Andexanet alfa therapy showed No increased rate of thromboembolic events in spontaneous intracranial hemorrhage patients: A multicenter electronic health record study.

•Intracranial hemorrhage accounts for two out of every three major intracranial hemorrhages.•Systemic anticoagulation is routinely prescribed for prevention of cerebrovascular accidents.•The FDA approved Andexanet alfa to treat life-threatening bleeding.•Andexanet alfa relationship to outcomes requires further investigation.

Preoperative Hounsfield Units Predict Pedicle Screw Loosening in Osteoporotic Patients Following Short Segment Lumbar Fusion.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: (1) To determine if vertebral HU values obtained from preoperative CT predict postoperative outcomes following 1-3 level lumbar fusion and (2) to investigate whether decreased BMD values determined by HU predict cage subsidence and screw loosening. SUMMARY OF BACKGROUND DATA: In light of suboptimal screening for osteoporosis, vertebral computerized tomography(CT) Hounsfield Units(HU), have been investigated as a surrogate for bone mineral density(BMD). METHODS: In this retrospective study, adult patients who underwent 1-3 level posterior lumbar decompression and fusion(PLDF) or transforaminal lumbar interbody and fusion(TLIF) for degenerative disease between the years 2017-2022 were eligible for inclusion. Demographics and surgical characteristics were collected. Outcomes assessed included 90-day readmissions, 90-day complications, revisions, patient reported outcomes(PROMs), cage subsidence, and screw loosening. Osteoporosis was defined as HU of ≤110 on preoperative CT at L1. RESULTS: We assessed 119 patients with a mean age of 59.1, of whom 80.7% were white and 64.7% were nonsmokers. The majority underwent PLDF(63%) compared to TLIF(37%), with an average of 1.63 levels fused. Osteoporosis was diagnosed in 37.8% of the cohort with a mean HU in the osteoporotic group of 88.4 compared to 169 in non-osteoporotic patients. Although older in age, osteoporotic individuals did not exhibit increased 90-day readmissions, complications, or revisions compared to non-osteoporotic patients. A significant increase in the incidence of screw loosening was noted in the osteoporotic group with no differences observed in subsidence rates. On multivariable linear regression osteoporosis was independently associated with less improvement in visual analog scale(VAS) scores for back pain. CONCLUSIONS: Osteoporosis predicts screw loosening and increased back pain. Clinicians should be advised of the importance of preoperative BMD optimization as part of their surgical planning and the utility of vertebral CT HU as a tool for risk stratification. LEVEL OF EVIDENCE: 3.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma.

Introduction: As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase. Research question: To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care. Materials and methods: We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition. Results: A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility. Discussion and conclusions: Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.

Radiology Reports Do Not Accurately Portray the Severity of Cervical Neural Foraminal Stenosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: (1) To compare cervical magnetic resonance imaging (MRI) radiology reports to a validated grading system for cervical foraminal stenosis (FS) and (2) to evaluate whether the severity of cervical neural FS on MRI correlates to motor weakness or patient-reported outcomes. BACKGROUND: Radiology reports of cervical spine MRI are often reviewed to assess the degree of neural FS. However, research looking at the association between these reports and objective MRI findings, as well as clinical symptoms, is lacking. PATIENTS AND METHODS: We retrospectively identified all adult patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion at a single academic center for an indication of cervical radiculopathy. Preoperative MRI was assessed for neural FS severity using the grading system described by Kim and colleagues for each level of fusion, as well as adjacent levels. Neural FS severity was recorded from diagnostic radiologist MRI reports. Motor weakness was defined as an examination grade <4/5 on the final preoperative encounter. Regression analysis was conducted to evaluate whether the degree of FS by either classification was related to patient-reported outcome measure severity. RESULTS: A total of 283 patients were included in the study, and 998 total levels were assessed. There were significant differences between the MRI grading system and the assessment by radio-logists (P< 0.001). In levels with moderate stenosis, 28.9% were classified as having no stenosis by radiology. In levels with severe stenosis, 29.7% were classified as having mild-moderate stenosis or less. Motor weakness was found similarly often in levels of moderate or severe stenosis (6.9% and 9.2%, respectively). On regression analysis, no associations were found between baseline patient-reported outcome measures and stenosis severity assessed by radiologists or MRI grading systems. CONCLUSION: Radiology reports on the severity of cervical neural FS are not consistent with a validated MRI grading system. These radiology reports underestimated the severity of neural foraminal compression and may be inappropriate when used for clinical decision-making. LEVEL OF EVIDENCE: Level III.

The 5-item modified frailty index predicts spinal osteotomy outcomes better than age in adult spinal deformity patients: an ACS - NSQIP analysis.

PURPOSE: To evaluate the utility of 5-Item Modified Frailty Index (mFI-5) as compared to chronological age in predicting outcomes of spinal osteotomy in Adult Spinal Deformity (ASD) patients. METHODS: Using Current Procedural and Terminology (CPT) codes, the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) database was queried for adult patients undergoing spinal osteotomy from 2015 to 2019. Multivariate regression analysis was performed to evaluate the effect of baseline frailty status, measured by mFI-5 score, and chronological age on postoperative outcomes. Receiver-operating characteristic (ROC) curve analysis was performed to analyze the discriminative performance of age versus mFI-5. RESULTS: A total of 1,789 spinal osteotomy patients (median age 62 years) were included in the analysis. Among the patients assessed, 38.5% (n = 689) were pre-frail, 14.6% frail (n = 262), and 2.2% (n = 39) severely frail using the mFI-5. Based on the multivariate analysis, increasing frailty tier was associated with worsening outcomes, and higher odds ratios (OR) for poor outcomes were found for increasing frailty tiers as compared to age. Severe frailty was associated with the worst outcomes, e.g., unplanned readmission (OR 9.618, [95% CI 4.054-22.818], p < 0.001) and major complications (OR 5.172, [95% CI 2.271-11.783], p < 0.001). In the ROC curve analysis, mFI-5 score (AUC 0.838) demonstrated superior discriminative performance than age (AUC 0.601) for mortality. CONCLUSIONS: The mFI5 frailty score was found to be a better predictor than age of worse postoperative outcomes in ASD patients. Incorporating frailty in preoperative risk stratification is recommended in ASD surgery.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty.

The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period. PURPOSE: The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. METHODS: Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. RESULTS: In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. CONCLUSIONS: Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

Racial disparities in readmission rates following surgical treatment of pediatric developmental dysplasia of the hip.

PURPOSE: Across orthopedic subspecialties, significant racial disparities have been identified with regard to postoperative outcomes. Despite these findings among adult patients, the literature assessing these disparities within pediatric orthopedics is limited. The purpose of this study was to determine the independent predictors for unplanned readmission following surgical treatment of developmental dysplasia of the hip. METHODS: Pediatric patients undergoing hip dysplasia surgery from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Two patient groups were defined: patients who had unplanned hospital readmission within 30 days of surgery and patients who were not readmitted. Clinical characteristics assessed included gender, race, and American Society of Anesthesiologists (ASA) class. Risk factors for complications were assessed using bivariate and multivariate analysis. RESULTS: Of 6561 pediatric patients undergoing surgical treatment for hip dysplasia, 540 (8.2%) had unplanned readmission. On bivariate analysis, non-white race (Black, Asian, Hispanic, American Indian, and Native Hawaiian), an ASA class of III, IV, or V, pulmonary, renal, neurological, and gastrointestinal comorbidities, as well as immune disease, steroid use, and nutritional support were significantly associated with unplanned readmission (p < 0.05 for all). After controlling for confounding variables on multivariate analysis, non-white race (OR 1.46; p = 0.042) and ASA class of III-V (OR 2.21; p = 0.002) were found to be independent predictors for readmission. CONCLUSION: Clinicians should be advised of the increased readmission rates observed in non-white patients and those of higher ASA scores. Further work is needed to combat existing disparities within pediatric orthopedics.

Preoperative frailty risk in deep brain stimulation patients: Risk analysis index predicts Clavien-Dindo IV complications.

OBJECTIVE: Deep brain stimulation (DBS) improves patients' quality of life in multiple movement disorders and chronic neurodegenerative diseases. There are no published studies assessing frailty's impact on DBS outcomes. We evaluated frailty's impacts on DBS outcomes, comparing discriminative thresholds of the risk analysis index (RAI) to modified frailty index-5 (mFI-5) for predicting Clavien-Dindo complications (CDIV). METHODS: Patients who underwent DBS between 2015 and 2019 in the ACS-NSQIP registry were included. We employed receiver operating characteristic (ROC) curve to examine the discriminative thresholds of RAI and mFI-5 and multivariable analyses for postoperative outcomes. Our primary outcome was CDIV, and secondary outcomes were discharge to higher-level care facility, unplanned reoperation within 30 days, in any hospital, for any procedure related to the index procedure, and extended length of stay. RESULTS: A total of 3795 patients were included. In the ROC analysis for CDIV, RAI showed superior discriminative threshold (C-statistic = 0.70, 95% CI 0.61-0.80, <0.001) than mFI-5 (C-statistic = 0.60, 95% CI 0.49-0.70, P = 0.08). On multivariable analyses, frailty stratified by RAI, had independent associations with CDIV, i.e., pre-frail 2-fold increase OR 2.04 (95% CI: 1.94-2.14) p < 0.001, and frail 39% increase OR 1.39 (95% CI: 1.27-1.53), p < 0.001. CONCLUSION: Frailty was an independent risk-factor for CDIV. The RAI had superior discriminative thresholds than mFI-5 in predicting CDIV after DBS. Our ability to identify frail patients prior to DBS presents a novel clinical opportunity for quality improvement strategies to target this specific patient population. RAI may be a useful primary frailty screening modality for potential DBS candidates.

Impact of COVID-19 on Spinal Diagnosis and Procedural Volume in the United States.

STUDY DESIGN: Retrospective analysis of a national database. OBJECTIVES: COVID-19 resulted in the widespread shifting of hospital resources to handle surging COVID-19 cases resulting in the postponement of surgeries, including numerous spine procedures. This study aimed to quantify the impact that COVID-19 had on the number of treated spinal conditions and diagnoses during the pandemic. METHODS: Using CPT and ICD-10 codes, TriNetX, a national database, was utilized to quantify spine procedures and diagnoses in patients >18 years of age. The period of March 2020-May 2021 was compared to a reference pre-pandemic period of March 2018-May 2019. Each time period was then stratified into four seasons of the year, and the mean average number of procedures per healthcare organization was compared. RESULTS: In total, 524,394 patient encounters from 53 healthcare organizations were included in the analysis. There were significant decreases in spine procedures and diagnoses during March-May 2020 compared to pre-pandemic levels. Measurable differences were noted for spine procedures during the winter of 2020-2021, including a decrease in lumbar laminectomy and anterior cervical arthrodesis. Comparing the pandemic period to the pre-pandemic period showed significant reductions in most spine procedures and treated diagnoses; however, there was an increase in open repair of thoracic fractures during this period. CONCLUSIONS: COVID-19 resulted in a widespread decrease in spinal diagnosis and treated conditions. An inverse relationship was observed between new COVID-19 cases and spine procedural volume. Recent increases in procedural volume from pre-pandemic levels are promising signs that the spine surgery community has narrowed the gap in unmet care produced by the pandemic.

Frailty as a Superior Predictor of Dysphagia and Surgically Placed Feeding Tube Requirement After Anterior Cervical Discectomy and Fusion Relative to Age.

Frailty is a measure of physiological reserve that has been demonstrated to be a discriminative predictor of worse outcomes across multiple surgical subspecialties. Anterior cervical discectomy and fusion (ACDF) is one of the most common neurosurgical procedures in the United States and has a high incidence of postoperative dysphagia. To determine the association between frailty and dysphagia after ACDF and compare the predictive value of frailty and age. 155,300 patients with cervical stenosis (CS) who received ACDF were selected from the 2016-2019 National Inpatient Sample (NIS) utilizing International Classification of Disease, tenth edition (ICD-10) codes. The 11-point modified frailty index (mFI-11) was used to stratify patients based on frailty: mFI-11 = 0 was robust, mFI-11 = 1 was prefrail, mFI-11 = 2 was frail, and mFI-11 = 3 + was characterized as severely frail. Demographics, complications, and outcomes were compared between frailty groups. A total of 155,300 patients undergoing ACDF for CS were identified, 33,475 (21.6%) of whom were frail. Dysphagia occurred in 11,065 (7.1%) of all patients, and its incidence was significantly higher for frail patients (OR 1.569, p < 0.001). Frailty was a risk factor for postoperative complications (OR 1.681, p < 0.001). Increasing frailty and undergoing multilevel ACDF were significant independent predictors of negative postoperative outcomes, including dysphagia, surgically placed feeding tube (SPFT), prolonged LOS, non-home discharge, inpatient death, and increased total charges (p < 0.001 for all). Increasing mFI-11 score has better prognostic value than patient age in predicting postoperative dysphagia and SPFT after ACDF.

Race Is Associated With Risk of Salvage Procedures and Postoperative Complications After Hip Procedures in Children With Cerebral Palsy.

BACKGROUND: Despite the many surgical interventions available for spastic hip dysplasia in children with cerebral palsy, a radical salvage hip procedure may still ultimately be required. The purpose of this study was to assess whether race is an independent risk factor for patients with cerebral palsy to undergo a salvage hip procedure or experience postoperative complications for hip dysplasia treatment. METHODS: This is a retrospective cohort analysis utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database from 2012 to 2019. International Classification of Diseases, 9th and 10th Revisions, Clinical Modifications (ICD-9-CM, ICD-10-CM), and current procedural terminology (CPT) codes were used to identify patients with cerebral palsy undergoing hip procedures for hip dysplasia and to stratify patients into salvage or reconstructive surgeries. RESULTS: There was a total of 3906 patients with cerebral palsy between the ages of 2 and 18 years undergoing a procedure for hip dysplasia, including 1995 (51.1%) White patients, 768 (19.7%) Black patients, and 1143 (29.3%) patients from other races. Both Black ( P =0.044) and White ( P =0.046) races were significantly associated with undergoing a salvage versus a reconstructive hip procedure, with Black patients having an increased risk compared to White patients [adjusted odds ratio (OR) 1.77, confidence interval (CI) 1.02-3.07]. Only Black patients were found to have an increased risk of any postoperative complication compared to White patients, with an adjusted OR of 1.26 (CI 1.02-1.56; P =0.033). Both White ( P =0.017) and black ( P =0.004) races were found to be significantly associated with medical complications, with Black patients having an increased risk (adjusted OR 1.43, CI 1.12-1.84) compared to White patients. There were no significant findings between the race and risk of surgical site complications, unplanned readmissions, or reoperations. CONCLUSION: This study demonstrates that patient race is an independent association for the risk of pediatric patients with cerebral palsy to both undergo a salvage hip procedure and to experience postoperative medical complications, with Black patients having an increased risk compared to White. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Association of baseline frailty status and age with outcomes in patients undergoing intracranial meningioma surgery: Results of a nationwide analysis of 5818 patients from the National Surgical Quality Improvement Program (NSQIP) 2015-2019.

PURPOSE: The objective of this study was to compare the effect of frailty, as measured by the 5-factor modified frailty index (mFI-5), with that of age on postoperative outcomes of patients undergoing surgery for intracranial meningiomas, using data from a large national registry. METHODS: The National Surgical Quality Improvement Program (NSQIP) database (2015-2019) was queried to analyze data from patients undergoing intracranial meningioma resection (N = 5,818). Univariate and multivariate analyses of age and mFI-5 score were performed for 30-day mortality, major complications, unplanned reoperation, unplanned readmission, extended hospital length of stay (eLOS), and discharge to a non-home destination. RESULTS: Both univariate and multivariate analyses (adjusted for sex, body mass index, transfer status, smoking, and operative time) demonstrated that mFI-5 and age were significant predictors of adverse postoperative outcomes in patients with intracranial meningioma. However, based on odds ratios (OR) and effect sizes, increasing frailty tiers were better predictors than age of adverse outcomes. Severely frail patients showed highest effects sizes for all postoperative outcome variables [OR 11.17 (95% CI 3.45-36.19), p<0.001 for mortality; OR 4.15 (95% CI 2.46-6.99), p<0.001 for major complications; OR 4.37 (95% CI 2.68-7.12), p<0.001 for unplanned readmission; OR 2.31 (95% CI 1.17-4.55), p<0.001 for unplanned reoperation; OR 4.28 (95% CI 2.74-6.68), p<0.001 for eLOS; and OR 9.34 (95% CI 6.03-14.47, p<0.001) for discharge other than home. CONCLUSION: In this national database study, baseline frailty status was a better independent predictor for worse postoperative outcomes than age in patients with intracranial meningioma.

Frailty Status Is a More Robust Predictor Than Age of Spinal Tumor Surgery Outcomes: A NSQIP Analysis of 4,662 Patients.

OBJECTIVE: The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry. METHODS: The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients' data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5. RESULTS: Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. 'Severely frail' patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21-35.44) for 30-day mortality, 3.02 (95% CI, 1.97-4.56) for major complications, and 2.94 (95% CI, 2.32-4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality. CONCLUSION: Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.

Trends in United States pediatric neurosurgical practice during the COVID-19 pandemic.

There is minimal information on COVID-19 pandemic's national impact on pediatric neurosurgical operative volumes. In this study, using a national database, TriNetX, we compared the overall and seasonal trends of pediatric neurosurgical procedure volumes in the United States during the pandemic to pre-pandemic periods. In the United States, the incidence of COVID-19 began to rise in September 2020 and reached its maximum peak between December 2020 and January 2021. During this time, there was an inverse relationship between pediatric neurosurgical operative volumes and the incidence of COVID-19 cases. From March 2020 to May 2021, there was a significant decrease in the number of pediatric shunt (-11.7% mean change, p = 0.006), epilepsy (-16.6%, p < 0.001), and neurosurgical trauma (-13.8%, p < 0.001) surgeries compared to pre-pandemic years. The seasonal analysis also yielded a broad decrease in most subcategories in spring 2020 with significant decreases in pediatric spine, epilepsy, and trauma cases. To the best of our knowledge, this is the first study to report a national decline in pediatric shunt, epilepsy, and neurosurgical trauma operative volumes during the pandemic. This could be due to fear-related changes in health-seeking behavior as well as underdiagnosis during the COVID-19 pandemic.

Nationwide analysis of plastic and reconstructive procedural volume in the United States during the COVID-19 pandemic.

INTRODUCTION: This study aims to define the impact of the novel Coronavirus Disease 2019 (COVID-19) pandemic on the volume of common plastic and reconstructive procedures in the United States. METHODS: TrinetX is a national, federated database that was utilized in surveying plastic and reconstructive procedural volumes among 53 Healthcare organizations (HCO) between March 2018 and May 2021. This timeframe was divided into pre-pandemic (March 2018 to February 2020) and pandemic periods (March 2020 to May 2021). Each period was then sub-divided into four seasons of the year and the mean monthly procedural volume per HCO was compared. A student's t-tests comparing pre-pandemic and pandemic seasonal mean procedural volumes were used for statistical analysis. RESULTS: A total of 366,032 patient encounters among 53 HCO were included. The average seasonal volume per HCO of all procedures reduced from 872.11 procedures during pre-pandemic seasons to 827.36 during pandemic seasons. Spring 2020 vol declined for most procedures as 15 of 24 (63%) assessed procedure categories experienced statistically significant decreases. Spring 2021 experienced rebounds with 15 of 24 (63%) assessed procedures showing statistically significant increases. CONCLUSION: During the pandemic period, the average procedural volume per HCO of 14 procedure categories was significantly less than the pre-pandemic average procedural volume. Overall, an inverse relationship was observed between novel COVID-19 cases and plastic and reconstructive surgery procedure volumes in the United States.