Impact of insurance status on healthcare resource utilization and outcomes in adolescent patients presenting with spinal cord injuries

OBJECTIVE

Insurance disparities have been suggested to influence the medical and surgical outcomes of adult patients with spinal cord injury (SCI), with a paucity of studies demonstrating their impact on the outcomes of pediatric and adolescent SCI patients. The aim of this study was to assess the impact of insurance status on healthcare utilization and outcomes in adolescent patients presenting with SCI.

METHODS

An administrative database study was performed using the 2017 admission year from 753 facilities using the National Trauma Data Bank. Adolescent patients (11-17 years old) with cervical/thoracic SCIs were identified using International Classification of Diseases, Tenth Revision, Clinical Modification coding. Patients were categorized by governmental insurance versus private insurance/self-pay. Patient demographics, comorbidities, imaging, procedures, hospital adverse events (AEs), and length of stay (LOS) data were collected. Multivariate regression analyses were used to determine the effect of insurance status on LOS, any imaging or procedure, or any AE.

RESULTS

Of the 488 patients identified, 220 (45.1%) held governmental insurance while 268 (54.9%) were privately insured. Age was similar between the cohorts (p = 0.616), with the governmental insurance cohort (GI cohort) having a significantly lower proportion of non-Hispanic White patients than the private insurance cohort (PI cohort) (GI: 43.2% vs PI: 72.4%, p < 0.001). While transportation accident was the most common mechanism of injury for both cohorts, assault was significantly greater in the GI cohort (GI: 21.8% vs PI: 3.0%, p < 0.001). A significantly greater proportion of patients in the PI cohort received any imaging (GI: 65.9% vs PI: 75.0%, p = 0.028), while there were no significant differences in procedures performed (p = 0.069) or hospital AEs (p = 0.386) between the cohorts. The median (IQR) LOS (p = 0.186) and discharge disposition (p = 0.302) were similar between the cohorts. On multivariate analysis, with respect to governmental insurance, private insurance was not independently associated with obtaining any imaging (OR 1.38, p = 0.139), undergoing any procedure (OR 1.09, p = 0.721), hospital AEs (OR 1.11, p = 0.709), or LOS (adjusted risk ratio -2.56, p = 0.203).

CONCLUSIONS

This study suggests that insurance status may not independently influence healthcare resource utilization and outcomes in adolescent patients presenting with SCIs. Further studies are needed to corroborate these findings.

Effects of delayed ambulation following posterior spinal fusion for adolescent idiopathic scoliosis: a single institutional study

OBJECTIVE

Mobilizing out of bed and ambulation are key components of recovery following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). However, there remains a paucity of studies identifying risk factors associated with delayed ambulation and its impact on postoperative outcomes. The aim of this study was to investigate patient- and surgical-level risk factors associated with delayed ambulation and the ramifications of delayed ambulation on healthcare utilization for patients undergoing PSF for AIS.

METHODS

The medical records of 129 adolescent (10-18 years) patients diagnosed with AIS undergoing posterior spinal fusion at a major academic institution between 2013 and 2020 were reviewed. Patients were categorized based on days from surgery to ambulation: early (≤ 1 day), intermediate (2 days), or late (≥ 3 days). Patient demographics, comorbidities, spinal deformity characteristics, intraoperative variables, postoperative complications, LOS, and unplanned readmissions were assessed. The odds ratios for risk-adjusted delayed ambulation and extended LOS were determined via multivariate stepwise logistic regressions.

RESULTS

One Hundred and Twenty Nine patients were included in this study, of which 10.8% (n = 14) were classified as Early ambulators, 41.9% (n = 54) Intermediate ambulators, and 47.3% (n = 61) were Late ambulators. Late ambulators were significantly younger than early and intermediate ambulators (Early: 15.7 ± 1.9 years vs. Intermediate: 14.8 ± 1.7 years vs. Late: 14.1 ± 1.9 years, p = 0.010). The primary and secondary spinal curves were significantly worse among Late ambulators (p < 0.001 and p = 0.002 respectively). Fusion levels (p < 0.01), EBL (p = 0.014), and the rate of RBC transfusions (p < 0.001) increased as time to ambulation increased. Transition time from IV to oral pain medications (Early: 1.6 ± 0.8 days vs. Intermediate: 2.2 ± 0.6 days vs. Late: 2.4 ± 0.6 days, p < 0.001) and total hospital length of stay (Early: 3.9 ± 1.4 days vs. Intermediate: 4.7 ± 0.9 days vs. Late: 5.1 ± 1.2 days, p < 0.001) were longer in Late ambulators. On multivariate analysis, significant predictors of delayed ambulation included primary curve degree ≥ 70° [aOR: 5.67 (1.29‒31.97), p = 0.030] and procedure time [aOR: 1.66 (1.1‒2.59), p = 0.019].

CONCLUSIONS

Our study suggests that there may be patient- and surgical-level factors that are independently associated with late ambulation following PSF for AIS, including extent of major curve and length of operative time. Additionally, delayed ambulation has implications to length of hospital stay and postoperative complications.

Association Between Intravenous to Oral Opioid Transition Time and Length of Hospital Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

Transitioning from intravenous (IV) to oral opioids after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is necessary during the postoperative course. However, few studies have assessed the effects of longer transition times on hospital length of stay (LOS). This study investigated the impact of longer IV to oral opioid transition times on LOS after PSF for AIS.

METHODS

The medical records of 129 adolescents (10-18 years old) with AIS undergoing multilevel PSF at a major academic institution from 2013 to 2020 were reviewed. Patients were categorized by IV to oral opioid transition time: normal (≤2 days) vs prolonged (≥3 days). Patient demographics, comorbidities, deformity characteristics, intraoperative variables, postoperative complications, and LOS were assessed. Multivariate analyses were used to determine odds ratios for risk-adjusted extended LOS.

RESULTS

Of the 129 study patients, 29.5% (n = 38) had prolonged IV to oral transitions. Demographics and comorbidities were similar between the cohorts. The major curve degree (P = 0.762) and median (interquartile range) levels fused (P = 0.447) were similar between cohorts, but procedure time was significantly longer in the prolonged cohort (normal: 6.6 ± 1.2 hours vs prolonged: 7.2 ± 1.3 hours, P = 0.009). Postoperative complication rates were similar between the cohorts. Patients with prolonged transitions had significantly longer LOS (normal: 4.6 ± 1.3 days vs prolonged: 5.1 ± 0.8 days, P < 0.001) but similar discharge disposition (P = 0.722) and 30-day readmission rates (P > 0.99). On univariate analysis, transition time was significantly associated with extended LOS (OR: 2.0, 95% CI [0.9, 4.6], P = 0.014), but this assocation was not significant on multivariate analysis (adjusted OR: 2.1, 95% CI [1.3, 4.8], P = 0.062).

CONCLUSIONS

Longer postoperative IV to oral opioid transitions after PSF for AIS may have implications for hospital LOS.

LEVEL OF EVIDENCE: 3

Impact of Racial Disparities on All-Cause Mortality in Patients With Tumors of the Spinal Cord or Spinal Meninges: A Propensity-Score Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The influence that race has on mortality rates in patients with spinal cord tumors is relatively unknown. The aim of this study was to investigate the influence of race on the outcomes of patients with primary malignant or nonmalignant tumors of the spinal cord or spinal meninges.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Registry was used to identify all patients with a code for primary malignant or nonmalignant tumor of the spinal cord (C72.0) or spinal meninges (C70.1) from 1973 through 2016. Racial groups (African-American/Black vs. White) were balanced using propensity-score (PS) matching using a non-parsimonious 1:1 nearest neighbor matching algorithm. Overall survival (OS) estimates were obtained using the Kaplan-Meier method and compared across non-PS-matched and PS-matched groups using log-rank tests. Associations of survival with clinical variables was assessed using doubly robust Cox proportional-hazards (CPH) regression analysis.

RESULTS

There were a total of 7,498 patients identified with 648 (6.8%) being African American. African-American patients with primary intradural spine tumors were more likely to die of all causes than were White patients in both the non-PS-matched [HR: 1.26, 95% CI: (1.04, 1.51), P = 0.01] and PS-matched cohorts [HR: 1.64, 95% CI: (1.28, 2.11), P < 0.0001]. On multivariate CPH regression analysis age at diagnosis [HR: 1.03, 95% CI: (1.02, 1.05), P < 0.0001], race [HR: 1.82, 95% CI: (1.22, 2.74), P = 0.004), and receipt of RT [HR: 2.62, 95% CI: (1.56, 4.37), P = 0.0002) were all significantly associated with all-cause mortality, when controlling for other demographic, tumor, and treatment variables.

CONCLUSIONS

Our study provides population-based estimates of the prognosis for patients with primary malignant or nonmalignant tumors of the spinal cord or spinal meninges and suggests that race may impact all-cause mortality.

Differences in Outcomes and Health Care Resource Utilization After Surgical Intervention for Metastatic Spinal Column Tumor in Safety-Net Hospitals

STUDY DESIGN

Observational cohort study.

OBJECTIVE

The aim of this study was to investigate the association between safety-net hospital (SNH) status and hospital length of stay (LOS), cost, and discharge disposition in patients undergoing surgery for metastatic spinal column tumors.

SUMMARY OF BACKGROUND DATA

SNHs serve a high proportion of Medicaid and uninsured patients. However, few studies have assessed the effects of SNH status on outcomes after surgery for metastatic spinal column tumors.

PATIENTS AND METHODS

This study was performed using the 2016-2019 Nationwide Inpatient Sample database. All adult patients undergoing metastatic spinal column tumor surgeries, identified using ICD-10-CM coding, were stratified by SNH status, defined as hospitals in the top quartile of Medicaid/uninsured coverage burden. Hospital characteristics, demographics, comorbidities, intraoperative variables, postoperative complications, and outcomes were assessed. Multivariable analyses identified independent predictors of prolonged LOS (>75th percentile of cohort), nonroutine discharge, and increased cost (>75th percentile of cohort).

RESULTS

Of the 11,505 study patients, 24.0% (n = 2760) were treated at an SNH. Patients treated at SNHs were more likely to be Black-identifying, male, and lower income quartile. A significantly greater proportion of patients in the non-SNH (N-SNH) cohort experienced any postoperative complication [SNH: 965 (35.0%) vs . N-SNH: 3535 (40.4%), P = 0.021]. SNH patients had significantly longer LOS (SNH: 12.3 ± 11.3 d vs . N-SNH: 10.1 ± 9.5 d, P < 0.001), yet mean total costs (SNH: $58,804 ± 39,088 vs . N-SNH: $54,569 ± 36,781, P = 0.055) and nonroutine discharge rates [SNH: 1330 (48.2%) vs . N-SNH: 4230 (48.4%), P = 0.715) were similar. On multivariable analysis, SNH status was significantly associated with extended LOS [odds ratio (OR): 1.41, P = 0.009], but not nonroutine discharge disposition (OR: 0.97, P = 0.773) or increased cost (OR: 0.93, P = 0.655).

CONCLUSIONS

Our study suggests that SNHs and N-SNHs provide largely similar care for patients undergoing metastatic spinal tumor surgeries. Patients treated at SNHs may have an increased risk of prolonged hospitalizations, but comorbidities and complications likely contribute greater to adverse outcomes than SNH status alone.

LEVEL OF EVIDENCE

3.

Prospective analysis of home narcotic consumption and management of excess narcotic prescription following adolescent idiopathic scoliosis surgery

PURPOSE

The aim of this study was to identify factors associated with the outpatient narcotic intake of patients following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and to introduce a safe and effective method of disposing of unused narcotics.

METHODS

Following Institutional Review Board approval, retrospective review of prospectively collected data from patients undergoing PSF for AIS took place. Pain scores, narcotic use, patient demographic data, pre-, intra-, and postoperative parameters, and discharge data were gathered via chart review. Patients were divided into two groups according to home narcotic use, high use (top 25th percentiles) and low use (bottom 75th percentiles), and multivariate statistical analysis was conducted. Narcotic surplus was collected during postoperative clinic visits and disposed of using biodegradable bags.

RESULTS

Statistical analysis of 27 patients included in the study showed that patients with a higher home narcotic use correlated with increased length of hospitalization with an average of 3.4 days compared to the lower-use group of 2.8 day (p = 0.03). Higher-use group also showed increased inpatient morphine milligram equivalent than the lower-use group. There was no significant difference of home narcotic use when looking at patient age, height, weight, BMI, levels fused, intraoperative blood loss, or length of surgery. A total of 502 narcotic doses were disposed of in the clinic.

CONCLUSION

Our study suggests that there are not a significant number of patient- or surgical-level factors predisposing patients to increased home narcotic usage following spinal fusion for adolescent idiopathic scoliosis.

LEVEL OF EVIDENCE

Level I, prospective study.

Leveraging HFRS to assess how frailty affects healthcare resource utilization after elective ACDF for CSM

BACKGROUND CONTEXT

Frailty is a common comorbidity associated with worsening outcomes in various medical and surgical fields. The Hospital Frailty Risk Score (HFRS) is a recently developed tool which assesses frailty using 109 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) comorbidity codes to assess severity of frailty. However, there is a paucity of studies utilizing the HFRS with patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

PURPOSE

The aim of this study was to investigate the impact of HFRS on health care resource utilization following ACDF for CSM.

STUDY DESIGN

A retrospective cohort study was performed using the Nationwide Inpatient Sample (NIS) database from 2016-2019.

PATIENT SAMPLE

All adult (≥18 years old) patients undergoing primary, ACDF for CSM were identified using the ICD-10 CM codes.

OUTCOME MEASURES

Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total admission costs were assessed.

METHODS

The 109 ICD-10 codes with pre-assigned values from 0.1 to 7.1 pertaining to frailty were queried in each patient, with a cumulative HFRS ≥5 indicating a frail patient. Patients were then categorized as either Low HFRS (HFRS<5) or Moderate to High HFRS (HFRS≥5). A multivariate stepwise logistic regression was used to determine the odds ratio for risk-adjusted extended LOS, non-routine discharge disposition, and increased hospital cost.

RESULTS

A total of 29,305 patients were identified, of which 3,135 (10.7%) had a Moderate to High HFRS. Patients with a Moderate to High HFRS had higher rates of 1 or more postoperative complications (Low HFRS: 9.5% vs. Moderate-High HFRS: 38.6%, p≤.001), significantly longer hospital stays (Low HFRS: 1.8±1.7 days vs. Moderate-High HFRS: 4.4 ± 6.0, p≤.001), higher rates of non-routine discharge (Low HFRS: 5.8% vs. Moderate-High HFRS: 28.2%, p≤.001), and increased total cost of admission (Low HFRS: $19,691±9,740 vs. Moderate-High HFRS: $26,935±22,824, p≤.001) than patients in the Low HFRS cohort. On multivariate analysis, Moderate to High HFRS was found to be a significant independent predictor for extended LOS [OR: 3.19, 95% CI: (2.60, 3.91), p≤.001] and non-routine discharge disposition [OR: 3.88, 95% CI: (3.05, 4.95), p≤.001] but not increased cost [OR: 1.10, 95% CI: (0.87, 1.40), p=.418].

CONCLUSIONS

Our study suggests that patients with a higher HFRS have increased total hospital costs, a longer LOS, higher complication rates, and more frequent nonroutine discharge compared with patients with a low HFRS following elective ACDF for CSM. Although frail patients should not be precluded from surgical management of cervical spine pathology, these findings highlight the need for peri-operative protocols to medically optimize patients to improve health care quality and decrease costs.

A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease

Background

Following orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology.

Methods

The 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD.

Results

After weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality.

Conclusions

After matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.

Octogenarians Are Independently Associated With Extended LOS and Non-Routine Discharge After Elective ACDF for CSM

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the impact age has on LOS and discharge disposition following elective ACDF for cervical spondylotic myelopathy (CSM).

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) database from 2016 and 2017. All adult patients >50 years old undergoing ACDF for CSM were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then stratified by age: 50 to 64 years-old, 65 to 79 years-old, and greater than or equal to 80 years-old. Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total cost of admission were assessed.

RESULTS

A total of 14 865 patients were identified. Compared to the 50-64 and 65-79 year-old cohorts, the 80+ years cohort had a significantly higher rate of postoperative complication (50-64 yo:10.2% vs. 65-79 yo:12.6% vs. 80+ yo:18.9%, P = 0.048). The 80+ years cohort experienced significantly longer hospital stays (50-64 yo: 2.0 ± 2.4 days vs. 65-79 yo: 2.2 ± 2.8 days vs. 80+ yo: 2.3 ± 2.1 days, P = 0.028), higher proportion of patients with extended LOS (50-64 yo:18.3% vs. 65-79 yo:21.9% vs. 80+ yo:28.4%, P = 0.009), and increased rates of non-routine discharges (50-64 yo:15.1% vs. 65-79 yo:23.0% vs. 80+ yo:35.8%, P < 0.001). On multivariate analysis, age 80+ years was found to be a significant independent predictor of extended LOS [OR:1.97, 95% CI:(1.10,3.55), P = 0.023] and non-routine discharge [OR:2.46, 95% CI:(1.44,4.21), P = 0.001].

CONCLUSIONS

Our study demonstrates that octogenarian age status is a significant independent risk factor for extended LOS and non-routine discharge after elective ACDF for CSM.

Analysis of the Frequency, Characteristics, and Reasons for Termination of Spine-related Clinical Trials

STUDY DESIGN

Cross-sectional analysis of completed and terminated spine-related clinical trials in the ClinicalTrials.gov registry.

OBJECTIVE

The aim was to quantify completed and terminated spine-related clinical trials, assess reasons for termination, and determine predictors of termination by comparing characteristics of completed and terminated trials.

SUMMARY OF BACKGROUND DATA

Clinical trials are key to the advancement of products and procedures related to the spine. Unfortunately, trials may be terminated before completion. ClinicalTrials.gov is a registry and results database maintained by the National Library of Medicine that catalogs trial characteristics and tracks overall recruitment status (eg, ongoing, completed, terminated) for each study as well as reasons for termination. Reasons for trial termination have not been specifically evaluated for spine-related clinical trials.

METHODS

The ClinicalTrials.gov database was queried on July 20, 2021 for all completed and terminated interventional studies registered to date using all available spine-related search terms. Trial characteristics and reason for termination, were abstracted. Univariate and multivariate analyses were performed determine predictors of trial termination.

RESULTS

A total of 969 clinical trials were identified and characterized (833 completed, 136 terminated). Insufficient rate of participant accrual was the most frequently reported reason for trial termination, accounting for 33.8% of terminated trials.Multivariate analysis demonstrated increased odds of trial termination for industry-sponsorship [odds ratio (OR)=1.59] relative to sponsorship from local groups, device studies (OR=2.18) relative to investigations of drug or biological product(s), and phase II (OR=3.07) relative to phase III studies ( P <0.05 for each).

CONCLUSIONS

Spine-related clinical trials were found to be terminated 14% of the time, with insufficient accrual being the most common reason for termination. With significant resources put into clinical studies and the need to advance scientific objectives, predictors, and reasons for trial termination should be considered and optimized to increase the completion rate of trials that are initiated.

Ramifications of Postoperative Dysphagia on Health Care Resource Utilization Following Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

The aim of this study was to investigate patient risk factors and health care resource utilization associated with postoperative dysphagia following elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

There is a paucity of data on factors predisposing patients to dysphagia and the burden this complication has on health care resource utilization following ACDF.

METHODS

A retrospective cohort study was performed using the Nationwide Inpatient Sample (NIS) database from 2016 to 2017. All adult (above 18 y old) patients undergoing ACDF for cervical spondylotic myelopathy were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then categorized by whether they had a recorded postoperative dysphagia or no dysphagia. Weighted patient demographics, comorbidities, perioperative complications, length of hospital stay (LOS), discharge disposition, and total cost of admission were assessed. A multivariate stepwise logistic regression was used to determine both the odds ratio for risk-adjusted postoperative dysphagia as well as extended LOS.

RESULTS

A total of 17,385 patients were identified, of which 1400 (8.1%) experienced postoperative dysphagia. Compared with the No-Dysphagia cohort, the Dysphagia cohort had a greater proportion of patients experiencing a complication (P=0.004), including 1 complication (No-Dysphagia: 2.9% vs. Dysphagia: 6.8%), and >1 complication (No-Dysphagia: 0.3% vs. Dysphagia: 0.4%). The Dysphagia cohort experienced significantly longer hospital stays (No-Dysphagia: 1.9±2.1 d vs. Dysphagia: 4.2±4.3 d, P<0.001), higher total cost of admission (No-Dysphagia: $19,441±10,495 vs. Dysphagia: $25,529±18,641, P<0.001), and increased rates of nonroutine discharge (No-Dysphagia: 16.5% vs. Dysphagia: 34.3%, P<0.001). Postoperative dysphagia was found to be a significant independent risk factor for extended LOS on multivariate analysis, with an odds ratio of 5.37 (95% confidence interval: 4.09, 7.05, P<0.001).

CONCLUSION

Patients experiencing postoperative dysphagia were found to have significantly longer hospital LOS, higher total cost of admission, and increased nonroutine discharge when compared with the patients who did not.

LEVEL OF EVIDENCE

Level III.

Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis

BACKGROUND

As health care expenditures continue to increase, standardizing health care delivery across geographic regions has been identified as a method to reduce costs. However, few studies have demonstrated how the practice of elective spine surgery varies by geographic location. The aim of this study was to assess the geographic variations in management, complications, and total cost of elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

The National Inpatient Sample database (2016-2017) was queried using the ICD-10-CM procedural and diagnostic coding systems to identify all adult (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF. Patients were divided into regional cohorts as defined by the U.S. Census Bureau: Northeast, Midwest, South, and West. Weighted patient demographics, Elixhauser comorbidities, perioperative complications, length of stay (LOS), discharge disposition, and total cost of admission were assessed.

RESULTS

A total of 17,385 adult patients were identified. While the age (p=0.116) and proportion of female patients (p=0.447) were similar among the cohorts, race (p<0.001) and healthcare coverage (p<0.001) varied significantly. The Northeast had the largest proportion of patients in the 76-100th household income quartile (Northeast: 32.1%; Midwest: 16.9%; South: 15.7%; West: 27.5%, p<0.001). Complication rates were similar between regional cohorts (Northeast: 10.1%; Midwest: 12.2%; South: 10.3%; West: 11.9%, p=0.503), as was LOS (Northeast: 2.2±2.4 days; Midwest: 2.1±2.4 days; South: 2.0±2.5 days; West: 2.1±2.4 days, p=0.678). The West incurred the greatest mean total cost of admission (Northeast: $19,167±10,267; Midwest: $18,903±9,114; South: $18,566±10,152; West: $24,322±15,126, p<0.001). The Northeast had the lowest proportion of patients with a routine discharge (Northeast: 72.0%; Midwest: 84.8%; South: 82.3%; West: 83.3%, p<0.001). The odds ratio for Western hospital region was 3.46 [95% CI: (2.41, 4.96), p<0.001] compared to the Northeast for increased cost.

CONCLUSION

Our study suggests that regional variations exist in elective ACDF for CSM, including patient demographics, hospital costs, and nonroutine discharges, while complication rates and LOS were similar between regions.

Hospital Consumer Assessment of Healthcare Providers and Systems survey response rates are significantly affected by patient characteristics and postoperative outcomes for patients undergoing primary total knee arthroplasty

INTRODUCTION

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures patients' satisfaction of their hospital experience. A minority of discharged patients return the survey. Underlying bias among who ultimately returns the survey (non-response bias) after total knee arthroplasty (TKA) may affect results of the survey. Thus, the objective of the current study is to assess the relationship between patient characteristics and postoperative outcomes on HCAHPS survey nonresponse.

METHODS

All adult patients at a single institution undergoing inpatient, elective, primary TKA between February 2013 and May 2020 were selected for analysis. Following discharge, all patients had been mailed the HCAHPS survey. The primary outcome analyzed in the current study is survey return. Patient characteristics, surgical variables, and 30-day postoperative outcomes were analyzed. Univariate and multivariate analyses were performed to identify factors independently associated with return of the HCAHPS survey.

RESULTS

Of 4,804 TKA patients identified, 1,498 (31.22%) returned HCAHPS surveys. On multivariate regression analyses controlling for patient factors, patients who did not return the survey were more likely to have a higher American Society of Anesthesia score (ASA score of 4 or higher, OR = 2.37; P<0.001), and be partially or totally dependent (OR = 2.37; P = 0.037). Similarly, patients who did not return the survey were more likely to have had a readmission (OR = 1.94; P<0.001), be discharged to a place other than home (OR = 1.52; P<0.001), or stay in the hospital for longer than 3 days (OR = 1.43; P = 0.004).

DISCUSSION

Following TKA, HCAHPS survey response rate was only 31.22% and completion of the survey was associated with several demographic and postoperative variables. These findings suggest that HCAHPS survey results capture a non-representative fraction of the true TKA patient population. This bias is necessary to consider when using HCAHPS survey results as a metric for quality of healthcare and federal reimbursement rates.

Thirty- and 90-day Readmissions After Spinal Surgery for Spine Metastases: A National Trend Analysis of 4423 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to investigate differences in 30- and 90-day readmissions for spine metastases treated with decompression and/or fusion spine surgery in a nationwide readmission database.

SUMMARY OF BACKGROUND DATA

Patients with metastases to the spine represent a particularly vulnerable patient group that may encounter frequent readmissions. However, the 30- and 90-day rates for readmission following surgery for spine metastases have not been well described.

METHODS

The Nationwide Readmission Database years 2013 to 2015 was queried. Patients were grouped by no readmission (non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). Weighted multivariate analysis assessed impact of treatment approach and clinical factors associated with 30- and 90-day readmissions.

RESULTS

There were a total of 4423 patients with a diagnosis of spine metastases identified who underwent spine surgery, of which 1657 (37.5%) encountered either a 30-or 90-day unplanned readmission (30-R: n = 1068 [24-.1%]; 90-R: n = 589 [13.3%]; non-R: n = 2766). The most prevalent inpatient complications observed were postoperative infection (30-R: 16.3%, 90-R: 14.3%, non-R: 11.5%), acute post-hemorrhagic anemia (30-R: 13.4%, 90-R: 14.2%, non-R: 14.5%), and genitourinary complication (30-R: 5.7%, 90-R: 2.9%, non-R: 6.2%). The most prevalent 30-day and 90-day reasons for admission were sepsis (30-R: 10.2%, 90-R: 10.8%), postoperative infection (30-R: 13.7%, 90-R: 6.5%), and genitourinary complication (30-R: 3.9%, 90-R: 4.1%). On multivariate regression analysis, surgery type, age, hypertension, and renal failure were independently associated with 30-day readmission; rheumatoid arthritis/collagen vascular diseases, and coagulopathy were independently associated with 90-day readmission.

CONCLUSION

In this study, we demonstrate several patient-level factors independently associated with unplanned hospital readmissions after surgical treatment intervention for spine metastases. Furthermore, we find that the most common reasons for readmission are sepsis, postoperative infection, and genitourinary complications.Level of Evidence: 3.

Independent Association of Obesity and Nonroutine Discharge Disposition After Elective Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

The prevalence of obesity continues to rise in the United States at a disparaging rate. Although previous studies have attempted to identify the influence obesity has on short-term outcomes following elective spine surgery, few studies have assessed the impact on discharge disposition following anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). The aim of this study was to determine whether obesity impacts the hospital management, cost, and discharge disposition after elective ACDF for adult CSM.

METHODS

The National Inpatient Sample database was queried using the International Classification of Diseases, 10th revision, Clinical Modification, coding system to identify all (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF for the years 2016 and 2017. Discharge weights were used to estimate national demographics, Elixhauser comorbidities, complications, length of stay, total cost of admission, and discharge disposition.

RESULTS

There were 17,385 patients included in the study, of whom 3035 (17.4%) had obesity (no obesity: 14,350; obesity: 3035). The cohort with obesity had a significantly greater proportion of patients with 3 or more comorbidities compared with the cohort with no obesity (no obesity: 28.1% vs. obesity: 43.5%, P < 0.001). The overall complication rates were greater in the cohort with obesity (no obesity: 10.3% vs. obesity: 14.3%, P = 0.003). On average, the cohort with obesity incurred a total cost of admission $1154 greater than the cost of the cohort with no obesity (no obesity: $19,732 ± 11,605 vs. obesity: $20,886 ± 10,883, P = 0.034) and a significantly greater proportion of nonroutine discharges (no obesity: 16.6% vs. obesity: 24.2%, P < 0.001). In multivariate regression analysis, obesity, age, race, health care coverage, hospital bed size, region, comorbidity, and complication rates all were independently associated with nonroutine discharge disposition.

CONCLUSIONS

Our study demonstrates that obesity is an independent predictor for nonroutine discharge disposition following elective anterior cervical discectomy and fusion for cervical spondylotic myelopathy.

Race Is an Independent Predictor for Nonroutine Discharges After Spine Surgery for Spinal Intradural/Cord Tumors

OBJECTIVE

The aim of this study was to determine if race was an independent predictor of extended length of stay (LOS), nonroutine discharge, and increased health care costs after surgery for spinal intradural/cord tumors.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult (>18 years old) inpatients who underwent surgical intervention for a benign or malignant spinal intradural/cord tumor were identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedural coding systems. Patients were then categorized based on race: White, African American (AA), Hispanic, and other. Postoperative complications, LOS, discharge disposition, and total cost of hospitalization were assessed. A backward stepwise multivariable logistic regression analysis was used to identify independent predictors of extended LOS and nonroutine discharge disposition.

RESULTS

Of 3595 patients identified, there were 2620 (72.9%) whites (W), 310 (8.6%) AAs/blacks, 275 (7.6%) Hispanic (H), and 390 (10.8%) other (O). Postoperative complication rates were similar among the cohorts (P = 0.887). AAs had longer mean (W, 5.4 ± 4.2 days vs. AA, 8.9 ± 9.5 days vs. H, 5.9 ± 3.9 days vs. O, 6.1 ± 3.9 days; P = 0.014) length of hospitalizations than the other cohorts. The overall incidence of nonroutine discharge was 55% (n = 1979), with AA race having the highest rate of nonroutine discharges (W, 53.8% vs. AA, 74.2% vs. H, 45.5% vs. O, 43.6%; P = 0.016). On multivariate regression analysis, AA race was the only significant racial independent predictor of nonroutine discharge disposition (odds ratio, 3.32; confidence interval, 1.67-6.60; P < 0.001), but not extended LOS (P = 0.209).

CONCLUSIONS

Our study indicates that AA race is an independent predictor of nonroutine discharge disposition in patients undergoing surgical intervention for a spinal intradural/cord tumor.

Patient Risk Factors Associated With 30- and 90-Day Readmission After Ventriculoperitoneal Shunt Placement for Idiopathic Normal Pressure Hydrocephalus in Elderly Patients: A Nationwide Readmission Study

OBJECTIVE

For idiopathic normal pressure hydrocephalus (iNPH), risk stratifying patients and identifying those who are likely to fare well after ventriculoperitoneal shunt (VP) surgery may help improve quality of care and reduce unplanned readmissions. The aim of this study was to investigate the drivers of 30- and 90-day readmissions after VP shunt surgery for iNPH in elderly patients.

METHODS

The Nationwide Readmission Database, years 2013 to 2015, was queried. Elderly patients (≥65 years old) undergoing VP shunt surgery were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and identify 30- and 31- to 90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R).

RESULTS

We identified 7199 elderly patients undergoing VP shunt surgery for iNPH. A total of 1413 (19.6%) patients were readmitted (30-R: n = 812 [11.3%] vs. 90-R: n = 601 [8.3%] vs. Non-R: n = 5786). The most prevalent 30- and 90-day complications seen among the readmitted cohort were mechanical complication of nervous system device implant (30-R: 16.1%, 90-R: 12.4%), extracranial postoperative infection (30-R: 10.4%, 90-R: 7.0%), and subdural hemorrhage (30-R: 6.0%, 90-R: 16.4%). On multivariate regression analysis, age, diabetes, and renal failure were independently associated with 30-day readmission; female sex, and 26th to 50th household income percentile were independently associated with reduced likelihood of 90-day readmission. Having any complication during the index admission independently associated with both 30- and 90-day readmission.

CONCLUSIONS

In this study, we identify the most common drivers for readmission for elderly patients with iNPH undergoing VP shunt surgery.

Cement Augmentation of Vertebral Compression Fractures May Be Safely Considered in the Very Elderly

Objective

The objective of the current study was to perform a retrospective review of a national database to assess the safety of cement augmentation for vertebral compression fractures in geriatric populations in varying age categories.

Methods

The 2005–2016 National Surgical Quality Improvement Program databases were queried to identify patients undergoing kyphoplasty or vertebroplasty in the following age categories: 60–69, 70–79, 80–89, and 90+ years old. Demographic variables, comorbidity status, procedure type, provider specialty, inpatient/outpatient status, number of procedure levels, and periprocedure complications were compared between age categories using chi-square analysis. Multivariate logistic regressions controlling for patient and procedural variables were then performed to assess the relative periprocedure risks of adverse outcomes of patients in the different age categories relative to those who were 60–69 years old.

Results

For the 60–69, 70–79, 80–89, and 90+ years old cohorts, 486, 822, 937, and 215 patients were identified, respectively. After controlling for patient and procedural variables, 30-day any adverse events, serious adverse events, reoperation, readmission, and mortality were not different for the respective age categories. Cases in the 80- to 89-year-old cohort were at increased risk of minor adverse events compared to cases in the 60- to 69-year-old cohort.

Conclusion

As the population ages, cement augmentation is being considered as a treatment for vertebral compression fractures in increasingly older patients. These results suggest that even the very elderly may be appropriately considered for these procedures (level of evidence: 3).

Post-traumatic seizures following pediatric traumatic brain injury

OBJECTIVES

The aim of this study was to investigate the national impact of demographic, hospital, and inpatient risk factors on post-traumatic seizure (PTS) development in pediatric patients who presented to the ED following a traumatic brain injury (TBI).

PATIENTS AND METHODS

The Nationwide Emergency Department Sample database years 2010-2014 was queried. Patients (<21 years old) with a primary diagnosis of TBI and subsequent secondary diagnosis of PTS were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. We identified demographic variables, hospital characteristics, pre-existing medical comorbidities, etiology of injuries, and type of injury. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with post-traumatic seizures.

RESULTS

We identified 1,244,087 patients who sustained TBI, of which 10,340 (0.83%) developed PTS. Of the patients who had seizures, the youngest cohort aged 0-5 years had the greatest proportion of seizure development (p < 0.001). Compared to those TBI patients with loss of consciousness (LOC), patients encountering no LOC after TBI had the smallest proportion of seizures while Prolonged LOC with baseline return had the greatest proportion. On univariate analysis of the effect of in-hospital complication on rate of seizures, respiratory, renal and urinary, hematoma, septicemia, and other neurological complications were all significantly associated with seizure development. On multivariate regression, age 6-10 years (OR: 0.48, p < 0.001) 11-15 years (OR: 0.41, p < 0.001), and 16-20 years (OR: 0.51, p < 0.001) were independently associated with decreased risk of developing seizures. Extended LOC with baseline return (OR: 6.33, p < 0.001), extended LOC without baseline return (OR: 1.95, p = 0.009), and Other LOC (OR: 3.02, p < 0.001) were independently associated with increased risk of developing seizures. Subarachnoid hemorrhage (OR: 4.14, p < 0.001), subdural hemorrhage [OR: 7.72, p < 0.001), and extradural hemorrhage (OR: 3.13, p < 0.001) were all independently associated with increased risk of developing seizures.

CONCLUSION

Out study demonstrates that various demographic, hospital, and clinical risk factors are associated with the development of seizures following traumatic brain injury. Enhancing awareness of these drivers may help provide greater awareness of patients likely to develop post-traumatic seizures such that this complication can be decreased in incidence so as to improve quality of care and decrease healthcare costs.

The Effects of Pulmonary Risk Factors on Hospital Resource Use After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis Correction

OBJECTIVE

The aim of this study was to determine the impact of preoperative pulmonary risk factors (PRFS) on surgical outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients with AIS undergoing PSF were identified. Patients were then categorized by whether they had recorded baseline PRF or no-PRF. Patient demographics, comorbidities, intraoperative variables, complications, length of stay, discharge disposition, and readmission rate were assessed.

RESULTS

A total of 4929 patients were identified, of whom 280 (5.7%) had baseline PRF. Compared with the no-PRF cohort, the PRF cohort had higher rates of complications (PRF, 4.3% vs. no-PRF, 2.2%; P = 0.03) and longer hospital stays (PRF, 4.6 ± 4.3 days vs. no-PRF, 3.8 ± 2.3 days; P < 0.001), yet, discharge disposition was similar between cohorts (P = 0.70). Rates of 30-day unplanned readmission were significantly higher in the PRF cohort (PRF, 6.3% vs. no-PRF, 2.7%; P = 0.009), yet, days to readmission (P = 0.76) and rates of 30-day reoperation (P = 0.16) were similar between cohorts. On multivariate analysis, PRF was found to be a significant independent risk factor for longer hospital stays (risk ratio, 0.74; 95% confidence interval, 0.44-1.04; P < 0.001) but not postoperative complication or 30-day unplanned readmission.

CONCLUSIONS

Our study showed that PRF may be a risk factor for slightly longer hospital stays without higher rates of complication or unplanned readmission for patients with AIS undergoing PSF and thus should not preclude surgical management.

Pre-operative headaches and obstructive hydrocephalus predict an extended length of stay following suboccipital decompression for pediatric Chiari I malformation

PURPOSE

For young children and adolescents with Chiari malformation type I (CM-I), the determinants of extended length of hospital stay (LOS) after neurosurgical suboccipital decompression are obscure. Here, we investigate the impact of patient- and hospital-level risk factors on extended LOS following surgical decompression for CM-I in young children to adolescents.

METHODS

The Kids' Inpatient Database year 2012 was queried. Pediatric CM-I patients (6-18 years) undergoing surgical decompression were identified. Weighted patient demographics, comorbidities, complications, LOS, disposition, and total cost were recorded. A multivariate logistic regression was used to determine the odds ratio for risk-adjusted LOS. The primary outcome was the degree patient comorbidities or post-operative complications correlated with extended LOS.

RESULTS

A total of 1592 pediatric CM-I patients were identified for which 328 (20.6%) patients had extended LOS (normal LOS, 1264; extended LOS, 328). Age, gender, race, median household income quartile, and healthcare coverage distributions were similar between the two cohorts. Patients with extended LOS had significantly greater admission comorbidities including headache symptoms, nausea and vomiting, obstructive hydrocephalus, lack of coordination, deficiency anemias, and fluid and electrolyte disorders. On multivariate logistic regression, several risk factors were associated with extended LOS, including headache symptoms, obstructive hydrocephalus, and fluid and electrolyte disorders.

CONCLUSIONS

Our study using the Kids' Inpatient Database demonstrates that presenting symptoms and signs, including headaches and obstructive hydrocephalus, respectively, are significantly associated with extended LOS following decompression for pediatric CM-I.

Impact of Preoperative Anemia on Outcomes After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

OBJECTIVE

The aim of this study was to investigate the relationship of preoperative anemia and outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients (age 10-18 years) with AIS undergoing PSF were identified. Two cohorts were categorized into anemic and nonanemic cohorts based on age-based and sex-based criteria for anemia. Thirty-day outcomes and readmission rates were evaluated.

RESULTS

A total of 4929 patients were identified, of whom 592 (12.0%) were found to have preoperative anemia. The anemic cohort had a greater prevalence of comorbidities and longer operative times. Compared with the nonanemic cohort, the anemic cohort experienced significantly higher rates of perioperative bleed/transfusion (nonanemic, 67.4% vs. anemic, 73.5%; P = 0.004) and required a greater total amount of blood transfused (nonanemic, 283.2 ± 265.5 mL vs. anemic, 386.7 ± 342.6 mL; P < 0.001). The anemic cohort experienced significantly longer hospital stays (nonanemic, 3.8 ± 2.2 days vs. anemic, 4.2 ± 3.9 days; P = 0.001), yet discharge disposition (P = 0.58), 30-day complication rates (P = 0.79) and unplanned reoperation rates (P = 0.90) were similar between cohorts. On multivariate analysis, anemia was found to be an independent predictor of perioperative bleed/transfusion (odds ratio, 1.36; 95% confidence interval, 1.12-1.66; P = 0.002) as well as a longer length of hospital stay (relative risk, 0.46; 95% confidence interval, 0.25-0.67; P < 0.001) but was not an independent predictor for postoperative complications (P = 0.85).

CONCLUSIONS

Our study suggests that preoperative anemia may be a risk factor for a greater perioperative bleed/transfusion event and slightly longer length of stay; however, it was not associated with greater 30-day complication and readmission rates in patients with AIS undergoing PSF.

Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample

BACKGROUND

In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms.

METHODS

The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75^th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS.

RESULTS

A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication.

CONCLUSIONS

Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.

Characteristics of Reported Industry Payments to Neurosurgeons: A 5-Year Open Payments Database Study

OBJECTIVE

The aim of this study was to characterize the payments made by medical industry to neurosurgeons from 2014 to 2018.

METHODS

A retrospective study was performed from January 1, 2014 to December 31, 2018 of the Open Payments Database. Collected data included the total number of industry payments, the aggregate value of industry payments, and the mean value of each industry payment made to neurosurgeons per year over the 5-year period.

RESULTS

A total of 105,150 unique surgeons, with 13,668 (12.99%) unique neurosurgeons, were identified to have received an industry payment during 2014-2018. Neurosurgeons were the second highest industry-paid surgical specialty, with a total 421,151 industry payments made to neurosurgeons, totaling $477,451,070. The mean average paid amount per surgeon was $34,932 (±$936,942). The largest proportion of payments were related to food and beverage (75.5%), followed by travel and lodging (14.9%), consulting fees (3.5%), nonconsulting service fees (2.1%), and royalties or licensing (1.9%), totaling 90.4% of all industry payments to neurologic surgeons. Summed across the 5-year period, the largest paid source types were royalties and licensing (64.0%; $305,517,489), consulting fees (11.8%; $56,445,950), nonconsulting service fees (7.3%; $34,629,109), current or prospective investments (6.8%, $32,307,959), and travel and lodging (4.8%, $22,982,165).

CONCLUSIONS

Our study shows that over the most recent 5-year period (2014-2018) of the Centers for Medicare and Medicaid Services Open Payments Database, there was a decreasing trend of the total number of payments, but an increasing trend of the total amount paid to neurosurgeons.

Posterior Reversible Encephalopathy Syndrome Caused by Induced Hypertension to Treat Cerebral Vasospasm Secondary to Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

The aim of the present study was to describe the case of a patient who had presented to a university hospital with induced-hypertension (IH) posterior reversible encephalopathy syndrome (PRES). We also reviewed all other reports of such patients.

METHODS

We have described the clinical course of a patient who had presented to the university hospital neurosurgical department. We also performed a systematic review of studies related to the incidence of PRES caused by the use of IH in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

RESULTS

The patient had presented with an acute-onset headache and found to have a subarachnoid hemorrhage due to anterior communicating artery aneurysm rupture. She underwent coiling the next day. During the subsequent days, she demonstrated fluctuating clinical examination findings, aphasia, and decreased levels of arousal. Digital subtraction angiography was performed, and the findings were concerning for mild vasospasm of the anterior and middle cerebral arteries. The systolic blood pressure goal was increased to 180-220 mm Hg for an IH trial, which had initially resulted in some transient clinical improvements in her level of arousal. However, the improvement was not sustained. During the next 36 hours, the patient worsened, and she developed left middle cerebral artery syndrome. Given the concern for a possible ischemic event, magnetic resonance imaging was performed, which demonstrated interval development of multiple areas of cortical-based fluid-attenuated inversion recovery hyperintensity consistent with PRES. The systolic blood pressure goal was relaxed to normotension, and ~48 hours later, the patient's clinical status had significantly improved.

CONCLUSION

IH-PRES is a rare complication that should be remembered in the differential diagnosis for at-risk patients.

Portending Influence of Racial Disparities on Extended Length of Stay after Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

The aim of this study was to investigate whether race is an independent predictor of extended length of stay (LOS) after elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult patients undergoing ACDF for CSM were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification coding system.

RESULTS

A total of 15,400 patients were identified, of whom 13,250 (86.0%) were Caucasian (C) and 2150 (14.0%) were African American (AA). The C cohort tended to be older, whereas the AA cohort had 2 times as many patients in the 0-25th income quartile. The prevalence of comorbidities was greater in the AA cohort. Intraoperative fusion levels were similar between the cohorts, whereas the AA cohort had a higher rate of cerebrospinal fluid leak/dural tear. In relation to the number of complications, the C cohort had a lower rate compared with the AA cohort (P = 0.006), including no complication (89.4% vs. 85.3%), 1 complication (9.9% vs. 12.8%), and >1 complication (0.7% vs. 1.9%). The AA cohort experienced significantly longer hospital stays (C, 1.9 ± 2.3 days vs. AA, 2.7 ± 3.5; P < 0.001), greater proportion of extended LOS (C, 17.5% vs. AA, 29.1%; P < 0.001) and nonroutine discharges (C, 16.1% vs. AA, 28.6%; P < 0.001). AA race was a significant independent risk factor for extended LOS (odds ratio, 1.98; 95% confidence interval, 1.50-2.61; P < 0.001).

CONCLUSIONS

Our study suggests that AA patients have a significantly higher risk of prolonged LOS after elective ACDF for CSM compared with C patients.

Risk Factors for the Development of Post-Traumatic Hydrocephalus in Children

OBJECTIVE

The aim of this study was to investigate the national impact of demographic, hospital, and inpatient risk factors on posttraumatic hydrocephalus (PTH) development in pediatric patients who presented to the emergency department after a traumatic brain injury (TBI).

METHODS

The Nationwide Emergency Department Sample database 2010-2014 was queried. Patients (<21 years old) with a primary diagnosis of TBI and subsequent secondary diagnosis of PTH were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system.

RESULTS

We identified 1,244,087 patients who sustained TBI, of whom 930 (0.07%) developed PTH. The rates of subdural hemorrhage and subarachnoid hemorrhage were both significantly higher for the PTH cohort. On multivariate regression, age 6-10 years (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.38-0.93; P = 0.022), 11-15 years (OR, 0.32; 95% CI, 0.21-0.48; P < 0.0001), and 16-20 years (OR, 0.24; 95% CI, 0.15-0.37; P < 0.0001) were independently associated with decreased risk of developing hydrocephalus, compared with ages 0-5 years. Extended loss of consciousness with baseline return and extended loss of consciousness without baseline return were independently associated with increased risk of developing hydrocephalus. Respiratory complication (OR, 28.35; 95% CI, 15.75-51.05; P < 0.0001), hemorrhage (OR, 37.12; 95% CI, 4.79-287.58; P = 0.0001), thromboembolic (OR, 8.57; 95% CI, 1.31-56.19; P = 0.025), and neurologic complication (OR, 64.64; 95% CI, 1.39-3010.2; P = 0.033) were all independently associated with increased risk of developing hydrocephalus.

CONCLUSIONS

Our study using the Nationwide Emergency Department Sample database shows that various demographic, hospital, and clinical risk factors are associated with the development of hydrocephalus after traumatic brain injury.

Thirty- and 90-Day Readmissions After Treatment of Traumatic Subdural Hematoma: National Trend Analysis

OBJECTIVE

Subdural hematoma (SDH), a form of traumatic brain injury, is a common disease that requires extensive patient management and resource utilization; however, there remains a paucity of national studies examining the likelihood of readmission in this patient population. The aim of this study is to investigate differences in 30- and 90-day readmissions for treatment of traumatic SDH using a nationwide readmission database.

METHODS

The Nationwide Readmission Database years 2013-2015 were queried. Patients with a diagnosis of traumatic SDH and a primary procedure code for incision of cerebral meninges for drainage were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R).

RESULTS

We identified a total of 14,355 patients, with 3106 (21.6%) patients encountering a readmission (30-R: n = 2193 [15.3%]; 90-R: n = 913 [6.3%]; Non-R: n = 11,249). The most prevalent 30- and 90-day diagnoses seen among the readmitted cohorts were postoperative infection (30-R: 10.5%, 90-R: 13.0%) and epilepsy (30-R: 3.7%, 90-R: 1.1%). On multivariate logistic regression analysis, Medicare, Medicaid, hypertension, diabetes, renal failure, congestive heart failure, and coagulopathy were independently associated with 30-day readmission; Medicare and rheumatoid arthritis/collagen vascular disease were independently associated with 90-day readmission.

CONCLUSIONS

In this study, we determine the relationship between readmission rates and complications associated with surgical intervention for traumatic subdural hematoma.

The Clinical Implications of Spontaneous Hemorrhage in Vestibular Schwannomas

Background  Spontaneous hemorrhage into vestibular schwannomas (VSs) is rare and can render more rapid symptom onset and a seemingly poorer prognosis for an otherwise benign pathology. We describe our series of hemorrhagic VS (HVSs) and systematically reviewed the literature to better understand relevant clinical factors and outcomes. Methods  Retrospective case review series and systematic review of the literature using PRISMA guidelines. Results  Fifty-three patients with HVS met inclusion criteria. Compared with historical data for all VS, patients with HVS had relatively higher rates of perioperative mortality, significant preoperative facial weakness, and harbored relatively larger tumors. Regardless of the extent of resection (EOR), surgery for HVS resulted in significant improvement of facial weakness ( p  = 0.041), facial numbness ( p  < 0.001), vertigo ( p  < 0.001), and headache ( p  < 0.001). Patients with facial weakness tended to have larger tumors ( p  = 0.058) on average and demonstrated significant improvement after surgery, irrespective of EOR ( p  < 0.01). The use of blood-thinning medications did not affect patient health outcome. Histopathology of HVS samples showed an increased number of dilated/ectatic thin-walled vascular channels, reflective of potentially increased vascular permeability and hypervascularity. Conclusion  HVS may be an aggressive subgroup of VS, associated with a surprisingly high mortality rate. When features of HVS are identified on imaging, these patients should be treated expeditiously, especially given that facial nerve dysfunction, which is identified in more than half of patients with HVS, appears to be reversible. Overall, this study has significant implications in the management of VS, raising awareness of a small, but highly morbid subgroup.

Risk Factors Portending Extended Length of Stay After Suboccipital Decompression for Adult Chiari I Malformation

OBJECTIVE

For adult patients undergoing surgical decompression for Chiari malformation type I (CM-I), the patient-level factors that influence extended length of stay (LOS) are relatively unknown. The aim of this study was to investigate the impact of patient-baseline comorbidities, demographics, and postoperative complications on extended LOS after intervention after adult CM-I decompression surgery.

METHODS

A retrospective cohort study using the National Inpatient Sample years 2010-2014 was performed. Adults (≥18 years) with a primary diagnosis of CM-I undergoing surgical decompression were identified. Weighted patient demographics, comorbidities, complications, LOS, disposition, and total cost were recorded. A multivariate logistic regression was used to determine the odds ratio for risk-adjusted LOS.

RESULTS

A total of 29,961 patients were identified, 6802 of whom (22.7%) had extended LOS. The extended LOS cohort had a significantly greater overall complication rate (normal LOS, 10.6% vs. extended LOS, 29.1%; P < 0.001) and total cost (normal LOS, $14,959 ± $6037 vs. extended LOS, $25,324 ± $21,629; P < 0.001) compared with the normal LOS cohort. On multivariate logistic regression, black race, income quartiles, private insurance, obstructive hydrocephalus, lack of coordination, fluid and electrolyte disorders, and paralysis were all independently associated with extended LOS. Additional duraplasty (P = 0.132) was not significantly associated with extended LOS after adjusting for other variables. The odds ratio for extended LOS was 2.07 (95% confidence interval, 1.59-2.71) for patients with 1 complication and 9.47 (95% confidence interval, 5.86-15.30) for patients with >1 complication.

CONCLUSIONS

Our study shows that extended LOS after adult CM-I decompression surgery may be influenced by multiple patient-level factors.

Comparison of epidemiology, treatments, and outcomes in pediatric versus adult ependymoma

Background

Mounting evidence supports the presence of heterogeneity in the presentation of ependymoma patients with respect to location, histopathology, and behavior between pediatric and adult patients. However, the influence of age on treatment outcomes in ependymoma remains obscure.

Methods

The SEER database years 1975–2016 were queried. Patients with a diagnosis of ependymoma were identified using the International Classification of Diseases for Oncology, Third Edition, coding system. Patients were classified into one of 4 age groups: children (age 0–12 years), adolescents (age 13–21 years), young adults (age 22–45 years), and older adults (age >45 years). The weighed multivariate analysis assessed the impact of age on survival outcomes following surgical treatment.

Results

There were a total of 6076 patients identified with ependymoma, of which 1111 (18%) were children, 529 (9%) were adolescents, 2039 (34%) were young adults, and 2397 (40%) were older adults. There were statistically significant differences between cohorts with respect to race (P < .001), anatomical location (P < .001), extent of resection (P < .001), radiation use (P < .001), tumor grade (P < .001), histological classification (P < .001), and all-cause mortality (P < .001). There was no significant difference between cohorts with respect to gender (P = .103). On multivariate logistic regression, factors associated with all-cause mortality rates included males (vs females), supratentorial location (vs spinal cord tumors), and radiation treatment (vs no radiation).

Conclusions

Our study using the SEER database demonstrates the various demographic and treatment risk factors that are associated with increased rates of all-cause mortality between the pediatric and adult populations following a diagnosis of ependymoma.

Preresidency Publication Productivity of U.S. Neurosurgery Interns

BACKGROUND

Research experience is believed to be an important component of the neurosurgery residency application process. One measure of research productivity is publication volume. The preresidency publication volume of U.S. neurosurgery interns and any potential association between applicant publication volume and the match results of top-ranked residency programs have not been well characterized.

OBJECTIVE

In this study, we sought to characterize the preresidency publication volume of U.S. neurosurgery residents in the 2018-2019 intern class using the Scopus database.

METHODS

For each intern, we recorded the total number of publications, total number of first or last author publications, total number of neuroscience-related publications, mean number of citations per publication, and mean impact factor of the journal per publication. Preresidency publication volumes of interns at the top-25 programs (based on a composite ranking score according to 4 different ranking metrics) were compared with those at all other programs.

RESULTS

We found that 82% of neurosurgery interns included in the analysis (190 interns from 95 programs) had at least 1 publication. The average number of publications per intern among all programs was 6 ± 0.63 (mean ± standard error of the mean). We also found that interns at top-25 neurosurgery residency programs tended to have a higher number of publications (8.3 ± 1.2 vs. 4.8 ± 0.7, P = 0.0137), number of neuroscience-related publications (6.8 ± 1.1 vs. 4.1 ± 0.7, P = 0.0419), and mean number of citations per publication (9.8 ± 1.7 vs. 5.7 ± 0.8, P = 0.0267) compared with interns at all other programs.

CONCLUSIONS

Our results provide a general estimate of the preresidency publication volume of U.S. neurosurgery interns and suggest a potential association between publication volume and matching in the top-25 neurosurgery residency programs.

Identification of KCC2 Mutations in Human Epilepsy Suggests Strategies for Therapeutic Transporter Modulation

Epilepsy is a common neurological disorder characterized by recurrent and unprovoked seizures thought to arise from impaired balance between neuronal excitation and inhibition. Our understanding of the neurophysiological mechanisms that render the brain epileptogenic remains incomplete, reflected by the lack of satisfactory treatments that can effectively prevent epileptic seizures without significant drug-related adverse effects. Type 2 K⁺-Cl⁻ cotransporter (KCC2), encoded by SLC12A5, is important for chloride homeostasis and neuronal excitability. KCC2 dysfunction attenuates Cl⁻ extrusion and impairs GABAergic inhibition, and can lead to neuronal hyperexcitability. Converging lines of evidence from human genetics have secured the link between KCC2 dysfunction and the development of epilepsy. Here, we review KCC2 mutations in human epilepsy and discuss potential therapeutic strategies based on the functional impact of these mutations. We suggest that a strategy of augmenting KCC2 activity by antagonizing its critical inhibitory phosphorylation sites may be a particularly efficacious method of facilitating Cl⁻ extrusion and restoring GABA inhibition to treat medication-refractory epilepsy and other seizure disorders.

Extent of resection of epidermoid tumors and risk of recurrence: case report and meta-analysis

OBJECTIVE

Intracranial epidermoid tumors are slow-growing, histologically benign tumors of epithelial cellular origin that can be symptomatic because of their size and mass effect. Neurosurgical resection, while the treatment of choice, can be quite challenging due to locations where these lesions commonly occur and their association with critical neurovascular structures. As such, subtotal resection (STR) rather than gross-total resection (GTR) can often be performed, rendering residual and recurrent tumor potentially problematic. The authors present a case of a 28-year-old man who underwent STR followed by aggressive repeat resection for regrowth, and they report the results of the largest meta-analysis to date of epidermoid tumors to compare recurrence rates for STR and GTR.

METHODS

The authors conducted a systemic review of PubMed, Web of Science, and the Cochrane Collaboration following the PRISMA guidelines. They then conducted a proportional meta-analysis to compare the pooled recurrence rates between STR and GTR in the included studies. The authors developed fixed- and mixed-effect models to estimate the pooled proportions of recurrence among patients undergoing STR or GTR. They also investigated the relationship between recurrence rate and follow-up time in the previous studies using linear regression and natural cubic spline models.

RESULTS

Overall, 27 studies with 691 patients met the inclusion criteria; of these, 293 (42%) underwent STR and 398 (58%) received GTR. The average recurrence rate for all procedures was 11%. The proportional meta-analysis showed that the pooled recurrence rate after STR (21%) was 7 times greater than the rate after GTR (3%). The average recurrence rate for studies with longer follow-up durations (≥ 4.4 years) (17.4%) was significantly higher than the average recurrence rate for studies with shorter follow-up durations (< 4.4 years) (5.7%). The cutoff point of 4.4 years was selected based on the significant relationship between the recurrence rate of both STR and GTR and follow-up durations in the included studies (p = 0.008).

CONCLUSIONS

STR is associated with a significantly higher rate of epidermoid tumor recurrence compared to GTR. Attempts at GTR should be made during the initial surgery with efforts to optimize success. Surgical expertise, as well as the use of adjuncts, such as intraoperative MRI and neuromonitoring, may increase the likelihood of completing a safe GTR and decreasing the long-term risk of recurrence. The most common surgical complications were transient cranial nerve palsies, occurring equally in STR and GTR cases when reported. In all postoperative epidermoid tumor cases, but particularly following STR, close follow-up with serial MRI, even years after surgery, is recommended.