Publications by authors named "Andrew J Schoenfeld"

249 Publications

Long-term Clinical Outcomes of Microendoscopic Laminotomy for Cervical Spondylotic Myelopathy: A 5-Year Follow-up Study Compared With Conventional Laminoplasty.

Clin Spine Surg 2021 Jun 14. Epub 2021 Jun 14.

Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama Department of Orthopaedic Surgery, Dokkyo Medical University, Tochigi, Japan Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: This was a retrospective cohort study.

Objective: The objective of this study was to characterize the long-term clinical and radiographic results of articular segmental decompression surgery using endoscopy [cervical microendoscopic laminotomy (CMEL)] for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP).

Summary Of Background Data: The spinal cord compression in CSM consists of a pincer mechanism due to bulging disk and a hypertrophied ligamentum flavum. The long-term clinical benefits of segmental decompression surgery, which removes the dorsal compressive elements of articular segment in CSM patients, have not yet been elucidated.

Materials And Methods: Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n=81) underwent CMEL or ELAP. All patients were followed postoperatively for >5 years. The preoperative and 5-year follow-up evaluation included neurological assessment [Japanese Orthopaedic Association (JOA) score], JOA recovery rates, axial neck pain (visual analog scale), and cervical sagittal alignment (C2-C7 subaxial cervical angle).

Results: Sixty-four patients (CMEL group: 33, ELAP group: 31) were included for analysis. The preoperative JOA score was 10.1 points in the CMEL group and 11.1 points in the ELAP group (P=0.15). The JOA recovery rates were similar, 58.6% in the CMEL group and 55.2% in the ELAP group (P=0.55). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (P<0.01). At 5-year follow-up, cervical alignment was more favorable in the CMEL group, with an average 2.9 degrees gain in lordosis [vs. 2.3 degrees loss of lordosis in the ELAP group (P<0.05)] and lower incidence of postoperative kyphosis.

Conclusions: CMEL is a novel, less invasive, technique that allows for multilevel posterior cervical decompression for treatment of CSM. Our 5-year follow-up data demonstrates that patients after CMEL have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis when compared with their traditional laminoplasty counterparts.
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http://dx.doi.org/10.1097/BSD.0000000000001200DOI Listing
June 2021

Characterizing Health-Related Quality of Life by Ambulatory Status in Patients With Spinal Metastases.

Spine (Phila Pa 1976) 2021 Jun 8. Epub 2021 Jun 8.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 Department of Orthopaedic Surgery, NYU Langone Medical Center, New York University, Westbury, NY 11590.

Study Design: Retrospective review of prospective longitudinal data.

Objective: To determine health-related quality of life (HRQL) utilities associated with specific ambulatory states in patients with spinal metastases: independent, ambulatory with assistance and non-ambulatory.

Summary Of Background Data: It is assumed that HRQL is aligned with ambulatory ability in patients with spinal metastases. Few studies have effectively considered these parameters while also accounting for clinical confounders.

Methods: We used prospective longitudinal data from patients treated at one of three tertiary medical centers (2017-2019). HRQL was characterized using the Euroquol-5-dimension (EQ5D) inventory. We performed standardized estimations of HRQL stratified by ambulatory state using generalized linear modeling that accounted for patient age at presentation, biologic sex, follow-up duration, operative or non-operative management and repeated measures within the same participant.

Results: We evaluated 675 completed EQ5D assessments, with 430 for independent ambulators, 205 for ambulators with assistance and 40 for non-ambulators. The average age of the cohort was 61.5. The most common primary cancer was lung (20%), followed by breast (18%). Forty-one percent of assessments were performed for participants treated surgically. Mortality occurred in 51% of the cohort. The standardized EQ5D utility for patients with spinal metastases and independent ambulatory function was 0.76 (95% CI 0.74, 0.78). Among those ambulatory with assistance, the standardized EQ5D utility was 0.59 (95% CI 0.57, 0.61). For non-ambulators, the standardized EQ5D utility was 0.14 (95% CI 0.09, 0.19).

Conclusions: Patients with spinal metastases and independent ambulatory function have a HRQL similar to patients with primary cancers and no spinal involvement. Loss of ambulatory ability leads to a 22% decrease in HRQL for ambulation with assistance and an 82% reduction among non-ambulators. Given prior studies demonstrate superior maintenance of ambulatory function with surgery for spinal metastases, our results support surgical consideration to the extent that it is clinically warranted.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004139DOI Listing
June 2021

Variability and contributions to cost associated with anterior versus posterior approaches to lumbar interbody fusion.

Clin Neurol Neurosurg 2021 Jul 15;206:106688. Epub 2021 May 15.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA. Electronic address:

Objective: Lumbar interbody fusions are being performed with increased frequency in the last decade. Anterior and posterior interbody techniques have demonstrated relatively similar success rates. Nonetheless, despite increased attention to cost-effective care delivery, approach-related differences in procedural cost and predictors for these differences remain poorly defined. The purpose of this investigation was to characterize the variability in cost for anterior versus posterior-based lumbar interbody fusions and to identify key predictors of procedural cost.

Methods: We evaluated the records of all patients who underwent a primary anterior (ALIF) or posterior/transforaminal (PLIF/TLIF) lumbar interbody fusion with concomitant posterior fusion from 2016 to 2020 at four hospitals in a major metropolitan area. We reviewed the records of all included patients and abstracted demographics, insurance status, approach, operative time, diagnosis, surgeon, institution, open versus minimally invasive technique, and components of procedural costs. Costs based upon interbody approach were compared via multivariable adjusted analyses using negative binomial regression.

Results: We included 139 interbody fusion procedures; 98 were performed via posterior approach (TLIF/PLIF) and 41 using an anterior approach. Anterior techniques were associated with significantly increased costs as compared to posterior procedures (anterior, $16316 [SE 556] vs. posterior, $9415 [SE 345]; p < 0.001). This determination remained significant following multivariable adjusted analysis (regression coefficient -0.22, 95% CI -0.34, -0.10, p < 0.001). Multivariable analysis also indicated that surgeon, invasiveness, and procedure time were significant predictors of total cost.

Conclusion: Our findings demonstrate that anterior interbody techniques are, on average, 173% (anterior, $16316 [SE 556] vs. posterior, $9415 [SE 345]; p < 0.001) more expensive than posterior-based procedures. Given the relative equipoise of these different approaches for many clinical applications, these findings should be considered in an ecosystem increasingly attentive to cost effective care delivery. This work has also provided specific procedural variables for surgeons and systems to target when optimizing procedural costs.
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http://dx.doi.org/10.1016/j.clineuro.2021.106688DOI Listing
July 2021

Evaluating ambulatory function as an outcome following treatment for spinal metastases: A systematic review.

Spine J 2021 May 13. Epub 2021 May 13.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115. Electronic address:

Background Context: Studies regarding treatment of spinal metastases are critical to evidence-based decision-making. However, variation exists in how a key outcome, ambulatory function, is assessed.

Purpose: To characterize the sources and tools investigators have used to evaluate ambulatory function as an outcome following treatment of spinal metastases. We also sought to understand the ways ambulatory function has been conceptualized in prior studies.

Study Design: Systematic review of the literature.

Patient Sample: We identified 44 published studies for inclusion. Samples within these investigations ranged from 20-2,096 subjects.

Outcome Measures: We describe the methods investigators have used to evaluate ambulatory function following treatment for spinal metastases.

Methods: We conducted a systematic review through PubMed, Scopus and Web of Science following PRISMA guidelines. We included studies that consisted of adult patients receiving operative or non-operative treatment for spinal metastases. We also required that study investigators specified post-treatment ambulatory function as an outcome. We recorded year of publication, study design, types of spinal metastases included in the study, treatments employed and sample size. We also described the source (medical record, study-specific observer/provider, patient/participant), tool (standardized measure, quantitative, qualitative) and concept (e.g. ambulatory vs non-ambulatory; independent ambulation vs ambulatory with assistance vs non-ambulatory) used to assess ambulatory function.

Results: We found the plurality of studies relied on medical record documentation as their source. Amongst prospective studies, only a minority used a quantitative measure (e.g. prespecified degree of walking ability) to assess ambulatory function. Most studies conceptualized ambulatory function as a dichotomized outcome, typically ambulatory vs non-ambulatory or a similar equivalent.

Conclusions: Wide variation exists in how ambulatory function is defined in studies involving patients with spinal metastases. We suggest several improvements that will allow a more robust assessment of the quality and quantity of ambulatory function among patients treated for spinal metastases.
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http://dx.doi.org/10.1016/j.spinee.2021.05.001DOI Listing
May 2021

Telemedicine Use in Orthopaedic Surgery Varies by Race, Ethnicity, Primary Language, and Insurance Status.

Clin Orthop Relat Res 2021 Jul;479(7):1417-1425

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Healthcare disparities are well documented across multiple subspecialties in orthopaedics. The widespread implementation of telemedicine risks worsening these disparities if not carefully executed, despite original assumptions that telemedicine improves overall access to care. Telemedicine also poses unique challenges such as potential language or technological barriers that may alter previously described patterns in orthopaedic disparities.

Questions/purposes: Are the proportions of patients who use telemedicine across orthopaedic services different among (1) racial and ethnic minorities, (2) non-English speakers, and (3) patients insured through Medicaid during a 10-week period after the implementation of telemedicine in our healthcare system compared with in-person visits during a similar time period in 2019?

Methods: This was a retrospective comparative study using electronic medical record data to compare new patients establishing orthopaedic care via outpatient telemedicine at two academic urban medical centers between March 2020 and May 2020 with new orthopaedic patients during the same 10-week period in 2019. A total of 11,056 patients were included for analysis, with 1760 in the virtual group and 9296 in the control group. Unadjusted analyses demonstrated patients in the virtual group were younger (median age 57 years versus 59 years; p < 0.001), but there were no differences with regard to gender (56% female versus 56% female; p = 0.66). We used self-reported race or ethnicity as our primary independent variable, with primary language and insurance status considered secondarily. Unadjusted and multivariable adjusted analyses were performed for our primary and secondary predictors using logistic regression. We also assessed interactions between race or ethnicity, primary language, and insurance type.

Results: After adjusting for age, gender, subspecialty, insurance, and median household income, we found that patients who were Hispanic (odds ratio 0.59 [95% confidence interval 0.39 to 0.91]; p = 0.02) or Asian were less likely (OR 0.73 [95% CI 0.53 to 0.99]; p = 0.04) to be seen through telemedicine than were patients who were white. After controlling for confounding variables, we also found that speakers of languages other than English or Spanish were less likely to have a telemedicine visit than were people whose primary language was English (OR 0.34 [95% CI 0.18 to 0.65]; p = 0.001), and that patients insured through Medicaid were less likely to be seen via telemedicine than were patients who were privately insured (OR 0.83 [95% CI 0.69 to 0.98]; p = 0.03).

Conclusion: Despite initial promises that telemedicine would help to bridge gaps in healthcare, our results demonstrate disparities in orthopaedic telemedicine use based on race or ethnicity, language, and insurance type. The telemedicine group was slightly younger, which we do not believe undermines the findings. As healthcare moves toward increased telemedicine use, we suggest several approaches to ensure that patients of certain racial, ethnic, or language groups do not experience disparate barriers to care. These might include individual patient- or provider-level approaches like expanded telemedicine schedules to accommodate weekends and evenings, institutional investment in culturally conscious outreach materials such as advertisements on community transport systems, or government-level provisions such as reimbursement for telephone-only encounters.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001775DOI Listing
July 2021

Performance assessment of the metastatic spinal tumor frailty index using machine learning algorithms: limitations and future directions.

Neurosurg Focus 2021 May;50(5):E5

Departments of1Neurosurgery and.

Objective: Frailty is recognized as an important consideration in patients with cancer who are undergoing therapies, including spine surgery. The definition of frailty in the context of spinal metastases is unclear, and few have studied such markers and their association with postoperative outcomes and survival. Using national databases, the metastatic spinal tumor frailty index (MSTFI) was developed as a tool to predict outcomes in this specific patient population and has not been tested with external data. The purpose of this study was to test the performance of the MSTFI with institutional data and determine whether machine learning methods could better identify measures of frailty as predictors of outcomes.

Methods: Electronic health record data from 479 adult patients admitted to the Massachusetts General Hospital for metastatic spinal tumor surgery from 2010 to 2019 formed a validation cohort for the MSTFI to predict major complications, in-hospital mortality, and length of stay (LOS). The 9 parameters of the MSTFI were modeled in 3 machine learning algorithms (lasso regularization logistic regression, random forest, and gradient-boosted decision tree) to assess clinical outcome prediction and determine variable importance. Prediction performance of the models was measured by computing areas under the receiver operating characteristic curve (AUROCs), calibration, and confusion matrix metrics (positive predictive value, sensitivity, and specificity) and was subjected to internal bootstrap validation.

Results: Of 479 patients (median age 64 years [IQR 55-71 years]; 58.7% male), 28.4% had complications after spine surgery. The in-hospital mortality rate was 1.9%, and the mean LOS was 7.8 days. The MSTFI demonstrated poor discrimination for predicting complications (AUROC 0.56, 95% CI 0.50-0.62) and in-hospital mortality (AUROC 0.69, 95% CI 0.54-0.85) in the validation cohort. For postoperative complications, machine learning approaches showed a greater advantage over the logistic regression model used to develop the MSTFI (AUROC 0.62, 95% CI 0.56-0.68 for random forest vs AUROC 0.56, 95% CI 0.50-0.62 for logistic regression). The random forest model had the highest positive predictive value (0.53, 95% CI 0.43-0.64) and the highest negative predictive value (0.77, 95% CI 0.72-0.81), with chronic lung disease, coagulopathy, anemia, and malnutrition identified as the most important predictors of postoperative complications.

Conclusions: This study highlights the challenges of defining and quantifying frailty in the metastatic spine tumor population. Further study is required to improve the determination of surgical frailty in this specific cohort.
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http://dx.doi.org/10.3171/2021.2.FOCUS201113DOI Listing
May 2021

Spnal metastases 2021: a review of the current state of the art and future directions.

Spine J 2021 Apr 19. Epub 2021 Apr 19.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard medical School, Boston, MD 02115, USA.

Spinal metastases are an increasing societal health burden secondary to improvements in systemic therapy. Estimates indicate that 100,000 or more people have symptomatic spine metastases requiring management. While open surgery and external beam radiotherapy have been the pillars of treatment, there is growing interest in more minimally invasive technologies (eg separation surgery) and non-operative interventions (eg percutaneous cementoplasty, stereotactic radiosurgery). The great expansion of these alternatives to open surgery and the prevalence of adjuvant therapeutic options means that treatment decision making is now complex and reliant upon multidisciplinary collaboration. To help facilitate construction of care plans that meet patient goals and expectations, clinical decision aids and prognostic scores have been developed. These have been shown to have superior predictive value relative to more classic prediction models and may become an increasingly important aspect of the clinical practice of spinal oncology. Here we overview current therapeutic advances in the management of spine metastases and highlight emerging areas for research. Given the rapid advancements in surgical technologies and adjuvants, the field is likely to undergo further transformative changes in the coming decade.
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http://dx.doi.org/10.1016/j.spinee.2021.04.012DOI Listing
April 2021

Telemedicine visits generate accurate surgical plans across orthopaedic subspecialties.

Arch Orthop Trauma Surg 2021 Apr 18. Epub 2021 Apr 18.

Department of Orthopaedic Spine Surgery, Brigham and Women's Hospital, Harvard Medical Schools, 75 Francis St, Boston, MA, 02115, USA.

Introduction: The role of telemedicine is rapidly evolving across medical specialties and orthopaedics. The utility of telemedicine to identify operative candidates and determine surgical plans has yet to be demonstrated. We sought to assess whether surgical plans proposed following telemedicine visits changed after subsequent in-person interaction across orthopaedic subspecialties.

Materials And Methods: We identified all elective telemedicine encounters across two academic institutions from March 1, 2020 to July 31, 2020. We identified patients indicated for surgery with a specific surgical plan during the virtual visit. The surgical plans delineated during the telemedicine encounter were then compared to final pre-operative plans documented following subsequent in-person evaluation. Changes in the surgical plan between telemedicine and in-person encounters were defined using a standardised schema. Regression analysis was used to evaluate factors associated with a change in surgical plan between visits across specialties, including the number of virtual examination manoeuvres performed.

Results: We identified 303 instances of a patient being indicated for orthopaedic surgery during a telemedicine encounter. In 11 cases (4%), the plan was changed between telemedicine and subsequent in-person encounter. No plans were changed amongst patients indicated for joint arthroplasty and foot and ankle surgery, whilst 4% of plans were changed amongst sports surgery and upper extremity/shoulder surgery. Surgical plans had the highest rate of change amongst spine surgery patients (8%). There was notable variability in the conduct of virtual examinations across subspecialties.

Conclusion: Our results demonstrate the capability of telemedicine to support development of accurate surgical plans for orthopaedic patients across several subspecialties. Our findings also highlight the substantial variation in the utilisation of physical examination manoeuvres conducted via telemedicine across institutions, subspecialties, and providers.

Description Of Study Type: Level IV, retrospective cohort study.
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http://dx.doi.org/10.1007/s00402-021-03903-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053078PMC
April 2021

Trends and Complications in Spinopelvic Fixation for Deformity for Spinal Surgeons in Early Independent Practice.

Clin Spine Surg 2021 Mar 29. Epub 2021 Mar 29.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Retrospective case series study.

Objective: Evaluate trends and complications following posterior spinal instrumented fusion for deformity with/without pelvic fixation using the American Board of Orthopaedic Surgery Part II Oral Examination Candidate Case List data from 2008 to 2017.

Summary Of Background Data: Complication rates for cases with pelvic fixation are widely reported in spine deformity literature but are typically derived from practices of senior surgeons. As surgical experience and clinical volume are shown to decrease complication rates, spine surgeons newly in practice may have higher risks of such events.

Materials And Methods: Surgical cases submitted by candidates taking the American Board of Orthopaedic Surgery Part II Oral Examination between 2008 and 2017 with a self-designated sub-specialty of spine surgery were retrospectively reviewed. Mortality, readmission/reoperation data, and complications as reported by candidates were tracked over time. Bivariate testing and multivariable Poisson analyses, respectively, were used to assess complication rates and time-related trends.

Results: A total of 37,539 cases were submitted between 2008 and 2017. Four hundred sixty-one cases (1.2%) were for deformity; of these, 60 cases included pelvic fixation (13% of deformity cases). For all deformity cases, we noted medical, surgical, and overall complication rates to be 17%, 22.3%, and 31.5%. Multivariable analyses demonstrated no difference in surgical/overall complication rates between spinopelvic and nonspinopelvic instrumented groups, but showed a consistently low number of cases using spinopelvic fixation over time.

Conclusions: Newly practicing spinal surgeons consistently performed low numbers of deformity cases with relatively high complication rates which remained stable over time.
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http://dx.doi.org/10.1097/BSD.0000000000001163DOI Listing
March 2021

Interventional procedure plans generated by telemedicine visits in spine patients are rarely changed after in-person evaluation.

Reg Anesth Pain Med 2021 06 23;46(6):478-481. Epub 2021 Mar 23.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA

Background And Objectives: The role of telemedicine in the evaluation and treatment of patients with spinal disorders is rapidly expanding, brought on largely by the COVID-19 pandemic. Within this context, the ability of pain specialists to accurately diagnose and plan appropriate interventional spine procedures based entirely on telemedicine visits, without an in-person evaluation, remains to be established. In this study, our primary objective was to assess the relevance of telemedicine to interventional spine procedure planning by determining whether procedure plans established solely from virtual visits changed following in-person evaluation.

Methods: We reviewed virtual and in-person clinical encounters from our academic health system's 10 interventional spine specialists. We included patients who were seen exclusively via telemedicine encounters and indicated for an interventional procedure with documented procedural plans. Virtual plans were then compared with the actual procedures performed following in-person evaluation. Demographic data as well as the type and extent of physical examination performed by the interventional spine specialist were also recorded.

Results: Of the 87 new patients included, the mean age was 60 years (SE 1.4 years) and the preprocedural plan established by telemedicine, primarily videoconferencing, did not change for 76 individuals (87%; 95% CI 0.79 to 0.94) following in-person evaluation. Based on the size of our sample, interventional procedures indicated solely during telemedicine encounters may be accurate in 79%-94% of cases in the broader population.

Conclusions: Our findings suggest that telemedicine evaluations are a generally accurate means of preprocedural assessment and development of interventional spine procedure plans. These findings clearly demonstrate the capabilities of telemedicine for evaluating spine patients and planning interventional spine procedures.
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http://dx.doi.org/10.1136/rapm-2021-102630DOI Listing
June 2021

Prospective comparison of the accuracy of the New England Spinal Metastasis Score (NESMS) to legacy scoring systems in prognosticating outcomes following treatment of spinal metastases.

Spine J 2021 Mar 16. Epub 2021 Mar 16.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.

Background Context: We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data.

Purpose: To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment.

Patient Sample: We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019.

Outcome Measures: One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily.

Methods: All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score.

Results: When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score.

Conclusions: The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases.
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http://dx.doi.org/10.1016/j.spinee.2021.03.007DOI Listing
March 2021

The Hidden Costs of War: Healthcare Utilization Among Individuals Sustaining Combat-related Trauma (2007-2018).

Ann Surg 2021 Mar 2. Epub 2021 Mar 2.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814 Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115.

Objective: We sought to evaluate long-term healthcare requirements of American military servicemembers with combat-related injuries.

Summary Of Background Data: US military conflicts since 2001 have produced the most combat casualties since Vietnam. Long-term consequences on healthcare utilization and associated costs remain unknown.

Methods: We identified servicemembers who were treated for combat-related injuries between 2007 and 2011. Controls consisted of active-duty servicemembers injured in the civilian sector, without any history of combat-related trauma, matched (1:1) on year of injury, biologic sex injury severity, and age at time of injury. Surveillance was performed through 2018. Total annual healthcare expenditures were evaluated overall and then as expenditures in the first year after injury and for subsequent years. Negative binomial regression was used to identify the adjusted influence of combat injury on healthcare costs.

Results: The combat-injured cohort consisted of 3981 individuals and we identified 3979 controls. Total healthcare utilization during the follow-up period resulted in median costs of $142,214 (IQR $61,428, $323,060) per combat-injured servicemember as compared to $50,741 (IQR $26,669, $104,134) among controls. Median expenditures, adjusted for duration of follow-up, for the combat-injured were $45,211 (IQR $18,698, $105,437). In adjusted analysis, overall costs were 30% higher (1.30; 95% confidence interval: 1.23, 1.37) for combat-injured personnel.

Conclusion: This investigation represents the longest continuous observation of healthcare utilization among individuals after combat injury and the first to assess costs. Expenditures were 30% higher for individuals injured as a result of combat-related trauma when compared to those injured in the civilian sector.
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http://dx.doi.org/10.1097/SLA.0000000000004844DOI Listing
March 2021

Learning from England's Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Hip Fracture Outcomes.

Ann Surg 2021 Jan 22. Epub 2021 Jan 22.

Yale School of Medicine, New Haven, CT Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom Center for Surgery and Public Health: Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA Yale School of Public Health, New Haven, CT Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, United Kingdom School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, MA.

Objective: The objective of this study was to evaluate England's Best Practice Tariff (BPT) and consider potential implications for Medicare patients should the US adopt a similar plan.

Summary Background Data: Since the beginning of the Affordable Care Act, Medicare has renewed efforts to improve the outcomes of older adults through introduction of an expanding set of alternative-payment models. Among trauma patients, recommended arrangements met with mixed success given concerns about the heterogeneous nature of trauma patients and resulting outcome variation. A novel approach taken for hip fractures in England could offer a viable alternative.

Methods: Linear regression, interrupted time-series, difference-in-difference, and counterfactual models of 2000-2016 Medicare (US), HES-APC (England) death certificate-linked claims (≥65y) were used to: track US hip fracture trends, look at changes in English hip fracture trends before-and-after BPT implementation, compare changes in US-versus-English mortality, and estimate total/theoretical lives saved.

Results: 806,036 English and 3,221,109 US hospitalizations were included. Following BPT implementation, England's 30-day mortality decreased by 2.6 percentage-points (95%CI: 1.7-3.5) from a baseline of 9.9% (relative reduction 26.3%). 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000-2016, US outcomes were stagnant (p > 0.05), resulting in an inversion of the countries' mortality and > 38,000 potential annual US lives saved.

Conclusions: Process measure pay-for-performance led to significant improvements in English hip fracture outcomes. As efforts to improve US older adult health continue to increase, there are important lessons to be learned from a successful initiative like the BPT.
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http://dx.doi.org/10.1097/SLA.0000000000004305DOI Listing
January 2021

Identifying Patterns and Predictors of Prescription Opioid Use After Total Joint Arthroplasty.

Mil Med 2021 05;186(5-6):587-592

Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

Introduction: Total hip arthroplasty and total knee arthroplasty account for over 1 million procedures annually. Opioids are the mainstay of postoperative pain management for these patients. In this context, the objective of this study was to determine patterns of use and factors associated with early discontinuation of opioids after total joint arthroplasty (TJA).

Methods: TRICARE claims data (2006-2014) were queried for adult (18-64 years) patients who underwent total hip arthroplasty or total knee arthroplasty. Prescription opioid use was identified from 6 months before and 6 months after surgical intervention. Prior opioid use was categorized as naïve, exposed (with non-sustained use), and sustained (6 month continuous use before surgery). Cox proportional-hazards models were used to identify factors associated with opioid discontinuation following TJA.

Results: Among the 29,767 patients included in the study, 15,271 (51.3%) had prior opioid exposure and 3,740 (12.5%) were sustained opioid users. At 6 months after the surgical intervention, 3,171 (10.6%) continued opioid use, 3.3% were among opioid naïve, 10.2% among exposed, and 33.3% among sustained users. In risk-adjusted models, prior opioid exposure (hazards ratio: 0.65, 95% CI: 0.62-0.67) and sustained prior use (hazards ratio: 0.33, 95% CI: 0.31-0.35) were the strongest predictors of lower likelihood of opioid discontinuation. Lower socio-economic status, depression, and anxiety were also strong predictors.

Conclusion: Prior opioid exposure was strongly associated with continued opioid dependence after TJA. Although one-third of prior sustained users continued use after surgery, approximately 10% of previously exposed patients became sustained users, making them the prime candidates for targeted interventions to reduce the likelihood of sustained opioid use after TJA.
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http://dx.doi.org/10.1093/milmed/usaa573DOI Listing
May 2021

Microendoscopic decompression for lumbar spinal stenosis caused by facet-joint cysts: a novel technique with a cyst-dyeing protocol and cohort comparison study.

J Neurosurg Spine 2021 Jan 15:1-7. Epub 2021 Jan 15.

1Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama.

Objective: Facet cysts may represent a sign of intrinsic facet disease and instability, increasing the importance of less-invasive approaches that limit tissue dissection and improve visualization. The authors developed an intraoperative cyst-dyeing technique, involving the injection of indigo carmine from the facet joint into the cyst, as an adjunct during decompression. This study aimed to evaluate the clinical outcomes and perioperative complication rates of microendoscopic spinal decompression for lumbar spinal stenosis (LSS) and lumbar foraminal stenosis (LFS), caused by facet cysts and to elucidate the efficacy of the cyst-dyeing method in microendoscopic surgery for facet cysts.

Methods: Forty-eight consecutive patients who underwent surgical treatment with microendoscopic decompression for symptomatic LSS or LFS caused by facet cysts from 2011 to 2018 were reviewed. These patients were divided into two groups: a group that did not receive dye (N), with the patients undergoing surgery from April 2011 to May 2015; and a group that received dye (D), with patients undergoing surgery from June 2015 to March 2018. The authors evaluated the operative time, blood loss, perioperative complications, visual analog scale scores for low-back and leg pain, and Japanese Orthopaedic Association scores. Surgical outcome was evaluated 2 years postoperatively and was compared between groups D and N.

Results: The clinical outcomes were generally excellent or good. Group N consisted of 36 patients and group D of 12 patients. Comparing the clinical results, it was found that the cyst-dyeing method reduced the perioperative complication rate, including reduction in dural tears to 0%, and shortened the average operative time by approximately 40 minutes.

Conclusions: In this study, the authors demonstrated that the clinical outcomes of microendoscopic spinal decompression in patients with LSS or LFS caused by facet-joint cysts are generally favorable. Additionally, the adjunctive cyst-dyeing method effectively delineated the cystic and dural boundaries, facilitating safer and more effective cyst separation and neural decompression. Microendoscopic surgery combined with this novel facet cyst-dyeing method is a safe and effective minimally invasive technique for facet-joint cysts.
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http://dx.doi.org/10.3171/2020.8.SPINE201209DOI Listing
January 2021

Emergency Department Utilization in the U.S. Military Health System.

Mil Med 2021 05;186(5-6):606-612

Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA.

Introduction: Emergency department (ED) utilization represents an expensive and growing means of accessing care for a variety of conditions. Prior studies have characterized ED utilization in the general population. We aim to identify the clinical conditions that drive ED utilization in a universally insured population and the impacts of care setting on ED use and admissions in the U.S. Military Health System.

Methods: We queried TRICARE claims data from October 1, 2012, to September 30, 2015, to identify all ED visits for adult patients (age 18-64). The primary presenting diagnoses of all ED visits and those leading to admission are presented with descriptive statistics. Logistic regression was used to identify clinical and sociodemographic factors associated with admission from the ED.

Results: A total of 4,687,205 ED visits were identified, of which 46% took place in the DoD healthcare facilities (direct care). The most common diagnoses across all ED visits were abdominal pain, chest pain, headache, nausea and vomiting, and urinary tract infection. A total of 270,127 (5.8%) ED visits led to inpatient admission. The most common diagnoses leading to admission were chest pain, abdominal pain, depression, conditions relating to acute psychological stress, and pneumonia. For patients presenting with 1 of the 10 most common ED diagnoses, those who were seen at a civilian ED were significantly less likely to be admitted (3.4%) compared to direct care facilities (4.1%) in an adjusted logistic regression model (Adjusted Odds Ratio 0.40 [95% CI: 0.40-0.41], P < .001).

Conclusions: Ultimately, we show that abdominal pain and chest pain are the most common reasons for presentation to the ED in the Military Health System and the most common presenting diagnoses for admission from the ED. Among patients presenting with the most common ED conditions, direct care EDs were significantly more likely to admit patients than civilian facilities.
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http://dx.doi.org/10.1093/milmed/usaa547DOI Listing
May 2021

Super-Utilization of the Emergency Department in a Universally Insured Population.

Mil Med 2020 Nov 28. Epub 2020 Nov 28.

Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Introduction: Super-utilizers (patients with 4 or more emergency department [ED] visits a year) account for 10% to 26% of all ED visits and are responsible for a growing proportion of healthcare expenditures. Patients recognize the ED as a reliable provider of acute care, as well as a timely resource for diagnosis and treatment. The value of ED care is indisputable in critical and emergent conditions, but in the case of non-urgent conditions, ED utilization may represent an inefficiency in the healthcare system. We sought to identify patient and clinical characteristics associated with ED super-utilization in a universally insured population.

Material And Methods: We performed a retrospective cohort study using TRICARE claims data from the Military Health System Data Repository (2011-2015). We reviewed the claims data of all adult patients (aged 18-64 years) who had at least one encounter at the ED for any cause. Multivariable logistic regression was used to determine independent factors associated with ED super-utilization.

Results: Factors associated with increased odds of ED super-utilization included Charlson Score ≥2 (adjusted odds ratio [aOR] 1.98, 95% confidence interval [CI]: 1.90-2.06), being eligible for Medicare (aOR 1.95, 95% CI: 1.90-2.01), and female sex (aOR 1.35, 95% CI: 1.33-1.37). Active duty service members (aOR 0.69, 95% CI 0.68-0.72) and beneficiaries with higher sponsor-rank (Officers: aOR 0.50, 95% CI: 0.55-0.57; Senior enlisted: aOR 0.82, 95% CI: 0.81-0.83) had lower odds of ED super-utilization. The most common primary diagnoses for ED visits among super-utilizers were abdominal pain, headache and migraine, chest pain, urinary tract infection, nausea and vomiting, and low back pain.

Conclusions: Risk of ED super-utilization appears to increase with age and diminished health status. Patient demographic and clinical characteristics of ED super-utilization identified in this study can be used to formulate healthcare policies addressing gaps in primary care in diagnoses associated with ED super-utilization and develop interventions to address modifiable risk factors of ED utilization.
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November 2020

National utilization and inpatient safety measures of lumbar spinal fusion methods by race/ethnicity.

Spine J 2021 May 20;21(5):785-794. Epub 2020 Nov 20.

Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA; Division of General Medicine, Massachusetts General Hospital, 50 Staniford St, 9th floor, Boston, MA 02114 USA.

Background Context: Degenerative lumbar conditions are prevalent, disabling, and frequently managed with decompression and fusion. Black patients have lower spinal fusion rates than White patients.

Purpose: Determine whether specific lumbar fusion procedure utilization differs by race/ethnicity and whether length of stay (LOS) or inpatient complications differ by race/ethnicity after accounting for procedure performed.

Study Design: Large database retrospective cohort study PATIENT SAMPLE: Lumbar fusion recipients at least age 50 in the 2016 National Inpatient Sample with diagnoses of degenerative lumbar conditions.

Outcome Measures: Type of fusion procedure used and inpatient safety measures including LOS, prolonged LOS, inpatient medical and surgical complications, mortality, and cost.

Methods: We examined the association between race/ethnicity and the safety measures above. Covariates included several patient and hospital factors. We used multiple linear or logistic regression to determine the association between race and fusion type (PLF, P/TLIF, ALIF, PLF + P/TLIF, and PLF + ALIF [anterior-posterior fusion]) and to determine whether race was associated independently with inpatient safety measures, after adjustment for patient and hospital factors.

Results: Fusion method use did not differ among racial/ethnic groups, except for somewhat lower anterior-posterior fusion utilization in Black patients compared to White patients (crude odds ratio [OR]: 0.81 [0.67-0.97]). Inpatient safety measures differed by race/ethnicity for rates of prolonged LOS (Blacks 18.1%, Hispanics 14.5%, and Whites 11.7%), medical complications (Blacks 9.9%, Hispanics 8.7%, and Whites 7.7%), and surgical complications (Blacks 5.2%, Hispanics 6.9%, and Whites 5.4%). Differences persisted after adjustment for procedure type as well as patient and hospital factors. Blacks and Hispanics had higher risk for prolonged LOS compared to Whites (adjusted OR Blacks 1.39 [95% confidence interval {CI} 1.22-1.59]; Hispanics 1.24 [95% CI 1.02-1.52]). Blacks had higher risk for inpatient medical complications compared to Whites (adjusted OR 1.24 [95% CI 1.05-1.48]), and Hispanics had higher risk for inpatient surgical complications compared to Whites (adjusted OR 1.34 [95% CI 1.06-1.68]).

Conclusions: Fusion method use was generally similar between racial/ethnic groups. Inpatient safety measures, adjusted for procedure type, patient and hospital factors, were worse for Blacks and Hispanics.
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http://dx.doi.org/10.1016/j.spinee.2020.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113062PMC
May 2021

Surgical plans generated from telemedicine visits are rarely changed after in-person evaluation in spine patients.

Spine J 2021 Mar 20;21(3):359-365. Epub 2020 Nov 20.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 USA. Electronic address:

Background Context: The role of telemedicine within the realm of spine surgery is evolving, catalyzed by the recent pandemic. Specifically, the capability of this technology to provide high-quality, cost-effective care without an in-person interaction and physical examination remains poorly defined.

Purpose: To characterize the impact of telemedicine on spine surgical planning by assessing whether surgical plans established in virtual visits changed following in-person evaluation.

Study Design: Retrospective cohort study.

Patient Sample: We evaluated the records of patients who were indicated for surgery with documented specific surgical plans during a virtual encounter (March-July 2020) and underwent subsequent in-person evaluation prior to surgery.

Outcome Measures: We determined whether surgical plans changed between the virtual encounter and the in-person interaction. Secondarily, we reviewed use of the virtual physical examination across surgeons.

Methods: We reviewed virtual and in-person clinical encounters from a single academic spine division, evaluating those patients who were seen exclusively via telemedicine encounters and indicated for surgery with documented specific surgical plans. These plans were compared to the surgical plan after these same patients underwent in-person evaluation. Demographic data, patient primary complaint, and the type and extent of physical examination performed by the surgeon were recorded.

Results: Of the 33 patients included, the surgical plan did not change among 31 individuals (94%) following in-person interaction. For the two patients where surgical plans were modified, multilevel fusions were increased by one level. There was notable inter- and intra-surgeon variability with regard to the use of virtual physical exams.

Conclusions: Our findings suggest that telemedicine evaluations are efficient means of preoperative assessment of spine patients and delineation of surgical plans. These results may support innovations that can optimize access to care for patients.
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http://dx.doi.org/10.1016/j.spinee.2020.11.009DOI Listing
March 2021

Does prophylactic use of topical gelatin-thrombin matrix sealant affect postoperative drainage volume and hematoma formation following microendoscopic spine surgery? A randomized controlled trial.

Spine J 2021 Mar 13;21(3):446-454. Epub 2020 Nov 13.

Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan.

Background Context: Microendoscopic spinal surgery has demonstrated efficacy and is increasingly utilized as a minimally invasive approach to neural decompression, but there is a theoretical concern that bleeding and postoperative epidural hematoma (PEH) may occur with increased frequency in a contained small surgical field. Hemostatic agents, such as topical gelatin-thrombin matrix sealant (TGTMS), are routinely used in spine surgery procedures, yet there has been no data on whether PEH is suppressed by these agents when administered in microendoscopic spine surgery.

Purpose: The purpose of this study was to investigate the effect of TGTMS on bleeding and PEH formation in lumbar micoroendoscopic surgery.

Study Design: This is a randomized controlled trial (RCT) with additional prospective observational cohort.

Patient Sample: Patients were registered from July 2017 to September 2018 and a hundred and three patients undergoing microendoscopic laminectomy for lumbar spinal stenosis at a single institution were enrolled in this study.

Outcome Measures: The primary outcome was the drainage volume within 48 hours after surgery. Secondary outcomes were the numerical rating scale (NRS) of leg pain on the second (NRS2) and seventh day (NRS7) after surgery and the hematoma area ratio (HAR) in horizontal images on magnetic resonance image (MRI).

Methods: In the RCT, 41 cases that received TGTMS (F group) were compared with 41 control group cases (C group) that did not receive TGTMS at the end of the procedure. Drainage volume, NRS2, NRS7, and HAR on MRI were evaluated. Nineteen cases were excluded from the RCT (I group) due to difficulty of hemostasis during surgery and the intentional use of TGTMS for hemostasis. I group was compared with C group in the drainage volume and NRS of leg pain as a prospective observational study.

Results: The RCT demonstrated no statistically significant difference in drainage volume between those receiving TGTMS (117.0±71.7; mean±standard deviation) and controls (125.0±127.0; p=.345). The NRS2 and NRS7 was 3.5±2.6 and 2.8±2.5 in the F group, respectively, and 3.1±2.6 and 2.1±2.3 in the C group, respectively. The HAR on MRI was 0.19±0.19 in the F group and 0.17±0.13 in the C group. There was no significant difference in postoperative leg pain and HAR (p=.644 for NRS2, p=.129 for NRS7, and p=.705 for HAR). In the secondary observational cohort, the drainage volume in the I group was 118.3±151.4, and NRS2 and NRS7 was 3.5±2.0 and 2.6±2.6, respectively. There were no statistically significant differences in drainage volume (p=.386) or postoperative NRS of leg pain between these two groups (p=.981 and .477 for NRS2 and NRS7, respectively).

Conclusions: The prophylactic use of TGTMS in patients undergoing microendoscopic laminotomy for lumbar spinal stenosis did not demonstrate any difference in postoperative bleeding or PEH. Nonetheless, for patients that had active bleeding that required the use of TGTMS, there was no evidence of difference in postoperative clinical outcomes relative to controls.
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http://dx.doi.org/10.1016/j.spinee.2020.11.004DOI Listing
March 2021

Clinician Experiences in Treatment Decision-Making for Patients with Spinal Metastases: A Qualitative Study.

J Bone Joint Surg Am 2021 Jan;103(1):e1

Departments of Orthopaedic Surgery (L.B.B., K.R.A., J.A.B., E.L., J.N.K., and A.J.S.), Neurosurgery (D.L.S.), and Radiation Oncology (T.A.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Effective management of metastatic disease requires multidisciplinary input and entails high risk of disease-related and treatment-related morbidity and mortality. The factors that influence clinician decision-making around spinal metastases are not well understood. We conducted a qualitative study that included a multidisciplinary cohort of physicians to evaluate the decision-making process for treatment of spinal metastases from the clinician's perspective.

Methods: We recruited operative and nonoperative clinicians, including orthopaedic spine surgeons, neurosurgeons, radiation oncologists, and physiatrists, from across North America to participate in either a focus group or a semistructured interview. All interviews were audiorecorded and transcribed verbatim. We then performed a thematic analysis using all of the available transcript data. Investigators sequentially coded transcripts and identified recurring themes that encompass overarching patterns in the data and directly bear on the guiding study question. This was followed by the development of a thematic map that visually portrays the themes, the subthemes, and their interrelatedness, as well as their influence on treatment decision-making.

Results: The thematic analysis revealed that numerous factors influence provider-based decision-making for patients with spinal metastases, including clinical elements of the disease process, treatment guidelines, patient preferences, and the dynamics of the multidisciplinary care team. The most prominent feature that resonated across all of the interviews was the importance of multidisciplinary care and the necessity of cohesion among a team of diverse health-care providers. Respondents emphasized aspects of care-team dynamics, including effective communication and intimate knowledge of team-member preferences, as necessary for the development of appropriate treatment strategies. Participants maintained that the primary role in decision-making should remain with the patient.

Conclusions: Numerous factors influence provider-based decision-making for patients with spinal metastases, including multidisciplinary team dynamics, business pressure, and clinician experience. Participants maintained a focus on shared decision-making with patients, which contrasts with patient preferences to defer decisions to the physician, as described in prior work.

Clinical Relevance: The results of this thematic analysis document the numerous factors that influence provider-based decision-making for patients with spinal metastases. Our results indicate that provider decisions regarding treatment are influenced by a combination of clinical characteristics, perceptions of patient quality of life, and the patient's preferences for care.
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http://dx.doi.org/10.2106/JBJS.20.00334DOI Listing
January 2021

Complication Events After Spinal Surgery Performed by American Board of Orthopaedic Surgery (ABOS) Part II Candidates (2008-2017).

Spine (Phila Pa 1976) 2021 Jan;46(2):101-106

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Retrospective cohort study.

Objective: To evaluate complications following spine surgery using American Board of Orthopaedic Surgeons (ABOS) Part II examination data from 2008 to 2017.

Summary Of Background Data: Recent research has demonstrated the importance of surgical experience and clinical volume in minimizing complications after spine surgery. This may be challenging for orthopedic spine surgeons who are just starting their practice.

Methods: We performed a retrospective review of surgical cases submitted to the ABOS by candidates taking the Part II Spine examination between 2008 and 2017. Complications, including peri-operative mortality as reported by candidates to the ABOS, were tracked over time. Complications were classified as surgical or medical using a predefined algorithm. Multivariable Poisson regression analyses adjusting for confounders were used to assess rates of complications and mortality over time. All analyses controlled for biologic sex, age, surgical diagnosis, and surgical location.

Results: A total of 37,539 spine surgical patients were analyzed, with an average of 3754 cases performed each year. Following adjusted Poisson analysis, we determined that cases in 2017 had an increased likelihood of complications when compared to those treated in 2008 (IRR 1.20; 95% CI 1.09, 1.32). Similar findings were encountered for surgical complications (IRR 1.20; 95% CI 1.07, 1.34). In contrast, spine surgical cases reported to the ABOS in 2017 had a 55% lower likelihood of mortality when compared to procedures performed in 2008 (IRR 0.45; 95% CI 0.24, 0.84; P = 0.01).

Conclusions: Our analysis of ABOS Part II candidates demonstrates that reported complication rates may be increasing while mortality is decreasing. The etiologies behind these findings are likely multifactorial. Encouragingly, we believe that observed reductions in mortality suggest overall improvements in patient safety following spine surgery. At a minimum, our data provide benchmarks through which spine surgeons, hospitals, and residency or fellowship programs can evaluate performance.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003741DOI Listing
January 2021

Trends in Spinal Surgery Performed by American Board of Orthopaedic Surgery Part II Candidates (2008 to 2017).

J Am Acad Orthop Surg 2021 Jun;29(11):e563-e575

From the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Introduction: The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination is typically taken two calendar years after fellowship completion. Despite previous studies using ABOS Part II Oral Examination data in other subspecialties, types of cases performed by spine surgeons in initial independent practice have not been well-studied. Such data may help trainees anticipate case composition observed in early practice and allow spine fellowship programs to understand emerging trends.

Methods: We retrospectively reviewed surgical cases submitted to the ABOS by candidates taking the Part II Oral Examination between 2008 and 2017 whose designated subspecialty was spine. A hierarchical, restrictive algorithm was used to determine procedures based on candidate-reported International Classification of Diseases 9th/10th Revision and Current Procedural Terminology codes. Adjusted multivariable Poisson regression analyses were used to assess changes in procedure incidence rates over time.

Results: We identified 37,539 cases, averaging 3,754 cases/yr, and an average of 49 cases per candidate per 6-month collection period. The most common procedures were lumbar diskectomy (22% of all procedures), posterolateral spinal fusion (PSF) (19%), and anterior cervical diskectomy and fusion (ACDF) (17%). Rates of ACDF and cervical disk arthroplasty significantly increased over time (incidence rate ratios of 1.41 and 23.3 times higher, respectively, at the end of the study period), whereas rates of cervical foraminotomy, lumbar diskectomy, PSF, and structural autograft use decreased (incidence rate ratios of 0.35, 0.84, 0.55, and 0.30). Rates of anterior lumbar interbody fusion/lateral lumbar interbody fusion and transforaminal lumbar interbody fusion did not significantly change over the study period.

Discussion: Recent spine fellowship graduates are performing more cervical disk arthroplasties and ACDFs while decreasingly using structural autograft as well as performing fewer PSFs and lumbar diskectomies. Techniques such as anterior lumbar interbody fusion/lateral lumbar interbody fusions and transforaminal lumbar interbody fusions have not changed significantly over the last decade.

Level Of Evidence: Level IV (retrospective case series study).
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http://dx.doi.org/10.5435/JAAOS-D-20-00437DOI Listing
June 2021

Use of low-value pediatric services in the Military Health System.

BMC Health Serv Res 2020 Aug 20;20(1):770. Epub 2020 Aug 20.

Center for Surgery and Public Health, Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA.

Background: Low-value care (LVC) is understudied in pediatric populations and in the Military Health System (MHS). This cross-sectional study applies previously developed measures of pediatric LVC diagnostic tests, procedures, and treatments to children receiving care within the direct and purchased care environments of the MHS.

Methods: We queried the MHS Data Repository (MDR) to identify children (n = 1,111,534) who received one or more of 20 previously described types of LVC in fiscal year 2015. We calculated the proportion of eligible children and all children who received the service at least once during fiscal year 2015. Among children eligible for each measure, we used logistic regressions to calculate the adjusted odds ratios (AOR) for receiving LVC at least once during fiscal year 2015 in direct versus purchased care.

Results: All 20 measures of pediatric LVC were found in the MDR. Of the 1,111,534 eligible children identified, 15.41% received at least one LVC service, and the two most common procedures were cough and cold medications in children under 6 years and acid blockers for infants with uncomplicated gastroesophageal reflux. Eighteen of the 20 measures of pediatric LVC were eligible for comparison across care environments: 6 were significantly more likely to be delivered in direct care and 10 were significantly more likely to be delivered in purchased care. The greatest differences between direct and purchased care were seen in respiratory syncytial virus testing in children with bronchiolitis (AOR = 21.01, 95% CI = 12.23-36.10) and blood tests in children with simple febrile seizure (AOR = 24.44, 95% CI = 5.49-108.82). A notably greater difference of inappropriate antibiotic prescribing was seen in purchased versus direct care.

Conclusions: Significant differences existed between provision of LVC services in direct and purchased care, unlike previous studies showing little difference between publicly and privately insured children. In fiscal year 2015, 1 in 7 children received one of 20 types of LVC. These proportions are higher than prior estimates from privately and publicly insured children, suggesting the particular need to focus on decreasing wasteful care in the MHS. Collectively, these studies demonstrate the high prevalence of LVC in children and the necessity of reducing potentially harmful care in this vulnerable population.
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http://dx.doi.org/10.1186/s12913-020-05640-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7441552PMC
August 2020

Microendoscopic decompression for lumbosacral foraminal stenosis: a novel surgical strategy based on anatomical considerations using 3D image fusion with MRI/CT.

J Neurosurg Spine 2020 Aug 7:1-7. Epub 2020 Aug 7.

1Department of Orthopedic Surgery, Wakayama Medical University, Wakayama.

Objective: Persistent lumbar foraminal stenosis (LFS) is one of the most common reasons for poor postoperative outcomes and is a major contributor to "failed back surgery syndrome." The authors describe a new surgical strategy for LFS based on anatomical considerations using 3D image fusion with MRI/CT analysis.

Methods: A retrospective review was conducted on 78 consecutive patients surgically treated for LFS at the lumbosacral junction (2013-2017). The location and extent of stenosis, including the narrowest site and associated pathology (bone or soft tissue), were measured using 3D image fusion with MRI/CT. Stenosis was defined as medial intervertebral foraminal (MF; inner edge to pedicle center), lateral intervertebral foraminal (LF; pedicle center to outer edge), or extraforaminal (EF; outside the pedicle). Lumbar (low-back pain, leg pain) and patient satisfaction visual analog scale (VAS) scores and Japanese Orthopaedic Association (JOA) scores were evaluated. Surgical outcome was evaluated 2 years postoperatively.

Results: Most instances of stenosis existed outside the pedicle's center (94%), including LF (58%), EF (36%), and MF (6%). In all MF cases, stenosis resulted from soft-tissue structures. The narrowest stenosis sites were localized around the pedicle's outer border. The areas for sufficient nerve decompression were extended in MF+LF (10%), MF+LF+EF (14%), LF+EF (39%), LF (11%), and EF (26%). No iatrogenic pars interarticularis damage occurred. The JOA score was 14.9 ± 2.6 points preoperatively and 22.4 ± 3.5 points at 2 years postoperatively. The JOA recovery rate was 56.0% ± 18.6%. The VAS score (low-back and leg pain) was significantly improved 2 years postoperatively (p < 0.01). According to patients' self-assessment of the minimally invasive surgery, 62 (79.5%) chose "surgery met my expectations" at follow-up. Nine patients (11.5%) selected "I did not improve as much as I had hoped but I would undergo the same surgery for the same outcome."

Conclusions: Most LFS existed outside the pedicle's center and was rarely noted in the pars region. The main regions of stenosis were localized to the pedicle's outer edge. Considering this anatomical distribution of LFS, the authors recommend that lateral fenestration should be the first priority for foraminal decompression. Other surgical options including foraminotomy, total facetectomy, and hemilaminectomy likely require more bone resections than LFS treatment. The microendoscopic surgery results were very good, indicating that this minimally invasive surgery was suitable for treating this disease.
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August 2020

Post-operative hyperglycemia and its association with surgical site infection after instrumented spinal fusion.

Clin Neurol Neurosurg 2020 10 20;197:106100. Epub 2020 Jul 20.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States. Electronic address:

Objective: To evaluate the correlation between postoperative hyperglycemia and surgical site infection among patients who underwent primary instrumented spinal fusion surgery.

Patients And Methods: We collected data on all eligible patients treated at our institution over the course of 2005-2017. We defined serum hyperglycemia using a primary threshold of serum glucose ≥140 mg/dL and used ≥115 mg/dL as a secondary test. We used logistic regression techniques to evaluate unadjusted results for serum hyperglycemia on revision surgeries for infection, followed by sequential adjustment for sociodemographic and procedural characteristics.

Results: We included 3664 patients. Surgical site infections occurred in 4%. Post-operative hyperglycemia was significantly associated with a higher rate of revision surgery for infection (p = 0.02). Following adjusted analysis, hyperglycemia remained a statistically significant predictor for revision surgery due to infection (OR 2.19; 95 % CI 1.13, 4.25). Similar results were evident when using the lower threshold of ≥115 mg/dL (OR 2.36; 95 % CI 1.06, 5.23).

Conclusions: This study highlights the importance of measuring serum glucose after spinal fusion and the need for heightened surveillance and/or treatment in those who exhibit postoperative hyperglycemia. In this context, it could be advantageous to use a lower threshold for hyperglycemia (115 mg/dL) in order to trigger interventions for glycemic control.
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October 2020

The Prognostic Value of Laboratory Markers and Ambulatory Function at Presentation for Post-Treatment Morbidity and Mortality Following Epidural Abscess.

Spine (Phila Pa 1976) 2020 Aug;45(15):E959-E966

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Retrospective cohort study.

Objective: To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess.

Summary Of Background Data: Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored.

Methods: We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet-lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement.

Results: We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43).

Conclusion: We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling.

Level Of Evidence: 3.
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August 2020

The Prognostic Value of Laboratory Markers and Ambulatory Function at Presentation for Post-Treatment Morbidity and Mortality Following Epidural Abscess.

Spine (Phila Pa 1976) 2020 Aug;45(15):E959-E966

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Retrospective cohort study.

Objective: To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess.

Summary Of Background Data: Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored.

Methods: We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet-lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement.

Results: We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43).

Conclusion: We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003454DOI Listing
August 2020