Academic Productivity of Spine Surgeons at United States Neurological Surgery and Orthopedic Surgery Training Programs.

OBJECTIVE: Spinal surgery is taught and practiced within 2 different surgical disciplines, neurological surgery and orthopedic surgery. We have provided a unified analysis of academic productivity measured using the h-index attributable to spine-focused faculty at U.S. residency programs. METHODS: A total of 278 Accreditation Council for Graduate Medical Education training programs were assessed to identify 923 full-time faculty members with a spinal surgery designation, as defined by spine fellowship training or case volume >75% in spine surgery. The faculty were assessed with respect to academic rank, duration of practice in years, and academic productivity (h-index). RESULTS: The comparison showed a significantly greater mean h-index for neurological spine surgeons. The mean h-index for both disciplines increased significantly as faculty rank increased. Within the academic ranks of assistant and associate professor, neurological spine surgeons had significantly greater mean h-indexes. Neurological spine surgeons had a significantly lower practice duration. At all ranks except for assistant professor, the mean practice duration was not significantly different statistically between the neurological spine and orthopedic spine surgeons. A positive correlation between the h-index and practice duration was found for both spine surgical disciplines. The proportional odds models for neurological and orthopedic spine surgeons were moderately successful at predicting faculty rank according to the h-index. CONCLUSIONS: We present a unified view of academic productivity as measured by the h-index among neurosurgical and orthopedic surgery spine faculty, with some noticeable differences. These results can be used for benchmark purposes to assess the relative productivity of its faculty and could be of interest to those pursuing academic opportunities in spine surgery.

Workforce Analysis of Spine Surgeons Involved with Neurological and Orthopedic Surgery Residency Training.

OBJECTIVE: Spinal surgery is taught and practiced within 2 different surgical disciplines: neurological surgery and orthopedic surgery. We have provided a unified analysis of spine-focused faculty at U.S. residency programs. METHODS: A total of 278 Accreditation Council for Graduate Medical Education training programs were assessed to identify 923 full-time faculty members with a spinal surgery designation, defined by spine fellowship training or surgeon case volume >75% spine surgeries. Faculty were assessed with respect to parent discipline, years of fellowship training, academic rank, gender, and academic productivity (h-index). RESULTS: The spine-teaching workforce contains 55% orthopedic surgeons and 45% neurosurgeons with wide gender asymmetry overall and at all faculty ranks. Of the female spine surgeons, those with neurosurgical training (64.44%) nearly doubled the number with orthopedic training (35.56%). Academic productivity increased with academic rank similarly for both genders and subspecialties. Orthopedic spine surgeons had a greater mean fellowship number compared with the neurological spine surgeons. Fellowship time of completion (intraresidency/infolded vs. postresidency) did not significantly affect the h-indexes. Addition of fellowship conferred academic productivity benefit for orthopedic surgeons only. CONCLUSIONS: Neurological and orthopedic spine surgery showed similar patterns for the spread of faculty across academic ranks and trends in academic productivity. Marked gender disparity was seen in both neurosurgical and orthopedic surgery, with fewer female spine surgeons seen at every academic rank. Orthopedic spine surgeons had a greater mean fellowship number than did their neurosurgical counterparts, and a lack of fellowship correlated with lower academic productivity in orthopedic, but not neurological, spine surgery.

c-index and Subindices of the h-index: New Variants of the h-index to Account for Variations in Author Contribution.

Objectives Bibliometrics are used to assess or compare the academic productivity of individuals or groups. Most of these metrics, including the widely used h-index, do not recognize the added contribution that is generally provided by authors listed first, second, second-to-last and last (enhanced positions) in a publication citation. We propose the c-index as a novel modification to the h-index that will better reflect an individual's academic output, incorporating authorship position. Methods One hundred and sixty-six academic neurosurgeons in eight New York City (NYC) metropolitan region training programs were identified through department websites. Using the Scopus citation database, bibliometric profiles were created for each surgeon. Once an individual's h-index was calculated, the h-core articles (those with h or more citations) were specifically assessed to determine citation author position. Novel bibliometric indices were created to reflect the number of h-core articles that accounted for primary (hp), senior (hs) or internal authorship (hi) position. Weighted "involvement factors" for primary (ip) and senior (is) author contribution were created to reflect the added value of "enhanced position" authorship in an individual's h-core publications. c-indices were created to reflect the author's h-index once augmented by primary (cp), senior (cs), and overall (co) "enhanced position" authorship. Comparisons were made within each institution and across institutions, according to academic rank (assistant professor, associate professor, professor and chairperson). Results Breakdown by academic rank showed an increasing average h-index progressing from assistant professor through professor rank with no significant difference demonstrated between professor and chair status. This pattern was seen across all departments (aggregate) but with fewer instances of significance at the level of individual departments. After h-index modification, cp, cs, and co indices showed a similarly significant trend. As faculty rank increased, there was a significant trend toward increasing numbers of articles with authors in enhanced positions and a higher percentage of articles with the author in a senior position. Academic faculty had higher h, cp, and cs indices than clinical faculty. Evaluation of each individual department revealed no significant trend regarding a department's higher average cp or cs. Average c-index for a department paralleled the average h-index of that department, with larger departments tending to have larger cumulative h, cp, cs, and co indices. No consistent correlation was seen between mean h-indices and academic rank at an individual departmental level. Conclusions This study examines the academic productivity of a subset of neurosurgical programs in the NYC metropolitan area as a test bed for novel bibliometric indices. hp, hi, and hs represent the respective number of primary, internal and senior authorship papers that comprise an individual's h-core papers. cp, cs, and co, variations of the h-index metric, are designed to more accurately reflect the contributions by primary, secondary and senior authors. Increasing academic rank was associated with an increased number of articles with the author in enhanced positions and a higher percentage of articles in a senior position.

The Effects of Altitude on Concussion Incidence in the 2013-2017 National Hockey League Seasons.

Background and objective The high incidence of traumatic brain injuries during contact sports has necessitated the need for further research pertaining to their implications and possible mitigation. Despite increasing attention to sports-related concussions, there is still a striking lack of detail pertaining to the environmental factors that contribute to their occurrence. One environmental condition that has yet to be considered is altitude. Altitude cannot be readily adjusted, yet can still impact quality of play and concussion incidence. The current body of published evidence evaluating environmental effects on concussion is divided on the degree to which altitude mitigates concussion incidence. We aim to systematically compare the prevalence of concussions that occur at high and low altitude utilizing 1000 feet (304.8 meters) as a cut-off marker for high altitude. Our research also takes a novel approach utilizing average games missed as a proxy for concussion severity. We hope to use this analysis to shed light on the implication of altitude on concussion incidence. Methods Individual player data on concussion incidence were retrospectively acquired for the 2013-2017 National Hockey League (NHL) seasons utilizing FOX Sports Injury tracker. NHL season schedules were acquired through the online source "Hockey Reference." In order to establish cutoff criteria for high vs low altitude we adopted 1000 feet (304.8 meters) as high-low altitude cutoff. We also evaluated our data utilizing a previously published high-low altitude cutoff of 644 feet (196.3 meters). Specific altitudes of each NHL arena were derived from "elevationmap.net". One caveat to our data collection was the striking lack of publicly available data pertaining to the concussions sustained by each NHL team. Data was analyzed utilizing SAS programing. Results Out of the 5281 games included in our data set, we documented a total of 133 concussions which occurred in 125 games through the 2013-2017 NHL seasons. We noted an increase in concussion reporting in the most recent 2016-2017 NHL season compared to the previous 2013-2016 seasons. Effect of altitude variance on concussion rate was evaluated utilizing 644 and 1000 ft as the low-high altitude split. We defined each variance by where the team is based at compared to where the game was played. This produced four distinct categories: 1) low-low altitude, 2) low-high altitude, 3) high-low altitude, and 4) high-high altitude. We noted a significant difference in concussion rate when teams based at high altitude above 1000 ft travel to play at low altitude; this trend was non-significant at 644 ft. The results of the average games missed analysis demonstrated that teams that play above 1000 feet had fewer games missed per concussion compared to teams that are based at a low altitude. Conclusions Though underreported in the total number of concussions in the 2013-2017 NHL seasons, our data suggests that teams who are based at a high altitude (>1000ft) experience a reduction in mean concussion rate when traveling to play at a lower altitude. Our data also indicated a reduction in average games missed post-concussion for teams based at a higher altitude. It is our goal that our findings here contribute to the larger discussion about concussion incidence and can be applied to other sports leagues and activities to mitigate their dangerous effects.

Does the Environment Influence the Frequency of Concussion Incidence in Professional Football?

Background Sports-related concussion is a major cause of mild traumatic brain injury (mTBI). It is possible that environmental factors, such as temperature, humidity, and stadium's altitude, may influence the overall incidence of concussions during a game. Purpose To examine the impact of environmental factors, such as temperature, humidity, barometric pressure, and dew point, on concussion incidence. Methods Public Broadcasting Service (PBS) FRONTLINE Concussion Watch was used to collect injury data on 32 NFL teams during regular season games from 2012 to 2015. Weather data points were collected from Weather Underground. Concussion incidence per game, the probability of a concussion during a game, and a difference in mean game-day temperature, humidity, dew point, and barometric pressure between concussion and concussion-free games were calculated. Our analysis included t-tests, analysis of variance (ANOVA), multivariate correlation tests, and logistic and Poisson regression.  Results Overall, 564 concussions were reported. There were 411 games with concussions and 549 games without concussions. We observed a significant decrease in concussion incidence with increasing temperature, both when the temperature was divided into 20oF increments or into quartiles (p = 0.005 and p = 0.002, respectively). We identified a statistically significant lower mean-game day temperature in concussion games compared to concussion-free games (p < 0.0006). We also observed a significant decrease in the incidence of concussion per game with increasing dew point. There was no significant difference in concussion incidence in barometric pressure and humidity. The logistic regression model predicted a decrease in the probability of a concussion in games with higher temperatures and dew points. Conclusions National Football League (NFL) players experienced an increased risk of concussion during football games played in colder temperatures and at lower dew points. Further research on environmental effects on concussions may aid in improving player safety in football leagues.

Effects of Game Characteristics and Player Positions on Concussion Incidence and Severity in Professional Football.

BACKGROUND: Increasing efforts have been made to reduce the incidence and severity of concussion in high-contact sports. Despite these efforts, a relative lack of knowledge is available regarding modulating factors affecting concussion injury. PURPOSE: To analyze the potential influence of game characteristics and outcomes on concussion incidence and severity in professional football. STUDY DESIGN: Descriptive epidemiology study. METHODS: PBS Frontline Concussion Watch was used to collect concussion injury data from regular-season games of 32 National Football League (NFL) teams from 2012 to 2015. Game characteristic variables such as rushing and passing attempts, turnovers, and margin of victory were collected from ESPN. Analysis included descriptive statistics, analysis of variance, t tests, and correlation tests. RESULTS: Away teams demonstrated a significantly greater concussion incidence per game than home teams. Losing teams had a significantly greater concussion incidence per game than winning teams. Being both the away team and the losing team appeared to have an additive effect. The home-versus-away and win-versus-loss effects were significant for offensive but not defensive positions. Within individual positions, significantly greater concussion incidence was associated with tight ends, running backs, wide receivers, and cornerbacks. When running versus passing positions were compared, passing positions (wide receiver, tight end, cornerback, safety) had significantly greater concussion incidence. A total of 626 games were missed as a result of reported concussions. Away teams had significantly more games missed due to concussion when they lost. Play time did not significantly differ before or after concussion injury. Other game characteristic variables did not significantly affect concussion frequency or intensity. CONCLUSION: Position, game location, and game outcome affect concussion incidence for professional football players. In a subset of analyses, the number of games missed aligned with concussion incidence, but this appeared to be an imperfect measure. These findings highlight new factors that may modulate concussion incidence and merit further study on how they may influence concussion evaluation.

Factors Affecting Length of Stay Following Elective Anterior and Posterior Cervical Spine Surgery.

Background Disease of the cervical spine is widely prevalent, most commonly secondary to degenerative disc changes and spondylosis. Objective The goal of the paper was to identify a possible discrepancy regarding the length of stay (LOS) between the anterior and posterior approaches to elective cervical spine surgery and identify contributing factors. Methods A retrospective study was performed on 587 patients (341 anterior, 246 posterior) that underwent elective cervical spinal surgery between October 2001 and March 2014. Pre- and intraoperative data were analyzed. Statistical analysis was performed using GraphPad Prism 5 (GraphPad Software, Inc., La Jolla, CA) and the Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY). Results Average LOS was 3.21 ± 0.32 days for patients that benefited from the anterior approach cervical spinal surgery and 5.28 ± 0.37 days for patients that benefited from the posterior approach surgery, P-value < 0.0001. Anterior patients had lower American Society of Anesthesiologists scores (2.43 ± 0.036 vs. 2.70 ± 0.044). Anterior patients also had fewer intervertebral levels operated upon (2.18 ± 0.056 vs. 4.11 ± 0.13), shorter incisions (5.49 ± 0.093 cm vs. 9.25 ± 0.16 cm), lower estimated blood loss (EBL) (183.8 ± 9.0 cc vs. 340.0 ± 8.7 cc), and shorter procedure times (4.12 ± 0.09 hours vs. 4.47 ± 0.10 hours). Chi-squared tests for hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and asthma showed no significant difference between groups. CONCLUSIONS: Patients with anterior surgery performed experienced a length of stay that was 2.07 days shorter on average. Higher EBL, longer incisions, more intervertebral levels, and longer operating time were significantly associated with the posterior approach. Future studies should include multiple surgeons. The goal would be to create a model that could accurately predict the postoperative length of stay based on patient and operative factors.

Reduced Surgical Site Infection Rates Following Spine Surgery Using an Enhanced Prophylaxis Protocol.

BACKGROUND: Postoperative surgical site infection (SSI) is a common complication after spine surgery. Reduction of SSI has many benefits including, but not limited to, the reduced length of stay, readmission rates, and morbidity and mortality. OBJECTIVE: To determine whether an enhanced antibiotic prophylaxis reduced the rate of surgical site infections in spine surgery. METHODS: This is a retrospective observation study which analyzed the incidence of postoperative SSI following a consecutive series of 1,486 cervical, thoracic and lumbar spine operations performed at a single institution by the senior author between the dates of October 2001 to March 2014. Patients with surgeries between October 2001 and November 2005 received a standard institutional antibiotic prophylaxis. Patients between December 2005 and March 2014 underwent an enhanced antibiotic protocol. RESULTS: A total of nine cases met the criteria for SSI. All nine cases were recorded during the initial time period when the standard institutional prophylaxis was used. Further, these cases were only observed under posterior operative approaches. No further cases of SSI were observed after the institution of the enhanced antibiotic prophylaxis (p < 0.0001). This was statistically significant in the cervical and lumbar regions (p < 0.0042 and p < 0.0119, respectively). CONCLUSIONS: Although difficult to predict the incidence of SSI, this study found that the use of an enhanced antibiotic prophylaxis protocol significantly reduced one surgeon's overall rates of surgical site infections after spine surgery.

Review of Assessment Scales for Diagnosing and Monitoring Sports-related Concussion.

Sports-related concussion has emerged as a public health crisis due to increased diagnosis of the condition and increased participation in organized and recreational athletics worldwide. Under-recognition of concussions can lead to premature clearance for athletic participation, leaving athletes vulnerable to repeat injury and subsequent short- and long-term complications. There is overwhelming evidence that assessment and management of sports-related concussions should involve a multifaceted approach. A number of assessment criteria have been developed for this purpose. It is important to understand the available and emerging diagnostic testing modalities for sports-related concussions. The most commonly used tools for evaluating individuals with concussion are the Post-Concussion Symptom Scale (PCSS), Standard Assessment of Concussion (SAC), Standard Concussion Assessment Tool (SCAT3), and the most recognized computerized neurocognitive test, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The strengths and limitations of each of these tools, and the Concussion Resolution Index (CRI), CogSport, and King-Devick tests were evaluated. Based on the data, it appears that the most sensitive and specific of these is the ImPACT test. Additionally, the King-Devick test is an effective adjunct due to its ability to test eye movements and brainstem function.