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Benjamin S. Hopkins, Mit R. Patel, Jonathan Tad Yamaguchi, Michael Brendan Cloney and Nader S. Dahdaleh

OBJECTIVE

Press Ganey surveys are common modalities used to assess patient satisfaction scores in an outpatient setting. Despite the existence of data, neurosurgical and orthopedic literature on patient satisfaction following spinal surgery is scarce.

METHODS

A total of 17,853 patients who underwent spinal procedures at the authors’ institution were analyzed retrospectively for Press Ganey survey participation. Appropriate demographic, surgical, comorbidity, and complication data were collected; 1936 patients had patient satisfaction survey data, and further survey metrics were collected for this subset of patients.

RESULTS

Male patients, patients with urgent/emergency procedures, and patients with longer length of stay (LOS) were less likely to fill out Press Ganey surveys (OR 0.822, p < 0.001; OR 0.781, p = 0.010; and OR 0.983, p < 0.001, respectively). Posterior approach was negatively associated with Press Ganey participation (OR 0.907, p = 0.055). Patients undergoing fusion procedures were more likely to participate in Press Ganey surveys (OR 1.419, p < 0.001). Of the patients who filled out surveys, there were no positive predictors associated with receiving perfect scores on Press Ganey surveys. High Charlson Comorbidity Index (OR 0.959, p = 0.02), increasing elapsed time since surgery or discharge (OR 0.996, p = 0.03), and increasing LOS (OR 0.965, p = 0.009) were all negatively associated with receiving a perfect score. Patients who underwent a posterior-approach procedure compared with other approaches were less likely to report a low Press Ganey score (OR 0.297, p = 0.046). Patient sex and race did not influence the likelihood of receiving perfect or low Press Ganey scores. Finally, the perceived skill of the surgeon was not a significant predictor for perfect (p > 0.99) or low (p = 0.828) Press Ganey scores.

CONCLUSIONS

Patient participation in Press Ganey surveys strongly correlated with preoperative factors such as procedure approach and type, as well as postoperative factors such as LOS and complications. No factors were associated with an increased likelihood of receiving a perfect Press Ganey score. Similarly, LOS and time elapsed since surgery to survey completion were significant negative predictors of perfect Press Ganey scores. Skill of surgeon, sex, and race did not correlate with a predictive value for Press Ganey outcomes. In addition, overall comorbid disease burden was found to be a significant negative predictor for high patient satisfaction scores. Further study on predictors of patient satisfaction within spine surgery is needed to better assist physicians in improving the surgical experience for patients.

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Benjamin S. Hopkins, Mit R. Patel, Jonathan Tad Yamaguchi, Michael Brendan Cloney and Nader S. Dahdaleh

OBJECTIVE

Patient satisfaction is a new and important metric in the American healthcare system. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a common modality used to assess patient satisfaction in inpatient settings. Despite the existence of data, neurosurgical literature on patient satisfaction following spinal surgery is scarce.

METHODS

A total of 17,853 patients who underwent spinal procedures at the authors’ institution were analyzed retrospectively for HCAHPS survey participation. Appropriate demographic, surgical, comorbidity, and complication data were collected; 1118 patients had patient satisfaction survey data, and further survey metrics were collected for this subset of patients.

RESULTS

Male patients, patients with urgent/emergency procedures, and patients with a longer length of stay were less likely to complete an HCAHPS survey (OR 0.820, p < 0.001; OR 0.818, p = 0.042; and OR 0.983, p < 0.001, respectively). Posterior approach was negatively associated with HCAHPS survey participation (OR 0.868, p = 0.007). Patients undergoing fusion procedures were more likely to participate in HCAHPS surveys (OR 1.440, p < 0.001). Of the completed HCAHPS surveys, there were no positive predictors associated with perfect scores. High Charlson Comorbidity Index (OR 0.931, p = 0.007), increasing elapsed time since surgery or discharge (OR 0.992, p = 0.004), and increasing length of stay (OR 0.928, p < 0.001) were all negatively associated with a perfect score. Finally, patient sex and race did not influence the likelihood of a perfect or low survey score.

CONCLUSIONS

Participation in HCAHPS surveys was correlated with preoperative and postoperative factors. Among these, procedure approach and type, length of stay, and complications seemed to influence participation the most. No factors were associated with an increased likelihood of receiving a perfect score. Similarly, length of stay and time elapsed since surgery to survey completion were significant negative predictors of receiving perfect HCAHPS survey scores. Increasing comorbid burden was also found to be a negative predictor for high scores. Further study on predictors of inpatient satisfaction within spine surgery is needed.

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Michael Brendan Cloney, Jack Goergen, Benjamin S. Hopkins, Ekamjeet Singh Dhillon and Nader S. Dahdaleh

OBJECTIVE

Venous thromboembolic events (VTEs) are a common cause of morbidity and mortality after spine surgery. Patients admitted to the intensive care unit (ICU) following spine surgery exhibit high-risk clinical characteristics.

METHODS

The authors retrospectively analyzed 1269 ICU patients who had undergone spine surgery between January 1, 2009, and May 31, 2015. Relevant demographic, procedural, and outcome variables were collected.

RESULTS

Patients admitted to the ICU postoperatively had a postoperative VTE rate of 10.2%, compared to 2.5% among all spine surgery patients during the study period. ICU patients had a higher comorbid disease burden (odds ratio [OR] 1.45, p < 0.001), and were more likely to have a history of a bleeding disorder (2.60% vs 0.46%, OR 2.85, p = 0.028), receive a transfusion (OR 4.81, p < 0.001), have a fracture repaired (OR 4.30, p < 0.001), have an estimated blood loss > 500 ml (OR 1.95, p = 0.009), have an osteotomy (OR 20.47, p = 0.006), or have a corpectomy (OR 3.48, p = 0.007) than patients not admitted to the ICU. There was a significant difference in time to VTE between patients undergoing osteotomy and patients undergoing scoliosis corrections without osteotomy (p = 0.0431), patients with fractures (p = 0.0113), and patients undergoing fusions for indications other than scoliosis or fracture (p = 0.0056). Patients who developed a deep vein thrombosis (DVT) during their ICU stay were more likely to have received a prophylactic inferior vena cava filter placement (OR 8.98, p < 0.001), have undergone an interbody fusion procedure (OR 2.38, p = 0.037), have a history of DVT (OR 3.25, p < 0.001), and have shorter surgery times (OR 0.30, p = 0.002). Patients who developed a pulmonary embolism (PE) during the ICU stay were more likely to have a history of PE (OR 12.68 p = 0.015), history of DVT (OR 5.11, p = 0.042), fracture diagnosis (OR 7.02, p = 0.040), and diagnosis of scoliosis (OR 7.78, p = 0.024). Patients with higher BMIs (OR 0.85, p = 0.036) and those who received anticoagulation treatment (OR 0.16, p = 0.031) were less likely to develop a PE during their ICU stay.

CONCLUSIONS

Patients admitted to the ICU following spine surgery have a higher rate of VTE than non-ICU patients. Time to VTE varied by pathology. Factors independently associated with VTE in the ICU are distinct from factors otherwise associated with VTE. Some factors are independently associated with VTE throughout the 30-day postoperative period, while others are associated with VTE specifically during the initial ICU stay or after leaving the ICU.

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Maged D. Fam, Royce W. Woodroffe, Logan Helland, Jennifer Noeller, Nader S. Dahdaleh, Arnold H. Menezes and Patrick W. Hitchon

OBJECTIVE

Adult spinal arachnoid cysts (SACs) are rare entities of indistinct etiology that present with pain or myelopathy. Diagnosis is made on imaging studies with varying degrees of specificity. In symptomatic cases, the standard treatment involves surgical exploration and relief of neural tissue compression. The aim of this study was to illustrate features of SACs in adults, surgical management, and outcomes.

METHODS

The authors searched medical records for all SACs in adults in the 10-year period ending in December 2016. Radiology and pathology reports were reviewed to exclude other spine cystic disorders. Recurrent or previously treated patients were excluded. Demographic variables (age, sex) and clinical presentation (symptoms, duration, history of infection or trauma, and examination findings) were extracted. Radiological features were collected from radiology reports and direct interpretation of imaging studies. Operative reports and media were reviewed to accurately describe the surgical technique. Finally, patient-reported outcomes were collected at every clinic visit using the SF-36.

RESULTS

The authors’ search identified 22 patients with SACs (mean age at presentation 53.5 years). Seventeen patients were women, representing an almost 3:1 sex distribution. Symptoms comprised back pain (n = 16, 73%), weakness (n = 10, 45%), gait ataxia (n = 11, 50%), and sphincter dysfunction (n = 4, 18%). The mean duration of symptoms was 15 months. Seven patients (32%) exhibited signs of myelopathy. All patients underwent preoperative MRI; in addition, 6 underwent CT myelography. SACs were located in the thoracic spine (n = 17, 77%), and less commonly in the lumbar spine (n = 3, 14%) and cervical/cervicothoracolumbar region (n = 2, 9%). Based on imaging findings, the cysts were interpreted as intradural SACs (n = 11, 50%), extradural SACs (n = 6, 27%), or ventral spinal cord herniation (n = 2, 9%); findings in 3 patients (14%) were inconclusive. Nineteen patients underwent surgical treatment consisting of laminoplasty in addition to cyst resection (n = 13, 68%), ligation of the connecting pedicle (n = 4, 21%), or fenestration/marsupialization (n = 2, 11%). Postoperatively, patients were followed up for an average of 8.2 months (range 2–30 months). Postoperative MRI showed complete resolution of the SAC in 14 of 16 patients. Patient-reported outcomes showed improvement in SF-36 parameters. One patient suffered a delayed wound infection.

CONCLUSIONS

In symptomatic patients with imaging findings suggestive of spinal arachnoid cyst, surgical exploration and complete resection is the treatment of choice. Treatment is usually well tolerated, carries low risks, and provides the best chances for optimal recovery.

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Najib E. El Tecle, Nader S. Dahdaleh, Mohamad Bydon, Wilson Z. Ray, James C. Torner and Patrick W. Hitchon

OBJECTIVE

The natural history of complete spinal cord injury (SCI) is poorly studied. The classically quoted rate of improvement or conversion for patients with American Spinal Injury Association (ASIA) grade A (ASIA A) injuries is 15%–20%; however, data supporting this rate are very limited. In this paper, the authors conducted a meta-analysis of modern data reporting on ASIA A patients and evaluated factors affecting the natural history of the disease.

METHODS

The authors conducted a systematic literature review of all randomized clinical trials (RCTs) and observational studies of patients with traumatic SCI. The Embase, MEDLINE, PubMed, Scopus, CINAHL, and Cochrane databases were reviewed for all studies reporting on SCI and published after 1992. A meta-analysis was conducted using the DerSimonian and Laird (random-effects) model with a summary odds ratio analysis.

RESULTS

Eleven RCTs and 9 observational studies were included in the final analysis. Overall, the 20 included studies reported on 1162 patients with ASIA A injuries. The overall conversion rate was 28.1%, with 327 of 1162 patients improving to at least ASIA B. The overall rate of conversion noted in cervical spine injuries was 33.3%, whereas that in thoracic injuries was 30.6%. Patients undergoing early surgery had a higher rate of conversion (46.1%) than patients undergoing late surgery (25%) (OR 2.31, 95% CI 1.08–4.96, p = 0.03).

CONCLUSIONS

The overall rate of conversion of ASIA A SCIs from pooled data of prospective trials and observational series is 28.1%. This rate of conversion is higher than what is reported in the literature. Early surgery is predictive of a higher conversion rate. However, there are not enough data to provide conclusions pertaining to the efficacy of biological and medical therapies.

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The timing of venous thromboembolic events after spine surgery: a single-center experience with 6869 consecutive patients

Presented at the 2017 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Michael B. Cloney, Benjamin Hopkins, Ekamjeet S. Dhillon and Nader S. Dahdaleh

OBJECTIVE

Venous thromboembolic events (VTEs), including both deep venous thrombosis (DVT) and pulmonary embolism, are a major cause of morbidity and mortality after spine surgery. Prophylactic anticoagulation, or chemoprophylaxis, can prevent VTE. However, the timing of VTEs after spine surgery and the effect of chemoprophylaxis on VTE timing remain underinvestigated.

METHODS

The records of 6869 consecutive spine surgeries were retrospectively examined. Data on patient demographics, surgical variables, hospital course, and timing of VTEs were collected. Patients who received chemoprophylaxis were compared with those who did not. Appropriate regression models were used to examine selection for chemoprophylaxis and the timing of VTEs.

RESULTS

Age (OR 1.037, 95% CI 1.023–1.051; p < 0.001), longer surgery (OR 1.003, 95% CI 1.002–1.004; p < 0.001), history of DVT (OR 1.697, 95% CI 1.038–2.776; p = 0.035), and fusion surgery (OR 1.917, 95% CI 1.356–2.709; p < 0.001) predicted selection for chemoprophylaxis. Chemoprophylaxis patients experienced more VTEs (3.62% vs 2.03% of patients, respectively; p < 0.001), and also required longer hospital stays (5.0 days vs 1.0 days; HR 0.5107; p < 0.0001) and had a greater time to the occurrence of VTE (median 6.8 days vs 3.6 days; HR 0.6847; p = 0.0003). The cumulative incidence of VTEs correlated with the postoperative day in both groups (Spearman r = 0.9746, 95% CI 0.9457–0.9883, and p < 0.0001 for the chemoprophylaxis group; Spearman r = 0.9061, 95% CI 0.8065–0.9557, and p < 0.0001 for the nonchemoprophylaxis group), and the cumulative incidence of VTEs was higher in the nonchemoprophylaxis group throughout the 30-day postoperative period. Cumulative VTE incidence and postoperative day were linearly correlated in the first 2 postoperative weeks (R = 0.9396 and p < 0.0001 for the chemoprophylaxis group; R = 0.8190 and p = 0.0003 for the nonchemoprophylaxis group) and the remainder of the 30-day postoperative period (R = 0.9535 and p < 0.0001 for the chemoprophylaxis group; R = 0.6562 and p = 0.0058 for the nonchemoprophylaxis group), but the linear relationships differ between these 2 postoperative periods (p < 0.0001 for both groups).

CONCLUSIONS

Anticoagulation reduces the cumulative incidence of VTE after spine surgery. The cumulative incidence of VTEs rises linearly in the first 2 postoperative weeks and then plateaus. Surgeons should consider early initiation of chemoprophylaxis for patients undergoing spine surgery.

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Ekamjeet S. Dhillon, Ryan Khanna, Michael Cloney, Helena Roberts, George R. Cybulski, Tyler R. Koski, Zachary A. Smith and Nader S. Dahdaleh

OBJECTIVE

Venous thromboembolism (VTE) after spinal surgery is a major cause of morbidity, but chemoprophylactic anticoagulation can prevent it. However, there is variability in the timing and use of chemoprophylactic anticoagulation after spine surgery, particularly given surgeons’ concerns for spinal epidural hematomas. The goal of this study was to provide insight into the safety, efficacy, and timing of anticoagulation therapy after spinal surgery.

METHODS

The authors retrospectively examined records from 6869 consecutive spinal surgeries performed in their departments at Northwestern University. Data on patient demographics, surgery, hospital course, timing of chemoprophylaxis, and complications, including deep venous thrombosis (DVT), pulmonary embolism (PE), and spinal epidural hematomas requiring evacuation, were collected. Data from the patients who received chemoprophylaxis (n = 1904) were compared with those of patients who did not (n = 4965). The timing of chemoprophylaxis, the rate of VTEs, and the incidence of spinal epidural hematomas were analyzed.

RESULTS

The chemoprophylaxis group had more risk factors, including greater age (59.70 vs 51.86 years, respectively; p < 0.001), longer surgery (278.59 vs 145.66 minutes, respectively; p < 0.001), higher estimated blood loss (995 vs 448 ml, respectively; p < 0.001), more comorbid diagnoses (2.69 vs 1.89, respectively; p < 0.001), history of VTE (5.8% vs 2.1%, respectively; p < 0.001), and a higher number were undergoing fusion surgery (46.1% vs 24.7%, respectively; p < 0.001). The prevalence of VTE was higher in the chemoprophylaxis group (3.62% vs 2.03%, respectively; p < 0.001). The median time to VTE occurrence was shorter in the nonchemoprophylaxis group (3.6 vs 6.8 days, respectively; p = 0.0003, log-rank test; hazard ratio 0.685 [0.505–0.926]), and the peak prevalence of VTE occurred in the first 3 postoperative days in the nonchemoprophylaxis group. The average time of initiation of chemoprophylaxis was 1.46 days after surgery. The rates of epidural hematoma were 0.20% (n = 4) in the chemoprophylaxis group and 0.18% (n = 9) in the nonchemoprophylaxis group (p = 0.622).

CONCLUSIONS

The risks of spinal epidural hematoma among patients who receive chemoprophylaxis and those who do not are low and equivalent. Administering anticoagulation therapy from 1 day before to 3 days after surgery is safe for patients at high risk for VTE.

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Patrick W. Hitchon, Mario Zanaty, Logan Helland, Kingsley Abode-Iyamah and Nader S. Dahdaleh

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Alejandro J. Lopez, Robert K. Campbell, Omar Arnaout, Yvonne M. Curran, Ali Shaibani and Nader S. Dahdaleh

The authors report the case of a 28-year-old woman with a spontaneous cerebrospinal fluid leak from the sleeve of a redundant thoracic nerve root. She presented with postural headaches and orthostatic symptoms indicative of intracranial hypotension. CT myelography revealed that the lesion was located at the T-11 nerve root. After failure of conservative management, including blood patches and thrombin glue injections, the patient was successfully treated with surgical decompression and ligation of the duplicate nerve, resulting in full resolution of her orthostatic symptoms.