Publications by authors named "Isaac Karikari"

134 Publications

Interhospital transfer status for spinal metastasis patients in the United States is associated with more severe clinical presentations and higher rates of inpatient complications.

Neurosurg Focus 2021 May;50(5):E4

Departments of1Neurosurgery and.

Objective: In patients with metastatic spinal disease (MSD), interhospital transfer can potentially impact clinical outcomes as the possible benefits of transferring a patient to a higher level of care must be weighed against the negative effects associated with potential delays in treatment. While the association of clinical outcomes and transfer status has been examined in other specialties, the relationship between transfer status, complications, and risk of mortality in patients with MSD has yet to be explored. The purpose of this study was to examine the impact of transfer status on in-hospital mortality and clinical outcomes in patients diagnosed with MSD.

Methods: The National (Nationwide) Inpatient Sample (NIS) database was retrospectively queried for adult patients diagnosed with vertebral pathological fracture and/or spinal cord compression in the setting of metastatic disease between 2012 and 2014. Demographics, baseline characteristics (e.g., metastatic spinal cord compression [MSCC] and paralysis), comorbidities, type of intervention, and relevant patient outcomes were controlled in a multivariable logistic regression model to analyze the association of transfer status with patient outcomes.

Results: Within the 10,360 patients meeting the inclusion and exclusion criteria, higher rates of MSCC (50.2% vs 35.9%, p < 0.001) and paralysis (17.3% vs 8.4%, p < 0.001) were observed in patients transferred between hospitals compared to those directly admitted. In univariable analysis, a higher percentage of transferred patients underwent surgical intervention (p < 0.001) when compared with directly admitted patients. After controlling for significant covariates and surgical intervention, transferred patients were more likely to develop in-hospital complications (OR 1.34, 95% CI 1.18-1.52, p < 0.001), experience prolonged length of stay (OR 1.33, 95% CI 1.16-1.52, p < 0.001), and have a discharge disposition other than home (OR 1.70, 95% CI 1.46-1.98, p < 0.001), with no significant difference in inpatient mortality rates.

Conclusions: Patients with MSD who were transferred between hospitals demonstrated more severe clinical presentations and higher rates of inpatient complications compared to directly admitted patients, despite demonstrating no difference in in-hospital mortality rates.
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http://dx.doi.org/10.3171/2021.2.FOCUS201085DOI Listing
May 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 optimization for patients undergoing elective spine surgery.

Clin Neurol Neurosurg 2021 Mar 14;202:106445. Epub 2021 Jan 14.

Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, NC, USA. Electronic address:

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http://dx.doi.org/10.1016/j.clineuro.2020.106445DOI Listing
March 2021

Gender disparities in clinical presentation, treatment, and outcomes in metastatic spine disease.

Cancer Epidemiol 2021 02 24;70:101856. Epub 2020 Dec 24.

Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States. Electronic address:

Background: The incidence of metastatic spine disease (MSD) is increasing among cancer patients. Given the poor outcomes and high rates of morbidity associated with MSD, it is important to determine demographic factors that could impact interventions and outcomes for this patient population. The objectives of this study were to compare in-hospital mortality and complication rates, clinical presentation, and interventions between female and male patients diagnosed with MSD.

Methods: Patient data were collected from the United States National Inpatient Sample (NIS) database from the years 2012-2014. Descriptive statistics were used to compare data from 51,800 cases; subsequently, multivariable logistic regression analyses were conducted to assess the effect of gender on outcomes.

Results: Males had significantly higher rates of in-hospital mortality (OR 1.30; 95 % CI 1.09-1.56, p = 0.004) and were more likely to have received surgical intervention than females (OR 1.34; 95 % CI 1.16-1.55, p < 0.001). Additionally, female patients were more likely to present with vertebral compression fracture (p < 0.001), while metastatic spinal cord compression (MSCC) and paralysis were more common in male patients (p < 0.001). There was no significant difference in rates of in-hospital complications between female and male patients.

Conclusion: Given the significant differences in mortality, disease course, treatment, and in-hospital complications between female and male patients diagnosed with MSD, additional prospective studies are necessary to understand how to meaningfully incorporate these differences into clinical care and prognostication going forward.
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http://dx.doi.org/10.1016/j.canep.2020.101856DOI Listing
February 2021

Biomechanics, evaluation, and management of subaxial cervical spine injuries: A comprehensive review of the literature.

J Clin Neurosci 2021 Jan 3;83:131-139. Epub 2020 Dec 3.

Departments of Neurosurgery, Duke University Medical Center, Durham, NC, USA. Electronic address:

Study Design: Literature review.

Objectives: It has been reported that 2.4-3.7% of all blunt trauma victims suffer some element of cervical spine fracture, with the majority of these patients suffering from C3-7 (subaxial) involvement. With the improvement of first-response to trauma in the community, there are an increasing number of patients who survive their initial trauma and thus arrive at the hospital in need of further evaluation, stabilization, and management of these injuries.

Methods: A comprehensive literature review compiled all relevant data on the biomechanics, imaging, evaluation, and medical and surgical management strategies for subaxial cervical spine fractures.

Results: After review of the current literature on subaxial cervical spine biomechanics, imaging characteristics, evaluation strategies and surgical and orthopedic management techniques, the authors created a comprehensive review and protocol for management of subaxial cervical spine fractures.

Conclusions: The subaxial cervical spine is biomechanically and anatomically unique from the remainder of the spinal axis. Evaluation of subaxial cervical spine injuries is nuanced, and improper management of these injuries can lead to significant patient morbidity and even death. This provides a comprehensive review combining anatomy, imaging characteristics, evaluation strategies, and surgical and orthopedic management principles for subaxial cervical spine fractures.
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http://dx.doi.org/10.1016/j.jocn.2020.11.004DOI Listing
January 2021

"The eye sees only what the mind is prepared to comprehend": Unrecognized incidental findings on intraoperative computed tomography during spine instrumentation surgery.

Clin Imaging 2021 Apr 14;72:64-69. Epub 2020 Nov 14.

Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA. Electronic address:

Background: Intraoperative computed tomography (CT) is becoming more widely utilized in spine fusion surgeries. The use of CT-based image guidance has been shown to increase the accuracy in instrumentation placement and to reduce the rate of reoperation. However, incidental findings that are obvious in retrospect are still missed in spinal fusion surgeries due to the concept of inattentional blindness and surgeons' preoccupation with the main objective of intraoperative CT (i.e. instrumentation accuracy).

Case Description: The first case describes a 60-year-old male who underwent posterior spinal laminectomy and interbody fusions from L2-L5. Intraoperative CT confirmed appropriate placement of hardware. However, when he was transferred out to the care unit and extubated, he developed a severe headache for which the source was confirmed to be a pneumocephalus from durotomy and cerebrospinal fluid leakage on repeat CT. A retrospective review of his intraoperative CT demonstrated the intrathecal air at L5-S1 interlaminar space that was missed on evaluation during surgery. The second case describes a 68-year-old female who was treated with a successful T4 to pelvis instrumentation and fusion with vertebral column resection at T10 confirmed with imaging. Postoperatively, she developed rapidly progressive oxygen desaturation and was found to have a pneumothorax which had been present on the intraoperative imaging.

Conclusion: This case report of two patients with missed intraoperative findings demonstrates the importance of looking beyond instrumentation placement and evaluating the entire intraoperative CT imaging to find abnormalities that could complicate the patients' postoperative recovery and overall hospital stay.
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http://dx.doi.org/10.1016/j.clinimag.2020.11.034DOI Listing
April 2021

Patient outcomes and tumor control in single-fraction versus hypofractionated stereotactic body radiation therapy for spinal metastases.

J Neurosurg Spine 2020 Nov 6:1-10. Epub 2020 Nov 6.

Departments of1Neurosurgery and.

Objective: Stereotactic body radiation therapy (SBRT) offers efficient, noninvasive treatment of spinal neoplasms. Single-fraction (SF) high-dose SBRT has a relatively narrow therapeutic window, while hypofractionated delivery of SBRT may have an improved safety profile with similar efficacy. Because the optimal approach of delivery is unknown, the authors examined whether hypofractionated SBRT improves pain and/or functional outcomes and results in better tumor control compared with SF-SBRT.

Methods: This is a single-institution retrospective study of adult patients with spinal metastases treated with SF- or three-fraction (3F) SBRT from 2008 to 2019. Demographics and baseline characteristics, radiographic data, and posttreatment outcomes at a minimum follow-up of 3 months are reported.

Results: Of the 156 patients included in the study, 70 (44.9%) underwent SF-SBRT (median total dose 1700 cGy) and 86 (55.1%) underwent 3F-SBRT (median total dose 2100 cGy). At baseline, a higher proportion of patients in the 3F-SBRT group had a worse baseline profile, including severity of pain (p < 0.05), average use of pain medication (p < 0.001), and functional scores (p < 0.05) compared with the SF-SBRT cohort. At the 3-month follow-up, the 3F-SBRT cohort experienced a greater frequency of improvement in pain compared with the SF-SBRT group (p < 0.05). Furthermore, patients treated with 3F-SBRT demonstrated a higher frequency of improved Karnofsky Performance Scale (KPS) scores (p < 0.05) compared with those treated with SF-SBRT, with no significant difference in the frequency of improvement in modified Rankin Scale scores. Local tumor control did not differ significantly between the two cohorts.

Conclusions: Patients who received spinal 3F-SBRT more frequently achieved significant pain relief and an increased frequency of improvement in KPS compared with those treated with SF-SBRT. Local tumor control was similar in the two groups. Future work is needed to establish the relationship between fractionation schedule and clinical outcomes.
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http://dx.doi.org/10.3171/2020.6.SPINE20349DOI Listing
November 2020

The medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the United States.

Neurosurg Focus 2020 11;49(5):E20

1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and.

Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. The authors of the current study aimed to describe this impact in the United States, as well as to suggest a potential method for mitigating the problem.This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). Litigation resulted in average payouts of $1,204,422 ± $753,832 between 1995 and 2019, when adjusted for inflation. The median time to case closure was 56.3 (35.2-67.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.4-77.2) months for defendant (surgeon) verdicts (p = 0.117).
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http://dx.doi.org/10.3171/2020.8.FOCUS20600DOI Listing
November 2020

Hematocrit as a predictor of preoperative transfusion-associated complications in spine surgery: A NSQIP study.

Clin Neurol Neurosurg 2021 Jan 23;200:106322. Epub 2020 Oct 23.

Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.

Background Context: Preoperative optimization of medical comorbidities prior to spinal surgery is becoming an increasingly important intervention in decreasing postoperative complications and ensuring a satisfactory postoperative course. The treatment of preoperative anemia is based on guidelines made by the American College of Cardiology (ACC), which recommends packed red blood cell transfusion when hematocrit is less than 21% in patients without cardiovascular disease and 24% in patients with cardiovascular disease. The literature has yet to quantify the risk profile associated with preoperative pRBC transfusion.

Purpose: To determine the incidence of complications following preoperative pRBC transfusion in a cohort of patients undergoing spine surgery.

Study Design: Retrospective review of a national surgical database.

Patient Sample: The national surgical quality improvement program database OUTCOME NEASURES: Postoperative physiologic complications after a preoperative transfusion. Complications were defined as the occurrence of any DVT, PE, stroke, cardiac arrest, myocardial infarction, longer length of stay, need for mechanical ventilation greater than 48 h, surgical site infections, sepsis, urinary tract infections, pneumonia, or higher 30-day mortality.

Methods: The national surgical quality improvement program database was queried, and patients were included if they had any type of spine surgery and had a preoperative transfusion.

Results: Preoperative pRBC transfusion was found to be protective against complications when the hematocrit was less than 20% and associated with more complications when the hematocrit was higher than 20%. In patients with a hematocrit higher than 20%, pRBC transfusion was associated with longer lengths of stay, and higher rates of ventilator dependency greater than 48 h, pneumonia, and 30-day mortality.

Conclusion: This is the first study to identify an inflection point in determining when a preoperative pRBC transfusion may be protective or may contribute to complications. Further studies are needed to be conducted to stratify by the prevalence of cardiovascular disease.
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http://dx.doi.org/10.1016/j.clineuro.2020.106322DOI Listing
January 2021

Improved Dysphagia Outcomes in Anchored Spacers Versus Plate-Screw Systems in Anterior Cervical Discectomy and Fusion: A Systematic Review.

Global Spine J 2020 Dec 26;10(8):1057-1065. Epub 2019 Dec 26.

22957Duke University Medical Center, Durham, NC, USA.

Study Design: Systematic review and meta-analysis.

Objective: To perform a systematic review of clinical outcomes between stand-alone anchored spacers and traditional cages with plate fixation for dysphagia and pseudoarthrosis using data from clinical trials.

Methods: Our search protocol was added to PROSPERO register and systematic review using PRISMA method was performed. Then, we systematically searched for studies addressing stand-alone anchored spacers in patients who underwent ACDF. Mean Neck Disability Index (NDI), dysphagia incidence % (Dinc%), and Swallowing-Quality of Life (SQOL) scores during preoperative, immediate postoperative and last follow-up visits were extracted. Chi-square and analysis of variance (ANOVA) tests were used for statistical comparisons ( ≤ .05).

Results: The initial search generated 506 articles in CENTRAL and 40 articles in MEDLINE. Finally, 14 articles were included. Total number of patients was 1173 (583 anchored stand-alone and 590 plate). Dinc% scores were statistically significantly lower in the stand-alone anchored spacer compared to the plate-screw construct ( ≤ .05). ANOVA showed no statistically significant difference in the comparisons of SQOL. On the other hand, NDI scores were statistically significantly lower in baseline of stand-alone anchored spacer and the plate-screw construct compared with both immediate postoperative and last follow-up visits ( ≤ .05).

Conclusions: Our study results revealed that the stand-alone anchored spacers were associated with less dysphagia in the immediate and last follow-up.
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http://dx.doi.org/10.1177/2192568219895266DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645096PMC
December 2020

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

State-Community System of Care Development: an Exploratory Longitudinal Review.

J Behav Health Serv Res 2021 Apr;48(2):240-258

Indiana University School of Social Work, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, USA.

The system of care (SOC) philosophy evolved into a framework to support access to effective behavioral health services for children. This study explored the use of the System of Care Implementation Survey (SOCIS) to monitor SOC development during one Midwestern state's federal planning and expansion grants. Utilizing a translational framework, results showed that despite fluctuations in SOC factor implementation over time, state and local SOCs had mid-level development. Further, inferential analysis of select factors indicated that outreach and access to services and the skilled provider network were significantly worse over time. Significant improvement in the treatment quality was documented but not sustained. Changes for Family Choice and Voice and Collaboration were not statistically significant. Variability in survey participation limited the evaluation. Refinement of evaluation methods is needed to monitor progress and to manage SOC development.
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http://dx.doi.org/10.1007/s11414-020-09702-8DOI Listing
April 2021

School Principals Putting Bullying Policy to Practice.

J Interpers Violence 2020 May 4:886260520914553. Epub 2020 May 4.

Indiana University Bloomington, USA.

School principals must rely on state statutes and district policies to navigate reports of school bullying. Investigating reports to determine the outcomes may vary depending upon the districts definition of bullying, the investigation process, and follow through to reporting the findings of the investigation to the involved children and youth's parents. However, investigating reports can be challenging due to the confusion of what constitutes bullying. This confusion can be especially troubling for parents who believe their child is being bullied. In order to understand principals' perspectives on bullying, two focus groups were conducted with nine urban school principals. Researchers examined principals' perceptions of how state- and district-level policies were used within their bully investigation practices. These principals suggest that a clear, specific district wide definition of bullying and step by step procedures to investigate reports, along with the state anti-bullying statute, provide a valuable guide for follow-through and back up in determining cases of school bullying. In addition, they identified how policies and district mandates affected parents, particularly when reporting their investigation findings. Implications for bully prevention policies are discussed.
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http://dx.doi.org/10.1177/0886260520914553DOI Listing
May 2020

Endovascular Treatment of Ruptured Enlarging Dissecting Anterior Spinal Artery Aneurysm.

World Neurosurg 2020 07 24;139:e658-e662. Epub 2020 Apr 24.

Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.

Background: Aneurysms of the anterior spinal artery are extremely rare. Unlike intracranial saccular aneurysms, they do not occur at branch points, are typically pseudoaneurysms, and rupture secondary to a dissection. They typically present with subarachnoid hemorrhage and demonstrate clinical and radiographic improvement over time without treatment.

Methods: We present here the first case to date of a ruptured anterior spinal artery aneurysm with clinical and radiographic progression treated with Onyx embolization. Our patient was unique in the presentation with acute onset of spinal cord injury American Spinal Injury Association B and an extensive thoracolumbar subdural hematoma.

Results: An emergent skip-level laminectomy and subdural decompression were performed with no improvement in examination. This was followed by progressive radiographic enlargement of the aneurysm, treated successfully with Onyx embolization.

Conclusions: We analyze this case and review the literature on thoracic anterior spinal artery and artery of Adamkiewicz aneurysms.
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http://dx.doi.org/10.1016/j.wneu.2020.04.100DOI Listing
July 2020

Adult Spinal Deformity Surgery in Patients With Movement Disorders: A Propensity-matched Analysis of Outcomes and Cost.

Spine (Phila Pa 1976) 2020 Mar;45(5):E288-E295

Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA.

Study Design: This was a retrospective study using national administrative data from the MarketScan database.

Objective: To investigate the complication rates, quality outcomes, and costs in a nationwide cohort of patients with movement disorders (MD) who undergo spinal deformity surgery.

Summary Of Background Data: Patients with MD often present with spinal deformities, but their tolerance for surgical intervention is unknown.

Methods: The MarketScan administrative claims database was queried to identify adult patients with MD who underwent spinal deformity surgery. A propensity-score match was conducted to create two uniform cohorts and mitigate interpopulation confounders. Perioperative complication rates, 90-day postoperative outcomes, and total costs were compared between patients with MD and controls.

Results: A total of 316 patients with MD (1.7%) were identified from the 18,970 undergoing spinal deformity surgery. The complication rate for MD patients was 44.6% and for the controls 35.6% (P = 0.009). The two most common perioperative complications were more likely to occur in MD patients, acute-posthemorrhagic anemia (26.9% vs. 20.8%, P < 0.05) and deficiency anemia (15.5% vs. 8.5%, P < 0.05). At 90 days, MD patients were more likely to be readmitted (17.4% vs. 13.2%, P < 0.05) and have a higher total cost ($94,672 vs. $85,190, P < 0.05). After propensity-score match, the overall complication rate remained higher in the MD group (44.6% vs. 37.6%, P < 0.05). 90-day readmissions and costs also remained significantly higher in the MD cohort. Multivariate modeling revealed MD was an independent predictor of postoperative complication and inpatient readmission. Subgroup analysis revealed that Parkinson disease was an independent predictor of inpatient readmission, reoperation, and increased length of stay.

Conclusion: Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of perioperative complications and 90-day readmissions compared with patients without these disorders.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003251DOI Listing
March 2020

Independent Association Between Type of Intraoperative Blood Transfusion and Postoperative Delirium After Complex Spinal Fusion for Adult Deformity Correction.

Spine (Phila Pa 1976) 2020 Feb;45(4):268-274

Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.

Study Design: Retrospective cohort study.

Objective: To determine whether type of intraoperative blood transfusion used is associated with increased incidence of postoperative delirium after complex spine fusion involving five levels or greater.

Summary Of Background Data: Postoperative delirium after spine surgery has been associated with age, cognitive status, and several comorbidities. Intraoperative allogenic blood transfusions have previously been linked to greater complication risks and length of hospital stay. However, whether type of intraoperative blood transfusion used increases the risk for postoperative delirium after complex spinal fusion remains relatively unknown.

Methods: The medical records of 130 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (more than or equal to five levels) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. We identified 104 patients who encountered an intraoperative blood transfusion. Of the 104, 15 (11.5%) had Allogenic-only, 23 (17.7%) had Autologous-only, and 66 (50.8%) had Combined transfusions. The primary outcome investigated was the rate of postoperative delirium.

Results: There were significant differences in estimated blood loss (Combined: 2155.5 ± 1900.7 mL vs. Autologous: 1396.5 ± 790.0 mL vs. Allogenic: 1071.3 ± 577.8 mL vs. None: 506.9 ± 427.3 mL, P < 0.0001) and amount transfused (Combined: 1739.7 ± 1127.6 mL vs. Autologous: 465.7 ± 289.7 mL vs. Allogenic: 986.9 ± 512.9 mL, P < 0.0001). The Allogenic cohort had a significantly higher proportion of patients experiencing delirium (Combined: 7.6% vs. Autologous: 17.4% vs. Allogenic: 46.7% vs. None: 11.5%, P = 0.002). In multivariate nominal-logistic regression analysis, Allogenic (odds ratio [OR]: 24.81, 95% confidence interval [CI] [3.930, 156.702], P = 0.0002) and Autologous (OR: 6.43, 95% CI [1.156, 35.772], P = 0.0335) transfusions were independently associated with postoperative delirium.

Conclusion: Our study suggests that there may be an independent association between intraoperative autologous and allogenic blood transfusions and postoperative delirium after complex spinal fusion. Further studies are necessary to identify the physiological effect of blood transfusions to better overall patient care and reduce healthcare expenditures.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003260DOI Listing
February 2020

Importance of Spinal Alignment in Primary and Metastatic Spine Tumors.

World Neurosurg 2019 Dec 30;132:118-128. Epub 2019 Aug 30.

Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina, USA. Electronic address:

Spinal alignment, particularly with respect to spinopelvic parameters, is highly correlated with morbidity and health-related quality-of-life outcomes. Although the importance of spinal alignment has been emphasized in the deformity literature, spinopelvic parameters have not been considered in the context of spine oncology. Because the aim of oncologic spine surgery is mostly palliative, consideration of spinopelvic parameters could improve postoperative outcomes in both the primary and metastatic tumor population by taking overall vertebral stability into account. This review highlights the relevance of focal and global spinal alignment, particularly related to spinopelvic parameters, in the treatment of spine tumors.
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http://dx.doi.org/10.1016/j.wneu.2019.08.161DOI Listing
December 2019

Total resection of primary and metastatic spine tumors.

Ann Transl Med 2019 May;7(10):226

Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.

Primary and metastatic tumors of the spine represent a significant cause of patient morbidity, and present a management challenge to treating providers. From a neurosurgical standpoint, resection surgery may be warranted in cases of spinal instability, progressive disease, neurological compromise, or intractable symptoms. Removal of a tumor "" offers a more aggressive modality over more conservative resection techniques. resection entails the removal of the entirety of a tumor without violation of its capsule, and may offer improved rates of local control and overall survival in appropriately selected patients. Conversely, this technique carries a higher complication rate, and requires a unique set of technical skills as compared to more traditional resection. Here, we describe the technical aspects of resection, as well as specific indications and considerations when employing this operative technique.
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http://dx.doi.org/10.21037/atm.2019.01.25DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595209PMC
May 2019

Clinical Outcomes Following Surgical Ligation of Cerebrospinal Fluid-Venous Fistula in Patients With Spontaneous Intracranial Hypotension: A Prospective Case Series.

Oper Neurosurg (Hagerstown) 2020 03;18(3):239-245

Duke University Department of Radiology, Durham, North Carolina.

Background: Cerebrospinal fluid-venous fistula (CVF) is a recently described cause of spontaneous intracranial hypotension (SIH). Surgical ligation of CVF has been reported, but clinical outcomes are not well described.

Objective: To determine the clinical efficacy of surgical ligation for treatment of CVF.

Methods: Outcomes metrics were collected in this prospective, single-arm, cross-sectional investigation. Inclusion criteria were as follows: diagnosis of SIH, demonstration of CVF on myelography, and surgical treatment of CVF. Pre- and postoperative headache severity was assessed with the Headache Impact Test (HIT-6), a validated headache scale ranging from 36 (asymptomatic) to 78 (most severe). Patient satisfaction with treatment was measured with Patient Global Impression of Change (PGIC).

Results: Twenty subjects were enrolled, with mean postoperative follow-up at 16.0 ± 9.7 mo. All CVFs were located in the thoracic region (between T4 and T12). Pretreatment headache severity was high (mean HIT-6 scores 65 ± 6). Surgical treatment resulted in marked improvement in headache severity (mean HIT-6 change of -21 ± -9, mean postoperative HIT-6 of 44 ± 8). Of subjects with baseline headache scores in the most severe category, 83% showed a major improvement in severity (transition to the lowest 2 severity categories) after surgery. All subjects (100%) reported clinically significant levels of satisfaction with treatment (PGIC score 6 or 7); 90% reported the highest level of satisfaction. There were no short- or long-term complications or 30-d readmissions.

Conclusion: Surgical ligation is highly effective for the treatment of SIH due to CVF. Larger controlled trials with longer follow-up period are indicated to better assess its long-term efficacy and safety profile.
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http://dx.doi.org/10.1093/ons/opz134DOI Listing
March 2020

Reduced Influence of Affective Disorders on 6-Week and 3-Month Narcotic Refills After Primary Complex Spinal Fusions for Adult Deformity Correction: A Single-Institutional Study.

World Neurosurg 2019 Sep 24;129:e311-e316. Epub 2019 May 24.

Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.

Objective: Previous studies have identified the impact of affective disorders on preoperative and postoperative perception of pain. However, there is a scarcity of data identifying the impact of affective disorders on postdischarge narcotic refills. The aim of this study was to determine whether patients with affective disorders have more narcotic refills after complex spinal fusion for deformity correction.

Methods: The medical records of 121 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, baseline and postoperative patient-reported pain scores, ambulatory status, and narcotic refills were collected for each patient. The primary outcome was the rate of 6-week and 3-month narcotic refills.

Results: Of the 121 patients, 43 (35.5%) had a clinical diagnosis of anxiety or depression (affective disorder) (AD n = 43; No-AD n = 78). Preoperative narcotic use was significantly higher in the AD cohort (AD 65.9% vs. No-AD 37.7%, P = 0.0035). The AD cohort had significantly higher pain scores at baseline (AD 6.5 ± 2.9 vs. No-AD 4.7 ± 3.1, P = 0.004) and at the first postoperative pain score reported (AD 6.7 ± 2.6 vs. No-AD 5.6 ± 2.9, P = 0.049). However, there were no significant differences in narcotic refills at 6 weeks (AD 34.9% vs. No-AD 25.6%, P = 0.283) and 3 months (AD 23.8% vs. No-AD 17.4%, P = 0.411) after discharge between the cohorts.

Conclusions: Our study suggests that whereas spinal deformity patients with affective disorders may have a higher baseline perception of pain and narcotic use, the impact of affective disorders on narcotic refills at 6 weeks and 3 months may be minimal after complex spinal fusion.
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http://dx.doi.org/10.1016/j.wneu.2019.05.135DOI Listing
September 2019

A novel radiographic classification of severe spinal curvatures exceeding 100°: the Omega (Ω), gamma (γ) and alpha (α) deformities.

Eur Spine J 2019 06 3;28(6):1265-1276. Epub 2019 May 3.

FOCOS Orthopedic Hospital, No 8 Teshie Street, Pantang, Accra, Ghana.

Purpose: For spine curvatures with Cobb angles > 100°, curve classification and characterization become more difficult with conventional radiographs. 3-D computerized axial tomography scans add relevant information to categorize and describe a new classification to aid preoperative assessment in communication and patient evaluation. The purpose of this study is to describe a radiographic classification system of curves exceeding 100°.

Methods: A consecutive series of patients with curves exceeding 100° underwent a full spine radiographic review using conventional radiographs and 3-D CT. A descriptive analysis was performed to categorize curves into 4 main types (1, 2, 3 and 4) and 6 subtypes (1C, 1S, 1CS, 2P, 2D and 2PD) based on the location of the Cobb angle of the major scoliotic and kyphotic deformity as well as the location of the upper/lower end vertebra relative to the apical vertebra.

Results: A total of 98 patients met the inclusion criteria. There were 51 males and 47 females with an average age of 17.8 ± 4.5 years. The diagnosis included idiopathic (48); congenital (24); neuromuscular (4); and neurofibromatosis (2). The mean major coronal and sagittal Cobb (kyphosis) were 131.2° ± 23.4° and 154 ± 45.6, respectively. The classification scheme yielded 4 main types (1, 2, 3 and 4) and 6 subtypes under types 1 and 2 (1C, 1S, 1CS, 2P, 2D and 2PD).

Conclusions: Our study describes a novel method of classifying severe spinal curvatures exceeding 100° using erect AP/lateral radiographs and 3-D CT reconstructive images. We hope that the descriptive analysis and classification will expand our understanding of these complex deformities. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-05963-wDOI Listing
June 2019

Intraoperative ketamine may increase risk of post-operative delirium after complex spinal fusion for adult deformity correction.

J Spine Surg 2019 Mar;5(1):79-87

Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.

Background: For complex surgery, intraoperative ketamine administration is readily used to reduce post-operative pain. However, there have been a few studies suggesting that intraoperative ketamine may have deleterious effects and impact post-operative delirium. Therefore, we sought to identify the impact that intraoperative ketamine has on post-operative outcomes after complex spinal surgery involving ≥5 level fusions.

Methods: The medical records of 138 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. We identified 98 (71.0%) who had intraoperative ketamine administration and 40 (29%) who did not (Ketamine-Use: n=98; No-Ketamine: n=40). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative delirium. A multivariate nominal-logistic regression analysis was used to determine the independent association between intraoperative ketamine and post-operative delirium.

Results: Patient demographics and comorbidities were similar between both cohorts, including age, gender, and BMI. The median number of fusion levels operated, length of surgery, estimated blood loss, and proportion of patients requiring blood transfusions were similar between both cohorts. Postoperative complication profile was similar between the cohorts, except for the Ketamine-Use cohort having significantly higher proportion of patients experiencing delirium (Ketamine-Use: 14.3% No-Ketamine: 2.6%, P=0.047). In a multivariate nominal-logistic regression analysis, intraoperative Ketamine-Use was independently associated with post-operative delirium (OR: 9.475, 95% CI: 1.026-87.508, P=0.047).

Conclusions: Our study suggests that the intraoperative use of ketamine may increase the risk of post-operative delirium. Further studies are necessary to understand the physiological effect intraoperative ketamine has on patients undergoing complex spinal fusions in order to better overall patient care and reduce healthcare resources.
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http://dx.doi.org/10.21037/jss.2018.12.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465460PMC
March 2019

Association Between Preoperative Narcotic Use with Perioperative Complication Rates, Patient Reported Pain Scores, and Ambulatory Status After Complex Spinal Fusion (≥5 Levels) for Adult Deformity Correction.

World Neurosurg 2019 Aug 19;128:e231-e237. Epub 2019 Apr 19.

Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.

Objective: The widespread over-use of narcotics has been increasing. However, whether narcotic use impacts surgical outcomes after complex spinal fusion remains understudied. The aim of this study was to evaluate whether there is an association between preoperative narcotic use with perioperative complication rates, patient-reported pain scores, and ambulatory status after complex spinal fusions.

Methods: The medical records of 134 adult (age ≥18 years) patients with spinal deformity undergoing elective, primary complex spinal fusion (≥5 levels) for deformity correction in a major academic institution from 2005-2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, pain scores, and ambulatory status were collected for each patient.

Results: Patient demographics and comorbidities were similar between both cohorts, except that the Narcotic-User cohort had a greater mean age (57.5 years vs. 50.7 years; P = 0.045) and prevalence of depression (39.4% vs. 16.2%; P = 0.003). Complication rates were similar between both cohorts. The Narcotic-User cohort had significantly higher pain scores at baseline (6.7 ± 2.4 vs. 4.0 ± 3.4; P < 0.001) and at the first postoperative pain score reported (6.7 ± 2.8 vs. 5.3 ± 2.9; P = 0.013), but had a significantly greater improvement from baseline to last pain score (Narcotic-User: -2.5 ± 3.9 vs. Non-User: -0.5 ± 4.7; P = 0.031). The Narcotic-User cohort had significantly greater ambulation on the first postoperative ambulatory day compared with the Non-User cohort (103.8 ± 144.4 vs. 56.4 ± 84.0; P = 0.031).

Conclusions: Our study suggests that the preoperative use of narcotics may impact patient perception of pain and improvement after complex spinal fusions (≥5 levels). Consideration of patients' narcotic status preoperatively may facilitate tailored pain management and physical therapy regimens.
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http://dx.doi.org/10.1016/j.wneu.2019.04.107DOI Listing
August 2019

Reduced Impact of Obesity on Short-Term Surgical Outcomes, Patient-Reported Pain Scores, and 30-Day Readmission Rates After Complex Spinal Fusion (≥7 Levels) for Adult Deformity Correction.

World Neurosurg 2019 Jul 12;127:e108-e113. Epub 2019 Mar 12.

Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.

Objective: In the past decade, prevalence of obesity in the United States have been soaring at a disparaging rate. Previous spine studies have associated obesity with inferior surgical outcomes, increased complication and 30-day readmission rates, and worsening patient-reported outcomes. However, there is a paucity of data identifying whether the impact of obesity is sustained in patients undergoing complex deformity correction involving 7 levels or greater. The aim of this study was to determine whether obesity impacts surgical outcomes, patient-reported pain scores, and 30-day readmission rates after complex spinal fusions ≥7 levels.

Methods: The medical records of 112 adult patients (≥18 years old) with spine deformity undergoing elective, primary complex spinal fusion (≥7 levels) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. Preoperative body mass index greater than or equal to 30 kg/m was classified as obese. Patient demographics, comorbidities, and intraoperative and postoperative complication rates were collected for each patient. Inpatient patient-reported pain scores and ambulatory status also were collected. The primary outcomes of this study were surgical outcomes, patient-reported pain scores, and 30-day readmission rates.

Results: Of the 112 patients, 33 (29.5%) were obese (obese: n = 33 vs. non-obese: n = 79). Patient demographics and comorbidities were similar between both cohorts, including age, sex, diabetes, hypertension, and home narcotic use. The median number of fusion levels operated, length of surgery, estimated blood loss, transfusion, and complication rates were similar between both cohorts. Moreover, the postoperative complication profiles between the cohorts also were similar, with a comparable length of hospital stay (obese: 6.5 ± 4.6 days vs. non-obese: 7.0 ± 3.9 days, P = 0.5833) and 30-day readmission rates (obese: 12.1% vs. non-obese: 13.9%, P = 0.7984). Baseline (P = 0.6826), first (P = 0.9691), and last (P = 0.9583) postoperative patient-reported pain scores were similar between cohorts. Analogously, ambulatory status was similar between the cohorts, including days from operating room to ambulation (P = 0.3471) and number of steps on first (P = 0.9173) and last (P = 0.1634) ambulatory day before discharge.

Conclusions: Our study suggests that obesity does not significantly affect surgical outcomes, patient-reported pain scores, and 30-day readmission rates after complex spinal surgery requiring ≥7 levels of fusion. Further studies are necessary to corroborate our findings.
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http://dx.doi.org/10.1016/j.wneu.2019.02.165DOI Listing
July 2019

Rate of instrumentation changes on postoperative and follow-up radiographs after primary complex spinal fusion (five or more levels) for adult deformity correction.

J Neurosurg Spine 2019 01;30(3):376-381

2Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.

OBJECTIVEIn the United States, healthcare expenditures have been soaring at a concerning rate. There has been an excessive use of postoperative radiographs after spine surgery and this has been a target for hospitals to reduce unnecessary costs. However, there are only limited data identifying the rate of instrumentation changes on radiographs after complex spine surgery involving ≥ 5-level fusions.METHODSThe medical records of 136 adult (≥ 18 years old) patients with spine deformity undergoing elective, primary complex spinal fusion (≥ 5 levels) for deformity correction at a major academic institution between 2010 and 2015 were reviewed. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient. The authors reviewed the first 5 subsequent postoperative and follow-up radiographs, and determined whether revision of surgery was performed within 5 years postoperatively. The primary outcome investigated in this study was the rate of hardware changes on follow-up radiographs.RESULTSThe majority of patients were female, with a mean age of 53.8 ± 20.0 years and a body mass index of 27.3 ± 6.2 kg/m2 (parametric data are expressed as the mean ± SD). The median number of fusion levels was 9 (interquartile range 7-13), with a mean length of surgery of 327.8 ± 124.7 minutes and an estimated blood loss of 1312.1 ± 1269.2 ml. The mean length of hospital stay was 6.6 ± 3.9 days, with a 30-day readmission rate of 14.0%. Postoperative and follow-up change in stability on radiographs (days from operation) included: image 1 (4.6 ± 9.3 days) 0.0%; image 2 (51.7 ± 49.9 days) 3.0%; image 3 (142.1 ± 179.8 days) 5.6%; image 4 (277.3 ± 272.5 days) 11.3%; and image 5 (463.1 ± 525.9 days) 15.7%. The 3rd year after surgery had the highest rate of hardware revision (5.55%), followed by the 2nd year (4.68%), and the 1st year (4.54%).CONCLUSIONSThis study suggests that the rate of instrumentation changes on radiographs increases over time, with no changes occurring at the first postoperative image. In an era of cost-conscious healthcare, fewer orders for early radiographs after complex spinal fusions (≥ 5 levels) may not impact patient care and can reduce the overall use of healthcare resources.
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http://dx.doi.org/10.3171/2018.9.SPINE18686DOI Listing
January 2019

Utility of Cervical Collars Following Cervical Fusion Surgery. Does It Improve Fusion Rates or Outcomes? A Systematic Review.

World Neurosurg 2018 Dec 26. Epub 2018 Dec 26.

Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

Background: The use of postoperative cervical collars following cervical fusions is common practice. Its use has been purported to improve fusion rates and outcomes. There is a paucity in the strength of evidence to support its clinical benefit. Our objective is to critically evaluate the published literature to determine the strength of evidence supporting the use of postoperative cervical collar use following cervical fusions.

Methods: A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (also known as PRISMA) was performed. An online search using Medline and Cochrane Central Register of Controlled Trials databases was used to query prospective and retrospective clinical trials evaluating cervical fusions with or without postoperative collar.

Results: The search identified 894 articles in Medline and 65 articles in the Cochrane database. From these articles, 130 were selected based on procedure and collar use. Only 3 studies directly compared between collar use and no collar use. Our analysis of the mean improvement in neck disability index scores and improvement over time intervals did not show a statistically significant difference between collar versus no collar (P = 0.86).

Conclusions: We found no strong evidence to support the use of cervical collars after 1- and 2-level anterior cervical discectomy and fusion procedures, and no studies comparing collar use and no collar use after posterior cervical fusions. Given the cost and likely impact of collar use on driving and the return to work, our study shows that currently there is no proven benefit to routine use of postoperative cervical collar in patients undergoing 1- and 2-level anterior cervical discectomy and fusion for degenerative cervical pathologies.
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http://dx.doi.org/10.1016/j.wneu.2018.12.066DOI Listing
December 2018

Neurological Outcomes After Surgical or Conservative Management of Spontaneous Spinal Epidural Abscesses: A Systematic Review and Meta-Analysis of Data From 1980 Through 2016.

Clin Spine Surg 2019 02;32(1):18-29

Department of Neurological Surgery, Duke University, Durham, NC.

Study Design: This is a meta-analysis.

Objective: Perform a systematic review and quantitative meta-analysis of neurological outcomes from all available spinal epidural abscess (SEA) literature published between 1980 and 2016.

Summary Of Background Data: Current literature on SEAs lacks large-scale data characterizing prognostic factors and surgical indications.

Materials And Methods: PubMed was queried for studies reporting neurological outcomes from patients undergoing conservative or surgical management for spontaneous SEA. Inclusion criteria included outcomes data measured ≥6 months after presentation, ≥10 human subjects, and diagnosis by magnetic resonance imaging or Computed tomography-myelogram. Where available, demographic data, abscess location, comorbidities, pretreatment neurological deficits, treatment methods, bacterial speciation, and complications were extracted from each study. Potential outcome predictors represented by continuous variables were compared using student t test and categorical variables were compared using the Pearson χ test. Variables identified as potentially associated with outcome (P≤0.05) were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

Results: In total, 808 patients were analyzed from 20 studies that met inclusion criteria. 456 (56.3%) patients were treated with surgery and antibiotics, and 353 (43.7%) patients were managed with antibiotics alone. Neither surgical intervention (OR=1.01, 95% CI=0.40-2.59), lumbosacral location (OR=1.51, 95% CI=0.23-9.79), nor neurological deficit on presentation (OR=0.88, 95% CI=0.40-1.92) were significantly associated with good (stable or improved) or bad (worsened) neurological outcome, whereas delayed surgery was significantly associated with bad outcome (OR=0.01, 95% CI=0.02-0.62) and cervicothoracic location approached significance for predicting bad outcome (OR=0.41, 95% CI=0.15-1.09).

Conclusions: Current literature does not definitively support or oppose surgical intervention in all SEA cases. Therefore, until better evidence exists, the decision to operate must be made on an individual case-by-case basis with the goals of preventing neurological decline, obtaining source control after failed conservative treatment, or restoring spinal stability.
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http://dx.doi.org/10.1097/BSD.0000000000000762DOI Listing
February 2019

Key Role of Preoperative Recumbent Films in the Treatment of Severe Sagittal Malalignment.

Spine Deform 2018 Sep - Oct;6(5):568-575

Norton Leatherman Spine Center, University of Louisville School of Medicine, 323 E Chestnut St, Louisville, KY 40202, USA.

Study Design: Retrospective cohort study.

Objective: To determine if severe sagittal malalignment (SM) patients without fixed deformities require a three-column osteotomy (3CO) to achieve favorable clinical and radiographic outcomes.

Summary Of Background Data: 3CO performed for severe SM has significantly increased in the last 15 years. Not all severe SM patients require a 3CO.

Methods: Severe SM patients (sagittal vertical axis [SVA] >10 cm) who underwent deformity correction between 2002 and 2011. Patients with <33% change in their lumbar lordosis (LL) on a preoperative supine radiograph were classified as stiff deformities, whereas those with ≥33% change were categorized as flexible deformities. The clinical/radiographic outcomes were assessed at minimum two years postoperatively.

Results: Seventy patients met the inclusion criteria, 35 patients with flexible and 35 with stiff deformities. Eighteen flexible-deformity patients underwent a 3CO versus 22 stiff-deformity patients. The remaining patients in each group underwent spinal realignment without a 3CO. The flexible-deformity patients not undergoing a 3CO had overall improvement in all sagittal radiographic parameters. Preoperative LL (22°), LL-pelvic incidence (PI) mismatch (43), SVA (17 cm), and pelvic tilt (PT, 34°) improved to 46°, 18, 6 cm, and 26°, respectively, p < .05. Flexible-deformity patients who underwent a 3CO also had overall improvement in all radiographic parameters. Preoperative LL (8.5°), LL-PI mismatch (47), SVA (19 cm), and PT (37°) improved to 39°, 15, 7 cm, and 24°, respectively (p < .05). Stiff-deformity patients who underwent a 3CO had statistically significant improvement in all radiographic parameters. However, stiff-deformity patients who did not undergo a 3CO had suboptimal improvement in all radiographic parameters, except for SVA (14 cm-9 cm, p < .05). Flexible patients who did not undergo a 3CO had statistical improvement in the SRS domains of function and self-mage as well as in their ODI scores (p < .05).

Conclusion: Severe SM that is flexible can be corrected without a 3CO without compromising clinical and radiographic outcomes.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jspd.2018.02.009DOI Listing
January 2019

Thirty-day complication and readmission rates associated with resection of metastatic spinal tumors: a single institutional experience.

J Spine Surg 2018 Jun;4(2):304-310

Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.

Background: This study aims to assess 30-day complication and unplanned readmission rates associated with resection of metastatic spinal tumors.

Methods: Medical records were reviewed for 135 adults who underwent elective resection of a spinal cord tumor. Patient demographics, comorbidities, and tumor characteristics were collected. Tumor pathology was analyzed and diagnosed by a pathologist. The primary outcomes were intra- and 30-day post-operative complication and readmission rates.

Results: Of the 135 spinal tumor resections, 30 (22.2%) cases were metastatic. The most common tumor pathology was bone (13.3%) and the most common locations were thoracic (45.2%), and cervical (32.7%). Most patients had an open surgery (96.7%), with a mean laminectomy/laminoplasty level of 1.9±1.5 and mean operative time of 328.4±658.0 min. There was a 3.3% incidence rate of intraoperative durotomies, with no spinal cord or nerve root injuries. Post-operatively, 44.8% of patients were transferred to the intensive care unit (ICU). The most common post-operative complications were weakness (20.0%), new sensory deficits (16.7%), and hypotension (13.3%). The mean length of stay was 8.8±7.6 days, with the majority of patients discharged home (96.7%). The 30-day readmission rate was 9.7%, with the most common 30-day complications being uncontrolled pain (16.7%), sensory-motor deficits (13.3%), and fever (10.0%).

Conclusions: Our study suggests that weakness, sensory deficits, and uncontrolled pain are the most common complications after resection of spinal metastases, with a relatively high associated 30-day readmission rate. Further studies are necessary to corroborate our findings and identify strategies to reduce complication and readmission rates after resection of spinal metastases.
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http://dx.doi.org/10.21037/jss.2018.05.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6046345PMC
June 2018