The Impact of Preoperative Spinal Injection Timing on Postoperative Complications of Lumbar Decompression Surgery

BACKGROUND AND OBJECTIVES

Epidural steroid injections (ESIs) are commonly used for lower back pain management. The effect of these injections on lumbar decompression surgery outcomes is hitherto underexplored. The study objective was to determine the impact of ESIs on postoperative rates of medical and surgical complications and to define the appropriate interval before lumbar decompression surgery.

METHODS

This retrospective all-payer database analysis identified 587 651 adult patients undergoing one- to three-level laminectomies from January 2010 to October 2021. A 2:1 propensity score match accounting for comorbidities, levels of surgery, and demographics was performed to create two cohorts: (1) 43 674 patients who had received an ESI in the 90 days before laminectomy and (2) 87 348 patients who had not received an ESI. The primary outcome was the rates of medical and surgical complications between groups at 30 days postoperatively. Patients were divided into five cohorts based on injection time before surgery: 1 to 30 days, 31 to 45 days, 46 to 60 days, 61 to 75 days, and 76 to 90 days. Logistic regression was performed between groups to identify temporal associations of complication rates. Confidence intervals of 95% are provided when appropriate. P values < .01 were considered significant.

RESULTS

Rates of medical complications within 30 days of surgery were significantly higher in those with ESI compared with control (4.83% vs 3.9%, P < .001). Cerebrospinal fluid (CSF) leak rates were increased in the ESI group at 0.28% vs 0.1% (P < .001), but surgical site infection rates were not significantly different between groups (1.31% vs 1.42% P = .11). ESI performed within 30 days was associated with increased odds of CSF leak (OR: 5.32, 95% CI: 3.96-7.15).

CONCLUSION

Preoperative ESI increases the risk of CSF leak and medical complications after lumbar decompression. Because these complications were significantly associated with ESIs given 1 to 30 days before surgery, avoiding ESIs at least 30 days before surgery may be advisable.

The Impact of Preoperative Antithrombotic Therapy on the Risks for Thrombo-ischemic Events and Bleeding among Patients Undergoing Elective Spine Surgery

STUDY DESIGN

Retrospective matched analysis.

PURPOSE

To evaluate the effect of antithrombotic drug therapy on the rates of thrombo-ischemic or bleeding events 90 days following elective spine surgery.

OVERVIEW OF LITERATURE

Thrombo-ischemic and bleeding complications in patients undergoing spine surgery are major causes of morbidity. Many patients who pursue elective spine surgery are concurrently receiving antithrombotic therapy for unrelated conditions; however, at this time, the effects of preoperative antithrombotic use on postoperative bleeding and thrombosis are unclear.

METHODS

Using an all-payer claims database, patients who underwent elective cervical and lumbar spine interventions between January 1, 2010, and June 30, 2018, were identified. Individuals were categorized into groups taking and not taking antithrombotics. A 1:1 analysis was constructed based on comorbidities found to be independently associated with bleeding or ischemic complications using logistic regression models. The primary outcomes were the rates of thrombo-ischemic events and bleeding complications.

RESULTS

A total of 660,866 patients were eligible for inclusion. Following the matching procedure, 56,476 patient records were analyzed, with 28,238 in each group. The antithrombotic agent group had significantly greater odds of developing any 90-day thromboischemic event after surgery: deep vein thrombosis (odds ratio [OR], 3.61; 95% confidence interval [CI], 3.06-4.25), pulmonary embolism (OR, 3.93; 95% CI, 3.34-4.62), myocardial infarction (OR, 6.20; 95% CI, 5.69-6.76), and ischemic stroke (OR, 3.76; 95% CI, 3.31-4.27). In addition, the antithrombotic agent group had an increased likelihood of experiencing hematoma (OR, 1.54; 95% CI, 1.35-1.76) and need for transfusion (OR, 2.61; 95% CI, 2.29-2.96).

CONCLUSIONS

Patients taking antithrombotic medications before elective surgery of the cervical and lumbar spine had increased risks of both ischemic and bleeding events. Spine surgeons should carefully consider these implications when appraising patients for surgery, given the lack of guidelines on perioperative management of antithrombotic agents.

Outcomes Following 2-Level Cervical Interventions with Cage-and-Plate, Zero-Profile, or Arthroplasty Constructs

BACKGROUND

Though cage-and-plate constructs are widely used for disk height restoration in surgery for cervical disc disease, concerns over range of motion limitations and adjacent disc space violations have fueled the development of artificial disc and zero-profile constructs. This study investigated the outcomes of patients undergoing two-level cervical interventions via arthroplasty, cage-and-plate, or zero-profile constructs.

METHODS

Patients undergoing two-level anterior cervical procedures between 2010 and 2020 were identified using an all-payer claims database. Logistic regression models were utilized to develop criteria for a 1:1:1-exact match procedure. The primary outcome was the need for additional surgery within 30 months, and the secondary outcomes included medical and surgical complications observed within 30 days of index intervention. P values < 0.05 were considered statistically significant.

RESULTS

133,831 patients were identified as undergoing two-level anterior cervical interventions. Seven thousand three hundred seventy-one records were analyzed through a 1:1:1 match. Patients who received zero-profile versus cage-and-plate constructs had significantly decreased odds of requiring additional surgery within 30 months (Odds Ratio [OR] 0.64; 95% Confidence Interval [CI] 0.51-0.81). However, postoperative medical complications were increased among patients who received zero-profile constructs compared to cage-and-plate (OR 1.59; 95%CI 1.07-2.37). Patients who underwent arthroplasty also had decreased odds for additional surgery versus cage-and-plate (OR 0.75; 95%CI 0.60-0.93). There was no significant difference between arthroplasty and cage-and-plate constructs in developing postoperative surgical or medical complications.

CONCLUSIONS

Among patients undergoing two-level interventions, cage-and-plate constructs were associated with increased odds of additional surgery within 30 months following index procedures when compared to zero-profile constructs or arthroplasty.

Gastrostomy Sequence With Ventriculoperitoneal Shunting-Does It Matter?

BACKGROUND

Neurological injury requiring ventriculoperitoneal shunt (VPS) placement often necessitates gastrostomy for nutritional support. The sequence of these procedures is debated over concerns for shunt infection and displacement requiring revisional surgery as a consequence of gastrostomy.

OBJECTIVE

To determine the optimal sequence of VPS shunt and gastrostomy tube placement in adults.

METHODS

In an all-payer database, adult patients undergoing gastrostomy and VPS placement were identified within 15 days between January 2010 and October 2021. Patients were categorized as receiving gastrostomy before, on the same day as, or after shunt placement. The primary outcomes of this study were rates of revision and infection. All outcomes were evaluated within 30 months after index shunting.

RESULTS

In total, 3015 patients were identified as undergoing VPS and gastrostomy procedures within 15 days. After a 1:1:1 match, 1080 patient records were analyzed. Revision rates at 30 months were significantly lower among patients who received VPS and gastrostomy procedures on the same day compared with gastrostomy after VPS (odds ratio [OR] 0.61, 95% CI 0.39-0.96). In addition, patients who received gastrostomy before VPS compared with those after had lower revision rates (OR 0.61, 95% CI 0.39-0.96) and infection (OR 0.46, 95% CI 0.21-0.99). No significant differences were noted in mechanical complication or shunt displacement rates.

CONCLUSION

Patients requiring VPS and gastrostomy may benefit from undergoing both procedures concurrently or with gastrostomy before VPS placement, secondary to lower revision rates. Patients undergoing gastrostomy before VPS have the added benefit of decreased infection rates.

Trends in Ruptured and Unruptured Aneurysmal Treatment from 2010 to 2020: A Focus on Flow Diversion

OBJECTIVE

Flow diverters are a promising new tool in the neurosurgeon's arsenal for aneurysm management. We sought to quantify the trends of flow diversion in comparison to traditional endovascular coiling and surgical clip ligation techniques in the United States from 2010 to 2020 with an emphasis on aneurysm location and preferences in usage for ruptured versus unruptured aneurysms.

METHODS

In this large cross-sectional study, patients aged 18 and older within the MARINER database were analyzed. Descriptive characteristics were calculated for all included patients. χ2 tests were used to compare categorical variables. P values < 0.05 were statistically significant.

RESULTS

A total of 45,542 procedures were conducted in the United States from 2010 to 2020 (clipping: 14,491; coiling: 28,840; flow diversion: 2211). The Southern United States had the largest operative volume across all 3 intervention types, closely followed by the Midwest. Aneurysms of the middle cerebral artery were mostly clipped, whereas coiling and flow diversion techniques were most utilized for anterior communicating and posterior communicating artery aneurysms. Flow diversion is growing most rapidly in the treatment of unruptured aneurysms, though there were also significant increases in usage for ruptured aneurysm treatment from 2019 to 2020.

CONCLUSIONS

Flow diverters have gained significant traction in the treatment for both unruptured and ruptured aneurysms. In the coming years, the indications and use of flow diversion will undoubtedly grow further, but excitement over their application should be tempered by the safety and efficacy data that continues to emerge.

Outcomes of patients undergoing single-level arthroplasty versus anterior lumbar interbody fusion

BACKGROUND

Compared to vertebral body fusion, artificial discs are thought to lessen the risks of adjacent segment disease and the need for additional surgery by maintaining spinal mobility as they mimic the intervertebral disc structure. No studies have compared the rates of postoperative complications and the requirement for secondary surgery at adjacent segments among patients who have undergone anterior lumbar interbody fusions (ALIF) versus those undergoing lumbar arthroplasty.

METHODS

An all-payer claims database identified 11,367 individuals who underwent single-level ALIF and lumbar arthroplasty for degenerative disc disease (DDD) between January 2010 and October 2020. Rates of complications following surgery, the need for additional lumbar surgeries, length of stay (LOS), and postoperative opioid utilization were assessed in matched cohorts based on logistic regression models. Kaplan-Meyer plots were created to model the probability of additional surgery.

RESULTS

Following 1:1 exact matching, 846 records of patients who had undergone ALIF or lumbar arthroplasty were analyzed. All-cause readmission within 30-30 days following surgery was significantly higher in patients undergoing ALIF versus arthroplasty (2.6% vs. 0.71%, p = 0.02). LOS was significantly lower among the patients who had undergone ALIF (1.043 ± 0.21 vs. 2.17 ± 1.7, p < .001).

CONCLUSIONS

ALIF and lumbar arthroplasty procedures are equally safe and effective in treating DDD. Our findings do not support that single-level fusions may biomechanically necessitate revisional surgeries.

Stem Cell Implants: Emerging Innovation for Stroke Recovery

Stroke is a debilitating neurovascular injury that those effects hundreds of thousands of Americans each year. Despite the high prevalence, disease morbidity and mortality, options for stroke intervention and rehabilitation are still limited. Stem cells have shown promise in stroke treatment due to their ability to self-renew and differentiate into different cell types. The primary sources of stem cells used today are bone marrow and fetal brain tissue, with mesenchymal stem cells, bone marrow stem cells and neural stem cells being particularly well-studied. By secreting therapeutic and neurogenic substances they are hypothesized to help foster recovery at the site of injury. Delivery mechanisms for stem cell therapy include intracerebral, intra-arterial, intraperitoneal, intravenous, intraventricular and intranasal routes with radiographic imaging now being used to monitor the progress of stem cell therapies. Stem cell implants have been found to be safe but optimal treatment strategies are still being established with several promising studies underway. Future efforts should continue to focus on improving efficacy, exploring alternative stem cell sources, enhancing migration capability and survival and educating stroke patients on the benefits and risks of stem cell therapy.

Postoperative Opioid Use Among Opioid-Naive Cannabis Users Following Single-Level Lumbar Fusions

BACKGROUND

As the literature grows on opioid use, the impact of simultaneous cannabis use has hitherto been mostly unexplored. In this study, we assessed the effects of cannabis use on postoperative opioid utilization in opioid-naive patients undergoing single level fusions of the lumbar spine.

METHODS

Using an all-payer claims database, the medical records of 91 million patients were analyzed to identify patients who had undergone single level lumbar fusions between January 2010 and October 2020. Rates of opioid utilization at 6 months following index procedure (morphine milligram equivalents/day), the development of opioid use disorder, and the rates of opioid overuse were assessed.

RESULTS

Following examination of 87,958 patient records, 454 patients were matched and distributed equally into cannabis user and non-cannabis user cohorts. At six months following index procedure, cannabis users were equal to non-users in their rates of prescribed opioid utilization (49.78%, p>.99). Cannabis users used smaller daily dosages compared to non-users (51.1±35.05 vs. 59.72±41, p=.003). On the other hand, the proportion of patients diagnosed with opioid use disorder was found to be significantly higher among patients using cannabis (18.94% vs. 3.96%, p<.0001).

CONCLUSION

Compared to non-cannabis users, opioid-naive patients who are cannabis users undergoing lumbar spinal fusions are at a higher risk of developing opioid dependence following surgery, despite having decreased daily dosages of opioids overall. Further studies should explore the factors associated with the development of opioid use disorder and the details of concurrent marijuana use to effectively treat pain while limiting the potential for abuse.

The impact of volunteering with a student-run free clinic on medical student specialty selection

BACKGROUND

The shortage of primary care physicians in the United States is expected to grow to 17,800-48,000 physicians by 2034. Student Run Free Clinics are an increasingly popular component of medical schools and may provide an avenue for increasing medical student interest in primary care specialties. However, there is limited research on the impact of Student Run Free Clinics on medical student specialty choice. This investigation sought to determine whether volunteering with the Interprofessional Community Clinic (ICC), the Student Run Free Clinic associated with Chicago Medical School, was associated with an increased likelihood of matching into primary care specialties. Secondarily, the authors investigated associations between volunteering and matching into family practice. Finally, the authors explored associations between volunteering and the competitiveness of specialty choice.

METHODS

This retrospective review utilized data on medical school graduates from 2015 - 2021 including their matched specialties, the number of ICC shifts they volunteered for, and whether they held an ICC leadership position (executive officers). Primary care specialties were defined as internal medicine, family practice, pediatrics, or combined internal medicine/pediatrics. Residency fill rate was used as a proxy for competitiveness.

RESULTS

This analysis included 506 medical students (254 ICC volunteers and 252 non-volunteers). Among ICC volunteers, 47.2% matched into a primary care specialty compared to 36.5% of non-volunteers (RR 1.29, 95% CI 1.05-1.59). Each additional shift worked at the ICC was correlated with increased odds of matching into family practice by a factor of 1.042 (95% CI 1.005-1.079).

CONCLUSIONS

Medical students who volunteered with the ICC were more likely to match into primary care residencies. Students who volunteered more frequently were more likely to match into family practice. Further investigation is warranted to determine whether these associations are causative and could thus be leveraged to encourage medical students to pursue primary care careers.

COVID-19 and Historic Influenza Vaccinations in the United States: A Comparative Analysis

The COVID-19 vaccination effort is a monumental global challenge. Recognizing and addressing the causes of vaccine hesitancy will improve vaccine uptake. The primary objective of this study was to compare the COVID-19 vaccination rates in US counties to historical vaccination rates for influenza in persons aged 65 and older. The secondary objective was to identify county-level demographic, socioeconomic, and political factors that influence vaccination rates. County level data were obtained from publicly available databases for comparison and to create predictive models. Overall, in US counties the COVID-19 vaccination rate exceeded influenza vaccination rates amongst those aged 65 or older (69.4.0% vs. 44%, p < 0.0001). 2690 (83.4%) of 3224 counties had vaccinated 50% or more of their 65 and older residents in the first seven months of the COVID-19 vaccination roll out. There were 467 (14.5%) of 3223 counties in which the influenza vaccination rate exceeded the COVID-19 vaccination rate. Most of these counties were in the Southern region, were considered politically "red" and had a significantly higher non-Hispanic Black resident population (14.4% vs. 8.2%, p < 0.0001). Interventions intended to improve uptake should account for nuances in vaccine access, confidence, and consider factual social media messaging, especially in vulnerable counties.

Artificial Intelligence in Epilepsy

Background

The study of seizure patterns in electroencephalography (EEG) requires several years of intensive training. In addition, inadequate training and human error may lead to misinterpretation and incorrect diagnosis. Artificial intelligence (AI)-based automated seizure detection systems hold an exciting potential to create paradigms for proper diagnosis and interpretation. AI holds the promise to transform healthcare into a system where machines and humans can work together to provide an accurate, timely diagnosis, and treatment to the patients.

Objective

This article presents a brief overview of research on the use of AI systems for pattern recognition in EEG for clinical diagnosis.

Material and Methods

The article begins with the need for understanding nonstationary signals such as EEG and simplifying their complexity for accurate pattern recognition in medical diagnosis. It also explains the core concepts of AI, machine learning (ML), and deep learning (DL) methods.

Results and Conclusions

In this present context of epilepsy diagnosis, AI may work in two ways; first by creating visual representations (e.g., color-coded paradigms), which allow persons with limited training to make a diagnosis. The second is by directly explaining a complete automated analysis, which of course requires more complex paradigms than the previous one. We also clarify that AI is not about replacing doctors and strongly emphasize the need for domain knowledge in building robust AI models that can work in real-time scenarios rendering good detection accuracy in a minimum amount of time.

The development and efficacy of a mobile phone application to improve medication adherence for persons with epilepsy in limited resource settings: A preliminary study

OBJECTIVE

Persons with epilepsy (PWE), especially those with limited education backgrounds from developing countries, are challenged by complicated medication regimens, debilitating seizures, and stigmatization in their daily life. Consequently, it is difficult for physicians to ensure medication adherence. This study validates a novel mobile application which was hypothesized to increase medication adherence and self-management skills in PWE. Created by medical professionals, the application included behavioral and educational components and was built to be easy-to-understand for those of socio-economically disadvantaged backgrounds.

METHODS

This was a parallel, two-armed randomized controlled trial in which a total of 96 participants were enrolled from a Neurology Outpatient Department into a control standard care group and a mobile application group that used the smartphone application (app) in addition to the standard medical treatment. The app was intuitive and easy to understand for those coming from a socio-economically disadvantaged background. Medication adherence and self-efficacy were assessed with the Morisky Green and Levine Scale (MGLS) and the Epilepsy Self Efficacy Scale (ESES). Patients were reassessed 12 weeks later. Change in seizure frequency following administration of the application was a secondary outcome.

RESULTS

In an intent-to-treat analysis, the mobile application interventional group showed over a 60% increase in the proportion of medication adherence (P < 0.0001). The mean self-efficacy score for the mobile application group was increased from 269.5 to 289.75 (P < 0.0001). The control group showed no statistically significant increases in either the proportion adherent or mean self-efficacy scores.

SIGNIFICANCE

This study demonstrated the statistically significant performance of a mobile application in improving medication adherence and self-management skills in Indian persons with epilepsy.