Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:Communication has a well-established effect on improving outcomes. The current study evaluated the effect of multidisciplinary preoperative team communication using a digital huddle software platform on operating room costs. METHODS:A digital huddle software platform was implemented in March 2022 for neurosurgical procedures performed at a single tertiary care center. Surgeons were encouraged, but not required, to participate. General linear models were used to test the association between participation and the difference in supply-related cost and case length, using intergroup comparison and historical controls. RESULTS:A total of 29626 cases (performed by 97 surgeons), conducted between March 2021 and June 2023, were included in our analysis. Cases from participating neurosurgeons (12 surgeons, 4064 cases) were compared with cases from nonparticipating neurosurgeons (6 surgeons, 2452 cases), non-neurosurgery cases carried out by the same operating room staff (20 orthopedic spine surgeons, 6073 cases), and non-neurosurgery cases performed in a different operating room unit (59 surgeons, 21 996 cases). In aggregate, operating room (OR) costs increased by 7.3% (95% CI: 0.9-14.1, P = .025) in the postintervention period. In the same period, participation in the digital huddle platform was associated with an OR utilization and supply-related cost decrease of 16.3% (95% CI: 8.3%-23.6%, P < .001). Among neurosurgeons specifically, participation was associated with a supply-related cost decrease of 17.5% (95% CI: 6.0%-27.5%, P = .0037). There was no change in case length (median case length 171 minutes, change: +2.7% increase, 95% CI:-2.2%-7.9%, P = .28). CONCLUSION/CONCLUSIONS:The implementation of a digital huddle software platform resulted in an OR utilization and supply cost decrease among participants during a period when the overall nonparticipating control cohort experienced an increase in cost.

BACKGROUND:Isocitrate dehydrogenase (IDH) mutant astrocytoma grading, until recently, has been entirely based on morphology. The 5th edition of the Central Nervous System World Health Organization (WHO) introduces CDKN2A/B homozygous deletion as a biomarker of grade 4. We sought to investigate the prognostic impact of DNA methylation-derived molecular biomarkers for IDH mutant astrocytoma. METHODS:We analyzed 98 IDH mutant astrocytomas diagnosed at NYU Langone Health between 2014 and 2022. We reviewed DNA methylation subclass, CDKN2A/B homozygous deletion, and ploidy and correlated molecular biomarkers with histological grade, progression free (PFS), and overall (OS) survival. Findings were confirmed using 2 independent validation cohorts. RESULTS:There was no significant difference in OS or PFS when stratified by histologic WHO grade alone, copy number complexity, or extent of resection. OS was significantly different when patients were stratified either by CDKN2A/B homozygous deletion or by DNA methylation subclass (P value = .0286 and .0016, respectively). None of the molecular biomarkers were associated with significantly better PFS, although DNA methylation classification showed a trend (P value = .0534). CONCLUSIONS:The current WHO recognized grading criteria for IDH mutant astrocytomas show limited prognostic value. Stratification based on DNA methylation shows superior prognostic value for OS.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Instrumented spinal fusion constructs sometimes fail because of fatigue loading, frequently necessitating open revision surgery. Favorable outcomes after percutaneous juxtapedicular cement salvage (perc-cement salvage) of failing instrumentation have been described; however, this approach is not widely known among spine surgeons , and its biomechanical properties have not been evaluated. We report our institutional experience with perc-cement salvage and investigate the relative biomechanical strength of this technique as compared with 3 other common open revision techniques. METHODS:A retrospective chart review of patients who underwent perc-cement salvage was conducted. Biomechanical characterization of revision techniques was performed in a cadaveric model of critical pedicle screw failure. Three revision cohorts involved removal and replacement of hardware: (1) screw upsizing, (2) vertebroplasty, and (3) fenestrated screw with cement augmentation. These were compared with a cohort with perc-cement salvage performed using a juxtapedicular trajectory with the failed primary screw remaining engaged in the vertebral body. RESULTS:Ten patients underwent perc-cement salvage from 2018 to 2022 to address screw haloing and/or endplate fracture threatening construct integrity. Pain palliation was reported by 8/10 patients. Open revision surgery was required in 4/10 patients, an average of 8.9 months after the salvage procedure (range 6.2-14.7 months). Only one revision was due to progressive hardware dislodgement. The remainder avoided open revision surgery through an average of 1.9 years of follow-up. In the cadaveric study, there were no significant differences in pedicle screw pullout strength among any of the revision cohorts. CONCLUSION/CONCLUSIONS:Perc-cement salvage of failing instrumentation is reasonably efficacious. The technique is biomechanically noninferior to other revision strategies that require open surgery for removal and replacement of hardware. Open revision surgery may be avoided by perc-cement salvage in select cases.

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.

OBJECTIVE:Controlling length of stay (LOS) reduces rates of nosocomial infections and falls, facilitates earlier return to daily activities, and decreases strain on the healthcare system. Complications following supratentorial tumor resection present early in the postoperative period, thereby enhancing the prospect of safe, early discharge. Here, the authors describe their initial experience with the development and implementation of an Enhanced Recovery After Cranial Surgery (ERACS) pathway following resection of supratentorial tumors in select patients. METHODS:This was a nonrandomized, ambispective quality improvement study of patients undergoing elective craniotomy for supratentorial tumor resection at New York University Langone Health between November 17, 2020, and May 19, 2022. Eligible patients were prospectively enrolled in either the ERACS pathway or the standard pathway. These prospective cohorts were compared to a retrospective cohort of patients who met eligibility criteria for the pathway. Patients in the ERACS pathway cohort were targeted for discharge on postoperative day 2. The primary outcome metric was hospital LOS. Secondary outcome metrics included duration of intensive care unit (ICU) care and rates of 30-day emergency department visits, readmissions, and complications. RESULTS:Over the study period, 188 of 317 patients (59.3%) who underwent supratentorial tumor resection met inclusion criteria for ERACS pathway enrollment. Sixty-three patients were enrolled in the ERACS pathway, and 125 patients completed the standard pathway. The historical cohort consisted of 332 patients who would have been eligible for ERACS enrollment. Patients in the ERACS pathway cohort had a median LOS of 1.93 days compared with 2.92 and 2.88 days for patients in the standard pathway and historical cohort, respectively (p < 0.001). There was a significant reduction in ICU utilization in ERACS pathway patients (16.0 ± 6.53 vs 29.5 ± 53.0 vs 21.8 ± 18.2 hours, p = 0.005). There were no differences in the rates of 30-day emergency department visits (12.7% vs 9.6% vs 10.9%, p = 0.809) and readmissions (4.8% vs 4.0% vs 7.8%, p = 0.279) between groups. CONCLUSIONS:Patients in the ERACS pathway cohort experienced reduced LOS and ICU utilization, with similar rates of adverse outcomes compared to standard pathway patients. The authors' initial experience suggests that an accelerated recovery pathway can be safely implemented following supratentorial tumor resection in select patients.

BACKGROUND:Patients presenting with large brain metastases (LBM) pose a management challenge to the multidisciplinary neuro-oncologic team. Treatment options include surgery, whole-brain or large-field radiation therapy (WBRT), stereotactic radiosurgery (SRS), or a combination of these. OBJECTIVE:To determine if corticosteroid therapy followed by SRS allows for efficient minimally invasive care in patients with LBMs not compromised by mass effect. METHODS:We analyzed the change in tumor volume to determine the efficacy of single-session SRS in the treatment of LBM in comparison to other treatment modalities. Twenty-nine patients with systemic cancer and brain metastasis (≥ 2.7 cm in greatest diameter) who underwent single-session SRS were included. RESULTS:(range 1.56-25.31). The median margin dose was 16 Gy (range 12-18). The average percent decrease in tumor volume compared to pre-SRS volume was 55% on imaging at 1-2 months, 58% at 3-5 months, 64% at 6-8 months, and 57% at > 8 months. There were no adverse events immediately following SRS. Median corticosteroid use after SRS was 21 days. Median survival after radiosurgery was 15 months. CONCLUSION/CONCLUSIONS:Initial high-dose corticosteroid therapy followed by prompt single-stage SRS is a safe and efficacious method to manage patients with LBMs (defined as ≥ 2.7 cm).