Cole A. Bortz

Traumatic Fractures of the Cervical Spine: Analysis of Changes in Incidence, Etiology, Concurrent Injuries and Complications Among 488,262 Patients from 2005-2013

OBJECTIVEnThe causes and epidemiology of traumatic cervical spine fracture have not been described with sufficient power or recency. Our goal is to describe demographics, incidence, cause, spinal cord injuries (SCIs), concurrent injuries, treatments, and complications of traumatic cervical spine fractures.nnnMETHODSnA retrospective review was carried out of the Nationwide Inpatient Sample. International Classification of Disease, Ninth Revision E-codes identified trauma cases from 2005 to 2013. Patients with cervical fracture were isolated. Demographics, incidence, cause, fracture levels, concurrent injuries, surgical procedures, and complications were analyzed. t tests elucidated significance for continuous variables and χ2 for categorical variables. Level of significance was P < 0.05.nnnRESULTSnA total of 488,262 patients were isolated (age, 55.96 years; male, 60.0%; white, 77.5%). Incidence (2005, 4.1% vs. 2013, 5.4%), Charlson Comorbidity Index (2005, 0.6150 vs. 2013, 1.1178), and total charges (2005,

Epidemiology and national trends in prevalence and surgical management of metastatic spinal disease

71,228.60 vs. 2013,

Predictors of Hospital Length of Stay and 30-Day Readmission in Cervical Spondylotic Myelopathy Patients: An Analysis of 3057 Patients Using the ACS-NSQIP Database

108,119.29) have increased since 2005, whereas length of stay decreased (2005, 9.22 vs. 2013, 7.86) (all Pxa0<xa00.05). The most common causes were motor vehicle accident (29.3%), falls (23.7%), and pedestrian accidents (15.7%). The most frequent fracture types were closed at C2 (32.0%) and C7 (20.9%). Concurrent injury rates have significantly increased since 2005 (2005, 62.3% vs. 2013, 67.6%). Common concurrent injuries included fractures to the rib/sternum/larynx/trachea (19.6%). Overall fusion rates have increased since 2005 (2005, 15.7% vs. 2013, 18.0%), whereas decompressions and halo insertion rates have decreased (all P < 0.05). SCIs have significantly decreased since 2005, except for upper cervical central cord syndrome. Complication rates have significantly increased since 2005 (2005, 31.6% vs. 2013, 36.2%). Common complications included anemia (7.7%), mortality (6.6%), and acute respiratory distress syndrome (6.6%).nnnCONCLUSIONSnIncidence, complications, concurrent injuries, and fusions have increased since 2005. Length of stay, SCIs, decompressions, and halo insertions have decreased. Indicated trends should guide future research in management guidelines.

The Influence of Body Mass Index on Achieving Age-Adjusted Alignment Goals in Adult Spinal Deformity Corrective Surgery with Full-Body Analysis at 1 Year

Surgical treatment for spinal metastasis has benefited from improvements in surgical techniques. However, the trends in treatment and outcomes for spinal metastasis surgery have not been well-established in a pediatric population. Patients <20u202fyears old with metastatic spinal tumors undergoing spinal surgery were identified in the KID database. Trends for spinal metastases treatment and patient outcomes were analyzed using weight-adjusted ANOVAs. 333 patients were identified in the KID database. The top five primary diagnoses were metastatic brain/spinal cord tumor (19.8%), metastatic nervous system tumor (15.9%), metastatic bone cancer (13.2%), spinal cord tumor (4.2%), and tumor of ventricles (3.0%). There was an increased incidence of spinal metastasis diagnoses from 2003 to 2012 (88.5-117.9 per 100,000; pu202f<u202f0.001) and an increased trend in the incidence of surgical treatment for spinal metastasis from 2003 to 2012 (pu202f=u202f0.014). The average age was 10.19u202f±u202f6.33u202fyears old and 38.4% were female. The average length of stay was 17.34u202f±u202f24.36u202fdays. Average CCI increased over time (2003: 7.87u202f±u202f1.40, 2012: 8.44u202f±u202f1.39; pu202f=u202f0.006). The most common surgeries were excision of spinal cord/meninges lesions (69.1%) and decompression of spinal canal (38.1%). Length of hospital stay and in-hospital mortality did not change over time (17.34-18.04u202fdays, pu202f=u202f0.337; 1.6%-2.9%, pu202f=u202f0.801). 10.5% of patients underwent a posterior fusion and 22.2% had at least one complication (nervous system, respiratory, dysphagia, infection). The overall complication rate remained stable over time (23.4%-21.8%, pu202f=u202f0.952). Surgical treatment for spinal metastasis in the last decade has increased, though the complication rates, in-hospital mortality, and length of stay have remained stable.

Full-Body Analysis of Adult Spinal Deformity Patients' Age-Adjusted Alignment at 1 Year

BACKGROUNDnHospital length of stay (LOS), 30-day readmission rate, and other metrics are increasingly being used to evaluate quality of surgical care. The factors most relevant to cervical spondylotic myelopathy (CSM) are not yet established.nnnOBJECTIVEnTo identify perioperative factors associated with extended LOS and 30-day readmission following elective surgery for CSM.nnnMETHODSnSurgical CSM patients at institutions represented by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) during 2010-2012 were included. Patients with fracture, 9 or more levels fused, or cancer were excluded. Extended LOS was defined as 75th percentile of the cohort. Univariate analysis and multivariate logistic regression identified predictors for extended LOS, 30-day readmission, and reoperation. Linear regression modeling was used to evaluate variables.nnnRESULTSnThree thousand fifty-seven surgical CSM cases were isolated. Age (odds ratio [OR], 1.496), diabetes (OR, 1.691), American Society of Anesthesiologists (ASA) class (OR, 2.081), posterior surgical approach (OR, 2.695), and operative time (OR, 1.008) were all positive predictors (Pxa0<xa00.05) for extended LOS (≥4 days). Thirty-two percent of the cohort (976 patients) had 30-day readmission data. Among these, 915 patients were not readmitted (93.8%), while 61 (6.2%) were readmitted. Diabetes (OR, 1.460) and ASA class (OR, 2.539) were significant positive predictors for hospital readmission. Age (OR, 0.918) was a negative predictor of re-operation in readmitted patients, and pulmonary comorbidities (OR, 4.584) were a positive predictor (P < 0.05).nnnCONCLUSIONSnPatients with diabetes and higher ASA class were at increased risk for extended LOS and readmission within 30-days. Patients with increased operative time have greater risk for extended LOS. Preoperative pulmonary comorbidities increased reoperation risk, whereas increased age reduced the risk. Attention to these factors may benefit CSM patients.

Cost-utility analysis of cervical deformity surgeries using 1-year outcome

BACKGROUNDnThe impact of obesity on global spinopelvic alignment is poorly understood. This study investigated the effect of body mass index on achieving alignment targets and compensation mechanisms after corrective surgery for adult spinal deformity (ASD).nnnMETHODSnRetrospective review of a single-center database. Inclusion: patients ≥18 years with full-body stereographic images (baseline and 1 year) and who met ASD criteria (sagittal vertical axis [SVA] >5 cm, pelvic incidence minus lumbar lordosis [PI-LL] >10°, coronal curvature >20° or pelvic tilt >20°). Patients were stratified by age (<40, 40-65, and ≥65 years) and body mass index (<25, 25-30, and >30). Postoperative alignment was compared with age-adjusted ideal values. Prevalence of patients who matched ideals and unmatched (undercorrected/overcorrected) was assessed. Health-related quality of life (HRQL) scores, alignment, and compensatory mechanisms were compared across cohorts using analysis of variance and temporally with paired t tests.nnnRESULTSnA total of 116 patients were included (average age, 62 years; 66% female). After corrective surgery, obese and overweight patients had more residual malalignment (worse PI-LL, T1 pelvic angle, pelvic tilt, and SVA) compared with normal patients (P < 0.05). In addition, obese and overweight patients recruited more pelvic shift (obese, 62.36; overweight, 49.80; normal, 31.50) and had a higher global sagittal angle (obese, 6.51; overweight, 6.35; normal, 3.40) (P < 0.05). Obese and overweight patients showed lower overcorrection rates and higher undercorrection rates (P < 0.05). Obese patients showed worse postoperative HRQL scores (Scoliosis Research Society 22 Questionnaire, Oswestry Disability Index, visual analog scale-leg) than did overweight and normal patients (P < 0.05). Obese and overweight patients who matched age-adjusted alignment targets for SVA or PI-LL showed no HRQL improvements (P > 0.05).nnnCONCLUSIONSnAfter surgery, obese patients were undercorrected, showed more residual malalignment, recruited more pelvic shift, and had a greater global sagittal angle and worse HRQL scores. The benefits from age-adjusted alignment targets seem to be less substantial for obese and overweight patients.

Differences in primary and revision deformity surgeries: following 1,063 primary thoracolumbar adult spinal deformity fusions over time

BACKGROUNDnPrevious studies have built a foundation for understanding compensation in patients with adult spinal deformity (ASD) by using full-body stereographic assessments. These mechanisms, in relation to age-adjusted alignment targets, have yet to be studied fully. The aim of this study was to assess lower-limb compensatory mechanisms of patients failing to meet age-adjusted alignment goals.nnnMETHODSnPatients with ASD ≥40 years with full body baseline and follow-up radiographs were included. Patients were stratified by age (40-65 years, >65 years) and spinopelvic correction. Lower-limb compensation parameters (pelvic shift, hip extension, knee flexion [KA], ankle flexion [AA], and global sagittal angle [GSA]) for patients who matched and failed to match age-adjusted alignment targets were compared with analysis of variance and t-test analysis.nnnRESULTSnIn total, 108 patients were included. At 1 year, AA increased with age in the match pelvic tilt (PT) andxa0spinopelvic mismatch (PI-LL) cohorts (PT: AA, 5.6-7.8, Pxa0= 0.041; PI-LL: 4.9-8.8, Pxa0= 0.026). KA, AA, and GSA increased with age in the match sagittal vertical axis (SVA) cohort (KA: 3.8-13.1, Pxa0= 0.002; AA: 5.8-10.2, Pxa0=xa00.008; GSA: 3.9-7.8, P < 0.001), as did KA and GSA in the match T1 pelvic angle group (KA: 1.8-8.7, Pxa0= 0.020; GSA: 2.6-5.7, Pxa0= 0.004).nnnCONCLUSIONSnGreater compensation captured by KA and GSA was associated with age progression in the match SVA and T1 pelvic angle cohorts. In addition, older SVA, PT, and PI-LL match cohorts used increased AA, suggesting that ideal postoperative alignment of aged individuals with ASD involves increased compensation.

Evaluating cervical deformity corrective surgery outcomes at 1-year using current patient-derived and functional measures: are they adequate?

BACKGROUND CONTEXTnCost-utility analysis, a special case of cost-effectiveness analysis, estimates the ratio between the cost of an intervention to the benefit it produces in number of quality-adjusted life years. Cervical deformity correction has not been evaluated in terms of cost-utility and in the context of value-based health care. Our objective, therefore, was to determine the cost-utility ratio of cervical deformity correction.nnnSTUDY DESIGNnThis is a retrospective review of a prospective, multicenter cervical deformity database. Patients with 1-year follow-up after surgical correction for cervical deformity were included. Cervical deformity was defined as the presence of at least one of the following: kyphosis (C2-C7 Cobb angle >10°), cervical scoliosis (coronal Cobb angle >10°), positive cervical sagittal malalignment (C2-C7 sagittal vertical axis >4u2009cm or T1-C6 >10°), or horizontal gaze impairment (chin-brow vertical angle >25°). Quality-adjusted life years were calculated by both EuroQol 5D (EQ5D) quality of life and Neck Disability Index (NDI) mapped to short form six dimensions (SF6D) index. Costs were assigned using Medicare 1-year average reimbursement for: 9+ level posterior fusions (PF), 4-8 level PF, 4-8 level PF with anterior fusion (AF), 2-3 level PF with AF, 4-8 level AF, and 4-8 level posterior refusion. Reoperations and deaths were added to cost and subtracted from utility, respectively. Quality-adjusted life year per dollar spent was calculated using standardized methodology at 1-year time point and subsequent time points relying on maintenance of 1-year utility.nnnRESULTSnEighty-four patients (average age: 61.2 years, 60% female, body mass index [BMI]: 30.1) were analyzed after cervical deformity correction (average levels fused: 7.2, osteotomy used: 50%). Costs associated with index procedures were 9+ level PF (

Developments in the treatment of Chiari type 1 malformations over the past decade

76,617), 4-8 level PF (

Recovery Kinetics: Comparison of Patients undergoing Primary or Revision Procedures for Adult Cervical Deformity Using a Novel Area Under the Curve Methodology

40,596), 4-8 level PF with AF (