1
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Agarwal N, Johnson SE, Bydon M, Bisson EF, Chan AK, Shabani S, Letchuman V, Michalopoulos GD, Lu DC, Wang MY, Lavadi RS, Haid RW, Knightly JJ, Sherrod BA, Gottfried ON, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Glassman SD, Shaffrey ME, Park P, Foley KT, Pennicooke B, Coric D, Slotkin JR, Upadhyaya C, Potts EA, Tumialán LM, Chou D, Fu KMG, Asher AL, Mummaneni PV. Cervical spondylotic myelopathy and driving abilities: defining the prevalence and long-term postoperative outcomes using the Quality Outcomes Database. J Neurosurg Spine 2024; 40:630-641. [PMID: 38364219 DOI: 10.3171/2023.11.spine23738] [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] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/28/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Cervical spondylotic myelopathy (CSM) can cause significant difficulty with driving and a subsequent reduction in an individual's quality of life due to neurological deterioration. The positive impact of surgery on postoperative patient-reported driving capabilities has been seldom explored. METHODS The CSM module of the Quality Outcomes Database was utilized. Patient-reported driving ability was assessed via the driving section of the Neck Disability Index (NDI) questionnaire. This is an ordinal scale in which 0 represents the absence of symptoms while driving and 5 represents a complete inability to drive due to symptoms. Patients were considered to have an impairment in their driving ability if they reported an NDI driving score of 3 or higher (signifying impairment in driving duration due to symptoms). Multivariable logistic regression models were fitted to evaluate mediators of baseline impairment and improvement at 24 months after surgery, which was defined as an NDI driving score < 3. RESULTS A total of 1128 patients who underwent surgical intervention for CSM were included, of whom 354 (31.4%) had baseline driving impairment due to CSM. Moderate (OR 2.3) and severe (OR 6.3) neck pain, severe arm pain (OR 1.6), mild-moderate (OR 2.1) and severe (OR 2.5) impairment in hand/arm dexterity, severe impairment in leg use/walking (OR 1.9), and severe impairment of urinary function (OR 1.8) were associated with impaired driving ability at baseline. Of the 291 patients with baseline impairment and available 24-month follow-up data, 209 (71.8%) reported postoperative improvement in their driving ability. This improvement seemed to be mediated particularly through the achievement of the minimal clinically important difference (MCID) in neck pain and improvement in leg function/walking. Patients with improved driving at 24 months noted higher postoperative satisfaction (88.5% vs 62.2%, p < 0.01) and were more likely to achieve a clinically significant improvement in their quality of life (50.7% vs 37.8%, p < 0.01). CONCLUSIONS Nearly one-third of patients with CSM report impaired driving ability at presentation. Seventy-two percent of these patients reported improvements in their driving ability within 24 months of surgery. Surgical management of CSM can significantly improve patients' driving abilities at 24 months and hence patients' quality of life.
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Affiliation(s)
- Nitin Agarwal
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Neurological Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sarah E Johnson
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Erica F Bisson
- 5Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Andrew K Chan
- 6Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Saman Shabani
- 7Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Vijay Letchuman
- 8Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | | | - Daniel C Lu
- 9Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Michael Y Wang
- 10Department of Neurological Surgery, University of Miami, Miami, Florida
| | - Raj Swaroop Lavadi
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Regis W Haid
- 11Atlanta Brain and Spine Care, Atlanta, Georgia
| | - John J Knightly
- 12Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Brandon A Sherrod
- 5Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Oren N Gottfried
- 13Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Jacob L Goldberg
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Ibrahim Hussain
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Mark E Shaffrey
- 16Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Paul Park
- 17Department of Neurosurgery, Semmes Murphey Clinic, University of Tennessee, Memphis, Tennessee
| | - Kevin T Foley
- 17Department of Neurosurgery, Semmes Murphey Clinic, University of Tennessee, Memphis, Tennessee
| | - Brenton Pennicooke
- 18Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Domagoj Coric
- 19Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | | | - Cheerag Upadhyaya
- 21Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina
| | - Eric A Potts
- 22Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
| | - Luis M Tumialán
- 23Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Dean Chou
- 6Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Kai-Ming G Fu
- 14Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Anthony L Asher
- 19Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Praveen V Mummaneni
- 8Department of Neurosurgery, University of California, San Francisco, San Francisco, California
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Agarwal N, Letchuman V, Lavadi RS, Le VP, Aabedi AA, Shabani S, Chan AK, Park P, Uribe JS, Turner JD, Eastlack RK, Fessler RG, Fu KM, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Mundis GM, Passias PG, Bess S, Shaffrey CI, Chou D, Mummaneni PV. What is the effect of preoperative depression on outcomes after minimally invasive surgery for adult spinal deformity? A prospective cohort analysis. J Neurosurg Spine 2024; 40:602-610. [PMID: 38364229 DOI: 10.3171/2023.12.spine221330] [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] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/08/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Depression has been implicated with worse immediate postoperative outcomes in adult spinal deformity (ASD) correction, yet the specific impact of depression on those patients undergoing minimally invasive surgery (MIS) requires further clarity. This study aimed to evaluate the role of depression in the recovery of patients with ASD after undergoing MIS. METHODS Patients who underwent MIS for ASD with a minimum postoperative follow-up of 1 year were included from a prospectively collected, multicenter registry. Two cohorts of patients were identified that consisted of either those affirming or denying depression on preoperative assessment. The patient-reported outcome measures (PROMs) compared included scores on the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back and leg pain, Scoliosis Research Society Outcomes Questionnaire (SRS-22), SF-36 physical component summary, SF-36 mental component summary (MCS), EQ-5D, and EQ-5D visual analog scale. RESULTS Twenty-seven of 147 (18.4%) patients screened positive for preoperative depression. The nondepressed cohort had an average of 4.83 levels fused, and the depressed cohort had 5.56 levels fused per patient (p = 0.267). At 1-year follow-up, 10 patients still reported depression, representing a 63% decrease. Postoperatively, both cohorts demonstrated improvement in their PROMs; however, at 1-year follow-up, those without depression had statistically better outcomes based on the EQ-5D, MCS, and SRS-22 scores (p < 0.05). Patients with depression continued to experience higher NRS leg scores at 1-year follow-up (3.63 vs 2.22, p = 0.018). After controlling for covariates, the authors found that depression significantly impacted only 1-year follow-up MCS scores (β = 8.490, p < 0.05). CONCLUSIONS Depressed and nondepressed patients reported similar improvements after MIS surgery, except MCS scores were more likely to improve in nondepressed patients.
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Affiliation(s)
- Nitin Agarwal
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 2Division of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Neurological Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Vijay Letchuman
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Raj Swaroop Lavadi
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vivian P Le
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Alexander A Aabedi
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Saman Shabani
- 6Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew K Chan
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Paul Park
- 7Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee
| | - Juan S Uribe
- 8Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D Turner
- 8Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert K Eastlack
- 9Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California
| | - Richard G Fessler
- 10Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kai-Ming Fu
- 11Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael Y Wang
- 12Department of Neurosurgery, University of Miami, Florida
| | - Adam S Kanter
- 13Division of Neurosurgery, Hoag Neurosciences Institute, Newport Beach, California
| | - David O Okonkwo
- 2Division of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Neel Anand
- 15Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gregory M Mundis
- 9Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California
| | - Peter G Passias
- 16Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Shay Bess
- 17Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and
| | | | - Dean Chou
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Praveen V Mummaneni
- 4Department of Neurological Surgery, University of California, San Francisco, California
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3
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Yang E, Mummaneni PV, Chou D, Izima C, Fu KM, Bydon M, Bisson EF, Shaffrey CI, Gottfried ON, Asher AL, Coric D, Potts E, Foley KT, Wang MY, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Uribe JS, Tumialán LM, Turner J, Haid RW, Chan AK. Is Upper Extremity or Lower Extremity Function More Important for Patient Satisfaction? An Analysis of 24-Month Outcomes from the QOD Cervical Spondylotic Myelopathy Cohort. Clin Spine Surg 2024; 37:188-197. [PMID: 38706113 DOI: 10.1097/bsd.0000000000001613] [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: 01/09/2024] [Accepted: 02/28/2024] [Indexed: 05/07/2024]
Abstract
STUDY DESIGN Retrospective analysis of a prospective, multicenter registry. OBJECTIVE To assess whether upper or lower limb mJOA improvement more strongly associates with patient satisfaction after surgery for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA The modified Japanese Orthopaedic Association (mJOA) is commonly used to assess functional status in patients with CSM. Patients present with upper and/or lower extremity dysfunction, and it is unclear whether improvement in one and/or both symptoms drives postoperative patient satisfaction. METHODS This study utilizes the prospective Quality Outcomes Database (QOD) CSM data set. Clinical outcomes included mJOA and North American Spine Society (NASS) satisfaction. The upper limb mJOA score was defined as upper motor plus sensory mJOA, and the lower limb mJOA as lower motor plus sensory mJOA. Ordered logistic regression was used to determine whether upper or lower limb mJOA was more closely associated with NASS satisfaction, adjusting for other covariates. RESULTS Overall, 1141 patients were enrolled in the QOD CSM cohort. In all, 780 had both preoperative and 24-month mJOA scores, met inclusion criteria, and were included for analysis. The baseline mJOA was 12.1±2.7, and postoperatively, 85.6% would undergo surgery again (NASS 1 or 2, satisfied). Patients exhibited mean improvement in both upper (baseline:3.9±1.4 vs. 24 mo:5.0±1.1, P<0.001) and lower limb mJOA (baseline:3.9±1.4 vs. 24 mon:4.5±1.5, P<0.001); however, the 24-month change in the upper limb mJOA was greater (upper:1.1±1.6 vs. lower:0.6±1.6, P<0.001). Across 24-month NASS satisfaction, the baseline upper and lower limb mJOA scores were similar (pupper=0.28, plower=0.092). However, as satisfaction decreased, the 24-month change in upper and lower limb mJOA decreased as well (pupper<0.001, plower<0.001). Patients with NASS scores of 4 (lowest satisfaction) did not demonstrate significant differences from baseline in upper or lower limb mJOA (P>0.05). In ordered logistic regression, NASS satisfaction was independently associated with upper limb mJOA improvement (OR=0.81; 95% CI: 0.68-0.97; P=0.019) but not lower limb mJOA improvement (OR=0.84; 95% CI: 0.70-1.0; P=0.054). CONCLUSIONS As the magnitude of upper and lower mJOA improvement decreased postoperatively, so too did patient satisfaction with surgical intervention. Upper limb mJOA improvement was a significant independent predictor of patient satisfaction, whereas lower limb mJOA improvement was not. These findings may aid preoperative counseling, stratified by patients' upper and lower extremity treatment expectations. LEVEL OF EVIDENCE Level-III.
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Affiliation(s)
- Eunice Yang
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | | | - Dean Chou
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | - Chiemela Izima
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | - Kai-Ming Fu
- Department of Neurosurgery, Weill Cornell Medical Center, New York, NY
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | | | | | - Anthony L Asher
- Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, NC
| | - Domagoj Coric
- Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, NC
| | - Eric Potts
- Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee; Semmes-Murphey Neurologic and Spine Institute, Memphis, TN
| | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami, FL
| | - Michael S Virk
- Department of Neurosurgery, University of Miami, Miami, FL
| | | | - Scott Meyer
- Atlantic Neurosurgical Specialists, Morristown, NJ
| | - Paul Park
- Department of Neurosurgery, University of Tennessee; Semmes-Murphey Neurologic and Spine Institute, Memphis, TN
| | | | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | | | | | - Jay Turner
- Barrow Neurological Institute, Phoenix, AZ
| | | | - Andrew K Chan
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
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4
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Mummaneni PV, Bisson EF, Michalopoulos G, Mualem WJ, El Sammak S, Wang MY, Chan AK, Haid RW, Knightly JJ, Chou D, Sherrod BA, Gottfried ON, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Agarwal N, Glassman SD, Shaffrey ME, Park P, Foley KT, Pennicooke B, Coric D, Slotkin JR, Potts EA, Fu KMG, Asher AL, Bydon M. Comparing posterior cervical foraminotomy with anterior cervical discectomy and fusion in radiculopathic patients: an analysis from the Quality Outcomes Database. J Neurosurg Spine 2024:1-13. [PMID: 38626479 DOI: 10.3171/2024.2.spine221280] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/05/2024] [Indexed: 04/18/2024]
Abstract
OBJECTIVE The objective of this study was to compare clinical and patient-reported outcomes (PROs) between posterior foraminotomy and anterior cervical discectomy and fusion (ACDF) in patients presenting with cervical radiculopathy. METHODS The Quality Outcomes Database was queried for patients who had undergone ACDF or posterior foraminotomy for radiculopathy. To create two highly homogeneous groups, optimal individual matching was performed at a 5:1 ratio between the two groups on 29 baseline variables (including demographic characteristics, comorbidities, symptoms, patient-reported scores, underlying pathologies, and levels treated). Outcomes of interest were length of stay, reoperations, patient-reported satisfaction, increase in EQ-5D score, and decrease in Neck Disability Index (NDI) scores for arm and neck pain as long as 1 year after surgery. Noninferiority analysis of achieving patient satisfaction and minimal clinically important difference (MCID) in PROs was performed with an accepted risk difference of 5%. RESULTS A total of 7805 eligible patients were identified: 216 of these underwent posterior foraminotomy and were matched to 1080 patients who underwent ACDF. The patients who underwent ACDF had more underlying pathologies, lower EQ-5D scores, and higher NDI and neck pain scores at baseline. Posterior foraminotomy was associated with shorter hospitalization (0.5 vs 0.9 days, p < 0.001). Reoperations within 12 months were significantly more common among the posterior foraminotomy group (4.2% vs 1.9%, p = 0.04). The two groups performed similarly in PROs, with posterior foraminotomy being noninferior to ACDF in achieving MCID in EQ-5D and neck pain scores but also having lower rates of maximal satisfaction at 12 months (North American Spine Society score of 1 achieved by 65.2% posterior foraminotomy patients vs 74.6% of ACDF patients, p = 0.02). CONCLUSIONS The two procedures were found to be offered to different populations, with ACDF being selected for patients with more complicated pathologies and symptoms. After individual matching, posterior foraminotomy was associated with a higher reoperation risk within 1 year after surgery compared to ACDF (4.2% vs 1.9%). In terms of 12-month PROs, posterior foraminotomy was noninferior to ACDF in improving quality of life and neck pain. The two procedures also performed similarly in improving NDI scores and arm pain, but ACDF patients had higher maximal satisfaction rates.
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Affiliation(s)
- Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 2Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Giorgos Michalopoulos
- 3Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - William J Mualem
- 3Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sally El Sammak
- 3Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael Y Wang
- 5Department of Neurosurgery, University of Miami, Florida
| | - Andrew K Chan
- 6Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | | | | | - Dean Chou
- 6Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Brandon A Sherrod
- 2Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Oren N Gottfried
- 9Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher I Shaffrey
- 9Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob L Goldberg
- 10Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 10Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Ibrahim Hussain
- 10Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Nitin Agarwal
- 11Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Paul Park
- 14Department of Neurosurgery, University of Tennessee, Memphis, Tennessee
| | - Kevin T Foley
- 14Department of Neurosurgery, University of Tennessee, Memphis, Tennessee
| | - Brenton Pennicooke
- 11Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Domagoj Coric
- 15Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Jonathan R Slotkin
- 16Department of Neurosurgery, Geisinger Health, Danville, Pennsylvania; and
| | - Eric A Potts
- 17Department of Neurological Surgery, Indiana University, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kai-Ming G Fu
- 10Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Anthony L Asher
- 15Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Mohamad Bydon
- 3Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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5
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Chan AK, Park C, Shaffrey CI, Gottfried ON, Than KD, Bisson EF, Bydon M, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya CD, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Michalopoulos G, Sherrod BA, Agarwal N, Chou D, Haid RW, Mummaneni PV. What predicts the best 24-month outcomes following surgery for cervical spondylotic myelopathy? A QOD prospective registry study. J Neurosurg Spine 2024; 40:453-464. [PMID: 38181405 DOI: 10.3171/2023.11.spine23222] [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] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 11/09/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE The aim of this study was to identify predictors of the best 24-month improvements in patients undergoing surgery for cervical spondylotic myelopathy (CSM). For this purpose, the authors leveraged a large prospective cohort of surgically treated patients with CSM to identify factors predicting the best outcomes for disability, quality of life, and functional status following surgery. METHODS This was a retrospective analysis of prospectively collected data. The Quality Outcomes Database (QOD) CSM dataset (1141 patients) at 14 top enrolling sites was used. Baseline and surgical characteristics were compared for those reporting the top and bottom 20th percentile 24-month Neck Disability Index (NDI), EuroQol-5D (EQ-5D), and modified Japanese Orthopaedic Association (mJOA) change scores. A multivariable logistic model was constructed and included candidate variables reaching p ≤ 0.20 on univariate analyses. Least important variables were removed in a stepwise manner to determine the significant predictors of the best outcomes (top 20th percentile) for 24-month NDI, EQ-5D, and mJOA change. RESULTS A total of 948 (83.1%) patients with 24-month follow-up were included in this study. For NDI, 204 (17.9%) had the best NDI outcome and 200 (17.5%) had the worst NDI outcome. Factors predicting the best NDI outcomes included symptom duration less than 12 months (OR 1.5, 95% CI 1.1-1.9; p = 0.01); procedure other than posterior fusion (OR 1.5, 95% CI 1.03-2.1; p = 0.03); higher preoperative visual analog scale neck pain score (OR 1.2, 95% CI 1.1-1.3; p < 0.001); and higher baseline NDI (OR 1.06, 95% CI 1.05-1.07; p < 0.001). For EQ-5D, 163 (14.3%) had the best EQ-5D outcome and 169 (14.8%) had the worst EQ-5D outcome. Factors predicting the best EQ-5D outcomes included arm pain-only complaints (compared to neck pain) (OR 1.9, 95% CI 1.3-2.9; p = 0.002) and lower baseline EQ-5D (OR 167.7 per unit lower, 95% CI 85.0-339.4; p < 0.001). For mJOA, 222 (19.5%) had the best mJOA outcome and 238 (20.9%) had the worst mJOA outcome. Factors predicting the best mJOA outcomes included lower BMI (OR 1.03 per unit lower, 95% CI 1.004-1.05; p = 0.02; cutoff value of ≤ 29.5 kg/m2); arm pain-only complaints (compared to neck pain) (OR 1.7, 95% CI 1.1-2.5; p = 0.02); and lower baseline mJOA (OR 1.6 per unit lower, 95% CI 1.5-1.7; p < 0.001). CONCLUSIONS Compared to the worst outcomes for EQ-5D, the best outcomes were associated with patients with arm pain-only complaints. For mJOA, lower BMI and arm pain-only complaints portended the best outcomes. For NDI, those with the best outcomes had shorter symptom durations, higher preoperative neck pain scores, and less often underwent posterior spinal fusions. Given the positive impact of shorter symptom duration on outcomes, these data suggest that early surgery may be beneficial for patients with CSM.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York; The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Christine Park
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Oren N Gottfried
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Khoi D Than
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony L Asher
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 6Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 7Department of Neurosurgery, University of Tennessee; Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 8Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 11Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag D Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 14Barrow Neurological Institute, Phoenix, Arizona
| | | | - Brandon A Sherrod
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 15Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Dean Chou
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York; The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 15Department of Neurological Surgery, University of California, San Francisco, California; and
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6
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Agarwal N, DiGiorgio A, Michalopoulos GD, Letchuman V, Chan AK, Shabani S, Lavadi RS, Lu DC, Wang MY, Haid RW, Knightly JJ, Sherrod BA, Gottfried ON, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Glassman SD, Shaffrey ME, Park P, Foley KT, Pennicooke B, Coric D, Upadhyaya C, Potts EA, Tumialán LM, Fu KMG, Asher AL, Bisson EF, Chou D, Bydon M, Mummaneni PV. Impact of Educational Background on Preoperative Disease Severity and Postoperative Outcomes Among Patients With Cervical Spondylotic Myelopathy. Clin Spine Surg 2024; 37:E137-E146. [PMID: 38102749 DOI: 10.1097/bsd.0000000000001557] [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: 10/31/2022] [Accepted: 10/03/2023] [Indexed: 12/17/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively maintained database. OBJECTIVE Assess differences in preoperative status and postoperative outcomes among patients of different educational backgrounds undergoing surgical management of cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA Patient education level (EL) has been suggested to correlate with health literacy, disease perception, socioeconomic status (SES), and access to health care. METHODS The CSM data set of the Quality Outcomes Database (QOD) was queried for patients undergoing surgical management of CSM. EL was grouped as high school or below, graduate-level, and postgraduate level. The association of EL with baseline disease severity (per patient-reported outcome measures), symptoms >3 or ≤3 months, and 24-month patient-reported outcome measures were evaluated. RESULTS Among 1141 patients with CSM, 509 (44.6%) had an EL of high school or below, 471 (41.3%) had a graduate degree, and 161 (14.1%) had obtained postgraduate education. Lower EL was statistically significantly associated with symptom duration of >3 months (odds ratio=1.68), higher arm pain numeric rating scale (NRS) (coefficient=0.5), and higher neck pain NRS (coefficient=0.79). Patients with postgraduate education had statistically significantly lower Neck Disability Index (NDI) scores (coefficient=-7.17), lower arm pain scores (coefficient=-1), and higher quality-adjusted life-years (QALY) scores (coefficient=0.06). Twenty-four months after surgery, patients of lower EL had higher NDI scores, higher pain NRS scores, and lower QALY scores ( P <0.05 in all analyses). CONCLUSIONS Among patients undergoing surgical management for CSM, those reporting a lower educational level tended to present with longer symptom duration, more disease-inflicted disability and pain, and lower QALY scores. As such, patients of a lower EL are a potentially vulnerable subpopulation, and their health literacy and access to care should be prioritized.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony DiGiorgio
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | | | - Vijay Letchuman
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Andrew K Chan
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Saman Shabani
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | | | | | | | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | | | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Kevin T Foley
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Brenton Pennicooke
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Cheerag Upadhyaya
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Eric A Potts
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Luis M Tumialán
- Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, AZ
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Dean Chou
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
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7
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Dave P, Lafage R, Smith JS, Line BG, Tretiakov PS, Mir J, Diebo B, Daniels AH, Gum JL, Hamilton DK, Buell T, Than KD, Fu KM, Scheer JK, Eastlack R, Mullin JP, Mundis G, Hosogane N, Yagi M, Nunley P, Chou D, Mummaneni PV, Klineberg EO, Kebaish KM, Lewis S, Hostin RA, Gupta MC, Kim HJ, Ames CP, Hart RA, Lenke LG, Shaffrey CI, Bess S, Schwab FJ, Lafage V, Burton DC, Passias PG. Predictors of pelvic tilt normalization: a multicenter study on the impact of regional and lower-extremity compensation on pelvic alignment after complex adult spinal deformity surgery. J Neurosurg Spine 2024; 40:505-512. [PMID: 38215449 DOI: 10.3171/2023.11.spine23766] [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] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/13/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVE The objective was to determine the degree of regional decompensation to pelvic tilt (PT) normalization after complex adult spinal deformity (ASD) surgery. METHODS Operative ASD patients with 1 year of PT measurements were included. Patients with normalized PT at baseline were excluded. Predicted PT was compared to actual PT, tested for change from baseline, and then compared against age-adjusted, Scoliosis Research Society-Schwab, and global alignment and proportion (GAP) scores. Lower-extremity (LE) parameters included the cranial-hip-sacrum angle, cranial-knee-sacrum angle, and cranial-ankle-sacrum angle. LE compensation was set as the 1-year upper tertile compared with intraoperative baseline. Univariate analyses were used to compare normalized and nonnormalized data against alignment outcomes. Multivariable logistic regression analyses were used to develop a model consisting of significant predictors for normalization related to regional compensation. RESULTS In total, 156 patients met the inclusion criteria (mean ± SD age 64.6 ± 9.1 years, BMI 27.9 ± 5.6 kg/m2, Charlson Comorbidity Index 1.9 ± 1.6). Patients with normalized PT were more likely to have overcorrected pelvic incidence minus lumbar lordosis and sagittal vertical axis at 6 weeks (p < 0.05). GAP score at 6 weeks was greater for patients with nonnormalized PT (0.6 vs 1.3, p = 0.08). At baseline, 58.5% of patients had compensation in the thoracic and cervical regions. Postoperatively, compensation was maintained by 42% with no change after matching in age-adjusted or GAP score. The patients with nonnormalized PT had increased rates of thoracic and cervical compensation (p < 0.05). Compensation in thoracic kyphosis differed between patients with normalized PT at 6 weeks and those with normalized PT at 1 year (69% vs 35%, p < 0.05). Those who compensated had increased rates of implant complications by 1 year (OR [95% CI] 2.08 [1.32-6.56], p < 0.05). Cervical compensation was maintained at 6 weeks and 1 year (56% vs 43%, p = 0.12), with no difference in implant complications (OR 1.31 [95% CI -2.34 to 1.03], p = 0.09). For the lower extremities at baseline, 61% were compensating. Matching age-adjusted alignment did not eliminate compensation at any joint (all p > 0.05). Patients with nonnormalized PT had higher rates of LE compensation across joints (all p < 0.01). Overall, patients with normalized PT at 1 year had the greatest odds of resolving LE compensation (OR 9.6, p < 0.001). Patients with normalized PT at 1 year had lower rates of implant failure (8.9% vs 19.5%, p < 0.05), rod breakage (1.3% vs 13.8%, p < 0.05), and pseudarthrosis (0% vs 4.6%, p < 0.05) compared with patients with nonnormalized PT. The complication rate was significantly lower for patients with normalized PT at 1 year (56.7% vs 66.1%, p = 0.02), despite comparable health-related quality of life scores. CONCLUSIONS Patients with PT normalization had greater rates of resolution in thoracic and LE compensation, leading to lower rates of complications by 1 year. Thus, consideration of both the lower extremities and thoracic regions in surgical planning is vital to preventing adverse outcomes and maintaining pelvic alignment.
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Affiliation(s)
- Pooja Dave
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Renaud Lafage
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton G Line
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Peter S Tretiakov
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Jamshaid Mir
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Bassel Diebo
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Alan H Daniels
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Jeffrey L Gum
- 6Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - D Kojo Hamilton
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas Buell
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Khoi D Than
- 8Departments of Neurosurgery and Orthopaedic Surgery, Spine Division, Duke University School of Medicine, Durham, North Carolina
| | - Kai-Ming Fu
- 9Department of Neurological Surgery, Weill Cornell Medicine Brain and Spine Center/NewYork-Presbyterian Lower Manhattan Hospital, New York, New York
| | - Justin K Scheer
- 10Department of Neurosurgery, Columbia University, New York, New York
| | - Robert Eastlack
- 11Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Jeffrey P Mullin
- 12Department of Neurosurgery at University at Buffalo Medical School, Buffalo, New York
| | - Gregory Mundis
- 11Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Naobumi Hosogane
- 13Division of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Mitsuru Yagi
- 14Department of Orthopedic surgery, Keio University School of Medicine, Shinjyuku, Tokyo, Japan
- 26Department of Orthopedic Surgery, International University of Health and Welfare School of Medicine, Chiba, Narita, Japan
| | - Pierce Nunley
- 15Spine Institute of Louisiana, Shreveport, Louisiana
| | - Dean Chou
- 10Department of Neurosurgery, Columbia University, New York, New York
| | - Praveen V Mummaneni
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Eric O Klineberg
- 17Department of Orthopedic Surgery, University of California Davis, Sacramento, California
| | - Khaled M Kebaish
- 18Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Stephen Lewis
- 19Department of Surgery, Division of Neurosurgery, University of Toronto, Ontario, Canada
| | - Richard A Hostin
- 20Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas
| | - Munish C Gupta
- 21Department of Orthopaedic Surgery, Washington University of St. Louis, Missouri
| | - Han Jo Kim
- 2Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - Christopher P Ames
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert A Hart
- 22Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Lawrence G Lenke
- 23Department of Orthopaedic Surgery, Columbia College of Physicians and Surgeons, New York, New York
| | - Christopher I Shaffrey
- 8Departments of Neurosurgery and Orthopaedic Surgery, Spine Division, Duke University School of Medicine, Durham, North Carolina
| | - Shay Bess
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Frank J Schwab
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Douglas C Burton
- 25Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Peter G Passias
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
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8
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Park C, Shaffrey CI, Than KD, Bisson EF, Sherrod BA, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Agarwal N, Chan AK, Chou D, Chaudhry NS, Haid RW, Mummaneni PV, Michalopoulos GD, Bydon M, Gottfried ON. Does the number of social factors affect long-term patient-reported outcomes and satisfaction in those with cervical myelopathy? A QOD study. J Neurosurg Spine 2024; 40:428-438. [PMID: 38241683 DOI: 10.3171/2023.11.spine23127] [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] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 11/16/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE It is not clear whether there is an additive effect of social factors in keeping patients with cervical spondylotic myelopathy (CSM) from achieving both a minimum clinically important difference (MCID) in outcomes and satisfaction after surgery. The aim of this study was to explore the effect of multiple social factors on postoperative outcomes and satisfaction. METHODS This was a multiinstitutional, retrospective study of the prospective Quality Outcomes Database (QOD) CSM cohort, which included patients aged 18 years or older who were diagnosed with primary CSM and underwent operative management. Social factors included race (White vs non-White), education (high school or below vs above), employment (employed vs not), and insurance (private vs nonprivate). Patients were considered to have improved from surgery if the following criteria were met: 1) they reported a score of 1 or 2 on the North American Spine Society index, and 2) they met the MCID in patient-reported outcomes (i.e., visual analog scale [VAS] neck and arm pain, Neck Disability Index [NDI], and EuroQol-5D [EQ-5D]). RESULTS Of the 1141 patients included in the study, 205 (18.0%) had 0, 347 (30.4%) had 1, 334 (29.3%) had 2, and 255 (22.3%) had 3 social factors. The 24-month follow-up rate was > 80% for all patient-reported outcomes. After adjusting for all relevant covariates (p < 0.02), patients with 1 or more social factors were less likely to improve from surgery in all measured outcomes including VAS neck pain (OR 0.90, 95% CI 0.83-0.99) and arm pain (OR 0.88, 95% CI 0.80-0.96); NDI (OR 0.90, 95% CI 0.83-0.98); and EQ-5D (OR 0.90, 95% CI 0.83-0.97) (all p < 0.05) compared to those without any social factors. Patients with 2 social factors (outcomes: neck pain OR 0.86, arm pain OR 0.81, NDI OR 0.84, EQ-5D OR 0.81; all p < 0.05) or 3 social factors (outcomes: neck pain OR 0.84, arm pain OR 0.84, NDI OR 0.84, EQ-5D OR 0.84; all p < 0.05) were more likely to fare worse in all outcomes compared to those with only 1 social factor. CONCLUSIONS Compared to those without any social factors, patients who had at least 1 social factor were less likely to achieve MCID and feel satisfied after surgery. The effect of social factors is additive in that patients with a higher number of factors are less likely to improve compared to those with only 1 social factor.
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Affiliation(s)
- Christine Park
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Khoi D Than
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brandon A Sherrod
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 3Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 3Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 4Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 5Department of Neurosurgery, Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 6Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 7Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 7Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | | | - Scott Meyer
- 8Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 9Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag Upadhyaya
- 10Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 11Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 11Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 12Barrow Neurological Institute, Phoenix, Arizona
| | - Nitin Agarwal
- 13Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Andrew K Chan
- 14Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Dean Chou
- 14Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Nauman S Chaudhry
- 15Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 17Department of Neurosurgery, University of California, San Francisco, California; and
| | | | - Mohamad Bydon
- 18Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Oren N Gottfried
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
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9
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Passias PG, Mir JM, Dave P, Smith JS, Lafage R, Gum J, Line BG, Diebo B, Daniels AH, Hamilton DK, Buell TJ, Scheer JK, Eastlack RK, Mullin JP, Mundis GM, Hosogane N, Yagi M, Schoenfeld AJ, Uribe JS, Anand N, Mummaneni PV, Chou D, Klineberg EO, Kebaish KM, Lewis SJ, Gupta MC, Kim HJ, Hart RA, Lenke LG, Ames CP, Shaffrey CI, Schwab FJ, Lafage V, Hostin RA, Bess S, Burton DC. Factors Associated with the Maintenance of Cost-Effectiveness at 5 Years in Adult Spinal Deformity Corrective Surgery. Spine (Phila Pa 1976) 2024:00007632-990000000-00613. [PMID: 38462731 DOI: 10.1097/brs.0000000000004982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/07/2024] [Indexed: 03/12/2024]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To evaluate factors associated with the long-term durability of cost-effectiveness (CE) in ASD patients. BACKGROUND A substantial increase in costs associated with the surgical treatment for adult spinal deformity (ASD) has given precedence to scrutinize the value and utility it provides. METHODS We included 327 operative ASD patients with 5-year (5 Y) follow-up. Published methods were used to determine costs based on CMS.gov definitions and were based on the average DRG reimbursement rates. Utility was calculated using quality-adjusted life-years (QALY) utilizing the Oswestry Disability Index (ODI) converted to Short-Form Six-Dimension (SF-6D), with a 3% discount applied for its decline with life expectancy. The CE threshold of $150,000 was used for primary analysis. RESULTS Major and minor complication rates were 11% and 47% respectively, with 26% undergoing reoperation by 5 Y. The mean cost associated with surgery was $91,095±$47,003, with a utility gain of 0.091±0.086 at 1Y, QALY gained at 2 Y of 0.171±0.183, and at 5 Y of 0.42±0.43. The cost per QALY at 2 Y was $414,885, which decreased to $142,058 at 5 Y.With the threshold of $150,000 for CE, 19% met CE at 2 Y and 56% at 5 Y. In those in which revision was avoided, 87% met cumulative CE till life expectancy. Controlling analysis depicted higher baseline CCI and pelvic tilt (PT) to be the strongest predictors for not maintaining durable CE to 5 Y (CCI OR: 1.821 [1.159-2.862], P=0.009) (PT OR: 1.079 [1.007-1.155], P=0.030). CONCLUSIONS Most patients achieved cost-effectiveness after four years postoperatively, with 56% meeting at five years postoperatively. When revision was avoided, 87% of patients met cumulative cost-effectiveness till life expectancy. Mechanical complications were predictive of failure to achieve cost-effectiveness at 2 Y, while comorbidity burden and medical complications were at 5 Y.
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Affiliation(s)
- Peter G Passias
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Jamshaid M Mir
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Pooja Dave
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Renaud Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - David Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Jeffrey P Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Gregory M Mundis
- Division of Orthopedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Naobumi Hosogane
- Department of Orthopedic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Stephen J Lewis
- Division of Orthopedics, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Robert A Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, The Och Spine Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher I Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Richard A Hostin
- Department of Orthopedic Surgery, Southwest Scoliosis Institute, Dallas, TX, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
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10
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Mooney J, Nathani KR, Zeitouni D, Michalopoulos GD, Wang MY, Coric D, Chan AK, Lu DC, Sherrod BA, Gottfried ON, Shaffrey CI, Than KD, Goldberg JL, Hussain I, Virk MS, Agarwal N, Glassman SD, Shaffrey ME, Park P, Foley KT, Chou D, Slotkin JR, Tumialán LM, Upadhyaya CD, Potts EA, Fu KMG, Haid RW, Knightly JJ, Mummaneni PV, Bisson EF, Asher AL, Bydon M. Does diabetes affect outcome or reoperation rate after lumbar decompression or arthrodesis? A matched analysis of the Quality Outcomes Database data set. J Neurosurg Spine 2024; 40:331-342. [PMID: 38039534 DOI: 10.3171/2023.9.spine23522] [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] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 09/25/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Diabetes mellitus (DM) is a known risk factor for postsurgical and systemic complications after lumbar spinal surgery. Smaller studies have also demonstrated diminished improvements in patient-reported outcomes (PROs), with increased reoperation and readmission rates after lumbar surgery in patients with DM. The authors aimed to examine longer-term PROs in patients with DM undergoing lumbar decompression and/or arthrodesis for degenerative pathology. METHODS The Quality Outcomes Database was queried for patients undergoing elective lumbar decompression and/or arthrodesis for degenerative pathology. Patients were grouped into DM and non-DM groups and optimally matched in a 1:1 ratio on 31 baseline variables, including the number of operated levels. Outcomes of interest were readmissions and reoperations at 30 and 90 days after surgery in addition to improvements in Oswestry Disability Index, back pain, and leg pain scores and quality-adjusted life-years at 90 days after surgery. RESULTS The matched decompression cohort comprised 7836 patients (3236 [41.3] females) with a mean age of 63.5 ± 12.6 years, and the matched arthrodesis cohort comprised 7336 patients (3907 [53.3%] females) with a mean age of 64.8 ± 10.3 years. In patients undergoing lumbar decompression, no significant differences in nonroutine discharge, length of stay (LOS), readmissions, reoperations, and PROs were observed. In patients undergoing lumbar arthrodesis, nonroutine discharge (15.7% vs 13.4%, p < 0.01), LOS (3.2 ± 2.0 vs 3.0 ± 3.5 days, p < 0.01), 30-day (6.5% vs 4.4%, p < 0.01) and 90-day (9.1% vs 7.0%, p < 0.01) readmission rates, and the 90-day reoperation rate (4.3% vs 3.2%, p = 0.01) were all significantly higher in the DM group. For DM patients undergoing lumbar arthrodesis, subgroup analyses demonstrated a significantly higher risk of poor surgical outcomes with the open approach. CONCLUSIONS Patients with and without DM undergoing lumbar spinal decompression alone have comparable readmission and reoperation rates, while those undergoing arthrodesis procedures have a higher risk of poor surgical outcomes up to 90 days after surgery. Surgeons should target optimal DM control preoperatively, particularly for patients undergoing elective lumbar arthrodesis.
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Affiliation(s)
- James Mooney
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Karim Rizwan Nathani
- 2Department of Neurologic Surgery, Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel Zeitouni
- 4Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
- 5Department of Neurosurgery, Atrium Health, Charlotte, North Carolina
| | - Giorgos D Michalopoulos
- 2Department of Neurologic Surgery, Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael Y Wang
- 6Department of Neurosurgery, University of Miami, Florida
| | - Domagoj Coric
- 7Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Andrew K Chan
- 8Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Daniel C Lu
- 9Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Brandon A Sherrod
- 10Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Oren N Gottfried
- 11Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher I Shaffrey
- 11Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Khoi D Than
- 11Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob L Goldberg
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Ibrahim Hussain
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Nitin Agarwal
- 24Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Mark E Shaffrey
- 14Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Paul Park
- 15Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kevin T Foley
- 16Department of Neurosurgery, University of Tennessee, Memphis, Tennessee
| | - Dean Chou
- 8Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | | | - Luis M Tumialán
- 18Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Cheerag D Upadhyaya
- 19Department of Neurosurgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Eric A Potts
- 20Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kai-Ming G Fu
- 12Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Regis W Haid
- 22Atlanta Brain and Spine Care, Atlanta, Georgia
| | - John J Knightly
- 23Atlantic Neurosurgical Specialists, Morristown, New Jersey; and
| | - Praveen V Mummaneni
- 21Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 10Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 4Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Mohamad Bydon
- 2Department of Neurologic Surgery, Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
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11
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Farber SH, Walker CT, Zhou JJ, Godzik J, Gandhi SV, de Andrada Pereira B, Koffie RM, Xu DS, Sciubba DM, Shin JH, Steinmetz MP, Wang MY, Shaffrey CI, Kanter AS, Yen CP, Chou D, Blaskiewicz DJ, Phillips FM, Park P, Mummaneni PV, Fessler RD, Härtl R, Glassman SD, Koski T, Deviren V, Taylor WR, Kakarla UK, Turner JD, Uribe JS. Reliability of a Novel Classification System for Thoracic Disc Herniations. Spine (Phila Pa 1976) 2024; 49:341-348. [PMID: 37134139 DOI: 10.1097/brs.0000000000004701] [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: 07/27/2022] [Accepted: 11/14/2022] [Indexed: 05/04/2023]
Abstract
STUDY DESIGN This is a cross-sectional survey. OBJECTIVE The aim was to assess the reliability of a proposed novel classification system for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA TDHs are complex entities varying substantially in many factors, including size, location, and calcification. To date, no comprehensive system exists to categorize these lesions. METHODS Our proposed system classifies 5 types of TDHs using anatomic and clinical characteristics, with subtypes for calcification. Type 0 herniations are small (≤40% of spinal canal) TDHs without significant spinal cord or nerve root effacement; type 1 are small and paracentral; type 2 are small and central; type 3 are giant (>40% of spinal canal) and paracentral; and type 4 are giant and central. Patients with types 1 to 4 TDHs have correlative clinical and radiographic evidence of spinal cord compression. Twenty-one US spine surgeons with substantial TDH experience rated 10 illustrative cases to determine the system's reliability. Interobserver and intraobserver reliability were determined using the Fleiss kappa coefficient. Surgeons were also surveyed to obtain consensus on surgical approaches for the various TDH types. RESULTS High agreement was found for the classification system, with 80% (range 62% to 95%) overall agreement and high interrater and intrarater reliability (kappa 0.604 [moderate to substantial agreement] and kappa 0.630 [substantial agreement], respectively). All surgeons reported nonoperative management of type 0 TDHs. For type 1 TDHs, most respondents (71%) preferred posterior approaches. For type 2 TDHs, responses were roughly equivalent for anterolateral and posterior options. For types 3 and 4 TDHs, most respondents (72% and 68%, respectively) preferred anterolateral approaches. CONCLUSIONS This novel classification system can be used to reliably categorize TDHs, standardize description, and potentially guide the selection of surgical approach. Validation of this system with regard to treatment and clinical outcomes represents a line of future study.
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Affiliation(s)
- S Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - James J Zhou
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Shashank V Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Bernardo de Andrada Pereira
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Robert M Koffie
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - David S Xu
- Department of Neurosurgery, Baylor University, Houston, TX
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra University, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | | | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami Hospital, Miami, FL
| | | | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA
| | - Dean Chou
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | | | - Frank M Phillips
- Department of Neurological Surgery, Rush University, Chicago, IL
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | | | - Roger Härtl
- Department of Neurosurgery, Weill Cornell Medicine, New York, NY
| | | | - Tyler Koski
- Department of Neurological Surgery, Northwestern University, Chicago, IL
| | - Vedat Deviren
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | - William R Taylor
- Department of Neurosurgery, University of California San Diego, San Diego, CA
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
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12
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Dada A, Tawil ME, Dietz N, Ambati VS, Chryssikos T, Theologis AA, Mummaneni PV. Resection of a Recurrent Lumbar Chordoma With Intradural Extension and Complex Dural Repair: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01063. [PMID: 38363140 DOI: 10.1227/ons.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/03/2024] [Indexed: 02/17/2024] Open
Abstract
Chordomas are derived from embryonic notochord remnants and comprise 1%-4% of all bone tumors.1 Nearly all chordomas arise in the axial skeleton, with 50% in the sacrococcygeal region, 35% in the skull base and 15% within mobile spine vertebrae.1,2 Regional recurrence after en bloc surgery is common and 30%-40% of patients develop metastatic disease.3-6 In this operative video, we present a 41-year old man who previously underwent en bloc lateral L1 corpectomy and received high-dose hybrid photon and proton radiation therapy for treatment of his L1 chordoma. On surveillance imaging, 2 years post op MRI revealed recurrence of the chordoma, now extending to the L2-3 epidural space. Further radiation alone was considered but was not performed due to lack of separation between the tumor and neural elements, thus increasing the risk of radiation-induced neurological injury. Combination revision surgical resection with subsequent boost radiation therapy was pursued instead. The technical nuances to achieve complex ventral and dorsal dural repair after removal of a transdural lumbar chordoma are shown in detail. Postoperatively, the patient had no new neurological deficits. At 13 months postoperatively, he reports no new pain, can ambulate without assistance, and completed 33 treatments of radiation therapy with proton beam. The patient consented to the procedure and to the publication of his image.
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Affiliation(s)
- Abraham Dada
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael E Tawil
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nicholas Dietz
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Vardhaan S Ambati
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Timothy Chryssikos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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13
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Park C, Shaffrey CI, Than KD, Michalopoulos GD, El Sammak S, Chan AK, Bisson EF, Sherrod BA, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner J, Agarwal N, Chou D, Chaudhry NS, Haid RW, Mummaneni PV, Bydon M, Gottfried ON. What factors influence surgical decision-making in anterior versus posterior surgery for cervical myelopathy? A QOD analysis. J Neurosurg Spine 2024; 40:206-215. [PMID: 37948703 DOI: 10.3171/2023.8.spine23194] [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] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/29/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE The aim of this study was to explore the preoperative patient characteristics that affect surgical decision-making when selecting an anterior or posterior operative approach in patients diagnosed with cervical spondylotic myelopathy (CSM). METHODS This was a multi-institutional, retrospective study of the prospective Quality Outcomes Database (QOD) Cervical Spondylotic Myelopathy module. Patients aged 18 years or older diagnosed with primary CSM who underwent multilevel (≥ 2-level) elective surgery were included. Demographics and baseline clinical characteristics were collected. RESULTS Of the 841 patients with CSM in the database, 492 (58.5%) underwent multilevel anterior surgery and 349 (41.5%) underwent multilevel posterior surgery. Surgeons more often performed a posterior surgical approach in older patients (mean 64.8 ± 10.6 vs 58.5 ± 11.1 years, p < 0.001) and those with a higher American Society of Anesthesiologists class (class III or IV: 52.4% vs 46.3%, p = 0.003), a higher rate of motor deficit (67.0% vs 58.7%, p = 0.014), worse myelopathy (mean modified Japanese Orthopaedic Association score 11.4 ± 3.1 vs 12.4 ± 2.6, p < 0.001), and more levels treated (4.3 ± 1.3 vs 2.4 ± 0.6, p < 0.001). On the other hand, surgeons more frequently performed an anterior surgical approach when patients were employed (47.2% vs 23.2%, p < 0.001) and had intervertebral disc herniation as an underlying pathology (30.7% vs 9.2%, p < 0.001). CONCLUSIONS The selection of approach for patients with CSM depends on patient demographics and symptomology. Posterior surgery was performed in patients who were older and had worse systemic disease, increased myelopathy, and greater levels of stenosis. Anterior surgery was more often performed in patients who were employed and had intervertebral disc herniation.
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Affiliation(s)
- Christine Park
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Khoi D Than
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Sally El Sammak
- 2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew K Chan
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Erica F Bisson
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brandon A Sherrod
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 6Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 7Department of Neurosurgery, University of Tennessee, Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 8Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 11Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay Turner
- 14Barrow Neurological Institute, Phoenix, Arizona
| | - Nitin Agarwal
- 15Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Dean Chou
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Nauman S Chaudhry
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia; and
| | - Praveen V Mummaneni
- 17Department of Neurosurgery, University of California, San Francisco, California
| | - Mohamad Bydon
- 2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Oren N Gottfried
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
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14
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Chryssikos T, Tawil ME, Ambati VS, Macki M, DiGiorgio AM, Mummaneni PV, Tan L. Real-Time Intraoperative Ultrasound Using a Minimally Invasive Transducer During Anterior Cervical Spine Surgery. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01034. [PMID: 38295396 DOI: 10.1227/ons.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/01/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intraoperative ultrasound (IOUS) during anterior cervical surgery is hindered by large transducer size and small operative corridor. We hypothesized that a linear (minimally invasive) transducer designed for transsphenoidal surgery can visualize the spinal cord, nerve roots, and surrounding structures during anterior cervical approaches, facilitating intraoperative assessment of central and foraminal decompression. METHODS IOUS was used to evaluate 26 levels in 17 patients (15 anterior cervical discectomy and fusion, 1 corpectomy, 1 arthroplasty) with a linear probe (7 × 6-mm end-fire transducer, 150-mm length, 12-15 MHz). After pin-based distraction, discectomy, and posterior longitudinal ligament resection, IOUS assessed adequacy of cord decompression and, following proximal foraminotomy or uncinectomy, nerve root decompression. If indicated, additional decompression was completed. Criteria for adequate central and foraminal decompression were visualization of subarachnoid space around the cord and cerebrospinal fluid pulsatility along the root sleeve/absence of nerve root compression distal to the root sleeve, respectively. RESULTS IOUS successfully visualized the cord, nerve roots, and surrounding structures in all 26 levels and influenced management in 11 levels (42.3%). IOUS indicated persistent cord and nerve root compression in 2 and 7 levels, respectively. Planned uncinectomy was aborted in 2 levels after IOUS demonstrated adequate nerve root decompression with intervertebral distraction/proximal foraminotomy alone. IOUS identified persistent nerve root compression after initial proximal foraminotomy in 4 levels and uncinectomy in 2 levels. An unplanned uncinectomy was performed in 1 level after IOUS showed persistent nerve root compression after multiple iterations of proximal foraminotomy. At follow-up (mean 3.1 months), the mean improvement in Numeric Rating Scale neck and arm pain, Neck Disability Index, and modified Japanese Orthopedic Association was 4.0%, 3.2%, 3.7%, and 0.7%, respectively. CONCLUSION The neural elements and their relationships to surrounding bone/soft tissue can be visualized using a minimally invasive IOUS transducer during anterior cervical surgery without having to remove pin-based distraction. This allows surgeons to intraoperatively verify the extent of central and foraminal decompression.
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Affiliation(s)
- Timothy Chryssikos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael E Tawil
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Vardhaan S Ambati
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Mohamed Macki
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Lee Tan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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15
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Tawil ME, Chryssikos T, Sorour O, Ambati VS, Jamieson A, Theologis AA, Kratz J, Mummaneni PV. Trans-Sternal Multilevel Corpectomy for Cervicothoracic Renal Cell Metastasis: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01024. [PMID: 38224228 DOI: 10.1227/ons.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/02/2023] [Indexed: 01/16/2024] Open
Abstract
The operative management of pathological fractures at the cervicothoracic junction is a surgical challenge. Here, we present the case of a 48-year-old male patient presenting with 2 months of progressive left upper extremity weakness as well as back and bilateral arm pain (Karnofsky Performance Status 60%) who was found to have pathological fractures from C7, T1, and T2 due to metastatic renal cell carcinoma. Renal cell carcinoma is known to metastasize to bone and cause cord compression.1 Given the extensive metastasis with this highly vascular tumor, endovascular embolization was performed preoperatively to minimize intraoperative blood loss.2 Surgical management consisted of a two-stage procedure. Posterior spinal fusion from C2-T7 with C7-T2 decompression was performed during stage 1. Stage 2 consisted of a trans-sternal approach for C7, T1, and T2 corpectomy for cord decompression and placement of a cage and plate for anterior column support.3 Although prior surgeons have suggested to access upper thoracic pathology through an interaortocaval window, in this case we demonstrate a trans-sternal approach to C6-T3 that starts superior to the innominate vein and aortic arch and angles inferiorly dorsal to these vascular structures.4 When planning for a manubriotomy/trans-sternal approach, access to T1/T2 remains the most decisive factor and is most successful with a sternotomy.5 At 12-month follow-up, the patient demonstrated improvement in his left upper extremity strength and overall functional status (3/5 strength in hand grip and interossei with 5/5 in all remaining motor groups; Karnofsky Performance Status 80%). The patient consented to participate in the surgery and surgical video.
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Affiliation(s)
- Michael E Tawil
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Timothy Chryssikos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Omar Sorour
- Department of Neurological Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Vardhaan S Ambati
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Alysha Jamieson
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Johannes Kratz
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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16
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Asher AL, Haid RW, Stroink AR, Michalopoulos GD, Alexander AY, Zeitouni D, Chan AK, Virk MS, Glassman SD, Foley KT, Slotkin JR, Potts EA, Shaffrey ME, Shaffrey CI, Park P, Upadhyaya C, Coric D, Tumialán LM, Chou D, Fu KMG, Knightly JJ, Orrico KO, Wang MY, Bisson EF, Mummaneni PV, Bydon M. Research using the Quality Outcomes Database: accomplishments and future steps toward higher-quality real-world evidence. J Neurosurg 2023; 139:1757-1775. [PMID: 37209070 DOI: 10.3171/2023.3.jns222601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/21/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE The Quality Outcomes Database (QOD) was established in 2012 by the NeuroPoint Alliance, a nonprofit organization supported by the American Association of Neurological Surgeons. Currently, the QOD has launched six different modules to cover a broad spectrum of neurosurgical practice-namely lumbar spine surgery, cervical spine surgery, brain tumor, stereotactic radiosurgery (SRS), functional neurosurgery for Parkinson's disease, and cerebrovascular surgery. This investigation aims to summarize research efforts and evidence yielded through QOD research endeavors. METHODS The authors identified all publications from January 1, 2012, to February 18, 2023, that were produced by using data collected prospectively in a QOD module without a prespecified research purpose in the context of quality surveillance and improvement. Citations were compiled and presented along with comprehensive documentation of the main study objective and take-home message. RESULTS A total of 94 studies have been produced through QOD efforts during the past decade. QOD-derived literature has been predominantly dedicated to spinal surgical outcomes, with 59 and 22 studies focusing on lumbar and cervical spine surgery, respectively, and 6 studies focusing on both. More specifically, the QOD Study Group-a research collaborative between 16 high-enrolling sites-has yielded 24 studies on lumbar grade 1 spondylolisthesis and 13 studies on cervical spondylotic myelopathy, using two focused data sets with high data accuracy and long-term follow-up. The more recent neuro-oncological QOD efforts, i.e., the Tumor QOD and the SRS Quality Registry, have contributed 5 studies, providing insights into the real-world neuro-oncological practice and the role of patient-reported outcomes. CONCLUSIONS Prospective quality registries are an important resource for observational research, yielding clinical evidence to guide decision-making across neurosurgical subspecialties. Future directions of the QOD efforts include the development of research efforts within the neuro-oncological registries and the American Spine Registry-which has now replaced the inactive spinal modules of the QOD-and the focused research on high-grade lumbar spondylolisthesis and cervical radiculopathy.
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Affiliation(s)
- Anthony L Asher
- 1Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | | | - Ann R Stroink
- 3Central Illinois Neuro Health Science, Bloomington, Illinois
| | - Giorgos D Michalopoulos
- 4Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 5Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - A Yohan Alexander
- 4Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 5Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel Zeitouni
- 1Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Andrew K Chan
- 6Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Michael S Virk
- 7Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Kevin T Foley
- 9Department of Neurosurgery, University of Tennessee, Memphis, Tennessee
| | | | - Eric A Potts
- 11Department of Neurological Surgery, Indiana University, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Mark E Shaffrey
- 12Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Christopher I Shaffrey
- 13Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Paul Park
- 9Department of Neurosurgery, University of Tennessee, Memphis, Tennessee
| | - Cheerag Upadhyaya
- 14Department of Neurosurgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Domagoj Coric
- 1Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Luis M Tumialán
- 15Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Dean Chou
- 6Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Kai-Ming G Fu
- 7Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 16Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Katie O Orrico
- 17Washington Office, American Association of Neurological Surgeons/Congress of Neurological Surgeons, Washington, DC
| | - Michael Y Wang
- 18Department of Neurosurgery, University of Miami, Florida
| | - Erica F Bisson
- 19Department of Neurological Surgery, University of Utah, Salt Lake City, Utah; and
| | - Praveen V Mummaneni
- 20Department of Neurological Surgery, University of California, San Francisco, California
| | - Mohamad Bydon
- 4Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 5Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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17
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Yee TJ, Mummaneni PV. Biomechanics of Cervical Disk Replacement: Classifying Arthroplasty Implants. Clin Spine Surg 2023; 36:386-390. [PMID: 37735758 DOI: 10.1097/bsd.0000000000001523] [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: 06/26/2023] [Accepted: 08/10/2023] [Indexed: 09/23/2023]
Abstract
Cervical disk arthroplasty has been employed with increased frequency over the past 2 decades as a motion-preserving alternative to anterior cervical discectomy and fusion in select patients with myelopathy or radiculopathy secondary to degenerative disk disease. As indications continue to expand, an understanding of cervical kinematics and materials science is helpful for optimal implant selection. Cervical disk arthroplasty implants can be classified according to the mode of articulation and df , articulation material, and endplate construction. The incorporation of translational and rotational df allows the implant to emulate the dynamic and coupled centers of movement in the cervical spine. Durable and low-friction interfaces at the articulation sustain optimal performance and minimize particulate-induced tissue reactions. Endplate materials must facilitate osseous integration to ensure implant stability after primary fixation. These cardinal considerations underlie the design of the 9 implants currently approved by the FDA and serve as the foundation for further biomimetic research and development.
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Affiliation(s)
- Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, CA
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18
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Yang E, Mummaneni PV, Chou D, Bydon M, Bisson EF, Shaffrey CI, Gottfried ON, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya CD, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Michalopoulos GD, Sherrod BA, Agarwal N, Haid RW, Chan AK. Cervical laminoplasty versus laminectomy and posterior cervical fusion for cervical myelopathy: propensity-matched analysis of 24-month outcomes from the Quality Outcomes Database. J Neurosurg Spine 2023; 39:671-681. [PMID: 37728378 DOI: 10.3171/2023.6.spine23345] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/08/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE Compared with laminectomy with posterior cervical fusion (PCF), cervical laminoplasty (CL) may result in different outcomes for those operated on for cervical spondylotic myelopathy (CSM). The aim of this study was to compare 24-month patient-reported outcomes (PROs) for laminoplasty versus PCF by using the Quality Outcomes Database (QOD) CSM data set. METHODS This was a retrospective study using an augmented data set from the prospectively collected QOD Registry Cervical Module. Patients undergoing laminoplasty or PCF for CSM were included. Using the nearest-neighbor method, the authors performed 1:1 propensity matching based on age, operated levels, and baseline modified Japanese Orthopaedic Association (mJOA) and visual analog scale (VAS) neck pain scores. The 24-month PROs, i.e., mJOA, Neck Disability Index (NDI), VAS neck pain, VAS arm pain, EQ-5D, EQ-VAS, and North American Spine Society (NASS) satisfaction scores, were compared. Only cases in the subaxial cervical region were included; those that crossed the cervicothoracic junction were excluded. RESULTS From the 1141 patients included in the QOD CSM data set who underwent anterior or posterior surgery for cervical myelopathy, 946 (82.9%) had 24 months of follow-up. Of these, 43 patients who underwent laminoplasty and 191 who underwent PCF met the inclusion criteria. After matching, the groups were similar for baseline characteristics, including operative levels (CL group: 4.0 ± 0.9 vs PCF group: 4.2 ± 1.1, p = 0.337) and baseline PROs (p > 0.05), except for a higher percentage involved in activities outside the home in the CL group (95.3% vs 81.4%, p = 0.044). The 24-month follow-up for the matched cohorts was similar (CL group: 88.4% vs PCF group: 83.7%, p = 0.534). Patients undergoing laminoplasty had significantly lower estimated blood loss (99.3 ± 91.7 mL vs 186.7 ± 142.7 mL, p = 0.003), decreased length of stay (3.0 ± 1.6 days vs 4.5 ± 3.3 days, p = 0.012), and a higher rate of routine discharge (88.4% vs 62.8%, p = 0.006). The CL cohort also demonstrated a higher rate of return to activities (47.2% vs 21.2%, p = 0.023) after 3 months. Laminoplasty was associated with a larger improvement in 24-month NDI score (-19.6 ± 18.9 vs -9.1 ± 21.9, p = 0.031). Otherwise, there were no 3- or 24-month differences in mJOA, mean NDI, VAS neck pain, VAS arm pain, EQ-5D, EQ-VAS, and distribution of NASS satisfaction scores (p > 0.05) between the cohorts. CONCLUSIONS Compared with PCF, laminoplasty was associated with decreased blood loss, decreased length of hospitalization, and higher rates of home discharge. At 3 months, laminoplasty was associated with a higher rate of return to baseline activities. At 24 months, laminoplasty was associated with greater improvements in neck disability. Otherwise, laminoplasty and PCF shared similar outcomes for functional status, pain, quality of life, and satisfaction. Laminoplasty and PCF achieved similar neck pain scores, suggesting that moderate preoperative neck pain may not necessarily be a contraindication for laminoplasty.
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Affiliation(s)
- Eunice Yang
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Praveen V Mummaneni
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Dean Chou
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Mohamad Bydon
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Erica F Bisson
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | | | - Oren N Gottfried
- 5Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Anthony L Asher
- 6Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 6Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 7Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 8Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 9Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 10Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 10Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 12Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag D Upadhyaya
- 13Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 14Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 14Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 15Barrow Neurological Institute, Phoenix, Arizona
| | | | - Brandon A Sherrod
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 16Department of Neurosurgery, University of Pittsburgh, Pennsylvania; and
| | - Regis W Haid
- 17Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Andrew K Chan
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
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19
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Patel A, Kondapavulur S, Umbach G, Chan AK, Le VP, Bisson EF, Bydon M, Chou D, Glassman SD, Foley KT, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin J, Asher AL, Virk MS, Haid RW, Gottfried O, Meyer S, Upadhyaya CD, Tumialán LM, Turner JD, Mummaneni PV. Greater improvement in Neck Disability Index scores in women after surgery for cervical myelopathy: an analysis of the Quality Outcomes Database. Neurosurg Focus 2023; 55:E7. [PMID: 37913530 DOI: 10.3171/2023.8.focus23423] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/29/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE There is a high prevalence of cervical myelopathy that requires surgery; as such, it is important to identify how different groups benefit from surgery. The American Association of Neurological Surgeons launched the Quality Outcomes Database (QOD), a prospective longitudinal registry, that includes demographic, clinical, and patient-reported outcome data to measure the safety and quality of neurosurgical procedures. In this study, the authors assessed the impact of gender on patient-reported outcomes in patients who underwent surgery for cervical myelopathy. METHODS The authors analyzed 1152 patients who underwent surgery for cervical myelopathy and were included in the QOD cervical module. Univariate comparison of baseline patient characteristics between males and females who underwent surgery for cervical spondylotic myelopathy was performed. Baseline characteristics that significantly differed between males and females were included in a multivariate generalized linear model comparing baseline and 1-year postoperative Neck Disability Index (NDI) scores. RESULTS This study included 546 females and 604 males. Females demonstrated significantly greater improvement in NDI score 1 year after surgery (p = 0.036). In addition to gender, the presence of axial neck pain and insurance status were also significantly predictive of improvement in NDI score after surgery (p = 0.0013 and p = 0.0058, respectively). CONCLUSIONS Females were more likely to benefit from surgery for cervical myelopathy compared with males. It is important to identify gender differences in postoperative outcomes after surgery in order to deliver more personalized and patient-centric care.
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Affiliation(s)
- Arati Patel
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Sravani Kondapavulur
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Gray Umbach
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew K Chan
- 2Department of Neurosurgery, Columbia University, New York, New York
| | - Vivian P Le
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 3Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 4Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Dean Chou
- 2Department of Neurosurgery, Columbia University, New York, New York
| | | | - Kevin T Foley
- 6Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | | | - Eric A Potts
- 8Goodman Campbell Brain and Spine, Carmel, Indiana
| | - Mark E Shaffrey
- 9Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Domagoj Coric
- 10Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - John J Knightly
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 6Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 12Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 13Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Anthony L Asher
- 10Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Michael S Virk
- 13Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Regis W Haid
- 15Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Oren Gottfried
- 7Department of Neurosurgery, Duke University Medical Center, Raleigh, North Carolina
| | - Scott Meyer
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Cheerag D Upadhyaya
- 16Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina; and
| | - Luis M Tumialán
- 17Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, Arizona
| | - Jay D Turner
- 17Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, Arizona
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
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20
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Campbell LJ, Mummaneni PV, Letchuman V, Langnas E, Agarwal N, Guan LS, Croci R, Vargas E, Reisner L, Bickler P, Chou D, Chang E, Guan Z. Mismatched opioid prescription in patients discharged after neurological surgeries: a retrospective cohort study. Pain 2023; 164:2615-2621. [PMID: 37326642 DOI: 10.1097/j.pain.0000000000002966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/22/2023] [Indexed: 06/17/2023]
Abstract
ABSTRACT Although postsurgical overprescription has been well-studied, postsurgical opioid underprescription remains largely overlooked. This retrospective cohort study was to investigate the extent of discharge opioid overprescription and underprescription in patients after neurological surgeries. Six thousand nine hundred forty-nine adult opioid-naive patients who underwent inpatient neurosurgical procedures at the University of California San Francisco were included. The primary outcome was the discrepancy between individual patient's prescribed daily oral morphine milligram equivalent (MME) at discharge and patient's own inpatient daily MME consumed within 24 hours of discharge. Analyses include Wilcoxon, Mann-Whitney, Kruskal-Wallis, and χ 2 tests, and linear or multivariable logistic regression. 64.3% and 19.5% of patients were opioid overprescribed and underprescribed, respectively, with median prescribed daily MME 360% and 55.2% of median inpatient daily MME in opioid overprescribed and underprescribed patients, respectively. 54.6% of patients with no inpatient opioid the day before discharge were opioid overprescribed. Opioid underprescription dose-dependently increased the rate of opioid refill 1 to 30 days after discharge. From 2016 to 2019, the percentage of patients with opioid overprescription decreased by 24.8%, but the percentage of patients with opioid underprescription increased by 51.2%. Thus, the mismatched discharge opioid prescription in patients after neurological surgeries presented as both opioid overprescription and underprescription, with a dose-dependent increased rate of opioid refill 1 to 30 days after discharge in opioid underprescription. Although we are fighting against opioid overprescription to postsurgical patients, we should not ignore postsurgical opioid underprescription.
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Affiliation(s)
- Liam J Campbell
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, United States
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Vijay Letchuman
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Erica Langnas
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
| | - Nitin Agarwal
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Lucy S Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Rhiannon Croci
- UCSF Health Informatics, University of California San Francisco, San Francisco, CA, United States
| | - Enrique Vargas
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Lori Reisner
- Department of Clinical Pharmacology, University of California San Francisco, San Francisco, CA, United States
| | - Phil Bickler
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurosurgery, Columbia University, New York, NY, United States
| | - Edward Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, United States
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21
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Lui A, Park C, Chryssikos T, Radabaugh H, Patel A, Aabedi AA, Ferguson AR, Torres Espin A, Mummaneni PV, Dhall SS, Duong-Fernandez X, Saigal R, Chou A, Pan J, Singh V, Hemmerle DD, Kyritsis N, Talbott JF, Pascual LU, Huie JR, Whetstone WD, Bresnahan JC, Beattie MS, Weinstein PR, Manley GT, DiGiorgio AM. Safety and comparative efficacy of initiating low-molecular-weight heparin within 24 hours of injury or surgery for venous thromboembolism prophylaxis in patients with spinal cord injury: a prospective TRACK-SCI registry study. Neurosurg Focus 2023; 55:E17. [PMID: 37778033 DOI: 10.3171/2023.7.focus23362] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) following traumatic spinal cord injury (SCI) is a significant clinical concern. This study sought to determine the incidence of VTE and hemorrhagic complications among patients with SCI who received low-molecular-weight heparin (LMWH) within 24 hours of injury or surgery and identify variables that predict VTE using the prospective Transforming Research and Clinical Knowledge in SCI (TRACK-SCI) database. METHODS The TRACK-SCI database was queried for individuals with traumatic SCI from 2015 to 2022. Primary outcomes of interest included rates of VTE (including deep vein thrombosis [DVT] and pulmonary embolism [PE]) and in-hospital hemorrhagic complications that occurred after LWMH administration. Secondary outcomes included intensive care unit and hospital length of stay, discharge location type, and in-hospital mortality. RESULTS The study cohort consisted of 162 patients with SCI. Fifteen of the 162 patients withdrew from the study, leading to loss of data for certain variables for these patients. One hundred thirty patients (87.8%) underwent decompression and/or fusion surgery for SCI. DVT occurred in 11 (7.4%) of 148 patients, PE in 9 (6.1%) of 148, and any VTE in 18 (12.2%) of 148 patients. The analysis showed that admission lower-extremity motor score (p = 0.0408), injury at the thoracic level (p = 0.0086), admission American Spinal Injury Association grade (p = 0.0070), and younger age (p = 0.0372) were significantly associated with VTE. There were 3 instances of postoperative spine surgery-related bleeding (2.4%) in the 127 patients who had spine surgery with bleeding complication data available, with one requiring return to surgery (0.8%). Thirteen (8.8%) of 147 patients had a bleeding complication not related to spine surgery. There were 2 gastrointestinal bleeds associated with nasogastric tube placement, 3 cases of postoperative non-spine-related surgery bleeding, and 8 cases of other bleeding complications (5.4%) not related to any surgery. CONCLUSIONS Initiation of LMWH within 24 hours was associated with a low rate of spine surgery-related bleeding. Bleeding complications unrelated to SCI surgery still occur with LMWH administration. Because neurosurgical intervention is typically the limiting factor in initializing chemical DVT prophylaxis, many of these bleeding complications would have likely occurred regardless of the protocol.
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Affiliation(s)
- Austin Lui
- 1College of Osteopathic Medicine, Touro University California, Vallejo
| | | | | | | | | | | | - Adam R Ferguson
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
- 5San Francisco Veterans Affairs Healthcare System, San Francisco, California
| | - Abel Torres Espin
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Praveen V Mummaneni
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Sanjay S Dhall
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Xuan Duong-Fernandez
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Rajiv Saigal
- 6Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Austin Chou
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Jonathan Pan
- Departments of2Neurological Surgery
- 7Anesthesia and Perioperative Care
| | | | - Debra D Hemmerle
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Nikos Kyritsis
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Jason F Talbott
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
- 9Radiology and Biomedical Imaging, and
| | - Lisa U Pascual
- 10Department of Orthopedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco
| | - J Russell Huie
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | | | - Jacqueline C Bresnahan
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Michael S Beattie
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
- 5San Francisco Veterans Affairs Healthcare System, San Francisco, California
| | - Philip R Weinstein
- Departments of2Neurological Surgery
- 8Neurology
- 12Weill Institute for Neurosciences, Institute for Neurodegenerative Diseases, Spine Center, University of California, San Francisco; and
| | - Geoffrey T Manley
- Departments of2Neurological Surgery
- 13Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Anthony M DiGiorgio
- Departments of2Neurological Surgery
- 3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
- 13Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
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22
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Berven SH, Mummaneni PV. Spinal Deformity Update. Neurosurg Clin N Am 2023; 34:xiii-xiv. [PMID: 37718116 DOI: 10.1016/j.nec.2023.06.017] [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] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Affiliation(s)
- Sigurd H Berven
- Department of Orthopaedic Surgery, UC San Francisco, 500 Parnassus Avenue, MU320W, San Francisco, CA 94143, USA.
| | - Praveen V Mummaneni
- UCSF Department of Neurosurgery, 505 Parnassus Avenue, M780, San Francisco, CA 94143, USA.
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23
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Park C, Agarwal N, Mummaneni PV, Berven SH. Spinopelvic Alignment: Importance in Spinal Pathologies and Realignment Strategies. Neurosurg Clin N Am 2023; 34:519-526. [PMID: 37718098 DOI: 10.1016/j.nec.2023.05.001] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Sagittal spinal malalignment can lead to pain, decreased function, dynamic imbalance, and compromise of patient-reported health status. The goal of reconstructive spine surgery is to restore spinal alignment parameters, and an understanding of appropriate patient-specific alignment is important for surgical planning and approaches. Radiographic spinopelvic parameters are strongly correlated with pain and function. The relationship between spinopelvic parameters and disability in adult spinal deformity patients is well-established, and optimal correction of sagittal alignment results in improved outcomes regarding patient health status and mechanical complications of surgery.
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Affiliation(s)
- Christine Park
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Sigurd H Berven
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
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24
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Macki M, Ambati VS, Park C, Tawil M, Dada A, Jamieson A, Wilkinson S, Chryssikos T, Mummaneni PV. Surgical resection of lumbar intradural metastatic renal cell carcinoma. Neurosurg Focus Video 2023; 9:V22. [PMID: 37859942 PMCID: PMC10583818 DOI: 10.3171/2023.7.focvid2379] [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] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/14/2023] [Indexed: 10/21/2023]
Abstract
A 60-year-old male with renal cell carcinoma (RCC) presented with back pain, weakness, and bowel and bladder urgency. MRI demonstrated a cauda equina tumor at L2. Following L1-3 laminectomies, intraoperative ultrasound localized the tumor. After dural opening, a vascular tumor was adherent to the cauda equina. Intraoperative nerve stimulation helped to identify the nerve rootlets. Tumor was removed in a piecemeal fashion. Tumor dissection caused periodic spasms in L1-3 distributions. A neuromonitoring checklist was used to recover motor evoked potential signals with elevated mean arterial pressures. Hemostasis was challenging with the vascular tumor. Intraoperative ultrasound confirmed tumor debulking. Pathology confirmed metastatic RCC.
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Affiliation(s)
- Mohamed Macki
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Vardhaan S Ambati
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Christine Park
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael Tawil
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Abraham Dada
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Alysha Jamieson
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Sean Wilkinson
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Timothy Chryssikos
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California
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25
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Park C, Shabani S, Agarwal N, Tan L, Mummaneni PV. Robotic-Assisted Surgery and Navigation in Deformity Surgery. Neurosurg Clin N Am 2023; 34:659-664. [PMID: 37718112 DOI: 10.1016/j.nec.2023.05.002] [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] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Deformity surgery is advancing quickly with the use of three-dimensional navigation and robotics. In spinal fusion, the use of robotics improves screw placement accuracy and reduces radiation, complications, blood loss, and recovery time. Currently, there is limited evidence showing that robotics is better than traditional freehand techniques. Most studies favoring robotics are small and retrospective due to the novelty of the technology in deformity surgery. Using these systems can also be expensive and time-consuming. Surgeons should use these advancements as tools, but not rely on them to replace surgical experience, anatomy knowledge, and good judgment.
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Affiliation(s)
- Christine Park
- Department of Neurological Surgery, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Saman Shabani
- Department of Neurological Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Lee Tan
- Department of Neurological Surgery, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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26
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Joiner EF, Mummaneni PV, Shaffrey CI, Chan AK. Posterior-based Osteotomies for Deformity Correction. Neurosurg Clin N Am 2023; 34:555-566. [PMID: 37718102 DOI: 10.1016/j.nec.2023.06.002] [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] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Posterior-based osteotomies are crucial to the restoration of lordosis in adult spinal deformity. Posterior-column osteotomies are suited for patients with an unfused anterior column and non-focal sagittal deformity requiring modest correction in lordosis. When performed on multiple levels, posterior-column osteotomy may provide significant harmonious correction in patients who require more extensive correction. Pedicle subtraction osteotomy and vertebral column resection are appropriate for patients with a fused anterior column and more severe deformity, particularly focal and/or multiplanar deformity. The power of pedicle subtraction osteotomy and vertebral column resection to provide greater correction and to address multiplanar deformity comes at the cost of higher complication rates than posterior-column osteotomy.
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Affiliation(s)
- Evan F Joiner
- Department of Neurological Surgery, Columbia University-NewYork Presbyterian Hospital, 710 West 168th Street, 4th Floor, New York, NY 10032, USA. https://twitter.com/efjoiner
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue M779, San Francisco, CA 94143, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Duke University, 40 Duke Medicine Circle Clinic 1B/1C, Durham, NC 27710, USA; Department of Orthopaedic Surgery, Duke University, 40 Duke Medicine Circle Clinic 1B/1C, Durham, NC 27710, USA
| | - Andrew K Chan
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Och Spine Hospital, 5141 Broadway, 3FW, New York, NY, USA.
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27
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Semonche A, Scheer JK, Shah VN, Fung M, Tan LA, Chou D, Mummaneni PV, Berven SH, Ames CP, Deviren V, Theologis AA, Clark AJ. Duration of neurological deficit and outcomes in the surgical treatment of spinal coccidioidomycosis. J Neurosurg Spine 2023; 39:419-426. [PMID: 37243554 DOI: 10.3171/2023.4.spine221210] [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] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 04/17/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention. METHODS This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery. RESULTS Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7-71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1-61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher's exact test). CONCLUSIONS The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.
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Affiliation(s)
| | | | | | - Monica Fung
- 3Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, California
| | | | | | | | - Sigurd H Berven
- 4Orthopaedic Surgery, University of California, San Francisco; and
| | | | - Vedat Deviren
- 4Orthopaedic Surgery, University of California, San Francisco; and
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28
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Liu J, Xie R, Chin CT, Rajagopalan P, Duan P, Li B, Burch S, Berven SH, Mummaneni PV, Chou D. Comparison of Lumbosacral Fusion Grade in Patients after Transforaminal and Anterior Lumbar Interbody Fusion with Minimum 2-Year Follow-Up. Orthop Surg 2023; 15:2334-2341. [PMID: 37526121 PMCID: PMC10475659 DOI: 10.1111/os.13812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 04/10/2023] [Accepted: 04/13/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE Generally, anterior lumbar interbody fusion (ALIF) was believed superior to transforaminal lumbar interbody fusion (TLIF) in induction of fusion. However, many studies have reported comparable results in lumbosacral fusion rate between the two approaches. This study aimed to evaluate the realistic lumbosacral arthrodesis rates following ALIF and TLIF in patients with degenerative spondylolisthesis as measured by CT and radiology. METHODS Ninety-six patients who underwent single-level L5-S1 fusion through ALIF (n = 48) or TLIF (n = 48) for degenerative spondylolisthesis at the Spine Center, University of California San Francisco, between October 2014 and December 2017 were retrospectively evaluated. Fusion was independently evaluated and categorized as solid fusion, indeterminate fusion, or pseudarthroses by two radiologists using the modified Brantigan-Steffee-Fraser (mBSF) grade. Clinical data on sex, age, body mass index, Meyerding grade, smoking status, follow-up times, complications, and radiological parameters including disc height, disc angle, segmental lordosis, and overall lumbar lordosis were collected. The fusion results and clinical and radiographic data were statistically compared between the ALIF and TLIF groups by using t-test or chi-square test. RESULTS The mean follow-up period was 37.5 (ranging from 24 to 51) months. Clear, solid radiographic fusions were higher in the ALIF group compared with the TLIF group at the last follow-up (75% vs 47.9%, p = 0.006). Indeterminate fusion occurred in 20.8% (10/48) of ALIF cases and in 43.8% (21/48) of TLIF cases (p = 0.028). Radiographic pseudarthrosis was not significantly different between the TLIF and ALIF groups (16.7% vs 8.3%; p = 0.677). In subgroup analysis of the patients without bone morphogenetic protein (BMP), the solid radiographic fusion rate was significantly higher in the ALIF group than that in the TLIF group (78.6% vs 45.5%; p = 0.037). There were no differences in sex, age, body mass index, Meyerding grade, smoking status, or follow-up time between the two groups (p > 0.05). The ALIF group had more improvement in disc height (7.8 mm vs 4.7 mm), disc angle (5.2° vs 1.5°), segmental lordosis (7.0° vs 2.5°), and overall lumbar lordosis (4.7° vs 0.7°) compared with the TLIF group (p < 0.05). Overall complication rates were similar between the TLIF and ALIF groups (10.4% vs 8.33%; p > 0.999). CONCLUSIONS With a minimum 2-year radiographic analysis of arthrodesis at lumbosacral level by radiologists, the rate of solid radiographic fusions was higher in the ALIF group compared with the TLIF group, whereas the TLIF group had a higher rate of indeterminate fusion. Radiographic pseudarthrosis did not differ significantly between the TLIF and ALIF groups.
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Affiliation(s)
- Jinping Liu
- Department of Neurosurgery, Sichuan Provincial People's HospitalUniversity of Electronic Science and Technology of ChinaChengduChina
- Department of NeurosurgeryUniversity of California San FranciscoSan FranciscoCAUSA
| | - Rong Xie
- Department of NeurosurgeryUniversity of California San FranciscoSan FranciscoCAUSA
- Department of NeurosurgeryHuashan Hospital, Fudan UniversityShanghaiChina
| | - Cynthia T. Chin
- Department of RadiologyUniversity of California San FranciscoSan FranciscoCAUSA
| | - Priya Rajagopalan
- Department of RadiologyUniversity of California San FranciscoSan FranciscoCAUSA
| | - Ping‐Guo Duan
- Department of NeurosurgeryUniversity of California San FranciscoSan FranciscoCAUSA
| | - Bo Li
- Department of NeurosurgeryUniversity of California San FranciscoSan FranciscoCAUSA
| | - Shane Burch
- Department of Orthopaedic SurgeryUniversity of California San FranciscoSan FranciscoCAUSA
| | - Sigurd H. Berven
- Department of Orthopaedic SurgeryUniversity of California San FranciscoSan FranciscoCAUSA
| | - Praveen V. Mummaneni
- Department of NeurosurgeryUniversity of California San FranciscoSan FranciscoCAUSA
| | - Dean Chou
- Department of NeurosurgeryColumbia UniversityNew YorkUSA
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29
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Ambati VS, Macki M, Chan AK, Michalopoulos GD, Le VP, Jamieson AB, Chou D, Shaffrey CI, Gottfried ON, Bisson EF, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Sherrod BA, Haid RW, Bydon M, Mummaneni PV. Three-level ACDF versus 3-level laminectomy and fusion: are there differences in outcomes? An analysis of the Quality Outcomes Database cervical spondylotic myelopathy cohort. Neurosurg Focus 2023; 55:E2. [PMID: 37657103 DOI: 10.3171/2023.6.focus23295] [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: 05/01/2023] [Accepted: 06/16/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE The authors sought to compare 3-level anterior with posterior fusion surgical procedures for the treatment of multilevel cervical spondylotic myelopathy (CSM). METHODS The authors analyzed prospective data from the 14 highest enrolling sites of the Quality Outcomes Database CSM module. They compared 3-level anterior cervical discectomy and fusion (ACDF) and posterior cervical laminectomy and fusion (PCF) surgical procedures, excluding surgical procedures crossing the cervicothoracic junction. Rates of reaching the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) were compared at 24 months postoperatively. Multivariable analyses adjusted for potential confounders elucidated in univariable analysis. RESULTS Overall, 199 patients met the inclusion criteria: 123 ACDF (61.8%) and 76 PCF (38.2%) patients. The 24-month follow-up rates were similar (ACDF 90.2% vs PCF 92.1%, p = 0.67). Preoperatively, ACDF patients were younger (60.8 ± 10.2 vs 65.0 ± 10.3 years, p < 0.01), and greater proportions were privately insured (56.1% vs 36.8%, p = 0.02), actively employed (39.8% vs 22.8%, p = 0.04), and independently ambulatory (14.6% vs 31.6%, p < 0.01). Otherwise, the cohorts had equivalent baseline modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), numeric rating scale (NRS)-arm pain, NRS-neck pain, and EQ-5D scores (p > 0.05). ACDF patients had reduced hospitalization length (1.6 vs 3.9 days, p < 0.01) and a greater proportion had nonroutine discharge (7.3% vs 22.8%, p < 0.01), but they had a higher rate of postoperative dysphagia (13.5% vs 3.5%, p = 0.049). Compared with baseline values, both groups demonstrated improvements in all outcomes at 24 months (p < 0.05). In multivariable analyses, after controlling for age, insurance payor, employment status, ambulation status, and other potential clinically relevant confounders, ACDF was associated with a greater proportion of patients with maximum satisfaction on the North American Spine Society Patient Satisfaction Index (NASS) (NASS score of 1) at 24 months (69.4% vs 53.7%, OR 2.44, 95% CI 1.17-5.09, adjusted p = 0.02). Otherwise, the cohorts shared similar 24-month outcomes in terms of reaching the MCID for mJOA, NDI, NRS-arm pain, NRS-neck pain, and EQ-5D score (adjusted p > 0.05). There were no differences in the 3-month readmission (ACDF 4.1% vs PCF 3.9%, p = 0.97) and 24-month reoperation (ACDF 13.5% vs PCF 18.6%, p = 0.36) rates. CONCLUSIONS In a cohort limited to 3-level fusion surgical procedures, ACDF was associated with reduced blood loss, shorter hospitalization length, and higher routine home discharge rates; however, PCF resulted in lower rates of postoperative dysphagia. The procedures yielded comparably significant improvements in functional status (mJOA score), neck and arm pain, neck pain-related disability, and quality of life at 3, 12, and 24 months. ACDF patients had significantly higher odds of maximum satisfaction (NASS score 1). Given comparable outcomes, patients should be counseled on each approach's complication profile to aid in surgical decision-making.
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Affiliation(s)
- Vardhaan S Ambati
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Mohamed Macki
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew K Chan
- 2Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | | | - Vivian P Le
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Alysha B Jamieson
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Dean Chou
- 2Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | | | - Oren N Gottfried
- 4Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 5Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 6Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 6Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 7Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 8Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 9Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 10Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 10Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 8Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Cheerag Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 14Barrow Neurological Institute, Phoenix, Arizona; and
| | - Brandon A Sherrod
- 5Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Regis W Haid
- 15Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Mohamad Bydon
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
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30
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Tawil ME, Chryssikos T, Rechav Ben-Natan A, Ambati VS, Guney E, Shah V, Abla AA, Mummaneni PV. Resection of a Thoracic Intradural Extramedullary Cavernoma Using Real-Time Intraoperative Ultrasound: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e174. [PMID: 37306964 PMCID: PMC10637418 DOI: 10.1227/ons.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/06/2023] [Indexed: 06/13/2023] Open
Affiliation(s)
- Michael E. Tawil
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Timothy Chryssikos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Alma Rechav Ben-Natan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Vardhaan S. Ambati
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ekin Guney
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Vinil Shah
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Adib A. Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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31
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Chan AK, Bisson EF, Bydon M, Mummaneni PV. Introduction. Toward a contemporaneous understanding of cervical spondylotic myelopathy. Neurosurg Focus 2023; 55:E1. [PMID: 37657106 DOI: 10.3171/2023.6.focus23412] [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] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Erica F Bisson
- 2Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Praveen V Mummaneni
- 4Department of Neurological Surgery, University of California, San Francisco, California
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32
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Bydon M, Bisson EF, Chan AK, Mummaneni PV. Editorial. Four-level anterior cervical discectomy and fusion: a cautionary tale. Neurosurg Focus 2023; 55:E5. [PMID: 37657111 DOI: 10.3171/2023.6.focus23449] [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] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Affiliation(s)
- Mohamad Bydon
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Erica F Bisson
- 2Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Andrew K Chan
- 3Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York; and
| | - Praveen V Mummaneni
- 4Department of Neurological Surgery, University of California, San Francisco, California
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33
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Arora A, Cummins DD, Wague A, Mendelis J, Samtani R, McNeill I, Theologis AA, Mummaneni PV, Berven S. Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review. Spine Deform 2023; 11:773-785. [PMID: 36811703 PMCID: PMC10261200 DOI: 10.1007/s43390-023-00654-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/21/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery. METHODS Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009). RESULTS Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization. CONCLUSIONS Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.
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Affiliation(s)
- Ayush Arora
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Daniel D Cummins
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Aboubacar Wague
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Joseph Mendelis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Rahul Samtani
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Ian McNeill
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University California, San Francisco, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA.
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Passias PG, Joujon-Roche R, Mir JM, Williamson TK, Tretiakov PS, Imbo B, Krol O, Passfall L, Ahmad S, Lebovic J, Owusu-Sarpong S, Lanre-Amos T, Protopsaltis T, Lafage R, Lafage V, Park P, Chou D, Mummaneni PV, Fu KMG, Than KD, Smith JS, Janjua MB, Schoenfeld AJ, Diebo BG, Vira S. Natural history of adult spinal deformity: how do patients with suboptimal surgical outcomes fare relative to nonoperative counterparts? J Neurosurg Spine 2023; 39:92-100. [PMID: 37060316 DOI: 10.3171/2023.2.spine22559] [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] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 02/20/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE Management of adult spinal deformity (ASD) has increasingly favored operative intervention; however, the incidence of complications and reoperations is high, and patients may fail to achieve idealized postsurgical results. This study compared health-related quality of life (HRQOL) metrics between patients with suboptimal surgical outcomes and those who underwent nonoperative management as a proxy for the natural history (NH) of ASD. METHODS ASD patients with 2-year data were included. Patients who were offered surgery but declined were considered nonoperative (i.e., NH) patients. Operative patients with suboptimal outcome (SOp)-defined as any reoperation, major complication, or ≥ 2 severe Scoliosis Research Society (SRS)-Schwab modifiers at follow-up-were selected for comparison. Propensity score matching (PSM) on the basis of baseline age, deformity, SRS-22 Total, and Charlson Comorbidity Index score was used to match the groups. ANCOVA and stepwise logistic regression analysis were used to assess outcomes between groups at 2 years. RESULTS In total, 441 patients were included (267 SOp and 174 NH patients). After PSM, 142 patients remained (71 SOp 71 and 71 NH patients). At baseline, the SOp and NH groups had similar demographic characteristics, HRQOL, and deformity (all p > 0.05). At 2 years, ANCOVA determined that NH patients had worse deformity as measured with sagittal vertical axis (36.7 mm vs 21.3 mm, p = 0.025), mismatch between pelvic incidence and lumbar lordosis (11.9° vs 2.9°, p < 0.001), and pelvic tilt (PT) (23.1° vs 20.7°, p = 0.019). The adjusted regression analysis found that SOp patients had higher odds of reaching the minimal clinically important differences in Oswestry Disability Index score (OR [95% CI] 4.5 [1.7-11.5], p = 0.002), SRS-22 Activity (OR [95% CI] 3.2 [1.5-6.8], p = 0.002), SRS-22 Pain (OR [95% CI] 2.8 [1.4-5.9], p = 0.005), and SRS-22 Total (OR [95% CI] 11.0 [3.5-34.4], p < 0.001). CONCLUSIONS Operative patients with SOp still experience greater improvements in deformity and HRQOL relative to the progressive radiographic and functional deterioration associated with the NH of ASD. The NH of nonoperative management should be accounted for when weighing the risks and benefits of operative intervention for ASD.
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Affiliation(s)
- Peter G Passias
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Rachel Joujon-Roche
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Jamshaid M Mir
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Tyler K Williamson
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Peter S Tretiakov
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Bailey Imbo
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Oscar Krol
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Lara Passfall
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Salman Ahmad
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Jordan Lebovic
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Stephane Owusu-Sarpong
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Tomi Lanre-Amos
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | - Themistocles Protopsaltis
- 1Departments of Orthopaedic and Neurological Surgery, Division of Spinal Surgery, NYU Langone Medical Center-Orthopaedic Hospital, New York
| | | | - Virginie Lafage
- 3Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Paul Park
- 4University of Michigan, Ann Arbor, Michigan
| | - Dean Chou
- 5Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - Praveen V Mummaneni
- 5Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - Kai-Ming G Fu
- 6Department of Neurosurgery, Cornell University School of Medicine, New York, New York
| | - Khoi D Than
- 7Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Justin S Smith
- 8Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - M Burhan Janjua
- 9Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Andrew J Schoenfeld
- 10Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bassel G Diebo
- 11Deparment of Orthopedic Surgery, SUNY Downstate, New York, New York; and
| | - Shaleen Vira
- 12Department of Orthopedic Surgery, UT Southwestern, Dallas, Texas
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35
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Chan AK, Shaffrey CI, Park C, Gottfried ON, Than KD, Bisson EF, Bydon M, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya CD, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Michalopoulos GD, Sherrod BA, Agarwal N, Chou D, Haid RW, Mummaneni PV. Do comorbid self-reported depression and anxiety influence outcomes following surgery for cervical spondylotic myelopathy? J Neurosurg Spine 2023; 39:11-27. [PMID: 37021762 DOI: 10.3171/2023.2.spine22685] [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] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 02/20/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Depression and anxiety are associated with inferior outcomes following spine surgery. In this study, the authors examined whether patients with cervical spondylotic myelopathy (CSM) who have both self-reported depression (SRD) and self-reported anxiety (SRA) have worse postoperative patient-reported outcomes (PROs) compared with patients who have only one or none of these comorbidities. METHODS This study is a retrospective analysis of prospectively collected data from the Quality Outcomes Database CSM cohort. Comparisons were made among patients who reported the following: 1) either SRD or SRA, 2) both SRD and SRA, or 3) neither comorbidity at baseline. PROs at 3, 12, and 24 months (scores for the visual analog scale [VAS] for neck pain and arm pain, Neck Disability Index [NDI], modified Japanese Orthopaedic Association [mJOA] scale, EQ-5D, EuroQol VAS [EQ-VAS], and North American Spine Society [NASS] patient satisfaction index) and achievement of respective PRO minimal clinically important differences (MCIDs) were compared. RESULTS Of the 1141 included patients, 199 (17.4%) had either SRD or SRA alone, 132 (11.6%) had both SRD and SRA, and 810 (71.0%) had neither. Preoperatively, patients with either SRD or SRA alone had worse scores for VAS neck pain (5.6 ± 3.1 vs 5.1 ± 3.3, p = 0.03), NDI (41.0 ± 19.3 vs 36.8 ± 20.8, p = 0.007), EQ-VAS (57.0 ± 21.0 vs 60.7 ± 21.7, p = 0.03), and EQ-5D (0.53 ± 0.23 vs 0.58 ± 0.21, p = 0.008) than patients without such disorders. Postoperatively, in multivariable adjusted analyses, baseline SRD or SRA alone was associated with inferior improvement in the VAS neck pain score and a lower rate of achieving the MCID for VAS neck pain score at 3 and 12 months, but not at 24 months. At 24 months, patients with SRD or SRA alone experienced less change in EQ-5D scores and were less likely to meet the MCID for EQ-5D than patients without SRD or SRA. Furthermore, patient self-reporting of both psychological comorbidities did not impact PROs at all measured time points compared with self-reporting of only one psychological comorbidity alone. Each cohort (SRD or SRA alone, both SRD and SRA, and neither SRD nor SRA) experienced significant improvements in mean PROs at all measured time points compared with baseline (p < 0.05). CONCLUSIONS Approximately 12% of patients who underwent surgery for CSM presented with both SRD and SRA, and 29% presented with at least one symptom. The presence of either SRD or SRA was independently associated with inferior scores for 3- and 12-month neck pain following surgery, but this difference was not significant at 24 months. However, at long-term follow-up, patients with SRD or SRA experienced lower quality of life than patients without SRD or SRA. The comorbid presence of both depression and anxiety was not associated with worse patient outcomes than either diagnosis alone.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork/Presbyterian, New York, New York
| | | | - Christine Park
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Oren N Gottfried
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Khoi D Than
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony L Asher
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 6Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 7Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 8Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 7Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
- 11Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag D Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 14Barrow Neurological Institute, Phoenix, Arizona
| | | | - Brandon A Sherrod
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 15Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Dean Chou
- 1Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork/Presbyterian, New York, New York
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 15Department of Neurological Surgery, University of California, San Francisco, California; and
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Mummaneni PV, Bydon M. Clinical Databases in Spine Surgery: Strength in Numbers. Neurosurgery 2023; 93:1-3. [PMID: 37318222 DOI: 10.1227/neu.0000000000002465] [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] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Affiliation(s)
- Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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37
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Shahrestani S, Chan AK, Bisson EF, Bydon M, Glassman SD, Foley KT, Shaffrey CI, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Park P, Wang MY, Fu KM, Slotkin JR, Asher AL, Virk MS, Michalopoulos GD, Guan J, Haid RW, Agarwal N, Chou D, Mummaneni PV. Developing nonlinear k-nearest neighbors classification algorithms to identify patients at high risk of increased length of hospital stay following spine surgery. Neurosurg Focus 2023; 54:E7. [PMID: 37283368 DOI: 10.3171/2023.3.focus22651] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 08/29/2022] [Accepted: 03/22/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Spondylolisthesis is a common operative disease in the United States, but robust predictive models for patient outcomes remain limited. The development of models that accurately predict postoperative outcomes would be useful to help identify patients at risk of complicated postoperative courses and determine appropriate healthcare and resource utilization for patients. As such, the purpose of this study was to develop k-nearest neighbors (KNN) classification algorithms to identify patients at increased risk for extended hospital length of stay (LOS) following neurosurgical intervention for spondylolisthesis. METHODS The Quality Outcomes Database (QOD) spondylolisthesis data set was queried for patients receiving either decompression alone or decompression plus fusion for degenerative spondylolisthesis. Preoperative and perioperative variables were queried, and Mann-Whitney U-tests were performed to identify which variables would be included in the machine learning models. Two KNN models were implemented (k = 25) with a standard training set of 60%, validation set of 20%, and testing set of 20%, one with arthrodesis status (model 1) and the other without (model 2). Feature scaling was implemented during the preprocessing stage to standardize the independent features. RESULTS Of 608 enrolled patients, 544 met prespecified inclusion criteria. The mean age of all patients was 61.9 ± 12.1 years (± SD), and 309 (56.8%) patients were female. The model 1 KNN had an overall accuracy of 98.1%, sensitivity of 100%, specificity of 84.6%, positive predictive value (PPV) of 97.9%, and negative predictive value (NPV) of 100%. Additionally, a receiver operating characteristic (ROC) curve was plotted for model 1, showing an overall area under the curve (AUC) of 0.998. Model 2 had an overall accuracy of 99.1%, sensitivity of 100%, specificity of 92.3%, PPV of 99.0%, and NPV of 100%, with the same ROC AUC of 0.998. CONCLUSIONS Overall, these findings demonstrate that nonlinear KNN machine learning models have incredibly high predictive value for LOS. Important predictor variables include diabetes, osteoporosis, socioeconomic quartile, duration of surgery, estimated blood loss during surgery, patient educational status, American Society of Anesthesiologists grade, BMI, insurance status, smoking status, sex, and age. These models may be considered for external validation by spine surgeons to aid in patient selection and management, resource utilization, and preoperative surgical planning.
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Affiliation(s)
- Shane Shahrestani
- 1Keck School of Medicine, University of Southern California, Los Angeles, California
- 2Department of Medical Engineering, California Institute of Technology, Pasadena, California
| | - Andrew K Chan
- 3Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Erica F Bisson
- 4Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 5Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin T Foley
- 7Department of Neurological Surgery, University of Tennessee
| | - Christopher I Shaffrey
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
- Departments of8Neurosurgery andOrthopedic Surgery, Duke University, Durham, North Carolina
| | - Eric A Potts
- 10Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Mark E Shaffrey
- 11Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Domagoj Coric
- 12Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - John J Knightly
- 13Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 7Department of Neurological Surgery, University of Tennessee
| | - Michael Y Wang
- 14Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 15Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Anthony L Asher
- 12Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Michael S Virk
- 15Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | | | - Jian Guan
- 4Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Regis W Haid
- 17Atlanta Brain and Spine Care, Atlanta, Georgia; and
| | - Nitin Agarwal
- 18Department of Neurological Surgery, University of California, San Francisco, California
| | - Dean Chou
- 3Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Praveen V Mummaneni
- 18Department of Neurological Surgery, University of California, San Francisco, California
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Park C, Mummaneni PV, Gottfried ON, Shaffrey CI, Tang AJ, Bisson EF, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Sherrod BA, Agarwal N, Chou D, Haid RW, Bydon M, Chan AK. Which supervised machine learning algorithm can best predict achievement of minimum clinically important difference in neck pain after surgery in patients with cervical myelopathy? A QOD study. Neurosurg Focus 2023; 54:E5. [PMID: 37283449 DOI: 10.3171/2023.3.focus2372] [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: 01/31/2023] [Accepted: 03/22/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the performance of different supervised machine learning algorithms to predict achievement of minimum clinically important difference (MCID) in neck pain after surgery in patients with cervical spondylotic myelopathy (CSM). METHODS This was a retrospective analysis of the prospective Quality Outcomes Database CSM cohort. The data set was divided into an 80% training and a 20% test set. Various supervised learning algorithms (including logistic regression, support vector machine, decision tree, random forest, extra trees, gaussian naïve Bayes, k-nearest neighbors, multilayer perceptron, and extreme gradient boosted trees) were evaluated on their performance to predict achievement of MCID in neck pain at 3 and 24 months after surgery, given a set of predicting baseline features. Model performance was assessed with accuracy, F1 score, area under the receiver operating characteristic curve, precision, recall/sensitivity, and specificity. RESULTS In total, 535 patients (46.9%) achieved MCID for neck pain at 3 months and 569 patients (49.9%) achieved it at 24 months. In each follow-up cohort, 501 patients (93.6%) were satisfied at 3 months after surgery and 569 patients (100%) were satisfied at 24 months after surgery. Of the supervised machine learning algorithms tested, logistic regression demonstrated the best accuracy (3 months: 0.76 ± 0.031, 24 months: 0.773 ± 0.044), followed by F1 score (3 months: 0.759 ± 0.019, 24 months: 0.777 ± 0.039) and area under the receiver operating characteristic curve (3 months: 0.762 ± 0.027, 24 months: 0.773 ± 0.043) at predicting achievement of MCID for neck pain at both follow-up time points, with fair performance. The best precision was also demonstrated by logistic regression at 3 (0.724 ± 0.058) and 24 (0.780 ± 0.097) months. The best recall/sensitivity was demonstrated by multilayer perceptron at 3 months (0.841 ± 0.094) and by extra trees at 24 months (0.817 ± 0.115). Highest specificity was shown by support vector machine at 3 months (0.952 ± 0.013) and by logistic regression at 24 months (0.747 ± 0.18). CONCLUSIONS Appropriate selection of models for studies should be based on the strengths of each model and the aims of the studies. For maximally predicting true achievement of MCID in neck pain, of all the predictions in this balanced data set the appropriate metric for the authors' study was precision. For both short- and long-term follow-ups, logistic regression demonstrated the highest precision of all models tested. Logistic regression performed consistently the best of all models tested and remains a powerful model for clinical classification tasks.
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Affiliation(s)
- Christine Park
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Praveen V Mummaneni
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Oren N Gottfried
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Anthony J Tang
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Erica F Bisson
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 6Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 7Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 8Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 11Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 14Barrow Neurological Institute, Phoenix, Arizona
| | - Brandon A Sherrod
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 15Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Dean Chou
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia; and
| | - Mohamad Bydon
- 17Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew K Chan
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
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Burke JF, Garcia JH, Safaee MM, Wong C, Gill SA, Chou D, Mummaneni PV, Deviren V, Ames CP, Clark AJ. Patient Frailty Influences Outcome After Open, But Not Minimally Invasive, Transforaminal Interbody Fusion: A Case Series of 115 Patients With Lumbar Degenerative Disease. Oper Neurosurg (Hagerstown) 2023; 24:565-571. [PMID: 36897093 PMCID: PMC10586842 DOI: 10.1227/ons.0000000000000665] [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] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 12/22/2022] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND For transforaminal lumbar interbody fusion (TLIF), there are equally good open and minimally invasive surgery (MIS) options. OBJECTIVE To determine if frailty has a differential effect on outcome for open vs MIS TLIF. METHODS We performed a retrospective review of 115 TLIF surgeries (1-3 levels) for lumbar degenerative disease performed at a single center; 44 MIS transforaminal interbody fusions and 71 open TLIFs were included. All patients had at least a 2-year follow up, and any revision surgery during that time was recorded. The Adult Spinal Deformity Frailty Index (ASD-FI) was used to separate patients into nonfrail (ASD-FI < 0.3) and frail (ASD-FI > 0.3) cohorts. The primary outcome variables were revision surgery and discharge disposition. Univariate analyses were performed to reveal associations in demographic, radiographic, and surgical data with the outcome variables. Multivariate logistic regression was used to assess independent predictors of outcome. RESULTS Frailty uniquely predicted both reoperation (odds ratio 8.1, 95% CI 2.5-26.1, P = .0005) and discharge to a location other than home (odds ratio 3.9, 95% CI 1.2-12.7, P = .0239). Post hoc analysis indicated that frail patients undergoing open TLIF had a higher revision surgery rate (51.72%) compared with frail patients undergoing MIS-TLIF (16.7%). Nonfrail patients undergoing open and MIS TLIF had a revision surgery rate of 7.5% and 7.7%, respectively. CONCLUSION Frailty was associated with increased revision rate and increased probability to discharge to a location other than home after open transforaminal interbody fusions, but not MIS transforaminal interbody fusions. These data suggest that patients with high frailty scores may benefit from MIS-TLIF procedures.
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Affiliation(s)
- John F. Burke
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Joseph H. Garcia
- School of Medicine, University of California, San Francisco, California, USA
| | - Michael M. Safaee
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Christopher Wong
- College of Osteopathic Medicine, Touro University California, Vallejo, California, USA
| | - Sabraj A. Gill
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, California, USA
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Aaron J. Clark
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Shabani S, Agarwal N, Ben-Natan AR, Huang J, Le VP, Chou D, Mummaneni PV. Technical Note: Hinged Table for Single-Position Navigated Lateral Surgery: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e441. [PMID: 36827189 DOI: 10.1227/ons.0000000000000648] [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] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/06/2022] [Indexed: 02/25/2023] Open
Affiliation(s)
- Saman Shabani
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Bydon M, Sardar ZM, Michalopoulos GD, El Sammak S, Chan AK, Carreon LY, Norheim E, Park P, Ratliff JK, Tumialán L, Pugely AJ, Steinmetz MP, Hsu W, Knightly JJ, Ziegenhorn DM, Donnelly PC, Mullen KJ, Rykowsky S, De A, Potts EA, Coric D, Wang MY, Qureshi S, Sethi RK, Fu KM, Patel AA, Yoon ST, Brodke D, Stroink AR, Bisson EF, Haid RW, Asher AL, Burton D, Mummaneni PV, Glassman SD. Representativeness of the American Spine Registry: a comparison of patient characteristics with the National Inpatient Sample. J Neurosurg Spine 2023:1-10. [PMID: 37148235 DOI: 10.3171/2023.3.spine221264] [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: 11/17/2022] [Accepted: 03/20/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE The American Spine Registry (ASR) is a collaborative effort between the American Academy of Orthopaedic Surgeons and the American Association of Neurological Surgeons. The goal of this study was to evaluate how representative the ASR is of the national practice with spinal procedures, as recorded in the National Inpatient Sample (NIS). METHODS The authors queried the NIS and the ASR for cervical and lumbar arthrodesis cases performed during 2017-2019. International Classification of Diseases, 10th Revision and Current Procedural Terminology codes were used to identify patients undergoing cervical and lumbar procedures. The two groups were compared for the overall proportion of cervical and lumbar procedures, age distribution, sex, surgical approach features, race, and hospital volume. Outcomes available in the ASR, such as patient-reported outcomes and reoperations, were not analyzed due to nonavailability in the NIS. The representativeness of the ASR compared to the NIS was assessed via Cohen's d effect sizes, and absolute standardized mean differences (SMDs) of < 0.2 were considered trivial, whereas > 0.5 were considered moderately large. RESULTS A total of 24,800 arthrodesis procedures were identified in the ASR for the period between January 1, 2017, and December 31, 2019. During the same time period, 1,305,360 cases were recorded in the NIS. Cervical fusions comprised 35.9% of the ASR cohort (8911 cases) and 36.0% of the NIS cohort (469,287 cases). The two databases presented trivial differences in terms of patient age and sex for all years of interest across both cervical and lumbar arthrodeses (SMD < 0.2). Trivial differences were also noted in the distribution of open versus percutaneous procedures of the cervical and lumbar spine (SMD < 0.2). Among lumbar cases, anterior approaches were more common in the ASR than in the NIS (32.1% vs 22.3%, SMD = 0.22), but the discrepancy among cervical cases in the two databases was trivial (SMD = 0.03). Small differences were illustrated in terms of race, with SMDs < 0.5, and a more significant discrepancy was identified in the geographic distribution of participating sites (SMDs of 0.7 and 0.74 for cervical and lumbar cases, respectively). For both of these measures, SMDs in 2019 were smaller than those in 2018 and 2017. CONCLUSIONS The ASR and NIS databases presented a very high similarity in proportions of cervical and lumbar spine surgeries, as well as similar distributions of age and sex, and distribution of open versus endoscopic approach. Slight discrepancies in anterior versus posterior approach among lumbar cases and patient race, and more significant discrepancies in geographic representation were also identified, yet decreasing trends in differences suggested the improving representativeness of the ASR over the course of time and its progressive growth. These conclusions are important to underline the external validity of quality investigations and research conclusions to be drawn from analyses in which the ASR is used.
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Affiliation(s)
- Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Giorgos D Michalopoulos
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sally El Sammak
- 1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew K Chan
- 4Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | | | | | - Paul Park
- 7Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - John K Ratliff
- 8Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Luis Tumialán
- 9Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew J Pugely
- 10Department of Orthopedic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Michael P Steinmetz
- 11Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wellington Hsu
- 12Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John J Knightly
- 13Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | | | | | - Kyle J Mullen
- 14American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | | | - Ayushmita De
- 14American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Eric A Potts
- 16Goodman Campbell Brain and Spine, St. Vincent Health, Indianapolis, Indiana
| | - Domagoj Coric
- 17Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Michael Y Wang
- 18Department of Neurosurgery, University of Miami, Florida
| | - Sheeraz Qureshi
- 19Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Rajiv K Sethi
- 20Neuroscience Institute, Virginia Mason Hospital, Seattle, Washington
| | - Kai-Ming Fu
- 21Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Alpesh A Patel
- 22Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - S Tim Yoon
- 23Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Darrel Brodke
- 22Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Ann R Stroink
- 24Central Illinois Neuro Health Science, Bloomington, Illinois
| | - Erica F Bisson
- 25Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Regis W Haid
- 26Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Anthony L Asher
- 17Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Doug Burton
- 27Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and
| | - Praveen V Mummaneni
- 28Department of Neurological Surgery, University of California, San Francisco, California
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Vargas E, Shabani S, Mummaneni PV, Park C, Rechav Ben-Natan A, Rivera JJ, Huang J, Berven S, Braunstein S, Chou D. Does surgery for metastatic spinal tumors improve functional outcomes in patients without spinal cord compression but with potentially unstable spines? J Neurosurg Spine 2023:1-8. [PMID: 37148234 DOI: 10.3171/2023.3.spine221120] [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: 10/06/2022] [Accepted: 03/21/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE In the absence of spinal cord compression, it is unclear if surgery is more effective than radiation treatment for improving functional outcomes in metastatic spinal tumor patients with potentially unstable spines. The authors compared functional status outcomes assessed with Karnofsky Performance Status (KPS) and Eastern Cooperative Oncology Group (ECOG) scores after surgery or radiation in patients without spinal cord compression with Spine Instability Neoplastic Score (SINS) values of 7-12 indicating possible instability (SINS 7-12). METHODS A retrospective review was performed of patients with metastatic spinal tumor SINS values of 7-12 at a single institution between 2004 and 2014. Patients were divided into two different groups: 1) those treated with surgery and 2) those treated with radiation. Baseline clinical characteristics were measured, and KPS and ECOG scores were obtained pre- and postradiation or postsurgery. The paired, nonparametric Wilcoxon signed-rank test and ordinal logistic regression analysis were used for statistical analysis. RESULTS A total of 162 patients met inclusion criteria; 63 patients were treated operatively and 99 patients were treated with radiation. The mean follow-up was 1.9 years, with a median of 1.1 years for the surgical cohort (ranging from 2.5 months to 13.8 years) and a mean of 2 years with a median of 0.8 years for the radiation cohort (ranging from 2 months to 9.3 years). After covariates were accounted for, the average posttreatment changes in KPS scores in the surgical cohort were 7.46 ± 17.3 and in the radiation cohort were -2 ± 13.6 (p = 0.045). No significant difference was observed in ECOG scores. KPS scores improved postoperatively in 60.3% of patients in the surgical group and postradiation in 32.3% of patients in the radiation cohort (p < 0.001). Subanalysis within the radiation cohort revealed no differences in fracture rates or local control between patients treated with external-beam radiation therapy versus stereotactic body radiation therapy. In patients initially treated with radiation, 21.2% eventually developed compression fractures at a treated level. Five of the 99 patients in the radiation cohort-all of whom had a fracture-eventually underwent either methyl methacrylate augmentation or instrumented fusion. CONCLUSIONS Patients with SINS values of 7-12 who underwent surgery had greater improvement in KPS scores-but not in ECOG scores-than patients undergoing radiation alone. In patients treated with radiation, treatment was converted to a procedural intervention such as surgery only in patients who sustained fractures. Of the patients with fractures after radiation (21 of 99), 5 patients underwent an invasive procedure and 16 did not.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Steve Braunstein
- 3Radiation Oncology, University of California, San Francisco, California; and
| | - Dean Chou
- Departments of1Neurological Surgery
- 4Department of Neurological Surgery, Columbia University, New York, New York
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Passias PG, Tretiakov PS, Nunley PD, Wang MY, Park P, Kanter AS, Okonkwo DO, Eastlack RK, Mundis GM, Chou D, Agarwal N, Fessler RG, Uribe JS, Anand N, Than KD, Brusko G, Fu KM, Turner JD, Le VP, Line BG, Ames CP, Smith JS, Shaffrey CI, Hart RA, Burton D, Lafage R, Lafage V, Schwab F, Bess S, Mummaneni PV. Incremental benefits of circumferential minimally invasive surgery for increasingly frail patients with adult spinal deformity. J Neurosurg Spine 2023:1-7. [PMID: 37086158 DOI: 10.3171/2023.2.spine221278] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/28/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE Circumferential minimally invasive surgery (cMIS) may provide incremental benefits compared with open surgery for patients with increasing frailty status by decreasing peri- and postoperative complications. METHODS Operative patients with adult spinal deformity (ASD) ≥ 18 years old with baseline and 2-year postoperative data were assessed. With propensity score matching, patients who underwent cMIS (cMIS group) were matched with similar patients who underwent open surgery (open group) based on baseline BMI, C7-S1 sagittal vertical axis, pelvic incidence to lumbar lordosis mismatch, and S1 pelvic tilt. The Passias modified ASD frailty index (mASD-FI) was used to determine patient frailty stratification as not frail, frail, or severely frail. Baseline and postoperative factors were assessed using two-way analysis of covariance (ANCOVA) and multivariate ANCOVA while controlling for baseline age, Charlson Comorbidity Index (CCI) score, and number of levels fused. RESULTS After propensity score matching, 170 ASD patients (mean age 62.71 ± 13.64 years, 75.0% female, mean BMI 29.25 ± 6.60 kg/m2) were included, split evenly between the cMIS and open groups. Surgically, patients in the open group had higher numbers of posterior levels fused (p = 0.021) and were more likely to undergo three-column osteotomies (p > 0.05). Perioperatively, cMIS patients had lower intraoperative blood loss and decreased use of cell saver across frailty groups (with adjustment for baseline age, CCI score, and levels fused), as well as fewer perioperative complications (p < 0.001). Adjusted analysis also revealed that compared to open patients, increasingly frail patients in the cMIS group were also more likely to demonstrate greater improvement in 1- and 2-year postoperative scores for the Oswestry Disability Index, SRS-36 (total), EQ-5D and SF-36 (all p < 0.05). With regard to postoperative complications, increasingly frail patients in the cMIS group were also noted to experience significantly fewer complications overall (p = 0.036) and fewer major intraoperative complications (p = 0.039). The cMIS patients were also less likely to need a reoperation than their open group counterparts (p = 0.043). CONCLUSIONS Surgery performed with a cMIS technique may offer acceptable outcomes, with diminishment of perioperative complications and mitigation of catastrophic outcomes, in increasingly frail patients who may not be candidates for surgery using traditional open techniques. However, further studies should be performed to investigate the long-term impact of less optimal alignment in this population.
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Affiliation(s)
- Peter G Passias
- 1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York
| | - Peter S Tretiakov
- 1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York
| | - Pierce D Nunley
- 2Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Michael Y Wang
- 3Department of Neurological Surgery, University of Miami, Florida
| | - Paul Park
- 4Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Adam S Kanter
- 5Department of Neurosurgery, Hoag Pickup Family Neurosciences Institute, Newport Beach, California
| | - David O Okonkwo
- 6Department of Neurological Surgery, Division of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert K Eastlack
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Gregory M Mundis
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Dean Chou
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Nitin Agarwal
- 6Department of Neurological Surgery, Division of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Richard G Fessler
- 9Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Juan S Uribe
- 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Neel Anand
- 11Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, California
| | - Khoi D Than
- 12Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Gregory Brusko
- 3Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 13Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Jay D Turner
- 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Vivian P Le
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Breton G Line
- 14Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Christopher P Ames
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Justin S Smith
- 15Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | | | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 17Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and
| | - Renaud Lafage
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Virginie Lafage
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Frank Schwab
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Shay Bess
- 14Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Praveen V Mummaneni
- 8Department of Neurological Surgery, University of California, San Francisco, California
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Vargas E, Haddad AF, Vasudevan H, Jacques LG, Mummaneni PV. 150 Genetic Markers of Peripheral Nerve Tumors: Results From the UCSF500 Cancer Gene Panel. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Patel A, Mummaneni PV, Zheng J, Rosner BI, Thombley R, Sorour O, Theodosopoulos PV, Aghi MK, Berger MS, Chang EF, Chou D, Manley GT, DiGiorgio AM. On-Call Junior Neurosurgery Residents Spend 9 hours of Their On-Call Shift Actively Using the Electronic Health Record. Neurosurgery 2023; 92:870-875. [PMID: 36729755 DOI: 10.1227/neu.0000000000002288] [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] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/03/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The electronic health record (EHR) is central to clinical workflow, yet few studies to date have explored EHR usage patterns among neurosurgery trainees. OBJECTIVE To describe the amount of EHR time spent by postgraduate year (PGY)-2 and PGY-3 neurosurgery residents during on-call days and the distribution of EHR activities in which they engage. METHODS This cohort study used the EHR audit logs, time-stamped records of user activities, to review EHR usage of PGY-2 and PGY-3 neurosurgery residents scheduled for 1 or more on-call days across 2 calendar years at the University of California San Francisco. We focused on the PGY-2 and PGY-3, which, in our training program, represent the primary participants in the in-house on-call pool. RESULTS Over 723 call days, 12 different residents took at least one on-call shift. The median (IQR) number of minutes that residents spent per on-call shift actively using the EHR was 536.8 (203.5), while interacting with an average (SD) of 68.1 (14.7) patient charts. There was no significant difference between Active EHR Time between residents as PGY-2 and PGY-3 on paired t -tests. Residents spent the most time on the following EHR activities: patient reports, notes, order management, patient list, and chart review. CONCLUSION Residents spent, on average, 9 hours of their on-call shift actively using the EHR, and there was no improved efficiency as residents gained experience. We noted several areas of administrative EHR burden, which could be reduced.
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Affiliation(s)
- Arati Patel
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jeff Zheng
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Benjamin I Rosner
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco, San Francisco, California, USA
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Robert Thombley
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco, San Francisco, California, USA
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Omar Sorour
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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Zaki MM, Joshi RS, Linzey JR, Strong MJ, Yee TJ, Saadeh YS, Upadhyaya CD, Coric D, Potts EA, Bisson EFR, Turner JD, Knightly J, Fu KMG, Foley KT, Tumialan LM, Shaffrey ME, Bydon M, Mummaneni PV, Chou D, Chan AK, Meyer SA, Asher AL, Shaffrey CI, Gottfried ON, Than KD, Wang MY, Buchholz A, Haid RW, Park P. 406 Assessing Correlations Between NASS Patient Satisfaction Index and Patient-Reported Outcomes (PROs) at 3-month, 12-month, and 24-month Timepoints in Patients Undergoing Cervical Spine Surgery Using the QOD Registry. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Chan AK, Letchuman V, Mummaneni PV, Burke JF, Agarwal N, Randy Bisson EF, Bydon M, Foley KT, Shaffrey CI, Glassman SD, Wang MY, Park P, Potts EA, Shaffrey ME, Coric D, Knightly JJ, Fu KMG, Slotkin J, Asher AL, Virk MS, Kerezoudis P, Alvi M, Guan J, Haid RW, DiGiorgio AM. 403 Inferior Clinical Outcomes for Patients with Medicaid Insurance Following Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Bisson EF, Mummaneni PV, Michalopoulos GD, El Sammak S, Chan AK, Agarwal N, Wang MY, Knightly JJ, Sherrod BA, Gottfried ON, Than KD, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Shabani S, Glassman SD, Tumialan LM, Turner JD, Uribe JS, Meyer SA, Lu DC, Buchholz AL, Upadhyaya C, Shaffrey ME, Park P, Foley KT, Coric D, Slotkin JR, Potts EA, Stroink AR, Chou D, Fu KMG, Haid RW, Asher AL, Bydon M. Sleep Disturbances in Cervical Spondylotic Myelopathy: Prevalence and Postoperative Outcomes-an Analysis From the Quality Outcomes Database. Clin Spine Surg 2023; 36:112-119. [PMID: 36920372 DOI: 10.1097/bsd.0000000000001454] [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: 10/16/2022] [Accepted: 01/25/2023] [Indexed: 03/16/2023]
Abstract
STUDY DESIGN Prospective observational study, level of evidence 1 for prognostic investigations. OBJECTIVES To evaluate the prevalence of sleep impairment and predictors of improved sleep quality 24 months postoperatively in cervical spondylotic myelopathy (CSM) using the quality outcomes database. SUMMARY OF BACKGROUND DATA Sleep disturbances are a common yet understudied symptom in CSM. MATERIALS AND METHODS The quality outcomes database was queried for patients with CSM, and sleep quality was assessed through the neck disability index sleep component at baseline and 24 months postoperatively. Multivariable logistic regressions were performed to identify risk factors of failure to improve sleep impairment and symptoms causing lingering sleep dysfunction 24 months after surgery. RESULTS Among 1135 patients with CSM, 904 (79.5%) had some degree of sleep dysfunction at baseline. At 24 months postoperatively, 72.8% of the patients with baseline sleep symptoms experienced improvement, with 42.5% reporting complete resolution. Patients who did not improve were more like to be smokers [adjusted odds ratio (aOR): 1.85], have osteoarthritis (aOR: 1.72), report baseline radicular paresthesia (aOR: 1.51), and have neck pain of ≥4/10 on a numeric rating scale. Patients with improved sleep noted higher satisfaction with surgery (88.8% vs 72.9%, aOR: 1.66) independent of improvement in other functional areas. In a multivariable analysis including pain scores and several myelopathy-related symptoms, lingering sleep dysfunction at 24 months was associated with neck pain (aOR: 1.47) and upper (aOR: 1.45) and lower (aOR: 1.52) extremity paresthesias. CONCLUSION The majority of patients presenting with CSM have associated sleep disturbances. Most patients experience sustained improvement after surgery, with almost half reporting complete resolution. Smoking, osteoarthritis, radicular paresthesia, and neck pain ≥4/10 numeric rating scale score are baseline risk factors of failure to improve sleep dysfunction. Improvement in sleep symptoms is a major driver of patient-reported satisfaction. Incomplete resolution of sleep impairment is likely due to neck pain and extremity paresthesia.
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Affiliation(s)
- Erica F Bisson
- Department of Neurological Surgery, University of Utah, Salt Lake City, UT
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
| | - Giorgos D Michalopoulos
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | - Sally El Sammak
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | - Andrew K Chan
- Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | - Nitin Agarwal
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO
| | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami, FL
| | | | - Brandon A Sherrod
- Department of Neurological Surgery, University of Utah, Salt Lake City, UT
| | - Oren N Gottfried
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | - Khoi D Than
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI
| | | | - Louis M Tumialan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | | | - Daniel C Lu
- Department of Neurosurgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Cheerag Upadhyaya
- Department of Neurosurgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Paul Park
- Department of Neurosurgery, University of Tennessee, Memphis, TN
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee, Memphis, TN
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery and Spine Associates, Carolinas Healthcare System, Charlotte, NC
| | | | - Eric A Potts
- Department of Neurological Surgery, Indiana University, Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Ann R Stroink
- Central Illinois Neuro Health Science, Bloomington, IL
| | - Dean Chou
- Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | | | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery and Spine Associates, Carolinas Healthcare System, Charlotte, NC
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
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49
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Patel A, Zheng J, Rosner B, Thombley R, Sorour O, Theodosopoulos PV, Aghi MK, Berger M, Chang E, Chou D, Manley G, Mummaneni PV, DiGiorgio AM. 416 On-Call Junior Neurosurgery Residents Spend 9 Hours of Their On-Call Shift Actively Using the Electronic Health Record. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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50
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Agarwal N, Blitstein J, Lui A, Torres-Espin A, Vasnarungruengkul C, Burke J, Mummaneni PV, Dhall SS, Weinstein PR, Duong-Fernandez X, Chou A, Pan J, Singh V, Ferguson AR, Hemmerle DD, Kyritsis N, Talbott JF, Whetstone WD, Bresnahan JC, Beattie MS, Manley GT, DiGiorgio A. Hypotension requiring vasopressor treatment and increased cardiac complications in elderly spinal cord injury patients: a prospective TRACK-SCI registry study. J Neurosurg Spine 2023:1-9. [PMID: 36933260 DOI: 10.3171/2023.2.spine221043] [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: 09/27/2022] [Accepted: 02/10/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE Increasing life expectancy has led to an older population. In this study, the authors analyzed complications and outcomes in elderly patients following spinal cord injury (SCI) using the established multi-institutional prospective study Transforming Research and Clinical Knowledge in SCI (TRACK-SCI) database collected in the Department of Neurosurgical Surgery at the University of California, San Francisco. METHODS TRACK-SCI was queried for elderly individuals (≥ 65 years of age) with traumatic SCI from 2015 to 2019. Primary outcomes of interest included total hospital length of stay, perioperative complications, postoperative complications, and in-hospital mortality. Secondary outcomes included disposition location, and neurological improvement based on the American Spinal Injury Association Impairment Scale (AIS) grade at discharge. Descriptive analysis, Fisher's exact test, univariate analysis, and multivariable regression analysis were performed. RESULTS The study cohort consisted of 40 elderly patients. The in-hospital mortality rate was 10%. Every patient in this cohort experienced at least 1 complication, with a mean of 6.6 separate complications (median 6, mode 4). The most common complication categories were cardiovascular, with a mean of 1.6 complications (median 1, mode 1), and pulmonary, with a mean of 1.3 (median 1, mode 0) complications, with 35 patients (87.5%) having at least 1 cardiovascular complication and 25 (62.5%) having at least 1 pulmonary complication. Overall, 32 patients (80%) required vasopressor treatment for mean arterial pressure (MAP) maintenance goals. The use of norepinephrine correlated with increased cardiovascular complications. Only 3 patients (7.5%) of the total cohort had an improved AIS grade compared with their acute level at admission. CONCLUSIONS Given the increased frequency of cardiovascular complications associated with vasopressor use in elderly SCI patients, caution is warranted when targeting MAP goals in these patients. A downward adjustment of blood pressure maintenance goals and prophylactic cardiology consultation to select the most appropriate vasopressor agent may be advisable for SCI patients ≥ 65 years of age.
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Affiliation(s)
| | - Jacob Blitstein
- 2College of Osteopathic Medicine, Touro University California, Vallejo
| | - Austin Lui
- 2College of Osteopathic Medicine, Touro University California, Vallejo
| | - Abel Torres-Espin
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | | | | | - Praveen V Mummaneni
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Sanjay S Dhall
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Philip R Weinstein
- 1Departments of Neurological Surgery.,5Radiology and Biomedical Imaging.,6Neurology
| | - Xuan Duong-Fernandez
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Austin Chou
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Jonathan Pan
- 1Departments of Neurological Surgery.,7Anesthesia and Perioperative Care, and
| | | | - Adam R Ferguson
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco.,8San Francisco Veterans Affairs Healthcare System, San Francisco, California; and
| | - Debra D Hemmerle
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Nikos Kyritsis
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Jason F Talbott
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco.,5Radiology and Biomedical Imaging
| | | | - Jacqueline C Bresnahan
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Michael S Beattie
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco.,8San Francisco Veterans Affairs Healthcare System, San Francisco, California; and
| | - Geoffrey T Manley
- 1Departments of Neurological Surgery.,10Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Anthony DiGiorgio
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco.,10Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
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