Kevin T. Huang

Effect of Advancing Age on Outcomes of Deep Brain Stimulation for Parkinson Disease

IMPORTANCE Deep brain stimulation (DBS) is a well-established modality for the treatment of advanced Parkinson disease (PD). Recent studies have found DBS plus best medical therapy to be superior to best medical therapy alone for patients with PD and early motor complications. Although no specific age cutoff has been defined, most clinical studies have excluded patients older than 75 years of age. We hypothesize that increasing age would be associated with an increased number of postoperative complications. OBJECTIVE To evaluate the stepwise effect of increasing age (in 5-year epochs) on short-term complications following DBS surgery. DESIGN, SETTING, AND PARTICIPANTS A large, retrospective cohort study was performed using the Thomson Reuters MarketScan national database that examined 1757 patients who underwent DBS for PD during the period from 2000 to 2009. MAIN OUTCOMES AND MEASURES Primary measures examined included hospital length of stay and aggregate and individual complications within 90 days following surgery. Multivariate logistic regression analysis was used to calculate complication-related odds ratios (ORs) for each 5-year age epoch after controlling for covariates. RESULTS Overall, 132 of 1757 patients (7.5%) experienced at least 1 complication within 90 days, including wound infections (3.6%), pneumonia (2.3%), hemorrhage or hematoma (1.4%), or pulmonary embolism (0.6%). After adjusting for covariates, we found that increasing age (ranging from <50 to 90 years of age) did not significantly affect overall 90-day complication rates (OR, 1.10 per 5-year increase [95% CI, 0.96-1.25]; P = .17). The 2 most common procedure-related complications, hemorrhage (OR, 0.82 [95% CI, 0.63-1.07]; P = .14) and infection (OR, 1.04 [95% CI, 0.87-1.24]; P = .69), did not significantly increase with age. CONCLUSIONS AND RELEVANCE Older patients with PD (>75 years) who were selected to undergo DBS surgery showed a similar 90-day complication risk (including postoperative hemorrhage or infection) compared with younger counterparts. Our findings suggest that age alone should not be a primary exclusion factor for determining candidacy for DBS. Instead, a clear focus on patients with medication-refractory and difficult to control on-off fluctuations with preserved cognition, regardless of age, may allow for an expansion of the traditional therapeutic window.

Spinal surgery: variations in health care costs and implications for episode-based bundled payments.

Study Design. Retrospective, observational. Objective. To simulate what episodes of care in spinal surgery might look like in a bundled payment system and to evaluate the associated costs and characteristics. Summary of Background Data. Episode-based payment bundling has received considerable attention as a potential method to help curb the rise in health care spending and is being investigated as a new payment model as part of the Affordable Care Act. Although earlier studies investigated bundled payments in a number of surgical settings, very few focused on spine surgery, specifically. Methods. We analyzed data from MarketScan. Patients were included in the study if they underwent cervical or lumbar spinal surgery during 2000–2009, had at least 2-year preoperative and 90-day postoperative follow-up data. Patients were grouped on the basis of their diagnosis-related group (DRG) and then tracked in simulated episodes-of-care/payment bundles that lasted for the duration of 30, 60, and 90 days after the discharge from the index-surgical hospitalization. The total cost associated with each episode-of-care duration was measured and characterized. Results. A total of 196,918 patients met our inclusion criteria. Significant variation existed between DRGs, ranging from

Preoperative serum albumin level as a predictor of postoperative complication after spine fusion.

11,180 (30-day bundle, DRG 491) to

Outcomes of percutaneous and paddle lead implantation for spinal cord stimulation: a comparative analysis of complications, reoperation rates, and health-care costs.

107,642 (30-day bundle, DRG 456). There were significant cost variations within each individual DRG. Postdischarge care accounted for a relatively small portion of overall bundle costs (range, 4%–8% in 90-day bundles). Total bundle costs remained relatively flat as bundle-length increased (total average cost of 30-day bundle:

Spinal Meningeal Diverticula in Spontaneous Intracranial Hypotension: Analysis of Prevalence and Myelographic Appearance

33,522 vs.

Current indications for the surgical treatment of prolactinomas

35,165 for 90-day bundle). Payments to hospitals accounted for the largest portion of bundle costs (76%). Conclusion. There exists significant variation in total health care costs for patients who undergo spinal surgery, even within a given DRG. Better characterization of impacts of a bundled payment system in spine surgery is important for understanding the costs of index procedure hospital, physician services, and postoperative care on potential future health care policy decision making. Level of Evidence: N/A

Disparities in the outcomes of lumbar spinal stenosis surgery based on insurance status.

Study Design. Retrospective cohort study. Objective. To investigate the association between preoperative baseline serum albumin and postoperative surgical complication. Summary of Background Data. The prevalence of malnutrition in the hospitalized patient population has only been recently recognized. Preoperative hypoalbuminemia (serum albumin <3.5 g/dL) has been shown to be associated with increased morbidity and mortality rates. The prognostic implications and significance of hypoalbuminemia after spine fusion surgery remain unknown. In this study, we assess the predictive value of preoperative nutritional status (serum albumin level) on postoperative complication rates. Methods. The medical records of 136 consecutive patients undergoing spine fusion at Duke University Medical Center were reviewed. Preoperative serum albumin level was assessed on all patients and used to quantify nutritional status. Albumin less than 3.5 g/dL was recognized as hypoalbuminemia (malnourished). Patient demographics, comorbidities, and postoperative complication rates were collected. Patients were also stratified into 2 groups based on their cause, namely elective degenerative/deformity versus nonelective cases. The association between preoperative serum albumin level and postoperative complication was assessed via logistic regression analysis. Results. Overall, 40 (29.4%) patients experience at least 1 postoperative complication. Patients undergoing elective surgery had more complications based on preoperative albumin levels (malnourished patients: 35.7% vs. nourished patients: 11.7%, P = 0.03), whereas those undergoing nonelective surgery had similar complication rates (malnourished patients: 46.5% vs. nourished patients: 42.1%, P = 0.75). For patients undergoing elective spinal surgery, logistic regression with and without propensity score adjustment for risk factors, demonstrated that preoperative serum albumin level was a significant predictor of postoperative complications (OR: 4.21; 95% CI: 1.09–16.19; P = 0.04) and (OR: 4.54; 95% CI: 1.17–19.32; P = 0.04), respectively. Conclusion. Preoperative hypoalbuminemia is an independent risk factor for postoperative complications after elective spine surgery for degenerative and deformity causes, and should be used more frequently as a prognostic tool to detect malnutrition and risk of adverse surgical outcomes. Level of Evidence: 2

Predictors and Rates of Delayed Symptomatic Hyponatremia after Transsphenoidal Surgery: A Systemastic Review

Spinal cord stimulation (SCS) is a well‐established modality for the treatment of chronic pain, and can utilize percutaneous or paddle leads. While percutaneous leads are less invasive, they have been shown to have higher lead migration rates. In this study, we compared the long‐term outcomes and health‐care costs associated with paddle and percutaneous lead implantation.

Complications after transsphenoidal surgery for patients with Cushing's disease and silent corticotroph adenomas

The prevalence and appearance of spinal meningeal diverticula in patients with spontaneous intracranial hypotension and healthy controls were compared by these authors. They used CT myelograms in 19 symptomatic patients and 18 healthy controls and found no differences in the numbers and morphologies of diverticula between the groups. Thus, the role of these diverticula in intracranial hypotension is still not clear. BACKGROUND AND PURPOSE: Spinal meningeal diverticula have been implicated in the pathogenesis of spontaneous intracranial hypotension and have been proposed as both diagnostic features of and therapeutic targets for the condition. We compared the prevalence and myelographic appearance of spinal diverticula in patients with SIH and healthy controls. MATERIALS AND METHODS: Patients satisfying the ICHD-2 criteria for SIH were retrospectively identified. CT myelograms of 19 patients with SIH were compared with CT myelograms of 18 control patients. Images were reviewed by 2 blinded neuroradiologists. The prevalence, morphology (round versus multilobulated), size, and location (cervical, upper thoracic, lower thoracic, or lumbar) of spinal meningeal diverticula were analyzed. RESULTS: There was no difference in the proportion of patients with diverticula in the SIH group compared with the control group (68% versus 44%, P = .14) or in the mean number of diverticula per patient (6.3 versus 2.2, P = .099). No difference was seen in the morphology (P = .95) or size (P = .71) of diverticula between groups. There was a difference between groups that just reached statistical significance (P = .050) in the location of the diverticula along the spinal axis, but substantial overlap was seen between groups for all spinal locations. CONCLUSIONS: Despite the well-established association between spinal meningeal diverticula and SIH, we found no difference in the prevalence or myelographic appearance of diverticula in patients with SIH compared with controls. Further investigation into the role of diverticula in the diagnosis and treatment of SIH is necessary.

Outcomes after cervical laminectomy with instrumented fusion versus expansile laminoplasty: A propensity matched study of 3185 patients

The purpose of this study was to examine the current indications for transsphenoidal surgery in the prolactinoma patient population, and to determine the outcomes of patients who undergo such operations. Transsphenoidal surgery may be indicated in prolactinoma patients who are resistant and/or intolerant to dopamine agonist (DA) therapy. We performed a retrospective review of the medical records of prolactinoma patients over a 6 year period (April 2008 to April 2014) at a large volume academic center. The median follow-up time was 12.0 months (range: 3-69). All patients who were included in the study (n=66) were treated with DA therapy and subsequently underwent an endonasal transsphenoidal operation. Of the 66 patients, 44 were women (mean age 34.2 years) and 22 were men (mean 41.7 years). There were 29 (43.9%) intolerant patients and 29 (43.9%) resistant patients. Postoperatively, 18 intolerant patients (66.7%) had normalized prolactin levels without the need for DA therapy, and five (17.2%) required DA to normalize their prolactin levels (p=0.02). Six patients (20.6%) had persistently elevated prolactin levels but were no longer receiving DA treatment (p<0.001). Postoperatively, 10 resistant patients (35.7%) had normal prolactin levels without DA therapy, and seven patients (25%) were treated with DA therapy to normalize their prolactin levels (p=0.22). Eight patients (28.6%) had supraphysiologic prolactin levels but were no longer taking a DA (p<0.001). Three patients (10.7%) were hyperprolactinemic, despite postoperative treatment with DA (p<0.001). After an appropriate treatment interval with multiple DA, radiographic follow-up, and careful clinical evaluation, prolactinoma patients can be offered surgery as an effective therapeutic option.