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Haider G, Shah V, Lopez I, Wagner KE, Stienen MN, Veeravagu A. Experience with the utilization of new-generation shared-control robotic system for spinal instrumentation. J Neurosurg Sci 2024:S0390-5616.24.06206-4. [PMID: 38619188 DOI: 10.23736/s0390-5616.24.06206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
BACKGROUND Robotic assistance in spine surgery is emerging as an accurate, effective and enabling technology utilized in the treatment of patients with surgical spinal pathology. The safety and reproducibility of robotic assistance in the placement of pedicle screw instrumentation is still being investigated. The objective of this study was to present our experience of instrumented spinal fusion utilizing an intraoperative robotic guidance system. METHODS We retrospectively reviewed all cases of spinal instrumentation of the thoracic and lumbo-sacral spine using the Mazor X robotic system (Medtronic Inc, Minneapolis, MN, USA), performed at our institution by one surgeon between July 2017 and June 2020. Wilcoxon Rank test was used to compare time taken to place each screw during the first 20 cases and the cases thereafter. RESULTS A total of 28 patients were included. A total of 159 screws were placed using the Mazor X robotic system. The overall mean time for screw placement was 7.8±2.3 minutes and there was a significant reduction in the mean time for screw placement after the 20th case or 120 screws (8.70 vs. 5.42 min, P=0.008). No postoperative neurologic deficit or new radiculopathy was noted to occur secondary to hardware placement. No revision surgery was required for replacement or removal of a mispositioned screw. CONCLUSIONS From this single-center, single-surgeon series we conclude that robot-assisted spine surgery can be safely and efficiently integrated into the operating room workflow, which improves after a learning curve of approximately 20 operative interventions. We found robot-assisted spinal instrumentation to be reliable, safe, effective and highly precise.
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Affiliation(s)
- Ghani Haider
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA -
| | - Vaibhavi Shah
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Ivan Lopez
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Katherine E Wagner
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Martin N Stienen
- Department of Neurosurgery and Spine Center of Eastern Switzerland, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
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Johnstone T, Shah V, Schonfeld E, Sadeghzadeh S, Haider G, Marianayagam NJ, Stienen M, Veeravagu A. Type II odontoid fractures in the elderly presenting to the emergency department: an assessment of factors affecting in-hospital mortality and discharge to skilled nursing facilities. Spine J 2024; 24:682-691. [PMID: 38101547 DOI: 10.1016/j.spinee.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/14/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND CONTEXT Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED). PURPOSE This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF). STUDY DESIGN This is a retrospective cohort study. PATIENT SAMPLE Data was used from the 2016-2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded. OUTCOME MEASURES The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs. METHODS Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs. RESULTS A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%-341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62-3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26-3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21-0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13-3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001). CONCLUSIONS This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making.
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Affiliation(s)
- Thomas Johnstone
- Stanford University School of Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA; Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA.
| | - Vaibhavi Shah
- Stanford University School of Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA; Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Ethan Schonfeld
- Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Sina Sadeghzadeh
- Stanford University School of Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA; Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Ghani Haider
- Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Neelan J Marianayagam
- Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Martin Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
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Schonfeld E, Shah A, Johnstone TM, Rodrigues A, Morris GK, Stienen MN, Veeravagu A. Deep Learning Prediction of Cervical Spine Surgery Revision Outcomes Using Standard Laboratory and Operative Variables. World Neurosurg 2024:S1878-8750(24)00325-5. [PMID: 38408699 DOI: 10.1016/j.wneu.2024.02.112] [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: 02/12/2024] [Accepted: 02/20/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Cervical spine procedures represent a major proportion of all spine surgery. Mitigating the revision rate following cervical procedures requires careful patient selection. While complication risk has successfully been predicted, revision risk has proven more challenging. This is likely due to the absence of granular variables in claims databases. The objective of this study was to develop a state-of-the-art model of revision prediction of cervical spine surgery using laboratory and operative variables. METHODS Using the Stanford Research Repository, patients undergoing a cervical spine procedure between 2016 and 2022 were identified (N = 3151), and recent laboratory values were collected. Patients were classified into separate cohorts by revision outcome and time frame. Machine and deep learning models were trained to predict each revision outcome from laboratory and operative variables. RESULTS Red blood cell count, hemoglobin, hematocrit, mean corpuscular hemoglobin concentration, red blood cell distribution width, platelet count, carbon dioxide, anion gap, and calcium all were significantly associated with ≥1 revision cohorts. For the prediction of 3-month revision, the deep neural network achieved an area under the receiver operating characteristic curve of 0.833. The model demonstrated increased performance for anterior versus posterior and arthrodesis versus decompression procedures. CONCLUSIONS Our deep learning approach successfully predicted 3-month revision outcomes from demographic variables, standard laboratory values, and operative variables in a cervical spine surgery cohort. This work used standard laboratory values and operative codes as meaningful predictive variables for revision outcome prediction. The increased performance on certain procedures evidences the need for careful development and validation of one-size-fits-all risk scores for spine procedures.
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Affiliation(s)
- Ethan Schonfeld
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, California, USA.
| | - Aaryan Shah
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, California, USA
| | - Thomas Michael Johnstone
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, California, USA
| | - Adrian Rodrigues
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, California, USA
| | - Garret K Morris
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Martin N Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Kantonsspital St. Gallen, St. Gallen Medical School, St. Gallen, Switzerland
| | - Anand Veeravagu
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, California, USA; Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
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Shah V, Johnstone T, Haider G, Marianayagam NJ, Stienen MN, Chandra V, Veeravagu A. Misplaced intraspinal venous stent causing cauda equina syndrome: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE23482. [PMID: 38346298 PMCID: PMC10865466 DOI: 10.3171/case23482] [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: 08/29/2023] [Accepted: 01/10/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Endovenous stents for deep venous thrombosis treatment can be unintentionally placed in the spinal canal, resulting in neurological deficit. OBSERVATIONS The authors report the case of a patient presenting to our institution with intraspinal misplacement of an endovenous stent, resulting in cauda equina syndrome. The authors also performed a systematic literature review, evaluating the few previously reported cases. This review was performed according to the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In four of five cases describing stent misplacement into the spinal canal, the authors report that only anteroposterior monoplanar imaging modalities were utilized for venous localization and stent deployment. The anteroposterior plane cannot assess the relative depth of structures, nor can it distinguish between superimposed structures well. Therefore, the use of biplanar imaging should at least be considered before stent deployment, as intraspinal stent placement can lead to disastrous consequences. LESSONS This report should serve as an impetus for the use of biplanar or three-dimensional imaging modalities for iliac venous stent placement. Additionally, this work should increase spine surgeons' awareness about management and operative techniques when faced with this complication.
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Affiliation(s)
- Vaibhavi Shah
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California
- School of Medicine, Stanford University, Stanford, California; and
| | - Thomas Johnstone
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California
- School of Medicine, Stanford University, Stanford, California; and
| | - Ghani Haider
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California
| | - Neelan J Marianayagam
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California
| | - Martin N Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Cantonal Hospital, St. Gallen, Switzerland
| | - Venita Chandra
- School of Medicine, Stanford University, Stanford, California; and
| | - Anand Veeravagu
- School of Medicine, Stanford University, Stanford, California; and
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Cantonal Hospital, St. Gallen, Switzerland
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Schonfeld E, Pant A, Shah A, Sadeghzadeh S, Pangal D, Rodrigues A, Yoo K, Marianayagam N, Haider G, Veeravagu A. Evaluating Computer Vision, Large Language, and Genome-Wide Association Models in a Limited Sized Patient Cohort for Pre-Operative Risk Stratification in Adult Spinal Deformity Surgery. J Clin Med 2024; 13:656. [PMID: 38337352 PMCID: PMC10856542 DOI: 10.3390/jcm13030656] [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: 12/19/2023] [Revised: 01/10/2024] [Accepted: 01/21/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Adult spinal deformities (ASD) are varied spinal abnormalities, often necessitating surgical intervention when associated with pain, worsening deformity, or worsening function. Predicting post-operative complications and revision surgery is critical for surgical planning and patient counseling. Due to the relatively small number of cases of ASD surgery, machine learning applications have been limited to traditional models (e.g., logistic regression or standard neural networks) and coarse clinical variables. We present the novel application of advanced models (CNN, LLM, GWAS) using complex data types (radiographs, clinical notes, genomics) for ASD outcome prediction. Methods: We developed a CNN trained on 209 ASD patients (1549 radiographs) from the Stanford Research Repository, a CNN pre-trained on VinDr-SpineXR (10,468 spine radiographs), and an LLM using free-text clinical notes from the same 209 patients, trained via Gatortron. Additionally, we conducted a GWAS using the UK Biobank, contrasting 540 surgical ASD patients with 7355 non-surgical ASD patients. Results: The LLM notably outperformed the CNN in predicting pulmonary complications (F1: 0.545 vs. 0.2881), neurological complications (F1: 0.250 vs. 0.224), and sepsis (F1: 0.382 vs. 0.132). The pre-trained CNN showed improved sepsis prediction (AUC: 0.638 vs. 0.534) but reduced performance for neurological complication prediction (AUC: 0.545 vs. 0.619). The LLM demonstrated high specificity (0.946) and positive predictive value (0.467) for neurological complications. The GWAS identified 21 significant (p < 10-5) SNPs associated with ASD surgery risk (OR: mean: 3.17, SD: 1.92, median: 2.78), with the highest odds ratio (8.06) for the LDB2 gene, which is implicated in ectoderm differentiation. Conclusions: This study exemplifies the innovative application of cutting-edge models to forecast outcomes in ASD, underscoring the utility of complex data in outcome prediction for neurosurgical conditions. It demonstrates the promise of genetic models when identifying surgical risks and supports the integration of complex machine learning tools for informed surgical decision-making in ASD.
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Affiliation(s)
- Ethan Schonfeld
- Stanford University School of Medicine, Stanford University, Stanford, CA 94304, USA; (A.P.); (S.S.)
| | - Aaradhya Pant
- Stanford University School of Medicine, Stanford University, Stanford, CA 94304, USA; (A.P.); (S.S.)
| | - Aaryan Shah
- Department of Computer Science, Stanford University, Stanford, CA 94304, USA;
| | - Sina Sadeghzadeh
- Stanford University School of Medicine, Stanford University, Stanford, CA 94304, USA; (A.P.); (S.S.)
| | - Dhiraj Pangal
- Department of Neurosurgery, Stanford University School of Medicine, Stanford University, Stanford, CA 94304, USA; (D.P.); (K.Y.); (N.M.); (G.H.); (A.V.)
| | - Adrian Rodrigues
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Kelly Yoo
- Department of Neurosurgery, Stanford University School of Medicine, Stanford University, Stanford, CA 94304, USA; (D.P.); (K.Y.); (N.M.); (G.H.); (A.V.)
| | - Neelan Marianayagam
- Department of Neurosurgery, Stanford University School of Medicine, Stanford University, Stanford, CA 94304, USA; (D.P.); (K.Y.); (N.M.); (G.H.); (A.V.)
| | - Ghani Haider
- Department of Neurosurgery, Stanford University School of Medicine, Stanford University, Stanford, CA 94304, USA; (D.P.); (K.Y.); (N.M.); (G.H.); (A.V.)
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford University, Stanford, CA 94304, USA; (D.P.); (K.Y.); (N.M.); (G.H.); (A.V.)
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Jin MC, Jensen M, Barros Guinle MI, Ren A, Zhou Z, Zygourakis CC, Desai AM, Veeravagu A, Ratliff JK. Getting what you pay for: impact of copayments on physical therapy and opioid initiation, timing, and continuation for newly diagnosed low back pain. Spine J 2024:S1529-9430(24)00019-6. [PMID: 38262499 DOI: 10.1016/j.spinee.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/19/2023] [Accepted: 01/16/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND CONTEXT Physical therapy (PT) is an important component of low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common. PURPOSE We sought to understand how copayments impact timing and utilization of PT in newly diagnosed LBP. STUDY DESIGN/SETTING The IBM Watson Health MarketScan claims database was used in a longitudinal setting. PATIENT SAMPLE Adult patients with LBP. OUTCOME MEASURES The primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing. METHODS Actual and inferred copayments based on non-nonprimary care provider visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage. RESULTS Overall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days postdiagnosis (IQR 1-55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use (0.77 prescriptions/patient [$0 PT copayment] versus 1.07 prescriptions/patient [$50-74 PT copayment]; 1.15 prescriptions/patient [$75+ PT copayment]). Among patients with known opioid and PT copayments, higher PT copayments were correlated with faster opioid use while higher opioid copayments were correlated with faster PT use (Spearman p<.05). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50-75th and 75-100th percentiles was significantly lower than those below the 50th percentile (HR=0.893 [95%CI 0.887-0.899] and HR=0.905 [95%CI 0.899-0.912], respectively). CONCLUSIONS Higher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Co-pays may impact long-term adherence to PT.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Jensen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Alexander Ren
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Zeyi Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Corinna C Zygourakis
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
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Lakomkin N, Eastlack RK, Uribe JS, Park P, Ryu SI, Kretzer R, Mimran RI, Holman P, Veeravagu A, Hassanzadeh H, Johnson MM, Sullivan L, Clark A, Mundis GM. An Integrated 3-Dimentional Navigation System Increases the Accuracy, Efficiency, and Safety of Percutaneous Thoracolumbar Pedicle Screw Placement in Minimally Invasive Approaches: A Randomized Cadaveric Study. Global Spine J 2024:21925682231224394. [PMID: 38165219 DOI: 10.1177/21925682231224394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
STUDY DESIGN Cadaveric study. OBJECTIVES The purpose of this study was to compare a novel, integrated 3D navigational system (NAV) and conventional fluoroscopy in the accuracy, efficiency, and radiation exposure of thoracolumbar percutaneous pedicle screw (PPS) placement. METHODS Twelve skeletally mature cadaveric specimens were obtained for twelve individual surgeons. Each participant placed bilateral PS at 11 segments, from T8 to S1. Prior to insertion, surgeons were randomized to the sequence of techniques and the side (left or right). Following placement, a CT scan of the spine was obtained for each cadaver, and an independent reviewer assessed the accuracy of screw placement using the Gertzbein grading system. Outcome metrics of interest included a comparison of breach incidence/severity, screw placement time, total procedure time, and radiation exposure between the techniques. Bivariate statistics were employed to compare outcomes at each level. RESULTS A total of 262 screws (131 using each technique) were placed. The incidence of cortical breaches was significantly lower with NAV compared to FG (9% vs 18%; P = .048). Of breaches with NAV, 25% were graded as moderate or severe compared to 39% in the FG subgroup (P = .034). Median time for screw placement was significantly lower with NAV (2.7 vs 4.1 min/screw; P = .012), exclusive of registration time. Cumulative radiation exposure to the surgeon was significantly lower for NAV-guided placement (9.4 vs 134 μGy, P = .02). CONCLUSIONS The use of NAV significantly decreased the incidence of cortical breaches, the severity of screw breeches, screw placement time, and radiation exposure to the surgeon when compared to traditional FG.
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Affiliation(s)
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, TN, USA
| | - Stephen I Ryu
- Department of Neurosurgery, Sutter Health, Palo Alto, CA, USA
| | - Ryan Kretzer
- Department of Neurosurgery, Western Neuro, Phoenix, AZ, USA
| | - Ronnie I Mimran
- Department of Neurosurgery, Sutter Health, Palo Alto, CA, USA
| | - Paul Holman
- Department of Neurosurgery, Houston Methodist, Houston, TX, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, Palo Alto, CA, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Michele M Johnson
- Department of Neurosurgery, Atlanta Brain and Spine, Atlanta, GA, USA
| | - Linda Sullivan
- Medical writing and Biostatistics, NuVasive, San Diego, CA, USA
| | - Aaron Clark
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Gregory M Mundis
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
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Schonfeld E, Mordekai N, Berg A, Johnstone T, Shah A, Shah V, Haider G, Marianayagam NJ, Veeravagu A. Machine Learning in Neurosurgery: Toward Complex Inputs, Actionable Predictions, and Generalizable Translations. Cureus 2024; 16:e51963. [PMID: 38333513 PMCID: PMC10851045 DOI: 10.7759/cureus.51963] [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: 08/27/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
Machine learning can predict neurosurgical diagnosis and outcomes, power imaging analysis, and perform robotic navigation and tumor labeling. State-of-the-art models can reconstruct and generate images, predict surgical events from video, and assist in intraoperative decision-making. In this review, we will detail the neurosurgical applications of machine learning, ranging from simple to advanced models, and their potential to transform patient care. As machine learning techniques, outputs, and methods become increasingly complex, their performance is often more impactful yet increasingly difficult to evaluate. We aim to introduce these advancements to the neurosurgical audience while suggesting major potential roadblocks to their safe and effective translation. Unlike the previous generation of machine learning in neurosurgery, the safe translation of recent advancements will be contingent on neurosurgeons' involvement in model development and validation.
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Affiliation(s)
- Ethan Schonfeld
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | | | - Alex Berg
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Thomas Johnstone
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Aaryan Shah
- School of Humanities and Sciences, Stanford University, Stanford, USA
| | - Vaibhavi Shah
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Ghani Haider
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | | | - Anand Veeravagu
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
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Haider G, Dadey DYA, Rodrigues A, Pollom EL, Adler JR, Veeravagu A. Socio-economic disparities influence likelihood of post-operative radiation to resection cavities of metastatic brain tumors. Acta Neurochir (Wien) 2023; 165:4253-4258. [PMID: 37816918 DOI: 10.1007/s00701-023-05826-w] [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: 08/07/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE Irradiating the surgical bed of resected brain metastases improves local and distant disease control. Over time, stereotactic radiosurgery (SRS) has replaced whole brain radiotherapy (WBRT) as the treatment standard of care because it minimizes long-term damage to neuro-cognition. Despite this data and growing adoption, socio-economic disparities in clinical access can result in sub-standard care for some patient populations. We aimed to analyze the clinical and socio-economic characteristics of patients who did not receive radiation after surgical resection of brain metastasis. METHODS Our sample was obtained from Clinformatics® Data Mart Database and included all patients from 2004 to 2021 who did or did not receive radiation treatment within sixty days after resection of tumors metastatic to the brain. Regression analysis was done to identify factors responsible for loss to adjuvant radiation treatment. RESULTS Of 8362 patients identified who had undergone craniotomy for resection of metastatic brain tumors, 3430 (41%) patients did not receive any radiation treatment. Compared to patients who did receive some form of radiation treatment (SRS or WBRT), patients who did not get any form of radiation were more likely to be older (p = 0.0189) and non-white (p = 0.008). Patients with Elixhauser Comorbidity Index ≥3 were less likely to receive radiation treatment (p < 0.01). Fewer patients with household income ≥ $75,000 did not receive radiation treatment (p < 0.01). CONCLUSION Age, race, household income, and comorbidity status were associated with differential likelihood to receive post-operative radiation treatment.
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Affiliation(s)
- Ghani Haider
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road, Stanford, CA, 94304, USA.
| | - David Y A Dadey
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road, Stanford, CA, 94304, USA
| | - Adrian Rodrigues
- School of Medicine, Stanford University, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford, CA, 94305, USA
| | - John R Adler
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road, Stanford, CA, 94304, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, 453 Quarry Road, Stanford, CA, 94304, USA
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10
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Hersh AM, Jimenez AE, Pellot KI, Gong JH, Jiang K, Khalifeh JM, Ahmed AK, Raad M, Veeravagu A, Ratliff JK, Jain A, Lubelski D, Bydon A, Witham TF, Theodore N, Azad TD. Contemporary Trends in Minimally Invasive Sacroiliac Joint Fusion Utilization in the Medicare Population by Specialty. Neurosurgery 2023; 93:1244-1250. [PMID: 37306413 DOI: 10.1227/neu.0000000000002564] [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: 02/13/2023] [Accepted: 04/20/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Sacroiliac (SI) joint dysfunction constitutes a leading cause of pain and disability. Although surgical arthrodesis is traditionally performed under open approaches, the past decade has seen a rise in minimally invasive surgical (MIS) techniques and new federally approved devices for MIS approaches. In addition to neurosurgeons and orthopedic surgeons, proceduralists from nonsurgical specialties are performing MIS procedures for SI pathology. Here, we analyze trends in SI joint fusions performed by different provider groups, along with trends in the charges billed and reimbursement provided by Medicare. METHODS We review yearly Physician/Supplier Procedure Summary data from 2015 to 2020 from the Centers for Medicare and Medicaid Services for all SI joint fusions. Patients were stratified as undergoing MIS or open procedures. Utilization was adjusted per million Medicare beneficiaries and weighted averages for charges and reimbursements were calculated, controlling for inflation. Reimbursement-to-charge (RCR) ratios were calculated, reflecting the proportion of provider billed amounts reimbursed by Medicare. RESULTS A total of 12 978 SI joint fusion procedures were performed, with the majority (76.5%) being MIS procedures. Most MIS procedures were performed by nonsurgical specialists (52.1%) while most open fusions were performed by spine surgeons (71%). Rapid growth in MIS procedures was noted for all specialty categories, along with an increased number of procedures offered in the outpatient setting and ambulatory surgical centers. The overall RCR increased over time and was ultimately similar between spine surgeons (RCR = 0.26) and nonsurgeon specialists (RCR = 0.27) performing MIS procedures. CONCLUSION Substantial growth in MIS procedures for SI pathology has occurred in recent years in the Medicare population. This growth can largely be attributed to adoption by nonsurgical specialists, whose reimbursement and RCR increased for MIS procedures. Future studies are warranted to better understand the impact of these trends on patient outcomes and costs.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | | | - Jung Ho Gong
- The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jawad M Khalifeh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Micheal Raad
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford , California , USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford , California , USA
| | - Amit Jain
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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11
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Haider G, Shah V, Johnstone T, Maldaner N, Stienen M, Veeravagu A. Accuracy of predicted postoperative segmental lumbar lordosis in spinal fusion using an intraoperative robotic planning and guidance system. J Neurosurg Sci 2023:S0390-5616.23.06142-8. [PMID: 37997323 DOI: 10.23736/s0390-5616.23.06142-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND Restoring lumbar lordosis is one of the main goals in lumbar spinal fusion surgery. The Mazor X-AlignTM software allows for the prediction of postoperative segmental lumbar lordosis based on preoperative imaging. There is limited data on the accuracy of this preoperative prediction, especially in patients undergoing short segment lumbar fusion. The objective of our study was to determine the accuracy of predicted postoperative segmental lumbar lordosis using the Mazor X-AlignTM software in patients requiring short segmental fusion. METHODS Retrospective analysis of adult patients undergoing pedicle screw spinal instrumentation of not more than four levels using the Mazor XTM Robot (Medtronic Inc., Minneapolis, MN, USA) between July 2017 to June 2020. The robotic guidance software, Mazor X-AlignTM (Medtronic Inc., Minneapolis, MN, USA) was used to calculate the predicted segmental lumbar lordosis based on preoperative CT-imaging and the plan was executed under intraoperative robotic guidance. Predicted segmental lumbar lordosis was compared to achieved segmental lumbar lordosis on 1-month postoperative x-rays using the Cobb angle methodology. RESULTS A total of 15 patients (46.6% female) with a mean age of 61.5±10.9 years were included. All patients underwent posterior lumbo-sacral spinal fusion with the Mazor XTM robotic system with 11 patients (73.3%) undergoing anterior column reconstruction prior to posterior fixation. Instrumentation was performed across a mean of 2.6 levels per case. Preoperative, the mean segmental lumbar lordosis was 30.2±13.6 degrees. The mean planned segmental lumbar lordosis was 35.5±17.0 degrees while the mean achieved segmental lumbar lordosis was 35.8±16.7 degrees. There was no significant mean difference between the planned and achieved segmental lumbar lordosis (P=0.334). CONCLUSIONS The Mazor XTM intraoperative robotic planning and guidance is accurate in predicting postoperative segmental lumbar lordosis after short segmental fusion. Our findings may assure surgical decision making and planning.
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Affiliation(s)
- Ghani Haider
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA -
| | - Vaibhavi Shah
- School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Nicolai Maldaner
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Martin Stienen
- Department of Neurosurgery and Spine Center of Eastern Switzerland, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
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12
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Shah A, Marianayagam NJ, Zamarud A, Park DJ, Persad AR, Soltys SG, Chang SD, Veeravagu A. Spinal metastases of pineal region glioblastoma with primitive neuroectodermal features highlighting the importance of molecular diagnoses: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23536. [PMID: 37956418 PMCID: PMC10651388 DOI: 10.3171/case23536] [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: 09/15/2023] [Accepted: 10/12/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Glioblastoma (GBM) is the most common primary brain tumor with poor patient prognosis. Spinal leptomeningeal metastasis has been rarely reported, with long intervals between the initial discovery of the primary tumor in the brain and eventual spine metastasis. OBSERVATIONS Here, the authors present the case of a 51-year-old male presenting with 7 days of severe headache, nausea, and vomiting. Magnetic resonance imaging of the brain and spine demonstrated a contrast-enhancing mass in the pineal region, along with spinal metastases to T8, T12, and L5. Initial frozen-section diagnosis led to the treatment strategy for medulloblastoma, but further molecular analysis revealed characteristics of isocitrate dehydrogenase-wild type, grade 4 GBM. LESSONS Glioblastoma has the potential to show metastatic spread at the time of diagnosis. Spinal imaging should be considered in patients with clinical suspicion of leptomeningeal spread. Furthermore, molecular analysis should be confirmed following pathological diagnosis to fine-tune treatment strategies.
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Affiliation(s)
- Aaryan Shah
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, California
| | - Neelan J Marianayagam
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, California
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Aroosa Zamarud
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - David J Park
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Amit R Persad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Anand Veeravagu
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, California
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
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13
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Haider G, Varshneya K, Rodrigues A, Marianayagam N, Stienen MN, Veeravagu A. Progression to fusion after lumbar laminectomy for degenerative lumbar spondylolisthesis: Rate and risk-factors. A national database study. Clin Neurol Neurosurg 2023; 233:107919. [PMID: 37536253 DOI: 10.1016/j.clineuro.2023.107919] [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: 07/03/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE Lumbar laminectomy is often utilized in the treatment of degenerative lumbar spondylolisthesis. Risk factors that contribute to reoperation rates, in particular to progression to fusion, are poorly understood. We aimed to identify rate and risk factors of lumbar fusion surgery following lumbar laminectomy for the treatment of degenerative lumbar spinal spondylolisthesis. METHODS Our sample was obtained from the national MarketScan Commercial Claims and Encounters Database. We reviewed patients undergoing lumbar laminectomy for stable degenerative lumbar spondylolisthesis (Grade-1) at one or two levels between January 2007 and December 2016. RESULTS A total of 33,681 patients were included. By 2 years after the index operation, 2.48 % of patients had required lumbar fusion surgery. Female sex was associated with lower odds (OR 0.8, 95 %CI 0.7-0.9) of reoperation for fusion. Diabetes (OR 1.2, 95 %CI 1.1-1.4), rheumatoid arthritis (OR 1.5, 95 %CI 1.2-1.7) and clinical presentation with LBP (OR 2.1, 95 %CI 1.6-2.9), lower extremity weakness (OR 1.4, 95 %CI 1.1-1.5), as well as occurrence of a postoperative neurological complications (OR 2.0, 95 %CI 1.1-3.4) increased the odds ratio for requiring fusion surgery within two years after lumbar laminectomy. CONCLUSION In this large cross-sectional sample of a national claims database consisting of lumbar laminectomy patients for the treatment of spondylolisthesis, approximately 2.5 % required subsequent lumbar fusion. Several modifiable risk factors for fusion progression were identified, which may guide clinicians in shared decision-making and to help identify patients with elevated post-operative risk providing potential leverage point for prevention.
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Affiliation(s)
- Ghani Haider
- Department of Neurosurgery, Stanford University, Stanford, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Kunal Varshneya
- School of Medicine, Stanford University, Stanford, 291 Campus Drive, Stanford, CA 94305, USA
| | - Adrian Rodrigues
- School of Medicine, Stanford University, Stanford, 291 Campus Drive, Stanford, CA 94305, USA
| | - Neelan Marianayagam
- Department of Neurosurgery, Stanford University, Stanford, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Martin N Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, Rorschacher Str. 95, CH-9007 St.Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, Stanford, 300 Pasteur Drive, Stanford, CA 94305, USA
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14
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Schonfeld E, Johnstone TM, Haider G, Shah A, Marianayagam NJ, Biswal S, Veeravagu A. Sigma-1 receptor expression in a subpopulation of lumbar spinal cord microglia in response to peripheral nerve injury. Sci Rep 2023; 13:14762. [PMID: 37679500 PMCID: PMC10484902 DOI: 10.1038/s41598-023-42063-8] [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: 05/27/2023] [Accepted: 09/05/2023] [Indexed: 09/09/2023] Open
Abstract
Sigma-1 Receptor has been shown to localize to sites of peripheral nerve injury and back pain. Radioligand probes have been developed to localize Sigma-1 Receptor and thus image pain source. However, in non-pain conditions, Sigma-1 Receptor expression has also been demonstrated in the central nervous system and dorsal root ganglion. This work aimed to study Sigma-1 Receptor expression in a microglial cell population in the lumbar spine following peripheral nerve injury. A publicly available transcriptomic dataset of 102,691 L4/5 mouse microglial cells from a sciatic-sural nerve spared nerve injury model and 93,027 age and sex matched cells from a sham model was used. At each of three time points-postoperative day 3, postoperative day 14, and postoperative month 5-gene expression data was recorded for both spared nerve injury and Sham cell groups. For all cells, 27,998 genes were sequenced. All cells were clustered into 12 distinct subclusters and gene set enrichment pathway analysis was performed. For both the spared nerve injury and Sham groups, Sigma-1 Receptor expression significantly decreased at each time point following surgery. At the 5-month postoperative time point, only one of twelve subclusters showed significantly increased Sigma-1 Receptor expression in spared nerve injury cells as compared to Sham cells (p = 0.0064). Pathway analysis of this cluster showed a significantly increased expression of the inflammatory response pathway in the spared nerve injury cells relative to Sham cells at the 5-month time point (p = 6.74e-05). A distinct subcluster of L4/5 microglia was identified which overexpress Sigma-1 Receptor following peripheral nerve injury consistent with neuropathic pain inflammatory response functioning. This indicates that upregulated Sigma-1 Receptor in the central nervous system characterizes post-acute peripheral nerve injury and may be further developed for clinical use in the differentiation between low back pain secondary to peripheral nerve injury and low back pain not associated with peripheral nerve injury in cases where the pain cannot be localized.
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Affiliation(s)
- Ethan Schonfeld
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, CA, USA.
| | - Thomas Michael Johnstone
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, CA, USA
| | - Ghani Haider
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, CA, USA
| | - Aaryan Shah
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, CA, USA
| | - Neelan Joseph Marianayagam
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, CA, USA
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Sandip Biswal
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Anand Veeravagu
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
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15
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Wadhwa H, Varshneya K, Stienen MN, Veeravagu A. Do Epidural Steroid Injections Affect Outcomes and Costs in Cervical Degenerative Disease? A Retrospective MarketScan Database Analysis. Global Spine J 2023; 13:1812-1820. [PMID: 34686085 PMCID: PMC10556907 DOI: 10.1177/21925682211050320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To investigate the effect of preoperative epidural steroid injection (ESI) on quality outcomes and costs in patients undergoing surgery for cervical degenerative disease. METHODS We queried the MarketScan database, a national administrative claims dataset, to identify patients who underwent cervical degenerative surgery from 2007 to 2016. Patients under 18 and patients with history of tumor or trauma were excluded. Patients were stratified by ESI use at 3, 6, 12, 18, and 24 or more months preoperative. Propensity score matched controls for these groups were obtained. Baseline demographics, postoperative complications, reoperations, readmissions, and costs were compared via univariate and multivariate analysis. RESULTS 97 117 patients underwent cervical degenerative surgery, of which 29 963 (30.7%) had ESI use at any time preoperatively. Overall, 90-day complication rate was not significantly different between groups. The ESI cohorts had shorter length of stay, but higher 90-day readmission and reoperation rates. ESI use was associated with higher total payments through the 2-year follow-up period. Among patients who received preoperative ESI, male sex, history of cancer, obesity, PVD, rheumatoid arthritis, nonsmokers, cervical myelopathy, BMP use, anterior approach, 90-day complication, 90-day reoperation, and 90-day readmission were independently associated with increased 90-day total cost. CONCLUSION ESI can offer pain relief in some patients refractory to other conservative management techniques, but those who eventually undergo surgery have greater healthcare resource utilization. Certain characteristics can predispose patients who receive preoperative ESI to incur higher healthcare costs.
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Affiliation(s)
- Harsh Wadhwa
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Martin N. Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
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16
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Schonfeld E, Veeravagu A. Demonstrating the successful application of synthetic learning in spine surgery for training multi-center models with increased patient privacy. Sci Rep 2023; 13:12481. [PMID: 37528216 PMCID: PMC10393976 DOI: 10.1038/s41598-023-39458-y] [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: 04/07/2023] [Accepted: 07/25/2023] [Indexed: 08/03/2023] Open
Abstract
From real-time tumor classification to operative outcome prediction, applications of machine learning to neurosurgery are powerful. However, the translation of many of these applications are restricted by the lack of "big data" in neurosurgery. Important restrictions in patient privacy and sharing of imaging data reduce the diversity of the datasets used to train resulting models and therefore limit generalizability. Synthetic learning is a recent development in machine learning that generates synthetic data from real data and uses the synthetic data to train downstream models while preserving patient privacy. Such an approach has yet to be successfully demonstrated in the spine surgery domain. Spine radiographs were collected from the VinDR-SpineXR dataset, with 1470 labeled as abnormal and 2303 labeled as normal. A conditional generative adversarial network (GAN) was trained on the radiographs to generate a spine radiograph and normal/abnormal label. A modified conditional GAN (SpineGAN) was trained on the same task. A convolutional neural network (CNN) was trained using the real data to label abnormal radiographs. A CNN was trained to label abnormal radiographs using synthetic images from the GAN and in a separate experiment from SpineGAN. Using the real radiographs, an AUC of 0.856 was achieved in abnormality classification. Training on synthetic data generated by the standard GAN (AUC of 0.814) and synthetic data generated by our SpineGAN (AUC of 0.830) resulted in similar classifier performance. SpineGAN generated images with higher FID and lower precision scores, but with higher recall and increased performance when used for synthetic learning. The successful application of synthetic learning was demonstrated in the spine surgery domain for the classification of spine radiographs as abnormal or normal. A modified domain-relevant GAN is introduced for the generation of spine images, evidencing the importance of domain-relevant generation techniques in synthetic learning. Synthetic learning can allow neurosurgery to use larger and more diverse patient imaging sets to train more generalizable algorithms with greater patient privacy.
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Affiliation(s)
- Ethan Schonfeld
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, CA, USA.
| | - Anand Veeravagu
- Neurosurgery Artificial Intelligence Lab, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
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17
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Rodrigues AJ, Varshneya K, Stienen MN, Schonfeld E, Than KD, Veeravagu A. Clinical Outcomes and Cost Profiles for Cage and Allograft Anterior Cervical Discectomy and Fusion Procedures in the Adult Population: A Propensity Score-Matched Study. Asian Spine J 2023; 17:620-631. [PMID: 37226385 PMCID: PMC10460669 DOI: 10.31616/asj.2022.0261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/04/2022] [Accepted: 09/13/2022] [Indexed: 05/27/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE To characterize the postoperative outcomes and economic costs of anterior cervical discectomy and fusion (ACDF) procedures using synthetic biomechanical intervertebral cage (BC) and structural allograft (SA) implants. OVERVIEW OF LITERATURE ACDF is a common spine procedure that typically uses an SA or BC for the cervical fusion. Previous studies that compared the outcomes between the two implants were limited by small sample sizes, short-term postoperative outcomes, and procedures with single-level fusion. METHODS Adult patients who underwent an ACDF procedure in 2007-2016 were included. Patient records were extracted from MarketScan, a national registry that captures person-specific clinical utilization, expenditures, and enrollments across millions of inpatient, outpatient, and prescription drug services. Propensity-score matching (PSM) was employed to match the patient cohorts across demographic characteristics, comorbidities, and treatments. RESULTS Of 110,911 patients, 65,151 (58.7%) received BC implants while 45,760 (41.3%) received SA implants. Patients who underwent BC surgeries had slightly higher reoperation rates within 1 year after the index ACDF procedure (3.3% vs. 3.0%, p=0.004), higher postoperative complication rates (4.9% vs. 4.6%, p=0.022), and higher 90-day readmission rates (4.9% vs. 4.4%, p =0.001). After PSM, the postoperative complication rates did not vary between the two cohorts (4.8% vs. 4.6%, p=0.369), although dysphagia (2.2% vs. 1.8%, p<0.001) and infection (0.3% vs. 0.2%, p=0.007) rates remained higher for the BC group. Other outcome differences, including readmission and reoperation, decreased. Physician's fees remained high for BC implantation procedures. CONCLUSIONS We found marginal differences in clinical outcomes between BC and SA ACDF interventions in the largest published database cohort of adult ACDF surgeries. After adjusting for group-level differences in comorbidity burden and demographic characteristics, BC and SA ACDF surgeries showed similar clinical outcomes. Physician's fees, however, were higher for BC implantation procedures.
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Affiliation(s)
- Adrian John Rodrigues
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Martin Nikolaus Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St.Gallen, St. Gallen,
Switzerland
| | - Ethan Schonfeld
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Khoi Duc Than
- Department of Neurosurgery, Duke University, Durham, NC,
USA
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
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18
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Rodrigues AJ, Schonfeld E, Varshneya K, Stienen MN, Veeravagu A. The Impact of Preoperative Myelopathy on Postoperative Outcomes among Anterior Cervical Discectomy and Fusion Procedures in the Nonelderly Adult Population: A Propensity-Score Matched Study. Asian Spine J 2023; 17:693-702. [PMID: 37226379 PMCID: PMC10460652 DOI: 10.31616/asj.2022.0347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/28/2022] [Accepted: 01/20/2023] [Indexed: 05/26/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for patients diagnosed with cervical degenerative diseases with or without myelopathy. A thorough understanding of outcomes in patients with and without myelopathy undergoing ACDF is required because of the widespread utilization of ACDF for these indications. OVERVIEW OF LITERATURE Non-ACDF approaches achieved inferior outcomes in certain myelopathic cases. Studies have compared patient outcomes across procedures, but few have compared outcomes concerning myelopathic versus nonmyelopathic cohorts. METHODS The MarketScan database was queried from 2007 to 2016 to identify adult patients who were ≤65 years old, and underwent ACDF using the international classification of diseases 9th version and current procedural terminology codes. Nearest neighbor propensity-score matching was employed to balance patient demographics and operative characteristics between myelopathic and nonmyelopathic cohorts. RESULTS Of 107,480 patients who met the inclusion criteria, 29,152 (27.1%) were diagnosed with myelopathy. At baseline, the median age of patients with myelopathy was higher (52 years vs. 50 years, p <0.001), and they had a higher comorbidity burden (mean Charlson comorbidity index, 1.92 vs. 1.58; p <0.001) than patients without myelopathy. Patients with myelopathy were more likely to undergo surgical revision at 2 years (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.54-1.73) or are readmitted within 90 days (OR, 1.27; 95% CI, 1.20-1.34). After patient cohorts were matched, patients with myelopathy remained at elevated risk for reoperation at 2 years (OR, 1.55; 95% CI, 1.44-1.67) and postoperative dysphagia (2.78% vs. 1.68%, p <0.001) compared to patients without myelopathy. CONCLUSIONS We found inferior postoperative outcomes at baseline for patients with myelopathy undergoing ACDF compared to patients without myelopathy. Patients with myelopathy remained at significantly greater risk for reoperation and readmission after balancing potential confounding variables across cohorts, and these differences in outcomes were largely driven by patients with myelopathy undergoing 1-2 level fusions.
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Affiliation(s)
- Adrian John Rodrigues
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Ethan Schonfeld
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Martin Nikolaus Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St.Gallen, St. Gallen,
Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
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19
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Tangsrivimol JA, Schonfeld E, Zhang M, Veeravagu A, Smith TR, Härtl R, Lawton MT, El-Sherbini AH, Prevedello DM, Glicksberg BS, Krittanawong C. Artificial Intelligence in Neurosurgery: A State-of-the-Art Review from Past to Future. Diagnostics (Basel) 2023; 13:2429. [PMID: 37510174 PMCID: PMC10378231 DOI: 10.3390/diagnostics13142429] [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: 05/31/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
In recent years, there has been a significant surge in discussions surrounding artificial intelligence (AI), along with a corresponding increase in its practical applications in various facets of everyday life, including the medical industry. Notably, even in the highly specialized realm of neurosurgery, AI has been utilized for differential diagnosis, pre-operative evaluation, and improving surgical precision. Many of these applications have begun to mitigate risks of intraoperative and postoperative complications and post-operative care. This article aims to present an overview of the principal published papers on the significant themes of tumor, spine, epilepsy, and vascular issues, wherein AI has been applied to assess its potential applications within neurosurgery. The method involved identifying high-cited seminal papers using PubMed and Google Scholar, conducting a comprehensive review of various study types, and summarizing machine learning applications to enhance understanding among clinicians for future utilization. Recent studies demonstrate that machine learning (ML) holds significant potential in neuro-oncological care, spine surgery, epilepsy management, and other neurosurgical applications. ML techniques have proven effective in tumor identification, surgical outcomes prediction, seizure outcome prediction, aneurysm prediction, and more, highlighting its broad impact and potential in improving patient management and outcomes in neurosurgery. This review will encompass the current state of research, as well as predictions for the future of AI within neurosurgery.
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Affiliation(s)
- Jonathan A Tangsrivimol
- Division of Neurosurgery, Department of Surgery, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok 10210, Thailand
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and Jame Cancer Institute, Columbus, OH 43210, USA
| | - Ethan Schonfeld
- Department Biomedical Informatics, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Anand Veeravagu
- Stanford Neurosurgical Artificial Intelligence and Machine Learning Laboratory, Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Timothy R Smith
- Department of Neurosurgery, Computational Neuroscience Outcomes Center (CNOC), Mass General Brigham, Harvard Medical School, Boston, MA 02115, USA
| | - Roger Härtl
- Weill Cornell Medicine Brain and Spine Center, New York, NY 10022, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute (BNI), Phoenix, AZ 85013, USA
| | - Adham H El-Sherbini
- Faculty of Health Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and Jame Cancer Institute, Columbus, OH 43210, USA
| | - Benjamin S Glicksberg
- Hasso Plattner Institute for Digital Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Chayakrit Krittanawong
- Cardiology Division, New York University Langone Health, New York University School of Medicine, New York, NY 10016, USA
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Haider G, Schonfeld E, Biswal S, Veeravagu A. 446 Accurate Localization of Back Pain by Radiomic Assessment of Sigma-1 Receptor Expression. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_446] [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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Haider G, Amoah Dadey DY, Rodrigues A, Pollom E, Adler JR, Veeravagu A. 869 Loss to Follow-Up for Radiation Treatment After Resection of Metastatic Brain Tumors: Analysis of a Non-Irradiated Cohort from a Private Insurance Database. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_869] [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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Hersh A, Dedrickson T, Gong JH, Jimenez A, Materi J, Veeravagu A, Ratliff JK, Azad TD. 171 Neurosurgical Utilization, Charges, and Reimbursement Following the Affordable Care Act: Trends from 2011 to 2019. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_171] [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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23
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Jin MC, Jensen M, Barros Guinle MI, Ren A, Zhou Z, Zygourakis CC, Desai A, Veeravagu A, Ratliff JK. 645 Getting What You Pay For: Impact of Copayments on Physical Therapy Initiation, Timing, and Continuation for Acute-Onset Low Back Pain. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_645] [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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24
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Haider G, Veeravagu A. Commentary: Technique for Validation of Intraoperative Navigation in Minimally Invasive Spine Surgery. Oper Neurosurg (Hagerstown) 2023; 24:e282-e283. [PMID: 36805416 DOI: 10.1227/ons.0000000000000639] [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: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 02/22/2023] Open
Affiliation(s)
- Ghani Haider
- Department of Neurosurgery, Stanford University, Stanford, California, USA
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Shah V, Haider G, Stienen MN, Veeravagu A. 356 Intraoperative Robotic Planning Software is Accurate at Predicting Postoperative Lumbar Lordosis After Anterior Column Reconstruction. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_356] [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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Hersh AM, Dedrickson T, Gong JH, Jimenez AE, Materi J, Veeravagu A, Ratliff JK, Azad TD. Neurosurgical Utilization, Charges, and Reimbursement After the Affordable Care Act: Trends From 2011 to 2019. Neurosurgery 2023; 92:963-970. [PMID: 36700751 DOI: 10.1227/neu.0000000000002306] [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: 06/15/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND An estimated 50 million Americans receive Medicare health care coverage. Prior studies have established a downward trend in Medicare reimbursement for commonly billed surgical procedures, but it is unclear whether these trends hold true across all neurosurgical procedures. OBJECTIVE To assess trends in utilization, charges, and reimbursement by Medicare for neurosurgical procedures after passage of the Affordable Care Act in 2010. METHODS We review yearly Physician/Supplier Procedure Summary datasets from the Centers for Medicare and Medicaid Services for all procedures billed by neurosurgeons to Medicare Part B between 2011 and 2019. Procedural coding was categorized into cranial, spine, vascular, peripheral nerve, and radiosurgery cases. Weighted averages for charges and reimbursements adjusted for inflation were calculated. The ratio of the weighted mean reimbursement to weighted mean charge was calculated as the reimbursement-to-charge ratio, representing the proportion of charges reimbursed by Medicare. RESULTS Overall enrollment-adjusted utilization decreased by 12.1%. Utilization decreased by 24.0% in the inpatient setting but increased by 639% at ambulatory surgery centers and 80.2% in the outpatient setting. Inflation-adjusted, weighted mean charges decreased by 4.0% while reimbursement decreased by 4.6%. Procedure groups that saw increases in reimbursement included cervical spine surgery, cranial functional and epilepsy procedures, cranial pain procedures, and endovascular procedures. Ambulatory surgery centers saw the greatest increase in charges and reimbursements. CONCLUSION Although overall reimbursement declined across the study period, substantial differences emerged across procedural categories. We further find a notable shift in utilization and reimbursement for neurosurgical procedures done in non-inpatient care settings.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tara Dedrickson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jung Ho Gong
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Rodrigues AJ, Schonfeld E, Varshneya K, Stienen MN, Staartjes VE, Jin MC, Veeravagu A. Comparison of Deep Learning and Classical Machine Learning Algorithms to Predict Postoperative Outcomes for Anterior Cervical Discectomy and Fusion Procedures With State-of-the-art Performance. Spine (Phila Pa 1976) 2022; 47:1637-1644. [PMID: 36149852 DOI: 10.1097/brs.0000000000004481] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/06/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE Due to anterior cervical discectomy and fusion (ACDF) popularity, it is important to predict postoperative complications, unfavorable 90-day readmissions, and two-year reoperations to improve surgical decision-making, prognostication, and planning. SUMMARY OF BACKGROUND DATA Machine learning has been applied to predict postoperative complications for ACDF; however, studies were limited by sample size and model type. These studies achieved ≤0.70 area under the curve (AUC). Further approaches, not limited to ACDF, focused on specific complication types and resulted in AUC between 0.70 and 0.76. MATERIALS AND METHODS The IBM MarketScan Commercial Claims and Encounters Database and Medicare Supplement were queried from 2007 to 2016 to identify adult patients who underwent an ACDF procedure (N=176,816). Traditional machine learning algorithms, logistic regression, and support vector machines, were compared with deep neural networks to predict: 90-day postoperative complications, 90-day readmission, and two-year reoperation. We further generated random deep learning model architectures and trained them on the 90-day complication task to approximate an upper bound. Last, using deep learning, we investigated the importance of each input variable for the prediction of 90-day postoperative complications in ACDF. RESULTS For the prediction of 90-day complication, 90-day readmission, and two-year reoperation, the deep neural network-based models achieved AUC of 0.832, 0.713, and 0.671. Logistic regression achieved AUCs of 0.820, 0.712, and 0.671. Support vector machine approaches were significantly lower. The upper bound of deep learning performance was approximated as 0.832. Myelopathy, age, human immunodeficiency virus, previous myocardial infarctions, obesity, and documentary weakness were found to be the strongest variable to predict 90-day postoperative complications. CONCLUSIONS The deep neural network may be used to predict complications for clinical applications after multicenter validation. The results suggest limited added knowledge exists in interactions between the input variables used for this task. Future work should identify novel variables to increase predictive power.
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Affiliation(s)
- Adrian J Rodrigues
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Ethan Schonfeld
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Michael C Jin
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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Wadhwa H, Leung C, Sklar M, Ames CP, Veeravagu A, Desai A, Ratliff J, Zygourakis CC. Utilization Trends, Cost, and Payments for Adult Spinal Deformity Surgery in Commercial and Medicare-Insured Populations. Neurosurgery 2022; 91:961-968. [PMID: 36136402 DOI: 10.1227/neu.0000000000002140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Previous studies have characterized utilization rates and cost of adult spinal deformity (ASD) surgery, but the differences between these factors in commercially insured and Medicare populations are not well studied. OBJECTIVE To identify predictors of increased payments for ASD surgery in commercially insured and Medicare populations. METHODS We identified adult patients who underwent fusion for ASD, 2007 to 2015, in 20% Medicare inpatient file (n = 21 614) and MarketScan commercial insurance database (n = 38 789). Patient age, sex, race, insurance type, geographical region, Charlson Comorbidity Index, and length of stay were collected. Outcomes included predictors of increased payments, surgical utilization rates, total cost (calculated using Medicare charges and hospital-specific charge-to-cost ratios), and total Medicare and commercial payments for ASD. RESULTS Rates of fusion increased from 9.0 to 8.4 per 10 000 in 2007 to 20.7 and 18.2 per 10 000 in 2015 in commercial and Medicare populations, respectively. The Medicare median total charges increased from $88 106 to $144 367 (compound annual growth rate, CAGR: 5.6%), and the median total cost increased from $31 846 to $39 852 (CAGR: 2.5%). Commercial median total payments increased from $58 164 in 2007 to $64 634 in 2015 (CAGR: 1.2%) while Medicare median total payments decreased from $31 415 in 2007 to $25 959 in 2015 (CAGR: -2.1%). The Northeast and Western regions were associated with higher payments in both populations, but there is substantial state-level variation. CONCLUSION Rate of ASD surgery increased from 2007 to 2015 among commercial and Medicare beneficiaries. Despite increasing costs, Medicare payments decreased. Age, length of stay, and BMP usage were associated with increased payments for ASD surgery in both populations.
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Affiliation(s)
- Harsh Wadhwa
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Christopher Leung
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Matthew Sklar
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Atman Desai
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - John Ratliff
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Corinna C Zygourakis
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
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Rodrigues AJ, Varshneya K, Schonfeld E, Malhotra S, Stienen MN, Veeravagu A. Chronic Opioid Use Prior to ACDF Surgery Is Associated with Inferior Postoperative Outcomes: A Propensity-Matched Study of 17,443 Chronic Opioid Users. World Neurosurg 2022; 166:e294-e305. [PMID: 35809840 DOI: 10.1016/j.wneu.2022.07.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Candidates for anterior cervical discectomy and fusion (ACDF) have a higher rate of opioid use than does the public, but studies on preoperative opioid use have not been conducted. We aimed to understand how preoperative opioid use affects post-ACDF outcomes. METHODS The MarketScan Database was queried from 2007 to 2015 to identify adult patients who underwent an ACDF. Patients were classified into separate cohorts based on the number of separate opioid prescriptions in the year before their ACDF. Ninety-day postoperative complications, postoperative readmission, reoperation, and total inpatient costs were compared between opioid strata. Propensity score-matched patient cohorts were calculated to balance comorbidities across groups. RESULTS Of 81,671 ACDF patients, 31,312 (38.3%) were nonusers, 30,302 (37.1%) were mild users, and 20,057 (24.6%) were chronic users. Chronic opioid users had a higher comorbidity burden, on average, than patients with less frequent opioid use (P < 0.001). Chronic opioid users had higher rates of postoperative complications (9.1%) than mild opioid users (6.0%) and nonusers (5.3%) (P < 0.001) and higher rates of readmission and reoperation. After balancing opioid nonusers versus chronic opioid users along with demographic characteristics, preoperative comorbidity, and operative characteristics, postoperative complications remained elevated for chronic opioid users relative to opioid nonusers (8.6% vs. 5.7%; P < 0.001), as did rates of readmission and reoperation. CONCLUSIONS Chronic opioid users had more comorbidities than opioid nonusers and mild opioid users, longer hospitalizations, and higher rates of postoperative complication, readmission, and reoperation. After balancing patients across covariates, the outcome differences persisted, suggesting a durable association between preoperative opioid use and negative postoperative outcomes.
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Affiliation(s)
- Adrian J Rodrigues
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Ethan Schonfeld
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Shreya Malhotra
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
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Xu JC, Haider SA, Sharma A, Blumenfeld K, Cheng J, Mazzola CA, Orrico KO, Rosenow J, Stacy J, Stroink A, Tomei K, Tumialán LM, Veeravagu A, Linskey ME, Schwalb J. Telehealth in Neurosurgery: 2021 Council of State Neurosurgical Societies National Survey Results. World Neurosurg 2022; 168:e328-e335. [DOI: 10.1016/j.wneu.2022.09.126] [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] [Received: 06/20/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
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Rodrigues AJ, Jokhai R, Varshneya K, Stienen MN, Veeravagu A. Factors Which Predict Adverse Outcomes in Anterior Cervical Discectomy and Fusion Procedures in the Nonelderly Adult Population. Clin Spine Surg 2022; 35:E584-E589. [PMID: 35385403 DOI: 10.1097/bsd.0000000000001326] [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: 07/21/2021] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The largest published cohort of anterior cervical discectomy and fusion (ACDF) patients was queried to better characterize demographic and operative factors that predict 90-day complication and 2-year reoperation risk. SUMMARY OF BACKGROUND DATA The MarketScan Database was queried from 2007 to 2016 to identify adult patients until 65 years, who underwent an ACDF procedure using International Classification of Diseases 9th Version (ICD-9) and Current Procedural Terminology (CPT) codes. MarketScan is a national insurance claims database that contains millions of patient records across all 50 states. METHODS Multivariate logistic regression was used to identify factors associated with complications until 90 days and reoperations until 2 years. RESULTS Of 138,839 ACDF procedures, 8500 patients (6.1%) experienced a complication within 90 days of the ACDF, and 7433 (5.4%) underwent surgical revision by 2 years. While the use of anterior cervical plating did not predict 2-year reoperation, it was associated with dramatically reduced 90-day complication risk (adjusted odds ratio [aOR]: 0.32; 95% confidence interval [CI]: 0.30-0.34; P <0.001). Upon multivariate analysis, female sex (aOR: 0.83; 95% CI: 0.79-0.87; P <0.001) was associated with decreased risk of 2-year reoperation, while depression predicted a 50% increase in reoperation risk (aOR: 1.51; 95% CI: 1.43-1.59; P <0.001). The single largest factor associated with reoperation risk, however, was the presence of a 90-day postoperative complication (aOR: 1.79; 95% CI: 1.66-1.94; P <0.001). CONCLUSION Increased patient comorbidities and the use of bone morphogenic protein were found to increase the risk for postoperative complications, while cervical plating was associated with a strong decline in this risk. In addition, poor patient mental health outweighed the adverse of impact of other comorbidities on 2-year revision risk. The presence of a postoperative complication was the key modifiable risk factor associated with reoperation risk. Conclusions from this study may help surgeons better identify high-risk ACDF patients for more careful patient selection, counseling, informed consent, and management.
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Affiliation(s)
- Adrian J Rodrigues
- Neurosurgery AI Lab and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Rayyan Jokhai
- Neurosurgery AI Lab and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Kunal Varshneya
- Neurosurgery AI Lab and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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Jin MC, Jensen M, Zhou Z, Rodrigues A, Ren A, Barros Guinle MI, Veeravagu A, Zygourakis CC, Desai AM, Ratliff JK. Health Care Resource Utilization in Management of Opioid-Naive Patients With Newly Diagnosed Neck Pain. JAMA Netw Open 2022; 5:e2222062. [PMID: 35816312 PMCID: PMC9280399 DOI: 10.1001/jamanetworkopen.2022.22062] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain. OBJECTIVE To understand health care utilization in patients with new-onset idiopathic neck pain. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used nationally sourced longitudinal data from the IBM Watson Health MarketScan claims database (2007-2016). Participants included adult patients with newly diagnosed neck pain, no recent opioid use, and at least 1 year of continuous postdiagnosis follow-up. Exclusion criteria included prior or concomitant diagnosis of traumatic cervical disc dislocation, vertebral fractures, myelopathy, and/or cancer. Only patients with at least 1 year of prediagnosis lookback were included. Data analysis was performed from January 2021 to January 2022. MAIN OUTCOMES AND MEASURES The primary outcome of interest was 1-year postdiagnosis health care expenditures, including costs, opioid use, and health care service utilization. Early services were those received within 30 days of diagnosis. Multivariable regression models and regression-adjusted statistics were used. RESULTS In total, 679 030 patients (310 665 men [45.6%]) met the inclusion criteria, of whom 7858 (1.2%) underwent surgery within 1 year of diagnosis. The mean (SD) age was 44.62 (14.87) years among nonsurgical patients and 49.69 (9.53) years among surgical patients. Adjusting for demographics and comorbidities, 1-year regression-adjusted health care costs were $24 267.55 per surgical patient and $515.69 per nonsurgical patient. Across all health care services, $95 379 949 was accounted for by nonsurgical patients undergoing early imaging who did not receive any additional conservative therapy or epidural steroid injections, for a mean (SD) of $477.53 ($1375.60) per patient and median (IQR) of $120.60 ($20.70-$452.37) per patient. On average, patients not undergoing surgery, physical therapy, chiropractic manipulative therapy, or epidural steroid injection, who underwent either early advanced imaging (magnetic resonance imaging or computed tomography) or both early advanced and radiographic imaging, accumulated significantly elevated health care costs ($850.69 and $1181.67, respectively). Early conservative therapy was independently associated with 24.8% (95% CI, 23.5%-26.2%) lower health care costs. CONCLUSIONS AND RELEVANCE In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael Jensen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Zeyi Zhou
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Adrian Rodrigues
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Alexander Ren
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | | | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Corinna C Zygourakis
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Haider G, Wagner KE, Chandra V, Cheng I, Stienen MN, Veeravagu A. Utilization of lateral anterior lumbar interbody fusion for revision of failed prior TLIF: illustrative case. Journal of Neurosurgery: Case Lessons 2022; 3:CASE2296. [PMID: 35733821 PMCID: PMC9204934 DOI: 10.3171/case2296] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of the lateral decubitus approach for L5–S1 anterior lumbar interbody fusion (LALIF) is a recent advancement capable of facilitating single-position surgery, revision operations, and anterior column reconstruction. To the authors’ knowledge, this is the first description of the use of LALIF at L5–S1 for failed prior transforaminal lumbar interbody fusion (TLIF) and anterior column reconstruction. Using an illustrative case, the authors discuss their experience using LALIF at L5–S1 for the revision of pseudoarthrosis and TLIF failure. OBSERVATIONS The patient had prior attempted L2 to S1 fusion with TLIF but suffered from hardware failure and pseudoarthrosis at the L5–S1 level. LALIF was used to facilitate same-position revision at L5–S1 in addition to further anterior column revision and reconstruction by lateral lumbar interbody fusion at the L1–2 level. Robotic posterior T10–S2 fusion was then added to provide stability to the construct and address the patient’s scoliotic deformity. No complications were noted, and the patient was followed until 1 year after the operation with a favorable clinical and radiological result. LESSONS Revision of a prior failed L5–S1 TLIF with an LALIF approach has technical challenges but may be advantageous for single position anterior column reconstruction under certain conditions.
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Affiliation(s)
| | | | | | - Ivan Cheng
- Orthopedic Surgery, Stanford University, Stanford, California; and
| | - Martin N. Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Cantonal Hospital, St. Gallen, Switzerland
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Wadhwa H, Oquendo YA, Tigchelaar SS, Warren SI, Koltsov JCB, Desai A, Veeravagu A, Alamin TF, Ratliff JK, Hu SS, Cheng I. Advanced Age Does Not Impact Outcomes After 1-level or 2-level Lateral Lumbar Interbody Fusion. Clin Spine Surg 2022; 35:E368-E373. [PMID: 34724454 DOI: 10.1097/bsd.0000000000001270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/30/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective comparative study. OBJECTIVE The objective of this study was to assess the effect of increased age on perioperative and postoperative complication rates, reoperation rates, and patient-reported pain and disability scores after lateral lumbar interbody fusion (LLIF). SUMMARY OF BACKGROUND DATA LLIF was developed to minimize soft tissue trauma and reduce the risk of vascular injury; however, there is little evidence regarding the effect of advanced age on outcomes of LLIF. METHODS Patients who underwent LLIF from 2009 to 2019 at one institution with a minimum 6-month follow-up were retrospectively reviewed. Patients less than 18 years old with musculoskeletal tumor or trauma were excluded. The primary outcome was the preoperative to postoperative change in the Numeric Pain Rating Scale (NPRS) for back pain. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and change in Oswestry Disability Index were also evaluated. Relationships with age were assessed both with age as a continuous variable and segmenting by age below 70 versus 70+. RESULTS In total, 279 patients were included. The median age was 65±13 years and 159 (57%) were female. Age was not related to improvements in back NPRS and Oswestry Disability Index. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and radiographic fusion rate also were not related to age. After multivariable risk adjustment, increasing age was associated with greater improvements in back NPRS. The decrease in back NPRS was 0.68 (95% confidence interval: 0.14, 1.22; P=0.014) points greater for every 10-year increase in age. Age was not associated with rates of complication, readmission, or reoperation. CONCLUSIONS LLIF is a safe and effective procedure in the elderly population. Advanced age is associated with larger improvements in preoperative back pain. Surgeons should consider the benefits of LLIF and other minimally invasive techniques when evaluating elderly candidates for lumbar fusion. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | | | | | - Atman Desai
- Neurosurgery, Stanford University Medical Center, Stanford, CA
| | - Anand Veeravagu
- Neurosurgery, Stanford University Medical Center, Stanford, CA
| | | | - John K Ratliff
- Neurosurgery, Stanford University Medical Center, Stanford, CA
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Wagner KE, Haider G, Veeravagu A. Commentary: Robotic Nerve Sheath Tumor Resection With Intraoperative Neuromonitoring: Case Series and Systematic Review. Oper Neurosurg (Hagerstown) 2022; 22:e227-e228. [PMID: 35316253 DOI: 10.1227/ons.0000000000000164] [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] [Received: 12/15/2021] [Accepted: 12/18/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Katherine E Wagner
- Department of Neurosurgery, Stanford University, Stanford, California, USA
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Rodrigues A, Varshneya K, Veeravagu A. 431 Chronic Opioid Use Prior to ACDF Surgery is Associated With Inferior Post-operative Outcomes. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Varshneya K, Wadhwa H, Ho AL, Medress ZA, Stienen MN, Desai A, Ratliff JK, Veeravagu A. Surgical Outcomes of Human Immunodeficiency Virus-positive Patients Undergoing Lumbar Degenerative Surgery. Clin Spine Surg 2022; 35:E339-E344. [PMID: 34183544 DOI: 10.1097/bsd.0000000000001221] [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: 01/05/2021] [Accepted: 06/01/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort studying using a national administrative database. OBJECTIVE The objective of this study was to determine the postoperative complications and quality outcomes of the human immunodeficiency virus (HIV)-positive patients undergoing surgical management for lumbar degenerative disease (LDD). METHODS This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether they were HIV positive at the time of surgery. Multivariate regression was utilized to reduce the confounding of baseline covariates. Patients who underwent 3 or more levels of surgical correction were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined. RESULTS A total of 120,167 patients underwent primary lumbar degenerative surgery, of which 309 (0.26%) were HIV positive. In multivariate regression analysis, the HIV-positive cohort was more likely to be readmitted at 30 days [odds ratio (OR)=1.9, 95% confidence interval (CI): 1.2-2.8], 60 days (OR=1.7, 95% CI: 1.2-2.5), and 90 days (OR=1.5, 95% CI: 1.0-2.2). The HIV-positive cohort was also more likely to experience any postoperative complication (OR=1.7, 95% CI: 1.2-2.3). Of the major drivers identified, HIV-positive patients had significantly greater odds of cerebrovascular disease and postoperative neurological complications (OR=3.8, 95% CI: 1.8-6.9) and acute kidney injury (OR=3.4, 95% CI: 1.3-7.1). Costs of index hospitalization were not significantly different between the 2 cohorts ($30,056 vs. $29,720, P=0.6853). The total costs were also similar throughout the 2-year follow-up period. CONCLUSION Patients who are HIV positive at the time of LDD surgery are at a higher risk for postoperative central nervous system and renal complications and unplanned readmissions.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Harsh Wadhwa
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Allen L Ho
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Zachary A Medress
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Martin N Stienen
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
- Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Atman Desai
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - John K Ratliff
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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Varshneya K, Bhattacharjya A, Sharma J, Stienen MN, Medress ZA, Ratliff JK, Veeravagu A. Outcome Measures of Medicare Patients With Diabetes Mellitus Undergoing Thoracolumbar Deformity Surgery. Clin Spine Surg 2022; 35:E31-E35. [PMID: 34183547 DOI: 10.1097/bsd.0000000000001229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective study. OBJECTIVE The objective of this study was to identify the impact of diabetes on postoperative outcomes in Medicare patients undergoing adult spinal deformity (ASD) surgery. METHODS We queried the MarketScan Medicare database to identify patients who underwent ASD surgery from 2007 to 2016. Patients were then stratified based on diabetes status at the time of the index operation. Patients not enrolled in the Medicare dataset and those with any prior history of trauma or tumor were excluded from this study. RESULTS A total of 2564 patients met the inclusion criteria of this study, of which n=746 (29.1.%) were diabetic. Patients with diabetes had a higher rate of postoperative infection than nondiabetic patients (3.1% vs. 1.7%, P<0.05) within 90 days. Renal complications were also more elevated in the diabetic cohort (3.2% vs. 1.3%, P<0.05). Readmission rates were significantly higher in the diabetes cohort through of 60 days (15.2% vs. 11.8%, P<0.05) and 90 days (17.0% vs. 13.4%, P<0.05). When looking specifically at the outpatient payments, patients with diabetes did have a higher financial burden at 60 days ($8147 vs. $6956, P<0.05) and 90 days ($10,126 vs. $8376, P<0.05). CONCLUSIONS In this study, diabetic patients who underwent ASD surgery had elevated rates of postoperative infection, outpatient costs, and rates of readmissions within 90 days. Further research should investigate the role of poor glycemic control on spine surgery outcomes.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Anika Bhattacharjya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Jigyasa Sharma
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Martin N Stienen
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
- Department of Neurosurgery, University Hospital Zurich
- Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Zachary A Medress
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - John K Ratliff
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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Varshneya K, Stienen MN, Medress ZA, Fatemi P, Pendharkar AV, Ratliff JK, Veeravagu A. Risk Factors for Revision Surgery After Primary Adult Thoracolumbar Deformity Surgery. Clin Spine Surg 2022; 35:E94-E98. [PMID: 33443943 DOI: 10.1097/bsd.0000000000001124] [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: 03/21/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE The aim was to identify the risk factors for revision surgery within 2 years of patients undergoing primary adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA Previous literature reports estimate 20% of patients undergoing thoracolumbar ASD correction undergo reoperation within 2 years. There is limited published data regarding specific risk factors for reoperation in ASD surgery in the short term and long term. METHODS The authors queried the MarketScan database in order to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2015. Patient-level factors and revision risk were investigated during 2 years after primary ASD surgery. Patients under the age of 18 years and those with any prior history of trauma or tumor were excluded from this study. RESULTS A total 7422 patients underwent ASD surgery during 2007-2015 in the data set. Revision rates were 13.1% at 90 days, 14.5% at 6 months, 16.7% at 1 year, and 19.3% at 2 years. In multivariate multiple logistic regression analysis, obesity [adjusted odds ratio (OR): 1.58, P<0.001] and tobacco use (adjusted OR: 1.38, P=0.0011) were associated with increased odds of reoperation within 2 years. Patients with a combined anterior-posterior approach had lower odds of reoperation compared with those with posterior only approach (adjusted OR: 0.66, P=0.0117). CONCLUSIONS Obesity and tobacco are associated with increased odds of revision surgery within 2 years of index ASD surgery. Male sex and combined surgical approach are associated with decreased odds of revision surgery.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Martin N Stienen
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
- Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Zachary A Medress
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Parastou Fatemi
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Arjun V Pendharkar
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - John K Ratliff
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Anand Veeravagu
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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Jin MC, Azad TD, Fatemi P, Ho AL, Vail D, Zhang Y, Feng AY, Kim LH, Bentley JP, Stienen MN, Li G, Desai AM, Veeravagu A, Ratliff JK. Defining and describing treatment heterogeneity in new-onset idiopathic lower back and extremity pain through reconstruction of longitudinal care sequences. Spine J 2021; 21:1993-2002. [PMID: 34033933 DOI: 10.1016/j.spinee.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/12/2021] [Accepted: 05/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite established guidelines, long-term management of surgically-treated low back pain (LBP) and lower extremity pain (LEP) remains heterogeneous. Understanding care heterogeneity could inform future approaches for standardization of practices. PURPOSE To describe treatment heterogeneity in surgically-managed LBP and LEP. STUDY DESIGN/SETTING Retrospective study of a nationwide commercial database spanning inpatient and outpatient encounters for enrollees of eligible employer-supplied healthcare plans (2007-2016). PATIENT SAMPLE A population-based sample of opioid-naïve adult patients with newly-diagnosed LBP or LEP were identified. Inclusion required at least 12-months of pre-diagnosis and post-diagnosis continuous follow-up. EXPOSURE Included treatments/evaluations include conservative management (chiropractic manipulative therapy, physical therapy, epidural steroid injections), imaging (x-ray, MRI, CT), pharmaceuticals (opioids, benzodiazepines), and spine surgery (decompression, fusion). OUTCOME MEASURES Primary outcomes-of-interest were 12-month net healthcare expenditures (inpatient and outpatient) and 12-month opioid usage. METHODS Analyses include interrogation of care sequence heterogeneity and temporal trends in sequence-initiating services. Comparisons were conducted in the framework of sequence-specific treatment sequences, which reflect the personalized order of healthcare services pursued by each patient. Outlier sequences characterized by high opioid use and costs were identified from frequently observed surgical treatment sequences using Mahalanobis distance. RESULTS A total of 2,496,908 opioid-naïve adult patients with newly-diagnosed LBP or LEP were included (29,519 surgical). In the matched setting, increased care sequence heterogeneity was observed in surgical patients (0.51 vs. 0.12 previously-unused interventions/studies pursued per month). Early opioid and MRI use has decreased between 2008 and 2015 but is matched by increases in early benzodiazepine and x-ray use. Outlier sequences, characterized by increased opioid use and costs, were found in 5.8% of surgical patients. Use of imaging prior to conservative management was common in patients pursuing outlier sequences compared to non-outlier sequences (96.5% vs. 63.8%, p<.001). Non-outlier sequences were more frequently characterized by early conservative interventions (31.9% vs. 7.4%, p<.001). CONCLUSIONS Surgically-managed LBP and LEP care sequences demonstrate high heterogeneity despite established practice guidelines. Outlier sequences associated with high opioid usage and costs can be identified and are characterized by increased early imaging and decreased early conservative management. Elements that may portend suboptimal longitudinal management could provide opportunities for standardization of patient care.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Parastou Fatemi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Daniel Vail
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Austin Y Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Jason P Bentley
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Martin N Stienen
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Tumialán LM, Veeravagu A, Ratliff JK. Commentary: Loss of Relativity: The Physician Fee Schedule, the Neurosurgeon, and the Trojan Horse. Neurosurgery 2021; 89:E323-E324. [PMID: 34498695 DOI: 10.1093/neuros/nyab339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Luis M Tumialán
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Palo Alto, California, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University Medical Center, Palo Alto, California, USA
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Varshneya K, Bhattacharjya A, Jokhai RT, Fatemi P, Medress ZA, Stienen MN, Ho AL, Ratliff JK, Veeravagu A. The impact of osteoporosis on adult deformity surgery outcomes in Medicare patients. Eur Spine J 2021; 31:88-94. [PMID: 34655336 DOI: 10.1007/s00586-021-06985-z] [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: 02/08/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify the impact of osteoporosis (OS) on postoperative outcomes in Medicare patients undergoing ASD surgery. BACKGROUND Patients with OP and advanced age experience higher than average rates of ASD. However, poor bone density could undermine the durability of a deformity correction. METHODS We queried the MarketScan Medicare Supplemental database to identify patients Medicare patients who underwent ASD surgery from 2007 to 2016. RESULTS A total of 2564 patients met the inclusion criteria of this study, of whom n = 971 (61.0%) were diagnosed with osteoporosis. Patients with OP had a similar 90-day postoperative complication rates (OP: 54.6% vs. non-OP: 49.2%, p = 0.0076, not significant after multivariate regression correction). This was primarily driven by posthemorrhagic anemia (37.6% in OP, vs. 33.1% in non-OP). Rates of revision surgery were similar at 90 days (non-OP 15.0%, OP 16.8%), but by 2 years, OP patients had a significantly higher reoperation rate (30.4% vs. 22.9%, p < 0.0001). In multivariate regression analysis, OP increased odds for revision surgery at 1 year (OR 1.4) and 2 years (OR 1.5) following surgery (all p < 0.05). OP was also an independent predictor of readmission at all time points (90 days, OR 1.3, p < 0.005). CONCLUSION Medicare patients with OP had elevated rates of complications, reoperations, and outpatient costs after undergoing primary ASD surgery.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA. .,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland.
| | - Anika Bhattacharjya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Rayyan T Jokhai
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Parastou Fatemi
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Zachary A Medress
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin N Stienen
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Allen L Ho
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - John K Ratliff
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
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Azad TD, Ehresman J, Ahmed AK, Staartjes VE, Lubelski D, Stienen MN, Veeravagu A, Ratliff JK. Fostering reproducibility and generalizability in machine learning for clinical prediction modeling in spine surgery. Spine J 2021; 21:1610-1616. [PMID: 33065274 DOI: 10.1016/j.spinee.2020.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/13/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
As the use of machine learning algorithms in the development of clinical prediction models has increased, researchers are becoming more aware of the deleterious effects that stem from the lack of reporting standards. One of the most obvious consequences is the insufficient reproducibility found in current prediction models. In an attempt to characterize methods to improve reproducibility and to allow for better clinical performance, we utilize a previously proposed taxonomy that separates reproducibility into 3 components: technical, statistical, and conceptual reproducibility. By following this framework, we discuss common errors that lead to poor reproducibility, highlight the importance of generalizability when evaluating a ML model's performance, and provide suggestions to optimize generalizability to ensure adequate performance. These efforts are a necessity before such models are applied to patient care.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, USA 21287
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, USA 21287
| | - Ali Karim Ahmed
- Department of Neurosurgery, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, USA 21287
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Lab, Clinical Neuroscience Centre, University of Zurich, Switzerland; Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, USA 21287
| | - Martin N Stienen
- Machine Intelligence in Clinical Neuroscience (MICN) Lab, Clinical Neuroscience Centre, University of Zurich, Switzerland; Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
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Jin MC, Ho AL, Feng AY, Zhang Y, Staartjes VE, Stienen MN, Han SS, Veeravagu A, Ratliff JK, Desai AM. Predictive modeling of long-term opioid and benzodiazepine use after intradural tumor resection. Spine J 2021; 21:1687-1699. [PMID: 33065272 DOI: 10.1016/j.spinee.2020.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/05/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection. METHODS The IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6 months of continuous preadmission baseline data and 12 months of continuous postdischarge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%. RESULTS A total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with postdischarge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% confidence interval [CI] 1.1-38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3-32.9). Pre- and perioperative use of prescribed nonsteroidal anti-inflammatory drugs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased postdischarge opioid and benzodiazepine use. Intramedullary location was associated with longer duration postdischarge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5-19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (area under curve [AUC]=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients. CONCLUSIONS We developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Austin Y Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Clinical Neuroscience Center, University Hospital Zurich, Switzerland; Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Summer S Han
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States.
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45
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Wadhwa H, Sharma J, Varshneya K, Fatemi P, Nathan J, Medress ZA, Stienen MN, Ratliff JK, Veeravagu A. Anterior Cervical Discectomy and Fusion Versus Laminoplasty for Multilevel Cervical Spondylotic Myelopathy: A National Administrative Database Analysis. World Neurosurg 2021; 152:e738-e744. [PMID: 34153482 DOI: 10.1016/j.wneu.2021.06.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) is effective for the treatment of single-level cervical spondylotic myelopathy (CSM). However, the data surrounding multilevel CSM have remained controversial. One alternative is laminoplasty, although evidence comparing these strategies has remained sparse. In the present report, we retrospectively reviewed the readmission and reoperation rates for patients who had undergone ACDF or laminoplasty for multilevel CSM from a national longitudinal administrative claims database. METHODS We queried the MarketScan Commercial Claims and Encounters database to identify patients who had undergone ACDF or laminoplasty for multilevel CSM from 2007 to 2016. The patients were stratified by operation type. Patients aged <18 years, patients with a history of tumor or trauma, and patients who had undergone anteroposterior approach were excluded from the present study. RESULTS A total of 5445 patients were included, of whom 1521 had undergone laminoplasty. A matched cohort who had undergone ACDF was identified. The overall 90-day postoperative complication rate was greater in the laminoplasty cohort (odds ratio, 1.48; 95% confidence interval, 1.18-1.86; P < 0.0001). The mean length of stay and 90-day readmission rates were greater in the laminoplasty cohort. The hospital and total payments of the index hospitalization were greater in the ACDF cohort, as were the total payments for ≤2 years after the index hospitalization. CONCLUSIONS In the present administrative claims database study, no difference was found in the reoperation rate between ACDF and laminoplasty. ACDF resulted in fewer complications and readmissions compared with laminoplasty but was associated with greater costs. Additional prospective research is required to investigate the factors driving the higher costs of ACDF in this population and the long-term clinical outcomes.
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Affiliation(s)
- Harsh Wadhwa
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Jigyasa Sharma
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Parastou Fatemi
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Jay Nathan
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Zachary A Medress
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - John K Ratliff
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA.
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Varshneya K, Medress ZA, Stienen MN, Nathan J, Ho A, Pendharkar AV, Loo S, Aikin J, Li G, Desai A, Ratliff JK, Veeravagu A. A Comparative Analysis of Patients Undergoing Fusion for Adult Cervical Deformity by Approach Type. Global Spine J 2021; 11:626-632. [PMID: 32875897 PMCID: PMC8165914 DOI: 10.1177/2192568220915717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To provide insight into postoperative complications, short-term quality outcomes, and costs of the surgical approaches of adult cervical deformity (ACD). METHODS A national database was queried from 2007 to 2016 to identify patients who underwent cervical fusion for ACD. Patients were stratified by approach type-anterior, posterior, or circumferential. Patients undergoing anterior and posterior approach surgeries were additionally compared using propensity score matching. RESULTS A total of 6575 patients underwent multilevel cervical fusion for ACD correction. Circumferential fusion had the highest postoperative complication rate (46.9% vs posterior: 36.7% vs anterior: 18.5%, P < .0001). Anterior fusion patients more commonly required reoperation compared with posterior fusion patients (P < .0001), and 90-day readmission rate was highest for patients undergoing circumferential fusion (P < .0001). After propensity score matching, the complication rate remained higher in the posterior, as compared to the anterior fusion group (P < .0001). Readmission rate also remained higher in the posterior fusion group; however, anterior fusion patients were more likely to require reoperation. At index hospitalization, posterior fusion led to 1.5× higher costs, and total payments at 90 days were 1.6× higher than their anterior fusion counterparts. CONCLUSION Patients who undergo posterior fusion for ACD have higher complication rates, readmission rates, and higher cost burden than patients who undergo anterior fusion; however, posterior correction of ACD is associated with a lower rate of reoperation.
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Affiliation(s)
| | | | - Martin N. Stienen
- Stanford University, Stanford, CA, USA,University Hospital Zurich, Zurich, Switzerland,University of Zurich, Zurich, Switzerland
| | - Jay Nathan
- University of Michigan, Ann Arbor, MI, USA
| | - Allen Ho
- Stanford University, Stanford, CA, USA
| | | | - Sheri Loo
- Stanford University, Stanford, CA, USA
| | | | - Gordon Li
- Stanford University, Stanford, CA, USA
| | | | | | - Anand Veeravagu
- Stanford University, Stanford, CA, USA,Anand Veeravagu, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Varshneya K, Jokhai R, Medress ZA, Stienen MN, Ho A, Fatemi P, Ratliff JK, Veeravagu A. Factors which predict adverse events following surgery in adults with cervical spinal deformity. Bone Joint J 2021; 103-B:734-738. [PMID: 33789479 DOI: 10.1302/0301-620x.103b4.bjj-2020-0845.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults. METHODS We identified adult patients who underwent corrective cervical spinal surgery between 1 January 2007 and 31 December 2015 from the MarketScan database. The baseline comorbidities and characteristics of the operation were recorded. Adverse events were defined as the development of a complication, an unanticipated deleterious postoperative event, or further surgery. Patients aged < 18 years and those with a previous history of tumour or trauma were excluded from the study. RESULTS A total of 13,549 adults in the database underwent primary corrective surgery for a cervical spinal deformity during the study period. A total of 3,785 (27.9%) had a complication within 90 days of the procedure, and 3,893 (28.7%) required further surgery within two years. In multivariate analysis, male sex (odds ratio (OR) 0.90 (95% confidence interval (CI) 0.8 to 0.9); p = 0.019) and a posterior approach (compared with a combined surgical approach, OR 0.66 (95% CI 0.5 to 0.8); p < 0.001) significantly decreased the risk of complications. Osteoporosis (OR 1.41 (95% CI 1.3 to 1.6); p < 0.001), dyspnoea (OR 1.48 (95% CI 1.3 to 1.6); p < 0.001), cerebrovascular accident (OR 1.81 (95% CI 1.6 to 2.0); p < 0.001), a posterior approach (compared with an anterior approach, OR 1.23 (95% CI 1.1 to 1.4); p < 0.001), and the use of bone morphogenic protein (BMP) (OR 1.22 (95% CI 1.1 to 1.4); p = 0.003) significantly increased the risks of 90-day complications. In multivariate regression analysis, preoperative dyspnoea (OR 1.50 (95% CI 1.3 to 1.7); p < 0.001), a posterior approach (compared with an anterior approach, OR 2.80 (95% CI 2.4 to 3.2; p < 0.001), and postoperative dysphagia (OR 2.50 (95% CI 1.8 to 3.4); p < 0.001) were associated with a significantly increased risk of further surgery two years postoperatively. A posterior approach (compared with a combined approach, OR 0.32 (95% CI 0.3 to 0.4); p < 0.001), the use of BMP (OR 0.48 (95% CI 0.4 to 0.5); p < 0.001) were associated with a significantly decreased risk of further surgery at this time. CONCLUSION The surgical approach and intraoperative use of BMP strongly influence the risk of further surgery, whereas the comorbidity burden and the characteristics of the operation influence the rates of early complications in adult patients undergoing corrective cervical spinal surgery. These data may aid surgeons in patient selection and surgical planning. Cite this article: Bone Joint J 2021;103-B(4):734-738.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Rayyan Jokhai
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Zachary Adam Medress
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin Nikolaus Stienen
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Allen Ho
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Parastou Fatemi
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - John Kevin Ratliff
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
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Varshneya K, Pangal DJ, Stienen MN, Ho AL, Fatemi P, Medress ZA, Herrick DB, Desai A, Ratliff JK, Veeravagu A. Postoperative Complication Burden, Revision Risk, and Health Care Use in Obese Patients Undergoing Primary Adult Thoracolumbar Deformity Surgery. Global Spine J 2021; 11:345-350. [PMID: 32875891 PMCID: PMC8013946 DOI: 10.1177/2192568220904341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN This is a retrospective cohort study using a nationally representative administrative database. OBJECTIVE To identify the impact of obesity on postoperative outcomes in patients undergoing thoracolumbar adult spinal deformity (ASD) surgery. BACKGROUND The obesity rate in the United States remains staggering, with approximately one-third of all Americans being overweight or obese. However, the impact of elevated body mass index on spine surgery outcomes remains unclear. METHODS We queried the MarketScan database to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2016. Patients were then stratified by whether or not they were diagnosed as obese at index surgical admission. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between obese and nonobese patients. Patients <18 years and those with any prior history of trauma or tumor were excluded from this study. Baseline demographics and comorbidities, postoperative complication rates, and short- and long-term reoperation rates were determined. RESULTS A total of 7423 patients met the inclusion criteria of this study, of whom 597 (8.0%) were obese. Initially, patients with obesity had a higher 90-day postoperative complication rate than nonobese patients (46.1% vs 40.8%, P < .05); however, this difference did not remain after PSM. Revision surgery rates after 2 years were similar across the 2 groups following primary surgery (obese, 21.4%, vs nonobese, 22.0%; P = .7588). Health care use occurred at a higher rate among obese patients through 2 years of long-term follow-up (obese, $152 930, vs nonobese, $140 550; P < .05). CONCLUSION Patients diagnosed with obesity who underwent ASD surgery did not demonstrate increased rates of complications, reoperations, or readmissions. However, overall health care use through 2 years of follow-up after index surgery was higher in the obesity cohort.
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Affiliation(s)
| | | | - Martin N. Stienen
- Stanford University School of Medicine, Stanford, CA, USA,University of Zurich, Zurich, Switzerland
| | - Allen L. Ho
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - Atman Desai
- Stanford University School of Medicine, Stanford, CA, USA
| | | | - Anand Veeravagu
- Stanford University School of Medicine, Stanford, CA, USA,Anand Veeravagu, Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Edwards Bldg, R281, Stanford, CA 94305, USA.
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Azad TD, Varshneya K, Herrick DB, Pendharkar AV, Ho AL, Stienen M, Zygourakis C, Bagshaw HP, Veeravagu A, Ratliff JK, Desai A. Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease. Global Spine J 2021; 11:44-49. [PMID: 32875859 PMCID: PMC7734271 DOI: 10.1177/2192568219889363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN This was an epidemiological study using national administrative data from the MarketScan database. OBJECTIVE To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease. METHODS We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into "Early RT" if they received RT within 4 weeks of surgery and as "Late RT" if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes. RESULTS A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications (P = .574). CONCLUSIONS When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.
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Affiliation(s)
- Tej D. Azad
- Stanford University School of Medicine, Stanford, CA, USA
- Tej D. Azad and Kunal Varshneya contributed equally toward this study
| | - Kunal Varshneya
- Stanford University School of Medicine, Stanford, CA, USA
- Tej D. Azad and Kunal Varshneya contributed equally toward this study
| | | | | | - Allen L. Ho
- Stanford University School of Medicine, Stanford, CA, USA
| | - Martin Stienen
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | - Atman Desai
- Stanford University School of Medicine, Stanford, CA, USA
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50
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Veeravagu A, Medress ZA, Ratliff J. Commentary: The Enforceability of Noncompete Clauses in the Medical Profession: A Review by the Workforce Committee and the Medico-legal Committee of the Council of State Neurosurgical Societies. Neurosurgery 2021; 88:E123-E124. [DOI: 10.1093/neuros/nyaa481] [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] [Received: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 11/14/2022] Open
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