A Learning Health System Approach to Long COVID Care.

Background: Global initiatives to mitigate COVID-19 transmission have shifted health system priorities to management of patients with prolonged long COVID symptoms. To better meet the needs of patients, clinicians, and systems, a learning health system approach can use rapid-cycle methods to integrate data and real-world experience to iteratively evaluate and adapt models of long COVID care. Observations: Employees in the Veterans Health Administration formed a multidisciplinary workgroup. We sought to develop processes to learn more about this novel long COVID syndrome and innovative long COVID care models that can be applied within and outside of our health care system. We describe our workgroup processes and goals to create a mechanism for cross-facility communication, identify gaps in care and research, and cocreate knowledge on best practices for long COVID care delivery. Conclusions: The learning health system approach will be critical in reimagining health care service delivery after the COVID-19 pandemic.

Prevalence and Predictors of Lower Limb Amputation in the Spinal Cord Injury Population.

Background: Despite limited data demonstrating altered hemodynamics in the lower extremities (LEs) among the population with spinal cord injury (SCI) and increased frequency of peripheral arterial disease (PAD), epidemiologic data are limited for amputations, a potential consequence. This study investigates the association of amputation due to vascular complications as a secondary outcome measure within the SCI population. Methods: A retrospective cohort study was performed within a veteran population with SCI at a US Department of Veteran Affairs hospital to determine the prevalence of limb loss. We hypothesized that premorbid SCI increased the likelihood of LE amputation. Results: Of 1055 charts reviewed, 91 (8.7%) patients had an amputation, 70 (76.1%) had a dysvascular etiology. Transfemoral amputations were the most common level (n = 53) of amputation. Our results showed a positive correlation between the completeness of injury and the prevalence of amputation. Conclusion: There is an increased frequency of amputation among the veteran population with SCI compared with that of the general US population. Amputations frequently occur at more proximal levels with motor complete injuries. Studies using a larger population and multiple centers are needed to confirm this alarming trend.

Percutaneous laser disc decompression for thoracic disc disease: report of 10 cases.

BACKGROUND: Discogenic pain or herniation causing neural impingement of the thoracic vertebrae is less common than that in the cervical or lumbar regions. Treatment of thoracic discogenic pain usually involves conservative measures. If this fails, conventional fusion or discectomy can be considered, but these procedures carry significant risk. OBJECTIVES: To assess the efficacy and safety of percutaneous laser disc decompression (PLDD) for the treatment of thoracic disc disease. METHODS: Ten patients with thoracic discogenic pain who were unresponsive to conservative intervention underwent the PLDD procedure. Thoracic pain was assessed using the Visual Analog Scale (VAS) scores preoperatively and at 6-month intervals with a minimum of 18-months follow-up. Patients were diagnosed and chosen for enrollment based on abnormal MRI findings and positive provocative discograms. Patients with gross herniations were not included. RESULTS: Length of follow-up ranged from 18 to 31 months (mean: 24.2 mo). Median pretreatment thoracic VAS score was 8.5 (range: 5-10) and median VAS score at final follow-up was 3.8 (range: 0-9). Postoperative improvement was significant with a 99% confidence interval. Of interest, patients generally fell into two groups, those with significant pain reduction and those with little to no improvement. Although complications such as pneumothorax, discitis, or nerve damage were possible, no adverse events occurred during the procedures. LIMITATIONS: The study is limited by its small size and lack of a sham group. Larger controlled studies are warranted. CONCLUSIONS: With further clinical evidence, PLDD could be considered a viable option with a low risk of complication for the treatment of thoracic discogenic pain that does not resolve with conservative treatment.

Endoscopic thoracic laminoforaminoplasty for the treatment of thoracic radiculopathy: report of 12 cases.

BACKGROUND: Spinal stenosis of the thoracic spine is less common than that of the cervical and lumbar regions. Due to the close proximity to thoracic and abdominal organs, surgical operations can be difficult and carry a greater risk of complications. The most efficacious intervention for thoracic stenosis, whether central or foraminal, refractory to conservative management is uncertain. We aimed to evaluate the efficacy of endoscopic laminoforaminoplasty (ELFP) in the treatment of thoracic radiculopathy. METHODS: Twelve patients with radicular pain involving the lower thoracic levels (at or below T6) were treated with ELFP. RESULTS: Seven of twelve patients showed marked improvement in pain scores. Average follow-up scores were 2.9 and 12.08 on the Visual Analog Scale (VAS) and Oswestry Disability Index, respectively. The significance was 0.005 between the pre and post surgical data. One patient with moderate symptoms, two with severe symptoms, and two with crippling symptoms did not report significant improvement on VAS or Oswestry. No complications were encountered. CONCLUSIONS: Endoscopic laminoforaminoplasty offers an alternative to fusion or conventional laminotomy with similar success rates. Patients additionally benefit from a decrease risk of complications, short hospital stay, and faster recovery.

Endoscopic laminoforaminoplasty success rates for treatment of foraminal spinal stenosis: report on sixty-four cases.

BACKGROUND: Foraminal stenosis is an important cause of radicular and generalized back pain. In patients who do not respond to conservative interventions, endoscopic spinal surgery provides similar results to open surgical approaches with lower rates of complication, postoperative pain, and shorter duration of hospital stay. METHODS: We performed a prospective, open, uncontrolled trial of 64 patients to evaluate endoscopic laminoforaminoplasty for the treatment of refractory foraminal stenosis. RESULTS: Fifty-nine percent of patients had at least 75% improvement in Oswestry Disability Index (Oswestry) and Visual Analog Scale (VAS) scores. All patients were discharged the day of surgery. Dural leaks occurred in two patients, which were repaired intraoperatively. No other adverse events occurred. CONCLUSIONS: Endoscopic laminoforaminoplasty appears to be a safe alternative to open decompression in patients with spinal foraminal stenosis; additional controlled trials are warranted.