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Single-center, multisurgeon, retrospective review.To evaluate the timing of return to commonly performed activities following minimally invasive spine surgery. Identify preoperative factors associated with these outcomes.Studies have reported return to activities with open techniques, but the precise timing of when patients return to these activities after minimally invasive surgery remains uncertain.Patients who underwent either minimally invasive lumbar laminectomy (MI-L) or minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) were included. Patient-reported outcome measures, return to drive, return to work, and discontinuation of opioids data were reviewed. Regression was conducted to identify factors associated with return to driving by 15 days, return to work by 30 days, and for discontinuing opioids by 15 days. A composite group analysis was also performed for patients who returned to all three activities by 30 days.In total, 123 MI-L patients and 107 MI-TLIF patients were included. Overall, 88.8% of MI-L patients and 96.4% of MI-TLIF patients returned to driving in 11 and 18.5 days, respectively. In all, 91.9% of MI-L patients and 85.7% of MI-TLIF patients returned to work in 14 and 25 days. In all, 88.7% of MI-L patients and 92.6% of MI-TLIF patients discontinued opioids in a median of seven and 11 days. Overall, 96.2% of MI-L patients and 100% of MI-TLIF patients returned to all three activities, with a median of 27 and 31 days, respectively. Male sex [odds ratio (OR)=3.57] and preoperative 12-Item Short Form Physical Component Score (OR=1.08) are associated with return to driving by 15 days. Male sex (OR=3.23) and preoperative 12-Item Short Form Physical Component Score (OR=1.07) are associated with return to work by 30 days. Preoperative Visual Analog Scale back was associated with decreased odds of discontinuing opioids by 15 days (OR=0.84).Most patients return to activity following MI-L and MI-TLIF. These findings serve as an important compass for preoperative counseling.

Retrospective review of prospectively collected data.To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF).Assessing postoperative inefficiencies is vital to increase the feasibility of ALF.Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge.Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS.Unavailability of PT, surgery after 1 pm , orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge.4.

With this manuscript the authors sought to write a succinct review of the origins, as well as the latest advancements in endoscopic spine surgery to serve as a reference frame for physicians looking to learn this approach.At its infancy, the indications for posterolateral and transforaminal endoscopic decompression remained narrow, which prevented the procedure from gaining rapid traction during those days. However, more recently the tides have turned and an increasing number of surgeons are starting to adopt this technique given all its advantages. With the advent of higher quality camera systems and instruments, indications to use a minimally invasive option have gotten significantly broader. The most basic indication for the use of this technology is a soft disc herniation causing compromise of a neural structure that has failed to be managed successfully with non-surgical therapies. The use of endoscopic techniques provides significant advantages to patient outcomes and patient recovery. Endoscopic procedures should not be used as a blanket approach to nerve root decompression, as they certainly have limitations. Most contraindications to this procedure are relative and serve mostly as points to consider when selecting the methods to address neural compression. As these techniques become more widely accepted, we expect its reach and indications to continue to broaden and diversify. The full integration of navigation technologies will likely leapfrog this procedure into the mainstream use.

Objective Spinal intradural arachnoid cysts (SIACs) are rare pathological lesions that can arise via outpouchings of the arachnoid layer in the spinal canal that can result in neurological deficits. We performed a systematic literature review regarding the current surgical techniques used in the management of SIACs and discussed the prevailing hypotheses surrounding the etiology of SIACs. Methods A systematic search of the literature was performed in December 2020 using EMBASE and MEDLINE for reports regarding the surgical management of SIACs. Data were collected regarding the demographics of the patients, classification system used, presence or absence of syrinxes, preoperative imaging modality, surgical approach and extent of resection, and postoperative outcomes and follow-up. Results Our search yielded 19 reports for inclusion in the present study. The 19 studies included a total of 414 cases, with an overall male/female ratio of 0.93:1. The most common site for the SIACs was the thoracic spinal cord at 77.5%. The symptoms were very similar across the 19 studies. Of the 19 studies, 15 had used resection to manage the SIACs, 10 had used fenestration or marsupialization, and 4 had used cystoarachnoid or cystoperitoneal shunts. Conclusions SIACs are rare and debilitating spinal pathological lesions, with the etiology of primary SIACs still not fully elucidated. Multiple surgical approaches have been effective, with the optimal operative strategy largely dependent on the individual patient and cyst factors on a case-by-case basis.

Objective To describe the utility of wrist circumference in the identification of cardiometabolic risk in overweight and obese children. Methods A cross-sectional study was conducted in the obesity clinic of a tertiary care referral hospital over a two year period. All children and adolescents aged 5–17 years with nutritional overweight and obesity were recruited. Data pertaining to chronological age, sex, risk factors and family history were collected. Clinical assessment of anthropometry: Weight, height, body mass index (BMI), Tanner’s stage, wrist circumference, blood pressure, waist circumference and triceps skinfold thickness done as per standard criteria. Biochemical assessment of blood glucose, serum insulin, lipid profile, and Homeostatic Model for Insulin Resistance performed after 12 h of fasting. Results We recruited 118 subjects (mean age 10.9 years, 71.1% males, 87.3% obese and 12.7% overweight); 30 (25.4%) had metabolic syndrome. The mean z scores of wrist circumference of children who presented with and without metabolic syndrome was 2.7 ± 0.8 and 2.1 ± 0.7, respectively (p Conclusions Wrist circumference with 97th percentile as a cut-off is a useful tool to identify metabolic syndrome amongst overweight and obese children and adolescents.

Retrospective cohort study.The aim was to compare clinical outcomes in patients with significant cervical spondylosis treated with cervical disc replacement (CDR) compared with anterior cervical discectomy and fusion (ACDF).As CDR utilization has increased over the past decade, recent studies have investigated the outcomes of CDR in patients with more significant spondylotic changes and demonstrated improved postoperative patient-reported outcomes (PROs). However, no prior study has investigated clinical outcomes of patients with significant spondylotic changes treated with CDR in comparison to ACDF.Patients who underwent 1-level or 2-level CDR or ACDF with significant cervical spondylosis, quantified using a validated grading scale, were identified, and prospectively collected data was retrospectively reviewed. The following PROs were analyzed: Neck Disability Index (NDI), visual analog scale-Neck, visual analog scale-Arm, and PROMIS Physical Function (PROMIS-PF) Computer Adaptive Test Score. Demographic, operative, and radiographic variables, and achievement of minimum clinically important difference (MCID) for each PRO were compared between the 2 groups.A total of 66 patients were included in the present study, of which 35 (53%) were treated with CDR and 31 (47%) with ACDF. The preoperative cervical spondylotic grade was similar between the 2 groups (1.8 vs. 2.2, P=0.27). At final follow-up, there was no significant difference in the absolute value for each PRO between the 2 groups (P0.19) and both groups demonstrated significant improvement in each PRO compared with preoperative values (P0.01). There was no significant difference in the percentage of patients achieving the MCID for each PRO when comparing CDR to ACDF (P0.09).A similar percentage of patients with significant degenerative cervical spondylosis achieved the MCID across multiple PROs when treated with CDR or ACDF. Patients in both treatment groups demonstrated significant improvement in all PROs assessed when compared with preoperative values.Level III.

Retrospective cohort study.The aim of this study was to examine sagittal alignment over time in adult spinal deformity (ASD) and to understand whether these changes vary by choice of upper instrumented vertebra (UIV).Recent ASD literature has focused on specific alignment goals. Less is known about how sagittal parameters evolve over time after surgical correction and whether these changes differ by choice of UIV.This was a retrospective review of ASD patients from a single institution. Routine 36″ sagittal x-rays were obtained preoperatively, before hospital discharge, and at 6 months, 1 year, and 2 years and sagittal parameters were measured. Patients with UIV T6 and above were classified as upper thoracic (UT) and T7 and below as lower thoracic (LT).A total of 102 patients with mean age 66.0 years (±7.7) were included in the analysis (49 UT, 53 LT). All sagittal and coronal alignment parameters demonstrated significant improvement from preoperatively to any postoperative time point. Although multiple parameters maintained correction over time, others (TK, TPA, and PT) demonstrated significant increase from discharge to 2 years postoperatively, with changes occurring relatively early after surgery, whereas overall global alignment was maintained. Both UT/LT groups demonstrated significantly greater TK from preoperatively to discharge to 6 months (P 0.05), stabilizing at that time point out to 2 years, whereas TLK preferentially increased in the LT group. There was significant improvement in sagittal vertical axis after surgery, which was maintained out to 2years of follow-up (P 0.05).Our data suggest that although several key parameters are maintained over time out to 2years postopera- tively, TK tends to worsen over time for all patients, whereas TLK preferentially increases in the LT group. Nevertheless, despite these trends, compensatory changes are seen in PT such that global alignment is relatively maintained.Level of Evidence: 3.

Computational dosimetry software is routinely used to evaluate the organ and effective doses from computed tomography (CT) examinations. Studies have shown a significant variation in dose estimates between software in adult cohorts, and few studies have evaluated software for pediatric dose estimates. This study aims to compare the primary organ and effective doses estimated by four commercially available CT dosimetry software to thermoluminescent dosimeter (TLD) measurements in a 1-year-old phantom.One hundred fifteen calibrated LiF (Mg, Cu, P)-TLD 100-H chips were embedded within an anthropomorphic phantom representing a 1-year-old child at positions that matched the approximate location of organs within an infant. The phantom was scanned under three protocols, each with whole-body coverage. The mean absorbed doses from 25 radiosensitive organs and skeletal tissues were determined from the TLD readings. Effective doses for each of the protocols were subsequently calculated using ICRP 103 formalism. Dose estimates by the four Monte Carlo-based dose calculation systems were determined and compared to the directly measured doses.Most organ doses determined by computation dosimetry software aligned to phantom measurements within 20%. Additionally, comparisons between effective doses are calculated using computational and direct measurement methods aligned within 20% across the three protocols. Significant variances were found in bone surface dose estimations among dosimetry methods, likely caused by differences in bone tissue modeling.All four-dosimetry software evaluated in this study provide adequate primary organ and effective dose estimations. Users should be aware, however, of the possible estimated uncertainty associated with each of the programs.

Surgical counseling enables shared decision-making (SDM) by improving patients' understanding.To provide answers to frequently asked questions (FAQs) in minimally invasive lumbar spine surgery.Retrospective review of prospectively collected data.Patients who underwent primary tubular minimally invasive lumbar spine surgery in form of transforaminal lumbar interbody fusion (MI-TLIF), decompression alone, or microdiscectomy and had a minimum of 1-year follow-up.(1) Surgical (radiation exposure and intraoperative complications) (2)Immediate postoperative (length of stay [LOS] and complications) (3) Clinical outcomes (Visual Analog Scale- back and leg, VAS; Oswestry Disability Index, ODI; 12-Item Short Form Survey Physical Component Score, SF-12 PCS; Patient-Reported Outcomes Measurement Information System Physical Function, PROMIS PF; Global Rating Change, GRC; return to activities; complications/reoperations) METHODS: The outcome measures were analyzed to provide answers to ten FAQs that were compiled based on the authors' experience and a review of literature. Changes in VAS back, VAS leg, ODI, and SF-12 PCS from preoperative values to the early (6 months) and late (6 months) postoperative time points were analyzed with Wilcoxon Signed Rank Tests. % of patients achieving minimal clinically important difference (MCID) for these patient-reported outcome measures (PROMs) at the two time points was evaluated. Changes in PROs from preoperative values too early (6 months) and late (≥6 months) postoperative time points were analyzed within each of the three groups. Percentage of patients achieving MCID was also evaluated.Three hundred sixty-six patients (104 TLIF, 147 decompression, 115 microdiscectomy) were included. The following FAQs were answered: (1) Will my back pain improve? Most patients report improvement by50%. About 60% of TLIF, decompression, and microdiscectomy patients achieved MCID at ≥6 months. (2) Will my leg pain improve? Most patients report improvement by50%. 56% of TLIF, 67% of decompression, and 70% of microdiscectomy patients achieved MCID at ≥6 months. (3) Will my activity level improve? Most patients report significant improvement. Sixty-six percent of TLIF, 55% of decompression, and 75% of microdiscectomy patients achieved MCID for SF-12 PCS. (4) Is there a chance I will get worse? Six percent after TLIF, 14% after decompression, and 5% after microdiscectomy. (5) Will I receive a significant amount of radiation? The radiation exposure is likely to be acceptable and nearly insignificant in terms of radiation-related risks. (6) What is the likelihood that I will have a complication? 17.3% (15.4% minor, 1.9% major) for TLIF, 10% (9.3% minor and 0.7% major) for decompression, and 1.7% (all minor) for microdiscectomy (7) Will I need another surgery? Six percent after TLIF, 16.3% after decompression, 13% after microdiscectomy. (8) How long will I stay in the hospital? Most patients get discharged on postoperative day one after TLIF and on the same day after decompression and microdiscectomy. (9) When will I be able to return to work?80% of patients return to work (average: 25 days after TLIF, 14 days after decompression, 11 days after microdiscectomy). (10) Will I be able to drive again?90% of patients return to driving (average: 22 days after TLIF, 11 days after decompression, 14 days after microdiscectomy).These concise answers to the FAQs in minimally invasive lumbar spine surgery can be used by physicians as a reference to enable patient education.

Introduction and objectivesThe novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had drastic effects on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population.MethodsA prospective single-centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multidisciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020–15th May 2020) compared to pre-COVID-19 (18th of January 2020–17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed.ResultsOverall, there was a reduction in neurosurgical emergency referrals by 33.6% and operations by 55.6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75.2% of total,n=155) when compared to pre-COVID-19 (n= 198, 43.7% of total,p< 0.00001). In contrast to other published series, the 30-day perioperative mortality remained low (2.0%) with the majority of post-operative COVID-19-infected patients (n= 13) having underlying medical co-morbidities and/or suffering from post-operative complications.ConclusionThe capacity to safely treat patients requiring urgent or emergency neurosurgical care was maintained at all times. Strategies adopted to enable this included proactively approaching the referrers to maintain lines of communications, incorporating modern technology to run clinics and MDTs, restructuring patient pathways/facilities, and initiating the delivery of NHS care within private sector hospitals. Through this multi-modal approach we were able to minimize service disruptions, the complications, and mortality.

Background Context Studies have found that most patients are satisfied after spine surgery, with rates ranging from 53% to 90%. Patient satisfaction appears to be closely related to achieving clinical improvement in pain and disability after surgery. While the majority of the literature has focused on patients who report both satisfaction and clinical improvement in disability and pain, there remains an important sub-population of patients who have clinically relevant improvement but report being dissatisfied with surgery. Purpose To examine why patients who achieve clinical improvement in disability or pain also report dissatisfaction at 1-year after spinal surgery. Study Design Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database (QOD). Patient Sample There were 32,076 participants undergoing elective surgery for degenerative spine pathology who had clinical improvement in disability or pain. Outcome Measures Satisfaction with surgery was assessed with 1-item from the North American Spine Society (NASS) lumbar spine outcome assessment. Participants with answer choices other than “treatment met my expectations” were classified as dissatisfied. Methods Patients completed a baseline and 12-month postoperative assessment to evaluate disability, pain, and satisfaction. Clinical improvement was defined as patients who achieved a 30% or greater improvement in spine related disability (Oswestry/Neck Disability Index) or extremity pain (11-point Numerical Rating Scale) from baseline to 12-months after surgery. A generalized linear mixed model (GLMM) was used to predict the odds of the patient being dissatisfied 1-year after surgery from demographic, clinical and surgical characteristics, postoperative complications and revision, and return to work and previous physical activity. Random effects were included to model the effect of both site and surgeon on dissatisfaction. Sensitivity analyses were conducted on samples who achieved 1) 30% or greater improvement in disability only, 2) 30% or greater improvement in axial (back/neck) pain only, and 3) 30% or greater improvement in both disability and axial pain. Results showed the same pattern of findings across all samples. Results Twenty-eight percent of patients were classified as dissatisfied with their spine surgery and 72% classified as satisfied. For patients with clinical improvement in disability or extremity pain at 1-year, significant predictors of higher odds of dissatisfaction included baseline psychological distress, current smoking status, worker's compensation claim, lower education, higher ASA grade, lumbar vs. cervical procedure, and increased axial pain, major complication within 90 days, and revision surgery within 12-months. The most important contributors to dissatisfaction were return to work and return to previous physical activity, with the odds of dissatisfaction being over 2 times and 4 times higher for these variables. Site and surgeon explained 3.8% of the variance in dissatisfaction, with more of the variance attributed to site than to surgeon. Conclusions Several modifiable factors, including psychological distress, current smoking status, and failure to return to work and physical activity, helped explain why patients report being dissatisfied with surgery despite clinical improvement in disability or pain. The findings of this study have the potential to help providers identify at-risk patients, set realistic expectations during preoperative counseling, and implement postoperative management strategies. A multidisciplinary approach to rehabilitation that includes functional goal setting or restoration may help to improve patients psychological distress as well as return to work and previous physical activity after spine surgery.

Intramedullary spinal cord tumours (IMSCTs) are comparatively rare neoplasms. We present a single-centre clinical case series of adult patients with surgically managed IMSCTs.We performed a retrospective analysis of electronic patient records in the time period spanning July 2010 to July 2021. All adult patients that had undergone surgical management for IMSCTs were eligible for inclusion. Baseline and post-operative clinical and radiological characteristics, along with follow-up data, were assessed. We also performed a literature review with a focus on surgical outcomes for IMSCTs.Sixty-six patients matched our selection criteria, with a median age of 42 years (range 23-85). Thirty-four ependymomas, 17 haemangioblastomas, 12 astrocytomas, 2 lymphomas and 1 teratoma were included. Statistical analysis yielded several significant findings: IMSCTs spanning a greater number of vertebral levels are significantly associated with poor McCormick outcomes (p = 0.03), presence of gait disturbance before surgery is significantly associated with poor outcome for both post-operative McCormick and Nurick scores (p = 0.007), and radicular pain present pre-operatively is significantly associated with a good post-operative McCormick score (p = 0.045). Haemangioblastomas are significantly more likely to have a clear intra-operative dissection plane compared to ependymomas and astrocytomas (p = 0.009). However, astrocytomas have a significantly higher prevalence of good McCormick outcomes compared to ependymomas and haemangioblastomas (p = 0.03).Histological diagnosis, cranio-caudal extent of the tumour and the presence or absence of baseline deficits-such as gait impairment and radicular pain-are significant in determining neurological outcomes after surgery for IMSCTs.

Retrospective cohort study.The aim was to compare the minimally clinically important difference (MCID) across multiple patient-reported outcomes (PROs) in patients undergoing cervical disc replacement (CDR) for cervical spondylotic radiculopathy versus myeloradiculopathy.To date, a limited number of studies have demonstrated mostly similar results in patients with cervical spondylotic radiculopathy or myeloradiculopathy undergoing CDR. However, each of these previous studies have focused on statistically significant differences, which may not correlate with patient perceived improvements in outcomes or success.Patients who underwent 1 or 2-level CDR with radiculopathy versus myeloradiculopathy were identified, and prospectively collected data was retrospectively reviewed. Demographic variables, preoperative diagnosis, and operative variables were collected for each patient. The following PROs were prospectively collected: Neck Disability Index (NDI), visual analog scale (VAS)-Neck, VAS-Arm, Short Form-12 Health Survey (SF-12) Physical Component Score (PCS), SF-12 Mental Component Score (MCS), PROMIS Physical Function (PF). An MCID analysis of PROs for each diagnosis group was performed and the percentage of patients achieving the MCID was compared between the two diagnosis groups.Eight-five patients, of which 56% had radiculopathy and 44% had myeloradiculopathy. MCID analysis demonstrated that at 6-week, 12-week, and final postoperative follow-up there was no significant difference in the percentage of patients with radiculopathy or myeloradiculopathy achieving the MCID for each PRO assessed. In both diagnosis groups the percentage of patients achieving the MCID for each PRO continued to increase from the 6-week to final postoperative follow-up except for the SF-12 MCS in patients with myeloradiculopathy.The percentage of patients achieving the MCID was not significantly different at each postoperative period assessed in the radiculopathy and myeloradiculopathy groups treated with CDR. In addition, the percentage of patients achieving the MCID continued to increase from 6 weeks to final follow-up in both groups for almost all PROs assessed.

BACKGROUND CONTEXT Low back pain has an immense impact on the US economy. A significant number of patients undergo surgical management in order to regain meaningful functionality in daily life and in the workplace. Return to work (RTW) is a key metric in surgical outcomes, as it has profound implications for both individual patients and the economy at large. PURPOSE In this study, we investigated the factors associated with RTW in patients who achieved otherwise favorable outcomes after lumbar spine surgery. STUDY DESIGN/SETTING This study retrospectively analyzes prospectively collected data from the lumbar module of national spine registry, the Quality Outcomes Database (QOD). PATIENT SAMPLE The lumbar module of QOD includes patients undergoing lumbar surgery for primary stenosis, disc herniation, spondylolisthesis (Grade I) and symptomatic mechanical disc collapse or revision surgery for recurrent same-level disc herniation, pseudarthrosis, and adjacent segment disease. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of lumbar-related pain. OUTCOME MEASURES The outcome of interest for this study was the return to work 12-month after surgery. METHODS The lumbar module of QOD was queried for patients who were employed at the time of surgery. Good outcomes were defined as patients who had no adverse events (readmissions/complications), had achieved 30% improvement in Oswestry disability index (ODI) and were satisfied (NASS satisfaction) at 3-month post-surgery. Distinct multivariable logistic regression models were fitted with 12-month RTW as outcome for a. overall population and b. the patients with good outcomes. The variables included in the models were age, gender, race, insurance type, education level, occupation type, currently working/on-leave status, workers’ compensation, ambulatory status, smoking status, anxiety, depression, symptom duration, number of spinal levels, diabetes, motor deficit, and preoperative back-pain, leg-pain and ODI score. RESULTS Of the total 12,435 patients, 10,604 (85.3%) had successful RTW at 1-year postsurgery. Among patients who achieved good surgical outcomes, 605 (7%) failed to RTW. For both the overall and subgroup analysis, older patients had lower odds of RTW. Females had lower odds of RTW compared with males and patients with higher back pain and baseline ODI had lower odds of RTW. Patients with longer duration of symptoms, more physically demanding occupations, worker's compensation claim and those who had short-term disability leave at the time of surgery had lower odds of RTW independent of their good surgical outcomes. CONCLUSIONS This study identifies certain risk factors for failure to RTW independent of surgical outcomes. Most of these risk factors are occupational; hence, involving the patient's employer in treatment process and setting realistic expectations may help improve the patients' work-related functionality.

Cauda equina syndrome (CES) can have devastating neurological sequelae if surgical treatment is delayed. However, out-of-hours surgery (weekdays from 6:00 pm to 8:00 am and all weekend operations) can potentially result in higher rates of intraoperative complications, resulting in worse outcomes. In the present study, we have described our outcomes for patients with CES during an 8-year period (December 2011 to October 2019) with the aim of assessing the risk of out-of-hours surgery.We performed a retrospective analysis of inpatient events and outcomes at 6 months of follow-up. Patient demographics, symptoms, and management data were extracted, and a risk factor analysis was performed using logistic regression. The outcome measures were the incidence of complications and symptom changes at follow-up. Symptom outcome changes between 2 time points were analyzed using repeated measures.A total of 278 patients were included in the present study. Surgery out-of-hours (P = 0.018) and prolonged operations (P = 0.018) were significant risk factors for intraoperative complications. Improved outcomes at 6 months of follow-up were found for lower back pain, sciatica, altered saddle sensation, and urinary sphincter disturbance, with no significant changes for the remaining symptoms. Out-of-hours surgeries did not significantly affect individual symptom outcomes.Our analysis has suggested that emergency decompressive surgery for patients with CES does not result in worsening of outcomes with out-of-hours surgery compared with in-hours. However, our findings also showed that no clear benefit exists to expediting surgery for those with severe presentations. Thus, decompressive surgery should be undertaken at the earliest possible time to safely do so.

This was an observational study.This study aims to determine the correlation between patient-reported outcomes (PROs) pulled from a national spine registry and physician ratings from physician review websites (PRWs).PRWs are frequently utilized by patients to make health care decisions; however, many PRWs appear to incorporate subjective experiences unrelated to a surgeon's clinical performance into ratings. As such, their utility as a health care decision-making tool remains unclear.This study evaluated 8834 patients from the Quality Outcomes Database (QOD) who underwent 1-level elective lumbar spine surgery. The lumbar module of QOD was queried to rank 124 surgeons using PROs (Oswestry Disability Index, EuroQOL, Numerical Rating Scale-back/leg pain, and patient satisfaction). The QOD PRO-ranking system was compared against PRWs including Healthgrades, Vitals, WebMD, and Google. The Spearman correlation coefficients, Kruskal-Wallis tests, and multiple linear regression models were used for statistical comparison. The primary outcome was the correlation between PRW scores and PROs.Surgeon PRO-derived ranking showed high intercorrelational congruence with coefficients between the 3 PROs (Oswestry Disability Index, EuroQOL, Numerical Rating Scale back/leg) ranging between 0.70 and 0.88. Low correlations were observed between PRO-derived rankings and PRWs, ranging from 0.23 to 0.37. Healthgrades performed most similarly to PRO-derived rankings, correlating best with patient satisfaction, though the correlation was low (ρ=0.37).While PRWs are often used to evaluate surgeon competency, these results demonstrate they poorly correlate with a surgeon's clinical ability measured by PROs. PRWs should be used with caution when making health care decisions by patients, payers, and administrators.Level III.

Background and objective Right ventricular (RV) volumes are crucial outcome determinants in pulmonary diseases. Little is known about the associations of RV volumes during hospitalized acute exacerbations of chronic obstructive pulmonary disease (AECOPD). We aimed to ascertain associations of RV end-diastolic volume indexed to body surface area (RVEDVI) during hospitalized AECOPD and its relationship with mortality in long-term follow-up. Methods This is a prospective observational cohort study (December 2013-November 2019, ACTRN12617001562369) using dynamic retrospective ECG-gated computed tomography during hospitalized AECOPD. RVEDVI was defined as normal or high using Framingham Offspring Cohort values. Cox regression determined the prognostic relevance of RVEDVI for death. Results A total of 148 participants (70 ± 10 years [mean ± SD], 88 [59%] men) were included, of whom 75 (51%) had high RVEDVI. This was associated with more frequent hospital admissions in the 12 months before admission (52/75 [69%] vs. 38/73 [52%], p = 0.04) and higher breathlessness (modified Medical Research Council score, 2.9 ± 1.3 vs. 2.4 ± 1.2, p = 0.007). During follow-up, high RVEDVI was associated with greater mortality (log-rank p = 0.001). In univariable Cox regression, increasing RVEDVI was associated with higher mortality (hazard ratio [HR]: 1.02 per ml/m2 ; 95% CI: 1.01, 1.03; p = 0.001). In multivariable Cox regression, RVEDVI was independently associated with mortality (HR: 1.01 per ml/m2 ; 95% CI: 1.00, 1.03; p = 0.050) at a borderline significance level. Adding RVEDVI to three COPD mortality prediction systems improved model fit (pooled chi-square test [BODE: p = 0.05, ADO: p = 0.04, DOSE: p = 0.02]). Conclusion In patients with hospitalized AECOPD, higher RV end-diastolic volume was associated with worse acute clinical parameters and greater mortality.

PURPOSE Evaluation of the presentation and outcomes of different surgical treatment approaches for spinal intradural arachnoid cysts (SIAC). METHODS Cases were identified from electronic records of two major neurosurgical centres in London over the last 10 years (October 2009-October 2019) that have been surgically treated in both institutions. Clinical findings, surgical technique, and recurrence by procedure were statistically analysed. Statistical analysis was performed with STATA 13.1 Software. RESULTS A total of 42 patients with SIAC were identified for this study with a mean age at the time of surgery of 53.6 years and a male:female ratio of 8:13. There were 31 patients with primary SIACs and 11 with secondary SIACs. The most common presenting symptom was paraesthesia (n = 27). The most common location of the cyst was in the thoracic region (n = 33). Syrinx was present in 26.2% of SIACs (n = 11). Resection was associated with significantly better postoperative pain compared to other surgical techniques (p = 0.01), significantly poorer postoperative urinary function (p = 0.029), and lower rates of sensory recovery in patients who presented preoperatively with sensory deficit (p = 0.041). No significant difference was seen in symptomatic outcomes between patients with primary and secondary SIACs. CONCLUSION Resection and drainage are both effective methods of managing SIACs. In this observational study, resection was associated with significantly reduced pain postoperatively when compared with drainage, however also with significantly less improvement in postoperative urinary function. Therefore, resection should be the gold standard management option for SIACs, with drainage as an option where resection is unsafe, and drainage should also be considered in patients presenting with urinary dysfunction.

BACKGROUND Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The modified Japanese Orthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored. OBJECTIVE To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM. METHODS This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (

Background Modern healthcare reforms focus on identifying and measuring the quality and value of care. Patient satisfaction is particularly important in the management of degenerative cervical radiculopathy (DCR) since it leads to significant neck pain and disability primarily affecting the patients' quality of life. Objective To determine the association of baseline and 12-mo Neck Disability Index (NDI) with patient satisfaction after elective surgery for DCR. Methods The Quality Outcomes Database cervical module was queried for patients who underwent elective surgery for DCR. A multivariable proportional odds regression model was fitted with 12-mo satisfaction as the outcome. The covariates for this model included patients' demographics, surgical characteristics, and baseline and 12-mo patient reported outcomes (PROs). Wald-statistics were calculated to determine the relative importance of each independent variable for 12-mo patient satisfaction. Results The analysis included 2206 patients who underwent elective surgery for DCR. In multivariable analysis, after adjusting for baseline and surgery specific variables, the 12-mo NDI score showed the highest association with 12-mo satisfaction (Waldχ2-df = 99.17, 58.1% of total χ2). The level of satisfaction increases with decrease in 12-mo NDI score regardless of the baseline NDI score. Conclusion Our study identifies 12-mo NDI score as a very influential driver of 12-mo patient satisfaction after surgery for DCR. In addition, there are lesser contributions from other 12-mo PROs, baseline Numeric Rating Scale for arm pain and American Society of Anesthesiologists (ASA) grade. The baseline level of disability was found to be irrelevant to patients. They seemed to only value their current level of disability, compared to baseline, in rating satisfaction with surgical outcome.

Longitudinal Cohort Study.Determine 1-year patient-reported outcomes associated with preoperative chronic opioid therapy and high-preoperative opioid dosages in patients undergoing elective spine surgery.Back pain is the most disabling condition worldwide and over half of patients presenting for spine surgery report using opioids. Preoperative dosage has been correlated with poor outcomes, but published studies have not assessed the relationship of both preoperative chronic opioids and opioid dosage with patient-reported outcomes.For patients undergoing elective spine surgery between 2010 and 2017, our prospective institutional spine registry data was linked to opioid prescription data collected from our state's Prescription Drug Monitoring Program to analyze outcomes associated with preoperative chronic opioid therapy and high-preoperative opioid dosage, while adjusting for confounders through multivariable regression analyses. Outcomes included 1-year meaningful improvements in pain, function, and quality of life. Additional outcomes included 1-year satisfaction, return to work, 90-day complications, and postoperative chronic opioid use.Of 2128 patients included, preoperative chronic opioid therapy was identified in 21% and was associated with significantly higher odds (adjusted odds ratio [95% confidence interval]) of not achieving meaningful improvements at 1-year in extremity pain (aOR:1.5 [1.2-2]), axial pain (aOR:1.7 [1.4-2.2]), function (aOR:1.7 [1.4-2.2]), and quality of life (aOR:1.4 [1.2-1.9]); dissatisfaction (aOR:1.7 [1.3-2.2]); 90-day complications (aOR:2.9 [1.7-4.9]); and postoperative chronic opioid use (aOR:15 [11.4-19.7]). High-preoperative opioid dosage was only associated with postoperative chronic opioid use (aOR:4.9 [3-7.9]).Patients treated with chronic opioids prior to spine surgery are significantly less likely to achieve meaningful improvements at 1-year in pain, function, and quality of life; and less likely to be satisfied at 1-year with higher odds of 90-day complications, regardless of dosage. Both preoperative chronic opioid therapy and high-preoperative dosage are independently associated with postoperative chronic opioid use.2.

Background Context No consensus exists for defining chronic preoperative opioid use. Most spine studies rely solely on opioid duration to stratify patients into preoperative risk categories. Purpose The purpose of this study is to compare established opioid definitions that contain both duration and dosage to opioid models that rely solely on duration, including the CDC Guideline for Prescribing Opioids for Chronic Pain, in patients undergoing spine surgery. Study Design This was a retrospective cohort study that used opioid data from the Tennessee Controlled Substance Monitoring Database and prospective clinical data from a single-center academic spine registry. Patient Sample The study cohort consisted of 2,373 patients who underwent elective spine surgery for degenerative conditions between January 2011 and February 2017 and who completed a follow-up assessment at 12 months after surgery. Outcome Measures Postoperative opioid use and patient-reported satisfaction (NASS Satisfaction Scale), disability (Oswestry/Neck Disability Index), and pain (Numeric Rating Scale) at 12 month follow-up. Methods Six different chronic preoperative opioid use variables were created based on the number of times a prescription was filled and/or daily morphine milligram equivalent for the one year before surgery. These variables defined chronic opioid use as 1) most days for > 3 months (CDC), 2) continuous use for ≥ 6 months (Schoenfeld), 3) >4,500 mg for at least 9 months (Svendsen wide), 4) >9,000 mg for 12 months (Svendsen intermediary), 5) >18,000 mg for 12 months (Svendsen strict), 6) low-dose chronic (1-36 mg for >91 days), medium-dose chronic (36-120 mg for >91 days), and high-dose chronic (>120 mg for >91 days) (Edlund). Multivariable regression models yielding C-index and R2 values were used to compare chronic preoperative opioid use definitions by postoperative outcomes, adjusting for type of surgery. Results Chronic preoperative opioid use was reported in 470 to 725 (19.8% to 30.6%) patients, depending on definition. The Edlund definition, accounting for duration and dosage, had the highest predictive ability for postoperative opioid use (77.5%), followed by Schoenfeld (75.7%), CDC (72.6%), and Svendsen (59.9% to 72.5%) definitions. A combined Edlund and Schoenfeld duration and dosage definition in post-hoc analysis, that included 3 and 6 month duration cut-offs, performed the best overall with a C-index of 78.4%. Both Edlund and Schoenfeld definitions explained similar amounts of variance in satisfaction, disability, and pain (4.2% to 8.5%). Svendsen and CDC definitions demonstrated poorer performance for patient-reported outcomes (1.4% to 7.2%). Conclusions The Edlund definition is recommended for identifying patients at highest risk for postoperative opioid use. When opioid dosage is unavailable, the Schoenfeld definition is a reasonable choice with similar predictive ability. For patient-reported outcomes, either the Edlund or Schoenfeld definition is recommended. Future work should consider combing dosage and duration, with 3 and 6 month cutoffs, into chronic opioid use definitions.

Introduction Healthcare reform places emphasis on maximizing the value of care. Methods A prospective registry was used to analyze outcomes before (1,596 patients) and after (151 patients) implementation of standardized, evidence-based order sets for six high-impact dimensions of perioperative care for all patients who underwent elective surgery for degenerative spine disease after July 1, 2015. Results Apart from symptom duration, chronic obstructive pulmonary disease prevalence, estimated blood loss, and baseline Oswestry Disability Index, no significant differences existed between pre- and post-protocol cohorts. No differences in readmissions, discharge status, or 3-month patient-reported outcomes were seen. Multivariate regression analyses demonstrated reduced length of stay (P = 0.013) and odds of 90-day complications (P = 0.009) for postprotocol patients. Conclusion Length of stay and 90-day complications for elective spine surgery improved after implementation of an evidence-based perioperative protocol. Standardization efforts can improve quality and reduce costs, thereby improving the value of spine care. Level of evidence Level III (retrospective review of prospectively collected data).

Introduction This case series summarises our institution's preliminary experience of using computed tomography skeletal surveys (CT-SS) for the assessment of infants with suspected non-accidental injury (NAI) who were unable to undergo radiographic skeletal surveys (SS). This paper describes our experience using CT-SS in terms of radiation doses achieved, occult bony injury detection and forensic utility. Methods Ten infants aged between two weeks and ten months underwent a CT-SS. The results of the CT-SS were compared with concurrent imaging results where available. Radiation doses from imaging procedures were calculated for each patient. Results Six infants had abnormalities identified on CT-SS. Two patients had both an ante-mortem CT-SS and post-mortem imaging. All fractures identified on alternate imaging modalities were visible on at least one CT-SS reconstruction. The radiation dose associated with CT-SS imaging ranged from 0.73 to 1.46mSv. Conclusion The radiation dose received by the ten infants in this study was greater than the two skeletal survey approach but was less than the dose received during a bone scintigraphy examination, sometimes used to assess for occult bony injury in this setting. While CT-SS imaging results could not be compared with those obtained with current contemporaneous gold standard imaging techniques, CT-SS identified all fractures observed on the radiographic images where performed. CT-SS also identified additional rib fractures in two patients. Our preliminary findings indicate the need for future prospective studies to clarify the ability of CT-SS to detect metaphyseal fractures reliably.

Magnetic Resonance Imaging (MRI) inputs are most noticeable in diagnosing brain tumors via computer and manual clinical understanding. Multi-level detection and classification of the images utilizing computer-aided processing depend on labels and annotations. Though the two processes are dynamic and time-consuming, without which the precise accuracy is less assured. For augmenting the accuracy in processing un-labeled or annotation-less images, this article introduces Absolute Classification-Detection Model (AC-DM). This model uses a conventional neural network for training the morphological variations proficient of achieving label-less classification and tumor detection. The traditional neural network trains the images based on differential lattice morphology for classification and detection. In this process, training for the lattices and their corresponding gradients is validated to improve the precision of the regional analysis. This helps to retain the precision of identifying tumors. The variations are recognized for their lattice mapping in the detected boundaries of the input image. The detected boundaries help to map accurate lattices for adapting morphological transforms. Thus, the partial and complex processing in detecting tumors is restrained in the suggested model, adapting to the classification. The efficiency of the suggested model is verified utilizing accuracy, precision, sensitivity, and classification time.

Cervical spine deformity is a debilitating condition that can be challenging to treat. For patients with fixed, focal, kyphotic deformities near the cervicothoracic junction, a pedicle subtraction osteotomy (PSO) can be considered. Classifying a given cervical spine deformity and quantifying the mismatch between current and desired alignment are critical steps in determining whether a PSO should be done. It is also important to understand the relative contraindications for a cervical PSO and the radiographic and patient-reported outcomes associated with the procedure. Here, we review these topics and the details of our surgical technique and postoperative considerations. Specific nuances of the setup, exposure/approach, osteotomy, closure, and postoperative protocol are highlighted. A surgical video is also included (Video 1). Our aim is to provide a conceptual framework for understanding when a cervical PSO should be considered, how it can be performed effectively, and the outcomes that can be expected.

There is limited evidence to direct the management of unruptured intracranial aneurysms. Models extrapolated from existing data have been proposed to guide treatment recommendations. The aim of this study is to assess whether a consensus-based treatment score (UIATS) or rupture rate estimation model (PHASES) can be used to benchmark UK multi-disciplinary team (MDT) practice.Prospective data was collected on a consecutive series of all patients with unruptured intracranial aneurysms (UIAs) presenting to a major UK neurovascular centre between 2012 and 2015. The agreement between the UIATS and PHASES scores, and their sensitivity and specificity in predicting the real-world MDT outcome were calculated and compared.A total of 366 patients (456 aneurysms) were included in the analysis. The agreement between UIATS and MDT recommendation was low (weighted kappa 0.26 [95% CI 0.19, 0.32]); sensitivity and specificity were also low at 36% and 52% respectively. Groups that the MDT allocated to treatment, equipoise or no treatment had significantly different PHASES scores (p = 0.004). There was no significant difference between the two scores when predicting patients for whom MDT outcome was to recommend aneurysm treatment, but the UIATS score was superior in predicting patients who received an MDT recommendation of 'treatment-equipoise', or 'not-for-treatment' (AUC of 0.73 compared to 0.59 for PHASES).The models studied failed to agree with the consensus view of multi-disciplinary team in a major neurovascular centre. We conclude that decision support tools such as the UIATS and PHASES scores should not be blindly introduced in respective institutions without prior internal validation, as they may not represent the local reality.

Study design This study is a retrospective review of patients' charts and data from longitudinally collected clinical outcomes and opioid use. Objective In the current study, we aim to compare short-term outcomes data for 139 Open transforaminal interbody fusion (TLIF) patients to recently published data for tubular and endoscopic MIS-TLIF. Background context In response to the downsides associated with Open TLIF, such as large incision, blood loss, delayed ambulation, prolonged hospitalization, and opioid-reliance, spine surgeons developed tubular retractor based "minimally-invasive" TLIF. However, the traditional Open TLIF retains its significance in terms of providing successful fusion and improved patient-reported outcomes (PROs). Methods We adapted several techniques with an aim to improve short-term outcomes for our Open TLIF patients that combined extensive perioperative counselling, an emphasis on early mobilization, avoidance of overuse of opioid analgesics, early discharge with home care arrangements, use of a posthospitalization drainage tube with intraoperative surgical modifications using small incisions (4-5 cm), a narrow 20 mm retractor, minimal muscle injury, and use of a cell saver to minimize net blood loss. The demographics and perioperative results were compared with data from recent MIS-TLIF studies using Student t test for continuous and χ2/exact test for categorical variables. Results Among the total 139 patients, 115 underwent a single-level procedure, 90% of whom were discharged on the first postoperative day (length of stay=1.13±0.47 d) with an average net estimated blood loss of 176.17±87.88 mL. There were 24 two-level procedures with an average length of stay of 1.57±0.84 days, average net estimated blood loss was 216.96±85.70 mL. The patients had statistically significant improvements in PROs at 3 and 12 months. Conclusions The results of this study identify that patients who underwent modified Open TLIF demonstrated favorable short-term outcomes, as compared with the tubular MIS-TLIF, by virtue of avoidance of blood transfusions, shorter hospital stays, and significantly less opioid usage while experiencing satisfactory PROs.

STUDY DESIGN Retrospective analysis of prospectively collected registry data. OBJECTIVE To develop and validate prediction models for 12-month patient-reported outcomes of disability, pain, and myelopathy in patients undergoing elective cervical spine surgery. SUMMARY OF BACKGROUND DATA Predictive models have the potential to be utilized preoperatively to set expectations, adjust modifiable characteristics, and provide a patient-centered model of care. METHODS This study was conducted using data from the cervical module of the Quality Outcomes Database. The outcomes of interest were disability (Neck Disability Index:), pain (Numeric Rating Scale), and modified Japanese Orthopaedic Association score for myelopathy. Multivariable proportional odds ordinal regression models were developed for patients with cervical radiculopathy and myelopathy. Patient demographic, clinical, and surgical covariates as well as baseline patient-reported outcomes scores were included in all models. The models were internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients. RESULTS Four thousand nine hundred eighty-eight patients underwent surgery for radiculopathy and 2641 patients for myelopathy. The most important predictor of poor postoperative outcomes at 12-months was the baseline Neck Disability Index score for patients with radiculopathy and modified Japanese Orthopaedic Association score for patients with myelopathy. In addition, symptom duration, workers' compensation, age, employment, and ambulatory and smoking status had a statistically significant impact on all outcomes (P

Intravenous iodinated contrast is a commonly used diagnostic aid to improve image quality on computed tomography. There exists a small risk of post-contrast acute kidney injury in patients receiving IV contrast. One of the biggest risk factors for developing PC-AKI is the presence of pre-existing renal dysfunction, making it important to measure the renal function prior to contrast administration. Point of care (POC) devices offer a quick estimation of renal function, potentially improving workflows in radiology departments. Two POC devices were evaluated, the Nova StatSensor and Abbott iSTAT. Patients undergoing routine radiological investigations had blood collected and analysed by a POC method and the laboratory method (Beckman AU5800). The two values were analysed and compared. Renal function was calculated using eGFR via the CKD-EPI result. eGFR values were stratified as high risk (eGFR

STUDY DESIGN Retrospective cohort analysis of prospectively collected data. OBJECTIVES Using a national cohort of patients undergoing elective anterior cervical discectomy and fusion (ACDF) in an inpatient/outpatient setting, the current objectives were to: (1) outline preoperative factors that were associated with complications, and (2) describe potentially catastrophic complications so that this data can help stratify the best suited patients for an ambulatory surgery center (ASC) compared with a hospital setting. SUMMARY OF BACKGROUND DATA ASCs are increasingly utilized for spinal procedures and represent an enormous opportunity for cost savings. However, ASCs have come under scrutiny for profit-driven motives, lack of adequate safety measures, and inability to handle complications. METHODS Adults who underwent ACDF between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure ACDF [Current Procedural Terminology (CPT) 22551, 22552], elective, neurological/orthopedic surgeons, length of stayof 0/1 day, and being discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications. RESULTS A total of 12,169 patients underwent elective ACDF with a length of stay of 0/1 day and were discharged directly home. A total of 179 (1.47%) patients experienced a complication. Multivariate logistic regression revealed the following factors were significantly associated with a complication: Charlson Comorbidity Index (CCI) >3, history of transient ischemic attack/cerebrovascular accident, abnormal bilirubin, and operative time of >2 hours. Approximate comorbidity score cutoffs associated with

OBJECTIVE The accuracy of percutaneous pedicle screw placement has increased with the advent of robotic and surgical navigation technologies. However, the effect of robotic intraoperative screw size and trajectory templating remains unclear. The purpose of this study was to compare pedicle screw sizes and accuracy of placement using robotic navigation (RN) versus skin-based intraoperative navigation (ION) alone in minimally invasive lumbar fusion procedures. METHODS A retrospective cohort study was conducted using a single-institution registry of spine procedures performed over a 4-year period. Patients who underwent 1- or 2-level primary or revision minimally invasive surgery (MIS)–transforaminal lumbar interbody fusion (TLIF) with pedicle screw placement, via either robotic assistance or surgical navigation alone, were included. Demographic, surgical, and radiographic data were collected. Pedicle screw type, quantity, length, diameter, and the presence of endplate breach or facet joint violation were assessed. Statistical analysis using the Student t-test and chi-square test was performed to evaluate the differences in pedicle screw sizes and the accuracy of placement between both groups. RESULTS Overall, 222 patients were included, of whom 92 underwent RN and 130 underwent ION MIS-TLIF. A total of 403 and 534 pedicle screws were placed with RN and ION, respectively. The mean screw diameters were 7.25 ± 0.81 mm and 6.72 ± 0.49 mm (p < 0.001) for the RN and ION groups, respectively. The mean screw length was 48.4 ± 4.48 mm in the RN group and 45.6 ± 3.46 mm in the ION group (p < 0.001). The rates of “ideal” pedicle screws in the RN and ION groups were comparable at 88.5% and 88.4% (p = 0.969), respectively. The overall screw placement was also similar. The RN cohort had 63.7% screws rated as good and 31.4% as acceptable, while 66.1% of ION-placed screws had good placement and 28.7% had acceptable placement (p = 0.661 and p = 0.595, respectively). There was a significant reduction in high-grade breaches in the RN group (0%, n = 0) compared with the ION group (1.2%, n = 17, p = 0.05). CONCLUSIONS The results of this study suggest that robotic assistance allows for placement of screws with greater screw diameter and length compared with surgical navigation alone, although with similarly high accuracy. These findings have implied that robotic platforms may allow for safe placement of the “optimal screw,” maximizing construct stability and, thus, the ability to obtain a successful fusion.

Objective To assess the effect depression has on outcomes after cervical epidural steroid injections (CESIs). Design Retrospective review of a prospectively collected database. Setting Single institution tertiary care center. Subjects Fifty-seven patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first were included. Methods Twenty-one of 57 (37%) patients with depression (defined as Zung Depression Scale >33) were included. Patient-reported outcomes including Neck Disability Index (NDI), numeric rating scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and three-month follow-up. Minimal clinically important differences were then calculated to provide dichotomous outcome measures of success. Results Overall, 24 and 28 patients achieved at least 50% improvement in AP and NP, respectively. In terms of disability, 25/57 (43.9%) patients achieved >13.2-point improvement on the NDI overall. In patients with depression, 4/21 (19.0%) and 5/21 (23.8%) achieved at least 50% improvement on the NRS for AP and NP, respectively, compared with 20/36 (55.5%) and 23/36 (63.8%) in patients without depression. This difference was statistically significant for both pain measures (P

In an era of rising health care costs, it is prudent to consider effective use of resources. Given the rapidly expanding elderly population with an anticipated increase in adult spinal deformity, identifying the significant cost drivers for the surgical management is an important step in the process of increasing sustainability and cost-effectiveness of adult spinal deformity surgery.A total of 129 patients undergoing elective spine surgery for thoraco-lumbar deformity were enrolled in a prospective longitudinal registry. Patient-reported resource use during the 3-month postoperative period, including outpatient visits, spine-related diagnostic tests, injections, emergency department room visits, rehabilitation/skilled nursing facility utilization, and use of all medications, was collected in a single-center prospective registry. Multiple linear regression analysis was conducted to find the significant patient coefficient for the cost variability.The study population showed significant improvement (P0.001) in all patient-reported outcomes including disability (Oswestry Disability Index), pain (Numeric Rating Scale for Back Pain and Numeric Rating Scale for Leg Pain), and quality of life (Euro-Qol-5D). In risk-adjusted multiple patient comorbidities including chronic obstructive pulmonary disease and diabetes, preoperative deformity diagnosis, number of levels involved, length of surgery and hospital stay, 90-day readmission and use of inpatient rehabilitation were the significant drivers of the cost.Our study demonstrates that several patient-specific, surgery-related factors, 90-day readmission and postdischarge inpatient rehabilitation use, were associated with increased cost associated with the adult deformity spine surgery.

Treatment of brain arteriovenous malformations (AVM) with stereotactic radiosurgery is rarely complicated by severe adverse radiation effects (ARE). The treatment of these sequelae is varied and often ineffectual. We present three cases of brain AVMs treated with SRS, all complicated by severe AREs. All three cases failed to respond to what is currently considered the standard treatment – corticosteroids – and indeed one patient died as a result of the side effects of their extended use. Two cases were successfully treated with surgical excision of the necrotic lesion resulting in immediate clinical improvement. Having considered the experience described in this paper and reviewed the published literature to date we suggest that surgical treatment of AREs should be considered early in the management of this condition should steroid therapy not result in early improvement.

BACKGROUND CONTEXT There have been no reported efforts to eliminate opioid use for elective spine surgery, despite its well-known drawbacks. PURPOSE We sought to test the hypothesis that opioid-free elective spine surgery, including lumbar fusions, can be performed with satisfactory pain control. STUDY DESIGN/ SETTING This study analyzes prospectively collected data from a single surgeon's patients who were enrolled into an institutional spine registry. PATIENT SAMPLE We enrolled every consecutive surgical patient of author RAB between January 1, 2018 and July 13, 2019. OUTCOME MEASURES The postsurgical opioid use, pain scores, emergency room visits, and readmissions were tracked. METHODS We developed a comprehensive program for opioid-free pain control after elective spine surgery. In the initial stage, opioids were given “PRN” only, while in the second stage, they were avoided altogether. Student's t tests were performed to compare pain scores, and regression analyses were performed to understand drivers of opioid use and pain. RESULTS Two hundred forty-four patients were studied, a third of whom underwent lumbar fusions. In the initial stage, 47% of patients took no opioids from recovery room departure until 1-month follow-up. During the second stage, 88% of patients took no opioids during that period. Pain scores were satisfactory, and there was no association between postoperative opioid use and either procedural invasiveness or pain scores. However, preoperative opioid use was associated with a nearly fivefold increased risk of postoperative use. Ninety-three percent of lumbar fusion patients who were opioid-free before surgery did not take a single opioid in the postoperative period. CONCLUSION Opioid-free elective spine surgery, including lumbar fusions, is feasible and effective. We suggest that opioid-free spine surgery be offered to patients who are opioid-naive or who can be weaned off before the operation.

Computed tomography fluoroscopy is now the preferred technique for percutaneous lung biopsies. However, concern regarding operator and patient radiation dose remains, which warrants further exploration into dose optimisation tools. This phantom-study aims to assess the dose reduction capabilities of RADPAD, a single-use patient drape designed to decrease staff exposure to scattered radiation. Dosemeters at the waist and eye levels were used to determine the whole-body and lens exposure during simulated lung biopsy procedures while using RADPAD and other combinations of personal protective equipment. RADPAD resulted in a 36% and 38% dose reduction for whole-body and eye exposure, respectively. However, when used in combination with radioprotective eyewear and aprons, RADPAD did not reduce the radiation dose further. Consequently, the use of standard personal protective equipment is a more cost-effective option for staff dose reduction. RADPAD is useful in the reduction of radiation dose to unprotected regions.

BACKGROUND Considerable variability exists in the cost of surgery following spine surgery for common degenerative spine diseases. This variation in the cost of surgery can affect the payment bundling during the postoperative 90 d. OBJECTIVE To determine the drivers of variability in total 90-d cost for laminectomy and fusion surgery. METHODS A total of 752 patients who underwent elective laminectomy and fusion for degenerative lumbar conditions and were enrolled into a prospective longitudinal registry were included in the study. Total cost during the 90-d global period was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multivariable regression models were built for total 90-d cost. RESULTS The mean 90-d direct cost was $29 295 (range, $28 612-$29 973). Based on our regression tree analysis, the following variables were found to drive the 90-d cost: age, BMI, gender, diagnosis, postop imaging, number of operated levels, ASA grade, hypertension, arthritis, preop and postop opioid use, length of hospital stay, duration of surgery, 90-d readmission, outpatient physical/occupational therapy, inpatient rehab, postop healthcare visits, postop nonopioid pain medication use nonsteroidal antiinflammatory drug (NSAIDs), and muscle relaxant use. The R2 for tree model was 0.64. CONCLUSION Utilizing prospectively collected data, we demonstrate that considerable variation exists in total 90-d cost, nearly 70% of which can be explained by those factors included in our modeling. Risk-adjusted payment schemes can be crafted utilizing the significant drivers presented here. Focused interventions to target some of the modifiable factors have potential to reduce cost and increase the value of care.

BACKGROUND The choice of anterior vs posterior approach for degenerative cervical myelopathy that spans multiple segments remains controversial. OBJECTIVE To compare the outcomes following the 2 approaches using multicenter prospectively collected data. METHODS Quality Outcomes Database (QOD) for patients undergoing surgery for 3 to 5 level degenerative cervical myelopathy was analyzed. The anterior group (anterior cervical discectomy [ACDF] or corpectomy [ACCF] with fusion) was compared with posterior cervical fusion. Outcomes included: patient reported outcomes (PROs): neck disability index (NDI), numeric rating scale (NRS) of neck pain and arm pain, EQ-5D, modified Japanese Orthopedic Association score for myelopathy (mJOA), and NASS satisfaction questionnaire; hospital length of stay (LOS), 90-d readmission, and return to work (RTW). Multivariable regression models were fitted for outcomes. RESULTS Of total 245 patients analyzed, 163 patients underwent anterior surgery (ACDF-116, ACCF-47) and 82 underwent posterior surgery. Patients undergoing an anterior approach had lower odds of having higher LOS (P < .001, odds ratio 0.16, 95% confidence interval 0.08-0.30). The 12-mo NDI, EQ-5D, NRS, mJOA, and satisfaction scores as well as 90-d readmission and RTW did not differ significantly between anterior and posterior groups. CONCLUSION Patients undergoing anterior approaches for 3 to 5 level degenerative cervical myelopathy had shorter hospital LOS compared to those undergoing posterior decompression and fusion. Also, patients in both groups exhibited similar long-term PROs, readmission, and RTW rates. Further investigations are needed to compare the differences in longer term reoperation rates and functional outcomes before the clinical superiority of one approach over the other can be established.

Background Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period. Objective To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. Methods Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost. Results The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616. Conclusion There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons' and institution-specific differences.

Background Context Chronic opioid therapy is associated with worse patient-reported outcomes (PROs) following spine surgery. However, little literature exists on the relationship between opioid use and PROs following epidural steroid injections for radicular pain. Purpose We evaluated the association between pre-injection opioid use and PROs following spine epidural steroid injection. Study Design This study is a retrospective analysis of a prospective longitudinal registry database. Patient Sample A total of 392 patients within our database who were undergoing epidural steroid injections (ESIs) at our institution for degenerative structural spine diagnoses and met our inclusion criteria were included in this study. Outcome Measures Patient-reported outcomes for disability (Oswestry Disability Index/Neck Disability Index [ODI/NDI)]), quality of life (EuroQol-5D [EQ-5D]), and pain (Numerical Rating Scale scores for back pain, neck pain, leg pain, and arm pain [NRS-BP/NP/LP/AP]) were assessed at baseline and at 3 and 12 months post-injection. Methods Multivariable proportional odds logistic regression models were created to examine the relationship between pre-injection opioid use and post-injection PROs. A logistic regression with Bayesian Markov chain Monte Carlo parameter estimation was used to investigate a possible cutoff value of pre-injection opioid use above which the effectiveness of ESI (as measured by minimum clinically important difference [MCID] for ODI/NDI) decreases. Results A total of 276 patients with complete 12-month follow-up following ESI were analyzed. The mean pre-injection daily morphine equivalent amount (MEA) was 14.7 mg (95% confidence interval [CI] 12.4 mg–19.1 mg) for the cohort. Pre-injection opioid use was associated with slightly higher odds of worse disability (odds ratio [OR] 1.03, p=.03) and leg/arm pain (OR 1.01, p=.04) scores at 3 months post-injection only. No significant association between pre-injection opioid use and MCID for ODI/NDI was found, although a cutoff of 55.5 mg/day might serve as a significant threshold. Conclusion Increased pre-injection opioid use does not impact long-term outcomes after ESIs for degenerative spine diseases. A pre-injection MEA around 50 mg/day may represent a threshold above which the 3-month effectiveness of ESI for back- and neck-related disability decreases. Epidural steroid injection is an effective treatment modality for pain in patients using opioids, and can be part of a multimodal strategy for opioid independence.

STUDY DESIGN A retrospective review of a prospective database. OBJECTIVE The aim of this study was to determine cost and outcomes of revision cervical spine surgery. SUMMARY OF BACKGROUND DATA Revision rates for cervical spine surgery are steadily increasing. It is important to counsel patients on expected results following a revision procedure. However, outcomes and cost of these procedures are poorly defined in the literature. METHODS Patients undergoing revision cervical spine surgery at a single institution were included between October 2010 and January 2016 in a prospective registry database. Patients were divided into three cohorts depending on their etiology for revision, including recurrent disease, pseudoarthrosis, or adjacent segment disease. Patient-reported outcomes (PROs), including Neck Disability Index (NDI), EuroQol-5D (EQ-5D), modified Japanese Orthopaedic Association (mJOA) score, numeric rating scale-neck pain (NRS-NP), and numeric rating scale-arm pain (NRS-AP), were measured at baseline and 12 months following revision surgery. Mean costs at 12 months following revision surgery were also calculated. Satisfaction was determined by the NASS patient satisfaction index. Variables were compared using Student t test. RESULTS A total of 115 patients underwent cervical revision surgery for recurrent disease (n = 21), pseudoarthrosis (n = 45), and adjacent segment disease (n = 49). There was significant improvement in all patient-reported outcomes at 12 months following surgery regardless of etiology (P

Here, we systematically review clinical studies that report morbidity and outcomes data for cervical and lumbar surgeries performed in ambulatory surgery centers (ASCs). We focus on anterior cervical discectomy and fusion (ACDF), posterior cervical foraminotomy, cervical arthroplasty, lumbar microdiscectomy, lumbar laminectomy, and minimally invasive transforaminal interbody fusion (TLIF) and lateral lumbar interbody fusion, as these are prevalent and surgical spine procedures that are becoming more commonly performed in ASC settings.A systematic search of PubMed was conducted, using combinations of the following phrases: "outpatient," "ambulatory," or "ASC" with "anterior cervical discectomy fusion," "ACDF," "cervical arthroplasty," "lumbar," "microdiscectomy," "laminectomy," "transforaminal lumbar interbody fusion," "spine surgery," or "TLIF."In reviewing the available literature to date, there is ample level 3 (retrospective comparisons) and level 4 (case series) evidence to support both the safety and effectiveness of outpatient cervical and lumbar surgery. While no level 1 or 2 (randomized clinical trials) evidence currently exists, the plethora of real-world clinical data creates a formidable argument for serious investments in ASCs for multiple spine procedures.

Background Modern medical management of metastatic renal cell carcinoma (RCC) includes therapies targeting tyrosine kinases, growth pathways (mammalian target of rapamycin (mTOR)), and immune checkpoints. Objective To test our hypothesis that patients with spinal metastases would benefit from postoperative systemic therapy despite presenting with disease that, in many cases, was resistant to prior systemic therapy. Methods This is an Institutional Review Board-approved clinical retrospective cohort analysis. A sample of adult patients with RCC metastatic to the spine who underwent operative intervention between January 2010 and December 2017 at 2 large academic medical centers was used in this study. Results We identified 78 patients with metastatic RCC in whom instrumented stabilization was performed in 79% and postoperative stereotactic radiosurgery was performed in 41% of patients. Of patients presenting with weakness or myelopathy, 93% noted postoperative improvement and 78% reported improvement in radicular and axial paraspinal pain severity. Increased overall survival (OS) (913 d (95% CI: 633-1975 d, n = 49) vs 222 d (95% CI: 143-1005 d, n = 29), P = .003) following surgery was noted in patients who received postoperative systemic therapy a median of 80 d (interquartile range 48-227 d) following the surgical intervention. Conclusion Postoperative outcomes and palliation of symptoms for metastatic RCC without targeted therapies in this cohort are similar to those reported in earlier series prior to the adoption of these systemic therapies. We observed a significantly longer OS among patients who received modern systemic therapies postoperatively. These findings have implications for the preoperative evaluation of patients with systemic disease who may have been deemed poor surgical candidates prior to the availability of these systemic therapies.

Background Preoperative opioid use is widespread and associated with worse patient-reported outcomes following spine surgery. Objective To calculate a threshold preoperative morphine equianalgesic (MEA) dose beyond which patients are less likely to achieve the minimum clinically important difference (MCID) following elective surgery for degenerative spine disease. Methods The study included 543 cervical and 1293 lumbar patients. Neck Disability Index and Oswestry Disability Index scores were collected at baseline and 12 mo postoperatively. Preoperative MEA doses were calculated retrospectively. Multivariate logistic regression was then performed to determine the relationship between MEA dose and the odds of achieving MCID. As a part of this regression, Bayesian inference and Markov Chain Monte Carlo methods were used to estimate the values of inflection points (or "thresholds") in MEA. Results Overall, 1020 (55.5%) patients used preoperative opioids. A total of 50.3% of cervical and 61.9% of lumbar patients achieved MCID. The final logistic regression model demonstrated that MCID achievement decreased significantly when mean preoperative MEA dose exceeded 47.8 mg/d, with a 95% credible interval of 29.0 to 60.0 mg/d. Conclusion Minimum and maximum MEA doses exist, between which increasing opioid dose is associated with decreased ability to achieve clinically meaningful improvement following spine surgery. Patients with preoperative MEA dose exceeding 29 mg/d, the lower limit of the 95% credible interval for the mean MEA dose above which patients exhibit significantly decreased achievement of MCID, may be considered for preoperative opioid weaning.

BACKGROUND The costs and outcomes following degenerative spine surgery may vary from surgeon to surgeon. Patient factors such as comorbidities may increase the health care cost. These variations are not well studied. OBJECTIVE To understand the variation in outcomes, costs, and comorbidity-adjusted cost for surgeons performing lumbar laminectomy and fusions surgery. METHODS A total of 752 patients undergoing laminectomy and fusion, performed by 7 surgeons, were analyzed. Patient-reported outcomes and 90-d cost were analyzed. Multivariate regression model was built for high-cost surgery. A separate linear regression model was built to derive comorbidity-adjusted 90-d costs. RESULTS No significant differences in improvement were found across all the patient-reported outcomes, complications, and readmission among the surgeons. In multivariable model, surgeons #4 (P < .0001) and #6 (P = .002) had higher odds of performing high-cost fusion surgery. The comorbidity-adjusted costs were higher than the actual 90-d costs for surgeons #1 (P = .08), #3 (P = .002), #5 (P < .0001), and #7 (P < .0001), whereas they were lower than the actual costs for surgeons #2 (P = .128), #4 (P < .0001), and #6 (P = .44). CONCLUSION Our study provides valuable insight into variations in 90-d costs among the surgeons performing elective lumbar laminectomy and fusion at a single institution. Specific surgeons were found to have greater odds of performing high-cost surgeries. Adjusting for preoperative comorbidities, however, led to costs that were higher than the actual costs for certain surgeons and lower than the actual costs for others. Patients' preoperative comorbidities must be accounted for when crafting value-based payment models. Furthermore, designing intervention targeting "modifiable" factors tied to the way the surgeons practice may increase the overall value of spine care.

Non-steroidal anti-inflammatory drugs (NSAIDs) play an important role in postoperative pain management. However, their use in the setting of spine fusion surgery setting has long been a topic of controversy. In this review we examined relevant research, including in vivo, animal, and clinical human studies, with the aim of understanding the effect of NSAIDs on spinal fusion. Systematic review of study designs of all types from randomized controlled trials and meta-analyses to single-institution retrospective reviews. A search of PubMed and Embase was conducted using the keywords: “spine,” “spinal fracture,” NSAIDs, anti-inflammatory non-steroidal agents, bone, bone healing, fracture, fracture healing, yielding a total of 110 studies. Other 28 studies were identified by cross-referencing, resulting in total 138 studies. There is no level I evidence from human studies regarding the use of NSAIDs on spinal fusion rates. The overall tone of the spine literature in the early 2000s was that NSAIDs increased the rate of non-union; however, nearly all human studies published after 2005 suggest that short-term (

Background Conus medullaris arteriovenous malformations (AVMs) are rare spinal vascular malformations presenting most frequently with features of myelopathy (Foix-Alajounine syndrome), radiculopathy, bowel/bladder dysfunction, or acute spinal hemorrhage (Coup de poignard of Michon) causing profound neurological deficit. Here we present the case of a young patient with progressive dysphagia and intractable hiccups as a rare first presentation symptom of later verified conus medullaris AVM. Case Description A 21-year-old male patient presented with acute onset of dysphagia and persistent hiccups. His magnetic resonance imaging of the spine demonstrated a lesion at the T11 and T12 levels with an associated holocord syrinx and syringobulbia to the level of the medulla. The patient underwent a decompressive suboccipital craniectomy and C1 (atlas) laminectomy with wide myelotomy of the medulla followed by T11 and T12 laminectomy and AVM reduction. Two days after partial AVM occlusion the patient developed transient worsening of his symptoms. Repeat magnetic resonance imaging showed recurrence of dilatation of the central canal. A syringo-subarachnoid shunt was sited at the level of the previous myelotomy of the medulla, after which his neurological symptoms resolved completely. Conclusions This is the first case report in the English literature to date of a conus AVM presenting with intractable hiccups. These are extremely rare sporadic vascular malformations, and although their natural history is poorly understood, symptomatic patients generally deteriorate, culminating in severe disability. Management requires a multimodality approach including combined endovascular and microsurgical treatment. The patient in our case made a full recovery confirmed at 2-year follow-up.

Minimum clinically important difference (MCID) for patient-reported outcome measures is commonly used to assess clinical improvement. However, recent literature suggests that an absolute point-change may not be an effective or reliable marker of response to treatment for patients with low or high baseline patient-reported outcome scores. The multitude of established MCIDs also makes it difficult to compare outcomes across studies and different spine surgery procedures.To determine whether a 30% reduction from baseline in disability and pain is a valid method for determining clinical improvement after lumbar spine surgery.Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database.There were 23,280 participants undergoing elective lumbar spine surgery for degenerative disease who completed a baseline and follow-up assessment at 12 months.Patient-reported disability (Oswestry Disability Index [ODI]), back and leg pain (11-point Numeric Rating Scale [NRS]), and satisfaction (NASS scale).Patients completed baseline and a 12-month postoperative assessment to evaluate the outcomes of disability, pain, and satisfaction. The change in ODI and NRS pain scores was categorized as met (≥30%) or not met (30%) percent reduction MCID. The 30% reduction from baseline was compared with a wide range of well-established absolute point-change MCID values. The relationship between 30% reduction and absolute change values and satisfaction were primarily compared using receiver operating characteristic (ROC) curves, area under the curve (AUROC), and logistic regression analyses. Analyses were conducted for overall scores and for disability and pain severity categories and by surgical procedure.Thirty percent reduction in ODI and back and leg pain predicted satisfaction with more accuracy than absolute point-change values for the total population and across all procedure categories (p.001), except for when compared with the highest absolute point-change threshold for leg pain (3.5-point reduction). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 21.8%) and bed-bound disability (ODI 81%-100%: 13.9%) categories. For pain, there was a 3.4%-12.4% and 1.3%-9.8% AUROC difference for no/mild back and leg pain (NRS 0-4), respectively, in favor of a 30% reduction threshold.A 30% reduction MCID either outperformed or was similar to absolute point-change MCID values. Results indicate that a 30% reduction (baseline to 12 months after surgery) in disability and pain is a valid method for determining clinically relevant improvement in a broad spine surgery population. Furthermore, a 30% reduction was most accurate for patients in the lowest and highest disability and lowest pain severity categories. A 30% reduction MCID allows for a standard cut-off for disability and pain that can be used to compare outcomes across various spine surgery procedures.