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Meng Huang, Avery Buchholz, Anshit Goyal, Erica Bisson, Zoher Ghogawala, Eric Potts, John Knightly, Domagoj Coric, Anthony Asher, Kevin Foley, Praveen V. Mummaneni, Paul Park, Mark Shaffrey, Kai-Ming Fu, Jonathan Slotkin, Steven Glassman, Mohamad Bydon, and Michael Wang


Surgical treatment for degenerative spondylolisthesis has been proven to be clinically challenging and cost-effective. However, there is a range of thresholds that surgeons utilize for incorporating fusion in addition to decompressive laminectomy in these cases. This study investigates these surgeon- and site-specific factors by using the Quality Outcomes Database (QOD).


The QOD was queried for all cases that had undergone surgery for grade 1 spondylolisthesis from database inception to February 2019. In addition to patient-specific covariates, surgeon-specific covariates included age, sex, race, years in practice (0–10, 11–20, 21–30, > 30 years), and fellowship training. Site-specific variables included hospital location (rural, suburban, urban), teaching versus nonteaching status, and hospital type (government, nonfederal; private, nonprofit; private, investor owned). Multivariable regression and predictor importance analyses were performed to identify predictors of the treatment performed (decompression alone vs decompression and fusion). The model was clustered by site to account for site-specific heterogeneity in treatment selection.


A total of 12,322 cases were included with 1988 (16.1%) that had undergone decompression alone. On multivariable regression analysis clustered by site, adjusting for patient-level clinical covariates, no surgeon-specific factors were found to be significantly associated with the odds of selecting decompression alone as the surgery performed. However, sites located in suburban areas (OR 2.32, 95% CI 1.09–4.84, p = 0.03) were more likely to perform decompression alone (reference = urban). Sites located in rural areas had higher odds of performing decompression alone than hospitals located in urban areas, although the results were not statistically significant (OR 1.33, 95% CI 0.59–2.61, p = 0.49). Nonteaching status was independently associated with lower odds of performing decompression alone (OR 0.40, 95% CI 0.19–0.97, p = 0.04). Predictor importance analysis revealed that the most important determinants of treatment selection were dominant symptom (Wald χ2 = 34.7, accounting for 13.6% of total χ2) and concurrent diagnosis of disc herniation (Wald χ2 = 31.7, accounting for 12.4% of total χ2). Hospital teaching status was also found to be relatively important (Wald χ2 = 4.2, accounting for 1.6% of total χ2) but less important than other patient-level predictors.


Nonteaching centers were more likely to perform decompressive laminectomy with supplemental fusion for spondylolisthesis. Suburban hospitals were more likely to perform decompression only. Surgeon characteristics were not found to influence treatment selection after adjustment for clinical covariates. Further large database registry experience from surgeons at high-volume academic centers at which surgically and medically complex patients are treated may provide additional insight into factors associated with treatment preference for degenerative spondylolisthesis.

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Captain Robert B. King

The pattern of ulnar and median nerve innervation for the intrinsic hand muscles commonly deviates from classical description. 1, 2 During the routine examination of approximately 500 consecutive nerve injuries seen at Walter Reed Army Hospital, variations in the innervation of the flexor carpi ulnaris, flexor pollicis brevis, the lumbricales and the interossei have been recognized frequently. One case has been outstanding in this respect. All of the intrinsic hand muscles received innervation, in part at least, from the median nerve. CASE SUMMARY A 17

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Cormac O. Maher

, Feudtner C , Wood JN : Hospital variation in cervical spine imaging of young children with traumatic brain injury . Acad Pediatr 16 : 684 – 691 , 2016 26854208 10.1016/j.acap.2016.01.017 6 Hymel KP , Armijo-Garcia V , Foster R , Frazier TN , Stoiko M , Christie LM , : Validation of a clinical prediction rule for pediatric abusive head trauma . Pediatrics 134 : e1537 – e1544 , 2014 7 Jenny C , Hymel KP , Ritzen A , Reinert SE , Hay TC : Analysis of missed cases of abusive head trauma . JAMA 282 : 621 – 629 , 1999

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Meghan E. Murphy, Hannah Gilder, Patrick R. Maloney, Brandon A. McCutcheon, Lorenzo Rinaldo, Daniel Shepherd, Panagiotis Kerezoudis, Daniel S. Ubl, Cynthia S. Crowson, William E. Krauss, Elizabeth B. Habermann, and Mohamad Bydon

were revisions; this may act as a confounder. Exclusion of “additional-level” CPTs without the appropriate corresponding initial CPT may have resulted in excluding patients who could have potentially contributed to our analysis; however, this was necessary to control for the extent of surgery though the number of levels. Another limitation of such a multiinstitutional population is the inability to control for hospital variation in procedures and protocols. For example, the ACS Risk Calculator now includes an algorithm for predicting nonhome discharge for certain

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Eisha A. Christian, Diana L. Jin, Frank Attenello, Timothy Wen, Steven Cen, William J. Mack, Mark D. Krieger, and J. Gordon McComb

-term follow-up in preterm infants with massive grade IV germinal matrix hemorrhage and progressive hydrocephalus . Neurosurgery 40 : 983 – 989 , 1997 34 Robinson S : Neonatal posthemorrhagic hydrocephalus from prematurity: pathophysiology and current treatment concepts . J Neurosurg Pediatr 9 : 242 – 258 , 2012 35 Rysavy MA , Li L , Bell EF , Das A , Hintz SR , Stoll BJ , : Between-hospital variation in treatment and outcomes in extremely preterm infants . N Engl J Med 372 : 1801 – 1811 , 2015 36 Spader HS , Hertzler DA , Kestle

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Linda W. Xu, Amy Li, Christian Swinney, Maya Babu, Anand Veeravagu, Stacey Quintero Wolfe, Brian V. Nahed, and John K. Ratliff

highlighted potentially significant problems in the way ProPublica chose to rate surgeons. These problems include issues with their “adjusted complication rates,” which do not incorporate complications occurring without readmission, during the index hospitalization (when the surgery took place), or beyond the 30 days postdischarge. 8 In addition, ProPublica ignores hospital-to-hospital variation in their analysis, assuming instead that the surgeon performs at a “hypothetical average hospital,” which may undermine comparisons between physicians operating in different

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Jonathan Dallas, Chevis N. Shannon, and Christopher M. Bonfield

adolescent idiopathic scoliosis surgery: implications for improving healthcare value . J Pediatr 195 : 213 – 219.e3 , 2018 25 Zygourakis CC , Liu CY , Wakam G , Moriates C , Boscardin C , Ames CP , : Geographic and hospital variation in cost of lumbar laminectomy and lumbar fusion for degenerative conditions . Neurosurgery 81 : 331 – 340 , 2017

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Nuriel Moghavem, Doug Morrison, John K. Ratliff, and Tina Hernandez-Boussard

of hospital variation in shortterm readmission rates after percutaneous coronary intervention . Circ Cardiovasc Interv 5 : 227 – 236 , 2012

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Ryota Kurogi, Akiko Kada, Kuniaki Ogasawara, Takanari Kitazono, Nobuyuki Sakai, Yoichiro Hashimoto, Yoshiaki Shiokawa, Shigeru Miyachi, Yuji Matsumaru, Toru Iwama, Teiji Tominaga, Daisuke Onozuka, Ataru Nishimura, Koichi Arimura, Ai Kurogi, Nice Ren, Akihito Hagihara, Yuriko Nakaoku, Hajime Arai, Susumu Miyamoto, Kunihiro Nishimura, and Koji Iihara

clipping and coiling groups. We used hierarchical logistic regression models to examine the associations between the case volumes of each modality and the CSC capabilities and in-hospital patient outcomes. The model had 2 levels (hospital and patient) and also employed the random effects of hospital variation and the fixed effects of CSC score and patient-related factors (age, sex, JCS score, and fiscal year of hospitalization). The lowest case volume and CSC score quartile (Q1) were used as reference values. For sensitivity analysis, the highest case volume and CSC

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Bobby D. Kim, Timothy R. Smith, Seokchun Lim, George R. Cybulski, and John Y. S. Kim

, Frencher SK Jr , Steeger JE , Rowell KS , Bartzokis K , Tomeh MG , : Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program . J Am Coll Surg 210 : 6 – 16 , 2010 64 Sobota A , Graham DA , Neufeld EJ , Heeney MM : Thirty-day readmission rates following hospitalization for pediatric sickle cell crisis at freestanding children's hospitals: risk factors and hospital variation . Pediatr Blood Cancer 58 : 61 – 65 , 2012 65 Strouse JJ