Combined Targeted Muscle Reinnervation With Regenerative Peripheral Nerve Interfaces Decreases Long-Term Narcotic Use in Amputees: A Case Control Study

PURPOSE

Combined targeted muscle reinnervation with regenerative peripheral nerve interfaces ("TMRpni") is a recently described nerve management strategy that leverages beneficial elements of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) techniques. This study aimed to evaluate the effect of TMRpni on long-term opioid consumption after amputation. We hypothesize that TMRpni decreases chronic opioid consumption in amputees.

METHODS

This is a retrospective cohort study of all patients who underwent TMRpni between 2019 and 2021. These patients were age-matched at a 1:1 ratio with a control group of patients who underwent amputation without TMRpni. Statistical analysis was performed using SPSS Version 28.0.

RESULTS

Thirty-one age-matched pairs of patients in the TMRpni and control groups were included. At 30 days after surgery, there was no significant difference in number of patients who required an additional refill of their opioid prescriptions (45% vs 55%, P = 0.45) or patients who continued to actively use opioids (36% vs 42%, P = 0.60). However, at 90 days after surgery, there was a significantly lower number of patients from the TMRpni group who reported continued opioid use compared with the control group (10% vs 32%, P = 0.03).

CONCLUSIONS

This study demonstrates that TMRpni may translate to decreased rates of chronic opiate use. Continued study is indicated to optimize TMRpni techniques and patient selection and to determine its long-term efficacy.

Tissue adjuncts in primary cleft palate reconstruction: A systematic review

BACKGROUND

Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty.

METHODS

A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables.

RESULTS

A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03).

CONCLUSIONS

Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

Surgical Trigger Finger Release Is Associated With New-Onset Dupuytren Contracture in the Short-Term Postoperative Period: A Matched Analysis

BACKGROUND

This article compares the rates and time-to-development of new-onset Dupuytren disease in patients with trigger finger treated by steroid injection, surgical release, or both.

METHODS

PearlDiver's Mariner 30 database was queried to identify patients with trigger finger between January 2010 and June 2019. One-to-one exact matching based on baseline patient demographics allowed us to create 4 identical groups defined by the type of trigger finger intervention received.

RESULTS

The matched population analyzed in this study consisted of 85 944 patients who were equally represented in the steroid injection cohort (n = 21 486, 25.00%), surgical release cohort (n = 21 486, 25.00%), steroids prior to surgery cohort (n = 21 486, 25.00%), and no intervention (control) cohort (n = 21 486, 25.00%). A new Dupuytren diagnosis after trigger finger treatment occurred in 1 in 128 patients overall, 1 in 156 patients treated with steroid injection, and 1 in 126 patients treated with surgical release. Trigger fingers treated by steroid injection only had the lowest rates of Dupuytren disease overall (n = 137, 0.64%, P = .0424) and treatment with fasciectomy (n = 14, 0.07%, P < .0005). In all, 171 patients in the surgery cohort developed Dupuytren disease 1 year after undergoing surgical trigger finger release. Furthermore, this cohort had the highest rates of fasciectomy (n = 55, 0.26%, P < .0005) and the lowest rates of no intervention (n = 103, 0.48%, P = .0471). Trigger fingers managed by surgical release developed Dupuytren disease (mean, 56.11 days; SD, 80.93 days, log-rank P = .02) and underwent fasciectomy (mean, 49.74 days; SD, 62.27 days; log-rank P < .0005) more quickly than all other cohorts.

CONCLUSIONS

Patients solely undergoing surgical release of their trigger finger had significantly higher odds and expedited rate of developing new-onset Dupuytren disease overall and undergoing subsequent treatment by fasciectomy compared with trigger fingers managed by other interventions.

Preinjury Social Determinants of Health Disparities Predict Postinjury Psychosocial Conditions in Adult Traumatic Brachial Plexus Injuries

BACKGROUND

Adult traumatic brachial plexus injuries (TBPIs) are life-altering events that can have detrimental effects on a patient's quality of life.

OBJECTIVE

To examine how social determinants of health (SDOH) disparities influence the risk of developing new psychosocial conditions after TBPIs in previously psychiatric-naïve patients.

METHODS

Between January 2010 and June 2019, a retrospective analysis was performed using PearlDiver's Mariner, an all-payer claims database, to create 3 cohorts: TBPI disparity cohort: patients with TBPI and presence of at least 1 SDOH disparity before injury, TBPI without disparity cohort: patients with TBPI and the absence of any SDOH disparity, and control cohort: patients without TBPIs.

RESULTS

The matched population analyzed in this study consisted of 1176 patients who were equally represented in the TBPI disparity cohort (n = 392, 33.33%), TBPI without disparity cohort (n = 392, 33.33%), and control cohort (n = 392, 33.33%). A total of 301 patients developed any psychosocial condition with 4 years of their injury. Patients in the TBPI disparity cohort had significantly higher rates of developing any psychosocial condition (31.12%, P < .0005), depression (22.70%, P = .0032), anxiety (18.62%, P = .0203), drug abuse (7.91%, P = .0060), and alcohol abuse (4.85%, P = .03499) when compared with the other cohorts. Furthermore, the disparity cohort carried a significantly increased risk of developing any psychosocial condition (hazard ratio 1.42, 95% CI 1.09-1.86). The rates of suicide attempt, post-traumatic stress disorder, and divorce did not significantly differ between groups.

CONCLUSION

TBPI patients with SDOH disparities are at increased risk of developing new-onset psychosocial conditions, such as depression, anxiety, drug abuse, and alcohol abuse. Level of Evidence: Prognostic Level III.

Outcomes of Calvarial and Soft Tissue Reconstruction with Latissimus Dorsi Rib Osteomyocutaneous Free Flap

PURPOSE

The latissimus dorsi-rib osteomyocutaneous free flap (LDRF) has been used for autologous reconstruction of large composite calvarial and scalp defects. In this study, we aim to present clinical and patient-reported outcomes after LDRF reconstruction.

METHODS

An anatomical study was conducted to evaluate the distribution of the connecting perforators between the thoraco-dorsal and intercostal system. An IRB-approved retrospective review of ten patients who underwent LDRF and one or two ribs for treatment of cranial defects was conducted. Patient-reported outcomes regarding quality of life, neurological and functional status were evaluated using validated surveys. One-way analysis of variance (ANOVA) and post hoc Tukey's tests were used for anatomical outcomes. Preoperative and postoperative scores were compared using paired t-tests.

RESULTS

The 10th rib (4.65± 2.01) followed by 9th rib (3.7±1.63) had the highest number of perforators. A combination of the 9 th and 11 th ribs exhibited maximal perforator number and pedicle length.All patients had stable LDRF reconstructions. Eight patients completed both pre and postoperative questionnaires; Median clinical follow-up was 48 [34-70] months. Scores trended toward improvement but did not reach statistical significance on the Karnofsky Performance Scale (p=0.22), Functional Independence Measure (FIM; Motor p=0.52, Cognitive p=0.55), Headache Disability Index (p=0.38). The minimum clinically important difference (MCID) was surpassed, demonstrating improvement of function for 71% of patients on the Barthel Index and 63% on the Selective Functional Movement Assessment test.

CONCLUSION

The LDRF can improve cognitive and physical functional status in complex patients with prior failed reconstructions for composite scalp and skull defects.

Temporalis Myofascial Flap and Conchal Bowl Cartilage Grafting for Temporomandibular Joint Arthritis

Temporomandibular joint (TMJ) arthritis arises from a multitude of etiologies; however, there is no consensus definitive treatment. The complication profile of artificial TMJs is well known, and outcomes are variable and are reserved for salvage attempts. This case details a patient with persistent traumatic TMJ pain, arthritis, and single-photon emission computed tomography scan of potential nonunion. The present study reports on the first novel use of an alternative composite myofascial flap to help arthritic TMJ pain. This study details the successful use of a temporalis myofascial flap and conchal bowl autologous cartilage graft in posttraumatic TMJ degeneration.

Materials Used in Cranial Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

Cranioplasty is a common neurological procedure with complication rates ranging from 20% to 50%. It is hypothesized that the risks of various complications are impacted by which material is used for cranioplasty.

OBJECTIVE

To evaluate existing literature comparing rates of complications following cranioplasty using different materials including autologous bone, hydroxyapatite, methyl methacrylate (MMA), demineralized bone matrix, polyetheretherketone, titanium, or composite materials.

METHODS

PubMed/MEDLINE database was searched for relevant articles published between 2010 and 2020. After screening, 35 articles were included. Outcomes included infection, wound problems, poor cosmesis, overall complications, duration of surgery, and length of stay. For each outcome, a frequentist network meta-analysis was conducted to compare materials used.

RESULTS

The risk of infection was 1.62 times higher when MMA was used compared to autologous bone (RR 1.62, 95% CI 1.07 to 2.45). Length of stay following cranioplasty was on average 3.62 days shorter when titanium was used compared autologous bone (95% CI -6.26 to -0.98). The networks constructed for other outcomes demonstrated moderate to substantial between-study heterogeneity, wide confidence intervals, and no significant differences between materials.

CONCLUSIONS

The quality of existing literature on this topic is relatively poor, almost exclusively comprised of single-center retrospective studies. There is currently not strong enough evidence available to make comprehensive conclusions regarding the risk-profiles of various cranioplasty materials across multiple outcomes. Prospective randomized trials are necessary to confirm the significant results found in this analysis and to further elucidate the differential risks of various cranioplasty materials.

The Effects of Obesity and Bariatric Surgery on Rates of Upper Extremity Compression Neuropathies

Objectives

To estimate the effects of obesity on all types of upper extremity compression neuropathies (UECN) (carpal tunnel syndrome and other median nerve, radial nerve, and ulnar nerve compression neuropathies) and to assess whether bariatric surgery modifies these effects.

Background

UECN are increasingly prevalent and decrease the quality of life of affected individuals. Studies suggest obesity as a risk factor for carpal tunnel syndrome, the most common type of UECN.

Methods

A retrospective cohort study was conducted using the PearlDiver Mariner Database, an all-payor claims database containing claims for over 53 million patients from 2010 to 2019 in all 50 US states. Rates and odds of all types of UECN were compared between 1:1:1 exact matched cohorts of obese patients who were medically managed, obese patients who underwent bariatric surgery, and nonobese patients (111,967 patients in each cohort).

Results

Compared with nonobese patients, patients with obesity were significantly more likely to develop any UECN (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.09-1.18), carpal tunnel syndrome (OR, 1.15; 95% CI, 1.10-1.30), and 2 or more UECN (OR, 1.34; 95% CI, 1.20-1.48). Compared with obese patients who were managed medically, obese patients who underwent bariatric surgery were significantly less likely to develop any UECN (OR, 0.87; 95% CI, 0.84-0.91) and carpal tunnel syndrome (OR, 0.85; 95% CI, 0.81-0.89).

Conclusions

Obese patients have higher odds of both single and concomitant UECN, specifically carpal tunnel syndrome, compared with nonobese patients. Bariatric surgery decreases the odds of developing UECN compared with obese patients not undergoing surgical intervention.

Association of Bariatric Surgery and Risk of Cancer in Patients With Morbid Obesity

OBJECTIVE

This study investigates the rates of obesity-related cancers in patients undergoing vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RYGB), or no surgical intervention.

SUMMARY BACKGROUND DATA

Obesity has been previously associated with increased rates of cancers; however, weight loss surgeries have not been explored to demonstrate their potential risk reduction impact.

METHODS

Patients meeting bariatric eligibility criteria between January 2010 and December 2018 were identified. Exact 1:1:1 matching based on baseline patient demographics and comorbidities was used to create 3 groups with identical covariates: patients undergoing VSG, RYGB, and no surgery.

RESULTS

A total of 28, bariatric-eligible patients equally split into patients undergoing VSG (n = 9636, 33.3%), RYGB (n = 9636, 33.3%), and those with no surgical intervention (n = 9636, 33.3%). Bariatric-eligible patients that did not undergo surgical intervention had significantly higher rates and odds of developing numerous cancer types included in our study when compared to either surgical cohorts, with any cancer type (4.61%), uterine (0.86%), colorectal (0.57%), and lung cancers (0.50%) being most common. Individuals undergoing RYGB were significantly less likely to develop colorectal cancer compared to patients without any surgical intervention [odds ratio (OR) 0.47, 95% confidence interval (CI) 0.30-0.75]. Additionally, those undergoing VSG were significantly less likely to develop lung cancer than the bariatric eligible no surgery cohort (OR 0.42, 95% CI 0.25-0.70).

CONCLUSION

Postoperative rates of any cancer type, lung, ovarian, and uterine cancer were significantly lower in obese patients undergoing either vertical sleeve gastrectomy (VSG) or RYGB compared to bariatric-eligible patients without any surgical intervention.

Social determinants of health and their impact on rates of postoperative complications among patients undergoing vertical sleeve gastrectomy

BACKGROUND

Vertical sleeve gastrectomy is one of the most common bariatric procedures worldwide, but the impact of social determinants of health on postoperative outcomes for this procedure has not been well characterized. The objective of this study was to analyze the impact that social determinants of health have on postoperative outcomes after vertical sleeve gastrectomy.

METHOD

This was a population-based study using the MARINER-15 database, an all-payer claims database. The primary endpoint of this study was the development of any complication, including cardiac complication, acute kidney injury, deep vein thrombosis, wound complication, hematoma, pneumonia, pulmonary embolism, transfusion, or urinary tract infection within 60 days, 30- and 90-day all-cause mortality, or readmission within 30 or 90 days in patients undergoing vertical sleeve gastrectomy procedures.

RESULTS

Individuals in the social determinants of health cohort had a significantly longer length of stay when compared with those without social determinants of health (3.07 days vs 1.582 days, P < .001). These patients were more likely to develop any complication within 60 days after surgery (hazard ratio 1.20, 95% confidence interval 1.03-1.40) but were less likely to return for readmission within 30 and 90 days (hazard ratio 0.80, 95% confidence interval 0.66-0.96; hazard ratio 0.85 95% confidence interval 0.72-0.99).

CONCLUSION

Vertical sleeve gastrectomy is an effective treatment for morbid obesity and its associated comorbidities. Although patients with social determinants of health are more likely to develop any of the analyzed postoperative complications within 60 days, they are less likely to return for readmission, highlighting the importance of focused follow-up and other measures to avoid lapses in care and eliminate further barriers to care in this population.

Laparoscopic-Assisted Versus Mini-Open Laparotomy for Ventriculoperitoneal Shunt Placement in the Medicare Population

BACKGROUND

Placement of the distal shunt catheter into the peritoneum during ventriculoperitoneal shunt (VPS) surgery can be done with either laparoscopic assistance or laparotomy.

OBJECTIVE

To compare outcomes in laparoscopic-assisted vs laparotomy for placement of VPS in the Medicare population.

METHODS

Patients undergoing VPS placement, between 2004 and 2014, were identified by International Classification of Disease, Ninth Revision and Current Procedural Terminology codes in the Medicare database. Demographic data including age, sex, comorbidities, and indications were collected. Six- and twelve-month complication rates were analyzed.

RESULTS

A total of 1966 (3.2%) patients underwent laparoscopic-assisted VPS and 60 030 (96.8%) patients underwent nonlaparoscopic-assisted VPS placement. Compared with traditional open VPS placement, the laparoscopic approach was associated with decreased odds of distal revision at 6- and 12-mo postoperatively (6 mo: odds ratio [OR] = 0.41, 95% confidence interval [CI]: 0.21-0.74; 12 mo: OR = 0.60, 95% CI: 0.39-0.94). At 6- and 12-mo postoperatively, multivariable regression analysis demonstrated increased odds of distal revision in patients with a body mass index (BMI) > 30 Kg/M2, history of open abdominal surgery, and history of laparoscopic abdominal surgery. Additionally, history of prior abdominal surgery and BMI > 30 Kg/M2 were significantly associated with increase odds of shunt infection at 6 and 12-mo, respectively.

CONCLUSION

In the largest retrospective analysis to date, patients with a history of abdominal surgery and obesity were found to be at increased risk of infection and distal revision after VPS placement. However, the laparoscopic approach for abdominal placement of the distal catheter was associated with reduced rates of distal revision in this population, suggesting an avenue for reducing complications in well-selected patients.

Pharmacologic and cellular therapies in the treatment of traumatic spinal cord injuries: A systematic review

OBJECTIVE

The objective of this review is to synthesize and consolidate the existing literature on the treatment of SCI, focusing on drugs in development and cellular therapeutics, including stem-cell treatments.

METHODS

Studies were identified through a systemic search of PubMed, Ovid MEDLINE, Embase and the Cochrane database from their respective inceptions through January 1, 2020. We used the keywords "spinal cord injuries", "therapeutics", "stem cells", and "pharmacology."

STUDY SELECTION

Studies that assessed treatment strategies for SCI were included.

DATA EXTRACTION AND SYNTHESIS

Data on SCIs were processed according to the Preferred Reporting Items for Systematic Reviews and meta-Analyses (PRISMA) guidelines.

FINDINGS

In total, 62 articles were found in the literature search and 13 clinical trials were identified and included in this study. This review article discusses the management and treatment of SCI with an emphasis on the pharmacology, molecular approaches, and the use of stem cells. Presently, none of the treatments examined has shown to be clearly effective.

CONCLUSIONS

Present management strategies of SCI are focused on improving spinal cord perfusion and decreasing secondary injuries such as hypoxia, inflammation, edema, excitotoxicity and disturbances of ion homeostasis. This review hopes to demonstrate the significant advances made in the field of SCI and the new methodologies and practices being employed by researchers to improve our knowledge of the pathology. Our hope is that by consolidating the past and current research, improvements can be made in the management, treatment, and outcomes for these patients and other who suffer from spinal pathologies.

Association of osteopenia and osteoporosis with higher rates of pseudarthrosis and revision surgery in adult patients undergoing single-level lumbar fusion

OBJECTIVE

Patients with osteopenia or osteoporosis who require surgery for symptomatic degenerative spondylolisthesis may have higher rates of postoperative pseudarthrosis and need for revision surgery than patients with normal bone mineral densities (BMDs). To this end, the authors compared rates of postoperative pseudarthrosis and need for revision surgery following single-level lumbar fusion in patients with normal BMD with those in patients with osteopenia or osteoporosis. The secondary outcome was to investigate the effects of pretreatment with medications that prevent bone loss (e.g., teriparatide, bisphosphonates, and denosumab) on these adverse outcomes in this patient cohort.

METHODS

Patients undergoing single-level lumbar fusion between 2007 and 2017 were identified. Based on 1:1 propensity matching for baseline demographic characteristics and comorbidities, 3 patient groups were created: osteopenia (n = 1723, 33.3%), osteoporosis (n = 1723, 33.3%), and normal BMD (n = 1723, 33.3%). The rates of postoperative pseudarthrosis and revision surgery were compared between groups.

RESULTS

The matched populations analyzed in this study included a total of 5169 patients in 3 groups balanced at baseline, with equal numbers (n = 1723, 33.3%) in each group: patients with a history of osteopenia, those with a history of osteoporosis, and a control group of patients with no history of osteopenia or osteoporosis and with normal BMD. A total of 597 complications were recorded within a 2-year follow-up period, with pseudarthrosis (n = 321, 6.2%) being slightly more common than revision surgery (n = 276, 5.3%). The odds of pseudarthrosis and revision surgery in patients with osteopenia were almost 2-fold (OR 1.7, 95% CI 1.26-2.30) and 3-fold (OR 2.73, 95% CI 1.89-3.94) higher, respectively, than those in patients in the control group. Similarly, the odds of pseudarthrosis and revision surgery in patients with osteoporosis were almost 2-fold (OR 1.92, 95% CI 1.43-2.59) and > 3-fold (OR 3.25, 95% CI 2.27-4.65) higher, respectively, than those in patients in the control group. Pretreatment with medications to prevent bone loss prior to surgery was associated with lower pseudarthrosis and revision surgery rates, although the differences did not reach statistical significance.

CONCLUSIONS

Postoperative pseudarthrosis and revision surgery rates following single-level lumbar spinal fusion are significantly higher in patients with osteopenia and osteoporosis than in patients with normal BMD. Pretreatment with medications to prevent bone loss prior to surgery decreased these complication rates, although the observed differences did not reach statistical significance.

Outcomes following percutaneous endoscopic gastrostomy versus fluoroscopic procedures in the Medicare population

Background

In the United States, few high-quality manuscripts have directly compared the complication profiles of percutaneous endoscopic versus fluoroscopic gastrostomy. Thus, it is our goal to compare these 2 common procedures to better understand their efficacy and complication profiles.

Materials and Methods

A retrospective analysis of patient records from Medicare parts A/B from 2007 to 2012 was used to identify percutaneous fluoroscopic gastrostomy and percutaneous endoscopic gastrostomy procedures. Patient demographics were stratified by age, sex, comorbidities, and complications.

Results

A total of 258,641 patients were found to have either percutaneous fluoroscopic gastrostomy (26,477, 10.2%) or percutaneous endoscopic gastrostomy (232,164, 89.8%). Percutaneous fluoroscopic gastrostomy experienced greater rates for all complications queried. Multivariate analysis revealed that the percutaneous fluoroscopic gastrostomy cohort had statistically significant increased odds for short-term complications, such as ileus (odds ratio 1.4, 95% confidence interval 1.22–1.54), mechanical (odds ratio 2.4, 95% confidence interval 2.28–2.58), wound infection (odds ratio 1.4, 95% confidence interval 1.24–1.52), persistent fistula after tube removal (odds ratio 1.9, 95% confidence interval 1.78–2.12), and other complications (odds ratio 2.2, 95% confidence interval 2.03–2.37), and long-term complications, including abdominal wall pain (odds ratio 1.4, 95% confidence interval 1.33–1.44), wound infection (odds ratio 1.1, 95% confidence interval 1.01–1.15), and persistent fistula after tube removal (odds ratio 1.8, 95% confidence interval 1.72–1.87).

Conclusion

Gastrostomy tubes are more frequently being placed via percutaneous endoscopic and fluoroscopic methods. This study suggests that those undergoing fluoroscopic placement have higher odds of developing short- and long-term postoperative complications.

•

Fluoroscopic g-tubes have higher odds of developing short- and long-term complications.

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Fluoroscopy has higher odds for abdominal wall pain and mechanical complications.

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Hyperlipidemia, smoking, and hypertension are risk factors for abdominal wall pain.

Outpatient and inpatient readmission rates of 3- and 4-level anterior cervical discectomy and fusion surgeries

OBJECTIVE

With the costs related to the United States medical system constantly rising, efforts are being made to turn traditional inpatient procedures into outpatient same-day surgeries. In this study the authors looked at the various comorbidities and perioperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 3- and 4-level anterior cervical discectomy and fusion (ACDF).

METHODS

This was a retrospective study of 337 3- and 4- level ACDF procedures in 332 patients (5 patients had both primary and revision surgeries that were included in this total of 337 procedures) between May 2012 and June 2017. In total, 331 procedures were analyzed, as 6 patients were lost to follow-up. Outpatient surgery was performed for 299 procedures (102 4-level procedures and 197 3-level procedures), and inpatient surgery was performed for 32 procedures (11 4-level procedures and 21 3-level procedures). Age, sex, comorbidities, number of fusion levels, pain level, and perioperative complications were compared between both cohorts.

RESULTS

Analysis was performed for 331 3- and 4-level ACDF procedures done at 6 different hospitals. The overall 30-day readmission rate was 1.2% (outpatient 3 [1.0%] vs inpatient 1 [3.1%], p = 0.847). Outpatients had increased readmission risk, with comorbidities of coronary artery disease (OR 1.058, p = 0.039), autoimmune disease (OR 1.142, p = 0.006), diabetes (OR 1.056, p = 0.001), and chronic kidney disease (OR 0.933, p = 0.035). Perioperative complications of delirium (OR 2.709, p < 0.001) and surgical site infection (OR 2.709, p < 0.001) were associated with increased risk of 30-day hospital readmission in outpatients compared to inpatients.

CONCLUSIONS

This study demonstrates the safety and effectiveness of 3- and 4-level ACDF surgery, although various comorbidities and perioperative complications may lead to higher readmission rates. Patient selection for outpatient 3- and 4-level ACDF cases might play a role in the safety of performing these procedures in the ambulatory setting, but further studies are needed to accurately identify which factors are most pertinent for appropriate selection.

Adult intradural intramedullary astrocytomas: a multicenter analysis

Background

Intramedullary tumors constitute approximately 20-30% of all spinal cord tumors and approximately 30-40% of these are astrocytomas. Furthermore, they comprise only about 2-4% of all primary central nervous system (CNS) tumors. Due to their rarity and poor prognosis, large population-based studies are needed to assess the epidemiology and survival risk factors associated with these tumors in the hope of improving outcomes. The authors undertook this retrospective study to explore factors that may influence survival in adult patients with intramedullary astrocytomas.

Methods

Utilizing the Surveillance, Epidemiology, and End Results (SEER) database, a prospective cancer registry, the authors retrospectively assessed survival in histologically confirmed, intramedullary spinal cord astrocytomas in patients 18 years of age and older. Survival was described with Kaplan-Meier curves and multivariate regression analysis was used to assess the association of several variables with survival while controlling for confounding variables.

Results

Analysis by multivariate regression of 131 cases showed that increasing age of diagnosis [hazard ratio (HR) 1.52, 95% CI: 1.17-1.99, P=0.001], WHO grade IV classification (HR 8.85, 95% CI: 2.83-27.69, P<0.001), tumor invasiveness (HR 2.94, 95% CI: 1.00-8.64, P=0.047), and sub-total resection (HR 5.80, 95% CI: 1.20-28.03, P=0.029) were associated with statistically significant decreases in survival.

Conclusions

This study suggest that older age, higher WHO grade, tumor invasiveness as well as sub-total resection were all associated with a worse prognosis.