Natural language processing augments comorbidity documentation in neurosurgical inpatient admissions

OBJECTIVE

To establish whether or not a natural language processing technique could identify two common inpatient neurosurgical comorbidities using only text reports of inpatient head imaging.

MATERIALS AND METHODS

A training and testing dataset of reports of 979 CT or MRI scans of the brain for patients admitted to the neurosurgery service of a single hospital in June 2021 or to the Emergency Department between July 1-8, 2021, was identified. A variety of machine learning and deep learning algorithms utilizing natural language processing were trained on the training set (84% of the total cohort) and tested on the remaining images. A subset comparison cohort (n = 76) was then assessed to compare output of the best algorithm against real-life inpatient documentation.

RESULTS

For "brain compression", a random forest classifier outperformed other candidate algorithms with an accuracy of 0.81 and area under the curve of 0.90 in the testing dataset. For "brain edema", a random forest classifier again outperformed other candidate algorithms with an accuracy of 0.92 and AUC of 0.94 in the testing dataset. In the provider comparison dataset, for "brain compression," the random forest algorithm demonstrated better accuracy (0.76 vs 0.70) and sensitivity (0.73 vs 0.43) than provider documentation. For "brain edema," the algorithm again demonstrated better accuracy (0.92 vs 0.84) and AUC (0.45 vs 0.09) than provider documentation.

DISCUSSION

A natural language processing-based machine learning algorithm can reliably and reproducibly identify selected common neurosurgical comorbidities from radiology reports.

CONCLUSION

This result may justify the use of machine learning-based decision support to augment provider documentation.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Lumbar Decompression with and without Fusion for Lumbar Stenosis with Spondylolisthesis: A Cost Utility Analysis

STUDY DESIGN

Markov model.

OBJECTIVE

To compare the cost-effectiveness of lumbar decompression alone (DA) with lumbar decompression with fusion (DF) for the management of adults undergoing surgery for lumbar stenosis with associated degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Rates of lumbar fusion have increased for all indications in the United States over the last 20 years. Recent randomized controlled trial data, however, have suggested comparable functional outcomes and lower reoperation rates for lumbar decompression and fusion as compared to lumbar decompression alone in the treatment of lumbar stenosis with degenerative spondylolisthesis.

MATERIALS AND METHODS

A multi-state Markov model was constructed from the U.S. payer perspective of a hypothetical cohort of patients with LSS requiring surgery. Data regarding clinical improvement, costs, and reoperation were generated from contemporary randomized trial evidence, meta-analyses of recent prospective studies, and large retrospective cohorts. Base case, one-way sensitivity analysis, and probabilistic sensitivity analyses were conducted and results were compared to a willingness to pay threshold of $100,000 (in 2022 USD) over a 2-year time horizon. A discount rate of 3% was utilized.

RESULTS

The incremental cost and utility of decompression with fusion relative to decompression alone were $12,778 and 0.00529 QALYs. The corresponding ICER of $2,416,281 far exceeded a willingness to pay threshold of $100,000. In sensitivity analysis, the results varied the most with respect to rate of improvement after lumbar decompression alone, rate of improvement after lumbar decompression and fusion, and odds ratio of reoperation between the two groups. 0% of one-way and probabilistic sensitivity analyses achieved cost-effectiveness at the willingness to pay threshold.

CONCLUSIONS

Within the context of contemporary surgical data, DF is not cost effective compared with DA in the surgical management of LSS over a 2-year time horizon.

Disparities in Primary Spinal Osseous Malignant Bone Tumor Survival by Medicaid Status: A National Population-Based Risk Analysis

BACKGROUND

The impact of Medicaid status on survival outcomes of patients with spinal primary malignant bone tumors (sPMBT) has not been investigated.

METHODS

Using the SEER-Medicaid database, adults diagnosed between 2006 and 2013 with sPMBT including chordoma, osteosarcoma, chondrosarcoma, Ewing sarcoma, or malignant giant cell tumor (GCT) were studied. Five-year survival analysis was performed using the Kaplan-Meier method. Adjusted survival analysis was performed using Cox proportional-hazards regression controlling for age, sex, marital status, cancer stage, poverty level, vertebral versus sacral location, geography, rurality, tumor diameter, tumor grade, tumor histology, and therapy.

RESULTS

A total of 572 patients with sPMBT (Medicaid: 59, non-Medicaid: 513) were identified. Medicaid patients were more likely to be younger (P < 0.001), Black (P < 0.001), live in high poverty neighborhoods (P = 0.006), have distant metastases at diagnosis (P < 0.001), and less likely to receive surgery (P = 0.006). The 5-year survival rate was 65.7% (chondrosarcoma: 70.0%, chordoma: 91.5%, Ewing sarcoma: 44.6%, GCT: 90.0%, osteosarcoma: 34.2%). Medicaid patients had significantly worse 5-year survival than non-Medicaid patients (52.0% vs. 67.2%, P = 0.02). Minority individuals on Medicaid were associated with an increased risk of cancer-specific mortality compared with White non-Medicaid patients (adjusted hazard ratio [aHR] = 2.51, [95% CI 1.18-5.35], P = 0.017). Among Medicaid patients, those who received surgery had significantly better survival than those who did not (64.5% vs. 30.6%, P = 0.001). For all patients, not receiving surgery (aHR = 1.90 [1.23-2.95], P = 0.004) and tumor diameter >50 mm (aHR=1.89 [1.10-3.25], P = 0.023) were associated with an increased risk of mortality.

CONCLUSIONS

Medicaid patients may be less likely to receive surgery and suffer from poorer survival. These disparities may be especially prominent among minorities.

Postnatal Myelomeningocele Repair in the United States: Rates and Disparities Before and After the Management of Myelomeningocele Study Trial

BACKGROUND AND OBJECTIVES

Evolving technologies have influenced the practice of myelomeningocele repair (MMCr), including mandatory folic acid fortification, advances in prenatal diagnosis, and the 2011 Management of Myelomeningocele Study (MOMS) trial demonstrating benefits of fetal over postnatal MMCr in select individuals. Postnatal MMCr continues to be performed, especially for those with limitations in prenatal diagnosis, health care access, anatomy, or personal preference. A comprehensive, updated national perspective on the trajectory of postnatal MMCr volumes and patient disparities is absent. We characterize national trends in postnatal MMCr rates before and after the MOMS trial publication (2000-2010 vs 2011-2019) and examine whether historical disparities persist.

METHODS

This retrospective, cross-sectional analysis queried Nationwide Inpatient Sample data for postnatal MMCr admissions. Annual and race/ethnicity-specific rates were calculated using national birth registry data. Time series analysis assessed for trends relative to the year 2011. Patient, admission, and outcome characteristics were compared between pre-MOMS and post-MOMS cohorts.

RESULTS

Between 2000 and 2019, 12 426 postnatal MMCr operations were estimated nationwide. After 2011, there was a gradual, incremental decline in the annual rate of postnatal MMCr. Post-MOMS admissions were increasingly associated with Medicaid insurance and the lowest income quartiles, as well as increased risk indices, length of stay, and hospital charges. By 2019, race/ethnicity-adjusted rates seemed to converge. The mortality rate remained low in both eras, and there was a lower rate of same-admission shunting post-MOMS.

CONCLUSION

National rates of postnatal MMCr gradually declined in the post-MOMS era. Medicaid and low-income patients comprise an increasing majority of MMCr patients post-MOMS, whereas historical race/ethnicity-specific disparities are improving. Now more than ever, we must address disparities in the care of MMC patients before and after birth.

Microsurgical approach for resection of the filum terminale internum in tethered cord syndrome-a case demonstration of technical nuances and vignettes

BACKGROUND

In tethered cord syndrome due to filum terminale pathology, the surgical approach to achieve detethering of the spinal cord may vary. Traditionally, sectioning the filum through a laminectomy at the lumbosacral level is performed.

METHOD

A microsurgical technique at a higher level to approach the filum below the conus tip is performed. This allows for removal of the entire distal portion of the filum through a limited interlaminar approach and dural opening.

CONCLUSION

We propose a technique to transect the filum terminale below the conus tip and extract the distal filum by releasing it from its intradural attachments to minimize any remnants of the filum terminale.

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019

Importance

Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population.

Objective

To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019.

Design, Setting, and Participants

This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023.

Main Outcome and Measure

The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone.

Results

Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001).

Conclusions and Relevance

In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.

Charlson comorbidity index applied to shunted idiopathic normal pressure hydrocephalus

A series of epidemiological studies have shown the limited life expectancy of patients suffering from idiopathic normal pressure hydrocephalus (iNPH). In most cases, comorbid medical conditions are the cause of death, rather than iNPH. Though it has also been shown that shunting improves both life quality and lifetime. We sought to investigate the utility of the Charlson comorbidity index (CCI) for improved preoperative risk-benefit assessment of shunt surgery in individual iNPH cases. 208 shunted iNPH cases were prospectively investigated. Two in-person follow up visits at 3 and 12 months assessed postoperative clinical status. The correlation of the age adjusted CCI with survival was investigated over the median observation time of 2.37 years (IQR 1.16-4.15). Kaplan Meier statistics revealed that patients with a CCI score of 0-5 have a 5-year survival rate of 87%, compared to only 55% in patients with CCI > 5. Cox multivariate statistics revealed that the CCI was an independent predictor of survival, while common preoperative iNPH scores (modified Rankin Scale (mRS), gait score, and continence score) are not. As expected, mRS, gait, and continence scores improved during the postoperative follow up period, though relative improvement on any of these was not predicted by baseline CCI. The CCI is an easily applicable preoperative predictor of survival time in shunted iNPH patients. The lack of a correlation between the CCI and functional outcome means that even patients with multiple comorbidities and limited remaining lifetime may appreciate benefit from shunt surgery.

The burden of unhelmeted motorcycle injury: A nationwide scoring-based analysis of helmet safety legislation

INTRODUCTION

Motorcycle collisions comprise a large portion of motor vehicle injuries and fatalities with over 80,000 injuries and 5,500 fatalities per year in the United States. Unhelmeted riders have poor medical outcomes and generate billions in costs. Despite helmet use having been shown to lower the risk of neurological injury and death, helmet compliance is not universal, and legislation concerning helmet use also varies widely across the United States.

METHODS

In this study, we systematically reviewed helmet-related statutes from all US jurisdictions. We evaluated the stringency of these statutes using a legislative scoring system termed the Helmet Safety Score (HSS) ranging from 0-7 points, with higher scores denoting more stringent statutes. Regression modeling was used to predict unhelmeted mortality using our safety scores.

RESULTS

The mean score across all jurisdictions was 4.73. We found jurisdictions with higher HSS's generally had lower percentages of unhelmeted fatalities in terms of total fatalities as well as per 100,000 people and 100,000 registered motorcycles. In contrast, some lower-scoring jurisdictions had over 100 times more unhelmeted fatalities than higher-scoring jurisdictions. Our HSS significantly predicted unhelmeted motorcycle fatalities per 100,000 people (β = -0.228 per 1-point increase, 95% CI: -0.288 to -0.169, p < .0001) and per 100,000 registered motorcycles (β = -6.17 per 1-point increase, 95% CI: -8.37 to -3.98, p < .0001) in each state. Aspects of our score concerning helmet exemptions for riders and motorcycle-type vehicles independently predicted higher fatalities (p < .0001). Higher safety scores predicted lower unhelmeted fatalities.

CONCLUSION

Stringent helmet laws may be an effective mechanism for decreasing unhelmeted mortality. Therefore, universal helmet laws may be one such mechanism to decrease motorcycle-related neurological injury and fatality burden. In states with existing helmet laws, elimination of exemptions for certain riders and motorcycle-type vehicles may also decrease fatalities.

Superficial temporal artery injury and delayed post-cranioplasty infection

OBJECTIVE

Complications after cranioplasty after decompressive craniectomy (DC) have been reported to be as high as 40%. The superficial temporal artery (STA) is at substantial risk for injury in standard reverse question-mark incisions that are typically used for unilateral DC. The authors hypothesize that STA injury during craniectomy predisposes patients to post-cranioplasty surgical site infection (SSI) and/or wound complication.

METHODS

A retrospective study of all patients at a single institution who underwent cranioplasty after decompressive craniectomy and who underwent imaging of the head (computed tomography angiogram, magnetic resonance imaging with intravenous contrast, or diagnostic cerebral angiography) for any indication between the two procedures was undertaken. The degree of STA injury was classified and univariate statistics were used to compare groups.

RESULTS

Fifty-four patients met inclusion criteria. Thirty-three patients (61%) had evidence of complete or partial STA injury on pre-cranioplasty imaging. Nine patients (16.7%) developed either an SSI or wound complication after cranioplasty and, among these, four (7.4%) experienced delayed (>2 weeks from cranioplasty) complications. Seven of 9 patients required surgical debridement and cranioplasty explant. There was a stepwise but non-significant increase in post-cranioplasty SSI (STA present: 10%, STA partial injury: 17%, STA complete injury: 24%, P=0.53) and delayed post-cranioplasty SSI (STA present: 0%, STA partial injury: 8%, STA complete injury: 14%, P=0.26).

CONCLUSIONS

There is a notable but statistically non-significant trend toward increased rates of SSI in patients with complete or partial STA injury during craniectomy.

Time of Discharge and 30-Day Re-Presentation to an Acute Care Setting After Elective Lumbar Decompression Surgery

BACKGROUND

Evidence regarding the consequence of efforts to increase patient throughput and decrease length of stay in the context of elective spine surgery is limited.

OBJECTIVE

To evaluate whether early time of discharge results in increased rates of hospital readmission or return to emergency department for patients admitted after elective, posterior, lumbar decompression surgery.

METHODS

We conducted a retrospective cohort study of 779 patients admitted to hospital after undergoing elective, posterior, lumbar decompression surgery. Multiple logistic regression evaluated the relationship between time of discharge and the primary outcome of return to acute care within 30 days, while controlling for sociodemographic, procedural, and discharge characteristics.

RESULTS

In multiple logistic regression, time of discharge earlier in the day was not associated with increased odds of return to acute care within 30 days (odds ratio [OR] 1.18, 95% CI 0.92-1.52, P = .19). Weekend discharge (OR 1.99, 95% CI 1.04-3.79, P = .04) increased the likelihood of return to acute care. Surgeon experience (<1 year of attending practice, OR 0.43, 95% CI 0.19-1.00, P = .05 and 2-5 years of attending practice, OR 0.50, 95% CI 0.25-1.01, P = .054), weekend discharge (OR 0.49, 95% CI 0.27-0.89, P = .02), and physical therapy evaluation (OR 0.20, 95% CI 0.12-0.33, P < .001) decreased the likelihood of discharge before noon.

CONCLUSION

Time of discharge is not associated with risk of readmission or presentation to the emergency department after elective lumbar decompression. Weekend discharge is independently associated with increased risk of readmission and decreased likelihood of prenoon discharge.

The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691 821 Nationwide Cases

BACKGROUND

Frailty, a decline in physiological reserve, prognosticates poorer outcomes for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury outcomes is not well characterized.

OBJECTIVE

To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort.

METHODS

We identified all adult admissions for tICH in the National Trauma Data Bank from 2007 to 2017. Frailty was quantified using the validated modified 5-item Frailty Index (mFI-5) metric (range = 0-5), with mFI-5 ≥2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition, complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression assessed the association between mFI-5 and outcomes, adjusting for patient demographics, hospital characteristics, injury severity, and neurosurgical intervention.

RESULTS

A total of 691 821 tICH admissions were analyzed. The average age was 57.6 years. 18.0% of patients were frail (mFI-5 ≥ 2). Between 2007 and 2017, the prevalence of frailty grew from 7.9% to 21.7%. Frailty was associated with increased odds of mortality (odds ratio [OR] = 1.36, P < .001) and decreased odds of favorable discharge disposition (OR = 0.72, P < .001). Frail patients exhibited an elevated rate of complications (OR = 1.06, P < .001), including unplanned return to the ICU (OR = 1.55, P < .001) and operating room (OR = 1.17, P = .003). Finally, frail patients experienced increased ventilator days (+12%, P < .001), ICU LOS (+11%, P < .001), and total LOS (+13%, P < .001). All associations with death and disposition remained significant after stratification for age, trauma severity, and neurosurgical intervention.

CONCLUSION

For patients with tICH, frailty predicted higher mortality and morbidity, independent of age or injury severity.

Frailty independently predicts unfavorable discharge in non-operative traumatic brain injury: A retrospective single-institution cohort study

BACKGROUND

Frailty is associated with adverse outcomes in traumatically injured geriatric patients but has not been well-studied in geriatric Traumatic Brain Injury (TBI).

OBJECTIVE

To assess relationships between frailty and outcomes after TBI.

METHODS

The records of all patients aged 70 or older admitted from home to the neurosurgical service of a single institution for non-operative TBI between January 2020 and July 2021 were retrospectively reviewed. The primary outcome was adverse discharge disposition (either in-hospital expiration or discharge to skilled nursing facility (SNF), hospice, or home with hospice). Secondary outcomes included major inpatient complication, 30-day readmission, and length of stay.

RESULTS

100 patients were included, 90% of whom presented with Glasgow Coma Score (GCS) 14-15. The mean length of stay was 3.78 days. 7% had an in-hospital complication, and 44% had an unfavorable discharge destination. 49% of patients attended follow-up within 3 months. The rate of readmission within 30 days was 13%. Patients were characterized as low frailty (FRAIL score 0-1, n = 35, 35%) or high frailty (FRAIL score 2-5, n = 65, 65%). In multivariate analysis controlling for age and other factors, frailty category (aOR 2.63, 95CI [1.02, 7.14], p = 0.005) was significantly associated with unfavorable discharge. Frailty was not associated with increased readmission rate, LOS, or rate of complications on uncontrolled univariate analyses.

CONCLUSION

Frailty is associated with increased odds of unfavorable discharge disposition for geriatric patients admitted with TBI.

Utility of automated MRI perfusion (RAPID) with or without MR angiography for detection of angiographic vasospasm after aneurysmal subarachnoid hemorrhage

Delayed cerebral ischemia (DCI) is a major etiology of poor neurologic outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Although the development of DCI is certainly multifactorial, the presence of vasospasm is strongly correlated with it. Cerebral angiography remains the gold standard for evaluation of vasospasm, though it is not always practical or cost-effective. In this study, the authors assess the utility of automated MRI Perfusion imaging, with or without MR Angiography (MRA), as a confirmatory tool for suspected angiographic vasospasm. All patients admitted to a single institution with aneurysmal subarachnoid hemorrhage between January 2014 and February 2020 and who underwent MR Perfusion imaging with or without MRA for suspected vasospasm no >24 h prior to an angiogram were identified. 43 subjects were identified. 29 of these patients (67%) underwent simultaneous MRA. 25 patients (53%) received intra-arterial treatment for symptomatic vasospasm. The sensitivity, specificity, PPV, and NPV of MR Perfusion were 43%, 82%, 53%, and 75% for any angiographic vasospasm and 57%, 81%, 42%, and 89% for treated vasospasm. The sensitivity, specificity, PPV, and NPV of MR Perfusion in conjunction with MRA were 61%, 81%, 59%, and 82% for any angiographic vasospasm and 62%, 74%, 35%, and 89% for treated vasospasm. The sensitivity, specificity, PPV, and NPV of transcranial Dopplers (TCDs) in these patients were 35%, 93%, 71%, and 75% for angiographic vasospasm and 42%, 90%, 47%, and 88% for treated vasospasm. Automated MR Perfusion imaging demonstrated relatively low sensitivity and PPV for detection of angiographic and treated vasospasm in this subset of patients after aSAH.

Influence of Time of Discharge and Length of Stay on 30-Day Outcomes After Elective Anterior Cervical Spine Surgery

BACKGROUND

Encouraging early time of discharge (TOD) for medical inpatients is commonplace and may potentially improve patient throughput. It is unclear, however, whether early TOD after elective spine surgery achieves this goal without a consequent increase in re-presentations to the hospital.

OBJECTIVE

To evaluate whether early TOD results in increased rates of hospital readmission or return to the emergency department after elective anterior cervical spine surgery.

METHODS

We analyzed 686 patients who underwent elective uncomplicated anterior cervical spine surgery at a single institution. Logistic regression was used to evaluate the relationship between sociodemographic, procedural, and discharge characteristics, and the outcomes of readmission or return to the emergency department and TOD.

RESULTS

In multiple logistic regression, TOD was not associated with increased risk of readmission or return to the emergency department within 30 days of surgery. Weekend discharge (odds ratio [OR] 0.33, 95% CI 0.21-0.53), physical therapy evaluation (OR 0.44, 95% CI 0.28-0.71), and occupational therapy evaluation (OR 0.32, 95% CI 0.17-0.63) were all significantly associated with decreased odds of discharge before noon. Disadvantaged status, as measured by area of deprivation index, was associated with increased odds of readmission or re-presentation (OR 1.86, 95% CI 0.95-3.66), although this result did not achieve statistical significance.

CONCLUSION

There does not appear to be an association between readmission or return to the emergency department and early TOD after elective spine surgery. Overuse of inpatient physical and occupational therapy consultations may contribute to decreased patient throughput in surgical admissions.

An Instructive Case of Cerebral Mucormycosis

BACKGROUND

Mucormycosis can lead to fatal rhinocerebral infection.

CASE

A 53-year-old male with diabetes presented with altered mental status. He had been recently discharged from an admission for COVID-19 pneumonia treated with remdesivir and methylprednisolone. Imaging demonstrated a large left frontal mass with midline shift suspicious for a primary brain neoplasm. His neurologic exam rapidly declined and the patient was taken to the operating room for decompressive hemicraniectomy. Post-operatively, the patient remained comatose and failed to improve. Autopsy revealed a cerebral mucormycosis infection.

DISCUSSION

Despite concern for a primary brain neoplasm the patient was diagnosed postmortem with a mucormycosis infection. Other features supporting this diagnosis included nasal sinusitis on initial scans, his fulminant clinical decline, rapidly progressive imaging findings, and persistent hyperglycemia throughout his clinical course.

CONCLUSION

In an era of high steroid usage to treat COVID-19, mucormycosis infection must be considered in high-risk patients demonstrating disproportionate clinical decline.

Toward more accurate documentation in neurosurgical care

OBJECTIVE

Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service.

METHODS

At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a "system-based" progress note template was changed to a "problem-based" progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention.

RESULTS

The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002).

CONCLUSIONS

Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially.

OBJECTIVE

To evaluate rates of adverse outcomes after CAS and CEA in a large national database.

METHODS

We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression.

RESULTS

In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients.

CONCLUSION

In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.

Demand for Essential Nonambulatory Neurosurgical Care Decreased While Acuity of Care Increased During the Coronavirus Disease 2019 (COVID-19) Surge

Background

In times of health resource reallocation, capacities must remain able to meet a continued demand for essential, nonambulatory neurosurgical acute care. This study sought to characterize the demand for and provision of neurosurgical acute care during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

This single-center cross-sectional observational analysis compared nonambulatory neurosurgical consult encounters during the peri-surge period (March 9 to May 31, 2020) with those during an analogous period in 2019. Outcomes included consult volume, distribution of problem types, disease severity, and rate of acute operative intervention.

Results

A total of 1494 neurosurgical consults were analyzed. Amidst the pandemic surge, 583 consults were seen, which was 6.4 standard deviations below the mean among analogous 2016–2019 periods (mean 873; standard deviation 45, P = 0.001). Between 2019 and 2020, the proportion of degenerative spine consults decreased in favor of spinal trauma (25.6% vs. 34% and 51.9% vs. 41.4%, P = 0.088). Among aneurysmal subarachnoid hemorrhage cases, poor-grade (Hunt and Hess grades 4–5) presentations were more common (30% vs. 14.8%, P = 0.086). A greater proportion of pandemic era consults resulted in acute operative management, with an unchanged absolute frequency of acutely operative consults (123/583 [21.1%] vs. 120/911 [13.2%], P < 0.001).

Conclusions

Neurosurgical consult volume during the pandemic surge hit a 5-year institutional low. Amidst vast reallocation of health care resources, demand for high-acuity nonambulatory neurosurgical care continued and proportionally increased for greater-acuity pathologies. In our continued current pandemic as well as any future situations of mass health resource reallocation, neurosurgical acute care capacities must be preserved.

Frailty and outcomes after craniotomy for brain tumor

Frailty has been associated with increased morbidity and mortality in a variety of surgical disciplines. Few data exist regarding the relationship of frailty with adverse outcomes in craniotomy for brain tumor resection. We assessed the relationship between frailty and the incidence of major post-operative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after elective craniotomy for brain tumor resection. A retrospective cohort study was conducted on 20,333 adult patients undergoing elective craniotomy for tumor resection in the 2012-2018 ACS-NSQIP Participant Use File. Multivariate logistic regression was performed using all covariates deemed eligible through clinical and statistical significance. 6,249 patients (30.7%) were low-frailty and 2,148 patients (10.6%) were medium-to-high frailty. In multivariate logistic regression adjusting for age, gender, BMI, ASA classification, smoking status, dyspnea, significant pre-operative weight loss, chronic steroid use, bleeding disorder, tumor type, and operative time, low frailty was associated with increased adjusted odds ratio of major complication (1.41, 95% CI: 1.23-1.60, p < 0.001), discharge destination other than home (1.32, 95% CI: 1.20-1.46, p < 0.001), 30-day readmission (1.29, 95% CI: 1.15-1.44, p < 0.001), and 30-day mortality (1.87, 95% CI: 1.41-2.47, p < 0.001). Moderate-to-high frailty was also associated with increased adjusted odds of major complication (1.61, 95% CI: 1.35-1.92, p < 0.001), discharge destination other than home (1.80, 95% CI: 1.58-2.05), 30-day readmission (1.39, 95% CI: 1.19-1.62, p < 0.001), and 30-day mortality (2.42, 95% CI: 1.74-3.38, p < 0.001). CONCLUSIONS: Frailty is associated with increased odds of major post-operative complication, discharge to destination other than home, 30-day readmission, and 30-day mortality.

Frailty and Outcomes after Craniotomy or Craniectomy for Atraumatic Chronic Subdural Hematoma

OBJECTIVE

Frailty is a measure of decreased physiologic reserve and has been associated with increased morbidity and mortality in a variety of surgical disciplines. No data exist regarding the relationship of frailty with adverse outcomes in craniotomy for chronic subdural evacuation. We assessed the relationship between frailty and the incidence of major postoperative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after craniotomy for atraumatic subdural evacuation.

METHODS

A retrospective cohort study was conducted on a population of 1647 adult patients undergoing craniotomy for evacuation of atraumatic subdural hematoma in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index (mFI-5). Multivariable logistic regression was performed using all covariates deemed eligible through clinical relevance and statistical significance.

RESULTS

The overall rates of major complication (25.4%), discharge to destination other than home (49.8%), 30-day readmission (11.7%), and 30-day mortality (12.8%) in this analysis were high and rose with increasing frailty. In multivariable regression analyses, medium frailty (mFI-5 = 2) was associated with increased odds of major complication (adjusted odds ratio [aOR] 1.64, 95% confidence interval [CI] 1.03-2.63), discharge to destination other than home (aOR 2.04, 95% CI 1.38-3.02), and 30-day mortality (aOR 2.27, 95% CI 1.08-4.78). High frailty (mFI-5 >2) was associated with increased odds of 30-day mortality (aOR 2.85, 95% CI 1.13-7.14).

CONCLUSIONS

Preoperative frailty, as determined by mFI-5, is associated with increased odds of major postoperative complication, discharge to destination other than home, and 30-day mortality after craniotomy for chronic subdural hematoma.

The impact of surgery on survival after progression of glioblastoma: A retrospective cohort analysis of a contemporary patient population

Despite updated management of glioblastoma (GB), progression is virtually inevitable. Previous data suggest a survival benefit from resection at progression; however, relatively few studies have evaluated the role of surgery in the context of contemporary GB treatment and widespread use of bevacizumab and chemotherapy. As such, the purpose of this study is to evaluate outcomes following surgical resection in patients with progressive GB since 2008. The records of all patients who underwent biopsy or resection of GB between January 1, 2008, and December 31, 2015, were retrospectively reviewed to identify 368 patients with progressive GB. Median survival and 95% confidence intervals were generated with the Kaplan-Meier method. Multivariate analysis, which controlled for age, Karnofsky Performance Status (KPS), extent of resection, adjuvant chemotherapy and radiation, tumor location, and tumor multifocality, of post-progression survival was carried out using a Cox proportional hazards model. Of 368 patients with progressive disease, 77 (20.9%) underwent resection at first documented progression. The median post-progression survivals for patients who did and did not undergo resection at this time were 12.8 and 7.0 months, respectively. In multivariate analysis, KPS ≥ 70 at progression (HR 0.438), receipt of bevacizumab at first progression (HR 0.756), and receipt of chemotherapy at first progression (HR 0.644) were associated with increased post-progression survival. Thus, surgery for progressive GB may not improve post-progression survival in the context of contemporary maximal non-surgical therapy. Further investigation is necessary to elucidate what role, if any, bevacizumab has in prolonging post-progression survival in patients with progressive GB.

Flow diversion of a recurrent, iatrogenic basilar tip aneurysm in a pediatric patient: case report

Endoscopic third ventriculostomy (ETV) is a common treatment for noncommunicating hydrocephalus. Although rare, vascular injury and traumatic pseudoaneurysm development during ETV have been reported. The authors present the case of a 13-year-old boy who underwent repeat ETV (rETV) for shunt and ETV failure, and who suffered an intraoperative subarachnoid hemorrhage due to iatrogenic injury to the basilar tip, with subsequent development of a pseudoaneurysm. Despite initial primary coil embolization, the aneurysm recurred and was definitively treated with flow diversion. In this report, the authors review complication rates associated with ETV and rETV as well as the emerging use of flow diversion and its applications in vessel reconstruction within the pediatric population.

Positive Peritoneal Lavage Cytology -Implications for Staging and Management of Gastric Cancer

The survival rates of gastric cancer patients with cytology-positive peritoneal lavage fluid without macroscopic dissemination (CY+/P-) is the same as that of patients with overt peritoneal metastasis.The 5-year survival rate of such patients is only 2%. The current study aims to highlight its significance in the staging of gastrointestinal malignancies and its implications for patient care. Prospective nonrandom analysis of peritoneal wash cytology in patients with gastrointestinal malignancies was conducted in the department of Surgical Gastroenterology, Nizams Institute of Medical Sciences, Hyderabad from January 2012 to June 2013. Descriptive statistics and ANOVA variance analysis was performed to estimate incidence, risk factors and the effect of surgery in causing peritoneal dissemination of malignancy. A total of 60 patients with operable gastric cancer underwent peritoneal lavage for evaluation of malignant cells. The incidence of Positive peritoneal lavage cytology was 8.3% (5/60).Four patients with positive lavage fluid belong to T3 stage (11.7%, p-0.309).Poorly differentiating and mucinous tumors had a higher incidence of positive cytology (18.1% and 25%).None of the patients with positive cytology had positive resection margin. Tumors with advanced T stage, lymph nodal involvement, lympho-vascular and perineural invasion have higher incidence of positive peritoneal cytology. Surgical handling has a negligible effect in peritoneal dissemination of tumor. Large scale studies are warranted to validate the findings and define it's role in management of gastric cancer.

ARID1B, a member of the human SWI/SNF chromatin remodeling complex, exhibits tumour-suppressor activities in pancreatic cancer cell lines

Background:

The human ATP-dependent SWItch/sucrose nonfermentable (SWI/SNF) complex functions as a primary chromatin remodeler during ontogeny, as well as in adult life. Several components of the complex have been suggested to function as important regulators of tumorigenesis in various cancers. In the current study, we have characterised a possible tumour suppressor role for the largest subunit of the complex, namely the AT-rich interaction domain 1B (ARID1B).

Methods:

We performed Azacytidine and Trichostatin A treatments, followed by bisulphite sequencing to determine the possible DNA methylation-induced transcription repression of the gene in pancreatic cancer (PaCa) cell lines. Functional characterisation of effect of ARID1B ectopic expression in MiaPaCa2 PaCa cell line, which harboured ARID1B homozygous deletion, was carried out. Finally, we evaluated ARID1B protein expression in pancreatic tumour samples using immunohistochemistry on a tissue microarray.

Results:

ARID1B was transcriptionally repressed due to promoter hypermethylation, and ectopic expression severely compromised the ability of MiaPaCa2 cells to form colonies in liquid culture and soft agar. In addition, ARID1B exhibited significantly reduced/loss of expression in PaCa tissue, especially in samples from advanced-stage tumours, when compared with normal pancreas.

Conclusion:

The results therefore suggest a possible tumour-suppressor function for ARID1B in PaCa, thus adding to the growing list of SWI/SNF components with a similar function. Given the urgent need to design efficient targeted therapies for PaCa, our study assumes significance.

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

BACKGROUND

There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.

MATERIALS AND METHODS

Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.

RESULTS

Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9-54). The median number of PDs per surgeon per year was 16 (range 7-38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2-5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3-32.2%), and the median post-operative duration of hospital stay was 16 days (range 4-100 days).

CONCLUSIONS

This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.

Postoperative infection of an abdominal mesh due to methicillin resistant Staphylococcus aureus - a case report

Methicillin resistant Stephylococcus aureus (MRSA) infection has now become a major problem in hospitals. We present a case of postoperative infection MRSA where the primary source of the infection was found to be an abdominal mesh that was used to reinforce the abdominal wall. After one year of surgery, the patient developed wound dehiscence and discharge. MRSA was isolated from the wound, mesh, external nares, throat and axilla. Initially she was started on clindamycin and discharged from the hospital. After 5 months, patient came back to the hospital with infection at the same site. The patient was then treated with vancomycin and MRSA clearance. She responded to the treatment with complete healing of the wound and clearance of MRSA.

Pancreatico-biliary ductal union

A long common channel distal to the pancreaticobiliary junction is the commonest anomalous arrangement of the pancreaticobiliary ductal system and is mostly observed in patients with congenital choledochal cysts. APBDU without choledochal cyst is a high-risk condition for the development of gallbladder carcinomas. Prophylactic excision of the extrahepatic biliary system and reconstruction of the biliary tract with hepatico-jejunostomy are recommended. APBDU should always be kept in mind when a patient with a long history of abdominal pain is found to have gall bladder wall thickness even without gallstones on imaging by a CT Scan or Ultra Sound. ERCP should be performed in these patients in order to detect APBDU. This may allow early detection of carcinoma of the biliary tract. Presence of common channel may be associated with a lower incidence of gallstones. However it requires corroboration by other studies. On the other hand carcinoma of the gall bladder appears to have a close association with abnormally long common channel.

Isolated splenic tuberculosis

The authors report two cases of isolated splenic tuberculosis treated since 1989 in Nizam's Institute of Medical Sciences. One case presented as pyrexia of unknown origin (PUO) and another with idiopathic thrombocytopenic purpura (ITP). Both were found to have splenic tuberculosis after splenectomy. Pre operative diagnosis could not be made in these cases. Splenectomy followed by antituberculous chemotherapy cured the condition in both the cases. The authors underline the diagnostic difficulties, essentially related to the rarity of this condition inspite of the progress in modern imaging.

Primary small intestinal adenocarcinoma

Seven patients with adeno-carcinoma of the small intestine were seen over a period of five years. Four were localized to the duodenum, the jejunum was involved in two and the ileum in one. Abdominal pain, weight loss, anemia and obstruction were the most common presenting complaints. Endoscopy was the primary diagnostic modality for the duodenal tumours. Diagnostic accuracy of barium contrast examination was 83%. Curative resections were performed in two patients and palliative surgery in the rest.

Icterus due to tumor emboli--a rare presentation of hepatoma

Two cases of hepatocellular carcinoma presenting with features of obstructive jaundice are reported because of their unusual presentation. Both of them had obstruction of the common bile duct by tumor emboli and underwent palliation with surgical evacuation of the tumor thrombus.