Predictive validity of the All Patients Refined Diagnosis Related Group modifiers for costs and outcomes from intracranial hemorrhage.

OBJECTIVE: The All Patients Refined Diagnosis Related Group (APR-DRG) modifiers-severity of illness (SOI) and risk of mortality (ROM)-inform hospital reimbursement nationally. The ubiquitous APR-DRG data bear the potential to inform public health research; however, the algorithms that generate these modifiers are proprietary and therefore should be independently verified. This study evaluated the predictive value of APR-DRG modifiers for the outcomes and costs of intracranial hemorrhage. METHODS: The New York Statewide Planning and Research Cooperative System databases were accessed and searched for the intracranial hemorrhage Diagnosis Related Group in records from 2012 to 2020. Receiver operating characteristic and multiple logistic regressions characterized the predictive validity of the APR-DRG modifiers for patient outcomes. One-way ANOVA compared costs and charges between SOI and ROM designations. RESULTS: Among 46,019 patients, 12,627 (27.4%) died. The mean ± SEM costs per patient were $21,342 ± $145 and the mean ± SEM charges per patient were $68,117 ± $408. For prediction of mortality, the area under the curve (AUC) was 0.74 for SOI and 0.83 for ROM. For prediction of discharge to a facility, AUC was 0.62 for SOI and 0.64 for ROM. Regression analysis showed that ROM was a strong predictor of mortality, while SOI was a weak predictor; both were modest predictors of discharge to a facility. SOI and ROM were significant predictors of costs and charges. CONCLUSIONS: Compared with the prior studies, the authors identified several limitations of APR-DRG modifiers, including low specificity, modest AUC, and limited outcomes prediction. This report supports the limited use of APR-DRG modifiers in independent research on intracranial hemorrhage epidemiology and reimbursement and advocates for general caution in their use for evaluation of neurosurgical disease.

DNA methylation provides diagnostic value for meningioma recurrence in clinical practice.

BACKGROUND: Meningiomas are the most common intracranial tumors. Recent advancements in the genetic profiling of tumors have allowed information including DNA copy number analysis, mutational analysis, and RNA sequencing to be more frequently reported, in turn allowing better characterization of meningiomas. In recent years, analysis of tumor methylomes that reflects both cell-origin methylation signatures and somatically acquired DNA methylation changes has been utilized to better classify meningiomas with great success. METHOD: We report DNA methylation profiling on meningiomas from 17 patients. Formalin-fixed paraffin-embedded (FFPE) meningioma tumor samples were processed, loaded onto the Infinium Methylation EPIC array, and scanned using the Illumina IScan system. Raw IDAT files were processed through the the CNS tumor classifier developed by the Molecular Neuropathology group at the German Cancer Research Center (DKFZ). Corresponding genomics were captured using targeted sequencing panels. RESULT: Among the meningioma samples, 13 samples were classified as "benign," two samples as "intermediate," and the remaining three samples (from two patients) as "malignant," based on previously validated classification algorithms. In addition to tumor methylation profiling, we also present information that includes patient demographics, clinical presentations, tumor characteristics (including size and location), surgical approaches, and mutational analysis. The two patients who provided the samples with "malignant" methylation classifications had tumor recurrence, reflecting a more aggressive disease course. CONCLUSION: In accordance with prior reports, our case series provides support that tumor DNA methylation profiling adds meaningful classification information and may be beneficial to incorporate in clinical practice. Our report also reveals that DNA methylation combined with WHO histology classification can more accurately predict tumor behavior than WHO classification alone.

Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review.

INTRODUCTION: The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery. METHODS: Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009). RESULTS: Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization. CONCLUSIONS: Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.

Breaking boundaries through Doctors Reaching Minority Men Exploring Neuroscience: a mentorship model to foster a pipeline for underrepresented minorities.

OBJECTIVE: In 2015, the Association of American Medical Colleges report titled "Altering the Course: Black Males in Medicine" showed a decline in the number of Black men matriculating into medical school. To alter this trend, the authors' hypothesis was that formally exposing Black men to the clinical neurosciences during high school would enhance their chances of entering the physician workforce. For this reason, in 2007, the Doctors Reaching Minority Men Exploring Neuroscience (DR. MMEN) program was established at the Icahn School of Medicine at Mount Sinai. The program aimed to provide early exposure, mentorship, and inspiration to high school-age Black and Latinx men. The aim of this study was to evaluate the impact of the DR. MMEN program in the context of the recent race and ethnicity trends among medical school matriculants (MSMs). METHODS: Association of American Medical Colleges data on MSMs stratified by race and ethnicity were reviewed for the period between 2015 and 2020. Data pertinent to the academic achievements of DR. MMEN participants, such as matriculation to college and/or medical school, were prospectively tracked and incorporated with mixed-methods exit assessment data. Qualitative responses were coded and analyzed using a thematic concept analysis method. RESULTS: Over the study period, the increase of MSMs in the US was 1.0% and 1.7% for Black and Latinx individuals, respectively. Changes for the male MSM cohort were negligible: 0.3% for Black and 0.7% for Latinx. With respect to DR. MMEN, 42% of participants from 2017 to 2019 earned college scholarships, and 25% of students from the 2017-2018 cohort matriculated to a combined college-medical program. Survey data showed that 100% of DR. MMEN participants found the program useful. Analysis of qualitative data revealed that participants considered pursuing a career in neurosurgery or in another medical field. Diligence and a passion for medicine were identified as the top two most important lessons in the program, and witnessing patient satisfaction and observing a neurosurgery operation were described as the most important experiences. Participants considered availability to give advice and feedback and a passion for teaching as the principal attributes of their mentors. CONCLUSIONS: Over the past 6 years, the slight increase in Black and Latinx MSMs has not been significant enough to remedy ethnoracial disparities among MSMs. In particular, Black male matriculation to medical school has remained stagnant. The DR. MMEN program is a promising model to inspire young scholars and improve diversity within neuroscience and medicine at large.

Comparative Analysis of Early Outcomes and Complications of PSO Among Neurosurgeons and Orthopedic Surgeons.

STUDY DESIGN: Retrospective comparative cohort study using the National Surgical Quality Improvement Program. OBJECTIVE: The aim of this study was to evaluate trends in the annual number of PSOs performed, describe the patient populations associated with each cohort, and compare outcomes between specialties.Summary of Background Data:Pedicle subtraction osteotomies (PSO) are complex and advanced spine deformity surgical procedures performed by neurosurgeons and orthopedic surgeons. Though both sets of surgeons can be equally qualified and credentialed to perform a PSO, it is possible that differences in training and exposure could translate into differences in patient management and outcomes. METHODS: Patients that underwent lumbar PSO from 2005 to 2014 in the American College of Surgeons-National Surgical Quality Improvement Program registry were identified. Relevant demographic, preoperative comorbidity, and postoperative 30-day complications were queried and analyzed. The data was divided into 2 cohorts consisting of those patients who were treated by neurosurgeons versus orthopedic surgeons. Additional data from the Scoliosis Research Society Morbidity and Mortality database was queried and analyzed for comparison. RESULTS: Demographic and comorbidity factors were similar between the neurosurgery and orthopedic surgery cohorts, except there were higher rates of hypertension among orthopedic surgeon-performed PSOs (65.66% vs. 48.67%, P =0.004). Except for 2012, in every year queried, orthopedic surgeons reported more PSOs than neurosurgeons. In patients who underwent lumbar fusion surgery, there was a higher rate of PSOs if the surgery was performed by an orthopedic surgeon (OR 1.7824, 95% CI: 1.4017-2.2665). The incidence of deep vein thrombosis after PSOs was higher for neurosurgery compared with orthopedic surgery (8.85% vs. 1.20%, P =0.004). However, besides deep vein thrombosis, there were no salient differences in surgical complication rates between neurosurgeon-performed PSOs and orthopedic surgeon-performed PSOs. CONCLUSIONS: The number of PSO procedures performed by neurosurgeons and orthopedic surgeons has increased annually. Differences in outcomes between neurosurgeons and orthopedic surgeons suggest an opportunity for wider assessment and alignment of adult spinal deformity surgery exposure and training across specialties.

Augmented reality-assisted microsurgical resection of brain arteriovenous malformations: illustrative case.

BACKGROUND: Arteriovenous malformations (AVMs) of the brain are vessel conglomerates of feeding arteries and draining veins that carry a risk of spontaneous and intraoperative rupture. Augmented reality (AR)-assisted neuronavigation permits continuous, real-time, updated visualization of navigation information through a heads-up display, thereby potentially improving the safety of surgical resection of AVMs. OBSERVATIONS: The authors report a case of a 37-year-old female presenting with a 2-year history of recurrent falls due to intermittent right-sided weakness and increasing clumsiness in the right upper extremity. Magnetic resonance imaging, magnetic resonance angiography, and cerebral angiography of the brain revealed a left parietal Spetzler-Martin grade III AVM. After endovascular embolization of the AVM, microsurgical resection using an AR-assisted neuronavigation system was performed. Postoperative angiography confirmed complete obliteration of arteriovenous shunting. The postsurgical course was unremarkable, and the patient remains in excellent health. LESSONS: Our case describes the operative setup and intraoperative employment of AR-assisted neuronavigation for AVM resection. Application of this technology may improve workflow and enhance patient safety.

Racial and Ethnical Diversity Within the Neurosurgery Resident and Faculty Workforce in the United States.

BACKGROUND: Promoting workplace diversity leads to a variety of benefits related to a broader range of perspectives and insights. Underrepresented in medicine (URiM), including African Americans, Latinx, and Natives (Americans/Alaskan/Hawaiians/Pacific Islanders), are currently accounting for approximately 40% of the US population. OBJECTIVE: To establish a snapshot of current URiM representation within academic neurosurgery (NS) programs and trends within NS residency. METHODS: All 115 NS residencies and academic programs accredited by the Accreditation Council for Graduate Medical Education in 2020 were included in this study. The National Residency Matching Program database was reviewed from 2011 to 2020 to analyze URiM representation trends over time within the NS resident workforce. The academic rank, academic and clinical title(s), subspecialty, sex, and race of URiM NS faculty (NSF) were obtained from publicly available data. RESULTS: The Black and Latinx NS resident workforce currently accounts for 4.8% and 5.8% of the total workforce, respectively. URiM NSF are present in 71% of the Accreditation Council for Graduate Medical Education-accredited NS programs and account for 8% (148 of 1776) of the workforce. Black and Latinx women comprise 10% of URiM NSF. Latinx NSFs are the majority within the URiM cohort for both men and women. URiM comprise 5% of all department chairs. All are men. Spine (26%), tumor (26%), and trauma (17%) were the top 3 subspecialties among URiM NSF. CONCLUSION: NS has evolved, expanded, and diversified in numerous directions, including race and gender representation. Our data show that ample opportunities remain to improve URiM representation within NS.

The Impact of American Society of Anesthesiologists Status on Cost of Care and Length of Stay Following Posterior Cervical Decompression and Fusion.

BACKGROUND: Increased posterior cervical decompression and fusion (PCDF) procedures over the past decade have raised the prospect of bundled payment plans. The American Society of Anesthesiologists (ASA) Physical Status Classification system may enable accurate estimation of health care costs, length of stay (LOS), and other postoperative outcomes in patients undergoing PCDF. METHODS: Low (I and II) versus high (III and IV) ASA class was used to evaluate 971 patients who underwent PCDF between 2008 and 2016 at a single institution. Demographics were compared using univariate analysis. Cost of care, LOS, and postoperative complications were compared using multivariable logistic and linear regression, controlling for sex, age, length of surgery, and number of segments fused. RESULTS: The high ASA class cohort was older (mean age 62 years vs. 55 years, P < 0.0001) and had higher Elixhauser comorbidity index scores (P < 0.0001). ASA class was independently associated with longer LOS (2.1 days, 95% confidence interval [CI] 1.3-2.9, P < 0.0001) and higher cost ($2936, 95% CI $1457-$4415, P < 0.0001). Patients with high ASA class were more likely to have a nonhome discharge (3.9, 95% CI 2.8-5.6, P < 0.0001), delayed extubation (3.2, 95% CI 1.4-7.3, P = 0.006), intensive care unit stay (2.4, 95% CI 1.5 3.7, P = 0.0001), in-hospital complications (1.5, 95% CI 1.0-2.2, P = 0.03), and 30-day (3.2, 95% CI 1.5-6.8, P = 0.003) and 90-day (3.2, 95% CI 1.8-5.7, P = 0.0001) readmission. CONCLUSIONS: High ASA class is strongly associated with increased costs, LOS, and adverse outcomes following PCDF and could be useful for preoperative prediction of these outcomes.

Comparison of Cost and Perioperative Outcome Profiles for Primary and Revision Posterior Cervical Fusion Procedures.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To compare perioperative outcomes and hospitalization costs between patients undergoing primary or revision posterior cervical discectomy and fusion (PCDF). SUMMARY OF BACKGROUND DATA: While prior studies found differences in outcomes between primary and revision anterior cervical discectomy and fusion (ACDF), risk, and outcome profiles for posterior cervical revision procedures have not yet been elucidated. METHODS: Institutional records were queried for cases involving isolated PCDF procedures to evaluate preoperative characteristics and outcomes for patients undergoing primary versus revision PCDF between 2008 and 2016. The primary outcome was perioperative complications, while perioperative and resource utilization measures such as hospitalization length, required stay in the intensive care unit (ICU), direct hospitalization costs, and 30-day emergency department (ED) admissions were explored as secondary outcomes. RESULTS: One thousand one hundred twenty four patients underwent PCDF, with 218 (19.4%) undergoing a revision procedure. Patients undergoing revision procedures were younger (53.0 vs. 60.5 yrs), but had higher Elixhauser scores compared with the non-revision cohort. Revision cases tended to involve fewer spinal segments (3.6 vs. 4.1 segments) and shorter surgical durations (179.3 vs. 206.3 min), without significant differences in estimated blood loss. There were no significant differences in the overall complication rates (P = 0.20), however, the primary cohort had greater rates of required ICU stays (P = 0.0005) and non-home discharges (P = 0.0003). The revision cohort did experience significantly increased odds of 30-day ED admission (P = 0.04) and had higher direct hospitalization (P = 0.03) and surgical (P < 0.0001) costs. CONCLUSION: Complication rates, including incidental durotomy, were similar between primary and revision PCDF cohorts. Although prior surgery status did not predict complication risk, comorbidity burden did. Nevertheless, patients undergoing revision procedures had decreased risk of required ICU stay but greater risk of 30-day ED admission and higher direct hospitalization and surgical costs.Level of Evidence: 3.

Time to Evacuation and Functional Outcome After Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation.

BACKGROUND AND PURPOSE: We present a retrospective analysis of patients who underwent minimally invasive endoscopic intracerebral hemorrhage (ICH) evacuation to identify variables that were associated with long-term outcome. METHODS: Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit prespecified clinical inclusion and exclusion criteria. Demographic, clinical, and radiographic factors previously demonstrated to impact functional outcome in ICH were included in a univariate analysis to identify factors associated with favorable outcome (modified Rankin Scale score, 0-3) at 6 months. Factors associated with a favorable outcome in the univariate analysis (P≤0.20) were included in a multivariate logistic regression analysis with the same dependent variable. RESULTS: Ninety patients underwent MIS endoscopic ICH evacuation within 72 hours of ictus. In a multivariate analysis, factors associated with good long-term functional outcome included time to evacuation (per hour; OR, 0.95 [95% CI, 0.92-0.98], P=0.004), age (per decade, odds ratio [OR], 0.49 [95% CI, 0.28-0.77], P=0.005), presence of intraventricular hemorrhage (OR, 0.15 [95% CI, 0.04-0.47], P=0.002), and lobar location (OR, 18.5 [95% CI, 4.5-103], P=0.0005). Early evacuation was not associated with an increased risk of rebleeding. CONCLUSIONS: Young age, lack of intraventricular hemorrhage, lobar location, and time to evacuation were independently associated with good long-term functional outcome in patients undergoing minimally invasive endoscopic ICH evacuation. The OR for time to evacuation suggests that for each additional hour, there was a 5% reduction in the odds of achieving a favorable outcome.

Comparison of Anterior and Posterior Surgical Approaches for Treatment of Thoracic Myelopathy.

OBJECTIVE: To study a large multi-institutional sample of patients undergoing anterior versus posterior approaches for surgical decompression of thoracic myelopathy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent decompression for thoracic myelopathy between 2007 and 2015 via anterior or posterior approaches. Patients were excluded if they were undergoing surgery for tumors to isolate a degenerative cohort. Demographics, patient comorbidities, operative details, and postoperative complications were compared between the 2 cohorts. RESULTS: Although there were no differences in age (P = 0.06), sex (P = 0.72), or American Society of Anesthesiologists class (P = 0.59), there were higher rates of steroid use (P = 0.01) and hematologic disorders that predispose to bleeding (P = 0.04) at baseline in the posterior approach cohort. The posterior approach patients had longer operative times (P = 0.03), but there were no differences in length of stay (P = 0.64). Although there were no significant differences in the rates of major organ system complications or return to the operating room (P = 0.52), the posterior approach cohort displayed a trend toward increased severe adverse complications (29.8% vs. 17.6%, P = 0.28) compared with the anterior approach cohort. CONCLUSION: Although the anterior approach to surgical decompression of thoracic myelopathy demonstrated a lower complication rate, this result did not reach statistical significance. The anterior approach was associated with significantly shorter mean operative time, but otherwise there were no significant differences in operative or postoperative outcomes. These findings may support the favorability of the anterior approach but warrant further investigation in a larger study.

The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified. METHODS: Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type. RESULTS: Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906-$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9-6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37-8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00-24.02, P < 0.0001). CONCLUSION: Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.Level of Evidence: 3.

Surgery for spinal deformity: non-elective admission status is associated with higher cost of care and longer length of stay.

INTRODUCTION: Surgery is commonly indicated for adult spinal deformity. Annual rates and costs of spinal deformity surgery have both increased over the past two decades. However, the impact of non-elective status on total cost of hospitalization and patient outcomes has not been quantified. OBJECTIVE: To evaluate the impact of admission status on patient outcomes and healthcare costs in spinal deformity surgery. METHODS: All patients who underwent spinal deformity surgery at a single institution between 2008 and 2016 were grouped by admission status: elective, emergency (ED), or transferred. Demographics were compared by univariate analysis. Cost of care and length of stay (LOS) were compared between admission statuses using multivariable linear regression with elective admissions as reference. Multivariate logistic regression was utilized to assess in-hospital complications, discharge destination, and readmission rates. RESULTS: There were 427 spinal deformity surgeries included in this study. Compared to elective patients, ED patients had higher Elixhauser Comorbidity Index scores (p < 0.0001), longer LOS (+ 10.9 days, 97.5% CI 6.1-15.6 days, p < 0.0001), and higher costs (+ $20,076, 97.5% CI $9,073-$31,080, p = 0.0008). Transferred patients had significantly higher Elixhauser scores (p = 0.0002), longer LOS (+ 8.8 days, 97.5% CI 3.0-14.7 days, p < 0.0001), and higher rates of non-home discharge (OR = 15.8, 97.5% CI 2.3-110.0, p = 0.001). CONCLUSION: Patients admitted from the ED undergoing spinal deformity surgery had significantly higher cost of care and longer LOS compared to elective patients. Transferred patients had significantly longer LOS and a higher rate of non-home discharge compared to elective patients.

A Comparison of Outcomes for Spinal Trauma Patients at Level I and Level II Centers.

STUDY DESIGN: Retrospective analysis of a national database. OBJECTIVE: To characterize the spine trauma population, describe trauma center (TC) resources, and compare rates of outcomes between the American College of Surgeons (ACS) level I and level II centers. SUMMARY OF BACKGROUND DATA: Each year, thousands of patients are treated for spinal trauma in the United States. Although prior analyses have explored postsurgical outcomes for patients with trauma, no study has evaluated these metrics for spinal trauma at level I and level II TCs. MATERIALS AND METHODS: The ACS Trauma Quality Improvement Program was queried for all spinal trauma cases between 2013 and 2015, excluding polytrauma cases, patients discharged within 24 hours, data from TCs without a designated level, and patients transferred for treatment. RESULTS: Although there were similar rates of severe spine traumas (Abbreviated Injury Scale≥3) at ACS level I and level II centers (P=0.7), a greater proportion of level I patients required mechanical ventilation upon emergency department arrival (P=0.0002). Patients at level I centers suffered from higher rates of infectious complications, including severe sepsis (0.58% vs. 0.31%, P=0.02) and urinary tract infections (3.26% vs. 2.34%, P=0.0009). Intensive care unit time (1.90 vs. 1.65 days, P=0.005) and overall length of stay (8.37 days vs. 7.44 days, P<0.0001) was higher at level I TCs. Multivariate regression revealed higher adjusted overall complication rates at level II centers (odds ratio, 1.15, 95% confidence interval, 1.06-1.24; P<0.001), but no difference in mortality (odds ratio, 1.18; 95% confidence interval, 0.92-1.52; P>0.10). CONCLUSIONS: ACS level I TCs possess larger surgical staff and are more likely to be academic centers. Patients treated at level I centers experience fewer overall complications but have a greater incidence of infectious complications. Mortality rates are not statistically different.

Lower Mortality and Morbidity with Low-Molecular-Weight Heparin for Venous Thromboembolism Prophylaxis in Spine Trauma.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: The objective of this study was to evaluate outcomes between patients receiving LMWH versus UH in a retrospective cohort of patients with spine trauma. SUMMARY OF BACKGROUND DATA: Although multiple clinical trials have been conducted, current guidelines do not have enough evidence to suggest low-molecular-weight heparin (LMWH) or unfractionated heparin (UH) for venous thromboembolism (VTE) prophylaxis in spine trauma. METHODS: Patients with spine trauma in the Trauma Quality Improvement Program datasets were identified. Those who died, were transferred within 72 hours, were deemed to have a fatal injury, were discharged within 24 hours, suffered from polytrauma, or were missing data for VTE prophylaxis were excluded. A propensity score was created using age, sex, severity of injury, time to prophylaxis, presence of a cord injury, and altered mental status or hypotension upon arrival, and inverse probability weighted logistic regression modeling was used to evaluate mortality, venous thromboembolic, return to operating room, and total complication rates. E values were used to calculate the likelihood of unmeasured confounders. RESULTS: Those receiving UH (n = 7172) were more severely injured (P < 0.0001), with higher rates of spinal cord injury (32.26% vs. 25.32%, P < 0.0001) and surgical stabilization (29.52% vs. 22.94%, P < 0.0001) compared to those receiving LMWH (n = 20,341). Patients receiving LMWH had lower mortality (odds ratio [OR]: 0.47; 95% CI: 0.42-0.53; P < 0.001; E = 3.68), total complication (OR: 0.92; 95% CI: 0.88-0.95; P < 0.001; E = 1.39), and VTE event (OR: 0.80; 95% CI: 0.72-0.88; P < 0.001; E = 1.81) rates than patients receiving UH. There were no differences in rates of unplanned return to the operating room (OR: 1.01; 95% CI: 0.80-1.27; P = 0.93; E = 1.11). CONCLUSION: There is an association between lower mortality and receiving LMWH for VTE prophylaxis in patients with spine trauma. A large randomized clinical trial is necessary to confirm these findings. LEVEL OF EVIDENCE: 3.

By the Numbers Analysis of Effect of COVID-19 on a Neurosurgical Residency at the Epicenter.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 pandemic has created challenges to neurosurgical patient care. Despite editorials evaluating neurosurgery responses to 2019 novel coronavirus disease (COVID-19), data reporting effects of COVID-19 on neurosurgical case volume, census, and resident illness are lacking. The aim of this study was to present a real-world analysis of neurosurgical volumes, resident deployment, and unique challenges encountered during the severe acute respiratory syndrome coronavirus 2 outbreak peak in New York City. METHODS: Daily census and case volume data were prospectively collected throughout the severe acute respiratory syndrome coronavirus 2 outbreak in spring 2020. Neurosurgical census was compared against COVID-19 system-wide data. Neurosurgical cases during the crisis were analyzed and compared with 7-week periods from 2019 and early 2020. Resident deployment and illness were reviewed. RESULTS: From March 16, 2020, to May 5, 2020, residents participated in 72 operations and 69 endovascular procedures compared with 448 operations and 253 endovascular procedures from January 2020 to February 2020 and 530 operations and 340 endovascular procedures from March 2019 to May 2019. There was a 59% reduction in neurosurgical census during the outbreak (median 24 patients, 2.75 average total cases daily). COVID-19 neurosurgical admissions peaked in concert with the system-wide pandemic. Three residents demonstrated COVID-19 symptoms (no hospitalizations occurred) for a total 24 workdays lost (median 7 workdays). CONCLUSIONS: These data provide real-world guidance on neurosurgical infrastructure needs during a COVID-19 outbreak. While redeployment to support the COVID-19 response was required, a significant need remained to continue to provide critical neurosurgical service.

Afternoon Surgical Start Time Is Associated with Higher Cost and Longer Length of Stay in Posterior Lumbar Fusion.

BACKGROUND: Existing research about surgical start time is equivocal about associations between outcomes and late start times, and there is only one published report investigating start time in spine surgery. Therefore, the objective of this study was to assess associations between surgical start time, length of stay (LOS), and cost in lumbar spine surgery. METHODS: Patients at a single institution undergoing posterior lumbar fusion (PLF) were grouped based on whether they received their surgery before or after 2 pm, with those receiving their surgery between 12 am and 6 am and receiving surgery for tumors, trauma, or infections being excluded. These 2 groups were then compared on the basis of demographics and outcomes with cost and LOS as the coprimary outcomes. RESULTS: A total of 2977 patients underwent PLF during the study period. There were minimal differences in preoperative characteristics of the cohorts. The patients who underwent PLF starting after 2 pm had longer LOS (0.45 days; 95% confidence interval [CI], 0.18-0.72; P = 0.001) and higher costs ($1343; 95% CI, $339-$2348; P = 0.009) than cases starting before 2 pm The late surgical start cohort also had higher rates of nonhome discharge (29.73% vs. 23.17%, P = 0.0004), and 30-day (4.36% vs. 2.5%, P = 0.01) and 90-day emergency department visits (5.72% vs. 2.94%, P = 0.0005). CONCLUSIONS: Late surgical start time is associated with longer LOS and higher cost in patients undergoing PLF.

A case of adult α-type spinal deformity with spinal cord rotation greater than 90°.

This report describes a 42-year-old man who presented with an α-type spinal deformity with a Cobb angle of 224.9° and associated spinal cord rotation greater than 90°. Preoperative imaging revealed extensive spinal deformity, and 3D modeling confirmed the α-type nature of his deformity. Intraoperative photography demonstrated spinal cord rotation greater than 90°, which likely contributed to the patient's poor neurological status. Reports of patients with Cobb angles ≥ 100° are rare, and to the authors' knowledge, there have been no published cases of adult α-type spinal deformity. Furthermore, very few cases or case series of spinal cord rotation have been published previously, with no single patient having rotation greater than 90° to the authors' knowledge. Given these two rarities presenting in the same patient, this report can provide important insights into the operative management of this difficult form of spinal deformity.

Neurosurgical management of brain and spine tumors in the COVID-19 era: an institutional experience from the epicenter of the pandemic.

The challenges of neurosurgical patient management and surgical decision-making during the 2019-2020 COVID-19 worldwide pandemic are immense and never-before-seen in our generation of neurosurgeons. In this case-based formatted report, we present the Mount Sinai Hospital (New York, NY) Department of Neurosurgery institutional experience in the epicenter of the pandemic and the guiding principles for our current management of intracranial, skull base, and spine tumors. The detailed explanations of our surgical reasoning for each tumor case is tailored to assist neurosurgeons across the United States as they face these complex operative decisions put forth by the realities of the pandemic.