Publications by authors named "Scott L Zuckerman"

187 Publications

Incidence and Risk Factors for Early Postoperative Complications and Mortality Following Adult Spinal Deformity Surgery: Data From the National Surgical Quality Improvement Program From 2011 to 2013.

Clin Spine Surg 2021 Jun 9. Epub 2021 Jun 9.

Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seoul, Republic of Korea Department of Orthopedic Surgery, Division of Spinal Surgery, The Och Spine Hospital at New York-Presbyterian/Allen Hospital, Columbia University, New York, NY.

Study Design: Retrospective cohort analysis using the American College of Surgeons National Surgical Quality Improvement Program database.

Objective: The objective of this study was to investigate the incidence and risk factors of perioperative complications and mortality in patients undergoing adult spinal deformity (ASD) surgery.

Summary Of Background Data: Although ASD surgery has been associated with a relatively high complication rate, a focus on perioperative complications in a large cohort has rarely been reported.

Materials And Methods: In the database of the 2011-2013 American College of Surgeons National Surgical Quality Improvement Program database, a cohort of patients (n=1484) above 20 years and underwent ASD surgery was established by primary and other Current Procedural Terminology and International Classification of Disease, Ninth Revision codes. The incidences of perioperative (within 30 d postsurgery) minor/major complications and mortality was investigated. Risk factors for minor/major complications and mortality were assessed using logistic regression modeling.

Results: Of 1484 patients undergoing ASD surgery, the overall complication rate was 15.8% (minor complications: 8.2%; major complications: 10.4%), and the mortality rate was 0.6% (9 patients). After multivariate analysis, dependent functional status [P=0.003; odds ratios (ORs), 4.838], anterior or anterior+posterior approaches (P=0.001; OR, 2.022), and prolonged operative time (>5 h) (P=0.004; OR, 1.821) were associated with an increased risk of minor complications. Male sex (P=0.013; OR, 1.567), osteotomy procedure (P=0.008; OR, 1.674) and prolonged operative time (>5 h) (P<0.001; OR, 2.142) were associated with an increased risk of major complications. The American Society of Anesthesiologists 4 status (P=0.009; OR, 34.697) was a strong risk factor for mortality.

Conclusions: After ASD surgery, the rates of minor complications, major complications, and mortality was 8.2%, 10.4%, and 0.6%, respectively. While mortality depended on patient physical status represented by the American Society of Anesthesiologists 4, minor and major complications were associated with male sex, dependent functional status, and surgical factors such as osteotomy procedure, prolonged operative time (>5 h), and having an anterior surgical approach. Therefore, this information may be helpful in surgical counseling and preoperative surgical planning.
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http://dx.doi.org/10.1097/BSD.0000000000001214DOI Listing
June 2021

Outcomes of Surgery for Sacral Chordoma and Impact of Complications: A Report of 50 Consecutive Patients With Long-Term Follow-Up.

Global Spine J 2021 Jun;11(5):740-750

Department of Neurological Surgery, 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Study Design: Retrospective case series.

Objective: To determine predictive factors of overall survival (OS) and local recurrence (LR), report complications, and assess the impact of complications on survival, recurrence, and function in patients undergoing en bloc resection of sacral chordoma.

Methods: This retrospective case series was obtained from a prospective database (1995-2016). All patients underwent en bloc resection of sacral chordoma. Demographic, perioperative, and complication data were collected. Outcomes included: overall survival(OS), local recurrence(LR), and complications. Survival analysis with multivariable cox regression was performed.

Results: Among 50 patients, median follow-up was 5.3 years (range = 1.3-17.2). The majority (82%) underwent a negative margin resection. 17 patients died (34%) with a median OS of 10.0 years (range = 1.3-17.2). Multivariable cox regression revealed that a negative margin resection was not significantly associated with improved survival (HR = 3.35, 95%CI 0.87-12.80, = .078). 20 patients (40%) experienced LR with a median time of 6.2 years (range = 0-16.9). Multivariable cox regression revealed that a negative margin resection was associated with a significant decreased risk of LR (HR = 4.96, 95%CI 1.84-13.34, = 0.002,). A 62% overall complication rate was seen (42% major), with 26% reoperation rate. Of the reoperations, 54% were delayed (>6 weeks after the index surgery). Multivariable cox regression demonstrated that neither major complication nor reoperation significantly impacted OS (HR = 0.62, 95%CI 0.22-1.79, = 0.380), LR (HR = 1.28, 95%CI 0.49-3.36, = 0.611), or functional outcomes (OR = 2.94, 95%CI 0.25-34.8, = 0.393).

Conclusions: Negative margin resection was associated with decreased LR. Neither major complication nor reoperation significantly impacted OS, LR, or functional outcome. Though additional studies are needed, it appears that despite the morbidity associated with sacral chordoma resection, the long-term clinical outcomes are favorable.
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http://dx.doi.org/10.1177/21925682211011444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165918PMC
June 2021

Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

Global Spine J 2021 May 26:21925682211019352. Epub 2021 May 26.

Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA.

Objective: Evaluate clinical improvement as measured by patient-reported outcomes (PROs) during the 1 to 2-year interval.

Study Design: Retrospective Cohort.

Methods: A single-institution registry of ASD patients undergoing surgery was queried for patients with ≥6 level fusions. Demographics and radiographic variables were collected. PROs collected were the ODI and SRS-22r scores at: preoperative, 1-year and 2-years. Outcome measures of clinical improvement during the 1-2 year time interval were: 1) group medians, 2) percent minimum clinically important difference (MCID), and 3) percent minimal symptom scale (MSS)(ODI < 20 or SRS-pain + function >8). Wilcoxon rank-sum tests, chi-squared tests, Kruskal-Wallis tests, and logistic regression were performed.

Results: 157 patients undergoing ASD surgery with minimum of 1-year follow-up were included. Mean age was 53.2 and mean instrumented levels was 13.1. Preoperative alignment was: Neutral Alignment (NA) 49%, Coronal Malalignment (CM) 17%, Sagittal Malalignment (SM 17%), and Combined Coronal/Sagittal Malalignment (CCSM) 18%. Preoperative to 1-year, and preoperative to 2-years, all ODI/SRS-22r significantly improved ( < .001). the only significant improvement in PROs between 1-and 2-year postoperative were those reaching ODI MCID (69% 1-year vs. 84% 2-years; < .001). ≥55 years had an improved median ODI (18 vs. 8; = .047) and an improved percent achieving ODI MCID (73% vs. 84%, = .048). CCSM patients experienced significant improvement in SRS-appearance score (75% vs. 100%; = .050), along with those with severe preoperative SM >7.5 cm (73% vs. 100%; = .032).

Conclusions: Most ASD patients experience the majority of PRO improvement by 1-year postoperative. However, subsets of patients that may continue to improve up to 2-years postoperative include patients ≥55 years, combined coronal/sagittal malalignment, and those with severe sagittal malalignment ≥7.5 cm.
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http://dx.doi.org/10.1177/21925682211019352DOI Listing
May 2021

Saliva RNA biomarkers predict concussion duration and detect symptom recovery: a comparison with balance and cognitive testing.

J Neurol 2021 May 24. Epub 2021 May 24.

Department of Pediatrics, Penn State College of Medicine, Hershey, PA, 17033, USA.

Objective: The goals of this study were to assess the ability of salivary non-coding RNA (ncRNA) levels to predict post-concussion symptoms lasting ≥ 21 days, and to examine the ability of ncRNAs to identify recovery compared to cognition and balance.

Methods: RNA sequencing was performed on 505 saliva samples obtained longitudinally from 112 individuals (8-24-years-old) with mild traumatic brain injury (mTBI). Initial samples were obtained ≤ 14 days post-injury, and follow-up samples were obtained ≥ 21 days post-injury. Computerized balance and cognitive test performance were assessed at initial and follow-up time-points. Machine learning was used to define: (1) a model employing initial ncRNA levels to predict persistent post-concussion symptoms (PPCS) ≥ 21 days post-injury; and (2) a model employing follow-up ncRNA levels to identify symptom recovery. Performance of the models was compared against a validated clinical prediction rule, and balance/cognitive test performance, respectively.

Results: An algorithm using age and 16 ncRNAs predicted PPCS with greater accuracy than the validated clinical tool and demonstrated additive combined utility (area under the curve (AUC) 0.86; 95% CI 0.84-0.88). Initial balance and cognitive test performance did not differ between PPCS and non-PPCS groups (p > 0.05). Follow-up balance and cognitive test performance identified symptom recovery with similar accuracy to a model using 11 ncRNAs and age. A combined model (ncRNAs, balance, cognition) most accurately identified recovery (AUC 0.86; 95% CI 0.83-0.89).

Conclusions: ncRNA biomarkers show promise for tracking recovery from mTBI, and for predicting who will have prolonged symptoms. They could provide accurate expectations for recovery, stratify need for intervention, and guide safe return-to-activities.
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http://dx.doi.org/10.1007/s00415-021-10566-xDOI Listing
May 2021

Is There a Difference Between Navigated and Non-Navigated Robot Cohorts in Robot-Assisted Spine Surgery? A Multicenter, Propensity-Matched Analysis of 2,800 Screws and 372 Patients.

Spine J 2021 May 19. Epub 2021 May 19.

Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA.

Background Context: Robot-assisted spine surgery continues to rapidly develop as evidenced by the growing literature in recent years. In addition to demonstrating excellent pedicle screw accuracy, early studies have explored the impact of robot-assisted spine surgery on reducing radiation time, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. Recently, the Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic's Stealth navigation technology into the Mazor X platform, which was introduced in 2016. It is unclear what the impact of these advancements have made on clinical outcomes.

Purpose: To compare the outcomes and complications between the most recent iterations of the Mazor Robot systems: Mazor X and Mazor X Stealth Edition.

Study Design: Multicenter cohort PATIENT SAMPLE: Among four different institutions, we included adult (≥18 years old) patients who underwent robot-assisted spine surgery with either the Mazor X (non-navigated robot) or Stealth (navigated robot) platforms.

Outcome Measures: Primary outcomes included robot time per screw, fluoroscopic radiation time, screw accuracy, robot abandonment, and clinical outcomes with a minimum 90 day follow up.

Methods: A one-to-one propensity-score matching algorithm based on perioperative factors (e.g. demographics, comorbidities, primary diagnosis, open vs. percutaneous instrumentation, prior spine surgery, instrumented levels, pelvic fixation, interbody fusion, number of planned robot screws) was employed to control for the potential selection bias between the two robotic systems. Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively.

Results: From a total of 646 patients, a total of 372 adult patients were included in this study (X: 186, Stealth: 186) after propensity score matching. The mean number of instrumented levels was 4.3. The mean number of planned robot screws was 7.8. Similar total operative time and robot time per screw occurred between cohorts (p>0.05). However, Stealth achieved significantly shorter fluoroscopic radiation time per screw (Stealth: 7.2 seconds vs. X: 10.4 seconds, p<0.001) than X. The screw accuracy for both robots was excellent (Stealth: 99.6% vs. X: 99.1%, p=0.120). In addition, Stealth achieved a significantly lower robot abandonment rate (Stealth: 0% vs. X: 2.2%, p=0.044). Furthermore, a lower blood transfusion rate was observed for Stealth than X (Stealth: 4.3% vs. X: 10.8%, p=0.018). Non-robot related complications such as dura tear, motor/sensory deficits, return to the operating room during same admission, and length of stay was similar between robots (p>0.05). The 90-day complication rates were low and similar between robot cohorts (Stealth: 5.4% vs. X: 3.8%, p=0.456).

Conclusion: In this multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, using Stealth led to significantly less fluoroscopic radiation time, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including length of stay, and 90-day complications were similar.
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http://dx.doi.org/10.1016/j.spinee.2021.05.015DOI Listing
May 2021

The odontoid-CSVL distance in a global population of asymptomatic volunteers: normative values and implications for spinal coronal alignment.

Eur Spine J 2021 May 19. Epub 2021 May 19.

Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, USA.

Purpose: In a population of asymptomatic volunteers across 5 countries, we sought to: (a) establish normative values of the Odontoid-Central Sacral Vertical Line (OD-CSVL) across patient factors, and (b) assess correlations of OD-CSVL with other radiographic parameters.

Methods: A prospective, cross-sectional study of asymptomatic adult volunteers, ages 18-80 years, were enrolled across 5 countries (France, Japan, Singapore, Tunisia, United States) forming the Multi-Ethnic Alignment Normative Study (MEANS) cohort. Included volunteers had no known spinal disorder(s), no significant neck/back pain (VAS ≤ 2; ODI ≤ 20), and no significant scoliosis (Cobb ≤ 20°). Radiographic measurements included commonly used coronal alignment parameters (mm) and angles (°). OD-CSVL was defined as the difference between the odontoid plumb line (line from the tip of the odontoid vertically down) and the CSVL (vertical line from the center of the sacrum). Chi-square, student's t tests, Kruskal-Wallis, Wilcoxon rank-sum, linear regression, and Pearson's correlation were used with significance at p < 0.05.

Results: 467 volunteers were included with normative OD-CSVL values by age decade, gender, BMI, and country. Mean ± SD OD-CSVL was 8.3 mm ± 6.5 mm and 31 (6.6%) volunteers were almost perfectly aligned (OD-CSVL < 1 mm). A linear relationship was seen between OD-CSVL with both age (p < 0.001) and BMI (p = 0.015). Significant variation was seen between OD-CSVL and 5 different ethnicities (p = 0.004). OD-CSVL correlated best with other coronal radiographic parameters, C7-CSVL (r = 0.743, p < 0.001), OD-knee (r = 0.230, p < 0.001), CAM-knee (r = 0.612, p < 0.001), and regional TL cobb angle (r = 0.4214, p = 0.005).

Conclusion: Among asymptomatic volunteers, increased OD-CSVL was significantly associated with increased age, increased BMI, and ethnicity, but not gender. OD-CSVL correlated strongest with C7-CSVL, TL cobb angle, OD-knee, and CAM-knee. OD-CSVL. These results support further study of OD-CSVL in symptomatic adult spine deformity patients.
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http://dx.doi.org/10.1007/s00586-021-06873-6DOI Listing
May 2021

Association of Preinjury Medical Diagnoses With Pediatric Persistent Postconcussion Symptoms in Electronic Health Records.

J Head Trauma Rehabil 2021 Apr 21. Epub 2021 Apr 21.

Department of Neurological Surgery (Drs Yengo-Kahn, Bonfield, and Zuckerman), Vanderbilt Sport Concussion Center (Drs Yengo-Kahn, Bonfield, Gifford, Zuckerman, and Dennis and Ms Hibshman), Division of Epidemiology, Department of Medicine (Mr Torstenson), Vanderbilt Epidemiology Center, Institute for Medicine and Public Health (Mr Torstenson), Vanderbilt Genetics Institute (Mr Torstenson and Drs Davis and Dennis), Department of Neurology (Dr Gifford), and Division of Genetic Medicine, Department of Medicine (Drs Davis and Dennis), Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt University School of Medicine, Nashville, Tennessee (Ms Hibshman); British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada (Ms Belikau and Dr Dennis); and Department of Medical Genetics, The University of British Columbia, Vancouver, British Columbia, Canada (Dr Dennis).

Objective: To identify risk factors and generate hypotheses for pediatric persistent postconcussion symptoms (PPCS).

Setting: A regional healthcare system in the Southeastern United States.

Participants: An electronic health record-based algorithm was developed and validated to identify PPCS cases and controls from an institutional database of more than 2.8 million patients. PPCS cases (n = 274) were patients aged 5 to 18 years with PPCS-related diagnostic codes or with PPCS key words identified by natural language processing of clinical notes. Age, sex, and year of index event-matched controls (n = 1096) were patients with mild traumatic brain injury codes only. Patients with moderate or severe traumatic brain injury were excluded. All patients used our healthcare system at least 3 times 180 days before their injury.

Design: Case-control study.

Main Measures: The outcome was algorithmic classification of PPCS. Exposures were all preinjury medical diagnoses assigned at least 180 days before the injury.

Results: Cases and controls both had a mean of more than 9 years of healthcare system use preinjury. Of 221 preinjury medical diagnoses, headache disorder was associated with PPCS after accounting for multiple testing (odds ratio [OR] = 2.9; 95% confidence interval [CI]: 1.6-5.0; P = 2.1e-4). Six diagnoses were associated with PPCS at a suggestive threshold for statistical significance (false discovery rate P < .10): gastritis/duodenitis (OR = 2.8; 95% CI: 1.6-5.1; P = 5.0e-4), sleep disorders (OR = 2.3; 95% CI: 1.4-3.7; P = 7.4e-4), abdominal pain (OR = 1.6; 95% CI: 1.2-2.2; P = 9.2e-4), chronic sinusitis (OR = 2.8; 95% CI: 1.5-5.2; P = 1.3e-3), congenital anomalies of the skin (OR = 2.9; 95% CI: 1.5-5.5; P = 1.9e-3), and chronic pharyngitis/nasopharyngitis (OR = 2.4; 95% CI: 1.4-4.3; P = 2.5e-3).

Conclusions: These results support the strong association of preinjury headache disorders with PPCS. An association of PPCS with prior gastritis/duodenitis, sinusitis, and pharyngitis/nasopharyngitis suggests a role for chronic inflammation in PPCS pathophysiology and risk, although results could equally be attributable to a higher likelihood of somatization among PPCS cases. Identified risk factors should be investigated further and potentially considered during the management of pediatric mild traumatic brain injury cases.
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http://dx.doi.org/10.1097/HTR.0000000000000686DOI Listing
April 2021

Coronal Alignment in Adult Spinal Deformity Surgery: Definitions, Measurements, Treatment Algorithms, and Impact on Clinical Outcomes.

Clin Spine Surg 2021 Apr 7. Epub 2021 Apr 7.

Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY.

The major focus of realignment in adult spinal deformity (ASD) surgery has been on the sagittal plane, and less emphasis has been given to the coronal plane. In light of this overlooked area within ASD surgery, we aimed to refocus the narrative on coronal alignment in ASD surgery. The objectives of the current narrative review were to (1) define coronal alignment and discuss existing measurements; (2) report the incidence and prevalence of coronal malalignment (CM); (3) discuss the impact of CM on clinical outcomes; and (4) describe our preferred treatment algorithm of surgical correction of CM in ASD.
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http://dx.doi.org/10.1097/BSD.0000000000001175DOI Listing
April 2021

Flexion-extension standing radiographs underestimate instability in patients with single-level lumbar spondylolisthesis: comparing flexion-supine imaging may be more appropriate.

J Spine Surg 2021 Mar;7(1):48-54

Department of Orthopaedics, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA.

Background: Generally, most spine surgeons agree that increased segmental motion viewed on flexion-extension radiographs is a reliable predictor of instability; however, these views can be limited in several ways and may underestimate the instability at a given lumbar segment.

Methods: Consecutively collected adult (≥18 years old) patients with symptomatic single-level lumbar spondylolisthesis were reviewed from a two-surgeon database from 2015 to 2019. Routine standing lumbar X-rays (neutral, flexion, extension) and supine lumbar MRI (sagittal T2-weighted imaging sequence) were performed. Patients were excluded if they had prior lumbar surgery, missing radiographic data, or if the time between X-rays and MRI was >6 months.

Results: All 39 patients with symptomatic, single-level lumbar spondylolisthesis were identified. The mean age was 57.3±16.7 years and 66% were female. There was good intra- and inter-rater reliability agreement between measured values on the presence of instability. The slip percentage (SP) difference was significantly highest in the flexion-supine (FS) (5.7 mm, 12.3%) and neutral standing-supine (NS) (4.3 mm, 8.7%) groups, both of which were significantly higher compared with the flexion-extension (FE) group (1.8 mm, 4.5%, P<0.001). Ventral instability based on SP >8% was observed more frequently in FS (79.5%) and NS (52.6%) groups compared with FE group (16.7%, P<0.001). No statistically significant correlation was found between SP and disc angle for all radiographic views.

Conclusions: Comparing standing lateral and flexion X-rays with supine MRIs provides higher sensitivity to assess instability than standard flexion-extension radiographs. The FS and NS comparisons also show greater slip percentage differences at higher slip grades, but not at different lumbar levels. These changes are not dependent on age or gender.
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http://dx.doi.org/10.21037/jss-20-631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8024755PMC
March 2021

L5 Vertebral Column Resection for Correction of Severe Lumbar Hyperlordosis and Pelvic Anteversion in an Adolescent With Prior Myelomeningocele Repair and Lumbar Fusion: Case Report.

Oper Neurosurg (Hagerstown) 2021 Apr 2. Epub 2021 Apr 2.

The Daniel and Jane Och Spine Hospital, New York Presbyterian/Columbia University Medical Center, New York, New York, USA.

Background And Importance: Lumbar hyperlordosis in ambulatory children is an uncommon but potentially problematic spinal deformity, and the operative management has not been comprehensively described.

Clinical Presentation: We report the case of a 14-yr-old girl presenting with severe progressive lumbar hyperlordosis (-122°) and sagittal imbalance (-6 cm). She had multiple prior surgeries, including myelomeningocele repair at 10 d old, midlumbar meningioma resection at 8 mo old, and posterior lumbar instrumented spinal fusion at 5 yr old. She presented with progressive lumbosacral back pain and intermittent numbness in her left lower extremity, and severe skin contractures over her prior posterior incisions. From an all posterior approach, prior implants and dural scar were removed and then an L5 vertebral column resection (VCR) was performed to disarticulate her lumbar spine from her anteverted pelvis, allowing for slow distraction forces to correct her lumbar hyperlordosis. This was followed by a T7-sacrum fusion using pedicle screws and iliac screws, with autologous bone graft and plastic surgery wound closure. Postoperatively, lumbar lordosis was corrected to -55° and sagittal balance reduced to -0.5 cm. At 10-wk and 14-mo follow-ups, the patient reported resolution of her back pain with no limitations in physical activities. Dramatic improvement was seen in both her preoperative to 14-mo postoperative Oswestry Disability Index (ODI) (54 to 12) and Scoliosis Research Society Scoliosis Research Society (SRS)-22r (54 to 93) scores.

Conclusion: This case highlights a rare presentation of severe progressive lumbar hyperlordosis in an ambulatory adolescent after myelomeningocele repair, meningioma resection, and posterior lumbar instrumented spinal fusion with subsequent surgical treatment incorporating important components of both spinal and plastic surgery involvement.
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http://dx.doi.org/10.1093/ons/opab085DOI Listing
April 2021

Neurosurgery Resident Interviews: The Prevalence and Impact of Inappropriate and Potentially Illegal Questions.

Neurosurgery 2021 Mar 17. Epub 2021 Mar 17.

Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont, USA.

Background: The impact of workplace discrimination has gained recognition. Nearly two-thirds of all medical residency applicants reported being asked inappropriate or potentially illegal interview questions. The use of such questions during neurosurgery residency interviews has not yet been studied.

Objective: To evaluate the prevalence of inappropriate or potentially illegal questions in residency interviews and the impact on applicants' rank lists.

Methods: All 2018 to 2019 United States neurosurgery resident applicants were anonymously surveyed. The survey included 46 questions focused on demographics; if they were asked questions regarding rank list, age, gender, marital status, family planning, religion, sexual orientation, or disability and whether such questions affected their rank list formation.

Results: Of 265 surveyed United States applicants, 133 (50%) responded. Most respondents were male (78%), 24% were married, and 10% had children. During the formal interview, 94% were asked at least 1 inappropriate or potentially illegal question. About 78% reported being asked about marital status, 29% were asked about intent to have children. About 46% reported being counseled on their personal life, 30% were asked about their ethnic background, and 15% were asked about their religion. A total of 2 candidates reported questions about mental illness/disability, and 2 candidates reported being asked about sexual orientation. About 45% of applicants that were asked at least 1 of these questions ranked those programs lower.

Conclusion: Nearly all (94%) neurosurgical residency applicants reported being asked at least 1 inappropriate or potentially illegal question during interviews. Our results indicate that inappropriate questions negatively affected program rankings.
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http://dx.doi.org/10.1093/neuros/nyab059DOI Listing
March 2021

Sport-Related Structural Brain Injury and Return to Play: Systematic Review and Expert Insight.

Neurosurgery 2021 May;88(6):E495-E504

Department of Neurosurgery, Johns Hopkins University Medical Center, Baltimore, Maryland, USA.

Background: Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI.

Objective: To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions.

Methods: A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted.

Results: Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033).

Conclusion: RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.
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http://dx.doi.org/10.1093/neuros/nyab041DOI Listing
May 2021

U.S. Neurosurgical Response to COVID-19: Forging a Path Toward Disaster Preparedness.

Mil Med 2021 05;186(5-6):549-555

Department of Surgery, US Naval Hospital Okinawa, Chatan, Okinawa 904-0103, Japan.

Introduction: The worldwide COVID-19 pandemic poses challenges to healthcare capacity and infrastructure. The authors discuss the structure and efficacy of the U.S. Navy's response to COVID-19 and evaluate the utility of this endeavor, with the objective of providing future recommendations for managing worldwide healthcare and medical operational demands from the perspective of Navy Neurosurgery.

Materials And Methods: The authors present an extensive review of topics and objectively highlight the efforts of U.S. Navy Neurosurgery as it pertains to the humanitarian mission during the COVID-19 pandemic.

Results: During the humanitarian mission (March 27, 2020-April 14, 2020), the response of active duty and reserve neurosurgeons in the U.S. Navy was robust. Neurosurgical coverage was present on board the U.S. Navy Ships Mercy and Comfort, with additional neurosurgical deployment to New York City for intensive care unit management and coverage.

Conclusions: The U.S. Navy neurosurgical response to the COVID-19 pandemic was swift and altruistic. Although neurosurgical pathologies were limited among the presenting patients, readiness and manpower continue to be strong influences within the Armed Forces. The COVID-19 response demonstrates that neurosurgical assets can be rapidly mobilized and deployed in support of wartime, domestic, and global humanitarian crises to augment both trauma and critical care capabilities.
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http://dx.doi.org/10.1093/milmed/usab081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989245PMC
May 2021

Patient-Reported Outcomes After Complex Adult Spinal Deformity Surgery: 5-Year Results of the Scoli-Risk-1 Study.

Global Spine J 2021 Feb 9:2192568220988276. Epub 2021 Feb 9.

University of Virginia, Charlottesville, VA, USA.

Study Design: Prospective cohort.

Objective: To prospectively evaluate PROs up to 5-years after complex ASD surgery.

Methods: The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers. Inclusion criteria was Cobb angle of >80°, corrective osteotomy for congenital or revision deformity, and/or 3-column osteotomy. The following PROs were measured prospectively at intervals up to 5-years postoperative: ODI, SF36-PCS/MCS, SRS-22, NRS back/leg. Among patients with 5-year follow-up, comparisons were made from both baseline and 2-years postoperative to 5-years postoperative. PROs were analyzed using mixed models for repeated measures.

Results: Seventy-seven patients (28.3%) had 5-year follow-up data. Comparing baseline to 5-year data among these 77 patients, significant improvement was seen in all PROs: ODI (45.2 vs. 29.3, < 0.001), SF36-PCS (31.5 vs. 38.8, < 0.001), SF36-MCS (44.9 vs. 49.1, = 0.009), SRS-22-total (2.78 vs. 3.61, < 0.001), NRS-back pain (5.70 vs. 2.95, < 0.001) and NRS leg pain (3.64 vs. 2.62, = 0.017). In the 2 to 5-year follow-up period, no significant changes were seen in any PROs. The percentage of patients achieving MCID from baseline to 5-years were: ODI (62.0%) and the SRS-22r domains of function (70.4%), pain (63.0%), mental health (37.5%), self-image (60.3%), and total (60.3%). Surprisingly, mean values ( > 0.05) and proportion achieving MCID did not differ significantly in patients with major surgery-related complications compared to those without.

Conclusions: After complex ASD surgery, significant improvement in PROs were seen at 5-years postoperative in ODI, SF36-PCS/MCS, SRS-22r, and NRS-back/leg pain. No significant changes in PROs occurred during the 2 to 5-year postoperative period. Those with major surgery-related complications had similar PROs and proportion of patients achieving MCID as those without these complications.
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http://dx.doi.org/10.1177/2192568220988276DOI Listing
February 2021

Advocacy to Government and Stakeholders.

World Neurosurg 2021 Feb 3. Epub 2021 Feb 3.

Department of Neurosurgery, University of South Alabama, Mobile, Alabama, USA; Department of Political Science, University of South Alabama, Mobile, Alabama, USA. Electronic address:

Participation in the health care and government advocacy arena may represent new and challenging perspectives for the traditional neurosurgeon. However, those with a strong understanding of the laws, rules, regulations, and fiscal allocation process can directly influence the practice of neurosurgery in the United States. We seek to shine light on the black box of how health care laws are passed, the influence and techniques of lobbying, and the role and rules surrounding political action committees. This practical review of health care advocacy is supplemented by a blueprint for engagement in the political arena for the practicing neurosurgeon.
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http://dx.doi.org/10.1016/j.wneu.2021.01.129DOI Listing
February 2021

Surgeons lack of agreement on determining preoperative radiographic and clinical shoulder balance in adolescent and adult idiopathic scoliosis patients.

Eur Spine J 2021 Mar 1;30(3):661-667. Epub 2021 Jan 1.

Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital At New York Presbyterian, New York, NY, USA.

Purpose: Preoperative shoulder balance is an important factor in determining the upper instrumented vertebrae (UIV). In adolescent and adult idiopathic scoliosis (AIS/AdIS) patients, we studied the intraobserver and interobserver reliability of spinal surgeons' assessment of preoperative shoulder balance using X-rays (XR) and anterior/posterior photographs.

Methods: An observational review of a prospective multicenter database (AIS Lenke Type 1/5/6) and prospective single-institution database (AdIS) was conducted. Ten spine surgeons reviewed AIS cases; 12 spine surgeons reviewed AdIS cases. Surgeons rated the higher shoulder: left/right/same/unsure. Reliability was calculated using Fleiss' kappa coefficient.

Results: Among 145 Type 1 AIS cases, intraobserver reliability was moderate-to-substantial: XR (κ = 0.59), anterior photographs (κ = 0.68), posterior photographs (k = 0.65). Interobserver reliability was fair to moderate for XR (κ = 0.31), anterior photographs (κ = 0.20), and posterior photographs (κ = 0.30). Among 52 Type 5/6 AIS cases, intraobserver reliability was substantial: XR (κ = 0.70), anterior photographs (κ = 0.76), posterior photographs (κ = 0.71). Interobserver reliability was fair to moderate for XR (κ = 0.49), anterior photographs (κ = 0.47), and posterior photographs (κ = 0.36). Among 66 AdIS cases, intraobserver reliability was substantial: XR (κ = 0.68), anterior photographs (κ = 0.67), posterior photographs (κ = 0.69). Interobserver reliability was moderate for XR (κ = 0.45), anterior photographs (κ = 0.43), posterior photographs (κ = 0.49). Within Type 1 AIS patients, attendings had better intraobserver reliabilities compared to fellows using X-rays (κ = 0.61 vs. 0.53), yet no effect of surgeon experience was seen with clinical photographs.

Conclusion: Though surgeons' ability to agree with themselves was moderate to substantial, surgeons' ability to agree with each other was fair to moderate. Combined measures to assess preoperative shoulder balance are needed for UIV selection.
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http://dx.doi.org/10.1007/s00586-020-06702-2DOI Listing
March 2021

Incidence and Risk Factors for Complications and Mortality After Vertebroplasty or Kyphoplasty in the Osteoporotic Vertebral Compression Fracture-Analysis of 1,932 Cases From the American College of Surgeons National Surgical Quality Improvement.

Global Spine J 2020 Dec 30:2192568220976355. Epub 2020 Dec 30.

Division of Spinal Surgery, Department of Orthopedic Surgery, Columbia University, The Spine Hospital at New York-Presbyterian/Allen Hospital, New York, NY, USA.

Study Design: Retrospective cohort.

Objective: The purpose was to investigate the incidence of and risk factors for complications associated with vertebroplasty (VP) or kyphoplasty (KP) for osteoporotic vertebral compression fracture (OVCF) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods: A cohort of patients undergoing VP/KP was constructed from the 2011-2013 ACS-NSQIP dataset using Current Procedural Terminology (CPT) codes. The incidences of minor complications (i.e. urinary tract infection, pneumonia, renal insufficiency, superficial infection, wound dehiscence), major complications (i.e. reoperation, deep vein thrombosis, pulmonary embolism, sepsis, dialysis, cardiac arrest, deep infection, stroke), and mortality within 30 days post-surgery were investigated, and their risk factors were assessed using logistic regression modeling.

Results: Of 1932 patients undergoing VP/KP, 166 (8.6%) experienced a complication, including minor complications in 53 (2.7%), major complications in 95 (4.9%), and death in 40 (2.1%). Multivariate logistic regression analysis indicated that the adjusted odds ratios (95% confidence interval [CI]) of mortality was significantly associated with ASA 4: 16.604 (1.956-140.959) and increased creatinine (≥ 1.3 mg/dL): 3.494 (1.128-10.823). History of chronic obstructive pulmonary disease was associated with minor complications. Increased WBC count and hypoalbuminemia (<3.0 g/dL) were also associated with major complications.

Conclusions: The major complication and mortality rates associated with VP/KP were 4.9% and 2.1% respectively, higher than previous reports. Increased creatinine and ASA 4 were independently associated with mortality after VP/KP. Therefore, cautious monitoring and counseling is needed for elderly, patients with preexisting kidney disease or ASA 4 undergoing VP/KP.
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December 2020

The cost of a single concussion in American high school football: a retrospective cohort study.

Concussion 2020 Oct 28;5(4):CNC81. Epub 2020 Oct 28.

Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.

Aim: The potential financial burden of American football-related concussions (FRC) is unknown. Our objective was to describe the healthcare costs associated with an FRC and determine factors associated with increased costs.

Methodology/results: A retrospective cohort study of concussed high school football players presenting between November 2017 and March 2020 was undertaken; 144 male high school football players were included. Total costs were about $115,000, for an average direct healthcare cost of $800.10/concussion. Visiting the emergency department (β = 502.29, 95% CI: 105.79-898.61; p = 0.01), the initial post-concussion symptom scale score (β = 0.39, 95% CI: 0.11-0.66; p = 0.01) and a post-concussion syndrome diagnosis (β = 670.37, 95% CI: 98.96-1241.79; p = 0.02) were each independently associated with total costs.

Conclusion: A granular understanding of cost-driving factors associated with FRC is the first step in understanding the cost-effectiveness of prevention and treatment methods.
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http://dx.doi.org/10.2217/cnc-2020-0012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653506PMC
October 2020

Interobserver and intraobserver reliability of determining the deformity angular ratio in severe pediatric deformity curves.

Spine Deform 2021 Mar 17;9(2):435-440. Epub 2020 Nov 17.

Department of Orthopaedics, Washington University, St. Louis, MO, USA.

Study Design: Cross-sectional reliability study.

Objective: The deformity angular ratio (DAR) is a means of quantifying magnitude of the coronal (C-DAR) and sagittal (S-DAR) plane of deformity curves to produce a total DAR (T-DAR). It has been shown to predict the risk of spinal cord monitoring alerts and actual neurologic deficits. We sought to assess the reliability of determining the C-DAR and S-DAR among pediatric spinal deformity surgeons.

Methods: Twelve preoperative anterior-posterior (AP) and lateral X-rays from the Fox multi-center pediatric deformity study were de-identified and sent to7 pediatric spinal deformity surgeons. Each surgeon measured: coronal/sagittal Cobb angles, upper/lower endplate vertebrae (UEV/LEV), apices, and number of vertebrae included in the main curve. The C-DAR and S-DAR were then calculated by dividing the Cobb angles by the number of vertebrae included in the curve. Intra- and interobserver reliability was calculated using interclass correlation (ICC).

Results: The mean C-DAR was 14.9 (range 1.3-51.5) with a mean Cobb angle of 88.8° (range 15.0-163.0) over a mean of 7.5 (range 2.0-14.0) levels. The mean S-DAR was 8.6 (range 1.0-19.6), with a mean Cobb angle of 68.0° (range 10.0-137.0) over a mean of 7.5 (range 3-11) levels. The intraobserver reliability of the C-DAR was ICC = 0.908 (range 0.846-0.960) and the S-DAR 0.914 (range 0.815-0.961). The interobserver reliability of the C-DAR was ICC = 0.868 (range 0.846-0.938), and the S-DAR was ICC = 0.848 (range 0.815-0.961). Despite poor reliability among UEV, LEV, and apex selection (aggregated range 0.340-0.724), the C-DAR and S-DAR were demonstrated to be reliable in our study CONCLUSIONS: Reliability was good to excellent for C-DAR and S-DAR, despite poor to moderate reliability among UEV, LEV, and apex selection. These data support the use of the C-DAR, S-DAR, and combined T-DAR as a means of quantifying deformity magnitude.
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http://dx.doi.org/10.1007/s43390-020-00239-6DOI Listing
March 2021

The behavioral, psychological, and social impacts of team sports: a systematic review and meta-analysis.

Phys Sportsmed 2020 Dec 16:1-16. Epub 2020 Dec 16.

Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

: To assess the association between team sport participation and behavioral, psychological, and social health outcomes in young athletes.: A systematic review and meta-analysis were undertaken to identify studies published between 01/01/1950-05/01/2020 investigating the association between team sport participation and health outcomes in young athletes (<25 years). Included studies compared team sport participants to controls or themselves, assessed health outcomes, and had a sample size >50. Prospective and retrospective studies were included; non-primary literature was excluded. Health outcomes were categorized as: 1) behavioral, 2) psychological, or 3) social. Data were extracted to form 2 × 2 tables for each study to calculate odds ratios (OR) and 95% confidence intervals (CI).: Of 371 queried articles, 34 studies from 10 countries across 4 continents were included, with 9 reporting homogenous outcomes for meta-analysis.Behavioral: Fifteen studies evaluated behavioral health outcomes of alcohol and/or drug use, fitness, and diet. Quantitatively, team sport participation was found to decrease rates of cigarette/tobacco use across 5 studies (OR 0.72, 95% CI 0.69-0.76) and alcohol/drug use across 7 studies (OR 0.73, 95% CI 0.69-0.77). Qualitatively, 12/15 (80%) of studies confirmed improved behavioral health outcomes with team sport participation.Psychological: Nineteen studies evaluated psychological health outcomes including anorexia, anxiety, depression, self-esteem, and suicidal ideation. Quantitatively, team sport participation was associated with decreased depression/anxiety rates across 5 studies (OR 0.59, 95%CI 0.54-0.64). Qualitatively, 14/19 (74%) of studies confirmed improved psychological health.Social: Ten studies evaluated social health outcomes including academic performance, commitment, psychosocial health, social behavior/identity, and delinquency/high-risk activity. Qualitatively, 7/10 (70%) of studies confirmed improved social health outcomes with team sport participation.: Team sport participation was associated with decreased odds of smoking/tobacco use, alcohol/drug use, and depression/anxiety. Though few studies mentioned potential negative effects of team sport participation, the majority reported improved behavioral, psychological, and social health outcomes in youth athletes worldwide.
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http://dx.doi.org/10.1080/00913847.2020.1850152DOI Listing
December 2020

Can pelvic incidence change after spinal deformity correction to the pelvis with S2-alar-iliac screws?

Eur Spine J 2020 Nov 11. Epub 2020 Nov 11.

Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital At New York Presbyterian, New York, NY, USA.

Purpose: Pelvic incidence (PI) is assumed to be fixed, yet studies have reported PI changes after long fusions to the pelvis. In a cohort of ASD patients undergoing surgery with S2-alar-iliac (S2AI) screws, we sought to: (1) report the magnitude of PI changes, and (2) evaluate subsequent pelvic parameter changes.

Methods: A retrospective case series of ASD patients undergoing surgical correction with S2AI screw placement and sagittal cantilever correction maneuvers was conducted. Patients were categorized based on preoperative PI: High-PI (H-PI) (PI ≥ 60°); Normal-PI (N-PI) (60° > PI > 40°); Low-PI (L-PI) (PI ≤ 40°). PI was measured preoperatively and immediately postoperatively. A significant PI change was established a priori at ≥ 6.0. PI, pelvic tilt (PT), lumbar lordosis (LL), and PI-LL mismatch were analyzed.

Results: In 68 patients (82.3% female, ages 22-75 years), the average change in PI was 4.6° ± 3.1, and 25 (36.8%) had a PI change ≥ 6.0° with breakdown as follows: H-PI 12 (66.7%) patients, 9 (25.87%) patients, and 4 (33.3%) patients. Of 25 patients with PI changes, 10 (14.7%) had a PI increase and 15 (22.1%) had a PI decrease. Significant improvements were seen in PT, LL, PI-LL mismatch in all patients with a PI change ≥ 6.0°, in addition to both subgroups with an increase or decrease in PI.

Conclusions: PI changes of ≥ 6.0° occurred in 36.8% of patients, and H-PI patients most commonly experienced PI changes. Despite PI alterations, pelvic parameters significantly improved postoperatively. These results may be explained by sacroiliac joint laxity, S2AI screw placement, or aggressive sagittal cantilever techniques.
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http://dx.doi.org/10.1007/s00586-020-06658-3DOI Listing
November 2020

Does the Global Alignment and Proportion score overestimate mechanical complications after adult spinal deformity correction?

J Neurosurg Spine 2020 Oct 2:1-7. Epub 2020 Oct 2.

2Department of Orthopedic Surgery Spine, Columbia University, New York.

Objective: The goal of this study was to validate the Global Alignment and Proportion (GAP) score in a cohort of patients undergoing adult spinal deformity (ASD) surgery. The GAP score is a novel measure that uses sagittal parameters relative to each patient's lumbosacral anatomy to predict mechanical complications after ASD surgery. External validation is required.

Methods: Adult ASD patients undergoing > 4 levels of posterior fusion with a minimum 2-year follow-up were included. Six-week postoperative standing radiographs were used to calculate the GAP score, classified into a spinopelvic state as proportioned (P), moderately disproportioned (MD), or severely disproportioned (SD). A chi-square analysis, receiver operating characteristic curve, and Cochran-Armitage analysis were performed to assess the relationship between the GAP score and mechanical complications.

Results: Sixty-seven patients with a mean age of 52.5 years (range 18-75 years) and a mean follow-up of 2.04 years were included. Patients with < 2 years of follow-up were included only if they had an early mechanical complication. Twenty of 67 patients (29.8%) had a mechanical complication. The spinopelvic state breakdown was as follows: P group, 21/67 (31.3%); MD group, 23/67 (34.3%); and SD group, 23/67 (34.3%). Mechanical complication rates were not significantly different among all groups: P group, 19.0%; MD group, 30.3%; and SD group, 39.1% (χ2 = 1.70, p = 0.19). The rates of mechanical complications between the MD and SD groups (30.4% and 39.1%) were less than those observed in the original GAP study (MD group 36.4%-57.1% and SD group 72.7%-100%). Within the P group, the rates in this study were higher than in the original study (19.0% vs 4.0%, respectively).

Conclusions: The authors found no statistically significant difference in the rate of mechanical complications between the P, MD, and SD groups. The current validation study revealed poor generalizability toward the authors' patient population.
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http://dx.doi.org/10.3171/2020.6.SPINE20538DOI Listing
October 2020

Operative Treatment of Traumatic Spinal Injuries in Tanzania: Surgical Management, Neurologic Outcomes, and Time to Surgery.

Global Spine J 2021 Jan 21;11(1):89-98. Epub 2020 Jan 21.

New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.

Study Design: Retrospective case series.

Objective: Little is known about operative management of traumatic spinal injuries (TSI) in low- and middle-income countries (LMIC). In patients undergoing surgery for TSI in Tanzania, we sought to (1) determine factors involved in the operative decision-making process, specifically implant availability and surgical judgment; (2) report neurologic outcomes; and (3) evaluate time to surgery.

Methods: All patients from October 2016 to June 2019 who presented with TSI and underwent surgical stabilization. Fracture type, operation, neurologic status, and time-to-care was collected.

Results: Ninety-seven patients underwent operative stabilization, 23 (24%) cervical and 74 (77%) thoracic/lumbar. Cervical operations included 4 (17%) anterior cervical discectomy and fusion with plate, 7 (30%) anterior cervical corpectomy with tricortical iliac crest graft and plate, and 12 (52%) posterior cervical laminectomy and fusion with lateral mass screws. All 74 (100%) of thoracic/lumbar fractures were treated with posterolateral pedicle screws. Short-segment fixation was used in 86%, and constructs often ended at an injured (61%) or junctional (62%) level. Sixteen (17%) patients improved at least 1 ASIA grade. The sole predictor of neurologic improvement was faster time from admission to surgery (odds ratio = 1.04, = .011, 95%CI = 1.01-1.07). Median (range) time in days included: injury to admission 2 (0-29), admission to operating room 23 (0-81), and operating room to discharge 8 (2-31).

Conclusions: In a cohort of LMIC patients with TSI undergoing stabilization, the principle driver of operative decision making was cost of implants. Faster time from admission to surgery was associated with neurologic improvement, yet significant delays to surgery were seen due to patients' inability to pay for implants. Several themes for improvement emerged: early surgery, implant availability, prehospital transfer, and long-term follow-up.
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http://dx.doi.org/10.1177/2192568219894956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734258PMC
January 2021

Neuroplastic Surgery Aboard USNS Comfort During the COVID-19 Pandemic in New York City.

J Craniofac Surg 2020 Sep;31(6):e636-e639

Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN.

In December of 2019, a novel virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) produced a cluster of viral pneumonia cases in Wuhan, China. In the United States (US), New York City was particularly devastated, with the volume and acuity of patients placing an unprecedented strain on the hospital system and health care workers. In response to this crisis, USNS Comfort (T-AH 20) was deployed to New York City with a 1100 member medical team to augment local hospitals. Comfort's mission to New York City was dynamic, and required special adaptation to care for both COVID positive and COVID negative patients. Neuroplastic surgery procedures were indicated in both COVID positive and COVID negative patients, and lessons learned with regard to performance of complex surgery in an unfamiliar environment consisted of developing a thorough understanding of ones capabilities, and working with a highly skilled team of Navy surgeons, anesthesiologists, and surgical support staff, in order to provide high quality care in a deployment platform.
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http://dx.doi.org/10.1097/SCS.0000000000006886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480802PMC
September 2020

The Institute for Healthcare Improvement-NeuroPoint Alliance collaboration to decrease length of stay and readmission after lumbar spine fusion: using national registries to design quality improvement protocols.

J Neurosurg Spine 2020 Aug 21:1-10. Epub 2020 Aug 21.

4Carolina Neurosurgery & Spine Associates, Neuroscience and Musculoskeletal Institutes, Atrium Health Charlotte, North Carolina.

Objective: National databases collect large amounts of clinical information, yet application of these data can be challenging. The authors present the NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) program as a novel attempt to create a quality improvement (QI) tool informed through registry data to improve the quality of care delivered. Reducing the length of stay (LOS) and readmission after elective lumbar fusion was chosen as the pilot module.

Methods: The NPA-IHI program prospectively enrolled patients undergoing elective 1- to 3-level lumbar fusions across 8 institutions. A three-pronged approach was taken that included the following phases: 1) Research Phase, 2) Development Phase, and 3) Implementation Phase. Primary outcomes were LOS and readmission. From January to June 2017, a learning system was created utilizing monthly conference calls, weekly data submission, and continuous refinement of the proposed QI tool. Nonparametric tests were used to assess the impact of the QI intervention.

Results: The novel QI tool included the following three areas of intervention: 1) preoperative discharge assessment (location, date, and instructions), 2) inpatient changes (LOS rounding checklist, daily huddle, and pain assessments), and 3) postdischarge calls (pain, primary care follow-up, and satisfaction). A total of 209 patients were enrolled, and the most common procedure was a posterior laminectomy/fusion (60.2%). Seven patients (3.3%) were readmitted during the study period. Preoperative discharge planning was completed for 129 patients (61.7%). A shorter median LOS was seen in those with a known preoperative discharge date (67 vs 80 hours, p = 0.018) and clear discharge instructions (71 vs 81 hours, p = 0.030). Patients with a known preoperative discharge plan also reported significantly increased satisfaction (8.0 vs 7.0, p = 0.028), and patients with increased discharge readiness (scale 0-10) also reported higher satisfaction (r = 0.474, p < 0.001). Those receiving postdischarge calls (76%) had a significantly shorter LOS than those without postdischarge calls (75 vs 99 hours, p = 0.020), although no significant relationship was seen between postdischarge calls and readmission (p = 0.342).

Conclusions: The NPA-IHI program showed that preoperative discharge planning and postdischarge calls have the potential to reduce LOS and improve satisfaction after elective lumbar fusion. It is our hope that neurosurgical providers can recognize how registries can be used to both develop and implement a QI tool and appreciate the importance of QI implementation as a separate process from data collection/analysis.
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http://dx.doi.org/10.3171/2020.5.SPINE20457DOI Listing
August 2020

Cost-Effectiveness of Operating on Traumatic Spinal Injuries in Low-Middle Income Countries: A Preliminary Report From a Major East African Referral Center.

Global Spine J 2020 Aug 17:2192568220944888. Epub 2020 Aug 17.

12295Weill Cornell Medicine, New York, NY, USA.

Study Design: Retrospective cost-effectiveness analysis.

Objectives: While the incidence of traumatic spine injury (TSI) is high in low-middle income countries (LMICs), surgery is rarely possible due to cost-prohibitive implants. The objective of this study was to conduct a preliminary cost-effectiveness analysis of operative treatment of TSI patients in a LMIC setting.

Methods: At a tertiary hospital in Tanzania from September 2016 to May 2019, a retrospective analysis was conducted to estimate the cost-effectiveness of operative versus nonoperative treatment of TSI. Operative treatment included decompression/stabilization. Nonoperative treatment meant 3 months of bed rest. Direct costs included imaging, operating fees, surgical implants, and length of stay. Four patient scenarios were chosen to represent the heterogeneity of spine trauma: Quadriplegic, paraplegic, neurologic improvement, and neurologically intact. Disability-adjusted-life-years (DALYs) and incremental-cost-effectiveness ratios were calculated to determine the cost per unit benefit of operative versus nonoperative treatment. was the primary outcome (i.e., the amount of money required to avoid losing 1 year of healthy life).

Results: A total of 270 TSI patients were included (125 operative; 145 nonoperative). Operative treatment averaged $731/patient. Nonoperative care averaged $212/patient. Comparing operative versus nonoperative treatment, the incremental for each patient outcome was: quadriplegic ($112-$158/DALY averted), paraplegic ($47-$67/DALY averted), neurologic improvement ($50-$71/DALY averted), neurologically intact ($41-$58/DALY averted). Sensitivity analysis confirmed these findings without major differences.

Conclusions: This preliminary cost-effectiveness analysis suggests that the upfront costs of spine trauma surgery may be offset by a reduction in disability. LMIC governments should consider conducting more spine trauma cost-effectiveness analyses and including spine trauma surgery in universal health care.
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August 2020

Do neurosurgeons receive more patient complaints than other physicians? Describing who is most at risk and how we can improve.

J Neurosurg 2020 Jul 31:1-8. Epub 2020 Jul 31.

4Center for Patient and Professional Advocacy, and.

Objective: The number of unsolicited patient complaints (UPCs) about surgeons correlates with surgical complications and malpractice claims. Using a large, national patient complaint database, the authors sought to do the following: 1) compare the rates of UPCs for neurosurgeons to those for other physicians, 2) analyze the risk of UPCs with individual neurosurgeon characteristics, and 3) describe the types of UPCs made about neurosurgeons.

Methods: Patient and family complaint reports among 36,265 physicians, including 423 neurosurgeons, 8292 other surgeons, and 27,550 nonsurgeons who practiced at 33 medical centers (22 academic and 11 regional) from January 1, 2014, to December 31, 2017, were coded with a previously validated Patient Advocacy Reporting System (PARS) algorithm.

Results: Among 423 neurosurgeons, 93% were male, and most (71%) practiced in academic medical centers. Neurosurgical subspecialties included general practice (25%), spine (25%), tumor (16%), vascular (13%), functional (10%), and pediatrics (10%). Neurosurgeons had more average total UPCs per physician (8.68; 95% CI 7.68-9.67) than nonsurgeons (3.40; 95% CI 3.33-3.47) and other surgeons (5.01; 95% CI 4.85-5.17; p < 0.001). In addition, a significantly higher percentage of neurosurgeons received at least one UPC (71.6%; 95% CI 67.3%-75.9%) than did nonsurgeons (50.2%; 95% CI 49.6%-50.8%) and other surgeons (58.2%; 95% CI 57.1%-59.3%; p < 0.001). Factors most associated with increased average UPCs were younger age, measured as median medical school graduation year (1990.5 in the 0-UPC group vs 1993 in the 14+-UPC group, p = 0.009) and spine subspecialty (13.4 mean UPCs in spine vs 7.9 mean UPCs in other specialties, 95% CI 2.3-8.5, p < 0.001). No difference in complaints was seen in those who graduated from non-US versus US medical schools (p = 0.605). The most common complaint types were related to issues surrounding care and treatment, communication, and accessibility, each of which was significantly more common for neurosurgeons than other surgical specialties (p < 0.001).

Conclusions: Neurosurgeons were more likely to generate UPCs than other surgical specialties, and almost 3 out of 4 neurosurgeons (71.6%) had at least one UPC during the study period. Prior studies have shown that feedback to physicians about behavior can result in fewer UPCs. These results suggest that neurosurgeons have opportunities to reduce complaints and potentially improve the overall quality of care delivered.
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http://dx.doi.org/10.3171/2020.4.JNS20870DOI Listing
July 2020

The neurosurgery residency interview: assessing applicant perspectives on question content, utility, and stress.

J Neurosurg 2020 Jul 17:1-9. Epub 2020 Jul 17.

2Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont.

Objective: Residency interviews are integral to the recruitment process yet imperfect. Through surveys of neurosurgery residency applicants, the authors describe interview content and the perceived utility and stress of topics from the applicant's perspective.

Methods: All 2018-2019 neurosurgery resident applicants applying to three particular programs were surveyed. Across 10 interview topics, survey questions assessed topic frequency and the applicant's opinion of the utility and stress of each topic (Likert scale 1-5). Analyses included descriptive statistics, Spearman's rank correlation, and logistic regression.

Results: One hundred thirty-three of 265 surveyed US residency applicants (50%) responded. Extracurricular activities, research, future career, non-medicine interests, and small talk were discussed in all interviews. The least frequent topics included neurosurgical knowledge assessment (79%) and manual dexterity tests (45%). The most useful topics according to respondents were future career objectives (4.78 ± 0.49) and prior research (4.76 ± 0.50); the least useful were neurosurgical knowledge assessment (2.67 ± 1.09) and manual dexterity tests (2.95 ± 1.05). The most stressful topics were neurosurgical knowledge assessment (3.66 ± 1.23) and ethical/behavioral scenarios (2.94 ± 1.28). The utility and stress of manual dexterity tests and neurosurgical knowledge assessments were inversely correlated (r = -0.40, p < 0.01; r = -0.36, p < 0.01), whereas no such correlation existed for ethical/behavioral questions (r = -0.12, p = 0.18), indicating that ethical/behavioral questions may have been stressful but were potentially useful topics. Respondents who attended ≥ 15 interviews were more likely to be asked about the three most stressful topics (each p < 0.05). Respondents with children were less likely to be asked about ethical/behavioral scenarios (OR 0.13, 95% CI 0.03-0.52, p < 0.01).

Conclusions: Applicants found several of the most frequently discussed topics to be less useful, indicating a potential disconnect between applicant opinion and the faculty's preferred questions. Ethical/behavioral scenarios were rated as stressful but still useful, representing a potentially worthwhile type of question. These data provide several avenues for potential standardization and improvement of the interview process.
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http://dx.doi.org/10.3171/2020.4.JNS2046DOI Listing
July 2020

Pressure ulcers after traumatic spinal injury in East Africa: risk factors, illustrative case, and low-cost protocol for prevention and treatment.

Spinal Cord Ser Cases 2020 06 15;6(1):48. Epub 2020 Jun 15.

Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA.

Study Design: Retrospective, case-control study.

Objectives: In a traumatic spinal injury (TSI) cohort from Tanzania, we sought to: (1) describe potential risk factors for pressure ulcer development, (2) present an illustrative case, and (3) propose a low-cost outpatient protocol for prevention and treatment.

Setting: Tertiary referral hospital.

Methods: All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, time to hospital, injury characteristics, operative management, length of hospitalization, and mortality. Pressure ulcer development was the primary outcome. Regressions were used to report potential predictors, and international guidelines were referenced to construct a low-cost outpatient protocol.

Results: Of 267 patients that met the inclusion criteria, 51 developed a pressure ulcer. Length of stay was greater for patients with pressure ulcers compared with those without (45 vs. 30 days, p < 0.001). Potential predictors for developing pressure ulcers were: increased days from injury to hospital admission (p = 0.036), American Spinal Injury Association Impairment Scale grade A upon admission (p < 0.001), and thoracic spine injury (p = 0.037). The illustrative case described a young male presenting ~2 months after complete thoracic spinal cord injury with a grade IV sacral pressure ulcer that lead to septic shock and death. Considering the dramatic consequences of pressure ulcers in lower- and middle-income countries (LMICs), we proposed a low-cost protocol for prevention and treatment targeting support surfaces, repositioning, skin care, nutrition, follow-up, and dressing.

Conclusions: Pressure ulcers after TSI in LMICs can lead to increased hospital stays and major adverse events. High-risk patients were those with delayed presentation, complete neurologic injuries, and thoracic injuries. We recommended aggressive prevention and treatment strategies suitable for resource-constrained settings.
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http://dx.doi.org/10.1038/s41394-020-0294-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295768PMC
June 2020

Benefits of team sport participation versus concerns of chronic traumatic encephalopathy: prioritizing the health of our youth.

Concussion 2020 May 14;5(2):CNC75. Epub 2020 May 14.

Department of Exercise & Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27154, USA.

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http://dx.doi.org/10.2217/cnc-2020-0006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270841PMC
May 2020