Search

Background: Intra-abdominal vascular injuries are rare during posterior lumbar spinal surgery, but they can result in major morbidity or mortality when they do occur. We are aware of no prior studies that have used prone patient positioning during magnetic resonance imaging for the purpose of characterizing the retroperitoneal iliac vasculature with respect to the intervertebral disc. The purpose of this study was to define the vascular anatomy adjacent to the lower lumbar spine with use of supine and prone magnetic resonance imaging.Methods: A prospective observational study included thirty patients without spinal abnormality who underwent supine and prone magnetic resonance imaging without abdominal compression. The spinal levels of the aortic bifurcation and confluence of the common iliac veins were identified. The proximity of the anterior iliac vessels to the anterior and posterior aspects of the anulus fibrosus in sagittal and coronal planes was measured by two observers, and interobserver reliability was calculated.Results: The aortic bifurcation and confluence of the common iliac veins were most commonly at the level of the L4 vertebral body and migrated cranially with prone positioning. The common iliac vessels were closer to the anterior aspect of the intervertebral disc and to the midline at L4-L5 as compared with L5-S1, consistent with the bifurcation at the L4 vertebral body. Prone positioning resulted in greater distances between the disc and iliac vessels at L4-L5 and L5-S1 by an average of 3 mm. The position of the anterior aspect of the anulus with respect to each iliac vessel demonstrated substantial variation between subjects. The intraclass correlation coefficient for measurement of vessel position exceeded 0.9, demonstrating excellent interobserver reliability.Conclusions: This study confirmed the L4 level of the aortic bifurcation and iliac vein coalescence but also demonstrated substantial mobility of the great vessels with positioning. Supine magnetic resonance imaging will underestimate the proximity of the vessels to the intervertebral disc. Large interindividual variation in the location of vasculature was noted, emphasizing the importance of careful study of the location of the retroperitoneal vessels on a case-by-case basis. [ABSTRACT FROM AUTHOR]

Objective: Readmission rates after posterior cervical fusion (PCF) significantly impact patients and healthcare, with complication rates at 15%-25% and up to 12% 90-day readmission rates. In this study, we aim to test whether machine learning (ML) models that capture interfactorial interactions outperform traditional logistic regression (LR) in identifying readmission-associated factors., Methods: The Optum Clinformatics Data Mart database was used to identify patients who underwent PCF between 2004-2017. To determine factors associated with 30-day readmissions, 5 ML models were generated and evaluated, including a multivariate LR (MLR) model. Then, the best-performing model, Gradient Boosting Machine (GBM), was compared to the LACE (Length patient stay in the hospital, Acuity of admission of patient in the hospital, Comorbidity, and Emergency visit) index regarding potential cost savings from algorithm implementation., Results: This study included 4,130 patients, 874 of which were readmitted within 30 days. When analyzed and scaled, we found that patient discharge status, comorbidities, and number of procedure codes were factors that influenced MLR, while patient discharge status, billed admission charge, and length of stay influenced the GBM model. The GBM model significantly outperformed MLR in predicting unplanned readmissions (mean area under the receiver operating characteristic curve, 0.846 vs. 0.829; p < 0.001), while also projecting an average cost savings of 50% more than the LACE index., Conclusion: Five models (GBM, XGBoost [extreme gradient boosting], RF [random forest], LASSO [least absolute shrinkage and selection operator], and MLR) were evaluated, among which, the GBM model exhibited superior predictive performance, robustness, and accuracy. Factors associated with readmissions impact LR and GBM models differently, suggesting that these models can be used complementarily. When analyzing PCF procedures, the GBM model resulted in greater predictive performance and was associated with higher theoretical cost savings for readmissions associated with PCF complications.

Background Context: Physical therapy (PT) is an important component of low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common., Purpose: We sought to understand how copayments impact timing and utilization of PT in newly diagnosed LBP., Study Design/setting: The IBM Watson Health MarketScan claims database was used in a longitudinal setting., Patient Sample: Adult patients with LBP., Outcome Measures: The primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing., Methods: Actual and inferred copayments based on nonnonprimary care provider visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage., Results: Overall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days postdiagnosis (IQR 1-55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use (0.77 prescriptions/patient [$0 PT copayment] versus 1.07 prescriptions/patient [$50-74 PT copayment]; 1.15 prescriptions/patient [$75+ PT copayment]). Among patients with known opioid and PT copayments, higher PT copayments were correlated with faster opioid use while higher opioid copayments were correlated with faster PT use (Spearman p<.05). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50-75th and 75-100th percentiles was significantly lower than those below the 50th percentile (HR=0.893 [95%CI 0.887-0.899] and HR=0.905 [95%CI 0.899-0.912], respectively)., Conclusions: Higher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Copays may impact long-term adherence to PT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objectives: Sacroiliac (SI) joint dysfunction constitutes a leading cause of pain and disability. Although surgical arthrodesis is traditionally performed under open approaches, the past decade has seen a rise in minimally invasive surgical (MIS) techniques and new federally approved devices for MIS approaches. In addition to neurosurgeons and orthopedic surgeons, proceduralists from nonsurgical specialties are performing MIS procedures for SI pathology. Here, we analyze trends in SI joint fusions performed by different provider groups, along with trends in the charges billed and reimbursement provided by Medicare., Methods: We review yearly Physician/Supplier Procedure Summary data from 2015 to 2020 from the Centers for Medicare and Medicaid Services for all SI joint fusions. Patients were stratified as undergoing MIS or open procedures. Utilization was adjusted per million Medicare beneficiaries and weighted averages for charges and reimbursements were calculated, controlling for inflation. Reimbursement-to-charge (RCR) ratios were calculated, reflecting the proportion of provider billed amounts reimbursed by Medicare., Results: A total of 12 978 SI joint fusion procedures were performed, with the majority (76.5%) being MIS procedures. Most MIS procedures were performed by nonsurgical specialists (52.1%) while most open fusions were performed by spine surgeons (71%). Rapid growth in MIS procedures was noted for all specialty categories, along with an increased number of procedures offered in the outpatient setting and ambulatory surgical centers. The overall RCR increased over time and was ultimately similar between spine surgeons (RCR = 0.26) and nonsurgeon specialists (RCR = 0.27) performing MIS procedures., Conclusion: Substantial growth in MIS procedures for SI pathology has occurred in recent years in the Medicare population. This growth can largely be attributed to adoption by nonsurgical specialists, whose reimbursement and RCR increased for MIS procedures. Future studies are warranted to better understand the impact of these trends on patient outcomes and costs., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objective: By 2030, the US will not have enough neurosurgeons to meet the clinical needs of its citizens. Replacement of neurosurgeons due to attrition can take more than a decade, given the time-intensive training process. To identify potential workforce retention targets, the authors sought to identify factors that might impact neurosurgeons' retirement considerations., Methods: The Council of State Neurosurgical Societies surveyed practicing AANS-registered neurosurgeons via email link to an online form with 25 factors that were ranked using a Likert scale of importance regarding retirement from the field (ranging from 1 for not important to 3 for very important). All participants were asked: "If you could afford it, would you retire today?", Results: A total of 447 of 3200 neurosurgeons (14%) responded; 6% had been in practice for less than 5 years, 19% for 6-15 years, 57% for 16-30 years, and 18% for more than 30 years. Practice types included academic (18%), hospital employed (31%), independent with academic appointment (9%), and full independent practice (39%). The most common practice size was between 2 and 5 physicians (46%), with groups of 10 or more being the next most common (20%). Career satisfaction, income, and the needs of patients were rated as the most important factors keeping neurosurgeons in the workforce. Increasing regulatory burden, decreasing clinical autonomy, and the burden of insurance companies were the highest rated for factors important in considering retirement. Subgroup analysis by career stage, practice size, practice type, and geographic region revealed no significant difference in responses. When considering if they would retire now, 45% of respondents answered "yes." Subgroup analysis revealed that midcareer neurosurgeons (16-25 years in practice) were more likely to respond "yes" than those just entering their careers or in practice for more than 25 years (p = 0.03). This effect was confirmed in multivariate logistic regression (p = 0.04). These surgeons found professional satisfaction (p = 0.001), recertification requirements (p < 0.001), and maintaining high levels of income (p = 0.008) important to maintaining employment within the neurosurgical workforce., Conclusions: This study demonstrates that midcareer neurosurgeons may benefit from targeted retention efforts. This effort should focus on maximizing professional satisfaction and financial independence, while decreasing the regulatory burden associated with certification and insurance authorization. End-of-career surgeons should be surveyed to determine factors contributing to resilience and persistence within the neurosurgical workforce.

Study Design: A retrospective cohort study., Objective: To identify the factors associated with readmissions after PLF using machine learning and logistic regression (LR) models., Summary of Background Data: Readmissions after posterior lumbar fusion (PLF) place significant health and financial burden on the patient and overall health care system., Materials and Methods: The Optum Clinformatics Data Mart database was used to identify patients who underwent posterior lumbar laminectomy, fusion, and instrumentation between 2004 and 2017. Four machine learning models and a multivariable LR model were used to assess factors most closely associated with 30-day readmission. These models were also evaluated in terms of ability to predict unplanned 30-day readmissions. The top-performing model (Gradient Boosting Machine; GBM) was then compared with the validated LACE index in terms of potential cost savings associated with the implementation of the model., Results: A total of 18,981 patients were included, of which 3080 (16.2%) were readmitted within 30 days of initial admission. Discharge status, prior admission, and geographic division were most influential for the LR model, whereas discharge status, length of stay, and prior admissions had the greatest relevance for the GBM model. GBM outperformed LR in predicting unplanned 30-day readmission (mean area under the receiver operating characteristic curve 0.865 vs. 0.850, P <0.0001). The use of GBM also achieved a projected 80% decrease in readmission-associated costs relative to those achieved by the LACE index model., Conclusions: The factors associated with readmission vary in terms of predictive influence based on standard LR and machine learning models used, highlighting the complementary roles these models have in identifying relevant factors for the prediction of 30-day readmissions. For PLF procedures, GBM yielded the greatest predictive ability and associated cost savings for readmission., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background Context: The 6-minute walking test (6WT) has been previously shown to be a reliable and valid outcome measure. It is unclear if the 6WT may further help to detect differences in well performing patients that reach a ceiling effect in PROMs after surgery., Purpose: To evaluate changes and timing of change in objective functional impairment (OFI) as measured with the smartphone-based 6WT in relation to patient-reported outcome measures (PROMs) after surgery for degenerative lumbar disorders (DLD)., Study Design: Prospective observational cohort study., Patient Sample: Fifty consecutive patients undergoing surgery for DLD., Outcome Measures: Patients self-determined their OFI using the 6WT application (6WT-app) and completed a set of paper-based PROMs before, 6 weeks and 3 months after surgery., Methods: Fifty patients undergoing surgery for DLD were assessed preoperatively (baseline), 6 weeks (6W) and 3 months (3M) postoperatively. Paired sample t-tests were used to establish significant changes in raw 6-minute walking distance (6WD) and standardized Z-scores, as well as PROMs. Pearson correlation coefficient was used to define the relationship between 6WT and PROMs. Floor and ceiling effects were assessed for each PROM (visual analogue scale [VAS], core outcome measure index [COMI], Zurich claudication questionnaire [ZCQ])., Results: Mean 6WT results improved from 377 m (standard deviation - SD 137; Z-score: 1.8, SD 1.8) to 490 m (SD 126; -0.7, SD 1.5) and 518 m (SD 112; -0.4, SD 1.41; all p<.05) at 6W and 3M follow-up. No significant improvement was observed between 6W and 3M for the ZCQ, VAS back and leg pain. While correlation between 6WT and all PROMs were weak at baseline, correlation coefficient increased to moderate at 3M. A considerable ceiling effect (best possible score) was observed, most notably for the ZCQ physical performance, VAS back and leg pain in 24%, 20%, and 16% of patient at 6W and in 30%, 24%, and 28% at 3M., Conclusions: Objective functional tests can describe the continued change in the physical recovery of a patient and may help to detect differences in well performing groups as well as in cases where patients' PROM results cannot further improve because of a ceiling effect., Competing Interests: Declaration of Competing Interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background Context: Bone morphogenic protein (BMP) promotes bony fusion but increases costs. Recent trends in BMP use among Medicare patients have not been well-characterized., Purpose: To assess utilization trends, complication, payments, and costs associated with BMP use in spinal fusion in a Medicare-insured population., Study Design/setting: Retrospective cohort study., Patient Sample: Total of 316,070 patients who underwent spinal fusion in a 20% sample of Medicare-insured patients, 2006 to 2015., Outcome Measures: Utilization trends across time and geography, complications, payments, and costs., Methods: Patients were stratified by fusion type and diagnosis. Multivariable logistic and linear regression were used to adjust for the effect of baseline characteristics on complications and total payments or cost, respectively., Results: BMP was used in 60,249 cases (19.1%). BMP utilization rates decreased from 23.1% in 2006 to 12.0% in 2015, most significantly in anterior cervical (7.5%-3.1%), posterior cervical (17.0%-8.3%), and posterior lumbar fusions (31.5%-15.8%). There are significant state- and region-level geographic differences in BMP utilization. Across all years, states with the highest BMP use were Indiana (28.5%), Colorado (26.6%), and Nevada (25.7%). States with the lowest BMP use were Maine (2.3%), Vermont (8.2%), and Mississippi (10.4%). After multivariate risk adjustment, BMP use was associated with decreased overall complications in thoracic (odds ratios [OR] [95% confidence intervals [CI]): 0.89 [0.81-0.99]) and anterior lumbar fusions (OR [95% CI]: 0.89 [0.84-0.95]), as well as increased reoperation rates in anterior cervical (OR [95% CI]: 1.11 [1.04-1.19]), posterior cervical (OR (95% CI): 1.14 (1.04-1.25)), thoracic (OR (95% CI): 1.32 (1.23-1.41)), and posterior lumbar fusions (OR (95% CI): 1.11 (1.06-1.16)). BMP use was also associated with greater total costs, independent of fusion type, after multivariate risk adjustment (p<.0001). Payments, however, were comparable between groups in anterior and posterior cervical fusion with or without BMP. BMP use was associated with greater total payments in thoracic, anterior lumbar, and posterior lumbar fusions. Notably, the difference in payments was smaller than the associated cost increase in all fusion types., Conclusions: BMP use has declined across all fusion types over the last decade, after a peak in 2007. While BMP is associated with greater costs, reimbursement does not increase proportionally with BMP cost., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The American Spine Registry (ASR) is a collaborative effort between the American Academy of Orthopaedic Surgeons and the American Association of Neurological Surgeons. The goal of this study was to evaluate how representative the ASR is of the national practice with spinal procedures, as recorded in the National Inpatient Sample (NIS)., Methods: The authors queried the NIS and the ASR for cervical and lumbar arthrodesis cases performed during 2017-2019. International Classification of Diseases, 10th Revision and Current Procedural Terminology codes were used to identify patients undergoing cervical and lumbar procedures. The two groups were compared for the overall proportion of cervical and lumbar procedures, age distribution, sex, surgical approach features, race, and hospital volume. Outcomes available in the ASR, such as patient-reported outcomes and reoperations, were not analyzed due to nonavailability in the NIS. The representativeness of the ASR compared to the NIS was assessed via Cohen's d effect sizes, and absolute standardized mean differences (SMDs) of < 0.2 were considered trivial, whereas > 0.5 were considered moderately large., Results: A total of 24,800 arthrodesis procedures were identified in the ASR for the period between January 1, 2017, and December 31, 2019. During the same time period, 1,305,360 cases were recorded in the NIS. Cervical fusions comprised 35.9% of the ASR cohort (8911 cases) and 36.0% of the NIS cohort (469,287 cases). The two databases presented trivial differences in terms of patient age and sex for all years of interest across both cervical and lumbar arthrodeses (SMD < 0.2). Trivial differences were also noted in the distribution of open versus percutaneous procedures of the cervical and lumbar spine (SMD < 0.2). Among lumbar cases, anterior approaches were more common in the ASR than in the NIS (32.1% vs 22.3%, SMD = 0.22), but the discrepancy among cervical cases in the two databases was trivial (SMD = 0.03). Small differences were illustrated in terms of race, with SMDs < 0.5, and a more significant discrepancy was identified in the geographic distribution of participating sites (SMDs of 0.7 and 0.74 for cervical and lumbar cases, respectively). For both of these measures, SMDs in 2019 were smaller than those in 2018 and 2017., Conclusions: The ASR and NIS databases presented a very high similarity in proportions of cervical and lumbar spine surgeries, as well as similar distributions of age and sex, and distribution of open versus endoscopic approach. Slight discrepancies in anterior versus posterior approach among lumbar cases and patient race, and more significant discrepancies in geographic representation were also identified, yet decreasing trends in differences suggested the improving representativeness of the ASR over the course of time and its progressive growth. These conclusions are important to underline the external validity of quality investigations and research conclusions to be drawn from analyses in which the ASR is used.

Introduction: Orthobiologics are increasingly used to augment healing of tissues. Despite growing demand for orthobiologic products, many health systems do not enjoy substantial savings expected with high-volume purchases. The primary goal of this study was to evaluate an institutional program designed to (1) prioritize high-value orthobiologics and (2) incentivize vendor participation in value-driven contractual programs., Methods: A three-step approach was used to reduce costs through optimization of orthobiologics supply chain. First, surgeons with orthobiologics expertise were engaged in key supply chain purchasing decisions. Second, eight orthobiologics formulary categories were defined. Capitated pricing expectations were established for each product category. Capitated pricing expectations were established for each product using institutional invoice data and market pricing data. In comparison with similar institutions, products offered by multiple vendors were priced at a lower benchmark (10th percentile of market price) than more rare products priced at the 25th percentile of the market price. Pricing expectations were transparent to vendors. Third, a competitive bidding process required vendors to submit pricing proposals for products. Clinicians and supply chain leaders jointly awarded contracts to vendors that met pricing expectations., Results: Compared with our projected estimate of $423,946 savings using capitated product prices, our actual annual savings was $542,216. Seventy-nine percent of savings came from allograft products. Although the number of total vendors decreased from 14 to 11, each of the nine returning vendors received a larger, three-year institutional contract. Average pricing decreased across seven of the eight formulary categories., Discussion: This study demonstrates a three-step replicable approach to increase institutional savings for orthobiologic products, engaging clinician experts, and strengthening relationships with select vendors. Vendor consolidation permits a symbiotic win-win relationship: Health systems achieve increased value by reducing unnecessary complexity of multiple contracts, and vendors obtain larger contracts with increased market share., Level of Evidence: Level IV study., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Objective: To assess opioid usage in surgical and nonsurgical patients with lumbar disc herniation receiving different treatments and timing of treatments., Methods: Individuals with newly diagnosed lumbar intervertebral disc herniation without myelopathy were queried from a health claims database. Patients were categorized into 3 cohorts: nonsurgical, early surgery, and late surgery. Early surgery cohort patients underwent surgery within 30 days postdiagnosis; late surgery cohort patients had surgery after 30 days but before 1 year postdiagnosis. The index date was defined as the diagnosis date for nonsurgical patients and the initial surgery date for surgical patients. The primary outcome was the average daily opioid morphine milligram equivalents (MME) prescribed. Additional outcomes included percentage of opioid-using patients and cumulative opioid burden., Results: Inclusion criteria were met by 573,082 patients: 533,226 patients received nonsurgical treatments, 22,312 patients received early surgery, and 17,544 patients received late surgery. Both surgical cohorts experienced a postsurgical increase in opioid usage, which then sharply declined and gradually plateaued, with daily opioid MME consistently lower in the early versus late surgery cohort. The early surgery cohort also consistently had a lower prevalence of opioid-using patients than the late surgery cohort. Patients receiving nonsurgical treatment demonstrated the highest 1-year post index cumulative opioid burden, and the early surgery cohort consistently had lower cumulative opioid MME than the late surgery cohort., Conclusions: Early surgery in patients with lumbar disc herniation is associated with lower long-term average daily MME, incidence of opioid use, and 1-year cumulative MME burden compared with nonsurgical and late surgery treatment approaches., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: An estimated 50 million Americans receive Medicare health care coverage. Prior studies have established a downward trend in Medicare reimbursement for commonly billed surgical procedures, but it is unclear whether these trends hold true across all neurosurgical procedures., Objective: To assess trends in utilization, charges, and reimbursement by Medicare for neurosurgical procedures after passage of the Affordable Care Act in 2010., Methods: We review yearly Physician/Supplier Procedure Summary datasets from the Centers for Medicare and Medicaid Services for all procedures billed by neurosurgeons to Medicare Part B between 2011 and 2019. Procedural coding was categorized into cranial, spine, vascular, peripheral nerve, and radiosurgery cases. Weighted averages for charges and reimbursements adjusted for inflation were calculated. The ratio of the weighted mean reimbursement to weighted mean charge was calculated as the reimbursement-to-charge ratio, representing the proportion of charges reimbursed by Medicare., Results: Overall enrollment-adjusted utilization decreased by 12.1%. Utilization decreased by 24.0% in the inpatient setting but increased by 639% at ambulatory surgery centers and 80.2% in the outpatient setting. Inflation-adjusted, weighted mean charges decreased by 4.0% while reimbursement decreased by 4.6%. Procedure groups that saw increases in reimbursement included cervical spine surgery, cranial functional and epilepsy procedures, cranial pain procedures, and endovascular procedures. Ambulatory surgery centers saw the greatest increase in charges and reimbursements., Conclusion: Although overall reimbursement declined across the study period, substantial differences emerged across procedural categories. We further find a notable shift in utilization and reimbursement for neurosurgical procedures done in non-inpatient care settings., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: In 2001, the National Academy of Medicine, formerly known as the Institute of Medicine (IOM), published their seminal work, Crossing the Quality Chasm: A New Health System for the 21st Century. In this work, the authors called for improved safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity in the United States' healthcare system. Two decades after the publication of this work, healthcare costs continue to rise, but outcomes lag other nations. The objective of this narrative review is to describe research efforts in pediatric neurosurgery with respect to the six quality aims proposed by the IOM, and highlight additional research opportunities., Methods: PubMed, Google Scholar, and EBSCOhost were queried to identify studies in pediatric neurosurgery that have addressed the aims proposed by the IOM. Studies were summarized and synthesized to develop a set of research opportunities to advance quality of care., Results: Twenty-three studies were reviewed which focused on the six quality aims proposed by the IOM. Out of these studies, five research opportunities emerged: (1) To examine performance of tools of care, (2) To understand processes surrounding care delivery, (3) To conduct cost-effectiveness analyses for a broader range of neurosurgical conditions, (4) To identify barriers driving healthcare disparities, and (5) To understand patients' and caregivers' experiences receiving care, and subsequently develop tools and programs to address their needs and preferences., Conclusion: There is a growing body of literature examining quality in pediatric neurosurgical care across all aims proposed by the IOM. However, there remains important gaps in the literature that, if addressed, will advance the quality of pediatric neurosurgical care delivery., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the "Non-Intensive CarE" (NICE) protocol to identify craniotomy patients who did not require postoperative ICU care., Objective: To determine the longitudinal impact of the NICE protocol on postoperative length of stay (LOS), ICU utilization, readmissions, and complications., Methods: In this retrospective cohort study, our institution's electronic medical record was queried to identify craniotomies before protocol deployment (May 2014-May 2018) and after deployment (May 2018-December 2021). The primary end points were average postoperative LOS and ICU utilization; secondary end points included readmissions, reoperation, and postoperative complications rate. End points were compared between pre- and postintervention cohorts., Results: Four thousand eight hundred thirty-seven craniotomies were performed from May 2014 to December 2021 (2302 preprotocol and 2535 postprotocol). Twenty-one percent of postprotocol craniotomies were enrolled in the NICE protocol. After protocol deployment, the overall postoperative LOS decreased from 4.0 to 3.5 days ( P = .0031), which was driven by deceased postoperative LOS among protocol patients (average 2.4 days). ICU utilization decreased from 57% of patients to 42% ( P < .0001), generating ∼$760 000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within 30 days; none could have been prevented through ICU stay., Conclusion: The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Importance: Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain., Objective: To understand health care utilization in patients with new-onset idiopathic neck pain., Design, Setting, and Participants: This cross-sectional study used nationally sourced longitudinal data from the IBM Watson Health MarketScan claims database (2007-2016). Participants included adult patients with newly diagnosed neck pain, no recent opioid use, and at least 1 year of continuous postdiagnosis follow-up. Exclusion criteria included prior or concomitant diagnosis of traumatic cervical disc dislocation, vertebral fractures, myelopathy, and/or cancer. Only patients with at least 1 year of prediagnosis lookback were included. Data analysis was performed from January 2021 to January 2022., Main Outcomes and Measures: The primary outcome of interest was 1-year postdiagnosis health care expenditures, including costs, opioid use, and health care service utilization. Early services were those received within 30 days of diagnosis. Multivariable regression models and regression-adjusted statistics were used., Results: In total, 679 030 patients (310 665 men [45.6%]) met the inclusion criteria, of whom 7858 (1.2%) underwent surgery within 1 year of diagnosis. The mean (SD) age was 44.62 (14.87) years among nonsurgical patients and 49.69 (9.53) years among surgical patients. Adjusting for demographics and comorbidities, 1-year regression-adjusted health care costs were $24 267.55 per surgical patient and $515.69 per nonsurgical patient. Across all health care services, $95 379 949 was accounted for by nonsurgical patients undergoing early imaging who did not receive any additional conservative therapy or epidural steroid injections, for a mean (SD) of $477.53 ($1375.60) per patient and median (IQR) of $120.60 ($20.70-$452.37) per patient. On average, patients not undergoing surgery, physical therapy, chiropractic manipulative therapy, or epidural steroid injection, who underwent either early advanced imaging (magnetic resonance imaging or computed tomography) or both early advanced and radiographic imaging, accumulated significantly elevated health care costs ($850.69 and $1181.67, respectively). Early conservative therapy was independently associated with 24.8% (95% CI, 23.5%-26.2%) lower health care costs., Conclusions and Relevance: In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.

Study Design: This was a retrospective comparative study., Objective: The objective of this study was to assess the effect of increased age on perioperative and postoperative complication rates, reoperation rates, and patient-reported pain and disability scores after lateral lumbar interbody fusion (LLIF)., Summary of Background Data: LLIF was developed to minimize soft tissue trauma and reduce the risk of vascular injury; however, there is little evidence regarding the effect of advanced age on outcomes of LLIF., Methods: Patients who underwent LLIF from 2009 to 2019 at one institution with a minimum 6-month follow-up were retrospectively reviewed. Patients less than 18 years old with musculoskeletal tumor or trauma were excluded. The primary outcome was the preoperative to postoperative change in the Numeric Pain Rating Scale (NPRS) for back pain. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and change in Oswestry Disability Index were also evaluated. Relationships with age were assessed both with age as a continuous variable and segmenting by age below 70 versus 70+., Results: In total, 279 patients were included. The median age was 65±13 years and 159 (57%) were female. Age was not related to improvements in back NPRS and Oswestry Disability Index. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and radiographic fusion rate also were not related to age. After multivariable risk adjustment, increasing age was associated with greater improvements in back NPRS. The decrease in back NPRS was 0.68 (95% confidence interval: 0.14, 1.22; P=0.014) points greater for every 10-year increase in age. Age was not associated with rates of complication, readmission, or reoperation., Conclusions: LLIF is a safe and effective procedure in the elderly population. Advanced age is associated with larger improvements in preoperative back pain. Surgeons should consider the benefits of LLIF and other minimally invasive techniques when evaluating elderly candidates for lumbar fusion., Level of Evidence: Level III., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The natural history of seizure risk after brain tumor resection is not well understood. Identifying seizure-naive patients at highest risk for postoperative seizure events remains a clinical need. In this study, the authors sought to develop a predictive modeling strategy for anticipating postcraniotomy seizures after brain tumor resection., Methods: The IBM Watson Health MarketScan Claims Database was canvassed for antiepileptic drug (AED)- and seizure-naive patients who underwent brain tumor resection (2007-2016). The primary event of interest was short-term seizure risk (within 90 days postdischarge). The secondary event of interest was long-term seizure risk during the follow-up period. To model early-onset and long-term postdischarge seizure risk, a penalized logistic regression classifier and multivariable Cox regression model, respectively, were built, which integrated patient-, tumor-, and hospitalization-specific features. To compare empirical seizure rates, equally sized cohort tertiles were created and labeled as low risk, medium risk, and high risk., Results: Of 5470 patients, 983 (18.0%) had a postdischarge-coded seizure event. The integrated binary classification approach for predicting early-onset seizures outperformed models using feature subsets (area under the curve [AUC] = 0.751, hospitalization features only AUC = 0.667, patient features only AUC = 0.603, and tumor features only AUC = 0.694). Held-out validation patient cases that were predicted by the integrated model to have elevated short-term risk more frequently developed seizures within 90 days of discharge (24.1% high risk vs 3.8% low risk, p < 0.001). Compared with those in the low-risk tertile by the long-term seizure risk model, patients in the medium-risk and high-risk tertiles had 2.13 (95% CI 1.45-3.11) and 6.24 (95% CI 4.40-8.84) times higher long-term risk for postdischarge seizures. Only patients predicted as high risk developed status epilepticus within 90 days of discharge (1.7% high risk vs 0% low risk, p = 0.003)., Conclusions: The authors have presented a risk-stratified model that accurately predicted short- and long-term seizure risk in patients who underwent brain tumor resection, which may be used to stratify future study of postoperative AED prophylaxis in highest-risk patient subpopulations.

Objective: Intradural spinal tumors are uncommon and while associations between clinical characteristics and surgical outcomes have been explored, there remains a paucity of literature unifying diverse predictors into an integrated risk model. To predict postresection outcomes for patients with spinal tumors., Methods: IBM MarketScan Claims Database was queried for adult patients receiving surgery for intradural tumors between 2007 and 2016. Primary outcomes-of-interest were nonhome discharge and 90-day postdischarge readmissions. Secondary outcomes included hospitalization duration and postoperative complications. Risk modeling was developed using a regularized logistic regression framework (LASSO, least absolute shrinkage and selection operator) and validated in a withheld subset., Results: A total of 5,060 adult patients were included. Most surgeries utilized a posterior approach (n = 5,023, 99.3%) and tumors were most commonly found in the thoracic region (n = 1,941, 38.4%), followed by the lumbar (n = 1,781, 35.2%) and cervical (n = 1,294, 25.6%) regions. Compared to models using only tumor-specific or patient-specific features, our integrated models demonstrated better discrimination (area under the curve [AUC] [nonhome discharge] = 0.786; AUC [90-day readmissions] = 0.693) and accuracy (Brier score [nonhome discharge] = 0.155; Brier score [90-day readmissions] = 0.093). Compared to those predicted to be lowest risk, patients predicted to be highest-risk for nonhome discharge required continued care 16.3 times more frequently (64.5% vs. 3.9%). Similarly, patients predicted to be at highest risk for postdischarge readmissions were readmitted 7.3 times as often as those predicted to be at lowest risk (32.6% vs. 4.4%)., Conclusion: Using a diverse set of clinical characteristics spanning tumor-, patient-, and hospitalization-derived data, we developed and validated risk models integrating diverse clinical data for predicting nonhome discharge and postdischarge readmissions.

Study Design: This was a retrospective cohort studying using a national administrative database., Objective: The objective of this study was to determine the postoperative complications and quality outcomes of the human immunodeficiency virus (HIV)-positive patients undergoing surgical management for lumbar degenerative disease (LDD)., Methods: This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether they were HIV positive at the time of surgery. Multivariate regression was utilized to reduce the confounding of baseline covariates. Patients who underwent 3 or more levels of surgical correction were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined., Results: A total of 120,167 patients underwent primary lumbar degenerative surgery, of which 309 (0.26%) were HIV positive. In multivariate regression analysis, the HIV-positive cohort was more likely to be readmitted at 30 days [odds ratio (OR)=1.9, 95% confidence interval (CI): 1.2-2.8], 60 days (OR=1.7, 95% CI: 1.2-2.5), and 90 days (OR=1.5, 95% CI: 1.0-2.2). The HIV-positive cohort was also more likely to experience any postoperative complication (OR=1.7, 95% CI: 1.2-2.3). Of the major drivers identified, HIV-positive patients had significantly greater odds of cerebrovascular disease and postoperative neurological complications (OR=3.8, 95% CI: 1.8-6.9) and acute kidney injury (OR=3.4, 95% CI: 1.3-7.1). Costs of index hospitalization were not significantly different between the 2 cohorts ($30,056 vs. $29,720, P=0.6853). The total costs were also similar throughout the 2-year follow-up period., Conclusion: Patients who are HIV positive at the time of LDD surgery are at a higher risk for postoperative central nervous system and renal complications and unplanned readmissions., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This is a retrospective cohort study., Objective: The aim was to identify the risk factors for revision surgery within 2 years of patients undergoing primary adult spinal deformity (ASD) surgery., Summary of Background Data: Previous literature reports estimate 20% of patients undergoing thoracolumbar ASD correction undergo reoperation within 2 years. There is limited published data regarding specific risk factors for reoperation in ASD surgery in the short term and long term., Methods: The authors queried the MarketScan database in order to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2015. Patient-level factors and revision risk were investigated during 2 years after primary ASD surgery. Patients under the age of 18 years and those with any prior history of trauma or tumor were excluded from this study., Results: A total 7422 patients underwent ASD surgery during 2007-2015 in the data set. Revision rates were 13.1% at 90 days, 14.5% at 6 months, 16.7% at 1 year, and 19.3% at 2 years. In multivariate multiple logistic regression analysis, obesity [adjusted odds ratio (OR): 1.58, P<0.001] and tobacco use (adjusted OR: 1.38, P=0.0011) were associated with increased odds of reoperation within 2 years. Patients with a combined anterior-posterior approach had lower odds of reoperation compared with those with posterior only approach (adjusted OR: 0.66, P=0.0117)., Conclusions: Obesity and tobacco are associated with increased odds of revision surgery within 2 years of index ASD surgery. Male sex and combined surgical approach are associated with decreased odds of revision surgery., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This was a retrospective study., Objective: The objective of this study was to identify the impact of diabetes on postoperative outcomes in Medicare patients undergoing adult spinal deformity (ASD) surgery., Methods: We queried the MarketScan Medicare database to identify patients who underwent ASD surgery from 2007 to 2016. Patients were then stratified based on diabetes status at the time of the index operation. Patients not enrolled in the Medicare dataset and those with any prior history of trauma or tumor were excluded from this study., Results: A total of 2564 patients met the inclusion criteria of this study, of which n=746 (29.1.%) were diabetic. Patients with diabetes had a higher rate of postoperative infection than nondiabetic patients (3.1% vs. 1.7%, P<0.05) within 90 days. Renal complications were also more elevated in the diabetic cohort (3.2% vs. 1.3%, P<0.05). Readmission rates were significantly higher in the diabetes cohort through of 60 days (15.2% vs. 11.8%, P<0.05) and 90 days (17.0% vs. 13.4%, P<0.05). When looking specifically at the outpatient payments, patients with diabetes did have a higher financial burden at 60 days ($8147 vs. $6956, P<0.05) and 90 days ($10,126 vs. $8376, P<0.05)., Conclusions: In this study, diabetic patients who underwent ASD surgery had elevated rates of postoperative infection, outpatient costs, and rates of readmissions within 90 days. Further research should investigate the role of poor glycemic control on spine surgery outcomes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To identify the impact of osteoporosis (OS) on postoperative outcomes in Medicare patients undergoing ASD surgery., Background: Patients with OP and advanced age experience higher than average rates of ASD. However, poor bone density could undermine the durability of a deformity correction., Methods: We queried the MarketScan Medicare Supplemental database to identify patients Medicare patients who underwent ASD surgery from 2007 to 2016., Results: A total of 2564 patients met the inclusion criteria of this study, of whom n = 971 (61.0%) were diagnosed with osteoporosis. Patients with OP had a similar 90-day postoperative complication rates (OP: 54.6% vs. non-OP: 49.2%, p = 0.0076, not significant after multivariate regression correction). This was primarily driven by posthemorrhagic anemia (37.6% in OP, vs. 33.1% in non-OP). Rates of revision surgery were similar at 90 days (non-OP 15.0%, OP 16.8%), but by 2 years, OP patients had a significantly higher reoperation rate (30.4% vs. 22.9%, p < 0.0001). In multivariate regression analysis, OP increased odds for revision surgery at 1 year (OR 1.4) and 2 years (OR 1.5) following surgery (all p < 0.05). OP was also an independent predictor of readmission at all time points (90 days, OR 1.3, p < 0.005)., Conclusion: Medicare patients with OP had elevated rates of complications, reoperations, and outpatient costs after undergoing primary ASD surgery., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background Context: We lack models that reliably predict 30-day postoperative adverse events (AEs) following spine surgery., Purpose: We externally validated a previously developed predictive model for common 30-day adverse events (AEs) after spine surgery., Study Design/setting: This prospective cohort study utilizes inpatient and outpatient data from a tertiary academic medical center., Patient Sample: We assessed a prospective cohort of all 276 adult patients undergoing spine surgery in the Department of Neurosurgery at a tertiary academic institution between April 1, 2018 and October 31, 2018. No exclusion criteria were applied., Outcome Measures: Incidence of observed AEs was compared with predicted incidence of AEs. Fifteen assessed AEs included: pulmonary complications, congestive heart failure, neurological complications, pneumonia, cardiac dysrhythmia, renal failure, myocardial infarction, wound infection, pulmonary embolus, deep venous thrombosis, wound hematoma, other wound complication, urinary tract infection, delirium, and other infection., Methods: Our group previously developed the Risk Assessment Tool for Adverse Events after Spine Surgery (RAT-Spine), a predictive model of AEs within 30 days following spine surgery using a cohort of approximately one million patients from combined Medicare and MarketScan databases. We applied RAT-Spine to the single academic institution prospective cohort by entering each patient's preoperative medical and demographic characteristics and surgical type. The model generated a patient-specific overall risk score ranging from 0 to 1 representing the probability of occurrence of any AE. The predicted risks are presented as absolute percent risk and divided into low (<17%), medium (17%-28%), and high (>28%)., Results: Among the 276 patients followed prospectively, 76 experienced at least one 30-day postoperative AE. Slightly more than half of the cohort were women (53.3%). The median age was slightly lower in the non-AE cohort (63 vs. 66.5 years old). Patients with Medicaid comprised 2.5% of the non-AE cohort and 6.6% of the AE cohort. Spinal fusion was performed in 59.1% of cases, which was comparable across cohorts. There was good agreement between the predicted AE and observed AE rates, Area Under the Curve (AUC) 0.64 (95% CI 0.56-0.710). The incidence of observed AEs in the prospective cohort was 17.8% among the low-risk group, 23.0% in the medium-risk group, and 38.4% in the high risk group (p =.003)., Conclusions: We externally validated a model for postoperative AEs following spine surgery (RAT-Spine). The results are presented as low-, moderate-, and high-risk designations., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background Context: Despite established guidelines, long-term management of surgically-treated low back pain (LBP) and lower extremity pain (LEP) remains heterogeneous. Understanding care heterogeneity could inform future approaches for standardization of practices., Purpose: To describe treatment heterogeneity in surgically-managed LBP and LEP., Study Design/setting: Retrospective study of a nationwide commercial database spanning inpatient and outpatient encounters for enrollees of eligible employer-supplied healthcare plans (2007-2016)., Patient Sample: A population-based sample of opioid-naïve adult patients with newly-diagnosed LBP or LEP were identified. Inclusion required at least 12-months of pre-diagnosis and post-diagnosis continuous follow-up., Exposure: Included treatments/evaluations include conservative management (chiropractic manipulative therapy, physical therapy, epidural steroid injections), imaging (x-ray, MRI, CT), pharmaceuticals (opioids, benzodiazepines), and spine surgery (decompression, fusion)., Outcome Measures: Primary outcomes-of-interest were 12-month net healthcare expenditures (inpatient and outpatient) and 12-month opioid usage., Methods: Analyses include interrogation of care sequence heterogeneity and temporal trends in sequence-initiating services. Comparisons were conducted in the framework of sequence-specific treatment sequences, which reflect the personalized order of healthcare services pursued by each patient. Outlier sequences characterized by high opioid use and costs were identified from frequently observed surgical treatment sequences using Mahalanobis distance., Results: A total of 2,496,908 opioid-naïve adult patients with newly-diagnosed LBP or LEP were included (29,519 surgical). In the matched setting, increased care sequence heterogeneity was observed in surgical patients (0.51 vs. 0.12 previously-unused interventions/studies pursued per month). Early opioid and MRI use has decreased between 2008 and 2015 but is matched by increases in early benzodiazepine and x-ray use. Outlier sequences, characterized by increased opioid use and costs, were found in 5.8% of surgical patients. Use of imaging prior to conservative management was common in patients pursuing outlier sequences compared to non-outlier sequences (96.5% vs. 63.8%, p<.001). Non-outlier sequences were more frequently characterized by early conservative interventions (31.9% vs. 7.4%, p<.001)., Conclusions: Surgically-managed LBP and LEP care sequences demonstrate high heterogeneity despite established practice guidelines. Outlier sequences associated with high opioid usage and costs can be identified and are characterized by increased early imaging and decreased early conservative management. Elements that may portend suboptimal longitudinal management could provide opportunities for standardization of patient care., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background Context: Despite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection., Methods: The IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6 months of continuous preadmission baseline data and 12 months of continuous postdischarge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%., Results: A total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with postdischarge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% confidence interval [CI] 1.1-38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3-32.9). Pre- and perioperative use of prescribed nonsteroidal anti-inflammatory drugs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased postdischarge opioid and benzodiazepine use. Intramedullary location was associated with longer duration postdischarge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5-19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (area under curve [AUC]=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients., Conclusions: We developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

As the use of machine learning algorithms in the development of clinical prediction models has increased, researchers are becoming more aware of the deleterious effects that stem from the lack of reporting standards. One of the most obvious consequences is the insufficient reproducibility found in current prediction models. In an attempt to characterize methods to improve reproducibility and to allow for better clinical performance, we utilize a previously proposed taxonomy that separates reproducibility into 3 components: technical, statistical, and conceptual reproducibility. By following this framework, we discuss common errors that lead to poor reproducibility, highlight the importance of generalizability when evaluating a ML model's performance, and provide suggestions to optimize generalizability to ensure adequate performance. These efforts are a necessity before such models are applied to patient care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose/aim: To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity., Methods: The Thomson Reuters MarketScan national longitudinal database was used to identify patients undergoing osteotomy, posterior instrumentation, and fusion for treatment of spinal deformity with or without image-guided navigation between 2007-2016. Conventional and navigated groups were propensity-matched (1:1) to normalize differences between demographics, comorbidities, and surgical characteristics. Clinical outcomes and charges were compared between matched groups using bivariate analyses., Results: A total of 4,604 patients were identified as having undergone deformity correction, of which 286 (6.2%) were navigated. Propensity-matching resulted in a total of 572 well-matched patients for subsequent analyses, of which half were navigated. Rate of mechanical instrumentation-related complications was found to be significantly lower for navigated procedures ( p  = 0.0371). Navigation was also associated with lower rates of 90-day unplanned readmissions ( p  = 0.0295), as well as 30- and 90-day postoperative revisions (30-day: p  = 0.0304, 90-day: p  = 0.0059). Hospital, physician, and total payments favored the conventional group for initial admission ( p  = 0.0481, 0.0001, 0.0019, respectively); however, when taking into account costs of readmissions, hospital payments became insignificantly different between the two groups., Conclusions: Procedures involving image-guided navigation resulted in decreased instrumentation-related complications, unplanned readmissions, and postoperative revisions, highlighting its potential utility for the treatment of spine deformity. Future advances in navigation technologies and methodologies can continue to improve clinical outcomes, decrease costs, and facilitate widespread adoption of navigation for deformity correction.

Study Design: Retrospective cohort studying using a national, administrative database., Objective: The aim of this study was to determine the postoperative complications and quality outcomes of patients with and without obesity undergoing surgical management for lumbar degenerative disease (LDD)., Summary of Background Data: Obesity is a global epidemic that negatively impacts health outcomes. Characterizing the effect of obesity on LDD surgery is important given the growing elderly obese population., Methods: This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether the patient had a concurrent diagnosis of obesity at time of surgery. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between patients with and without obesity. Patients who underwent three or more levels surgical correction, were under the age of 18 years, or those with any previous history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined., Results: A total of 67,215 patients underwent primary lumbar degenerative surgery, of which 22,405 (33%) were obese. After propensity score matching, baseline covariates of the two cohorts were similar. The complication rate was 8.3% in the nonobese cohort and 10.4% in the obese cohort (P < 0.0001). Patients with obesity also had longer lengths of stay (2.7 days vs. 2.4 days, P < 0.05), and higher rates of reoperation and readmission at all time-points through the study follow-up period to their nonobese counterparts (P < 0.05). Including payments after discharge, lumbar degenerative surgery in patients with obesity was associated with higher payments throughout the 2-year follow-up period ($68,061 vs. $59,068 P < 0.05)., Conclusion: Patients with a diagnosis of obesity at time of LDD surgery are at a higher risk for postoperative complications, reoperation, and readmission.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Venous thromboembolism (VTE) management increasingly involves anticoagulation with direct oral anticoagulants (DOACs). Few studies have used competing-risks analyses to ascertain the mortality-adjusted hemorrhage and recurrent VTE (rVTE) risk of individual DOACs. Furthermore, hemorrhage risk factors in patients treated with apixaban remain underexplored., Materials and Methods: Patients diagnosed with VTE receiving anticoagulation were identified from the Optum Clinformatics Data Mart (2003-2019). Study endpoints included readmissions for intracranial hemorrhage (ICH), non-intracranial hemorrhage (non-ICH hemorrhage), and rVTE. Coarsened exact matching was used to balance baseline clinical characteristics. Complication incidence was evaluated using a competing-risks framework. We additionally modeled hemorrhage risk in apixaban-treated patients., Results: Overall, 225,559 patients were included, of whom 34,201 received apixaban and 46,007 received rivaroxaban. Compared to rivaroxaban, apixaban was associated with decreased non-ICH hemorrhage (sHR = 0.560, 95%CI = 0.423-0.741), but not ICH, and rVTE (sHR = 0.802, 95%CI = 0.651-0.988) risk. This was primarily in emergent readmissions (sHR[emergent hemorrhage] = 0.515, 95%CI = 0.372-0.711; sHR[emergent rVTE] = 0.636, 95%CI = 0.488-0.830). Contributors to emergent hemorrhage in apixaban-treated patients include older age (sHR = 1.025, 95%CI = 1.011-1.039), female sex (sHR = 1.662, 95%CI = 1.252-2.207), prior prescription antiplatelet therapy (sHR = 1.591, 95%CI = 1.130-2.241), and complicated hypertension (sHR = 1.936, 95%CI = 1.134-3.307). Patients anticipated to be "high-risk" experienced elevated ICH (sHR = 3.396, 95%CI = 1.375-8.388) and non-ICH hemorrhage (sHR = 3.683, 95%CI = 2.957-4.588) incidence., Conclusions: In patients with VTE receiving anticoagulation, apixaban was associated with reduced non-ICH hemorrhage and rVTE risk, compared to rivaroxaban. Risk reduction was restricted to emergent readmissions. We present a risk-stratification approach to predict hemorrhage in patients receiving apixaban, potentially guiding future clinical decision-making., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Anterior cervical discectomy and fusion (ACDF) is effective for the treatment of single-level cervical spondylotic myelopathy (CSM). However, the data surrounding multilevel CSM have remained controversial. One alternative is laminoplasty, although evidence comparing these strategies has remained sparse. In the present report, we retrospectively reviewed the readmission and reoperation rates for patients who had undergone ACDF or laminoplasty for multilevel CSM from a national longitudinal administrative claims database., Methods: We queried the MarketScan Commercial Claims and Encounters database to identify patients who had undergone ACDF or laminoplasty for multilevel CSM from 2007 to 2016. The patients were stratified by operation type. Patients aged <18 years, patients with a history of tumor or trauma, and patients who had undergone anteroposterior approach were excluded from the present study., Results: A total of 5445 patients were included, of whom 1521 had undergone laminoplasty. A matched cohort who had undergone ACDF was identified. The overall 90-day postoperative complication rate was greater in the laminoplasty cohort (odds ratio, 1.48; 95% confidence interval, 1.18-1.86; P < 0.0001). The mean length of stay and 90-day readmission rates were greater in the laminoplasty cohort. The hospital and total payments of the index hospitalization were greater in the ACDF cohort, as were the total payments for ≤2 years after the index hospitalization., Conclusions: In the present administrative claims database study, no difference was found in the reoperation rate between ACDF and laminoplasty. ACDF resulted in fewer complications and readmissions compared with laminoplasty but was associated with greater costs. Additional prospective research is required to investigate the factors driving the higher costs of ACDF in this population and the long-term clinical outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To determine postoperative complications and quality outcomes of single-stage and multistage surgical management for lumbar degenerative disease (LDD)., Methods: This retrospective cohort study using a national administrative database identified patients who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether their surgeon chose to perform single-stage or multistage LDD surgery, and these cohorts were mutually exclusive. Propensity score matching was used to mitigate intergroup differences between single-stage and multistage patients. Patients who underwent ≥3 levels of surgical correction, who were <18 years old, or who had any prior history of trauma or tumor were excluded from the study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined., Results: Primary surgery for LDD was performed in 47,190 patients; 9438 (20%) of these patients underwent multistage surgery. After propensity score matching, baseline covariates of the 2 cohorts were similar. The complication rate was 6.1% in the single-stage cohort and 11.0% in the multistage cohort. Rates of posthemorrhagic anemia, infection, wound complication, deep vein thrombosis, and hematoma all were higher in the multistage cohort. Length of stay, revisions, and readmissions were also significantly higher in the multistage cohort. Through 2 years of follow-up, multistage surgery was associated with higher payments throughout the 2-year follow-up period ($57,036 vs. $39,318, P < 0.05)., Conclusions: Single-stage surgery for LDD demonstrated improved outcomes and lower health care utilization. Spine surgeons should carefully consider single-stage surgery when treating patients with LDD requiring <3 levels of correction., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To provide insight into postoperative complications, short-term quality outcomes, and costs of the surgical approaches of adult cervical deformity (ACD)., Methods: A national database was queried from 2007 to 2016 to identify patients who underwent cervical fusion for ACD. Patients were stratified by approach type-anterior, posterior, or circumferential. Patients undergoing anterior and posterior approach surgeries were additionally compared using propensity score matching., Results: A total of 6575 patients underwent multilevel cervical fusion for ACD correction. Circumferential fusion had the highest postoperative complication rate (46.9% vs posterior: 36.7% vs anterior: 18.5%, P < .0001). Anterior fusion patients more commonly required reoperation compared with posterior fusion patients ( P < .0001), and 90-day readmission rate was highest for patients undergoing circumferential fusion ( P < .0001). After propensity score matching, the complication rate remained higher in the posterior, as compared to the anterior fusion group ( P < .0001). Readmission rate also remained higher in the posterior fusion group; however, anterior fusion patients were more likely to require reoperation. At index hospitalization, posterior fusion led to 1.5× higher costs, and total payments at 90 days were 1.6× higher than their anterior fusion counterparts., Conclusion: Patients who undergo posterior fusion for ACD have higher complication rates, readmission rates, and higher cost burden than patients who undergo anterior fusion; however, posterior correction of ACD is associated with a lower rate of reoperation.

Objective: Status epilepticus (SE) is associated with significant mortality, cost, and risk of future seizures. In one of the first studies of SE after neurosurgery, the authors assess the incidence, risk factors, and outcome of postneurosurgical SE (PNSE)., Methods: Neurosurgical admissions from the MarketScan Claims and Encounters database (2007 through 2015) were assessed in a longitudinal cross-sectional sample of privately insured patients who underwent qualifying cranial procedures in the US and were older than 18 years of age. The incidence of early (in-hospital) and late (postdischarge readmission) SE and associated mortality was assessed. Procedural, pathological, demographic, and anatomical covariates parameterized multivariable logistic regression and Cox models. Multivariable logistic regression and Cox proportional hazards models were used to study the incidence of early and late PNSE. A risk-stratification simulation was performed, combining individual predictors into singular risk estimates., Results: A total of 197,218 admissions (218,217 procedures) were identified. Early PNSE occurred during 637 (0.32%) of 197,218 admissions for cranial neurosurgical procedures. A total of 1045 (0.56%) cases of late PNSE were identified after 187,771 procedure admissions with nonhospice postdischarge follow-up. After correction for comorbidities, craniotomy for trauma, hematoma, or elevated intracranial pressure was associated with increased risk of early PNSE (adjusted OR [aOR] 1.538, 95% CI 1.183-1.999). Craniotomy for meningioma resection was associated with an increased risk of early PNSE compared with resection of metastases and parenchymal primary brain tumors (aOR 2.701, 95% CI 1.388-5.255). Craniotomies for infection or abscess (aHR 1.447, 95% CI 1.016-2.061) and CSF diversion (aHR 1.307, 95% CI 1.076-1.587) were associated with highest risk of late PNSE. Use of continuous electroencephalography in patients with early (p < 0.005) and late (p < 0.001) PNSE rose significantly over the study time period. The simulation regression model predicted that patients at high risk for early PNSE experienced a 1.10% event rate compared with those at low risk (0.07%). Similarly, patients predicted to be at highest risk for late PNSE were significantly more likely to eventually develop late PNSE than those at lowest risk (HR 54.16, 95% CI 24.99-104.80)., Conclusions: Occurrence of early and late PNSE was associated with discrete neurosurgical pathologies and increased mortality. These data provide a framework for prospective validation of clinical and perioperative risk factors and indicate patients for heightened diagnostic suspicion of PNSE.

Study Design: This is a retrospective cohort study using a nationally representative administrative database., Objective: To identify the impact of obesity on postoperative outcomes in patients undergoing thoracolumbar adult spinal deformity (ASD) surgery., Background: The obesity rate in the United States remains staggering, with approximately one-third of all Americans being overweight or obese. However, the impact of elevated body mass index on spine surgery outcomes remains unclear., Methods: We queried the MarketScan database to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2016. Patients were then stratified by whether or not they were diagnosed as obese at index surgical admission. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between obese and nonobese patients. Patients <18 years and those with any prior history of trauma or tumor were excluded from this study. Baseline demographics and comorbidities, postoperative complication rates, and short- and long-term reoperation rates were determined., Results: A total of 7423 patients met the inclusion criteria of this study, of whom 597 (8.0%) were obese. Initially, patients with obesity had a higher 90-day postoperative complication rate than nonobese patients (46.1% vs 40.8%, P < .05); however, this difference did not remain after PSM. Revision surgery rates after 2 years were similar across the 2 groups following primary surgery (obese, 21.4%, vs nonobese, 22.0%; P = .7588). Health care use occurred at a higher rate among obese patients through 2 years of long-term follow-up (obese, $152 930, vs nonobese, $140 550; P < .05)., Conclusion: Patients diagnosed with obesity who underwent ASD surgery did not demonstrate increased rates of complications, reoperations, or readmissions. However, overall health care use through 2 years of follow-up after index surgery was higher in the obesity cohort.

Aims: The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults., Methods: We identified adult patients who underwent corrective cervical spinal surgery between 1 January 2007 and 31 December 2015 from the MarketScan database. The baseline comorbidities and characteristics of the operation were recorded. Adverse events were defined as the development of a complication, an unanticipated deleterious postoperative event, or further surgery. Patients aged < 18 years and those with a previous history of tumour or trauma were excluded from the study., Results: A total of 13,549 adults in the database underwent primary corrective surgery for a cervical spinal deformity during the study period. A total of 3,785 (27.9%) had a complication within 90 days of the procedure, and 3,893 (28.7%) required further surgery within two years. In multivariate analysis, male sex (odds ratio (OR) 0.90 (95% confidence interval (CI) 0.8 to 0.9); p = 0.019) and a posterior approach (compared with a combined surgical approach, OR 0.66 (95% CI 0.5 to 0.8); p < 0.001) significantly decreased the risk of complications. Osteoporosis (OR 1.41 (95% CI 1.3 to 1.6); p < 0.001), dyspnoea (OR 1.48 (95% CI 1.3 to 1.6); p < 0.001), cerebrovascular accident (OR 1.81 (95% CI 1.6 to 2.0); p < 0.001), a posterior approach (compared with an anterior approach, OR 1.23 (95% CI 1.1 to 1.4); p < 0.001), and the use of bone morphogenic protein (BMP) (OR 1.22 (95% CI 1.1 to 1.4); p = 0.003) significantly increased the risks of 90-day complications. In multivariate regression analysis, preoperative dyspnoea (OR 1.50 (95% CI 1.3 to 1.7); p < 0.001), a posterior approach (compared with an anterior approach, OR 2.80 (95% CI 2.4 to 3.2; p < 0.001), and postoperative dysphagia (OR 2.50 (95% CI 1.8 to 3.4); p < 0.001) were associated with a significantly increased risk of further surgery two years postoperatively. A posterior approach (compared with a combined approach, OR 0.32 (95% CI 0.3 to 0.4); p < 0.001), the use of BMP (OR 0.48 (95% CI 0.4 to 0.5); p < 0.001) were associated with a significantly decreased risk of further surgery at this time., Conclusion: The surgical approach and intraoperative use of BMP strongly influence the risk of further surgery, whereas the comorbidity burden and the characteristics of the operation influence the rates of early complications in adult patients undergoing corrective cervical spinal surgery. These data may aid surgeons in patient selection and surgical planning. Cite this article: Bone Joint J  2021;103-B(4):734-738.

Objective: Anticipating postdischarge complications after neurosurgery remains difficult. The LACE index, based on 4 hospitalization descriptors, stratifies patients by risk of 30-day postdischarge adverse events but has not been validated in a procedure-specific manner in neurosurgery. Our study sought to explore the usefulness of the LACE index in a population undergoing cranial neurosurgery and to develop an enhanced model, LACE-Cranial., Methods: The OptumClinformatics Database was used to identify cranial neurosurgery admissions (2004-2017). Procedures were grouped as trauma/hematoma/intracranial pressure, open vascular, functional/pain, skull base, tumor, or endovascular. Adverse events were defined as postdischarge death/readmission. LACE-Cranial was developed using a logistic regression framework incorporating an expanded feature set in addition to the original LACE components., Results: A total of 40,431 admissions were included. Predictions of 30-day readmissions was best for skull base (area under the curve [AUC], 0.636) and tumor (AUC, 0.63) admissions but was generally poor. Predictive ability of 30-day mortality was best for functional/pain admissions (AUC, 0.957) and poorest for trauma/hematoma/intracranial pressure admissions (AUC, 0.613). Across procedure types except for functional/pain, a high-risk LACE score was associated with higher postdischarge bundled payment costs. Incorporating features identified to contribute independent predictive value, the LACE-Cranial model achieved procedure-specific 30-day mortality AUCs ranging from 0.904 to 0.98. Prediction of 30-day and 90-day readmissions was also improved, with tumor and skull base cases achieving 90-day readmission AUCs of 0.718 and 0.717, respectively., Conclusions: Although the unmodified LACE index shows inconsistent classification performance, the enhanced LACE-Cranial model offers excellent prediction of short-term postdischarge mortality across procedure groups and significantly improved anticipation of short-term postdischarge readmissions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: This was an epidemiological study using national administrative data from the MarketScan database., Objective: To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease., Methods: We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into "Early RT" if they received RT within 4 weeks of surgery and as "Late RT" if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes., Results: A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications ( P = .574)., Conclusions: When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.

Study Design: Retrospective longitudinal cohort., Objective: We investigated opioid prescribing patterns amongst adults in the United States diagnosed with low back or lower extremity pain (LBP/LEP) who underwent spine surgery., Summary of Background Data: Opioid-based treatment of LBP/LEP and postsurgical pain has separately been associated with chronic opioid use, but a combined and large-scale cohort study is missing., Methods: This study utilizes commercial inpatient, outpatient, and pharmaceutical insurance claims. Between 2008 and 2015, patients without previous prescription opioids with a new diagnosis of LBP/LEP who underwent surgery within 1 year after diagnosis were enrolled. Opioid prescribing patterns after LBP/LEP diagnosis and after surgery were evaluated. All patients had 1-year postoperative follow-up. Low and high frequency (6 or more refills in 12 months) opioid prescription groups were identified., Results: A total of 25,506 patients without previous prescription opioids were diagnosed with LBP/LEP and underwent surgery within 1 year of diagnosis. After LBP/LEP diagnosis, 18,219 (71.4%) were prescribed opioids, whereas 7287 (28.6%) were not. After surgery, 2952 (11.6%) were prescribed opioids with high frequency and 22,554 (88.4%) with low frequency. Among patients prescribed opioids before surgery, those with high-frequency prescriptions were more likely to continue this pattern postoperatively than those with low frequency prescriptions preoperatively (OR 2.15, 95% CI 1.97-2.34). For those prescribed opioids preoperatively, average daily morphine milligram equivalent (MME) decreased after surgery (by 2.62 in decompression alone cohort and 0.25 in arthrodesis cohort, P < 0.001). Postoperative low-frequency patients were more likely than high-frequency patients to discontinue opioids one-year after surgery (OR 3.78, 95% CI 3.59-3.99). Postoperative high-frequency patients incurred higher cost than low-frequency patients. Postoperative high-frequency prescribing varied widely across states (4.3%-20%)., Conclusion: A stepwise association exists between opioid use after LEP or LBP diagnosis and frequency and duration of opioid prescriptions after surgery. Simultaneously, the strength of prescriptions as measured by MME decreased following surgery., Level of Evidence: 3.

Background: In cases of adult spinal deformity (ASD) with severe sagittal malalignment, the use of osteotomies may be necessary in addition to posterior fusion. However, few data exist describing the impact of osteotomies on complications and quality outcomes during ASD surgery., Methods: We queried the MarketScan database to identify patients who underwent ASD surgery in 2007-2016. Patients were stratified according to whether or not an osteotomy was used in the index operation. Propensity score matching was used to mitigate intergroup differences between osteotomy and nonosteotomy groups. Patients <18 years old and patients with any prior history of trauma or tumor were excluded from the study., Results: Of 7423 patients who met the inclusion criteria of this study, 2700 (36.4%) received an osteotomy. After propensity score matching, baseline comorbidities and approach type were similar between cohorts. The overall 90-day complication rate was 43.2% in the nonosteotomy group and 52.8% in the osteotomy group (P < 0.0001). The osteotomy cohort also had significantly higher rates of revision surgeries through 2 years (21.1% vs. 18.0%, P < 0.05) following index surgery. Patients who received a 3-column osteotomy had the highest procedural payments, costing $155,885 through 90 days and $167,161 through 1 year following surgery., Conclusions: This analysis confirms high costs and complication, readmission, and reoperation rates until 2 years after ASD surgery in general, which are even higher in cases where an osteotomy is required. Future research should explore strategies for optimizing patient outcomes following osteotomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: An epidemiological study using national administrative data from the MarketScan database., Objective: The aim of this study was to identify the impact of bone morphogenetic protein (BMP) on postoperative outcomes in patients undergoing adult cervical deformity (ACD) surgery., Summary of Background Data: BMP has been shown to stimulate bone growth and improve fusion rates in spine surgery. However, the impact of BMP on reoperation rates and postoperative complication rate is controversial., Methods: We queried the MarketScan database to identify patients who underwent ACD surgery from 2007 to 2015. Patients were stratified by BMP use in the index operation. Patients <18 years and those with any history of tumor or trauma were excluded. Baseline demographics and comorbidities, postoperative complication rates, and reoperation rates were analyzed., Results: A total of 13,549 patients underwent primary ACD surgery, of which 1155 (8.5%) had intraoperative BMP use. The overall 90-day complication rate was 27.6% in the non-BMP cohort and 31.1% in the BMP cohort (P < 0.05). Patients in the BMP cohort had longer average length of stay (4.0 days vs. 3.7 days, P < 0.05) but lower revision surgery rates at 90 days (14.5% vs. 28.3%, P < 0.05), 6 months (14.9% vs. 28.6%, P < 0.05), 1 year (15.7% vs. 29.2%, P < 0.05), and 2 years (16.5% vs. 29.9%, P < 0.05) postoperatively. BMP use was associated with higher payments throughout the 2-year follow-up period ($107,975 vs. $97,620, P < 0.05). When controlling for baseline group differences, BMP use independently increased the odds of postoperative complication (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.1-1.4) and reduced the odds of reoperation throughout 2 years of follow-up (OR 0.49, 95% CI 0.4-0.6)., Conclusion: Intraoperative BMP use has benefits for fusion integrity in ACD surgery but is associated with increased postoperative complication rate. Spine surgeons should weigh these benefits and drawbacks to identify optimal candidates for BMP use in ACD surgery., Level of Evidence: 3.

: Level of Evidence: 3.

We determined how often patients with epilepsy presented to the emergency department (ED) for seizure and the frequency and predictors for undergoing emergent neuroimaging during those visits. We conducted a retrospective population-based cohort study using administrative claims' data from 2007 to 2015. Adults with epilepsy were identified based on a diagnosis of epilepsy and an outpatient prescription for an antiepileptic medication. The Bonferroni corrected significance level was 0.0018. We identified 381,362 patients with a mean follow-up period of 1.99 years, of whom 35,015 (9.2%) patients presented to the ED for seizure at least once. Patients with at least one ED visit were younger, more likely to be male, had fewer comorbidities, and had longer follow-up as compared with those with no ED visit (all p < 0.001). Among the 35,015 patients presenting to the ED, 13.6% had neuroimaging, mostly commonly head computed tomography (CT; 95.5%). Patients undergoing neuroimaging were younger (46 versus 48 years) and with higher rates of psychosis (17.4% versus 13.8%) and depression (16.1% versus 12.2%; p < 0.001). This helps to quantify the burden of ED and emergent neuroimaging utilization for patients with epilepsy and can help inform efforts to curtail unnecessary neuroimaging., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to report. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Neurosurgical spine specialists receive considerable amounts of industry support that may impact the cost of care. The aim of this study was to evaluate the association between industry payments received by spine surgeons and the total hospital and operating room (OR) costs of an anterior cervical discectomy and fusion (ACDF) procedure among Medicare beneficiaries., Methods: All ACDF cases were identified among the Medicare carrier files from January 1, 2013, to December 31, 2014, and matched to the Medicare inpatient baseline file. The total hospital and OR charges were obtained for these cases. Charges were converted to cost using year-specific cost-to-charge ratios. Surgeons were identified among the Open Payments database, which is used to quantify industry support. Analyses were performed to examine the association between industry payments received and ACDF costs., Results: Matching resulting in the inclusion of 2209 ACDF claims from 2013-2014. In 2013 and 2014, the mean total cost for an ACDF was $21,798 and $21,008, respectively; mean OR cost was $5878 and $6064, respectively. Mann-Whitney U test demonstrated no significant differences in the mean total or OR cost for an ACDF based on quartile of general industry payment received (P = 0.21 and P = 0.54), and linear regression found no association between industry general payments, research support, or investments on the total hospital cost (P = 0.41, P = 0.13, and P = 0.25, respectively), or OR cost for an ACDF (P = 0.35, P = 0.24, and P = 0.40, respectively)., Conclusions: This study suggests that spine surgeons performing ACDF surgeries may receive industry support without impacting the cost of care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Migraine headache is a common condition with an estimated lifetime prevalence of greater than 20%. While it is a well-established risk factor for cardiovascular disease and ischemic stroke, its association with subarachnoid hemorrhage is largely unexplored. We sought to compare the incidence of aneurysmal subarachnoid hemorrhage in a cohort of migraine patients with a cohort of patients with tension headache. A cohort comparison study utilizing the MarketScan insurance claims database compared patients diagnosed with migraine who were undergoing treatment with abortive or prophylactic pharmacotherapy (treatment cohort) and patients diagnosed with tension headache who had never been diagnosed with a migraine and who were naïve to migraine pharmacotherapy (control cohort). Patients with major pre-existing risk factors for aSAH were excluded from the study, and minor risk factors such as smoking status and hypertension were accounted for using coarsened exact matching (CEM) and subsequent cox proportional-hazards (CPH) regression. More than 679,000 patients (~125,000 treatment and ~ 550,000 control) with an average follow-up of more than three years were analyzed for aneurysmal subarachnoid hemorrhage. CPH regression on matched data showed that treated migraine patients had a significantly lower hazard of aneurysmal subarachnoid hemorrhage compared with tension headache patients (HR = 0.40, 95% CI: 0.19 - 0.86, p = 0.02). This large cohort comparison study, analyzing more than 679,000 patients, demonstrated that migraine patients undergoing pharmacologic treatment had a lower hazard of aneurysmal subarachnoid hemorrhage than patients diagnosed with tension headaches. Future work specifically focusing on migraine medications may identify the mechanisms underlying this association., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background Context: Outpatient postoperative pain management in spine patients, specifically involving the use of opioids, demonstrates significant variability., Purpose: Using preoperative risk factors and 30-day postoperative opioid prescribing patterns, we developed models for predicting long-term opioid use in patients after elective spine surgery., Study Design/setting: This retrospective cohort study utilizes inpatient, outpatient, and pharmaceutical data from MarketScan databases (Truven Health)., Patient Sample: In all, 19,317 patients who were newly diagnosed with low back or lower extremity pain (LBP or LEP) between 2008 and 2015 and underwent thoracic or lumbar surgery within 1 year after diagnosis were enrolled. Some patients initiated opioids after diagnosis but all patients were opioid-naïve before the diagnosis., Outcome Measures: Long-term opioid use was defined as filling ≥180 days of opioids within one year after surgery., Methods: Using demographic variables, medical and psychiatric comorbidities, preoperative opioid use, and 30-day postoperative opioid use, we generated seven models on 80% of the dataset and tested the models on the remaining 20%. We used three regression-based models (full logistic regression, stepwise logistic regression, least absolute shrinkage and selection operator), support vector machine, two tree-based models (random forest, stochastic gradient boosting), and time-varying convolutional neural network. Area under the curve (AUC), Brier index, sensitivity, and calibration curves were used to assess the discrimination and calibration of the models., Results: We identified 903 (4.6%) of patients who met criteria for long-term opioid use. The regression-based models demonstrated the highest AUC, ranging from 0.835 to 0.847, and relatively high sensitivities, predicting between 74.9% and 76.5% of the long-term opioid use patients in the test dataset. The three strongest positive predictors of long-term opioid use were high preoperative opioid use (OR 2.70; 95% confidence interval [CI] 2.27-3.22), number of days with active opioid prescription between postoperative days 15 to 30 (OR 1.10; 95%CI 1.07-1.12), and number of dosage increases between postoperative day 15 to 30 (OR 1.71, 95%CI 1.41-2.08). The strongest negative predictors were number of dosage decreases in the 30-day postoperative period., Conclusions: We evaluated several predictive models for postoperative long-term opioid use in a large cohort of patients with LBP or LEP who underwent surgery. A regression-based model with high sensitivity and AUC is provided online to screen patients for high risk of long-term opioid use based on preoperative risk factors and opioid prescription patterns in the first 30 days after surgery. It is hoped that this work will improve identification of patients at high risk of prolonged opioid use and enable early intervention and counseling., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: This was a retrospective cohort study in which the authors used a nationally representative administrative database. Their goal was to identify the risk factors for reoperation in Medicare patients undergoing primary thoracolumbar adult spinal deformity (ASD) surgery. Previous literature reports estimate that 20% of patients undergoing thoracolumbar ASD correction undergo revision surgery within 2 years. Most published data discuss risk factors for revision surgery in the general population, but these have not been explored specifically in the Medicare population., Methods: Using the MarketScan Medicare Supplemental database, the authors identified patients who were diagnosed with a spinal deformity and underwent ASD surgery between 2007 and 2015. The interactions of patient demographics, surgical factors, and medical factors with revision surgery were investigated during the 2 years following primary ASD surgery. The authors excluded patients without Medicare insurance and those with any prior history of trauma or tumor., Results: Included in the data set were 2564 patients enrolled in Medicare who underwent ASD surgery between 2007 and 2015. The mean age at diagnosis with spinal deformity was 71.5 years. A majority of patients (68.5%) were female. Within 2 years of follow-up, 661 (25.8%) patients underwent reoperation. Preoperative osteoporosis (OR 1.58, p < 0.0001), congestive heart failure (OR 1.35, p = 0.0161), and paraplegia (OR 2.41, p < 0.0001) independently increased odds of revision surgery. The use of intraoperative bone morphogenetic protein was protective against reoperation (OR 0.71, p = 0.0371). Among 90-day postoperative complications, a wound complication was the strongest predictor of undergoing repeat surgery (OR 2.85, p = 0.0061). The development of a pulmonary embolism also increased the odds of repeat surgery (OR 1.84, p = 0.0435)., Conclusions: Approximately one-quarter of Medicare patients with ASD who underwent surgery required an additional spinal surgery within 2 years. Baseline comorbidities such as osteoporosis, congestive heart failure, and paraplegia, as well as short-term complications such as pulmonary embolism and wound complications significantly increased the odds of repeat surgery.