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Razzouk J, Case T, Vyhmeister E, Nguyen K, Carter D, Carter M, Sajdak G, Kricfalusi M, Taylor R, Bedward D, Shin D, Wycliffe N, Ramos O, Lipa SA, Bono CM, Cheng W, Danisa O. Morphometric Analysis of Cervical Neuroforaminal Dimensions from C2-T1 Using Computed Tomography of 1,000 Patients. Spine J 2024:S1529-9430(24)00219-5. [PMID: 38705281 DOI: 10.1016/j.spinee.2024.05.001] [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: 12/11/2023] [Revised: 04/22/2024] [Accepted: 05/01/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Race and sex differences are not consistently reported in the literature. Fundamentally, anatomical differences of cervical neuroforaminal dimensions (CNFD) amongst these groups would be important to know. PURPOSE To establish normative radiographic morphometric measurements of CNFD and uncover the influence of patient sex, race, and ethnicity while also considering anthropometric characteristics. STUDY DESIGN Retrospective radiographic morphometric study. PATIENT SAMPLE 1,000 patients between 18 and 35 years of age who were free of spinal pathology. OUTCOME MEASURES Foraminal height, axial width, and area of cervical neural foramen. METHODS Cervical CTs were reviewed to measure CNFD, defined as follows: foraminal height, axial width, and area. Statistical analyses were performed to assess associations between CNFD, and patient height, weight, sex, race, and ethnicity. RESULTS CNFD measurements followed a bimodal distribution pattern moving caudally from C2-T1. Irrespective of disc level, cervical CNFD were as follows: left and right widths of 6.6 ± 1.5 and 6.6 ± 1.5 mm, heights of 9.4 ± 2.4 and 9.4 ± 3.2 mm, and areas of 60.0 ± 19.5 and 60.6 ± 20.7 mm2. Left and right foraminal width were highest at C2-C3 and lowest at C3-C4. Left and right foraminal height were highest at C7-T1 and C6-C7 respectively and lowest at C3-C4. Left and right foraminal areas were highest at C2-C3 and lowest at C3-C4. Significant differences were observed for all CNFD measurements across disc levels. CNFD did not vary based on laterality. Significant CNFD differences were observed with respect to patient sex, race, and ethnicity. Male height and area were larger compared to females. In contrast, female foraminal width was larger compared to males. The Asian cohort demonstrated the largest foraminal widths. White and Hispanic patients demonstrated the largest foraminal heights and areas. Black patients demonstrated the smallest foraminal widths, heights, and areas. Patient height and weight were only weakly correlated with CNFD measurements across all levels from C2-T1. CONCLUSIONS This study describes 36,000 normative measurements of 12,000 foramina from C2-T1. CNFD measurements vary based on disc level, but not laterality. Contrasting left- versus right-sided neuroforamina of the same level may aid in determining the presence of unilateral stenosis. Patient sex, race, and ethnicity are associated with CNFD, while patient anthropometric factors are weakly correlated with CNFD.
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Affiliation(s)
- Jacob Razzouk
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Trevor Case
- California University of Science and Medicine, Colton, CA, USA
| | | | - Kai Nguyen
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Davis Carter
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Mei Carter
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Grant Sajdak
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | | | - Rachel Taylor
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Derran Bedward
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - David Shin
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Nathaniel Wycliffe
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Omar Ramos
- Twin Cities Spine Center, Minneapolis, MN, USA
| | - Shaina A Lipa
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis Memorial Veterans Hospital, Loma Linda, CA, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA.
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Bernstein DN, Hammoor BT, Clements CU, Tobert DG, Cha TD, Aidlen JP, Hershman SH, Bono CM, Fogel HA. Assessing the variation and drivers of cost in 1-level lumbar fusion: a time-driven activity-based costing analysis. Spine J 2024:S1529-9430(24)00184-0. [PMID: 38663483 DOI: 10.1016/j.spinee.2024.04.012] [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: 02/02/2024] [Accepted: 04/19/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND CONTEXT As value-based health care arrangements gain traction in spine care, understanding the true cost of care becomes critical. Historically, inaccurate cost proxies have been used, including negotiated reimbursement rates or list prices. However, time-driven activity-based costing (TDABC) allows for a more accurate cost assessment, including a better understanding of the primary drivers of cost in 1-level lumbar fusion. PURPOSE To determine the variation of total hospital cost, differences in characteristics between high-cost and non-high-cost patients, and to identify the primary drivers of total hospital cost in a sample of patients undergoing 1-level lumbar fusion. STUDY DESIGN/SETTING Retrospective, multicenter (one academic medical center, one community-based hospital), observational study. PATIENT SAMPLE A total of 383 patients undergoing elective 1-level lumbar fusion for degenerative spine conditions between November 2, 2021 and December 2, 2022. OUTCOME MEASURES Total hospital cost of care (normalized); preoperative, intraoperative, and postoperative cost of care (normalized); ratio of most to least expensive 1-level lumbar fusion. METHODS Patients undergoing a 1-level lumbar fusion between November 2, 2021 and December 2, 2022 were identified at two hospitals (one quaternary referral academic medical center and one community-based hospital) within our health system. TDABC was used to calculate total hospital cost, which was also broken up into: pre-, intra-, and postoperative timeframes. Operating surgeon and patient characteristics were also collected and compared between high- and non-high-cost patients. The correlation of surgical time and cost was determined. Multivariable linear regression was used to determine factors associated with total hospital cost. RESULTS The most expensive 1-level lumbar fusion was 6.8x more expensive than the least expensive 1-level lumbar fusion, with the intraoperative period accounting for 88% of total cost. On average. the implant cost accounted for 30% of the total, but across the patient sample, the implant cost accounted for a range of 6% to 44% of the total cost. High-cost patients were younger (55 years [SD: 13 years] vs.63 years [SD: 13 years], p=.0002), more likely to have commercial health insurance (24 out of 38 (63%) vs. 181 out of 345 (52%), p=.003). There was a poor correlation between time of surgery (i.e., incision to close) and total overall cost (ρ: .26, p<.0001). Increase age (RC: -0.003 [95% CI: -0.006 to -0.000007], p=.049) was associated with decreased cost. Surgery by certain surgeons was associated with decreased total cost when accounting for other factors (p<.05). CONCLUSIONS A large variation exists in the total hospital cost for patients undergoing 1-level lumbar fusion, which is primarily driven by surgeon-level decisions and preferences (e.g., implant and technology use). Also, being a "fast" surgeon intraoperatively does not mean your total cost is meaningfully lower. As efforts continue to optimize patient value through ensuring appropriate clinical outcomes while also reducing cost, spine surgeons must use this knowledge to lead, or at least be active participants in, any discussions that could impact patient care.
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Affiliation(s)
- David N Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Bradley T Hammoor
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Chierika Ukogu Clements
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Jessica P Aidlen
- Department of Orthopaedic Surgery, Newton-Wellesley Hospital, 2014 Washington St., Newton, MA 02462, USA
| | - Stuart H Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Harold A Fogel
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA.
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Bono CM. Time to Change the Treatment Paradigm for Vertebral Osteomyelitis? Not Quite!: Commentary on an article by Nikolaus Kernich, MD, et al.: "Surgery for Vertebral Osteomyelitis Lowers 1-Year Mortality and Failure Rates Compared with Nonsurgical Treatment. A Propensity-Matched Analysis". J Bone Joint Surg Am 2024; 106:e18. [PMID: 38568195 DOI: 10.2106/jbjs.23.01365] [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: 04/05/2024]
Affiliation(s)
- Christopher M Bono
- Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
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Cabrera A, Bouterse A, Nelson M, Dietrich C, Razzouk J, Oyoyo U, Bono CM, Danisa O. Prediction of In-Hospital Mortality Following Vertebral Fracture Fixation in Patients With Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis: Machine Learning Analysis. Int J Spine Surg 2024; 18:62-68. [PMID: 38282419 DOI: 10.14444/8567] [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] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are distinct pathological entities that similarly increase the risk of vertebral fractures. Such fractures can be clinically devastating and frequently portend significant neurological injury, thus making their prevention a critical focus. Of particular significance, spinal fractures in patients with AS or DISH carry a considerable risk of mortality, with reports on 1-year injury-related deaths ranging from 24% to 33%. As such, the purpose of this study was to conduct machine learning (ML) analysis to predict postoperative mortality in patients with AS or DISH using the Nationwide Inpatient Sample Healthcare Cost and Utilization Project (HCUP-NIS) database. METHODS HCUP-NIS was queried to identify adult patients carrying a diagnosis of AS or DISH who were admitted for spinal fractures and underwent subsequent fusion or corpectomy between 2016 and 2018. Predictions of in-hospital mortality in this cohort were then generated by three independent ML algorithms. RESULTS An in-hospital mortality rate of 5.40% was observed in our selected population, including a rate of 6.35% in patients with AS, 2.81% in patients with DISH, and 8.33% in patients with both diagnoses. Increasing age, hypertension with end-organ complications, spinal cord injury, and cervical spinal fractures each carried considerable predictive importance across the algorithms utilized in our analysis. Predictions were generated with an average area under the curve of 0.758. CONCLUSIONS This study's application of ML algorithms to predict in-hospital mortality among patients with AS or DISH identified a number of clinical risk factors relevant to this outcome. CLINICAL RELEVANCE These findings may serve to provide physicians with an awareness of risk factors for in-hospital mortality and, subsequently, guide management and shared decision-making among patients with AS or DISH. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Andrew Cabrera
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | | | - Michael Nelson
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | | | - Jacob Razzouk
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Udochukwu Oyoyo
- Office of Dental Education Services, Loma Linda University School of Dentistry, Loma Linda, CA, USA
| | - Christopher M Bono
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Olumide Danisa
- Department of Orthopedics, Loma Linda University, Loma Linda, CA, USA
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Agaronnik ND, Giberson-Chen C, Bono CM. Using advanced imaging to measure bone density, compression fracture risk, and risk for construct failure after spine surgery. Spine J 2024:S1529-9430(24)00103-7. [PMID: 38437918 DOI: 10.1016/j.spinee.2024.02.018] [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: 07/04/2023] [Revised: 01/22/2024] [Accepted: 02/23/2024] [Indexed: 03/06/2024]
Abstract
Low bone mineral density (BMD) can predispose to vertebral body compression fractures and postoperative instrumentation failure. DEXA is considered the gold standard for measurement of BMD, however it is not obtained for all spine surgery patients preoperatively. There is a growing body of evidence suggesting that more routinely acquired spine imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can be opportunistically used to measure BMD. Here we review available studies that assess the validity of opportunistic screening with CT-derived Hounsfield Units (HU) and MRI-derived vertebral vone quality (VBQ) to measure BMD of the spine as well the utility of these measures in predicting post-operative outcomes. Additionally, we provide screening thresholds based on HU and VBQ for prediction of osteopenia/ osteoporosis and post-operative outcomes such as cage subsidence, screw loosening, proximal junctional kyphosis, and implant failure.
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Affiliation(s)
| | - Carew Giberson-Chen
- Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114
| | - Christopher M Bono
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114; Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114.
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Urrutia J, Camino-Willhuber G, Guerrero A, Diaz-Ledezma C, Bono CM. An international consensus based on the Delphi method to define failure of medical treatment in pyogenic spinal infections. Spine J 2024; 24:250-255. [PMID: 37774980 DOI: 10.1016/j.spinee.2023.09.018] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/13/2023] [Accepted: 09/24/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND CONTEXT Pyogenic spinal infections (PSIs) are severe conditions with high morbidity and mortality. If medical treatment fails, patients may require surgery, but there is no consensus regarding the definition of medical treatment failure. PURPOSE To determine criteria for defining failure of medical treatment in PSI through an international consensus of experts. STUDY DESIGN A two-round basic Delphi method study. SAMPLE One hundred and fifty experts from 22 countries (authors or co-authors of clinical guidelines or indexed publications on the topic) were invited to participate; 33 answered both rounds defining the criteria. OUTCOME MEASURES A scale of 1 to 9 (1: no relevance; 9: highly relevant) applied to each criterion. METHODS We created an online survey with 10 criteria reported in the literature to define the failure of medical treatment in PSIs. We sent this survey via email to the experts. Agreement among the participants on relevant criteria (score ≥7) was determined. One month later, the second round of evaluations was sent. An extra criterion suggested by six responders in the first round was incorporated. The final version was reached with the criteria considered relevant and with high agreement. RESULTS The consensus definition is: (1) There is an uncontrolled sepsis despite broad spectrum antibiotic treatment, and (2) There is an infection relapse, following a six-week period of antibiotics with clinical and laboratory improvement. CONCLUSIONS Our definition of failure following nonsurgical treatment of PSI can offer a standardized approach to guide clinical decision-making. Furthermore, it has the potential to enhance scientific reporting within this field.
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Affiliation(s)
- Julio Urrutia
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, Santiago, Chile.
| | | | - Alonso Guerrero
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, Santiago, Chile.
| | | | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Cabrera A, Bouterse A, Nelson M, Razzouk J, Ramos O, Bono CM, Cheng W, Danisa O. Accounting for age in prediction of discharge destination following elective lumbar fusion: a supervised machine learning approach. Spine J 2023; 23:997-1006. [PMID: 37028603 DOI: 10.1016/j.spinee.2023.03.015] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/01/2023] [Accepted: 03/26/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND CONTEXT The number of elective spinal fusion procedures performed each year continues to grow, making risk factors for post-operative complications following this procedure increasingly clinically relevant. Nonhome discharge (NHD) is of particular interest due to its associations with increased costs of care and rates of complications. Notably, increased age has been found to influence rates of NHD. PURPOSE To identify aged-adjusted risk factors for nonhome discharge following elective lumbar fusion through the utilization of Machine Learning-generated predictions within stratified age groupings. STUDY DESIGN Retrospective Database Study. PATIENT SAMPLE The American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database years 2008 to 2018. OUTCOME MEASURES Postoperative discharge destination. METHODS ACS-NSQIP was queried to identify adult patients undergoing elective lumbar spinal fusion from 2008 to 2018. Patients were then stratified into the following age ranges: 30 to 44 years, 45 to 64 years, and ≥65 years. These groups were then analyzed by eight ML algorithms, each tasked with predicting post-operative discharge destination. RESULTS Prediction of NHD was performed with average AUCs of 0.591, 0.681, and 0.693 for those aged 30 to 44, 45 to 64, and ≥65 years respectively. In patients aged 30 to 44, operative time (p<.001), African American/Black race (p=.003), female sex (p=.002), ASA class three designation (p=.002), and preoperative hematocrit (p=.002) were predictive of NHD. In ages 45 to 64, predictive variables included operative time, age, preoperative hematocrit, ASA class two or class three designation, insulin-dependent diabetes, female sex, BMI, and African American/Black race all with p<.001. In patients ≥65 years, operative time, adult spinal deformity, BMI, insulin-dependent diabetes, female sex, ASA class four designation, inpatient status, age, African American/Black race, and preoperative hematocrit were predictive of NHD with p<.001. Several variables were distinguished as predictive for only one age group including ASA Class two designation in ages 45 to 64 and adult spinal deformity, ASA class four designation, and inpatient status for patients ≥65 years. CONCLUSIONS Application of ML algorithms to the ACS-NSQIP dataset identified a number of highly predictive and age-adjusted variables for NHD. As age is a risk factor for NHD following spinal fusion, our findings may be useful in both guiding perioperative decision-making and recognizing unique predictors of NHD among specific age groups.
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Affiliation(s)
- Andrew Cabrera
- School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | | | - Michael Nelson
- School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Jacob Razzouk
- School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Omar Ramos
- Orthopaedic Surgery, Twin Cities Spine Center, MN 55404, USA
| | - Christopher M Bono
- Department of Orthopedics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis VA Medical Center, Loma Linda, CA 92354 , USA
| | - Olumide Danisa
- Department of Orthopedics, Loma Linda University, Loma Linda, CA, 92354, USA.
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M. Lightsey H, Maier SP, Bono CM, Kang JD, Harris MB. In-Hospital, 24-Hour Exercise Spaces for Resident and Staff Wellness. HSS J 2023; 19:140-145. [PMID: 37065098 PMCID: PMC10090845 DOI: 10.1177/15563316221131031] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 08/22/2022] [Indexed: 04/18/2023]
Affiliation(s)
- Harry M. Lightsey
- Harvard Combined Orthopaedic Residency
Program, Harvard Medical School, Boston, MA, USA
| | - Stephen P. Maier
- Harvard Combined Orthopaedic Residency
Program, Harvard Medical School, Boston, MA, USA
| | - Christopher M. Bono
- Department of Orthopaedic Surgery,
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James D. Kang
- Department of Orthopaedic Surgery, Brigham
and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchel B. Harris
- Department of Orthopaedic Surgery,
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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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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Goh BC, Lightsey HM, Lopez WY, Tobert DG, Fogel HA, Cha TD, Schwab JH, Bono CM, Hershman SH. Magnetic Resonance Imaging Is Inadequate to Assess Cervical Sagittal Alignment Parameters. Clin Spine Surg 2023; 36:E70-E74. [PMID: 35969678 DOI: 10.1097/bsd.0000000000001382] [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: 02/18/2021] [Accepted: 06/29/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective radiographic study. OBJECTIVE To evaluate cervical sagittal alignment measurement reliability and correlation between upright radiographs and magnetic resonance imaging (MRI). SUMMARY OF BACKGROUND DATA Cervical sagittal alignment (CSA) helps determine the surgical technique employed to treat cervical spondylotic myelopathy. Traditionally, upright lateral radiographs are used to measure CSA, but obtaining adequate imaging can be challenging. Utilizing MRI to evaluate sagittal parameters has been explored; however, the impact of positional change on these parameters has not been determined. METHODS One hundred seventeen adult patients were identified who underwent laminoplasty or laminectomy and fusion for cervical spondylotic myelopathy from 2017 to 2019. Two clinicians independently measured the C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and the T1 tilt. Interobserver and intraobserver reliability were assessed by intraclass correlation coefficient. RESULTS Intraobserver and interobserver reliabilities were highly correlated, with correlations greater than 0.85 across all permutations; intraclass correlation coefficients were highest with MRI measurements. The C2-C7 sagittal angle was highly correlated between x-ray and MRI at 0.76 with no significant difference ( P =0.46). There was a weaker correlation with regard to C2-C7 SVA (0.48) and T1 tilt (0.62) with significant differences observed in the mean values between the 2 modalities ( P <0.01). CONCLUSIONS The C2-C7 sagittal angle is highly correlated and not significantly different between upright x-ray and supine MRIs. However, cervical SVA and T1 tilt change with patient position. Since MRI does not accurately reflect the CSA in the upright position, upright lateral radiographs should be obtained to assess global sagittal alignment when planning a posterior-based cervical procedure.
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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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Xiong GX, Greene NE, Hershman SH, Fogel HA, Schwab JH, Bono CM, Tobert DG. Does Nasal Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevent Deep Surgical Site Infections for Elective Cervical Spinal Fusion? Clin Spine Surg 2023; 36:E51-E58. [PMID: 35676748 DOI: 10.1097/bsd.0000000000001350] [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: 01/13/2022] [Accepted: 05/18/2022] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery. SUMMARY OF BACKGROUND DATA Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. MATERIALS AND METHODS Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates. RESULTS This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA. CONCLUSIONS There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.
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Shah AA, Karhade AV, Groot OQ, Olson TE, Schoenfeld AJ, Bono CM, Harris MB, Ferrone ML, Nelson SB, Park DY, Schwab JH. External validation of a predictive algorithm for in-hospital and ninety-day mortality after spinal epidural abscess. Spine J 2023; 23:760-765. [PMID: 36736740 DOI: 10.1016/j.spinee.2023.01.013] [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: 09/28/2022] [Revised: 01/05/2023] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND CONTEXT Mortality in patients with spinal epidural abscess (SEA) remains high. Accurate prediction of patient-specific prognosis in SEA can improve patient counseling as well as guide management decisions. There are no externally validated studies predicting short-term mortality in patients with SEA. PURPOSE The purpose of this study was to externally validate the Skeletal Oncology Research Group (SORG) stochastic gradient boosting algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA. STUDY DESIGN/SETTING Retrospective, case-control study at a tertiary care academic medical center from 2003 to 2021. PATIENT SAMPLE Adult patients admitted for radiologically confirmed diagnosis of SEA who did not initiate treatment at an outside institution. OUTCOME MEASURES In-hospital and 90-day postdischarge mortality. METHODS We tested the SORG stochastic gradient boosting algorithm on an independent validation cohort. We assessed its performance with discrimination, calibration, decision curve analysis, and overall performance. RESULTS A total of 212 patients met inclusion criteria, with a short-term mortality rate of 10.4%. The area under the receiver operating characteristic curve (AUROC) of the SORG algorithm when tested on the full validation cohort was 0.82, the calibration intercept was -0.08, the calibration slope was 0.96, and the Brier score was 0.09. CONCLUSIONS With a contemporaneous and geographically distinct independent cohort, we report successful external validation of a machine learning algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA.
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Affiliation(s)
- Akash A Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA.
| | - Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Thomas E Olson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Tanaka MJ, Routt ML, Ireland ML, Bono CM. When the Physician Becomes the Patient: Considerations for Work, Life, and Leadership. Instr Course Lect 2023; 72:11-15. [PMID: 36534842] [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: 06/17/2023]
Abstract
Most orthopaedic surgeons are unprepared for serious medical illnesses. In such cases, the unique work-related and personal considerations for orthopaedic surgeons affect their career, their practice partners, and their patients. Planning together as an orthopaedic business organization for such issues can provide a framework to better navigate these difficult situations. Understanding the considerations and stressors from the individual's perspective can help provide the appropriate level of support while maintaining privacy. Throughout these considerations, open communication regarding expectations and concerns and expressions of empathy are the cornerstones of dealing with physician illness. Being a physician-patient adds complexity to an already difficult and stressful profession. Further dialogue regarding the physician-patient experience can help increase awareness of this issue and allow organizations to create a structure to best manage this almost inevitable occurrence.
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Karhade AV, Fenn B, Groot OQ, Shah AA, Yen HK, Bilsky MH, Hu MH, Laufer I, Park DY, Sciubba DM, Steyerberg EW, Tobert DG, Bono CM, Harris MB, Schwab JH. Development and external validation of predictive algorithms for six-week mortality in spinal metastasis using 4,304 patients from five institutions. Spine J 2022; 22:2033-2041. [PMID: 35843533 DOI: 10.1016/j.spinee.2022.07.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 02/02/2022] [Revised: 06/06/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Historically, spine surgeons used expected postoperative survival of 3-months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics, and advanced radiotherapy. Recent studies have suggested that a life expectancy of 6 weeks may be enough to achieve significant improvements in postoperative health-related quality of life. PURPOSE The purpose of this study was to develop a model capable of predicting 6-week mortality in patients with spinal metastases treated with radiation or surgery. STUDY DESIGN/SETTING A retrospective review was conducted at five large tertiary centers in the United States and Taiwan. PATIENT SAMPLE The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions. OUTCOME MEASURES The primary outcome was 6-week mortality. METHODS Five models were considered to predict 6-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis, and overall performance was integrated into an open access web-based application. RESULTS The most important variables for prediction of 6-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. The model is available here: https://sorg-apps.shinyapps.io/spinemetssurvival/. CONCLUSIONS While this study does not advocate for the use of a 6-week life expectancy as criteria for considering operative management, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making in spinal metastasis patients with shorter life expectancy.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA.
| | - Brian Fenn
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Akash A Shah
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Hung-Kuan Yen
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taiwan
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Ming-Hsiao Hu
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taiwan
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
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Karhade AV, Bernstein DN, Desai V, Bedair HS, O’Donnell EA, Tanaka MJ, Bono CM, Harris MB, Schwab JH, Tobert DG. What Is the Clinical Benefit of Common Orthopaedic Procedures as Assessed by the PROMIS Versus Other Validated Outcomes Tools? Clin Orthop Relat Res 2022; 480:1672-1681. [PMID: 35543521 PMCID: PMC9384920 DOI: 10.1097/corr.0000000000002241] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 10/24/2021] [Accepted: 04/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs), including the Patient-reported Outcomes Measurement Information System (PROMIS), are increasingly used to measure healthcare value. The minimum clinically important difference (MCID) is a metric that helps clinicians determine whether a statistically detectable improvement in a PROM after surgical care is likely to be large enough to be important to a patient or to justify an intervention that carries risk and cost. There are two major categories of MCID calculation methods, anchor-based and distribution-based. This variability, coupled with heterogeneous surgical cohorts used for existing MCID values, limits their application to clinical care. QUESTIONS/PURPOSES In our study, we sought (1) to determine MCID thresholds and attainment percentages for PROMIS after common orthopaedic procedures using distribution-based methods, (2) to use anchor-based MCID values from published studies as a comparison, and (3) to compare MCID attainment percentages using PROMIS scores to other validated outcomes tools such as the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Knee Disability and Osteoarthritis Outcome Score (KOOS). METHODS This was a retrospective study at two academic medical centers and three community hospitals. The inclusion criteria for this study were patients who were age 18 years or older and who underwent elective THA for osteoarthritis, TKA for osteoarthritis, one-level posterior lumbar fusion for lumbar spinal stenosis or spondylolisthesis, anatomic total shoulder arthroplasty or reverse total shoulder arthroplasty for glenohumeral arthritis or rotator cuff arthropathy, arthroscopic anterior cruciate ligament reconstruction, arthroscopic partial meniscectomy, or arthroscopic rotator cuff repair. This yielded 14,003 patients. Patients undergoing revision operations or surgery for nondegenerative pathologies and patients without preoperative PROMs assessments were excluded, leaving 9925 patients who completed preoperative PROMIS assessments and 9478 who completed other preoperative validated outcomes tools (HOOS, KOOS, numerical rating scale for leg pain, numerical rating scale for back pain, and QuickDASH). Approximately 66% (6529 of 9925) of patients had postoperative PROMIS scores (Physical Function, Mental Health, Pain Intensity, Pain Interference, and Upper Extremity) and were included for analysis. PROMIS scores are population normalized with a mean score of 50 ± 10, with most scores falling between 30 to 70. Approximately 74% (7007 of 9478) of patients had postoperative historical assessment scores and were included for analysis. The proportion who reached the MCID was calculated for each procedure cohort at 6 months of follow-up using distribution-based MCID methods, which included a fraction of the SD (1/2 or 1/3 SD) and minimum detectable change (MDC) using statistical significance (such as the MDC 90 from p < 0.1). Previously published anchor-based MCID thresholds from similar procedure cohorts and analogous PROMs were used to calculate the proportion reaching MCID. RESULTS Within a given distribution-based method, MCID thresholds for PROMIS assessments were similar across multiple procedures. The MCID threshold ranged between 3.4 and 4.5 points across all procedures using the 1/2 SD method. Except for meniscectomy (3.5 points), the anchor-based PROMIS MCID thresholds (range 4.5 to 8.1 points) were higher than the SD distribution-based MCID values (2.3 to 4.5 points). The difference in MCID thresholds based on the calculation method led to a similar trend in MCID attainment. Using THA as an example, MCID attainment using PROMIS was achieved by 76% of patients using an anchor-based threshold of 7.9 points. However, 82% of THA patients attained MCID using the MDC 95 method (6.1 points), and 88% reached MCID using the 1/2 SD method (3.9 points). Using the HOOS metric (scaled from 0 to 100), 86% of THA patients reached the anchor-based MCID threshold (17.5 points). However, 91% of THA patients attained the MCID using the MDC 90 method (12.5 points), and 93% reached MCID using the 1/2 SD method (8.4 points). In general, the proportion of patients reaching MCID was lower for PROMIS than for other validated outcomes tools; for example, with the 1/2 SD method, 72% of patients who underwent arthroscopic partial meniscectomy reached the MCID on PROMIS Physical Function compared with 86% on KOOS. CONCLUSION MCID calculations can provide clinical correlation for PROM scores interpretation. The PROMIS form is increasingly used because of its generalizability across diagnoses. However, we found lower proportions of MCID attainment using PROMIS scores compared with historical PROMs. By using historical proportions of attainment on common orthopaedic procedures and a spectrum of MCID calculation techniques, the PROMIS MCID benchmarks are realizable for common orthopaedic procedures. For clinical practices that routinely collect PROMIS scores in the clinical setting, these results can be used by individual surgeons to evaluate personal practice trends and by healthcare systems to quantify whether clinical care initiatives result in meaningful differences. Furthermore, these MCID thresholds can be used by researchers conducting retrospective outcomes research with PROMIS. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Aditya V. Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - David N. Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Vineet Desai
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hany S. Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Evan A. O’Donnell
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Miho J. Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M. Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchel B. Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G. Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 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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Ogink PT, Groot OQ, van Steijn N, Im GH, Cha TD, Hershman SH, Bono CM, Schwab JH. Practice Variation Within a Single Institution in Management of Degenerative Spondylolisthesis. Clin Spine Surg 2022; 35:E546-E550. [PMID: 35249973 DOI: 10.1097/bsd.0000000000001305] [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: 05/09/2021] [Accepted: 02/02/2022] [Indexed: 11/03/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to assess variation in care for degenerative spondylolisthesis (DS) among surgeons at the same institution, to establish diagnostic and therapeutic variables contributing to this variation, and to determine whether variation in care changed over time. SUMMARY OF BACKGROUND DATA Like other degenerative spinal disorders, DS is prone to practice variation due to the wide array of treatment options. Focusing on a single institution can identify more individualized drivers of practice variation by omitting geographic variability of demographics and socioeconomic factors. MATERIALS AND METHODS We collected number of office visits, imaging procedures, injections, electromyography (EMG), and surgical procedures within 1 year after diagnosis. Multivariable logistic regression was used to determine predictors of surgery. The coefficient of variation (CV) was calculated to compare the variation in practice over time. RESULTS Patients had a mean 2.5 (±0.6) visits, 1.8 (±0.7) imaging procedures, and 0.16 (±0.09) injections in the first year after diagnosis. Thirty-six percent (1937/5091) of patients had physical therapy in the 3 months after diagnosis. CV was highest for EMG (95%) and lowest for office visits (22%). An additional spinal diagnosis [odds ratio (OR)=3.99, P <0.001], visiting a neurosurgery clinic (OR=1.81, P =0.016), and diagnosis post-2007 (OR=1.21, P =0.010) were independently associated with increased surgery rates. The CVs for all variables decreased after 2007, with the largest decrease seen for EMG (132% vs. 56%). CONCLUSIONS While there is variation in the management of patients diagnosed with DS between surgeons of a single institution, this variation seems to have gone down in recent years. All practice variables showed diminished variation. The largest variation and subsequent decrease of variation was seen in the use of EMG. Despite the smaller amount of variation, the rate of surgery has gone up since 2007.
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Affiliation(s)
- Paul T Ogink
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier Q Groot
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Nicole van Steijn
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Gi Hye Im
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Thomas D Cha
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Stuart H Hershman
- 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
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
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Bernstein DN, Karhade AV, Bono CM, Schwab JH, Harris MB, Tobert DG. Sociodemographic Factors Are Associated with Patient-Reported Outcome Measure Completion in Orthopaedic Surgery: An Analysis of Completion Rates and Determinants Among New Patients. JB JS Open Access 2022; 7:e22.00026. [PMID: 35935603 PMCID: PMC9355105 DOI: 10.2106/jbjs.oa.22.00026] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Patient-reported outcome measures (PROMs) and, specifically, the Patient-Reported Outcomes Measurement Information System (PROMIS), are increasingly utilized for clinical research, clinical care, and health-care policy. However, completion of these outcome measures can be inconsistent and challenging. We hypothesized that sociodemographic variables are associated with the completion of PROM questionnaires. The purposes of the present study were to calculate the completion rate of assigned PROM forms and to identify sociodemographic and other variables associated with completion to help guide improved collection efforts. Methods All new orthopaedic patients at a single academic medical center were identified from 2016 to 2020. On the basis of subspecialty and presenting condition, patients were assigned certain PROMIS forms and legacy PROMs. Demographic and clinical information was abstracted from the electronic medical record. Bivariate analyses were performed to compare characteristics among those who completed assigned PROMs and those who did not. A multivariable logistic regression model was created to determine which variables were associated with successful completion of assigned PROMs. Results Of the 219,891 new patients, 88,052 (40%) completed all assigned PROMs. Patients who did not activate their internet-based patient portal had a 62% increased likelihood of not completing assigned PROMs (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.58 to 1.66; p < 0.001). Non-English-speaking patients had a 90% (OR, 1.90; 95% CI, 1.82 to 2.00; p < 0.001) increased likelihood of not completing assigned PROMs at presentation. Older patients (≥65 years of age) and patients of Black race had a 23% (OR, 1.23; 95% CI, 1.19 to 1.27; p < 0.001) and 24% (OR, 1.24; 95% CI, 1.19 to 1.30; p < 0.001) increased likelihood of not completing assigned PROMs, respectively. Conclusions The rate of completion of PROMs varies according to sociodemographic variables. This variability could bias clinical outcomes research in orthopaedic surgery. The present study highlights the need to uniformly increase completion rates so that outcomes research incorporates truly representative cohorts of patients treated. Furthermore, the use of these PROMs to guide health-care policy decisions necessitates a representative patient distribution to avoid bias in the health-care system. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David N. Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Aditya V. Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Christopher M. Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mitchel B. Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel G. Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Bono CM. We're not puffer fish doctors: the road to the first spine emoji. Spine J 2022; 22:707-708. [PMID: 35283293 DOI: 10.1016/j.spinee.2022.02.011] [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)
- Christopher M Bono
- Department of Orthopedic Surgery, MGH/BWH Orthopedic Spine Surgery Fellowship Program, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Orthopedic Surgery, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; The Spine Journal, North American Spine Society, 7075 Veterans Boulevard, Burr Ridge, IL 60527, USA
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Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Bono CM, Hershman S. Response to Assessing impacts of gender on adverse postoperative outcomes in patients undergoing osteoporotic vertebral compression fracture surgery. Osteoporos Int 2022; 33:947-948. [PMID: 35061051 DOI: 10.1007/s00198-021-06243-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Mount Sinai Hospital, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Thomas Cha
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Joseph Schwab
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Harold Fogel
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Daniel Tobert
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christopher M Bono
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Stuart Hershman
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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21
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Xiong GX, Greene NE, Hershman SH, Schwab JH, Bono CM, Tobert DG. Nasal screening for methicillin-resistant Staphylococcus aureus does not reduce surgical site infection after primary lumbar fusion. Spine J 2022; 22:113-125. [PMID: 34284131 DOI: 10.1016/j.spinee.2021.07.008] [Citation(s) in RCA: 4] [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: 04/09/2021] [Revised: 06/07/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Preoperative methicillin-resistant Staphylococcus aureus (MRSA) testing and decolonization has demonstrated success for arthroplasty patients in surgical site infections (SSIs) prevention. Spine surgery, however, has seen varied results. PURPOSE The purpose of this study was to determine the impact of nasal MRSA testing and operative debridement rates on surgical site infection after primary lumbar fusion. STUDY DESIGN/SETTING Retrospective cohort study and/or Consolidated medical enterprise PATIENT SAMPLE: Adult patients undergoing primary instrumented lumbar fusions from January 2015 to December 2019 were reviewed. OUTCOME MEASURES The primary outcome was incision and drainage performed in the operating room within 90 days of surgery. METHODS MRSA testing <90-day's before surgery, mupirocin prescription <30-day's before surgery, perioperative antibiotics, and Elixhauser comorbidity index were collected for each subject. Bivariate analysis used Wilcoxon rank-sum testing and logistic regression modeling Multivariable logistic regression modeling assessed for associations with MRSA testing, intravenous vancomycin use, and I&D rate. RESULTS The study included 1,884 patients for analysis, with mean age of 63.1 (SE 0.3) and BMI 29.5 (SE 0.1). MRSA testing was performed in 755 patients (40.1%) and was more likely to be performed in patients with lower Elixhauser index scores (OR 0.98, 95% CI 0.96-0.99, p=.021) on multivariable analysis. Vancomycin use increased significantly over time (OR 1.49 and/or year, 95% CI 1.3-1.8, p<.001) despite no change in mupirocin or I&D rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on I&D rates. I&D risk was associated with higher BMI (OR 1.06, 95% CI 1.02-1.12, p=.009) and higher number of blood product units transfused (OR 1.23, 95% CI 1.03-1.46, p=.022). CONCLUSIONS The present study demonstrates no impact on surgical I&D rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative I&D rates for surgical site infection. As a result of the hospital directive, vancomycin use increased over time with no associated change in infection rates, underscoring the need for focused interventions, and engagement with antibiotic stewardship programs.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopedic Residency Program, Boston, MA, USA
| | | | - Stuart H Hershman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel G Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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22
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Urrutia J, Bono CM. Update on the Diagnosis and Management of Spinal Infections. Instr Course Lect 2022; 71:439-449. [PMID: 35254800] [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
Pyogenic spinal infections are uncommon, but their incidence has increased. Diagnosis is based on clinical, laboratory, and imaging findings. Delayed diagnosis occurs frequently and can lead to poor outcomes. Early radiographic findings are nonspecific; MRI is the best imaging study for diagnosis. The goal of treatment is to eradicate infection, prevent recurrence, preserve spinal stability, avoid deformity, relieve pain, and prevent or reverse neurologic deficit. Current guidelines recommend antibiotics be administered for 6 weeks if there is resolution of symptoms and normalization of inflammatory parameters. Surgery is required in patients with neurologic deficit, uncontrolled sepsis, spinal instability, deformity, and failure of medical treatment and to manage epidural abscess. Classic treatment of epidural abscess is surgical, but recent studies have challenged this approach. Surgical techniques used to manage these infections are varied; they include anterior, posterior, and combined approaches, and minimally invasive surgery. Current management has decreased mortality; however, the prognosis is affected by treatment failure, recurrent infection, or potential of persistent disability secondary to deformity, chronic pain, or permanent neurologic impairment.
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23
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Karhade AV, Bono CM, Schwab JH, Tobert DG. Minimum Clinically Important Difference: A Metric That Matters in the Age of Patient-Reported Outcomes. J Bone Joint Surg Am 2021; 103:2331-2337. [PMID: 34665785 DOI: 10.2106/jbjs.21.00773] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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] [Indexed: 02/01/2023]
Abstract
➤ As the Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly utilized in orthopaedic research and clinical practice, there is not a consensus regarding the minimum clinically important difference (MCID) calculation. ➤ The varied MCID calculation methods can lead to a range of possible values, which limits the translatability of research efforts. ➤ The completion rate and follow-up period also influence MCID values and should be reported alongside study results.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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24
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Khurana B, Keraliya A, Velmahos G, Maung AA, Bono CM, Harris MB. Clinical significance of "positive" cervical spine MRI findings following a negative CT. Emerg Radiol 2021; 29:307-316. [PMID: 34850316 DOI: 10.1007/s10140-021-01992-5] [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: 09/12/2021] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To review and analyze the clinical significance of positive acute traumatic findings seen on MRI of the cervical spine (MRCS) following a negative CT of the cervical spine (CTCS) for trauma. METHODS We performed a sub-cohort analysis of 54 patients with negative CTCS and a positive MRCS after spine trauma from the previous multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Both CTCS and MRCS were independently reviewed by two emergency radiologists and two spine surgeons. The surgeons also commented on the clinical significance of the traumatic findings seen on MRCS and grouped them into unstable, potentially unstable, and stable injuries. RESULTS Among 35 unevaluable patients, MRCS showed one unstable (hyperextension) and two potentially unstable (hyperflexion) injuries. Subtle findings were seen on CTCS in 2 of 3 patients upon careful retrospective review that would have suggested these injuries. Of 19 patients presenting with cervicalgia, 2/5 (40%) patients with neurological deficit demonstrated clinically significant findings on MRCS with predisposing factors seen on CT. None of the 14 patients with isolated cervicalgia and no neurological deficit had clinically significant findings on their MRCS. CONCLUSION While CTCS is adequate for clearing the cervical spine in patients with isolated cervicalgia, MRCS can play a critical role in patients with neurological deficits and normal CTCS. Clinically significant traumatic findings were seen in 8.5% of unevaluable patients on MRCS, though these injuries in fact could be identified on the CT in 2 of 3 patients upon careful retrospective review.
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Affiliation(s)
- Bharti Khurana
- Trauma Imaging Research and Innovation Center, Department of Radiology, Brigham and Women's Hospital, 75 Francis St., MA, 02115, Boston, USA.
| | - Abhishek Keraliya
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - George Velmahos
- Trauma, Emergency Surgery, Surgery Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Adrian A Maung
- Yale New Haven Hospital, New Haven, USA.,Department of Surgery, Yale School of Medicine, New Haven, USA
| | - Christopher M Bono
- Department of Orthopedics, Massachusetts General Hospital, MA, 02114, Boston, USA
| | - Mitchel B Harris
- Department of Orthopedics, Massachusetts General Hospital, MA, 02114, Boston, USA
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Affiliation(s)
- Brook I Martin
- Departments of Orthopaedics and Population Health Sciences, University of Utah, Salt Lake City, UT, USA.
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA; The Spine Journal, North American Spine Society, 7075 Veterans Boulevard, Burr Ridge, IL, USA
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26
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Reitman CA, Hills JM, Standaert CJ, Bono CM, Mick CA, Furey CG, Kauffman CP, Resnick DK, Wong DA, Prather H, Harrop JS, Baisden J, Wang JC, Spivak JM, Schofferman J, Riew KD, Lorenz MA, Heggeness MH, Anderson PA, Rao RD, Baker RM, Emery SE, Watters WC, Sullivan WJ, Mitchell W, Tontz W, Ghogawala Z. Cervical fusion for treatment of degenerative conditions: development of appropriate use criteria. Spine J 2021; 21:1460-1472. [PMID: 34087478 DOI: 10.1016/j.spinee.2021.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 05/07/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking. PURPOSE Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine. STUDY DESIGN/SETTING Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations. OUTCOME MEASURES Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters. METHODS Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed. RESULTS Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p<.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance. CONCLUSIONS Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."
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Affiliation(s)
- Charles A Reitman
- Baylor College of Medicine, 7200 Cambridge Street Suite 10A 10th Floor, Houston, TX 77030-4202, USA.
| | - Jeffrey M Hills
- Washington University Orthopaedics, 660 S. Euclid Avenue Campus Box 8233, Saint Louis, MO 63110-1010, USA
| | | | - Christopher M Bono
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115-6110, USA
| | - Charles A Mick
- Pioneer Spine & Sports, 766 N. King Street, Northampton, MA 01060-1142, USA
| | - Christopher G Furey
- Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-1716, USA
| | | | - Daniel K Resnick
- Department Neurosurgery, University of Wisconsin Medical School, 600 Highland K4/834 Clinical Science Center, Madison, WI 53792-0001, USA
| | - David A Wong
- Denver Spine Surgeons, 7800 E. Orchard Road Ste. 100, Greenwood Village, CO 80111-2584, USA
| | - Heidi Prather
- C/O Melissa Armbrecht, Washington University in St. Louis-School of Medicine, 660 S. Euclid Campus Box 8233, Saint Louis, MO 63110, USA
| | - James S Harrop
- Thomas Jefferson University, 909 Walnut Street Floor 2, Philadelphia, PA 19107-5211, USA
| | - Jamie Baisden
- Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226-3522, USA
| | - Jeffrey C Wang
- USC Spine Center, 1520 San Pablo Street Ste. 2000, Los Angeles, CA 90033-5322, USA
| | | | - Jerome Schofferman
- SpineCare Medical Group, 455 Hickey Boulevard #310, Daly City, CA 94015-2204, USA
| | - K Daniel Riew
- 425 S Euclid Avenue Ste. 5505, Saint Louis, MO 63110-1005, USA
| | - Mark A Lorenz
- Hinsdale Orthopaedic Associates, 550 W. Ogden Avenue, Hinsdale, IL 60521-3186, USA
| | - Michael H Heggeness
- University of Kansas SOM-Wichita Orthopaedic Surgery Residency Office, 929 N. Saint Francis Street Room 4076, Via Christi Regional Medical Center, Wichita, KS 67214-3821, USA
| | - Paul A Anderson
- University of Wisconsin Orthopedics & Rehabilitation, 1685 Highland Avenue Floor 6, Madison, WI 53705-2281, USA
| | - Raj D Rao
- Department of Orthopedic Surgery, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226-3522, USA
| | - Ray M Baker
- Washington Interventional Spine Associates, 11800 NE 128th Street,Ste. 200 MS 65, Kirkland, WA 98034-7211, USA
| | - Sanford E Emery
- Department of Orthopaedics, West Virginia University, PO Box 9196, Morgantown, WV 26506-9196, USA
| | - William C Watters
- Bone and Joint Clinic of Houston, 6624 Fannin Street Ste. 2600, Houston, TX 77030-2338, USA
| | - William J Sullivan
- Denver VA Medical Center, 1055 N. Clermont 2B-124, Denver, CO, 80220, USA
| | - William Mitchell
- Coastal Spine, 4000 Church Road, Mount Laurel, NJ 08054-1110, USA
| | | | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Hospital & Medical Center, 41 Mall Road Charles A, Tufts University School of Medicine, Burlington, MA 01805-0105, USA
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Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Qureshi S, Hecht A, Bono CM, Hershman S. Age Is Just a Number: Patient Age Does Not Affect Outcome Following Surgery for Osteoporotic Vertebral Compression Fractures. Global Spine J 2021; 11:1083-1088. [PMID: 32762371 PMCID: PMC8351062 DOI: 10.1177/2192568220941451] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Multiple studies have shown that osteoporotic patients are at an increased risk for medical and surgical complications, making optimal management of these patients challenging. The purpose of this study was to determine the relationship between patient age and the likelihood of surgical complications, mortality, and 30-day readmission rates following surgery for osteoporotic vertebral compression fractures (OVCFs). METHODS A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients who met inclusion criteria. A multivariate logistic regression analysis was conducted to calculate odds ratios (OR), with corresponding P values and 95% confidence intervals, of the relationship between age (treated as a continuous variable) and perioperative mortality, surgical complications, and 30-day readmission rates. RESULTS Younger patients were statistically more likely to endure a minor (OR = 0.98; P = .002) or major complication (OR = 0.97; P = .009). The older a patient was, on the other hand, the higher the likelihood that patient would be readmitted within 30 days of surgery (OR =1.02; P = .004). Mortality within the 30-day perioperative period was not statistically correlated with age. CONCLUSIONS The impact of age on adverse outcomes following surgery for OVCF is mixed. While younger patients are more likely to endure complications, older patients are more likely to be readmitted within 30 days following surgery. Patient age showed no correlation with mortality rates. In the setting of surgical treatment for an OVCF, a patient's age can help determine the risk of complications and the rate of readmission following intervention.
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Affiliation(s)
- Anmol Gupta
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY, USA,Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas Cha
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Schwab
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Harold Fogel
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Tobert
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Sheeraz Qureshi
- Weill Cornell Medical College, Hospital for Special Surgery, New York, NY, USA
| | - Andrew Hecht
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY, USA
| | | | - Stuart Hershman
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA,Stuart Hershman, Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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28
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Karhade AV, Bono CM, Makhni MC, Schwab JH, Sethi RK, Simpson AK, Feeley TW, Porter ME. Value-based health care in spine: where do we go from here? Spine J 2021; 21:1409-1413. [PMID: 33857667 DOI: 10.1016/j.spinee.2021.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Aditya V Karhade
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA; Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Melvin C Makhni
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rajiv K Sethi
- Neuroscience Institute, Virginia Mason Medical Center, Seattle, WA, USA; Department of Neurosurgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andrew K Simpson
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas W Feeley
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
| | - Michael E Porter
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, MA, USA
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Reitman CA, Cho CH, Bono CM, Ghogawala Z, Glaser J, Kauffman C, Mazanec D, O'Brien D, O'Toole J, Prather H, Resnick D, Schofferman J, Smith MJ, Sullivan W, Tauzell R, Truumees E, Wang J, Watters W, Wetzel FT, Whitcomb G. Management of degenerative spondylolisthesis: development of appropriate use criteria. Spine J 2021; 21:1256-1267. [PMID: 33689838 DOI: 10.1016/j.spinee.2021.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN A Modified Delphi process was used. METHODS The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).
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Affiliation(s)
- Charles A Reitman
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Charles H Cho
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zoher Ghogawala
- Department of Neurosurgery, Tufts University School of Medicine, Lahey Comparative Effectiveness Research Institute, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - John Glaser
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | - Heidi Prather
- Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Resnick
- Department of Neurosurgery, University of Wisconsin Medical School, Madison, WI, USA
| | | | | | | | - Ryan Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | - Eeric Truumees
- Seton Spine and Scoliosis Center, Brackenridge University Hospital & Seton Medical Center, Austin, TX, USA
| | - Jeffrey Wang
- Department of Orthopaedic Surgery and Neurosurgery, USC Spine Center, Los Angeles, CA, USA
| | - William Watters
- University of Texas Medical Branch, Baylor School of Medicine, Houston, TX, USA
| | - F Todd Wetzel
- Department of Orthopaedic Surgery & Sports Medicine; Department of Neurosurgery, Temple University School of Medicine, Philadelphia, PA, USA
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30
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Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Razi AE, Paulino C, Bono CM, Hershman S. Quantifying the Impact of Comorbidities on Outcomes Following Surgery for Osteoporotic Vertebral Compression Fractures. Journal of Clinical Interventional Radiology ISVIR 2021. [DOI: 10.1055/s-0041-1729466] [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: 12/13/2022] Open
Abstract
Abstract
Introduction Studies have shown that osteoporotic patients are more likely to have medical or surgical complications postoperatively. In this study, we determine the predictive value of various comorbidities on the likelihood of postoperative complications, mortality, and 30-day readmission following cement augmentation for osteoporotic vertebral compression fractures (OVCFs).
Materials and Methods A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients who met inclusion criteria. A multivariate logistic regression analysis was utilized to determine the relationship between various comorbidities and perioperative mortality, postoperative complications, and 30-day readmission rates.
Results A history of cerebrovascular accident (CVA), coagulopathy, diminished preoperative functional status, and/or an American Society of Anesthesiologists (ASA) class > 2 were statistical predictors of postoperative complications. CVA generated the highest odds ratio among these comorbidities (OR = 5.36, p = 0.02 for minor complications; OR = 4.60 p = 0.05 for major complications). Among the 15 comorbidities considered, steroid use (OR =1.81; p = 0.03) and an ASA class > 2 (OR = 14.65; p = 0.01) were the only ones that were correlated with mortality; an ASA class > 2 had a particularly strong effect on the likelihood of mortality (OR = 14.65). Chronic obstructive pulmonary disorder (COPD), obesity, significant weight loss, and an ASA class > 2 were correlated with 30-day readmissions. Congestive heart failure (CHF), diabetes, dialysis, hypertension, or smoking was not correlated with adverse postoperative outcomes.
Conclusion Of the 15 comorbidities considered in this study, four were statistically associated with increased rates of postoperative complications, two were associated with increased mortality, and four were associated with increased rates of readmission at 30 days. The presence of CHF, diabetes mellitus (DM), hypertension, ascites, renal failure, or smoking were not associated with the adverse outcomes studied.
Level of Evidence III.
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Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Thomas Cha
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Joseph Schwab
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Harold Fogel
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Daniel Tobert
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Afshin E. Razi
- Department of Orthopaedics, Maimonides Bone and Joint Center, Maimonides Medical Center, Brooklyn, New York, United States
| | - Carl Paulino
- Department of Orthopaedic Surgery, SUNY Downstate Health Sciences University, NYP Brooklyn Methodist Hospital, Brooklyn, New York, United States
| | - Christopher M. Bono
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Stuart Hershman
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
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Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Corrigendum to "Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain" [The Spine Journal 20/7 (2020) p 998-1024]. Spine J 2021; 21:726-727. [PMID: 33640275 DOI: 10.1016/j.spinee.2021.02.006] [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)
- D Scott Kreiner
- Barrow Neurological Institute, 4530 E. Muirwood Dr. Ste. 110, Phoenix, AZ 85048-7693, USA.
| | - Paul Matz
- Advantage Orthopedics and Neurosurgery, Casper, WY, USA
| | | | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Zoher Ghogawala
- Lahey Hospital and Medical Center, Burlington, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | | | - William C Watters
- Institute of Academic Medicine Houston Methodist Hospital, Houston, TX, USA
| | - Thiru M Annaswamy
- VA North Texas Health Care System, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Randall P Brewer
- River Cities Interventional Pain Specialists, Shreveport, LA, USA
| | | | - David S Cheng
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Park
- University Of Michigan, Ann Arbor, MI, USA
| | | | | | - Ravi Prasad
- University of California, Davis, Sacramento, CA, USA
| | | | - Kris E Radcliff
- Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | - Ryan A Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | | | - Yakov Vorobeychik
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amy M Yahiro
- North American Spine Society, Burr Ridge, IL, USA
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Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Cho S, Hecht A, Bono CM, Hershman S. Males Have Higher Rates of Peri-operative Mortality Following Surgery for Osteoporotic Vertebral Compression Fracture. Osteoporos Int 2021; 32:699-704. [PMID: 32929524 DOI: 10.1007/s00198-020-05630-7] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/01/2020] [Indexed: 11/29/2022]
Abstract
UNLABELLED In this study, we evaluated the association between sex and the incidence of postoperative mortality in the peri-operative period following surgical intervention for OVCF. We found no statistical association between surgical complications and patient sex. However, males exhibited higher rates of mortality and 30-day readmissions relative to females. INTRODUCTION Osteoporotic vertebral compression fractures (OVCF) contribute substantially to the financial burden of the US healthcare system. As the size of the elderly population grows, the number of fractures attributed to osteoporosis is expected to increase. Studies have shown that osteoporotic patients are at an increased risk for medical and surgical complications. The purpose of this study was to evaluate the association between sex and the incidence of postoperative mortality in the peri-operative period following surgical intervention for OVCF. METHODS A retrospective analysis of the American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database from 2007 to 2014 identified 1979 patients. Patients were grouped as male or female. Mortality within 30 days of surgery due to any cause, incidence of surgical complications, and 30-day readmission rates following surgery were tabulated. A multivariate logistic regression analysis was conducted to calculate odds ratios (OR) with corresponding p values and 95% confidence intervals. RESULTS In total, 1979 patients met inclusion and exclusion criteria. Mortality within the 30 days following surgery for OVCF was statistically greater in men than in women (OR = 1.58; p = 0.050). The 30-day readmission rate was also statistically higher in men (OR = 1.41; p = 0.017). Neither minor (OR = 0.90; p = 0.560) nor major (OR = 1.14; p = 0.569) complications were statistically correlated with sex. On average, men underwent surgery for OVCF at a younger age than women. CONCLUSIONS Male patients undergoing surgery for OVCF have higher rates of peri-operative mortality and 30-day readmissions following surgery. Sex was not found to be associated with postoperative complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- A Gupta
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Mount Sinai Hospital, 425 West 59th St., New York, NY, 10019, USA
| | - T Cha
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - J Schwab
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - H Fogel
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - D Tobert
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - S Cho
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Mount Sinai Hospital, 425 West 59th St., New York, NY, 10019, USA
| | - A Hecht
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Mount Sinai Hospital, East 98th St., New York, NY, 10029, USA
| | - C M Bono
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA
| | - S Hershman
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, MA, 02114, Boston, USA.
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Shah NG, Keraliya A, Harris MB, Bono CM, Khurana B. Spinal trauma in DISH and AS: is MRI essential following the detection of vertebral fractures on CT? Spine J 2021; 21:618-626. [PMID: 33130303 DOI: 10.1016/j.spinee.2020.10.027] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/01/2020] [Accepted: 10/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Both ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) cause a rigid spine, but through different pathophysiology. Recent data has shown that characteristic fracture patterns may also differ following trauma since the posterior osseous and soft tissue elements are often spared in DISH. CT and MRI are important in diagnosing spine injury, but given the differences between AS and DISH, the utility of obtaining both studies in all patients warrants scrutiny. PURPOSE To assess the prevalence of posterior element injury on CT and MRI in DISH and AS patients with known vertebral body injury detected on CT; to determine whether MRI demonstrates additional injuries in neurologically intact patients presumed to have isolated vertebral body injuries on CT. STUDY DESIGN Multicenter, retrospective, case-control study. PATIENT SAMPLE DISH and AS patients presenting after spine trauma between 2007 and 2017. OUTCOME MEASURES Review of CT and MRI findings at the time of presentation. METHODS One hundred sixty DISH and 85 AS patients presenting after spine trauma were identified from 2 affiliated academic hospitals serving as level 1 trauma and tertiary referral centers. A diagnosis of DISH or AS was verified by a board-certified emergency radiologist with 3 years of experience. Age, gender, mechanism of injury, fracture type, spine CT and MRI imaging findings, surgical intervention, and neurologic deficit were recorded. The CT and MRI studies were reviewed by the same radiologist for fracture location and type using the AO spine classification. No funding source or conflict of interest was present. RESULTS Median age was 72 and 79 years old for the AS and DISH groups, respectively. Both were predominantly male (81%) and most presented after a low energy mechanism of injury (74% and 73%). Type C AO spine injuries were seen in 52% of AS patients but only 4% of DISH patients. In patients with known vertebral body injury on CT, additional injury to the posterior elements on CT or MRI in DISH patients was 51% versus 92% in AS patients. However, in patients with an isolated vertebral body fracture on CT and no neurological deficit, MRI identified posterior element injury in only 4/22 (18%) DISH patients compared to 5 of 7 (71%) AS patients. None of the MRI findings in the DISH patients were considered clinically important while all 5 AS patients eventually underwent operative treatment despite having no neurological deficit. Epidural hematoma on MRI was seen in 43% of AS patients as opposed to 5% of DISH patients. CONCLUSION Based on our small sample size, CT alone may be adequate in DISH patients with isolated vertebral body fractures and no neurologic deficit, but an additional MRI should be considered in the presence of an unclear neurological exam or deficit. MRI should be strongly considered for any AS patient regardless of neurologic status.
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Affiliation(s)
- Nandish G Shah
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA
| | - Abhishek Keraliya
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA
| | - Mitchel B Harris
- Massachusetts General Hospital, Department of Orthopedic Surgery, Boston, MA, USA
| | - Christopher M Bono
- Massachusetts General Hospital, Department of Orthopedic Surgery, Boston, MA, USA
| | - Bharti Khurana
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA.
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Lopez WY, Goh BC, Upadhyaya S, Ziino C, Georgakas PJ, Gupta A, Tobert DG, Fogel HA, Cha TD, Schwab JH, Bono CM, Hershman SH. Laminoplasty-an underutilized procedure for cervical spondylotic myelopathy. Spine J 2021; 21:571-577. [PMID: 33152508 DOI: 10.1016/j.spinee.2020.10.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 05/31/2020] [Revised: 09/09/2020] [Accepted: 10/19/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTENT Cervical laminoplasty (LP) and laminectomy and fusion (LF) are commonly used surgical techniques for cervical spondylotic myelopathy (CSM). Several recent studies have demonstrated superior perioperative metrics and decreased overall costs with LP, yet LF is performed far more often in the United States. PURPOSE To determine the percentage of patients with CSM who are radiographically candidates for LP. STUDY DESIGN Retrospective comparative cohort study. PATIENT SAMPLE Patients >18 years old who underwent LF or LP for CSM at 2 large academic institutions from 2017 to 2019. OUTCOME MEASURES Candidacy for LP based on radiographic criteria. METHODS Radiographs were assessed by 2 spine surgeons not involved in the care of the patients to determine the C2-C7 Cobb angle and the presence and extent of cervical instability. Patients with kyphosis >13°, > 3.5 mm of listhesis on static imaging, or > 2.5 mm of motion on flexion-extension or standing-supine films were not considered candidates for LP. Intraclass coefficient (ICC) was calculated to assess the interobserver reliability of angular measurements and the presence of instability. The percentage of patients for whom LP was contraindicated was calculated. RESULTS One hundred eight patients underwent LF while 142 underwent LP. Of the 108 patients who underwent LF, 79.6% were radiographically deemed candidates for LP, as were all 142 patients who underwent LP. The ICC for C2-C7 alignment was 0.90; there was 97% agreement with respect to the presence of instability. CONCLUSIONS In 250 patients with CSM, 228 (91.2%) were radiographically candidates for LP. These data suggest that LP may be an underutilized procedure for the treatment for CSM.
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Affiliation(s)
- Wylie Y Lopez
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian C Goh
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shivam Upadhyaya
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chason Ziino
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter J Georgakas
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anmol Gupta
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harold A Fogel
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stuart H Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Gupta A, Cha T, Schwab J, Fogel H, Tobert DG, Razi AE, Paulino C, Hecht AC, Bono CM, Hershman S. Osteoporosis is under recognized and undertreated in adult spinal deformity patients. J Spine Surg 2021; 7:1-7. [PMID: 33834122 DOI: 10.21037/jss-20-668] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Adult spinal deformity (ASD) patients may have osteoporosis, predisposing them to an increased risk for surgical complications. Prior studies have demonstrated that treating osteoporosis improves surgical outcomes. In this study we determine the prevalence of osteoporosis in ASD patients undergoing long spinal fusions and the rate at which osteoporosis is treated. Methods ASD patients who frequented either of two major academic medical centers from 2010 through 2019 were studied. All study participants were at least 40 years of age and endured a spinal fusion of at least seven vertebral levels. Medical records were explored for a diagnosis of osteoporosis via ICD-10 code and, if present, whether pharmacological treatment was prescribed. T-tests and chi-squared analyses were used to determine statistical significance. Results Three hundred ninety-nine patients matched the study's inclusion criteria. Among this group, 131 patients (32.8%) had been diagnosed with osteoporosis prior to surgery. With a mean age of 66.4 years, osteoporotic patients were on average three years older than non-osteoporotic (P=0.002) and more likely to be female (74.8% vs. 61.9%; P=0.01). At the time of surgery, 34.4% of osteoporotic patients were receiving pharmacological treatment. Although not statistically significant, women were more likely to receive medical treatment than men (P=0.07). Conclusions The prevalence of osteoporosis in ASD patients undergoing a long spinal fusion is substantially higher than that of the general population. Surgeons should have a low threshold for bone density testing in ASD patients. With only about one-third of osteoporotic patients treated, there is a classic "missed opportunity" in this population.
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Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Cha
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph Schwab
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harold Fogel
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G Tobert
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Afshin E Razi
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Maimonides Bone and Joint Center, Maimonides Medical Center, Brooklyn, NY, USA
| | - Carl Paulino
- Department of Orthopaedic Surgery, Fe Health Sciences University, New York-Presbyterian (NYP) Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Andrew C Hecht
- Department of Orthopaedics, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher M Bono
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stuart Hershman
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Karhade AV, Fogel HA, Cha TD, Hershman SH, Doorly TP, Kang JD, Bono CM, Harris MB, Schwab JH, Tobert DG. Development of prediction models for clinically meaningful improvement in PROMIS scores after lumbar decompression. Spine J 2021; 21:397-404. [PMID: 33130302 DOI: 10.1016/j.spinee.2020.10.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 08/06/2020] [Revised: 10/11/2020] [Accepted: 10/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The ability to preoperatively predict which patients will achieve a minimal clinically important difference (MCID) after lumbar spine decompression surgery can help determine the appropriateness and timing of surgery. Patient-Reported Outcome Measurement Information System (PROMIS) scores are an increasingly popular outcome instrument. PURPOSE The purpose of this study was to develop algorithms predictive of achieving MCID after primary lumbar decompression surgery. PATIENT SAMPLE This was a retrospective study at two academic medical centers and three community medical centers including adult patients 18 years or older undergoing one or two level posterior decompression for lumbar disc herniation or lumbar spinal stenosis between January 1, 2016 and April 1, 2019. OUTCOME MEASURES The primary outcome, MCID, was defined using distribution-based methods as one half the standard deviation of postoperative patient-reported outcomes (PROMIS physical function, pain interference, pain intensity). METHODS Five machine learning algorithms were developed to predict MCID on these surveys and assessed by discrimination, calibration, Brier score, and decision curve analysis. The final model was incorporated into an open access digital application. RESULTS Overall, 906 patients completed at least one PROMs survey in the 90 days before surgery and at least one PROMs survey in the year after surgery. Attainment of MCID during the study period by PROMIS instrument was 74.3% for physical function, 75.8% for pain interference, and 79.2% for pain intensity. Factors identified for preoperative prediction of MCID attainment on these outcomes included preoperative PROs, percent unemployment in neighborhood of residence, comorbidities, body mass index, private insurance, preoperative opioid use, surgery for disc herniation, and federal poverty level in neighborhood of residence. The discrimination (c-statistic) of the final algorithms for these outcomes was 0.79 for physical function, 0.74 for pain interference, and 0.69 for pain intensity with good calibration. The open access digital application for these algorithms can be found here: https://sorg-apps.shinyapps.io/promis_pld_mcid/ CONCLUSION: Lower preoperative PROMIS scores, fewer comorbidities, and certain sociodemographic factors increase the likelihood of achieving MCID for PROMIS after lumbar spine decompression.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harold A Fogel
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Thomas D Cha
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Stuart H Hershman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Terence P Doorly
- Department of Neurosurgery, North Shore Medical Center, Boston, MA, USA
| | - James D Kang
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Daniel G Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA.
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Karhade AV, Sisodia RC, Bono CM, Fogel HA, Hershman SH, Cha TD, Doorly TP, Kang JD, Schwab JH, Tobert DG. Surgeon-level variance in achieving clinical improvement after lumbar decompression: the importance of adequate risk adjustment. Spine J 2021; 21:405-410. [PMID: 33039548 DOI: 10.1016/j.spinee.2020.10.005] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/23/2020] [Accepted: 10/05/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patient-Reported Outcome Measurement Information System (PROMIS) scores are increasingly utilized in clinical care. However, it is unclear if PROMIS can discriminate surgeon performance on an individual level. PURPOSE The purpose of this study was to examine surgeon-level variance in rates of achieving minimal clinically important difference (MCID) after lumbar decompression. PATIENT SAMPLE This is a prospective, observational cohort study performed across a healthcare enterprise (two academic medical centers and three community centers). Patients 18 years or older undergoing one- to two-level primary decompression for lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) were included. OUTCOME MEASURES The primary outcome was achievement of MCID, using a distribution-based method, on paired PROMIS physical function scores. METHODS Descriptive statistics were generated to examine the baseline characteristics of the study cohort. Bivariate analyses were used to examine the impact of surgeon-level variance on rates of MCID. Multivariable analyses were used to examine the risk-adjusted impact of surgeon-level variance on rates of MCID. RESULTS Overall, 636 patients treated by nine surgeons were included. The median patient age was 58 [interquartile range (IQR): 46-70] and 62.3% (n=396) were female. Among all patients, 56.9% (n=362) underwent surgery for LDH. The overall rate of achieving MCID was 75.8% (n=482). Of the surgeons, the median years in practice were 12 (range 4-31) and 55.6% (n=5) were in academic practice settings. On bivariate analysis, patients treated by one of the surgeons had lower rates of achieving MICD (odds ratio=0.37, 95% confidence interval: 0.15-0.91, p=.03). However, on multivariable analysis adjusting for operative indication (LDH vs. LSS), body mass index, number of comorbidities, percent unemployment in patient zip code, and preoperative PROMIS physical function scores, all surgeons were equally likely to obtain MCID. CONCLUSIONS In this cohort, variance in PROMIS scores after primary lumbar decompression is influenced by patient-related factors and not by individual surgeon. Adequate risk adjustment is needed if ascertaining clinical improvement on an individual surgeon basis. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Rachel C Sisodia
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Harold A Fogel
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Stuart H Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Terence P Doorly
- Department of Neurosurgery, North Shore Medical Center, Boston, MA 01923, USA
| | - James D Kang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA 02130, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA 02462, USA.
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Affiliation(s)
- Christopher M Bono
- Department of Orthopedic Surgery, MGH/BWH Orthopedic Spine Surgery Fellowship Program, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Orthopedic Surgery, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; The Spine Journal, North American Spine Society, 7075 Veterans Boulevard, Burr Ridge, IL 60527, USA.
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Gupta A, Cha T, Schwab J, Fogel H, Tobert D, Razi AE, Hecht A, Bono CM, Hershman S. Osteoporosis increases the likelihood of revision surgery following a long spinal fusion for adult spinal deformity. Spine J 2021; 21:134-140. [PMID: 32791242 DOI: 10.1016/j.spinee.2020.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 05/31/2020] [Revised: 07/10/2020] [Accepted: 08/05/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Adult spinal deformity (ASD) can be a debilitating condition that requires surgical intervention. ASD patients often present with osteoporosis, predisposing them to increased rates of instrumentation failure and postoperative fractures, frequent reasons for revision surgery. We hypothesized that the rate and timing of revision surgery are different in osteoporotic and nonosteoporotic patients undergoing long fusions for ASD. To our knowledge, the timing of revision surgeries, in particular, have not previously been explored. PURPOSE To determine the rate and timing of revision surgery in osteoporotic and nonosteoporotic patients following a long fusion for ASD. STUDY DESIGN Retrospective comparative study. PATIENT SAMPLE ASD patients who underwent a long spinal fusion surgery at two large academic medical centers from 2010 to 2019. OUTCOME MEASURES Occurrence of revision surgery. METHODS Inclusion criteria were patient age of least 40 years and spinal fusion spanning at least seven levels for ASD. Patient records were reviewed for a diagnosis of osteoporosis as per ICD codes and revision surgery within 2 years of the index procedure. Revision surgery was defined as an unplanned procedure related to the index surgery for the treatment of a spine-related complication. Chi-squared tests comparing demographic data, revision rates, and multiple revisions were conducted. The incidence and prevalence of revision surgeries as a function of time and osteoporotic status were evaluated for significant differences via the Mann-Whitney U and Mantel-Haenszel log rank tests. Finally, a logistic regression analysis was utilized to determine the predictive value of osteoporosis, age, and gender on the likelihood for complications. RESULTS Three hundred ninety-nine patients matched the study criteria. In the osteoporotic group, 40.5% of patients underwent a revision surgery compared to 28.0% in the nonosteoporotic group (p=.01). The occurrence of multiple revision surgeries following the index procedure was similar in both groups: 8.4% in osteoporotic patients and 8.6% in nonosteoporotic patients. Age and gender were not statistically correlated with the incidence of revision surgery. CONCLUSIONS ASD patients with osteoporosis have an increased risk of undergoing revision for a surgery-related complication within 2 years of the index procedure. These complications included failure of hardware, pseudoarthrosis, proximal junction failure, and infection, among other issues that required surgical intervention. As others have also highlighted the importance of poor bone density on construct failure, our data further underscore the importance of preoperative osteoporosis surveillance. Though intuitive, further study is needed to demonstrate that improving patients' bone density can decrease the incidence of related complications and the need or revision surgery.
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Affiliation(s)
- Anmol Gupta
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Thomas Cha
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Joseph Schwab
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Harold Fogel
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Daniel Tobert
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Afshin E Razi
- Department of Orthopaedics, Maimonides Bone and Joint Center, Maimonides Medical Center, 6010 Bay Pkwy, Brooklyn, NY 11204, USA
| | - Andrew Hecht
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, 5 East 98th St, New York, NY 10029, USA
| | - Christopher M Bono
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Stuart Hershman
- Department of Orthopaedics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA.
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Goh BC, Striano BM, Lopez WY, Upadhyaya S, Ziino C, Georgakas PJ, Tobert DG, Fogel HA, Cha TD, Schwab JH, Bono CM, Hershman SH. Laminoplasty versus laminectomy and fusion for cervical spondylotic myelopathy: a cost analysis. Spine J 2020; 20:1770-1775. [PMID: 32730986 DOI: 10.1016/j.spinee.2020.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 05/04/2020] [Revised: 06/28/2020] [Accepted: 07/21/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Laminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered. PURPOSE We aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM. STUDY DESIGN Retrospective comparative study. PATIENT SAMPLE Adult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded. OUTCOME MEASURES The primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs. METHODS Patient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material - both implant and non-implant - cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables. RESULTS Two hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF. CONCLUSIONS This study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM.
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Affiliation(s)
- Brian C Goh
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Brendan M Striano
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Wylie Y Lopez
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Shivam Upadhyaya
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Chason Ziino
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Peter J Georgakas
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Harold A Fogel
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Thomas D Cha
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
| | - Stuart H Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA.
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Karhade AV, Bongers MER, Groot OQ, Cha TD, Doorly TP, Fogel HA, Hershman SH, Tobert DG, Schoenfeld AJ, Kang JD, Harris MB, Bono CM, Schwab JH. Can natural language processing provide accurate, automated reporting of wound infection requiring reoperation after lumbar discectomy? Spine J 2020; 20:1602-1609. [PMID: 32145358 DOI: 10.1016/j.spinee.2020.02.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 12/17/2019] [Revised: 02/05/2020] [Accepted: 02/28/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgical site infections are a major driver of morbidity and increased costs in the postoperative period after spine surgery. Current tools for surveillance of these adverse events rely on prospective clinical tracking, manual retrospective chart review, or administrative procedural and diagnosis codes. PURPOSE The purpose of this study was to develop natural language processing (NLP) algorithms for automated reporting of postoperative wound infection requiring reoperation after lumbar discectomy. PATIENT SAMPLE Adult patients undergoing discectomy at two academic and three community medical centers between January 1, 2000 and July 31, 2019 for lumbar disc herniation. OUTCOME MEASURES Reoperation for wound infection within 90 days after surgery METHODS: Free-text notes of patients who underwent surgery from January 1, 2000 to December 31, 2015 were used for algorithm training. Free-text notes of patients who underwent surgery after January 1, 2016 were used for algorithm testing. Manual chart review was used to label which patients had reoperation for wound infection. An extreme gradient-boosting NLP algorithm was developed to detect reoperation for postoperative wound infection. RESULTS Overall, 5,860 patients were included in this study and 62 (1.1%) had a reoperation for wound infection. In patients who underwent surgery after January 1, 2016 (n=1,377), the NLP algorithm detected 15 of the 16 patients (sensitivity=0.94) who had reoperation for infection. In comparison, current procedural terminology and international classification of disease codes detected 12 of these 16 patients (sensitivity=0.75). At a threshold of 0.05, the NLP algorithm had positive predictive value of 0.83 and F1-score of 0.88. CONCLUSION Temporal validation of the algorithm developed in this study demonstrates a proof-of-concept application of NLP for automated reporting of adverse events after spine surgery. Adapting this methodology for other procedures and outcomes in spine and orthopedics has the potential to dramatically improve and automatize quality and safety reporting.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michiel E R Bongers
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Q Groot
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas D Cha
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Terence P Doorly
- Department of Neurosurgery, North Shore Medical Center, Boston, MA, USA
| | - Harold A Fogel
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Stuart H Hershman
- 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; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - James D Kang
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA.
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Heckman JD, Swiontkowski M, Katz JN, Losina E, Schoenfeld AJ, Bedard NA, Bono CM, Carey JL, Graham B, Hensinger RN, Gebhardt MC, Mallon WJ, Rossi MJ, Matzkin E, Pinzur MS. Pain management research. Spine J 2020; 20:1165-1166. [PMID: 32713513 DOI: 10.1016/j.spinee.2020.04.020] [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] [Received: 04/17/2020] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 02/03/2023]
Affiliation(s)
| | | | | | - Elena Losina
- Deputy Editor, The Journal of Bone and Joint Surgery
| | | | | | | | - James L Carey
- Associate Editor, American Journal of Sports Medicine
| | | | | | | | | | | | - Elizabeth Matzkin
- Editorial Board, Arthroscopy: The Journal of Arthroscopic and Related Surgery
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Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J 2020; 20:998-1024. [PMID: 32333996 DOI: 10.1016/j.spinee.2020.04.006] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [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: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN This is a guideline summary review. METHODS This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. RESULTS Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.
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Affiliation(s)
- D Scott Kreiner
- Barrow Neurological Institute, 4530 E. Muirwood Dr. Ste. 110, Phoenix, AZ 85048-7693, USA.
| | - Paul Matz
- Advantage Orthopedics and Neurosurgery, Casper, WY, USA
| | | | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Zoher Ghogawala
- Lahey Hospital and Medical Center, Burlington, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | | | - William C Watters
- Institute of Academic Medicine Houston Methodist Hospital, Houston, TX, USA
| | - Thiru M Annaswamy
- VA North Texas Health Care System, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Randall P Brewer
- River Cities Interventional Pain Specialists, Shreveport, LA, USA
| | | | - David S Cheng
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Park
- University Of Michigan, Ann Arbor, MI, USA
| | | | | | - Ravi Prasad
- University of California, Davis, Sacramento, CA, USA
| | | | - Kris E Radcliff
- Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | - Ryan A Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | | | - Yakov Vorobeychik
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amy M Yahiro
- North American Spine Society, Burr Ridge, IL, USA
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Heckman JD, Swiontkowski M, Katz JN, Losina E, Schoenfeld AJ, Bedard NA, Bono CM, Carey JL, Graham B, Hensinger RN, Gebhardt MC, Mallon WJ, Rossi MJ, Matzkin E, Pinzur MS. Pain Management Research. Foot Ankle Int 2020; 41:761-762. [PMID: 32538196 PMCID: PMC7294527 DOI: 10.1177/1071100720925494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Karhade AV, Cha TD, Fogel HA, Hershman SH, Tobert DG, Schoenfeld AJ, Bono CM, Schwab JH. Predicting prolonged opioid prescriptions in opioid-naïve lumbar spine surgery patients. Spine J 2020; 20:888-895. [PMID: 31901553 DOI: 10.1016/j.spinee.2019.12.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [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: 10/24/2019] [Revised: 12/14/2019] [Accepted: 12/30/2019] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Preoperative determination of the potential for postoperative opioid dependence in previously naïve patients undergoing elective spine surgery may facilitate targeted interventions. OBJECTIVE The purpose of this study was to develop supervised machine learning algorithms for preoperative prediction of prolonged opioid prescription use in opioid-naïve patients following lumbar spine surgery. DESIGN Retrospective review of clinical registry data. Variables considered for prediction included demographics, insurance status, preoperative medications, surgical factors, laboratory values, comorbidities, and neighborhood characteristics. Five supervised machine learning algorithms were developed and assessed by discrimination, calibration, Brier score, and decision curve analysis. SETTING One healthcare entity (two academic medical centers, three community hospitals), 2000 to 2018. PARTICIPANTS Opioid-naïve patients undergoing decompression and/or fusion for lumbar disk herniation, stenosis, and spondylolisthesis. MAIN OUTCOME Sustained prescription opioid use exceeding 90 days after surgery. RESULTS Overall, of 8,435 patients included, 359 (4.3%) were found to have prolonged postoperative opioid prescriptions. The elastic-net penalized logistic regression achieved the best performance in the independent testing set not used for algorithm development with c-statistic=0.70, calibration intercept=0.06, calibration slope=1.02, and Brier score=0.039. The five most important factors for prolonged opioid prescriptions were use of instrumented spinal fusion, preoperative benzodiazepine use, preoperative antidepressant use, preoperative gabapentin use, and uninsured status. Individual patient-level explanations were provided for the algorithm predictions and the algorithms were incorporated into an open access digital application available here: https://sorg-apps.shinyapps.io/lumbaropioidnaive/. CONCLUSION AND RELEVANCE The clinician decision aid developed in this study may be helpful to preoperatively risk-stratify opioid-naïve patients undergoing lumbar spine surgery. The tool demonstrates moderate discriminative capacity for identifying those at greatest risk of prolonged prescription opioid use. External validation is required to further support the potential utility of this tool in practice.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas D Cha
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harold A Fogel
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stuart H Hershman
- 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
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Heckman JD, Swiontkowski M, Katz JN, Losina E, Schoenfeld AJ, Bedard NA, Bono CM, Carey JL, Graham B, Hensinger RN, Gebhardt MC, Mallon WJ, Rossi MJ, Matzkin E, Pinzur MS. Pain Management Research. J Bone Joint Surg Am 2020; 102:855. [PMID: 32433323 PMCID: PMC7508273 DOI: 10.2106/jbjs.20.00289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Scarpitta F, Restivo V, Bono CM, Sannasardo CE, Vella C, Ventura G, Bono S, Palmeri S, Caracci F, Casuccio A, Costantino C. The role of the Community Pharmacist in promoting vaccinations among general population according to the National Vaccination Plan 2017-2019: results from a survey in Sicily, Italy. Ann Ig 2020; 31:25-35. [PMID: 30994161 DOI: 10.7416/ai.2019.2274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The 2017-2019 Italian National Vaccination Plan promotes the improvement of knowledge and attitudes of healthcare workers about vaccine prevention, in order to spread a vaccination culture among general population. Similarly to the General Practitioner, the Pharmacist represents a fundamental forefront for both patients and healthy people, also in promoting vaccine acceptance. This research aims to analyze knowledge and attitudes about vaccines of Community Pharmacists and to evaluate the burden of vaccination counselling during their work activities. MATERIAL AND METHODS A standardized, self-administered and previously validated questionnaire, including 5 sections and 28 items, was submitted to a sample of Community Pharmacists working in Western Sicily. The survey was carried out through an online questionnaire, that investigated socio-demographic data, knowledge and attitudes towards vaccination and the role of the Pharmacist as vaccination counselor during his work. RESULTS A total of 120 Pharmacists were surveyed. 99.2% of them were definitely agreed with the Regional Vaccination Schedule. A large majority (n = 114, or 95%) were fully vaccinated and have vaccinated, or would vaccinate in future, their children. According to Community Pharmacists interviewed, at least 90% of clients asked for further explanations about vaccination, and the citizens' trust towards vaccination increased (30%) or remained stable (54.2%) over time in the last 5 years. Finally, as reported by interviewed Pharmacists, a correct counselling provided by General Practitioners (GPs) and Family Pediatricians was the main boost in increasing vaccination confidence, instead of mass-media and web misinformation that has led to skepticisms among general population. CONCLUSION The study demonstrated the key role of the Community Pharmacist for their consumers in vaccination counselling. In future, a strong collaboration between Community Pharmacists and all the actors promoting vaccination themes (GPs, family Pediatricians, public health workers) will be essential, as well as a uniform and standardized University training on vaccination themes for all these categories.
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Affiliation(s)
- F Scarpitta
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - V Restivo
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - C M Bono
- Pharmacist, Study course in Pharmacology, University of Palermo, Italy
| | - C E Sannasardo
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - C Vella
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - G Ventura
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - S Bono
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - S Palmeri
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - F Caracci
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - A Casuccio
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
| | - C Costantino
- Department of Health Promotion, Mother Child Care, Internal Medicine and Excellence Specialist "G. D'Alessandro", University of Palermo, Italy
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Karhade AV, Thio QCBS, Ogink PT, Shah AA, Bono CM, Oh KS, Saylor PJ, Schoenfeld AJ, Shin JH, Harris MB, Schwab JH. Development of Machine Learning Algorithms for Prediction of 30-Day Mortality After Surgery for Spinal Metastasis. Neurosurgery 2020; 85:E83-E91. [PMID: 30476188 DOI: 10.1093/neuros/nyy469] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [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: 04/19/2018] [Accepted: 08/31/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Preoperative prognostication of short-term postoperative mortality in patients with spinal metastatic disease can improve shared decision making around end-of-life care. OBJECTIVE To (1) develop machine learning algorithms for prediction of short-term mortality and (2) deploy these models in an open access web application. METHODS The American College of Surgeons, National Surgical Quality Improvement Program was used to identify patients that underwent operative intervention for metastatic disease. Four machine learning algorithms were developed, and the algorithm with the best performance across discrimination, calibration, and overall performance was integrated into an open access web application. RESULTS The 30-d mortality for the 1790 patients undergoing surgery for spinal metastatic disease was 8.49%. Preoperative factors used for prognostication were albumin, functional status, white blood cell count, hematocrit, alkaline phosphatase, spinal location (cervical, thoracic, lumbosacral), and severity of comorbid systemic disease (American Society of Anesthesiologist Class). In this population, machine learning algorithms developed to predict 30-d mortality performed well on discrimination (c-statistic), calibration (assessed by calibration slope and intercept), Brier score, and decision analysis. An open access web application was developed for the best performing model and this web application can be found here: https://sorg-apps.shinyapps.io/spinemets/. CONCLUSION Machine learning algorithms are promising for prediction of postoperative outcomes in spinal oncology and these algorithms can be integrated into clinically useful decision tools. As the volume of data in oncology continues to grow, creation of learning systems and deployment of these systems as accessible tools may significantly enhance prognostication and management.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quirina C B S Thio
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul T Ogink
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Akash A Shah
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher M Bono
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin S Oh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Phil J Saylor
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- Christopher M Bono
- Department of Orthopedic Surgery, MGH/BWH Orthopedic Spine Surgery Fellowship Program, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Orthopedic Surgery, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; The Spine Journal, North American Spine Society, 7075 Veterans Boulevard, Burr Ridge, IL 60527, USA.
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Karhade AV, Ogink PT, Thio QC, Cha TD, Hershman SH, Schoenfeld AJ, Bono CM, Schwab JH. Discharge Disposition After Anterior Cervical Discectomy and Fusion. World Neurosurg 2019; 132:e14-e20. [DOI: 10.1016/j.wneu.2019.09.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 12/23/2022]
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