Search

From real–time tumor classification to operative outcome prediction, applications of machine learning to neurosurgery are powerful. However, the translation of many of these applications are restricted by the lack of "big data" in neurosurgery. Important restrictions in patient privacy and sharing of imaging data reduce the diversity of the datasets used to train resulting models and therefore limit generalizability. Synthetic learning is a recent development in machine learning that generates synthetic data from real data and uses the synthetic data to train downstream models while preserving patient privacy. Such an approach has yet to be successfully demonstrated in the spine surgery domain. Spine radiographs were collected from the VinDR–SpineXR dataset, with 1470 labeled as abnormal and 2303 labeled as normal. A conditional generative adversarial network (GAN) was trained on the radiographs to generate a spine radiograph and normal/abnormal label. A modified conditional GAN (SpineGAN) was trained on the same task. A convolutional neural network (CNN) was trained using the real data to label abnormal radiographs. A CNN was trained to label abnormal radiographs using synthetic images from the GAN and in a separate experiment from SpineGAN. Using the real radiographs, an AUC of 0.856 was achieved in abnormality classification. Training on synthetic data generated by the standard GAN (AUC of 0.814) and synthetic data generated by our SpineGAN (AUC of 0.830) resulted in similar classifier performance. SpineGAN generated images with higher FID and lower precision scores, but with higher recall and increased performance when used for synthetic learning. The successful application of synthetic learning was demonstrated in the spine surgery domain for the classification of spine radiographs as abnormal or normal. A modified domain–relevant GAN is introduced for the generation of spine images, evidencing the importance of domain–relevant generation techniques in synthetic learning. Synthetic learning can allow neurosurgery to use larger and more diverse patient imaging sets to train more generalizable algorithms with greater patient privacy. [ABSTRACT FROM AUTHOR]

Background Spontaneous intrauterine depressed skull fractures (IDSFs) are rare fractures that often require neurosurgical evaluation and therapy. Most of the reported congenital depressions are secondary to maternal abdominal trauma or instrumentation during delivery. Spontaneous IDSFs occur in the setting of uneventful normal spontaneous vaginal delivery or cesarean section, without obvious predisposing risk factors. The etiology and optimal management of spontaneous IDSFs remain controversial. Case Description We describe 2 cases of spontaneous IDSF who underwent cranioplasty at our institution using an absorbable mesh, as well as review the current state of knowledge regarding the diagnosis and management of spontaneous IDSF. The 2 neonates, 1 male and 1 female, presented at Lucile Packard Children's Hospital with spontaneous IDSF after uneventful normal spontaneous vaginal deliveries. The fractures were located in the left frontal and right parietotemporal calvarium, respectively. Both patients underwent open craniotomy and elevation of their IDSFs with mesh cranioplasty. At last follow-up, both patients were normocephalic and neurologically intact. Conclusions Neurosurgery consultation is necessary for initial evaluation of spontaneous IDSF. Surgical intervention is indicated for larger defects and/or intracranial involvement. Expectant management and negative-pressure elevation have also been shown to be effective. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective 2:1 propensity score-matched analysis on a national longitudinal database between 2006 and 2010.Objective: To compare rates of adverse events, revisions procedure rates, and payment differences in anterior cervical fusion procedures compared with posterior laminectomy and fusion procedures with at least 3 levels of instrumentation.Summary Of Background Data: The comparative benefits of anterior versus posterior approach to multilevel degenerative cervical disease remain controversial. Recent systematic reviews have reached conflicting conclusions. We demonstrate the comparative economic and clinical outcomes of anterior and posterior approaches for multilevel cervical degenerative disk disease.Methods: We identified 13,662 patients in a national billing claims database who underwent anterior or posterior cervical fusion procedures with 3 or more levels of instrumentation. Cohorts were balanced using 2:1 propensity score matching and outcomes were compared using bivariate analysis.Results: With the exception of dysphagia (6.4% in anterior and 1.4% in posterior), overall 30-day complication rates were lower in the anterior approach group. The rate of any complication excluding dysphagia with anterior approaches was 12.3%, significantly lower (P < 0.0001) than that of posterior approaches, 17.8%. Anterior approaches resulted in lower hospital ($18,346 vs. $23,638) and total payments ($28,963 vs. $33,526). Patients receiving an anterior surgical approach demonstrated significantly lower rate of 30-day readmission (5.1% vs. 9.9%, P < 0.0001), were less likely to require revision surgery (12.8% vs. 18.1%, P < 0.0001), and had a shorter length of stay by 1.5 nights (P < 0.0001).Conclusion: Anterior approaches in the surgical management of multilevel degenerative cervical disease provide clinical advantages over posterior approaches, including lower overall complication rates, revision procedure rates, and decreased length of stay. Anterior approach procedures are also associated with decreased overall payments. These findings must be interpreted in light of limitations inherent to retrospective longitudinal studies including absence of subjective and radiographical outcomes.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective 2:1 propensity score-matched anal-ysis on a national longitudinal database between 2006 and 2010. Objective. To compare rates of adverse events, revisions procedure rates, and payment differences in anterior cervical fusion procedures compared with posterior laminectomy and fusion procedures with at least 3 levels of instrumentation. Summary of Background Data. The comparative benefits of anterior versus posterior approach to multilevel degenerative cervical disease remain controversial. Recent systematic reviews have reached conflicting conclusions. We demonstrate the comparative economic and clinical outcomes of anterior and posterior approaches for multilevel cervical degenerative disk disease. Methods. We identified 13,662 patients in a national billing claims database who underwent anterior or posterior cervical fusion procedures with 3 or more levels of instrumentation. Cohorts were balanced using 2:1 propensity score matching and outcomes were compared using bivariate analysis. Results. With the exception of dysphagia (6.4% in anterior and 1.4% in posterior), overall 30-day complication rates were lower in the anterior approach group. The rate of any complication excluding dysphagia with anterior approaches was 12.3%, significantly lower (P < 0.0001) than that of posterior approaches, 17.8%. Anterior approaches resulted in lower hospital ($18,346 vs. $23,638) and total payments ($28,963 vs. $33,526). Patients receiving an anterior surgical approach demonstrated significantly lower rate of 30-day readmission (5.1% vs. 9.9%, P < 0.0001), were less likely to require revision surgery (12.8% vs. 18.1%, P < 0.0001), and had a shorter length of stay by 1.5 nights (P < 0.0001). Conclusion. Anterior approaches in the surgical management of multilevel degenerative cervical disease provide clinical advantages over posterior approaches, including lower overall complication rates, revision procedure rates, and decreased length of stay. Anterior approach procedures are also associated with decreased overall payments. These findings must be interpreted in light of limitations inherent to retrospective longitudinal studies including absence of subjective and radiographical outcomes. [ABSTRACT FROM AUTHOR]

Objective To review the pathophysiology and therapeutic modalities availble for Nelson syndrome. Methods We reviewed the current literature including managment for Nelson syndrome. Results For patients with NS, surgical intervention is often the first-line therapy. With refractory NS or tumors with extrasellar involvement, radiosurgery offers an important alternative or adjuvant option. Pharmacologic interventions have demonstrated limited usefulness, although recent evidence supports the feasibility of a novel somatostatin analog for patients with NS. Modern neuroimaging, improved surgical techniques, and the advent of stereotactic radiotherapy have transformed the management of NS. Conclusions An up-to-date understanding of the pathophysiology underlying Nelson Syndrome and evidence-based management is imperative. Early detection may allow for more successful therapy in patients with Nelson Syndrome. Improved radiotherapeutic interventions and rapidly evolving pharmacologic therapies offer an opportunity to create targeted, multifocal treatment regiments for patients with Nelson Syndrome. [ABSTRACT FROM AUTHOR]

Background context The use of recombinant human bone morphogenetic protein (BMP) in the thoracolumbar spine remains controversial, with many questioning the risks and benefits of this new biologic. Purpose To describe national trends, incidence of complications, and revision rates associated with BMP use in thoracolumbar spine procedures. Study design/setting Administrative database study. Patient sample A matched cohort of 52,259 patients undergoing thoracolumbar fusion surgery from 2006 to 2010 were identified in the MarketScan database. Patients without BMP treatment were matched 2:1 to patients receiving intraoperative BMP. Outcome measures Revision rates and postoperative complications. Methods The MarketScan database was used to select patients undergoing thoracolumbar fusion procedures, with and without intraoperative BMP. We ascertained outcome measures using either International Classification of Disease , ninth revision , or Current Procedural Terminology coding, and matched groups were evaluated using a bivariate and multivariate analyses. Kaplan-Meier estimates of fusions failure rates were also calculated. Results Patients receiving intraoperative BMP underwent fewer refusions, decompressions, posterior and anterior revisions, or any revision procedure (single level 4.53% vs. 5.85%, p<.0001; multilevel 5.02% vs. 6.83%, p<.0001; overall cohort 4.73% vs. 6.09%, p<.0001). After adjusting for comorbidities, demographics, and levels of procedure, BMP was not associated with the postoperative development of cancer (odds ratio 0.92). Bone morphogenetic protein use was associated with an increase in any complication at 30 days (15.8% vs. 14.9%, p=.0065), which is only statistically significant among multilevel procedures (19.74% vs. 18.02%, p=.0013). Thirty-day complications in multilevel procedures associated with BMP use included new dysrhythmia (4.68% vs. 4.01%, p=.0161) and delirium (1.08% vs. 0.69%, p=.0024). A new diagnosis of chronic pain was associated with BMP use in both single-level (2.74% vs. 2.15%, p=.0019) and multilevel (3.7% vs. 2.52%, p<.0001) procedures. Bone morphogenetic protein was negatively associated with infection in single-level procedures (2.12% vs. 2.64%, p=.0067) and wound dehiscence in multilevel procedures (0.84% vs. 1.18%, p=.0167). Conclusions In national data analysis of thoracolumbar procedures, we found that BMP was associated with decreased incidence of revision spinal surgery and with a slight increased risk of overall complications at 30 days. Although no BMP-associated increased risk of malignancy was found, lack of long-term follow-up precludes detection of between-group differences in malignancies and other rare events that may not appear until later. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Retrospective propensity score-matched analysis on a national database (MarketScan) between 2006 and 2010. OBJECTIVE: To compare rates of neurological deficits after elective single-level spinal procedures with and without intraoperative neuromonitoring, as well as associated payment differences and geographic variance. SUMMARY OF BACKGROUND DATA: Intraoperative neurophysiologic monitoring is a technique that may contribute to avoiding permanent neurological injury during some spine surgery procedures. However, it is unclear whether all patients undergoing spine surgery benefit from neuromonitoring. METHODS: An identified 85,640 patients underwent single-level spinal procedures including anterior cervical discectomy and fusion (ACDF), lumbar fusion, lumbar laminectomy, or lumbar discectomy. Neuromonitoring was identified with appropriate Current Procedural Terminology (CPT) codes. Cohorts were balanced on baseline comorbidities and procedure characteristics using propensity score matching. Trauma and spinal tumors cases were excluded. RESULTS: Patients (12.66%) received neuromonitoring intraoperatively. Lumbar laminectomies had reduced 30-day neurological complication rate with neuromonitoring (0.0% vs. 1.18%, P = 0.002). Neuromonitoring did not correlate with reduced intraoperative neurological complications in ACDFs (0.09% vs. 0.13%), lumbar fusions (0.32% vs. 0.58%), or lumbar discectomy (1.24% vs. 0.91%). With the addition of neuromonitoring, payments for ACDFs increased 16.24% ($3842), lumbar fusions 7.84% ($3540), lumbar laminectomies 24.33% ($3704), and lumbar discectomies 22.54% ($2859). Significant geographic variation was evident. Some states had no recorded single-level spinal cases with concurrent neuromonitoring. Rates for ACDFs and lumbar fusions, laminectomies, and discectomies ranged as high as 61%, 58%, 22%, and 21%, respectively. CONCLUSION: With intraoperative neurological monitoring in single-level procedures, neurological complications were decreased only among lumbar laminectomies. No difference was observed in ACDFs, lumbar fusions, or lumbar discectomies. There was a significant increase in total payments associated with the index procedure and hospitalization. We demonstrate significant geographic variation in neuromonitoring. LEVEL OF EVIDENCE: 3. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective propensity score-matched analysis on a national database (MarketScan) between 2006 and 2010. Objective. To compare rates of neurological deficits after elective single-level spinal procedures with and without intraoperative neuromonitoring, as well as associated payment differences and geographic variance. Summary of Background Data. Intraoperative neurophysiologic monitoring is a technique that may contribute to avoiding permanent neurological injury during some spine surgery procedures. However, it is unclear whether all patients undergoing spine surgery benefit from neuromonitoring. Methods. An identified 85,640 patients underwent single-level spinal procedures including anterior cervical discectomy and fusion (ACDF), lumbar fusion, lumbar laminectomy, or lumbar discectomy. Neuromonitoring was identified with appropriate Current Procedural Terminology (CPT) codes. Cohorts were balanced on baseline comorbidities and procedure characteristics using propensity score matching. Trauma and spinal tumors cases were excluded. Results. Patients (12.66%) received neuromonitoring intraoperatively. Lumbar laminectomies had reduced 30-day neurological complication rate with neuromonitoring (0.0% vs. 1.18%, P = 0.002). Neuromonitoring did not correlate with reduced intraoperative neurological complications in ACDFs (0.09% vs. 0.13%), lumbar fusions (0.32% vs. 0.58%), or lumbar discectomy (1.24% vs. 0.91%). With the addition of neuromonitoring, payments for ACDFs increased 16.24% ($3842), lumbar fusions 7.84% ($3540), lumbar laminectomies 24.33% ($3704), and lumbar discectomies 22.54% ($2859). Significant geographic variation was evident. Some states had no recorded single-level spinal cases with concurrent neuromonitoring. Rates for ACDFs and lumbar fusions, laminectomies, and discectomies ranged as high as 61%, 58%, 22%, and 21%, respectively. Conclusion. With intraoperative neurological monitoring in single-level procedures, neurological complications were decreased only among lumbar laminectomies. No difference was observed in ACDFs, lumbar fusions, or lumbar discectomies. There was a significant increase in total payments associated with the index procedure and hospitalization. We demonstrate significant geographic variation in neuromonitoring. [ABSTRACT FROM AUTHOR]

Background: Usage of recombinant human bone morphogenetic protein (rhBMP) in anterior cervical discectomy and fusion (ACDF) procedures is controversial. Studies suggest increased rates of dysphagia, hematoma or seroma, and severe airway compromise in anterior cervical spine procedures using rhBMP. The purpose of the present study was to determine and describe national utilization trends and complication rates associated with rhBMP usage in anterior cervical spine procedures. Methods: The MarketScan database from 2006 to 2010 was retrospectively queried to identify 91,543 patients who underwent ACDF with or without cervical corpectomy. Patient selection and outcomes were ascertained with use of ICD- 9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) and CPT (Current Procedural Terminology) coding. A total of 3197 patients were treated with rhBMP intraoperatively. Mean follow-up was 588 days (interquartile range [IQR], 205 to 886 days) in the non-treated cohort and 591 days (IQR, 203 to 925 days) in the rhBMP-treated cohort. Multivariate logistic regression as well as propensity score analysis were used to evaluate the association of rhBMP usage with postoperative complications. Results: In propensity score-adjusted models, rhBMP usage was associated with an increased risk of any complication (odds ratio [OR] = 1.34, 95% confidence interval [CI] = 1.2 to 1.5) and specific complications such as hematoma or seroma (OR = 1.8, 95% CI = 1.4 to 2.3), dysphagia (OR = 1.3, 95% CI = 1.1 to 1.5), and any pulmonary complication (OR = 1.5, 95% CI = 1.2 to 1.8) within thirty days postoperatively. There were no significant differences in the rates of readmission, in-hospital mortality, referral to pain management, new malignancy, or reoperation between the two cohorts. Usage of rhBMP was associated with a mean increase of $5545 (19%) in total payments to the hospital and primary physician (p < 0.001). Conclusions: We found an increased overall rate of postoperative complications in patients receiving rhBMP for cervical spinal fusion procedures compared with patients not receiving rhBMP. Hematoma or seroma, pulmonary complications, and dysphagia were also more common in the rhBMP cohort. Usage of rhBMP in a case was associated with $311 greater payments to the surgeon and $4213 greater payments to the hospital. [ABSTRACT FROM AUTHOR]

Abstract: Background context: The natural history of cervical degenerative disease with operative management has not been well described. Even with symptomatic and radiographic evidence of multilevel cervical disease, it is unclear whether single- or multilevel anterior cervical discectomy and fusion (ACDF) procedures produce superior long-term outcomes. Purpose: To describe national trends in revision rates, complications, and readmission for patients undergoing single and multilevel ACDF. Study design: Administrative database study. Patient sample: Between 2006 and 2010, 92,867 patients were recorded for ACDF procedures in the Thomson Reuters MarketScan database. Restricting to patients with >24 months follow-up, 28,777 patients fulfilled our inclusion criteria, of which 12,744 (44%) underwent single-level and 16,033 (56%) underwent multilevel ACDFs. Outcome measures: Revision rates and postoperative complications. Methods: We used the MarketScan database from 2006 to 2010 to select ACDF procedures based on Current Procedural Terminology coding at inpatient visit. Outcome measures were ascertained using either International Classification of Disease version 9 or Current Procedural Terminology coding. Results: Perioperative complications were more common in multilevel procedures (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2–1.6; p<.0001). Single-level ACDF patients had higher rates of postoperative cervical epidural steroid injections (OR, 0.88; 95% CI, 0.8–1.0; p=.01). Within 30 days after index procedure, the multilevel ACDF cohort was 1.6 times more likely to have undergone revision (OR, 1.6; 95% CI, 1.1–2.4; p=.02). At 2 years follow-up, revision rates were 9.13% in the single-level ACDF cohort and 10.7% for multilevel ACDFs (OR, 1.2; 95% CI, 1.1–1.3; p<.0001). In a multivariate analysis at 2 years follow-up, patients from the multilevel cohort were more likely to have received a surgical revision (OR, 1.1; 95% CI, 1.0–1.2; p=.001), to be readmitted into the hospital for any cause (OR, 1.2; 95% CI, 1.1–1.4; p=.007), and to have suffered complications (OR, 1.3; 95% CI, 1.1–1.5; p=.0003). Conclusions: In this study, we report rates of adverse events and the need for revision surgery in patients undergoing single versus multilevel ACDFs. Increasing number of levels fused at the time of index surgery correlated with increased rate of reoperations. Multilevel ACDF patients requiring additional surgery more often underwent more extensive revision surgeries. [Copyright &y& Elsevier]

Introduction: Although vertebral and epidural metastases are common, intradural metastases and intramedullary spinal cord metastases are rare. The indications for the treatment of intramedullary spinal cord metastases remain controversial. We present the first biopsy-proven case of an intramedullary spinal cord metastasis from adenocarcinoma of the prostate.Case Presentation: Our patient was a 68-year-old right-handed Caucasian man with a Gleason grade 4 + 3 prostate adenocarcinoma who had previously undergone a prostatectomy, androgen blockade and transurethral debulking. He presented with new-onset saddle anesthesia and fecal incontinence. Magnetic resonance imaging demonstrated a spindle-shaped intramedullary lesion of the conus medullaris. Our patient underwent decompression and an excisional biopsy; the lesion's pathology was consistent with metastatic adenocarcinoma of the prostate. Postoperatively, our patient received CyberKnife® radiosurgery to the resection cavity at a marginal dose of 27Gy to the 85% isodose line. At three months follow-up, our patient remains neurologically stable with no new deficits or lesions.Conclusions: We review the literature and discuss the indications for surgery and radiosurgery for intramedullary spinal cord metastases. We also report the novel use of stereotactic radiosurgery to sterilize the resection cavity following an excisional biopsy of the metastasis. [ABSTRACT FROM AUTHOR]

Objective: Hemangiopericytoma is a rare and aggressive meningeal tumor. Although surgical resection is the standard treatment, hemangiopericytomas often recur with high incidences of metastasis. The purpose of this study was to evaluate the role of CyberKnife stereotactic radiosurgery (CK) in the management of recurrent, metastatic, and residual hemangiopericytomas. Methods: In a review of the Stanford radiosurgery database between 2002 and 2009, the authors found 14 patients who underwent CK therapy for recurrent, metastatic, and residual hemangiopericytomas. A total of 24 tumors were treated and the median patient age was 52 years (range 29-70 years) at the time of initial CK therapy. The median follow-up period was 37 months (10-73 months) and all patients had been previously treated with surgical resection. Mean tumor volume was 9.16 cm³ and the mean marginal and maximum radiosurgical doses to the tumors were 21.2 Gy and 26.8 Gy, respectively. Results: Of the 24 tumors treated, 22 have clinical follow-up data at this time. Of those 22 tumors, 12 decreased in size (54.5%), 6 remained unchanged (27.3%), and 4 showed recurrence (18.2%) after CK therapy. Progression-free survival rate was 95%, 71.5%, and 71.5% at 1, 3, and 5 years after multiple CK treatments. The 5-year survival rate after CK was 81%. Conclusions: CK is an effective and safe management option for hemangiopericytomas. The current series demonstrates a tumor control of 81.8%. Other institutions have demonstrated similar outcomes with stereotactic radiosurgery, with tumor control ranging from 46.4% to 100%. [ABSTRACT FROM AUTHOR]

The article presents a study which investigates the preoperative and intraoperative risk factors for postoperative wound infections in patients who have undergone spinal surgery. Data of veterans who had undergone spinal surgery from 1997-2006 from the database of U.S. Veterans Affairs' National Surgical Quality Improvement Program were analyzed using multivariate, bivariate, and univariate analyses. Results show that out of 27,774 patients, 752 has postoperative infection.

Physical therapy (PT) is an important component of low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common. We sought to understand how copayments impact timing and utilization of PT in newly diagnosed LBP. The IBM Watson Health MarketScan claims database was used in a longitudinal setting. Adult patients with LBP. The primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing. 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. 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). 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. [ABSTRACT FROM AUTHOR]

Cervical spine procedures represent a major proportion of all spine surgery. Mitigating the revision rate following cervical procedures requires careful patient selection. While complication risk has successfully been predicted, revision risk has proven more challenging. This is likely due to the absence of granular variables in claims databases. The objective of this study was to develop a state-of-the-art model of revision prediction of cervical spine surgery using laboratory and operative variables. Using the Stanford Research Repository, patients undergoing a cervical spine procedure between 2016 and 2022 were identified (N = 3151), and recent laboratory values were collected. Patients were classified into separate cohorts by revision outcome and time frame. Machine and deep learning models were trained to predict each revision outcome from laboratory and operative variables. Red blood cell count, hemoglobin, hematocrit, mean corpuscular hemoglobin concentration, red blood cell distribution width, platelet count, carbon dioxide, anion gap, and calcium all were significantly associated with ≥1 revision cohorts. For the prediction of 3-month revision, the deep neural network achieved an area under the receiver operating characteristic curve of 0.833. The model demonstrated increased performance for anterior versus posterior and arthrodesis versus decompression procedures. Our deep learning approach successfully predicted 3-month revision outcomes from demographic variables, standard laboratory values, and operative variables in a cervical spine surgery cohort. This work used standard laboratory values and operative codes as meaningful predictive variables for revision outcome prediction. The increased performance on certain procedures evidences the need for careful development and validation of one-size-fits-all risk scores for spine procedures. [ABSTRACT FROM AUTHOR]

Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED). This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF). This is a retrospective cohort study. Data was used from the 2016–2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded. The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs. Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs. A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%–341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62–3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26–3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21–0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13–3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001). This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making. [ABSTRACT FROM AUTHOR]

Brain tuberculoma has previously accounted for up to a third of new intracranial lesions in areas endemic with tuberculosis, but is unexpected in the United States and other Western countries with improved disease control. Here we show the importance of considering this diagnosis in at-risk patients, even with no definitive pulmonary involvement. We describe a young man who presented with partial seizures and underwent craniotomy for resection of a frontoparietal tuberculoma. He subsequently completed six months of antituberculosis therapy and was doing well without neurological sequelae or evidence of recurrence five months after completion of therapy. With resurgence of tuberculosis cases in the United States and other Western countries, intracerebral tuberculoma should remain a diagnostic consideration in at-risk patients with new space occupying lesions. Mass lesions causing neurological sequelae can be safely addressed surgically and followed with antituberculosis therapy. [ABSTRACT FROM AUTHOR]

Background: Adult spinal deformities (ASD) are varied spinal abnormalities, often necessitating surgical intervention when associated with pain, worsening deformity, or worsening function. Predicting post-operative complications and revision surgery is critical for surgical planning and patient counseling. Due to the relatively small number of cases of ASD surgery, machine learning applications have been limited to traditional models (e.g., logistic regression or standard neural networks) and coarse clinical variables. We present the novel application of advanced models (CNN, LLM, GWAS) using complex data types (radiographs, clinical notes, genomics) for ASD outcome prediction. Methods: We developed a CNN trained on 209 ASD patients (1549 radiographs) from the Stanford Research Repository, a CNN pre-trained on VinDr-SpineXR (10,468 spine radiographs), and an LLM using free-text clinical notes from the same 209 patients, trained via Gatortron. Additionally, we conducted a GWAS using the UK Biobank, contrasting 540 surgical ASD patients with 7355 non-surgical ASD patients. Results: The LLM notably outperformed the CNN in predicting pulmonary complications (F1: 0.545 vs. 0.2881), neurological complications (F1: 0.250 vs. 0.224), and sepsis (F1: 0.382 vs. 0.132). The pre-trained CNN showed improved sepsis prediction (AUC: 0.638 vs. 0.534) but reduced performance for neurological complication prediction (AUC: 0.545 vs. 0.619). The LLM demonstrated high specificity (0.946) and positive predictive value (0.467) for neurological complications. The GWAS identified 21 significant (p < 10−5) SNPs associated with ASD surgery risk (OR: mean: 3.17, SD: 1.92, median: 2.78), with the highest odds ratio (8.06) for the LDB2 gene, which is implicated in ectoderm differentiation. Conclusions: This study exemplifies the innovative application of cutting-edge models to forecast outcomes in ASD, underscoring the utility of complex data in outcome prediction for neurosurgical conditions. It demonstrates the promise of genetic models when identifying surgical risks and supports the integration of complex machine learning tools for informed surgical decision-making in ASD. [ABSTRACT FROM AUTHOR]

Purpose: Irradiating the surgical bed of resected brain metastases improves local and distant disease control. Over time, stereotactic radiosurgery (SRS) has replaced whole brain radiotherapy (WBRT) as the treatment standard of care because it minimizes long-term damage to neuro-cognition. Despite this data and growing adoption, socio-economic disparities in clinical access can result in sub-standard care for some patient populations. We aimed to analyze the clinical and socio-economic characteristics of patients who did not receive radiation after surgical resection of brain metastasis. Methods: Our sample was obtained from Clinformatics® Data Mart Database and included all patients from 2004 to 2021 who did or did not receive radiation treatment within sixty days after resection of tumors metastatic to the brain. Regression analysis was done to identify factors responsible for loss to adjuvant radiation treatment. Results: Of 8362 patients identified who had undergone craniotomy for resection of metastatic brain tumors, 3430 (41%) patients did not receive any radiation treatment. Compared to patients who did receive some form of radiation treatment (SRS or WBRT), patients who did not get any form of radiation were more likely to be older (p = 0.0189) and non-white (p = 0.008). Patients with Elixhauser Comorbidity Index ≥3 were less likely to receive radiation treatment (p < 0.01). Fewer patients with household income ≥ $75,000 did not receive radiation treatment (p < 0.01). Conclusion: Age, race, household income, and comorbidity status were associated with differential likelihood to receive post-operative radiation treatment. [ABSTRACT FROM AUTHOR]

Sigma-1 Receptor has been shown to localize to sites of peripheral nerve injury and back pain. Radioligand probes have been developed to localize Sigma-1 Receptor and thus image pain source. However, in non-pain conditions, Sigma-1 Receptor expression has also been demonstrated in the central nervous system and dorsal root ganglion. This work aimed to study Sigma-1 Receptor expression in a microglial cell population in the lumbar spine following peripheral nerve injury. A publicly available transcriptomic dataset of 102,691 L4/5 mouse microglial cells from a sciatic-sural nerve spared nerve injury model and 93,027 age and sex matched cells from a sham model was used. At each of three time points—postoperative day 3, postoperative day 14, and postoperative month 5—gene expression data was recorded for both spared nerve injury and Sham cell groups. For all cells, 27,998 genes were sequenced. All cells were clustered into 12 distinct subclusters and gene set enrichment pathway analysis was performed. For both the spared nerve injury and Sham groups, Sigma-1 Receptor expression significantly decreased at each time point following surgery. At the 5-month postoperative time point, only one of twelve subclusters showed significantly increased Sigma-1 Receptor expression in spared nerve injury cells as compared to Sham cells (p = 0.0064). Pathway analysis of this cluster showed a significantly increased expression of the inflammatory response pathway in the spared nerve injury cells relative to Sham cells at the 5-month time point (p = 6.74e−05). A distinct subcluster of L4/5 microglia was identified which overexpress Sigma-1 Receptor following peripheral nerve injury consistent with neuropathic pain inflammatory response functioning. This indicates that upregulated Sigma-1 Receptor in the central nervous system characterizes post-acute peripheral nerve injury and may be further developed for clinical use in the differentiation between low back pain secondary to peripheral nerve injury and low back pain not associated with peripheral nerve injury in cases where the pain cannot be localized. [ABSTRACT FROM AUTHOR]

Sigma-1 Receptor has been shown to localize to sites of peripheral nerve injury and back pain. Radioligand probes have been developed to localize Sigma-1 Receptor and thus image pain source. However, in non-pain conditions, Sigma-1 Receptor expression has also been demonstrated in the central nervous system and dorsal root ganglion. This work aimed to study Sigma-1 Receptor expression in a microglial cell population in the lumbar spine following peripheral nerve injury. A publicly available transcriptomic dataset of 102,691 L4/5 mouse microglial cells from a sciatic-sural nerve spared nerve injury model and 93,027 age and sex matched cells from a sham model was used. At each of three time points—postoperative day 3, postoperative day 14, and postoperative month 5—gene expression data was recorded for both spared nerve injury and Sham cell groups. For all cells, 27,998 genes were sequenced. All cells were clustered into 12 distinct subclusters and gene set enrichment pathway analysis was performed. For both the spared nerve injury and Sham groups, Sigma-1 Receptor expression significantly decreased at each time point following surgery. At the 5-month postoperative time point, only one of twelve subclusters showed significantly increased Sigma-1 Receptor expression in spared nerve injury cells as compared to Sham cells (p = 0.0064). Pathway analysis of this cluster showed a significantly increased expression of the inflammatory response pathway in the spared nerve injury cells relative to Sham cells at the 5-month time point (p = 6.74e−05). A distinct subcluster of L4/5 microglia was identified which overexpress Sigma-1 Receptor following peripheral nerve injury consistent with neuropathic pain inflammatory response functioning. This indicates that upregulated Sigma-1 Receptor in the central nervous system characterizes post-acute peripheral nerve injury and may be further developed for clinical use in the differentiation between low back pain secondary to peripheral nerve injury and low back pain not associated with peripheral nerve injury in cases where the pain cannot be localized. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study. Purpose: Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for patients diagnosed with cervical degenerative diseases with or without myelopathy. A thorough understanding of outcomes in patients with and without myelopathy undergoing ACDF is required because of the widespread utilization of ACDF for these indications. Overview of Literature: Non-ACDF approaches achieved inferior outcomes in certain myelopathic cases. Studies have compared patient outcomes across procedures, but few have compared outcomes concerning myelopathic versus nonmyelopathic cohorts. Methods: The MarketScan database was queried from 2007 to 2016 to identify adult patients who were =65 years old, and underwent ACDF using the international classification of diseases 9th version and current procedural terminology codes. Nearest neighbor propensity-score matching was employed to balance patient demographics and operative characteristics between myelopathic and nonmyelopathic cohorts. Results: Of 107,480 patients who met the inclusion criteria, 29,152 (27.1%) were diagnosed with myelopathy. At baseline, the median age of patients with myelopathy was higher (52 years vs. 50 years, p <0.001), and they had a higher comorbidity burden (mean Charlson comorbidity index, 1.92 vs. 1.58; p <0.001) than patients without myelopathy. Patients with myelopathy were more likely to undergo surgical revision at 2 years (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.54-1.73) or are readmitted within 90 days (OR, 1.27; 95% CI, 1.20-1.34). After patient cohorts were matched, patients with myelopathy remained at elevated risk for reoperation at 2 years (OR, 1.55; 95% CI, 1.44-1.67) and postoperative dysphagia (2.78% vs. 1.68%, p <0.001) compared to patients without myelopathy. Conclusions: We found inferior postoperative outcomes at baseline for patients with myelopathy undergoing ACDF compared to patients without myelopathy. Patients with myelopathy remained at significantly greater risk for reoperation and readmission after balancing potential confounding variables across cohorts, and these differences in outcomes were largely driven by patients with myelopathy undergoing 1-2 level fusions. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study. Purpose: To characterize the postoperative outcomes and economic costs of anterior cervical discectomy and fusion (ACDF) procedures using synthetic biomechanical intervertebral cage (BC) and structural allograft (SA) implants. Overview of Literature: ACDF is a common spine procedure that typically uses an SA or BC for the cervical fusion. Previous studies that compared the outcomes between the two implants were limited by small sample sizes, short-term postoperative outcomes, and procedures with single-level fusion. Methods: Adult patients who underwent an ACDF procedure in 2007-2016 were included. Patient records were extracted from MarketScan, a national registry that captures person-specific clinical utilization, expenditures, and enrollments across millions of inpatient, outpatient, and prescription drug services. Propensity-score matching (PSM) was employed to match the patient cohorts across demographic characteristics, comorbidities, and treatments. Results: Of 110,911 patients, 65,151 (58.7%) received BC implants while 45,760 (41.3%) received SA implants. Patients who underwent BC surgeries had slightly higher reoperation rates within 1 year after the index ACDF procedure (3.3% vs. 3.0%, p =0.004), higher postoperative complication rates (4.9% vs. 4.6%, p =0.022), and higher 90-day readmission rates (4.9% vs. 4.4%, p =0.001). After PSM, the postoperative complication rates did not vary between the two cohorts (4.8% vs. 4.6%, p =0.369), although dysphagia (2.2% vs. 1.8%, p <0.001) and infection (0.3% vs. 0.2%, p =0.007) rates remained higher for the BC group. Other outcome differences, including readmission and reoperation, decreased. Physician's fees remained high for BC implantation procedures. Conclusions: We found marginal differences in clinical outcomes between BC and SA ACDF interventions in the largest published database cohort of adult ACDF surgeries. After adjusting for group-level differences in comorbidity burden and demographic characteristics, BC and SA ACDF surgeries showed similar clinical outcomes. Physician's fees, however, were higher for BC implantation procedures. [ABSTRACT FROM AUTHOR]

In recent years, there has been a significant surge in discussions surrounding artificial intelligence (AI), along with a corresponding increase in its practical applications in various facets of everyday life, including the medical industry. Notably, even in the highly specialized realm of neurosurgery, AI has been utilized for differential diagnosis, pre-operative evaluation, and improving surgical precision. Many of these applications have begun to mitigate risks of intraoperative and postoperative complications and post-operative care. This article aims to present an overview of the principal published papers on the significant themes of tumor, spine, epilepsy, and vascular issues, wherein AI has been applied to assess its potential applications within neurosurgery. The method involved identifying high-cited seminal papers using PubMed and Google Scholar, conducting a comprehensive review of various study types, and summarizing machine learning applications to enhance understanding among clinicians for future utilization. Recent studies demonstrate that machine learning (ML) holds significant potential in neuro-oncological care, spine surgery, epilepsy management, and other neurosurgical applications. ML techniques have proven effective in tumor identification, surgical outcomes prediction, seizure outcome prediction, aneurysm prediction, and more, highlighting its broad impact and potential in improving patient management and outcomes in neurosurgery. This review will encompass the current state of research, as well as predictions for the future of AI within neurosurgery. [ABSTRACT FROM AUTHOR]

Background Osteochondromas are the most frequent benign bone tumors but only rarely occur along the spinal column and even more rarely induce symptoms from spinal cord compression. Case Descriptions We report 2 adult patients, both with a history of hereditary multiple exostoses, who presented with cervical myelopathy secondary to osteochondromas. The first patient is a 22-year-old man with numbness and weakness of his right upper limb and neck pain. Radiologic images showed a bony tumor arising from the C3 lamina with evidence of severe spinal cord compression. The second patient is a 20-year-old woman with weakness of her left upper and lower limbs and progressive numbness of the left hand, as well as neck and back pain. Radiologic images showed a bony tumor arising from the C4 lamina with evidence of significant spinal cord compression and cord signal abnormality. Both patients underwent surgical excision of the epidural mass and pathology confirmed a diagnosis of osteochondroma. Conclusions We discuss the role of surgical intervention, management, and postoperative follow-up in adult patients with cervical osteochondromas. Recommended management includes radiographic imaging and surgical intervention, particularly when evidence of spinal cord impingement occurs. Consistent postoperative follow-up is necessary to ensure appropriate recovery of neurologic function. Surgical management of cervical osteochondromas typically results in excellent and stable clinical outcomes with rare recurrence. [ABSTRACT FROM AUTHOR]

Background Avulsion of the abducens nerve in the setting of geniculate ganglion injury after temporal bone fracture is unreported previously. We discuss clinical assessment and management of a patient with traumatic avulsion of cranial nerve (CN) VI in the setting of an ipsilateral CN VII injury after temporal bone fracture and call attention to this unusual injury. Case Description A 26-year-old man suffered a temporal bone fracture after a motor vehicle accident and developed diplopia and right-sided facial droop. Six weeks after the accident, the patient was readmitted with worsening diplopia and ipsilateral facial weakness. He demonstrated absent lateral gaze on the right suggestive of either restrictive movement or right. CN VI Deficit In addition, he had right-sided facial palsy graded as 6/6 House-Brackmann. High-resolution computed tomography demonstrated a right-sided longitudinal otic capsule-sparing temporal bone fracture that propagated into the facial nerve canal and geniculate fossa. Magnetic resonance imaging revealed discontinuity of the right CN VI between the pons and the Dorello canal, as well as injury to the ipsilateral geniculate ganglion. CN VII was intact proximally, from the pons through the internal auditory canal. Consensus was reached to proceed with conservative management. At 13 months after injury, the patient reported 1/6 House-Brackmann with no improvement in CN VI function. Conclusions This case illustrates 2 subtle findings on imaging with potential therapeutic implications, notably the role of surgical intervention for facial nerve palsy. [ABSTRACT FROM AUTHOR]

We assessed whether the insurance type reflects a patient's quality of care after an anterior discectomy and fusion (ACDF) procedure by comparing differences in the postoperative complications, readmission rates, reoperation rates, lengths of hospital stay, and cost of treatment between patients with Medicare versus private insurance. Propensity score matching was used to match patient cohorts insured by Medicare and private insurance in the MarketScan Commercial Claims and Encounters Database (2007–2016). Age, sex, year of operation, geographic region, comorbidities, and operative factors were used to match cohorts of patients who had undergone an ACDF procedure. A total of 110,911 patients met the inclusion criteria. Of these patients, 97,543 patients (87.9%) were privately insured and 13,368 patients (12.1%) were insured by Medicare. The propensity score matching algorithm matched 7026 privately insured patients to 7026 Medicare patients. After matching, no significant differences were found in the 90-day postoperative complication rates, lengths of stay, or reoperation rates between the Medicare and privately insured cohorts. The Medicare group had had lower postoperative readmission rates for all time points: 30 days (1.8% vs. 4.6%; P < 0.001), 60 days (2.5% vs. 6.3%; P < 0.001), and 90 days (4.2% vs. 7.7%; P < 0.001). The median payment to physicians was significantly lower for the Medicare group ($3885 vs. $5601; P < 0.001). In the present study, propensity score matched patients covered by Medicare and private insurance who had undergone an ACDF procedure had had similar treatment outcomes. [ABSTRACT FROM AUTHOR]

Objective To determine national trends for patients with subarachnoid hemorrhage (SAH) and pulmonary complications including acute respiratory distress syndrome (ARDS). Methods The Nationwide Inpatient Sample database was used to sample 193,209 admissions for SAH with and without ARDS during the period 1993–2008 using International Classification of Diseases, Ninth Revision, Clinical Modification coding. A multivariate stepwise regression analysis was performed. Results The incidence of ARDS in patients with SAH increased from 35.51% in 1993 to 37.60% in 2008. However, the overall mortality in patients with SAH and in patients with SAH and ARDS decreased in the same period, from 42.30% to 31.99% and from 75.13% to 60.76%, respectively. Multivariate analysis showed that the predictors of developing ARDS in patients with SAH include older age; larger hospital size; and comorbidities such as epilepsy, cardiac arrest, sepsis, congestive heart failure, hypertension, chronic obstructive pulmonary disease, hematologic dysfunction, renal dysfunction, and neurologic dysfunction. Predictors of mortality in patients with SAH include age and hospital complications, such as coronary artery disease, ARDS, cancer, hematologic dysfunction, and renal dysfunction. Conclusions Patients with SAH are at increased risk of developing ARDS. The identification of certain risk factors may alert and aid practitioners in preventing worsening disease. [ABSTRACT FROM AUTHOR]

Background: Spondyloepiphyseal dysplasia (SED) is a rare disease that causes vertebral abnormalities and short-trunk dwarfism. The two forms of SED are congenita and tarda. Each form arises in a genetically distinct fashion and manifests with a different set of complications. SED congenita is more severe, and patients usually display atlantoaxial instability and odontoid hypoplasia. Patients often have various neurologic deficits caused by compression of the spinal cord. The region most affected is the craniovertebral junction (CVJ). Methods: A review of the PubMed Database, 1970 to the present, was performed using the search term “spondyloepiphyseal dysplasia” and limited to English-language articles. The search identified 22 articles discussing COL2A1 gene mutations and 10 clinical articles describing patients with SED and associated spinal abnormalities. Results: Findings from the literature concerning diagnosis, presenting symptoms, and intervention taken are discussed. Additionally, a patient with a diagnosis of SED congenita who presented with bilateral hand numbness is described. The patient underwent a suboccipital craniotomy; posterior decompression of the foramen magnum, the arch of C1, and the lamina of C2; and instrumented fusion of C1-3 to relieve his symptoms. Conclusions: In this article, the authors survey the current literature surrounding neurosurgical interventions and present an algorithm for treatment. [Copyright &y& Elsevier]

Background: Histoplasmosis is a fungal disease caused by Histoplasma capsulatum, commonly found in the Americas, and Histoplasma duboisii, located in Africa. In the United States, H. capsulatum is prevalent in the Ohio and Mississippi river valleys. In rare circumstances, central nervous system (CNS) histoplasmosis infection can be caused by shunt placement. We present a case report of a 45-year-old woman in whom CNS histoplasmosis developed after having a ventriculoperitoneal (VP) shunt placed for communicating hydrocephalus. A review of the literature on fungal infections after CNS shunt placement as well as treatment options for this subset of patients was undertaken. Methods: The PubMed database current to 1958 was filtered and limited to English-language articles. Fifty-eight articles were selected for review based on evidence of information regarding the fungal organism responsible for shunt infection, symptoms, treatment, and/or outcomes. Also included in this review is our case study. Results: A thorough analysis of the PubMed database revealed 58 reported cases of CNS shunt–related fungal infections in the English-language medical literature as well as 7 therapeutic agents used to treat patients in whom postshunt fungal infections developed. Conclusions: We describe the steps in diagnosis of histoplasmosis after shunt placement, provide an effective therapeutic regimen, and review the present understanding of CNS fungal infections. The medical literature was surveyed to compare and analyze various CNS fungal infections that can arise from shunt placement as well as treatments rendered. [ABSTRACT FROM AUTHOR]

Background: Dialysis-associated destructive spondyloarthropathy (DSA) is the major bony complication of end-stage renal disease, most commonly found in the lower cervical region. The risk factors for developing dialysis-associated DSA include duration of hemodialysis and patient age. Patients with DSA have a higher incidence of osteoporosis and poor bone mineral density, which may place them at greater risk of atraumatic fractures, instrumentation failure, and neurologic compromise. Methods: We describe a case of cervical radiculopathy due to dialysis-associated DSA atraumatic vertebral body fractures with a postoperative course that was complicated by instrumentation failure. We reviewed the literature regarding all 138 published cases, presenting the complications, surgical treatment options, and outcomes. Results: A 44-year-old dialysis-dependent man presented with acute neck pain, radiculopathy, and weakness due to atraumatic fracture of C5 and C6 vertebral bodies. He underwent anterior C5 and C6 corpectomies, reconstruction with mesh cage and plate, and supplemental posterior instrumentation (C4-T1). Six weeks later, a computed tomography scan revealed anterior translation across the instrumented area with failure of the posterior instrumentation. He subsequently underwent traction, revision reinstrumentation from C2 to T5, and placement of external halo ring/jacket for 6 months. At 18 months later, he remains ambulatory without evidence of construct failure. Conclusions: Patients with renal osteodystrophy present a challenge for the spine surgeon due to compromised bone density. Hardware failure at the bone-construct interface is common in these patients, with revision surgery needed in 22% of published cases. Longer constructs with circumferential instrumentation and halo immobilization may minimize the risk of pseudoarthrosis and construct pull-out. [Copyright &y& Elsevier]

Objective To characterize cranioplasty complications and costs at a population level using a longitudinal national claims database. Methods We identified patients undergoing cranioplasty between 2007 and 2014 in the MarketScan national database. We evaluated age, autograft usage, cranioplasty size, and cranioplasty timing stratified by postoperative outcomes. We further analyzed associated costs. A subset analysis of adult patients with emergent indications, including stroke and trauma, was performed. Results We identified 8275 patients (mean age 44.0 years ± 20.0, 45.2% male), including 13.8% children (<18 years old), 76.0% adults (18–64 years old), and 10.2% elderly adults (≥65 years old). Overall complication rate was 36.6%, mortality rate was 0.5%, and 30-day readmission rate was 12.0%. Elderly patients had the highest complication rate ( P < 0.0001). Large cranioplasties (>5 cm) had higher complication rates than small cranioplasties (≤5 cm; P = 0.047). In patients with emergent indications ( n = 1282), size did not influence complications, although large cranioplasties showed higher infection risk ( P = 0.02). Autograft use did not affect outcomes but was associated with higher complication risk, including infections, in the subset with emergent indications ( P < 0.001, P = 0.001). Late (>90 days) cranioplasty timing had higher complication rates in the overall cohort and the subset with emergent indications ( P < 0.001, P < 0.001). Index costs of care were mainly driven by hospital payments in both the overall cohort and the cohort with emergent indications. Conclusions A high complication rate is associated with cranioplasty in the United States. Older age, large cranioplasties, and delayed cranioplasties increased complication risk overall. Among patients with emergent indications, complications were associated with delayed time to cranioplasty and autograft usage. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort.Objective: Due to anterior cervical discectomy and fusion (ACDF) popularity, it is important to predict postoperative complications, unfavorable 90-day readmissions, and two-year reoperations to improve surgical decision-making, prognostication, and planning.Summary Of Background Data: Machine learning has been applied to predict postoperative complications for ACDF; however, studies were limited by sample size and model type. These studies achieved ≤0.70 area under the curve (AUC). Further approaches, not limited to ACDF, focused on specific complication types and resulted in AUC between 0.70 and 0.76.Materials and Methods: The IBM MarketScan Commercial Claims and Encounters Database and Medicare Supplement were queried from 2007 to 2016 to identify adult patients who underwent an ACDF procedure (N=176,816). Traditional machine learning algorithms, logistic regression, and support vector machines, were compared with deep neural networks to predict: 90-day postoperative complications, 90-day readmission, and two-year reoperation. We further generated random deep learning model architectures and trained them on the 90-day complication task to approximate an upper bound. Last, using deep learning, we investigated the importance of each input variable for the prediction of 90-day postoperative complications in ACDF.Results: For the prediction of 90-day complication, 90-day readmission, and two-year reoperation, the deep neural network-based models achieved AUC of 0.832, 0.713, and 0.671. Logistic regression achieved AUCs of 0.820, 0.712, and 0.671. Support vector machine approaches were significantly lower. The upper bound of deep learning performance was approximated as 0.832. Myelopathy, age, human immunodeficiency virus, previous myocardial infarctions, obesity, and documentary weakness were found to be the strongest variable to predict 90-day postoperative complications.Conclusions: The deep neural network may be used to predict complications for clinical applications after multicenter validation. The results suggest limited added knowledge exists in interactions between the input variables used for this task. Future work should identify novel variables to increase predictive power. [ABSTRACT FROM AUTHOR]

Telehealth was rapidly adopted during the COVID-19 pandemic. A survey was distributed to neurosurgeons in the United States (U.S.) to understand its use within neurosurgery, what barriers exist, unique issues related to neurosurgery, and opportunities for improvement. A survey was distributed via email and used the SurveyMonkey platform. The survey was sent to 3828 practicing neurosurgeons within the U.S., 404 responses were collected between October 30, 2021 and December 4, 2021. During the pandemic, telehealth was used multiple times per week by 60.65% and used daily by an additional 12.78% of respondents. A supermajority (89.84%) of respondents felt that evaluating patients across state lines with telemedicine is beneficial. Most respondents (95.81%) believed that telehealth improves patient access to care. The major criticism of telehealth was the inability to perform a neurological exam. Telehealth has been widely implemented within the field of neurosurgery during the COVID-19 pandemic and has increased access to care. It has allowed patients to be evaluated remotely, including across state lines. While certain aspects of the neurological exam are suited for video evaluation, sensation and reflexes cannot be adequately assessed. Neurosurgeons believe that telehealth adds value to their ability to deliver care. [ABSTRACT FROM AUTHOR]

Candidates for anterior cervical discectomy and fusion (ACDF) have a higher rate of opioid use than does the public, but studies on preoperative opioid use have not been conducted. We aimed to understand how preoperative opioid use affects post-ACDF outcomes. The MarketScan Database was queried from 2007 to 2015 to identify adult patients who underwent an ACDF. Patients were classified into separate cohorts based on the number of separate opioid prescriptions in the year before their ACDF. Ninety-day postoperative complications, postoperative readmission, reoperation, and total inpatient costs were compared between opioid strata. Propensity score-matched patient cohorts were calculated to balance comorbidities across groups. Of 81,671 ACDF patients, 31,312 (38.3%) were nonusers, 30,302 (37.1%) were mild users, and 20,057 (24.6%) were chronic users. Chronic opioid users had a higher comorbidity burden, on average, than patients with less frequent opioid use (P < 0.001). Chronic opioid users had higher rates of postoperative complications (9.1%) than mild opioid users (6.0%) and nonusers (5.3%) (P < 0.001) and higher rates of readmission and reoperation. After balancing opioid nonusers versus chronic opioid users along with demographic characteristics, preoperative comorbidity, and operative characteristics, postoperative complications remained elevated for chronic opioid users relative to opioid nonusers (8.6% vs. 5.7%; P < 0.001), as did rates of readmission and reoperation. Chronic opioid users had more comorbidities than opioid nonusers and mild opioid users, longer hospitalizations, and higher rates of postoperative complication, readmission, and reoperation. After balancing patients across covariates, the outcome differences persisted, suggesting a durable association between preoperative opioid use and negative postoperative outcomes. [ABSTRACT FROM AUTHOR]

Background: Postoperative metrics are increasingly important in determining standards of quality for physicians and hospitals. Although complications following spinal surgery have been described, procedural and patient variables have yet to be incorporated into a predictive model of adverse-event occurrence. We sought to develop a predictive model of complication occurrence after spine surgery.Methods: We used longitudinal prospective data from a national claims database and developed a predictive model incorporating complication type and frequency of occurrence following spine surgery procedures. We structured our model to assess the impact of features such as preoperative diagnosis, patient comorbidities, location in the spine, anterior versus posterior approach, whether fusion had been performed, whether instrumentation had been used, number of levels, and use of bone morphogenetic protein (BMP). We assessed a variety of adverse events. Prediction models were built using logistic regression with additive main effects and logistic regression with main effects as well as all 2 and 3-factor interactions. Least absolute shrinkage and selection operator (LASSO) regularization was used to select features. Competing approaches included boosted additive trees and the classification and regression trees (CART) algorithm. The final prediction performance was evaluated by estimating the area under a receiver operating characteristic curve (AUC) as predictions were applied to independent validation data and compared with the Charlson comorbidity score.Results: The model was developed from 279,135 records of patients with a minimum duration of follow-up of 30 days. Preliminary assessment showed an adverse-event rate of 13.95%, well within norms reported in the literature. We used the first 80% of the records for training (to predict adverse events) and the remaining 20% of the records for validation. There was remarkable similarity among methods, with an AUC of 0.70 for predicting the occurrence of adverse events. The AUC using the Charlson comorbidity score was 0.61. The described model was more accurate than Charlson scoring (p < 0.01).Conclusions: We present a modeling effort based on administrative claims data that predicts the occurrence of complications after spine surgery.Clinical Relevance: We believe that the development of a predictive modeling tool illustrating the risk of complication occurrence after spine surgery will aid in patient counseling and improve the accuracy of risk modeling strategies. [ABSTRACT FROM AUTHOR]

Objective We sought to describe complications after resection for meningioma with the use of longitudinal administrative data, which our group has shown recently to be superior to nonlongitudinal administrative data. Methods We identified patients who underwent resection for meningioma between 2010 and 2012 in the Thomson Reuters MarketScan database. Current Procedural Terminology coding at inpatient visit was used to select for meningioma resection procedure. Comorbidities and complications were obtained by use of the International Classification of Diseases , Ninth Revision or Current Procedural Terminology coding. Associations between complications and demographic and clinical factors were evaluated with logistic regression. Results We identified a total of 2216 patients. Approximately 41% developed 1 or more perioperative complications. Approximately 15% were readmitted within 30 days of their procedure. The most frequent complications that occurred in our cohort were new postoperative seizures (11.8%), postoperative dysrhythmia (7.9%), intracranial hemorrhage (5.9%), and cerebral artery occlusion (5.4%). General neurosurgical complications and general neurologic complications occurred in 4.4% and 16.1% of patients, respectively. Nearly 55% of elderly patients (≥70 years) developed 1 or more perioperative complication (vs. 39% of nonelderly patients). After we adjusted for comorbidities, elderly status and male sex were found to be significantly associated with increased odds for a variety of complications. Conclusions In this study, we report complication rates in patients undergoing resection for meningioma. Because of the longitudinal nature of the MarketScan database, we were able to capture a wide array of specific postoperative complications associated with meningioma resection procedures. Care should be taken in the selection of candidates for meningioma resection. [ABSTRACT FROM AUTHOR]

Background Postoperative visual loss (POVL) is a potentially devastating complication of lumbar spine surgery that may lead to significant functional impairment. Although POVL is rare, a review of the literature shows that it is being reported with increasing frequency. A systematic analysis detailing the etiology and prognosis of the 3 main types of POVL has yet to be published. We reviewed potential preoperative and intraoperative risk factors for ischemic optic neuropathy (ION), central retinal artery occlusion (CRAO), and cortical blindness (CB) after lumbar spine surgery. Methods A PubMed and Google literature search was completed in the absence of time constraints. Relevant articles on POVL after spine surgery were identified and reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results We identified 4 large-scale studies that statistically analyzed risk factors for POVL. ION, CRAO, and CB were the most frequently reported POVL types in the literature. Data were abstracted from 19 ION case reports, 3 CRAO case reports, and 5 CB case reports. Conclusions We reviewed the preoperative and intraoperative risk factors for each of the 3 main POVL types, using several published case reports to supplement the limited large-scale studies available. ION risks may be influenced by a longer operative time in the prone position with anemia, hypotension, and blood transfusion. The risk for CRAO is usually due to improper positioning during the surgery. Prone positioning and obesity were found to be most commonly associated with CB development. The prognosis, prevention techniques, and treatment of each POVL type can vary considerably. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

: Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Recent technological advancements have led to the development and implementation of robotic surgery in several specialties, including neurosurgery. Our aim was to carry out a worldwide survey among neurosurgeons to assess the adoption of and attitude toward robotic technology in the neurosurgical operating room and to identify factors associated with use of robotic technology. The online survey was made up of nine or ten compulsory questions and was distributed via the European Association of the Neurosurgical Societies (EANS) and the Congress of Neurological Surgeons (CNS) in February and March 2018. From a total of 7280 neurosurgeons who were sent the survey, we received 406 answers, corresponding to a response rate of 5.6%, mostly from Europe and North America. Overall, 197 neurosurgeons (48.5%) reported having used robotic technology in clinical practice. The highest rates of adoption of robotics were observed for Europe (54%) and North America (51%). Apart from geographical region, only age under 30, female gender, and absence of a non-academic setting were significantly associated with clinical use of robotics. The Mazor family (32%) and ROSA (26%) robots were most commonly reported among robot users. Our study provides a worldwide overview of neurosurgical adoption of robotic technology. Almost half of the surveyed neurosurgeons reported having clinical experience with at least one robotic system. Ongoing and future trials should aim to clarify superiority or non-inferiority of neurosurgical robotic applications and balance these potential benefits with considerations on acquisition and maintenance costs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity. 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. 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. 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. [ABSTRACT FROM AUTHOR]