Faculty Bibliography
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189
Reliability of a Smartphone App to Objectively Monitor Performance Outcomes in Degenerative Cervical Myelopathy: Observational Study
BACKGROUND:Developing new clinical measures for degenerative cervical myelopathy (DCM) is an AO Spine RECODE-DCM Research, an international and multi-stakeholder partnership, priority. Difficulties in detecting DCM and its changes cause diagnostic and treatment delays in clinical settings and heightened costs in clinical trials due to elevated recruitment targets. Digital outcome measures can tackle these challenges due to their ability to measure disease remotely, repeatedly, and more economically. OBJECTIVE:The aim of this study is to assess the reliability of the MoveMed battery of performance outcome measures. METHODS:A prospective observational study in decentralized secondary care was performed in England, United Kingdom. The primary outcome was to determine the test-retest reliability of the MoveMed performance outcomes using the intraclass correlation (ICC) of agreement . The secondary outcome was to determine the measurement error of the MoveMed performance outcomes using both the SE of the mean (SEM) of agreement and the smallest detectable change (SDC) of agreement . Criteria from the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) manual were used to determine adequate reliability (ie, ICC of agreement ≥0.7) and risk of bias. Disease stability was controlled using 2 minimum clinically important difference (MCID) thresholds obtained from the literature on the patient-derived modified Japanese Orthopaedic Association (p-mJOA) score, namely, MCID ≤1 point and MCID ≤2 points. RESULTS:In total, 7 adults aged 59.5 (SD 12.4) years who live with DCM and possess an approved smartphone participated in the study. All tests demonstrated moderate to excellent test-retest coefficients and low measurement errors. In the MCID ≤1 group, ICC of agreement values were 0.84-0.94 in the fast tap test, 0.89-0.95 in the hold test, 0.95 in the typing test, and 0.98 in the stand and walk test. SEM of agreement values were ±1 tap, ±1%-3% stability score points, ±0.06 keys per second, and ±10 steps per minute, respectively. SDC of agreement values were ±3 taps, ±4%-7% stability score points, ±0.2 keys per second, and ±27 steps per minute, respectively. In the MCID ≤2 group, ICC of agreement values were 0.61-0.91, 0.75-0.77, 0.98, and 0.62, respectively; SEM of agreement values were ±1 tap, ±2%-4% stability score points, ±0.06 keys per second, and ±10 steps per minute, respectively; and SDC of agreement values were ±3-7 taps, ±7%-10% stability score points, ±0.2 keys per second, and ±27 steps per minute, respectively. Furthermore, the fast tap, hold, and typing tests obtained sufficient ratings (ICC of agreement ≥0.7) in both MCID ≤1 and MCID ≤2 groups. No risk of bias factors from the COSMIN Risk of Bias checklist were recorded. CONCLUSIONS:The criteria from COSMIN provide "very good" quality evidence of the reliability of the MoveMed tests in an adult population living with DCM.
PMID: 38787602
ISSN: 2561-326x
CID: 5655152
Spine MRI Identifies Clinically Relevant Findings in Patients With Cancer Presenting With Back Pain
STUDY DESIGN/METHODS:This is a retrospective, cross-sectional study. OBJECTIVE:The primary aim was to identify the diagnostic yield of spine magnetic resonance imaging (MRI) in detecting malignant pathology in cancer patients with back pain. We also sought to evaluate the role of MRI extent ( i.e. regional vs. total) in identifying malignant pathology. SUMMARY OF BACKGROUND DATA/BACKGROUND:No prior study has systematically investigated the yield of spine MRI in a large cohort of cancer patients. METHODS:Spine MRI reports from 2017 to 2021 for back pain (acute and nonspecified chronicity) in cancer patients were reviewed to identify clinically relevant findings: malignant (1) epidural, (2) leptomeningeal, (3) intramedullary, (4) osseous disease, and (5) fracture. Logistic regression was used to evaluate the association between MRI extent and the presence of cancer-related findings. For patients with multiple MRIs, short-interval scans (≤4 mo) were evaluated to assess the yield of repeat imaging. RESULTS:At least one cancer-related finding was identified on 52% of 5989 spine MRIs ordered for back pain and 57% of 1130 spine MRIs ordered specifically for acute back pain. The most common pathology was malignant osseous disease (2545; 43%). Across all five categories, most findings (77%-89%) were new/progressive. Odds of identifying a finding were significantly higher with total versus regional spine MRIs ( P <0.001). Although only 14 patients had a positive regional MRI followed shortly by a positive total spine MRI, most of these repeat total spine MRIs (78%) identified findings outside the scope of the initial regional scan. Twenty-one patients had both computed tomography and MRI within 30 days of each other; eight (38%) had compression fractures appreciated on MRI but not on computed tomography. CONCLUSIONS:Our findings suggest imaging the total spine in cancer patients with back pain given higher odds of identifying malignant pathology and instances of capturing otherwise not visualized disease. Further work is warranted to confirm these findings.
PMCID:10879457
PMID: 37602415
ISSN: 1528-1159
CID: 5892272
A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery
STUDY DESIGN/METHODS:Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. OBJECTIVE:The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. METHODS:All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. RESULTS:Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. CONCLUSION/CONCLUSIONS:We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.
PMCID:10964898
PMID: 38526921
ISSN: 2192-5682
CID: 5644482
Treatment of intramedullary spinal cord tumors: a modified Delphi technique of the North American Spine Society Section of Spine Oncology
OBJECTIVE:Intramedullary spinal cord tumors (IMSCTs) are rare tumors with heterogeneous presentations and natural histories that complicate their management. Standardized guidelines are lacking on when to surgically intervene and the appropriate aggressiveness of resection, especially given the risk of new neurological deficits following resection of infiltrative tumors. Here, the authors present the results of a modified Delphi method using input from surgeons experienced with IMSCT removal to construct a framework for the operative management of IMSCTs based on the clinical, radiographic, and tumor-specific characteristics. METHODS:A modified Delphi technique was conducted using a group of 14 neurosurgeons experienced in IMSCT resection. Three rounds of written correspondence, surveys, and videoconferencing were carried out. Participants were queried about clinical and radiographic criteria used to determine operative candidacy and guide decision-making. Members then completed a final survey indicating their choice of observation or surgery, choice of resection strategy, and decision to perform duraplasty, in response to a set of patient- and tumor-specific characteristics. Consensus was defined as ≥ 80% agreement, while responses with 70%-79% agreement were defined as agreement. RESULTS:Thirty-six total characteristics were assessed. There was consensus favoring surgical intervention for patients with new-onset myelopathy (86% agreement), chronic myelopathy (86%), or progression from mild to disabling numbness (86%), but disagreement for patients with mild numbness or chronic paraplegia. Age was not a determinant of operative candidacy except among frail patients, who were deemed more suitable for observation (93%). Well-circumscribed (93%) or posteriorly located tumors reaching the surface (86%) were consensus surgical lesions, and participants agreed that the presence of syringomyelia (71%) and peritumoral T2 signal change (79%) were favorable indications for surgery. There was consensus that complete loss of transcranial motor evoked potentials with a 50% decrease in the D-wave amplitude should halt further resection (93%). Preoperative symptoms seldom influenced choice of resection strategy, while a distinct cleavage plane (100%) or visible tumor-cord margins (100%) strongly favored gross-total resection. CONCLUSIONS:The authors present a modified Delphi technique highlighting areas of consensus and agreement regarding surgical management of IMSCTs. Although not intended as a substitute for individual clinical decision-making, the results can help guide care of these patients. Additionally, areas of controversy meriting further investigation are highlighted.
PMID: 37856379
ISSN: 1547-5646
CID: 5625762
Canadian journal of surgery = Journal canadien de chirurgie. 2024:67(6suppl1):S17-S76.DOI: 10.1503/cjs.011424
Canadian Spine Society: 24th Annual Scientific Conference, Wednesday, February 28 - Saturday, March 2, Fairmont Chateau Whistler, Whistler, B.C., Canada
PMID: 39537311
ISSN: 1488-2310
CID: 5753252
Management of Refractory Cancer Pain with Intrathecal Drug Delivery and Spinal Cord Stimulation
BACKGROUND/UNASSIGNED:Intrathecal pumps (ITPs) are indicated for refractory cancer pain and decrease systemic opioid requirements. While not yet indicated for cancer pain, spinal cord stimulators (SCSs) are used off-label for cancer pain, with increasing evidence of their efficacy. MATERIALS AND METHODS/UNASSIGNED:A retrospective chart review was conducted of patients who underwent both ITP and at least SCS trial for cancer pain. Primary outcomes were pain numeric rating scale (NRS) and daily morphine equivalents (MEQs). RESULTS/UNASSIGNED:Seventeen patients were identified. Both ITP and SCS were associated with significant decreases in pain ratings at the 3-month follow-up, but this decrease became nonsignificant subsequently. ITP, but not SCS, was associated with a significant decrease in MEQ. CONCLUSIONS/UNASSIGNED:ITP and SCS may both provide efficacy for cancer pain, but the opioid-sparing effects of SCS may be limited. ITP and SCS may potentially be complementary in their ability to provide relief from cancer-related pain.
PMCID:11319851
PMID: 39144131
ISSN: 2689-2820
CID: 5892282
Gender and Sex Differences in Health-related Quality of Life, Clinical Outcomes and Survival after Treatment of Metastatic Spine Disease
STUDY DESIGN/METHODS:Retrospective review of prospective, multicenter and international cohort study. OBJECTIVE:To describe the effect of gender on HRQoL, clinical outcomes and survival for patients with spinal metastases treated with either surgery and/or radiation. SUMMARY OF BACKGROUND DATA/BACKGROUND:Gender differences in health-related outcomes are demonstrated in numerous studies, with women experiencing worse outcomes and receiving lower standards of care than men, however, the influence that gender has on low health-related quality of life (HRQoL) and clinical outcomes after spine surgery remains unclear. METHODS:Patient demographic data, overall survival, treatment details, perioperative complications, and HRQoL measures including EQ-5D, pain NRS, the short form 36 version 2 (SF-36v2) and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) were reviewed. Patients were stratified by sex, and a separate sensitivity analysis that excluded gender-specific cancers (i.e., breast, prostate, etc.) was performed. RESULTS:The study cohort included 207 female and 183 male patients, with age, smoking status, and site of primary cancer being significantly different between the two cohorts (P<0.001). Both males and females experienced significantly improved SOSGOQ2.0, EQ-5D, and pain NRS scores at all study time points from baseline (P<0.001). Upon sensitivity analysis, (gender-specific cancers removed from analysis), the significant improvement in SOSGOQ physical, mental, and social subdomains and on SF-36 domains disappeared for females. Males experienced higher rates of postoperative complications. Kaplan-Meier survival analysis of both the overall and sensitivity analysis cohorts showed females lived longer than males after treatment (P=0.001 and 0.043, respectively). CONCLUSION/CONCLUSIONS:Both males and females experienced significantly improved HRQoL scores after treatment, but females demonstrated longer survival and a lower complication rate. This study suggests that gender may be a prognostic factor in survival and clinical outcomes for patients undergoing treatment for spine metastases and should be taken into consideration when counseling patients accordingly.
PMID: 38149519
ISSN: 1528-1159
CID: 5623572
Developing an Automated Registry (Autoregistry) of Spine Surgery Using Natural Language Processing and Health System Scale Databases
BACKGROUND AND OBJECTIVES/OBJECTIVE:Clinical registries are critical for modern surgery and underpin outcomes research, device monitoring, and trial development. However, existing approaches to registry construction are labor-intensive, costly, and prone to manual error. Natural language processing techniques combined with electronic health record (EHR) data sets can theoretically automate the construction and maintenance of registries. Our aim was to automate the generation of a spine surgery registry at an academic medical center using regular expression (regex) classifiers developed by neurosurgeons to combine domain expertise with interpretable algorithms. METHODS:We used a Hadoop data lake consisting of all the information generated by an academic medical center. Using this database and structured query language queries, we retrieved every operative note written in the department of neurosurgery since our transition to EHR. Notes were parsed using regex classifiers and compared with a random subset of 100 manually reviewed notes. RESULTS:A total of 31 502 operative cases were downloaded and processed using regex classifiers. The codebase required 5 days of development, 3 weeks of validation, and less than 1 hour for the software to generate the autoregistry. Regex classifiers had an average accuracy of 98.86% at identifying both spinal procedures and the relevant vertebral levels, and it correctly identified the entire list of defined surgical procedures in 89% of patients. We were able to identify patients who required additional operations within 30 days to monitor outcomes and quality metrics. CONCLUSION/CONCLUSIONS:This study demonstrates the feasibility of automatically generating a spine registry using the EHR and an interpretable, customizable natural language processing algorithm which may reduce pitfalls associated with manual registry development and facilitate rapid clinical research.
PMID: 37345933
ISSN: 1524-4040
CID: 5542832
Role of Frailty Status in Prediction of Clinical Outcomes of Traumatic Spinal Injury: A Systematic Review and Meta-Analysis
Although many frailty tools have been used to predict traumatic spinal injury (TSI) outcomes, identifying predictors of outcomes after TSI in the aged population is difficult. Frailty, age and TSI association are interesting topics of discussion in geriatric literature. However, the association between these variables are yet to be clearly elucidated. We conducted a systematic review to investigate the association between frailty and TSI outcomes. The authors searched Medline, EMBASE, Scopus, and Web of Science for relevant studies. Studies with observational designs that assessed baseline frailty status in individuals suffering from TSI published from inception until 26th March 2023 were included. LoS, AEs, and mortality were the outcomes of interest. Of the 2425 citations, 16 studies involving 37,640 participants were included. The modified frailty index (mFI) was the most common tool used to assess frailty. Meta-analysis was employed only in studies that used mFI for measuring frailty. Frailty was significantly associated with increased in-hospital or 30-day mortality (pooled OR: 1.93 [1.19; 3.11]), non-routine discharge (pooled OR: 2.44 [1.34; 4.44]), and AEs or complications (pooled OR: 2.00 [1.14; 3.50]). However, no significant relationship was found between frailty and LoS (pooled OR: 3.02 [0.86; 10.60]). Heterogeneity was observed across multiple factors, including age, injury level, frailty assessment tool, and spinal cord injury (SCI) characteristics. In conclusion, although there is limited data concerning using frailty scales to predict short-term outcomes after TSI, the results showed that frailty status may be a predictor of in-hospital mortality, AEs and unfavorable discharge destination.
PMID: 37432902
ISSN: 1557-9042
CID: 5537522
Digital Biomarkers and the Evolution of Spine Care Outcomes Measures: Smartphones and Wearables
Over the past generation, outcome measures in spine care have evolved from a reliance on clinician-reported assessment toward recognizing the importance of the patient's perspective and the wide incorporation of patient-reported outcomes (PROs). While patient-reported outcomes are now considered an integral component of outcomes assessments, they cannot wholly capture the state of a patient's functionality. There is a clear need for quantitative and objective patient-centered outcome measures. The pervasiveness of smartphones and wearable devices in modern society, which passively collect data related to health, has ushered in a new era of spine care outcome measurement. The patterns emerging from these data, so-called "digital biomarkers," can accurately describe characteristics of a patient's health, disease, or recovery state. Broadly, the spine care community has thus far concentrated on digital biomarkers related to mobility, although the researcher's toolkit is anticipated to expand in concert with advancements in technology. In this review of the nascent literature, we describe the evolution of spine care outcome measurements, outline how digital biomarkers can supplement current clinician-driven and patient-driven measures, appraise the present and future of the field in the modern era, as well as discuss present limitations and areas for further study, with a focus on smartphones (see Supplemental Digital Content , http://links.lww.com/NEU/D809 , for a similar appraisal of wearable devices).
PMID: 37246874
ISSN: 1524-4040
CID: 5866212
