Publications by authors named "Doniel Drazin"

143 Publications

Burden of Pre-operative Opioid Use and Its Impact on Healthcare Utilization After Primary Single Level Lumbar Discectomy.

Spine J 2021 Apr 16. Epub 2021 Apr 16.

Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, U.S.A. 40202. Electronic address:

Background Context: The complication profile and higher cost of care associated with pre-operative opioid use and spinal fusion is well described. However, the burden of opioid use and its impact in patients undergoing lumbar discectomy is not known. Knowledge of this, especially for a relatively benign and predictable procedure will be important in bundled and value-based payment models.

Purpose: To study the burden of pre-operative opioid use and its effect on post-operative healthcare utilization, cost, and opioid use in patients undergoing primary single level lumbar discectomy.

Study Design: Retrospective cohort study PATIENT SAMPLE: 29,745 patients undergoing primary single level lumbar discectomy from the IBM® MarketScan® (2000-2018) database.

Outcome Measures: 90-day and 1-year utilization of lumbar epidural steroid injections (ESIs), emergency department (ED) services, lumbar magnetic resonance imaging (MRI), hospital readmission, and revision lumbar surgery. Continued opioid use beyond 3-months post-operatively until 1-year was also studied. We have reported costs associated with healthcare utilization among opioid groups.

Methods: Patients were categorized in opioid use groups based on the duration and number of oral prescriptions prior to discectomy (opioid naïve, < 3-months opioid use, chronic pre-operative use, chronic pre-operative opioid use with 3-month gap before surgery, and other). The risk of association of pre-operative opioid use with outcome measures was studied using multivariable logistic regression analysis with adjustment for various demographic and clinical variables.

Results: A total of 29,745 patients with mean age of 45.3± 9.6 years were studied. Pre-operatively, 29.0% were opioid naïve, 35.0% had < 3-months use and 12.0% were chronic opioid users. There was a significantly higher rate of post-operative lumbar ESIs, MRI, ED visits, readmission and revision surgery within 90-days and 1-year after surgery in chronic pre-operative opioid users as compared to patients with < 3-months use and opioid naïve patients (p<0.001). Chronic post-operative opioid use was present in 62.6% of the pre-operative chronic opioid users as compared to 5.6% of patients with < 3-months opioid use. A 3-month prescription free period before surgery in chronic pre-operative opioid users cut the incidence of chronic post-operative opioid use by more than half, at 25.7%. Cost of care and adjusted analysis of risk have been described.

Conclusion: Chronic pre-operative opioid use was present in 12% of a national cohort of lumbar discectomy patients. Such opioid use was associated with significantly higher post-operative healthcare utilization, risk of revision surgery, and costs at 90-days and 1-year post-operatively. Two-third of chronic pre-operative opioid users had continued long-term post-operative opioid use. However, a 3-month prescription free period before surgery in chronic opioid users reduces the risk of long-term post-operative use. This data will be useful for patient education, pre-operative opioid use optimization, and risk-adjustment in value-based payment models.
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http://dx.doi.org/10.1016/j.spinee.2021.04.013DOI Listing
April 2021

Patterns and Impact of Electronic Health Records-Defined Depression Phenotypes in Spine Surgery.

Neurosurgery 2021 Apr 16. Epub 2021 Apr 16.

Pacific Northwest University of Health Sciences, Yakima, Washington, USA.

Background: Preoperative depression is a risk factor for poor outcomes after spine surgery.

Objective: To understand effects of depression on spine surgery outcomes and healthcare resource utilization.

Methods: Using IBM's MarketScan Database, we identified 52 480 patients who underwent spinal fusion. Retained patients were classified into 6 depression phenotype groups based on International Classification of Disease, 9th/10th Revision (ICD-9/10) codes and use/nonuse of antidepressant medications: major depressive disorder (MDD), other depression (OthDep), antidepressants for other psychiatric condition (PsychRx), antidepressants for physical (nonpsychiatric) condition (NoPsychRx), psychiatric condition only (PsychOnly), and no depression (NoDep). We analyzed baseline demographics, comorbidities, healthcare utilization/payments, and chronic opioid use.

Results: Breakdown of groups in our cohort: MDD (15%), OthDep (12%), PsychRx (13%), NonPsychRx (15%), PsychOnly (12%), and NoDep (33%). Postsurgery: increased outpatient resource utilization, admissions, and medication refills at 1, 2, and 5 yr in the NoDep, PsychOnly, NonPsychRx, PsychRx, and OthDep groups, and highest in MDD. Postoperative opioid usage rates remained unchanged in MDD (44%) and OthDep (36%), and reduced in PsychRx (40%), NonPsychRx (31%), and PsychOnly (20%), with greatest reduction in NoDep (13%). Reoperation rates: 1 yr after index procedure, MDD, OthDep, PsychRx, NonPsychRx, and PsychOnly had more reoperations compared to NoDep, and same at 2 and 5 yr. In NoDep patients, 45% developed new depressive phenotype postsurgery.

Conclusion: EHR-defined classification allowed us to study in depth the effects of depression in spine surgery. This increased understanding of the interplay of mental health will help providers identify cohorts at risk for high complication rates, and health care utilization.
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http://dx.doi.org/10.1093/neuros/nyab096DOI Listing
April 2021

Health Care Utilization and Associated Economic Burden of Postoperative Surgical Site Infection after Spinal Surgery with Follow-Up of 24 Months.

J Neurol Surg A Cent Eur Neurosurg 2021 Apr 12. Epub 2021 Apr 12.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States.

Background:  Surgical site infection (SSI) may lead to vertebral osteomyelitis, diskitis, paraspinal musculoskeletal infection, and abscess, and remains a significant concern in postoperative management of spinal surgery. SSI is associated with greater postoperative morbidity and increased health care payments.

Methods:  We conducted a retrospective analysis using MarketScan to identify health care utilization payments and risk factors associated with SSI that occurs postoperatively. Known patient- or procedure-related risk factors were searched across those receiving spine surgery who developed postoperative infection.

Results:  A total of 33,061 patients who developed infection after spinal surgery were identified in Marketscan. Overall payments at 6 months, including index hospitalization for those with infection, were $53,573 and $46,985 for the cohort with no infection. At 24 months, the infection group had overall payments of $83,280 and $66,221 for no infection. Risk factors with largest effect size most likely to contribute to infection versus no infection were depression (4.6%), diabetes (3.7), anemia (3.3%), two or more levels (2.8%), tobacco use (2.2%), trauma (2.1%), neoplasm (1.8%), congestive heart failure (1.3%), instrumentation (1.1%), renal failure (0.9%), intravenous drug use (0.8%), and malnutrition (0.5%).

Conclusions:  SSIs were associated with significant health care utilization payments at 24 months of follow-up. The following clinical and procedural risk factors appear to be predictive of postoperative SSI: depression, diabetes, anemia, two or more levels, tobacco use, trauma, neoplasm, congestive heart failure, instrumentation, renal failure, intravenous drug use, and malnutrition. Interpretation of modifiable and nonmodifiable risk factors for infection informs surgeons of expected postoperative course and preoperative risk for this most common and deleterious postoperative complication to spinal surgery.
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http://dx.doi.org/10.1055/s-0040-1720984DOI Listing
April 2021

Preoperative and Postoperative Opioid Dependence in Patients Undergoing Anterior Cervical Diskectomy and Fusion for Degenerative Spinal Disorders.

J Neurol Surg A Cent Eur Neurosurg 2021 May 4;82(3):232-240. Epub 2021 Feb 4.

Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States.

Background:  Anterior cervical diskectomy and fusion (ACDF) is a procedure for effectively relieving radiculopathy. Opioids are commonly overprescribed in postsurgical settings and prescriptions vary widely among providers. We identify trends in opioid dependence before and after ACDF.

Methods:  We used the Truven Health MarketScan data to identify adult patients undergoing ACDF for degenerative cervical spine conditions between 2009 and 2015. Patients were segregated in four cohorts of preoperative and postoperative opioid nondependence (ND) or dependence (D) with 15 months of postoperative follow-up.

Results:  A total of 25,403 patients with median age of 52 years (18-92) who underwent ACDF met the inclusion criteria. Breakdown of the four cohorts was as follows: prior nondependent who remain nondependent (NDND): 62.76% ( = 15,944); prior nondependent who become dependent (NDD): 4.6% ( = 1,168); prior dependent who become nondependent (DND): 14.03% ( = 3,564); and prior dependent who remain dependent (DD): 18.61% ( = 4,727). Opioid dependence decreased 9.43% postoperatively. Overall payments and 30-day readmissions increased 1.96 and 1.79 times for opioid dependent versus nondependent cohorts, respectively. Adjusted payments at 3 to 15 months were significantly increased for dependent cohorts with 3.56-fold increase for the DD cohort when compared with the NDND cohort. Length of stay, complications, medication refills, outpatient measures, and hospital admissions were also higher in those groups with postoperative opioid dependence when compared with those who were not opioid dependent.

Conclusions:  Opioid dependence after ACDF is associated with increased hospital readmissions, complication rates at 30 days, and payments within 3 months and 3 to 15 months postdischarge. Overall opioid dependence was decreased after ACDF procedure, however, a smaller number of opioid-dependent and opioid-naive patients became dependent postoperatively and should be followed carefully.
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http://dx.doi.org/10.1055/s-0040-1718759DOI Listing
May 2021

Impact of Surgical Approaches on Complications, Emergency Room Admissions, and Health Care Utilization in Patients Undergoing Lumbar Fusions for Degenerative Disc Diseases: A MarketScan Database Analysis.

World Neurosurg 2021 Jan 15;145:e305-e319. Epub 2020 Oct 15.

Department of Neurosurgery, Pacific Northwest University of Health Sciences, Yakima, Washington, USA. Electronic address:

Objective: To identify the impact of different surgical approaches for lumbar degenerative disc disease (DDD) on complications, reoperations/readmissions, and health care utilization.

Methods: We used International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Terminology codes to extract data from MarketScan. Patients were divided into 6 groups: single-level anterior only (sA), single-level anterior + posterior (sAP), single-level posterior (sP), multilevel anterior (mA), multilevel anterior + posterior (mAP), and multilevel posterior only (mP). Outcomes of interest were cumulative complication rates, reoperation rates, readmission, and health care utilization at 6, 12, and 24 months.

Results: Of 148,499 patients, 3% had sA fusion and 54% had mP procedures. Patients in the mAP cohort incurred higher cumulative complication rates (21%) compared with sA (13%), sAP (15%), sP (14%), mA (18%), and mP (18%). Emergency room admissions within 30 days were highest in the mA cohort (14%) followed by mAP (11%) and mP (8%). At 12 and 24 months, patients with mA procedures were most likely to have either new fusion or refusion (8% and 12%) followed by sA (7% and 10%), sAP (4% and 7%), mAP (4% and 8%) mP (4% and 7%), and sP (3% and 7%). Compared with the mP cohort, patients in the mA cohort incurred 1.2 times the overall median payments, whereas mAP and sA incurred 1.1 times the payments at 12 months. This difference was further reduced at 24 months.

Conclusions: mAP procedures are associated with higher cumulative complications and health care utilization compared with other procedures and the difference in health care utilization tends to decrease over 12 and 24 months.
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http://dx.doi.org/10.1016/j.wneu.2020.10.048DOI Listing
January 2021

Recombinant Human Bone Morphogenetic Protein-2 Use in Adult Spinal Deformity Surgery: Comparative Analysis and Healthcare Utilization at 24 Months' Follow-up.

Global Spine J 2020 Aug 26:2192568220947377. Epub 2020 Aug 26.

5170University of Louisville, Louisville, KY, USA.

Study Design: Retrospective cohort study.

Objective: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used to achieve fusion in adult spinal deformity (ASD) surgery. Our aim was to investigate the long-term impact of rhBMP-2 use for clinical outcomes and health care utilization in this patient population.

Methods: We conducted an analysis using MarketScan to identify health resource utilization of rhBMP-2 use for ASD after surgical intervention compared to fusion without rhBMP-2 at 24 months' follow-up. Outcomes assessed included length of stay, complications, pseudoarthrosis, reoperation, outpatient services, and health care payments.

Results: Of 7115 patients who underwent surgery for ASD, 854 received rhBMP-2 and 6261 were operated upon without use of rhBMP-2. One month after discharge, the rhBMP-2 cohort had a nonsignificant trend in fewer complications (15.38%) than those who did not receive rhBMP-2 (18.07%), = .0558. At 12 months, pseudoarthrosis was reported in 2.8% of cases with no BMP and 01.14% of cases with BMP, = .0048. Average payments at 12 months were $120 138 for the rhBMP-2 group and $118 373 for the no rhBMP-2 group, = .8228. At 24 months, payments were $141 664 for the rhBMP-2 group and $144 179 for the group that did not receive rhBMP-2, = .5946.

Conclusions: In ASD surgery, use of rhBMP-2 was not associated with increased complications or reoperations at index hospitalization and 1-month follow-up. Overall payments, including index hospitalization, readmissions, reoperations, and outpatient services were not different compared to those without the use of rhBMP-2 at 12 months and 24 months after discharge.
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http://dx.doi.org/10.1177/2192568220947377DOI Listing
August 2020

Evaluation of Predictive Models for Complications following Spinal Surgery.

J Neurol Surg A Cent Eur Neurosurg 2020 Nov 14;81(6):535-545. Epub 2020 Aug 14.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States.

Background:  Complications rates vary across spinal surgery procedures and are difficult to predict due to heterogeneity in patient characteristics, surgical methods, and hospital volume. Incorporation of predictive models for complications may guide surgeon decision making and improve outcomes.

Methods:  We evaluate current independently validated predictive models for complications in spinal surgery with respect to study design and model generation, accuracy, reliability, and utility. We conducted our search using Preferred Reporting Items for Systematic Review and Meta-analysis guidelines and the Participants, Intervention, Comparison, Outcomes, Study Design model through the PubMed and Ovid Medline databases.

Results:  A total of 18 articles met inclusion criteria including 30 validated predictive models of complications after adult spinal surgery. National registry databases were used in 12 studies. Validation cohorts were used in seven studies for verification; three studies used other methods including random sample bootstrapping techniques or cross-validation. Reported area under the curve (AUC) values ranged from 0.37 to 1.0. Studies described treatment for deformity, degenerative conditions, inclusive spinal surgery (neoplasm, trauma, infection, deformity, degenerative), and miscellaneous (disk herniation, spinal epidural abscess). The most commonly cited risk factors for complications included in predictive models included age, body mass index, diabetes, sex, and smoking. Those models in the deformity subset that included radiographic and anatomical grading features reported higher AUC values than those that included patient demographics or medical comorbidities alone.

Conclusions:  We identified a cohort of 30 validated predictive models of complications following spinal surgery for degenerative conditions, deformity, infection, and trauma. Accurate evidence-based predictive models may enhance shared decision making, improve rehabilitation, reduce adverse events, and inform best practices.
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http://dx.doi.org/10.1055/s-0040-1709709DOI Listing
November 2020

Factors Impacting Outcomes and Health Care Utilization in Osteoporotic Patients Undergoing Lumbar Spine Fusions: A MarketScan Database Analysis.

World Neurosurg 2020 09 22;141:e976-e988. Epub 2020 Jun 22.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Objective: To identify factors impacting long-term complications, reoperations, readmission rates, and health care utilization in patients with osteoporosis (OP) following lumbar fusions.

Methods: We used International Classification of Disease, Ninth Revision, International Classification of Disease, Tenth Revision , and Current Procedural Terminology codes to extract data from MarketScan (2000-2016). Patients undergoing lumbar spine fusion were divided into 2 groups based on preoperative diagnosis: OP or non-OP. We used multivariable generalized linear regression models to analyze outcomes of interest (reoperation rates, readmissions, complications, health care utilization) at 1, 6, 12, and 24 months after discharge.

Results: MarketScan identified 116,749 patients who underwent lumbar fusion with ≥24 months of follow-up; 6% had OP. OP patients had a higher incidence of complications (14% vs. 9%); were less likely to be discharged home (77% vs. 86%, P < 0.05); had more new fusions or refusions at 6 months (2.9% vs. 2.1%), 12 months (5% vs. 3.8%), and 24 months (8.5% vs. 7.4%); incurred more outpatient services at 12 months (80 vs. 61) and 24 months (148 vs. 115); and incurred higher overall costs at 12 months ($22,932 vs. $17,017) and 24 months ($48,379 vs. $35,888). Elderly OP patients (>65 years old) who underwent multilevel lumbar fusions had longer hospitalization, had higher complication rates, and incurred lower costs at 6, 12, and 24 months compared with young non-OP patients who underwent single-level lumbar fusion.

Conclusions: Patients of all ages with OP had higher complication rates and required revision surgeries at 6, 12, and 24 months compared with non-OP patients. Elderly OP patients having multilevel lumbar fusions were twice as likely to have complications and lower health care utilization compared with younger non-OP patients who underwent single-level fusion.
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http://dx.doi.org/10.1016/j.wneu.2020.06.107DOI Listing
September 2020

A Two-decade Assessment of Changing Practice for Surgical Decompression and Fixation after Traumatic Spinal Cord Injury - Impact on Healthcare Utilization and Cost.

Cureus 2019 Nov 14;11(11):e6156. Epub 2019 Nov 14.

Neurosurgery, University of Louisville School of Medicine, Louisville, USA.

Early surgery after traumatic spinal cord injury (TSCI) has been associated with a greater neurological recovery and reduced secondary complications. In this study, we aimed to evaluate the trend of early TSCI surgery (within 24 hours) over two decades and the effect on length of hospitalization, complications, and hospital charges. We extracted emergency admissions of adults diagnosed with TSCI from the National Inpatient Sample database (1998-2016). We analyzed the trend of early surgery and concurrent trends of complication rate, length of stay (LOS) and hospital charges. These outcomes were then compared between early and late surgery cohorts. There were 3942 (53%) TSCI patients who underwent early surgery, and 3446 (47%) were operated after 24 hours. The combined patient group characteristics consisted of median age 43 years (IQR: 29-59), 73% males, 72% white, 44% private payer, 18% Medicare, 17% Medicaid, 51% cervical, 30% thoracic, 75% from large hospitals, and 79% from teaching hospitals. The trend of early surgery, adjusted for annual case-mix, increased from 45% in 1998 to 64% in 2016. Each year was associated with 1.60% more patients undergoing early surgery than the previous year (-value <0.05). During these years, the total LOS decreased, while hospital charges increased. Patients who underwent early surgery spent four fewer days in the hospital, accrued $28,705 lower in hospital charges and had 2.8% fewer complications than those with delay surgery. We found that the rate of early surgery has significantly increased from 1998 to 2016. However, as of 2016, one-third of patients still did not undergo spinal surgery within 24 hours. Late surgery is associated with higher complications, longer stays, and higher charges. The causes of delayed surgery are undoubtedly justified in some situations but require further delineation. Surgeons should consider performing surgery within 24 hours on patients with TSCI whenever feasible.
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http://dx.doi.org/10.7759/cureus.6156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913978PMC
November 2019

Demographics and Outcomes of Spine Surgery in Octogenarians and Nonagenarians: A Comparison of the National Inpatient Sample, MarketScan and National Surgical Quality Improvement Program Databases.

Cureus 2019 Nov 19;11(11):e6195. Epub 2019 Nov 19.

Medicine, Pacific Northwest University of Health Sciences, Yakima, USA.

Introduction Despite the increasing use of national databases to conduct spine research, questions remain regarding their study validity and consistency. This study tested for similarity and inter-database reliability in reported measures between three commonly used national databases. Methods International Classification of Diseases, 9th edition (ICD-9) codes were used to identify elderly (80-100 years) who underwent spine surgery patients in Truven Health Analytics MarketScan® claims database, National (Nationwide) Inpatient Sample (NIS) discharge database and National Surgical Quality Improvement Program (NSQIP) database (2006-2016). Patient baseline characteristics, comorbid status, insurance enrollment, and outcomes were queried and compared.  Results We analyzed 15,105 MarketScan, 40,854 NIS, and 7682 NSQIP patients between ages 80 to 100 years (median, 82 years) who underwent spine surgeries during the study period. A majority of patients in both MarketScan and NIS were insured by Medicare (97% vs. 94%). Patients in MarketScan had lower comorbidity scores (comorbidity, 0-2) compared to those in NIS and NSQIP databases. The most common diagnosis was spinal stenosis in MarketScan (54.4%), NIS (54.6%), and NSQIP databases (65.2%). Fusion was the most common procedure performed in MarketScan (48.9%) and NIS databases (46.2%), whereas decompression (laminectomy/laminotomy) was the most common procedure in the NSQIP database (51.84%). In-hospital complications (any) were 6.5% in the MarketScan cohort, 5.3% in the NIS, and 2.02% in the NSQIP cohort. In terms of 30-day complications (any), the MarketScan database reported higher complications rate (12.7%) compared to the NSQIP database (5.08%). In-hospital mortality was slightly higher in the NIS database (0.32%) compared to MarketScan (0.21%) and NSQIP database (0.2%). MarketScan and NIS databases showed an increased risk of complications with increasing age, whereas NIS and NSQIP showed increasing complications with a higher number of comorbidities. Male gender had higher complication at 30-day post-discharge using MarketScan and NSQIP database. Conclusions Patients in the NSQIP and NIS database have more comorbidities; patients in the MarketScan database had the highest number of perioperative and 30-day post-discharge complications with the highest number of fusion procedures performed. Patients in the NSQIP database had the lowest number of fusion procedures and complication rates. As databases gain popularity in spine surgery, clinicians and reviewers should be cautious in generalizing results to whole populations and pay close attention to the population being represented by the data from which the statistical significance was derived.
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http://dx.doi.org/10.7759/cureus.6195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6922298PMC
November 2019

Ninety-Day Bundled Payment Reimbursement for Patients Undergoing Anterior and Posterior Procedures for Degenerative Cervical Radiculopathy.

Neurosurgery 2019 11;85(5):E851-E859

Department of Neurosurgery, University of Louisville, Louisville, Kentucky.

Background: Anterior cervical discectomy with fusion (ACDF) or posterior cervical foraminotomy (PCF) are the mainstay surgical treatment options for patients with degenerative cervical radiculopathy (DCR).

Objective: To compare 90-d bundled payments between ACDF and PCF for DCR in a cohort study.

Methods: Data were extracted from MarketScan database (2000-2016) using ICD-9, ICD-10, and CPT-4 codes. The bundle payments were calculated as the payments accumulated from the index hospitalization admission to 90 d postsurgery. We also analyzed the index hospitalization (physician, hospital, and total) and the postdischarge payments (hospital readmission, outpatient services, medications, and total). Surgical groups were matched based on baseline characteristics (age, sex, insurance type, and Elixhauser score).

Results: A total of 100 041 patients met the inclusion criteria. 94.9% of patients (n = 95 031). Patients underwent ACDF with 5.1% (n = 5 010) treated via PCF. Overall, median 90-d costs were significantly higher for ACDF than for PCF ($31567 vs $18412; P < .0001). The median total index hospitalization ($27841 vs $15043), physician ($4572 vs $1920), and hospital payments ($14540 vs $7404) were higher for ACDF compared to PCF for both single- and multiple-level cohorts (P < .0001). There was no difference in overall 90-d postdischarge payments. Factors associated with higher 90-d payments for both cohorts included age and comorbidity scores.

Conclusion: ACDF is associated with greater bundle payments in patients diagnosed with DCR. No difference was noted for the total postdischarge payments. PCF may be a cost-effective surgical option in appropriately selected patients with unilateral, paracentral, and foraminal soft herniated discs.
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http://dx.doi.org/10.1093/neuros/nyz123DOI Listing
November 2019

Enhanced Recovery After Surgery (ERAS) for Spine Surgery: A Systematic Review.

World Neurosurg 2019 Oct 2;130:415-426. Epub 2019 Jul 2.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Background: Enhanced recovery after surgery (ERAS) represents an evidence-based multidisciplinary approach to perioperative management after major surgery that decreases complications and readmissions and improves functional recovery. Spine surgery is a traditionally invasive intervention with an extended recovery phase and may benefit from ERAS protocol integration.

Methods: We analyzed the use of ERAS in spine surgery by completing a search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PICOS (Participants, Intervention, Comparison, Outcomes, Study Design) model through PubMed and Ovid databases to identify studies that fit our search criteria. We assess the outcomes and ERAS elements selected across protocols as well as the study design and internal validation methods.

Results: A total of 19 studies met the inclusion criteria and were used in our analysis. Patient populations differed significantly across all 4 studies. Reduction in length of stay was reported in 7 studies using the ERAS protocol. Comparative studies between ERAS and non-ERAS show improved pain scores and reduced opioid consumption postoperatively, but no differences in complications or readmissions between groups. Complication rates under ERAS protocols ranged from 2.0% to 31.7%. Significant pain reduction in visual analog scale scores was observed with 3 ERAS protocols. Direct, indirect, and total cost decreases were also observed with implementation of ERAS protocols.

Conclusions: A limited cohort of studies with significant variability in patient population and ERAS protocol implementation have evaluated the integration of ERAS within spine surgery. ERAS in spine surgery may provide reductions in complications, readmissions, length of stay, and opioid use, in combination with improvements in patient-reported outcomes and functional recovery.
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http://dx.doi.org/10.1016/j.wneu.2019.06.181DOI Listing
October 2019

Health Care Utilization and Payments of Postoperative and Drug Abuse-Related Spinal Infections.

Spine (Phila Pa 1976) 2019 Oct;44(20):1449-1455

Department of Neurosurgery, University of Louisville, Louisville, Kentucky.

Study Design: Retrospective analysis of data extracted from the MarketScan database (2000-2016) using International Classification of Diseases (ICD)-9, ICD-10, and Current Procedural Terminology-4 codes.

Objective: Evaluate the economic costs and health care utilization associated with spine infections.

Summary Of Background Data: Spinal infections (SI) are associated with significant morbidity and mortality. A recent spike in SI is attributed to the drug abuse epidemic. Management of SI represents a large burden on the health care system.

Methods: We assessed payments and outcomes at the index hospitalization, 1-, 3-, 6-, and 12-month follow up. Outcomes assessed included length of stay, complications, operation rates, and health care utilization. Outcomes were compared between cohorts with spinal infections: (1) with prior surgery, (2) drug abuse, and (3) without previous exposure to surgery or drug abuse, denoted as control.

Results: We identified 43,972 patients; 15.6% (N = 6847) of patients underwent prior surgery, 3.8% (N = 1,668) were previously expose to drug abuse while 80.6% fell into the control group. Both the postsurgical and drug abuse groups longer hospital stay compared with the control cohort (5 d vs. 4 d, P < 0.0001). Exposure to IV drug abuse was associated with increased risk of complications compared with the control group (43% vs. 38%, P < 0.0001). Payments at 1-month follow-up were significantly (P < 0.0001) higher among the postsurgical group compared with both groups. However, at 12-months follow-up, payments were significantly (P < 0.0001) higher in the drug abuse group compared with both groups. Only postsurgical infections were associated with higher number of surgical interventions both at presentation and 1 year follow up.

Conclusion: SI following surgery or IV drug abuse are associated with higher payments, complication rates, and longer hospital stays. Drug abuse related SI are associated with the highest complication rates, readmissions, and overall payments at 1 year of follow up despite the lower rate of surgical interventions.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003102DOI Listing
October 2019

Differences in clinical outcomes and health care utilization between octogenarians and nonagenarians following decompression for lumbar spinal stenosis. A market scan analysis.

Clin Neurol Neurosurg 2019 07 1;182:63-69. Epub 2019 May 1.

Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA. Electronic address:

Objective: Lumbar spinal stenosis (LSS) in octogenarians and beyond has a significant impact on quality of life requiring surgical decompression and hence impact on health care utilization. Risk of surgical failure and impact on health care resources is always a concern in this patient population (more so in nonagenarians). The aim of our study was to compare clinical outcomes and healthcare utilization in patients (80-89 vs.90+) undergoing decompression for LSS.

Patients And Methods: Data was extracted using ICD9/10 and CPT codes from MarketScan (2001-2015) in this retrospective study. We defined the comparative groups based on the age groups (80-89 and 90+), in patients with LSS. Outcomes of interest were: length of hospital stay, discharge disposition and utilization in the index hospitalization, 6- months, 12 months following index procedure as well as the associated health care utilization. Patient characteristics and outcomes among cohorts were compared using univariate tests. Outcomes were further compared using adjusted multivariable regression models. Statistical analysis was performed with SAS 9.4.

Results: A cohort of 5387 was identified from the database, 96.38% were in the 80-89 age group and 3.62%were in the 90+ age group. The proportion of patients undergoing surgery for LSS among 80-89 (95.7-98.5%) and 90+ age group (1.5-4.3%) remained constant through the years. Interestingly, 13.83% and 16.92% of patients had Elixhauser comorbidity index of 3+ in 80-89 age group and 90+ age groups respectively. Decompression with fusion was performed in 19.4% of patients in 80-89 age group, compared to 9.74% of patients in 90+ age group. There was no difference in median length of hospital stay (3 days, p = 0.19) and complications across the cohorts (80-89: 16.7%; 90+: 18.46% p = 0.51). 70.6% of patients in 80-89 age groups were discharged to home compared to 60.5% in 90+ age group (p = 0.0023). At 6 months follow-up, overall rate of new decompression, new fusion, re-fusion at index level were 2.38%, 0.59% and 0.33% only, with no differences across the cohorts. Interestingly, patients in 80-89 age group incurred higher outpatient services, number of medication refills and related payments at 6-months and 12-months follow-up, compared to patients in 90+ age group. Overall, combined median post-discharge payments at 12 months were similar across the groups [80-89 (median $ 40,257) and 90+ (median$ 36,161), p = 0.14].

Conclusion: Using MarketScan database, there has been a gradual decline in the number of decompressions being performed for LSS in elderly patients (>80 years of age), however there is no change in the proportion of octogenarians and nonagenarians undergoing decompression for LSS. There was no difference in rate of reoperations and overall health care utilization among the groups. Surgery for LSS can be offered to nonagenarians (in appropriately selected patients) with no difference in clinical outcomes and health care utilization, compared to octogenarians.
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http://dx.doi.org/10.1016/j.clineuro.2019.04.031DOI Listing
July 2019

Biomechanical evaluation of traditional posterior versus anterior spondylolisthesis reduction in a cadaveric grade I slip model.

J Neurosurg Spine 2019 May 3:1-9. Epub 2019 May 3.

2Musculoskeletal Education and Research Center, A Division of Globus Medical, Inc., Audubon, Pennsylvania.

OBJECTIVEPosterior reduction with pedicle screws is often used for stabilization of unstable spondylolisthesis to directly reduce misalignment or protect against micromotion while fusion of the affected level occurs. Optimal treatment of spondylolisthesis combines consistent reduction with a reduced risk of construct failure. The authors compared the reduction achieved with a novel anterior integrated spacer with a built-in reduction mechanism (ISR) to the reduction achieved with pedicle screws alone, or in combination with an anterior lumbar interbody fusion (ALIF) spacer, in a cadaveric grade I spondylolisthesis model.METHODSGrade I slip was modeled in 6 cadaveric L5-S1 segments by creation of a partial nucleotomy and facetectomy and application of dynamic cyclic loading. Following the creation of spondylolisthesis, reduction was performed under increasing axial loads, simulating muscle trunk forces between 50 and 157.5 lbs, in the following order: bilateral pedicle screws (BPS), BPS with an anterior spacer (BPS+S), and ISR. Percent reduction and reduction failure load-the axial load at which successful reduction (≥ 50% correction) was not achieved-were recorded along with the failure mechanism. Corrections were evaluated using lateral fluoroscopic images.RESULTSThe average loads at which BPS and BPS+S failed were 92.5 ± 6.1 and 94.2 ± 13.9 lbs, respectively. The ISR construct failed at a statistically higher load of 140.0 ± 27.1 lbs. Reduction at the largest axial load (157.5 lbs) by the ISR device was tested in 67% (4 of 6) of the specimens, was successful in 33% (2 of 6), and achieved 68.3 ± 37.4% of the available reduction. For the BPS and BPS+S constructs, the largest axial load was 105.0 lbs, with average reductions of 21.3 ± 0.0% (1 of 6) and 32.4 ± 5.7% (3 of 6) respectively.CONCLUSIONSWhile both posterior and anterior reduction devices maintained reduction under gravimetric loading, the reduction capacity of the novel anterior ISR device was more effective at greater loads than traditional pedicle screw techniques. Full correction was achieved with pedicle screws, with or without ALIF, but under significantly lower axial loads. The anterior ISR may prove useful when higher reduction forces are required; however, additional clinical studies will be needed to evaluate the effectiveness of anterior devices with built-in reduction mechanisms.
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http://dx.doi.org/10.3171/2019.2.SPINE18726DOI Listing
May 2019

Outcomes of decompression and fusion for treatment of spinal infection

Neurosurg Focus 2019 02 15;46(1):E7. Epub 2019 Feb 15.

1Department of Neurosurgery, University of Louisville, Louisville, Kentucky.

Objective: Spine infection including vertebral osteomyelitis, discitis, paraspinal musculoskeletal infection, and spinal abscess refractory to medical management poses significant challenges to the treating physician. Surgical management is often required in patients suffering neurological deficits or spinal deformity with significant pain. To date, best practices have not been elucidated for the optimization of health outcomes and resource utilization in the setting of surgical intervention for spinal infection. The authors conducted the present study to assess the magnitude of reoperation rates in both fusion and nonfusion groups as well as overall health resource utilization following surgical decompression for spine infection.

Methods: The authors performed an analysis using MarketScan (2001–2015) to identify health outcomes and healthcare utilization metrics of spine infection following surgical intervention with decompression alone or combined with fusion. Adult patients underwent surgical management for primary or secondary spinal infection and were followed up for at least 12 months postoperatively. Assessed outcomes included reoperation, healthcare utilization and payment at the index hospitalization and within 12 months after discharge, postoperative complications, and infection recurrence.

Results: A total of 2662 patients in the database were eligible for inclusion in this study. Rehospitalization for infection was observed in 3.99% of patients who had undergone fusion and in 11.25% of those treated with decompression alone. Reoperation was needed in 12.7% of the patients without fusion and 8.16% of those with fusion. Complications within 30 days were more common in the nonfusion group (24.64%) than in the fusion group (16.49%). Overall postoperative payments after 12 months totaled $33,137 for the nonfusion group and $23,426 for the fusion group.

Conclusions: In this large cohort study with a 12-month follow-up, the recurrence of infection, reoperation rates, and complications were higher in patients treated with decompression alone than in those treated with decompression plus fusion. These findings along with imaging characteristics, disease severity, extent of bony resection, and the presence of instability may help surgeons decide whether to include fusion at the time of initial surgery. Further studies that control for selection bias in appropriately matched cohorts are necessary to determine the additive benefits of fusion in spinal infection management.
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http://dx.doi.org/10.3171/2018.10.FOCUS18460DOI Listing
February 2019

Disaster Scenarios in Spine Surgery: A Survey Analysis.

Spine (Phila Pa 1976) 2019 Jul;44(14):1018-1024

Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA.

Study Design: Survey analysis among spine surgeons.

Objective: To identify current consensus and discrepancies in managing adverse intraoperative events among spine surgeons.

Summary Of Background Data: Major intraoperative events are not commonly the subject of formal medical training, in part due to the relative paucity of their occurrence and in part due to an insufficient evidence base. Given the clinical impact of appropriate complication management, it is important to identify where surgeons may be able to improve decision making when choosing interventions.

Methods: A survey was created including five hypothetical unpredicted scenarios affecting different organ systems to assess the respondents' preferred reactions. The five clinical vignettes that were selected by the researchers involved: 1) loss of spinal signals in neuro-monitoring, 2) prone position cardiac arrest, 3) prone position hypoxia during thoracic corpectomy and instrumentation, 4) supine cervical vertebral artery injury, and 5) sudden onset hypotension in major prone position reconstructive spine surgery. Twenty-eight surveys (Spine Fellows n = 11; Spine surgeon Faculty n = 17) were completed and returned to the investigators. Results were sorted and ranked according to the frequency each action was identified as a top five choice.

Results: Following formal statistical evaluation loss of signals in neuro-monitoring had the statistically significantly most uniform response while the scenario involving cardiac compromise had the most heterogeneous. Many "best" responses had near or complete consensus while some "distractor" possibilities that could harm a patient were also selected by the respondents.

Conclusion: The heterogeneity of responses in the face of "disaster scenario" intraoperative events shows there is room for more thorough and directed education of spine surgeons during training. As surgical teaching moves toward increased use of patient simulation and situational learning, these vignettes hopefully serve to provide direction for training future spine surgeons on how best to approach difficult situations.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003040DOI Listing
July 2019

Introduction. Primary and secondary infections of the spine.

Neurosurg Focus 2019 01;46(1):E1

4Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.3171/2018.10.FOCUS18588DOI Listing
January 2019

Insights into complication rates, reoperation rates, and healthcare utilization associated with use of recombinant human bone morphogenetic protein-2 in patients with spine infections.

Neurosurg Focus 2019 01;46(1):E8

1Department of Neurosurgery, University of Louisville, Louisville, Kentucky; and.

OBJECTIVEUse of recombinant human bone morphogenetic protein-2 (rhBMP-2) in patients with spine infections is controversial. The purpose of this study was to identify long-term complications, reoperations, and healthcare utilization associated with rhBMP-2 use in patients with spine infections.METHODSThis retrospective study extracted data using ICD-9/10 and CPT codes from MarketScan (2000-2016). Patients were dichotomized into 2 groups (rhBMP-2, no rhBMP-2) based on whether rhBMP-2 was used during fusion surgery for spinal infections. Outcomes of interest were reoperation rates (index level, other levels), readmission rates, discharge disposition, length of stay, complications, and healthcare resource utilization at the index hospitalization and 1, 3, 6, 12, and 24 months following discharge. Outcomes were compared using nonparametric 2-group tests and generalized linear regression models.RESULTSThe database search identified 2762 patients with > 24 months' follow-up; rhBMP-2 was used in 8.4% of their cases. The patients' median age was 53 years, 52.43% were female, and 15.11% had an Elixhauser Comorbidity Index ≥ 3. Patients in the rhBMP-2 group had higher comorbidity indices, incurred higher costs at index hospitalization, were discharged home in most cases, and had lower complication rates than those in the no-rhBMP-2 group. There was no statistically significant between-groups difference in complication rates 1 month following discharge or in reoperation rates at 3, 6, 12, and 24 months following the procedure. Patients in the no-rhBMP-2 group incurred higher utilization of outpatient services and medication refill costs at 1, 3, 6, 12, and 24 months following surgery.CONCLUSIONSIn patients undergoing surgery for spine infection, rhBMP-2 use was associated with lower complication rates and higher median payments during index hospitalization compared to cases in which rhBMP-2 was not used. There was no significant between-groups difference in reoperation rates (index and other levels) at 3, 6, 12, and 24 months after the index operation. Patients treated with rhBMP-2 incurred lower utilization of outpatient services and overall payments. These results indicate that rhBMP-2 can be used safely in patients with spine infections with cost-effective utilization of healthcare resources and without an increase in complications or reoperation rates.
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http://dx.doi.org/10.3171/2018.10.FOCUS18448DOI Listing
January 2019

Bundled Payment Models in Spine Surgery: Current Challenges and Opportunities, a Systematic Review.

World Neurosurg 2019 Mar 12;123:177-183. Epub 2018 Dec 12.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Background: Bundled payments offer a lump sum for management of particular conditions over a specified period that has the potential to reduce health care payments. In addition, bundled payments represent a shift toward patient-centered reimbursement, which has the upside of improved care coordination among providers and may lead to improved outcomes.

Objective: To review the challenges and sources of payment variation and opportunities for restructuring bundled payments plans in the context of spine surgery.

Methods: We reviewed episodes of care over the past 10 years. We completed a search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PICOS (Participants, Intervention, Comparison, Outcomes, Study Design) model in PubMed and Ovid databases to identify studies that met our search criteria.

Results: Ten studies met the search criteria, which were retrospective in design. The primary recipient of reimbursement was the hospital associated with the index procedure (59.7%-77% of the bundled payment), followed by surgeon reimbursement (12.8%-14%) and post-acute care rehabilitation (3.6%-7.3%). On average, the index hospitalization was $32,467, ranging from $11,880 to $107,642, depending on number of levels fused, complications, and malignancy. Readmission was shown to increase the 90-day payment by 50%-200% for uncomplicated fusion.

Conclusions: The implementation of spine surgery in bundled payment models offers opportunity for health care cost reduction. Patient heterogeneity, complications, and index hospitalization pricing are among factors that contribute to the challenge of payment variation. Development of standard care pathways, multidisciplinary coordination between inpatient and outpatient postoperative care, and empowerment of patients are also key elements of progress in the evolution of bundled payments in spine surgery. We anticipate more individualized risk-adjusted prediction models of payment for spine surgery, contributing to more manageable variation in payment and favorable models of bundled payments for payers and providers.
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http://dx.doi.org/10.1016/j.wneu.2018.12.001DOI Listing
March 2019

Variability in the utility of predictive models in predicting patient-reported outcomes following spine surgery for degenerative conditions: a systematic review.

Neurosurg Focus 2018 11;45(5):E10

1Department of Neurosurgery, University of Louisville, Kentucky.

OBJECTIVEThere is increasing emphasis on patient-reported outcomes (PROs) to quantitatively evaluate quality outcomes from degenerative spine surgery. However, accurate prediction of PROs is challenging due to heterogeneity in outcome measures, patient characteristics, treatment characteristics, and methodological characteristics. The purpose of this study was to evaluate the current landscape of independently validated predictive models for PROs in elective degenerative spinal surgery with respect to study design and model generation, training, accuracy, reliability, variance, and utility.METHODSThe authors analyzed the current predictive models in PROs by performing a search of the PubMed and Ovid databases using PRISMA guidelines and a PICOS (participants, intervention, comparison, outcomes, study design) model. They assessed the common outcomes and variables used across models as well as the study design and internal validation methods.RESULTSA total of 7 articles met the inclusion criteria, including a total of 17 validated predictive models of PROs after adult degenerative spine surgery. National registry databases were used in 4 of the studies. Validation cohorts were used in 2 studies for model verification and 5 studies used other methods, including random sample bootstrapping techniques. Reported c-index values ranged from 0.47 to 0.79. Two studies report the area under the curve (0.71-0.83) and one reports a misclassification rate (9.9%). Several positive predictors, including high baseline pain intensity and disability, demonstrated high likelihood of favorable PROs.CONCLUSIONSA limited but effective cohort of validated predictive models of spine surgical outcomes had proven good predictability for PROs. Instruments with predictive accuracy can enhance shared decision-making, improve rehabilitation, and inform best practices in the setting of heterogeneous patient characteristics and surgical factors.
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http://dx.doi.org/10.3171/2018.8.FOCUS18331DOI Listing
November 2018

Myxopapillary ependymoma with anaplastic features: A case report with review of the literature.

Surg Neurol Int 2018 20;9:191. Epub 2018 Sep 20.

House Clinic, Los Angeles, California, USA.

Background: Myxopapillary ependymoma (MPE) with anaplastic features is extremely rare, with only three case reports in the literature.

Case Description: We report the case of a MPE with anaplastic features in a 24-year-old female who presented with a dominant lumbar mass along with intracranial and sacral metastases. Upon gross total resection of the dominant tumor located at L2-L3, it appeared to arise from the filum terminale, and had a solid component in addition to soft or necrotic areas. Histologically, the tumor was composed of the two classic components of MPE: (1) low-grade ependymal cells surrounding blood vessels, producing the papillary appearance and (2) perivascular myxoid material between blood vessels and ependymal cells, creating the myxopapillary appearance. The high-grade anaplastic component showed hypercellularity, brisk mitotic rate, and vascular proliferation, with frequent pleomorphic cells and atypical mitotic figures. It was positive for vimentin and glial fibrillary acidic protein (GFAP); negative for epithelial membrane antigen (EMA), CAM5.2, creatine kinase 7 (CK7), CK20; and the MIB-1 index (Ki-67) was 8-38%. Ten months after initial resection, follow-up magnetic resonance imaging revealed new lesions in (1) the hypothalamus, (2) the left pons, and (3) the left medial temporal lobe, which were treated with radiosurgery. Eight months later (18 months from initial surgery), the patient underwent thoracic laminectomy for a large leptomeningeal metastasis at T6 and T8.

Conclusion: The present case of MPE with anaplastic features is the fourth case on record in the medical literature.
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http://dx.doi.org/10.4103/sni.sni_422_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6169347PMC
September 2018

Long-term impact of abusive head trauma in young children.

Child Abuse Negl 2018 11 23;85:39-46. Epub 2018 Aug 23.

Department of Neurosurgery, University of Louisville, Louisville, KY, USA.

Objective: Abusive head trauma is the leading cause of physical abuse deaths in children under the age of 5 and is associated with severe long-lasting health problems and developmental disabilities. This study evaluates the long-term impact of AHT and identifies factors associated with poor long-term outcomes (LTOs).

Methods: We used the Truven Health MarketScan Research Claims Database (2000-2015) to identify children diagnosed with AHT and follow them up until they turn 5. We identified the incidence of behavioral disorders, communication deficits, developmental delays, epilepsy, learning disorders, motor deficits, and visual impairment as our primary outcomes.

Results: The incidence of any disability was 72% (676/940) at 5 years post-injury. The rate of developmental delays was 47%, followed by 42% learning disorders, and 36% epilepsy. Additional disabilities included motor deficits (34%), behavioral disorders (30%), visual impairment (30%), and communication deficits (11%). Children covered by Medicaid experienced significantly greater long-term disability than cases with private insurance. In a propensity-matched cohort that differ primarily by insurance, the risk of behavioral disorders (RD 36%), learning disorders (RD 30%), developmental delays (RD 30%), epilepsy (RD 18%), and visual impairment (RD 12%) was significantly higher in children with Medicaid than kids with private insurance.

Conclusion: AHT is associated with a significant long-term disability (72%). Children insured by Medicaid have a disproportionally higher risk of long-term disability. Efforts to identify and reduce barriers to health care access for children enrolled in Medicaid are critical for the improvement of outcomes and quality of life.
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http://dx.doi.org/10.1016/j.chiabu.2018.08.011DOI Listing
November 2018

Recent Increase in the Rate of Spinal Infections May be Related to Growing Substance-use Disorder in the State of Washington: Wide Population-based Analysis of the Comprehensive Hospital Abstract Reporting System (CHARS) Database.

Spine (Phila Pa 1976) 2019 02;44(4):291-297

Swedish Neuroscience Institute, Seattle, WA.

Study Design: Epidemiological study.

Objective: The aim of this study was to evaluate trends in the incidence of spinal infections (SI) and the possible role of substance use disorder (SUD) as a key associated factor.

Summary Of Background Data: SI pose major diagnostic and therapeutic challenge in developed countries, resulting in substantial morbidity and mortality. With an estimated incidence of up to 1:20,000, recent clinical experiences suggest that this rate may be rising.

Methods: To evaluate a possible change in trend in the proportion of SI, we searched the Washington state Comprehensive Hospital Abstract Reporting System (CHARS) data during a period of 15 years. We retrieved ICD-9 and 10 codes, searching for all conditions that are regarded as SI (discitis, osteomyelitis, and intraspinal abscess), as well as major known SI-related risk factors.

Results: We found that the proportion of SI among discharged patients had increased by around 40% during the past 6 years, starting at 2012 and increasing steadily thereafter. Analysis of SI-related risk factors within the group of SI revealed that proportion of SUD and malnutrition had undergone the most substantial change, with the former increasing >3-fold during the same period.

Conclusion: Growing rates of drug abuse, drug dependence, and malnutrition throughout the State of Washington may trigger a substantial increase in the incidence of spinal infections in discharged patients. These findings may provide important insights in planning prevention strategies on a broader level.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000002819DOI Listing
February 2019

Factors predicting opioid dependence in patients undergoing surgery for degenerative spondylolisthesis: analysis from the MarketScan databases.

J Neurosurg Spine 2018 Sep 19;29(3):271-278. Epub 2018 Jun 19.

1Department of Neurosurgery, University of Louisville, Louisville, Kentucky.

OBJECTIVE The opioid crisis is identified as a national emergency and epidemic in the United States. The aim of this study was to identify risk factors associated with opioid dependence in patients undergoing surgery for degenerative spondylolisthesis (DS). METHODS The authors queried MarketScan databases to investigate the factors affecting postsurgery opioid use in patients with DS between 2000 and 2012. The outcome of interest was opioid dependence, which was defined as continued opioid use, > 10 opioid prescriptions, or diagnosis of or prescription for opioid dependence disorder in the period of 1 year before or 3-15 months after the procedure. Comparisons of outcomes were performed using nonparametric 2-group tests and generalized regression models. RESULTS A cohort of 10,708 patients was identified from the database. The median patient age was 61 years (interquartile range 54-69 years), and 65.1% were female (n = 6975). A majority of patients had decompression with fusion (n = 10,068; 94%) and underwent multilevel procedures (n = 8123; 75.9%). Of 10,708 patients, 14.85% (n = 1591) were identified as having opioid dependence within 12 months prior to the index surgical procedure and 9.90% (n = 1060) were identified as having opioid dependence within 3-15 months after the procedure. Of all the variables, prior opioid dependence (OR 16.29, 95% CI 14.10-18.81, p < 0.001) and younger age (1-year increase in age: OR 0.972, 95% CI 0.963-0.980, p < 0.001) were independent predictors of opioid dependence following surgery for DS. The use of fusion was not associated with opioid dependence following the procedure (p = 0.8396). Following surgery for DS, patients were more likely to become opioid independent than they were to become opioid dependent (8.54% vs 3.58%, p < 0.001). CONCLUSIONS The majority of patients underwent fusion for DS. Surgical decompression with fusion was not associated with increased risk of postsurgery opioid dependence in patients with DS. Overall, opioid dependence was reduced by 4.96% after surgery for DS. Prior opioid dependence is associated with increased risk and increasing age is associated with decreased risk of opioid dependence following surgery for DS.
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http://dx.doi.org/10.3171/2018.1.SPINE171258DOI Listing
September 2018

Highlights from the First Annual Spinal Navigation, Emerging Technologies and Systems Integration Meeting.

Ann Transl Med 2018 Mar;6(6):110

Cedars-Sinai Medical Center, Los Angeles, CA, USA.

This paper provides a detailed report of the "First Annual Spinal Navigation, Emerging Technologies and Systems Integration" meeting held December 3, 2016 at the Seattle Science Foundation.
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http://dx.doi.org/10.21037/atm.2018.03.22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5900067PMC
March 2018

Autologous Bone Harvest in Anterior Cervical Spine Surgery: A Quantitative and Qualitative In Vitro Analysis of Cadaveric Tissue.

World Neurosurg 2018 Apr 6;112:e134-e139. Epub 2018 Jan 6.

Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University, Bochum, Germany.

Background: The cervical spine may be used as a harvesting site of local autograft material during anterior cervical discectomy and fusion procedures. We analyzed the quality and composition of bone grafts obtained from different parts of the cervical vertebrae in a cadaveric model.

Methods: Five fresh adult human cadavers with intact cervical spines were used. Using a Smith-Robinson anterior approach to expose C4-5 and C5-6 vertebrae, samples from 4 vertebral sites were harvested under a microscope. Anterior osteophytes were removed piecemeal by a Leksell rongeur (sample A). A high-speed burr was used to drill the endplates of C4-5 and C5-6 (sample C) and uncovertebral joints of C4-5 (sample B) and C5-6 (sample D). Then 20 slides (4 per cadaver) were prepared and analyzed.

Results: Tissue fragmentation was associated with use of the high-speed burr. Sample A had minimal tissue fragmentation. Samples B-D showed moderate to high fragmentation. Cartilage was found in all samples. Of the 20 slides, 6 contained soft tissues (sample A in 4, sample D in 2). Disc material was identified in 6 slides (sample A in 1, sample B in 4, sample D in 1). Sample A had the greatest number of intact osteocytes and chondrocytes, and sample B had the least.

Conclusions: Anterior osteophytes provide the highest number of osteocytes, with the highest osteocyte/chondrocyte ratio. Osteocyte viability is a function of vertebral body site and collection technique, with fragmentation caused by use of a high-speed burr decreasing the number of viable osteocytes.
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http://dx.doi.org/10.1016/j.wneu.2017.12.175DOI Listing
April 2018

Intracranial Anatomical Triangles: A Comprehensive Illustrated Review.

Cureus 2017 Oct 4;9(10):e1741. Epub 2017 Oct 4.

Neurosurgery, Seattle Science Foundation.

There are multiple anatomical triangles of the skull base. However, to our knowledge, there has been no comprehensive review of these geometric landmarks. To allow for a safe and consistent approach to lesions of the skull base such as those near the internal carotid artery, internal acoustic meatus, and cavernous sinus, a comprehensive review of the variations with illustrations is required. This article provides an overview of the anatomical borders, dimensions, and surgical implications as well as illustrations of the major skull base triangles.
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http://dx.doi.org/10.7759/cureus.1741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5714398PMC
October 2017

Intraoperative navigation-guided resection of anomalous transverse processes in patients with Bertolotti's syndrome.

Surg Neurol Int 2017 26;8:236. Epub 2017 Sep 26.

Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States.

Background: Bertolotti's syndrome is characterized by enlargement of the transverse process at the most caudal lumbar vertebra with a pseudoarticulation between the transverse process and sacral ala. Here, we describe the use of intraoperative three-dimensional image-guided navigation in the resection of anomalous transverse processes in two patients with Bertolotti's syndrome.

Case Descriptions: Two patients diagnosed with Bertolotti's syndrome who had undergone the above-mentioned procedure were identified. The patients were 17- and 38-years-old, and presented with severe, chronic low back pain that was resistant to conservative treatment. Imaging revealed lumbosacral transitional vertebrae at the level of L5-S1, which was consistent with Bertolotti's syndrome. Injections of the pseudoarticulations resulted in only temporary symptomatic relief. Thus, the patients subsequently underwent O-arm neuronavigational resection of the bony defects. Both patients experienced immediate pain resolution (documented on the postoperative notes) and remained asymptomatic 1 year later.

Conclusion: Intraoperative three-dimensional imaging and navigation guidance facilitated the resection of anomalous transverse processes in two patients with Bertolotti's syndrome. Excellent outcomes were achieved in both patients.
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http://dx.doi.org/10.4103/sni.sni_173_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629866PMC
September 2017