decompression). Outcomes of interest included PROs at 2 years; perioperative outcomes such as blood loss and complications; and postoperative outcomes such as length of stay, discharge disposition, and reoperations. RESULTS: A total of 140 patients undergoing decompression were selected, of whom 71 (50.7%) underwent MIS and 69 (49.3%) underwent an open decompression. On univariate analysis, the authors observed no significant differences between the 2 groups in terms of PROs at 2-year follow-up, including back pain, leg pain, Oswestry Disability Index score, EQ-5D score, and patient satisfaction. On multivariable analysis, compared to MIS, open decompression was associated with higher satisfaction (OR 7.5, 95% CI 2.41-23.2, p = 0.0005). Patients undergoing MIS decompression had a significantly shorter length of stay compared to the open group (0.68 days [SD 1.18] vs 1.83 days [SD 1.618], p < 0.001). CONCLUSIONS: In this multiinstitutional prospective study, the authors found comparable PROs as well as clinical outcomes at 2 years between groups of patients undergoing open or MIS decompression for low-grade spondylolisthesis.

4.
Spine J ; 2020 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-32413486

RESUMO

BACKGROUND CONTEXT: Patient reported outcome measures (PROMs) are valuable tools for evaluating the success of spine surgery, with the Neck Disability Index (NDI) commonly used to assess pain-related disability. Recently, PROMIS has gained attention in its ability to measure PROs across general patient populations. However, PROMIS is not condition-specific so spine researchers are reluctant to incorporate it in place of common legacy measures. PURPOSE: To compare the PROMIS-29 (v2.0) to the NDI and compute a conversion equation. STUDY DESIGN/SETTING: This study retrospectively analyzes prospectively collected data from the cervical module of national spine registry, the Quality Outcomes Database (QOD). PATIENT SAMPLE: The QOD was queried for cervical spine surgery patients with PROMIS-29 and NDI scores. The cervical module of QOD includes patients undergoing primary or revision surgery cervical degenerative spine diseases. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of lumbar-related pain. OUTCOME MEASURES: The outcome of interest for this study was a conversion equation from PROMIS-29 to NDI. METHODS: The PROMIS-29 includes seven 4-item domains each rated on a 5-point scale: Physical function, depression, anxiety, fatigue, sleep disturbance, ability to participate in social roles and activities (social roles), pain interference, and one pain intensity item. The NDI contains 10 pain-related questions scored from 0 (no pain) to 5 (most severe pain). Outcomes were collected prior to surgery and at 3- and 12-months post-surgery. Patients were included in the current analysis if they had outcome data available at one or more time points. Multivariable mixed effects regression models predicting NDI scores from PROMIS-29 domains were conducted in a development data set and validated in a separate data set. Predicted NDI scores were plotted against NDI scores to determine how well PROMIS-29 domains predicted NDI. Conversion equations were created from the PROMIS regression coefficients. RESULTS: 2,018 patients from 18 US hospitals were included (mean age=58 years (SD=12)) with 47% female, 88% Caucasian, and 11% had revision surgery. Strong correlations were found between NDI and pain interference (r=0.79), pain intensity (r=0.74), social roles (r=-0.71), physical function (r=-0.69), sleep disturbance (r=0.63), fatigue (r=0.63), and anxiety (r=0.54). Correlation between NDI and depression (r=0.49) was slightly weaker. The pattern of correlations was consistent across timepoints. Four conversion equations were created for NDI using 1) only pain interference, 2) only physical function, 3) pain interference and physical function, and 4) the six statistically significant domains of pain interference, physical function, pain intensity, social roles, sleep disturbance, and anxiety. Equations 1, 3, and 4 were the best predictors of NDI, predicting approximately 80% of NDI scores within 15 points in the validation data set. Equation 4 (NDI%=18.897+0.855*[pain interferenceraw]-0.694*[physical functionraw]+2.010*[pain intensityraw]-0.663*[social rolesraw]+0.732*[sleep disturbanceraw] +0.426*[anxietyraw]) predicted NDI most accurately with an R2 between the predicted and actual NDI scores of 0.72. Model 1 (R2 = 0.62; NDI%=-4.055 + 3.164*[pain interferenceraw])) and Model 3 (R2 = 0.65; NDI%=17.321+2.543*[pain interferenceraw]-1.012*[physical functionraw]) also had good accuracy. CONCLUSION: Findings suggest accurate NDI scores can be derived from PROMIS-29 domains. Clinicians who want to move from NDI to PROMIS-29 can use this equation to obtain estimated NDI scores when only collecting PROMIS-29. These results support the use of PROMIS-29 in cervical surgery populations and underscore the idea that PROMIS-29 domains have the potential to replace disease-specific traditional PROMs.

5.
Bosn J Basic Med Sci ; 2020 May 11.
Artigo em Inglês | MEDLINE | ID: mdl-32415820

RESUMO

Bone marrow aspiration (BMA) through the iliac crest is potentially unsafe due to the vicinity of neurovascular structures in the greater sciatic notch. Our objective was to investigate the safety of a recently described BMA technique, specifically a trajectory from the posterior superior iliac spine (PSIS) to the anterior inferior iliac spine (AIIS). We conducted a chart review of 260 patients, analyzing three-dimensional reconstructed computed tomography images of the pelvis and sacrum to validate that this new approach offers a wide safety margin from the greater sciatic notch. Analysis of three-dimensional computed tomography scans demonstrated that the PSIS to AIIS trajectory never crossed the greater sciatic notch. The trajectory was noted to be at least one cm away from the greater sciatic notch in all measurements. The new trajectory entered the PSIS at 25.29 ± 4.34° (left side) and 24.93 ± 4.15° (right side) cephalad from the transverse plane, and 24.58 ± 4.99° (left side) and 24.56 ± 4.67° (right side) lateral from the mid-sagittal plane. The area of bone marrow encountered with the new approach was approximately 22.5 cm2. Utilizing the same CT scans, the trajectory from the traditional approach crossed the greater sciatic notch in all scans, highlighting the potential for violating the greater sciatic notch boundary and damaging important neurovascular structures. Statistically significant sex-related differences were identified in needle trajectory angles for both approaches. We conclude that based on this three-dimensional computed tomography study, a trajectory from the PSIS to the AIIS for BMA may offer a wide safety margin from the greater sciatic notch.

6.
Neurosurg Focus ; 48(5): E2, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32357320

RESUMO

The Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality Outcomes Database (N2QOD), was established by the NeuroPoint Alliance (NPA) in collaboration with relevant national stakeholders and experts. The overarching goal of this project was to develop a centralized, nationally coordinated effort to allow individual surgeons and practice groups to collect, measure, and analyze practice patterns and neurosurgical outcomes. Specific objectives of this registry program were as follows: "1) to establish risk-adjusted national benchmarks for both the safety and effectiveness of neurosurgical procedures, 2) to allow practice groups and hospitals to analyze their individual morbidity and clinical outcomes in real time, 3) to generate both quality and efficiency data to support claims made to public and private payers and objectively demonstrate the value of care to other stakeholders, 4) to demonstrate the comparative effectiveness of neurosurgical and spine procedures, 5) to develop sophisticated 'risk models' to determine which subpopulations of patients are most likely to benefit from specific surgical interventions, and 6) to facilitate essential multicenter trials and other cooperative clinical studies." The NPA has launched several neurosurgical specialty modules in the QOD program in the 7 years since its inception including lumbar spine, cervical spine, and spinal deformity and cerebrovascular and intracranial tumor. The QOD Spine modules, which are the primary subject of this paper, have evolved into the largest North American spine registries yet created and have resulted in unprecedented cooperative activities within our specialty and among affiliated spine care practitioners. Herein, the authors discuss the experience of QOD Spine programs to date, with a brief description of their inception, some of the key achievements and milestones, as well as the recent transition of the spine modules to the American Spine Registry (ASR), a collaboration between the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons (AAOS).

7.
Neurosurg Focus ; 48(5): E5, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32357321

RESUMO

OBJECTIVE: Return to work (RTW) and satisfaction are important outcome measures after surgery for degenerative spine disease. The authors queried the prospective Quality Outcomes Database (QOD) to determine if RTW correlated with patient satisfaction. METHODS: The QOD was queried for patients undergoing surgery for degenerative lumbar spondylolisthesis. The primary outcome of interest was correlation between RTW and patient satisfaction, as measured by the North American Spine Society patient satisfaction index (NASS). Secondarily, data on satisfied patients were analyzed to see what patient factors correlated with RTW. RESULTS: Of 608 total patients in the QOD spondylolisthesis data set, there were 292 patients for whom data were available on both satisfaction and RTW status. Of these, 249 (85.3%) were satisfied with surgery (NASS score 1-2), and 224 (76.7%) did RTW after surgery. Of the 68 patients who did not RTW after surgery, 49 (72.1%) were still satisfied with surgery. Of the 224 patients who did RTW, 24 (10.7%) were unsatisfied with surgery (NASS score 3-4). There were significantly more people who had an NASS score of 1 in the RTW group than in the non-RTW group (71.4% vs 42.6%, p < 0.05). Failure to RTW was associated with lower level of education, worse baseline back pain (measured with a numeric rating scale), and worse baseline disability (measured with the Oswestry Disability Index [ODI]). CONCLUSIONS: There are a substantial number of patients who are satisfied with surgery even though they did not RTW. Patients who were satisfied with surgery and did not RTW typically had worse preoperative back pain and ODI and typically did not have a college education. While RTW remains an important measure after surgery, physicians should be mindful that patients who do not RTW may still be satisfied with their outcome.

9.
J Neurooncol ; 2020 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-32363470

RESUMO

PURPOSE: Glioblastoma multiforme (GBM) is a common and aggressive malignancy associated with poor prognosis. Characteristics and treatment of long-term survivors are of particular interest in efforts to improve outcomes. Therefore, the objective of this study was to examine trends and prognostic factors for 3-year survival from a national database. METHODS: The National Cancer Database (NCDB) was queried for patients diagnosed with cranial GBM from 2004 to 2013 and with 3-year follow-up. Trends in 3-year and overall survival, patient characteristics, tumor properties, and treatment modalities were examined. Multivariable logistic regression was utilized to investigate the association of these factors with 3-year survival. Predictor importance analysis was conducted using a metric defined as Wald χ2 penalized by degrees of freedom. RESULTS: A total of 88,919 GBM patients with 3-year follow-up were identified. Overall, 8757 (9.8%) patients survived ≥ 3 years. Three-year survival significantly improved from 8.0 to 10.5% (p < 0.001) from 2004 to 2013. Trimodal treatment administration also significantly increased from 38.7 to 55.9% (p < 0.001). During this span, patients increasingly presented as older (p = 0.040), without private insurance (p < 0.001), and with a higher comorbidity index (p < 0.001). On multivariable regression, factors such as trimodal treatment (p < 0.001), younger age (p < 0.001), and MGMT methylation (p < 0.001) were significantly associated with increased odds of 3-year survival. Predictor importance analysis indicated that MGMT methylation, age, and treatment modality were the most significant relative determinants of 3-year survival. CONCLUSION: These findings illustrate an improved 3-year survival rate for GBM patients from 2004 to 2013 with a concurrent increase in trimodal treatment administration despite more adverse patient presenting characteristics.

10.
Gene ; 750: 144634, 2020 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-32240779

RESUMO

Lumbar degenerative disc disease (DDD) is a multifaceted progressive condition and often accompanied by disc herniation (DH) and/or degenerative spondylolisthesis (DS). Given the high prevalence of the disease (up to 20% according to some estimates) and the high costs associated with its care, there is a need to explore novel therapies such as regenerative medicine. Exploring these novel therapies first warrants investigation of molecular pathways underlying these disorders. Here, we show results from next generation RNA sequencing (RNA-seq) on mRNA isolated from 10 human nucleus pulposus (NP) samples of lumbar degenerated discs (DH and DS; n = 5 for each tissue) and other musculoskeletal tissues (Bone, cartilage, growth plate, and muscle; n = 7 for each tissue). Pathway and network analyses based on gene ontology (GO) terms were used to identify the biological functions of differentially expressed mRNAs. A total of 701 genes were found to be significantly upregulated in lumbar NP tissue compared to other musculoskeletal tissues. These differentially expressed mRNAs were primarily involved in DNA damage, immunity and G1/S transition of mitotic cell cycle. Interestingly, DH-specific signaling genes showed major network in chemotactic (e.g., CXCL10, CXCL11, IL1RL2 and IL6) and matrix-degrading pathway (e.g., MMP16, ADAMTSL1, 5, 8, 12, and 15), while DS-specific signaling genes were found to be those involved in cell adhesion (e.g., CDH1, EPHA1 and EFNA2) and inflammatory cytokines (e.g., CD19, CXCL5, CCL24, 25 and XCL2). Our findings provide new leads for therapeutic drug discovery that would permit optimization of medical or pharmacological intervention for cases of lumbar DDD.

11.
World Neurosurg ; 2020 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-32113995

RESUMO

OBJECTIVE: Regional differences in outcomes after spine surgery are poorly understood. We assessed disability and quality-of-life outcomes by geographic region in the United States using the NeuroPoint Alliance Quality Outcomes Database. METHODS: We queried the prospective Quality Outcomes Database patient registry to identify patients who underwent elective 1- or 2-level lumbar surgery for grade I degenerative spondylolisthesis from July 2014 through June 2016. Primary outcome measures included Oswestry Disability Index (ODI) and EuroQOL-5D (EQ-5D) reported at 24 months postoperatively. Differences in EQ-5D and ODI were compared across geographic regions of the United States (Northeast, Midwest, South, West). RESULTS: We identified 608 patients from 12 centers who underwent surgery. Of these, 517 (85.0%) had ODI data and 492 (80.9%) had EQ-5D data at 24 months. Southern states had the largest representation (304 patients; 5 centers), followed by Northeastern (114 patients; 3 centers), Midwestern (96 patients; 2 centers), and Western (94 patients; 2 centers) states. Baseline ODI scores were significantly different among regions, with the South having the greatest baseline disability burden (Northeast: 40.9 ± 16.9, South: 51.2 ± 15.8, Midwest: 40.9 ± 17.8, West: 45.0 ± 17.1, P < 0.001). The change in ODI at 24 months postoperatively was significantly different among regions, with the South showing the greatest ODI improvement (Northeast: -21.1 ± 18.2, South: -26.5 ± 20.2, Midwest: -18.2 ± 22.9, West: -21.7 ± 19.6, P < 0.001). All regions had ≥60% achievement of the minimum clinically important difference in ODI at 24 months postoperatively. No regional differences were observed for EQ-5D. CONCLUSION: Significant regional variation exists for disability outcomes, but not quality of life, at 24 months after spinal surgery for grade I degenerative spondylolisthesis.

13.
J Neurosurg ; : 1-13, 2020 Mar 13.
Artigo em Inglês | MEDLINE | ID: mdl-32168482

RESUMO

OBJECTIVE: The nature of the volume-outcome relationship in cases with severe traumatic brain injury (TBI) remains unclear, with considerable interhospital variation in patient outcomes. The objective of this study was to understand the state of the volume-outcome relationship at different levels of trauma centers in the United States. METHODS: The authors queried the National Trauma Data Bank for the years 2007-2014 for patients with severe TBI. Case volumes for each level of trauma center organized into quintiles (Q1-Q5) served as the primary predictor. Analyzed outcomes included in-hospital mortality, total hospital length of stay (LOS), and intensive care unit (ICU) stay. Multivariable regression models were performed for in-hospital mortality, overall complications, and total hospital and ICU LOSs to adjust for possible confounders. The analysis was stratified by level designation of the trauma center. Statistical significance was established at p < 0.001 to avoid a type I error due to a large sample size. RESULTS: A total of 122,445 patients were included. Adjusted analysis did not demonstrate a significant relationship between increasing hospital volume of severe TBI cases and in-hospital mortality, complications, and nonhome hospital discharge disposition among level I-IV trauma centers. However, among level II trauma centers, hospital LOS was longer for the highest volume quintile (adjusted mean difference [MD] for Q5: 2.83 days, 95% CI 1.40-4.26 days, p < 0.001, reference = Q1). For level III and IV trauma centers, both hospital LOS and ICU LOS were longer for the highest volume quintile (adjusted MD for Q5: LOS 4.6 days, 95% CI 2.3-7.0 days, p < 0.001; ICU LOS 3.2 days, 95% CI 1.6-4.8 days, p < 0.001). CONCLUSIONS: Higher volumes of severe TBI cases at a lower level of trauma center may be associated with a longer LOS. These results may assist policymakers with target interventions for resource allocation and point to the need for careful prehospital decision-making in patients with severe TBI.

14.
Clin Neurol Neurosurg ; 193: 105737, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32169744

RESUMO

Heterotopic ossification(HO) is a common complication following spinal cord injury(SCI); however, its underlying pathophysiology remains relatively unknown. Although there are options for treating HO, prophylactic treatment is limited. Additionally, evidence supporting the effectiveness of these prophylactic treatments is scarce. Electronic literature search was conducted using four databases. Studies comparing prophylactic medication for HO versus placebo for patients with acute spinal cord injury were included. A meta-analysis comparing the incidence of HO between the two groups was conducted, with a subgroup analysis of non-steroidal anti-inflammatory drugs (NSAIDs) and non-NSAIDs. A total of 5 studies and 815 patients were included. Overall incidence of HO was 9.73 % (n = 25) in the medication group versus 16.5 %(n = 92) in the placebo group. However, the two groups do not statistcally differ(p = 0.21). In the subgroup analysis for NSAIDs, those who received prophylactic treatment with NSAIDs had a lower incidence of HO compared to those who received placebo (RR[95 % CI]:0.32[0.15, 0.68]; p = 0.003). As for studies that used bisphosphonates, a statistically significant difference in incidence of HO was not found (RR[95 % CI]:1.30[0.52, 3.24];p = 0.58) and the overall evidence was inconclusive. In present systematic review and meta-analysis comparing prophylactic medications to placebo for prevention of HO, we found similar incidence rates for both groups. However, subgroup analysis showed a significantly lower incidence rate for those who recevied NSAIDs for HO prophylaxis. Altough this finding is promising for secondary prevention of HO among patients suffering from SCI, further prospective studies with longer follow-ups are required to assess other appropriate medications for HO prevention.

15.
Clin Neurol Neurosurg ; 193: 105765, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32200215

RESUMO

OBJECTIVE: Patients with a comorbid mental illness have been observed to have worse outcomes following surgery. However, little is known about the effects of mental disorders on patient outcomes following spinal surgery. In the current study, we sought to investigate the characteristics of patients with mental illness, particularly anxiety, major depressive disorder, concurrent anxiety and schizophrenia, and the impact of these comorbid conditions on outcomes of patients undergoing anterior cervical discectomy and fusion (ACDF) using a national administrative database. PATIENTS AND METHODS: The National Readmissions Database (NRD) was queried for patients undergoing an ACDF between 2012 and September 30th, 2015. The presence of anxiety, major depressive disorder, concurrent anxiety and schizophrenia were captured using International Classification of Diseases, Ninth Revision (ICD-9) codes. Multivariable logistic regression was used to establish an association between a mental comorbidity and risk of 30- and 90- day readmission. RESULTS: A total of 139,877 patients undergoing elective ACDF between 2012-2015 were identified, of which 15,927 (11.39 %) had anxiety, 514 (0.38 %) had major depressive disorder, 248 (0.18 %) had concurrent anxiety and major depressive disorder, and 287 (0.21 %) had schizophrenia. Upon multivariable analysis of procedural related readmissions, adjusting for an array of patient and hospital related factors, patients with schizophrenia, compared to controls, had a significantly higher risk of 30-day readmission (OR 2.62, 95 %CI 1.42-4.84, p = 0.002); moreover, schizophrenia (OR = 1.92, 95 % CI 1.13-3.25, p = 0.016) anxiety (OR = 1.13, 95 %CI 1.02-1.26, p = 0.023) were also associated with significantly higher risk of 90-day readmission. CONCLUSION: Our analysis indicates that mental illness comorbidities may be associated with increased rates of procedure related readmission and longer length of stay following elective ACDF.

16.
Artigo em Inglês | MEDLINE | ID: mdl-32097272

RESUMO

STUDY DESIGN: Prospective database analysis OBJECTIVE.: To assess the effect of age on patient-reported outcomes (PROs) and complication rates after surgical treatment for spondylolisthesis SUMMARY OF BACKGROUND DATA.: Degenerative lumbar spondylolisthesis affects 3-20% of the population and up to 30% of the elderly. There is not yet consensus on whether age is a contraindication for surgical treatment of elderly patients. METHODS: The Quality Outcomes Database lumbar registry was used to evaluate patients from 12 U.S. academic and private centers who underwent surgical treatment for grade 1 lumbar spondylolisthesis between July 2014 and June 2016. RESULTS: A total of 608 patients who fit the inclusion criteria were categorized by age into the following groups: <60 (n = 239), 60-70 (n = 209), 71-80 (n = 128), and >80 (n = 32) years. Older patients showed lower mean body mass index (p < 0.001) and higher rates of diabetes (p = 0.007), coronary artery disease (p < 0.001), and osteoporosis (p = 0.005). A lower likelihood for home disposition was seen with higher age (89.1% in <60-year-old vs. 75% in >80-year-old patients; p = 0.002). There were no baseline differences in PROs (Oswestry Disability Index, EQ-5D, Numeric Rating Scale for leg pain and back pain) among age categories. A significant improvement for all PROs was seen regardless of age (p < 0.05), and most patients met minimal clinically important differences (MCIDs) for improvement in postoperative PROs. No differences in hospital readmissions or reoperations were seen among age groups (p < 0.05). Multivariate analysis demonstrated that, after controlling other variables, a higher age did not decrease the odds of achieving MCID at 12 months for the PROs. CONCLUSION: Our results indicate that well-selected elderly patients undergoing surgical treatment of grade 1 spondylolisthesis can achieve meaningful outcomes. This modern, multicenter U.S. study reflects the current use and limitations of spondylolisthesis treatment in the elderly, which may be informative to patients and providers. LEVEL OF EVIDENCE: 4.

17.
J Neurosurg Spine ; : 1-9, 2020 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-32109871

RESUMO

OBJECTIVE: Loss to follow-up has been shown to bias outcomes assessment among studies utilizing clinical registries. Here, the authors analyzed patients enrolled in a national surgical registry and compared the baseline characteristics of patients captured with those lost to follow-up at 2 years. METHODS: The authors queried the Quality Outcomes Database for patients with grade I lumbar degenerative spondylolisthesis undergoing a surgical intervention between July 2014 and June 2016. Only those patients enrolled in a multisite study investigating the impact of fusion on clinical and patient-reported outcomes (PROs) among patients with grade I spondylolisthesis were evaluated. RESULTS: Of the 608 patients enrolled in the study undergoing 1- or 2-level decompression (23.0%, n = 140) or 1-level fusion (77.0%, n = 468), 14.5% (n = 88) were lost to follow-up at 2 years. Patients who were lost to follow-up were more likely to be younger (59.6 ± 13.5 vs 62.6 ± 11.7 years, p = 0.031), be employed (unemployment rate: 53.3% [n = 277] for successful follow-up vs 40.9% [n = 36] for those lost to follow-up, p = 0.017), have anxiety (26.1% [n = 23] vs 16.3% [n = 85], p = 0.026), have higher back pain scores (7.4 ± 2.9 vs 6.6 ± 2.8, p = 0.010), have higher leg pain scores (7.4 ± 2.5 vs 6.4 ± 2.9, p = 0.003), have higher Oswestry Disability Index scores (50.8 ± 18.7 vs 46 ± 16.8, p = 0.018), and have lower EQ-5D scores (0.481 ± 0.2 vs 0.547 ± 0.2, p = 0.012) at baseline. CONCLUSIONS: To execute future, high-quality studies, it is important to identify patients undergoing surgery for spondylolisthesis who might be lost to follow-up. In a large, prospective registry, the authors found that those lost to follow-up were more likely to be younger, be employed, have anxiety disorder, and have worse PRO scores.

18.
Spine J ; 2020 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-32001385

RESUMO

BACKGROUND CONTEXT: Minimum clinically important difference (MCID) for patient-reported outcome measures is commonly used to assess clinical improvement. However, recent literature suggests that an absolute point-change may not be an effective or reliable marker of response to treatment for patients with low or high baseline patient-reported outcome scores. The multitude of established MCIDs also makes it difficult to compare outcomes across studies and different spine surgery procedures. PURPOSE: To determine whether a 30% reduction from baseline in disability and pain is a valid method for determining clinical improvement after lumbar spine surgery. STUDY DESIGN: Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database. PATIENT SAMPLE: There were 23,280 participants undergoing elective lumbar spine surgery for degenerative disease who completed a baseline and follow-up assessment at 12 months. OUTCOME MEASURES: Patient-reported disability (Oswestry Disability Index [ODI]), back and leg pain (11-point Numeric Rating Scale [NRS]), and satisfaction (NASS scale). METHODS: Patients completed baseline and a 12-month postoperative assessment to evaluate the outcomes of disability, pain, and satisfaction. The change in ODI and NRS pain scores was categorized as met (≥30%) or not met (<30%) percent reduction MCID. The 30% reduction from baseline was compared with a wide range of well-established absolute point-change MCID values. The relationship between 30% reduction and absolute change values and satisfaction were primarily compared using receiver operating characteristic (ROC) curves, area under the curve (AUROC), and logistic regression analyses. Analyses were conducted for overall scores and for disability and pain severity categories and by surgical procedure. RESULTS: Thirty percent reduction in ODI and back and leg pain predicted satisfaction with more accuracy than absolute point-change values for the total population and across all procedure categories (p<.001), except for when compared with the highest absolute point-change threshold for leg pain (3.5-point reduction). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 21.8%) and bed-bound disability (ODI 81%-100%: 13.9%) categories. For pain, there was a 3.4%-12.4% and 1.3%-9.8% AUROC difference for no/mild back and leg pain (NRS 0-4), respectively, in favor of a 30% reduction threshold. CONCLUSIONS: A 30% reduction MCID either outperformed or was similar to absolute point-change MCID values. Results indicate that a 30% reduction (baseline to 12 months after surgery) in disability and pain is a valid method for determining clinically relevant improvement in a broad spine surgery population. Furthermore, a 30% reduction was most accurate for patients in the lowest and highest disability and lowest pain severity categories. A 30% reduction MCID allows for a standard cut-off for disability and pain that can be used to compare outcomes across various spine surgery procedures.

19.
World Neurosurg ; 136: e398-e406, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31931235

RESUMO

BACKGROUND: Preoperative laboratory tests are varied in their administration among physicians, and previous studies have published conflicting reports on their utility. Anterior cervical discectomy and fusion (ACDF) is a commonly performed spine surgery, and patients often undergo preoperative testing. We sought to assess the relationship between preoperative laboratory values and risk for adverse postoperative outcomes after ACDF. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program was queried from 2012 to 2017 to identify patients undergoing elective ACDF. Multivariable logistic regression was performed to assess the association between abnormal laboratory test values and adverse 30-day outcomes. Relative predictor importance was determined using an importance metric defined as Wald χ2 penalized by degrees of freedom. RESULTS: A total of 47,111 patients were included. On multivariable analysis, high creatinine (P = 0.030), anemia (P < 0.001), hyponatremia (P = 0.034), and leukocytosis (P < 0.001) were found to be significantly associated with any 30-day complications. Anemia (P < 0.001), hypernatremia (P = 0.028), hyponatremia (P = 0.016), and leukocytosis (P < 0.001) were found to be significantly associated with serious 30-day complications. High creatinine (P = 0.027), anemia (P < 0.001), hyponatremia (P = 0.047), and leukocytosis (P = 0.004) were found to be significantly associated with 30-day unplanned readmissions. High blood urea nitrogen (P = 0.007), high creatinine (P = 0.028), anemia (P < 0.001), low platelet count (P < 0.001), hyponatremia (P < 0.001), and leukocytosis (P < 0.001) were found to be significantly associated with nonhome discharge. Predictor importance analysis revealed that abnormal preoperative laboratory values were important determinants in predicting these 30-day outcomes. CONCLUSIONS: Our analyses indicate that abnormal preoperative laboratory values are associated with increased risk for adverse outcomes after elective ACDF and can be used in predictive analyses of outcomes.


Assuntos
Discotomia/efeitos adversos , Cuidados Pré-Operatórios/estatística & dados numéricos , Doenças da Coluna Vertebral/cirurgia , Fusão Vertebral/efeitos adversos , Técnicas de Laboratório Clínico/estatística & dados numéricos , Testes Diagnósticos de Rotina , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Sistema de Registros , Medição de Risco , Estados Unidos/epidemiologia
20.
World Neurosurg ; 137: 443-450.e13, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31926357

RESUMO

BACKGROUND: There have been several clinical trials as well as observational studies that have compared the outcomes of different cervical disc replacement (CDR) devices with anterior cervical disc replacement and fusion (ACDF). Although the results of these studies have provided sufficient evidence for the safety of CDR, there is still a lack of consensus in terms of longer-term outcomes, with studies providing equivocal results for the 2 procedures. In the current study, we used a novel methodology, a meta-epidemiologic study, to investigate the impact of study characteristics on the observed effects in the literature on CDR and ACDF. METHODS: Data were abstracted from available meta-analyses regarding author, study author, year, intervention events, control events, and sample size, as well as year and geographic location of each study within the meta-analyses. We grouped the studies based on median year of publication as well as the region of the submitting author(s). Odds ratios, 95% confidence intervals (CIs), and standard errors of individual studies were calculated based on the number of events and sample size for each arm (ACDF or CDR). Further, results of outcomes from individual studies were pooled and a meta-analysis was conducted. Ratio of odds ratio (ROR) was used to assess the impact of each of these factors on estimates of the study for CDR versus ACDF. RESULTS: A total of 13 meta-analyses were analyzed after exclusions. Using the results from 10 meta-analyses, we found that studies published before 2012 reported significantly lower odds of a reoperation after CDR (vs. ACDF), compared with studies published after 2012 (ROR, 0.51; 95% CI, 0.38-0.67; P < 0.001). We did not observe a significant impact of study year on difference in estimates between CDR and ACDF for adjacent segment disease (ROR, 0.99; 95% CI, 0.64-1.55; P = 0.465). The region of submitting author was also found to have no impact on results of published studies. CONCLUSIONS: These results indicate that there may be a publication bias regarding the year of publication, with earlier studies reporting lower reoperation rates for CDR compared with ACDF.

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