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Striano BM, Crawford AM, Lightsey HM, Ukogu C, Acosta Julbe JI, Gabriel DC, Schoenfeld AJ, Simpson AK. Do Hounsfield Units From Intraoperative CT Scans Correlate With Preoperative Values? Clin Orthop Relat Res 2024:00003086-990000000-01612. [PMID: 38728612 DOI: 10.1097/corr.0000000000003122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/19/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND There is increasing interest in forecasting postoperative complications using bone density metrics. Vertebral Hounsfield unit measurements obtained from CT scans performed for surgical planning or other purposes, known as opportunistic CTs, have shown promise for their ease of measurement and the ability to target density measurement to a particular region of interest. Concomitant with the rising interest in prognostic bone density measurement use has been the increasing adoption of intraoperative advanced imaging techniques. Despite the interest in both outcome prognostication and intraoperative advanced imaging, there is little information regarding the use of CT-based intraoperative imaging as a means to measure bone density. QUESTIONS/PURPOSES (1) Can vertebral Hounsfield units be reliably measured by physician reviewers from CT scans obtained intraoperatively? (2) Do Hounsfield units measured from intraoperative studies correlate with values measured from preoperative CT scans? METHODS To be eligible for this retrospective study, patients had to have been treated with the use of an intraoperative CT scan for instrumented spinal fusion for either degenerative conditions or traumatic injuries between January 2015 and December 2022. Importantly, patients without a preoperative CT scan of the fused levels within 180 days before surgery or who were indicated for surgery because of infection, metastatic disease, or who were having revision surgery after prior instrumentation were excluded from the query. Of the 285 patients meeting these inclusion criteria, 53% (151) were initially excluded for the following reasons: 36% (102) had intraoperative CT scans obtained after placement of instrumentation, 16% (47) had undergone intraoperative CT scans but the studies were not accessible for Hounsfield unit measurement, and 0.7% (2) had prior kyphoplasty wherein the cement prevented Hounsfield unit measurement. Finally, an additional 19% (53) of patients were excluded because the preoperative CT and intraoperative CT were obtained at different peak voltages, which can influence Hounsfield unit measurement. This yielded a final population of 81 patients from whom 276 preoperative and 276 intraoperative vertebral Hounsfield unit measurements were taken. Hounsfield unit data were abstracted from the same vertebra(e) from both preoperative and intraoperative studies by two physician reviewers (one PGY3 and one PGY5 orthopaedic surgery resident, both pursuing spine surgery fellowships). For a small, representative subset of patients, measurements were taken by both reviewers. The feasibility and reliability of Hounsfield unit measurement were then assessed with interrater reliability of values measured from the same vertebra by the two different reviewers. To compare Hounsfield unit values from intraoperative CT scans with preoperative CT studies, an intraclass correlation using a two-way random effects, absolute agreement testing technique was employed. Because the data were formatted as multiple measurements from the same vertebra at different times, a repeated measures correlation was used to assess the relationship between preoperative and intraoperative Hounsfield unit values. Finally, a linear mixed model with patients handled as a random effect was used to control for different patient and clinical factors (age, BMI, use of bone density modifying agents, American Society of Anesthesiologists [ASA] classification, smoking status, and total Charlson comorbidity index [CCI] score). RESULTS We found that Hounsfield units can be reliably measured from intraoperative CT scans by human raters with good concordance. Hounsfield unit measurements of 31 vertebrae from a representative sample of 10 patients, measured by both reviewers, demonstrated a correlation value of 0.82 (95% CI 0.66 to 0.91), indicating good correlation. With regard to the relationship between preoperative and intraoperative measurements of the same vertebra, repeated measures correlation testing demonstrated no correlation between preoperative and intraoperative measurements (r = 0.01 [95% CI -0.13 to 0.15]; p = 0.84). When controlling for patient and clinical factors, we continued to observe no relationship between preoperative and intraoperative Hounsfield unit measurements. CONCLUSION As intraoperative CT and measurement of vertebral Hounsfield units both become increasingly popular, it would be a natural extension for spine surgeons to try to extract Hounsfield unit data from intraoperative CTs. However, we found that although it is feasible to measure Hounsfield data from intraoperative CT scans, the obtained values do not have any predictable relationship with values obtained from preoperative studies, and thus, these values should not be used interchangeably. With this knowledge, future studies should explore the prognostic value of intraoperative Hounsfield unit measurements as a distinct entity from preoperative measurements. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Chierika Ukogu
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Jose I Acosta Julbe
- Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Crawford AM, Striano BM, Amakiri IC, Williams DL, Lindsey MH, Gong J, Simpson AK, Schoenfeld AJ. The utility of vertebral Hounsfield units as a prognostic indicator of adverse events following treatment of spinal epidural abscess. N Am Spine Soc J 2024; 17:100308. [PMID: 38264152 PMCID: PMC10803939 DOI: 10.1016/j.xnsj.2024.100308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/25/2024]
Abstract
Background Spinal epidural abscesses (SEAs) are a devastating condition with high levels of associated morbidity and mortality. Hounsfield units (HUs), a marker of radiodensity on CT scans, have previously been correlated with adverse events following spinal interventions. We evaluated whether HUs might also be associated with all-cause complications and/or mortality in this high-risk population. Methods This retrospective cohort study was carried out within an academic health system in the United States. Adults diagnosed with a SEA between 2006 and 2021 and who also had a CT scan characterizing their SEA within 6 months of diagnosis were considered. HUs were abstracted from the 4 vertebral bodies nearest to, but not including, the infected levels. Our primary outcome was the presence of composite 90-day complications and HUs represented the primary predictor. A multivariable logistic regression analysis was conducted adjusting for demographic and disease-specific confounders. In sensitivity testing, separate logistic regression analyses were conducted (1) in patients aged 65 and older and (2) with mortality as the primary outcome. Results Our cohort consisted of 399 patients. The overall incidence of 90-day complications was 61.2% (n=244), with a 7.8% (n=31) 90-day mortality rate. Those experiencing complications were more likely to have undergone surgery to treat their SEA (58.6% vs. 46.5%; p=.018) but otherwise the cohorts were similar. HUs were not associated with composite 90-day complications (Odds ratio [OR] 1.00 [95% CI 1.00-1.00]; p=.842). Similar findings were noted in sensitivity testing. Conclusions While HUs have previously been correlated with adverse events in certain clinical contexts, we found no evidence to suggest that HUs are associated with all-cause complications or mortality in patients with SEAs. Future research hoping to leverage 3-dimensional imaging as a prognostic measure in this patient population should focus on alternative targets. Level of Evidence Level III; Observational Cohort study.
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Affiliation(s)
- Alexander M. Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA 02115,United States
| | - Brendan M. Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA 02115,United States
| | - Ikechukwu C. Amakiri
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA 02115,United States
| | | | - Matthew H. Lindsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA 02115,United States
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115,United States
| | - Andrew K. Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115,United States
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115,United States
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Striano BM, Crawford AM, Verhofste BP, Hresko AM, Hedequist DJ, Schoenfeld AJ, Simpson AK. Intraoperative navigation increases the projected lifetime cancer risk in patients undergoing surgery for adolescent idiopathic scoliosis. Spine J 2024:S1529-9430(24)00018-4. [PMID: 38262498 DOI: 10.1016/j.spinee.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 12/20/2023] [Accepted: 01/16/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND CONTEXT Adolescent idiopathic scoliosis (AIS) is a common condition, often requiring surgical correction. Computed tomography (CT) based navigation technologies, which rely on ionizing radiation, are increasingly being utilized for surgical treatment. Although this population is highly vulnerable to radiation, given their age and female predominance, there is little available information elucidating modeled iatrogenic cancer risk. PURPOSE To model lifetime cancer risk associated with the use of intraoperative CT-based navigation for surgical treatment of AIS. STUDY DESIGN/SETTING This retrospective cross-sectional study took place in a quaternary care academic pediatric hospital in the United States. PATIENT SAMPLE Adolescents aged 10-18 who underwent posterior spinal fusion for a diagnosis of AIS between July 2014 and December 2019. OUTCOMES MEASURES Effective radiation dose and projected lifetime cancer risk associated with intraoperative doses of ionizing radiation. METHODS Clinical and radiographic parameters were abstracted, including total radiation dose during surgery from flat plate radiographs, fluoroscopy, and intraoperative CT scans. Multivariable regression analysis was used to assess differences in radiation exposure between patients treated with conventional radiography versus intraoperative navigation. Radiation exposure was translated into lifetime cancer risk using well-established algorithms. RESULTS In total, 245 patients were included, 119 of whom were treated with navigation. The cohort was 82.9% female and 14.4 years of age. The median radiation exposure (in millisieverts, mSv) for fluoroscopy, radiography, and navigation was 0.05, 4.14, and 8.19 mSv, respectively. When accounting for clinical and radiographic differences, patients treated with intraoperative navigation received 8.18 mSv more radiation (95%CI: 7.22-9.15, p<.001). This increase in radiation projects to 0.90 iatrogenic malignancies per 1,000 patients (95%CI 0.79-1.01). CONCLUSIONS Ours is the first work to define cancer risk in the setting of radiation exposure for navigated AIS surgery. We project that intraoperative navigation will generate approximately one iatrogenic malignancy for every 1,000 patients treated. Given that spine surgery for AIS is common and occurs in the context of a multitude of other radiation sources, these data highlight the need for radiation budgeting protocols and continued development of lower radiation dose technologies. LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Bram P Verhofste
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Andrew M Hresko
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Daniel J Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Zijlstra H, Pierik RJ, Crawford AM, Tobert DG, Wolterbeek N, Oosterhoff JHF, Delawi D, Terpstra WE, Kempen DHR, Verlaan JJ, Schwab JH. Analysis of complications and revisions after spine surgery in 270 multiple myeloma patients with spinal involvement. Eur Spine J 2023; 32:4335-4354. [PMID: 37707603 DOI: 10.1007/s00586-023-07903-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/05/2023] [Accepted: 08/13/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND CONTEXT Patients with multiple myeloma (MM) are at increased risk of infections and suffer from poor bone quality due to their disseminated malignant bone disease. Therefore, postoperative complications may occur following surgical treatment of MM lesions. PURPOSE In this study, we aimed to determine the incidence of postoperative complications and retreatments after spinal surgery in MM patients. Additionally, we sought to identify risk factors associated with complications and retreatments. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE In total, 270 patients with MM who received surgical treatment for spinal involvement between 2008 and 2021 were included. OUTCOME MEASURES The incidence of perioperative complications within 6 weeks and reoperations within 2.5 years and individual odds ratios for factors associated with these complications and reoperations. METHODS Data were collected through manual chart review. Hosmer and Lemeshow's purposeful regression method was used to identify risk factors for complications and reoperations. RESULTS The median age of our cohort was 65 years (SD = 10.8), and 58% were male (n = 57). Intraoperative complications were present in 24 patients (8.9%). The overall 6-week complication rate after surgery was 35% (n = 95). The following variables were independently associated with 6-week complications: higher Genant grading of a present vertebral fracture (OR 1.41; 95% CI 1.04-1.95; p = .031), receiving intramuscular or intravenous steroids within a week prior to surgery (OR 3.97; 95% CI 1.79-9.06; p = .001), decompression surgery without fusion (OR 6.53; 95% CI 1.30-36.86; p = .026), higher creatinine levels (OR 2.18; 95% CI 1.19-5.60; p = .014), and lower calcium levels (OR 0.58; 95% CI 0.37-0.88; p = .013). A secondary surgery was indicated for 53 patients (20%), of which 13 (4.8%) took place within two weeks after the initial surgery. We additionally discovered factors associated with retreatments, which are elucidated within the manuscript. CONCLUSION The goal of surgical treatment for MM bone disease is to enhance patient quality of life and reduce symptom burden. However, postoperative complication rates remain relatively high after spine surgery in patients with MM, likely attributable to both inherent characteristics of the disease and patient comorbidities. The risk for complications and secondary surgeries should be explored and a multidisciplinary approach is crucial.
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Affiliation(s)
- H Zijlstra
- Department of Orthopedic Surgery/Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - R J Pierik
- Department of Orthopedic Surgery/Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - A M Crawford
- Department of Orthopedic Surgery/Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - D G Tobert
- Department of Orthopedic Surgery/Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - N Wolterbeek
- Department of Orthopedic Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - J H F Oosterhoff
- Department of Orthopedic Surgery/Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - D Delawi
- Department of Orthopedic Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - W E Terpstra
- Department of Hematology/Oncology, OLVG, Amsterdam, The Netherlands
| | - D H R Kempen
- Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
| | - J J Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J H Schwab
- Department of Orthopedic Surgery/Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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Crawford AM, Striano BM, Gong J, Simpson AK, Schoenfeld AJ. Does the Stopping Opioids After Surgery Score Perform Well Among Racial and Socioeconomic Subgroups? Clin Orthop Relat Res 2023; 481:2343-2351. [PMID: 37159263 PMCID: PMC10642872 DOI: 10.1097/corr.0000000000002697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND The Stopping Opioids After Surgery (SOS) score is a validated tool that was developed to determine the risk of sustained opioid use after surgical interventions, including orthopaedic procedures. Despite prior investigations validating the SOS score in diverse contexts, its performance across racial, ethnic, and socioeconomic subgroups has not been assessed. QUESTIONS/PURPOSES In a large, urban, academic health network, did the performance of the SOS score differ depending on (1) race and ethnicity or (2) socioeconomic status? METHODS This retrospective investigation was conducted using data from an internal, longitudinally maintained registry of a large, urban, academic health system in the Northeastern United States. Between January 1, 2018, and March 31, 2022, we treated 26,732 adult patients via rotator cuff repair, lumbar discectomy, lumbar fusion, TKA, THA, ankle or distal radius open reduction and internal fixation, or ACL reconstruction. We excluded 1% of patients (274 of 26,732) because of missing length of stay information, 0.06% (15) for missing discharge information, 1% (310) for missing medication information related to loss to follow-up, and 0.07% (19) who died during their hospital stay. Based on these inclusion and exclusion criteria, 26,114 adult patients were left for analysis. The median age in our cohort was 63 years (IQR 52 to 71), and most patients were women (52% [13,462 of 26,114]). Most patients self-reported their race and ethnicity as non-Hispanic White (78% [20,408 of 26,114]), but the cohort also included non-Hispanic Black (4% [939]), non-Hispanic Asian (2% [638]), and Hispanic (1% [365]) patients. Five percent (1295) of patients were of low socioeconomic status, defined by prior SOS score investigations as patients with Medicaid insurance. Components of the SOS score and the observed frequency of sustained postoperative opioid prescriptions were abstracted. The performance of the SOS score was compared across racial, ethnic, and socioeconomic subgroups using the c-statistic, which measures the capacity of the model to differentiate between patients with and without sustained opioid use. This measure should be interpreted on a scale between 0 and 1, where 0 represents a model that perfectly predicts the wrong classification, 0.5 represents performance no better than chance, and 1.0 represents perfect discrimination. Scores less than 0.7 are generally considered poor. The baseline performance of the SOS score in past investigations has ranged from 0.76 to 0.80. RESULTS The c-statistic for non-Hispanic White patients was 0.79 (95% CI 0.78 to 0.81), which fell within the range of past investigations. The SOS score performed worse for Hispanic patients (c-statistic 0.66 [95% CI 0.52 to 0.79]; p < 0.001), where it tended to overestimate patients' risks of sustained opioid use. The SOS score for non-Hispanic Asian patients did not perform worse than in the White patient population (c-statistic 0.79 [95% CI 0.67 to 0.90]; p = 0.65). Similarly, the degree of overlapping CIs suggests that the SOS score did not perform worse in the non-Hispanic Black population (c-statistic 0.75 [95% CI 0.69 to 0.81]; p = 0.003). There was no difference in score performance among socioeconomic groups (c-statistic 0.79 [95% CI 0.74 to 0.83] for socioeconomically disadvantaged patients; 0.78 [95% CI 0.77 to 0.80] for patients who were not socioeconomically disadvantaged; p = 0.92). CONCLUSION The SOS score performed adequately for non-Hispanic White patients but performed worse for Hispanic patients, where the 95% CI nearly included an area under the curve value of 0.5, suggesting that the tool is no better than chance at predicting sustained opioid use for Hispanic patients. In the Hispanic population, it commonly overestimated the risk of opioid dependence. Its performance did not differ among patients of different sociodemographic backgrounds. Future studies might seek to contextualize why the SOS score overestimates expected opioid prescriptions for Hispanic patients and how the utility performs among more specific Hispanic subgroups. CLINICAL RELEVANCE The SOS score is a valuable tool in ongoing efforts to combat the opioid epidemic; however, disparities exist in terms of its clinical applicability. Based on this analysis, the SOS score should not be used for Hispanic patients. Additionally, we provide a framework for how other predictive models should be tested in various lesser-represented populations before implementation.
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Affiliation(s)
| | | | - Jonathan Gong
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew K. Simpson
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Crawford AM. Short courses fall short of health system strengthening. Anaesthesia 2023; 78:1323-1326. [PMID: 37527548 DOI: 10.1111/anae.16106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/03/2023]
Affiliation(s)
- A M Crawford
- Department of Anaesthesiology, Peri-operative and and Pain Management, Stanford University, Stanford, CA, USA
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Crawford AM, Striano BM, Gong J, Koehlmoos TP, Simpson AK, Schoenfeld AJ. Validation of the Stopping Opioids After Surgery (SOS) Score for the Sustained Use of Prescription Opioids Following Orthopaedic Surgery. J Bone Joint Surg Am 2023; 105:1403-1409. [PMID: 37410854 DOI: 10.2106/jbjs.23.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND The Stopping Opioids after Surgery (SOS) score was developed to identify patients at risk for sustained opioid use following surgery. The SOS score has not been specifically validated for patients in a general orthopaedic context. Our primary objective was to validate the SOS score within this context. METHODS In this retrospective cohort study, we considered a broad array of representative orthopaedic procedures performed between January 1, 2018, and March 31, 2022. These procedures included rotator cuff repair, lumbar discectomy, lumbar fusion, total knee and total hip arthroplasty, open reduction and internal fixation (ORIF) of ankle fracture, ORIF of distal radial fracture, and anterior cruciate ligament reconstruction. The performance of the SOS score was evaluated by calculating the c-statistic, receiver operating characteristic curve, and the observed rates of sustained prescription opioid use (defined as uninterrupted prescriptions of opioids for ≥90 days) following surgery. For our sensitivity analysis, we compared these metrics among various time epochs related to the COVID-19 pandemic. RESULTS A total of 26,114 patients were included, of whom 51.6% were female and 78.1% were White. The median age was 63 years. The observed prevalence of sustained opioid use was 1.3% (95% confidence interval [CI], 1.2% to 1.5%) in the low-risk group (SOS score of <30), 7.4% (95% CI, 6.9% to 8.0%) in the medium-risk group (SOS score of 30 to 60), and 20.8% (95% CI, 17.7% to 24.2%) in the high-risk group (SOS score of >60). The performance of the SOS score in the overall group was strong, with a c-statistic of 0.82. The performance of the SOS score showed no evidence of worsening over time. The c-statistic was 0.79 before the COVID-19 pandemic and ranged from 0.77 to 0.80 throughout the waves of the pandemic. CONCLUSIONS We validated the use of the SOS score for sustained prescription opioid use following a diverse array of orthopaedic procedures across subspecialties. This tool is easy to implement for the purpose of prospectively identifying patients in musculoskeletal service lines who are at higher risk for sustained opioid use, thereby enabling the future implementation of upstream interventions and modifications to avert opioid abuse and to combat the opioid epidemic. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Crawford AM, Karhade AV, Agaronnik ND, Lightsey HM, Xiong GX, Schwab JH, Schoenfeld AJ, Simpson AK. Development of a machine learning algorithm to identify surgical candidates for hip and knee arthroplasty without in-person evaluation. Arch Orthop Trauma Surg 2023; 143:5985-5992. [PMID: 36905425 PMCID: PMC10008010 DOI: 10.1007/s00402-023-04827-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/26/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION Arthroplasty care delivery is facing a growing supply-demand mismatch. To meet future demand for joint arthroplasty, systems will need to identify potential surgical candidates prior to evaluation by orthopaedic surgeons. MATERIALS AND METHODS Retrospective review was conducted at two academic medical centers and three community hospitals from March 1 to July 31, 2020 to identify new patient telemedicine encounters (without prior in-person evaluation) for consideration of hip or knee arthroplasty. The primary outcome was surgical indication for joint replacement. Five machine learning algorithms were developed to predict likelihood of surgical indication and assessed by discrimination, calibration, overall performance, and decision curve analysis. RESULTS Overall, 158 patients underwent new patient telemedicine evaluation for consideration of THA, TKA, or UKA and 65.2% (n = 103) were indicated for operative intervention prior to in-person evaluation. The median age was 65 (interquartile range 59-70) and 60.8% were women. Variables found to be associated with operative intervention were radiographic degree of arthritis, prior trial of intra-articular injection, trial of physical therapy, opioid use, and tobacco use. In the independent testing set (n = 46) not used for algorithm development, the stochastic gradient boosting algorithm achieved the best performance with AUC 0.83, calibration intercept 0.13, calibration slope 1.03, Brier score 0.15 relative to a null model Brier score of 0.23, and higher net benefit than the default alternatives on decision curve analysis. CONCLUSION We developed a machine learning algorithm to identify potential surgical candidates for joint arthroplasty in the setting of osteoarthritis without an in-person evaluation or physical examination. If externally validated, this algorithm could be deployed by various stakeholders, including patients, providers, and health systems, to direct appropriate next steps in patients with osteoarthritis and improve efficiency in identifying surgical candidates. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Aditya V Karhade
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | | | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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Zijlstra H, Striano BM, Crawford AM, Groot OQ, Raje N, Tobert DG, Patel CG, Wolterbeek N, Delawi D, Kempen DHR, Verlaan JJ, Schwab JH. Neurologic Outcomes After Radiation Therapy for Severe Spinal Cord Compression in Multiple Myeloma: A Study of 162 Patients. J Bone Joint Surg Am 2023; 105:1261-1269. [PMID: 37262176 DOI: 10.2106/jbjs.22.01335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Bone destruction is the most frequent disease-defining clinical feature of multiple myeloma (MM), resulting in skeletal-related events such as back pain, pathological fractures, or neurologic compromise including epidural spinal cord compression (ESCC). Up to 24% of patients with MM will be affected by ESCC. Radiation therapy has been proven to be highly effective in pain relief in patients with MM. However, a critical knowledge gap remains with regard to neurologic outcomes in patients with high-grade ESCC treated with radiation. METHODS We retrospectively included 162 patients with MM and high-grade ESCC (grade 2 or 3) who underwent radiation therapy of the spine between January 2010 and July 2021. The primary outcome was the American Spinal Injury Association (ASIA) score after 12 to 24 months, or the last known ASIA score if the patient had had a repeat treatment or died. Multivariable logistic regression was used to assess factors associated with poor neurologic outcomes after radiation, defined as neurologic deterioration or lack of improvement. RESULTS After radiation therapy, 34 patients (21%) had no improvement in their impaired neurologic function and 27 (17%) deteriorated neurologically. Thirty-six patients (22%) underwent either surgery or repeat irradiation after the initial radiation therapy. There were 100 patients who were neurologically intact at baseline (ASIA score of E), of whom 16 (16%) had neurologic deterioration. Four variables were independently associated with poor neurologic outcomes: baseline ASIA (odds ratio [OR] = 6.50; 95% confidence interval [CI] = 2.70 to 17.38; p < 0.001), Eastern Cooperative Oncology Group (ECOG) performance status (OR = 6.19; 95% CI = 1.49 to 29.49; p = 0.015), number of levels affected by ESCC (OR = 4.02; 95% CI = 1.19 to 14.18; p = 0.026), and receiving steroids prior to radiation (OR = 4.42; 95% CI = 1.41 to 16.10; p = 0.015). CONCLUSIONS Our study showed that 38% of patients deteriorated or did not improve neurologically after radiation therapy for high-grade ESCC. The results highlight the need for multidisciplinary input and efforts in the treatment of high-grade ESCC in patients with MM. Future studies will help to improve patient selection for specific and standardized treatments and to clearly delineate which patients are likely to benefit from radiation therapy. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- H Zijlstra
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B M Striano
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - A M Crawford
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - O Q Groot
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N Raje
- Department of Hematology/Oncology-Center for Multiple Myeloma, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - D G Tobert
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - C G Patel
- Department of Radiation Oncology, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - N Wolterbeek
- Department of Orthopedic Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - D Delawi
- Department of Orthopedic Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - D H R Kempen
- Department of Orthopedic Surgery, OLVG, Amsterdam, Amsterdam, The Netherlands
| | - J J Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
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Zijlstra H, Crawford AM, Striano BM, Pierik RJ, Tobert DG, Wolterbeek N, Delawi D, Terpstra WE, Kempen DHR, Verlaan JJ, Schwab JH. Neurological Outcomes and the Need for Retreatments Among Multiple Myeloma Patients With High-Grade Spinal Cord Compression: Radiotherapy vs Surgery. Global Spine J 2023:21925682231188816. [PMID: 37452005 DOI: 10.1177/21925682231188816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Up to 30% of Multiple Myeloma (MM) patients are expected to experience Epidural Spinal Cord Compression (ESCC) during the course of their disease. To prevent irreversible neurological damage, timely diagnosis and treatment are important. However, debate remains regarding the optimal treatment regimen. The aim of this study was to investigate the neurological outcomes and frequency of retreatments for MM patients undergoing isolated radiotherapy and surgical interventions for high-grade (grade 2-3) ESCC. METHODS This study included patients with MM and high-grade ESCC treated with isolated radiotherapy or surgery. Pre- and post-treatment American Spinal Injury Association (ASIA) impairment scale and retreatment rate were compared between the 2 groups. Adjusted multivariable logistic regression was utilized to examine differences in neurologic compromise, pain, and retreatments. RESULTS A total of 247 patients were included (Radiotherapy: n = 154; Surgery: n = 93). After radiotherapy, 82 patients (53%) achieved full neurologic function (ASIA E) at the end of follow-up. Of the surgically treated patients, 67 (64%) achieved full neurologic function. In adjusted analyses, patients treated with surgery were less likely to experience neurologic deterioration within 2 years (OR = .15; 95%CI .05-.44; P = .001) and had less pain (OR = .29; 95%CI .11-.74; P = .010). Surgical treatment was not associated with an increased risk of retreatments (OR = .64; 95%CI .28-1.47; P = .29) or death (HR = .62, 95%CI .28-1.38; P = .24). CONCLUSIONS After adjusting for baseline differences, surgically treated patients with high-grade ESCC showed better neurologic outcomes compared to patients treated with radiotherapy. There were no differences in risk of retreatment or death.
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Affiliation(s)
- Hester Zijlstra
- Department of Orthopedic Surgery, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander M Crawford
- Department of Orthopedic Surgery, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Brendan M Striano
- Department of Orthopedic Surgery, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Robert-Jan Pierik
- Department of Orthopedic Surgery, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Daniel G Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
| | - Nienke Wolterbeek
- Department of Orthopedic Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Diyar Delawi
- Department of Orthopedic Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Wim E Terpstra
- Department of Hematology/Oncology, OLVG, Amsterdam, The Netherlands
| | | | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA
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Crawford AM, Striano BM, Giberson-Chen CC, Xiong GX, Lightsey HM, Schoenfeld AJ, Simpson AK. Projected Lifetime Cancer Risk Associated With Intraoperative Computed Tomography for Lumbar Spine Surgery. Spine (Phila Pa 1976) 2023; 48:893-900. [PMID: 37040462 DOI: 10.1097/brs.0000000000004685] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023]
Abstract
STUDY DESIGN Retrospective cross-sectional study. OBJECTIVE (1) To determine the incremental increase in intraoperative ionizing radiation conferred by computed tomography (CT) as compared with conventional radiography; and (2) to model different lifetime cancer risks contextualized by the intersection between age, sex, and intraoperative imaging modality. SUMMARY OF BACKGROUND DATA Emerging technologies in spine surgery, like navigation, automation, and augmented reality, commonly utilize intraoperative CT. Although much has been written about the benefits of such imaging modalities, the inherent risk profile of increasing intraoperative CT has not been well evaluated. MATERIALS AND METHODS Effective doses of intraoperative ionizing radiation were extracted from 610 adult patients who underwent single-level instrumented fusion for lumbar degenerative or isthmic spondylolisthesis from January 2015 through January 2022. Patients were divided into those who received intraoperative CT (n=138) and those who underwent conventional intraoperative radiography (n=472). Generalized linear modeling was utilized with intraoperative CT use as a primary predictor and patient demographics, disease characteristics, and preference-sensitive intraoperative considerations ( e.g. surgical approach and surgical invasiveness) as covariates. The adjusted risk difference in radiation dose calculated from our regression analysis was used to prognosticate the associated cancer risk across age and sex strata. RESULTS (1) After adjusting for covariates, intraoperative CT was associated with 7.6 mSv (interquartile range: 6.8-8.4 mSv; P <0.001) more radiation than conventional radiography. (2) For the median patient in our population (a 62-year-old female), intraoperative CT use increased lifetime cancer risk by 2.3 incidents (interquartile range: 2.1-2.6) per 10,000. Similar projections for other age and sex strata were also appreciated. CONCLUSIONS Intraoperative CT use significantly increases cancer risk compared with conventional intraoperative radiography for patients undergoing lumbar spinal fusions. As emerging technologies in spine surgery continue to proliferate and leverage intraoperative CT for cross-sectional imaging data, strategies must be developed by surgeons, institutions, and medical technology companies to mitigate long-term cancer risks.
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Affiliation(s)
- Alexander M Crawford
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brendan M Striano
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Carew C Giberson-Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Grace X Xiong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Harry M Lightsey
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Andrew K Simpson
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
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Lightsey Iv HM, Giberson-Chen CC, Crawford AM, Striano BM, Harris MB, Bono CM, Simpson AK, Schoenfeld AJ. Thoracolumbar Injury Classification Systems: The Importance of Concepts and Language in the Move Toward Standardization. Spine (Phila Pa 1976) 2023; 48:436-443. [PMID: 36728030 DOI: 10.1097/brs.0000000000004578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Narrative review. OBJECTIVE To describe the evolution of acute traumatic thoracolumbar (TL) injury classification systems; to promote standardization of concepts and vocabulary with respect to TL injuries. SUMMARY OF BACKGROUND DATA Over the past century, numerous TL classification systems have been proposed and implemented, each influenced by the thought, imaging modalities, and surgical techniques available at the time. While much progress has been made in our understanding and management of these injuries, concepts, and terms are often intermixed, leading to potential confusion and miscommunication. METHODS We present a narrative review of the current state of the literature regarding classification systems for TL trauma. RESULTS The evolution of TL classification systems has broadly been characterized by a transition away from descriptive categorizations of fracture patterns to schema incorporating morphology, stability, and neurological function. In addition to these features, more recent systems have demonstrated the importance of predictive/prognostic capability, reliability, validity, and generalizability. The Arbeitsgemeinschaft fur Osteosynthesenfragen Spine Thoracolumbar Injury Classification System/Thoracolumbar Arbeitsgemeinschaft fur Osteosynthesenfragen Spine Injury Score represents the most modern and recently updated system, retiring past concepts and terminology in favor of clear, internationally agreed upon descriptors. CONCLUSIONS Advancements in our understanding of blunt TL trauma injuries have led to changes in management. Such advances are reflected in modern, dedicated classification systems. Over time, various key factors have been acknowledged and incorporated. In an effort to promote standardization of thought and language, past ideas and terminology should be retired.
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Affiliation(s)
- Harry M Lightsey Iv
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
| | | | - Alexander M Crawford
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
| | - Brendan M Striano
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew K Simpson
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Crawford AM, Striano BM, Lightsey HM, Gong J, Simpson AK, Schoenfeld AJ. Intraoperative CT for Lumbar Fusion Is Not Associated with Improved Short- or Long-Term Complication Profiles. Spine J 2023; 23:791-798. [PMID: 36870450 DOI: 10.1016/j.spinee.2023.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND CONTEXT The use of intraoperative CT has continued to grow in recent years, as various techniques leverage the promise of improved instrumentation accuracy and the hope for decreased complications. Nonetheless, the literature regarding the short- and long-term complications associated with such techniques remains scant and/or confounded by indication and selection bias. PURPOSE To use causal inference techniques to determine whether intraoperative CT use is associated with an improved complication profile as compared to conventional radiography for single-level lumbar fusions, an increasingly commonplace application for this technology. STUDY DESIGN/SETTING Inverse probability weighted retrospective cohort study carried out within a large integrated healthcare network PATIENT SAMPLE: Adult patients who underwent surgical treatment of spondylolisthesis via lumbar fusion from January 2016 through December 2021 OUTCOME MEASURES: Our primary outcome was the incidence rate of revision surgery. Our secondary outcome was the incidence of composite 90-day complications (deep and superficial surgical site infection, venous thromboembolic events, and unplanned readmissions). METHODS Demographics, intraoperative information, and postoperative complications were abstracted from electronic health records. A propensity score was developed utilizing a parsimonious model to account for covariate interaction with our primary predictor, intraoperative imaging technique. This propensity score was utilized in the creation of inverse probability weights to adjust for indication and selection bias. The rate of revisions within 3 years as well as the rate of revisions at any time-point were compared between cohorts using Cox regression analysis. The incidence of composite 90-day complications were compared using negative binomial regression. RESULTS Our patient population consisted of 583 patients, with 132 who underwent intraoperative CT and 451 who underwent conventional radiographic techniques. There were no significant differences between cohorts following inverse probability weighting. No significant differences were detected in 3-year revision rates (HR 0.74 [95% CI 0.29, 1.92]; p=0.5), overall revision rates (HR 0.54 [95% CI 0.20, 1.46]; p=0.2), or 90-day complications (RC -0.24 [95% CI -1.35, 0.87]; p=0.7). CONCLUSIONS Intraoperative CT use was not associated with an improved complication profile in either the short- or long-term for patients undergoing single-level instrumented fusion. This observed clinical equipoise should be weighed against resource and radiation-related costs when considering intraoperative CT for low complexity fusions.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
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14
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Crawford AM, Striano BM, Lightsey HM, Zhu JS, Xiong GX, Schoenfeld AJ, Simpson AK. Projected lifetime cancer risk for patients undergoing spine surgery for isthmic spondylolisthesis. Spine J 2023; 23:824-831. [PMID: 36736738 DOI: 10.1016/j.spinee.2023.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/15/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND CONTEXT Radiographs, fluoroscopy, and computed tomography (CT) are increasingly utilized in the diagnosis and management of various spine pathologies. Such modalities utilize ionizing radiation, a known cause of carcinogenesis. While the radiation doses such studies confer has been investigated previously, it is less clear how such doses translate to projected cancer risks, which may be a more interpretable metric. PURPOSE (1) Calculate the lifetime cancer risk and the relative contributions of preference-sensitive selection of imaging modalities associated with the surgical management of a common spine pathology, isthmic spondylolisthesis (IS); (2) Investigate whether the use of intraoperative CT, which is being more pervasively adopted, increases the risk of cancer. STUDY DESIGN/SETTING Retrospective cross-sectional study carried out within a large integrated health care network. PATIENT SAMPLE Adult patients who underwent surgical treatment of IS via lumbar fusion from January 2016 through December 2021. OUTCOME MEASURES (1) Effective radiation dose and lifetime cancer risk associated with each exposure to ionizing radiation; (2) Difference in effective radiation dose (and lifetime cancer risk) among patients who received intraoperative CT compared to other intraoperative imaging techniques. METHODS Baseline demographics and differences in surgical techniques were characterized. Radiation exposure data were collected from the 2-year period centered on the operative date. Projected risk of cancer from this radiation was calculated utilizing each patient's effective radiation dose in combination with age and sex. Generalized linear modeling was used to adjust for covariates when determining the comparative risk of intraoperative CT as compared to alternative imaging modalities. RESULTS We included 151 patients in this cohort. The range in calculated cancer risk exclusively from IS management was 1.3-13 cases of cancer per 1,000 patients. During the intraoperative period, CT imaging was found to significantly increase radiation exposure as compared to alternate imaging modalities (adjusted risk difference (ARD) 12.33mSv; IQR 10.04, 14.63mSv; p<.001). For a standardized 40 to 49-year-old female, this projects to an additional 0.72 cases of cancer per 1,000. For the entire 2-year perioperative care episode, intraoperative CT as compared to other intraoperative imaging techniques was not found to increase total ionizing radiation exposure (ARD 9.49mSv; IQR -0.83, 19.81mSv; p=.072). The effect of intraoperative imaging choice was mitigated in part due to preoperative (ARD 13.1mSv, p<.001) and postoperative CTs (ARD 22.7mSv, p<.001). CONCLUSIONS Preference-sensitive imaging decisions in the treatment of IS impart substantial cancer risk. Important drivers of radiation exposure exist in each phase of care, including intraoperative CT and/or CT scans during the perioperative period. Knowledge of these data warrant re-evaluation of current imaging protocols and suggest a need for the development of radiation-sensitive approaches to perioperative imaging.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Jimmy S Zhu
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Guild TT, Crawford AM, Striano BM, Mortensen S, Wixted JJ. The epidemiology and management of iliopsoas hematoma with femoral nerve palsy: A descriptive systematic review of 174 cases. Injury 2023; 54:280-287. [PMID: 36586813 DOI: 10.1016/j.injury.2022.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/18/2022] [Accepted: 11/26/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Iliopsoas hematoma with femoral nerve palsy is a rare phenomenon with no consensus treatment algorithm. The objective of this study was to perform a systematic review of all reported cases of femoral nerve palsy secondary to iliopsoas hematoma to better elucidate it's optimal treatment. MATERIALS AND METHODS Queries of the PubMed, Embase, and Cochrane databases were performed for reports available in English of femoral nerve palsy secondary to iliopsoas, psoas, or iliacus hematoma. 1491 articles were identified. After removal of duplicated publications and review of abstract titles via a majority reviewer consensus, 217 articles remained for consideration. Dedicated review of the remaining articles (including their reference sections) yielded 122 articles representing 174 distinct cases. Clinical data including patient age, sex, medical history, use of pharmacologic anticoagulation, sensory and motor examination at presentation and follow-up, hematoma etiology and location, time to intervention, and type of intervention were collected. Descriptive statistics were generated for each variable. RESULTS Femoral nerve palsy secondary to iliopsoas hematoma occurred at a mean age of 44.5 years old. A majority of patients (60%) were male, and a majority of hematomas (54%) occurred due to pharmacologic anticoagulation. Most hematomas (57%) were treated conservatively, and almost half (49%) - regardless of treatment modality - resulted in persistent motor deficits at final follow-up. A minority of patients treated surgically (34%) had residual motor deficit at final follow-up, while 66% of those treated medically had resultant motor deficits, although no direct statistical comparison was able to be performed. DISCUSSION AND CONCLUSIONS The disparate available data on iliopsoas hematoma with femoral nerve palsy precludes the completion of a true metanalysis, and therefore any conclusions on an optimal treatment algorithm. Based on review of the literature, small to moderate hematomas are often treated conservatively, while larger hematomas with progressive neurological symptoms are usually managed with a percutaneous decompression or surgery. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Theodore T Guild
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA.
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Sharri Mortensen
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Boston, MA
| | - John J Wixted
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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16
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Crawford AM, Lightsey Iv HM, Xiong GX, Ye J, Call CM, Pomer A, Cooper Z, Simpson AK, Koehlmoos TP, Weissman JS, Schoenfeld AJ. Changes in Elective and Urgent Surgery Among TRICARE Beneficiaries During the COVID-19 Pandemic. Mil Med 2022; 188:usac391. [PMID: 36519498 DOI: 10.1093/milmed/usac391] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/14/2022] [Accepted: 11/22/2022] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System. METHODS We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March-September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status. RESULTS During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97-1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97-1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care. CONCLUSIONS We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.
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Affiliation(s)
- Alexander M Crawford
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Harry M Lightsey Iv
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Grace X Xiong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jamie Ye
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Alysa Pomer
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Crawford AM, Striano BM, Simpson AK, Schoenfeld AJ. Support for a Unified Health Record to Combat Disparities in Health Care. J Bone Joint Surg Am 2022; 105:638-640. [PMID: 36730067 DOI: 10.2106/jbjs.22.01186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Xiong GX, Goh BC, Agaronnik N, Crawford AM, Smith JT, Hershman SH, Schoenfeld AJ, Simpson AK. Impact of insurance type on patient-reported outcome measures in patients with lumbar disc herniation. Spine J 2022; 22:1309-1317. [PMID: 35351668 DOI: 10.1016/j.spinee.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/22/2022] [Accepted: 03/22/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Lumbar disc herniations (LDH) are among the most common spinal conditions. Despite increased appreciation for the importance of social determinants of health, the role that these factors play in patients with lumbar disc herniations is poorly defined. PURPOSE To elucidate the association between insurance status and baseline patient reported outcome measures (PROMs) in the setting of lumbar disc herniations. STUDY DESIGN/SETTING Retrospective cohort study PATIENT SAMPLE: Baseline patient-reported outcome measures (PROMS) were reviewed from 924 adult patients presenting for treatment of lumbar disc herniation within our institutional healthcare system (2015-2020). OUTCOME MEASURES The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed. METHODS PROMIS scores at presentation were defined at the primary outcome and insurance status as the primary predictor. Differences in clinical and sociodemographic characteristics between our cohorts, stratified by insurance status, were evaluated using Wilcoxon rank-sum or chi-squared testing. We used multivariable negative binomial regression modeling to adjust for potential confounders including age, gender, race, language, ethnicity, comorbidity index, and median geospatial household income. RESULTS We included 924 patients, with mean age of 58.4 +/- 15.2 years and 52.6% male prevalence. Patients insured through Medicaid were more likely to be Black, Hispanic, and non-English speaking patients compared with the commercially insured. The Charlson Comorbidity index was significantly higher in the Medicare group. Following adjusted analysis, patients with Medicaid insurance had significantly worse PF10a (IRR, 0.90, 95% CI 0.85-0.96), as well as PROMIS Global-Physical score (IRR 0.88, 95% CI 0.82-0.94), and VAS low back pain (IRR 1.20, 95% CI 1.04-1.40) when compared to the commercially insured. CONCLUSIONS We encountered worse physical function, mental, and pain-related patient-reported outcomes for those with Medicaid insurance in a population of patients presenting for evaluation of lumbar disc herniation. These findings, including worse depression, anxiety, and higher axial back pain scores, merit further investigation into potential health system asymmetries, and should be accounted for by treating providers.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Brian C Goh
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | | | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Jeremy T Smith
- Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Stuart H Hershman
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.
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Goh BC, Striano BM, Crawford AM, Tobert DG, Fogel HA, Cha TD, Schwab JH, Bono CM, Hershman SH. Surgical Intervention is Associated With Improvements in the ASIA Impairment Scale in Gunshot-induced Spinal Injuries of the Thoracic and Lumbar Spine. Clin Spine Surg 2022; 35:323-327. [PMID: 35276720 DOI: 10.1097/bsd.0000000000001308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 02/02/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective cohort study of patients from the National Spinal Cord Injury Statistical Center (NSCISC). OBJECTIVE The aim was to compare the outcomes of patients with gunshot-induced spinal injuries (GSIs) treated operatively and nonoperatively. SUMMARY OF BACKGROUND DATA The treatment of neurological deficits associated with gunshot wounds to the spine has been controversial. Treatment has varied widely, ranging from nonoperative to aggressive surgery. METHODS Patient demographics, clinical information, and outcomes were extracted. Surgical intervention was defined as a "laminectomy, neural canal restoration, open reduction, spinal fusion, or internal fixation of the spine." The primary outcome was the American Spinal Injury Association (ASIA) Impairment Scale. Statistical comparisons of baseline demographics and neurological outcomes between operative and nonoperative cohorts were performed. RESULTS In total, 961 patients with GSI and at least 1-year follow-up were identified from 1975 to 2015. The majority of patients were Black/African American (55.6%), male (89.7%), and 15-29 years old (73.8%). Of those treated surgically (19.7% of all patients), 34.2% had improvement in their ASIA Impairment Scale score at 1 year, compared with 20.6% treated nonoperatively. Overall, surgery was associated with a 2.0 [95% confidence interval (CI): 1.4-2.8] times greater likelihood of ASIA Impairment Scale improvement at 1 year. Specifically, benefit was seen in thoracic (odds ratio: 2.5; 95% CI: 1.4-4.6) and lumbar injuries (odds ratio: 1.7; 95% CI: 1.1-3.1), but not cervical injuries. CONCLUSIONS While surgical indications are always determined on an individualized basis, in our review of GSIs, surgical intervention was associated with a greater likelihood of neurological recovery. Specifically, patients with thoracic and lumbar GSIs had a 2.5 and 1.7-times greater likelihood of improvement in their ASIA Impairment Scale score 1 year after injury, respectively, if they underwent surgical intervention.
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Affiliation(s)
- Brian C Goh
- Harvard Combined Orthopaedic Residency Program
| | | | | | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Harold A Fogel
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Stuart H Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Amakiri IC, Xiong GX, Verhofste B, Crawford AM, Schoenfeld AJ, Simpson AK. Insurance types are correlated with baseline patient-reported outcome measures in patients with adult spinal deformity. J Clin Neurosci 2022; 103:180-187. [PMID: 35908366 DOI: 10.1016/j.jocn.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/04/2022] [Accepted: 07/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are increasingly recognized as a key component of healthcare value, allowing comparison of therapeutic impact across different specialties. Prior literature suggests that insurance type may be associated with differing baseline PROMs among patients with degenerative conditions, including lumbar stenosis and hip arthritis. This association, however, has not been investigated for adult spinal deformity (ASD). METHODS Baseline PROMs were reviewed from 207 patients with ASD presenting for treatment between 2015 and 2019. The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, PROMIS Global-Physical, and visual analogue scale (VAS) for back and leg pain were assessed. Negative binomial regression was used to determine the impact of sociodemographic factors, including insurance type, on severity of symptoms and degree of disability at baseline. RESULTS Mean age of the study population was 62.2 +/- 15 years, with 61.8 % male prevalence. The Medicaid population had a greater proportion of Hispanic and non-English speaking patients, compared to commercially insured patients. Medicaid insured patients had significantly greater VAS low back pain scores compared with commercially insured individuals (IRR 1.535, 95 % CI 1.122-2.101, p = 0.007). CONCLUSIONS Medicaid insured patients demonstrated worse baseline PROMs at presentation with ASD, as compared to commercially insured or Medicare patients. Stakeholders across spine care delivery should elucidate the etiology of baseline disparities in ASD patients, as they may result from health system asymmetries. In an ecosystem moving toward value-driven treatment algorithms, accounting for and addressing these differences will be necessary to provide equitable care for ASD populations.
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Affiliation(s)
- Ikechukwu C Amakiri
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Bram Verhofste
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
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Lightsey HM, Pisano AJ, Striano BM, Crawford AM, Xiong GX, Hershman S, Schoenfeld AJ, Simpson AK. ALIF Versus TLIF for L5-S1 Isthmic Spondylolisthesis: ALIF Demonstrates Superior Segmental and Regional Radiographic Outcomes and Clinical Improvements Across More Patient-reported Outcome Measures Domains. Spine (Phila Pa 1976) 2022; 47:808-816. [PMID: 35125462 DOI: 10.1097/brs.0000000000004333] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of this study was to compare segmental and regional radiographic parameters between anterior interbody fusion (ALIF) and posterior interbody fusion (TLIF) for treatment of L5-S1 isthmic spondylolisthesis, and to assess for changes in these parameters over time. Secondarily, we sought to compare clinical outcomes via patient-reported outcome measures (PROMs) between techniques and within groups over time. SUMMARY OF BACKGROUND DATA Isthmic spondylolistheses are frequently treated with interbody fusion via ALIF or TLIF approaches. Robust comparisons of radiographic and clinical outcomes are lacking. METHODS We reviewed pre- and postoperative radiographs as well as Patient-Reported Outcomes Measurement Information System (PROMIS) elements for patients who received L5-S1 interbody fusions for isthmic spondylolisthesis in the Mass General Brigham (MGB) health system (2016-2020). Intraclass correlation testing was used for reliability assessments; Mann-Whitney U tests and Sign tests were employed for intercohort and intracohort comparative analyses, respectively. RESULTS ALIFs generated greater segmental and L4-S1 lordosis than TLIF, both at first postoperative visit (mean 26 days [SE = 4]; 11.3° vs. 1.3°, P < 0.001; 6.2° vs. 0.3°, P = 0.005) and at final follow-up (mean 410days [SE = 45]; 9.6° vs. 0.2°, P < 0.001; 7.9° vs. 2.1°, P = 0.005). ALIF also demonstrated greater increase in disc height than TLIF at first (9.6 vs. 5.5 mm, P < 0.001) and final follow-up (8.7 vs. 3.6 mm, P < 0.001). Disc height was maintained in the ALIF group but decreased over time in the TLIF cohort (ALIF 9.6 vs. 8.7 mm, P = 0.1; TLIF 5.5 vs. 3.6 mm, P < 0.001). Both groups demonstrated improvements in Pain Intensity and Pain Interference scores; ALIF patients also improved in Physical Function and Global Health - Physical domains. CONCLUSION ALIF generates greater segmental lordosis, regional lordosis, and restoration of disc height compared to TLIF for treatment of isthmic spondylolisthesis. Additionally, ALIF patients demonstrate significant improvements across more PROMs domains relative to TLIF patients.Level of Evidence: 3.
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Affiliation(s)
- Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Alfred J Pisano
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Stuart Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, mA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, mA
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Agaronnik N, Xiong GX, Uzosike A, Crawford AM, Lightsey HM, Simpson AK, Schoenfeld AJ. The role of gender in academic productivity, impact, and leadership among academic spine surgeons. Spine J 2022; 22:716-722. [PMID: 34902588 DOI: 10.1016/j.spinee.2021.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND/CONTEXT Women represent a small minority of practicing orthopedic surgeons and neurosurgeons, with spine surgery having a disproportionately low representation relative to other subspecialties. Previous efforts have attempted to characterize gender patterns in authorship amongst select spine journals. However, no study to our knowledge has done a comprehensive assessment of the influence of gender on academic productivity, impact, and leadership amongst academic spine faculty. PURPOSE To evaluate the impact of gender on academic productivity, promotion to leadership positions, and career advancement among academic spine faculty in the United States. STUDY DESIGN Cross-sectional study. PATIENT SAMPLE Academic spine faculty associated with orthopedic residency, North American Spine Society spine fellowship programs, and American Association of Neurological Surgeons spine fellowship programs. OUTCOME MEASURES Academic productivity as measured by publications counts, h-index, authorship ranking as well as academic rank and leadership roles METHODS: We identified all spine faculty across orthopedic residency, orthopedic spine fellowship, and neurosurgical spine fellowship programs in the United States, and abstracted academic performance characteristics, cumulative h-index, and complete publication records for each individual faculty member. Proportions of men and women by specialty, academic rank, and leadership were compared with Fisher's exact testing, and comparison of mean h-index and publication counts compared with Wilcoxon rank-sum testing. Adjusted analyses on publication count and h-index were achieved with poisson regression analysis with gender as the primary predictor adjusting for specialty, degrees, academic rank, and seniority based on time since fellowship completion. RESULTS The representation of women among spine faculty associated with orthopedic residency and North American Spine Society spine fellowship programs was 5.6%. On average, women had 40% fewer total publications (p=.025), h-indices approximately 5 units lower than men (p=.006), 40% fewer total high-impact publications (p=.030), half the senior author publications (p=.005), and half the high-impact senior author publications (p=.007) compared to men. After adjusting for seniority and academic rank, the number of publications in high impact journals no longer differed between men and women, although differences persisted for total publication count and the h-index. Men were significantly more likely to occupy higher academic ranks, with 25.6% of men and 9.5% of women holding the rank of full professor (p=.031), although there was no significant difference in the rate of appointment to leadership positions. Similar findings were encountered among American Association of Neurological Surgeons spine fellowship faculty. CONCLUSIONS The present study details the low rate of women in academic spine surgery. Furthermore, gender disparities exist in publication volume, impact, and h-indices. A much lower proportion of women hold higher-ranking academic positions compared to men, though appointment to leadership positions was similar between genders. Differences in seniority and publication metrics may in part be due to the relatively younger cohort of women faculty. These findings underscore the need for active investment in diversity and pipeline efforts that facilitate recruitment and support academic productivity of women in spine surgery.
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Affiliation(s)
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114, USA
| | - Akachimere Uzosike
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114, USA
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114, USA
| | - Andrew K Simpson
- Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
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Grisdela PT, Crawford AM, Evans DC, von Keudell AG. Hematoma Formation After Hip Corticosteroid Injection in a Patient with Chronic Myelomonocytic Leukemia: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00013. [PMID: 37440607 DOI: 10.2106/jbjs.cc.21.00806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
CASE We present a 70-year-old woman with history of chronic myelomonocytic leukemia with a right thigh hematoma after a corticosteroid hip injection. Aspiration of the hematoma was attempted, but she developed a significant transfusion requirement with paresthesias in a lateral femoral cutaneous nerve distribution, prompting transfer. Imaging demonstrated no active extravasation, and she was managed conservatively. At 8-month follow-up, she had a persistent consolidated hematoma on the right side, and she subsequently died of complications of her cancer. CONCLUSION This case demonstrates an unusual complication from a common nonoperative modality, as well as important coagulopathies that must be considered in patients with leukemia.
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Affiliation(s)
- Phillip T Grisdela
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - David C Evans
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Arvind G von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Xiong GX, Crawford AM, Goh BC, Striano BM, Bensen GP, Schoenfeld AJ. Does Operative Management of Epidural Abscesses Increase Healthcare Expenditures up to 1 Year After Treatment? Clin Orthop Relat Res 2022; 480:382-392. [PMID: 34463660 PMCID: PMC8747673 DOI: 10.1097/corr.0000000000001967] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The incidence of spinal epidural abscesses is increasing. What is more, they are associated with high rates of morbidity and mortality. Advances in diagnostic imaging and antibiotic therapies have made earlier diagnosis and nonoperative management feasible in appropriately selected patients. Nonoperative treatment also has the advantage of lower immediate healthcare charges; however, it is unknown whether initial nonoperative care leads to higher healthcare charges long term. QUESTIONS/PURPOSES (1) Does operative intervention generate higher charges than nonoperative treatment over the course of 1 year after the initial treatment of spinal epidural abscesses? (2) Does the treatment of spinal epidural abscesses in people who actively use intravenous drugs generate higher charges than management in people who do not? METHODS This retrospective comparative study at two tertiary academic centers compared adult patients with spinal epidural abscesses treated operatively and nonoperatively from January 2016 through December 2017. Ninety-five patients were identified, with four excluded for lack of billing data and one excluded for concomitant intracranial abscess. Indications for operative management included new or progressive motor deficit, lack of response to nonoperative treatment including persistent or progressive systemic illness, or initial sepsis requiring urgent source control. Of the included patients, 52% (47 of 90) received operative treatment with no differences in age, gender, BMI, and Charlson comorbidity index between groups, nor any difference in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Furthermore, 29% (26 of 90) of patients actively used intravenous drugs and were younger, with a lower BMI and lower Charlson comorbidity index, with no differences in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Cumulative charges at the index hospital discharge and 90 days and 1 year after discharge were compared based on operative or nonoperative management and secondarily by intravenous drug use status. Medical records, laboratory results, and hospital billing data were reviewed for data extraction. Demographic factors including age, gender, region of abscess, intravenous drug use, and comorbidities were extracted, along with clinical factors such as symptoms and ambulatory function at presentation, spinal instability, intensive care unit admission, and complications. The primary outcome was charges associated with care at the index hospital discharge and 90 days and 1 year after discharge. All covariates extracted were included in this analysis using negative binomial regression that accounted for confounders and the nonparametric nature of charge data. Results are presented as an incidence rate ratio with 95% confidence intervals. RESULTS After adjusting for demographic and clinical variables such as age, gender, BMI, ambulatory status, presence of mechanical instability, and intensive care unit admission among others, we found higher charges for the group treated with surgery compared with those treated nonoperatively at the index admission (incidence rate ratio [IRR] 1.62 [95% CI 1.35 to 1.94]; p < 0.001) and at 1 year (IRR 1.36 [95% CI 1.10 to 1.68]; p = 0.004). Adjusted analysis also showed that active intravenous drug use was also associated with higher charges at the index admission (IRR 1.57 [95% CI 1.16 to 2.14]; p = 0.004) but no difference at 1 year (IRR 1.11 [95% CI 0.79 to 1.57]; p = 0.55). CONCLUSION Multidisciplinary teams caring for patients with spinal epidural abscesses should understand that the decreased charges associated with selecting nonoperative management during the index admission persist at 1 year with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. On the other hand, patients with active intravenous drug use have higher index admission charges that do not persist at 1 year, with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. These results suggest possible economic benefit to nonoperative management of epidural abscesses without increases in readmission or mortality rates, further tipping the scale in an evolving framework of clinical decision-making. Future studies should investigate if these economic implications are mirrored on the patient-facing side to determine whether any financial burden is shifted onto patients and their families in nonoperative management. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Grace X. Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Alexander M. Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Brian C. Goh
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Brendan M. Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Gordon P. Bensen
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Crawford AM, Lightsey HM, Xiong GX, Striano BM, Schoenfeld AJ, Simpson AK. Telemedicine visits generate accurate surgical plans across orthopaedic subspecialties. Arch Orthop Trauma Surg 2022; 142:3009-3016. [PMID: 33866406 PMCID: PMC8053078 DOI: 10.1007/s00402-021-03903-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/08/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The role of telemedicine is rapidly evolving across medical specialties and orthopaedics. The utility of telemedicine to identify operative candidates and determine surgical plans has yet to be demonstrated. We sought to assess whether surgical plans proposed following telemedicine visits changed after subsequent in-person interaction across orthopaedic subspecialties. MATERIALS AND METHODS We identified all elective telemedicine encounters across two academic institutions from March 1, 2020 to July 31, 2020. We identified patients indicated for surgery with a specific surgical plan during the virtual visit. The surgical plans delineated during the telemedicine encounter were then compared to final pre-operative plans documented following subsequent in-person evaluation. Changes in the surgical plan between telemedicine and in-person encounters were defined using a standardised schema. Regression analysis was used to evaluate factors associated with a change in surgical plan between visits across specialties, including the number of virtual examination manoeuvres performed. RESULTS We identified 303 instances of a patient being indicated for orthopaedic surgery during a telemedicine encounter. In 11 cases (4%), the plan was changed between telemedicine and subsequent in-person encounter. No plans were changed amongst patients indicated for joint arthroplasty and foot and ankle surgery, whilst 4% of plans were changed amongst sports surgery and upper extremity/shoulder surgery. Surgical plans had the highest rate of change amongst spine surgery patients (8%). There was notable variability in the conduct of virtual examinations across subspecialties. CONCLUSION Our results demonstrate the capability of telemedicine to support development of accurate surgical plans for orthopaedic patients across several subspecialties. Our findings also highlight the substantial variation in the utilisation of physical examination manoeuvres conducted via telemedicine across institutions, subspecialties, and providers. DESCRIPTION OF STUDY TYPE Level IV, retrospective cohort study.
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Affiliation(s)
| | - Harry M. Lightsey
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA 02114 USA
| | - Grace X. Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA 02114 USA
| | - Brendan M. Striano
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA 02114 USA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Spine Surgery, Brigham and Women’s Hospital, Harvard Medical Schools, 75 Francis St, Boston, MA 02115 USA
| | - Andrew K. Simpson
- Department of Orthopaedic Spine Surgery, Brigham and Women’s Hospital, Harvard Medical Schools, 75 Francis St, Boston, MA 02115 USA
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Simpson AK, Lightsey HM, Xiong GX, Crawford AM, Minamide A, Schoenfeld AJ. Spinal endoscopy: evidence, techniques, global trends, and future projections. Spine J 2022; 22:64-74. [PMID: 34271213 DOI: 10.1016/j.spinee.2021.07.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/13/2021] [Accepted: 07/06/2021] [Indexed: 02/03/2023]
Abstract
The utilization of indirect visualization during procedures has been increasingly replacing traditional forms of direct visualization across many different surgical specialties. The adoption of arthroscopy, using small cameras placed inside joints, has transformed musculoskeletal care over the last several decades, allowing surgeons to provide the same anatomic solutions with less tissue dissection, resulting in lower requirements for inpatient care, reduced costs, and expedited recovery. For a variety of reasons, spine surgery has lagged behind other specialties in the adoption of indirect visualization. Nonetheless, patient demand for less invasive spine procedures and surgeon drive to provide these solutions and improve care quality has driven global adoption of spinal endoscopy. There are numerous endoscopic platforms and techniques currently utilized, and these systems are rapidly evolving. Additionally, the variance in technology and health system incentives across the globe has generated tremendous regional heterogeneity in the utilization of spinal endoscopic procedures. We present a consolidated review, including the background, evidence, techniques, and trends in spinal endoscopy, so that clinicians can gain a deeper understanding of this rapidly evolving domain of spinal healthcare.
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Affiliation(s)
- Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Microendoscopic Spine Institute, 75 Francis St, Boston, MA 02115.
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Akihito Minamide
- Spine Center, Department of Orthopaedic Surgery, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko City, Tochigi, Japan
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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Abstract
The utilization of indirect visualization during procedures has been increasingly replacing traditional forms of direct visualization across many different surgical specialties. The adoption of arthroscopy, using small cameras placed inside joints, has transformed musculoskeletal care over the last several decades, allowing surgeons to provide the same anatomic solutions with less tissue dissection, resulting in lower requirements for inpatient care, reduced costs, and expedited recovery. For a variety of reasons, spine surgery has lagged behind other specialties in the adoption of indirect visualization. Nonetheless, patient demand for less invasive spine procedures and surgeon drive to provide these solutions and improve care quality has driven global adoption of spinal endoscopy. There are numerous endoscopic platforms and techniques currently utilized, and these systems are rapidly evolving. Additionally, the variance in technology and health system incentives across the globe has generated tremendous regional heterogeneity in the utilization of spinal endoscopic procedures. We present a consolidated review, including the background, evidence, techniques, and trends in spinal endoscopy, so that clinicians can gain a deeper understanding of this rapidly evolving domain of spinal healthcare.
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Affiliation(s)
- Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Microendoscopic Spine Institute, 75 Francis St, Boston, MA 02115.
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Akihito Minamide
- Spine Center, Department of Orthopaedic Surgery, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko City, Tochigi, Japan
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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Crawford AM, Liu CY, Lange JK, Hershman SH. Is It the Back or the Hip? Differentiating Lumbar Spine From Hip Pathologies: Key Points of Evaluation and Treatment. Instr Course Lect 2022; 71:387-398. [PMID: 35254796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Disorders of the hip and spine commonly coexist and are difficult to disentangle. When they do occur together, the pathology is often referred to as hip-spine syndrome. When hip-spine syndrome is suspected, it is critically important to properly identify the relative contributions that the hip and spine each provide to a patient's overall clinical presentation. To focus on the incorrect anatomic site would be a disservice to the patient. The interconnectivity of hip and spine pathology, the various clinical presentations of the most commonly seen hip and spine disorders, the broad differential and suggested workup that should be considered for such patients, the various treatment modalities available, and the clinical predictors and expected outcomes for patients with hip-spine syndrome are important factors for review.
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Xiong GX, Crawford AM, Striano B, Lightsey HM, Nelson SB, Schwab JH. The NIMS framework: an approach to the evaluation and management of epidural abscesses. Spine J 2021; 21:1965-1972. [PMID: 34010684 DOI: 10.1016/j.spinee.2021.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | | | - Brendan Striano
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Bulfinch 130, 55 Fruit St., Boston, MA, 02114
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit St., Boston, MA 02114.
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Striano BM, Xiong GX, Lightsey HM, Crawford AM, Pisano AJ, Schoenfeld AJ, Simpson AK. Comparison of Radiation Exposure Between Anterior, Lateral, and Posterior Interbody Fusion Techniques and the Influence of Patient and Procedural Factors. Spine (Phila Pa 1976) 2021; 46:1669-1675. [PMID: 34610614 DOI: 10.1097/brs.0000000000004247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The aim of this study was to elucidate the relative influence of multiple factors on radiation usage for anterior, lateral, and posterior based lumbar interbody fusion techniques. SUMMARY OF BACKGROUND DATA There has been substantial global growth in the performance of lumbar interbody fusions, due to evolution of techniques and approaches and increased attention to sagittal alignment. Utilization of intraoperative imaging guidance has similarly expanded, with a predominance of fluoroscopy and consequent increased radiation exposure. There have been no larger-scale studies examining the role of patient and procedural factors in driving radiation exposure across different interbody techniques. METHODS We used a clinical registry to review all single-level lumbar interbody fusions performed between January 2016 and October 2020. Operative records were reviewed for the amount of radiation exposure during the procedure. Patient age, biologic sex, body mass index (BMI), operative surgeon, surgical level, surgical time, and fusion technique were recorded. Multivariable adjusted analyses using negative binomial regression were used to account for confounding. RESULTS We included 134 interbody fusions; 80 performed with a posterior approach (TLIF/PLIF), 43 via an anterior approach (ALIF) with posterior pedicle fixation, and 9 performed with a lateral approach (LLIF/XLIF). Average radiation per case was 136.4 mGy (SE 17.3) for ALIF, 108.6 mGy (16.9) for LLIF/XLIF, and 60.5 mGy (7.4) for TLIF/PLIF. We identified lateral approaches, increased BMI, minimally invasive techniques, and more caudal operative levels as significantly associated with increased radiation exposure. CONCLUSION We identified several novel drivers of radiation exposure during interbody fusion procedures, including the relative importance of technique and the level at which the fusion is performed. More caudal levels of intervention and lateral based techniques had significantly greater radiation exposure.Level of Evidence: 4.
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Affiliation(s)
- Brendan M Striano
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, M
| | - Grace X Xiong
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, M
| | - Harry M Lightsey
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, M
| | - Alexander M Crawford
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, M
| | - Alfred J Pisano
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew K Simpson
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Xiong G, Greene NE, Lightsey HM, Crawford AM, Striano BM, Simpson AK, Schoenfeld AJ. Telemedicine Use in Orthopaedic Surgery Varies by Race, Ethnicity, Primary Language, and Insurance Status. Clin Orthop Relat Res 2021; 479:1417-1425. [PMID: 33982979 PMCID: PMC8208394 DOI: 10.1097/corr.0000000000001775] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/17/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Healthcare disparities are well documented across multiple subspecialties in orthopaedics. The widespread implementation of telemedicine risks worsening these disparities if not carefully executed, despite original assumptions that telemedicine improves overall access to care. Telemedicine also poses unique challenges such as potential language or technological barriers that may alter previously described patterns in orthopaedic disparities. QUESTIONS/PURPOSES Are the proportions of patients who use telemedicine across orthopaedic services different among (1) racial and ethnic minorities, (2) non-English speakers, and (3) patients insured through Medicaid during a 10-week period after the implementation of telemedicine in our healthcare system compared with in-person visits during a similar time period in 2019? METHODS This was a retrospective comparative study using electronic medical record data to compare new patients establishing orthopaedic care via outpatient telemedicine at two academic urban medical centers between March 2020 and May 2020 with new orthopaedic patients during the same 10-week period in 2019. A total of 11,056 patients were included for analysis, with 1760 in the virtual group and 9296 in the control group. Unadjusted analyses demonstrated patients in the virtual group were younger (median age 57 years versus 59 years; p < 0.001), but there were no differences with regard to gender (56% female versus 56% female; p = 0.66). We used self-reported race or ethnicity as our primary independent variable, with primary language and insurance status considered secondarily. Unadjusted and multivariable adjusted analyses were performed for our primary and secondary predictors using logistic regression. We also assessed interactions between race or ethnicity, primary language, and insurance type. RESULTS After adjusting for age, gender, subspecialty, insurance, and median household income, we found that patients who were Hispanic (odds ratio 0.59 [95% confidence interval 0.39 to 0.91]; p = 0.02) or Asian were less likely (OR 0.73 [95% CI 0.53 to 0.99]; p = 0.04) to be seen through telemedicine than were patients who were white. After controlling for confounding variables, we also found that speakers of languages other than English or Spanish were less likely to have a telemedicine visit than were people whose primary language was English (OR 0.34 [95% CI 0.18 to 0.65]; p = 0.001), and that patients insured through Medicaid were less likely to be seen via telemedicine than were patients who were privately insured (OR 0.83 [95% CI 0.69 to 0.98]; p = 0.03). CONCLUSION Despite initial promises that telemedicine would help to bridge gaps in healthcare, our results demonstrate disparities in orthopaedic telemedicine use based on race or ethnicity, language, and insurance type. The telemedicine group was slightly younger, which we do not believe undermines the findings. As healthcare moves toward increased telemedicine use, we suggest several approaches to ensure that patients of certain racial, ethnic, or language groups do not experience disparate barriers to care. These might include individual patient- or provider-level approaches like expanded telemedicine schedules to accommodate weekends and evenings, institutional investment in culturally conscious outreach materials such as advertisements on community transport systems, or government-level provisions such as reimbursement for telephone-only encounters. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Grace Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Nattaly E Greene
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Crawford AM, Grisdela PT, Maguire JH, von Keudell AG. Septic Iliopsoas Bursitis After Intra-articular Methylprednisolone Injection to the Hip: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00127. [PMID: 34161307 DOI: 10.2106/jbjs.cc.21.00056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We describe the case of a 74-year-old man who developed severe hip pain several days after an intra-articular methylprednisolone injection to his right hip. Culture of the ipsilateral iliopsoas bursa revealed a Staphylococcus lugdunensis infection, which was successfully eradicated through irrigation and debridement as well as antibiotics. CONCLUSION Infection after hip injection is a known theoretical risk but is rarely reported in the literature. We present a case of septic bursitis after corticosteroid injection. Readers should be mindful that these complications do occur in clinical practice and portend significant morbidity.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Philip T Grisdela
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - James H Maguire
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Crawford AM, Lightsey HM, Xiong GX, Striano BM, Pisano AJ, Schoenfeld AJ, Simpson AK. Variability and contributions to cost associated with anterior versus posterior approaches to lumbar interbody fusion. Clin Neurol Neurosurg 2021; 206:106688. [PMID: 34015696 DOI: 10.1016/j.clineuro.2021.106688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Lumbar interbody fusions are being performed with increased frequency in the last decade. Anterior and posterior interbody techniques have demonstrated relatively similar success rates. Nonetheless, despite increased attention to cost-effective care delivery, approach-related differences in procedural cost and predictors for these differences remain poorly defined. The purpose of this investigation was to characterize the variability in cost for anterior versus posterior-based lumbar interbody fusions and to identify key predictors of procedural cost. METHODS We evaluated the records of all patients who underwent a primary anterior (ALIF) or posterior/transforaminal (PLIF/TLIF) lumbar interbody fusion with concomitant posterior fusion from 2016 to 2020 at four hospitals in a major metropolitan area. We reviewed the records of all included patients and abstracted demographics, insurance status, approach, operative time, diagnosis, surgeon, institution, open versus minimally invasive technique, and components of procedural costs. Costs based upon interbody approach were compared via multivariable adjusted analyses using negative binomial regression. RESULTS We included 139 interbody fusion procedures; 98 were performed via posterior approach (TLIF/PLIF) and 41 using an anterior approach. Anterior techniques were associated with significantly increased costs as compared to posterior procedures (anterior, $16316 [SE 556] vs. posterior, $9415 [SE 345]; p < 0.001). This determination remained significant following multivariable adjusted analysis (regression coefficient -0.22, 95% CI -0.34, -0.10, p < 0.001). Multivariable analysis also indicated that surgeon, invasiveness, and procedure time were significant predictors of total cost. CONCLUSION Our findings demonstrate that anterior interbody techniques are, on average, 173% (anterior, $16316 [SE 556] vs. posterior, $9415 [SE 345]; p < 0.001) more expensive than posterior-based procedures. Given the relative equipoise of these different approaches for many clinical applications, these findings should be considered in an ecosystem increasingly attentive to cost effective care delivery. This work has also provided specific procedural variables for surgeons and systems to target when optimizing procedural costs.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Alfred J Pisano
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
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Crawford AM. What's Important: Widespread Vaccination: Reflections on the Pandemic, Contracting COVID-19, and the Opportunity Before Us. J Bone Joint Surg Am 2021; 103:565-566. [PMID: 33587516 DOI: 10.2106/jbjs.21.00056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
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Crawford AM, Lightsey HM, Xiong GX, Striano BM, Greene N, Schoenfeld AJ, Simpson AK. Interventional procedure plans generated by telemedicine visits in spine patients are rarely changed after in-person evaluation. Reg Anesth Pain Med 2021; 46:478-481. [PMID: 33757998 DOI: 10.1136/rapm-2021-102630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/06/2021] [Accepted: 03/07/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES The role of telemedicine in the evaluation and treatment of patients with spinal disorders is rapidly expanding, brought on largely by the COVID-19 pandemic. Within this context, the ability of pain specialists to accurately diagnose and plan appropriate interventional spine procedures based entirely on telemedicine visits, without an in-person evaluation, remains to be established. In this study, our primary objective was to assess the relevance of telemedicine to interventional spine procedure planning by determining whether procedure plans established solely from virtual visits changed following in-person evaluation. METHODS We reviewed virtual and in-person clinical encounters from our academic health system's 10 interventional spine specialists. We included patients who were seen exclusively via telemedicine encounters and indicated for an interventional procedure with documented procedural plans. Virtual plans were then compared with the actual procedures performed following in-person evaluation. Demographic data as well as the type and extent of physical examination performed by the interventional spine specialist were also recorded. RESULTS Of the 87 new patients included, the mean age was 60 years (SE 1.4 years) and the preprocedural plan established by telemedicine, primarily videoconferencing, did not change for 76 individuals (87%; 95% CI 0.79 to 0.94) following in-person evaluation. Based on the size of our sample, interventional procedures indicated solely during telemedicine encounters may be accurate in 79%-94% of cases in the broader population. CONCLUSIONS Our findings suggest that telemedicine evaluations are a generally accurate means of preprocedural assessment and development of interventional spine procedure plans. These findings clearly demonstrate the capabilities of telemedicine for evaluating spine patients and planning interventional spine procedures.
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Affiliation(s)
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA
| | - Nattaly Greene
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Lightsey HM, Crawford AM, Xiong GX, Schoenfeld AJ, Simpson AK. Surgical plans generated from telemedicine visits are rarely changed after in-person evaluation in spine patients. Spine J 2021; 21:359-365. [PMID: 33227550 DOI: 10.1016/j.spinee.2020.11.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/06/2020] [Accepted: 11/14/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The role of telemedicine within the realm of spine surgery is evolving, catalyzed by the recent pandemic. Specifically, the capability of this technology to provide high-quality, cost-effective care without an in-person interaction and physical examination remains poorly defined. PURPOSE To characterize the impact of telemedicine on spine surgical planning by assessing whether surgical plans established in virtual visits changed following in-person evaluation. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE We evaluated the records of patients who were indicated for surgery with documented specific surgical plans during a virtual encounter (March-July 2020) and underwent subsequent in-person evaluation prior to surgery. OUTCOME MEASURES We determined whether surgical plans changed between the virtual encounter and the in-person interaction. Secondarily, we reviewed use of the virtual physical examination across surgeons. METHODS We reviewed virtual and in-person clinical encounters from a single academic spine division, evaluating those patients who were seen exclusively via telemedicine encounters and indicated for surgery with documented specific surgical plans. These plans were compared to the surgical plan after these same patients underwent in-person evaluation. Demographic data, patient primary complaint, and the type and extent of physical examination performed by the surgeon were recorded. RESULTS Of the 33 patients included, the surgical plan did not change among 31 individuals (94%) following in-person interaction. For the two patients where surgical plans were modified, multilevel fusions were increased by one level. There was notable inter- and intra-surgeon variability with regard to the use of virtual physical exams. CONCLUSIONS Our findings suggest that telemedicine evaluations are efficient means of preoperative assessment of spine patients and delineation of surgical plans. These results may support innovations that can optimize access to care for patients.
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Affiliation(s)
- Harry M Lightsey
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 USA
| | - Alexander M Crawford
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 USA
| | - Grace X Xiong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 USA.
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Crawford AM, Guild TT, Striano BM, Von Keudell AG. Spontaneous iliacus haematoma with femoral nerve palsy: an appeal to involve surgical teams early. BMJ Case Rep 2021; 14:14/1/e239024. [PMID: 33462039 PMCID: PMC7816894 DOI: 10.1136/bcr-2020-239024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
We report the case of a 68-year-old man who was placed on heparin as bridge therapy and subsequently developed an iliacus haematoma with associated femoral nerve palsy. His team involved the orthopaedic surgery team in delayed fashion after his symptom onset. Due to his active medical conditions, he did not undergo surgical decompression of his haematoma until late into his hospital course. Unfortunately, this patient did not regain meaningful function from his femoral nerve deficit. We believe this case highlights the high index of suspicion necessary for making this diagnosis as well as the repercussions of an untimely decompression for this acute, compressive neuropathy. Although we are surgeons and this is a surgical case, we hope to publish this case in a medical journal to raise awareness that surgical decompression does have a role in this diagnosis and should ultimately be pursued early in its course for optimal patient benefit.
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Affiliation(s)
| | - Theodore T Guild
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA
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Crawford AM, Chen AF, Sabeti A, Jay JF, Shah VM. Team Approach: Same-Day Discharge of Patients Undergoing Total Joint Arthroplasty. JBJS Rev 2020; 8:e0176. [DOI: 10.2106/jbjs.rvw.19.00176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Affiliation(s)
- N J Wood
- DSIR Grasslands, Palmerston North, New Zealand
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40
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Affiliation(s)
- P A Swarbrick
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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41
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Affiliation(s)
- F C Buchanan
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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42
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Affiliation(s)
- P A Swarbrick
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Affiliation(s)
- P A Swarbrick
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Affiliation(s)
- P A Swarbrick
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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45
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Affiliation(s)
- F C Buchanan
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Crawford AM, Buchanan FC, Fraser KM, Robinson AJ, Hill DF. Repeat sequences from complex ds DNA viruses can be used as minisatellite probes for DNA fingerprinting. Anim Genet 2009; 22:177-81. [PMID: 1892249 DOI: 10.1111/j.1365-2052.1991.tb00660.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In a search for new fingerprinting probes for use with sheep, repeat sequences derived from five poxviruses, an iridovirus and a baculovirus were screened against DNA from sheep pedigrees. Probes constructed from portions of the parapox viruses, orf virus and papular stomatitis virus and the baculovirus from the alfalfa looper, Autographa californica, nuclear polyhedrosis virus all gave fingerprint patterns. Probes from three other poxviruses and an iridovirus did not give useful banding patterns.
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Affiliation(s)
- A M Crawford
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Affiliation(s)
- A M Crawford
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Ede AJ, Peirson CA, Henry H, Crawford AM. Ovine Microsatellites at the OarAE64, OarHH22, OarHH56, OarHH62 and OarVH4 loci. Anim Genet 2009. [DOI: 10.1111/j.1365-2052.1994.tb00057.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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49
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Affiliation(s)
- P A Swarbrick
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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50
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Affiliation(s)
- F C Buchanan
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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