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Preoperative symptom severity in cervical spondylotic myelopathy (CSM) can be variable. Radiomic signatures could provide an imaging biomarker for symptom severity in CSM. This study utilizes radiomic signatures of T1-weighted and T2-weighted magnetic resonance imaging images to correlate with preoperative symptom severity based on modified Japanese Orthopaedic Association (mJOA) scores for patients with CSM. Sixty-two patients with CSM were identified. Preoperative T1-weighted and T2-weighted magnetic resonance imaging images for each patient were segmented from C2-C7. A total of 205 texture features were extracted from each volume of interest. After feature normalization, each second-order feature was further subdivided to yield a total of 400 features from each volume of interest for analysis. Supervised machine learning was used to build radiomic models. The patient cohort had a median mJOA preoperative score of 13; of which, 30 patients had a score of >13 (low severity) and 32 patients had a score of ≤13 (high severity). Radiomic analysis of T2-weighted imaging resulted in 4 radiomic signatures that correlated with preoperative mJOA with a sensitivity, specificity, and accuracy of 78%, 89%, and 83%, respectively (P < 0.004). The area under the curve value for the ROC curves were 0.69, 0.70, and 0.77 for models generated by independent T1 texture features, T1 and T2 texture features in combination, and independent T2 texture features, respectively. Radiomic models correlate with preoperative mJOA scores using T2 texture features in patients with CSM. This may serve as a surrogate, objective imaging biomarker to measure the preoperative functional status of patients. [ABSTRACT FROM AUTHOR]

• Spontaneous intraparenchymal hematoma is commonly encountered in clinical practice. • The utilization of robotic assisted devices for intraparenchymal and intraventricular catheter placement has not been investigated before. • We achieved up to 95% reduction of intraparenchymal hematoma volume with a statistically significant decrease following ROSA assisted catheter drainage. • The error margin is miniscule and far adequate for the management of a hematoma. Large supratentorial intraparenchymal hemorrhages are managed emergently with image-guided catheters that aim to minimize injury to surrounding parenchyma. Robotic assistance may offer advantages for stereotactic guidance and placement of such catheters. We describe our center's experience with minimally invasive ROSA-assisted intraventricular and intraparenchymal hemorrhage catheter placement and delineate its safety and outcomes. A retrospective analysis was performed including all patients with intraparenchymal hematoma that underwent ROSA-assisted intraparenchymal and intraventricular catheter placement at the University of Pittsburgh Medical Center between 2017 and 2019. All patients received tissue plasminogen activator (tPA) through the intraparenchymal catheter. We performed a manual chart review of these patients. Pertinent clinical and radiological characteristics and patient outcomes were recorded and analyzed. Catheter trajectory was independently quantified and analyzed by two independent reviewers. Error between the planned trajectory and final position was calculated and analyzed. Four patients (2 males and 2 females, mean age of 64 years) with deep brain large volume intraparenchymal hemorrhages were treated with catheter evacuation with robotic assistance. For 2 of the 4 patients, thin-cut CT imaging allowed for the real trajectory of the catheter to be compared to the targeted trajectory to calculate error. The mean error of catheter placement was 3.48 mm. ROSA-assisted catheter placement achieved up to 95% reduction of intraparenchymal hematoma volume with a statistically significant decrease following catheter drainage (pre- 51.8 ± 19.1 cc vs. post- 13.0 ± 14.4; p < 0.01). Robotic stereotactic assistance offers a safe and sufficiently accurate technique for intraparenchymal hematoma and intraventricular catheter placement. [ABSTRACT FROM AUTHOR]

• Routine imaging during anticoagulation for VTE is common practice in neurosurgery. • We detected subclinical intracranial hemorrhage in a small subset of patients. • Temporary discontinuation of heparin drip resulted in fatal progression of VTE. • Cessation of anticoagulation to manage subclinical hemorrhage may be precarious. Anticoagulation for postoperative venous thromboembolism (VTE) may infer a higher risk of intracranial hemorrhage. We treat patients with VTE using slowly titrating intravenous heparin drip without bolus. When PTT is greater than 60 s, a head CT is obtained to monitor for the development of a intracranial hemorrhage before transition to oral anticoagulation. We evaluated the utility of routine surveillance head CT to monitor for intracranial hemorrhage during anticoagulation. This is a case series of neurosurgical patients in an academic quaternary hospital who developed a VTE after cranial procedures between 2007 and 2017. Over 11,000 patients were screened for the study. Patients' demographics data, surgical indication, PTT at the time of surveillance CT head, surveillance CT head findings, and patient's clinical course were reviewed. A total of 83 patients were included. Three patients (3.6%) developed a new subclinical hemorrhage on CT head imaging while on heparin drip. Interval CT head showed stable hemorrhage in all patients. Heparin drip was stopped in two patients and they both progressed from DVT to pulmonary embolism: one patient died due to cardiac arrest, the other patient was transitioned to oral anticoagulation. In the third patient heparin drip was continued uneventfully and transitioned to oral anticoagulation with no further clinical sequalae. Surveillance CT while on heparin drip for VTE management detected subclinical intracranial hemorrhage in a small subset of patients. Patients whose anticoagulation was stopped had progression of VTE. Undertreatment of VTE in the presence of subclinical hemorrhage may lead to significant morbidity and mortality. [ABSTRACT FROM AUTHOR]

The current pandemic crisis, caused by a novel human coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), has forced a dramatic change in our society. A key portion of the medical work force on the frontline is composed of resident physicians. Thus, it becomes imperative to create an adequate and effective action plan to restructure this valuable human resource amid the SARS-CoV2 pandemic. We sought to describe a comprehensive approach taken by a Neurosurgery Department in quaternary care academic institution in the United States of America amid the SARS-CoV2 pandemic focused in resident training and support. To describe a comprehensive approach taken by a Neurosurgery Department in quaternary care academic institution in the United States of America amid the SARS-CoV2 pandemic focused on resident training and support. A restructuring of the Neurosurgery Department at our academic institution was performed focused on decreasing their risk of infection/exposure and transmission to others, while minimizing negative consequences in the training experience. An online academic platform was built for resident education, guidance, and support, as well as continue channel for pandemic update by the department leadership. The SARS-CoV2 pandemic constitutes a global health emergency full of uncertainty. Treatment, scope, duration, and economic burden forced a major restructuring of our medical practice. In this regard, academic institutions must direct efforts to diminish further negative impact in the training and education of the upcoming generation of physicians, including those currently in medical school. Perhaps the only silver lining in this terrible disruption will be greater appreciation of the role of current health care providers and educators, whose contributions to our society are often neglected or unrecognized. [ABSTRACT FROM AUTHOR]

• Telemedicine is an emerging field with diverse applications. • Mild TBI patients may be candidates for screening before inter-facility transfer. • Avoiding unnecessary hospital transfers can better optimize resource utilization. We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14–15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In "screened" patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the "unscreened" group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38). In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14–15. The true potential in cost-reduction will be realized in system-wide large-scale implementation. [ABSTRACT FROM AUTHOR]

Degenerative diseases of the lumbar spine decrease lumbar lordosis (LL). Anterior lumbar interbody fusion (ALIF) at the L5-S1 disc space improves segmental lordosis, LL, and sagittal balance. This study investigated reciprocal changes in spinopelvic alignment after L5-S1 ALIF. A retrospective chart review identified patients who underwent L5-S1 ALIF with or without posterior fixation at a single institution (November 1, 2016 to October 1, 2021). Changes in pelvic tilt, sacral slope, proximal LL (L1-L4), distal LL (L4-S1), total LL (L1-S1), segmental lordosis, pelvic incidence–LL mismatch, thoracic kyphosis, cervical lordosis, and sagittal vertical axis were measured on preoperative and postoperative radiographs. Forty-eight patients were identified. Immediate postoperative radiographs were obtained at a mean (SD) of 17 (20) days after surgery; delayed radiographs were obtained 184 (82) days after surgery. After surgery, patients had significantly decreased pelvic tilt (15.71° [7.25°] vs. 17.52° [7.67°], P = 0.003) and proximal LL (11.86° [10.67°] vs. 16.03° [10.45°], P < 0.001) and increased sacral slope (39.49° [9.27°] vs. 36.31° [10.39°], P < 0.001), LL (55.35° [13.15°] vs. 51.63° [13.38°], P = 0.001), and distal LL (43.17° [9.33°] vs. 35.80° [8.02°], P < 0.001). Segmental lordosis increased significantly at L5-S1 and decreased significantly at L2-3, L3-4, and L4-5. Lordosis distribution index increased from 72.55 (19.53) to 81.38 (22.83) (P < 0.001). L5-S1 ALIF was associated with increased L5-S1 segmental lordosis accompanied by pelvic anteversion and a reciprocal decrease in proximal LL. These changes may represent a reversal of compensatory mechanisms, suggesting an overall relaxation of spinopelvic alignment after L5-S1 ALIF. [ABSTRACT FROM AUTHOR]

Anterior cervical diskectomy and fusion (ACDF) is a standard surgical procedure used widely in the treatment of degenerative cervical spine conditions. Although the safety and effectiveness of single-level ACDF is well supported in the literature, reports of multilevel ACDF are sparse and present mixed results. There is concern for greater complications with increasing levels of fusion given the increased complexity, procedure duration, and invasiveness of multilevel ACDF. In this retrospective review, we report complications data for 105 adult neurosurgical patients who underwent elective multilevel ACDF at a single institution by a single surgeon between 2004 and 2016. Fifty-four patients underwent 3-level ACDF and 51 patients underwent 4-level ACDF with a mean follow-up of 2.7 ± 1.9 years. Although patients with 4-level fusion were more likely than those with 3-level fusion to have estimated blood loss ≥100 mL (P = 0.04), we found no significant differences in other peri- and postoperative complications, need for revision, and presence of symptoms at the time of last follow-up between groups. This study suggests that 4-level ACDF is not necessarily associated with a greater number of or more severe complications than 3-level ACDF. [ABSTRACT FROM AUTHOR]

Minimally invasive surgery (MIS) for correction of adult spinal deformity was developed to address the high rate of medical and surgical complications rate in open surgical treatment of increasingly aging and frail patient population. In the past decade, MIS group within the International Spine Study Group (ISSG) has been in the forefront of the application of MIS techniques to fulfill the well-established principles of ASD surgery. These efforts have resulted in landmark studies. Here, we review these studies that encompass all aspects of MIS surgical treatment of ASD including patient selection with Minimally Invasive Spinal Deformity Surgery (MISDEF) and MISDEF-2 algorithms, surgical planning with anterior column realignment classification and the Minimally Invasive Interbody Selection Algorithm (MIISA), and surgical execution with Spinal Deformity Complexity Checklist (SDCC). We will highlight that with careful selection, diligent planning and meticulous execution the MIS techniques can treat patients with ASD, abiding to correction principles and radiographic parameters. [ABSTRACT FROM AUTHOR]

Citation analysis was performed in order to identify the top 50 most cited articles pertaining to the field of primary spinal tumors. This collection of articles highlights important trends in the neurosurgical literature. We searched the Thomson Reuters Web of Knowledge in order to identify articles pertaining to primary tumors of the spine. Impertinent articles were removed. The top 50 most cited articles were identified. Thereafter, article characteristics were determined including article type, article topic, level of evidence, and citation rate. The selected articles were published between 1951 and 2008. The most productive year was 1997 with 6 publications. The top 50 articles were published in twenty-two different journals, most commonly in Neurosurgery (12), Journal of Neurosurgery (8), and Spine (6). The most frequently cited article was by Tomita et al. written in 1997 which described total en bloc spondylectomy as a novel surgical technique in management of primary tumors of the vertebral column. We identified the 50 most-cited articles in the field of primary spinal tumors. This collection of articles serves as a reference for recognizing impactful studies in the field. [ABSTRACT FROM AUTHOR]

We studied the impact of preoperative steroids on 30 day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾10 days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n = 1611) and primary malignant gliomas 62.5% (n = 2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n = 1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6–0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2–1.8) was increased. In the propensity score matched cohort (n = 465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Individuals with high spinal cord injury (SCI) are prone to significant fluctuation in blood pressure with episodes of very high and low blood pressure during autonomic dysreflexia (AD) and orthostatic hypotension, respectively. We do not know how such blood pressure lability affects the vasculature. Purpose: We used a well-characterized animal model of AD to determine whether increasing the frequency of AD during recovery from SCI would exacerbate injury-induced dysfunction in resistance vessels. Study design/setting: Experimental animal study. International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Canada. Methods: Complete transection of the T3 spinal cord was performed in male Wistar rats. For 14 days after injury, AD was induced via colorectal distension (CRD; 30 minutes per day) in the experimental group (SCI-CRD). One month after SCI, baseline cardiovascular parameters and severity of CRD-induced AD were assessed in SCI-CRD animals and SCI-only controls. Mesenteric arteries were harvested for in vitro myography to characterize vasoactive responses to phenylephrine (PE) and acetylcholine (ACh). Results: Mesenteric arteries from SCI-CRD animals exhibited larger maximal responses to PE than arteries from SCI-only controls. Hyperresponsiveness to PE was not a product of endothelial dysfunction because mesenteric arteries from both groups had similar vasodilator responses to ACh. Both SCI-only controls and SCI-CRD animals exhibited CRD-evoked AD 1 month after SCI; however, CRD-induced hypertension was less pronounced in animals that were previously exposed to CRD. Conclusions: Injury-induced changes within the vasculature may contribute to the development of AD after SCI. Here, we provide evidence that AD itself has significant and long-lasting effects on vascular function. This finding has implications for the medical management of AD and provides an impetus for maintaining stable blood pressure. [ABSTRACT FROM AUTHOR]

Hip-spine syndrome (HSS) was first described in 1983 to describe the symptomatology resulting from concomitant lumbar degenerative stenosis and hip osteoarthritis. Numerous studies have sought to understand the underlying pathology and appropriate management of this syndrome. The purpose of this article is to review the literature for the specific imaging characteristics and the optimal surgical treatment of HSS. A systematic review was conducted via an electronic database search through PubMed to identify all publications related to HSS. All publications that contained data on patients who underwent surgical treatment for HSS and reported patient-reported outcome measures or radiographic data were included. Exclusion criteria consisted of publications in a language other than English, review articles, and technique articles. Fifteen articles that focused on the surgical management of HSS were identified. Of these 15 articles, 8 reported radiographic outcomes, with most reporting no significant change in spinopelvic parameters before and after surgery. Thirteen articles reported clinical outcomes, with 8 of those 13 articles identifying patient-reported outcome measures to be significantly improved following surgery. The data on the surgical management of HSS remains sparse. While there is some evidence that total hip arthroplasty in patients who previously underwent spinal fusion may have higher complication rates, there remains debate regarding which surgical problem to address first, the hip or the spine. [ABSTRACT FROM AUTHOR]

Multiple surgical specialties perform carotid endarterectomy (CEA). As indications for CEA narrows, neurosurgery residents are less exposed to this procedure. This study aims to determine trends in CEA training among graduating trainees in neurosurgery and compare these to general and vascular surgery. ACGME case log reports were retrospectively reviewed from 2013 to 2019 for neurologic, general, and vascular surgery residencies and vascular surgery fellowship. These annual reports contain the mean number of logged cases for graduating trainees and their level of participation. We analyzed trends in logged cases over the study period and compared mean number of logged cases between specialties and their respective required minimum numbers. Neurosurgery residents (13.5 ± 0.76) performed significantly more CEAs than their counterparts in general surgery (9.4 ± 0.34, P < 0.01) but less in integrated vascular surgery (57.7 ± 0.88) and vascular surgery fellowship (47.9 ± 0.79, both P < 0.001). The only statistically significant change over the study period was a decline in mean number of cases logged by general surgery residents at −0.4 cases/year (P < 0.001). Trainees in all specialties reported around twice as many cases as the respective Accreditation Council for Graduate Medical Education required minimum numbers. Neurosurgery residents demonstrated increasing participation as lead surgeons by 0.7 cases/year (P = 0.04) and a concurrent decline as senior surgeons by 1.4 cases/year (P < 0.01). Neurosurgery residents exceeded their minimum requirements for CEA, with increasing trend in higher level of participation. But neurosurgery residents' exposure to this procedure was far less significant than their colleagues in vascular surgery, a gap that may widen over time and should be addressed proactively. [ABSTRACT FROM AUTHOR]

Background In patients with supratentorial spontaneous intracerebral hemorrhage, intrahematomal catheter placement may allow for intraclot thrombolysis and drainage. Robotic assistance may be used for the stereotactic placement of catheters. Case Description A 76-year-old male presented with altered mental status and left-sided weakness. Noncontrast computed tomography of the head showed a right ganglionic intraparenchymal hemorrhage with resultant entrapment of the temporal horn. Using Robotic Stereotactic Assistance, intrahematomal and intraventricular catheters were placed. The temporal horn was immediately decompressed, and the hematoma almost completely resolved with scheduled administration of intrathecal alteplase in the ensuing 48 hours postoperatively. Conclusion Frameless image-guided placement of intraparenchymal hematoma catheter using Robotic Stereotactic Assistance is safe and efficient. [ABSTRACT FROM AUTHOR]

Traumatic carotid cavernous fistula may occur as a complication of endovascular treatment of acute stroke. We report 3 cases of such lesions. All patients were initially managed conservatively. Two patients have remained asymptomatic. One patient became symptomatic with right eye proptosis, chemosis, and right lateral gaze diplopia 3 weeks post thrombectomy. He underwent endovascular embolization via transfemoral transvenous approach via the inferior ophthalmic vein. [ABSTRACT FROM AUTHOR]

Anterior column realignment (ACR) was developed as a minimally invasive method for treating sagittal imbalance. However, rod fracture (RF) rates associated with ACR are not known. Our objective was to assess the rate of and risk factors for RF following ACR in deformity correction surgery. We conducted a retrospective multicenter review of patients with adult spinal deformity (ASD) who underwent ACR for deformity correction. ASD was defined as coronal Cobb angle ≥20°, pelvic incidence–lumbar lordosis >10°, sagittal vertical axis ≥5 cm, pelvic tilt ≥25°, or thoracic kyphosis ≥60°. Inclusion criteria were ASD, age >18 years, use of ACR, and development of RF or full radiographs obtained at least 1 year after surgery that did not demonstrate RF. Ninety patients were identified, with mean follow-up of 2.3 ± 1.4 years (age, 64.1 ± 9.4; 54 [60%] women). The most common ACR location was L3/4 (42 cases; 47%). Mean fusion length was 7.5 ± 3.6 levels. Four (4.4%) of 90 patients developed RF within 12 months of surgery. RF occurred adjacent to ACR in all cases; RF was not associated with focal correction (P = 0.49), rod material (P = 0.8), degree of correction (P > 0.07), or interbody at L5/S1 (P = 0.06). RF was associated with longer fusion constructs in univariate (P = 0.002) and multivariate (P = 0.03) analyses. RF occurred in 4.4% of patients with ASD who underwent ACR with a minimum of 1-year follow-up. RF was not associated with focal correction but appears to be associated with global correction and extent of fixation. [ABSTRACT FROM AUTHOR]

Prealbumin levels correlate with overall nutritional status, and low values are associated with poor wound healing. We investigated whether low preoperative prealbumin levels predict risk of endoscopic endonasal skull base surgery (EESBS) reconstruction failure, as demonstrated by postoperative cerebrospinal fluid (CSF) leak and/or infection. Between October 2018 and February 2020, 98 patients with documented preoperative prealbumin levels were prospectively followed. The incidence of CSF leak and infection in patients with low prealbumin levels (≤20 mg/dL) was compared with those with normal prealbumin levels (>20 mg/dL). Numerous factors previously shown to influence CSF leak rates were assessed. Both univariate and multivariable analyses were performed to identify independent predictive factors. Within this prospectively gathered patient cohort composed of >95% "high-risk" expanded EESBS, 14 of 98 patients (14.3%) experienced a postoperative CSF leak. Factors univariately associated with postoperative complications at the 0.2 level of significance were used in a multivariable model. Low prealbumin levels (≤20 mg/dL) proved to be a strong independent predictive factor associated with a 5-fold increased risk of postoperative CSF leak (odds ratio 5.01, P = 0.01), and postoperative surgical-site infection (P = 0.0009). These associations remained after controlling for multiple other factors, including body mass index, surgical pathology, previous EESBS, risk assessment index, and high- versus low-flow intraoperative CSF leaks. Preoperative prealbumin levels are an independent predictor of EESBS associated CSF leak and infection. Future studies are needed to investigate the utility of screening and correcting prealbumin levels to limit postoperative complications. [ABSTRACT FROM AUTHOR]

Achieving ideal sagittal alignment is critical to durable alignment and thereby achieving optimal clinical outcomes and avoiding complications or radiographic deterioration. Existing schemas such as the Global Alignment and Proportion (GAP) score and the Sagittal Age-Adjusted Score (SAAS) acknowledge the dynamic relationship between the pelvis and the spine. Consideration of vertebral pelvic angles (VPA) thresholds for PJK may provide further insight with special attention to the relationship of each individual vertebra to the pelvis, which may allow for greater individualization of operative targets. Consideration of vertebral pelvic angles (VPA) thresholds for PJK may provide further insight with special attention to the relationship of each individual vertebra to the pelvis, which may allow for greater individualization of operative targets. Herein, we examine VPA's utility in preventing mechanical complications and its possible unification with prevalent scoring systems. Retrospective cohort study of prospectively collected database. A total of 902 operative adult spinal deformity patients. N/A Operative ASD patients ≥ 18 years with complete baseline (BL) and two-year (Y) operative, radiographic, and health-related quality of life metric data were included. Descriptive analyses and means comparison tests were applied to understand differences in baseline demographics and surgical metrics. Cohorts were grouped as patients who met VPA non-PJK thresholds, as defined by Duvvuri et al. 2023 (36625677) alone versus traditional GAP/SAAS alignment matching versus combined VPA + SAAS + GAP. The Non-PJK VPA validated mean for L1PA was 10.4±7.0 and T9PA 8.9±7.5. In total, 398 patients met inclusion criteria (mean age 60.6±14.2 years, 78.1% female, BL BMI 27.1±5.6, BL CCI 1.7±1.7). Surgically, the mean operative time was 357.5±123.5 minutes, mean EBL 1529.5±1447.6, mean posterior levels fused 11.1±4.2). Some form of osteotomy was performed in 72.9% of patients, while 56% underwent decompressions, and 62.6% of patient's operation incorporated interbody fusions. Mean length of stay was 7.8±4.0. At baseline, the mean vertebral pelvic angles were as follows: T1PA: 24.4±13.5; T4PA 20.4±13.1, T9PA 14.6±12.2, L1PA 11.2±10.4, L4PA 10.6±5.5. Mean vertebral pelvic angles at 6 weeks postoperatively: T1PA 15.8±10.0, T4PA 12.0±9.7, T9PA 7.7±9.1, L1PA 9.4±8.4, L4PA 11.4±5.1. 240 (60.3%) patients attained optimal L1PA, while 104 patients (26.1%) reached the non-PJK mean for T9PA. 89 patients (22.4%) were optimal by both VPA standards. The VPA-Optimal group demonstrated significantly lower rates of 1Y PJK (17.0% vs 83.0%, p=0.042) and PJF by 2Y (6.9% vs 93.1%, p=0.038). When patients attained VPA goals in addition to GAP/SAAS goals at 6W, they demonstrated significantly lower rates of Y1 PJK (p=0.026) and Y1 and Y2 Lafage PJF. When considering QoL, those with optimal VPA registered significantly greater SRS-22 scores across multiple domains (satisfaction, appearance, p<0.02) as well as a greater rate of normal neurological examination at 6W (p=0.048). When comparing the additive effect of integrating VPA goals with existing GAP/SAAS schema, the Y1 ODI was significantly greater when the schemas were used in conjunction in comparison to optimal VPA and also GAP/SAAS alone (all: 46.0; GAP/SAAS: 25.0, VPA: 28.3, p=0.042). Vertebral pelvic angles are a reliable measure of global alignment, and respecting certain targets may help prevent the development of PJK/PJF. The value of VPA can be augmented through integration with GAP/SAAS frameworks to prevent complications and improve quality of life. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Residents in multiple surgical specialties are trained to perform peripheral nerve surgery (PNS), but the extent of exposure to this field varies among specialties. This study evaluates trends in volume of PNS performed during residency for neurologic surgery trainees compared to those in plastic and orthopedic surgery between 2009 and 2019. We queried ACGME for neurologic, plastic, and orthopedic surgery resident case-logs and compared mean number of PNS between graduating residents of each specialty using a one-way analysis of variance test. Linear regression was utilized to determine trends within and across the specialties over the study period. Neurosurgery residents (24.76 ± 3.41) performed significantly fewer PNS than their counterparts in orthopedic (54.56 ± 6.85) and plastic surgery (71.96 ± 12.20), P < 0.001. Residents in neurologic surgery reported over 1.5-fold as many cases as their ACGME-required minimum, in contrast to plastic (2.5-fold) and orthopedic (5-fold). Plastics residents (3.46 cases/year) demonstrated the greatest longitudinal increase in PNS, followed by neurosurgery residents (0.81 cases/year). PNS accounted for a mean of 5.81% of neurosurgery resident cases, 4.20% of plastic surgery resident cases, and 2.98% of orthopedic surgery resident cases (P < 0.001). Neurosurgery residents exceeded the required minimum number of PNS and were increasingly more exposed to PNS. However, compared with their counterparts in orthopedic and plastic surgery, neurosurgery residents performed significantly fewer cases. Exposure for neurosurgery residents remains unchanged over the study period while plastic surgery residents experienced an increase in case volume. The deficiency in exposure for neurosurgical residents must be addressed to harness interest and proficiency in PNS. [ABSTRACT FROM AUTHOR]

Standalone single and multilevel lateral lumbar interbody fusion (LLIF) have been increasingly applied to treat degenerative spinal conditions in a less invasive fashion. Graft subsidence following LLIF is a known complication and has been associated with poor bone mineral density (BMD). Previous research has demonstrated the utility of computed tomography (CT) Hounsfield units (HUs) as a surrogate for BMD. In the present study, we investigated the relationship between the CT HUs and subsidence and reoperation after standalone and multilevel LLIF. A prospectively maintained single-institution database was retrospectively reviewed for LLIF patients from 2017 to 2020, including single and multilevel standalone cases with and without supplemental posterior fixation. Data on demographics, graft parameters, BMD determined by dual-energy x-ray absorptiometry, preoperative mean segmental CT HUs, and postoperative subsidence and reoperation were collected. We used 36-in. standing radiographs to measure the preoperative global sagittal alignment and disc height and subsidence at last follow-up. Subsidence was classified using the Marchi grading system corresponding to disc height loss: grade 0, 0%–24%; grade I, 25%–49%; grade II, 50%–74%; and grade III, 75%–100%. A total of 89 LLIF patients had met the study criteria, with a mean follow-up of 19.9 ± 13.9 months. Of the 54 patients who had undergone single-level LLIF, the mean segmental HUs were 152.0 ± 8.7 for 39 patients with grade 0 subsidence, 136.7 ± 10.4 for 9 with grade I subsidence, 133.9 ± 23.1 for 3 with grade II subsidence, and 119.9 ± 30.9 for 3 with grade III subsidence (P = 0.032). Of the 96 instrumented levels in the 35 patients who had undergone multilevel LLIF, 85, 9, 1, and 1 level had had grade 0, grade I, grade II, and grade III subsidence, with no differences in the HU levels. On multivariate logistic regression, increased CT HU levels were independently associated with a decreased risk of reoperation after both single-level and multilevel LLIF (odds ratio, 0.98; 95% confidence interval, 0.97–0.99; P = 0.044; and odds ratio, 0.97; 95% confidence interval, 0.94–0.99; P = 0.017, respectively). Overall, the BMD determined using dual-energy x-ray absorptiometry was not associated with graft subsidence or reoperation. Using a receiver operating characteristic curve to separate the patients who had and had not required reoperation, the threshold HU level determined for single-level and multilevel LLIF was 131.4 (sensitivity, 0.62; specificity 0.65) and 131.0 (sensitivity, 0.67; specificity, 0.63), respectively. Lower CT HUs were independently associated with an increased risk of graft subsidence after single-level LLIF. In addition, lower CT HUs significantly increased the risk of reoperation after both single and multilevel LLIF with a critical threshold of 131 HUs. The determination of the preoperative CT HUs might provide a more robust gauge of local bone quality and the likelihood of graft subsidence requiring reoperation following LLIF than overall BMD. [ABSTRACT FROM AUTHOR]

Preoperative chronic narcotic use has been linked to poor outcomes after surgery for degenerative spinal disorders in the form of lower health-related quality of life scores, higher revision rates, increased infections, lower likelihood of return to work, and higher 90-day readmission rates. This study evaluated the impact of preoperative chronic narcotic use on patient reported outcome measures following adult spinal reconstructive surgery. Patients who underwent adult spinal reconstructive surgery over 2 years at our institution were identified from a prospectively maintained spine registry. These patients were grouped into chronic opiate users as defined by a 6-month duration of use with a minimum morphine equivalent dose of 30 mg/day. Patient reported outcome measures were collected prospectively. Of 140 patients included for analysis, 30 (21.4%) patients were categorized as chronic opiate users. No differences were identified in mean preoperative patient reported outcome measures, including Oswestry Disability Index, health state, visual analog scale, and EQ-5D indices. At both 6 weeks and 6 months postoperatively, patients in the opiate group demonstrated significantly worse mean visual analog scale back pain scores relative to the nonopiate group. At 6 months postoperatively and at the last known clinical follow-up, Oswestry Disability Index scores were higher in the opiate group. Chronic opiate use before adult spinal reconstructive surgery was associated with worse pain and disability following intervention. Further work is needed to understand the role of opiate weaning as part of a larger prehabilitation strategy for adult spinal reconstructive surgery. [ABSTRACT FROM AUTHOR]

Perioperative neurologic complication after an anterior cervical discectomy and fusion (ACDF) is uncommon but may have significant clinical consequences. We aim to estimate the incidence of perioperative neurologic complications, identify their risk factors, and evaluate their impact on morbidity and mortality after ACDF. ACDF cases (n = 317,789 patients) were extracted from the National Inpatient Sample between 1999 and 2011. Based on their Elixhauser-van Walraven score (VWR), patients were classified as low (VWR < 5), moderate (5–14), or high risk (>14) for surgery. The primary outcome was perioperative neurologic complications. Secondary outcomes included morbidity (hospital length of stay >14 days or discharge disposition to a location other than home) and in-hospital mortality. The rate of perioperative neurologic complications, morbidity, and mortality after ACDF was 0.4%, 8.4%, and 0.1%, respectively. Perioperative neurologic complications were highly associated with in-house morbidity (odds ratio [OR], 3.7 [3.1–4.4]) and mortality (OR, 8.0 [4.1–15.5]). The strongest predictors for perioperative neurologic complications were moderate- (OR, 3.1 [2.6–3.7]) and high-risk VWR (OR, 5.4 [3.3–8.9]), postoperative hematoma/seroma formation (OR, 5.4 [3.9–7.4]), and obesity (OR, 1.9 [1.6–2.3]). The rate of perioperative neurologic complications increased from 0.2% to 0.7% from 1999 to 2011, which was temporally associated with the rise in moderate- (P = 0.002) and high-risk patients (P = 0.001) undergoing ACDF. Perioperative neurologic complications are independent predictors of in-hospital morbidity and mortality after ACDF. Both morbidity and perioperative neurologic complications have increased between 1999 and 2011, which may be due, in part, to increasing numbers of moderate- and high-risk patients undergoing ACDF. [ABSTRACT FROM AUTHOR]

Background Patients undergoing posterior spinal fusion surgery can lose a substantial amount of blood. This can prolong operative time and require transfusion of allogeneic blood components, which increases the risk of infection and can be the harbinger of serious complications. Does a saline-irrigated bipolar radiofrequency hemostatic sealer (RFHS) help reduce transfusion requirements? Methods In an observational cohort study, we compared transfusion requirements in 30 patients undergoing surgery for adult spinal deformity using the RFHS with that of a historical control group of 30 patients in which traditional hemostasis was obtained with bipolar electrocautery and matched them for blood loss–related variables. Total expense to the hospital for the RFHS, laboratory expenses, and blood transfusions was used for cost calculations. The incremental cost-effectiveness ratio was calculated using the number of blood transfusions avoided as the effectiveness payoff. Results Using a multivariable linear regression model, we found that only estimated blood loss (EBL) was an independent significant predictor of transfusion requirement in both groups. We evaluated the variables of age, EBL, time duration of surgery, preoperative hemoglobin, hemoglobin nadir during surgery, body mass index, length of stay, and number of levels operated on. Mean EBL was greater in the control group (2201 vs. 1416 mL, P = 0.0099). The number of transfusions also was greater in the control group (14.5 vs. 6.5, P = 0.0008). In the cost-effectiveness analysis, we found that the RFHS cost $108 more (compared with not using the RFHS) to avoid 1 unit of blood transfusion. Conclusions The cost-effectiveness analysis revealed that if we are willing to pay $108 to avoid 1 unit of blood transfusion, the use of the RFHS is a reasonable choice to use in open surgery for adult spinal deformity. [ABSTRACT FROM AUTHOR]

Bone Morphogenetic Protein-2 (BMP-2) has not shown superior benefit in terms of overall cost-effectiveness after implementation during adult spinal deformity (ASD) surgery. However, it remains to be shown whether certain discrete populations do obtain cost-utility from use of BMP-2. Generate a score to determine usage of BMP-2 and correlate with rates of pseudarthrosis. Retrospective cohort study of a single-center ASD database. A total of 689 ASD patients. Cost utility, pseudarthrosis. ASD patients with BL and 2-year(2Y) data included. BMP-2 kit size and cost: small - 4.2 mg ($21,800), medium - 8.4 mg ($23,667), large - 12 mg ($25,617). Published methods converted ODI to SF-6D. QALYs utilized a 3% discount rate for residual decline. Cost was calculated using the PearlDiver database and assessed for Complications and Comorbidities and Major Complications and Comorbidities according to CMS.gov definitions. Binary logistic regression analyses determined significant predictors for development of pseudarthrosis. Established weights were generated for predictive variables via back-step logistic regression for a risk score to predict development of pseudarthrosis. Risk score was then validated via Receiver Operating Characteristic (ROC) curve method analysis. Categories via conditional inference tree (CIT) analysis-derived thresholds were tested for cost-utility of BMP-2 usage. Marginalized means for utility gained and Cost per QALY were calculated within each risk score category, controlling for age, history of prior fusion, and baseline deformity and disability. Included: 387 ASD patients. Of 387, 64% received BMP-2 (1% small, 4% medium, 59% large). There were 17 (4.4%) of patients that developed pseudarthrosis by two years, 9 (2.3%) of which underwent reoperation. BMP-2 use, regardless of kit size, did not significantly lower pseudarthrosis rates overall (OR: 0.4, [0.2-1.04]). A predictive risk score for development of pseudarthrosis was formed by the following preoperative variables: age, frailty, history of diabetes, osteoporosis, depression, ASA grade, and baseline L4-S1 and T1PA. Via ROC method, this predictive risk score generated an AUC of 0.87. Following CIT machine learning, thresholds for the BMP Risk Score were derived: >5 No Risk (NoR), 3-5 Low Risk (LowR), 2-3 Moderate Risk (ModR), and <2 High Risk (HighR). The rates of pseudarthrosis for each category were: NoR - 0%; LowR - 1.6%; ModR - 9.3%; HighR - 24.3%. When assessing BMP-2 use and its cost-utility within each group, patients receiving BMP-2 had similar QALYs to those that did not receive BMP-2 (0.163 vs 0.171, p=.65). BMP-2 usage had significantly worse cost-utility in both NoR and LowR cohorts (both p<.05). In ModR patients, BMP-2 usage had equivocal cost-utility ($680,532.35 vs $580,380.21, p=.14). In the HighR cohort, the cost-utility difference narrowed even further (BMP-2 use: $743,155.21 vs $719,628.79, p=.82). Our study shows BMP-2 has equivocal cost-utility within those at moderate and high risk for developing pseudarthrosis within two years following spinal deformity correction. The generated predictive score can better aid spine surgeons assess risk and enhance justification for the use of BMP-2 during surgical intervention for adult spinal deformity. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Surgical correction of adult spinal deformity (ASD) has been associated with superior alignment and functional outcomes. However, postoperative complication rates remain relatively high. The extent to which potentially modifiable patient-related factors can influence complication rates in adult spinal deformity patients has not been effectively evaluated. Evaluate the association between modifiable patient-related factors on complications following ASD corrective surgery. Retrospective. A total of 689 ASD patients. Complication and reoperation rates. ASD patients with 2-year (2Y) data were included. Complication groups were defined as follows: 1) any complication; 2) major; 3) medical (cardiac event, ileus, etc.); surgical (site infection, wound dehiscence, etc.); 5) major mechanical (implant failure, rod fracture); 6) major radiographic (PJF [proximal junctional failure], pseudarthrosis, adjacent segment disease); and 7) reoperation. Modifiable risk factors included current smoker, obesity (BMI >30kg/m2), osteoporosis, alcohol use, depression (BL SF-36 MCS <35, perMatcham), psychiatric diagnosis and hypertension. Patients were stratified by BL deformity severity in T1PA (LowDef/HighDef) and age above or below 65 (Young/Older). Means comparison tests assessed prevalence of modifiable risk factors present in those developing specified complications. Binary logistic regression analysis was used to adjust for confounders. A total of 480 ASD patients met inclusion criteria (age 59±15 yrs, 77%F, BMI 27±5 kg/m2, CCI: 1.7±1.7). By 2Y, comp rates: 72% one complication, 28% major, 21% medical, 27% surgical, 11% major radiographic, and 8% had a major mechanical complication. A total of 106 patients (22%) required reoperation. Overall, 318 patients (66%) had at least one of the preoperative risk factors. Age-Deformity Groups: 32% Young LowDef, 19% Young HighDef, 18% Older LowDef, 31% Older HighDef. Within Young LowDef, patients with osteoporosis were more likely to suffer either a major mechanical or radiographic comp (both OR >6, p<.05), although this trend was not seen in the overall cohort. Young HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR: 2.8, [1.04-8.6]; p=.045), while patients with depression or a psychiatric diagnosis suffered major radiographic comps and underwent reoperation more often. Older patients with HighDef developed significantly more complications when diagnosed with depression, including major radiographic comps (23% vs 8%, OR: 3.5, [1.1-10.6]; p=.03). Overall, when controlling for baseline deformity, frailty, and osteoporosis, a diagnosis of depression proved to be a significant risk factor for development of major radiographic complications (OR: 2.4, [1.3-4.5]; p=.005). Certain modifiable patient-related factors, especially mental health status, are associated with increased risk for complications following spinal deformity surgery. Therefore, with consideration to clinical presentation, elaborate on the utility in medical intervention prior to undergoing spinal deformity corrective surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Adult spinal deformity (ASD) corrective surgery is often a highly invasive procedure portending patients to both immediate and long-term complications. However, the impact of each of these complications and their timing of occurrence on cost-utility has yet to be assessed. To compare the economic impact of certain complications before and after two years following ASD surgery. Retrospective. A total of 689 ASD Patients. Complications, cost utility. ASD patients with minimum 3-year and up to 5-year data were included. Complication groups were defined as follows: 1) any complication, 2) major, 3) medical [cardiac event, ileus, etc.], 4) mechanical [implant failure, rod fracture, 5) radiographic [PJK, pseudarthrosis, adjacent segment disease], and 6) reoperation. Complications were stratified by occurrence before or after two years postoperatively. Published methods converted ODI to SF-6D. QALYs utilized a 3% discount rate for residual decline. Cost was calculated using the PearlDiver database and assessed for Complications and Comorbidities and Major Complications and Comorbidities according to CMS.gov definitions. Reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for services within a 30-day window. Marginalized means for utility gained and Cost per QALY were calculated, controlling for age, history of prior fusion, and baseline deformity and disability. There were 244 ASD patients included, with an average age of 59±15 yrs, that were predominantly female (77%) and a high CCI (1.7±1.7). By 2Y, comp rates: 76% 1 complication, 18% major, 16% medical, 16% neurological, 50% radiographic, 5% infection and 20% mechanical, and 64 patients (26%) required reoperation. After 2Y, comp rates: 32% 1 complication, 4% major, 0.4% medical, 2% neurological, 22% radiographic, and 5% mechanical, and 6 patients (2.5%) required reoperation. Overall, any complications occurring after 2 years had a lower cost and cost-utility than those before two years, while major complications happening after two years had worse cost-utility due to lower utility gained (0.320 vs. 0.441, p=.1). Patients developing PJK by and after two years had the lowest cost-utility of any time points. When examining complications occurring before 2 years, patients suffering a mechanical complication accrued the highest overall cost ($130,482.22) followed by infection and PJF. Those suffering a mechanical complication also had the highest utility gained of any complication before 2 years, lowering their cost-utility below that of infection. In contrast, despite having a lower utility gained, those suffering a mechanical complication after 2 years had a lower cost ($109,197.71 vs $130,482.22, p=.041) and cost-utility overall. Similarly, patients developing PJF after 2 years accrued a higher utility gained, lower cost and cost-utility ($77,227.84 vs. $96,873.57, p=.038) than those developing PJF before 2 years. Mechanical complications had the single greatest impact on cost and cost-utility when occurring before or after 2 years following correction of adult spinal deformity. However, mechanical and radiographic complications occurring after 2 years had less detrimental effects on both cost and cost-utility. This study increases our understanding of the complications following adult spinal deformity correction in order to mitigate the outcomes that most drastically impact the economic benefit of surgical intervention. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The institution of single positioning throughout a combined approach to adult spinal surgery has many theorized benefits, including minimizing surgical measures like operative time and estimated blood loss that are highly correlated with higher rates of postoperative complications. However, prone lateral positioning has yet to be correlated to other important outcomes, including radiographic realignment and patient-reported outcomes. To investigate the surgical and postoperative outcomes of the prone lateral single-position approach to adult spinal deformity surgery. Retrospective review of a single-center database. This study included 524 MIS patients. Perioperative outcomes [EBL, LOS, op-time, lvls fused], intraoperative and postoperative complication rates, patient-reported outcomes. Operative spine fusion patients available baseline (BL) and up to two-year (2Y) data from a single-center database were isolated. Patients were stratified into two groups based on undergoing a prone lateral single-position combined approach, Prone Lateral (PL) vs MIS Non-Prone Lateral (NPL). Descriptive analyses and means comparison tests identified differences in baseline (BL) demographics, surgical details, radiographic parameters, rates of intraoperative and postoperative complications, and follow-up patient-reported outcomes up to 2 years. A total of 233 patients (average age: 56.1±11.4 years, average BMI: 30.6±6.6 kg/m2, 54% of the cohort was male, CCI: 1.2±1.9) met inclusion criteria and underwent surgery (operative time: 320±152, EBL: 374±400 mL, levels fused: 2.4±1.2, LOS: 4.6±3.7 days). Regarding approach, 3 (1.3%) underwent lateral approach, 86 (38.6%) posterior, and 144 (60.1%) were combined. BL radiographic parameters: PI: 56.2±11.2, lumbar lordosis (LL): 53.0±12.9, PI-LL: 3.3±13.1, PT: 18.2±8.4, sacral slope (SS): 38.3±8.6. There were 103 same-day combined (lateral and posterior) procedures included in the cohort, with 22 of those being performed in the prone-lateral single position. When examining baseline demographics, the PL patients had mean age of 65.0±10.7, BMI of 28.3±4.7, CCI: 2.1±3.7, with 59% being male. Patients undergoing a prone lateral procedure had an average of 2.4±1.1 levels fused, EBL of 192±152 mLs, operative time of 200±103 minutes, while undergoing decompressions in 64% of procedures and osteotomies in 10%. Patients in the PL group were significantly older compared to non-PL patients (p <.001) with a lower BMI (p=.030) and higher CCI (p=.013). Patients undergoing PL procedures had lower EBL and operative time compared to non-PL patients (both p-value <.001), along with less osteotomies performed (10% vs. 43%, p=.002). Although, PL patients had a similar number of levels fused, they had a higher average LIV (L5 vs S1, p=.003) and UIV (L2 vs L3, p=.004) compared to the rest of the cohort. There were no radiographic differences preoperatively or postoperatively, although 50% of PL patients improved to aligned in PI-based sacral slope (GAP Relative Pelvic Version). PL patients suffered significantly less pulmonary (0% vs 4%, p=.019) and GI complications (0% vs 3%, p=.039), but endured higher rates of urinary retention (14% vs 5%, p=.032). This translated to a shorter length of stay (3.3 days vs 4.7, p=.004) for PL patients, with discharge to a rehab facility less often after leaving the hospital (0% vs 13%, p <.001). When examining patient-reported outcomes within one year after surgery, PL patients had greater improvement in NRS-Back (-6.0 vs -3.3, p=.031) and trending toward greater improvement in NRS-Leg (-4.6 vs -3.6, p=.132). Patients undergoing prone lateral single-position procedures in this single-center database displayed less invasive procedures with similar degree of correction, endured lower rates of certain complications correlating to going home earlier and more often. These perioperative outcomes correlated to greater improvement of back pain following spinal corrective surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]