Publications by authors named "Yagiz U Yolcu"

25 Publications

  • Page 1 of 1

Economic Burden of Hospitalizations Associated with Opioid Dependence Among Patients Undergoing Spinal Fusion.

World Neurosurg 2021 Jul;151:e738-e746

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

Background: The current study seeks to examine the association between chronic opioid use and postoperative outcomes for patients undergoing anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF).

Methods: The National Inpatient Sample was queried for patients with and without chronic opioid use undergoing ACDF or PLF for degenerative disc disease between 2012 and 2015 using ICD-9 diagnosis and procedure codes. Multivariable conditional logistic regression was performed to assess the association between chronic opioid use and length of stay (LOS), nonhome discharge, and hospital charge.

Results: A total of 391 patients undergoing ACDF and 644 patients undergoing PLF with opioid dependence were identified. On multivariable regression analysis, opioid dependence was significantly associated with an increased LOS (mean, 3.09 days vs. 2.16 days; odds ratio (OR) for prolonged LOS (>3 days), 2.11; 95% confidence interval [CI], 1.43-3.14; P < 0.001). Although on unadjusted analyses, patients with opioid dependence undergoing ACDF were found to have higher hospital charges (mean, U.S. $18,698.42 vs. $11,378.61; P < 0.001) and higher rates of nonroutine discharge (19.18% vs. 10.21%; P < 0.001), the multivariable regression analyses found no significant association between opioid dependence and odds of hospital charges >75th percentile (OR, 1.44; 95% CI, 0.84-2.47; P = 0.188) or nonroutine discharge (OR, 1.48; 95% CI, 0.93-2.34; P = 0.098). For those undergoing PLF, opioid dependence was significantly associated with increased hospital charges (mean, U.S. $37,712.98 vs. $30,475.43, P < 0.001; OR for hospital charge >75th percentile, 1.78, 95% CL, 1.23-2.58, P = 0.002), LOS (mean, 3.42 days vs. 2.30 days; OR for prolonged LOS, 1.53; 95% CI, 1.16-2.00; P = 0.003), and nonroutine discharge (46.89% vs. 36.47%; OR, 1.74; 95% CI, 1.34-2.26; P < 0.001) on both unadjusted and adjusted multivariable regression analyses.

Conclusions: Our analysis using a national administrative database showed that opioid dependence may be associated with worse economic outcomes for patients undergoing ACDF and PLF.
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http://dx.doi.org/10.1016/j.wneu.2021.04.116DOI Listing
July 2021

Impact of predominant symptom location among patients undergoing cervical spine surgery on 12-month outcomes: an analysis from the Quality Outcomes Database.

J Neurosurg Spine 2021 Jul 9:1-11. Epub 2021 Jul 9.

4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.

Objective: The impact of the type of pain presentation on outcomes of spine surgery remains elusive. The aim of this study was to assess the impact of predominant symptom location (predominant arm pain vs predominant neck pain vs equal neck and arm pain) on postoperative improvement in patient-reported outcomes.

Methods: The Quality Outcomes Database cervical spine module was queried for patients undergoing 1- or 2-level anterior cervical discectomy and fusion (ACDF) for degenerative spine disease.

Results: A total of 9277 patients were included in the final analysis. Of these patients, 18.4% presented with predominant arm pain, 32.3% presented with predominant neck pain, and 49.3% presented with equal neck and arm pain. Patients with predominant neck pain were found to have higher (worse) 12-month Neck Disability Index (NDI) scores (coefficient 0.24, 95% CI 0.15-0.33; p < 0.0001). The three groups did not differ significantly in odds of return to work and achieving minimal clinically important difference in NDI score at the 12-month follow-up.

Conclusions: Analysis from a national spine registry showed significantly lower odds of patient satisfaction and worse NDI score at 1 year after surgery for patients with predominant neck pain when compared with patients with predominant arm pain and those with equal neck and arm pain after 1- or 2-level ACDF. With regard to return to work, all three groups (arm pain, neck pain, and equal arm and neck pain) were found to be similar after multivariable analysis. The authors' results suggest that predominant pain location, especially predominant neck pain, might be a significant determinant of improvement in functional outcomes and patient satisfaction after ACDF for degenerative spine disease. In addition to confirmation of the common experience that patients with predominant neck pain have worse outcomes, the authors' findings provide potential targets for improvement in patient management for these specific populations.
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http://dx.doi.org/10.3171/2020.12.SPINE202002DOI Listing
July 2021

Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database.

J Neurosurg Spine 2021 May 7:1-9. Epub 2021 May 7.

15Department of Neurological Surgery, University of Utah, Salt Lake City, Utah.

Objective: Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry.

Methods: The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics.

Results: Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance).

Conclusions: The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.
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http://dx.doi.org/10.3171/2020.11.SPINE201442DOI Listing
May 2021

Gonadotroph Pituitary Adenoma Causing Treatable Infertility and Ovarian Hyperstimulation Syndrome in Female Patients: Neurosurgical, Endocrinologic, Gynecologic, and Reproductive Outcomes.

World Neurosurg 2021 Jun 5;150:e162-e175. Epub 2021 Mar 5.

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Background: Gonadotroph pituitary adenoma (Gn-PA) may rarely cause ovarian hyperstimulation syndrome, leading to infertility in women, although this remains poorly described.

Methods: We present a quantitative systematic review including 2 patients from our institutional and 48 from the literature with Gn-PA causing ovarian hyperstimulation syndrome to thoroughly describe the clinical features and therapeutic outcomes from multidisciplinary aspects.

Results: The patients had a mean age of 31.5 years and a mean follicle-stimulating hormone level of 14.4 IU/L. Estradiol level was high in 82% of patients, at >350 pg/mL. The mean maximal adenoma diameter was 22 mm, with a Knosp grade ≥3 in 10 patients. Abdominal surgery preceded adenoma resection in 24 patients (48%). Among 25 patients for whom extent of resection was recorded, total adenoma resection was achieved in 12. Through a mean follow-up of 25 months, adenoma recurrence was observed in 5 patients, who were treated with re-resection (n = 2), radiation (n = 2), and medical therapy followed by bilateral oophorectomy (n = 1). Medical therapies were partially effective or ineffective, and adenoma shrinkage did not follow; gonadotropin-releasing hormone agonists/antagonists were partially effective in 20% of patients (2/10), dopamine agonists in 44% (8/18), and somatostatin analogues in 50% (1/2). Four experienced swelling of tumor/ovaries after gonadotropin-releasing hormone agonists/antagonists administration. Overall, chemical remission was obtained in 26 of 28 patients, normalization of ovaries in 25 of 27, and successful pregnancy in 12 of 14.

Conclusions: Adenoma resection is the main treatment, leading to reduction in ovarian size and biochemical remission, with a high likelihood of subsequent spontaneous pregnancy. Increased awareness of this rare condition may help avoid unnecessary abdominal procedures.
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http://dx.doi.org/10.1016/j.wneu.2021.02.115DOI Listing
June 2021

Determining the Difference in Clinical and Radiologic Outcomes Between Expandable and Nonexpandable Titanium Cages in Cervical Fusion Procedures: A Systematic Review and Meta-Analysis.

World Neurosurg 2021 05 28;149:249-264.e1. Epub 2021 Jan 28.

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

Background: Expandable cages have been increasingly used in cervical and lumbar reconstructions; however, there is a paucity in the literature on how they compare with traditional nonexpandable cages in the cervical spine. We present a systematic review and meta-analysis, comparing the clinical and radiologic outcomes of expandable versus nonexpandable corpectomy cage use in the cervical spine.

Methods: A database search identified studies detailing the outcomes of expandable and nonexpandable titanium cage use in the cervical spine. These studies were screened using the PRISMA protocol. Fixed-effects and random-effects models were used with a 95% confidence interval. Two analyses were carried out for each outcome: one including all studies and the other including only studies reporting on exclusively 1-level and 2-level cases.

Results: Forty-one studies were included. The mean change in segmental lordosis was significantly greater in expandable cages (all, 6.72 vs. 3.69°, P < 0.001; 1-level and 2-level, 6.81° vs. 4.31°, P < 0.001). The mean change in cervical lordosis was also significantly greater in expandable cages (all, 5.71° vs. 3.11°, P = 0.027; 1-level and 2-level, 5.71° vs. 2.07°, P = 0.002). No significant difference was found between the complication rates (all, P = 0.43; 1-level and 2-level, P = 0.94); however, the proportion of revisions was significantly greater in expandable cages (all, 0.06 vs. 0.02, P = 0.03; 1-level and 2-level, 0.08 vs. 0.01, P = 0.017).

Conclusions: The use of expandable cages may carry a modest improvement in radiologic outcomes compared with nonexpandable cages in the cervical spine; however, they may also lead to a higher rate of revisions based on our analyses.
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http://dx.doi.org/10.1016/j.wneu.2021.01.027DOI Listing
May 2021

Rate and Characteristics of Vertebral Artery Injury Following C1-C2 Posterior Cervical Fusion: A Systematic Review and Meta-Analysis.

World Neurosurg 2021 04 28;148:118-126. Epub 2021 Jan 28.

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

Background: Intraoperative vascular injuries in the cervical spine are rare, but carry significant morbidity and mortality when they do occur. There is a need to better characterize the risk of vertebral artery injury (VAI) after posterior C1-C2 fusion. The aim of this study was to investigate the rate of VAI in patients undergoing posterior C1-C2 cervical fusion.

Methods: An electronic database search was performed to identify studies that reported rates of VAI following posterior cervical fusion at C1-C2 level. Patient-specific risk factors, surgical indication, surgical technique, and other data were collected for each study. Forest plots were created to outline the pooled ratios of VAI in the literature.

Results: Eleven studies with 773 patients were identified. Mean age of patients was 48.47 years (range, 6-78 years), and most patients were female (61.7%, n = 399). Trauma was the most frequent indication for surgery (18.8%, n = 146), followed by inflammatory processes affecting the vertebrae (13.2%, n = 102). The rate of VAI per patient was 2% (95% confidence interval = 1%-4%) among 773 patients, while injury rate per screw was 1% (95% confidence interval = 0%-2%) among 2238 screws placed.

Conclusions: The rate of VAI after C1-C2 posterior cervical fusion was found to be 2% for each operated patient and 1% for each screw placed.
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http://dx.doi.org/10.1016/j.wneu.2020.12.165DOI Listing
April 2021

Initiation of a Robotic Program in Spinal Surgery: Experience at a Three-Site Medical Center.

Mayo Clin Proc 2021 05 28;96(5):1193-1202. Epub 2020 Dec 28.

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

Objective: To highlight the early experience of implementing a robotic spine surgery program at a three-site medical center, evaluating the impact of increasing experience on the operative time and number of procedures performed.

Patients And Methods: A retrospective chart review of patients undergoing robotic screw placement between September 4, 2018, and October 16, 2019, was conducted. Baseline characteristics as well as intraoperative and post-operative outcomes were obtained.

Results: For a total of 77 patients, the mean age (SD) was 55.7 years (11.5) and 49.4% (n=38) were female. A total of 402 screws were placed (384 pedicle screws, 18 cortical screws) using robotic guidance with a median of two operative levels (interquartile range [IQR], 1 to 2). Median (IQR) estimated blood loss was 100 mL (50 to 200 mL) and the median (IQR) operative time was 224 minutes (193 to 307 minutes). With accrual of surgical experience, operative time declined significantly (R=-0.39; P<.001) whereas the number of procedures performed per week increased (R=0.30; P=.05) throughout the study period. Median (IQR) length of hospital stay following surgery was 2 days (IQR, 2 to 3 days). There were two screws requiring revision intraoperatively. No postoperative revisions were required, and no complications were encountered related to screw placement.

Conclusion: Early experience at our institution using a spinal robot has demonstrated no requirement for postoperative screw revisions and no complications related to screw malposition. The increased operative times were reduced as the frequency of procedures increased. Moreover, procedural times diminished over a short period with a weekly increasing number of procedures.
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http://dx.doi.org/10.1016/j.mayocp.2020.07.034DOI Listing
May 2021

Minimally Invasive Versus Open Surgery for Degenerative Spine Disorders for Elderly Patients: Experiences from a Single Institution.

World Neurosurg 2021 02 1;146:e1262-e1269. Epub 2020 Dec 1.

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

Background: Minimally invasive surgery (MIS) of the spine has been associated with lower complication rates and improved patient-reported outcomes in recent studies. In this study, we aimed to investigate operative and postoperative outcomes associated with both surgical techniques in elderly patients.

Methods: Patients who are 65 years old or older underwent either minimally invasive or open surgery for lumbar degenerative conditions. Patients with a nondegenerative cause such as infection or trauma were excluded from the analysis. Patient characteristics such as demographics and associated comorbidities as well as perioperative and postoperative complications were collected. Outcomes of interest were operative time, estimated blood loss (EBL), length of stay (LOS), readmissions, reoperations, and any complications.

Results: A total of 107 elderly patients were identified for this study, with a median age of 73.0 years. Demographics and comorbidities in both groups were similar in both groups. Univariate analysis yielded an MIS group with significantly lower EBL (P < 0.001), operative time (P < 0.001), and LOS (P < 0.001). In multivariable analysis, EBL and LOS were found to be significantly lower in the MIS group (P = 0.02 and 0.001, respectively). Rates of complications, readmissions (no readmissions in MIS group), reoperations, and pain improvement also favored the MIS group and although they were not found to be significantly different between the 2 groups on univariate and multivariable analysis, the results trended toward significance.

Conclusions: These findings suggest that minimally invasive spine surgery in the elderly is safe and may pose a lower risk of associated perioperative and postoperative complications with faster recovery time.
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http://dx.doi.org/10.1016/j.wneu.2020.11.145DOI Listing
February 2021

Utility of the 5-Item Modified Frailty Index for Predicting Adverse Outcomes Following Elective Anterior Cervical Discectomy and Fusion.

World Neurosurg 2021 02 3;146:e670-e677. Epub 2020 Nov 3.

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

Background: Frailty is an increasingly studied tool for preoperative risk stratification, but its prognostic value for anterior cervical discectomy and fusion (ACDF) patients is unclear. We sought to evaluate the association of the 5-item modified Frailty Index (5i-mFI) with 30-day adverse outcomes following ACDF and its predictive performance compared with other common metrics.

Methods: The National Surgical Quality Improvement Program was queried from 2016-2018 for patients undergoing elective ACDF for degenerative diseases. Outcomes of interest included 30-day complications, extended length of stay (LOS), non-home discharge, and unplanned readmissions. Unadjusted/adjusted odds ratios were calculated. The discriminatory performance of the 5i-mFI compared with age, American Society of Anesthesiologists (ASA) classification, and body mass index was computed using the area under the receiver operating characteristic curve (AUC).

Results: A total of 23,754 patients were identified. On adjusted analysis, an index of 1 was significantly associated with extended LOS, non-home discharge, and unplanned readmissions (P < 0.001, P = 0.023, P = 0.003, respectively), but not complications (all P > 0.05). An index ≥2 was significantly associated with each outcome (all P < 0.001). The 5i-mFI was found to have a significantly higher AUC than body mass index for each outcome, a similar AUC compared with ASA classification and age for complications and unplanned readmissions, and a significantly lower AUC than ASA classification and age for extended LOS and non-home discharge.

Conclusions: The 5i-mFI was found to be significantly associated with 30-day adverse outcomes following ACDF but had similar or lesser predictive performance compared with more universally available and easily implemented metrics, such as ASA classification and age.
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http://dx.doi.org/10.1016/j.wneu.2020.10.154DOI Listing
February 2021

Early and sustained improvements in motor function in rats after infusion of allogeneic umbilical cord-derived mesenchymal stem cells following spinal cord injury.

Spinal Cord 2021 Mar 2;59(3):319-327. Epub 2020 Nov 2.

Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA.

Study Design: Animal study.

Objectives: Umbilical cord-derived mesenchymal stem cells (UC-MSCs) have recently been shown to hold great therapeutic potential for spinal cord injury (SCI). However, majority of the studies have been done using human cells transplanted into the rat with immunosuppression; this may not represent the outcomes that occur in humans. Herein, we present the therapeutic effect of using rat UC-MSCs (rUC-MSC) without immunosuppression in a rat model of SCI.

Setting: Mayo Clinic, Rochester, MN, USA.

Methods: Twelve female rats were randomly divided into two groups, control, and rUC-MSC group, and then subjected to a T9 moderate contusion SCI. Next, 2 × 10 rUC-MSCs or ringer-lactate solution were injected through the tail vein at 7 days post injury. Rats were assessed for 14 weeks by an open-field Basso, Beattie, and Bresnahan (BBB) motor score as well as postmortem quantification of axonal sparing/regeneration, cavity volume, and glial scar.

Results: Animals treated with rUC-MSCs were found to have early and sustained motor improvement (BBB score of 14.6 ± 1.9 compared to 10.1 ± 1.7 in the control group) at 14 weeks post injury (mean difference: 4.55, 95% CI: 2.04 to 7.06; p value < 0.001). Total cavity volume in the injury epicenter was significantly reduced in the rUC-MSC group; control: 33.0% ± 2.1, rUC-MSC: 25.3% ± 3.8 (mean difference: -7.7% (95% CI: -12.3 to -2.98); p value < 0.05). In addition, spinal cords from rats treated with rUC-MSCs were found to have a significantly greater number of myelinated axons, decreased astrogliosis, and reduced glial scar formation compared to control rats.

Conclusions: Our study indicates that intravenous injection of allogenic UC-MSCs without immunosuppression exert beneficial effects in subacute SCI and thus could be a useful therapy to improve the functional capacity among patients with SCI.
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http://dx.doi.org/10.1038/s41393-020-00571-8DOI Listing
March 2021

Is postoperative atelectasis following lumbar fusion more prevalent among patients with chronic opioid use?

Clin Neurol Neurosurg 2020 12 14;199:106308. Epub 2020 Oct 14.

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

Objective: Chronic opioid use (COU) remains on the rise globally, acting as a marker for patient morbidity and a risk factor for adverse health outcomes. Opioid use is a risk factor for respiratory depression, which may lead to dysfunctional breathing, a known cause of atelectasis. The objective of this study was to determine whether COU is associated with increased rates of postoperative atelectasis among patients undergoing lumbar fusion.

Materials & Methods: Three State Inpatient Databases were used to identify patients who underwent an elective lumbar fusion through an anterior, posterior or circumferential approach in Florida, Kentucky and New York between 2013-2015. Patients with COU and those with postoperative atelectasis were identified using ICD diagnosis codes. Three operative groups were created and subsequently matched using propensity scores in order to provide comparable cohorts for analysis. Three-to-one propensity score matching was conducted using the variables of age, sex, race, number of chronic diagnoses and geographic state of admission. Multivariable logistic regressions were used to examine the relationship between COU and postoperative atelectasis.

Results: A total of 3618 lumbar fusions were identified. Atelectasis was noted in 1.33 % of NCOU patients and 2.32 % of COU patients. On multivariable analysis, while controlling for the Elixhauser Mortality Index and patient insurance status, COU was significantly associated with atelectasis in posterior lumbar fusion (OR = 2.27; CI: 1.09-4.72; p = 0.028) and circumferential lumbar fusion (OR = 4.68; CI: 1.52-14.45; p = 0.007). The Elixhauser Mortality Index was also significantly associated with atelectasis in posterior lumbar fusion (OR = 1.08; CI: 1.04-1.11; p < 0.001) and circumferential lumbar fusion (OR = 1.09; CI: 1.03-1.16; p = 0.002).

Conclusion: Higher rates of postoperative atelectasis were found among patients with COU following posterior and circumferential lumbar fusions. The Elixhauser Mortality Index was also independently associated with atelectasis. Knowledge of these risks may allow for earlier identification and intervention in patients who are at risk.
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http://dx.doi.org/10.1016/j.clineuro.2020.106308DOI Listing
December 2020

Use of teriparatide prior to lumbar fusion surgery lowers two-year complications for patients with poor bone health.

Clin Neurol Neurosurg 2020 11 21;198:106244. Epub 2020 Sep 21.

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

Introduction: Poor bone health can create challenges in management which are amplified for patients undergoing spinal fusion. Although previously shown to improve outcomes postoperatively, the impact of preoperative teriparatide use on long-term complications remains unclear. In this study, we investigated the complication rates within two years of surgery for osteoporotic and osteopenic patients using teriparatide prior to lumbar fusion procedures.

Methods: Patients with poor bone health undergoing any lumbar fusion surgery at a single institution between 2008 and 2018 were identified and subsequently divided into two groups as teriparatide and non-teriparatide group. Baseline demographics, patient and surgery related factors, and two-year complications were collected through a retrospective chart review. Multivariable logistic regression was performed to evaluate the association between teriparatide usage and development of any related postoperative complication.

Results: A total of 42 and 114 patients were identified for the teriparatide and non-teriparatide groups, respectively. The median age (IQR) for the teriparatide group was 62 years (55.8-68.8), while the non-teriparatide group had a median (IQR) age of 70 years (64-75.8). Overall, there were no statistically significant differences in terms of individual complications between the groups. However, on adjusted regression analysis, teriparatide use was associated with significantly lower odds of related complications for lumbar fusion patients (p = 0.049).

Conclusion: Teriparatide use prior to lumbar fusion procedures resulted in reduced rate of osteoporosis-related complications within two years postoperatively. Results suggest improved outcomes might be seen in patients with osteopenia and osteoporosis when pre-treating with teriparatide.
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http://dx.doi.org/10.1016/j.clineuro.2020.106244DOI Listing
November 2020

Does Hospital Teaching Status Affect the Outcomes of Patients Undergoing Anterior Cervical Discectomy and Fusion?

World Neurosurg 2020 12 2;144:e395-e404. Epub 2020 Sep 2.

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

Background: Teaching hospitals are responsible for the training and education of residents and have been centers of research and advancement in an era of evidence-based medicine. Several studies have reported conflicting findings regarding the effects of teaching status on the outcomes of patients. In the present study, we aimed to identify the differences in surgical outcomes among patients who had undergone anterior cervical discectomy and fusion (ACDF) between teaching and nonteaching hospitals.

Methods: We queried the National Inpatient Sample for 2012-2015. We identified patients with cervical degenerative disease who had undergone single-level ACDF using the International Classification of Disease, 9th revision, diagnosis and procedure codes. One-to-one propensity score matching was conducted, using appropriate and clinically relevant variables. Stepwise multivariable logistic regression was performed to assess the effect of teaching status on the outcomes of interest. Finally, a marginal effect analysis was conducted to compare the differences in admission costs stratified by teaching status within each insurance type.

Results: A total of 52,212 patients who had undergone elective ACDF from 2012 to 2015 were identified and matched, with 26,106 patients in each group. On multivariable regression, after adjusting for demographics and hospital characteristics, teaching hospitals were associated with greater odds of nonroutine discharge (odds ratio, 1.25; P < 0.001) and higher admission cost (coefficient, 414.31; P = 0.002). However, teaching status was not associated with inpatient mortality or morbidity. The marginal effect analysis results indicated that privately insured patients incurred greater costs in nonteaching hospitals.

Conclusion: Our results have shown that patients undergoing ACDF at nonteaching hospitals had a greater odds of routine discharge and higher admission costs compared with those at teaching hospitals but similar outcomes in terms of inpatient mortality and morbidity.
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http://dx.doi.org/10.1016/j.wneu.2020.08.164DOI Listing
December 2020

Chronic opioid use is associated with increased postoperative urinary retention, length of stay and non-routine discharge following lumbar fusion surgery.

Clin Neurol Neurosurg 2020 10 19;197:106161. Epub 2020 Aug 19.

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

Background: The incidence of chronic opioid use (COU) is increasing with health related complications impacting both patients and healthcare services.

Objective: The aim of this study was to identify the impact of COU on postoperative urinary retention (PUR) in patients following lumbar fusion surgery as well as its impact on length of stay (LOS) and non-routine discharges (NRD).

Materials & Methods: The State Inpatient Databases were utilised to identify patients undergoing elective lumbar fusion procedures. Patients with and without COU were separated into groups and matched using 3:1 propensity score matching. PUR, LOS in the upper quartile and discharge to a location other than home were the outcomes of interest. Multivariable logistic regression was used to examine the impact of COU on the above outcomes and Wald chi-square tests were used to determine the factors with the most significant associations.

Results: COU was significant for PUR (p = 0.037), prolonged LOS (p < 0.001), and NRD (p < 0.001). Factors most significantly associated with PUR were Elixhauser Mortality Index and COU both with p < 0.05. Factors associated with prolonged LOS and NRD were Elixhauser Mortality Index, COU, and insurance status.

Conclusion: COU has a notable impact on PUR, LOS, and NRD. The Elixhauser Mortality Index and insurance status of patients also showed predictive utility for these outcomes. This knowledge enables us to identify sources of pressure for health services and approach them strategically through increased awareness.
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http://dx.doi.org/10.1016/j.clineuro.2020.106161DOI Listing
October 2020

Patients with a depressive and/or anxiety disorder can achieve optimum Long term outcomes after surgery for grade 1 spondylolisthesis: Analysis from the quality outcomes database (QOD).

Clin Neurol Neurosurg 2020 10 17;197:106098. Epub 2020 Jul 17.

Department of Neurologic Surgery, University of Michigan, Ann Arbor, Michigan, United States.

Introduction: In the current study, we sought to compare baseline demographic, clinical, and operative characteristics, as well as baseline and follow-up patient reported outcomes (PROs) of patients with any depressive and/or anxiety disorder undergoing surgery for low-grade spondylolisthesis using a national spine registry.

Patients And Methods: The Quality Outcomes Database (QOD) was queried for patients undergoing surgery for Meyerding grade 1 lumbar spondylolisthesis undergoing 1-2 level decompression or 1 level fusion at 12 sites with the highest number of patients enrolled in QOD with 2-year follow-up data.

Results: Of the 608 patients identified, 25.6 % (n = 156) had any depressive and/or anxiety disorder. Patients with a depressive/anxiety disorder were less likely to be discharged home (p < 0.001). At 3=months, patients with a depressive/anxiety disorder had higher back pain (p < 0.001), lower quality of life (p < 0.001) and higher disability (p = 0.013); at 2 year patients with depression and/or anxiety had lower quality of life compared to those without (p < 0.001). On multivariable regression, depression was associated with significantly lower odds of achieving 20 % or less ODI (OR 0.44, 95 % CI 0.21-0.94,p = 0.03). Presence of an anxiety disorder was not associated with decreased odds of achieving that milestone at 3 months. The presence of depressive-disorder, anxiety-disorder or both did not have an impact on ODI at 2 years. Finally, patient satisfaction at 2-years did not differ between the two groups (79.8 % vs 82.7 %,p = 0.503).

Conclusion: We found that presence of a depressive-disorder may impact short-term outcomes among patients undergoing surgery for low grade spondylolisthesis but longer term outcomes are not affected by either a depressive or anxiety disorder.
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http://dx.doi.org/10.1016/j.clineuro.2020.106098DOI Listing
October 2020

Comparison of Costs and Postoperative Outcomes between Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Compression Fractures: Analysis from a State-Level Outpatient Database.

World Neurosurg 2020 09 10;141:e801-e814. Epub 2020 Jun 10.

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

Background: Vertebral cement augmentation techniques are routinely used to treat osteoporotic vertebral compression fractures (VCFs). In the current study, we used a state-level outpatient database to compare costs and postoperative outcomes between vertebroplasty and kyphoplasty.

Methods: We queried the 2016 Florida State-Ambulatory Surgery Database of the Healthcare Cost and Utilization Project for patients undergoing thoracolumbar vertebroplasty or kyphoplasty for osteoporotic VCFs. Demographic and clinical characteristics, as well as postoperative outcomes were compared between the 2 groups.

Results: A total of 105 patients (11.6%) who underwent vertebroplasty and 801 patients (88.4%) who underwent kyphoplasty were identified. Patients undergoing kyphoplasty were more likely to stay overnight or longer, with the P value trending toward significance (kyphoplasty with >1 day stay: 7.4% vs. vertebroplasty with >1 day stay: 1.9%; P = 0.086). Patients undergoing vertebroplasty had a significantly higher rate of discharge to home routine compared with patients undergoing kyphoplasty (97.1% [n = 102] vs. 94.1% [n = 754]; P < 0.001). Undergoing kyphoplasty was also associated with higher index admission costs ($40,706 vs. $18,965; P < 0.001) and higher readmission costs ($27,038 vs. $11,341; P = 0.046). The rates of 30-day and 90-day readmission were similar between the 2 groups (all P > 0.05). The rates of 30-day, 90-day, and overall readmission because of a new-onset fracture were also similar (all P > 0.05). However, vertebroplasty had a higher rate of readmissions associated with a procedure within a year (21.9% [n = 23] vs. 14.5% [n = 116]; P = 0.047).

Conclusions: Our analyses from a state-level database of patients undergoing vertebroplasty and kyphoplasty for osteoporotic VCFs show similar postoperative outcomes for the 2 procedures but a higher cost for kyphoplasty.
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http://dx.doi.org/10.1016/j.wneu.2020.06.008DOI Listing
September 2020

Improved 3-year survival rates for glioblastoma multiforme are associated with trends in treatment: analysis of the national cancer database from 2004 to 2013.

J Neurooncol 2020 May 3;148(1):69-79. Epub 2020 May 3.

Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA.

Purpose: Glioblastoma multiforme (GBM) is a common and aggressive malignancy associated with poor prognosis. Characteristics and treatment of long-term survivors are of particular interest in efforts to improve outcomes. Therefore, the objective of this study was to examine trends and prognostic factors for 3-year survival from a national database.

Methods: The National Cancer Database (NCDB) was queried for patients diagnosed with cranial GBM from 2004 to 2013 and with 3-year follow-up. Trends in 3-year and overall survival, patient characteristics, tumor properties, and treatment modalities were examined. Multivariable logistic regression was utilized to investigate the association of these factors with 3-year survival. Predictor importance analysis was conducted using a metric defined as Wald χ penalized by degrees of freedom.

Results: A total of 88,919 GBM patients with 3-year follow-up were identified. Overall, 8757 (9.8%) patients survived ≥ 3 years. Three-year survival significantly improved from 8.0 to 10.5% (p < 0.001) from 2004 to 2013. Trimodal treatment administration also significantly increased from 38.7 to 55.9% (p < 0.001). During this span, patients increasingly presented as older (p = 0.040), without private insurance (p < 0.001), and with a higher comorbidity index (p < 0.001). On multivariable regression, factors such as trimodal treatment (p < 0.001), younger age (p < 0.001), and MGMT methylation (p < 0.001) were significantly associated with increased odds of 3-year survival. Predictor importance analysis indicated that MGMT methylation, age, and treatment modality were the most significant relative determinants of 3-year survival.

Conclusion: These findings illustrate an improved 3-year survival rate for GBM patients from 2004 to 2013 with a concurrent increase in trimodal treatment administration despite more adverse patient presenting characteristics.
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http://dx.doi.org/10.1007/s11060-020-03469-wDOI Listing
May 2020

Quality Outcomes Database Spine Care Project 2012-2020: milestones achieved in a collaborative North American outcomes registry to advance value-based spine care and evolution to the American Spine Registry.

Neurosurg Focus 2020 05;48(5):E2

4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.

The Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality Outcomes Database (N2QOD), was established by the NeuroPoint Alliance (NPA) in collaboration with relevant national stakeholders and experts. The overarching goal of this project was to develop a centralized, nationally coordinated effort to allow individual surgeons and practice groups to collect, measure, and analyze practice patterns and neurosurgical outcomes. Specific objectives of this registry program were as follows: "1) to establish risk-adjusted national benchmarks for both the safety and effectiveness of neurosurgical procedures, 2) to allow practice groups and hospitals to analyze their individual morbidity and clinical outcomes in real time, 3) to generate both quality and efficiency data to support claims made to public and private payers and objectively demonstrate the value of care to other stakeholders, 4) to demonstrate the comparative effectiveness of neurosurgical and spine procedures, 5) to develop sophisticated 'risk models' to determine which subpopulations of patients are most likely to benefit from specific surgical interventions, and 6) to facilitate essential multicenter trials and other cooperative clinical studies." The NPA has launched several neurosurgical specialty modules in the QOD program in the 7 years since its inception including lumbar spine, cervical spine, and spinal deformity and cerebrovascular and intracranial tumor. The QOD Spine modules, which are the primary subject of this paper, have evolved into the largest North American spine registries yet created and have resulted in unprecedented cooperative activities within our specialty and among affiliated spine care practitioners. Herein, the authors discuss the experience of QOD Spine programs to date, with a brief description of their inception, some of the key achievements and milestones, as well as the recent transition of the spine modules to the American Spine Registry (ASR), a collaboration between the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons (AAOS).
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http://dx.doi.org/10.3171/2020.2.FOCUS207DOI Listing
May 2020

Lumbar intervertebral disc mRNA sequencing identifies the regulatory pathway in patients with disc herniation and spondylolisthesis.

Gene 2020 Aug 30;750:144634. Epub 2020 Mar 30.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States; Department of Biochemistry & Molecular Biology, Mayo Clinic, Rochester, MN, United States. Electronic address:

Lumbar degenerative disc disease (DDD) is a multifaceted progressive condition and often accompanied by disc herniation (DH) and/or degenerative spondylolisthesis (DS). Given the high prevalence of the disease (up to 20% according to some estimates) and the high costs associated with its care, there is a need to explore novel therapies such as regenerative medicine. Exploring these novel therapies first warrants investigation of molecular pathways underlying these disorders. Here, we show results from next generation RNA sequencing (RNA-seq) on mRNA isolated from 10 human nucleus pulposus (NP) samples of lumbar degenerated discs (DH and DS; n = 5 for each tissue) and other musculoskeletal tissues (Bone, cartilage, growth plate, and muscle; n = 7 for each tissue). Pathway and network analyses based on gene ontology (GO) terms were used to identify the biological functions of differentially expressed mRNAs. A total of 701 genes were found to be significantly upregulated in lumbar NP tissue compared to other musculoskeletal tissues. These differentially expressed mRNAs were primarily involved in DNA damage, immunity and G1/S transition of mitotic cell cycle. Interestingly, DH-specific signaling genes showed major network in chemotactic (e.g., CXCL10, CXCL11, IL1RL2 and IL6) and matrix-degrading pathway (e.g., MMP16, ADAMTSL1, 5, 8, 12, and 15), while DS-specific signaling genes were found to be those involved in cell adhesion (e.g., CDH1, EPHA1 and EFNA2) and inflammatory cytokines (e.g., CD19, CXCL5, CCL24, 25 and XCL2). Our findings provide new leads for therapeutic drug discovery that would permit optimization of medical or pharmacological intervention for cases of lumbar DDD.
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http://dx.doi.org/10.1016/j.gene.2020.144634DOI Listing
August 2020

Predictors of Neurological Outcome Following Subaxial Cervical Spine Trauma.

Cureus 2019 Dec 17;11(12):e6402. Epub 2019 Dec 17.

Neurosurgery, University of Pennsylvania, Philadelphia, USA.

Background The treatment of traumatic subaxial cervical spine injuries remains controversial. The American Spinal Injury Association (ASIA) impairment scale (AIS) is a widely-used metric to score neurological function after spinal cord injury (SCI). Here, we evaluated the outcomes of patients who underwent treatment of subaxial cervical spine injuries to identify predictors of neurologic function after injury and treatment. Methods We performed a retrospective logistic regression analysis to determine predictors of neurological outcome; 76 patients met the inclusion criteria and presented for a three-month follow-up. The mean age was 50.6±18.7 years old and the majority of patients were male (n=49, 64%). Results The majority of patients had stable AIS scores at three months (n=56, 74%). A subset of patients showed improvement at three months (n=16, 21%), while a small subset of patients had neurological decline at three months (n=4, 5%). In our model, increasing patient age (odds ratio [OR] 1.39, 1.10-2.61 95% confidence interval [CI], P<0.001) and a previous or current diagnosis of cancer (OR 22.4, 1.25-820 95% CI, P=0.04) significantly increased the odds of neurological decline at three months. In patients treated surgically, we found that delay in surgical treatment (>24 hours) was associated with a decreased odds of neurological improvement (OR 0.24, 0.05-0.99 95% CI, P=0.048). Cervical spine injuries are heterogeneous and difficult to manage. Conclusion We found that increasing patient age and an oncologic history were associated with neurological deterioration while a delay in surgical treatment was associated with decreased odds of improvement. These predictors of outcome may be used to guide prognosis and treatment decisions.
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http://dx.doi.org/10.7759/cureus.6402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964960PMC
December 2019

The T2-FLAIR-mismatch sign as an imaging biomarker for IDH and 1p/19q status in diffuse low-grade gliomas: a systematic review with a Bayesian approach to evaluation of diagnostic test performance.

Neurosurg Focus 2019 12;47(6):E13

1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota; and.

Objective: With the revised WHO 2016 classification of brain tumors, there has been increasing interest in imaging biomarkers to predict molecular status and improve the yield of genetic testing for diffuse low-grade gliomas (LGGs). The T2-FLAIR-mismatch sign has been suggested to be a highly specific radiographic marker of isocitrate dehydrogenase (IDH) gene mutation and 1p/19q codeletion status in diffuse LGGs. The presence of T2-FLAIR mismatch indicates a T2-hyperintense lesion that is hypointense on FLAIR with the exception of a hyperintense rim.

Methods: In accordance with PRISMA guidelines, we performed a systematic review of the Ovid Medline, Embase, Scopus, and Cochrane databases for reports of studies evaluating the diagnostic performance of T2-FLAIR mismatch in predicting the IDH and 1p/19q codeletion status in diffuse LGGs. Results were combined into a 2 × 2 format, and the following diagnostic performance parameters were calculated: sensitivity, specificity, positive predictive value, negative predictive value, and positive (LR+) and negative (LR-) likelihood ratios. In addition, we utilized Bayes theorem to calculate posttest probabilities as a function of known pretest probabilities from previous genome-wide association studies and the calculated LRs. Calculations were performed for 1) IDH mutation with 1p/19q codeletion (IDHmut-Codel), 2) IDH mutation without 1p/19q codeletion (IDHmut-Noncodel), 3) IDH mutation overall, and 4) 1p/19q codeletion overall. The QUADAS-2 (revised Quality Assessment of Diagnostic Accuracy Studies) tool was utilized for critical appraisal of included studies.

Results: A total of 4 studies were included, with inclusion of 2 separate cohorts from a study reporting testing and validation (n = 746). From pooled analysis of all cohorts, the following values were obtained for each molecular profile-IDHmut-Codel: sensitivity 30%, specificity 73%, LR+ 1.1, LR- 1.0; IDHmut-Noncodel: sensitivity 33.7%, specificity 98.5%, LR+ 22.5, LR- 0.7; IDH: sensitivity 32%, specificity 100%, LR+ 32.1, LR- 0.7; 1p/19q codeletion: sensitivity 0%, specificity 54%, LR+ 0.01, LR- 1.9. Bayes theorem was used to calculate the following posttest probabilities after a positive and negative result, respectively-IDHmut-Codel: 32.2% and 29.4%; IDHmut-Noncodel: 95% and 40%; IDH: 99.2% and 73.5%; 1p/19q codeletion: 0.4% and 35.1%.

Conclusions: The T2-FLAIR-mismatch sign is an insensitive but highly specific marker of IDH mutation but not 1p/19q codeletion in diffuse LGGs, although there may be significant exceptions. These findings support the utility of T2-FLAIR mismatch as an imaging-based biomarker for positive selection of patients with IDH-mutant gliomas.
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http://dx.doi.org/10.3171/2019.9.FOCUS19660DOI Listing
December 2019

Novel Intervertebral Technologies.

Neurosurg Clin N Am 2020 Jan 15;31(1):49-56. Epub 2019 Oct 15.

Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Charlton building, Room 6-124, 201 West Center Street, Rochester, MN 55902, USA.

Surgical procedures, such as spinal fusion and disk replacement, are commonly used for treatment following failure of conservative treatment in degenerative spine disease. However, there is growing consensus that currently available surgical technologies may have long-term inefficacy for successful management. Intervertebral disk degeneration is the most common manifestation of degenerative spine disease, hence, replacement/repair of this tissue is an important component of surgical treatment. Restoration of spinal alignment and preservation of natural kinematics is also essential to a good outcome. This article reviews novel intervertebral implant technologies that have the potential to significantly impact elective spine surgery for degenerative spine disease.
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http://dx.doi.org/10.1016/j.nec.2019.08.006DOI Listing
January 2020

Cost of Readmissions Following Anterior Cervical Discectomy and Fusion: Insights from the Nationwide Readmissions Database.

Neurosurgery 2020 09;87(4):679-688

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

Background: Postoperative readmissions are a significant driver of variation in bundled care costs associated with cervical spine surgery.

Objective: To determine the factors predicting the cost of readmission episodes following elective anterior cervical discectomy and fusion (ACDF).

Methods: We queried the Healthcare Cost and Utilization Project Nationwide Readmissions Database for patients undergoing elective ACDF during 2012 to 2015. Multivariable linear regression was performed to establish the factors associated with the cost of each 30-/90-d readmission episode.

Results: A total of 139 877 and 113 418 patients met inclusion criteria for the evaluation of 30- and 90-d readmissions, respectively. Among these, the national rates of 30- and 90-d readmission after an elective ACDF were 3% and 6%, respectively. The median cost of a 30- and 90-d readmission episode was $6727 (IQR: $3844-$13 529) and $8507 (IQR: $4567-$17 460), respectively. Relative predictor importance analysis revealed that the number of procedures at index admission (IA), length of stay at IA, and time elapsed between index surgical admission and readmission were the top predictors of both 30- and 90-d readmission costs (all P < .001). Although cervical myelopathy accounted for only 3.6% of all 30-d readmissions, it accounted for the largest share (8%) of 30-d readmission costs.

Conclusion: In this analysis from a national all-payer database, we determined the factors associated with the cost of readmissions following elective ACDF. These results are important in assisting policymakers and payers with a better risk adjustment in bundled care payment systems and for surgeons in implementing readmission cost-reduction efforts.
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http://dx.doi.org/10.1093/neuros/nyz443DOI Listing
September 2020

Endoscopic versus open approach in craniosynostosis repair: a systematic review and meta-analysis of perioperative outcomes.

Childs Nerv Syst 2018 09 30;34(9):1627-1637. Epub 2018 Jun 30.

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

Introduction: Surgery for craniosynostosis remains a crucial element in successful management. Intervention by both endoscopic and open approaches has been proven effective. Given the differences in timing and indications for these procedures, differences in perioperative outcomes have yet to be thoroughly compared between the two approaches. The aim of the systematic review and meta-analysis was to assess the available evidence of perioperative outcomes between the two approaches in order to better influence the management paradigm of craniosynostosis.

Methods: We followed recommended PRISMA guidelines for systematic reviews. Seven electronic databases were searched to identify all potentially relevant studies published from inception to February 2018 which were then screened against a set of selection criteria. Data were extracted and analyzed using meta-analysis of proportions.

Results: Twelve studies satisfied all the selection criteria to be included, which described a pooled cohort involving 2064 craniosynostosis patients, with 965 (47%) and 1099 (53%) patients undergoing surgery by endoscopic and open approaches respectively. When compared to the open approach, it was found that the endoscopic approach conferred statistically significant reductions in blood loss (MD = 162.4 mL), operative time (MD = 112.38 min), length of stay (MD = 2.56 days), and rates of perioperative complications (OR = 0.58), reoperation (OR = 0.37) and transfusion (OR = 0.09), where all p < 0.001.

Conclusion: Both endoscopic and open approaches for the surgical management of craniosynostosis are viable considerations. The endoscopic approach confers a significant reduction in operative and postoperative morbidity when compared to the open approach. Given that specific indications for either approach should be considered when managing a patient, the difference in perioperative outcomes remain an important element of this paradigm. Future studies will validate the findings of this study and consider long-term outcomes, which will all contribute to rigor of craniosynostosis management.
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http://dx.doi.org/10.1007/s00381-018-3852-4DOI Listing
September 2018
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