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Doniel Drazin, Ziya L. Gokaslan and J. Patrick Johnson

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Rani Nasser, Doniel Drazin, Jonathan Nakhla, Lutfi Al-Khouja, Earl Brien, Eli M. Baron, Terrence T. Kim, J. Patrick Johnson and Reza Yassari

OBJECTIVE

The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions.

METHODS

This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance.

RESULTS

The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14–87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62–865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5–7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1–36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden.

CONCLUSIONS

O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

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Sandi Lam, I-Wen Pan, Andrew Jea and Thomas G. Luerssen

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Doniel Drazin, Miriam Nuño, Chirag G. Patil, Kimberly Yan, John C. Liu and Frank L. Acosta Jr.

OBJECTIVE

The objective of this study was to determine factors associated with admission to the hospital through the emergency room (ER) for patients with a primary diagnosis of low-back pain (LBP). The authors further evaluated the impact of ER admission and patient characteristics on mortality, discharge disposition, and hospital length of stay.

METHODS

The authors conducted a retrospective analysis of patients with LBP discharged from hospitals according to the Nationwide Inpatient Sample (NIS) between 1998 and 2007. Univariate comparisons of patient characteristics according to the type of admission (ER versus non-ER) were conducted. Multivariate analysis evaluated factors associated with an ER admission, risk of mortality, and nonroutine discharge.

RESULTS

According to the NIS, approximately 183,151 patients with a primary diagnosis of LBP were discharged from US hospitals between 1998 and 2007. During this period, an average of 65% of these patients were admitted through the ER, with a significant increase from 1998 (54%) to 2005 (71%). Multivariate analysis revealed that uninsured patients (OR 2.1, 95% CI 1.7–2.6, p < 0.0001) and African American patients (OR 1.5, 95% CI 1.2–1.7, p < 0.0001) were significantly more likely to be admitted through the ER than private insurance patients or Caucasian patients, respectively. Additionally, a moderate but statistically significant increase in the likelihood of ER admission was noted for patients with more preexisting comorbidities (OR 1.1, 95% CI 1.0–1.2, p < 0.001). An 11% incremental increase in the odds of admission through the ER was observed with each year increment (OR 1.1, 95% CI 1.0–1.2, p < 0.001). Highest income patients ($45,000+) were more likely to be admitted through the ER (OR 1.3, 95% CI 1.1–1.6, p = 0.007) than the lowest income cohort. While ER admission did not impact the risk of mortality (OR 0.95, 95% CI 0.60–1.51, p = 0.84), it increased the odds of a nonroutine discharge (OR 1.39, 95% CI 1.26–1.53, p < 0.0001).

CONCLUSIONS

A significant majority of patients discharged from hospitals in the US from 1998 to 2007 with a primary diagnosis of LBP were admitted through the ER, with more patients being admitted via this route each year. These patients were less likely to be discharged directly home compared with patients with LBP who were not admitted through the ER. Uninsured and African American patients with LBP were more likely to be admitted through the ER than their counterparts, as were patients with more preexisting health problems. Interestingly, patients with LBP at the highest income levels were more likely to be admitted through hospital ERs. The findings suggest that socioeconomic factors may play a role in the utilization of ER resources by patients with LBP, which in turn appears to impact at least the short-term outcome of these patients.

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Faris Shweikeh, David Foulad, Miriam Nuño, Doniel Drazin and Matthew A. Adamo

OBJECT

Craniosynostosis is often treated with neurosurgical intervention. The aim of this study was to report and analyze the clinical and socioeconomic characteristics of patients with craniosynostosis and to present current national trends.

METHODS

Using the Kids’ Inpatient Database for the years 2000, 2003, 2006, and 2009, the authors identified patients with craniosynostosis using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and their associated procedure codes. Clinical features, demographics, inpatient procedures, outcomes, and charges were collected and analyzed.

RESULTS

Of the 3415 patients identified, 65.8% were White, 21.4% were Hispanic, and 3.2% were Black. More than 96% were treated at urban teaching hospitals and 54.2% in southern or western regions. White patients were younger (mean 6.1 months) as compared with Blacks (mean 10.9 months) and Hispanics (mean 9.1 months; p < 0.0001) at the time of surgery. A higher fraction of Whites had private insurance (70.3%) compared with nonwhites (34.0%–41.6%; p < 0.001). Approximately 12.2% were nonelective admissions, more so among Blacks (16.9%). Mean hospital length of stay (LOS) was 3.5 days with no significant differences among races. Following surgical treatment, 12.1% of patients developed complications, most commonly pulmonary/respiratory (4.8%), wound infection (4.4%), and hydrocephalus (1.4%). The mean overall hospital charges were significantly lower for Whites than nonwhites ($34,527 vs $44,890–$48,543, respectively; p < 0.0001).

CONCLUSIONS

The findings of this national study suggest a higher prevalence of craniosynostosis in Hispanics. The higher predisposition among males was less evident in Hispanics and Blacks. There was a significant percentage of nonelective admissions, more commonly among Blacks. Additionally, Hispanics and Blacks were more likely to receive surgery at an older age, past the current recommendation of the optimum age for surgical intervention. These findings are likely associated with a lack of early detection. Although mean LOS and rate of complications did not significantly differ among different races, nonwhites had, on average, higher hospital charges of $10,000–$14,000. This discrepancy may be due to differences in type of insurance, craniosynostosis type, rates of comorbidities, and delay in treatment. Although there are several limitations to this analysis, the study reports on relevant disparities regarding a costly neurosurgical intervention, and ways to diminish these disparities should be further explored.

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Doniel Drazin, Mir Hussain, Jonathan Harris, John Hao, Matt Phillips, Terrence T. Kim, J. Patrick Johnson and Brandon Bucklen

OBJECT

Abnormal sacral slope (SS) has shown to increase progression of spondylolisthesis, yet there exists a paucity in biomechanical studies investigating its role in the correction of adult spinal deformity, its influence on lumbosacral shear, and its impact on the instrumentation selection process. This in vitro study investigates the effect of SS on 3 anterior lumbar interbody fusion constructs in a biomechanics laboratory.

METHODS

Nine healthy, fresh-frozen, intact human lumbosacral vertebral segments were tested by applying a 550-N axial load to specimens with an initial SS of 20° on an MTS Bionix test system. Testing was repeated as SS was increased to 50°, in 10° increments, through an angulated testing fixture. Specimens were instrumented using a standalone integrated spacer with self-contained screws (SA), an interbody spacer with posterior pedicle screws (PPS), and an interbody spacer with anterior tension band plate (ATB) in a randomized order. Stiffness was calculated from the linear portion of the load-deformation curve. Ultimate strength was also recorded on the final construct of all specimens (n = 3 per construct) with SS of 40°.

RESULTS

Axial stiffness (N/mm) of the L5–S1 motion segment was measured at various angles of SS: for SA 292.9 ± 142.8 (20°), 277.2 ± 113.7 (30°), 237.0 ± 108.7 (40°), 170.3 ± 74.1 (50°); for PPS 371.2 ± 237.5 (20°), 319.8 ± 167.2 (30°), 280.4 ± 151.7 (40°), 233.0 ± 117.6 (50°); and for ATB 323.9 ± 210.4 (20°), 307.8 ± 125.4 (30°), 249.4 ± 126.7 (40°), 217.7 ± 99.4 (50°). Axial compression across the disc space decreased with increasing SS, indicating that SS beyond 40° threshold shifted L5–S1 motion into pure shear, instead of compression-shear, defining a threshold. Trends in ultimate load and displacement differed from linear stiffness with SA > PPS > ATB.

CONCLUSIONS

At larger SSs, bilateral pedicle screw constructs with spacers were the most stable; however, none of the constructs were significantly stiffer than intact segments. For load to failure, the integrated spacer performed the best; this may be due to angulations of integrated plate screws. Increasing SS significantly reduced stiffness, which indicates that surgeons need to consider using more aggressive fixation techniques.

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Miriam Nuño, Lindsey Pelissier, Kunal Varshneya, Matthew A. Adamo and Doniel Drazin

OBJECT

Head trauma is the leading cause of death in abused children, particularly prior to the age of 2 years. An awareness of factors associated with this condition as well as with a higher risk of mortality is important to improve outcomes and prevent the occurrence of these events. The objective of this study was to evaluate outcomes and factors associated with poor outcomes in infants with diagnosed abusive head trauma (AHT). Patient characteristics, socioeconomic factors, and secondary conditions such as retinal bleeding, contusion, and fractures were considered.

METHODS

Data were obtained from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. From the Kids’ Inpatient Database (KID) sample, the authors identified infants no older than 23 months who had been diagnosed with AHT in 2000, 2003, 2006, and 2009. All statistical analyses were conducted in SAS 9.2. Descriptive statistics were provided, and multivariate logistic regression models were applied to evaluate factors associated with mortality and nonroutine discharge.

RESULTS

A total of 5195 infants were analyzed in this study. Most infants (85.5%) had ages ranging between 0 and 11 months and were male (61.6%). Overall mortality was 10.8%, with a rate of 9.8% in the 0- to 11-month-old cohort and 16.5% in the 12- to 23-month-olds (p = 0.0003). The overall nonroutine discharge rate of 25.6% increased significantly from 23.3% to 39.0% with increasing age (0–11 vs 12–23 months of age, p < 0.0001). Assuming a multivariate model that adjusted for multiple confounders, the authors found that older infants (12–23 vs 0–11 months, OR 1.81, 95% CI 1.18–2.77) with a secondary diagnosis of retinal bleeding (OR 2.85, 95% CI 2.02–4.00) or shaken baby syndrome (OR 2.09, 95% CI 1.48–2.94) had an increased risk of mortality; these factors were similarly associated with an increased odds of a nonroutine discharge. A higher income ($30,001–$35,000 vs $1–$24,999) was associated with a reduction in the odds of mortality (OR 0.46, 95% CI 0.29–0.72). In the subset of cases (1695 [32.6%]) that specified the perpetrator involved in infant injury, the authors found that the father, stepfather, or boyfriend was most frequently reported (67.4%). A trend for a higher AHT incidence was documented in the early ages (peak at 2 months) compared with older ages.

CONCLUSIONS

Despite the higher incidence of AHT among infants during the earlier months of life, higher mortality was documented in the 12- to 23-month-olds. Retinal bleeding and shaken baby syndrome were secondary diagnoses associated with higher mortality and nonroutine discharge. Males (67.4%) were overwhelmingly documented as the perpetrators involved in the injury of these infants.

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Shiveindra B. Jeyamohan, Tyler J. Kenning, Karen A. Petronis, Paul J. Feustel, Doniel Drazin and Darryl J. DiRisio

OBJECT

Anterior cervical discectomy and fusion (ACDF) is an effective procedure for the treatment of cervical radiculopathy and/or myelopathy; however, postoperative dysphagia is a significant concern. Dexamethasone, although potentially protective against perioperative dysphagia and airway compromise, could inhibit fusion, a generally proinflammatory process. The authors conducted a prospective, randomized, double-blinded, controlled study of the effects of steroids on swallowing, the airway, and arthrodesis related to multilevel anterior cervical reconstruction in patients who were undergoing ACDF at Albany Medical Center between 2008 and 2012. The objective of this study was to determine if perioperative steroid use improves perioperative dysphagia and airway edema.

METHODS

A total of 112 patients were enrolled and randomly assigned to receive saline or dexamethasone. Data gathered included demographics, functional status (including modified Japanese Orthopaedic Association myelopathy score, neck disability index, 12-Item Short-Form Health Survey score, and patient-reported visual analog scale score of axial and radiating pain), functional outcome swallowing scale score, interval postoperative imaging, fusion status, and complications/reoperations. Follow-up was performed at 1, 3, 6, 12, and 24 months, and CT was performed 6, 12, and 24 months after surgery for fusion assessment.

RESULTS

Baseline demographics were not significantly different between the 2 groups, indicating adequate randomization. In terms of patient-reported functional and pain-related outcomes, there were no differences in the steroid and placebo groups. However, the severity of dysphagia in the postoperative period up to 1 month proved to be significantly lower in the steroid group than in the placebo group (p = 0.027). Furthermore, airway difficulty and a need for intubation trended toward significance in the placebo group (p = 0.057). Last, fusion rates at 6 months proved to be significantly lower in the steroid group but lost significance at 12 months (p = 0.048 and 0.57, respectively).

CONCLUSIONS

Dexamethasone administered perioperatively significantly improved swallowing function and airway edema and shortened length of stay. It did not affect pain, functional outcomes, or long-term swallowing status. However, it significantly delayed fusion, but the long-term fusion rates remained unaffected.

Clinical trial registration no.: NCT01065961 (clinicaltrials.gov)

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Doniel Drazin, Ziya L. Gokaslan, Ehud Mendel and J. Patrick Johnson