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Study Design: Retrospective database study. Objective: Tobacco use is associated with complications after surgical procedures, including poor wound healing, surgical site infections, and cardiovascular events. We used the Nationwide Readmissions Database (NRD) to determine if tobacco use is associated with increased 30- and 90-day readmission among patients undergoing surgery for degenerative spine disorders. Methods: Patients who underwent elective spine surgery were identified in the NRD from 2010 to 2014. The study population included patients with degenerative spine disorders treated with discectomy, fusion, or decompression. Descriptive and multivariate logistic regression analyses were performed to identify patient and hospital factors associated with 30- and 90-day readmission, with significance set at P value Results: Within 30 days, 4.8% of patients were readmitted at a median time of 9 days. The most common reasons for 30-day readmission were postoperative infection (12.5%), septicemia (3.5%), and postoperative pain (3.0%). Within 90 days, 7.3% were readmitted at a median time of 18 days. The most common reasons for 90-day readmission were postoperative infection (9.6%), septicemia (3.5%), and pneumonia (2.3%). After adjustment for patient and hospital characteristics, tobacco use was independently associated with readmission at 90 days (odds ratio 1.05, 95% confidence interval 1.03-1.07, P < .0001) but not 30 days (odds ratio 1.02, 95% confidence interval 1.00-1.05, P = .045). Conclusions: Tobacco use is associated with readmission within 90 days after cervical and thoracolumbar spine surgery for degenerative disease. Tobacco use is a known risk factor for adverse health events and therefore should be considered when selecting patients for spine surgery.

Study Design: Review. Objective: A comparative overview of cost-effectiveness between minimally invasive versus and equivalent open spinal surgeries. Methods: A literature search using PubMed was performed to identify articles of interest. To maximize the capture of studies in our initial search, we combined variants of the terms “cost,” “minimally invasive,” “spine,” “spinal fusion,” “decompression” as either keywords or MeSH terms. PearlDiver database was queried for open and minimally invasive surgery (MIS; endoscopic or percutaneous) reimbursements between Q3 2015 and Q2 2018. Results: In general, MIS techniques appeared to decrease blood loss, shorten hospital lengths of stay, mitigate complications, decrease perioperative pain, and enable quicker return to daily activities when compared to equivalent open surgical techniques. With regard to cost, primarily as a result of these latter benefits, MIS was associated with lower costs of care when compared to equivalent open techniques. However, cost reporting was sparse, and relevant methodology was inconsistent throughout the spine literature. Within the PearlDiver data sets, MIS approaches had lower reimbursements than open approaches for both lumbar posterior fusion and discectomy. Conclusions: Current data suggests that overall cost-savings may be incurred with use of MIS techniques. However, data reporting on costs lacks in uniformity, making it difficult to formulate any firm conclusions regarding any incremental improvements in cost-effectiveness that may be incurred when utilizing MIS techniques when compared to equivalent open techniques.

Meningiomas are the most common benign primary brain tumors. The mainstay of treatment, surgical resection, is often curative. Given the excellent prognosis of these lesions, minimizing perioperative complications is of the utmost importance. With the establishment of the National Readmissions Database (NRD), researchers are now able to identify variables associated with postoperative complications beyond the index admission. In this study, we sought to identify the leading causes for non-elective readmission and variables associated with increased likelihood of readmission at 30 and 90 days after discharge following a craniotomy for meningioma resection. Adult inpatients who underwent craniotomy for meningioma resection between 2010 and 2014 were queried from the NRD. All-cause readmissions following craniotomy at 30 and 90 days were identified, and a multivariable logistic regression model was used to characterize independent risk factors. Among 26,034 patients who received craniotomy for meningioma resection, 2825 (10.9%) were readmitted at 30 days and 3436 (16.1%) were readmitted at 90 days. Postoperative wound infection was the most common readmission diagnosis, occurring in 9.32% and 10.2% of 30- and 90-day readmissions respectively. Patient factors associated with increased likelihood of readmission included male gender, greater illness severity, non-routine discharge, index length of hospitalization, and having Medicare or Medicaid insurance. Readmission following craniotomy for meningioma resection occurs at a clinically significant rate. Several patient factors were identified in association with all-cause 30- and 90-day readmissions. Further studies are required to identify means for preventing complications following discharge in these vulnerable patient populations.

We present a case report of a patient who had delayed small bowel obstruction secondary to an incarcerated loop of small bowel within an acute lumbar spine fracture. The patient was involved in a rollover motor vehicle accident, resulting in lumbar spine fractures at L2-4. A comminuted fracture of the L3 vertebral body with likely disruption of the anterior longitudinal ligament (ALL) was noted. The patient underwent L1-4 posterior spinal fusion with the introduction of mild lumbar lordosis to prevent future complications of flatback syndrome. On postoperative Day 4, the patient was noted to have signs and symptoms of progressive small bowel obstruction. Conservative management was initiated with minimal improvement. The patient was taken to the operating room on postoperative Day 7 for an exploratory laparotomy. A necrotic loop of small bowel was noted to be entrapped in the ventral L3 vertebral body defect. This bowel was released and resected, with side-to-side anastomosis performed. No previous cases describe small bowel incarceration because of posterior spinal fusion for trauma. The introduction of increased lumbar lordosis is thought to have contributed to this risk of small bowel herniation, and care must be taken when determining appropriate spinopelvic parameters in these cases.

Background and importance In an era of curtailed work hours and concerns over achieving technical proficiency in the repertoire of procedures necessary for independent practice, many residencies have turned to model simulation as an educational adjunct. Cerebrospinal fluid (CSF) leak repair after inadvertent durotomy in spine surgery is a fundamental skillset for any spine surgeon. While primary closure with suture is not always necessary for small durotomies, larger defects, on the other hand, must be repaired. However, the dire consequences of inadequate repair dictate that it is generally performed by the most experienced surgeon. Few intraoperative opportunities, therefore, exist for CSF leak repair by trainees. Objective To simulate dural repair in spine surgery using minimal-access techniques. Methods A cohort of 8 neurosurgery residents was evaluated on their durotomy repair efforts in a perfusion-based cadaveric model. Results Study participants demonstrated consistent improvement across trials, with a significant reduction in closure times between their initial (12 min, 7 sec ± 4 min, 43 sec) and final attempts (7 min, 4 sec ± 2 min, 6 sec; P = .02). Moreover, all trainees-irrespective of postgraduate year-were able to accomplish robust dural closures resistant to simulated Valsalva maneuvers. Participants reported high degrees of model realism and exhibited significant increases in postprocedure confidence scores. Conclusion Our results support use of perfusion-based simulation models as a complement to neurosurgery training, as it affords unrestricted opportunities for honing psychomotor skillsets when resident learning is increasingly being challenged by work-hour limitations and stricter oversight in the context of value-based healthcare.

INTRODUCTION: Optimal post-surgical treatment of glioblastoma multiforme (GBM) includes concurrent radiation therapy and temozolomide. However, there is conflicting data regarding the ideal timing of radiation. Proponents of early therapy cite the rapid proliferation rate of WHO grade IV tumors and advocate treatment with minimal delays. Others believe extra time allows the surgical cavity to collapse and tempers the risk of infection, minimizing complications from radiation. METHODS: We retrospectively reviewed records of 97 patients with a pathologic diagnosis of GBM at our institution who underwent postoperative treatment with at least 6 weeks of radiation according to Radiation Therapy Oncology Group guidelines and concurrent temozolomide therapy. Demographic, clinical, radiographic and operative data were reviewed. Analysis of variance(ANOVA) was used to identify differences between surgical and demographic subgroups. Kaplan-Meier survival analysis was used to estimate overall(OS) and progression free survival(PFS). Cox regression analyses were performed to determine the effect of radiation timing on survival. RESULTS: 49 male and 47 female patients had a median age at surgery of 57 years (range 18-77). Sixteen patients underwent biopsy, 64 had a subtotal resection(STR) and 16 had a gross total resection(GTR). One year OS and PFS were 70% and 16%, respectively. The median time to radiation(TTR) was 26 days (range 9-51 days). TTR was significantly longer in patients with resection compared to biopsy (p < 0.001). TTR did not significantly affect OS (p = 0.732) or PFS (p = 0.699) of the entire cohort or the subgroup treated with resection (OS, p = 0.809; PFS, p = 0.812). CONCLUSIONS: The precise timing of radiation initiation does not appear to affect survival of patients with GBM who are optimally treated with radiation and temozolomide. Therefore practitioners may allow extra time within the recommended 6 week window for optimal medical stabilization and wound healing without fear that this may adversely affect patient outcomes.