Syed I. Khalid

The Impact of Chronic Kidney Disease on Postoperative Outcomes in Patients Undergoing Lumbar Decompression and Fusion

OBJECTIVEnTo determine whether preoperative chronic kidney disease (CKD) is associated with inferior perioperative outcomes in patients undergoing lumbar arthrodesis.nnnMETHODSnMedical records of 293 adult (≥18 years old) patients with spine deformity undergoing elective lumbar spine decompression and fusion at a major academic institution from 2006 to 2015 were reviewed. We identified 18 (6.1%) patients with a clinical diagnosis of CKD (CKDxa0group, nxa0= 18; no-CKD group, nxa0= 275). Patient demographics, comorbidities, and intraoperative and postoperative complication rates were collected for each patient. The primary endpoint was incidence of postoperative complications.nnnRESULTSnPatient demographics, including age, sex, and body mass index, and comorbidities were similar between cohorts. The CKD group had a significantly higher prevalence of hypertension, hyperlipidemia, and anemia compared with the no-CKD group. Median number of fusion levels, length of surgery, and estimated blood loss were similar between both cohorts. Postoperative complication profile was significantly different between the cohorts, with the CKD group having a significantly higher proportion of patients transferred to the intensive care unit (52.9% vs. 29.3%, Pxa0= 0.04) with episodes of delirium (27.8% vs. 8.4%, Pxa0= 0.007), urinary tract infection (27.8% vs. 6.9%, Pxa0=xa00.0002), and deep vein thrombosis (5.6% vs. 0.4%, Pxa0= 0.01). Although not significant, the CKD group had a 2-fold higher rate of 30-day readmissions compared with the no-CKD group (CKD group: 27.8% vs. no-CKD group: 12.7%, Pxa0= 0.07).nnnCONCLUSIONSnOur study suggests that patients with CKD may be more likely to develop perioperative complications after lumbar arthrodesis. Future studies are necessary to corroborate our findings.

Opioid Prescribing Practices of Neurosurgeons: An Analysis of Medicare Part D

OBJECTIVEnThe Centers for Disease Control have declared that the United States is amidst a continuing opioid epidemic, with drug overdose-related death tripling between 1999 and 2014. Among the 47,055 overdose-related deaths that occurred in 2014, 28,647 (60.9%) of them involved an opioid.nnnMETHODSnThe Part D Prescriber Public Use File, which is based on beneficiaries enrolled in the Medicare Part D prescription drug program, was used to query information on prescription drug events incurred by Medicare beneficiaries with a Part D prescription drug plan from 31 June 2014 to 30 June 2015. Only those providers with the specialty description of neurosurgeon, as reported on the providers Part B claims, were included in this study.nnnRESULTSnA total of 271,502 beneficiaries, accounting for 971,581 claims and 22,152,689 day supplies of medication, accounted for the

Relationship Among Koenig Depression Scale and Postoperative Outcomes, Ambulation, and Perception of Pain in Elderly Patients (≥65 Years) Undergoing Elective Spinal Surgery for Adult Scoliosis

52,956,428.40 paid by the Centers for Medicare and Medicaid Services for medication that the 4085 neurosurgeons submitted to the Centers for Medicare and Medicaid Services Part D program in the 2014 calendar year. During the same year, 402,767 (41.45%) claims forxa0158,749 (58.47%) beneficiaries accounted for 6,458,624 (29.16%) of the day supplies of medications and

Pediatric Spinal Ependymomas: An Epidemiologic Study

13,962,630.11 (26.37%) of the total money spent by the Centers for Medicare and Medicaid Services Part D that year. Nationwide, the ratio of opioid claims to total Medicare Part D beneficiaries was 1.48. No statistically significant regional differences were found.nnnCONCLUSIONSnThe opioid misuse epidemic is a complex and national issue with patterns of prescription not significantly different between regions. All neurosurgeons must be cognizant of their prescribing practices so as to best support the resolution of this public health crisis.

Interdisciplinary Care Model Independently Decreases Use of Critical Care Services After Corrective Surgery for Adult Degenerative Scoliosis

BACKGROUNDnThe aim of this study was to assess whether the Koenig Depression Scale (KDS) can identify depressed elderly patients undergoing elective spine surgery for deformity at risk for inferior postoperative outcomes including complication rates, ambulation ability, and patient-reported outcomes.nnnMETHODSnThe medical records of 92 elderly patients (≥65 years) undergoing a planned elective spinal surgery for correction of adult degenerative scoliosis were reviewed for this study. Preoperative baseline depression was assessed using the validated KDS that was administered by a board-certified geriatrician. KDS is made up of 11 questions with a maximum of 11 points (No-Depressionxa0= KDS <4, Depressionxa0= KDS ≥4). The primary outcomes of this study were complication rates, duration of hospital stay, ambulation ability, and follow-up visual analog scale (VAS) scores at 6 weeks, 3 months, and 6 months after hospital discharge.nnnRESULTSnOf the 92 patients, 20 of them (21.7%) were found to have a KDS ≥4. Baseline demographics and comorbidities were similar between both cohorts. Intraoperative variables and complications were similar between both cohorts. There were no significant differences in postoperative complications including length of hospital stay. There was no significant difference in ambulation abilities including preoperative gait speed (Pxa0= 0.38), days from operation to ambulation (Pxa0= 0.86), steps on first day of ambulation (Pxa0= 0.57), and steps before hospital discharge (Pxa0= 0.35). There was no significant difference between the cohorts in VAS scores at baseline (Pxa0= 0.19), 6 weeks (Pxa0= 0.91), 3 months (Pxa0= 0.58), and 6 months (Pxa0= 0.97) after hospital discharge.nnnCONCLUSIONSnOur study found no difference in complication rates, ambulation abilities, and follow-up VAS scores between patients with and without depression using preoperative KDS.

Does Nasal Carriage of Staphylococcus aureus Increase the Risk of Postoperative Infections After Elective Spine Surgery: Do Most Infections Occur in Carriers?

OBJECTIVEnPediatric intramedullary spinal cord ependymomas represent a rare central nervous system neoplasm with few available data regarding incidence and outcomes. To this end, large population-based studies are needed to assess the epidemiology and survival risk factors associated with these tumors in the hope of better understanding these tumors as well as improving outcomes. This retrospective study was undertaken to explore factors that may influence survival in pediatric patients with intramedullary spinal cord ependymomas.nnnMETHODSnUsing the SEER (Surveillance Epidemiology and End Results) database, a prospective cancer registry, we retrospectively assessed survival in histologically confirmed spinal ependymomas in patients 17 years of age and younger. Survival was described with Kaplan-Meier curves, and a multivariate regression analysis was used to assess the association of several variables with survival, controlling for confounding variables.nnnRESULTSnInvasive tumor extension (P < 0.001) was associated with decreased survival, whereas gross total resection (Pxa0= 0.028) correlated with better rates of survival. Age, gender, tumor size, tumor extension, the use and sequence of radiation therapy, or use of chemotherapy were not found to have a statistically significant association with survival outcomes.nnnCONCLUSIONSnInvasive ependymomas occurring in the spine have a worse prognosis, whereas higher tumor grades do not clearly show worse rates of survival. Early diagnosis and surgery seem to be associated with improved survival and outcomes, whereas radiation therapy and chemotherapy have an unclear role.

Extended Length of Stay in Elderly Patients After Lumbar Decompression and Fusion Surgery May Not Be Attributable to Baseline Illness Severity or Postoperative Complications

OBJECTIVEnInterdisciplinary management of elderly patients requiring spine surgery has been shown to improve short- and long-term outcomes. The aim of this study was to determine whether an interdisciplinary team approach mitigates use of intensive care unit (ICU) resources.nnnMETHODSnA unique comanagement model for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Peri-operative Optimization of Senior Health Program (POSH) was launched with the aim of improving outcomes in elderly patients (>65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, comanages daily throughout hospital course, and coordinates multidisciplinary rehabilitation, along with the neurosurgical team. We retrospectively reviewed the first 100 cases after the initiation of the POSH protocol and compared them with the immediately preceding 25 cases to assess the rates of ICU transfer and independent predictors of ICU admission.nnnRESULTSnA total of 125 patients undergoing lumbar decompression and fusion surgery were enrolled in this pilot program. Baseline characteristics and intraoperative variables, as well as number of fusion levels and duration of surgery, were similar between both cohorts. There was a significant difference in the use of ICU services (ICU admission rates) between both cohorts, with the non-POSH cohort having a 3-fold increase compared with the POSH cohort (P < 0.0001). In a multivariate analysis, lack of an interdisciplinary comanagement team approach was an independent predictor for ICU transfers in elderly patients undergoing corrective surgery (odds ratio 8.51, 95% confidence interval 2.972-24.37, P < 0.0001).nnnCONCLUSIONSnOur study suggests that an interdisciplinary comanagement model between geriatrics and neurosurgery is independently associated with reduced use of critical care services.

Extended Length of Stay in Elderly Patients after Anterior Cervical Discectomy and Fusion Is Not Attributable to Baseline Illness Severity or Postoperative Complications

BACKGROUNDnWound infections after adult spinal deformity surgery place a high toll on patients, providers, and the healthcare system. Staphylococcus aureus is a common cause of postoperative wound infections, and nasal colonization by this organism may be an important factor in the development of surgical site infections (SSIs). The aim is to investigate whether post-operative surgical site infections after elective spine surgery occur at a higher rate in patients with methicillin-resistant S.xa0aureus (MRSA) nasal colonization.nnnMETHODSnConsecutive patients undergoing adult spinal deformity surgery between 2011-2013 were enrolled. Enrolled patients were followed up for a minimum of 3 months after surgery and received similar peri-operative infection prophylaxis. Baseline characteristics, operative details, rates of wound infection, and microbiologic data for each case of post-operative infection were gathered by direct medical record review. Local vancomycin powder was used in all patients and sub-fascial drains were used in the majority (88%) of patients.nnnRESULTSn1200 operative spine cases were performed for deformity between 2011 and 2013. The mean ± standard deviation age and body mass index were 62.08 ± 14.76 years and 30.86 ± 7.15 kg/m2, respectively. 29.41% had a history of diabetes. All SSIs occurred within 30 days of surgery, with deep wound infections accounting for 50% of all SSIs. Of the 34 (2.83%) cases of SSIs that were identified, only 1 case occurred in a patient colonized with MRSA.nnnCONCLUSIONnOur study suggests that the preponderance of SSIs occurred in patients without nasal colonization by methicillin-resistant S.xa0aureus. Future prospective multi-institutional studies are needed to corroborate our findings.

Limited post-operative dexamethasone use does not affect lumbar fusion: a single institutional experience

BACKGROUNDnHospital leaders are seeking ways to improve resource utilization and minimize long postoperative hospital stays. Common explanations for extended length of stay (LOS) are baseline patient illness, postoperative complications, and physician practice differences. The degree to which extended LOS represents illness severity or postoperative complications is unknown. We investigated influence of postoperative complications and patient comorbidities on extended LOS after lumbar spine surgery in elderly patients.nnnMETHODSnThis retrospective cohort study from 2008 to 2014 analyzed data from the American College of Surgeons National Surgical Quality Improvement Program for elderly patients undergoing lumbar spine surgery. Patient demographics, comorbidities, LOS, and complications were recorded. Multivariable logistic regression analysis was used to determine odds ratio for risk-adjusted LOS. Primary outcome was the degree extended LOS represented patient illness or postoperative complications.nnnRESULTSnOf 9482 patients, 1909 (20.13%) had extended LOS. A few patients with extended LOS had a history of relevant comorbidities, including diabetes (21.76%), chronic obstructive pulmonary disease (8.17%), congestive heart failure (0.94%), myocardial infarction (0%), acute renal failure (0.47%), and stroke (2.23%). Of patients with normal LOS, 93% had no complications, 5.19% had 1xa0complication, and 1.69% had >1 complication. Among patients with extended LOS, 73.65% had no complications, 18.96% had 1 complication, and 7.39% had >1 complication (P < 0.000).nnnCONCLUSIONSnOur study suggests that much of the variation in LOS for elderly patients undergoing lumbar spine surgery is not attributable to baseline patient illness or postoperative complications and most likely represents differences in practice style or surgeon preference.

Non-neurological outcomes of anterior and posterolateral approaches in the surgical treatment of thoracic disc disease: a retrospective study

BACKGROUNDnHealth care systems are increasing efforts to minimize postoperative hospital stays to improve resource use. Common explanations for extended postoperative stay are baseline patient sickness, postoperative complications, or physician practice differences. However, the degree to which extended length of stay (LOS) represents patient illness or postoperative complications remains unknown. The aim is to investigate the influence of postoperative complications and elderly patient comorbidities on extended LOS after anterior cervical discectomy and fusion.nnnMETHODSnThis retrospective study was performed from January 1, 2008, to December 31, 2014, on data from the American College of Surgeons National Surgical Quality Improvement Program. Patient demographics, comorbidities, LOS, and inpatient complications were recorded. Multivariable logistic regression analysis was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree extended LOS represented patient illness or postoperative complications.nnnRESULTSnOf 4730 participants, 1351 (28.56%) had extended LOS. A minority of patients with extended LOS had a history of relevant comorbidities-diabetes (29.53%), chronic obstructive pulmonary disease (9.4%), congestive heart failure (1.04%), myocardial infarction (0.33%), acute renal failure (0.3%), and stroke (5.92%). Among patients with normal LOS, 96.8% had no complications, 2.7% had 1 complication, and 0.5% had greater than 1 complication. In patients with extended LOS, 79.4% had no complications, 14.5% had 1 complication, and 6.1% had greater than 1 complication (P < 0.0001).nnnCONCLUSIONSnOur study suggests much of LOS variation after an anterior cervical discectomy and fusion is not attributable to baseline patient illness or complications and most likely represents differences in practice style or surgeon preference.