Publications by authors named "Mohamad Bydon"

431 Publications

Semispinalis Cervicis Sarcopenia is Associated With Worsening Cervical Sagittal Balance and Junctional Alignment Following Posterior Cervical Fusion for Myelopathy.

Clin Spine Surg 2022 Aug 9. Epub 2022 Aug 9.

Department of Orthopedic Surgery, Mayo Clinic.

Study Design: This was a retrospective cohort study.

Objective: The present study is the first to investigate whether cervical paraspinal sarcopenia is associated with cervicothoracic sagittal alignment parameters after posterior cervical fusion (PCF).

Summary Of Background Data: Few studies have investigated the association between sarcopenia and postoperative outcomes after cervical spine surgery.

Methods: We retrospectively reviewed patients undergoing PCF from C2-T2 at a single institution between the years 2017-2020. Two independent reviewers utilized axial cuts of T2-weighted magnetic resonance imaging sequences to perform Goutallier classification of the bilateral semispinalis cervicis (SSC) muscles. Cervical sagittal alignment parameters were compared between subgroups based upon severity of SSC sarcopenia.

Results: We identified 61 patients for inclusion in this study, including 19 patients with mild SSC sarcopenia and 42 patients with moderate or severe SSC sarcopenia. The moderate-severe sarcopenia subgroup demonstrated a significantly larger change in C2-C7 sagittal vertical axis (+6.8 mm) from the 3-month to 1-year postoperative follow-up in comparison to the mild sarcopenia subgroup (-2.0 mm; P=0.02). The subgroup of patients with moderate-severe sarcopenia also demonstrated an increase in T1-T4 kyphosis (10.9-14.2, P=0.007), T1 slope (28.2-32.4, P=0.003), and C2 slope (24.1-27.3, P=0.05) from 3-month to 1-year postoperatively and a significant decrease in C1-occiput distance (6.3-4.1, P=0.002) during this same interval.

Conclusions: In a uniform cohort of patients undergoing PCF from C2-T2, SSC sarcopenia was associated with worsening cervicothoracic alignment from 3-month to 1-year postoperatively.
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http://dx.doi.org/10.1097/BSD.0000000000001366DOI Listing
August 2022

Positive impact of the pandemic: the effect of post-COVID-19 virtual visit implementation on departmental efficiency and patient satisfaction in a quaternary care center.

Neurosurg Focus 2022 Jun;52(6):E10

1Department of Neurologic Surgery and.

Objective: The coronavirus disease 2019 (COVID-19) pandemic has significantly changed clinical practice across US healthcare. Increased adoption of telemedicine has emerged as an alternative to in-person contact for patient-physician interactions. The aim of this study was to analyze the impact of telemedicine on workflow and care delivery from January 2019 to December 2021 in a neurosurgical department at a quaternary care center.

Methods: Prospectively captured data on clinic appointment utilization, duration, and outcomes were queried. Visits were divided into in-person visits and telemedicine appointments, categorized as follow-up visits of previously surgically treated patients, internal consultations, new patient visits, and early postoperative returns after surgery. Appointment volume was compared pre- and postpandemic using March 2020 as the pandemic onset. Clinical efficiency was measured by time to appointment, rate of on-time appointments, proportion of appointments resulting in surgical intervention (surgical yield), and patient-reported satisfaction, the latter measured as the proportion of patients indicating "high likelihood to recommend practice."

Results: A total of 54,562 visits occurred, most commonly for follow-up for previously operated patients (51.8%), internal new patient referrals (24.5%), and external new patient referrals (19.8%). Total visit volume was stable pre- to postpandemic (1521.3 vs 1512, p = 0.917). However, in-person visits significantly decreased (1517/month vs 1220/month, p < 0.001), with a nadir in April 2020, while telemedicine appointment utilization increased significantly (0.3% vs 19.1% of all visits). Telemedicine utilization remained stable throughout the 1st calendar year following the pandemic. Telemedicine appointments were associated with shorter time to appointment than in-person visits both before and after the pandemic onset (0-5 days from appointment request: 60% vs 33% vs 29.8%, p < 0.001). Patients had on-time appointments in 87% of telemedicine encounters. Notably, telemedicine appointments resulted in surgery in 31.8% of internal consultations or new patient visits, a significantly lower rate than that for in-person visits (51.8%). After the widespread integration of telemedicine, patient satisfaction for all visits was higher than before the pandemic onset (85.9% vs 88.5%, p = 0.027).

Conclusions: Telemedicine use significantly increased following the pandemic onset, compensating for observed decreases in face-to-face visits. Utilization rates have remained stable, suggesting effective integration, and delays between referrals and appointments were lower than for in-person visits. Importantly, telemedicine integration was not associated with a decrease in overall patient satisfaction, although telemedicine appointments had a lower surgical yield. These data suggest that telemedicine smoothened the impact of the pandemic on clinical workflow and helped to maintain continuity and quality of outpatient care.
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http://dx.doi.org/10.3171/2022.3.FOCUS2243DOI Listing
June 2022

A mentorship model for neurosurgical training: the Mayo Clinic experience.

Neurosurg Focus 2022 Aug;53(2):E11

3Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.

Neurosurgical education is a continually developing field with an aim of training competent and compassionate surgeons who can care for the needs of their patients. The Mayo Clinic utilizes a unique mentorship model for neurosurgical training. In this paper, the authors detail the historical roots as well as the logistical and experiential characteristics of this teaching model. This model was first established in the late 1890s by the Mayo brothers and then adopted by the Mayo Clinic Department of Neurological Surgery at its inception in 1919. It has since been implemented enterprise-wide at the Minnesota, Florida, and Arizona residency programs. The mentorship model is focused on honing resident skills through individualized attention and guidance from an attending physician. Each resident is closely mentored by a consultant during a 2- or 3-month rotation, which allows for exposure to more complex cases early in their training. In this model, residents take ownership of their patients' care, following them longitudinally during their hospital course with guided oversight from their mentors. During the chief year, residents have their own clinic, operating room (OR) schedule, and OR team and service nurse. In this model, chief residents conduct themselves more in the manner of an attending physician than a trainee but continue to have oversight from staff to provide a "safety net." The longitudinal care of patients provided by the residents under the mentorship model is not only beneficial for the trainee and the hospital, but also has a positive impact on patient satisfaction and safety. The Mayo Clinic Mentorship Model is one of many educational models that has demonstrated itself to be an excellent approach for resident education.
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http://dx.doi.org/10.3171/2022.5.FOCUS22170DOI Listing
August 2022

Determining the time frame of maximum clinical improvement in surgical decompression for cervical spondylotic myelopathy when stratified by preoperative myelopathy severity: a cervical Quality Outcomes Database study.

J Neurosurg Spine 2022 Jun 17:1-9. Epub 2022 Jun 17.

1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia.

Objective: While surgical decompression is an important treatment modality for cervical spondylotic myelopathy (CSM), it remains unclear if the severity of preoperative myelopathy status affects potential benefit from surgical intervention and when maximum postoperative improvement is expected. This investigation sought to determine if retrospective analysis of prospectively collected patient-reported outcomes (PROs) following surgery for CSM differed when stratified by preoperative myelopathy status. Secondary objectives included assessment of the minimal clinically important difference (MCID).

Methods: A total of 1151 patients with CSM were prospectively enrolled from the Quality Outcomes Database at 14 US hospitals. Baseline demographics and PROs at baseline and 3 and 12 months were measured. These included the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), quality-adjusted life-years (QALYs) from the EQ-5D, and visual analog scale from the EQ-5D (EQ-VAS). Patients were stratified by preoperative myelopathy severity using criteria established by the AO Spine study group: mild (mJOA score 15-17), moderate (mJOA score 12-14), or severe (mJOA score < 12). Univariate analysis was used to identify demographic variables that significantly varied between myelopathy groups. Then, multivariate linear regression and linear mixed regression were used to model the effect of severity and time on PROs, respectively.

Results: For NDI, EQ-VAS, and QALY, patients in all myelopathy cohorts achieved significant, maximal improvement at 3 months without further improvement at 12 months. For mJOA, moderate and severe myelopathy groups demonstrated significant, maximal improvement at 3 months, without further improvement at 12 months. The mild myelopathy group did not demonstrate significant change in mJOA score but did maintain and achieve higher PRO scores overall when compared with more advanced myelopathy cohorts. The MCID threshold was reached in all myelopathy cohorts at 3 months for mJOA, NDI, EQ-VAS, and QALY, with the only exception being mild myelopathy QALY at 3 months.

Conclusions: As assessed by statistical regression and MCID analysis, patients with cervical myelopathy experience maximal improvement in their quality of life, neck disability, myelopathy score, and overall health by 3 months after surgical decompression, regardless of their baseline myelopathy severity. An exception was seen for the mJOA score in the mild myelopathy cohort, improvement of which may have been limited by ceiling effect. The data presented here will aid surgeons in patient selection, preoperative counseling, and expected postoperative time courses.
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http://dx.doi.org/10.3171/2022.5.SPINE211425DOI Listing
June 2022

Outcomes Following Direct versus Indirect Decompression Techniques for Lumbar Spondylolisthesis: A Propensity-Matched Analysis.

Spine (Phila Pa 1976) 2022 Jul 15. Epub 2022 Jul 15.

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States.

Study Design: Retrospective Review.

Objective: To compare outcomes at 3 and 12-months for patients with lumbar spondylolisthesis treated with direct decompression (DD) versus indirect decompression (ID) techniques.

Summary Of Background Data: Debate persists regarding the optimal surgical strategy to treat lumbar spondylolisthesis. Novel techniques relying on ID have shown superior radiographic outcomes compared to DD, however, doubt remains regarding their effectiveness in achieving adequate decompression. Currently, there is a paucity of data comparing the clinical efficacy of DD to ID.

Methods: The Quality Outcomes Database (QOD), a national, multicenter prospective spine registry, was queried for patients who underwent DD and ID between 04/13-01/19. Propensity scores (PS) for each treatment were estimated using logistic regression dependent on baseline covariates potentially associated with outcomes. The PS's were used to exclude non-similar patients. Multivariable regression analysis was performed with the treatment and covariate as independent variables and outcomes as dependent variables.

Results: 4163 patients were included in the DD group and 86 in the ID group. The ID group had significantly lower odds of having a longer hospital stay and for achieving 30% improvement in back and leg pain at 3-months. These trends were not statistically significant at 12-months. There were no differences in ED5D scores or ODI 30% improvement scores at 3 or 12-months. ID patient had a significantly higher rate of undergoing a repeat operation at 3 months (4.9% vs. 1.5%, P=0.015).

Conclusion: Our study suggests that both direct and indirect decompression for the treatment of lumbar spondylolisthesis result in similar clinical outcomes, with the exception that those treated with indirect decompression experienced a lower reduction in back and leg pain at 3-months and a higher 3-month reoperation rate. This data can provide surgeons with additional information when counseling patients on the pros and cons of ID versus DD surgery.
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http://dx.doi.org/10.1097/BRS.0000000000004396DOI Listing
July 2022

Utilizing Data from Wearable Technologies In the Era of Telemedicine to Assess Patient Function and Outcomes in Neurosurgery: Systematic Review and Time-Trend Analysis of the Literature.

World Neurosurg 2022 Jul 14. Epub 2022 Jul 14.

Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

Introduction: The COVID-19 pandemic has driven the increased use of telemedicine and the adoption of wearable technology in neurosurgery. We reviewed studies exploring use of wearables on neurosurgical patients and analyzed wearables' scientific production trends.

Methods: The review encompassed PubMed, EMBASE, Web of Science, and Cochrane Library. Bibliometric analysis was performed using citation data of the included studies through Elsevier's Scopus database. Linear regression was utilized to understand scientific production trends. All analyses were performed on R 4.1.2.

Results: We identified 979 studies. After screening, 49 studies were included. Most studies evaluated wearable technology use for patients with spinal pathology (n=31). The studies were published in a 24-year period (1998-2021). Forty-seven studies involved wearable device-use relevant to telemedicine. Bibliometric analysis revealed a compounded annual growth rate (CAGR) of 7.3%, adjusted for inflation, in annual scientific production from 1998 to 2021 (coefficient=1.3; 95% C.I. = [0.7, 1.9], p<0.01). Scientific production steadily increased in 2014 (n=1) and peaked from 2019 (n=8) to 2021 (n=13) in correlation with the COVID-19 pandemic. Publications spanned 34 journals, averaged 24.4 citations per article, 3.0 citations per year per article, and 8.3 authors per article.

Conclusion: Wearables can provide clinicians with objective measurements to determine patient function and quality of life. The rise in articles related to wearables in neurosurgery demonstrates the increased adoption of wearable devices during the COVID-19 pandemic. Wearable devices appear to be a key component in this era of telemedicine and their positive utility and practicality are increasingly being realized in neurosurgery.
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http://dx.doi.org/10.1016/j.wneu.2022.07.036DOI Listing
July 2022

Multifidus Sarcopenia is Associated with Worse Patient Reported Outcomes following Posterior Cervical Decompression and Fusion.

Spine (Phila Pa 1976) 2022 Jul 1. Epub 2022 Jul 1.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

Study Design: Retrospective cohort study.

Objective: The present study is the first to assess the impact of paraspinal sarcopenia on PROMs following PCDF.

Summary Of Background Data: While the impact of sarcopenia on patient-reported outcome measures (PROMs) following lumbar spine surgery is well-established, the impact of sarcopenia on PROMs following posterior cervical decompression and fusion (PCDF) has not been investigated.

Methods: We performed a retrospective review of patients undergoing PCDF from C2-T2 at a single institution between the years 2017-2020. Two independent reviewers who were blinded to the clinical outcome scores utilized axial cuts of T2-weighted MRI sequences to assess fatty infiltration of the bilateral multifidus muscles at the C5-6 level and classify patients according to the Fuchs Modification of the Goutalier grading system. PROMs were then compared between subgroups.

Results: We identified 99 patients for inclusion in this study, including 28 patients with mild sarcopenia, 45 patients with moderate sarcopenia, and 26 patients with severe sarcopenia. There was no difference in any preoperative PROM between the subgroups. Mean postoperative NDI scores were lower in the mild and moderate sarcopenia subgroups (12.8 and 13.4, respectively) than in the severe sarcopenia subgroup (21.0, P<0.001). A higher percentage of patients with severe multifidus sarcopenia reported postoperative worsening of their NDI (10 patients, 38.5%; P=0.003), VAS Neck scores (7 patients, 26.9%; P=0.02), PROMIS Physical Component scores (10 patients, 38.5%; P=0.02), and PROMIS Mental Component scores (14 patients, 53.8%; P=0.02).

Conclusion: Patients with more severe paraspinal sarcopenia demonstrate less improvement in neck disability and physical function postoperatively and are substantially more likely to report worsening PROMs postoperatively.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004386DOI Listing
July 2022

Complications, Readmissions, Revisions and Patient-Reported Outcomes in Patients with Parkinson's Disease Undergoing Elective Spine Surgery- a Propensity Matched Analysis.

Spine (Phila Pa 1976) 2022 Jun 29. Epub 2022 Jun 29.

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States.

Study Design: Retrospective analysis on prospectively collected data.

Objective: Determine the effectiveness of elective spine surgery in patients with Parkinson's Disease (PD).

Background Context: PD has become increasingly prevalent in an aging population. While surgical treatment for degenerative spine pathology is often required in this population, previous literature has provided mixed results regarding its effectiveness.

Methods: Data from the Quality Outcomes Database (QOD) was queried between 04/2013-01/2019. Three surgical groups were identified: (1) Elective lumbar surgery, (2) Elective cervical surgery for myelopathy, (3) Elective cervical surgery for radiculopathy. Patients without PD were propensity matched against patients with PD in a 5 to 1 ratio without replacement based on ASA grade, arthrodesis, surgical approach, number of operated levels, age, and baseline ODI, NRS extremity pain, NRS back pain, and EQ-5D. The mean difference was calculated for continuous outcomes (ODI, NRS leg pain, NRS back pain, and EQ-5D at 3 and 12-months after surgery) and the risk difference was calculated for binary outcomes (patient satisfaction, complications, readmission, reoperation, and mortality).

Results: For the lumbar analysis, PD patients had a higher rate of reoperation at 12-months (risk difference=0.057, P=0.015) and lower mean EQ-5D score at 12-months (mean difference=-0.053, P=0.005) when compared to patients without PD. For the cervical myelopathy cohort, PD patients had lower NRS neck pain scores at 3-months (mean difference=-0.829, P=0.005) and lower patient satisfaction at 3-months (risk difference=-0.262, P=0.041) compared to patients without PD. For the cervical radiculopathy cohort, PD patients demonstrated a lower readmission rate at 3-months (risk difference=-0.045, P=0.014) compared to patients without PD.

Conclusion: For the matched analysis, in general, patients with and without PD had similar PROs and complication, readmission, and reoperation rates. These results demonstrate that a diagnosis of PD alone should not represent a major contraindication to elective spine surgery.
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http://dx.doi.org/10.1097/BRS.0000000000004401DOI Listing
June 2022

The Role of Alginate Hydrogels as a Potential Treatment Modality for Spinal Cord Injury: A Comprehensive Review of the Literature.

Neurospine 2022 Jun 30;19(2):272-280. Epub 2022 Jun 30.

Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.

Objective: To comprehensively characterize the utilization of alginate hydrogels as an alternative treatment modality for spinal cord injury (SCI).

Methods: An extensive review of the published literature on studies using alginate hydrogels to treat SCI was performed. The review of the literature was performed using electronic databases such as PubMed, EMBASE, and OVID MEDLINE electronic databases. The keywords used were "alginate," "spinal cord injury," "biomaterial," and "hydrogel."

Results: In the literature, we identified a total of 555 rat models that were treated with alginate scaffolds for regenerative biomarkers. Alginate hydrogels were found to be efficient and promising substrates for tissue engineering, drug delivery, neural regeneration, and cellbased therapies for SCI repair. With its ability to act as a pro-regenerative and antidegenerative agent, the alginate hydrogel has the potential to improve clinical outcomes.

Conclusion: The emerging developments of alginate hydrogels as treatment modalities may support current and future tissue regenerative strategies for SCI.
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http://dx.doi.org/10.14245/ns.2244186.093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9260541PMC
June 2022

Complications, readmissions, reoperations and patient-reported outcomes in patients with multiple sclerosis undergoing elective spine surgery - a propensity matched analysis.

Spine J 2022 Jun 30. Epub 2022 Jun 30.

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA. Electronic address:

Background Context: Multiple sclerosis (MS) is an autoimmune, neurodegenerative disease that can lead to significant functional disability. Improving treatment regimens have extended life expectancy and led to an increase in the number of elective spine surgeries for degenerative conditions in the MS population. Recent literature has reported mixed results regarding the efficacy of elective spine surgery for patients with MS. There is also a paucity of literature comparing postoperative patient reported outcomes (PROs) and reoperation rates between patients with and without MS.

Purpose: To determine if patients with MS have worse PROs and higher complication, readmission and reoperation rates after elective spine surgery compared with patients without neurodegenerative conditions when adjusting for baseline covariates through propensity matching.

Study Design/setting: Retrospective review of prospectively collected data from the Quality Outcomes Database (QOD), a national, longitudinal, multicenter spine outcomes registry.

Patient Sample: For the lumbar cohort, 312 patients with MS and 46,738 patients without MS were included. The cervical myelopathy cohort included 91 patients with MS and 6,426 patients without MS. The cervical radiculopathy cohort consisted of 103 patients with MS and 13,751 patients without MS.

Outcome Measures: 1) complication rates, 2) readmission rates, 3) reoperation rates, and 4) PROs at 3- and 12-months including ODI/NDI, NRS back/neck/arm/leg pain, mJOA scores and patient satisfaction ratings.

Methods: Data from the QOD was queried for patients with surgeries occurring between 04/2013-01/2019. Three surgical groups were included: 1) Elective lumbar surgery, 2) Elective cervical surgery for myelopathy, 3) Elective cervical surgery for radiculopathy. Patients with any neurodegenerative condition other than MS were excluded. Patients without MS were propensity matched against patients with MS in a 5 to 1 ratio without replacement based on ASA grade, arthrodesis, surgical approach, number of operated levels, age, and baseline ODI/NDI, NRS leg/arm pain, NRS back/neck pain, and EQ-5D. Multivariable regressions with cluster-robust standard errors were used to estimate average effect of how the outcome would change if the MS patient didn't have the disease. The mean difference was used for continuous outcomes and the risk difference was used for binary outcomes.

Results: For the lumbar cohort, no differences were found between the 2 groups at 3 or 12 months in any of the outcome measures. For the myelopathy cohort, patients with MS patients had a lower rate of reoperation at 12 months (risk difference=-0.036, p=.007) and worse 3-month mJOA scores (mean difference=-1.044, p=.004) compared with patients without MS. For the radiculopathy cohort, patients with MS had a lower rate of reoperation at 3 months (risk difference=-0.019, p=.018) and 12 months (risk difference=-0.029, p=.007) compared with those without MS.

Conclusions: Patients with MS had similar PROs compared with patients without MS when adjusting for baseline covariates through propensity matching, except for 3-month mJOA scores in the myelopathy cohort. Reoperation rates were found to be lower in patients with MS undergoing elective cervical surgery for both myelopathy and radiculopathy. These results suggest that when analyzed independently, a diagnosis of MS does not significantly impact complication, readmission and reoperation rates or PROs, and therefore should not represent a major contraindication to elective spine surgery. Surgical decisions in this patient population should be made based on careful consideration of patient factors including other comorbidities as well as baseline patient functional status.
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http://dx.doi.org/10.1016/j.spinee.2022.06.009DOI Listing
June 2022

Surgical management of sacral schwannomas: a 21-year mayo clinic experience and comparative literature analysis.

J Neurooncol 2022 Aug 25;159(1):1-14. Epub 2022 Jun 25.

Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.

Introduction: Sacral and presacral schwannomas are rare, accounting for a minority of spinal schwannomas. We present our institution's experience surgically treating spinal schwannomas and compare it to the literature.

Methods: Data were collected for 27 patients treated surgically for sacral or presacral schwannoma between 1997 and 2018 at all Mayo Clinic locations and 93 patients in the literature. Kaplan-Meier disease-free survival analysis was conducted. Unpaired two-sample t tests and Fisher's exact tests assessed statistical significance between groups.

Results: Our patients and those in the literature experienced a similar age at diagnosis (49.9 y/o. vs 43.4 y/o., respectively). Most of our patients (59.3%) reported full recovery from symptoms, while a minority reported partial recovery (33.3%) and no recovery (11.1%). A smaller percentage in the literature experienced full recovery (31.9%) and partial recovery (29.8%) but also no recovery (1.1%). Our patients experienced fewer complications (14.8% versus 25.5%). Disease-free survival curves for all patients showed no significant variation in progression by extent of resection of schwannoma (log-rank P = 0.26). No lesion progression was associated with full or partial symptom improvement (p = 0.044), and female patients were more likely to undergo resection via a posterior approach (p = 0.042).

Conclusion: Outcomes of patients with sacral or presacral schwannomas vary based on patient demographics, tumor characteristics, symptoms, and surgical treatment. Among the range of symptoms experienced by these patients, the most common is pain. Prognosis improves and overall survival is high when the surgical approach towards sacral schwannomas is prepared and executed appropriately.
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http://dx.doi.org/10.1007/s11060-022-03986-wDOI Listing
August 2022

Recent Trends in Medicare Utilization and Reimbursement for Lumbar Fusion Procedures: 2000-2019.

World Neurosurg 2022 Jun 18. Epub 2022 Jun 18.

Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, USA; Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA.

Objective: Lumbar fusions are commonly performed spinal procedures. Despite this, publicly available lumbar fusion procedural and monetary data are sparse. This study aimed to evaluate trends in utilization and reimbursement for Medicare patients from 2000-2019.

Methods: Medicare National Summary Data Files were used. Data were collected for true physician reimbursements and procedural rates for posterolateral fusion, anterior lumbar interbody fusion, posterior lumbar interbody fusion (PLIF), and combined PLIF and posterolateral fusion from 2000-2019. Reimbursement was adjusted to inflation utilizing the 2019 Consumer Price Index.

Results: From 2000-2019, 1,266,942 lumbar fusion procedures were billed to Medicare Part B. Annual number of lumbar interbody fusion procedures increased by 57,740 procedures (+95%) from 61,017 in 2000 to 118,757 in 2019. This change in annual volume varied by procedure type, with posterolateral fusion increasing from 24,873 procedures in 2000 to 45,665 procedures in 2019 (+20,792, +83.59%), anterior lumbar interbody fusion increasing from 4227 in 2000 to 29,285 procedures in 2019 (+25,058, 592.81%), PLIF increasing from 5579 procedures in 2000 to 5628 procedures in 2019 (+49, +0.88%), and combined PLIF and posterolateral fusion increasing from 26,338 procedures in 2012 to 38,179 procedures in 2019 (+11,841, +44.96%). The mean inflation-adjusted reimbursement decreased for posterolateral fusion from $1662.96 to $1245.85 (-$417.11, -25.08%), anterior lumbar interbody fusion from $1159.45 to $750.33 (-$409.12, -35.29%), PLIF from $1225.02 to $1223.72 (-$1.3, -0.11%), and combined PLIF and posterolateral fusion from $1541.59 per procedure in 2012 to $1467.08 per procedure in 2019.

Conclusions: Lumbar fusions have increased in the last 2 decades, although reimbursement for all procedures has decreased. Knowledge of these trends is important to ensure adequate resource allocation to surgeons as treating lumbar pathologies becomes more common among the aging Medicare population.
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http://dx.doi.org/10.1016/j.wneu.2022.05.131DOI Listing
June 2022

SPECT-CT as a Predictor of Pain Generators in Patients Undergoing Intra-Articular Injections for Chronic Neck and Back Pain.

World Neurosurg 2022 Aug 9;164:e1243-e1250. Epub 2022 Jun 9.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA. Electronic address:

Background: The ability to accurately predict pain generators for chronic neck and back pain remains elusive.

Objective: We evaluated whether injections targeted at foci with uptake on single-photon emission computerized tomography-computed tomography (SPECT-CT) were associated with improved outcomes in patients with chronic neck and back pain.

Methods: A retrospective review was completed on patients undergoing SPECT-CT for chronic neck and back pain between 2016 and 2020 at a tertiary academic center. Patients' records were reviewed for demographic, clinical, imaging, and outcomes data. Only those patients who had facet injections after SPECT-CT were included in this evaluation. Patients undergoing injections targeted at foci of abnormal radiotracer uptake were compared with patients without uptake concerning immediate positive response, visual analog scale, and the need for additional injection or surgery at the target level.

Results: A total of 2849 patients were evaluated with a SPECT-CT for chronic neck and back pain. Of those, 340 (11.9%) patients received facet joint injections after SPECT-CT. A propensity score regression analysis adjusted for age, gender, body mass index, hypertension, multiple target injections, and injection location showed uptake targeted injections not being associated with an improved immediate positive response (odds ratio: 0.64; 95% confidence interval: 0.34-1.21; P = 0.172). In patients with a failed facet injection preceding SPECT-CT, adding SPECT-CT to guide facet injections was associated with a decrease in visual analog scale pain scores 2 weeks after injection (P = 0.018), particularly when changes were made to the facets being targeted (P = 0.010).

Conclusion: This study suggests that there is benefit with SPECT-CT specially to guide facet injections after failed prior facet injections.
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http://dx.doi.org/10.1016/j.wneu.2022.06.013DOI Listing
August 2022

Does Direct Surgical Repair Benefit Pars Interarticularis Fracture? A Systematic Review and Meta-analysis.

Pain Physician 2022 05;25(3):265-282

Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung, and School of Medicine, Chang Gung University, Taoyuan, Taiwan.

Background: Promising results have been shown in previous studies from direct pars interarticularis repair. These include Scott wiring, Buck repair, pedicle screw repair, and Morscher techniques. In addition, several minimally invasive techniques have been reported to show high union rates, low rates of implant failure and wound complications, shorter length of stay, a lower postoperative pain score with faster recovery, and minimal blood loss.

Objectives: To compare the evidence on techniques for direct pars interarticularis repair.

Study Design: Systematic review and meta-analysis.

Setting: Review article.

Methods: We conducted a comprehensive search of databases to identify studies assessing outcomes of direct pars interarticularis defect repair. Two authors independently screened electronic search results, performed study selection, and extracted data for meta-analysis. Sensitivity and subgroup analyses were performed to assess risk of bias.

Results: Forty studies were included in the final analysis. Union rate was higher in the pedicle screw repair group (effect size [ES] 95%; 95% CI, 86% to 100%), followed by the Buck repair group (ES 93%; 95% CI, 86% to 98%), Scott wiring (ES 85%; 95% CI, 63% to 99%), and Morscher method group (ES 63%; 95% CI, 2% to 100%). Positive functional outcome was higher for the Morscher method (ES 91%; 95% CI, 86% to 96%), followed by the Buck repair group (ES 85%; 95% CI, 68% to 97%), pedicle screw repair (ES 84%; 95% CI, 59% to 99%) and Scott repair group (ES 80%; 95% CI, 60% to 95%). Complication rates were highest among the Scott repair group (ES 12%; 95% CI, 4% to 22%) and Morscher method group (ES 12%; 95% CI, 0% to 34%).

Limitations: Heterogeneity of the included studies were noted. However, we performed sensitivity analyses from the available data to address this issue.

Conclusion: Our results indicate that pedicle screw repair and Buck repair may be associated with a higher union rate and lower complication rates compared to the Scott repair and Morscher method. Ultimately, the choice of technique should be based on the surgeon's preference and experience.
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May 2022

Inferior Clinical Outcomes for Patients with Medicaid Insurance After Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients.

World Neurosurg 2022 Aug 27;164:e1024-e1033. Epub 2022 May 27.

Department of Neurological Surgery, University of California, San Francisco, California, USA.

Background: It remains unclear how type of insurance coverage affects long-term, spine-specific patient-reported outcomes (PROs). This study sought to elucidate the impact of insurance on clinical outcomes after lumbar spondylolisthesis surgery.

Methods: The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. Twenty-four-month PROs were compared and included Oswestry Disability Index, Numeric Rating Scale (NRS) back pain, NRS leg pain, EuroQol-5D, and North American Spine Society Satisfaction.

Results: A total of 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age, 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n = 319; 52.5%), Medicare (n = 235; 38.7%), Medicaid (n = 36; 5.9%), and Veterans Affairs (VA)/government (n = 17; 2.8%). One patient (0.2%) was uninsured and was removed from the analyses. Regardless of insurance status, compared to baseline, all 4 cohorts improved significantly regarding ODI, NRS-BP, NRS-LP, and EQ-5D scores (P < 0.001). In adjusted multivariable analyses, compared with patients with private insurance, Medicaid was associated with worse 24-month postoperative Oswestry Disability Index (β = 10.2; 95% confidence interval [CI], 3.9-16.5; P = 0.002) and NRS leg pain (β =1.3; 95% CI, 0.3-2.4; P = 0.02). Medicaid was associated with worse EuroQol-5D scores compared with private insurance (β = -0.07; 95% CI -0.01 to -0.14; P = 0.03), but not compared with Medicare and VA/government insurance (P > 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (odds ratio, 0.2; 95% CI, 0.03-0.7; P = 0.02) compared with VA/government insurance. NRS back pain and North American Spine Society satisfaction did not differ by insurance coverage (P > 0.05).

Conclusions: Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs after lumbar spondylolisthesis surgery compared with other payer types. Although all improved postoperatively, those with Medicaid coverage had relatively inferior improvements.
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http://dx.doi.org/10.1016/j.wneu.2022.05.094DOI Listing
August 2022

Perioperative risk stratification of spine trauma patients with ankylosing spinal disorders: a comparison of 3 quantitative indices.

J Neurosurg Spine 2022 May 27:1-7. Epub 2022 May 27.

1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and.

Objective: Patients with ankylosing spinal disorders (ASDs), including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), have been shown to experience significantly increased rates of postoperative complications. Despite this, very few risk stratification tools have been validated for this population. As such, the purpose of this study was to identify predictors of adverse events and mortality in ASD patients undergoing surgery for 3-column fractures.

Methods: All adult patients with a documented history of AS or DISH who underwent surgery for a traumatic 3-column fracture between 2000 and 2020 were identified. Perioperative variables, including comorbidities, time to diagnosis, and number of fused segments, were collected. Three instruments, including the Charlson Comorbidity Index (CCI), modified frailty index (mFI), and Injury Severity Score (ISS), were computed for each patient. The primary outcomes of interest included 1-year mortality, as well as postoperative complications.

Results: A total of 108 patients were included, with a mean ± SD age of 73 ± 11 years. Of these, 41 (38%) experienced at least 1 postoperative complication and 22 (20.4%) died within 12 months after surgery. When the authors controlled for potential known confounders, the CCI score was significantly associated with postoperative adverse events (OR 1.20, 95% CI 1.00-1.42, p = 0.045) and trended toward significance for mortality (OR 1.19, 95% CI 0.97-1.45, p = 0.098). In contrast, mFI score and ISS were not significantly predictive of either outcome.

Conclusions: Complications in spine trauma patients with ASD may be driven by comorbidity burden rather than operative or injury-related factors. The CCI may be a valuable tool for the evaluation of this unique population.
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http://dx.doi.org/10.3171/2022.4.SPINE211449DOI Listing
May 2022

Transradial versus Transfemoral Approaches in Diagnostic and Therapeutic Neuroendovascular Interventions: A Meta-Analysis of Current Literature.

World Neurosurg 2022 Aug 14;164:e694-e705. Epub 2022 May 14.

Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.

Background: The adoption of the transradial approach (TRA) has been increasing in popularity as a primary method to conduct both diagnostic and therapeutic interventions. As this technique gains broader acceptance and use within the neuroendovascular community, comparing its complication profile with a better-established alternative technique, the transfemoral approach (TFA), becomes more important. This study aimed to evaluate the safety of TRA compared with TFA in patients undergoing diagnostic, therapeutic, and combined neuroendovascular procedures.

Methods: A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and other databases was conducted for studies from all available dates. To compare TRA and TFA, we performed an indirect meta-analysis between studies that mentioned the complications of the procedures.

Results: Our search yielded 532 studies, of which 108 met full inclusion criteria. A total of 54,083 patients (9137 undergoing TRA and 44,946 undergoing TFA) were included. Access site complication rate was lower in TRA (1.62%) compared with TFA (3.31%) (P < 0.01). Neurological complication rate was lower in TRA (1.64%) compared with TFA (3.82%) (P = 0.02 and P < 0.01, respectively). Vascular spasm rate was higher in TRA (3.65%) compared with TFA (0.88%) (P < 0.01). Wound infection complication rate was higher in TRA (0.32%) compared with TFA (0.2%) (P < 0.01).

Conclusions: Patients undergoing TFA are significantly more likely to experience access site complications and neurological complications compared with patients undergoing TRA. Patients undergoing TRA are more likely to experience complications such as wound infections and vascular spasm.
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http://dx.doi.org/10.1016/j.wneu.2022.05.031DOI Listing
August 2022

Factors associated with increased inpatient charges following aneurysmal subarachnoid hemorrhage with vasospasm: A nationwide analysis.

Clin Neurol Neurosurg 2022 07 22;218:107259. Epub 2022 Apr 22.

Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: Cerebral vasospasm, following aneurysmal subarachnoid hemorrhage (aSAH), can have high-cost implications for inflicted individuals and their families. To our knowledge, factors associated with high inpatient charges have not been explored. We aimed to address this gap.

Methods: The National Inpatient Sample (NIS) was queried between 2016 and 2018 to identify patients with vasospasm following aSAH. Patients in the upper quartile of charges were identified and analyzed using univariate and multivariate analyses for significant contributing variables.

Results: We identified 1861 patients with aSAH complicated by vasospasm. Multivariate analysis revealed ten statistically significant variables as independent risk factors in association with higher charges. Patients were more likely to be in the upper quartile of charge when younger (OR 0.99 [0.99-0.98]; p < 0.01), a never smoker (OR 1.38 [1.04-1.83]; p < 0.05), concurrent congestive heart failure (OR 1.63 [1.05-2.54]; p < 0.05), requiring VP shunt placement (OR 2.29 [1.68-3.14]; p < 0.001) or tracheostomy (OR 3.05 [2.22-4.18]; p < 0.001), on mechanical ventilation (OR 1.90 [1.40-2.58]; p < 0.001), paralysis (OR 1.34 [1.04-1.74]; p < 0.05) or neurological deficit (OR 1.59 [1.24-2.03]; p < 0.001) as a complication, and being Hispanic (OR 1.89 [1.36-2.64]; p < 0.001) or "other" (OR 1.76 [1.08-2.88]; p < 0.05) for race.

Conclusion: Our study elucidates several factors, from certain demographics and requiring adjunctive mechanical support to several procedures, that may contribute to the high-cost implications faced by aSAH patients suffering vasospasm. While many of these factors may not be unexpected, further research is warranted to help elucidate controllable factors and develop trials to identify early interventions to reduce the financial burden on such patients.
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http://dx.doi.org/10.1016/j.clineuro.2022.107259DOI Listing
July 2022

Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine.

J Neurosurg Spine 2022 May 13:1-9. Epub 2022 May 13.

1Department of Neurological Surgery, Mayo Clinic, Rochester.

Objective: The aim of this study was to analyze risk factors and avoidance techniques for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in the upper thoracic spine with an emphasis on bone mineral density (BMD) as estimated by Hounsfield units (HU).

Methods: A retrospective chart review identified patients at least 50 years of age who underwent instrumented fusion extending from the pelvis to an upper instrumented vertebra (UIV) between T1 and T6 and had a preoperative CT, pre- and postoperative radiographs, and a minimum follow-up of 12 months. HU were measured in the UIV, the vertebral body cephalad to the UIV (UIV+1), and the L3 and L4 vertebral bodies. Numerous perioperative variables were collected, including basic demographics, smoking and steroid use, preoperative osteoporosis treatment, multiple frailty indices, use of a proximal junctional tether, UIV soft landing, preoperative dual-energy x-ray absorptiometry, spinopelvic parameters, UIV screw tip distance to the superior endplate, UIV pedicle screw/pedicle diameter ratio, lumbar lordosis distribution, and postoperative spinopelvic parameters compared with age-adjusted normal values.

Results: Eighty-one patients were included in the study (21 men and 60 women) with a mean (SD) age of 66 years (6.9 years), BMI of 29 (5.5), and follow-up of 38 months (25 months). Spinal fusion constructs at the time of surgery extended from the pelvis to a UIV of T1 (5%), T2 (15%), T3 (25%), T4 (33%), T5 (21%), and T6 (1%). Twenty-seven patients (33%) developed PJK and/or PJF; 21 (26%) had PJK and 15 (19%) had PJF. Variables associated with PJK/PJF with p < 0.05 were included in the multivariable analysis, including HU at the UIV/UIV+1, HU at L3/L4, DXA femoral neck T-score, UIV screw tip distance to the superior endplate, UIV pedicle screw/pedicle diameter ratio, and postoperative lumbar lordosis distribution. Multivariable analysis (area under the curve = 0.77) demonstrated HU at the UIV/UIV+1 to be the only independent predictor of PJK and PJF with an OR of 0.96 (p = 0.005). Patients with < 147 HU (n = 27), 147-195 HU (n = 27), and > 195 HU (n = 27) at the UIV/UIV+1 had PJK/PJF rates of 59%, 33%, and 7%, respectively.

Conclusions: In patients with upper thoracic-to-pelvis spinal reconstruction, lower HU at the UIV and UIV+1 were independently associated with PJK and PJF, with an optimal cutoff of 159 HU that maximizes sensitivity and specificity.
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http://dx.doi.org/10.3171/2022.3.SPINE22197DOI Listing
May 2022

Outpatient versus inpatient lumbar decompression surgery: a matched noninferiority study investigating clinical and patient-reported outcomes.

J Neurosurg Spine 2022 May 6:1-13. Epub 2022 May 6.

2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.

Objective: Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery.

Methods: The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval.

Results: A total of 18,689 eligible one- and two-level decompression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery.

Conclusions: Outpatient lumbar decompression surgery demonstrated slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.
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http://dx.doi.org/10.3171/2022.3.SPINE211558DOI Listing
May 2022

Commentary: Machine Learning to Predict Successful Opioid Dose Reduction or Stabilization After Spinal Cord Stimulation.

Neurosurgery 2022 Aug 9;91(2):e41-e42. Epub 2022 May 9.

Department of Neurologic Surgery, Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1227/neu.0000000000001989DOI Listing
August 2022

Rating Spine Surgeons: Physician Review Websites Versus a Patient-reported Outcomes-derived Ranking.

Clin Spine Surg 2022 May 5. Epub 2022 May 5.

Departments of Orthopedic Surgery.

Study Design: This was an observational study.

Objectives: This study aims to determine the correlation between patient-reported outcomes (PROs) pulled from a national spine registry and physician ratings from physician review websites (PRWs).

Summary Of Background Data: PRWs are frequently utilized by patients to make health care decisions; however, many PRWs appear to incorporate subjective experiences unrelated to a surgeon's clinical performance into ratings. As such, their utility as a health care decision-making tool remains unclear.

Materials And Methods: This study evaluated 8834 patients from the Quality Outcomes Database (QOD) who underwent 1-level elective lumbar spine surgery. The lumbar module of QOD was queried to rank 124 surgeons using PROs (Oswestry Disability Index, EuroQOL, Numerical Rating Scale-back/leg pain, and patient satisfaction). The QOD PRO-ranking system was compared against PRWs including Healthgrades, Vitals, WebMD, and Google. The Spearman correlation coefficients, Kruskal-Wallis tests, and multiple linear regression models were used for statistical comparison. The primary outcome was the correlation between PRW scores and PROs.

Results: Surgeon PRO-derived ranking showed high intercorrelational congruence with coefficients between the 3 PROs (Oswestry Disability Index, EuroQOL, Numerical Rating Scale back/leg) ranging between 0.70 and 0.88. Low correlations were observed between PRO-derived rankings and PRWs, ranging from 0.23 to 0.37. Healthgrades performed most similarly to PRO-derived rankings, correlating best with patient satisfaction, though the correlation was low (ρ=0.37).

Conclusions: While PRWs are often used to evaluate surgeon competency, these results demonstrate they poorly correlate with a surgeon's clinical ability measured by PROs. PRWs should be used with caution when making health care decisions by patients, payers, and administrators.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001333DOI Listing
May 2022

Letter to the Editor Regarding "Fifth Generation Cellular Networks and Neurosurgery: A Narrative Review".

World Neurosurg 2022 May;161:207

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2022.01.065DOI Listing
May 2022

Predictors of airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion.

Clin Neurol Neurosurg 2022 06 14;217:107245. Epub 2022 Apr 14.

Department of Neurologic Surgery, Rochester, MN, USA.

Introduction: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure on the cervical spine. While the procedure is generally well tolerated, respiratory and pulmonary complications (RPC) are an unlikely yet possible complication following ACDF. Few previous studies have specifically identified risk factors associated with RPC following ACDF. As the incidence of an RPC is rare at a single institution, a large national database is required for meaningful analysis.

Objective: The goal of this study is to characterize the predictors for RPC following an ACDF by utilizing a large national database.

Methods: The National Inpatient Sample (NIS) was queried from 2016 to 2018 for all patients who had received elective ACDF for degenerative cervical spine disease. We categorized several complications as airway complications including various abscess, angioedema, laryngeal edema, vocal cord paralysis, dysphonia, various etiologies of pneumonia, and acute respiratory distress syndrome. A Firth's logistic regression model was used to identify predictors of RPC.

Results: We identified a final cohort of 52,575 admissions in which an ACDF was performed of which 1454 admissions had an RPC. Older patients were 1.03 times more likely to have an RPC (OR = 1.03, 95%CI: 1.02-1.04). African American patients compared to Caucasian patients were 1.44 times more likely to have an RPC (OR = 1.44, 95%CI: 1.23-1.68). Obese patients were found to be 1.64 to have an RPC (OR = 1.64, 95%CI: 1.45-1.85). Diabetic patients are 2.07 times more likely to have an RPC (OR = 2.07, 95%CI: 1.76-2.44). Hypertensive patients are 1.91 times more likely to have an RPC (OR = 1.91, 95%CI: 1.59-2.27). Urban based hospitals were 1.11 and 1.46 times more likely to have an RPC (OR = 1.11, 95%CI: 0.79-1.59; OR = 1.46, 95%CI: 1.06-2.08; teaching and non-teaching respectively). Patients who underwent multilevel procedure were 1.32 times more likely to experience a follow-on RPC (OR = 1.32, 95%CI: 1.17-1.49) DISCUSSION: Our study identified modifiable predictors of RPC after elective ACDF (e.g. obesity, diabetes) which can be used to guide preoperative patient optimization.
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http://dx.doi.org/10.1016/j.clineuro.2022.107245DOI Listing
June 2022

Assessing the differences in operative and patient-reported outcomes between lateral approaches for lumbar fusion: a systematic review and indirect meta-analysis.

J Neurosurg Spine 2022 Apr 22:1-17. Epub 2022 Apr 22.

1Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota.

Objective: Anterior-to-psoas lumbar interbody fusion (ATP-LIF), more commonly referred to as oblique lateral interbody fusion, and lateral transpsoas lumbar interbody fusion (LTP-LIF), also known as extreme lateral interbody fusion, are the two commonly used lateral approaches for performing a lumbar fusion procedure. These approaches help overcome some of the technical challenges associated with traditional approaches for lumbar fusion. In this systematic review and indirect meta-analysis, the authors compared operative and patient-reported outcomes between these two select approaches using available studies.

Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, the authors conducted an electronic search using the PubMed, EMBASE, and Scopus databases for studies published before May 1, 2019. Indirect meta-analysis was conducted on fusion rate, cage movement (subsidence plus migration), permanent deficits, and transient deficits; results were depicted as forest plots of proportions (effect size [ES]).

Results: A total of 63 studies were included in this review after applying the exclusion criteria, of which 26 studies investigated the outcomes of ATP-LIF, while 37 studied the outcomes of LTP-LIF. The average fusion rate was found to be similar between the two groups (ES 0.97, 95% CI 0.84-1.00 vs ES 0.94, 95% CI 0.91-0.97; p = 0.561). The mean incidence of cage movement was significantly higher in the ATP-LIF group compared with the LTP-LIF group (stand-alone: ES 0.15, 95% CI 0.06-0.27 vs ES 0.09, 95% CI 0.04-0.16 [p = 0.317]; combined: ES 0.18, 95% CI 0.07-0.32 vs ES 0.02, 95% CI 0.00-0.05 [p = 0.002]). The mean incidence of reoperations was significantly higher in patients undergoing ATP-LIF than in those undergoing LTP-LIF (ES 0.02, 95% CI 0.01-0.03 vs ES 0.04, 95% CI 0.02-0.07; p = 0.012). The mean incidence of permanent deficits was similar between the two groups (stand-alone: ES 0.03, 95% CI 0.01-0.06 vs ES 0.05, 95% CI 0.01-0.12 [p = 0.204]; combined: ES 0.03, 95% CI 0.01-0.06 vs ES 0.03, 95% CI 0.00-0.08 [p = 0.595]). The postoperative changes in visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were both found to be higher for ATP-LIF relative to LTP-LIF (VAS: weighted average 4.11 [SD 2.03] vs weighted average 3.75 [SD 1.94] [p = 0.004]; ODI: weighted average 28.3 [SD 5.33] vs weighted average 24.3 [SD 4.94] [p < 0.001]).

Conclusions: These analyses indicate that while both approaches are associated with similar fusion rates, ATP-LIF may be related to higher odds of cage movement and reoperations as compared with LTP-LIF. Furthermore, there is no difference in rates of permanent deficits between the two procedures.
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http://dx.doi.org/10.3171/2022.2.SPINE211164DOI Listing
April 2022

The Effect of Preoperative Mental Health Status on Outcomes After Anterior Cervical Discectomy and Fusion.

Int J Spine Surg 2022 Apr;16(2):233-239

Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA

Background: The effect of preoperative mental health on outcomes after anterior cervical discectomy and fusion (ACDF) is of increasing interest. The purpose of this study was to utilize patient-reported outcome measures (PROMs) to compare outcomes after ACDF in patients with and without poor mental health. We hypothesized that patients with worse baseline mental health would report worse outcomes after surgery.

Methods: Patients undergoing ACDF for degenerative cervical spondylosis with at least 12 months of follow-up were included. Outcomes collected before and after surgery included the RAND-36, Neck Disability Index (NDI), EuroQol 5-dimension (EQ-5D), and Single Assessment Numeric Evaluation (SANE) score.

Results: Seventy-one patients were included and assigned to the depression or nondepression group based on baseline mental health. The depression group had worse baseline preoperative scores across all PROMs: NDI (44.2 vs 36.8, = 0.05), RAND (1511.4 vs 2198.18, < 0.001), EQ-5D (12.55 vs 10.14, < 0.001), and SANE (56.3 vs 72.9, < 0.001). Postoperatively, the depression group had worse scores at the final follow-up for RAND (2242.8 vs 2662.2, = 0.03) and SANE (71.5 vs 80.8, = 0.02). Both groups experienced improvements with ACDF across all PROMs. The changes in each PROM were not statistically significant between groups. There were no statistically significant differences in the percentage of patients achieving the minimal clinically important difference across PROMs.

Conclusion: This study is the first to utilize the RAND-36, EQ-5D, NDI, and SANE scores to assess preoperative mental health and its effect on postoperative outcomes after ACDF. While poor preoperative mental health status yielded significantly worse baseline and postoperative outcomes scores, patients experienced significant improvement in symptoms after ACDF.

Level Of Evidence: 2:

Clinical Relevance: Clinicians should be aware of the effects of poor mental health status on clinical outcomes in patients undergoing anterior cervical fusion, but can still expect significant clinical improvements after surgery.
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http://dx.doi.org/10.14444/8211DOI Listing
April 2022

Estimating Intraoperative Neurophysiological Monitoring Rates for Anterior Cervical Discectomy and Fusion: Are Diagnostic or Procedural Codes Accurate?

Int J Spine Surg 2022 Apr;16(2):208-214

Department of Neurology, Mayo Clinic, Rochester, MN, USA

Background: The utility of intraoperative neurophysiological monitoring (IONM) is well established for some spine surgeries (eg, intramedullary tumor resection, scoliosis deformity correction), but its benefit for most degenerative spine surgery, including anterior cervical discectomy and fusion (ACDF), remains debated. National datasets provide "big data" approaches to study the impact of IONM on spine surgery outcomes; however, if administrative coding in these datasets misrepresents actual IONM usage, conclusions will be unreliable. The objective of this study was to compare estimated rates (administrative coding) to actual rates (chart review) of IONM for ACDF at our institution and extrapolate findings to estimated rates from 2 national datasets.

Methods: Patients were included from 3 administrative coding databases: the authors' single institution database, the Nationwide Inpatient Sample (NIS), and the National Surgical Quality Improvement Program (NSQIP). Estimated and actual institutional rates of IONM during ACDF were determined by administrative codes (International Classification of Diseases [ICD] or Current Procedural Terminology [CPT]) and chart review, respectively. National rates of IONM during ACDF were estimated using the NIS and NSQIP datasets.

Results: Estimated institutional rates of IONM for ACDF were much higher with CPT than ICD coding (73.2% vs 16.5% in 2019). CPT coding for IONM better approximated actual IONM usage at our institution (74.6% in 2019). Estimated IONM utilization rates for ACDF in national datasets varied widely: 0.76% in CPT-based NSQIP and 18.4% in ICD-based NIS.

Conclusions: ICD coding underestimated IONM usage during ACDF at our institution, whereas CPT coding was more accurate. Unfortunately, the CPT-based NSQIP is nearly devoid of IONM codes, as it has not been a collection focus of that surgical registry. ICD-based datasets, such as the NIS, likely fail to accurately capture IONM usage. Multicenter and/or national datasets with accurate IONM utilization data are needed to inform surgeons, insurers, and guideline authors on whether IONM has benefit for various spine surgery types.

Level Of Evidence: 4:

Clinical Relevance: Currently available national databases based on administrative codes do not accurately reflect IONM usage.
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http://dx.doi.org/10.14444/8205DOI Listing
April 2022

Independent predictors of vertebral compression fracture following radiation for metastatic spine disease.

J Neurosurg Spine 2022 Apr 15:1-7. Epub 2022 Apr 15.

1Department of Neurological Surgery.

Objective: The goal of this study was to determine independent risk factors for vertebral compression fracture (VCF) following radiation for metastatic spine disease, including low bone mineral density as estimated by Hounsfield units (HU).

Methods: A retrospective chart review identified patients with a single vertebral column metastasis treated with radiation therapy, a pretreatment CT scan, and a follow-up CT scan at least 6 weeks after treatment. Patients with primary spine tumors, preradiation vertebroplasty, preradiation spine surgery, prior radiation to the treatment field, and proton beam treatment modality were excluded. The HU were measured in the vertebral bodies at the level superior to the metastasis, within the tumor and medullary bone of the metastatic level, and at the level inferior to the metastasis. Variables collected included basic demographics, Spine Instability Neoplastic Score (SINS), presenting symptoms, bone density treatment, primary tumor pathology, Weinstein-Boriani-Biagini (WBB) classification, Enneking stage, radiation treatment details, chemotherapy regimen, and prophylactic vertebroplasty.

Results: One hundred patients with an average age of 63 years and average follow-up of 18 months with radiation treatment dates ranging from 2017 to 2020 were included. Fifty-nine patients were treated with external-beam radiation therapy, with a median total dose of 20 Gy (range 8-40 Gy). Forty-one patients were treated with stereotactic body radiation therapy, with a median total dose of 24 Gy (range 18-39 Gy). The most common primary pathologies included lung (n = 22), prostate (n = 21), and breast (n = 14). Multivariable logistic regression analysis (area under the curve 0.89) demonstrated pretreatment HU (p < 0.01), SINS (p = 0.02), involvement of ≥ 3 WBB sectors (p < 0.01), primary pathology other than prostate (p = 0.04), and ongoing chemotherapy treatment (p = 0.04) to be independent predictors of postradiation VCF. Patients with pretreatment HU < 145 (n = 32), 145-220 (n = 31), and > 220 (n = 37) had a fracture rate of 59%, 39%, and 11%, respectively. An HU cutoff of 157 was found to maximize sensitivity (71%) and specificity (75%) in predicting postradiation VCF.

Conclusions: Low preradiation HU, higher SINS, involvement of ≥ 3 WBB sectors, ongoing chemotherapy, and nonprostate primary pathology were independent predictors of postradiation VCF in patients with metastatic spine disease. Low bone mineral density, as estimated by HU, is a novel and potentially modifiable risk factor for VCF.
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http://dx.doi.org/10.3171/2022.2.SPINE211613DOI Listing
April 2022

Hypothermia Therapy for Traumatic Spinal Cord Injury: An Updated Review.

J Clin Med 2022 Mar 13;11(6). Epub 2022 Mar 13.

Department of Neurological Surgery, Mayo Clinic, Rochester, MN 55902, USA.

Although hypothermia has shown to protect against ischemic and traumatic neuronal death, its potential role in neurologic recovery following traumatic spinal cord injury (TSCI) remains incompletely understood. Herein, we systematically review the safety and efficacy of hypothermia therapy for TSCI. The English medical literature was reviewed using PRISMA guidelines to identify preclinical and clinical studies examining the safety and efficacy of hypothermia following TSCI. Fifty-seven articles met full-text review criteria, of which twenty-eight were included. The main outcomes of interest were neurological recovery and postoperative complications. Among the 24 preclinical studies, both systemic and local hypothermia significantly improved neurologic recovery. In aggregate, the 4 clinical studies enrolled 60 patients for treatment, with 35 receiving systemic hypothermia and 25 local hypothermia. The most frequent complications were respiratory in nature. No patients suffered neurologic deterioration because of hypothermia treatment. Rates of American Spinal Injury Association (AIS) grade conversion after systemic hypothermia (35.5%) were higher when compared to multiple SCI database control studies (26.1%). However, no statistical conclusions could be drawn regarding the efficacy of hypothermia in humans. These limited clinical trials show promise and suggest therapeutic hypothermia to be safe in TSCI patients, though its effect on neurological recovery remains unclear. The preclinical literature supports the efficacy of hypothermia after TSCI. Further clinical trials are warranted to conclusively determine the effects of hypothermia on neurological recovery as well as the ideal means of administration necessary for achieving efficacy in TSCI.
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http://dx.doi.org/10.3390/jcm11061585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8949322PMC
March 2022
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