Faculty Bibliography

BACKGROUND/UNASSIGNED:In the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery. METHODS/UNASSIGNED:We employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively. RESULTS/UNASSIGNED:779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge. CONCLUSIONS/UNASSIGNED:Patient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.

BACKGROUND/UNASSIGNED:Lateral lumbar interbody fusion (LLIF) is a minimally invasive surgical option for treating symptomatic degenerative lumbar spinal stenosis (DLSS) in select patients. However, the efficacy of LLIF for indirectly decompressing the lumbar spine in DLSS, as well as the best radiographic metrics for evaluating such changes, are incompletely understood. METHODS/UNASSIGNED:A single-institutional cohort of patients who underwent LLIF for DLSS between 5/2015 - 12/2019 was retrospectively reviewed. Diameter, area, and stenosis grades were measured for the central canal (CC) and neural foramina (NF) at each LLIF level based on preoperative and postoperative T2-weighted MRI. Baseline facet joint (FJ) space, degree of FJ osteoarthritis, presence of spondylolisthesis, interbody graft position, and posterior disc height were analyzed as potential predictors of radiographic outcomes. Changes to all metrics after LLIF were analyzed and compared across lumbar levels. Preoperative and intraoperative predictors of decompression were then assessed using multivariate linear regression. RESULTS/UNASSIGNED:< 0.05, one-way ANOVA). There were no baseline or postoperative differences in NF stenosis grade across lumbar levels. CONCLUSIONS/UNASSIGNED:Radiographically, LLIF is effective at indirect compression of the CC and NF at all lumbar levels, though worse FJ osteoarthritis predicted higher degrees of post-operative stenosis.

OBJECTIVE:This study aims to report the clinical outcome of treating lumbar radiculopathy in the setting of retropulsed polyetheretherketone (PEEK) transforaminal lumbar interbody fusion (TLIF) cages with transforaminal endoscopic spine surgery. METHODS:A retrospective study of 8 patients with lumbar radiculopathy in the setting of a retropulsed PEEK TLIF cage were included from January 2014 to January 2019. The inclusion criteria were 1) lumbar radiculopathy in the setting of a retropulsed PEEK TLIF cage causing nerve compression and 2) follow-up at least 1 year. Patients were asked to complete the following questionnaires for outcome evaluation: visual analog scales (VAS) for leg pain and the Oswestry Disability Index (ODI). RESULTS:Eight patients underwent transforaminal endoscopic surgery for treatment of radiculopathy in the setting of a retropulsed PEEK TLIF cage in the 5-year period evaluated. One year after surgery, the VAS and ODI scores showed a significant decrease: average preoperative VAS and ODI scores were 6.9 ± 1.2 and 50.5 ± 10.9, and 1-year postoperative VAS and ODI scores were 2.3 ± 1.3 and 17.3 ± 5.1. CONCLUSIONS:Transforaminal endoscopic spine surgery for the treatment of a retropulsed PEEK TLIF cage is a safe and effective approach with low morbidity and acceptable complication rates for patients with radiculopathy secondary to a retropulsed PEEK TLIF cage. Compared with a more invasive approach to removing or drilling the PEEK TLIF cage, endoscopic spine surgery could achieve a similar improvement in the patient-reported outcomes with possibly fewer complications.

OBJECTIVE:Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS:At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a "system-based" progress note template was changed to a "problem-based" progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS:The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS:Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

BACKGROUND:Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI). METHODS:We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression. RESULTS:We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression. CONCLUSIONS:Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.

Spinal endoscopy has the stigma of being reserved for only a few surgeons who can figure out how to master the steep learning curve and develop clinical practice settings where endoscopic spine surgery can thrive. In essence, endoscopic treatment of herniated discs specifically and nerve root compression in the lumbar spine in general amounts to replacing traditional open spine surgery protocols with spinal endoscopic surgery techniques. In doing so, the endoscopic spine surgeon must be confident that the degenerative spine's common painful problems can be handled with endoscopic spinal surgery techniques with at least comparable clinical results and complication rates. In this review article, the authors illustrate the difficulties and challenges of the endoscopic lumbar decompression procedure. In addition, they shed light on how to master the learning curve by systematically looking at all sides of the problem, ranging from the ergonomic aspects of the endoscopic platform and its instruments, surgical access planning, challenging clinical scenarios, complications, and sequelae, as well as the training gaps after postgraduate residency and fellowship programs.

BACKGROUND:Endoscopic spine surgery in the cervicothoracic spine is generating continued interest in a rapidly evolving field. The authors present 4 techniques for fully endoscopic cervical spine surgery: (1) posterior cervical unilateral laminectomy and bilateral decompression, (2) posterior cervical foraminotomy, (3) anterior cervical discectomy, and (4) anterior transcorporal discectomy. Two techniques for fully endoscopic thoracic spine surgery are also presented: (1) posterior thoracic unilateral laminectomy and bilateral decompression and (2) transforaminal thoracic endoscopic discectomy and foraminotomy. METHODS:We describe 6 different surgical approaches and review the relevant literature about each technique. RESULTS:The clinical application of endoscopic spine surgery techniques has evolved over the past 40 years. Recent data suggest comparable outcomes to other procedures and perhaps fewer complications and quicker recovery when these techniques are used in the cervical and thoracic spine. Significant variability exists in these approaches depending on the goal of canal decompression, root decompression, and the site of the pathology. CONCLUSIONS:Each endoscopic approach in the cervicothoracic spine has its technical nuances, outcomes, advantages, and disadvantages, making fully endoscopic cervicothoracic spine surgery an exciting and growing field.

OBJECTIVE:Three-dimensional (3D) printing has emerged as a visualization tool for clinicians and patients. We sought to use patient-specific 3D-printed anatomic modeling for preoperative planning and live intraoperative guidance in a series of complex primary spine tumors. METHODS:Over 9 months, patients referred to a single neurosurgical provider for complex primary spinal column tumors were included. Most recent spinal magnetic resonance and computed tomography (CT) imaging were semiautomatically segmented for relevant anatomy and models were printed using polyjet multicolor printing technology. Models were available to surgical teams before and during the operative procedure. Patients also viewed the models preoperatively during surgeon explanation of disease and surgical plan to aid in their understanding. RESULTS:). Lesions were located at cervical, thoracic, and sacral levels and were treated by various surgical approaches. Models were intraoperatively used as patient-specific anatomic references throughout 7 cases and were found to be technically useful by the surgical teams. CONCLUSIONS:We present the largest case series of 3D-printed spine tumor models reported to date. 3D-printed models are broadly useful for operative planning and intraoperative guidance in spinal oncology surgery.