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Sport-related concussion (SRC) prevention and management is a focus of the National Football League (NFL). While most prior reports evaluated sport-related concussion incidence, few have studied same-year repeat concussions. This study aimed to evaluate the frequency of same-year repeat concussions in the NFL. A retrospective, observational cohort study of same-year repeat concussions in the NFL from 2015 to 2019 was performed. The NFL's electronic health record was reviewed for players sustaining concussions and same-year repeat concussions. Wilcoxon rank sum tests were used to calculate same-year repeat concussion rates, and risk ratios and 95% confidence intervals were estimated using log-binomial regression. From 2015 to 2019, the risk of sustaining a same-year repeat concussion in the NFL was 0.38%–0.69% per season. Among players who sustained a concussion, the risk of a same-year repeat concussion was 5.3%–8.3%, which did not differ significantly from the risk of sustaining a single concussion (6.2%–8.3%). There was a median of 38 participation days between initial and same-year repeat concussion. Players missed more time from same-year repeat concussions (median 12 days) compared with both single (median 9 days; P < 0.0001) and initial (median 9.5 days; P = 0.002) concussions. The risk of a repeat concussion was similar to the risk of sustaining a single concussion among NFL players. More time was missed following a same-year repeat concussion compared with single or initial concussions. Further research is needed to maximize player safety and minimize same-year repeat concussions. [ABSTRACT FROM AUTHOR]

Acute cervical spinal cord injury (SCI) represents a significant challenge, with substantial implications for individual well-being and societal costs. In this chapter, we highlighted the importance of early surgical intervention within a critical time frame following injury to mitigate the risk of secondary damage and optimize neurological recovery. The chapter also delineated the dichotomy of primary and secondary injuries in traumatic cervical SCI, elucidating the pathophysiological mechanisms underlying each phase. Insights into the inflammatory cascade and cellular responses offer a nuanced understanding of injury progression, paving the way for targeted therapeutic interventions. Therefore, we delved into the current landscape of traumatic cervical SCI, addressing the advances in the medical and surgical care. Regarding surgical management, attention was directed towards established practices such as immobilization, respiratory support, and optimal timing of surgery, alongside emerging modalities including intraspinal pressure management, stem cell therapy, and nerve/tendon transfer. Similarly, the medical management section highlighted the importance of spinal cord perfusion, neurogenic shock management, and the role of steroids, while also exploring novel avenues such as genetic modification for spinal recovery. Overall, this chapter underscored the dynamic nature of SCI care, advocating for a holistic approach that integrates traditional and innovative treatment modalities. [ABSTRACT FROM AUTHOR]

• Lumbar spondylosis leads to decreased quality of life. • Among common medical diagnoses, lumbar spondylosis had the lowest EQ-5D score (0.36). • The greatest QALY gains were seen in lumbar spine surgery and hip/knee arthroplasty. Degenerative lumbar spondylosis is a common indication for patients undergoing spine surgery. As healthcare costs rise, measuring quality of life (QOL) gains after surgical procedures is critical in assessing value. We set out to: 1) compare baseline and postoperative EuroQol-5D (EQ-5D) scores for lumbar spine surgery and common surgical procedures to obtain post-operative quality-adjusted life year (QALY) gain, and 2) establish the relative utility of lumbar spine surgery as compared to other commonly performed surgical procedures. A systematic literature review was conducted to identify all studies reporting preoperative/baseline and postoperative EQ-5D scores for common surgical procedures. For each study, the number of patients included and baseline/preoperative and follow-up mean EQ-5D scores were recorded, and mean QALY gained for each intervention was calculated. A total of 67 studies comprising 95,014 patients were identified. Patients with lumbar spondylosis had the worst reported QOL at baseline compared to other surgical cohorts. The greatest QALY gain was seen in patients undergoing hip arthroplasty (0.38), knee arthroplasty (0.35) and lumbar spine surgery (0.32), nearly 2.5-fold greater QALY gained than for all other procedures. The low preoperative QOL, coupled with the improvements offered with surgery, highlight the utility and value of lumbar spine surgery compared to other common surgical procedures. [ABSTRACT FROM AUTHOR]

Background Context: Robot-assisted spine surgery continues to rapidly develop as evidenced by the growing literature in recent years. In addition to demonstrating excellent pedicle screw accuracy, early studies have explored the impact of robot-assisted spine surgery on reducing radiation time, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. Recently, the Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic's Stealth navigation technology into the Mazor X platform, which was introduced in 2016. It is unclear what the impact of these advancements have made on clinical outcomes.Purpose: To compare the outcomes and complications between the most recent iterations of the Mazor Robot systems: Mazor X and Mazor X Stealth Edition.Study Design: Multicenter cohort PATIENT SAMPLE: Among four different institutions, we included adult (≥18 years old) patients who underwent robot-assisted spine surgery with either the Mazor X (non-navigated robot) or Stealth (navigated robot) platforms.Outcome Measures: Primary outcomes included robot time per screw, fluoroscopic radiation time, screw accuracy, robot abandonment, and clinical outcomes with a minimum 90 day follow up.Methods: A one-to-one propensity-score matching algorithm based on perioperative factors (e.g. demographics, comorbidities, primary diagnosis, open vs. percutaneous instrumentation, prior spine surgery, instrumented levels, pelvic fixation, interbody fusion, number of planned robot screws) was employed to control for the potential selection bias between the two robotic systems. Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively.Results: From a total of 646 patients, a total of 372 adult patients were included in this study (X: 186, Stealth: 186) after propensity score matching. The mean number of instrumented levels was 4.3. The mean number of planned robot screws was 7.8. Similar total operative time and robot time per screw occurred between cohorts (p>0.05). However, Stealth achieved significantly shorter fluoroscopic radiation time per screw (Stealth: 7.2 seconds vs. X: 10.4 seconds, p<.001) than X. The screw accuracy for both robots was excellent (Stealth: 99.6% vs. X: 99.1%, p=0.120). In addition, Stealth achieved a significantly lower robot abandonment rate (Stealth: 0% vs. X: 2.2%, p=0.044). Furthermore, a lower blood transfusion rate was observed for Stealth than X (Stealth: 4.3% vs. X: 10.8%, p=0.018). Non-robot related complications such as dura tear, motor/sensory deficits, return to the operating room during same admission, and length of stay was similar between robots (p>0.05). The 90-day complication rates were low and similar between robot cohorts (Stealth: 5.4% vs. X: 3.8%, p=0.456).Conclusion: In this multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, using Stealth led to significantly less fluoroscopic radiation time, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including length of stay, and 90-day complications were similar. [ABSTRACT FROM AUTHOR]

• Patient population selected from inpatient or outpatient hospital setting. • 2.83% had complications while 0.48% had potentially catastrophic complications. • Prior cardiac intervention was sole, independent predictor of complications. • Need to validate these findings in patient population treated at ambulatory centers. To minimize healthcare related costs, ambulatory surgery centers (ASCs) have become increasingly favored venues for outpatient spine surgery. Using a national cohort of patients undergoing elective lumbar decompression (LD) in an inpatient or outpatient hospital setting, the current objectives were to: 1) outline specific factors that were associated with complications, and 2) describe potentially catastrophic complications. Adults who underwent LD between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure LD (CPT 63030), elective, neurologic/orthopaedic surgeons, length of stay (LOS) of 0/1 days, and discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications. Univariate/multivariable logistic regression was performed. A total of 19,908 patients met the inclusion criteria. 564 (2.83%) patients experienced a complication. Cardiac intervention remained the only independent predictor of complications after multivariate testing (OR: 2.02, 95% CI: 1.00, 4.07, p = 0.049). Approximate comorbidity score cut-offs associated with <2% risk of complication were: ASA ≤ 3, CCI ≤ 5, mFI ≤ 0.182. A total of 96 (0.48%) patients experienced potentially catastrophic complications. We utilized a national cohort of patients undergoing elective inpatient and outpatient LD in a hospital setting to identify preoperative risk factors for postoperative complications. Previous cardiac intervention was the sole independent predictor of complications. Although no patients treated at ASCs were studied, we believe these factors can aid in selecting patients most appropriate for ASCs and begin the process of selecting the best patients for an ambulatory setting. [ABSTRACT FROM AUTHOR]

Highlights • Advanced brain imaging is used to assess recovery after sport-related concussion. • Differences in imaging modalities complicate study interpretation. • Positive imaging findings may not persist into the subacute time period. • Studies reporting positive findings are subject to methodologic limitations. Abstract Sport-related concussion (SRC) has emerged as a major public health problem. The results of brain imaging studies following SRC have raised questions about long-term neurologic health, but the clinical implications of these findings remain unknown. A systematic review of brain imaging findings after SRC was performed utilizing the following inclusion criteria: football players, brain imaging within 6 months of SRC, and sample size >5. Studies were assessed for: 1) methodology, 2) imaging outcomes, and 3) number of positive statistical comparisons. Imaging was classified as immediate (≤1 week post-injury) or subacute (>1 week to 6 months post-injury). Eleven studies met inclusion criteria. Eight of the 11 studies conducted a total of 809 comparisons of brain function, of which 149 (18%) were statistically significant. Nine of the 11 studies (82%) reported positive immediate findings, but were more likely to be subject to recall bias (86% vs. 0%) and to lack baseline advanced brain imaging (78% vs. 50%) than negative studies. Only 3 of 9 studies that reported subacute findings (33%) reported positive results, and these positive studies were also more likely to be subject to recall bias (100% vs. 40%) and to lack baseline advanced brain imaging (100% vs. 67%) than negative studies. The results of the study demonstrate the transitory nature of positive imaging findings and methodological limitations that complicate study interpretation. Further research is required to correlate imaging findings with clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Adult spinal deformity (ASD) operations are complex and often require a multisurgeon team. Simultaneously, it is the responsibility of academic spine surgeons to train future complex spine surgeons. Our objective was to assess the effect of resident and fellow involvement (RFI) on ASD surgery in 4 areas: 1) perioperative outcomes, 2) length of stay (LOS), 3) discharge status, and 4) complications. Methods Adults undergoing thoracolumbar spinal deformity correction from 2008 to 2014 were identified in the National Surgical Quality Improvement Program database. Cases were divided into those with RFI and those with attendings only. Outcomes were operative time, transfusions, LOS, discharge status, and complications. Univariate and multivariable regression modeling was used. Covariates included preoperative comorbidities, specialty, and levels undergoing instrumentation. Results A total of 1471 patients underwent ASD surgery with RFI in 784 operations (53%). After multivariable regression modeling, RFI was independently associated with longer operations (β = 66.01 minutes; 95% confidence interval [CI], 35.82–96.19; P < 0.001), increased odds of transfusion (odds ratio, 2.80; 95% CI, 1.81–4.32; P < 0.001), longer hospital stay (β = 1.76 days; 95% CI, 0.18–3.34; P = 0.030), and discharge to an inpatient rehabilitation or a skilled nursing facility (odds ratio, 2.02; 95% CI, 1.34–3.05; P < 0.001). However, RFI was not associated with any increase in major or minor complications. Conclusion RFI in ASD surgery was associated with increased operative time, the need for additional transfusions, longer LOS, and nonhome discharge. However, no increase in major, minor, or severe complications occurred. These data support the continued training of future deformity and complex spine surgeons without fear of worsening complications; however, areas of improvement exist. [ABSTRACT FROM AUTHOR]

Background Conventional external beam radiation and stereotactic radiosurgery are common radiation techniques used to treat spinal tumors. Intraoperative brachytherapy (BT) may serve as an alternative when other options have been exhausted or as an adjunct in combination with other therapies. The objective of this study was to systematically review the literature on BT use in spinal tumor surgery. Methods PubMed and Embase databases were systematically queried for literature reporting the use of BT in the surgical treatment of spinal tumors. PRISMA guidelines were followed. A meta-analysis was performed. Results Of the 203 initial articles queried, 15 studies were included. Of the 370 total patients described, 78% were treated for spine metastases. Indications for BT included tumors refractory to previous treatments and inability to tolerate chemotherapy, radiation, and/or open surgery. Seed placement was the most common method of delivery (58%) compared with plaques (42%). BT was placed during an open procedure in 52%, and of the remaining percutaneous procedures, 47% were combined with cement augmentation. Tumor recurrence rates varied from 13% to 49%. Seven studies reporting visual analog scale scores reported significant improvement in pain control. Conclusions BT was used to treat metastatic disease in patients who failed previous therapies and could not tolerate open surgery or further therapy. This review summarizes the major findings in the available literature pertaining to patient background, indications, and outcomes. Spinal BT seems to be a viable option for spine tumor treatment and should be made available at treating centers. Highlights • Indications for BT include tumors refractory to previous treatments and inability to tolerate more therapy and/or surgery. • Iridium 125 in the form of seeds (58%) during an open procedure (52%) was the most common isotope. • Percutaneous delivery combined with cement augmentation (47%) was also common. • Studies with pre- and posttreatment outcomes reported statistically significant improvement in pain and performance status. • Spinal BT seems to be a viable option for spine tumor treatment and should be considered by centers treating spine tumors. [ABSTRACT FROM AUTHOR]

Objectives: To identify factors associated with post-concussion syndrome (PCS) among a national sample of high school student-athletes from the 2011/12-2013/14 academic years.Design: Ambispective cohort study from sports injury surveillance data.Methods: Sport-related concussion data originated from the National Athletic Treatment, Injury and Outcomes Network (NATION) surveillance program, consisting of 27 sports from a convenience sample of 196 high schools across 26 states. All SRCs were reported by certified athletic trainers. The PCS and non-PCS groups consisted of concussed individuals with symptoms resolution time of >4 weeks and ≤2 weeks, respectively. Logistic regression estimated the association of athlete and concussion characteristics on the odds of PCS, and calculated adjusted odds ratios (OR) and 95% confidence intervals (CI).Results: Overall, 1334 concussed high school athletes met inclusion criteria: 215 in the PCS group and 1119 in the non-PCS group. In the multivariable analysis, concussion symptoms associated with increased odds of PCS included: retrograde amnesia (OR=3.01, 95%CI: 1.31-6.91), difficulty concentrating (OR=2.72, 95%CI: 1.56-4.77), disorientation (OR=1.86; 95%CI: 1.04-3.33), insomnia (OR=2.79; 95%CI: 1.62-4.80), loss of balance (OR=1.76; 95%CI: 1.00-3.10), sensitivity to noise (OR=1.80; 95%CI: 1.02-3.17), and visual disturbance (OR=2.21; 95%CI: 1.23-3.97). Sex and recurrent concussion were not associated with PCS.Conclusions: As in previous research, somatic and cognitive symptoms were associated with PCS. The identification of factors associated with PCS may assist clinicians in identifying concussed athletes at greater risk of having longer symptom resolution time. [ABSTRACT FROM AUTHOR]

Summary Introduction Two main hypotheses have been proposed for the pathophysiology of long thoracic nerve (LTN) palsy: nerve compression and nerve inflammation. We hypothesized that critical reinterpretation of electrodiagnostic (EDX) studies and MRIs of patients with a diagnosis of non-traumatic isolated LTN palsy could provide insight into the pathophysiology and, potentially, the treatment. Material and methods A retrospective review was performed of all patients with a diagnosis of non-traumatic isolated LTN palsy and an EDX and brachial plexus or shoulder MRI studies performed at our institution. The original EDX studies and MR examinations were reinterpreted by a neuromuscular neurologist and musculoskeletal radiologist, respectively, both blinded to our hypothesis. Results Seven patients met the inclusion criteria as having a non-traumatic isolated LTN palsy. Upon reinterpretation, all of them were found to have findings not consistent with an isolated LTN. On physical examination, three of them (43%) presented with weakness in muscles not innervated by the LTN. Four of them (57%) had additional EDX abnormalities beyond the distribution of the LTN. Five of them (71%) had MRI evidence of enlargement of nerves or denervation atrophy of muscles outside the innervation of the LNT, without evidence of compression of the LTN in the middle scalene muscle. Conclusion In our series, all 7 patients, originally diagnosed as having an isolated LTN, on reinterpretation, were found to have a more diffuse muscle/nerve involvement pattern, without MR findings to suggest nerve compression. These data strongly support an inflammatory pathophysiology. [ABSTRACT FROM AUTHOR]

Patients undergoing transsphenoidal surgery (TSS) have an anterior skull base defect that limits the use of positive pressure ventilation post-operatively. Obstructive sleep apnea (OSA) can be seen in these patients and is treated with continuous positive airway pressure (CPAP). In our study we documented the incidence of pre-existing OSA and reported the incidence of diagnosed pneumocephalus and its relationship to OSA. A retrospective review was conducted from a surgical outcomes database. Electronic medical records were reviewed, with an emphasis on diagnosis of OSA and documented symptomatic pneumocephalus. A total of 324 patients underwent 349 TSS for sellar mass resection. The average body mass index of the study cohort was 32.5 kg/m 2 . Sixty-nine patients (21%) had documented OSA. Only 25 out of 69 (36%) had a documented post-operative CPAP plan. Out of all 349 procedures, there were two incidents of pneumocephalus diagnosed. Neither of the patients had pre-existing OSA. One in five patients in our study had pre-existing OSA. Most patients returned to CPAP use within several weeks of TSS for resection of a sellar mass. Neither of the patients with pneumocephalus had pre-existing OSA and none of the patients with early re-initiation of CPAP developed this complication. This study provides preliminary evidence that resuming CPAP early in the post-operative period might be less dangerous than previously assumed. [ABSTRACT FROM AUTHOR]

Objective Exposure to surgical subspecialties is limited during the preclinical years of medical school. To offset this limitation, the authors created a neurosurgery elective for first- and second-year medical students. The objective was to provide each student with early exposure to neurosurgery by combining clinical experience with faculty discussions about the academic and personal realities of a career in neurosurgery. Methods From 2012 to 2013, the authors offered a neurosurgery elective course to first- and second-year medical students. Each class consisted of the following: 1) peer-reviewed article analysis; 2) student presentation; 3) faculty academic lecture; 4) faculty personal lecture with question and answer period. Results Thirty-five students were enrolled over a 2-year period. After completing the elective, students were more likely to: consider neurosurgery as a future career ( P < 0.0001), perceive the personalities of attending physicians to be more collegial and friendly ( P = 0.0002), perceive attending quality of life to be higher ( P < 0.0001), and believe it was achievable to be a neurosurgeon and have a family ( P < 0.0001). The elective did not alter students' perceived difficulty of training ( P = 0.7105). Conclusions The neurosurgery elective course significantly increased student knowledge across several areas and changed perceptions about collegiality, quality of life, and family–work balance, while not altering the students' views about the difficulty of training. Adopting a neurosurgery elective geared towards preclinical medical students can significantly change attitudes about the field of neurosurgery and has potential to increase interest in pursuing a career in neurosurgery. [ABSTRACT FROM AUTHOR]

Robot-assisted spine surgery continues to rapidly develop as evidenced by the growing literature in the last few years. Numerous reports demonstrate excellent pedicle screw accuracy and early studies have explored the impact of robot-assisted spine surgery on reducing radiation exposure, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. Recently, the Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic's Stealth navigation technology into the Mazor X platform. It is unclear what the impact of these advancements have made on clinical outcomes. This is the first study to compare the outcomes and complications between the most recent iterations of the Mazor Robot systems: Mazor X and the Mazor X Stealth Edition. Multicenter cohort. Among four different institutions, we included adult (≥18 years old) patients who underwent robot-assisted spine surgery with either the Mazor X or Stealth platforms. Primary outcomes included robot time per screw, robot abandonment, screw accuracy, radiation exposure and 90-day reoperation rate. A propensity-score matching algorithm based on perioperative factors (eg, demographics, comorbidities, primary diagnosis, prior spine surgery, pelvic fixation, instrumented levels, number of planned robot screws) was employed to control for the potential selection bias between the two robotic systems. The minimum follow-up was 90 days after surgery. Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively. A total of 372 adult patients were included in this study (Stealth: 186, X: 186). The mean number of instrumented levels was 4.3. The mean number of planned robot screws was 7.8. Similar total operative time (Stealth: 197 minutes vs X: 211, p=0.591) and robot time per screw (Stealth: 6.1 minutes/screw vs X: 6.1 minutes/screw, p=0.930) occurred between cohorts. However, Stealth achieved a significantly lower robot abandonment rate (Stealth: 0% vs X: 2.2%, p=0.044). The screw accuracy for both robots was excellent (Stealth: 99.6% vs X: 99.1%, p=0.120). Stealth achieved significantly shorter radiation time than X (Stealth: 7.2 seconds/screw vs X: 10.4 seconds/screw, p<0.001). Furthermore, a lower blood transfusion rate was observed for Stealth than X (Stealth: 4.3% vs X: 10.8%, p=0.018). Non-robot related complications such as dura tear, motor/sensory deficits, return to the OR during same admission, and LOS was similar between robots (p>0.05). The 90-day reoperation rates were low and similar between robot cohorts. In this multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, Stealth achieved significantly less radiation exposure, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including LOS, and 90-day reoperation rates were similar. Medtronic Mazor X and Mazor X stealth are FDA approved in the US. [ABSTRACT FROM AUTHOR]

Little is known regarding the incidence and risk factors for postop CM after ASD surgery. A subset of patients undergoing adult spinal deformity (ASD) surgery will have postoperative coronal malalignment (CM) with suboptimal outcomes. Retrospective cohort. A total of 243 adult spinal deformity patients. Postoperative Coronal Malalignment. A single-institution database was queried for ASD patients undergoing ≥6 level fusions from 2015-19. Postop coronal malalignment was defined as C7 coronal vertical axis (CVA) >3cm. Iatrogenic coronal malalignment was defined as postop CVA>3cm in patients without preop CM. Demographic, radiographic, and surgical variables were collected. 2-year outcomes included: complications, readmissions, reoperations, and aODI/SRS-22r. Logistic regression was performed. A total of 243 ASD patients had preop and immediate postop measurements; 174 patients (72%) had 2-year follow-up. Mean age was 50.9±17.6 & mean instrumented levels was 13.5±3.9. Mean preop CVA was 2.9±2.7cm, and 90 (37%) had preop CM. Postop CM was seen in 43 (18%) patients, 13 (5%) of which were iatrogenic. Significant risk factors for postop CM were: EBL (OR 1.00, p=0.026), operative time (OR 1.16, p=0.045), preop CVA (OR 1.21, p=0.001), preop SVA (OR 1.05, p=0.046), pelvic obliquity (angle between horizontal & iliac crests) (OR 1.21, p=0.008), lumbosacral fractional (LSF) curve concavity to the same side as the CVA (OR 2.31, p=0.043), & max cobb angle concavity opposite the CVA (OR 2.10, p=0.033). The single significant risk factor for iatrogenic postoperative CM was a LSF curve concavity to the same side as the CVA (OR 11.39, p=0.020). Patients with postop CM were more likely to sustain a postop complication (31.0% vs 14.3%, p=0.009), yet no differences were seen in readmissions (p=0.743) or reoperations (p=1.000). No significant differences were seen in 2-year PROs according to postop coronal malalignment. Postoperative coronal malalignment occurred in 18% of adult spinal deformity patients and was most associated with preoperative CVA, pelvic obliquity, LSF curve to the same side as the CVA, and max cobb angle to the opposite side of the CVA. Though postoperative coronal malalignment was significantly associated with increased complications, surprisingly, readmission, reoperation, & 2-year PROs were similar in those with and without coronal malalignment. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Objective To review the poor natural history of intracerebral hemorrhage (ICH), current treatment options for ICH, discuss ongoing trials evaluating minimally invasive techniques for clot evacuation, and offer future directions of investigation for the management of this devastating disease. Methods A selective review of recent trials regarding treatment of ICH was performed. Results Completed trials of medical and surgical management are reviewed. The supportive research for clot evacuation to limit secondary injury is surveyed. We also provide a comprehensive discussion of current data evaluating minimally invasive techniques to achieve clot removal, including Minimally Invasive Surgery plus tPA for ICH Evacuation (MISTIE), Clot Lysis: Evaluating Accelerated Resolution (CLEAR), and endoscopic evacuation. Conclusion We encourage the neurosurgical community to pursue improved therapies for ICH. Practice New minimally invasive treatments for ICH are being developed. Implications Treatment of ICH is an important area of research and should continue to be aggressively pursued because of the significant societal burden and poor outcomes associated with ICH. [ABSTRACT FROM AUTHOR]

Objective Sports-related concussions and traumatic brain injury (TBI) represent a growing public health concern. We reviewed the literature regarding equestrian-related brain injury, ranging from concussion to severe TBI. Methods A literature review was performed to address the epidemiology of sports-related concussion and TBI in equestrian-related sports. MEDLINE and PUBMED databases were searched to identify all studies pertaining to brain injury in equestrian-related sports. We included two broad types of brain injury using a distinction established in the literature: 1) TBI with functional impairment, including concussion, or mild TBI, with negative imaging findings; and 2) TBI with structural impairment, with positive imaging and at least one of the following pathologies identified: subdural hemorrhage, epidural hemorrhage, subarachnoid hemorrhage, intraparenchymal hemorrhage, cerebral contusions, and skull fractures. Results Our literature search yielded 199 results. We found 26 studies describing functional TBI and 25 mentioning structural TBI, and 8 including both. Of all modern sporting activities, equestrian sports were found to cause some of the highest rates of total bodily injury, severe brain injury, and mortality. Concussions comprise 9.7%–15% of all equestrian-related injuries brought to hospitals for evaluation. Structural TBI was rare, and documentation of these injuries was poor. Although demographic risk factors like age and sex are minimally discussed in the literature, two studies identified a protective effect of increasing rider experience on all forms of bodily injury. However, it remains unclear whether increasing rider experience protects specifically against head injury. Finally, rates of helmet use in horseback riding remain dismally low—ranging from 9%–25%, depending on the activity. These low rates have persisted over time, despite evidence in this literature that helmets lead to an absolute risk reduction for head injury of 40%–50% in equestrian sports. Conclusions Equestrian-related functional and structural TBI represent a significant public health burden. Rider and horse characteristics make the sport uniquely dangerous, as the athlete has limited control over an animal weighing a thousand pounds. Helmet use rates remain very low despite clear evidence of risk reduction. Health care providers are strongly urged to lobby professional and governmental organizations for mandatory helmet use in all equestrian sports. [ABSTRACT FROM AUTHOR]

Background: Immediate-use steam sterilization (IUSS) is a safe method to sterilize emergently contaminated instruments, but inappropriate use may lead to an increased risk for surgical site infection. This study aimed to identify risk factors, rationale, and variability in procedural adherence in cases of IUSS. Methods: This retrospective, case-control study compared adult patients undergoing hip and knee arthroplasty in which IUSS was (n = 104) and was not (n = 81) performed. Results: Multivariate analysis revealed 4 predictive risk factors for IUSS: history of malignancy (odds ratio [OR], 3.2 [95% confidence interval (CI) 1.1-9.3]), obesity (OR, 2.3 [95% CI: 1.02-5.2]), procedure performed in operating room 13 (OR, 2.5 [95% CI: 1.2-5.4]), and Monday procedure (OR, 3.6 [95% CI: 1.4-9.1]). The only factor that protected against IUSS was performing the procedure in the morning (OR, 0.4 [95% CI: 0.2-0.96]). Only 9.5% of cases of IUSS involved an acceptable indication. Documented adherence to core practices was also variable. Conclusion: Several patient- and case-specific factors can help predict the incidence of IUSS. Furthermore, practices should be hardwired to ensure IUSS is utilized for the correct indication. Documentation must be improved to allow institutions to accurately track IUSS. [Copyright &y& Elsevier]

No radiographic alignment threshold defines preop CM in ASD patients based on disability. An optimal threshold exists that defines CM based on patient-reported outcomes (PROs) in ASD patients. Cross-sectional. This study included 368 adult deformity patients. Patient-reported outcomes (ODI and SRS22r) and postoperative coronal and sagittal alignment A single-institution registry was searched for all patients undergoing ASD surgery with ≥6 level fusions. Coronal vertical axis (CVA) & sagittal vertical axis (SVA) were collected. PROs were preop ODI/SRS-22r scores. First, CVA & SVA thresholds were derived to accurately differentiate patients with ODI>40 & SRS-pain+function scores<6. Second, patients were separated and compared based on 4 groups: (1) neutral alignment (NA); 2) coronal malalignment only (CM); (3) sagittal malalignment only (SM); (4) combined coronal & sagittal malalignment (CCSM). Chi-square, Kruskal-Wallis, & linear regression were performed. A total of 368 patients underwent ASD surgery with a mean CVA of 3.1±4.1cm. Part 1: thresholds to distinguish patients with ODI>40 and SRS-pain/fx <6 were: (1) CVA=3.96cm (ODI) and 3.17cm (SRS) and (2) SVA=4.97cm (ODI) and 7.52cm (SRS). To stay conservative, the lower numbers were chosen to define each threshold: CVA=3cm; SVA=5cm. Part 2: alignment breakdown was: NA 179 (48.6%), CM 66 (17.9%), SM 65 (17.7%), & CCSM 58 (15.8%). Based on preop ODI scores, both SM (p=0.006) & CCSM (p<0.001) patients were significantly worse than NA patients. CCSM patients were significantly worse than SM alone (p=0.010). Based on preop total SRS-22r scores, only CCSM (p=0.003) patients were significantly worse than the NA group. CVA significantly correlated with 4/7 (57%) PROs (ODI/SRS-total/function/image), while SVA correlated with 5/7 (71%) PROs (ODI/SRS-total/function/image/pain). A linear relationship was seen between increasing CVA & worsening ODI (β=0.92, p=0.001). A significant yet slightly stronger relationship was seen between increasing SVA & worsening ODI (β=1.28, p<0.001). Alignment thresholds that accurately distinguished ASD patients with severe pain and disability preoperatively were 3cm for CVA and 5cm for SVA. Preop CM was significantly associated with worse ODI, SRS-22r total/function/image scores. CCSM lead to more disability than SM alone. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Conventional adult spinal deformity (ASD) measurements evaluate coronal alignment from C7-sacrum. Little is known about coronal alignment from the skull. Assess coronal alignment evaluated from the skull and correlations with preoperative/postoperative measurements and function. Retrospective cohort. Adult spinal deformity patients from a multi-surgeon single-institution database. Patient-reported outcomes and postoperative radiographic parameters. A single-institution, ASD database was searched for adult spinal deformity patients with at least six or more levels fused. Traditional C7-coronal vertical axis (C7-CVA) measurements were obtained, as was the orbital-CVA (ORB-CVA): the distance between the sacral plumb line and a vertical line from the mid-point between medial orbital walls. The ORB-CVA was correlated with traditional coronal measurements, including C7-CVA, maximum coronal cobb angle, pelvic obliquity (PO), & leg length discrepancy (LLD). Coronal malalignment (CM) was defined as C7-CVA >3cm. Measures of clinical improvement were: (1) group PRO means, (2) minimum clinically important difference (MCID) and (3) minimal symptom scale (MSS) (ODI<20 or SRS-pain+fx>8). A total of 243 patients underwent ASD surgery, and 175 had 2-year follow-up. Ninety (37%) patients had preop CM while mean (range) ORB-CVA at each time point was: preoperative 2.9±3.1 (-14.2-25.6), 1-year postoperative 2.0±1.6 (-12.4-6.7), 2-year postoperative 1.8±1.7 (-6.0, 11.1) (p<0.001 from preoperative to 1-year and 2-year). Preoperative ORB-CVA correlated best with CVA (r=0.842, p<0.001), max coronal Cobb (r=0.166, p=0.010), PO (r=0.293, p<0.001), and LLD (r=0.158, p=0.006). Postoperative, ORB-CVA correlated only with CVA (r=0.627, p<0.001) & LLD (r=0.160, p=0.013). Of the total, 155 (63.2%) patients had an ORB-CVA that was ≥5mm different than C7-CVA. Women were more likely than men to have an ORB-CVA closer to midline than C7-CVA (69% vs 45%, p=0.004). ORB-CVA correlated as well and sometimes better than C7-CVA in SRS-22r subdomains. The ORB-CVA slightly outperformed C7-CVA in its ability to capture patients achieving MCID for SRS-appearance (AUC=0.664 vs 0.513) and with MSS (AUC 0.609 vs AUC 0.542). The ORB-CVA correlated well with known coronal measurements and PROs. Sixty-three percent of patients had an ORB-CVA >5mm different than the C7-CVA, and women were more likely than men to have an ORB-CVA closer to midline than the C7-CVA, indicating a potential compensatory ability. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The lumbosacral fractional curve is often more challenging to correct vs the thoracolumbar/lumbar (TL/L) curve during adult spinal deformity (ASD) surgery, with implications for postoperative coronal alignment. In patients undergoing ASD surgery, the lumbosacral fractional (LSF) curve significantly impacts preop & postop coronal malalignment (CM). Retrospective cohort A total of 243 adult spine deformity patients. Postoperative lumbosacral fractional and maximum Cobb curve correction, coronal vertical axis. Patients undergoing ≥6 level ASD surgery at a single-institution were collected. The LSF curve was the Cobb angle between the sacrum & most tilted lower lumbar vertebra. Coronal vertical axis (CVA) from C7-mid sacrum (cm) was collected. Patients were grouped by alignment: 1) Neutral alignment (N): CVA≤3cm & SVA≤5cm, 2) Coronal malalignment only (CM): CVA>3cm, 3) Sagittal malalignment only (SM): SVA>5cm, or 4) Coronal and sagittal malalignment (CCSM): both CVA>3cm & SVA>5cm. A total of 243 patients underwent ASD surgery: N 115 (47.3%), CM 48 (19.8%), SM 38 (15.6%), CCSM 42 (17.6%). Mean LSF curve was 12.1±9.9° (0.2-62.3). An LSF curve >5° was seen in 174 (71.6%) of all patients & 81.1% of patients with preoperative CM (p=0.012). Largest LSF curves were seen in the CM (14.6±11.9°) & CCSM (13.1±8.3°) groups. 83% of patients had the LSF curve opposite the max Cobb angle. A significant linear relationship was seen between preop LSF curve & preoperative CVA (β =0.03, p=0.042). Immediately postoperative, a linear relationship was seen between CVA and the postop LSF curve (r=0.147, p=0.022), as well as CVA & max Cobb angle (r=0.148, p=0.021), indicating that postoperative coronal alignment is correlated to how much each curve is corrected. Max coronal Cobb angle achieved more % correction than LSF curve (54.5% Cobb vs 46.5% LSF, p=0.025). Postop CM was significantly associated with both the LSF curve to the same side as the CVA (OR 2.3, 95%CI 1.14-4.68, p=0.021) and the max coronal Cobb opposite the CVA (OR 2.1, 95%CI 1.1-4.2, p=0.033), with LSF curve directionality being the stronger predictor. A lumbosacral fractional curve >5° was seen in 81% of adult spinal deformity patients with preoperative coronal malalignment. The lumbosacral fractional curve opposed the max Cobb angle in 83% of cases. The lumbosacral fractional curve was a slightly stronger driver of postop CM than max Cobb angle, potentially due to it being corrected less or not included in the surgery as compared to the max Cobb angle. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Achieving optimal coronal alignment can be a formidable challenge in adult spinal deformity surgery, and how pelvic obliquity and leg length discrepancy relate to coronal malalignment remains poorly studied. Pelvic obliquity (PO) and leg length discrepancy (LLD) are associated with preoperative and postoperative coronal malalignment (CM) in surgical adult spinal deformity (ASD) patients. Retrospective cohort. A total of 237 patients undergoing ASD surgery at a single institution. Pelvic obliquity, leg-length discrepancy, coronal malalignment. Patients undergoing ASD surgery (≥6 level fusions) were reviewed from a single-institution. Variables were:1) Pelvic obliquity (PO): angle between horizontal plane and a line touching bilateral iliac crests; 2) Leg-length discrepancy (LLD): distance from femoral head to the tibial plafond. Coronal vertical axis (CVA) and sagittal vertical axis (SVA) were collected, both measured from C7. Coronal malalignment (CM)= CVA >3cm. Oswestry Disability Index (ODI) was collected at preoperative and 2-years postoperative. Of 237 patients undergoing ASD surgery, 90 (37.0%) had preoperative CM. Patients with preoperative CM had a higher PO (2.8±3.2 vs 2.0±1.7, p=0.013), higher percent of patients with PO>3° (35.6% vs 23.5%, p=0.044), and higher percent of patients with LLD>1 cm (21.1% vs 9.8%, p=0.014). While preoperative PO was significantly correlated with CVA (r=0.26, p<0.001) and max Cobb angle (r=0.30, p<0.001), preoperative LLD was only correlated with CVA (r=0.14, p=0.035). 12.2% of CM patients had both clinically significant PO and LLD. Postoperatively, preop PO was significantly associated with both postoperative CM (OR=1.22, 95%CI, p=0.008) and postoperative CVA (β=0.11, p<0.001). A higher preop PO was independently associated with postop complications after multivariate logistic regression (OR=1.24, p=0.010); however, 2-year ODI scores were not. Preoperative LLD had no significant relationship to postop CM, CVA, ODI or complications. Clinically significant pelvic obliquity ≥3° or leg-length discrepancy ≥1 cm was seen in 44.1% of patients with preoperative coronal malalignment, but also 23.5% of patients with normal coronal alignment. Preoperative pelvic obliquity was significantly associated with preoperative coronal vertical axis and max Cobb angle, while preoperative leg-length discrepancy was only associated with preoperative coronal vertical axis. The direction of pelvic obliquity and leg-length discrepancy showed no consistent pattern with coronal vertical axis. Preoperative pelvic obliquity was independently associated with complications but not 2-year ODI scores. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

In patients undergoing metastatic spine surgery, we sought to 1) report time to postoperative radiation therapy (RT), 2) describe the predictive factors of time to postoperative RT, and 3) determine if earlier postoperative RT is associated with improved local recurrence (LR) and overall survival (OS). A single-center retrospective cohort study was undertaken of all patients undergoing spine surgery for extradural metastatic disease and receiving RT within 3 months postoperatively between January 2010 and January 2021. Time to postoperative RT was dichotomized at <1 month versus 1–3 months. The primary outcomes were LR, OS, and 1-year survival. Secondary outcomes were wound complication, Karnofsky Performance Status, and modified McCormick Scale (MMS) score. Regression analyses controlled for age, body mass index, tumor size, preoperative RT, preoperative/postoperative chemotherapy, and type of RT. Of 76 patients undergoing spinal metastasis surgery and receiving postoperative RT within 3 months, 34 (44.7%) received RT within 1 month and 42 (55.2%) within 1–3 months. Patients with larger tumor size (β = –3.58; 95% confidence interval [CI], –6.59 to –0.57; P = 0.021) or new neurologic deficits (β = –16.21; 95% CI, –32.21 to –0.210; P = 0.047) had a shorter time to RT. No significant association was found between time to RT and LR or OS on multivariable logistic/Cox regression. However, patients who received RT between 1 and 3 months had a lower odds of 1-year survival compared with those receiving RT within 1 month (odds ratio, 0.18; 95% CI, 0.04–0.74; P = 0.022). Receiving RT within 1 month versus 1–3 months was not associated with wound complications (7.1% vs. 2.9%; P = 0.556) (odds ratio, 4.40; 95% CI, 0.40–118.0; P = 0.266) or Karnofsky Performance Status/modified McCormick Scale score. Spine surgeons, oncologists, and radiation oncologists should make every effort to start RT within 1 month to improve 1-year survival after metastatic spine tumor surgery. [ABSTRACT FROM AUTHOR]

Participation in the health care and government advocacy arena may represent new and challenging perspectives for the traditional neurosurgeon. However, those with a strong understanding of the laws, rules, regulations, and fiscal allocation process can directly influence the practice of neurosurgery in the United States. We seek to shine light on the black box of how health care laws are passed, the influence and techniques of lobbying, and the role and rules surrounding political action committees. This practical review of health care advocacy is supplemented by a blueprint for engagement in the political arena for the practicing neurosurgeon. [ABSTRACT FROM AUTHOR]

In patients undergoing surgery for primary bone tumors of the spine, we sought to compare Bilsky score 0–1 versus 2–3 in: 1) preoperative presentation, 2) perioperative variables, and 3) long-term outcomes. A single-center, retrospective cohort study was undertaken of patients undergoing surgery for extradural, primary bone tumors of the spine between January 2010 and January 2021. The primary exposure variable was Bilsky score, dichotomized as 0–1 versus 2–3. Survival analysis was performed to assess local recurrence (LR) and overall survival (OS). Of 38 patients undergoing resection of primary spinal tumors, 19 (50.0%) patients presented with Bilsky 0–1 and 19 (50.0%) Bilsky 2–3 grades. The most common diagnosis was chondrosarcoma (33.3%), followed by chordoma (16.7%). There were 15 (62.5%) malignant tumors. Preoperatively, there was no significant difference in demographics, Karnofsky Performance Scale (KPS) (P > 0.999), or motor deficit (P > 0.999). Perioperatively, no difference was found in operative time (P = 0.954), blood loss (P = 0.416), length of stay (P = 0.641), neurologic deficit (P > 0.999), or discharge disposition (P = 0.256). No difference was found in Enneking resection status (69.2% vs. 54.5%, P = 0.675). Long-term, no differences were found regarding reoperation (P = 0.327), neurologic deficit (P > 0.999), postoperative KPS (P = 0.605) and modified McCormick Scale (MMS) (P = 0.870). No difference was observed in KPS (P = 0.418) and MMS (P = 0.870) at last follow-up. However, patients with Bilsky 2–3 had shorter time to LR (1715.0 vs. 513.0 ± 633.4 days, log-rank; P = 0.002) and shorter OS (2025.0 ± 1165.3 vs. 794.0 ± 952.6 days, log-rank; P = 0.002). Bilsky 2–3 lesions were associated with shorter time to LR and shorter OS. Patients harboring primary spinal tumors with higher grade Bilsky score appear to be at a higher risk for worse outcomes. [ABSTRACT FROM AUTHOR]

Unplanned readmissions following lumbar spine surgery have immense clinical and financial implications. However, little is known regarding the impact of unplanned readmissions on patient-reported outcomes (PROs) following lumbar spine surgery. To evaluate the impact of unplanned readmissions, including specific readmission reasons, on patient reported outcomes 12 months after lumbar spine surgery. A retrospective cohort study of prospectively collected data was conducted using patients included in the lumbar module of the Quality and Outcomes Database (QOD), a national, multicenter spine registry. A total of 33,447 patients who underwent elective lumbar spine surgery for degenerative diseases were included. Mean age was 59.8 (SD=14.04), 53.6% were male, 89.5% were white, 45.9% were employed, and 47.5% had private insurance. Unplanned 90-day readmissions and 12-month patient-reported outcomes (PROs) including numeric rating scale (NRS) scores for back and leg pain, Oswestry Disability Index (ODI) scores, EuroQol-5 Dimension (EQ-5D) scores, and North American Spine Society (NASS) patient-satisfaction scores. The lumbar module of the QOD was queried for adults undergoing elective lumbar spine surgery for degenerative disease. Unplanned 90-day readmissions were classified into 4 groups: medical, surgical, pain-only, and no readmissions. Medical and surgical readmissions were further categorized into primary reason for readmission. 12-month PROs assessing patient back and leg pain (NRS), disability (ODI), quality of life (EQ-5D), and patient satisfaction were collected. Multivariable models predicting 12-month PROs were built controlling for covariates. A total of 31,430 patients (94%) had no unplanned readmission while 2,017 patients (6%) had an unplanned readmission within 90 days following lumbar surgery. Patients with readmissions had significantly worse 12-month PROs compared with those with no unplanned readmissions in covariate-adjusted models. Using Wald-df as a measure of predictor importance, surgical readmissions were associated with the worst 12-month outcomes, followed by pain-only, then medical readmissions. In separate covariate adjusted models, we found that readmissions for pain, SSI/wound dehiscence, and revisions were among the most important predictors of worse outcomes at 12-months. Unplanned 90-day readmissions were associated with worse pain, disability, quality of life, and greater dissatisfaction at 12-months, with surgical readmissions having the greatest impact, followed by pain-only readmissions, then medical readmissions. Readmissions for pain, SSI/wound dehiscence, and revisions were the most important predictors of worse outcomes. These results may help providers better understand the factors that impact outcomes following lumbar spine surgery and promote improved patient counseling and perioperative management. [ABSTRACT FROM AUTHOR]

Background Chordomas are rare primary bone tumors that arise from the axial skeleton. Our objective was to analyze trends in radiation and surgery over time and determine location-based survival predictors for chordomas of the skull base, mobile spine, and sacrum. Methods A retrospective cohort study of the SEER (Surveillance Epidemiology and End Results) database from 1973 to 2013 was conducted. All patients had histologically confirmed chordomas. The principal outcome measure was overall survival (OS). Results The cohort included 1616 patients: skull base (664), mobile spine (444), and sacrum (508). Skull base tumors presented earliest in life (47.4 years) and sacral tumors presented latest (62.7 years). Rates of radiation remained stable for skull base and mobile spine tumors but declined for sacral tumors ( P = 0.006). Rates of surgical resection remained stable for skull base and sacral tumors but declined for mobile spine tumors ( P = 0.046). Skull base chordomas had the longest median survival (162 months) compared with mobile spine (94 months) and sacral tumors (87 months). Being married was independently associated with improved OS for skull base tumors (hazard ratio, 0.73; 95% confidence interval, 0.53–0.99; P = 0.044). Surgical resection was independently associated with improved OS for sacral chordomas (hazard ratio, 0.48; 95% confidence interval, 0.34–0.69; P < 0.001). Conclusions Surgical resection for mobile spine chordomas and radiation for sacral chordomas decreased over time. Patients with skull base tumors survived longer than did patients with mobile spine and sacral chordomas, and surgical resection was associated with improved survival in sacral chordomas only. Understanding the behavior of these tumors can help cranial and spinal surgeons improve treatment in this patient population. [ABSTRACT FROM AUTHOR]

Background Neurosurgical educators strive to identify the best applicants, yet formal study of resident selection has proved difficult. We conducted a systematic review to answer the following question: What objective and subjective preresidency factors predict resident success? Methods PubMed, ProQuest, Embase, and the CINAHL databases were queried from 1952 to 2015 for literature reporting the impact of preresidency factors (PRFs) on outcomes of residency success (RS), among neurosurgery and all surgical subspecialties. Due to heterogeneity of specialties and outcomes, a qualitative summary and heat map of significant findings were constructed. Results From 1489 studies, 21 articles met inclusion criteria, which evaluated 1276 resident applicants across five surgical subspecialties. No neurosurgical studies met the inclusion criteria. Common objective PRFs included standardized testing (76%), medical school performance (48%), and Alpha Omega Alpha (43%). Common subjective PRFs included aggregate rank scores (57%), letters of recommendation (38%), research (33%), interviews (19%), and athletic or musical talent (19%). Outcomes of RS included faculty evaluations, in-training/board exams, chief resident status, and research productivity. Among objective factors, standardized test scores correlated well with in-training/board examinations but poorly correlated with faculty evaluations. Among subjective factors, aggregate rank scores, letters of recommendation, and athletic or musical talent demonstrated moderate correlation with faculty evaluations. Conclusion Standardized testing most strongly correlated with future examination performance but correlated poorly with faculty evaluations. Moderate predictors of faculty evaluations were aggregate rank scores, letters of recommendation, and athletic or musical talent. The ability to predict success of neurosurgical residents using an evidence-based approach is limited, and few factors have correlated with future resident performance. Given the importance of recruitment to the greater field of neurosurgery, these data provide support for a national, prospective effort to improve the study of neurosurgery resident selection. [ABSTRACT FROM AUTHOR]

In patients undergoing cervical spine surgery for metastatic spine disease, we sought to 1) compare perioperative and oncologic outcomes among 3 different operative approaches, 2) report fusion rates, and 3) compare different types of anterior vertebral body replacement. A single-center retrospective cohort study of patients undergoing extradural cervical/cervicothoracic spine metastasis surgery between February 2010 and January 2021 was conducted. Operative approaches were anterior-alone, posterior-alone, or combined anterior-posterior, and the grafts/cages used in the anterior fusions were cortical allografts, static cages, or expandable cages. All cages were filled with autograft/allograft. Outcomes included perioperative/postoperative variables, along with fusion rates, functional status, local recurrence (LR), and overall survival (OS). Sixty-one patients underwent cervical spine surgery for metastatic disease, including 11 anterior (18.0%), 28 posterior (45.9%), and 22 combined (36.1%). New postoperative neurologic deficit was the highest in the anterior approach group (P = 0.038), and dysphagia was significantly higher in the combined approach group (P = 0.001). LR (P > 0.999), OS (P = 0.655), and time to both outcomes (log-rank test, OS, P = 0.051, LR, P = 0.187) were not significantly different. Of the 51 patients alive at 3 months, only 19 (37.2%) obtained imaging ≥3 months. Fusion was seen in 11/19 (57.8%) at a median of 8.3 months (interquartile range, 4.6–13.7). Among the anterior corpectomies, the following graft/cage was used: 6 allografts (54.5%), 4 static cages (36.3%), and 1 expandable cage (9.0%), with no difference found in outcomes among the 3 groups. The only discernible differences between operative approaches were that patients undergoing an anterior approach had higher rates of new postoperative neurologic deficit, and the combined approach group had higher rates of postoperative dysphagia. [ABSTRACT FROM AUTHOR]

In patients undergoing adult spinal deformity (ASD) surgery, we sought to: (1) determine the relationship between dual-energy x-ray absorptiometry (DEXA)-measured bone mineral density (BMD), T-scores, and Hounsfield units (HU), and (2) compare the ability of DEXA-measured BMD, T-scores, and HU to predict mechanical complications and reoperations. A single-institution retrospective cohort study was undertaken for cases from 2013 to 2017. Inclusion criteria: ≥5-level-fusion, sagittal/coronal deformity, and 2-year follow-up. Multivariable regression controlled for age, body mass index, receiving anabolic medications, and postoperative sagittal vertical axis and pelvic-incidence lumbar-lordosis mismatch. A subanalysis was performed for osteopenic patients (–1 < T-score < –2). Of 145 patients undergoing ASD surgery, 72 (49.6%) had both preoperative DEXA and computed tomography scans. Mean DEXA-measured BMD was 0.91 ± 0.52 g/cm2, mean T-score was –1.61 ± 1.03, and mean HU was 153.5 ± 52.8. While no correlation was found between DEXA-measured BMD and HU (r = 0.17, P = 0.144), T-score and HU had a weakly positive correlation (r = 0.31, P = 0.007). Mechanical complications occurred in 48 (66.7%) patients, including 27 (37.5%) proximal junctional kyphosis (PJK), 1 (1.4%) distal junctional kyphosis, 5 (6.9%) implant failure, 30 (41.7%) rod fracture/pseudarthrosis, 42 (58.3%) reoperations, and 16 (22.2%) reoperations due to PJK. No association was found between DEXA-measured BMD or T-scores with mechanical complications or reoperations. While univariate regression showed a significant association between lower HU and PJK (OR 0.98, 95%CI 0.97–0.99, P = 0.011), the significance was lost after multivariable analysis. When considering osteopenic patients (n = 37), only DEXA-measured BMD was an independent risk factor for PJK (OR 0.01, 95%CI 0.00–0.09, P = 0.017), with a threshold of 0.82 g/cm2 (AUC 0.70, 95%CI 0.53–0.84, P = 0.019). Poor correlation was found between the 3 BMD modalities. DEXA-measured BMD may be superior to T-scores and HU in predicting PJK among patients with osteopenia with a threshold of BMD <0.82 g/cm2. [ABSTRACT FROM AUTHOR]

In patients undergoing surgery for spinal metastasis, we sought to: (1) describe patterns of palliative care consultation, (2) evaluate the factors that trigger palliative care consultation, and (3) determine the association of palliative care consultation on longer-term outcomes. A single-center, retrospective, case-control study was conducted for patients undergoing spinal metastasis surgery from February 2010 to January 2021. The primary outcome was receiving a palliative care consultation, and the timing of consultation was divided into same hospital stay consultation, preoperative versus postoperative consultation, and early (

Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors. Data from patients aged 12–18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P = 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR] = 1.35, 95% CI 1.03–1.77, P = 0.030), which remained significant (HR = 1.32, 95% CI 1.002–1.73, P = 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR = 1.12, 95% CI 0.85–1.48, P = 0.410). Adding prior concussion history further reduced the association between race/recovery (HR = 1.01, 95% CI 0.77–1.34, P = 0.925). Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors. [ABSTRACT FROM AUTHOR]

Patients undergoing surgery for cervical spine metastases are at risk for unplanned readmission due to comorbidities and chemotherapy/radiation. Our objectives were to: 1) report the incidence of unplanned readmission, 2) identify risk factors associated with unplanned readmission, and 3) determine the impact of an unplanned readmission on long-term outcomes. A single-center, retrospective, case-control study was undertaken of patients undergoing cervical spine surgery for metastatic disease between 02/2010 and 01/2021. The primary outcome of interest was unplanned readmission within 6 months. Survival analysis was performed for overall survival (OS) and local recurrence (LR). A total of 61 patients underwent cervical spine surgery for metastatic disease with the following approaches: 11 (18.0%) anterior, 28 (45.9%) posterior, and 22 (36.1%) combined. Mean age was 60.9 ± 11.2 years and 38 (62.3%) were males. A total of 9/61 (14.8%) patients had an unplanned readmission, 3 for surgical reasons and 6 for medical reasons. No difference was found in demographics, preoperative Karnofsky Performance Scale (P = 0.992), motor strength (P = 0.477), or comorbidities (P = 0.213) between readmitted patients versus not. Readmitted patients had a higher rate of preoperative radiation (P = 0.009). No statistical differences were found in operative time (P = 0.893), estimated blood loss (P = 0.676), length of stay (P = 0.720), discharge disposition (P = 0.279), and operative approach (P = 0.450). Furthermore, no difference was found regarding complications (P = 0.463), postoperative Karnofsky Performance Scale (P = 0.535), and postoperative Modified McCormick Scale (P = 0.586). Lastly, unplanned readmissions were not associated with OS (log-rank; P = 0.094) or LR (log-rank; P = 0.110). In patients undergoing cervical spine metastasis surgery, readmission occurred in 15% of patients, 33% for surgical reasons, and 67% for medical reasons. Preoperative radiotherapy was associated with an increased rate of unplanned readmissions, yet readmission had no association with OS or LR. [ABSTRACT FROM AUTHOR]

This study aims to evaluate the rate of improvement in neurologic recovery of patients with sports-related spinal cord injury (SRSCI) who had surgical intervention (SS) and those who did not (NSS). We aimed to 1) evaluate the rate of American Spinal Injury Association (ASIA) conversion in patients with and without surgery, and 2) assess predictors of conversion in ASIA grade. The National Spinal Cord Injury Model Systems Database (SCIMS) was used from 1973 to 2016. Patients with SRSCI were included. The primary outcome was rate of conversion in ASIA grade. Multivariate logistic regression was performed with separate subgroup analysis on patients with cervical injury (represented by odds ratio [OR]; 95% confidence interval [CI]). A total of 1647 patients had SRSCI with 1502 (91%) SSs. Most patients (88%) were male, white (87%), and between the ages of 15 and 29 years (63%). Patients undergoing SS had significantly longer inpatient rehabilitation length of stay (LOS) (P < 0.001) and a more patients undergoing SS had complete motor or sensory loss compared with the NSS group. Multivariate logistic regression showed that injury at the thoracic level (OR, 0.41; 95% CI, 0.21–0.78), age 15–29 years (OR, 0.44; 95% CI, 0.20–0.97]), water-based injury (OR, 0.45; 95% CI, 0.21–0.95), and ASIA impairment grades of B, C, and D at admission were significantly associated with ASIA SCORE conversion. We found that patients undergoing SS had longer LOS and a higher prevalence of complete injuries. Surgical intervention was not associated with conversion in ASIA grade to an improved status at time of discharge in a large cohort of patients with SRSCI and in a subcohort of patients with cervical SRSCI. [ABSTRACT FROM AUTHOR]

Private insurers use the calendar deductible system, placing pressure on patients and medical personnel to perform medical services before the end of the year to maximize patient savings. The impact of the deductible calendar on patient-reported outcomes (PROs) after spine surgery is poorly understood. The objective of our study was to investigate if patients undergoing surgery in December had different PROs and demographics compared with all other months. The Quality Outcome Database, a national spine registry, was queried for patients who underwent elective spine surgery between January 2012 and January 2021 for degenerative spine conditions. PROs and demographics were compared between the December and non-December groups using various statistical tests. A total of 978 patients (9.3%) underwent anterior cervical discectomy and fusion in December versus 9548 (90.7%) in other months. There was a significantly higher percentage of patients in December who had private insurance and were employed. A total of 1104 patients (8.5%) underwent lumbar fusion in December versus 11,826 (91.5%) in other months. There was a significantly greater chance of undergoing surgery in December if patients had private insurance and were employed. Although some PROs were statistically significant for the lumbar and cervical cohorts between December and non-December patients, none were clinically significant. Patients undergoing elective spine surgery in December were more likely to have private insurance and be employed. PROs for ACDF and lumbar fusions were not affected by surgical timing (December yes/no). Other spinal procedures directed at more chronic diseases might be more susceptible to external influence of insurance deductibles. [ABSTRACT FROM AUTHOR]

To compare postoperative outcomes after cranioplasties performed by neurosurgery only (N) versus neurosurgery and plastic surgery combined (N+P). A single-center, multisurgeon, retrospective cohort study was undertaken on all cranioplasties performed from November 2006 to December 2021. The primary exposure variable was operating team (N vs. N+P). The primary outcome was the need for reoperation. Secondary outcomes included surgical site infections, complications, length of stay (LOS), and length of drain placement. Of 188 patients undergoing cranioplasty during the study period, 106 (56%) patients were in the N group, and 82 (44%) were in the N+P group. Patient demographics were similar between the 2 groups. For the primary outcome, a total of 20 (18.9%) reoperations were seen in the N group, and 13 (15.9%) in the N+P group (P = 0.708). However, the median time to reoperation was slightly longer in the N+P group in the survival analysis. Wound dehiscence (1.9% vs. 3.7%, P = 0.454), surgical site infection (5.7% vs. 9.8%, P = 0.289), and complication rate (30.2% vs. 32.9%, P = 0.688) did not differ between the 2 groups. Furthermore, the N group had less Jackson-Pratt drain use (58.5% vs. 85.4%, P < 0.001), earlier drain removal (1.9 ± 1.6 vs. 3.4 ± 3.9 days, P < 0.001), and shorter LOS (3.8 ± 5.9 vs. 4.7 ± 3.9 days, P < 0.001). On multivariate regression analysis controlling for age, body mass index, smoking, craniectomy type, reason for craniectomy, and graft type, N+P was associated with increased drain use (odds ratio = 4.90, 95% confidence interval 2.28–11.30, P < 0.001) and longer drain duration (β = 1.50, 95% confidence interval 0.43–2.60, P = 0.007). Despite similar complication and reoperation rates between groups, reoperations in the N group occurred sooner, whereas the N+P group more commonly used drains and kept drains in for longer. [ABSTRACT FROM AUTHOR]

We conducted a systematic review and meta-analysis to: 1) compare time from traumatic spinal injury (TSI) to operating room (OR) in high-income countries (HICs) versus low-middle-income countries (LMICs), and 2) evaluate hospital length of stay (LOS) in HICs versus LMICs. A systematic literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving articles of all languages. Inclusion criteria: published between 1991 and 2021, spine trauma population, single country/region, and recorded time from injury to OR. The primary outcome was time from injury to OR, and the secondary outcome was LOS. Means and standard deviations were estimated in a random effects model by DerSimonian and Laird methods. Of 2367 articles, 163 met the inclusion criteria for systematic review. Regarding time from injury to OR, 23 articles were eligible for meta-analysis; 16 studies were conducted in HICs and 7 in LMICs, comprising 3819 patients with TSI. A significantly shorter mean time from injury to OR was found in HICs (1.92 days, 95% confidence interval 1.44–2.41) compared with LMICs (3.27 days, 95% confidence interval 2.27–4.27) (P = 0.020). Regarding length of stay, 14 articles were eligible for meta-analysis, 10 studies were conducted in HICs and 4 in LMICs, comprising 11,003 patients. There was no difference in LOS between HICs and LMICs (25.76 days vs. 20.48 days, P = 0.140). Patients with traumatic spinal injuries in HICs were more likely to undergo earlier surgery compared to patients in LMICs. No difference was found in total LOS between HICs and LMICs. While multiple factors can influence time to surgery, these findings draw attention to the global disparity in spinal trauma care. [ABSTRACT FROM AUTHOR]

Background Context: Multiple sclerosis (MS) is an autoimmune, neurodegenerative disease that can lead to significant functional disability. Improving treatment regimens have extended life expectancy and led to an increase in the number of elective spine surgeries for degenerative conditions in the MS population. Recent literature has reported mixed results regarding the efficacy of elective spine surgery for patients with MS. There is also a paucity of literature comparing postoperative patient reported outcomes (PROs) and reoperation rates between patients with and without MS.Purpose: To determine if patients with MS have worse PROs and higher complication, readmission and reoperation rates after elective spine surgery compared with patients without neurodegenerative conditions when adjusting for baseline covariates through propensity matching.Study Design/setting: Retrospective review of prospectively collected data from the Quality Outcomes Database (QOD), a national, longitudinal, multicenter spine outcomes registry.Patient Sample: For the lumbar cohort, 312 patients with MS and 46,738 patients without MS were included. The cervical myelopathy cohort included 91 patients with MS and 6,426 patients without MS. The cervical radiculopathy cohort consisted of 103 patients with MS and 13,751 patients without MS.Outcome Measures: 1) complication rates, 2) readmission rates, 3) reoperation rates, and 4) PROs at 3- and 12-months including ODI/NDI, NRS back/neck/arm/leg pain, mJOA scores and patient satisfaction ratings.Methods: Data from the QOD was queried for patients with surgeries occurring between 04/2013-01/2019. Three surgical groups were included: 1) Elective lumbar surgery, 2) Elective cervical surgery for myelopathy, 3) Elective cervical surgery for radiculopathy. Patients with any neurodegenerative condition other than MS were excluded. Patients without MS were propensity matched against patients with MS in a 5 to 1 ratio without replacement based on ASA grade, arthrodesis, surgical approach, number of operated levels, age, and baseline ODI/NDI, NRS leg/arm pain, NRS back/neck pain, and EQ-5D. Multivariable regressions with cluster-robust standard errors were used to estimate average effect of how the outcome would change if the MS patient didn't have the disease. The mean difference was used for continuous outcomes and the risk difference was used for binary outcomes.Results: For the lumbar cohort, no differences were found between the 2 groups at 3 or 12 months in any of the outcome measures. For the myelopathy cohort, patients with MS patients had a lower rate of reoperation at 12 months (risk difference=-0.036, p=.007) and worse 3-month mJOA scores (mean difference=-1.044, p=.004) compared with patients without MS. For the radiculopathy cohort, patients with MS had a lower rate of reoperation at 3 months (risk difference=-0.019, p=.018) and 12 months (risk difference=-0.029, p=.007) compared with those without MS.Conclusions: Patients with MS had similar PROs compared with patients without MS when adjusting for baseline covariates through propensity matching, except for 3-month mJOA scores in the myelopathy cohort. Reoperation rates were found to be lower in patients with MS undergoing elective cervical surgery for both myelopathy and radiculopathy. These results suggest that when analyzed independently, a diagnosis of MS does not significantly impact complication, readmission and reoperation rates or PROs, and therefore should not represent a major contraindication to elective spine surgery. Surgical decisions in this patient population should be made based on careful consideration of patient factors including other comorbidities as well as baseline patient functional status. [ABSTRACT FROM AUTHOR]