Faculty Bibliography

The application of minimally invasive spine surgery (MISS) in degenerative spine disease and deformity has seen rapid growth in the past 20 years. Building on this experience, such methods have been adopted into spine oncology in the past decade, particularly for metastatic disease. The impetus for this growth stems from the benefits of surgical decompression combined with radiation treatment in patients with metastatic disease in conjunction with the need for less morbid interventions in a patient population with limited life expectancy. The result of these two realizations was the application of minimally invasive techniques for the treatment of spine tumors including re-establishment of spinal stability, decompression of the spinal cord or nerve roots, and restoration of spinal alignment. Technological advancement and improvement in biomaterials have allowed for durable stabilization with short constructs even for patients with poor bone quality. The implementation of navigation and robotic capabilities has transformed MISS by streamlining surgery and further reducing the surgical footprint while laser ablation, endoscopy, and robotic surgery hold the potential to minimize the surgical footprint even further. MISS for intradural tumors is commonly performed, while the role for other primary tumors has yet to be defined. In this article, we describe the evolution of and indications for MISS in spine oncology through a retrospective literature review.

OBJECTIVE:To assess trends in risk for obstetric venous thromboembolism (VTE). METHODS:This retrospective cohort study analyzed data from the 2008-2019 Merative MarketScan Commercial Claims and Encounters and Medicaid Multi-State databases. Women aged 15-54 years with a delivery hospitalization and health care enrollment from 1 year before pregnancy to 60 days after delivery were identified. Risk for VTE during pregnancy from 2009 to 2019 was analyzed with joinpoint regression, with trends reported as the average annual percent change (APC). Venous thromboembolism events were identified with diagnosis codes along with pharmacy receipt of anticoagulants. Additionally, the association between risk factors for VTE and VTE events was evaluated with log-Poisson regression models with unadjusted and adjusted risk ratios (aRR) with 95% CIs as measures of association. RESULTS:Among 1,970,971 pregnancies, there were 5,270 VTE events, of which 35.5% (n=1,871) included a pulmonary embolism diagnosis and 64.5% (3,399) included a deep vein thrombosis diagnosis, alone. Risk for VTE increased significantly during pregnancy over the study period, with an APC of 9.2% (95% CI, 5.7-12.9%). Rates of VTE also increased individually during the antenatal period (APC 8.2%, 95% CI, 3.7-12.9%), during delivery hospitalizations (APC 12.2%, 95% CI, 7.4-17.3%), during the postpartum period (APC 8.4%, 95% CI, 5.9-11.0%), and individually for vaginal and cesarean delivery hospitalizations. Trends analyses individually for pulmonary embolism (APC 12.4%, 95% CI, 8.6-16.4%) and deep vein thrombosis (APC 7.6%, 95% CI, 4.0-11.3%) also demonstrated significant increases. In adjusted analyses for VTE, obesity (aRR 1.91, 95% CI, 1.78-2.05), chronic heart disease (aRR 3.14, 95% CI, 2.93-3.37), tobacco use (aRR 1.61, 95% CI, 1.34-1.95), asthma (aRR 1.46, 95% CI, 1.33-1.60), and preeclampsia (aRR 1.44, 95% CI, 1.31-1.58) were the factors associated the greatest increased adjusted relative risk. CONCLUSION/CONCLUSIONS:Risk for obstetric VTE increased significantly over the study period. Risk increased during the antenatal, delivery, and postpartum periods and for both cesarean and vaginal delivery.

Hypertensive disorders of pregnancy (HDP) may account for a considerable and growing clinical burden at rural hospitals which have been providing fewer obstetric services over the past two decades. The objectives of this analysis were to evaluate trends, risk factors, and outcomes associated with HDP during delivery hospitalizations at rural hospitals in the United States.The 2000 to 2020 National Inpatient Sample was used for this repeated-cross sectional analysis. Delivery hospitalizations at rural hospitals to women 15 to 54 years of age with and without HDP (including preeclampsia and gestational hypertension) were identified. Trends in HDP were characterized with joinpoint regression and estimated as the average annual percent change (AAPC) with 95% confidence intervals (CIs). The associations between (i) HDP risk factors and HDP and (ii) HDP and adverse maternal outcomes were estimated with adjusted logistic regression models.Among 8,885,683 deliveries that occurred at rural hospitals, the proportion with a HDP diagnosis increased significantly from 6.0% in 2000 to 11.1% in 2020 (AAPC: 3.1%; 95% CI: 2.8 and 3.4%). Preeclampsia with severe features (AAPC: 5.5%; 95% CI: 4.8 and 6.2%) and superimposed preeclampsia (AAPC: 6.5%; 95% CI: 5.6 and 7.5%) underwent the largest relative increases over the study period. Obesity, pregestational diabetes, chronic hypertension, multiple gestation, and chronic kidney disease were all associated with increased adjusted odds of HDP. HDP diagnoses were significantly associated with severe maternal morbidity (SMM), transfusion, stroke, and disseminated intravascular coagulation. The proportion of overall delivery SMM associated with HDP more than doubled from 11.3% in 2000 to 24.7% in 2020.Among delivery hospitalizations at rural hospitals, HDP, and associated risk factors increased significantly over the study period. Deliveries with HDP accounted for an increasing proportion of population-level SMM. HDP is a major, growing contributor to maternal risk and adverse outcomes during deliveries at rural hospitals. · Hypertensive disorders accounted for an increasing proportion of population-level severe morbidity.. · Hypertensive disorders increased among rural delivery hospitalizations.. · Risk factors associated with hypertensive disorders increased among rural delivery hospitalizations..

BACKGROUND/UNASSIGNED:While guideline-based multidisciplinary care is increasingly emphasized for managing von Willebrand disease (VWD) in pregnancy, most outcomes data are derived from outdated studies. OBJECTIVES/UNASSIGNED:This study aimed to evaluate temporal trends in the prevalence of VWD, estimate hemorrhagic complication trends with VWD, and examine associations with adverse pregnancy outcomes with VWD. METHODS/UNASSIGNED:We conducted a cross-sectional analysis leveraging data from the National Inpatient Sample from 2000 to 2022 and identified VWD delivery hospitalizations using International Classification of Diseases codes. Outcomes included placental abruption or antepartum hemorrhage, postpartum hemorrhage, transfusion, nontransfusion severe maternal morbidity, and cesarean and operative vaginal delivery. Joinpoint regression was used to analyze trends by estimating the average annual percentage change. Unadjusted and adjusted logistic regression models were used to determine the strength of association between VWD and adverse pregnancy outcomes. RESULTS/UNASSIGNED:Among 87,151,596 delivery hospitalizations, 4.2 per 10,000 had a diagnosis of VWD. VWD prevalence rose from 2.1 to 5.1 per 10,000 deliveries between 2000 and 2022 (average annual percentage change, 6.6%; 95% CI, 5.3%-19.5%). Delivery hospitalizations with VWD were associated with increased rates of antepartum hemorrhage, postpartum hemorrhage, transfusion, nontransfusion severe maternal morbidity, and cesarean delivery. Of these associations, during the study period for deliveries with VWD, rates of antepartum hemorrhage and transfusion decreased significantly, and delivery route showed a decrease in operative vaginal delivery. CONCLUSION/UNASSIGNED:Declining transfusion and antepartum hemorrhage rates suggest improvements in diagnosis and management of VWD during pregnancy. However, stable rates of postpartum hemorrhage rate highlight continued gaps in care. These contemporary, population-level findings will inform preconception counseling and intrapartum planning for individuals with VWD.

OBJECTIVE:To assess variation in inpatient antepartum management strategies for placenta accreta spectrum (PAS) disorder and their association with hospitalization costs in a national sample. METHODS:This retrospective cohort study used the 2016-2021 Nationwide Readmissions Database to identify individuals aged 15-54 years who underwent cesarean hysterectomy for PAS between 23 and 35 weeks of gestation. Patients were categorized into four management groups based on whether they had a separate antepartum hospitalization and their predelivery length of stay (LOS) during the delivery hospitalization. Median total hospitalization costs (inclusive of separate antepartum and delivery hospitalization), adjusted to 2023 dollars, were analyzed as continuous and dichotomized outcomes (above the 90th percentile). Unadjusted and adjusted logistic and median regression models assessed whether inpatient management variation, postpartum LOS, demographic, and clinical factors influenced hospitalization costs. RESULTS:Among 3,237 individuals with PAS, 50.5% had no prior antepartum admission and a predelivery LOS of 2 days or less, 31.9% had no prior antepartum admission and a predelivery LOS of more than 2 days, 11.8% had a prior antepartum admission and a predelivery LOS of 2 days or less, and 5.8% had a prior antepartum admission and a predelivery LOS of more than 2 days. Median total hospitalization costs varied significantly by management group, with mean costs ranging from $21,829 to $51,039. Management variation was associated with nearly 3- to 29-times higher likelihood of high total hospitalization costs and $8,907-29,021 adjusted higher median cost depending on the specific management group. Of evaluated clinical factors, only disseminated intravascular coagulation was associated with an adjusted median cost increase of $12,921. CONCLUSION/CONCLUSIONS:Nearly one in five patients with PAS experienced an all-cause antepartum hospitalization. Variation in inpatient admission for management of PAS was evident in this national sample and was a significant driver of hospitalization costs. Although some antepartum hospitalizations and prolonged predelivery lengths of stay are unavoidable due to the complexity and severity of PAS, efforts to reduce unnecessary variations could reduce total hospitalization costs.

OBJECTIVE:To determine risks for non-transfusion severe maternal morbidity and transfusion during a second delivery hospitalisation based on clinical risk factors and obstetric complications from an index, first delivery hospitalisation. DESIGN/METHODS:Retrospective cohort. POPULATION/METHODS:Delivery hospitalisations in the 2010-2017 New York State Inpatient Database. METHODS:Patients with a first index delivery hospitalisation followed by a second delivery hospitalisation during the study period were included. Clinical risk factors and obstetric complications were obtained from the first index delivery hospitalisation. Adjusted logistic regression models for non-transfusion severe maternal morbidity during the second delivery were performed with adjusted (aORs) odds ratios as measures of effect. These analyses were then repeated for the outcome of transfusion. RESULTS:Of 624 500 paired delivery hospitalisations to 312 250 women, severe maternal morbidity occurred among 0.85% of second deliveries (n = 2672). When adjusted analysis was performed, several clinical factors were associated with severe maternal morbidity in a subsequent pregnancy, including severe maternal morbidity during the index pregnancy (aOR 8.4, 95% CI 7.0, 9.9), transfusion (aOR 2.0, 95% CI 1.6, 2.4) and pregestational diabetes (aOR 2.2, 95% 1.6, 2.9). When analyses were repeated for transfusion, several factors were associated with increased risk, including severe maternal morbidity (aOR 1.5, 95% CI 1.2, 1.8), index transfusion (aOR 6.3, 95% CI 5.6, 7.0), chronic heart disease (aOR 1.6, 95% 1.4, 1.9) and pregestational diabetes (aOR 1.7, 95% 1.3, 2.2). CONCLUSION/CONCLUSIONS:Many obstetric complications and chronic conditions identified during an index delivery hospitalisation are associated with severe morbidity during a second, subsequent delivery. Index severe maternal morbidity is associated with the highest odds. These findings may be of use in patient counselling and risk stratification.

PURPOSE/OBJECTIVE:Spine stereotactic body radiation therapy (SBRT) outperforms conventional radiation therapy in preventing local failure (LF). Data comparing dose-fractionation schemes on the likelihood of LF and vertebral compression fracture (VCF) are limited. METHODS AND MATERIALS/METHODS:This is a retrospective cohort study of 1838 patients (2702 lesions) treated between 2014 and 2023 at a single institution with de novo spine SBRT. LF was defined as progressive disease on magnetic resonance imaging. VCF was defined as progressive or new fracture on magnetic resonance imaging without LF. Death was considered a competing risk. RESULTS:Median follow-up after SBRT for surviving patients was 25 months (IQR 13-43 months). Eleven hundred ninety-seven lesions (44%) received 27 Gy in 3 fractions, 931 (34%) received 30 Gy in 3 fractions, and 574 lesions (21%) received 24 Gy in 1 fraction. Three hundred nine treatment courses involved separation surgery (11%), and 311 lesions (11%) were epidural spinal cord compression score 2 to 3. For lesions treated with 24 Gy in 1 fraction, 30 Gy in 3 fractions, and 27 Gy in 3 fractions, 2-year LF rates (95% CI) were 7% (5%-9%), 11% (9%-13%), and 17% (15%-20%), respectively (P < .001). Two-year VCF rates (95% CI) requiring stabilization were 10% (8%-13%; 24 Gy in 1 fraction), 2% (1%-3%; 27 Gy in 3 fractions), and 3% (2%-5%; 30 Gy in 3 fractions) (P < .001). For the 3-fraction regimens specifically, 30 Gy was associated with a higher overall VCF rate (P = .022) and lower LF rate (P < .001), but there was no significant difference in the risk of VCF requiring intervention (P = .15). Univariable and multivariable regression revealed histologic-based differences in LF: 2-year LF rates were 8.6% (95% CI, 6.4%-11%) for class A lesions (prostate and breast cancers), 26% (95% CI, 20%-32%) for class C lesions (cholangio-, hepatocellular, and colorectal carcinoma), and 13% (95% CI, 12%-15%) for class B lesions (other histologies) (P < .001). For class B to C, epidural spinal cord compression 2 to 3 lesions (n = 261), surgery plus SBRT reduced LF compared to SBRT alone (7.9 vs 20% at 2 years, P = .051), though this did not reach statistical significance. CONCLUSIONS:The preferred hypofractionated SBRT regimen-even for class A histologies-is 30 Gy in 3 fractions, offering superior local control with similar risk of VCF requiring intervention, compared to 27 Gy. For class B to C lesions with high-grade epidural disease, separation surgery prior to SBRT may improve local control.

BACKGROUND:birthday but its effectiveness in reducing SMM has not been evaluated. OBJECTIVE:To assess the association of the DCP with SMM during delivery hospitalization. STUDY DESIGN/METHODS:Difference-in-differences analysis of US delivery hospitalizations from January 2006 to September 2015, stratified according to maternal race and ethnicity. The outcome was SMM exclusive of blood transfusion only, as defined by the Centers for Disease Control and Prevention criteria. The exposure was maternal age categorized into 21 to 25 years (covered by the DCP) and 27 to 31 years (not covered the DCP). The intervention was the DCP categorized into pre- and post-DCP periods (January 2006-September 2010 and October 2010-September 2015, respectively). RESULTS:Of the 4,007,937 delivery hospitalizations in the sample, 22,540 (56.2 per 10,000) recorded SMM. For birthing people aged 21 to 25 years (covered by the DCP), the mean SMM rate was 48.9 per 10,000 during the pre-DCP period and 58.2 per 10,000 during the post-DCP period (crude difference: 9.3 per 10,000). For birthing people aged 27 to 31 years (not covered the DCP), the mean SMM rate was 53.4 per 10,000 during the pre-DCP period and 63.6 per 10,000 during the post-DCP period (crude difference: 10.2 per 10,000). Implementation of DCP was associated with a 1.2% (95% CI: -3.6, 1.3) relative decrease in the mean SMM rate (adjusted odds ratio (aOR): 0.988; 95% CI: 0.964, 1.013). For non-Hispanic White people, the DCP was associated with a 10.7% (95% CI: 7.1, 14.2) relative decrease in the mean SMM rate (aOR: 0.893; 95% CI: 0.858, 0.929). The DCP was associated with an increase in the proportion of privately insured (aOR: 1.225; 95% CI: 1.220, 1.231), a decrease in the proportion of Medicaid beneficiaries (aOR: 0.853; 95% CI: 0.849, 0.856), and a decrease in the proportion of uninsured (aOR: 0.807; 95% CI: 0.798, 0.816). CONCLUSIONS:Maternal health benefit of the DCP appears to be limited to non-Hispanic White birthing people.