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James Xie and Maxwell Boakye

Electrophysiological measures can provide information that complements clinical assessments such as the American Spinal Injury Association sensory and motor scores in the evaluation of outcomes after spinal cord injury (SCI). The authors review and summarize the literature regarding tests that are most relevant to the study of SCI recovery—in particular, motor evoked potentials and somatosensory evoked potentials (SSEPs). In addition, they discuss the role of other tests, including F-wave nerve conductance tests and electromyography, sympathetic skin response, and the Hoffman reflex (H-reflex) test as well as the promise of dermatomal SSEPs and the electrical perceptual threshold test, newer quantitative tests of sensory function.

It has been shown that motor evoked potential amplitudes improve with SCI recovery but latencies do not. Somatosensory evoked potentials are predictive of ambulatory capacity and hand function. Hoffman reflexes are present during spinal shock despite the loss of tendon reflexes, but their amplitudes increase with time after injury. Further, H-reflex modulation is reflective of changes in spinal excitability. While these tests have produced data that is congruent with clinical evaluations, they have yet to surpass clinical evaluations in predicting outcomes. Continuing research using these methodologies should yield a better understanding of the mechanisms behind SCI recovery and thus provide potentially greater predictive and evaluative power.

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Mayur Sharma, Beatrice Ugiliweneza, Zaid Aljuboori and Maxwell Boakye

OBJECTIVE

Opioid abuse is highly prevalent in patients with back pain. The aim of this study was to identify health care utilization and overall costs associated with opioid dependence in patients undergoing surgery for degenerative spondylolisthesis (DS).

METHODS

The authors queried the MarketScan database using ICD-9 and CPT-4 codes from 2000 to 2012. Opioid dependency was defined as having a diagnosis of opioid use disorder, having a prescription for opioid use disorder, or having 10 or more opioid prescriptions. Opioid dependency was evaluated in 12-month period leading to surgery and in the period 3–15 months following the procedure. Patients were segregated into 4 groups based on opioid dependence before and after surgery: group NDND (prior nondependent who remain nondependent), group NDD (prior nondependent who become dependent), group DND (prior dependent who become nondependent), and group DD (prior dependent who remain dependent). The outcomes of interest were discharge disposition, hospital length of stay (LOS), complications, and health care resource costs. The 4 groups were compared using the Kruskal-Wallis test and linear contrasts built from generalized regression models.

RESULTS

A total of 10,708 patients were identified, with 81.57%, 3.58%, 8.54%, and 6.32% of patients in groups NDND, NDD, DND, and DD, respectively. In group DD, 96.31% of patients had decompression with fusion, compared with 93.59% in group NDND. Patients in group NDD, DND, and DD had longer hospital LOS compared with those in group NDND. Patients in group DD were less likely to be discharged home compared with those in group NDND (odds ratio 0.639, 95% confidence interval 0.52–0.785). At 3–15 months postdischarge, patients in group DD incurred 21% higher hospital readmission costs compared with those in group NDND. However, patients in groups NDD and DD were likely to incur 2.8 times the overall costs compared with patients in group NDND (p < 0.001) at 3–15 months after surgery (median overall payments: group NDD $20,033 and group DD $19,654, vs group NDND $7994).

CONCLUSIONS

Patients who continued to be opioid dependent or became opioid dependent following surgery for DS incurred significantly higher health care utilization and costs within 3 months and in the period 3–15 months after discharge from surgery.

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Mayur Sharma, Pooja SirDeshpande, Beatrice Ugiliweneza, Nicholas Dietz and Maxwell Boakye

OBJECTIVE

Symptomatic perineural or Tarlov cysts (TCs) are a rare cause of chronic low-back pain. Given the rarity of the disease, there is no literature consensus regarding the optimal management of these cysts.

METHODS

The authors conducted a systematic comparative outcome analysis of symptomatic TCs treated with surgery (group A, 32 studies, n = 333) or percutaneous interventions (group B, 6 studies, n = 417) analyzing the demographic characteristics, baseline characteristics of the cysts, clinical presentations, types of interventions, complication rates, and the recurrence rate in both treatment groups. The literature search was performed using the PubMed, MEDLINE, Cochrane, and Ovid databases up to 2018. The MeSH search terms used were “Tarlov cyst,” “sacral perineural cyst,” “sacral nerve root cyst,” “meningeal cyst of the sacral spine,” “extra meningeal cyst with spinal nerve root fibers,” “spinal extradural arachnoid pouch,” and “cyst of the sacral nerve root sheath.” The authors used statistical tests for two proportions using the “N-1” chi-square test with the free version of MedCalc for Windows for comparison among the groups.

RESULTS

Overall symptomatic improvement was reported in 83.5% of patients in both groups; however, exacerbation of preprocedural symptoms was significantly higher in group B than group A (10.1% vs 3.3%, p = 0.0003). The overall complication rates in the surgical and nonsurgical groups were 21% and 12.47%, respectively. Transient sciatica was the most common complication in both groups (17% vs 8%, respectively; p = 0.017). The incidence of cyst recurrence was much lower in group A than group B (8% vs 20%, p = 0.0018). The mean follow-up duration for the surgical group was 38 ± 29 months (25 studies, n = 279), while that for the nonsurgical group was 15 ± 12 months (4 studies, n = 290) (p < 0.0001).

CONCLUSIONS

The authors noted that although the surgical interventions were associated with higher postprocedural complication rates, long-term efficacy and success in terms of cyst resolution were superior following surgery compared to percutaneous procedures in the management of symptomatic TCs. There was no difference in symptom recurrence with either of the techniques.

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Paul Kalanithi, Ryan D. Schubert, Shivanand P. Lad, Odette A. Harris and Maxwell Boakye

Object

This study provides the first US national data regarding frequency, cost, and mortality rate of traumatic subdural hematoma (SDH), and identifies demographic factors affecting morbidity and death in patients with traumatic SDH undergoing surgical drainage.

Methods

A retrospective analysis was conducted by querying the Nationwide Inpatient Sample, the largest all-payer database of nonfederal community hospitals. All cases of traumatic SDH were identified using ICD-9 codes. The study consisted of 2 parts: 1) trends data, which were abstracted from the years 1993–2006, and 2) univariate analysis and multivariate logistic regression of demographic variables on inhospital complications and deaths for the years 1993–2002.

Results

Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006. Inhospital deaths decreased from 16.4% to 11.6% for traumatic SDH. Average costs increased 67% to $47,315 per admission. For the multivariate regression analysis, between 1993 and 2002, 67,864 patients with traumatic SDH underwent operative treatment. The inhospital mortality rate was 14.9% for traumatic SDH drainage, with an 18% inhospital complication rate. Factors affecting inhospital deaths included presence of coma (OR = 2.45) and more than 2 comorbidities (OR = 1.60). Increased age did not worsen the inhospital mortality rate.

Conclusions

Nationally, frequency and cost of traumatic SDH cases are increasing rapidly.

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Mark H. Bilsky, Maxwell Boakye, Frederic Collignon, Dennis Kraus and Patrick Boland

Object. The authors describe the preoperative assessment, intraoperative strategies, and long-term outcomes in 41 consecutive patients who underwent spinal reconstruction after resection of subaxial cervical neoplasms.

Methods. Thirty-three tumors were metastatic and eight were primary. Preoperative studies included direct laryngoscopy and vertebral artery (VA) balloon occlusion tests in selected patients. Based on the tumor location, approaches included 12 anterior, 13 posterior, and 16 combined. All patients underwent aggressive intralesional resection and spinal reconstruction. In 12 patients, the VA was dissected from the periphery of the tumor, two cases of which required ligation. Fibula allograft and an anterior rigid plate fixation were most commonly used for anterior reconstruction. Posterior reconstruction was initially performed using lateral mass plates (LMPs) in 13 patients and screw/rod systems in the remaining patients.

At follow up, pain level improved to mild or was absent in 39 patients (95%) who had presented with moderate or severe pain. The American Spinal Injury Association (ASIA) Scale scores were stable in 25 patients who presented with ASIA Score E and improved in 14 patients (88%) who presented with ASIA Score B, C, or D. Functional radiculopathy significantly improved in 16 (94%) of 17 patients.

Complications occurred in 10 patients (24%) and included three fixation failures requiring revision. Two fixation failures involved cervical LMP screw pullout. The overall mean survival duration was 8.6 months for patients with metastatic tumors and 33.4 months for primary tumors.

Conclusions. Surgery for the treatment of subaxial spine neoplasms is effective for relieving pain, encouraging functional nerve root recovery, and preserving spinal cord function with acceptable complication rates.

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Chirag G. Patil, Shivanand P. Lad, Griffith R. Harsh, Edward R. Laws Jr. and Maxwell Boakye

Object

Information about complications, patient outcomes, and mortality rate after transsphenoidal surgery (TSS) for Cushing's disease has been derived largely from single-institution series. In this study the authors report on inpatient death, morbidity, and outcomes following TSS for Cushing's disease on a national level.

Methods

All patients in the Nationwide Inpatient Sample (NIS) database who had undergone transsphenoidal resection of a pituitary tumor for Cushing's disease between 1993 and 2002 were included in the study. The number of cases per year, length of stay (LOS), and rates of inpatient complications, death, and adverse outcomes (death or discharge to institution other than home) were abstracted. Univariate and multivariate analyses were performed to determine the effects of patient and hospital characteristics on outcome measures.

Results

According to the NIS, there were an estimated 3525 cases of TSS for Cushing's disease in the US between 1993 and 2002. During this period, there was a trend toward a small increase in the number of TSSs for Cushing's disease. The in-hospital mortality rate was 0.7%, and the complication rate was 42.1%. Diabetes insipidus (15%), fluid and electrolyte abnormalities (12.5%), and neurological deficits (5.6%) were the most common complications reported. Multivariate analysis showed that complications were more likely in patients with pre-operative comorbidities. Patients older than 64 years were much more likely to have an adverse outcome (odds ratio [OR] 20.8) and a prolonged hospital stay (OR 2.2). Women were less likely than men to have an adverse outcome (OR 0.3). A single postoperative complication increased the mean LOS by 3 days, more than tripled the odds of an adverse outcome, and increased the hospital charges by more than US $7000.

Conclusions

The authors provided a national perspective on trends, inpatient complications, and outcomes after TSS for Cushing's disease in the US. Postoperative complications had a significantly negative effect on LOS, adverse outcome, and resource utilization. Advanced age and multiple preoperative comorbidities were identified as important risk factors, and their effects on patient outcomes were quantified.

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Shivanand P. Lad, Chirag G. Patil, Eleonora Maries Lad and Maxwell Boakye

Object

Pathological vertebral fractures (PVFs) are an increasingly important cause of disability and have many clinical and economic implications. The authors examined trends in epidemiology and surgical management of pathological vertebral fractures in the US between 1993 and 2004.

Methods

The Nationwide Inpatient Sample database was used to analyze data collected from 1993 through 2004 to determine general trends in PVFs. Patients with PVFs were identified using the appropriate International Classification of Diseases, 9th Revision (ICD-9) diagnostic code (ICD-9 733.13). Trends in vertebral augmentation procedures and spinal fusions as well as comparison with incidences of other major pathological fractures, such as hip and upper limb, were also examined.

Results

In 2004, there were more than 55,000 inpatient admissions for PVFs. The majority of patients admitted were women (78%) in the 65 to 84 year–age group (60%). Medicare accounted for greater than 80% of insurance, and nearly 50% of all patients were admitted from the emergency department. The mean duration of hospitalization has continued to decrease, from 8.1 days in 1993 to 5.4 days in 2004. The mortality rate has remained relatively constant at approximately 1.5%. The discharge disposition has continued to change with an increasing number of patients being discharged to other institutions such as nursing homes and rehabilitation facilities. There was a staggering increase in the number of vertebral augmentation procedures performed between 1993 and 2004. The “national bill” for inpatient hospitalizations for PVFs totaled $1.3 billion in 2004.

Conclusions

With the continued aging of the population, PVFs represent an important cause of disability and a significant source of healthcare resource utilization.

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Maxwell Boakye, Praveen V. Mummaneni, Mark Garrett, Gerald Rodts and Regis Haid

Object. The authors reviewed clinical and radiographic outcomes in patients who had undergone anterior cervical discectomy and fusion (ACDF) involving the placement of polyetheretherketone (PEEK) spacers filled with recombinant human bone morphogenetic protein (rhBMP)—2.

Methods. Data obtained in 24 cases were retrospectively evaluated. The follow-up period ranged from 12 to 16 months (mean 13 months). Fifteen patients presented with radiculopathy, eight with myeloradiculopathy, and one with quadriparesis. Single-level ACDF was performed in 12 patients, two-level ACDF in nine, and three-level ACDF in three. Clinical outcomes were assessed using Odom criteria, and fusion was assessed by examining flexion—extension radiographs and computerized tomography scans in cases in which arthrodesis was questionable. Follow-up data were available for 23 patients. One patient died of medical complications unrelated to surgery 4 weeks after ACDF. Clinical outcomes were rated as good/excellent in 22 patients (95%) and fair in one (5%). Solid radiographically documented fusion, with evidence of solid bridging bone and no instability on flexion—extension x-ray films, was present in all cases. Complications included transient recurrent laryngeal nerve injury in one case, transient C-5 paresis in one, cerebrospinal fluid leakage in one, and transient dysphagia in two.

Conclusions. Analysis of the results indicated that ACDF involving an rhBMP-2—filled PEEK spacer leads to good clinical outcomes (by Odum criteria) and solid fusion (even in multilevel cases) while avoiding the complications associated with harvesting iliac crest bone grafts.

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Maxwell Boakye, Susan Harkema, Peter H. Ellaway and Andrea C. Skelly

Object

The objective of this study was to identify commonly used physiological outcome measures and summarize evidence on the reliability and predictive validity of quantitative measures used in monitoring persons with spinal cord injury (SCI).

Methods

A systematic search of PubMed through January 5, 2012, was conducted to identify publications using common outcome measures in persons with SCI and for studies that were specifically designed to evaluate the reliability and predictive validity of selected quantitative measures. Quantitative measures were defined as tests that quantify sensory and motor function, such as amount of force or torque, as well as thresholds, amplitudes, and latencies of evoked potentials that might be useful in studies and monitoring of patients with SCI. Reliability studies reporting interclass correlation coefficients (ICCs) or weighted κ coefficients were considered for inclusion. Studies explicitly evaluating correlation between measures and specific functional outcomes were considered for predictive validity.

Results

From a total of 121 potentially relevant citations, 6 studies of reliability and 4 studies of predictive validity for quantitative tests met the inclusion criteria. In persons with incomplete SCI, ICCs for both interrater and intrarater reliability of electrical perceptual threshold (EPT) were ≥ 0.7 above the sensory level of SCI but were less reliable below the sensory level. Interclass correlation coefficients for interrater and intrarater reliability of the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) components ranged from 0.84 to 0.98. For electromyography, the ICC was consistently high for within-day tests. The overall quality of reliability of the majority of studies was poor, due to the potential for selection bias and small sample sizes. No classic validation studies were found for the selected measures, and evidence regarding the predictive validity of the measures was limited. Somatosensory evoked potentials (SSEPs) may be correlated with ambulatory capacity, as well as the Barthel Index and motor index scores, but this correlation was limited for evaluation of bladder function recovery in 3 studies that assessed the correlation between baseline or initial SSEPs and a specific clinical outcome at a later follow-up time. All studies used convenience samples and the overall sample quality was low.

Conclusions

Evidence on the reliability and validity of the quantitative measures selected for this review is limited, and the overall quality of existing studies is poor. There is some evidence for the reliability of the EPT, dermatomal SSEPs, and the GRASSP to suggest that they may be useful in longitudinal studies of patients with SCI. There is a need for high quality studies of reliability, responsiveness, and validity for quantitative measures to monitor the level and degree of SCI.

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Shivanand P. Lad, Chirag G. Patil, Christopher Ho, Michael S. B. Edwards and Maxwell Boakye

Object

Previous investigations of health outcome after spinal surgery for tethered cord syndrome (TCS) have been single-institution studies. The aim of this study was to report inpatient complications and outcomes on a nationwide level.

Methods

The Nationwide Inpatient Sample (NIS) was used to identify patients who underwent spinal surgery for TCS in the US between 1993 and 2002. Patients who had a primary diagnosis of TCS (ICD-9 742.59) and also underwent spinal laminectomies were included in this study. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on variables such as mortality rate, nonfatal complications, LOS, and adverse outcomes in general (defined as death or discharge to an institution rather than home).

Results

The NIS sample included data on 9733 patients with TCS who underwent surgery. The means for mortality rate, complication rate, and LOS, respectively, were 0.0005%, 9.48%, and 5.6 days. Postoperative hemorrhages or hematomas (mean rate 2.3%) were the most common complications reported. Age and complications were the only significant predictors of adverse outcome on multivariate analysis. Patients older than 65 years had a threefold increase in risk of adverse outcome compared with patients 18 to 44 years of age. On average, one postoperative complication led to a 3-day increase in mean LOS and added more than $9000 to hospital charges.

Conclusions

This study provides a national perspective on inpatient complications and outcomes after spinal surgery for TCS in the United States. The authors have demonstrated the impact of age, complications, and medical comorbidities on the outcome of surgery for patients with this common disorder.