Publications by authors named "Silky Chotai"

105 Publications

Longitudinal scoliosis behavior in Chiari malformation with and without syringomyelia.

J Neurosurg Pediatr 2021 Sep 3:1-7. Epub 2021 Sep 3.

5Department of Neurosurgery, Washington University, St. Louis, Missouri.

Objective: The objective of this study was to understand the natural history of scoliosis in patients with Chiari malformation type I (CM-I) with and without syringomyelia.

Methods: A retrospective review of data was conducted. Patients with CM-I were identified from a cohort of 14,118 individuals age 18 years or younger who had undergone MRI over an 11-year period at the University of Michigan. Patients eligible for study inclusion had a coronal curve ≥ 10° on radiography, associated CM-I with or without syringomyelia, and at least 1 year of clinical follow-up prior to any surgery. Curve magnitude at initial diagnosis, prior to posterior fossa decompression (PFD; if applicable), and at the last follow-up (prior to any surgical correction of scoliosis) was recorded, and clinical and radiographic characteristics were noted. The change in curve magnitude by 10° was defined as curve progression (increase by 10°) or regression (decrease by 10°).

Results: Forty-three patients met the study inclusion criteria and were analyzed. About one-third (35%) of the patients presented with symptoms attributed to their CM-I. The mean degree of scoliosis at presentation was 32.6° ± 17.7°. Twenty-one patients (49%) had an associated syrinx. The mean tonsil position below the level of the foramen magnum was 9.8 ± 5.8 mm. Patients with a syrinx were more likely to have a curve > 20° (86% vs 41%, p = 0.002). Curve magnitude remained stable (≤ ±10°) in 77% of patients (33/43), progressed in 16% (7/43), and regressed in 7% (3/43). Mean age was higher (14.8 ± 0.59 years) among patients with regressed curves (p = 0.026). All regressed curves initially measured ≤ 20° (mean 14° ± 5.3°), and none of the patients with regressed curves had a syrinx. The change in curve magnitude was statistically similar in patients with (7.32° ± 17.7°) and without (5.32° ± 15.8°) a syrinx (p = 0.67). After a mean follow-up of 3.13 ± 2.04 years prior to surgery, 27 patients (63%) ultimately underwent posterior fossa or scoliosis correction surgery. For those who eventually underwent PFD only, the rate of change in curve magnitude prior to surgery was 0.054° ± 0.79°. The rate of change in curve magnitude was statistically similar before (0.054° ± 0.79°) and after (0.042° ± 0.33°) surgery (p = 0.45) for patients who underwent PFD surgery only.

Conclusions: The natural history of scoliosis in the presence of CM-I is variable, though most curves remained stable. All curves that regressed were ≤ 20° at initial diagnosis, and most patients in such cases were older at scoliosis diagnosis. Patients who underwent no surgery or PFD only had similar profiles for the change in curve magnitude, which remained relatively stable overall, as compared to patients who underwent PFD and subsequent fusion, who demonstrated curve progression. Among the patients with a syrinx, no curves regressed, most remained stable, and some progressed. Understanding this variability is a first step toward building a prediction model for outcomes for these patients.
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http://dx.doi.org/10.3171/2021.5.PEDS20915DOI Listing
September 2021

A Systematic Review of Definitions for Dysphagia and Dysphonia in Patients Treated Surgically for Degenerative Cervical Myelopathy.

Global Spine J 2021 Aug 19:21925682211035714. Epub 2021 Aug 19.

Spinal Cord Injury Clinical Research Unit, Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.

Study Design: Systematic review. Surgical decompression for degenerative cervical myelopathy (DCM) is associated with perioperative complications, including difficulty or discomfort with swallowing (dysphagia) as well as changes in sound production (dysphonia). This systematic review aims to (1) outline how dysphagia and dysphonia are defined in the literature and (2) assess the quality of definitions using a novel 4-point rating system.

Methods: An electronic database search was conducted for studies that reported on dysphagia, dysphonia or other related complications of DCM surgery. Data extracted included study design, surgical details, as well as definitions and rates of surgical complications. A 4-point rating scale was developed to assess the quality of definitions for each complication.

Results: Our search yielded 2,673 unique citations, 11 of which met eligibility criteria and were summarized in this review. Defined complications included odynophagia (n = 1), dysphagia (n = 11), dysphonia (n = 2), perioperative swelling complications (n = 2), and soft tissue swelling (n = 3). Rates of dysphagia varied substantially (0.0%-50.0%) depending on whether this complication was patient-reported (4.4%); patient-reported using a modified Swallowing Quality of Life questionnaire (43.1%) or the Bazaz criteria (8.8%-50.0%); or diagnosed using an extensive protocol consisting of clinical assessment, a bedside swallowing test, evaluation by a speech and language pathologist and a modified barium swallowing test/fiberoptic endoscopy (42.9%). The reported incidences of dysphonia also ranged significantly from 0.6% to 38.0%.

Conclusion: There is substantial variability in reported rates of dysphagia and dysphonia due to differences in data collection methods, diagnostic strategies, and definitions. Consolidation of nomenclature will improve evaluation of the overall safety of surgery.
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http://dx.doi.org/10.1177/21925682211035714DOI Listing
August 2021

Outcomes of Transzygomatic Middle Cranial Fossa Approach for Skull Base Tumors-A Single Institutional Experience.

J Neurol Surg B Skull Base 2021 Jul 28;82(Suppl 3):e205-e210. Epub 2020 Mar 28.

Department of Otolaryngology, The Otology Group of Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, United States.

 This study aimed to evaluate surgical outcomes after transzygomatic middle cranial fossa (MCF) (TZ-MCF) approach for tumor control in patients with large skull base lesions involving the MCF and adjacent sites.  This study was done at the tertiary skull base center.  This is a retrospective case series.  The main outcome measures were tumor control (recurrence), new-onset cranial neuropathies, facial nerve and audiometric outcomes, cerebrospinal fluid (CSF) leak, and wound complications.  Sixteen patients were identified with a median age of 45 years (range: 20-72). The mean maximum tumor dimension was 5.49 cm (standard deviation [SD]: 1.2, range: 3.1-7.3) and the mean tumor volume was 28.5 cm (SD: 18.8, range: 2.9-63.8). Ten (62.5%) tumors were left sided. The most common pathology encountered was meningioma (  = 7) followed by chondrosarcoma (  = 4). Mean follow-up was 36.3 (SD: 26.9) months. Gross total resection or near total resection was achieved in nine (56.2%) and planned subtotal resection was used in seven (43.7%). Postoperative additional new cranial nerve (CN) deficits included CN V (  = 1), CN III (  = 2), CN VI (  = 1), and CN X (  = 1). Major neurological morbidity (hemiplegia) was encountered in two patients with resolution. There were no cases of CSF leak, meningitis, hemorrhage, seizures, aphasia, or death. There was no recurrence or regrowth of residual tumor. Facial nerve function was preserved in all but one patient (House-Brackmann grade 2).  Various skull base tumors involving MCF with extension to adjacent sites can be successfully resected using the TZ-MCF approach in a multidisciplinary fashion. This approach yields optimal exposure and permits excellent tumor control with acceptable CN and neurological morbidity.
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http://dx.doi.org/10.1055/s-0040-1708881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289522PMC
July 2021

Primary Cerebellopontine Angle Rathke's Cleft Cyst: Case Report.

Turk Neurosurg 2021 ;31(4):665

The Affiliated Hospital of Southwest Medical University, Department of Neurosurgery, Lu Zhou, PR China.

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http://dx.doi.org/10.5137/1019-5149.JTN.33800-21.0DOI Listing
January 2021

Compliance With Preferred Reporting Items for Systematic Review and Meta-Analysis Individual Participant Data Statement for Meta-Analyses Published for Stroke Studies.

Stroke 2021 Aug 4;52(9):2817-2826. Epub 2021 Jun 4.

Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School & University Hospital, New Brunswick, NJ (F.J., O.A., M.S.R., B.R., A.G., H.S., V.N., G.G., A.N.).

[Figure: see text].
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http://dx.doi.org/10.1161/STROKEAHA.120.033288DOI Listing
August 2021

Colloid cysts of the third ventricle in children.

J Neurosurg Pediatr 2021 Apr 23:1-7. Epub 2021 Apr 23.

1Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York.

Objective: The rarity of colloid cysts in children makes it difficult to characterize this entity and offer meaningful advice on treatment. Infrequent case reports exist, but to date there has been no age-specific assessment. The purpose of this study was to define any differences between children and adults who are evaluated and treated for colloid cysts of the third ventricle.

Methods: Patients with colloid cysts were reviewed and stratified by age. Individuals ≤ 18 years of age were defined as pediatric patients and those > 18 years of age as adults. Clinical and radiographic data, treatment, and postoperative outcomes were compared between both groups. Bivariate analysis was conducted using the Fisher exact test for categorical variables and Mann-Whitney U-test for continuous variables.

Results: Of 132 endoscopic resections (121 primary, 10 secondary, and 1 tertiary) of a colloid cyst, 9 (6.8%) were performed in pediatric patients (mean age 14.1 years, range 9-18 years) and 123 (93.2%) were performed in adult patients (mean age 43.8 years, range 19-73 years). Cases were found incidentally more commonly in pediatric than adult patients (66.7% vs 37.4%, p > 0.05), and pediatric patients had lower rates of hydrocephalus than adult patients (11.1% vs 63.4%, p < 0.05). Acute decompensation at presentation was found in 8 adults (6.5%) but no children. Complete cyst removal (88.9% vs 90.2%, p > 0.05) and length of stay (1.6 days vs 2.9 days, p > 0.05) were not significantly different between the groups. Postoperative complications (6.5% in adults, 0% in children) and recurrence (2.4% in adults, 0% in children) were rare in both groups, and there were no treatment-related deaths. The mean postoperative radiological follow-up was longer in pediatric patients (45 months, range 4-89 months) than adults (44.1 months, range 1-171 months).

Conclusions: While differences exist between children and adults regarding colloid cyst presentation, these are in keeping with the predicted evolution of a slow-growing lesion. Consistent with this observation, children had lower rates of hydrocephalus and a smaller mean maximal cyst diameter. Contrary to the published literature, however, sudden deterioration was not observed in pediatric patients but occurred in adult patients. In this limited pediatric sample size, the authors have not recorded any postoperative complications or recurrences to date. These encouraging results with endoscopic removal may positively impact future decisions related to children given their protracted life expectancy and projected rates of progression.
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http://dx.doi.org/10.3171/2020.10.PEDS18458DOI Listing
April 2021

Statins as a Medical Adjunct in the Surgical Management of Chronic Subdural Hematomas.

World Neurosurg 2021 05 18;149:e281-e291. Epub 2021 Feb 18.

Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA. Electronic address:

Background: By stabilizing immature leaky vessel formation in neomembranes, statin drugs have been suggested as a nonsurgical treatment option for chronic subdural hematomas (cSDH). Statin therapy seems to reduce conservatively managed cSDH volume. However, the usefulness of these medications in supplementing surgical treatment is unknown.

Objective: To investigate the effect of concurrent statin therapy on outcomes after surgical treatment of cSDH.

Methods: A retrospective single-institution cohort study of surgically managed patients with convexity cSDH between 2009 and 2019 was conducted. Patients receiving this diagnosis who underwent surgical decompression were included, and those without follow-up scans were excluded. Demographic, clinical, and radiographic variables were collected. cSDH size was defined as maximum radial thickness in millimeters on axial computed tomography of the head. Multivariable linear regression was performed to identify factors (including statin use) that were associated with preoperative to follow-up cSDH size change.

Results: Overall, 111 patients, including 36 patients taking statins on admission, were evaluated. Median time to follow-up postoperative imaging was 30 days (interquartile range, 17-42 days). Patients on statins were older (median, 75 years, range, 68-78.25 years vs. 69 years, range, 59-7 years; P = 0.006) and reported more antiplatelet use (67% vs. 28%; P < 0.001). Median change in follow-up size was 13 mm in both statin and nonstatin groups. Adjusting for other clinical covariates, statin use was associated with greater reduction in cSDH size (CE = -6.72 mm, 95% confidence interval, -13.18 to -0.26 mm; P = 0.042).

Conclusions: Statin use is associated with improved cSDH size postoperatively. Statin drugs might represent a low-cost and low-risk supplement to the surgical management for patients with cSDH.
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http://dx.doi.org/10.1016/j.wneu.2021.02.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102393PMC
May 2021

Impact of Neurovascular Comorbidities and Complications on Outcomes After Procedural Management of Intracranial Aneurysm: Part 2, Ruptured Intracranial Aneurysm.

World Neurosurg 2021 02 24;146:e270-e312. Epub 2020 Oct 24.

Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital, Vanderbilt, Nashville, Tennessee, USA.

Objective: We aim to define the dynamic interplay between neurovascular-specific comorbidities and in-hospital complications on outcomes (functional outcome and mortality), length of stay (LOS), and cost of hospital stay.

Methods: The 2012-2015 National Inpatient Sample (NIS) was queried for intracranial aneurysm treatment after subarachnoid hemorrhage using International Classification of Diseases, Ninth Revision codes. Neurovascular comorbidity index (NCI) was aggregated. NIS-Subarachnoid Hemorrhage Severity Score (NIS-SSS) was used as a Hunt-Hess grade proxy. In-hospital complications were medical complications, surgical complications, seizures, and cerebral vasospasm. Outcomes were functional outcome (modified Rankin Scale [mRS]-equivalent measure), in-hospital mortality, LOS, and cost. Multivariable logistic regression models were built for mRS equivalent and in-hospital mortality. Multivariable linear regression models in log scale were built for LOS and cost.

Results: A total of 5353 patients were included. The median NCI was 4.00 (interquartile range [IQR], 0.00-7.00) and 2882 patients (54%) had in-hospital complication. Higher NCI (odds ratio [OR], 1.13 if NCI = 1; OR, 2.05 if NCI = 7; P < 0.001) was associated with any complication, seizure (OR, 1.11, NCI = 1; OR, 1.60, NCI = 7; P < 0.001), medical complication (OR, 1.18, NCI = 1; OR, 2.50, NCI = 7; P < 0.001), surgical complication (OR, 1.13, NCI = 1; OR, 1.91, NCI = 7; P < 0.001), and cerebral vasospasm (OR, 1.09, NCI = 1; OR, 1.49, NCI = 7; P < 0.001). Patients with higher NCI (OR, 1.06, NCI = 1; OR, 1.95, NCI = 7; P < 0.001) or with in-hospital complication (P < 0.001) had poorer mRS equivalent outcome. Similar trends were observed for other outcomes including in-hospital mortality, LOS, and cost.

Conclusions: Neurovascular comorbidities are the primary driver of poor mRS equivalent outcome, in-hospital mortality, higher LOS, and higher cost after ruptured intracranial aneurysm procedural treatment. The conditional event of complication influences patients with moderate comorbidities more so than those with low or high comorbidities.
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http://dx.doi.org/10.1016/j.wneu.2020.10.091DOI Listing
February 2021

Predicting for Lost to Follow-up in Surgical Management of Patients with Chronic Subdural Hematoma.

World Neurosurg 2021 04 4;148:e294-e300. Epub 2021 Jan 4.

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

Background: Lost to follow-up (LTF) represents an understudied barrier to effective management of chronic subdural hematoma (cSDH). Understanding the factors associated with LTF after surgical treatment of cSDH could uncover pathways for quality improvement efforts and modify discharge planning. We sought to identify the demographic and clinical factors associated with patient LTF.

Methods: A single-institution, retrospective cohort study of patients treated surgically for convexity cSDH from 2009 to 2019 was conducted. The primary outcome was LTF, with neurosurgical readmission as the secondary outcome. Univariate analysis was conducted using the student-t test and χ test. Multivariate logistic regression was performed to identify the factors associated with LTF and neurosurgical readmission.

Results: A total of 139 patients were included, 29% of whom were LTF. The mean first postoperative follow-up duration was 60 days. On univariate analysis, uninsured/Medicaid coverage was associated with increased LTF compared with private insurance/Medicare coverage (62.5% vs. 41.4%; P = 0.039). A higher discharge modified Rankin scale score was also associated with LTF (3.7 vs. 3.5; P < 0.001). On multivariate analysis, uninsured/Medicaid patients had a significantly greater risk of LTF compared with private insurance/Medicare patients (odds ratio, 2.44; 95% confidence interval, 1.13-5.23; P = 0.022). LTF was independently associated with an increased risk of neurosurgical readmission (odds ratio, 1.94; 95% confidence interval, 1.17-3.24; P = 0.011).

Conclusions: Uninsured and Medicaid patients had a greater likelihood of LTF compared with private insurance and Medicare patients. LTF was further associated with an increased risk of neurosurgical readmission. The results from the present study emphasize the need to address barriers to follow-up to reduce readmission after surgery for cSDH. These findings could inform improved discharge planning, such as predischarge repeat imaging studies and postdischarge contact.
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http://dx.doi.org/10.1016/j.wneu.2020.12.128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054037PMC
April 2021

Impact of Neurovascular Comorbidities and Complications on Outcomes After Procedural Management of Intracranial Aneurysm: Part 1, Unruptured Intracranial Aneurysm.

World Neurosurg 2021 02 26;146:e233-e269. Epub 2020 Oct 26.

Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.

Objective: This study investigates the relationship between neurovascular comorbidities and in-hospital complications in determining functional outcome, mortality, length of stay (LOS), and cost of stay.

Methods: Patients were identified from the 2012-2015 National Inpatient Sample (NIS) using International Classification of Diseases, Ninth Revision codes for unruptured intracranial aneurysm (UIA) treatment in patients without subarachnoid hemorrhage. In-hospital complications were divided into medical complications, surgical complications, and seizures. Primary outcomes were functional outcome measured by modified Rankin Scale (mRS)-equivalent measure, in-hospital mortality, LOS, and cost. Multivariable logistic regression models were built for mRS-equivalent and in-hospital mortality. Multivariable linear regression models in log scale were built for LOS and cost.

Results: A total of 7398 procedurally managed patients with UIA were included (median age, 58 years; 75% female; 66% white; 43% private insurance). Higher Neurovascular Comorbidities Index (NCI) was associated with seizure (odds ratio [OR], 1.11 if NCI = 1; OR, 2.49 if NCI = 7; P < 0.001), medical complication (OR, 1.21, NCI = 1; OR, 3.46, NCI = 7; P < 0.001), and surgical complication (OR, 1.25, NCI = 1; OR, 3.47, NCI = 7; P < 0.001). NCI remained significantly predictive of poor mRS-equivalent outcome (OR, 1.20, NCI = 1; OR, 5.79, NCI = 7; P < 0.001), in-hospital mortality (OR, 1.98, NCI = 1; OR, 10.9, NCI = 7; P < 0.001), LOS (coefficient dependent on multiple variables, P < 0.001), and cost (coefficient dependent on multiple variables, P < 0.001) after adjustment.

Conclusions: Neurovascular comorbidities are the primary driver of poor mRS-equivalent outcome, in-hospital mortality, higher LOS, and higher cost after procedural treatment of UIA. The conditional event of complication influences patients with fewer comorbidities more so than those with no comorbidities or high comorbidities. It is imperative to precisely account for these factors to optimize targeted resource allocation and increase the value of care for patients with UIA.
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http://dx.doi.org/10.1016/j.wneu.2020.10.092DOI Listing
February 2021

Transposition of Vessels for Microvascular Decompression of Posterior Fossa Cranial Nerves: Review of Literature and Intraoperative Decision-Making Scheme.

World Neurosurg 2021 01 2;145:64-72. Epub 2020 Sep 2.

Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq.

Introduction: Microvascular decompression with transposition of the involved vessels provides good surgical outcomes in cases of complex and recurrent neurovascular compression syndromes. We conducted a literature review to illustrate the variations in the surgical techniques used for transposition and to provide a practical decision-making scheme for transposition of the involved vessel.

Methods: A PubMed Medline database record search was conducted using the following algorithm ("Microvascular Decompression Surgery"[Mesh]) OR (((Microvascular) OR (Macrovascular)) AND decompression AND surgery) AND (transposition). Only articles that detailed the intraoperative techniques were included.

Results: A total of 48 articles were included. The adjacent anatomical walls to which the compressing vessel can be anchored were divided into 4 groups; A: roof (tentorium cerebelli), B: anterior wall (posterior surface of petrous bone and clivus), C: posterior wall (petrosal surface of the cerebellum), and D: "no wall" required. A new decision-making scheme based on the following 2 questions was designed: 1) is the conflicting vessel amenable to transposition to a nearby wall in the cerebello-brainstem space? 2) what is the closest wall to secure the transposed vessel?

Conclusions: Transposition of the involved vessel is a valuable procedure for microvascular decompression of the posterior fossa cranial nerves. Anchoring the vessel to the adjacent anatomical wall ensures secure transposition. The proposed algorithm provides a systemic scheme to identify the optimal anatomical wall, and to determine the technique and material that can be used to anchor involved vessel. This scheme is an efficient method to inform the intraoperative decision-making process.
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http://dx.doi.org/10.1016/j.wneu.2020.08.173DOI Listing
January 2021

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

Development and Validation of Cervical Prediction Models for Patient-Reported Outcomes at 1 Year After Cervical Spine Surgery for Radiculopathy and Myelopathy.

Spine (Phila Pa 1976) 2020 Nov;45(22):1541-1552

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University School of Medicine, Nashville, Tennessee.

Study Design: Retrospective analysis of prospectively collected registry data.

Objective: To develop and validate prediction models for 12-month patient-reported outcomes of disability, pain, and myelopathy in patients undergoing elective cervical spine surgery.

Summary Of Background Data: Predictive models have the potential to be utilized preoperatively to set expectations, adjust modifiable characteristics, and provide a patient-centered model of care.

Methods: This study was conducted using data from the cervical module of the Quality Outcomes Database. The outcomes of interest were disability (Neck Disability Index:), pain (Numeric Rating Scale), and modified Japanese Orthopaedic Association score for myelopathy. Multivariable proportional odds ordinal regression models were developed for patients with cervical radiculopathy and myelopathy. Patient demographic, clinical, and surgical covariates as well as baseline patient-reported outcomes scores were included in all models. The models were internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.

Results: Four thousand nine hundred eighty-eight patients underwent surgery for radiculopathy and 2641 patients for myelopathy. The most important predictor of poor postoperative outcomes at 12-months was the baseline Neck Disability Index score for patients with radiculopathy and modified Japanese Orthopaedic Association score for patients with myelopathy. In addition, symptom duration, workers' compensation, age, employment, and ambulatory and smoking status had a statistically significant impact on all outcomes (P < 0.001). Clinical and surgical variables contributed very little to predictive models, with posterior approach being associated with higher odds of having worse 12-month outcome scores in both the radiculopathy and myelopathy cohorts (P < 0.001). The full models overall discriminative performance ranged from 0.654 to 0.725.

Conclusions: These predictive models provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical disease. Predictive models have the potential to be used as a shared decision-making tool for evidence-based preoperative counselling.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003610DOI Listing
November 2020

Timing of syrinx reduction and stabilization after posterior fossa decompression for pediatric Chiari malformation type I.

J Neurosurg Pediatr 2020 Apr 24:1-7. Epub 2020 Apr 24.

1Department of Neurosurgery, Vanderbilt University Medical Center.

Objective: The aim of this study was to determine the timeline of syrinx regression and to identify factors mitigating syrinx resolution in pediatric patients with Chiari malformation type I (CM-I) undergoing posterior fossa decompression (PFD).

Methods: The authors conducted a retrospective review of records from pediatric patients (< 18 years old) undergoing PFD for the treatment of CM-I/syringomyelia (SM) between 1998 and 2015. Patient demographic, clinical, radiological, and surgical variables were collected and analyzed. Radiological information was reviewed at 4 time points: 1) pre-PFD, 2) within 6 months post-PFD, 3) within 12 months post-PFD, and 4) at maximum available follow-up. Syrinx regression was defined as ≥ 50% decrease in the maximal anteroposterior syrinx diameter (MSD). The time to syrinx regression was determined using Kaplan-Meier analysis. Multivariate analysis was conducted using a Cox proportional hazards model to determine the association between preoperative, clinical, and surgery-related factors and syrinx regression.

Results: The authors identified 85 patients with CM-I/SM who underwent PFD. Within 3 months post-PFD, the mean MSD regressed from 8.1 ± 3.4 mm (preoperatively) to 5.6 ± 2.9 mm within 3 months post-PFD. Seventy patients (82.4%) achieved ≥ 50% regression in MSD. The median time to ≥ 50% regression in MSD was 8 months (95% CI 4.2-11.8 months). Using a risk-adjusted multivariable Cox proportional hazards model, the patients who underwent tonsil coagulation (n = 20) had a higher likelihood of achieving ≥ 50% syrinx regression in a shorter time (HR 2.86, 95% CI 1.2-6.9; p = 0.02). Thirty-six (75%) of 45 patients had improvement in headache at 2.9 months (IQR 1.5-4.4 months).

Conclusions: The maximum reduction in syrinx size can be expected within 3 months after PFD for patients with CM-I and a syrinx; however, the syringes continue to regress over time. Tonsil coagulation was associated with early syrinx regression in this cohort. However, the role of surgical maneuvers such as tonsil coagulation and arachnoid veil identification and sectioning in the overall role of CM-I surgery remains unclear.
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http://dx.doi.org/10.3171/2020.2.PEDS19366DOI Listing
April 2020

Initial Experience with Using a Structured Light 3D Scanner and Image Registration to Plan Bedside Subdural Evacuating Port System Placement.

World Neurosurg 2020 05 4;137:350-356. Epub 2020 Feb 4.

Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Background: Chronic subdural hematoma evacuation can be achieved in select patients through bedside placement of the Subdural Evacuation Port System (SEPS; Medtronic, Inc., Dublin, Ireland). This procedure involves drilling a burr hole at the thickest part of the hematoma. Identifying this location is often difficult, given the variable tilt of available imaging and distant anatomic landmarks. This paper evaluates the feasibility and accuracy of a bedside navigation system that relies on visible light-based 3-dimensional (3D) scanning and image registration to a pre-procedure computed tomography scan. The information provided by this system may increase accuracy of the burr hole location.

Methods: In Part 1, the accuracy of this system was evaluated using a rigid 3D printed phantom head with implanted fiducials. In Part 2, the navigation system was tested on 3 patients who underwent SEPS placement.

Results: The error in registration of this system was less than 2.5 mm when tested on a rigid 3D printed phantom head. Fiducials located in the posterior aspect of the head were difficult to reliably capture. For the 3 patients who underwent 5 SEPS placements, the distance between anticipated SEPS burr hole location based on registration and actual burr hole location was less than 1cm.

Conclusions: A bedside cranial navigation system based on 3D scanning and image registration has been introduced. Such a system may increase the success rate of bedside procedures, such as SEPS placement. However, technical challenges such as the ability to scan hair and practical challenges such as minimization of patient movement during scans must be overcome.
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http://dx.doi.org/10.1016/j.wneu.2020.01.203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354700PMC
May 2020

A Systematic Review of Definitions for Neurological Complications and Disease Progression in Patients Treated Surgically for Degenerative Cervical Myelopathy.

Spine (Phila Pa 1976) 2019 Sep;44(18):1318-1331

Spinal Cord Injury Clinical Research Unit, Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada.

Study Design: Systematic review.

Objective: This review aims to (1) outline how neurological complications and disease progression are defined in the literature and (2) evaluate the quality of definitions using a novel four-point rating system.

Summary Of Background Data: Degenerative cervical myelopathy (DCM) is a progressive, degenerative spine disease that is often treated surgically. Although uncommon, surgical decompression can be associated with neurological complications, such as C5 nerve root palsy, perioperative worsening of myelopathy, and longer-term deterioration. Unfortunately, important questions surrounding these complications cannot be fully addressed due to the heterogeneity in definitions used across studies. Given this variability, there is a pressing need to develop guidelines for the reporting of surgical complications in order to accurately evaluate the safety of surgical procedures.

Methods: An electronic database search was conducted in MEDLINE, MEDLINE in Process, EMBASE and Cochrane Central Register of Controlled Trials for studies that reported on complications related to DCM surgery and included at least 10 surgically treated patients. Data extracted included study design, surgical details, as well as definitions and rates of surgical complications. A four-point rating scale was developed to assess definition quality for each complication.

Results: Our search yielded 2673 unique citations, 42 of which met eligibility criteria and were summarized in this review. Defined complications included neurological deterioration, late onset deterioration, perioperative worsening of myelopathy, C5 palsy, nerve root or upper limb palsy or radiculopathy, surgery failure, inadequate decompression and progression of ossified lesions. Reported rates of these complications varied substantially, especially those for neurological deterioration (0.2%-33.3%) and progression of ossified lesions (0.0%-86.7%).

Conclusion: Reported incidences of various complications vary widely in DCM surgery, especially for neurological deterioration and progression of ossified lesions. This summary serves as a first step for standardizing definitions and developing guidelines for accurately reporting surgical complications.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003066DOI Listing
September 2019

Factors Associated With Return-to-Work Following Cervical Spine Surgery in Non-Worker's Compensation Setting.

Spine (Phila Pa 1976) 2019 Jul;44(13):903-907

Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Study Design: This study retrospectively analyzes prospectively collected data.

Objective: Here in this study we aim to determine the factors which impact a patient's ability to return to work (RTW) in the setting of cervical spine surgery in patients without worker's compensation status.

Summary Of Background Data: Surgical management of degenerative cervical disease has proven cost-effectiveness and shown significant improvement in quality of life. However, the ability to RTW is an important clinical outcome for preoperatively employed patients.

Methods: All adult patients undergoing elective surgery for cervical degenerative disease at our institution are enrolled in a prospective, web-based registry. A multivariable Cox proportional hazards regression model was built for time to RTW. The variables included in the model were age, sex, smoking status, occupation type, number of levels operated on, ASA grade, body mass index, history of diabetes, history of coronary artery disease (CAD), history of chronic obstructive pulmonary disease (COPD), anxiety, depression, myelopathy at presentation, duration of symptoms more than 12 months, diagnosis, type of surgery performed, and preoperative Neck Disability Index, EuroQol Five Dimensions, and Numeric Rating Scale pain scores for neck pain and arm pain scores.

Results: Of the total 324 patients with complete 3-month follow-up data 83% (n = 269) returned to work following surgery. The median time to RTW was 35 days (range, 2-90 d). Patients with a labor-intensive occupation, higher ASA grade, history of CAD, and history of COPD were less likely to RTW. The likelihood of RTW was lower in patients with a diagnosis of disc herniation compared with cervical stenosis, patients undergoing cervical corpectomy compared laminectomy and fusion and patient with longer operative time.

Conclusion: Our study identifies the various factors associated with a lower likelihood of RTW at 3 months after cervical spine surgery in the non-worker's compensation setting. This information provides expectations for the patient and employer when undergoing cervical spine surgery.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002978DOI Listing
July 2019

Utility of Anxiety/Depression Domain of EQ-5D to Define Psychological Distress in Spine Surgery.

World Neurosurg 2019 Jun 14;126:e1075-e1080. Epub 2019 Mar 14.

Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA. Electronic address:

Background: Prospective patient-reported outcomes (PROs) registries are central to emerging evidence-driven reform models. These registries entail significant operator and responder burden to capture PROs data. It is important to limit the number of PROs administered. We sought to determine whether the anxiety/depression domain of EQ-5D could be used to define preoperative psychological distress in patients undergoing elective spine surgery.

Methods: Patients undergoing elective spine surgery and enrolled into a prospective registry were analyzed. The 12-Item Short-Form Health Survey Mental Component Summary, Zung depression scale, Modified Somatic Perception Questionnaire, and EQ-5D were completed. The anxiety/depression domain of EQ-5D was used to define psychological distress; responses were captured as 1) not anxious or depressed, 2) moderately anxious or depressed, or 3) extremely anxious or depressed. Univariate correlation and proportional odds logistic regression analyses were conducted.

Results: Of 2470 included patients undergoing elective spine surgery, 45% (n = 1109) reported no psychological distress, 47% (n = 1168) reported moderate psychological distress, and 8% (n = 193) reported extreme psychological distress on EQ-5D. Psychological distress on EQ-5D had positive correlation with Zung depression scale (P < 0.0001, r = 0.620) and Modified Somatic Perception Questionnaire (P < 0.0001, r = 0.450) and negative correlation with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, r = -0.662). In proportional odds logistic regression models, EQ-5D psychological distress had significant correlations with 12-Item Short-Form Health Survey Mental Component Summary (P < 0.0001, C-index = 0.831), Zung depression scale (P < 0.0001, C-index = 0.802), and Modified Somatic Perception Questionnaire (P < 0.0001, C-index = 0.711).

Conclusions: The anxiety/depression domain of EQ-5D could be used to categorize preoperative psychological distress. Spine registries could use this information to potentially limit the number of validated PROs administered.
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http://dx.doi.org/10.1016/j.wneu.2019.02.211DOI Listing
June 2019

Laminectomy alone versus fusion for grade 1 lumbar spondylolisthesis in 426 patients from the prospective Quality Outcomes Database.

J Neurosurg Spine 2018 11;30(2):234-241

1Department of Neurological Surgery, University of California, San Francisco, California.

OBJECTIVEThe AANS launched the Quality Outcomes Database (QOD), a prospective longitudinal registry that includes demographic, clinical, and patient-reported outcome (PRO) data to measure the safety and quality of spine surgery. Registry data offer "real-world" insights into the utility of spinal fusion and decompression surgery for lumbar spondylolisthesis. Using the QOD, the authors compared the initial 12-month outcome data for patients undergoing fusion and those undergoing laminectomy alone for grade 1 degenerative lumbar spondylolisthesis.METHODSData from 12 top enrolling sites were analyzed and 426 patients undergoing elective single-level spine surgery for degenerative grade 1 lumbar spondylolisthesis were found. Baseline, 3-month, and 12-month follow-up data were collected and compared, including baseline clinical characteristics, readmission rates, reoperation rates, and PROs. The PROs included Oswestry Disability Index (ODI), back and leg pain numeric rating scale (NRS) scores, and EuroQol-5 Dimensions health survey (EQ-5D) results.RESULTSA total of 342 (80.3%) patients underwent fusion, with the remaining 84 (19.7%) undergoing decompression alone. The fusion cohort was younger (60.7 vs 69.9 years, p < 0.001), had a higher mean body mass index (31.0 vs 28.4, p < 0.001), and had a greater proportion of patients with back pain as a major component of their initial presentation (88.0% vs 60.7%, p < 0.001). There were no differences in 12-month reoperation rate (4.4% vs 6.0%, p = 0.93) and 3-month readmission rates (3.5% vs 1.2%, p = 0.45). At 12 months, both cohorts improved significantly with regard to ODI, NRS back and leg pain, and EQ-5D (p < 0.001, all comparisons). In adjusted analysis, fusion procedures were associated with superior 12-month ODI (β -4.79, 95% CI -9.28 to -0.31; p = 0.04).CONCLUSIONSSurgery for grade 1 lumbar spondylolisthesis-regardless of treatment strategy-was associated with significant improvements in disability, back and leg pain, and quality of life at 12 months. When adjusting for covariates, fusion surgery was associated with superior ODI at 12 months. Although fusion procedures were associated with a lower rate of reoperation, there was no statistically significant difference at 12 months. Further study must be undertaken to assess the durability of either surgical strategy in longer-term follow-up.
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http://dx.doi.org/10.3171/2018.8.SPINE17913DOI Listing
November 2018

Effect of Modified Japanese Orthopedic Association Severity Classifications on Satisfaction With Outcomes 12 Months After Elective Surgery for Cervical Spine Myelopathy.

Spine (Phila Pa 1976) 2019 Jun;44(11):801-808

Department of Neurosurgery, University of Tennessee Health Sciences Center, Semmes-Murphey Neurologic and Spine Institute, Memphis, TN.

Study Design: This study retrospectively analyzes prospectively collected data.

Objective: Here, we aim to determine the influence of preoperative and 12-month modified Japanese Orthopedic Association (mJOA) on satisfaction and understand the change in mJOA severity classification after surgical management of degenerative cervical myelopathy (DCM).

Summary Of Background Data: DCM is a progressive degenerative spine disease resulting from cervical cord compression. The natural progression of DCM is variable; some patients experience periods of stability, while others rapidly deteriorate following disease onset. The mJOA is commonly used to grade and categorize myelopathy symptoms, but its association with postoperative satisfaction has not been previously explored.

Methods: The quality and outcomes database (QOD) was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9 to 13), or severe (<9) categories on the mJOA scores. A McNemar-Bowker test was used to assess whether a significant proportion of patients changed mJOA category between preoperative and 12 months postoperative. A multivariable proportional odds ordinal logistic regression model was fitted with 12-month satisfaction as the outcome of interest.

Results: We identified 1963 patients who underwent elective surgery for DCM and completed 12-months follow-ups. Comparing mJOA severity level preoperatively and at 12 months revealed that 55% remained in the same category, 37% improved, and 7% moved to a worse category. After adjusting for baseline and surgery-specific variables, the 12-month mJOA category had the highest impact on patient satisfaction (P < 0.001).

Conclusion: Patient satisfaction is an indispensable tool for measuring quality of care after spine surgery. In this sample, 12-month mJOA category, regardless of preop mJOA, was significantly correlated with satisfaction. Given these findings, it is important to advise patients of the probability that surgery will change their mJOA severity classification and the changes required to achieve postoperative satisfaction.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002946DOI Listing
June 2019

Effect of Depression on Patient-Reported Outcomes Following Cervical Epidural Steroid Injection for Degenerative Spine Disease.

Pain Med 2018 12;19(12):2371-2376

Departments of Orthopaedic Surgery.

Objective: To assess the effect depression has on outcomes after cervical epidural steroid injections (CESIs).

Design: Retrospective review of a prospectively collected database.

Setting: Single institution tertiary care center.

Subjects: Fifty-seven patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first were included.

Methods: Twenty-one of 57 (37%) patients with depression (defined as Zung Depression Scale >33) were included. Patient-reported outcomes including Neck Disability Index (NDI), numeric rating scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and three-month follow-up. Minimal clinically important differences were then calculated to provide dichotomous outcome measures of success.

Results: Overall, 24 and 28 patients achieved at least 50% improvement in AP and NP, respectively. In terms of disability, 25/57 (43.9%) patients achieved >13.2-point improvement on the NDI overall. In patients with depression, 4/21 (19.0%) and 5/21 (23.8%) achieved at least 50% improvement on the NRS for AP and NP, respectively, compared with 20/36 (55.5%) and 23/36 (63.8%) in patients without depression. This difference was statistically significant for both pain measures (P < 0.002 AP, P < 0.006 NP). Statistically fewer patients, 5/21 (24%), with depression achieved ≥13.2-point improvement on the NDI compared with 20/36 (55%) nondepressed patients (P < 0.01). There was no difference in outcomes between groups on the EQ-5D.

Conclusions: Patients with cervical spondylosis and comorbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared with nondepressed patients at three months.
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http://dx.doi.org/10.1093/pm/pny196DOI Listing
December 2018

Perioperative Protocol for Elective Spine Surgery Is Associated With Reduced Length of Stay and Complications.

J Am Acad Orthop Surg 2019 Mar;27(5):183-189

From the Department of Neurological Surgery (Dr. Sivaganesan, Dr. Chotai, Ms. Cherkesky, and Dr. Devin), and the Department of Orthopaedic Surgery (Mr. Wick, Dr. Chotai, Dr. Stephens, and Dr. Devin), Vanderbilt University, Nashville, TN.

Introduction: Healthcare reform places emphasis on maximizing the value of care.

Methods: A prospective registry was used to analyze outcomes before (1,596 patients) and after (151 patients) implementation of standardized, evidence-based order sets for six high-impact dimensions of perioperative care for all patients who underwent elective surgery for degenerative spine disease after July 1, 2015.

Results: Apart from symptom duration, chronic obstructive pulmonary disease prevalence, estimated blood loss, and baseline Oswestry Disability Index, no significant differences existed between pre- and post-protocol cohorts. No differences in readmissions, discharge status, or 3-month patient-reported outcomes were seen. Multivariate regression analyses demonstrated reduced length of stay (P = 0.013) and odds of 90-day complications (P = 0.009) for postprotocol patients.

Conclusion: Length of stay and 90-day complications for elective spine surgery improved after implementation of an evidence-based perioperative protocol. Standardization efforts can improve quality and reduce costs, thereby improving the value of spine care.

Level Of Evidence: Level III (retrospective review of prospectively collected data).
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http://dx.doi.org/10.5435/JAAOS-D-17-00274DOI Listing
March 2019

Drivers of Variability in 90-Day Cost for Elective Laminectomy and Fusion for Lumbar Degenerative Disease.

Neurosurgery 2019 05;84(5):1043-1049

Departments of Orthopedic and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Considerable variability exists in the cost of surgery following spine surgery for common degenerative spine diseases. This variation in the cost of surgery can affect the payment bundling during the postoperative 90 d.

Objective: To determine the drivers of variability in total 90-d cost for laminectomy and fusion surgery.

Methods: A total of 752 patients who underwent elective laminectomy and fusion for degenerative lumbar conditions and were enrolled into a prospective longitudinal registry were included in the study. Total cost during the 90-d global period was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multivariable regression models were built for total 90-d cost.

Results: The mean 90-d direct cost was $29 295 (range, $28 612-$29 973). Based on our regression tree analysis, the following variables were found to drive the 90-d cost: age, BMI, gender, diagnosis, postop imaging, number of operated levels, ASA grade, hypertension, arthritis, preop and postop opioid use, length of hospital stay, duration of surgery, 90-d readmission, outpatient physical/occupational therapy, inpatient rehab, postop healthcare visits, postop nonopioid pain medication use nonsteroidal antiinflammatory drug (NSAIDs), and muscle relaxant use. The R2 for tree model was 0.64.

Conclusion: Utilizing prospectively collected data, we demonstrate that considerable variation exists in total 90-d cost, nearly 70% of which can be explained by those factors included in our modeling. Risk-adjusted payment schemes can be crafted utilizing the significant drivers presented here. Focused interventions to target some of the modifiable factors have potential to reduce cost and increase the value of care.
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http://dx.doi.org/10.1093/neuros/nyy264DOI Listing
May 2019

Drivers of Cost in Adult Thoracolumbar Spine Deformity Surgery.

World Neurosurg 2018 Oct 30;118:e206-e211. Epub 2018 Jun 30.

Department of Orthopedic Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Spinal Column Surgical Quality and Outcomes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA. Electronic address:

Background: In an era of rising health care costs, it is prudent to consider effective use of resources. Given the rapidly expanding elderly population with an anticipated increase in adult spinal deformity, identifying the significant cost drivers for the surgical management is an important step in the process of increasing sustainability and cost-effectiveness of adult spinal deformity surgery.

Methods: A total of 129 patients undergoing elective spine surgery for thoraco-lumbar deformity were enrolled in a prospective longitudinal registry. Patient-reported resource use during the 3-month postoperative period, including outpatient visits, spine-related diagnostic tests, injections, emergency department room visits, rehabilitation/skilled nursing facility utilization, and use of all medications, was collected in a single-center prospective registry. Multiple linear regression analysis was conducted to find the significant patient coefficient for the cost variability.

Results: The study population showed significant improvement (P < 0.001) in all patient-reported outcomes including disability (Oswestry Disability Index), pain (Numeric Rating Scale for Back Pain and Numeric Rating Scale for Leg Pain), and quality of life (Euro-Qol-5D). In risk-adjusted multiple patient comorbidities including chronic obstructive pulmonary disease and diabetes, preoperative deformity diagnosis, number of levels involved, length of surgery and hospital stay, 90-day readmission and use of inpatient rehabilitation were the significant drivers of the cost.

Conclusions: Our study demonstrates that several patient-specific, surgery-related factors, 90-day readmission and postdischarge inpatient rehabilitation use, were associated with increased cost associated with the adult deformity spine surgery.
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http://dx.doi.org/10.1016/j.wneu.2018.06.155DOI Listing
October 2018

Development and validation of a predictive model for 90-day readmission following elective spine surgery.

J Neurosurg Spine 2018 Sep 15;29(3):327-331. Epub 2018 Jun 15.

3Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and.

OBJECTIVE Hospital readmissions lead to a significant increase in the total cost of care in patients undergoing elective spine surgery. Understanding factors associated with an increased risk of postoperative readmission could facilitate a reduction in such occurrences. The aims of this study were to develop and validate a predictive model for 90-day hospital readmission following elective spine surgery. METHODS All patients undergoing elective spine surgery for degenerative disease were enrolled in a prospective longitudinal registry. All 90-day readmissions were prospectively recorded. For predictive modeling, all covariates were selected by choosing those variables that were significantly associated with readmission and by incorporating other relevant variables based on clinical intuition and the Akaike information criterion. Eighty percent of the sample was randomly selected for model development and 20% for model validation. Multiple logistic regression analysis was performed with Bayesian model averaging (BMA) to model the odds of 90-day readmission. Goodness of fit was assessed via the C-statistic, that is, the area under the receiver operating characteristic curve (AUC), using the training data set. Discrimination (predictive performance) was assessed using the C-statistic, as applied to the 20% validation data set. RESULTS A total of 2803 consecutive patients were enrolled in the registry, and their data were analyzed for this study. Of this cohort, 227 (8.1%) patients were readmitted to the hospital (for any cause) within 90 days postoperatively. Variables significantly associated with an increased risk of readmission were as follows (OR [95% CI]): lumbar surgery 1.8 [1.1-2.8], government-issued insurance 2.0 [1.4-3.0], hypertension 2.1 [1.4-3.3], prior myocardial infarction 2.2 [1.2-3.8], diabetes 2.5 [1.7-3.7], and coagulation disorder 3.1 [1.6-5.8]. These variables, in addition to others determined a priori to be clinically relevant, comprised 32 inputs in the predictive model constructed using BMA. The AUC value for the training data set was 0.77 for model development and 0.76 for model validation. CONCLUSIONS Identification of high-risk patients is feasible with the novel predictive model presented herein. Appropriate allocation of resources to reduce the postoperative incidence of readmission may reduce the readmission rate and the associated health care costs.
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http://dx.doi.org/10.3171/2018.1.SPINE17505DOI Listing
September 2018

Drivers of Variability in 90-day Cost for Primary Single-level Microdiscectomy.

Neurosurgery 2018 12;83(6):1153-1160

Department of Orthopedics Surgery, Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: The healthcare reimbursement models are rapidly transitioning to pay-per-performance episode of care payment models. These models, if designed well, must account for the variability in the cost of index surgeries during the global period.

Objective: To analyze the variability in 90-d cost and determine the drivers of the variability in total 90-d cost associated with single-level microdiscectomy.

Methods: A total of 203 patients undergoing primary microdiscectomy for degenerative lumbar conditions were included in the study. The total 90-d cost was derived as the sum of cost of surgery, cost associated with postdischarge utilization. A multivariable linear regression model for total 90-d cost was built.

Results: The mean total cost within 90-d after single-level primary microdiscectomy was $7962 ± $2092. In a multivariable linear regression model, obesity, history of myocardial infarction, factors that lengthen the time of surgery and hospital stay, complications and readmission within 90-d, postdischarge healthcare utilization including emergency room visits, time to opioid independence, number of days on nonopioid pain medications, diagnostic imaging, and the number of days in outpatient and inpatient rehabilitation contribute to the total 90-d cost. The model performance as measured by R2 is 0.76.

Conclusion: Utilizing prospectively collected data, we highlight major drivers of variation in cost following a single-level primary microdiscectomy. Our model explains about three-quarters of the variation in cost. The risk-adjusted cost estimates powered by models such as the one presented here can be used to formulate a sustainable total 90-d episode of care bundle payment.
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http://dx.doi.org/10.1093/neuros/nyy209DOI Listing
December 2018

Comparison of Outcomes Following Anterior vs Posterior Fusion Surgery for Patients With Degenerative Cervical Myelopathy: An Analysis From Quality Outcomes Database.

Neurosurgery 2019 04;84(4):919-926

Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota.

Background: The choice of anterior vs posterior approach for degenerative cervical myelopathy that spans multiple segments remains controversial.

Objective: To compare the outcomes following the 2 approaches using multicenter prospectively collected data.

Methods: Quality Outcomes Database (QOD) for patients undergoing surgery for 3 to 5 level degenerative cervical myelopathy was analyzed. The anterior group (anterior cervical discectomy [ACDF] or corpectomy [ACCF] with fusion) was compared with posterior cervical fusion. Outcomes included: patient reported outcomes (PROs): neck disability index (NDI), numeric rating scale (NRS) of neck pain and arm pain, EQ-5D, modified Japanese Orthopedic Association score for myelopathy (mJOA), and NASS satisfaction questionnaire; hospital length of stay (LOS), 90-d readmission, and return to work (RTW). Multivariable regression models were fitted for outcomes.

Results: Of total 245 patients analyzed, 163 patients underwent anterior surgery (ACDF-116, ACCF-47) and 82 underwent posterior surgery. Patients undergoing an anterior approach had lower odds of having higher LOS (P < .001, odds ratio 0.16, 95% confidence interval 0.08-0.30). The 12-mo NDI, EQ-5D, NRS, mJOA, and satisfaction scores as well as 90-d readmission and RTW did not differ significantly between anterior and posterior groups.

Conclusion: Patients undergoing anterior approaches for 3 to 5 level degenerative cervical myelopathy had shorter hospital LOS compared to those undergoing posterior decompression and fusion. Also, patients in both groups exhibited similar long-term PROs, readmission, and RTW rates. Further investigations are needed to compare the differences in longer term reoperation rates and functional outcomes before the clinical superiority of one approach over the other can be established.
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http://dx.doi.org/10.1093/neuros/nyy144DOI Listing
April 2019

Complication rates for preexisting baclofen pumps and ventricular shunts following scoliosis correction: a preliminary study.

J Neurosurg Pediatr 2018 07 4;22(1):108-112. Epub 2018 May 4.

1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt; and.

OBJECTIVE Many patients undergoing spinal fusion for neuromuscular scoliosis have preexisting neurosurgical implants, including ventricular shunts (VSs) for hydrocephalus and baclofen pumps (BPs) for spastic cerebral palsy. Recent studies have discussed a possible increase in implant complication rates following spinal fusion, but published data are inconclusive. The authors therefore, sought to investigate: 1) the rate of implant complications following fusion, 2) possible causes of these complications, and 3) factors that place patients at higher risk for implant-related complications. METHODS Cases involving pediatric patients with a preexisting VS or BP who underwent spinal fusion for scoliosis correction between 2005 and 2016 at a single tertiary children's hospital were retrospectively analyzed. Patient demographics, implant characteristics, spinal fusion details, neurosurgical follow-up, and implant complications in the 180 days following fusion were recorded and analyzed. RESULTS Overall, 75 patients who underwent scoliosis correction had preexisting implants: 39 had BPs, 31 VSs, and 5 both. The patients' mean age at fusion was 13.49 ± 2.78 years (range 3.62-18.81 years), and the mean time from the most recent previous implant surgery to fusion was 5.70 ± 4.65 years (range 0.10-17.3 years). The mean preoperative and postoperative Cobb angles were 62.4° ± 18.9° degrees (range 20.9°-109.0°) and 23.5° ± 13.3° degrees (range 2.00°-67.3°), respectively. No VS complications were identified. Two patients with BPs were found to have complications (unintentional cutting of their BP catheter during posterior spinal fusion) within 180 days postfusion. There were no recorded neurosurgical implant infections, failures, fractures, or dislodgements. Although 10 patients required at least 1 surgical procedure for irrigation and debridement of the spine wound following fusion, there were no abdominal or cranial implant wound infections requiring revision, and no implants required removal. CONCLUSIONS The results of this study suggest that spinal fusion for scoliosis correction does not increase the rates of complications involving previously placed neurosurgical implants. A large-scale, prospective, multicenter study is needed to fully explore and confirm this finding.
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http://dx.doi.org/10.3171/2018.2.PEDS17713DOI Listing
July 2018

Drivers of Variability in 90-Day Cost for Elective Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disease.

Neurosurgery 2018 11;83(5):898-904

Department of Orthopedics Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period.

Objective: To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease.

Methods: Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost.

Results: The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616.

Conclusion: There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons' and institution-specific differences.
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http://dx.doi.org/10.1093/neuros/nyy140DOI Listing
November 2018

Timing of Operative Intervention in Traumatic Spine Injuries Without Neurological Deficit.

Neurosurgery 2018 11;83(5):1015-1022

Department of Orthopaedic Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Numerous studies have demonstrated the benefits of early decompression and stabilization in unstable spine injuries with incomplete neurological deficits. However, a clear consensus on timing to operative intervention still does not exist in those with a normal neurological exam and unstable spine.

Objective: To determine the optimal timing of operative intervention in traumatic spine injuries without neurological deficit.

Methods: Retrospective chart review at a single institution was performed including patients with traumatic spine injuries without neurological deficit admitted from December 2001 to August 2012. Estimated intraoperative blood loss (EBL), in-hospital complications, postoperative hospital length of stay (HLOS), intensive care unit length of stay (ICULOS), and ventilator days were recorded. Delayed surgery was defined as surgery 72 h after admission.

Results: A total of 456 patients were included for analysis. There was a trend towards statistical significance between the time to operative intervention and EBL in bivariate analysis (P = .07). In the risk-adjusted multivariable analysis delayed vs early surgery was not associated with increased EBL or complications. Delayed surgery was associated with increased ICULOS (odds ratio [OR] = 2.19; 95% confidence interval [CI]: 1.38-3.51; P = .001), ventilator days (OR = 2.09; 95% CI: 1.28-3.43; P = .004), and increased postoperative HLOS (OR = 1.84; 95% CI: 1.22-2.76; P = .004).

Conclusion: Earlier operative intervention was associated with decreased ICULOS, ventilator days, and postoperative HLOS and did not show a statistically significant increase in EBL or complications. Earlier operative intervention for traumatic spine injuries without neurological deficit provides better outcomes compared to delayed surgery.
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http://dx.doi.org/10.1093/neuros/nyx569DOI Listing
November 2018
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