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Nitin Agarwal, Andrew Faramand, Johanna Bellon, Jeffrey Borrebach, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

OBJECTIVE

The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) is a standardized patient experience survey that is used to evaluate the quality of care delivered by physicians. The authors sought to determine which factors influenced CG-CAHPS scores for spine surgery, and compare them to their cranial-focused cohorts.

METHODS

A retrospective study of prospectively obtained data was performed to evaluate CG-CAHPS scores. Between May 2013 and May 2017, all patients 18 years of age or older with an outpatient encounter with a neurosurgeon (5 spine-focused neurosurgeons and 20 cranial-focused neurosurgeons) received a CG-CAHPS survey. Three domains were assessed: overall physician rating, likelihood to recommend, and physician communication. Statistical analyses were performed using chi-square tests.

RESULTS

Seven thousand four hundred eighty-five patient surveys (2319 spine and 5166 cranial) were collected from patients presenting to the outpatient offices of an attending neurosurgeon. Analysis of the overall physician rating showed that 81.1% of spine neurosurgeons received a “top-box” score (answers of “yes, definitely”), whereas 86.2% of cranial neurosurgeons received a top-box response (p < 0.001). A similar difference was observed with the domains of “likelihood to recommend” and “physician communication.” Overall physician rating was also significantly influenced by the general and mental health of the patients surveyed (p < 0.001). For spine surgeons seeing patients at more than one facility, the scores with respect to location were also significantly different in all domains for each individual provider (p < 0.001).

CONCLUSIONS

Overall, spine-focused neurosurgeon ratings differed significantly from those of cranial-focused neurosurgical subspecialty providers. Office location also affected provider ratings for spine neurosurgeons. These results suggest that physician ratings obtained via patient experience surveys may be representative of factors aside from just the quality of physician care provided. This information should be considered as payers, government, and health systems design performance programs based on patient experience scores.

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Lateral lumbar interbody fusion in the elderly: a 10-year experience

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Nitin Agarwal, Andrew Faramand, Nima Alan, Zachary J. Tempel, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

OBJECTIVE

Elderly patients, often presenting with multiple medical comorbidities, are touted to be at an increased risk of peri- and postoperative complications following spine surgery. Various minimally invasive surgical techniques have been developed and employed to treat an array of spinal conditions while minimizing complications. Lateral lumbar interbody fusion (LLIF) is one such approach. The authors describe clinical outcomes in patients over the age of 70 years following stand-alone LLIF.

METHODS

A retrospective query of a prospectively maintained database was performed for patients over the age of 70 years who underwent stand-alone LLIF. Patients with posterior segmental fixation and/or fusion were excluded. The preoperative and postoperative values for the Oswestry Disability Index (ODI) were analyzed to compare outcomes after intervention. Femoral neck t-scores were acquired from bone density scans and correlated with the incidence of graft subsidence.

RESULTS

Among the study cohort of 55 patients, the median age at the time of surgery was 74 years (range 70–87 years). Seventeen patients had at least 3 medical comorbidities at surgery. Twenty-three patients underwent a 1-level, 14 a 2-level, and 18 patients a 3-level or greater stand-alone lateral fusion. The median estimated blood loss was 25 ml (range 5–280 ml). No statistically significant relationship was detected between volume of blood loss and the number of operative levels. The median length of hospital stay was 2 days (range 1–4 days). No statistically significant relationship was observed between the length of hospital stay and age at the time of surgery. There was one intraoperative death secondary to cardiac arrest, with a mortality rate of 1.8%. One patient developed a transient femoral nerve injury. Five patients with symptomatic graft subsidence subsequently underwent posterior instrumentation. A lower femoral neck t-score < −1.0 correlated with a higher incidence of graft subsidence (p = 0.006). The mean ODI score 1 year postoperatively of 31.1 was significantly (p = 0.003) less than the mean preoperative ODI score of 46.2.

CONCLUSIONS

Stand-alone LLIF can be safely and effectively performed in the elderly population. Careful evaluation of preoperative bone density parameters should be employed to minimize risk of subsidence and need for additional surgery. Despite an association with increased comorbidities, age alone should not be a deterrent when considering stand-alone LLIF in the elderly population.

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Nitin Agarwal, Prateek Agarwal, Ashley Querry, Anna Mazurkiewicz, Zachary J. Tempel, Robert M. Friedlander, Peter C. Gerszten, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

OBJECTIVE

Previous studies have demonstrated the efficacy of infection prevention protocols in reducing infection rates. This study investigated the effects of the development and implementation of an infection prevention protocol that was augmented by increased physician awareness of spinal fusion surgical site infection (SSI) rates and resultant cost savings.

METHODS

A cohort clinical investigation over a 10-year period was performed at a single tertiary spine care academic institution. Preoperative infection control measures (chlorohexidine gluconate bathing, Staphylococcus aureus nasal screening and decolonization) followed by postoperative infection control measures (surgical dressing care) were implemented. After the implementation of these infection control measures, an awareness intervention was instituted in which all attending and resident neurosurgeons were informed of their individual, independently adjudicated spinal fusion surgery infection rates and rankings among their peers. During the course of these interventions, the overall infection rate was tracked as well as the rates for those neurosurgeons who complied with the preoperative and postoperative infection control measures (protocol group) and those who did not (control group).

RESULTS

With the implementation of postoperative surgical dressing infection control measures and physician awareness, the postoperative spine surgery infection rate decreased by 45% from 3.8% to 2.1% (risk ratio 0.55; 95% CI 0.32–0.93; p = 0.03) for those in the protocol cohort, resulting in an estimated annual cost savings of $291,000. This reduction in infection rate was not observed for neurosurgeons in the control group, although the overall infection rate among all neurosurgeons decreased by 54% from 3.3% to 1.5% (risk ratio 0.46; 95% CI 0.28–0.73; p = 0.0013).

CONCLUSIONS

A novel paradigm for spine surgery infection control combined with physician awareness methods resulted in significantly decreased SSI rates and an associated cost reduction. Thus, information sharing and physician engagement as a supplement to formal infection control measures result in improvements in surgical outcomes and costs.

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Zachary J. Tempel, Michael M. McDowell, David M. Panczykowski, Gurpreet S. Gandhoke, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

OBJECTIVE

Lateral lumbar interbody fusion (LLIF) is a less invasive surgical option commonly used for a variety of spinal conditions, including in high-risk patient populations. LLIF is often performed as a stand-alone procedure, and may be complicated by graft subsidence, the clinical ramifications of which remain unclear. The aim of this study was to characterize further the sequelae of graft subsidence following stand-alone LLIF.

METHODS

A retrospective review of prospectively collected data was conducted on consecutive patients who underwent stand-alone LLIF between July 2008 and June 2015; 297 patients (623 levels) met inclusion criteria. Imaging studies were examined to grade graft subsidence according to Marchi criteria, and compared between those who required revision surgery and those who did not. Additional variables recorded included levels fused, DEXA (dual-energy x-ray absorptiometry) T-score, body mass index, and routine demographic information. The data were analyzed using the Student t-test, chi-square analysis, and logistic regression analysis to identify potential confounding factors.

RESULTS

Of 297 patients, 34 (11.4%) had radiographic evidence of subsidence and 18 (6.1%) required revision surgery. The median subsidence grade for patients requiring revision surgery was 2.5, compared with 1 for those who did not. Chi-square analysis revealed a significantly higher incidence of revision surgery in patients with high-grade subsidence compared with those with low-grade subsidence. Seven of 18 patients (38.9%) requiring revision surgery suffered a vertebral body fracture. High-grade subsidence was a significant predictor of the need for revision surgery (p < 0.05; OR 12, 95% CI 1.29–13.6), whereas age, body mass index, T-score, and number of levels fused were not. This relationship remained significant despite adjustment for the other variables (OR 14.4; 95% CI 1.30–15.9).

CONCLUSIONS

In this series, more than half of the patients who developed graft subsidence following stand-alone LLIF required revision surgery. When evaluating patients for LLIF, supplemental instrumentation should be considered during the index surgery in patients with a significant risk of graft subsidence.

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The effect of vancomycin powder on human dural fibroblast culture and its implications for dural repair during spine surgery

Presented at the 2016 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Ezequiel Goldschmidt, Jorge Rasmussen, Joseph D. Chabot, Gurpreet Gandhoke, Emilia Luzzi, Lina Merlotti, Romina Proni, Mónica Loresi, D. Kojo Hamilton, David O. Okonkwo, Adam S. Kanter and Peter C. Gerszten

OBJECTIVE

Surgical site infections (SSIs) are a major source of morbidity after spinal surgery. Several recent studies have described the finding that applying vancomycin powder to the surgical bed may reduce the incidence of SSI. However, applying vancomycin in high concentrations has been shown in vitro to inhibit osteoblast proliferation and to induce cell death. Vancomycin may have a deleterious effect on dural healing after repair of an intentional or unintentional durotomy. This study was therefore undertaken to assess the effect of different concentrations of vancomycin on a human dura mater cell culture.

METHODS

Human dura intended for disposal after decompressive craniectomy was harvested. Explant primary cultures and subcultures were subsequently performed. Cells were characterized through common staining and immunohistochemistry. A growth curve was performed to assess the effect of different concentrations of vancomycin (40, 400, and 4000 μg/ml) on cell count. The effect of vancomycin on cellular shape, intercellular arrangement, and viability was also evaluated.

RESULTS

All dural tissue samples successfully developed into fusiform cells, demonstrating pseudopod projections and spindle formation. The cells demonstrated vimentin positivity and also had typical features of fibroblasts. When applied to the cultures, the highest dose of vancomycin induced generalized cell death within 24 hours. The mean (± SD) cell counts for control, 40, 400, and 4000 μg/ml were 38.72 ± 15.93, 36.28 ± 22.87, 19.48 ± 6.53, and 4.07 ± 9.66, respectively (p < 0.0001, ANOVA). Compared with controls, vancomycin-exposed cells histologically demonstrated a smaller cytoplasm and decreased pseudopodia formation resulting in the inhibition of normal spindle intercellular arrangement.

CONCLUSIONS

When vancomycin powder is applied locally, dural cells are exposed to a concentration several times greater than when delivered systemically. In this in vitro model, vancomycin induced dural cell death, inhibited growth, and altered cellular morphology in a concentration-dependent fashion. Defining a safe vancomycin concentration that is both bactericidal and also does not inhibit normal dural healing is necessary.

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Gurpreet S. Gandhoke, Christian Ricks, Zachary Tempel, Brian Zuckerbraun, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

In deformity surgery, anterior lumbar interbody fusion provides excellent biomechanical support, creates a broad surface area for arthrodesis, and induces lordosis in the lower lumbar spine. Preoperative MRI, plain radiographs, and, when available, CT scan should be carefully assessed for sacral slope as it relates to pubic symphysis, position of the great vessels (especially at L4/5), disc space height, or contraindication to an anterior approach. This video demonstrates the steps in an anterior surgical procedure with minimal open exposure.

The video can be found here: https://youtu.be/r3bC4_vu1hQ.