Publications by authors named "Zach Pennington"

107 Publications

Plastic surgery wound closure following resection of spinal metastases.

Clin Neurol Neurosurg 2021 Jul 9;207:106800. Epub 2021 Jul 9.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA. Electronic address:

Objective: Surgical site infection and dehiscence are devastating complications of surgery for spinal metastases. Wound closure involving plastic surgeons has been proposed as a strategy to lower post-operative complications. Here we investigated whether plastic surgery closure is associated with lower rates of wound complications, wound infection, and wound reoperation compared to simple closure by spine surgeons.

Methods: Patients surgically treated for metastatic tumors at a single comprehensive cancer center between April 2013-2020 were retrospectively identified. Primary pathology, demographic information, clinical characteristics, pre-operative laboratory values, tumor location, operative characteristics, and post-operative outcomes were collected. Univariable analyses used student t-tests for continuous variables and χ tests for categorical variables. Multivariable regressions were performed to control for confounders.

Results: We included 317 patients, of which 56 underwent closure by plastic surgeons and 291 by neurosurgeons. Patients in the plastic surgery cohort were more likely to have received prior radiation to the surgical site, more often on long-term corticosteroid therapy, and more likely to have sacrococcygeal tumors. Operations involving plastic surgeons were more likely to be revision surgeries, corpectomies, and to involve a staged approach. Additionally, patients in the plastic surgery cohort had longer incision lengths, longer surgeries, greater intraoperative blood loss (IOBL), were more likely to receive transfusions, and had longer hospitalizations. Local paraspinous advancement flaps were the most common complex wound closure technique. Plastic surgery closure was not significantly associated with a difference in rates of post-operative wound complications, wound infection, or wound-related reoperations compared to simple wound closure.

Conclusion: We identified that patients undergoing plastic surgery wound closure had worse baseline risk, longer surgeries, greater IOBL, and longer hospitalizations compared to patients receiving simple closure. Despite their increased risk, complex wound closure did not significantly alter the rates of post-operative wound complications, wound infection, or wound-related reoperations. Consideration may be given to plastic surgery closure in patients at high risk of wound complications or with extensive wound defects.
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http://dx.doi.org/10.1016/j.clineuro.2021.106800DOI Listing
July 2021

Interrater and Intra-rater Reliability of the Vertebral Bone Quality Score.

World Neurosurg 2021 Jul 9. Epub 2021 Jul 9.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY USA 11030. Electronic address:

Background: Vertebral bone quality had a significant impact on postoperative outcomes in spinal fusion surgery. New MRI-based measures, such as the Vertebral Bone Quality (VBQ) score may allow for bone quality assessment without the radiation associated with conventional testing. In the present study, we sought to assess the intra- and interrater reliability of VBQ scores calculated by medical professionals and trainees.

Methods: Thirteen reviewers of various specialties and levels of training were recruited and asked to calculate VBQ scores for 30 patients at two time points separated by 2-months. Scored volumes were acquired from patients treated for both degenerative and oncologic indications. Intra-rater and interrater agreement, quantified by intraclass correlation coefficient (ICC), was assessed using two-way random effects modeling. Square-weight Cohen's κ and Kendall's Tau-b were used to determine whether raters assigned similar scores during both evaluations.

Results: All raters showed moderate to excellent reliability for VBQ score (ICC 0.667-0.957; κ0.648-0.921) and excellent reliability for all constituent components used to calculate VBQ score (ICC all ≥0.97). Interrater reliability was also found to be good for VBQ score on both the first (ICC=0.818) and second (ICC=0.800) rounds of assessment; scores for the constituent component all had ICC values ≥0.97 for the constituent components.

Conclusions: The VBQ score appears to have both good intra-rater and interrater reliability. Additionally, there appeared to be no correlation between score reliability and level of training. External validation and further investigations of its ability to accurately model bone biomechanical properties are necessary.
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http://dx.doi.org/10.1016/j.wneu.2021.07.020DOI Listing
July 2021

Removal of instrumentation for postoperative spine infection: systematic review.

J Neurosurg Spine 2021 Jul 9:1-13. Epub 2021 Jul 9.

Objective: Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient's spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation.

Methods: PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction.

Results: Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections.

Conclusions: The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.
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http://dx.doi.org/10.3171/2020.12.SPINE201300DOI Listing
July 2021

Impact of Multidisciplinary Intraoperative Teams on Thirty-Day Complications After Sacral Tumor Resection.

World Neurosurg 2021 Jun 16. Epub 2021 Jun 16.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Objective: To evaluate the impact of multidisciplinary intraoperative teams on surgical complications in patients undergoing sacral tumor resection.

Methods: We reviewed all patients with primary or metastatic sacral tumors managed at a single comprehensive cancer center over a 7-year period. Perioperative complication rates were compared between those treated by an unassisted spinal oncologist and those treated with the assistance of at least 1 other surgical specialty. Statistical analysis involved univariable and stepwise multivariable logistic regression models to identify predictors of multidisciplinary management and 30-day complications.

Results: A total of 107 patients underwent 132 operations for sacral tumors; 92 operations involved multidisciplinary teams, including 54% of metastatic tumor operations and 74% of primary tumor operations. Patients receiving multidisciplinary management had higher body mass indexes (29.8 vs. 26.3 kg/m; P = 0.008), larger tumors (258 vs. 55 cm³; P < 0.001), and higher American Society of Anesthesiologists scores (3 vs. 2; P = 0.049). Only larger tumor volume (odds ratio [OR], 1.007 per cm³; P < 0.001) and undergoing treatment for a malignant primary versus a metastatic tumor (OR, 23.4; P < 0.001) or benign primary tumor (OR, 29.3; P < 0.001) were predictive of multidisciplinary management. Although operations involving multidisciplinary teams were longer (467 vs. 231 minutes; P < 0.001) and had higher blood loss (1698 vs. 774 mL; P = 0.004), 30-day complication rates were similar (37 vs. 27%; P = 0.39). On multivariable analysis, only larger tumor volume (OR, 1.004 per cm³; P = 0.005) and longer surgical duration (OR, 1.002 per minute; P = 0.03) independently predicted higher 30-day complications.

Conclusions: Although patients managed with multidisciplinary teams had larger tumors and worse baseline health, 30-day complications were similar. This finding suggests that the use of multidisciplinary teams may help to mitigate surgical morbidity in those with high baseline risk.
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http://dx.doi.org/10.1016/j.wneu.2021.06.040DOI Listing
June 2021

Commentary: Present and Future Spinal Robotic and Enabling Technologies.

Oper Neurosurg (Hagerstown) 2021 06;21(Suppl 1):S57-S58

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1093/ons/opaa405DOI Listing
June 2021

Giant Myxoid Spindle Cell Neoplasm Presenting with Abdominal Swelling and Concurrent Weight Loss.

World Neurosurg 2021 May 28;152:1-2. Epub 2021 May 28.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA. Electronic address:

Retroperitoneal sarcomas may grow extremely large before becoming clinically symptomatic, and curative resection often has high associated morbidity. An 83-year-old man presented with insidious-onset abdominal pain and weight loss owing to a 16.3 × 13.1 × 25.8-cm retroperitoneal high-grade myxoid spindle cell sarcoma. The patient was ultimately deemed to be unfit for surgery before rapidly succumbing to his disease. This case illustrates both the indolent growth seen in these lesions and the importance of proper patient selection. Older patients with large, high-grade lesions and multiple associated comorbidities are often poor surgical candidates, as the associated surgical morbidity outweighs the potential survival benefit. While the ultimate treatment plan relies on shared decision making by the patient and the healthcare provider, the decision to pursue surgical intervention should take into consideration the patient's broader clinical condition.
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http://dx.doi.org/10.1016/j.wneu.2021.05.084DOI Listing
May 2021

Radiotherapy and Surgical Advances in the Treatment of Metastatic Spine Tumors: A Narrative Review.

World Neurosurg 2021 Jul 21;151:147-154. Epub 2021 May 21.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA. Electronic address:

Spine tumors encompass a wide range of diseases with a commensurately broad spectrum of available treatments, ranging from radiation for spinal metastases to highly invasive en bloc resection for primary vertebral column malignancies. This high variability in treatment approaches stems both from variability in the goals of surgery (e.g., oncologic cure vs. symptom palliation) and from the significant advancements in surgical technologies that have been made over the past 2 decades. Among these advancements are improvements in surgical technique, namely minimally invasive approaches, increased availability of focused radiation modalities (e.g., proton therapy and linear accelerator devices), and new surgical technologies, such as carbon fiber-reinforced polyether ether ketone rods. In addition, several groups have described nonsurgical interventions, such as vertebroplasty and kyphoplasty for spinal instability secondary to pathologic fracture, and lesion ablation with spinal laser interstitial thermoablation, radiofrequency ablation, or cryoablation. We provide an overview of the latest technological advancements in spinal oncology and their potential usefulness for modern spinal oncologists.
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http://dx.doi.org/10.1016/j.wneu.2021.05.032DOI Listing
July 2021

Fenestrated pedicle screws for thoracolumbar instrumentation in patients with poor bone quality: Case series and systematic review of the literature.

Clin Neurol Neurosurg 2021 Jul 11;206:106675. Epub 2021 May 11.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA. Electronic address:

Objective: To describe the results of a single-surgeon series and systematically review the literature on cement-augmented instrumented fusion with fenestrated pedicle screws.

Methods: All patients treated by the senior surgeon using fenestrated screws between 2017 and 2019 with a minimum of 6-months of clinical and radiographic follow-up were included. For the systematic review, we used PRISMA guidelines to identify all prior descriptions of cement-augmented instrumented fusion with fenestrated pedicle screws in the English literature. Endpoints of interest included hardware loosening, cement leakage, and pulmonary cement embolism (PCE).

Results: Our series included 38 patients (mean follow-up 14.8 months) who underwent cement-augmented instrumentation for tumor (47.3%), deformity/degenerative disease (39.5%), or osteoporotic fracture (13.2%). Asymptomatic screw lucency was seen in 2.6%, cement leakage in 445, and pulmonary cement embolism (PCE) in 5.2%. Our literature review identified 23 studies (n = 1526 patients), with low reported rates of hardware loosening (0.2%) and symptomatic PCE (1.0%). Cement leakage, while common (55.6%), produced symptoms in fewer than 1% of patients. Indications for cement-augmentation in this cohort included: spine metastasis with or without pathologic fracture (n = 18; 47.3%), degenerative spine disease or fixed deformity with poor underlying bone quality (n = 15; 39.5%), and osteoporotic fracture (n = 5; 13.2%).

Conclusion: Cement-augmented fusion with fenestrated screws appears to be a safe, effective means of treating patients with poor underlying bone quality secondary to tumor or osteoporosis. High-quality evidence with direct comparisons to non-augmented patients is needed.
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http://dx.doi.org/10.1016/j.clineuro.2021.106675DOI Listing
July 2021

Modified-frailty index does not independently predict complications, hospital length of stay or 30-day readmission rates following posterior lumbar decompression and fusion for spondylolisthesis.

Spine J 2021 May 16. Epub 2021 May 16.

Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD.

Background Context: Frailty has been associated with inferior surgical outcomes in various fields of spinal surgery. With increasing healthcare costs, hospital length of stay (LOS) and unplanned readmissions have emerged as clinical proxies reflecting overall value of care. However, there is a paucity of data assessing the impact that baseline frailty has on quality of care in patients with spondylolisthesis.

Purpose: The aim of this study was to investigate the impact that frailty has on LOS, complication rate, and unplanned readmission after posterior lumbar spinal fusion for spondylolisthesis.

Study Design: A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016.

Patient Sample: All adult (≥18 years old) patients who underwent lumbar spinal decompression and fusion for spondylolisthesis were identified using ICD-9-CM diagnosis and procedural coding systems. We calculated the modified frailty index (mFI) for each patient using 5 dichotomous comorbidities - diabetes mellitus, congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, and dependent functional status. Each comorbidity is assigned 1 point and the points are summed to give a score between 0 and 5. As in previous literature, we defined a score of 0 as "not frail", 1 as "mild" frailty, and 2 or greater as "moderate to severe" frailty.

Outcome Measures: Patient demographics, comorbidities, complications, LOS, readmission, and reoperation were assessed.

Methods: A multivariate logistic regression analysis was used to identify independent predictors of adverse events (AEs), extended LOS, complications, and unplanned readmission.

Results: There were a total of 5,296 patients identified, of which 2,030 (38.3%) were mFI=0, 2,319 (43.8%) patients mFI=1, and 947 (17.9%) were mFI ≥2. The mFI≥2 cohort was older (p≤.001) and had a greater average BMI (p≤.001). The mFI≥2 cohort had a slightly longer hospital stay (3.7 ± 2.3 days vs. mFI=1: 3.5 ± 2.8 days and mFI=0: 3.2 ± 2.1 days,p≤.001). Both surgical AEs and medical AEs were significantly greater in the mFI≥2 cohort than the other cohorts, (2.6% vs. mFI=1: 1.8% and mFI=0: 1.2%,p=.022) and (6.3% vs. mFI=1: 4.8% and mFI=0: 2.6%,p≤.001), respectively. While there was no significant difference in reoperation rates, the mFI≥2 cohort had greater unplanned 30-day readmission rates (8;4% vs. mFI=5.6: 4.8% and mFI=0: 3.4%,p≤.001). However, on multivariate regression analysis, mFI≥2 was not a significant independent predictor of LOS (p=.285), complications (p=.667), or 30-day unplanned readmission (p=.378).

Conclusions: Our study indicates that frailty, as measured by the mFI, does not significantly predict LOS, 30-day adverse events, or 30-day unplanned readmission in patients undergoing lumbar spinal decompression and fusion for spondylolisthesis. Further work is needed to better define variable inputs that make up frailty to optimize surgical outcome prediction tools that impact the value of care.
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http://dx.doi.org/10.1016/j.spinee.2021.05.011DOI Listing
May 2021

Sacrectomy for sacral tumors: Perioperative outcomes in a large-volume comprehensive cancer center.

Spine J 2021 May 14. Epub 2021 May 14.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA. Electronic address:

Background Context: Sacral tumors are incredibly rare lesions affecting fewer than one in every 10,000 persons. Reported perioperative morbidity rates range widely, varying from 30% to 70%, due to the relatively low volumes seen by most centers. Factors affecting perioperative outcome following sacrectomy remain ill-defined.

Purpose: To characterize perioperative outcomes of sacral tumor patients undergoing sacrectomy and identify independent risk factors of perioperative morbidity STUDY DESIGN/SETTING: Retrospective cohort study at a single comprehensive cancer center PATIENT SAMPLE: Consecutively treated sacral tumor patients (primary or metastatic) undergoing sacrectomy for oncologic resection between April 2013 and April 2020 OUTCOME MEASURES: Perioperative complications, hospital length of stay, non-home discharge, 30-day readmission, and 30-day reoperation METHODS: Details were gathered about tumor pathology and morphology, surgery performed, baseline medical comorbidities, preoperative lab data, and patient demographics. Stepwise multivariable regressions were conducted to identify independent risk factors of perioperative outcomes while evaluating predictive accuracy.

Results: 57 sacral tumor patients were included (mean age 55.5±13.0 years; 60% female). The complication, non-home discharge, 30-day readmission, and 30-day reoperation rates were 39%, 56%, 16%, and 14%, respectively. Independent predictors of perioperative complications included ASA>2 (OR=10.7; 95%CI [1.3, 86.0]; p=0.026), radicular pain (OR=10.9; p=0.014), platelet count (OR=0.989 per 10³/μL; p=0.049), and instrumentation (OR=10.7; p=0.009). Independent predictors of length of stay included iliac vessel involvement (β=15.8; p=0.005), larger tumor volume (β=0.027 per cm³; p<0.001), a staged procedure (β=10.0; p=0.018), and S1 nerve root sacrifice (OR=15.8; p=.011). The optimal model predictive of non-home discharge included bilateral S3-S5 or higher nerve root sacrifice (OR=3.9; p=0.054), instrumentation (OR=8.6; p=0.005), and vertical rectus abdominis musculocutaneous flap closure (OR=5.3; p=0.067). 30-day readmission was independently predicted by history of chronic kidney disease (OR=26.7; p=0.021), radicular pain (OR=8.1; p=0.039), and preoperative saddle anesthesia (OR=12.6; p=0.026). All multivariable models achieved good discrimination (AUC>0.8 and R>0.7).

Conclusion: Clinical and operative factors were important predictors of complications and 30-day readmission, while tumor-related and operative factors accounted for most of the variability in length of stay and non-home discharge.
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http://dx.doi.org/10.1016/j.spinee.2021.05.004DOI Listing
May 2021

Chondrosarcoma of the spine: a narrative review.

Spine J 2021 May 8. Epub 2021 May 8.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD USA 21287; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY USA 11030. Electronic address:

Chondrosarcoma is an uncommon primary bone tumor with an estimated incidence of 0.5 per 100,000 patient-years. Primary chondrosarcoma of the mobile spine and sacrum cumulatively account for less than 20% of all cases, most .commonly causing patients to present with focal pain with or without radiculopathy, or myelopathy secondary to neural element compression. Because of the rarity, patients benefit from multidisciplinary care at academic tertiary-care centers. Current standard-of-care consists of en bloc surgical resection with negative margins; for high grade lesions adjuvant focused radiation with ≥60 gray equivalents is taking an increased role in improving local control. Prognosis is dictated by lesion grade at the time of resection. Several groups have put forth survival calculators and epidemiological evidence suggests prognosis is quite good for lesions receiving R0 resection. Future efforts will be focused on identifying potential chemotherapeutic adjuvants and refining radiation treatments as a means of improving local control.
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http://dx.doi.org/10.1016/j.spinee.2021.04.021DOI Listing
May 2021

Web-Based Calculator Predicts Surgical-Site Infection After Thoracolumbar Spine Surgery.

World Neurosurg 2021 Jul 30;151:e571-e578. Epub 2021 Apr 30.

Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA. Electronic address:

Background: Surgical-site infection (SSI) after spine surgery leads to increased length of stay, reoperation, and worse patient quality of life. We sought to develop a web-based calculator that computes an individual's risk of a wound infection following thoracolumbar spine surgery.

Methods: We performed a retrospective review of consecutive patients undergoing elective degenerative thoracolumbar spine surgery at a tertiary-care institution between January 2016 and December 2018. Patients who developed SSI requiring reoperation were identified. Regression analysis was performed and model performance was assessed using receiver operating curve analysis to derive an area under the curve. Bootstrapping was performed to check for overfitting, and a Hosmer-Lemeshow test was employed to evaluate goodness-of-fit and model calibration.

Results: In total, 1259 patients were identified; 73% were index operations. The overall infection rate was 2.7%, and significant predictors of SSI included female sex (odds ratio [OR] 3.0), greater body mass index (OR 1.1), active smoking (OR 2.8), worse American Society of Anesthesiologists physical status (OR 2.1), and greater surgical invasiveness (OR 1.1). The prediction model had an optimism-corrected area under the curve of 0.81. A web-based calculator was created: https://jhuspine2.shinyapps.io/Wound_Infection_Calculator/.

Conclusions: In this pilot study, we developed a model and simple web-based calculator to predict a patient's individualized risk of SSI after thoracolumbar spine surgery. This tool has a predictive accuracy of 83%. Through further multi-institutional validation studies, this tool has the potential to alert both patients and providers of an individual's SSI risk to improve informed consent, mitigate risk factors, and ultimately drive down rates of SSIs.
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http://dx.doi.org/10.1016/j.wneu.2021.04.086DOI Listing
July 2021

Race Is an Independent Predictor for Nonroutine Discharges After Spine Surgery for Spinal Intradural/Cord Tumors.

World Neurosurg 2021 Jul 30;151:e707-e717. Epub 2021 Apr 30.

Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, Maryland, USA.

Objective: The aim of this study was to determine if race was an independent predictor of extended length of stay (LOS), nonroutine discharge, and increased health care costs after surgery for spinal intradural/cord tumors.

Methods: A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult (>18 years old) inpatients who underwent surgical intervention for a benign or malignant spinal intradural/cord tumor were identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedural coding systems. Patients were then categorized based on race: White, African American (AA), Hispanic, and other. Postoperative complications, LOS, discharge disposition, and total cost of hospitalization were assessed. A backward stepwise multivariable logistic regression analysis was used to identify independent predictors of extended LOS and nonroutine discharge disposition.

Results: Of 3595 patients identified, there were 2620 (72.9%) whites (W), 310 (8.6%) AAs/blacks, 275 (7.6%) Hispanic (H), and 390 (10.8%) other (O). Postoperative complication rates were similar among the cohorts (P = 0.887). AAs had longer mean (W, 5.4 ± 4.2 days vs. AA, 8.9 ± 9.5 days vs. H, 5.9 ± 3.9 days vs. O, 6.1 ± 3.9 days; P = 0.014) length of hospitalizations than the other cohorts. The overall incidence of nonroutine discharge was 55% (n = 1979), with AA race having the highest rate of nonroutine discharges (W, 53.8% vs. AA, 74.2% vs. H, 45.5% vs. O, 43.6%; P = 0.016). On multivariate regression analysis, AA race was the only significant racial independent predictor of nonroutine discharge disposition (odds ratio, 3.32; confidence interval, 1.67-6.60; P < 0.001), but not extended LOS (P = 0.209).

Conclusions: Our study indicates that AA race is an independent predictor of nonroutine discharge disposition in patients undergoing surgical intervention for a spinal intradural/cord tumor.
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http://dx.doi.org/10.1016/j.wneu.2021.04.085DOI Listing
July 2021

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

Neurosurg Focus 2021 05;50(5):E4

Departments of1Neurosurgery and.

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

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

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

Conclusions: Patients with MSD who were transferred between hospitals demonstrated more severe clinical presentations and higher rates of inpatient complications compared to directly admitted patients, despite demonstrating no difference in in-hospital mortality rates.
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http://dx.doi.org/10.3171/2021.2.FOCUS201085DOI Listing
May 2021

Systematic review of charged-particle therapy for chordomas and sarcomas of the mobile spine and sacrum.

Neurosurg Focus 2021 05;50(5):E17

1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: Long-term local control in patients with primary chordoma and sarcoma of the spine and sacrum is increasingly reliant upon en bloc resection with negative margins. At many institutions, adjuvant radiation is recommended; definitive radiation is also recommended for the treatment of unresectable tumors. Because of the high off-target radiation toxicities associated with conventional radiotherapy, there has been growing interest in the use of proton and heavy-ion therapies. The aim of this study was to systematically review the literature regarding these therapies.

Methods: The PubMed, OVID, Embase, and Web of Science databases were queried for articles describing the use of proton, combined proton/photon, or heavy-ion therapies for adjuvant or definitive radiotherapy in patients with primary sarcoma or chordoma of the mobile spine and sacrum. A qualitative synthesis of the results was performed, focusing on overall survival (OS), progression-free survival (PFS), disease-free survival (DFS), and disease-specific survival (DSS); local control; and postradiation toxicities.

Results: Of 595 unique articles, 64 underwent full-text screening and 38 were included in the final synthesis. All studies were level III or IV evidence with a high risk of bias; there was also significant overlap in the reported populations, with six centers accounting for roughly three-fourths of all reports. Five-year therapy outcomes were as follows: proton-only therapies, OS 67%-82%, PFS 31%-57%, and DFS 52%-62%; metastases occurred in 17%-18% and acute toxicities in 3%-100% of cases; combined proton/photon therapy, local control 62%-85%, OS 78%-87%, PFS 90%, and DFS 61%-72%; metastases occurred in 12%-14% and acute toxicities in 84%-100% of cases; and carbon ion therapy, local control 53%-100%, OS 52%-86%, PFS (only reported for 3 years) 48%-76%, and DFS 50%-53%; metastases occurred in 2%-39% and acute toxicities in 26%-48%. There were no studies directly comparing outcomes between photon and charged-particle therapies or comparing outcomes between radiation and surgical groups.

Conclusions: The current evidence for charged-particle therapies in the management of sarcomas of the spine and sacrum is limited. Preliminary evidence suggests that with these therapies local control and OS at 5 years are comparable among various charged-particle options and may be similar between those treated with definitive charged-particle therapy and historical surgical cohorts. Further research directly comparing charged-particle and photon-based therapies is necessary.
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http://dx.doi.org/10.3171/2021.2.FOCUS201059DOI Listing
May 2021

Comparison of operator and patient radiation exposure during fluoroscopy-guided vertebroplasty and kyphoplasty: a systematic review and meta-analysis.

J Neurosurg Spine 2021 Apr 30:1-10. Epub 2021 Apr 30.

Departments of1Neurosurgery and.

Objective: Percutaneous vertebroplasty (PV) and balloon kyphoplasty (BK) are two minimally invasive techniques used to treat mechanical pain secondary to spinal compression fractures. A concern for both procedures is the radiation exposure incurred by both operators and patients. The authors conducted a systematic review of the available literature to examine differences in interventionalist radiation exposure between PV and BK and differences in patient radiation exposure between PV and BK.

Methods: The authors conducted a search of the PubMed, Ovid Medline, Cochrane Reviews, Embase, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text articles in English describing one of the primary endpoints in ≥ 5 unique patients treated with PV or BK of the mobile spine were included. Estimates of mean operative time, radiation exposure, and fluoroscopy duration were reported as weighted averages. Additionally, annual occupational dose limits provided by the United States Nuclear Regulatory Commission (USNRC) were used to determine the number needed to harm (NNH).

Results: The meta-analysis included 27 articles. For PV, the mean fluoroscopy times were 4.9 ± 3.3 minutes per level without protective measures and 5.2 ± 3.4 minutes with protective measures. The mean operator radiation exposures per level in mrem were 4.6 ± 5.4 at the eye, 7.8 ± 8.7 at the neck, 22.7 ± 62.4 at the torso, and 49.2 ± 62.2 at the hand without protective equipment and 0.3 ± 0.1 at the torso and 95.5 ± 162.5 at the hand with protection. The mean fluoroscopy times per level for BK were 6.1 ± 2.5 minutes without protective measures and 6.0 ± 3.2 minutes with such measures. The mean exposures were 31.3 ± 39.3, 19.7 ± 4.6, 31.8 ± 34.2, and 174.4 ± 117.3 mrem at the eye, neck, torso, and hand, respectively, without protection, and 1, 9.2 ± 26.2, and 187.7 ± 100.4 mrem at the neck, torso, and hand, respectively, with protective equipment. For protected procedures, radiation to the hand was the limiting factor and the NNH estimates were 524 ± 891 and 266 ± 142 for PV and BK, respectively. Patient exposure as measured by flank-mounted dosimeters, entrance skin dose, and dose area product demonstrated lower exposure with PV than BK (p < 0.01).

Conclusions: Operator radiation exposure is significantly decreased by the use of protective equipment. Radiation exposure to both the operator and patient is lower for PV than BK. NNH estimates suggest that radiation to the hand limits the number of procedures an operator can safely perform. In particular, radiation to the hand limits PV to 524 and BK to 266 procedures per year before surpassing the threshold set by the USNRC.
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http://dx.doi.org/10.3171/2020.9.SPINE201525DOI Listing
April 2021

Guest Editorial: Predictive Analytics, Calculators and Cost Modeling in Spine Surgery.

Global Spine J 2021 Apr;11(1_suppl):4S-6S

Department of Neurosurgery, 1500Johns Hopkins University School of Medicine, Baltimore, MD USA.

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http://dx.doi.org/10.1177/2192568220977185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076808PMC
April 2021

Spnal metastases 2021: a review of the current state of the art and future directions.

Spine J 2021 Apr 19. Epub 2021 Apr 19.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard medical School, Boston, MD 02115, USA.

Spinal metastases are an increasing societal health burden secondary to improvements in systemic therapy. Estimates indicate that 100,000 or more people have symptomatic spine metastases requiring management. While open surgery and external beam radiotherapy have been the pillars of treatment, there is growing interest in more minimally invasive technologies (eg separation surgery) and non-operative interventions (eg percutaneous cementoplasty, stereotactic radiosurgery). The great expansion of these alternatives to open surgery and the prevalence of adjuvant therapeutic options means that treatment decision making is now complex and reliant upon multidisciplinary collaboration. To help facilitate construction of care plans that meet patient goals and expectations, clinical decision aids and prognostic scores have been developed. These have been shown to have superior predictive value relative to more classic prediction models and may become an increasingly important aspect of the clinical practice of spinal oncology. Here we overview current therapeutic advances in the management of spine metastases and highlight emerging areas for research. Given the rapid advancements in surgical technologies and adjuvants, the field is likely to undergo further transformative changes in the coming decade.
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http://dx.doi.org/10.1016/j.spinee.2021.04.012DOI Listing
April 2021

Cost and Health Care Resource Utilization Differences After Spine Surgery for Bony Spine versus Primary Intradural Spine Tumors.

World Neurosurg 2021 Jul 15;151:e286-e298. Epub 2021 Apr 15.

Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, Maryland, USA.

Objective: The aim of this study was to compare complication rates, length of stay (LOS), and hospital costs after spine surgery for bony spine tumors and intradural spinal neoplasms.

Methods: A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult inpatients who underwent surgical intervention for a primary intradural spinal tumor or primary/metastatic bony spine tumor were identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis/procedural coding systems. Patient demographics, comorbidities, intraoperative variables, complications, LOS, discharge disposition, and total cost of hospitalization were assessed. Backward stepwise multivariable logistic regression analyses were used to identify independent predictors of perioperative complication, extended LOS (≥75th percentile), and increased cost (≥75th percentile).

Results: A total of 9855 adult patients were included in the study; 3850 (39.1%) were identified as having a primary intradural spinal tumor and 6005 (60.9%) had a primary or metastatic bony spine tumor. Those treated for bony tumors had more comorbidities (≥3, 67.8% vs. 29.2%) and more commonly experienced ≥1 complications (29.9% vs. 7.9%). Multivariate analyses also showed those in the bony spine cohort had a higher odds of experiencing ≥1 complications (odds ratio [OR], 4.26; 95% confidence interval [CI], 3.04-5.97; P < 0.001), extended LOS (OR, 2.44; 95% CI, 1.75-3.38; P < 0.001), and increased cost (OR, 5.32; 95% CI, 3.67-7.71; P < 0.001).

Conclusions: Relative to patients being treated for primary intradural tumors, those undergoing spine surgery for bony spine tumors experience significantly higher risk for perioperative complications, extended LOS, and increased cost of hospital admission. Further identification of patient and treatment characteristics that may optimize management of spine oncology may reduce adverse outcomes, improve patient care, and reduce health care resources.
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http://dx.doi.org/10.1016/j.wneu.2021.04.015DOI Listing
July 2021

Translocation of Cervical Vertebral Body Replacement Device into the Esophagus.

World Neurosurg 2021 06 2;150:144-146. Epub 2021 Apr 2.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Expandable vertebrectomy devices are a key technology that has facilitated the adoption of minimally invasive approaches to spine oncology surgery. However, advanced technology still requires proper attention to surgical fundamentals. Here we illustrate a cage of a misplaced expandable vertebrectomy device causing esophageal perforation. Examination of the postoperative radiographs suggests that haptic feedback from the expandable technology may have given the false impression of bony engagement. This case highlights the need for proper mortise work and complete visualization of the segments to be instrumented even during minimally invasive surgery.
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http://dx.doi.org/10.1016/j.wneu.2021.03.136DOI Listing
June 2021

Neuroblastoma of the Lumbar Spine.

World Neurosurg 2021 Jul 2;151:2-4. Epub 2021 Apr 2.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Queens, New York, New York, USA. Electronic address:

Neuroblastoma is a primitive small-round-blue-cell tumor predominately found in pediatric patients. Few cases of neuroblastoma involving the adult spine have been reported. Herein we present the case of a healthy 34-year-old man treated for a large neuroblastoma involving the L3-5 vertebral bodies and prevertebral great vessels. Neoadjuvant chemotherapy led to significant cytoreduction, enabling en bloc resection of the initially unresectable tumor. Adjuvant differentiating therapy was employed, and curative radiation therapy was used to address the first instance of locoregional recurrence. The patient remains alive with stable disease more than 2 years after his initial diagnosis.
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http://dx.doi.org/10.1016/j.wneu.2021.03.137DOI Listing
July 2021

Hybrid Therapy for Metastatic Disease.

Clin Spine Surg 2021 Mar 24. Epub 2021 Mar 24.

Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD Department of Neurosurgery, University of Michigan, Ann Arbor, MI.

Metastatic spine disease represents a complex clinical entity, requiring a multidisciplinary treatment team to formulate treatment plans that treat disease, palliate symptoms, and give patients the greatest quality-of-life. With the improvement in focused radiation technologies, the role of surgery has changed from a standalone treatment to an adjuvant supporting other treatment modalities. As patients within this population are often exceptionally frail, there has been increased emphasis on the smallest possible surgery to achieve the team's treatment goals. Surgeons have increasingly turned to more minimally invasive techniques for treating spinal metastases. The use of these procedures, called separation surgery, centers around the goal of decompressing the neural elements, creating or maintaining mechanical stability, and allowing enough room for high-dose radiation to minimize cord dose.
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http://dx.doi.org/10.1097/BSD.0000000000001173DOI Listing
March 2021

Sciatic-to-Femoral Nerve End-to-End Coaptation for Proximal Lower Extremity Function in Patients With Acute Flaccid Myelitis: Technical Note and Review of the Literature.

Oper Neurosurg (Hagerstown) 2021 06;21(1):20-26

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: Acute flaccid myelitis (AFM) is an acute-onset anterior horn disease resulting in flaccid paralysis of extremities, trunk, facial, and cervical musculature in children following upper respiratory or gastrointestinal viral illness. Nerve transfer procedures have been shown to restore function.

Objective: To present a technical description of sciatic-to-femoral nerve transfers in 4 children with AFM.

Methods: Retrospective review of relevant cases was performed.

Results: A total of 4 cases are presented of young children with persistent quadriparesis in the setting of AFM, presenting between 4 and 15 mo following initial diagnosis. Electromyography showed denervation of muscles innervated by the femoral nerve, with sparing of the sciatic distribution. The obturator nerve was also denervated in all patients. We therefore elected to pursue sciatic-to-femoral transfers to restore active knee extension. These transfers involved end-to-end coaptation of a sciatic nerve fascicle to the femoral nerve motor branches supplying quadriceps muscles.

Conclusion: We present technical descriptions of bilateral sciatic-to-femoral nerve neurotization for the restoration of quadriceps function in 4 patients with AFM. The sciatic nerve fascicles are a reasonable alternative donor nerve for patients with proximal muscle paralysis and limited donor options in the lower extremity.
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http://dx.doi.org/10.1093/ons/opab057DOI Listing
June 2021

Dataset of the first report of pharmacogenomics profiling in an outpatient spine setting.

Data Brief 2021 Apr 3;35:106832. Epub 2021 Feb 3.

Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.

Here we describe the dataset of the first report of pharmacogenomics profiling in an outpatient spine setting with the primary aims to catalog: 1) the genes, alleles, and associated rs Numbers (accession numbers for specific single-nucleotide polymorphisms) analysed and 2) the genotypes and corresponding phenotypes of the genes involved in metabolizing 37 commonly used analgesic medications. The present description applies to analgesic medication-metabolizing enzymes and may be especially valuable to investigators who are exploring strategies to optimize pharmacologic pain management (e.g., by tailoring analgesic regimens to the genetically identified sensitivities of the patient). Buccal swabs were used to acquire tissue samples of 30 adult patients who presented to an outpatient spine clinic with the chief concern of axial neck and/or back pain. Array-based assays were then used to detect the alleles of genes involved in the metabolism of pain medications, including all common (wild type) and most rare variant alleles with known clinical significance. Both CYP450 isozymes - including CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A4, and CYP3A5 - and the phase II enzyme UDP-glucuronosyltransferase-2B7 (UGT2B7) were examined. Genotypes/phenotypes were then used to evaluate each patient's relative ability to metabolize 37 commonly used analgesic medications. These medications included both non-opioid analgesics (i.e., aspirin, diclofenac, nabumetone, indomethacin, meloxicam, piroxicam, tenoxicam, lornoxicam, celecoxib, ibuprofen, flurbiprofen, ketoprofen, fenoprofen, naproxen, and mefenamic acid) and opioid analgesics (i.e., morphine, codeine, dihydrocodeine, ethylmorphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, alfentanil, fentanyl, sufentanil, meperidine, ketobemidone, dextropropoxyphene, levacetylmethadol, loperamide, methadone, buprenorphine, dextromethorphan, tramadol, tapentadol, and tilidine). The genes, alleles, and associated rs Numbers that were analysed are provided. Also provided are: 1) the genotypes and corresponding phenotypes of the genes involved in metabolizing 37 commonly used analgesic medications and 2) the mechanisms of metabolism of the analgesic medications by primary and ancillary pathways. In supplemental spreadsheets, the raw and analysed pharmacogenomics data for all 30 patients evaluated in the primary research article are additionally provided. Collectively, the presented data offer significant reuse potential in future investigations of pharmacogenomics for pain management.
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http://dx.doi.org/10.1016/j.dib.2021.106832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893444PMC
April 2021

Utility of prediction model score: a proposed tool to standardize the performance and generalizability of clinical predictive models based on systematic review.

J Neurosurg Spine 2021 Feb 26:1-9. Epub 2021 Feb 26.

1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: The objective of this study was to evaluate the characteristics and performance of current prediction models in the fields of spine metastasis and degenerative spine disease to create a scoring system that allows direct comparison of the prediction models.

Methods: A systematic search of PubMed and Embase was performed to identify relevant studies that included either the proposal of a prediction model or an external validation of a previously proposed prediction model with 1-year outcomes. Characteristics of the original study and discriminative performance of external validations were then assigned points based on thresholds from the overall cohort.

Results: Nine prediction models were included in the spine metastasis category, while 6 prediction models were included in the degenerative spine category. After assigning the proposed utility of prediction model score to the spine metastasis prediction models, only 1 reached the grade of excellent, while 2 were graded as good, 3 as fair, and 3 as poor. Of the 6 included degenerative spine models, 1 reached the excellent grade, while 3 studies were graded as good, 1 as fair, and 1 as poor.

Conclusions: As interest in utilizing predictive analytics in spine surgery increases, there is a concomitant increase in the number of published prediction models that differ in methodology and performance. Prior to applying these models to patient care, these models must be evaluated. To begin addressing this issue, the authors proposed a grading system that compares these models based on various metrics related to their original design as well as internal and external validation. Ultimately, this may hopefully aid clinicians in determining the relative validity and usability of a given model.
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http://dx.doi.org/10.3171/2020.8.SPINE20963DOI Listing
February 2021

Chordoma of the sacrum and mobile spine: a narrative review.

Spine J 2021 03 10;21(3):500-517. Epub 2020 Oct 10.

Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA. Electronic address:

Chordoma is a notochord-derived primary tumor of the skull base and vertebral column known to affect 0.08 to 0.5 per 100,000 persons worldwide. Patients commonly present with mechanical, midline pain with or without radicular features secondary to nerve root compression. Management of these lesions has classically revolved around oncologic resection, defined by en bloc resection of the lesion with negative margins as this was found to significantly improve both local control and overall survival. With advancement in radiation modalities, namely the increased availability of focused photon therapy and proton beam radiation, high-dose (>50 Gy) neoadjuvant or adjuvant radiotherapy is also becoming a standard of care. At present chemotherapy does not appear to have a role, but ongoing investigations into the ontogeny and molecular pathophysiology of chordoma promise to identify therapeutic targets that may further alter this paradigm. In this narrative review we describe the epidemiology, histopathology, diagnosis, and treatment of chordoma.
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http://dx.doi.org/10.1016/j.spinee.2020.10.009DOI Listing
March 2021

Octogenarians Are Independently Associated With Extended LOS and Non-Routine Discharge After Elective ACDF for CSM.

Global Spine J 2021 Jan 29:2192568221989293. Epub 2021 Jan 29.

Department of Neurosurgery, 1500John Hopkins School of Medicine, Baltimore, MD, USA.

Study Design: Retrospective cohort study.

Objective: The aim of this study was to determine the impact age has on LOS and discharge disposition following elective ACDF for cervical spondylotic myelopathy (CSM).

Methods: A retrospective cohort study was performed using the National Inpatient Sample (NIS) database from 2016 and 2017. All adult patients >50 years old undergoing ACDF for CSM were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then stratified by age: 50 to 64 years-old, 65 to 79 years-old, and greater than or equal to 80 years-old. Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total cost of admission were assessed.

Results: A total of 14 865 patients were identified. Compared to the 50-64 and 65-79 year-old cohorts, the 80+ years cohort had a significantly higher rate of postoperative complication (50-64 yo:10.2% vs. 65-79 yo:12.6% vs. 80+ yo:18.9%, = 0.048). The 80+ years cohort experienced significantly longer hospital stays (50-64 yo: 2.0 ± 2.4 days vs. 65-79 yo: 2.2 ± 2.8 days vs. 80+ yo: 2.3 ± 2.1 days, = 0.028), higher proportion of patients with extended LOS (50-64 yo:18.3% vs. 65-79 yo:21.9% vs. 80+ yo:28.4%, = 0.009), and increased rates of non-routine discharges (50-64 yo:15.1% vs. 65-79 yo:23.0% vs. 80+ yo:35.8%, < 0.001). On multivariate analysis, age 80+ years was found to be a significant independent predictor of extended LOS [OR:1.97, 95% CI:(1.10,3.55), = 0.023] and non-routine discharge [OR:2.46, 95% CI:(1.44,4.21), = 0.001].

Conclusions: Our study demonstrates that octogenarian age status is a significant independent risk factor for extended LOS and non-routine discharge after elective ACDF for CSM.
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http://dx.doi.org/10.1177/2192568221989293DOI Listing
January 2021

Low-Intensity Pulsed Ultrasound as a Potential Adjuvant Therapy to Promote Spinal Fusion: Systematic Review and Meta-analysis of the Available Data.

J Ultrasound Med 2020 Dec 8. Epub 2020 Dec 8.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Despite extensive research, nonunion continues to affect a nontrivial proportion of patients undergoing spinal fusion. Recently, preclinical studies have suggested that low-intensity pulsed ultrasound (LIPUS) may increase rates of spinal fusion. In this study, we summarized the available in vivo literature evaluating the effect of LIPUS on spinal fusion and performed a meta-analysis of the available data to estimate the degree to which LIPUS may mediate higher fusion rates. Across 13 preclinical studies, LIPUS was associated with a 9-fold increase in the odds of successful spinal fusion. Future studies are necessary to establish the benefit of LIPUS on spinal fusion in clinical populations.
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http://dx.doi.org/10.1002/jum.15587DOI Listing
December 2020

Posterior Vertebral Column Subtraction Osteotomy for Recurrent Tethered Cord Syndrome: A Multicenter, Retrospective Analysis.

Neurosurgery 2021 02;88(3):637-647

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Background: Few have explored the safety and efficacy of posterior vertebral column subtraction osteotomy (PVCSO) to treat tethered cord syndrome (TCS).

Objective: To evaluate surgical outcomes after PVCSO in adults with TCS caused by lipomyelomeningocele, who had undergone a previous detethering procedure(s) that ultimately failed.

Methods: This is a multicenter, retrospective analysis of a prospectively collected cohort. Patients were prospectively enrolled and treated with PVCSO at 2 institutions between January 1, 2011 and December 31, 2018. Inclusion criteria were age ≥18 yr, TCS caused by lipomyelomeningocele, previous detethering surgery, and recurrent symptom progression of less than 2-yr duration. All patients undergoing surgery with a 1-yr minimum follow-up were evaluated.

Results: A total of 20 patients (mean age: 36 yr; sex: 15F/5M) met inclusion criteria and were evaluated. At follow-up (mean: 23.3 ± 7.4 mo), symptomatic improvement/resolution was seen in 93% of patients with leg pain, 84% in back pain, 80% in sensory abnormalities, 80% in motor deficits, 55% in bowel incontinence, and 50% in urinary incontinence. Oswestry Disability Index improved from a preoperative mean of 57.7 to 36.6 at last follow-up (P < .01). Mean spinal column height reduction was 23.4 ± 2.7 mm. Four complications occurred: intraoperative durotomy (no reoperation), wound infection, instrumentation failure requiring revision, and new sensory abnormality.

Conclusion: This is the largest study to date assessing the safety and efficacy of PVCSO in adults with TCS caused by lipomyelomeningocele and prior failed detethering. We found PVCSO to be an excellent extradural approach that may afford definitive treatment in this particularly challenging population.
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http://dx.doi.org/10.1093/neuros/nyaa491DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884146PMC
February 2021
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