System-wide integration of patient reported outcome measure collection through an electronic medical record system: A state-wide retrospective study.

BACKGROUND AND PURPOSE: In spine neurosurgery practice, patient-reported outcome measures (PROMs) are tools used to convey information about a patient's health experience and are an integral component of a clinician's decision-making process as they help guide treatment strategies to improve outcomes and minimize pain. Currently, there is limited research showing effective integration strategies of PROMs into electronic medical records. This study aims to provide a framework for other healthcare systems by outlining the process from start to finish in seven Hartford Healthcare Neurosurgery outpatient spine clinics throughout the state of Connecticut. METHODS: On March 1, 2021, a pilot implementation program began in one clinic and on July 1, 2021, all outpatient clinics were implementing the revised clinical workflow that included the electronic collection of PROMs within the electronic health record (EHR). A retrospective chart analysis studied all adult (18+) new patient visits in seven outpatient clinics by comparing the rates of PROMs collection in Half 1 (March 1, 2021-August 31, 2022) and in Half 2 (September 1, 2022-February 28, 2022) across all sites. Additionally, patient characteristics were studied to identify any variables that may lead to higher rates of collection. RESULTS: During the study period, 3528 new patient visits were analyzed. There was a significant change in rates of PROMs collection across all departments between H1 and H2 (p < 0.05). Additional significant predictors for PROMs collection were the sex and ethnicity of the patient as well as the provider type for the visit (p < 0.05). CONCLUSIONS: This study proved that implementing the electronic collection of PROMs into an already existing clinical workflow reduces previously identified collection barriers and enables PROMs collection rates that meet or exceed current benchmarks. Our results provide a successful step-by-step framework for other spine neurosurgery clinics to implement a similar approach.

Clinical Outcomes between Stand-Alone Zero-Profile Spacers and Cervical Plate with Cage Fixation for Anterior Cervical Discectomy and Fusion: A Retrospective Analysis of 166 Patients.

Stand-alone (SA) zero-profile implants are an alternative to cervical plating (CP) in anterior cervical discectomy and fusion (ACDF). In this study, we investigate differences in surgical outcomes between SA and CP in ACDF. We conducted a retrospective analysis of 166 patients with myelopathy and/or radiculopathy who had ACDF with SA or CP from Jan 2013-Dec 2016. We measured surgical outcomes including Bazaz dysphagia score at 3 months, Nurick grade at last follow-up, and length of hospital stay. 166 patients (92F/74M) were reviewed. 92 presented with radiculopathy (55%), 37 with myelopathy (22%), and 37 with myeloradiculopathy (22%). The average operative time with CP was longer than SA (194 ± 69 vs. 126 ± 46 min) (p < 0.001), as was the average length of hospital stay (2.1 ± 2 vs. 1.5 ± 1 days) (p = 0.006). At 3 months, 82 patients (49.4%) had a follow-up for dysphagia, with 3 patients reporting mild dysphagia and none reporting moderate or severe dysphagia. Nurick grade at last follow-up for the myelopathy and myeloradiculopathy cohorts improved in 63 patients (85%). Prolonged length of stay was associated with reduced odds of having an optimal outcome by 0.50 (CI = 0.35-0.85, p = 0.003). Overall, we demonstrate that there is no significant difference in neurological outcome or rates of dysphagia between SA and CP, and that both lead to overall improvement of symptoms based on Nurick grading. However, we also show that the SA group has shorter length of hospital stay and operative time compared to CP.

Thirty- and 90-day Readmissions After Spinal Surgery for Spine Metastases: A National Trend Analysis of 4423 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to investigate differences in 30- and 90-day readmissions for spine metastases treated with decompression and/or fusion spine surgery in a nationwide readmission database. SUMMARY OF BACKGROUND DATA: Patients with metastases to the spine represent a particularly vulnerable patient group that may encounter frequent readmissions. However, the 30- and 90-day rates for readmission following surgery for spine metastases have not been well described. METHODS: The Nationwide Readmission Database years 2013 to 2015 was queried. Patients were grouped by no readmission (non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). Weighted multivariate analysis assessed impact of treatment approach and clinical factors associated with 30- and 90-day readmissions. RESULTS: There were a total of 4423 patients with a diagnosis of spine metastases identified who underwent spine surgery, of which 1657 (37.5%) encountered either a 30-or 90-day unplanned readmission (30-R: n = 1068 [24-.1%]; 90-R: n = 589 [13.3%]; non-R: n = 2766). The most prevalent inpatient complications observed were postoperative infection (30-R: 16.3%, 90-R: 14.3%, non-R: 11.5%), acute post-hemorrhagic anemia (30-R: 13.4%, 90-R: 14.2%, non-R: 14.5%), and genitourinary complication (30-R: 5.7%, 90-R: 2.9%, non-R: 6.2%). The most prevalent 30-day and 90-day reasons for admission were sepsis (30-R: 10.2%, 90-R: 10.8%), postoperative infection (30-R: 13.7%, 90-R: 6.5%), and genitourinary complication (30-R: 3.9%, 90-R: 4.1%). On multivariate regression analysis, surgery type, age, hypertension, and renal failure were independently associated with 30-day readmission; rheumatoid arthritis/collagen vascular diseases, and coagulopathy were independently associated with 90-day readmission. CONCLUSION: In this study, we demonstrate several patient-level factors independently associated with unplanned hospital readmissions after surgical treatment intervention for spine metastases. Furthermore, we find that the most common reasons for readmission are sepsis, postoperative infection, and genitourinary complications.Level of Evidence: 3.

Patient Risk Factors Associated With 30- and 90-Day Readmission After Cervical Discectomy: A Nationwide Readmission Database Study.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: The aim of this study was to assess the patient-level risk factors associated with 30- and 90-day unplanned readmissions following elective anterior cervical decompression and fusion (ACDF) or cervical disk arthroplasty (CDA). SUMMARY OF BACKGROUND DATA: For cervical disk pathology, both ACDF and CDA are increasingly performed nationwide. However, relatively little is known about the adverse complications and rates of readmission for ACDF and CDA. METHODS: A retrospective cohort study was performed using the Nationwide Readmission Database from the years 2013 to 2015. All patients undergoing either CDA or ACDF were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and to identify 30- and 31-90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R). RESULTS: There were a total of 13,093 index admissions with 856 (6.5%) readmissions [30-R: n=532 (4.0%); 90-R: n=324 (2.5%)]. Both overall length of stay and total cost were greater in the 30-R cohort compared with 90-R and Non-R cohorts. The most prevalent 30- and 90-day complications seen among the readmitted cohorts were infection, genitourinary complication, and device complication. On multivariate regression analysis, age, Medicaid status, medium and large hospital bed size, deficiency anemia, and any complication during index admission were independently associated with increased 30-day readmission. Whereas age, large hospital bed size, coagulopathy, and any complication during the initial hospitalization were independently associated with increased 90-day readmission. CONCLUSION: Our nationwide study identifies the 30- and 90-day readmission rates and several patient-related risk factors associated with unplanned readmission after common anterior cervical spine procedures. LEVEL OF EVIDENCE: Level III.

Associated risk factors for extended length of stay following anterior cervical discectomy and fusion for cervical spondylotic myelopathy.

OBJECTIVES: There is a paucity of literature describing the predictors associated with extended length of hospital stay (LOS) for patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS for patients with cervical spondylotic myelopathy undergoing ACDF. PATIENTS AND METHODS: The National Inpatient Sample database was queried to identify patients with a diagnosis of cervical spondylotic myelopathy undergoing ACDF between 2010 and 2014. Updated trend weights were used to assess patient demographics, comorbidities, complications, LOS, discharge disposition and total cost. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted LOS. The primary outcome was the degree to which patient comorbidities or postoperative complications correlated with extended LOS (>3 days). RESULTS: We identified 144,514 patients with 29,947 (20.7%) experiencing an extended LOS (Normal LOS: 114,567; Extended LOS: 29,947). Comorbidities were overall significantly higher in the extended LOS cohort compared to the normal LOS cohort. Patients with extended LOS had a significantly greater proportion of blood transfusion (p < 0.001) and 2-3 vertebral levels fused (p < 0.001). The overall complication rates were greater in the extended LOS cohort (Normal LOS: 7.4% vs. Extended LOS: 44.8%, p < 0.001). The extended LOS cohort incurred $14,489 more in total cost (Normal LOS: $15,486 [11,787-20,623] vs. Extended LOS: $29,975 [21,286-45,285], p < 0.001) and had more patients discharged to non-routine locations (p < 0.001) compared to the normal LOS cohort. On multivariate logistic regression, several risk-factors were associated with extended LOS including: age, male gender, Black and Hispanic race, patient income, insurance, multiple comorbidities, blood transfusion, and number of complications. The odds ratio for extended LOS was 5.15 (95% CI: 4.68-5.67) for patients with 1 complication and 25.54 (95% CI: 20.54-31.75) for patients with >1 complication. CONCLUSION: Our national cohort study demonstrated multiple patient- and hospital-level factors associated with extended LOS (>3 days) after ACDF for CSM. Specifically, patients with an extended LOS had lower socioeconomic status, higher rate of comorbidities, greater percentage of postoperative complications and non-routine discharges, with greater overall costs. Further investigational studies are necessary to identify quality improvement strategies targeted to better optimizing patients preoperatively and reducing perioperative complications in order to improve quality of patient care and reduce hospital LOS.

Influence of gender on discharge disposition after spinal fusion for adult spine deformity correction.

OBJECTIVES: Gender has been shown to impact several aspects of spine surgical care. However, the influence of gender disparities on discharge disposition after adult spine deformity correction (ASD) is relatively understudied. The aim of this study was to investigate the influence of gender on discharge disposition after elective spinal fusion involving ≥4 levels for ASD correction. PATIENTS AND METHODS: The Nationwide Inpatient Sample database (2011-2014) was queried for patients with ASD (≥26 years-old) and elective spine fusion surgery involving ≥4 levels using ICD-9 codes. Patients were stratified by gender: Male or Female. Multivariate linear and logistic regressions were used to assess the impact of gender on length of hospital stay and discharge disposition. RESULTS: A total of 4972 patients were identified of which 3282 (66.0%) were Female and 1690 (34.0%) were Male. The Male cohort had a higher prevalence of comorbidities than the Female cohort. There was a difference in the number of levels operated on between cohorts, with the Female cohort having fewer 4-8-level fusions (77.6% vs. 86.8%) and more 9+-level fusions (23.0% vs. 13.6%) compared to Males. The Female cohort had greater rates of postoperative UTI (5.5% vs. 2.5%) and surgical site hematomas (2.6% vs. 1.3%), while the Male cohort had more postoperative MI (5.4% vs. 1.5%). The Female cohort spent slightly more time in the hospital than Male cohort (6.2 days vs. 5.9 days, P = 0.035). Female patients had a significantly greater proportion of non-routine discharge disposition (F: 48.5% vs. M: 40.3%, P < 0.001) compared to Male patients. However, in a multivariate analysis including patient and hospital factors, gender was not an independent predictor of discharge disposition (OR: 0.976, CI: 0.865-1.101, P = 0.688), but was independently associated with increased LOS [female (RR: 0.331, CI: 0.106-0.556, P = 0.004)]. CONCLUSION: Our study suggests gender disparities may not have a significant impact on discharge disposition after spinal fusion for ASD involving four levels or greater. Further studies are necessary to understand risk factors for non-routine discharges in ASD patients to improve quality of patient care and reduced healthcare costs.

Independent Association Between Type of Intraoperative Blood Transfusion and Postoperative Delirium After Complex Spinal Fusion for Adult Deformity Correction.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine whether type of intraoperative blood transfusion used is associated with increased incidence of postoperative delirium after complex spine fusion involving five levels or greater. SUMMARY OF BACKGROUND DATA: Postoperative delirium after spine surgery has been associated with age, cognitive status, and several comorbidities. Intraoperative allogenic blood transfusions have previously been linked to greater complication risks and length of hospital stay. However, whether type of intraoperative blood transfusion used increases the risk for postoperative delirium after complex spinal fusion remains relatively unknown. METHODS: The medical records of 130 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (more than or equal to five levels) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. We identified 104 patients who encountered an intraoperative blood transfusion. Of the 104, 15 (11.5%) had Allogenic-only, 23 (17.7%) had Autologous-only, and 66 (50.8%) had Combined transfusions. The primary outcome investigated was the rate of postoperative delirium. RESULTS: There were significant differences in estimated blood loss (Combined: 2155.5 ±â€Š1900.7 mL vs. Autologous: 1396.5 ±â€Š790.0 mL vs. Allogenic: 1071.3 ±â€Š577.8 mL vs. None: 506.9 ±â€Š427.3 mL, P < 0.0001) and amount transfused (Combined: 1739.7 ±â€Š1127.6 mL vs. Autologous: 465.7 ±â€Š289.7 mL vs. Allogenic: 986.9 ±â€Š512.9 mL, P < 0.0001). The Allogenic cohort had a significantly higher proportion of patients experiencing delirium (Combined: 7.6% vs. Autologous: 17.4% vs. Allogenic: 46.7% vs. None: 11.5%, P = 0.002). In multivariate nominal-logistic regression analysis, Allogenic (odds ratio [OR]: 24.81, 95% confidence interval [CI] [3.930, 156.702], P = 0.0002) and Autologous (OR: 6.43, 95% CI [1.156, 35.772], P = 0.0335) transfusions were independently associated with postoperative delirium. CONCLUSION: Our study suggests that there may be an independent association between intraoperative autologous and allogenic blood transfusions and postoperative delirium after complex spinal fusion. Further studies are necessary to identify the physiological effect of blood transfusions to better overall patient care and reduce healthcare expenditures. LEVEL OF EVIDENCE: 3.

Validating the Transformation of PROMIS-GH to EQ-5D in Adult Spine Patients.

Spinal disorders and associated interventions are costly in the United States, putting them in the limelight of economic analyses. The Patient-Reported Outcomes Measurement Information System Global Health Survey (PROMIS-GHS) requires mapping to other surveys for economic investigation. Previous studies have proposed transformations of PROMIS-GHS to EuroQol 5-Dimension (EQ-5D) health index scores. These models require validation in adult spine patients. In our study, PROMIS-GHS and EQ-5D were randomly administered to 121 adult spine patients. The actual health index scores were calculated from the EQ-5D instrument and estimated scores were calculated from the PROMIS-GHS responses with six models. Goodness-of-fit for each model was determined using the coefficient of determination (R2), mean squared error (MSE), and mean absolute error (MAE). Among the models, the model treating the eight PROMIS-GHS items as categorical variables (CATReg) was the optimal model with the highest R2 (0.59) and lowest MSE (0.02) and MAE (0.11) in our spine sample population. Subgroup analysis showed good predictions of the mean EQ-5D by gender, age groups, education levels, etc. The transformation from PROMIS-GHS to EQ-5D had a high accuracy of mean estimate on a group level, but not at the individual level.

Reduced Influence of Affective Disorders on 6-Week and 3-Month Narcotic Refills After Primary Complex Spinal Fusions for Adult Deformity Correction: A Single-Institutional Study.

OBJECTIVE: Previous studies have identified the impact of affective disorders on preoperative and postoperative perception of pain. However, there is a scarcity of data identifying the impact of affective disorders on postdischarge narcotic refills. The aim of this study was to determine whether patients with affective disorders have more narcotic refills after complex spinal fusion for deformity correction. METHODS: The medical records of 121 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, baseline and postoperative patient-reported pain scores, ambulatory status, and narcotic refills were collected for each patient. The primary outcome was the rate of 6-week and 3-month narcotic refills. RESULTS: Of the 121 patients, 43 (35.5%) had a clinical diagnosis of anxiety or depression (affective disorder) (AD n = 43; No-AD n = 78). Preoperative narcotic use was significantly higher in the AD cohort (AD 65.9% vs. No-AD 37.7%, P = 0.0035). The AD cohort had significantly higher pain scores at baseline (AD 6.5 ± 2.9 vs. No-AD 4.7 ± 3.1, P = 0.004) and at the first postoperative pain score reported (AD 6.7 ± 2.6 vs. No-AD 5.6 ± 2.9, P = 0.049). However, there were no significant differences in narcotic refills at 6 weeks (AD 34.9% vs. No-AD 25.6%, P = 0.283) and 3 months (AD 23.8% vs. No-AD 17.4%, P = 0.411) after discharge between the cohorts. CONCLUSIONS: Our study suggests that whereas spinal deformity patients with affective disorders may have a higher baseline perception of pain and narcotic use, the impact of affective disorders on narcotic refills at 6 weeks and 3 months may be minimal after complex spinal fusion.

Association Between Preoperative Narcotic Use with Perioperative Complication Rates, Patient Reported Pain Scores, and Ambulatory Status After Complex Spinal Fusion (≥5 Levels) for Adult Deformity Correction.

OBJECTIVE: The widespread over-use of narcotics has been increasing. However, whether narcotic use impacts surgical outcomes after complex spinal fusion remains understudied. The aim of this study was to evaluate whether there is an association between preoperative narcotic use with perioperative complication rates, patient-reported pain scores, and ambulatory status after complex spinal fusions. METHODS: The medical records of 134 adult (age ≥18 years) patients with spinal deformity undergoing elective, primary complex spinal fusion (≥5 levels) for deformity correction in a major academic institution from 2005-2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, pain scores, and ambulatory status were collected for each patient. RESULTS: Patient demographics and comorbidities were similar between both cohorts, except that the Narcotic-User cohort had a greater mean age (57.5 years vs. 50.7 years; P = 0.045) and prevalence of depression (39.4% vs. 16.2%; P = 0.003). Complication rates were similar between both cohorts. The Narcotic-User cohort had significantly higher pain scores at baseline (6.7 ± 2.4 vs. 4.0 ± 3.4; P < 0.001) and at the first postoperative pain score reported (6.7 ± 2.8 vs. 5.3 ± 2.9; P = 0.013), but had a significantly greater improvement from baseline to last pain score (Narcotic-User: -2.5 ± 3.9 vs. Non-User: -0.5 ± 4.7; P = 0.031). The Narcotic-User cohort had significantly greater ambulation on the first postoperative ambulatory day compared with the Non-User cohort (103.8 ± 144.4 vs. 56.4 ± 84.0; P = 0.031). CONCLUSIONS: Our study suggests that the preoperative use of narcotics may impact patient perception of pain and improvement after complex spinal fusions (≥5 levels). Consideration of patients' narcotic status preoperatively may facilitate tailored pain management and physical therapy regimens.

Cost-effectiveness of Magnetic Resonance Imaging in Cervical Clearance of Obtunded Blunt Trauma After a Normal Computed Tomographic Finding.

Importance: Magnetic resonance imaging (MRI) continues to be performed for cervical clearance of obtunded blunt trauma, despite poor evidence regarding its utility after a normal computed tomographic (CT) finding. Objective: To evaluate the utility and cost-effectiveness of MRI vs no follow-up after a normal cervical CT finding in patients with obtunded blunt trauma. Design, Setting and Participants: This cost-effectiveness analysis evaluated an average patient aged 40 years with blunt trauma from an institutional practice. The analysis used a Markov decision model over a lifetime horizon from a societal perspective with variables from systematic reviews and meta-analyses and reimbursement rates from the Centers for Medicare & Medicaid Services, National Spinal Cord Injury Database, and other large published studies. Data were collected from the most recent literature available. Interventions: No follow-up vs MRI follow-up after a normal cervical CT finding. Results: In the base case of a 40-year-old patient, the cost of MRI follow-up was $14 185 with a health benefit of 24.02 quality-adjusted life-years (QALY); the cost of no follow-up was $1059 with a health benefit of 24.11 QALY, and thus no follow-up was the dominant strategy. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10 000 iterations. No follow-up was the better strategy when the negative predictive value of the initial CT was relatively high (>98%) or the risk of an injury treated with a cervical collar turning into a permanent neurologic deficit was higher than 25% or when the risk of a missed injury turning into a neurologic deficit was less than 58%. The sensitivity and specificity of MRI were varied simultaneously in a 2-way sensitivity analysis, and no follow-up remained the optimal strategy. Conclusions and Relevance: Magnetic resonance imaging had a lower health benefit and a higher cost compared with no follow-up after a normal CT finding in patients with obtunded blunt trauma to the cervical spine, a finding that does not support the use of MRI in this group of patients. The conclusion is robust in sensitivity analyses varying key variables in the model. More literature on these key variables is needed before MRI can be considered to be beneficial in the evaluation of obtunded blunt trauma.

Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT.

PURPOSE: To determine the utility of cervical spine MRI in blunt trauma evaluation for instability after a negative non-contrast cervical spine CT. METHODS: A review of medical records identified all adult patients with blunt trauma who underwent CT cervical spine followed by MRI within 48 h over a 33-month period. Utility of subsequent MRI was assessed in terms of findings and impact on outcome. RESULTS: A total of 1,271 patients with blunt cervical spine trauma underwent both cervical spine CT and MRI within 48 h; 1,080 patients were included in the study analysis. Sixty-six percent of patients with a CT cervical spine study had a negative study. Of these, the subsequent cervical spine MRI had positive findings in 20.9%; 92.6% had stable ligamentous or osseous injuries, 6.0% had unstable injuries and 1.3% had potentially unstable injuries. For unstable injury, the NPV for CT was 98.5%. In all 712 patients undergoing both CT and MRI, only 1.5% had unstable injuries, and only 0.42% had significant change in management. CONCLUSIONS: MRI for blunt trauma evaluation remains not infrequent at our institution. MRI may have utility only in certain patients with persistent abnormal neurological examination. KEY POINTS: • MRI has limited utility after negative cervical CT in blunt trauma. • MRI is frequently positive for non-specific soft-tissue injury. • Unstable injury missed on CT is infrequent.

"White Cord Syndrome" of Acute Hemiparesis After Posterior Cervical Decompression and Fusion for Chronic Cervical Stenosis.

BACKGROUND: "White cord syndrome" is a very rare condition thought to be due to acute reperfusion of chronically ischemic areas of the spinal cord. Its hallmark is the presence of intramedullary hyperintense signal on T2-weighted magnetic resonance imaging sequences in a patient with unexplained neurologic deficits following spinal cord decompression surgery. The syndrome is rare and has been reported previously in 2 patients following anterior cervical decompression and fusion. We report an additional case of this complication. CASE DESCRIPTION: A 68-year-old man developed acute left-sided hemiparesis after posterior cervical decompression and fusion for cervical spondylotic myelopathy. The patient improved with high-dose steroid therapy. CONCLUSIONS: The rare white cord syndrome following either anterior cervical decompression and fusion or posterior cervical decompression and fusion may be due to ischemic-reperfusion injury sustained by chronically compressed parts of the spinal cord. In previous reports, patients have improved following steroid therapy and acute rehabilitation.

Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma.

STUDY OBJECTIVE: Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population. METHODS: A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies. RESULTS: The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed. CONCLUSION: MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result.

Cervical Cord-Canal Mismatch: A New Method for Identifying Predisposition to Spinal Cord Injury.

The risk for spinal cord injuries (SCIs) ranging from devastating traumatic injuries, compression because of degenerative pathology, and neurapraxia is increased in patients with congenital spinal stenosis. Classical diagnostic criteria include an absolute anteroposterior diameter of <12-13 mm or a Torg-Pavlov ratio of <0.80-0.82; however, these factors do not take into account the size of the spinal cord, which varies across patients, independent of canal size. Recent large magnetic resonance imaging studies of population cohorts have allowed newer methods to emerge that account for both cord and canal size by measuring a spinal cord occupation ratio (SCOR). A SCOR defined as ≥70% on midsagittal imaging or ≥80% on axial imaging appears to be an effective method of identifying cord-canal mismatch, but requires further validation. Cord-canal size mismatch predisposes patients to SCI because of 1) less space within the canal lowering the amount of degenerative changes needed for cord compression, and 2) less cerebrospinal fluid surrounding the spinal cord decreasing the ability to absorb kinetic forces directed at the spine. Patients with cord-canal mismatch have been reported to be at a substantially higher risk of traumatic SCI, and present with degenerative cervical myelopathy at a younger age than patients without cord-canal mismatch. However, neurologic outcome after SCI has occurred does not appear to be different in patients with or without a cord-canal mismatch. Recognition that canal and cord size are both factors which predispose to SCI supports that cord-canal size mismatch rather than a narrow cervical canal in isolation should be viewed as the underlying mechanism predisposing to SCI.

Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis.

OBJECTIVES: To quantify the rate of unstable injuries detected by MRI missed on CT in blunt cervical spine (CS) trauma patients and assess the utility of MRI in CS clearance. METHODS: We undertook a systematic review of worldwide evidence across five major medical databases and performed a meta-analysis. Studies were included if they reported the number of unstable injuries or gave enough details for inference. Variables assessed included severity, CT/MRI specifications, imaging timing, and outcome/follow-up. Pooled incidences of unstable injury on follow-up weighted by inverse-of-variance among all included and obtunded or alert patients were reported. RESULTS: Of 428 unique citations, 23 proved eligible, with 5,286 patients found, and 16 unstable injuries reported in five studies. The overall pooled incidence is 0.0029 %. Among studies reporting only obtunded patients, the pooled incidence is 0.017 %. In alert patients, the incidence is 0.011 %. All reported positive findings were critically reviewed, and only 11 could be considered truly unstable. CONCLUSIONS: There is significant heterogeneity in the literature regarding the use of imaging after a negative CT. The finding rate on MRI for unstable injury is extremely low in obtunded and alert patients. Although MRI is frequently performed, its utility and cost-effectiveness needs further study. KEY POINTS: • There were 16 unstable injuries on follow-up MRI among 5286 patients. • The positive finding rate among obtunded patients was 0.12 %. • The positive finding rate among alert, awake patients was 0.72 %. • MRI has a high false-positive rate; its utility mandates further studies. • The use and role of "confirmatory" tests shows wide variations.

Imaging of lumbar spinal surgery complications.

UNLABELLED: Lumbar spine surgery for spinal stenosis is a frequently performed procedure and was the fastest growing type of surgery in the US from 1980 to 2000. With increasing surgical invasiveness, postoperative complications also tend to be higher. Cross-sectional imaging techniques (CT and MRI) are more sensitive than radiographs and play an increasingly important role in evaluation of patients with lumbar spine surgery. Their use in patients with metallic implants is somewhat limited by artefacts, which can obscure pathology and decrease accuracy and reader confidence. Metal artefact reduction techniques have been developed, which can significantly improve image quality and enable early detection of postoperative complications. Complications can occur throughout postoperative course. Early complications include hardware displacement, incidental durotomy, postoperative collections-most commonly seroma, and less likely haematoma and/or infection. Incidental durotomy with CSF leak causing intracranial hypotension has characteristic MR brain findings and diagnosis of occult leak sites have been improved with use of dynamic CT myelography. Haematomas, even when compressing the thecal sac, are usually asymptomatic. Early infection, with nonspecific MR findings, can be diagnosed accurately using dual radiotracer studies. Delayed complications include loosening, hardware failure, symptomatic new or recurrent disc herniation, peri-/epidural fibrosis, arachnoiditis, and radiculitis. TEACHING POINTS: • CT and MRI play an increasingly important role in evaluation of patients with lumbar spine surgery • Complications can occur throughout the postoperative course and early detection is critical • Artefact reduction techniques can improve image quality for early and improved detection of complications.

The Neuroprotective Effect of Syringic Acid on Spinal Cord Ischemia/Reperfusion Injury in Rats.

Acute arterial occlusions via different vascular pathologies are the main causes of spinal cord ischemia. We investigated neuroprotective effects of syringic acid on spinal cord ischemia injury in rats. Rats were divided into four groups: (I) sham-operated control rats, (II) spinal cord ischemia group, (III) spinal cord ischemia group performed syringic acid, and (IV) spinal cord ischemia group performed methylprednisolone intraperitoneally. Spinal cord ischemia was performed by the infrarenal aorta cross-clamping model. The spinal cord was removed after the procedure. The biochemical and histopathological changes were observed within the samples. Functional assessment was performed for neurological deficit scores. A significant decrease was seen in malondialdehyde levels in group III as compared to group II (P < 0.05). Besides these, nuclear respiratory factor-1 and superoxide dismutase activity of group III were significantly higher than group II (P < 0.05). In histopathological samples, when group III was compared with group II, there was a significant decrease in numbers of apoptotic neurons (P < 0.05). In immunohistochemical staining, BECN1 and caspase-3-immunopositive neurons were significantly decreased in group III compared with group II (P < 0.05). The neurological deficit scores of group III were significantly higher than group II at twenty-fourth hour of ischemia (P < 0.05). Our study revealed that syringic acid pretreatment in spinal cord ischemia/reperfusion reduced oxidative stress and neuronal degeneration as a neuroprotective agent. Ultrastructural studies are required for syringic acid to be developed as a promising therapeutic agent to be utilized for human spinal cord ischemia in the future.

Predictors of Vertebral Artery Injury in Isolated C2 Fractures Based on Fracture Morphology Using CT Angiography.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: To determine C2 fracture patterns associated with vertebral artery injury (VAI) as assessed by computed tomography angiography. SUMMARY OF BACKGROUND DATA: The incidence of C2 fracture hospitalizations has increased significantly in the last decade. The vertebral arteries are susceptible to injury as each courses through the C2 transverse foramen. Early screening for VAI to institute antithrombotic treatment is critical to prevent ischemic neurological sequelae. Imaging-based fracture classification schemes to determine which patterns are predictors of VAI in isolated C2 fractures using computed tomography angiography have not been described. METHODS: Cervical spine computed tomographic (CT) scans at a level I trauma center were reviewed for isolated C2 fractures from 2004 to 2014 under institutional board review approval. Exclusion criteria included penetrating injury or additional cervical/occipital fractures. Fractures were classified using multiplanar CT scans into type I/II/IIa/III spondylolisthesis, type I/IIA/IIB/IIC/III dens, transverse foramen (displacement/comminution/intraforaminal fragments), and miscellaneous vertebral body fractures. Corresponding CT angiograms were assessed for VAI on the basis of the Denver grading criteria. Fisher exact test and Student t test were performed to determine predictors of VAI on the basis of fracture type. RESULTS: Sixty-seven patients met inclusion criteria. Fracture pattern analysis revealed that the majority were dens fractures (50.8%) and traumatic spondylolisthesis (41.8%); 29.9% had miscellaneous coronal/sagittal fractures and 22.4% were a combination.VAI was identified in 37.3% of patients with isolated C2 fractures, and 88% of patients had transverse foramen involvement. Fracture patterns significantly associated with VAI were type III dens and transverse foramen fractures with intraforaminal fragments, with or without comminution. CONCLUSION: The C2 fracture pattern most associated with VAI was comminuted transverse foramen fracture with intraforaminal fragments. Transverse foramen fracture alone was not found to be significant. These results help stratify patients with isolated C2 fractures who are at high VAI risk and should be further evaluated with computed tomography angiography. LEVEL OF EVIDENCE: 3.

Management of acute traumatic spinal cord injury.

OPINION STATEMENT: Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90 mm Hg should be kept for at least 1 week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72 h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72 h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.