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BackgroundPredicting neurological recovery after spinal cord injury (SCI) is challenging. Using topological data analysis, we have previously shown that mean arterial pressure (MAP) during SCI surgery predicts long-term functional recovery in rodent models, motivating the present multicenter study in patients.MethodsIntra-operative monitoring records and neurological outcome data were extracted (n = 118 patients). We built a similarity network of patients from a low-dimensional space embedded using a non-linear algorithm, Isomap, and ensured topological extraction using persistent homology metrics. Confirmatory analysis was conducted through regression methods.ResultsNetwork analysis suggested that time outside of an optimum MAP range (hypotension or hypertension) during surgery was associated with lower likelihood of neurological recovery at hospital discharge. Logistic and LASSO (least absolute shrinkage and selection operator) regression confirmed these findings, revealing an optimal MAP range of 76-[104-117] mmHg associated with neurological recovery.ConclusionsWe show that deviation from this optimal MAP range during SCI surgery predicts lower probability of neurological recovery and suggest new targets for therapeutic intervention.FundingNIH/NINDS: R01NS088475 (ARF); R01NS122888 (ARF); UH3NS106899 (ARF); Department of Veterans Affairs: 1I01RX002245 (ARF), I01RX002787 (ARF); Wings for Life Foundation (ATE, ARF); Craig H. Neilsen Foundation (ARF); and DOD: SC150198 (MSB); SC190233 (MSB).

Importance: Traumatic brain injury (TBI) is associated with chronic medical conditions. Evidence from diverse clinical administrative datasets may improve care delivery., Objective: To characterize post-TBI risk of incident neuropsychiatric and medical conditions in a California health care system administrative database and validate findings from a Massachusetts dataset., Design, Setting, and Participants: In this cohort study, prospective longitudinal cohorts using data from 5 University of California health care settings between 2013 and 2022 were studied. Patients aged 18 years and older with mild (mTBI) or moderate to severe TBI (msTBI) were included. Unexposed individuals were propensity matched by age, race and ethnicity, sex, University of California site, insurance coverage, area deprivation index (ADI) score, and duration from index date to most recent clinical encounter. Patients with study comorbidities of interest before the index date were excluded. Data were analyzed August to October 2024., Exposure: TBI., Main Outcomes and Measures: International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were used to identify patients with TBI and patients with up to 22 comorbidities within neurological, psychiatric, cardiovascular, and endocrine umbrella groupings. Cox proportional hazard models were used to generate yearly hazard ratios (HRs) from 6 months up to 10 years after a TBI. Models were further stratified by age and ADI score., Results: The study consisted of 20 400 patients (9264 female [45.4%]; 1576 Black [7.7%], 3944 Latinx [19.3%], and 10 480 White [51.4%]), including 5100 patients with mTBI (median [IQR] age, 36.0 [25.0-51.0] years), 5100 patients with msTBI (median [IQR age, 35.0 [25.0-52.0] years), and 10 200 matched patients in the control group (median [IQR] age, 36.0 [25.0-51.0] years). By ADI score quintile, there were 2757 unexposed patients (27.0%), 1561 patients with mTBI (30.6%), and 1550 patients with msTBI (30.4%) in the lowest (1-2) quintiles and 1523 unexposed patients (14.9%), 769 patients with mTBI (15.1%), and 804 patients with msTBI (15.8%) in the highest quintiles (9-10). TBI of any severity was associated with increased risk of nearly all conditions (mTBI HRs ranged from 1.30; 95% CI, 1.07-1.57 for hypothyroidism to 4.06; 95% CI, 3.06-5.39 for dementia, and msTBI HRs ranged from 1.35; 95% CI, 1.12-1.62 for hypothyroidism to 3.45; 95% CI, 2.73-4.35 for seizure disorder). Separate age and ADI stratifications revealed patient populations at increased risk, including middle-age adults (ages 41-60 years), with increased risk of suicidality (mTBI: HR, 4.84; 95% CI, 3.01-7.78; msTBI: HR, 4.08; 95% CI, 2.51-6.62). Suicidality risk persisted for patients with mTBI in the high ADI subgroup (HR, 2.23; 95% CI, 1.36-3.66)., Conclusions and Relevance: In this cohort study, TBI was a risk factor associated with treatable incident neuropsychiatric and other medical conditions, validating similar findings from a Massachusetts dataset. Additional exploratory findings suggested varying demographic and regional risk patterns, which may generate causal hypotheses for further research and inform clinical surveillance strategies.

Background and Objectives: Despite profound medico-socio-legal consequences of traumatic brain injury (TBI) from intimate partner violence and domestic violence (IPV/DV), the incidence and acute outcomes of concurrent IPV/DV-TBI are not well understood. We examined US IPV/DV patients with/without TBI (IPV/DV-TBI; non-TBI) using the National Trauma Data Bank. We hypothesized IPV/DV-TBI would be associated with elevated morbidity., Methods: National Trauma Data Bank Trauma Quality Programs Participant Use Files years 2018 to 2021 were queried for patients aged ≥18 years with IPV/DV using International Classification of Diseases, Tenth Revision external cause codes. TBI/non-TBI was defined using International Classification of Diseases, Tenth Revision diagnosis codes. TBI severity was defined by the Glasgow Coma Scale (severe = 3-8, moderate = 9-12, and mild = 13-15). Outcomes were intensive care unit (ICU) admission, in-hospital mortality, length of stay (LOS), and discharge home. Multivariable regressions examined associations between TBI and outcomes, controlling for sociodemographic and injury severity variables., Results: Of 3891 IPV/DV-related cases, 31.1% were IPV/DV-TBI. Cranial injuries included skull fracture (30.2%), subdural (19.8%), subarachnoid (13.4%), and epidural (1.1%) hemorrhage, contusion (8.1%), and cerebral edema (3.3%). In IPV/DV-TBI, mild/moderate/severe TBI proportions were 87.4%/4.3%/8.3%, with mean LOS 11.5 ± 10.9/14.4 ± 27.3/5.0 ± 7.7-days and mortality 0.9%/22.5%/28.6%, respectively. Compared with non-TBI, IPV/DV-TBI had more female (77.2%/64.6%, P < .001) and fewer Black patients (28.9%/36.6%, P < .001), more ICU admissions (20.9%/7.5%, P < .001) and mortality (4.1%/1.8%, P < .001), longer LOS (5.3 ± 9.5/4.5 ± 6.4-days, P = .008), and decreased discharge home (79.8%/83.8%, P = .005). Multivariable regressions confirmed the associations between TBI and ICU admission (adjusted odds ratio [aOR] = 4.29, 95% CI [3.46-5.33]), mortality (aOR = 3.20 [1.99-5.15]), LOS (adjusted mean difference = +1.22 [0.68-1.76]), and inability to discharge home (aOR = 0.57 [0.46-0.71])., Conclusion: One-third of US IPV/DV-related trauma cases have TBI, comprising predominantly female patients. Black patients with IPV/DV-related trauma were overrepresented compared with US census estimates. IPV/DV-TBI had increased ICU admissions, LOS, in-hospital mortality, and inability to discharge home compared with non-TBI. Investigating morbidity risk factors and providing sociomedical resources during acute care are critically needed in this vulnerable population., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background: Contemporary surgical practices for traumatic brain injury (TBI) remain unclear. We describe the clinical profile of an 18-centre US TBI cohort with cranial surgery., Methods: The prospective, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (2014-2018; ClinicalTrials.gov #NCT02119182) enrolled subjects who presented to trauma centre and received head computed tomography within 24-h (h) post-TBI. We performed a secondary data analysis in subjects aged ≥17-years with hospitalisation. Clinical characteristics, surgery type/timing, hospital and six-month outcomes were reported., Findings: Of 2032 subjects (age: mean = 41.4-years, range = 17-89-years; male = 71% female = 29%), 260 underwent cranial surgery, comprising 65% decompressive craniectomy, 23% craniotomy, 12% other surgery. Subjects with surgery (vs. without surgery) presented with worse neurological injury (median Glasgow Coma Scale = 6 vs. 15; midline shift ≥5 mm: 48% vs. 2%; cisternal effacement: 61% vs. 4%; p < 0.0001). Median time-to-craniectomy/craniotomy was 1.8 h (interquartile range = 1.1-5.0 h), and 67% underwent intracranial pressure monitoring. Seventy-three percent of subjects with decompressive craniectomy and 58% of subjects with craniotomy had ≥3 intracranial lesion types. Decompressive craniectomy (vs. craniotomy) was associated with intracranial injury severity (median Rotterdam Score = 4 vs. 3, p < 0.0001), intensive care length of stay (median = 13 vs. 4-days, p = 0.0002), and six-month unfavourable outcome (62% vs. 30%; p = 0.0001). Earlier time-to-craniectomy was associated with intracranial injury severity., Interpretation: In a large representative cohort of patients hospitalised with TBI, surgical decision-making and time-to-surgery aligned with intracranial injury severity. Multifocal TBIs predominated in patients with cranial surgery. These findings summarise current TBI surgical practice across US trauma centres and provide the foundation for analyses in targeted subpopulations., Funding: National Institute of Neurological Disorders and Stroke; US Department of Defense; Neurosurgery Research and Education Foundation., Competing Interests: AMD declares: grant funding from the Mercatus Center at George Mason University (not related to the current work). DKM declares: grant funding from United Kingdom National Institute for Health Research (not related to the current work). KKWW declares: is a shareholder of Gryphon Bio, Inc. (not related to the current work). All other authors declare no conflict of interest., (© 2024 The Author(s).)

Objective: The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) assessment is the gold standard for evaluation of neurological function after spinal cord injury (SCI). Although it is an invaluable tool for diagnostic and research purposes, it is time consuming and can be impractical in acute injury settings. Clinical neurosurgery motor examinations (NMEs) could serve as an expeditious surrogate for SCI research when ISNCSCI motor examinations are not feasible. The aim of this study was to evaluate the agreement between motor examinations performed by the neurosurgery clinical team and ISNCSCI examiners., Methods: The multicenter prospective Transforming Research and Clinical Knowledge in Spinal Cord Injury (TRACK-SCI) registry was queried to identify patients with recorded neurosurgery and research motor examinations within 24 hours of each other. Pearson correlations and modified Bland-Altman analyses were performed using data from matching upper-extremity, lower-extremity, and combined examinations. Kappa analysis was used to test interrater reliability with respect to determination of American Spinal Injury Association Impairment Scale (AIS) grade., Results: There were 72 pairs of matching clinical and research examinations in 63 patients. NME scores were strongly correlated with ISNCSCI motor scores (R = 0.962, p < 0.001). Both upper- and lower-extremity NME scores were strongly correlated with upper- and lower-extremity ISNCSCI motor scores, respectively (R = 0.939, p < 0.001; and R = 0.959, p < 0.001, respectively). In modified Bland-Altman analyses, total, upper-extremity, and lower-extremity NME scores and ISNCSCI motor scores showed low systematic bias and high agreeability (total: bias = 0.3, limit of agreement [LoA] = 36.6; upper extremity: bias = -0.5, LoA = 17.6; lower extremity: bias = 0.8, LoA = 24.0). There were 66 pairs of examinations that had thorough sensory and rectal examinations for AIS grade calculation. Using kappa analysis to test the interrater reliability of AIS grade calculation using NME versus ISNCSCI motor scores, the authors found a weighted kappa of 0.883 (SE 0.061, 95% CI 0.736-0.976), indicating strong agreement., Conclusions: Overall, this study suggests that ISNCSCI motor scores and NME scores are strongly correlated and highly agreeable. When conducting SCI research, a thorough clinical motor examination may be a useful surrogate when ISNCSCI examinations are missing.

Objective: This study aimed to report changes in utilization and payment trends of low-back pain (LBP) interventions and the impact of nonsurgeon interventionalists on these changes., Methods: Medicare Part B national summary data files were used to gather annual utilization and Centers for Medicare and Medicaid Services (CMS) payment data for LBP interventions from 2000 to 2021. Healthcare Common Procedure Coding System (HCPCS) codes were grouped as decompression, spinal fusion, sacroiliac (SI) joint fusion, epidural steroid injections (ESIs), physical therapy (PT), and chiropractic manipulation (Chiro). The total allowed services and payments were collected for each HCPCS group. CMS provider-level files, available from 2013 to 2021, were used to collect neurosurgeon, orthopedic surgeon, and nonsurgeon interventionalist (interventional radiology and pain management) data for each surgical HCPCS code group (decompression, spinal fusion, and SI joint fusion). The United States Consumer Price Index was used to adjust for inflation., Results: From 2000 to 2021, there were 339,720,725 Medicare-approved interventions and payments of approximately $21 billion for LBP (percentage of cumulative payments: 41.8% Chiro, 16.5% ESI, 14.4% spinal fusion, 14.3% PT, 10.2% decompression, and 0.4% SI joint fusion). In a subgroup analysis, spinal fusions for Medicare patients were performed by orthopedic surgeons (59.2%), neurosurgeons (40.6%), and nonsurgeon interventionalists (< 1%) from 2013 to 2021. From 2013 to 2021, neurosurgeon and orthopedic surgeon fusion utilization each grew by < 3% and associated Medicare payments to each specialty declined by 1% each year. During the same period, nonsurgeon interventionalist utilization grew 26% each year and associated Medicare payments to nonsurgeon interventionalists for spine fusions grew 62% each year. In a subgroup analysis, SI joint fusions for Medicare patients were performed by orthopedic surgeons (50.7%), neurosurgeons (24.8%), and nonsurgeon interventionalists (24.5%) from 2018 to 2021. Neurosurgeon utilization of SI joint fusion declined by 1% each year and associated Medicare payments to this group grew 2% each year. Orthopedic surgeon utilization of SI joint fusion declined 1% and associated Medicare payments to this group grew 4% each year. Nonsurgeon interventionalist use of SI joint fusions grew 415% and payments grew 435% each year., Conclusions: The substantial growth in Medicare payments for surgical LBP interventions is disproportionally driven by nonsurgeon interventionalists. The exponential growth of nonsurgeon interventionalists performing spinal fusion surgeries, particularly SI joint fusions, largely accounts for the significant increase in Medicare expenditures.

Objective: Posterior lumbar interbody fusion (PLIF) and/or transforaminal lumbar interbody fusion (TLIF), referred to as "PLIF/TLIF," is a commonly performed operation for lumbar spondylolisthesis. Its long-term cost-effectiveness has not been well described. The aim of this study was to determine the 5-year cost-effectiveness of PLIF/TLIF for grade 1 degenerative lumbar spondylolisthesis using prospective data collected from the multicenter Quality Outcomes Database (QOD)., Methods: Patients enrolled in the prospective, multicenter QOD grade 1 lumbar spondylolisthesis module were included if they underwent single-stage PLIF/TLIF. EQ-5D scores at baseline, 3 months, 12 months, 24 months, 36 months, and 60 months were used to calculate gains in quality-adjusted life years (QALYs) associated with surgery relative to preoperative baseline. Healthcare-related costs associated with the index surgery and related reoperations were calculated using Medicare reimbursement-based cost estimates and validated using price transparency diagnosis-related group (DRG) charges and Medicare charge-to-cost ratios (CCRs). Cost per QALY gained over 60 months postoperatively was assessed., Results: Across 12 surgical centers, 385 patients were identified. The mean patient age was 60.2 (95% CI 59.1-61.3) years, and 38% of patients were male. The reoperation rate was 5.7%. DRG 460 cost estimates were stable between our Medicare reimbursement-based models and the CCR-based model, validating the focus on Medicare reimbursement. Across the entire cohort, the mean QALY gain at 60 months postoperatively was 1.07 (95% CI 0.97-1.18), and the mean cost of PLIF/TLIF was $31,634. PLIF/TLIF was associated with a mean 60-month cost per QALY gained of $29,511. Among patients who did not undergo reoperation (n = 363), the mean 60-month QALY gain was 1.10 (95% CI 0.99-1.20), and cost per QALY gained was $27,591. Among those who underwent reoperation (n = 22), the mean 60-month QALY gain was 0.68 (95% CI 0.21-1.15), and the cost per QALY gained was $80,580., Conclusions: PLIF/TLIF for degenerative grade 1 lumbar spondylolisthesis was associated with a mean 60-month cost per QALY gained of $29,511 with Medicare fees. This is far below the well-established societal willingness-to-pay threshold of $100,000, suggesting long-term cost-effectiveness. PLIF/TLIF remains cost-effective for patients who undergo reoperation.

Background and Objectives: Intraoperative ultrasound (IOUS) during anterior cervical surgery is hindered by large transducer size and small operative corridor. We hypothesized that a linear (minimally invasive) transducer designed for transsphenoidal surgery can visualize the spinal cord, nerve roots, and surrounding structures during anterior cervical approaches, facilitating intraoperative assessment of central and foraminal decompression., Methods: IOUS was used to evaluate 26 levels in 17 patients (15 anterior cervical discectomy and fusion, 1 corpectomy, 1 arthroplasty) with a linear probe (7 × 6-mm end-fire transducer, 150-mm length, 12-15 MHz). After pin-based distraction, discectomy, and posterior longitudinal ligament resection, IOUS assessed adequacy of cord decompression and, following proximal foraminotomy or uncinectomy, nerve root decompression. If indicated, additional decompression was completed. Criteria for adequate central and foraminal decompression were visualization of subarachnoid space around the cord and cerebrospinal fluid pulsatility along the root sleeve/absence of nerve root compression distal to the root sleeve, respectively., Results: IOUS successfully visualized the cord, nerve roots, and surrounding structures in all 26 levels and influenced management in 11 levels (42.3%). IOUS indicated persistent cord and nerve root compression in 2 and 7 levels, respectively. Planned uncinectomy was aborted in 2 levels after IOUS demonstrated adequate nerve root decompression with intervertebral distraction/proximal foraminotomy alone. IOUS identified persistent nerve root compression after initial proximal foraminotomy in 4 levels and uncinectomy in 2 levels. An unplanned uncinectomy was performed in 1 level after IOUS showed persistent nerve root compression after multiple iterations of proximal foraminotomy. At follow-up (mean 3.1 months), the mean improvement in Numeric Rating Scale neck and arm pain, Neck Disability Index, and modified Japanese Orthopedic Association was 4.0%, 3.2%, 3.7%, and 0.7%, respectively., Conclusion: The neural elements and their relationships to surrounding bone/soft tissue can be visualized using a minimally invasive IOUS transducer during anterior cervical surgery without having to remove pin-based distraction. This allows surgeons to intraoperatively verify the extent of central and foraminal decompression., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Objectives: An estimated 14-23% of patients with traumatic brain injury (TBI) incur multiple lifetime TBIs. The relationship between prior TBI and outcomes in patients with moderate to severe TBI (msTBI) is not well delineated. We examined the associations between prior TBI, in-hospital mortality, and outcomes up to 12 months after injury in a prospective US msTBI cohort., Methods: Data from hospitalized subjects with Glasgow Coma Scale score of 3-12 were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (enrollment period: 2014-2019). Prior TBI with amnesia or alteration of consciousness was assessed using the Ohio State University TBI Identification Method. Competing risk regressions adjusting for age, sex, psychiatric history, cranial injury and extracranial injury severity examined the associations between prior TBI and in-hospital mortality, with hospital discharged alive as the competing risk. Adjusted HRs (aHR (95% CI)) were reported. Multivariable logistic regressions assessed the associations between prior TBI, mortality, and unfavorable outcome (Glasgow Outcome Scale-Extended score 1-3 (vs. 4-8)) at 3, 6, and 12 months after injury., Results: Of 405 acute msTBI subjects, 21.5% had prior TBI, which was associated with male sex (87.4% vs. 77.0%, p=0.037) and psychiatric history (34.5% vs. 20.7%, p=0.010). In-hospital mortality was 10.1% (prior TBI: 17.2%, no prior TBI: 8.2%, p=0.025). Competing risk regressions indicated that prior TBI was associated with likelihood of in-hospital mortality (aHR=2.06 (1.01-4.22)), but not with hospital discharged alive. Prior TBI was not associated with mortality or unfavorable outcomes at 3, 6, and 12 months., Conclusions: After acute msTBI, prior TBI history is independently associated with in-hospital mortality but not with mortality or unfavorable outcomes within 12 months after injury. This selective association underscores the importance of collecting standardized prior TBI history data early after acute hospitalization to inform risk stratification. Prospective validation studies are needed., Level of Evidence: IV., Trial Registration Number: NCT02119182., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) scan is often regarded as a "mild" injury, with reduced need for additional workup. However, tSAH is also a predictor of incomplete recovery and unfavorable outcome. This study aimed to evaluate the characteristics of CT-occult intracranial injuries on brain magnetic resonance imaging (MRI) scan in TBI patients with emergency department (ED) arrival Glasgow Coma Scale (GCS) score 13-15 and isolated tSAH on CT. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI; enrollment years 2014-2019) enrolled participants who presented to the ED and received a clinically-indicated head CT within 24 h of TBI. A subset of TRACK-TBI participants underwent venipuncture within 24 h for plasma glial fibrillary acidic protein (GFAP) analysis, and research MRI at 2-weeks post-injury. In the current study, TRACK-TBI participants age ≥17 years with ED arrival GCS 13-15, isolated tSAH on initial head CT, plasma GFAP level, and 2-week MRI data were analyzed. In 57 participants, median age was 46.0 years [quartile 1 to 3 (Q1-Q3): 34-57] and 52.6% were male. At ED disposition, 12.3% were discharged home, 61.4% were admitted to hospital ward, and 26.3% to intensive care unit. MRI identified CT-occult traumatic intracranial lesions in 45.6% (26 of 57 participants; one additional lesion type: 31.6%; 2 additional lesion types: 14.0%); of these 26 participants with CT-occult intracranial lesions, 65.4% had axonal injury, 42.3% had subdural hematoma, and 23.1% had intracerebral contusion. GFAP levels were higher in participants with CT-occult MRI lesions compared with without (median: 630.6 pg/mL, Q1-Q3: [172.4-941.2] vs. 226.4 [105.8-436.1], p  = 0.049), and were associated with axonal injury (no: median 226.7 pg/mL [109.6-435.1], yes: 828.6 pg/mL [204.0-1194.3], p  = 0.009). Our results indicate that isolated tSAH on head CT is often not the sole intracranial traumatic injury in GCS 13-15 TBI. Forty-six percent of patients in our cohort (26 of 57 participants) had additional CT-occult traumatic lesions on MRI. Plasma GFAP may be an important biomarker for the identification of additional CT-occult injuries, including axonal injury. These findings should be interpreted cautiously given our small sample size and await validation from larger studies.

Objective: Policy concern and debate surround the concept of overlapping spine surgery. Overlapping surgery specifically refers to nonessential portions of the case or noncutting time overlap. This differs from concurrent surgery, in which critical portions of the procedure overlap. Here the authors explore the barriers for safe and efficient overlapping surgery in academic spinal deformity practice., Methods: Over a 24-month period, cases of spinal deformity, degenerative cases, anterior cervical discectomy and fusions (ACDFs), and laminectomy were reviewed for duration in operating room (OR) prior to surgery, duration of cutting time, duration in OR after surgery, turnover duration, and time delay from initial start time. Standard degenerative cases were referenced as 1-2 ACDFs as well as 1- to 2-level laminectomy surgery. The blocks of time between two consecutive cutting periods were investigated to determine the feasibility of overlapping an additional surgery. Specifically, the authors compared the blocks of time that include the postsurgery period, the turnover period, and the presurgery period to cutting periods., Results: One hundred twenty-six complex spinal deformity procedures and 85 degenerative cases (including 49 ACDFs and 36 laminectomies) from one center and one neurosurgeon were reviewed. These procedures were performed between September 2019 and December 2021 with a 3-month gap in military deployment. On average, the procedure's duration for cases of deformity was 236.5 minutes, for cases of ACDFs it was 84 minutes, and for cases of laminectomies it was 105.5 minutes. The block of noncutting time while the patient was in the OR showed no difference from the surgical cut time. The turnover time between cases was 52.35 minutes. Of 100 cases scheduled as the first case of the day, 94 had a delay to the OR averaging 18.2 minutes., Conclusions: The data in this study indicate that estimates for pre- and postsurgical times alone are not sufficient to allow for overlapping surgery. The average cut-time duration of ACDF was 84 minutes; the average presurgical time for deformity was 68 minutes. This highlights the critical analysis for further examination of optimal scheduling, on-time first start, turnover periods, and the orchestration of all members of the providing team to optimize the cutting time for safe and consistent implementation of overlapping spine surgery.

Background: Although many molecules have been investigated as biomarkers for spinal cord injury (SCI) or ischemic stroke, none of them are specifically induced in central nervous system (CNS) neurons following injuries with low baseline expression. However, neuronal injury constitutes a major pathology associated with SCI or stroke and strongly correlates with neurological outcomes. Biomarkers characterized by low baseline expression and specific induction in neurons post-injury are likely to better correlate with injury severity and recovery, demonstrating higher sensitivity and specificity for CNS injuries compared to non-neuronal markers or pan-neuronal markers with constitutive expressions., Methods: In animal studies, young adult wildtype and global Atf3 knockout mice underwent unilateral cervical 5 (C5) SCI or permanent distal middle cerebral artery occlusion (pMCAO). Gene expression was assessed using RNA-sequencing and qRT-PCR, while protein expression was detected through immunostaining. Serum ATF3 levels in animal models and clinical human samples were measured using commercially available enzyme-linked immune-sorbent assay (ELISA) kits., Results: Activating transcription factor 3 (ATF3), a molecular marker for injured dorsal root ganglion sensory neurons in the peripheral nervous system, was not expressed in spinal cord or cortex of naïve mice but was induced specifically in neurons of the spinal cord or cortex within 1 day after SCI or ischemic stroke, respectively. Additionally, ATF3 protein levels in mouse blood significantly increased 1 day after SCI or ischemic stroke. Importantly, ATF3 protein levels in human serum were elevated in clinical patients within 24 hours after SCI or ischemic stroke. Moreover, Atf3 knockout mice, compared to the wildtype mice, exhibited worse neurological outcomes and larger damage regions after SCI or ischemic stroke, indicating that ATF3 has a neuroprotective function., Conclusions: ATF3 is an easily measurable, neuron-specific biomarker for clinical SCI and ischemic stroke, with neuroprotective properties., Highlights: ATF3 was induced specifically in neurons of the spinal cord or cortex within 1 day after SCI or ischemic stroke, respectively. Serum ATF3 protein levels are elevated in clinical patients within 24 hours after SCI or ischemic stroke. ATF3 exhibits neuroprotective properties, as evidenced by the worse neurological outcomes and larger damage regions observed in Atf3 knockout mice compared to wildtype mice following SCI or ischemic stroke., (© 2024 The Authors. Clinical and Translational Medicine published by John Wiley & Sons Australia, Ltd on behalf of Shanghai Institute of Clinical Bioinformatics.)

Objective: The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization After Significant Head Injury (CRASH) prognostic models for mortality and outcome after traumatic brain injury (TBI) were developed using data from 1984 to 2004. This study examined IMPACT and CRASH model performances in a contemporary cohort of US patients., Methods: The prospective 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years 2014-2018) enrolled subjects aged ≥ 17 years who presented to level I trauma centers and received head CT within 24 hours of TBI. Data were extracted from the subjects who met the model criteria (for IMPACT, Glasgow Coma Scale [GCS] score 3-12 with 6-month Glasgow Outcome Scale-Extended [GOSE] data [n = 441]; for CRASH, GCS score 3-14 with 2-week mortality data and 6-month GOSE data [n = 831]). Analyses were conducted in the overall cohort and stratified on the basis of TBI severity (severe/moderate/mild TBI defined as GCS score 3-8/9-12/13-14), age (17-64 years or ≥ 65 years), and the 5 top enrolling sites. Unfavorable outcome was defined as GOSE score 1-4. Original IMPACT and CRASH model coefficients were applied, and model performances were assessed by calibration (intercept [< 0 indicated overprediction; > 0 indicated underprediction] and slope) and discrimination (c-statistic)., Results: Overall, the IMPACT models overpredicted mortality (intercept -0.79 [95% CI -1.05 to -0.53], slope 1.37 [1.05-1.69]) and acceptably predicted unfavorable outcome (intercept 0.07 [-0.14 to 0.29], slope 1.19 [0.96-1.42]), with good discrimination (c-statistics 0.84 and 0.83, respectively). The CRASH models overpredicted mortality (intercept -1.06 [-1.36 to -0.75], slope 0.96 [0.79-1.14]) and unfavorable outcome (intercept -0.60 [-0.78 to -0.41], slope 1.20 [1.03-1.37]), with good discrimination (c-statistics 0.92 and 0.88, respectively). IMPACT overpredicted mortality and acceptably predicted unfavorable outcome in the severe and moderate TBI subgroups, with good discrimination (c-statistic ≥ 0.81). CRASH overpredicted mortality in the severe and moderate TBI subgroups and acceptably predicted mortality in the mild TBI subgroup, with good discrimination (c-statistic ≥ 0.86); unfavorable outcome was overpredicted in the severe and mild TBI subgroups with adequate discrimination (c-statistic ≥ 0.78), whereas calibration was nonlinear in the moderate TBI subgroup. In subjects ≥ 65 years of age, the models performed variably (IMPACT-mortality, intercept 0.28, slope 0.68, and c-statistic 0.68; CRASH-unfavorable outcome, intercept -0.97, slope 1.32, and c-statistic 0.88; nonlinear calibration for IMPACT-unfavorable outcome and CRASH-mortality). Model performance differences were observed across the top enrolling sites for mortality and unfavorable outcome., Conclusions: The IMPACT and CRASH models adequately discriminated mortality and unfavorable outcome. Observed overestimations of mortality and unfavorable outcome underscore the need to update prognostic models to incorporate contemporary changes in TBI management and case-mix. Investigations to elucidate the relationships between increased survival, outcome, treatment intensity, and site-specific practices will be relevant to improve models in specific TBI subpopulations (e.g., older adults), which may benefit from the inclusion of blood-based biomarkers, neuroimaging features, and treatment data.

Background and Objectives: Hospital length of stay (HLOS) is a metric of injury severity, resource utilization, and healthcare access. Recent evidence has shown an association between Medicaid insurance and increased HLOS after traumatic brain injury (TBI). This study aims to validate the association between Medicaid and prolonged HLOS after TBI using the National Trauma Data Bank., Methods: National Trauma Data Bank Trauma Quality Programs Participant Use Files (2003-2021) were queried for adult patients with TBI using traumatic intracranial injury ICD-9/ICD-10 codes. Patients with complete HLOS, age, sex, race, insurance payor, Glasgow Coma Scale, Injury Severity Score, and discharge disposition data were included (N = 552 949). Analyses were stratified by TBI severity using Glasgow Coma Scale. HLOS was coded into Tiers according to percentiles within TBI severity categories (Tier 1: 1-74th; 2: 75-84th; 3: 85-94th; 4: 95-99th). Multivariable logistic regressions evaluated associations between insurance payor and prolonged (Tier 4) HLOS, controlling for sociodemographic, Injury Severity Score, cranial surgery, and discharge disposition variables. Adjusted odds ratios (aOR) and 95% CI were reported., Results: HLOS Tiers consisted of 0-19, 20-27, 28-46, and ≥47 days (Tiers 1-4, respectively) in severe TBI (N = 103 081); 0-15, 16-21, 22-37, and ≥38 days in moderate TBI (N = 39 904); and 0-7, 8-10, 11-19, and ≥20 days in mild TBI (N = 409 964). Proportion of Medicaid patients increased with Tier ([Tier 1 vs Tier 4] severe: 16.0% vs 36.1%; moderate: 14.1% vs 31.6%; mild TBI: 10.2% vs 17.4%; all P < .001). On multivariable analyses, Medicaid was associated with prolonged HLOS (severe TBI: aOR = 2.35 [2.19-2.52]; moderate TBI: aOR = 2.30 [2.04-2.61]; mild TBI: aOR = 1.75 [1.67-1.83]; reference category: private/commercial)., Conclusion: This study supports Medicaid as an independent predictor of prolonged HLOS across TBI severity strata. Reasons may include different efficacies in care delivery and reimbursement, which require further investigation. Our findings support the development of discharge coordination pathways and policies for Medicaid patients with TBI., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background and Objectives: Under the Merit-Based Incentive Payment System (MIPS), Medicare evaluates provider performance to determine payment adjustments. Studies examining the first year of MIPS (2017) showed that safety-net providers had lower MIPS scores, but the performance of safety-net physicians over time has not been studied. This study aimed to examine the performance of safety-net vs non-safety-net neurosurgeons in MIPS from 2017 to 2020., Methods: Safety-net neurosurgeons were defined as being in the top quartile according to proportion of dual-eligible beneficiaries and non-safety-net in the bottom quartile. Outcomes were total MIPS scores and dual-eligible proportion over time. In this descriptive study, we evaluated ordinary least squares regression models with SEs clustered at the physician level. Covariates of interest included safety-net status, year, and average Hierarchical Condition Category risk score of beneficiaries., Results: There were 2796-3322 physicians included each year between 2017 and 2020. Mean total MIPS scores were not significantly different for safety-net than non-safety-net physicians in 2017 but were greater for safety-net in 2018 (90.7 vs 84.5, P < .01), 2019 (86.4 vs 81.5, P < .01), and 2020 (90.9 vs 86.7, P < .01). Safety-net status (coefficient -9.11; 95% CI [-13.15, -5.07]; P < .01) and participation in MIPS as an individual (-9.89; [-12.66, -7.13]; P < .01) were associated with lower scores while year, the interaction between safety-net status and year, and participation in MIPS as a physician group or alternative payment model were associated with higher scores. Average Hierarchical Condition Category risk score of beneficiaries (-.011; [-.015, -.006]; P < .01) was associated with decreasing dual-eligible case mix, whereas average age of beneficiaries (.002; [.002, .003]; P < .01) was associated with increasing dual-eligible case mix., Conclusion: Being a safety-net physician was associated with lower MIPS scores, but safety-net neurosurgeons demonstrated greater improvement in MIPS scores than non-safety-net neurosurgeons over time. Providers with higher-risk patients were more likely to decrease their dual-eligible case mix over time., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Objective: Venous thromboembolism (VTE) following traumatic spinal cord injury (SCI) is a significant clinical concern. This study sought to determine the incidence of VTE and hemorrhagic complications among patients with SCI who received low-molecular-weight heparin (LMWH) within 24 hours of injury or surgery and identify variables that predict VTE using the prospective Transforming Research and Clinical Knowledge in SCI (TRACK-SCI) database., Methods: The TRACK-SCI database was queried for individuals with traumatic SCI from 2015 to 2022. Primary outcomes of interest included rates of VTE (including deep vein thrombosis [DVT] and pulmonary embolism [PE]) and in-hospital hemorrhagic complications that occurred after LWMH administration. Secondary outcomes included intensive care unit and hospital length of stay, discharge location type, and in-hospital mortality., Results: The study cohort consisted of 162 patients with SCI. Fifteen of the 162 patients withdrew from the study, leading to loss of data for certain variables for these patients. One hundred thirty patients (87.8%) underwent decompression and/or fusion surgery for SCI. DVT occurred in 11 (7.4%) of 148 patients, PE in 9 (6.1%) of 148, and any VTE in 18 (12.2%) of 148 patients. The analysis showed that admission lower-extremity motor score (p = 0.0408), injury at the thoracic level (p = 0.0086), admission American Spinal Injury Association grade (p = 0.0070), and younger age (p = 0.0372) were significantly associated with VTE. There were 3 instances of postoperative spine surgery-related bleeding (2.4%) in the 127 patients who had spine surgery with bleeding complication data available, with one requiring return to surgery (0.8%). Thirteen (8.8%) of 147 patients had a bleeding complication not related to spine surgery. There were 2 gastrointestinal bleeds associated with nasogastric tube placement, 3 cases of postoperative non-spine-related surgery bleeding, and 8 cases of other bleeding complications (5.4%) not related to any surgery., Conclusions: Initiation of LMWH within 24 hours was associated with a low rate of spine surgery-related bleeding. Bleeding complications unrelated to SCI surgery still occur with LMWH administration. Because neurosurgical intervention is typically the limiting factor in initializing chemical DVT prophylaxis, many of these bleeding complications would have likely occurred regardless of the protocol.

Lumbar interbody fusion (LIF) is a well-established approach in treating spinal deformity and degenerative conditions of the spine. Since its inception in the 20th century, LIF has continued to evolve, allowing for minimally invasive approaches, high fusion rates, and improving disability scores with favorable complication rates. The anterior to the psoas (ATP) approach utilizes a retroperitoneal pathway medial to the psoas muscle to access the L1-S1intervertebral disc spaces. In contrast to the transpsoas arppoach, its primary advantage is avoiding transgressing the psoas muscle and the contained lumbar plexus, which potentially decreases the risk of injury to the lumbar plexus. Avoiding transgression of the psoas may minimize the risk of transient or permanent neurological deficits secondary to lumbar plexus injury. Indications for ATP approaches may expand as it is shown to be a safe and effective method of achieving spinal arthrodesis., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited., Objective: To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years., Design, Setting, and Participants: This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023., Exposures: Postindex TBI(s)., Main Outcomes and Measures: Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs., Results: Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains., Conclusions and Relevance: In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.

Background: Hospital length of stay (HLOS) after traumatic brain injury (TBI) is a metric of injury severity, resource utilization, and access to services. This study aimed to evaluate socioeconomic and clinical factors associated with prolonged HLOS after TBI., Methods: Retrospective data from adult hospitalized patients diagnosed with acute TBI at a US Level 1 trauma center between August 1, 2019 - April 1, 2022 were extracted from the electronic health record. HLOS was stratified by Tier (1: 1-74th percentile; 2: 75-84th; 3: 85-94th; 4: 95-99th). Demographic, socioeconomic, injury severity, and level-of-care factors were compared by HLOS. Multivariable logistic regressions evaluated associations between socioeconomic and clinical variables and prolonged HLOS, using multivariable odds ratios (mOR) and [95% confidence intervals]. Estimated daily charges were calculated for a subset of medically-stable inpatients awaiting placement. Statistical significance was assessed at p < 0.05., Results: In 1443 patients, median HLOS was 4 days (interquartile range 2-8; range 0-145). HLOS Tiers were 0-7, 8-13, 14-27, and ≥28 days (Tiers 1-4, respectively). Patients with Tier 4 HLOS differed significantly from others, with increased Medicaid insurance (53.4% vs. 30.3-33.1%, p = 0.003), severe TBI (Glasgow Coma Scale 3-8: 38.4% vs. 8.7-18.2%, p < 0.001), younger age (mean 52.3-years vs. 61.1-63.7-years, p = 0.003), low socioeconomic status (53.4% vs. 32.0-33.9%, p = 0.003), and need for post-acute care (60.3% vs. 11.2-39.7%, p < 0.001). Independent factors associated with prolonged (Tier 4) HLOS were Medicaid (mOR = 1.99 [1.08-3.68], vs. Medicare/commercial), moderate and severe TBI (mOR = 3.48 [1.61-7.56]; mOR = 4.43 [2.18-8.99], respectively, vs. mild TBI), and need for post-acute placement (mOR = 10.68 [5.74-19.89], while age was protective (per-year mOR = 0.98 [0.97-0.99]). Estimated daily charges for a medically-stable inpatient was $17126., Conclusions: Medicaid insurance, moderate/severe TBI, and need for post-acute care were independently associated with prolonged HLOS ≥28 days. Medically-stable inpatients awaiting placement accrue immense daily healthcare costs. At-risk patients should be identified early, receive care transitions resources, and be prioritized for discharge coordination pathways., Competing Interests: Declaration of Competing Interest All other authors declare no conflicts of interest., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The electronic health record (EHR) is central to clinical workflow, yet few studies to date have explored EHR usage patterns among neurosurgery trainees., Objective: To describe the amount of EHR time spent by postgraduate year (PGY)-2 and PGY-3 neurosurgery residents during on-call days and the distribution of EHR activities in which they engage., Methods: This cohort study used the EHR audit logs, time-stamped records of user activities, to review EHR usage of PGY-2 and PGY-3 neurosurgery residents scheduled for 1 or more on-call days across 2 calendar years at the University of California San Francisco. We focused on the PGY-2 and PGY-3, which, in our training program, represent the primary participants in the in-house on-call pool., Results: Over 723 call days, 12 different residents took at least one on-call shift. The median (IQR) number of minutes that residents spent per on-call shift actively using the EHR was 536.8 (203.5), while interacting with an average (SD) of 68.1 (14.7) patient charts. There was no significant difference between Active EHR Time between residents as PGY-2 and PGY-3 on paired t -tests. Residents spent the most time on the following EHR activities: patient reports, notes, order management, patient list, and chart review., Conclusion: Residents spent, on average, 9 hours of their on-call shift actively using the EHR, and there was no improved efficiency as residents gained experience. We noted several areas of administrative EHR burden, which could be reduced., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Objective: Virtual mentorship and research programs are becoming increasingly popular to facilitate education and career development for students and residents. We review virtual research initiatives for early trainees in neurosurgery and describe our effort to expand access to resources and shared objective mentorship (SOM) via the novel Neurosurgery Education and Research Virtual Group (NERVE)., Methods: A systematic review of neurosurgical programming delivered via a virtual platform was conducted using PubMed, Embase, and Scopus databases. Identified articles were screened. Those meeting prespecified inclusion criteria were reviewed in full and examined for relevant data. Data analysis was performed using Microsoft Excel, and means and standard deviations were calculated. Descriptive analysis of NERVE characteristics was also performed., Results: Of the 2438 identified articles, 10 were included. The most common (70%) implementation style was a webinar-based lecture series. The least common (10%) was a longitudinal curricular interest group. Of the total NERVE cohort, 90% were first generation medical students and 82% attended institutions without home programs. Survey results indicated 73.8% had contributed to at least 2 research projects throughout the year., Conclusions: There is a scarcity of virtual neurosurgical resources which facilitate SOM opportunities for trainees. In our systematic review, NERVE is the only multi-institutional virtual initiative aimed at increasing access to neurosurgical education and research opportunities for the purpose of SOM among early trainees from disadvantaged backgrounds. This highlights the group's niche and potential impact on increasing diversity in neurosurgery, improving trainees' career development, and facilitating future resident research productivity., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization., Methods: Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported., Results: In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35])., Conclusions: Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.

Background: Hospital length of stay (HLOS) after traumatic brain injury (TBI) is an important metric of injury severity, resource utilization, and access to post-acute care services. Risk factors for protracted HLOS after TBI require further characterization., Methods: Data regarding adult inpatients admitted to a single U.S. level 1 trauma center with a diagnosis of acute TBI between August 1, 2019, and April 1, 2022, were extracted from the electronic health record. Patients with extreme HLOS (XHLOS, >99th percentile of institutional TBI HLOS) were compared with those without XHLOS. Socioeconomic status (SES), clinical/injury factors, and discharge disposition were analyzed., Results: In 1638 patients, the median HLOS was 3 days (interquartile range [IQR]: 2-8 days). XHLOS threshold was >70 days (N = 18; range: 72-146 days). XHLOS was associated with younger age (XHLOS/non-XHLOS: 50.4/59.6 years; P = 0.042) and greater proportions with severe TBI (55.6%/11.4%; P < 0.001), low SES (72.2%/31.4%; P < 0.001), and Medicaid insurance (77.8%/30.1%; P < 0.001). XHLOS patients were more likely to die in hospital (22.2%/8.1%) and discharge to post-acute facility (77.8%/16.3%; P < 0.001). No XHLOS patients were discharged to home. In XHLOS patients alive at discharge, medical stability was documented at median 39 days (IQR: 28-58 days) and were hospitalized for another 56 days (IQR: 26.5-78.5 days)., Conclusions: XHLOS patients were more likely to have severe injuries, low SES, and Medicaid. XHLOS is associated with in-hospital mortality and need for post-acute placement. XHLOS patients often demonstrated medical stability long before placement, underscoring complex relationships between SES, health insurance, and outcome. These findings have important implications for quality improvement and resource utilization at acute care hospitals and await validation from larger trials., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) coding is a risk adjustment model that allows for the estimation of risk-and cost-associated with health care provision. Current models may not include key factors that fully delineate the risk associated with spine surgery., Objective: To augment CMS HCC risk adjustment methodology with socioeconomic data to improve its predictive capabilities for spine surgery., Methods: The National Inpatient Sample was queried for spinal fusion, and the data was merged with county-level coverage and socioeconomic status variables obtained from the Brookings Institute. We predicted outcomes (death, nonroutine discharge, length of stay [LOS], total charges, and perioperative complication) with pairs of hierarchical, mixed effects logistic regression models-one using CMS HCC score alone and another augmenting CMS HCC scores with demographic and socioeconomic status variables. Models were compared using receiver operating characteristic curves. Variable importance was assessed in conjunction with Wald testing for model optimization., Results: We analyzed 653 815 patients. Expanded models outperformed models using CMS HCC score alone for mortality, nonroutine discharge, LOS, total charges, and complications. For expanded models, variable importance analyses demonstrated that CMS HCC score was of chief importance for models of mortality, LOS, total charges, and complications. For the model of nonroutine discharge, age was the most important variable. For the model of total charges, unemployment rate was nearly as important as CMS HCC score., Conclusion: The addition of key demographic and socioeconomic characteristics substantially improves the CMS HCC risk-adjustment models when modeling spinal fusion outcomes. This finding may have important implications for payers, hospitals, and policymakers., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Background: The Glasgow Coma Scale (GCS) is intended to be an objective, reliable measure of a patient's mental status. It is included as a metric for trauma registries, having implications for performance metrics and research. Our study compared the GCS recorded in the trauma registry (GCS-1) with that recorded in the neurosurgery consultation (GCS-2)., Methods: This retrospective review compared GCS-1 with GCS-2. The Trauma Injury Severity Score (TRISS) method was used to calculate probability of survival (POS) for patients using both GCS-1 and GCS-2., Results: GCS-1 score significantly differed from GCS-2 score (6.69 vs. 7.84, ± 2.553; P < 0.001). There were 172 patients (37.55%) with a GCS-1 score of 3 and 87 (19.00%) with a GCS-2 score of 3 (χ 2 P < 0.001). The POS calculated using TRISS methodology with GCS-1 (POS-1) was 74.7% ± 26.6% compared with GCS-2 (POS-2), which was 79.3% ± 24.4%. There was a statistically significant difference in the means of POS-2 and POS-2 (P < 0.001). The actual observed survival for the cohort was 71.0% (325/458)., Conclusions: The immediate GCS score recorded on patient arrival after trauma differs significantly from the GCS score recorded at later times. This finding significantly altered the probability of survival as calculated by the TRISS methodology. This situation could have profound effects on risk-adjusted benchmarking, assessments of quality of care, and injury severity stratification for research. More studies into the optimal timing of GCS score recording or changes in GCS score and their impact on survival are warranted., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Traumatic subdural hematomas (SDH) can have devastating neurologic consequences. Acute-on-chronic SDHs are more frequent in the elderly, who have increased comorbidities and perioperative risks. The subdural evacuation port system (SEPS) procedure consists of a twist drill hole connected to a single drain on suction, which can be performed at bedside to evacuate SDHs without requiring general anesthesia. However, a single SEPS can be limited due to inability to evacuate across septations between SDHs of different ages., Purpose: We present to our knowledge the first case of using tandem SEPS to evacuate a multi-loculated SDH. We discuss the technical nuances of the procedure as a treatment option for complex SDHs., Findings: An 86-year-old man with cognitive impairment and recurrent falls presented acutely after ground-level fall with worsening dysarthria and right hemiparesis. Computed tomography scan showed a 11 mm left holohemispheric mixed-density SDH with loculated acute and subacute/chronic components with 2 mm midline shift. Following two interval stability scans, the patient underwent drainage of a superficial chronic component, and a posterolateral acute/subacute component using two sequential SEPS drains at bedside in the intensive care unit. The patient's symptoms markedly improved, drains were removed, and the patient was discharged home with home health on post-procedure day 6., Conclusions: Judicious patient selection and pre-procedural planning can enable the use of tandem SEPS to evacuate multi-loculated SDHs under moderate sedation. Using multiple subdural ports to evacuate complex SDHs should be an option for proceduralists in settings where general anesthesia is not feasible., Competing Interests: None., (© 2022 The Authors.)

Importance: Mild traumatic brain injury (mTBI) may impair the ability to work. Strategies to facilitate return to work are understudied., Objective: To assess employment and economic outcomes for employed, working-age adults with mTBI in the 12 months after injury and the association between return to work and employer assistance., Design, Setting, and Participants: Using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a cohort study of patients with mTBI presenting to emergency departments of 11 level I US trauma centers was performed. Patients with mTBI enrolled in the TRACK-TBI cohort study from February 26, 2014, to May 4, 2016, were followed up at 2 weeks and 3, 6, and 12 months after injury. Work status and income decline of participants were documented in the first year after injury. Associations between work status, injury characteristics, and offer of employer assistance and associations between follow-up care and employer assistance were investigated. Results were adjusted for unobserved outcomes using inverse probability weighting. Data were extracted July 12, 2020; analyses were completed March 24, 2021. Analyses included 435 participants aged 18 to 64 years who were working before the injury, had a Glasgow Coma Scale score of 13 to 15, and completed all postinjury follow-up surveys., Main Outcomes and Measures: Primary outcomes were work status (working or not working) at each study follow-up milestone. Employer assistance included sick leave, reduced hours, modified schedule, transfer to different tasks, assistive technology, and coaching offered during the first 3 months after injury., Results: Of 435 participants (147 [34%] female; 320 [74%] White; mean [SD] age 37.3 [12.9] years), 258 (59%) reported not working at 2 weeks after injury and 74 (17%) reported not working at 12 months after injury. More than one-fifth (92 [21%]) experienced a decline in annual income. Work status at 12 months was significantly associated with postconcussion symptoms experienced at 3 months after injury (73% of patients with 3 or more symptoms reported working at 12 months after injury vs 89% of patients with 2 or fewer symptoms; P < .001) but not with other injury characteristics. Participants offered employer assistance in the first 3 months after injury were more likely to report working after injury than those not offered such assistance (at 6 months: 88% vs 78%; P = .02; at 12 months: 86% vs 72%; P = .005)., Conclusions and Relevance: In this cohort study, mTBI was associated with substantial employment and economic consequences for some patients. Clinicians should systematically follow up with patients with mTBI and coordinate with employers to promote successful return to work.

Objective: Previous work has shown that maintaining mean arterial pressures (MAPs) between 76 and 104 mm Hg intraoperatively is associated with improved neurological function at discharge in patients with acute spinal cord injury (SCI). However, whether temporary fluctuations in MAPs outside of this range can be tolerated without impairment of recovery is unknown. This retrospective study builds on previous work by implementing machine learning to derive clinically actionable thresholds for intraoperative MAP management guided by neurological outcomes., Methods: Seventy-four surgically treated patients were retrospectively analyzed as part of a longitudinal study assessing outcomes following SCI. Each patient underwent intraoperative hemodynamic monitoring with recordings at 5-minute intervals for a cumulative 28,594 minutes, resulting in 5718 unique data points for each parameter. The type of vasopressor used, dose, drug-related complications, average intraoperative MAP, and time spent in an extreme MAP range (< 76 mm Hg or > 104 mm Hg) were collected. Outcomes were evaluated by measuring the change in American Spinal Injury Association Impairment Scale (AIS) grade over the course of acute hospitalization. Features most predictive of an improvement in AIS grade were determined statistically by generating random forests with 10,000 iterations. Recursive partitioning was used to establish clinically intuitive thresholds for the top features., Results: At discharge, a significant improvement in AIS grade was noted by an average of 0.71 levels (p = 0.002). The hemodynamic parameters most important in predicting improvement were the amount of time intraoperative MAPs were in extreme ranges and the average intraoperative MAP. Patients with average intraoperative MAPs between 80 and 96 mm Hg throughout surgery had improved AIS grades at discharge. All patients with average intraoperative MAP > 96.3 mm Hg had no improvement. A threshold of 93 minutes spent in an extreme MAP range was identified after which the chance of neurological improvement significantly declined. Finally, the use of dopamine as compared to norepinephrine was associated with higher rates of significant cardiovascular complications (50% vs 25%, p < 0.001)., Conclusions: An average intraoperative MAP value between 80 and 96 mm Hg was associated with improved outcome, corroborating previous results and supporting the clinical verifiability of the model. Additionally, an accumulated time of 93 minutes or longer outside of the MAP range of 76-104 mm Hg is associated with worse neurological function at discharge among patients undergoing emergency surgical intervention for acute SCI.

Objective: This study attempts to use neurosurgical workforce distribution to uncover the social determinants of health that are associated with disparate access to neurosurgical care., Methods: Data were compiled from public sources and aggregated at the county level. Socioeconomic data were provided by the Brookings Institute. Racial and ethnicity data were gathered from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research. Physician density was retrieved from the Health Resources and Services Administration Area Health Resources Files. Catchment areas were constructed based on the 628 counties with neurosurgical coverage, with counties lacking neurosurgical coverage being integrated with the nearest covered county based on distances from the National Bureau of Economic Research's County Distance Database. Catchment areas form a mutually exclusive and collectively exhaustive breakdown of the entire US population and licensed neurosurgeons. Socioeconomic factors, race, and ethnicity were chosen as independent variables for analysis. Characteristics for each catchment area were calculated as the population-weighted average across all contained counties. Linear regression analysis modeled two outcomes of interest: neurosurgeon density per capita and average distance to neurosurgical care. Coefficient estimates (CEs) and 95% confidence intervals were calculated and scaled by 1 SD to allow for comparison between variables., Results: Catchment areas with higher poverty (CE = 0.64, 95% CI 0.34-0.93) and higher prime age employment (CE = 0.58, 95% CI 0.40-0.76) were significantly associated with greater neurosurgeon density. Among categories of race and ethnicity, catchment areas with higher proportions of Black residents (CE = 0.21, 95% CI 0.06-0.35) were associated with greater neurosurgeon density. Meanwhile, catchment areas with higher proportions of Hispanic residents displayed lower neurosurgeon density (CE = -0.17, 95% CI -0.30 to -0.03). Residents of catchment areas with higher housing vacancy rates (CE = 2.37, 95% CI 1.31-3.43), higher proportions of Native American residents (CE = 4.97, 95% CI 3.99-5.95), and higher proportions of Hispanic residents (CE = 2.31, 95% CI 1.26-3.37) must travel farther, on average, to receive neurosurgical care, whereas people living in areas with a lower income (CE = -2.28, 95% CI -4.48 to -0.09) or higher proportion of Black residents (CE = -3.81, 95% CI -4.93 to -2.68) travel a shorter distance., Conclusions: Multiple factors demonstrate a significant correlation with neurosurgical workforce distribution in the US, most notably with Hispanic and Native American populations being associated with greater distances to care. Additionally, higher proportions of Hispanic residents correlated with fewer neurosurgeons per capita. These findings highlight the interwoven associations among socioeconomics, race, ethnicity, and access to neurosurgical care nationwide.

Objective: To examine the perceived effectiveness of the virtual neurosurgery training camps (VNTC) among medical students with (HP) and without (NHP) home neurosurgery residency programs., Methods: A survey assessing demographics, baseline interests, and ratings of usefulness and interest of programming was sent to attendees after the VNTC. Ratings were quantified on modified 7-point Likert scales. Ratings were compared between attendees HP and NHP neurosurgery residency programs using Wilcoxon sum-rank or χ 2 tests. A P value of 0.05 determined significance., Results: There were 119 respondents, with 80 (67.2%) HP and 39 (32.8%) NHP students. Differences were observed between the groups for medical school type (P = 0.002), highest degree achieved (P = 0.030), previous participation in a Medical Student Neurosurgery Training Center event (P = 0.004), having a neurosurgery interest group (P < 0.001), and primary reason for VNTC attendance (P = 0.028). Increased interest in peripheral nerve neurosurgery was greater for the NHP (P = 0.047) but not neurosurgery or other subspecialties. A significant difference in usefulness of the different VNTC sessions was observed (P = 0.002), whereas none was seen in willingness to pursue neurosurgery (P = 0.33), likelihood of taking a year off (P = 0.44), and preparedness for subinternships (P = 0.57) or applications (P = 0.77)., Conclusions: The 2020 VNTC benefited both HPO and NHP medical students, but there were differences in perceived usefulness of virtual education. Future initiatives should continue to be tailored toward disadvantaged students., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Evaluating market competition is an important practice to assess how the forces and components at play in a select market interact. Healthcare markets are similar to any other market present in the world, where competition can be present or absent in the exchange of goods and services. Applying a standard measure of assessing market competition, the Herfindahl-Hirschman Index, to California's Medi-Cal managed care marketplace, it is found that there is no competition present in all of California's counties as defined by the common interpretation of the Herfindahl-Hirschman Index. A distinctive trend in markets is that when less competition is present, the cost of goods and services increases to reflect the principles of supply and demand. California Medi-Cal markets follow this trend of less competitive markets being associated with increased adult midpoint costs. These findings help further to elucidate California's Medi-Cal marketplace on a county-by county level.

Background: Geriatric patients have the highest rates of Traumatic Brain Injury (TBI)-related hospitalization and death. This contributes to an assumption of futility in aggressive management in this population., Objective: To evaluate the effect of surgical intervention on the morbidity and mortality of geriatric patients with TBI., Methods: A retrospective analysis of patients ≥80 yr old with TBI from 2003 to 2016 was performed using the National Trauma Data Bank. Univariate and multivariate analyses were performed to compare outcomes between surgery and nonsurgery groups., Results: A total of 127 129 patient incidents were included: 121 185 (95.3%) without surgery and 5944 (4.7%) with surgery. The surgical group was slightly younger (84.0 vs 84.3, P < .001) and predominantly male (60.2% vs 44.4%, P < .001). Mean emergency department (ED) Glasgow Coma Scale (GCS) was lower in surgical patients (12.4 vs 13.7, P < .001). Complications (OR = 1.91, CI:1.80-2.02, P < .001) and hospital length of stay (LOS, ß = 5.25, CI:5.08-5.42, P < .001) were independently associated with surgery. Intensive care unit (ICU) LOS (ß = 3.19, CI:3.05-3.34, P < .001), ventilator days (ß = 1.57, CI:1.22-1.92, P < .001), and reduced discharge home (OR = 0.434, CI:0.400-0.470, P < .001) were also independently associated with surgery. However, surgery was not independently associated with mortality on multivariate analysis (OR = 1.03, CI:0.955-1.12, P = .423). Recursive partitioning analysis identified ED GCS and injury severity score (ISS) as prognosticators of mortality following surgical intervention., Conclusion: Surgical treatment of geriatric patients with TBI is associated with increased complications, hospital LOS, ICU LOS, and ventilator days as well as reduced discharge to home. However, surgery is not associated with increased mortality. ISS and ED GCS are prognosticators of mortality following surgical intervention., (© Congress of Neurological Surgeons 2021.)

In this review, we provide an overview of the current research and treatment of all types of traumatic brain injury (TBI) before illustrating the need for improved care specific to mild TBI patients. Contemporary issues pertaining to acute care of mild TBI including prognostication, neurosurgical intervention, repeat radiographic imaging, reversal of antiplatelet and anticoagulation medications, and cost savings initiatives are reviewed. Lastly, the effect of COVID-19 on TBI is addressed., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Krueger et al.)

Objective: Ankylosing spondylitis, the most common spondyloarthritis, fuses individual spinal vertebrae into long segments. The unique biomechanics of the ankylosed spine places patients at unusually high risk for unstable fractures secondary to low-impact mechanisms. These injuries are unique within the spine trauma population and necessitate thoughtful management. Therefore, the authors aimed to present a richly annotated data set of operative AS spine fractures with a significant portion of patients with simultaneous dual noncontiguous fractures., Methods: Patients with ankylosing spondylitis with acute fractures who received operative management between 2012 and 2020 were reviewed. Demographic, admission, surgical, and outcome parameters were retrospectively collected and reviewed., Results: In total, 29 patients were identified across 30 different admissions. At admission, the mean age was 71.7 ± 11.8 years. The mechanism of injury in 77% of the admissions was a ground-level fall; 30% also presented with polytrauma. Of admissions, 50% were patient transfers from outside hospitals, whereas the other half presented primarily to our emergency departments. Fifty percent of patients sustained a spinal cord injury, and 35 operative fractures were identified and treated in 32 surgeries. The majority of fractures clustered around the cervicothoracic (C4-T1, 48.6%) and thoracolumbar (T8-L3, 37.11%) junctions. Five patients (17.2%) had simultaneous dual noncontiguous operative fractures; these patients were more likely to have presented with a higher-energy mechanism of injury such as a bicycle or motor vehicle accident compared with patients with a single operative fracture (60% vs 8%, p = 0.024). On preoperative MRI, 56.3% of the fractures had epidural hematomas (EDHs); 25% were compressive of the underlying neural elements, which dictated the number of laminectomy levels performed (no EDH, 2.1 ± 2.36; noncompressive EDH, 2.1 ± 1.85; and compressive EDH, 7.4 ± 4 [p = 0.003]). The mean difference in instrumented levels was 8.7 ± 2.6 with a mean estimated blood loss (EBL) of 1183 ± 1779.5 mL. Patients on a regimen of antiplatelet therapy had a significantly higher EBL (2635.7 mL vs 759.4 mL, p = 0.015). Overall, patients had a mean hospital length of stay of 15.2 ± 18.5 days; 5 patients died during the same admission or after transfer to an outside hospital. Nine of 29 patients (31%) had died by the last follow-up (the mean follow-up was 596.3 ± 878.9 days)., Conclusions: Patients with AS who have been found to have unstable spine fractures warrant a thorough diagnostic evaluation to identify secondary fractures as well as compressive EDHs. These patients experienced prolonged inpatient hospitalizations with significant morbidity and mortality.

Objective: The use of telemedicine has dramatically increased due to the coronavirus disease 2019 pandemic. Many neurosurgeons are now using telemedicine technologies for preoperative evaluations and routine outpatient visits. Our goal was to standardize the telemedicine motor neurologic examination, summarize the evidence surrounding clinical use of telehealth technologies, and discuss financial and legal considerations., Methods: We identified a 12-member panel composed of spine surgeons, fellows, and senior residents at a single institution. We created an initial telehealth strength examination protocol based on published data and developed 10 agree/disagree statements summarizing the protocol. A blinded Delphi method was utilized to build consensus for each statement, defined as > 80% agreement and no significant disagreement using a 2-way binomial test (significance threshold of p < 0.05). Any statement that did not meet consensus was edited and iteratively resubmitted to the panel until consensus was achieved. In the final round, the panel was unblinded and the protocol was finalized., Results: After the first round, 4/10 statements failed to meet consensus ( < 80% agreement, and p = 0.031, p = 0.031, p = 0.003, and p = 0.031 statistical disagreement, respectively). The disagreement pertained to grading of strength of the upper (3/10 statements) and lower extremities (1/10 statement). The amended statements clarified strength grading, achieved consensus ( > 80% agreement, p > 0.05 disagreement), and were used to create the final telehealth strength examination protocol., Conclusion: The resulting protocol was used in our clinic to standardize the telehealth strength examination. This protocol, as well as our summary of telehealth clinical practice, should aid neurosurgical clinics in integrating telemedicine modalities into their practice.

Diagnosis of spinal cord injury (SCI) severity at the ultra-acute stage is of great importance for emergency clinical care of patients as well as for potential enrollment into clinical trials. The lack of a diagnostic biomarker for SCI has played a major role in the poor results of clinical trials. We analyzed global gene expression in peripheral white blood cells during the acute injury phase and identified 197 genes whose expression changed after SCI compared with healthy and trauma controls and in direct relation to SCI severity. Unsupervised coexpression network analysis identified several gene modules that predicted injury severity (AIS grades) with an overall accuracy of 72.7% and included signatures of immune cell subtypes. Specifically, for complete SCIs (AIS A), ROC analysis showed impressive specificity and sensitivity (AUC: 0.865). Similar precision was also shown for AIS D SCIs (AUC: 0.938). Our findings indicate that global transcriptomic changes in peripheral blood cells have diagnostic and potentially prognostic value for SCI severity., Competing Interests: Disclosures: G.T. Manley reported grants from NIH-NINDS and grants from United States Department of Defense during the conduct of the study. S. Dhall reported personal fees from Depuy Synthes, personal fees from Globus Medical, and other from Great Circle Technologies outside the submitted work. M.S. Beattie reported that he is on the board of directors of two nonprofits that support spinal cord injury research, the American Spinal Injury Association and the Praxis Spinal Cord Institute. Only travel expenses are reimbursed. No other disclosures were reported., (© 2021 Kyritsis et al.)

Conventional MRI measures of traumatic spinal cord injury severity largely rely on 2-dimensional injury characteristics such as intramedullary lesion length and cord compression. Recent advances in spinal cord (SC) analysis have led to the development of a robust anatomic atlas incorporated into an open-source platform called the Spinal Cord Toolbox (SCT) that allows for quantitative volumetric injury analysis. In the current study, we evaluate the prognostic value of volumetric measures of spinal cord injury on MRI following registration of T2-weighted (T2w) images and segmented lesions from acute SCI patients with a standardized atlas. This IRB-approved prospective cohort study involved the image analysis of 60 blunt cervical SCI patients enrolled in the TRACK-SCI clinical research protocol. Axial T2w MRI data obtained within 24 h of injury were processed using the SCT. Briefly, SC MRIs were automatically segmented using the sct&#95;deepseg&#95;sc tool in the SCT and segmentations were manually corrected by a neuro-radiologist. Lesion volume data were used as predictor variables for correlation with lower extremity motor scores at discharge. Volumetric MRI measures of T2w signal abnormality comprising the SCI lesion accurately predict lower extremity motor scores at time of patient discharge. Similarly, MRI measures of injury volume significantly correlated with motor scores to a greater degree than conventional 2-D metrics of lesion size. The volume of total injury and of injured spinal cord motor regions on T2w MRI is significantly and independently associated with neurologic outcome at discharge after injury., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: Spine surgery is especially susceptible to malpractice claims. Critics of the US medical liability system argue that it drives up costs, whereas proponents argue it deters negligence. Here, the authors study the relationship between malpractice claim density and outcomes., Methods: The following methods were used: 1) the National Practitioner Data Bank was used to determine the number of malpractice claims per 100 physicians, by state, between 2005 and 2010; 2) the Nationwide Inpatient Sample was queried for spinal fusion patients; and 3) the Area Resource File was queried to determine the density of physicians, by state. States were categorized into 4 quartiles regarding the frequency of malpractice claims per 100 physicians. To evaluate the association between malpractice claims and death, discharge disposition, length of stay (LOS), and total costs, an inverse-probability-weighted regression-adjustment estimator was used. The authors controlled for patient and hospital characteristics. Covariates were used to train machine learning models to predict death, discharge disposition not to home, LOS, and total costs., Results: Overall, 549,775 discharges following spinal fusions were identified, with 495,640 yielding state-level information about medical malpractice claim frequency per 100 physicians. Of these, 124,425 (25.1%), 132,613 (26.8%), 130,929 (26.4%), and 107,673 (21.7%) were from the lowest, second-lowest, second-highest, and highest quartile states, respectively, for malpractice claims per 100 physicians. Compared to the states with the fewest claims (lowest quartile), surgeries in states with the most claims (highest quartile) showed a statistically significantly higher odds of a nonhome discharge (OR 1.169, 95% CI 1.139-1.200), longer LOS (mean difference 0.304, 95% CI 0.256-0.352), and higher total charges (mean difference [log scale] 0.288, 95% CI 0.281-0.295) with no significant associations for mortality. For the machine learning models-which included medical malpractice claim density as a covariate-the areas under the curve for death and discharge disposition were 0.94 and 0.87, and the R2 values for LOS and total charge were 0.55 and 0.60, respectively., Conclusions: Spinal fusion procedures from states with a higher frequency of malpractice claims were associated with an increased odds of nonhome discharge, longer LOS, and higher total charges. This suggests that medicolegal climate may potentially alter practice patterns for a given spine surgeon and may have important implications for medical liability reform. Machine learning models that included medical malpractice claim density as a feature were satisfactory in prediction and may be helpful for patients, surgeons, hospitals, and payers.