Bio


Dr. John Ratliff is Professor and Vice Chair of Neurosurgery, Departmental Quality Officer, and Co-Director of the Spine and Peripheral Nerve Surgery Division. As a spine surgeon, he treats a diverse array of degenerative spinal conditions. He has a specific research emphasis on quality improvement, decreasing complications in spine surgery, and improving surgical treatment of intramedullary spinal cord tumors.

Dr. Ratliff is Chair of the Joint AANS/CNS Washington Committee. He has served on the Executive Committee of the Congress of Neurological Surgeons and the Joint Section of Disorders of Spine and Peripheral Nerves, is Recording Secretary for the Council of State Neurosurgical Societies, and is on the Board of Directors of Neuropoint Alliance. He is immediate past-chairman of the joint AANS/CNS Neurosurgery Quality Council.

Clinical Focus


  • Adult reconstructive spinal surgery
  • Spinal cord neoplasms
  • Spinal stenosis
  • Minimally invasive spinal surgery
  • Spinal metastatic disease
  • Spinal disc herniation
  • Radiosurgery of spinal tumors
  • Peripheral Nerve Neoplasms
  • Neurological Surgery

Academic Appointments


Administrative Appointments


  • Instructor, New York University, Manhattan Veteran's Affairs Medical Center, Bellevue Medical Center, New York University, New York, New York (2001 - 2002)
  • Assistant Professor, Rush University School of Medicine, Chicago, Illinois (2002 - 2005)
  • Director of Spine and Peripheral Nerve Surgery, Rush University School of Medicine, Chicago, Illinois (2002 - 2005)
  • Assistant Professor, Thomas Jefferson University, Philadelphia, Pennsylvania (2005 - 2008)
  • Associate Professor, Thomas Jefferson University, Philadelphia, Pennsylvania (2008 - 2011)
  • Chair, Quality Improvement Workgroup, American Association of Neurological Surgeons/Congress of Neurological Surgeons (2010 - Present)
  • Associate Professor, Stanford University School of Medicine (2011 - Present)
  • Co-Director, Division of Spine and Peripheral Nerve Surgery, Department of Neurosurgery, Stanford University (2011 - Present)
  • Vice Chair, Operations and Development, Department of Neurosurgery, Stanford University (2013 - Present)
  • Member at Large, Congress of Neurological Surgeons (2014 - 2016)
  • Professor of Neurosurgery, Stanford University School of Medicine (2016 - Present)
  • Recording Secretary, Council of State Neurosurgical Societies (2019 - 2021)
  • Chair, Washington Committee, AANS/CNS (2021 - 2023)

Honors & Awards


  • Charlie Kuntz Scholar Award, AANS/CNS Disorders of Spine and Peripheral Nerves Joint Section (2016)
  • Denise O'Leary Award for Clinical Excellence, Stanford University Hospital and Clinics Board of Directors (2015)
  • Top Oral Platform Presentation, AANS/CNS Disorders of Spine and Peripheral Nerves Joint Section (2015)
  • Stanford University Department of Neurosurgery Excellence in Education and Mentorship Award, Stanford University Department of Neurosurgery (2013)
  • Walsh Foundation Research Grant, Walsh Foundation (2013)
  • Orthopedic Research and Education Foundation research grant award, Orthopedic Research and Education Foundation (2012)
  • Robert Florin, MD Award for Excellence in Research, American Association of Neurological Surgeons (2010)
  • Brandeis University Health Policy Leaders Program Scholarship, American College of Surgeons (2009)
  • Chicago Institute for Neurosurgery and Neuroresearch Foundation Research Grant, Chicago Institute of Neurosurgery and Neuroresearch Foundation (2003)

Professional Education


  • Medical Education: Tulane University School of Medicine Registrar (1995) LA
  • Board Certification: American Board of Neurological Surgery, Neurological Surgery (2005)
  • Fellowship: New York University Medical Center (2002) NY
  • Residency: Louisiana State University - New Orleans (2001) LA
  • Internship: Louisiana State University - New Orleans (1996) LA
  • MD, Tulane Medical School, Medicine (1995)

Current Research and Scholarly Interests


At present, I am working on a prospective measure to assess the risk of complications in spine surgery procedures. I am studying the impact of patient disease process, choice of operative approach, and patient pre-operative comorbidities on complication occurrence. The goal of this effort will be to develop a clinical tool that may be used in patient counseling.

Presently, a prospectively developed measure of comorbidities is being modeled to ICD-9 nomencature for use in the Nationwide Inpatient Sample database.

My longer term research goals are to develop clearer means of assessing outcomes in spine surgery procedures and developing patient-centered outcomes assessments that may be scalable for larger populations.

Clinical Trials


  • MR Guided High Intensity Focused Ultrasound for Lumbar Back Pain Not Recruiting

    The primary purpose of this protocol is to assess the ExAblate 2100 MR guided high intensity focused ultrasound device as an intervention for treatment of facetogenic lower back pain.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kara Richardson, 650-561-5237.

    View full details

  • Restore CLINICAL TRIAL Not Recruiting

    This is a prospective, concurrently controlled, multi-center study to evaluate the safety and effectiveness of the Spinal Kinetics M6-C artificial cervical disc compared to anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical radiculopathy with or without cord compression. Some participating sites will enroll just M6-C patients, while others will enroll just ACDF patients. Patients eligible for study enrollment will present with degenerative cervical radiculopathy requiring surgical intervention, confirmed clinically and radiographically, at one vertebral level from C3 to C7. A total of 243 subjects will be included at up to 20 sites.

    Stanford is currently not accepting patients for this trial. For more information, please contact Kara Richardson, 650-736-6171.

    View full details

2023-24 Courses


Stanford Advisees


All Publications


  • Health Care Resource Utilization in Management of Opioid-Naive Patients With Newly Diagnosed Neck Pain. JAMA network open Jin, M. C., Jensen, M., Zhou, Z., Rodrigues, A., Ren, A., Barros Guinle, M. I., Veeravagu, A., Zygourakis, C. C., Desai, A. M., Ratliff, J. K. 2022; 5 (7): e2222062

    Abstract

    Importance: Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain.Objective: To understand health care utilization in patients with new-onset idiopathic neck pain.Design, Setting, and Participants: This cross-sectional study used nationally sourced longitudinal data from the IBM Watson Health MarketScan claims database (2007-2016). Participants included adult patients with newly diagnosed neck pain, no recent opioid use, and at least 1 year of continuous postdiagnosis follow-up. Exclusion criteria included prior or concomitant diagnosis of traumatic cervical disc dislocation, vertebral fractures, myelopathy, and/or cancer. Only patients with at least 1 year of prediagnosis lookback were included. Data analysis was performed from January 2021 to January 2022.Main Outcomes and Measures: The primary outcome of interest was 1-year postdiagnosis health care expenditures, including costs, opioid use, and health care service utilization. Early services were those received within 30 days of diagnosis. Multivariable regression models and regression-adjusted statistics were used.Results: In total, 679 030 patients (310 665 men [45.6%]) met the inclusion criteria, of whom 7858 (1.2%) underwent surgery within 1 year of diagnosis. The mean (SD) age was 44.62 (14.87) years among nonsurgical patients and 49.69 (9.53) years among surgical patients. Adjusting for demographics and comorbidities, 1-year regression-adjusted health care costs were $24 267.55 per surgical patient and $515.69 per nonsurgical patient. Across all health care services, $95 379 949 was accounted for by nonsurgical patients undergoing early imaging who did not receive any additional conservative therapy or epidural steroid injections, for a mean (SD) of $477.53 ($1375.60) per patient and median (IQR) of $120.60 ($20.70-$452.37) per patient. On average, patients not undergoing surgery, physical therapy, chiropractic manipulative therapy, or epidural steroid injection, who underwent either early advanced imaging (magnetic resonance imaging or computed tomography) or both early advanced and radiographic imaging, accumulated significantly elevated health care costs ($850.69 and $1181.67, respectively). Early conservative therapy was independently associated with 24.8% (95% CI, 23.5%-26.2%) lower health care costs.Conclusions and Relevance: In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.

    View details for DOI 10.1001/jamanetworkopen.2022.22062

    View details for PubMedID 35816312

  • Expenditures and Health Care Utilization Among Adults With Newly Diagnosed Low Back and Lower Extremity Pain. JAMA network open Kim, L. H., Vail, D. n., Azad, T. D., Bentley, J. P., Zhang, Y. n., Ho, A. L., Fatemi, P. n., Feng, A. n., Varshneya, K. n., Desai, M. n., Veeravagu, A. n., Ratliff, J. K. 2019; 2 (5): e193676

    Abstract

    Low back pain (LBP) with or without lower extremity pain (LEP) is one of the most common reasons for seeking medical care. Previous studies investigating costs in this population targeted patients receiving surgery. Little is known about health care utilization among patients who do not undergo surgery.To assess use of health care resources for LBP and LEP management and analyze associated costs.This cohort study used a retrospective analysis of a commercial database containing inpatient and outpatient data for more than 75 million individuals. Participants were US adults who were newly diagnosed with LBP or LEP between 2008 and 2015, did not have a red-flag diagnosis, and were opiate naive prior to diagnosis. Dates of analysis were October 6, 2018, to March 7, 2019.Newly diagnosed LBP or LEP.The primary outcome was total cost of care within the first 6 and 12 months following diagnosis, stratified by whether patients received spinal surgery. An assessment was performed to determine whether patients who did not undergo surgery received care in accordance with proposed guidelines for conservative LBP and LEP management. Costs resulting from use of different health care services were estimated.A total of 2 498 013 adult patients with a new LBP or LEP diagnosis (median [interquartile range] age, 47 [36-58] years; 1 373 076 [55.0%] female) were identified. More than half (55.7%) received no intervention. Only 1.2% of patients received surgery, but they accounted for 29.3% of total 12-month costs ($784 million). Total costs of care among the 98.8% of patients who did not receive surgery were $1.8 billion. Patients who did not undergo surgery frequently received care that was inconsistent with clinical guidelines for LBP and LEP: 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy.The findings suggest that surgery is rare among patients with newly diagnosed LBP and LEP but remains a significant driver of spending. Early imaging in patients who do not undergo surgery was also a major driver of increased health care expenditures. Avoidable costs among patients with typically self-limited conditions result in considerable economic burden to the US health care system.

    View details for PubMedID 31074820

  • A machine learning approach for predictive models of adverse events following spine surgery. The spine journal : official journal of the North American Spine Society Han, S. S., Azad, T. D., Suarez, P. A., Ratliff, J. K. 2019

    Abstract

    Rates of adverse events following spine surgery vary widely by patient-, diagnosis-, and procedure-related factors. It is critical to understand the expected rates of complications and to be able to implement targeted efforts at limiting these events.To develop and evaluate a set of predictive models for common adverse events after spine surgery.A retrospective cohort study PATIENT SAMPLES: We extracted 345,510 patients from the Truven MarketScan (MKS) and MarketScan Medicaid Databases and 760,724 patients from the Centers for Medicare and Medicaid Services (CMS) Medicare database who underwent spine surgeries between 2009 and 2013.Overall adverse event (AE) occurrence and types of AE occurrence during the 30-day post-operative follow-up.We applied a least absolute shrinkage and selection operator (LASSO) regularization method and a logistic regression approach for predicting the risks of an overall AE and the top six most commonly observed AEs. Predictors included patient demographics, location of the spine procedure, comorbidities, type of surgery performed, and pre-operative diagnosis.The median ages of MKS and CMS patients were 49 years and 69, respectively. The most frequent individual AE was a cardiac dysfunction in CMS (10.6%) patients and a pulmonary complication (4.7%) in MKS. The AUC of a prediction model for an overall AE was 0.7. Among the six individual prediction models, the model for predicting the risk of a pulmonary complication showed the greatest accuracy (AUC 0.76), and the range of AUC for these six models was 0.7 and 0.76. Medicaid status was one of the most important factors in predicting the occurrences of AEs; Medicaid recipients had increased odds of AEs by 20-60% compared to non-Medicaid patients (odds ratios: 1.28-1.6; P<10-10). Logistic regression showed higher AUCs than LASSO across these different models.We present a set of predictive models for AEs following spine surgery that account for patient-, diagnosis-, and procedure-related factors which can contribute to patient-counseling, accurate risk adjustment, and accurate quality metrics.

    View details for DOI 10.1016/j.spinee.2019.06.018

    View details for PubMedID 31229662

  • Intracranial Hemorrhage in Deep Vein Thrombosis/Pulmonary Embolus Patients Without Atrial Fibrillation: Direct Oral Anticoagulants Versus Warfarin. Stroke Lamsam, L., Sussman, E. S., Iyer, A. K., Bhambhvani, H. P., Han, S. S., Skirboll, S., Ratliff, J. K. 2018

    Abstract

    BACKGROUND AND PURPOSE: Deep vein thrombosis (DVTs) is a common disease with high morbidity if it progresses to pulmonary embolus (PE). Anticoagulation is the treatment of choice; warfarin has long been the standard of care. Early experience with direct oral anticoagulants (DOACs) suggests that these agents may be may be a safer and equally effective alternative in the treatment of DVT/PE. Nontraumatic intracranial hemorrhage (ICH) is one of the most devastating potential complications of anticoagulation therapy. We sought to compare the rates of ICH in patients treated with DOACs versus those treated with warfarin for DVT/PE.METHODS: The MarketScan Commercial Claims and Medicare Supplemental databases were used. Adult DVT/PE patients without known atrial fibrillation and with prescriptions for either a DOAC or warfarin were followed for the occurrence of inpatient admission for ICH. Coarsened exact matching was used to balance the treatment cohorts. Cox proportional-hazards regressions and Kaplan-Meier survival curves were used to estimate the association between DOACs and the risk of ICH compared with warfarin.RESULTS: The combined cohort of 218 620 patients had a median follow-up of 3.0 months, mean age of 55.4 years, and was 52.1% women. The DOAC cohort had 26 980 patients and 8 ICH events (1.0 cases per 1000 person-years), and the warfarin cohort had 191 640 patients and 324 ICH events (3.3 cases per 1000 person-years; P<0.0001). The DOAC cohort had a lower hazard ratio for ICH compared with warfarin in both the unmatched (hazard ratio=0.26; P=0.0002) and matched (hazard ratio=0.20; P=0.0001) Cox proportional-hazards regressions.CONCLUSIONS: DOACs show superior safety to warfarin in terms of risk of ICH in patients with DVT/PE.

    View details for PubMedID 29991654

  • Initial Provider Specialty is Associated with Long-term Opiate Use in Patients with Newly Diagnosed Low Back and Lower Extremity Pain. Spine Azad, T. n., Vail, D. n., Bentley, J. n., Han, S. n., Suarez, P. n., Varshneya, K. n., Mittal, V. n., Veeravagu, A. n., Desai, M. n., Bhattacharya, J. n., Ratliff, J. n. 2018

    Abstract

    Retrospective longitudinal cohort analysis of patients diagnosed in 2010, with continuous enrollment six months prior to and 12 months following the initial visit.To determine whether provider specialty influences patterns of opiate utilization long after initial diagnosis.Patients with low back pain present to a variety of providers and receive a spectrum of treatments, including opiate medications. The impact of initial provider type on opiate use in this population is uncertain.We performed a retrospective analysis of opiate-naïve adult patients in the United States with newly diagnosed low back or lower extremity pain. We estimated the risk of early opiate prescription (≤ 14 days from diagnosis) and long-term opiate use (≥ six prescriptions in 12 months) based on the provider type at initial diagnosis using multivariable logistic regression, adjusting for patient demographics and comorbidities.We identified 478,981 newly diagnosed opiate-naïve patients. Of these, 40.4% received an opiate prescription within one year and 4.0% met criteria for long-term use. The most common initial provider type was family practice, associated with a 24.4% risk of early opiate prescription (95% CI, 24.1-24.6) and a 2.0% risk of long-term opiate use (95% CI, 2.0-2.1). Risk of receiving an early opiate prescription was higher among patients initially diagnosed by emergency medicine (43.1%; 95% CI, 41.6-44.5) or at an urgent care facility (40.8%; 95% CI, 39.4-42.3). Risk of long-term opiate use was highest for patients initially diagnosed by pain management/anesthesia (6.7%; 95% CI, 6.0-7.3) or physical medicine and rehabilitation (3.4%; 95% CI, 3.1-3.8) providers.Initial provider type influences early opiate prescription and long-term opiate use among opiate-naïve patients with newly diagnosed low back and lower extremity pain.3.

    View details for PubMedID 30095796

  • Predicting complication risk in spine surgery: a prospective analysis of a novel risk assessment tool. Journal of neurosurgery. Spine Veeravagu, A., Li, A., Swinney, C., Tian, L., Moraff, A., Azad, T. D., Cheng, I., Alamin, T., Hu, S. S., Anderson, R. L., Shuer, L., Desai, A., Park, J., Olshen, R. A., Ratliff, J. K. 2017: 1-11

    Abstract

    OBJECTIVE The ability to assess the risk of adverse events based on known patient factors and comorbidities would provide more effective preoperative risk stratification. Present risk assessment in spine surgery is limited. An adverse event prediction tool was developed to predict the risk of complications after spine surgery and tested on a prospective patient cohort. METHODS The spinal Risk Assessment Tool (RAT), a novel instrument for the assessment of risk for patients undergoing spine surgery that was developed based on an administrative claims database, was prospectively applied to 246 patients undergoing 257 spinal procedures over a 3-month period. Prospectively collected data were used to compare the RAT to the Charlson Comorbidity Index (CCI) and the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator. Study end point was occurrence and type of complication after spine surgery. RESULTS The authors identified 69 patients (73 procedures) who experienced a complication over the prospective study period. Cardiac complications were most common (10.2%). Receiver operating characteristic (ROC) curves were calculated to compare complication outcomes using the different assessment tools. Area under the curve (AUC) analysis showed comparable predictive accuracy between the RAT and the ACS NSQIP calculator (0.670 [95% CI 0.60-0.74] in RAT, 0.669 [95% CI 0.60-0.74] in NSQIP). The CCI was not accurate in predicting complication occurrence (0.55 [95% CI 0.48-0.62]). The RAT produced mean probabilities of 34.6% for patients who had a complication and 24% for patients who did not (p = 0.0003). The generated predicted values were stratified into low, medium, and high rates. For the RAT, the predicted complication rate was 10.1% in the low-risk group (observed rate 12.8%), 21.9% in the medium-risk group (observed 31.8%), and 49.7% in the high-risk group (observed 41.2%). The ACS NSQIP calculator consistently produced complication predictions that underestimated complication occurrence: 3.4% in the low-risk group (observed 12.6%), 5.9% in the medium-risk group (observed 34.5%), and 12.5% in the high-risk group (observed 38.8%). The RAT was more accurate than the ACS NSQIP calculator (p = 0.0018). CONCLUSIONS While the RAT and ACS NSQIP calculator were both able to identify patients more likely to experience complications following spine surgery, both have substantial room for improvement. Risk stratification is feasible in spine surgery procedures; currently used measures have low accuracy.

    View details for DOI 10.3171/2016.12.SPINE16969

    View details for PubMedID 28430052

  • An assessment of data and methodology of online surgeon scorecards JOURNAL OF NEUROSURGERY-SPINE Xu, L. W., Li, A., Swinney, C., Babu, M., Veeravagu, A., Wolfe, S. Q., Nahed, B. V., Ratliff, J. K. 2017; 26 (2): 235-242

    Abstract

    OBJECTIVE Recently, 2 surgeon rating websites (Consumers' Checkbook and ProPublica) were published to allow the public to compare surgeons through identifying surgeon volume and complication rates. Among neurosurgeons and orthopedic surgeons, only cervical and lumbar spine, hip, and knee procedures were included in this assessment. METHODS The authors examined the methodology of each website to assess potential sources of inaccuracy. Each online tool was queried for reports on neurosurgeons specializing in spine surgery and orthopedic surgeons specializing in spine, hip, or knee surgery. Surgeons were chosen from top-ranked hospitals in the US, as recorded by a national consumer publication ranking system, within the fields of neurosurgery and orthopedic surgery. The results were compared for accuracy and surgeon representation, and the results of the 2 websites were also compared. RESULTS The methodology of each site was found to have opportunities for bias and limited risk adjustment. The end points assessed by each site were actually not complications, but proxies of complication occurrence. A search of 510 surgeons (401 orthopedic surgeons [79%] and 109 neurosurgeons [21%]) showed that only 28% and 56% of surgeons had data represented on Consumers' Checkbook and ProPublica, respectively. There was a significantly higher chance of finding surgeon data on ProPublica (p < 0.001). Of the surgeons from top-ranked programs with data available, 17% were quoted to have high complication rates, 13% with lower volume than other surgeons, and 79% had a 3-star out of 5-star rating. There was no significant correlation found between the number of stars a surgeon received on Consumers' Checkbook and his or her adjusted complication rate on ProPublica. CONCLUSIONS Both the Consumers' Checkbook and ProPublica websites have significant methodological issues. Neither site assessed complication occurrence, but rather readmissions or prolonged length of stay. Risk adjustment was limited or nonexistent. A substantial number of neurosurgeons and orthopedic surgeons from top-ranked hospitals have no ratings on either site, or have data that suggests they are low-volume surgeons or have higher complication rates. Consumers' Checkbook and ProPublica produced different results with little correlation between the 2 websites in how surgeons were graded. Given the significant methodological issues, incomplete data, and lack of appropriate risk stratification of patients, the featured websites may provide erroneous information to the public.

    View details for DOI 10.3171/2016.7.SPINE16183

    View details for Web of Science ID 000393088900015

  • Predicting Occurrence of Spine Surgery Complications Using "Big Data" Modeling of an Administrative Claims Database JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Ratliff, J. K., Balise, R., Veeravagu, A., Cole, T. S., Cheng, I., Olshen, R. A., Tian, L. 2016; 98 (10): 824-834

    Abstract

    Postoperative metrics are increasingly important in determining standards of quality for physicians and hospitals. Although complications following spinal surgery have been described, procedural and patient variables have yet to be incorporated into a predictive model of adverse-event occurrence. We sought to develop a predictive model of complication occurrence after spine surgery.We used longitudinal prospective data from a national claims database and developed a predictive model incorporating complication type and frequency of occurrence following spine surgery procedures. We structured our model to assess the impact of features such as preoperative diagnosis, patient comorbidities, location in the spine, anterior versus posterior approach, whether fusion had been performed, whether instrumentation had been used, number of levels, and use of bone morphogenetic protein (BMP). We assessed a variety of adverse events. Prediction models were built using logistic regression with additive main effects and logistic regression with main effects as well as all 2 and 3-factor interactions. Least absolute shrinkage and selection operator (LASSO) regularization was used to select features. Competing approaches included boosted additive trees and the classification and regression trees (CART) algorithm. The final prediction performance was evaluated by estimating the area under a receiver operating characteristic curve (AUC) as predictions were applied to independent validation data and compared with the Charlson comorbidity score.The model was developed from 279,135 records of patients with a minimum duration of follow-up of 30 days. Preliminary assessment showed an adverse-event rate of 13.95%, well within norms reported in the literature. We used the first 80% of the records for training (to predict adverse events) and the remaining 20% of the records for validation. There was remarkable similarity among methods, with an AUC of 0.70 for predicting the occurrence of adverse events. The AUC using the Charlson comorbidity score was 0.61. The described model was more accurate than Charlson scoring (p < 0.01).We present a modeling effort based on administrative claims data that predicts the occurrence of complications after spine surgery.We believe that the development of a predictive modeling tool illustrating the risk of complication occurrence after spine surgery will aid in patient counseling and improve the accuracy of risk modeling strategies.

    View details for DOI 10.2106/JBJS.15.00301

    View details for Web of Science ID 000378644500009

    View details for PubMedID 27194492

  • Building an electronic health record integrated quality of life outcomes registry for spine surgery JOURNAL OF NEUROSURGERY-SPINE Azad, T. D., Kalani, M., Wolf, T., Kearney, A., Lee, Y., Flannery, L., Chen, D., Berroya, R., Eisenberg, M., Park, J., Shuer, L., Kerr, A., Ratliff, J. K. 2016; 24 (1): 176-185

    Abstract

    Demonstrating the value of spine care requires adequate outcomes assessment. Long-term outcomes are best measured as overall improvement in quality of life (QOL) after surgical intervention. Present registries often require parallel data entry, introducing inefficiencies and limiting compliance. The authors detail the methodology of constructing an integrated electronic health record (EHR) system to collect QOL metrics and demonstrate the effect of data collection on routine clinical workflow. A streamlined approach to collecting QOL data can capture patient data without requiring dual data entry and without increasing clinic visit times.Through extensive literature review, a combination of QOL assessments was selected, consisting of the Patient Health Questionnaire-2 and -9, Oswestry Disability Index, Neck Disability Index, and visual analog scale for pain. These metrics were used to provide assessment of QOL following spine surgery and were incorporated into standard clinic workflow by a multidisciplinary team of surgeons, advanced practice providers, and health care information technology specialists. A clinical dashboard tracking more than 25 patient variables was developed. Clinic flow was assessed and opportunities for improvement reviewed. Duration of clinic visits before and after initiation of QOL measure capture was recorded, with assessment of mean clinic visit times for the 12 months before and the 12 months after implementation.The integrated QOL capture was instituted for 3 spine surgeons in a tertiary care academic center. In the 12-month period prior to initiating collection of QOL data, 806 new patient visits were completed with an average visit time of 127.9 ± 51.5 minutes. In the 12 months after implementation, 1013 new patient visits were recorded, with 791 providing QOL measures with an average visit time of 117.0 ± 45.7 minutes. Initially the primary means of collecting patient outcome data was via paper form, with gradual transition to collection via entry into the electronic medical records system. To improve electronic data capture, paper forms were eliminated and an online portal used as part of the patient rooming process. This improved electronic capture to nearly 98% without decreasing the number of patients enrolled in the process.A systematic approach to collecting spine-related QOL data within an EHR system is feasible and offers distinct advantages over registries that require dual data entry. The process of data collection does not impact patients' clinical visit or providers' clinical workflow. This approach is scalable, and may form the foundation for a decentralized outcomes registry network.

    View details for DOI 10.3171/2015.3.SPINE141127

    View details for Web of Science ID 000367028000022

    View details for PubMedID 26431073

  • Intraoperative Neuromonitoring in Single-Level Spinal Procedures A Retrospective Propensity Score-Matched Analysis in a National Longitudinal Database SPINE Cole, T., Veeravagu, A., Zhang, M., Li, A., Ratliff, J. K. 2014; 39 (23): 1950-1959

    Abstract

    Study Design. Retrospective propensity score-matched analysis on a national database (MarketScan) between 2006 and 2010.Objective. To compare rates of neurological deficits after elective single level spinal procedures with and without intraoperative neuromonitoring, as well as associated payment differences and geographic variance.Summary of Background Data. Intraoperative neurophysiologic monitoring is a technique that may contribute to avoiding permanent neurological injury during some spine surgery procedures. However, it is unclear if all patients undergoing spine surgery benefit from neuromonitoring.Methods. An identified 85,640 patients underwent single level spinal procedures including anterior cervical discectomy and fusion (ACDF), lumbar fusion, lumbar laminectomy, or lumbar discectomy. Neuromonitoring was identified with appropriate Current Procedural Terminology (CPT) codes. Cohorts were balanced on baseline comorbidities and procedure characteristics using propensity score matching. Trauma and spinal tumors cases were excluded.Results. 12.66% patients received neuromonitoring intraoperatively. Lumbar laminectomies had reduced 30-day neurological complication rate with neuromonitoring (0.0% vs 1.18%, p = 0.002). Neuromonitoring did not correlate with reduced intraoperative neurological complications in ACDFs (0.09% vs 0.13%), lumbar fusions (0.32% vs 0.58%), or lumbar discectomy (1.24% vs. 0.91%). With the addition of neuromonitoring, payments for ACDFs increased 16.24% ($3,842), lumbar fusions 7.84% ($3,540), lumbar laminectomies 24.33% ($3,704), and lumbar discectomies 22.54% ($2.859). Significant geographic variation was evident. Some states had no recorded single-level spinal cases with concurrent neuromonitoring. Rates for ACDFs and lumbar fusions, laminectomies, and discectomies ranged as high as 61%, 58%, 22%, and 21%, respectively.Conclusions. With intraoperative neurological monitoring in single level procedures, neurological complications were only decreased among lumbar laminectomies. No difference was observed in ACDFs, lumbar fusions, or lumbar discectomies. There was a significant increase in total payments associated with the index procedure and hospitalization. We demonstrate significant geographic variation in neuromonitoring.

    View details for DOI 10.1097/BRS.0000000000000593

    View details for Web of Science ID 000344606100014

  • Usage of Recombinant Human Bone Morphogenetic Protein in Cervical Spine Procedures: Analysis of the MarketScan Longitudinal Database. journal of bone and joint surgery. American volume Cole, T., Veeravagu, A., Jiang, B., Ratliff, J. K. 2014; 96 (17): 1409-1416

    Abstract

    Usage of recombinant human bone morphogenetic protein (rhBMP) in anterior cervical discectomy and fusion (ACDF) procedures is controversial. Studies suggest increased rates of dysphagia, hematoma or seroma, and severe airway compromise in anterior cervical spine procedures using rhBMP. The purpose of the present study was to determine and describe national utilization trends and complication rates associated with rhBMP usage in anterior cervical spine procedures.The MarketScan database from 2006 to 2010 was retrospectively queried to identify 91,543 patients who underwent ACDF with or without cervical corpectomy. Patient selection and outcomes were ascertained with use of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) and CPT (Current Procedural Terminology) coding. A total of 3197 patients were treated with rhBMP intraoperatively. Mean follow-up was 588 days (interquartile range [IQR], 205 to 886 days) in the non-treated cohort and 591 days (IQR, 203 to 925 days) in the rhBMP-treated cohort. Multivariate logistic regression as well as propensity score analysis were used to evaluate the association of rhBMP usage with postoperative complications.In propensity score-adjusted models, rhBMP usage was associated with an increased risk of any complication (odds ratio [OR] = 1.34, 95% confidence interval [CI] = 1.2 to 1.5) and specific complications such as hematoma or seroma (OR = 1.8, 95% CI = 1.4 to 2.3), dysphagia (OR = 1.3, 95% CI = 1.1 to 1.5), and any pulmonary complication (OR = 1.5, 95% CI = 1.2 to 1.8) within thirty days postoperatively. There were no significant differences in the rates of readmission, in-hospital mortality, referral to pain management, new malignancy, or reoperation between the two cohorts. Usage of rhBMP was associated with a mean increase of $5545 (19%) in total payments to the hospital and primary physician (p < 0.001).We found an increased overall rate of postoperative complications in patients receiving rhBMP for cervical spinal fusion procedures compared with patients not receiving rhBMP. Hematoma or seroma, pulmonary complications, and dysphagia were also more common in the rhBMP cohort. Usage of rhBMP in a case was associated with $311 greater payments to the surgeon and $4213 greater payments to the hospital.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.M.01016

    View details for PubMedID 25187578

  • The perils of comparative effectiveness, cost-effectiveness, and value of care research: lessons learned from washington state. Neurosurgery Ratliff, J. K. 2014; 61: 12-15

    View details for DOI 10.1227/NEU.0000000000000385

    View details for PubMedID 25032524

  • Impact of bone morphogenetic proteins on frequency of revision surgery, use of autograft bone, and total hospital charges in surgery for lumbar degenerative disease: review of the Nationwide Inpatient Sample from 2002 to 2008 SPINE JOURNAL Dagostino, P. R., Whitmore, R. G., Smith, G. A., Maltenfort, M. G., Ratliff, J. K. 2014; 14 (1): 20-30

    Abstract

    Bone morphogenetic proteins (BMPs) were developed with the goal of improving clinical outcomes through the promotion of bony healing and reducing morbidity from iliac crest bone graft harvest.To complete a population-based assessment of the impact of BMP on use of autograft, rates of operative treatment for lumbar pseudoarthrosis, and hospital charges.Nationwide Inpatient Sample (NIS) retrospective cohort assessment of 46,452 patients from 2002 to 2008.All patients who underwent lumbar arthrodesis procedures for degenerative spinal disease.Use of BMP, revision surgery status as a percentage of total procedures, and autograft harvest in lumbar fusion procedures completed for degenerative diagnoses.Demographic and geographic/practice data, hospital charges, and length of stay of all NIS patients with thoracolumbar and lumbosacral procedure codes for degenerative spinal diagnoses were recorded. Codes for autograft harvest, use of BMP, and revision surgery were included in multivariable regression analysis.The assessment found 46,452 patients from 2002 to 2008 undergoing thoracolumbar or lumbar arthrodesis procedures for degenerative disease. Assuming a representative sample, this cohort models more than 200,000 US patients. There was steady growth in lumbar spine fusion and in the use of BMP. The use of BMP increased from 2002 to 2008 (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.48-1.52). Revision procedures decreased over the study period (OR, 0.94; 95% CI, 0.91-0.96). The use of autograft decreased substantially after introduction of BMP but then returned to baseline levels; there was no net change in autograft use from 2002 to 2008. The use of BMP correlated with significant increases in hospital charges ($13,362.39; standard deviation ± 596.28, p<.00001). The use of BMP in degenerative thoracolumbar procedures potentially added more than $900 million to hospital charges from 2002 to 2008.There was an overall decrease in rates of revision fusion procedures from 2002 to 2008. Introduction of BMP did not correlate with decrease in use of autograft bone harvest. Use of BMP correlated with substantial increase in hospital charges. The small decrease in revision surgeries recorded, combined with lack of significant change in autograft harvest rates, may question the financial justification for the use of BMP.

    View details for DOI 10.1016/j.spinee.2012.10.035

    View details for Web of Science ID 000328496600007

    View details for PubMedID 23218827

  • ASA grade and Charlson Comorbidity Index of spinal surgery patients: correlation with complications and societal costs SPINE JOURNAL Whitmore, R. G., Stephen, J. H., Vernick, C., Campbell, P. G., Yadla, S., Ghobrial, G. M., Maltenfort, M. G., Ratliff, J. K. 2014; 14 (1): 31-38

    Abstract

    The Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) Physical Status Classification System (ASA grade) are useful for predicting morbidity and mortality for a variety of disease processes.To evaluate CCI and ASA grade as predictors of complications after spinal surgery and examine the correlation between these comorbidity indices and the cost of care.Prospective observational study.All patients undergoing any spine surgery at a single academic tertiary center over a 6-month period.Direct health-care costs estimated from diagnosis related group and Current Procedural Terminology (CPT) codes.Demographic data, including all patient comorbidities, procedural data, and all complications, occurring within 30 days of the index procedure were prospectively recorded. Charlson Comorbidity Index was calculated from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and ASA grades determined from the operative record. Diagnosis related group and CPT codes were captured for each patient. Direct costs were estimated from a societal perspective using Medicare rates of reimbursement. A multivariable analysis was performed to assess the association of the CCI and ASA grade to the rate of complication and direct health-care costs.Two hundred twenty-six cases were analyzed. The average CCI score for the patient cohort was 0.92, and the average ASA grade was 2.65. The CCI and ASA grade were significantly correlated, with Spearman ρ of 0.458 (p<.001). Both CCI and ASA grade were associated with increasing body mass index (p<.01) and increasing patient age (p<.0001). Increasing CCI was associated with an increasing likelihood of occurrence of any complication (p=.0093) and of minor complications (p=.0032). Increasing ASA grade was significantly associated with an increasing likelihood of occurrence of a major complication (p=.0035). Increasing ASA grade showed a significant association with increasing direct costs (p=.0062).American Society of Anesthesiologists and CCI scores are useful comorbidity indices for the spine patient population, although neither was completely predictive of complication occurrence. A spine-specific comorbidity index, based on ICD-9-CM coding that could be easily captured from patient records, and which is predictive of patient likelihood of complications and mortality, would be beneficial in patient counseling and choice of operative intervention.

    View details for DOI 10.1016/j.spinee.2013.03.011

    View details for Web of Science ID 000328496600008

    View details for PubMedID 23602377

  • Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study THE SPINE JOURNAL Veeravagu, A., Cole, T., Jiang, B., Ratliff, J. K. 2013
  • Patient comorbidity score predicting the incidence of perioperative complications: assessing the impact of comorbidities on complications in spine surgery Clinical article JOURNAL OF NEUROSURGERY-SPINE Campbell, P. G., Yadla, S., Nasser, R., Malone, J., Maltenfort, M. G., Ratliff, J. K. 2012; 16 (1): 37-43

    Abstract

    Present attempts to control health care costs focus on reducing the incidence of complications and hospital-acquired conditions (HACs). One approach uses restriction or elimination of hospital payments for HACs. Present approaches assume that all HACs are created equal and that payment restrictions should be applied uniformly. Patient factors, and especially patient comorbidities, likely impact complication incidence. The relationship of patient comorbidities and complication incidence in spine surgery has not been prospectively reported.The authors conducted a prospective assessment of complications in spine surgery during a 6-month period; an independent auditor and a validated definition of perioperative complications were used. Initial demographics captured relevant patient comorbidities. The authors constructed a model of relative risk assessment based on the presence of a variety of comorbidities. They examined the impact of specific comorbidities and the cumulative effect of multiple comorbidities on complication incidence.Two hundred forty-nine patients undergoing 259 procedures at a tertiary care facility were evaluated during the 6-month duration of the study. Eighty percent of the patients underwent fusion procedures. One hundred thirty patients (52.2%) experienced at least 1 complication, with major complications occurring in 21.4% and minor complications in 46.4% of the cohort. Major complications doubled the median duration of hospital stay, from 6 to 12 days in cervical spine patients and from 7 to 14 days in thoracolumbar spine patients. At least 1 comorbid condition was present in 86% of the patients. An increasing number of comorbidities strongly correlated with increased risk of major, minor, and any complications (p = 0.017, p < 0.0001, and p < 0.0001, respectively). Patient factors correlating with increased risk of specific complications included systemic malignancy and cardiac conditions other than hypertension.Comorbidities significantly increase the risk of perioperative complications. An increasing number of comorbidities in an individual patient significantly increases the risk of a perioperative adverse event. Patient factors significantly impact the relative risk of HACs and perioperative complications.

    View details for DOI 10.3171/2011.9.SPINE11283

    View details for Web of Science ID 000298631100009

    View details for PubMedID 22035101

  • Geographic variation and regional trends in adoption of endovascular techniques for cerebral aneurysms JOURNAL OF NEUROSURGERY Smith, G. A., Dagostino, P., Maltenfort, M. G., Dumont, A. S., Ratliff, J. K. 2011; 114 (6): 1768-1777

    Abstract

    Considerable evolution has occurred in treatment options for cerebral aneurysms. Development of endovascular techniques has produced a significant change in the treatment of ruptured and unruptured intracranial aneurysms. Adoption of endovascular techniques and increasing numbers of patients undergoing endovascular treatment may affect health care expenditures. Geographic assessment of growth in endovascular procedures has not been assessed.The National Inpatient Sample (NIS) was queried for ICD-9 codes for clipping and coiling of ruptured and unruptured cerebral aneurysms from 2002 to 2008. Patients with ruptured and unruptured cerebral aneurysms were compared according to in-hospital deaths, hospital length of stay, total hospital cost, and selected procedure. Hospital costs were adjusted to bring all costs to 2008 equivalents. Regional variation over the course of the study was explored.The NIS recorded 12,588 ruptured cerebral aneurysm cases (7318 clipped and 5270 coiled aneurysms) compared with 11,606 unruptured aneurysm cases (5216 clipped and 6390 coiled aneurysms), representing approximately 121,000 aneurysms treated in the study period. Linear regression analysis found that the number of patients treated endovascularly increased over time, with the total number of endovascular patients increasing from 17.28% to 57.59% for ruptured aneurysms and from 29.70% to 62.73% for unruptured aneurysms (p < 0.00001). Patient age, elective status, and comorbidities increased the likelihood of endovascular treatment (p < 0.00001, p < 0.00004, and p < 0.02, respectively). In patients presenting with subarachnoid hemorrhage (SAH), endovascular treatments were more commonly chosen in urban and academic medical centers (p = 0.009 and p = 0.05, respectively). In-hospital deaths decreased over the study period in patients with both ruptured and unruptured aneurysms (p < 0.00001); presentation with SAH remained the single greatest predictor of death (OR 38.09, p < 0.00001). Geographic analysis showed growth in endovascular techniques concentrated in eastern and western coastal states, with substantial variation in adoption of endovascular techniques (range of percentage of endovascular patients [2008] 0%-92%). There were higher costs in patients treated endovascularly, but these differences were likely secondary to presenting diagnosis and site-of-service variations.The NIS database reveals a significant increase in the use of endovascular techniques, with the majority of both ruptured and unruptured aneurysms treated endovascularly by 2008. Differences in hospital costs between open and endovascular techniques are likely secondary to patient and site-of-service factors. Presentation with SAH was the primary factor affecting hospital cost and a greater percentage of endovascular procedures completed at urban academic medical centers. There is substantial regional variation in the adoption of endovascular techniques.

    View details for Web of Science ID 000291123300051

    View details for PubMedID 21314274

  • Comparison of ICD-9 based, retrospective, and prospective assessments of perioperative complications assessment of accuracy in reporting Clinical article JOURNAL OF NEUROSURGERY-SPINE Campbell, P. G., Malone, J., Yadla, S., Chitale, R., Nasser, R., Maltenfort, M. G., Vaccaro, A., Ratliff, J. K. 2011; 14 (1): 16-22

    Abstract

    large studies of ICD-9-based complication and hospital-acquired condition (HAC) chart reviews have not been validated through a comparison with prospective assessments of perioperative adverse event occurrence. Retrospective chart review, while generally assumed to underreport complication occurrence, has not been subjected to prospective study. It is unclear whether ICD-9-based population studies are more accurate than retrospective reviews or are perhaps equally susceptible to bias. To determine the validity of an ICD-9-based assessment of perioperative complications, the authors compared a prospective independent evaluation of such complications with ICD-9-based HAC data in a cohort of patients who underwent spine surgery. For further comparison, a separate retrospective review of the same cohort of patients was completed as well.a prospective assessment of complications in spine surgery over a 6-month period (May to December 2008) was completed using an independent auditor and a validated definition of perioperative complications. The auditor maintained a prospective database, which included complications occurring in the initial 30 days after surgery. All medical adverse events were included in the assessment. All patients undergoing spine surgery during the study period were eligible for inclusion; the only exclusionary criterion used was the availability of the auditor for patient assessment. From the overall patient database, 100 patients were randomly extracted for further review; in these patients ICD-9-based HAC data were obtained from coder data. Separately, a retrospective assessment of complication incidence was completed using chart and electronic medical record review. The same definition of perioperative adverse events and the inclusion of medical adverse events were applied in the prospective, ICD-9-based, and retrospective assessments.ninety-two patients had adequate records for the ICD-9 assessment, whereas 98 patients had adequate chart information for retrospective review. The overall complication incidence among the groups was similar (major complications: ICD-9 17.4%, retrospective 19.4%, and prospective 22.4%; minor complications: ICD-9 43.8%, retrospective 31.6%, and prospective 42.9%). However, the ICD-9-based assessment included many minor medical events not deemed complications by the auditor. Rates of specific complications were consistently underreported in both the ICD-9 and the retrospective assessments. The ICD-9 assessment underreported infection, the need for reoperation, deep wound infection, deep venous thrombosis, and new neurological deficits (p = 0.003, p < 0.0001, p < 0.0001, p = 0.0025, and p = 0.04, respectively). The retrospective review underestimated incidences of infection, the need for revision, and deep wound infection (p < 0.0001 for each). Only in the capture of new cardiac events was ICD-9-based reporting more accurate than prospective data accrual (p = 0.04). The most sensitive measure for the appreciation of complication occurrence was the prospective review, followed by the ICD-9-based assessment (p = 0.05).an ICD-9-based coding of perioperative adverse events and major complications in a cohort of spine surgery patients revealed an overall complication incidence similar to that in a prospectively executed measure. In contrast, a retrospective review underestimated complication incidence. The ICD-9-based review captured many medical events of limited clinical import, inflating the overall incidence of adverse events demonstrated by this approach. In multiple categories of major, clinically significant perioperative complications, ICD-9-based and retrospective assessments significantly underestimated complication incidence. These findings illustrate a significant potential weakness and source of inaccuracy in the use of population-based ICD-9 and retrospective complication recording.

    View details for DOI 10.3171/2010.9.SPINE10151

    View details for Web of Science ID 000285669700007

    View details for PubMedID 21142455

  • Getting What You Pay For: Impact of Copayments on Physical Therapy and Opioid Initiation, Timing, and Continuation for Newly Diagnosed Low Back Pain. The spine journal : official journal of the North American Spine Society Jin, M. C., Jensen, M., Barros Guinle, M. I., Ren, A., Zhou, Z., Zygourakis, C. C., Desai, A. M., Veeravagu, A., Ratliff, J. K. 2024

    Abstract

    Physical therapy (PT) is an important component of low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common.We sought to understand how copayments impact timing and utilization of PT in newly diagnosed LBP.The IBM Watson Health MarketScan claims database was utilized in a longitudinal setting.Adult patients with LBP.The primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing.Actual and inferred copayments based on non-PCP visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage.Overall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days post-diagnosis (IQR 1-55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use (0.77 prescriptions/patient [$0 PT copayment] vs 1.07 prescriptions/patient [$50-74 PT copayment]; 1.15 prescriptions/patient [$75+ PT copayment]). Among patients with known opioid and PT copayments, higher PT copayments were correlated with faster opioid use while higher opioid copayments were correlated with faster PT use (Spearman p < 0.05). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50-75th and 75th-100th percentiles was significantly lower than those below the 50th percentile (HR=0.893 [95%CI 0.887-0.899] and HR=0.905 [95%CI 0.899-0.912], respectively).Higher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Co-pays may impact long-term adherence to PT.

    View details for DOI 10.1016/j.spinee.2024.01.008

    View details for PubMedID 38262499

  • Factors affecting retirement and workforce attrition in neurosurgery: results of a Council of State Neurosurgical Societies national survey. Journal of neurosurgery Sharma, A. M., Tenny, S., Yang, G. L., Cheng, J., Ratliff, J. K., Steinmetz, M. P., Krishnamurthy, S., Adogwa, O., Swartz, K. 2023: 1-10

    Abstract

    By 2030, the US will not have enough neurosurgeons to meet the clinical needs of its citizens. Replacement of neurosurgeons due to attrition can take more than a decade, given the time-intensive training process. To identify potential workforce retention targets, the authors sought to identify factors that might impact neurosurgeons' retirement considerations.The Council of State Neurosurgical Societies surveyed practicing AANS-registered neurosurgeons via email link to an online form with 25 factors that were ranked using a Likert scale of importance regarding retirement from the field (ranging from 1 for not important to 3 for very important). All participants were asked: "If you could afford it, would you retire today?"A total of 447 of 3200 neurosurgeons (14%) responded; 6% had been in practice for less than 5 years, 19% for 6-15 years, 57% for 16-30 years, and 18% for more than 30 years. Practice types included academic (18%), hospital employed (31%), independent with academic appointment (9%), and full independent practice (39%). The most common practice size was between 2 and 5 physicians (46%), with groups of 10 or more being the next most common (20%). Career satisfaction, income, and the needs of patients were rated as the most important factors keeping neurosurgeons in the workforce. Increasing regulatory burden, decreasing clinical autonomy, and the burden of insurance companies were the highest rated for factors important in considering retirement. Subgroup analysis by career stage, practice size, practice type, and geographic region revealed no significant difference in responses. When considering if they would retire now, 45% of respondents answered "yes." Subgroup analysis revealed that midcareer neurosurgeons (16-25 years in practice) were more likely to respond "yes" than those just entering their careers or in practice for more than 25 years (p = 0.03). This effect was confirmed in multivariate logistic regression (p = 0.04). These surgeons found professional satisfaction (p = 0.001), recertification requirements (p < 0.001), and maintaining high levels of income (p = 0.008) important to maintaining employment within the neurosurgical workforce.This study demonstrates that midcareer neurosurgeons may benefit from targeted retention efforts. This effort should focus on maximizing professional satisfaction and financial independence, while decreasing the regulatory burden associated with certification and insurance authorization. End-of-career surgeons should be surveyed to determine factors contributing to resilience and persistence within the neurosurgical workforce.

    View details for DOI 10.3171/2023.7.JNS231117

    View details for PubMedID 37657112

  • Contemporary Trends in Minimally Invasive Sacroiliac Joint Fusion Utilization in the Medicare Population by Specialty. Neurosurgery Hersh, A. M., Jimenez, A. E., Pellot, K. I., Gong, J. H., Jiang, K., Khalifeh, J. M., Ahmed, A. K., Raad, M., Veeravagu, A., Ratliff, J. K., Jain, A., Lubelski, D., Bydon, A., Witham, T. F., Theodore, N., Azad, T. D. 2023

    Abstract

    Sacroiliac (SI) joint dysfunction constitutes a leading cause of pain and disability. Although surgical arthrodesis is traditionally performed under open approaches, the past decade has seen a rise in minimally invasive surgical (MIS) techniques and new federally approved devices for MIS approaches. In addition to neurosurgeons and orthopedic surgeons, proceduralists from nonsurgical specialties are performing MIS procedures for SI pathology. Here, we analyze trends in SI joint fusions performed by different provider groups, along with trends in the charges billed and reimbursement provided by Medicare.We review yearly Physician/Supplier Procedure Summary data from 2015 to 2020 from the Centers for Medicare and Medicaid Services for all SI joint fusions. Patients were stratified as undergoing MIS or open procedures. Utilization was adjusted per million Medicare beneficiaries and weighted averages for charges and reimbursements were calculated, controlling for inflation. Reimbursement-to-charge (RCR) ratios were calculated, reflecting the proportion of provider billed amounts reimbursed by Medicare.A total of 12 978 SI joint fusion procedures were performed, with the majority (76.5%) being MIS procedures. Most MIS procedures were performed by nonsurgical specialists (52.1%) while most open fusions were performed by spine surgeons (71%). Rapid growth in MIS procedures was noted for all specialty categories, along with an increased number of procedures offered in the outpatient setting and ambulatory surgical centers. The overall RCR increased over time and was ultimately similar between spine surgeons (RCR = 0.26) and nonsurgeon specialists (RCR = 0.27) performing MIS procedures.Substantial growth in MIS procedures for SI pathology has occurred in recent years in the Medicare population. This growth can largely be attributed to adoption by nonsurgical specialists, whose reimbursement and RCR increased for MIS procedures. Future studies are warranted to better understand the impact of these trends on patient outcomes and costs.

    View details for DOI 10.1227/neu.0000000000002564

    View details for PubMedID 37306413

  • Letter: Commentary: The Anatomy of Disvalued Codes: The 63047 and the 22633. Neurosurgery Ratliff, J. K., Tumialan, L. M., Orrico, K. O., Cheng, J. S. 2023

    View details for DOI 10.1227/neu.0000000000002526

    View details for PubMedID 37204228

  • Objective outcome measures may demonstrate continued change in functional recovery in patients with ceiling effects of subjective patient-reported outcome measures after surgery for lumbar degenerative disorders. The spine journal : official journal of the North American Spine Society Ziga, M., Sosnova, M., Zeitlberger, A. M., Regli, L., Bozinov, O., Weyerbrock, A., Ratliff, J. K., Stienen, M. N., Maldaner, N. 2023

    Abstract

    BACKGROUND CONTEXT: The 6-minute walking test (6WT) has been previously shown to be a reliable and valid outcome measure. It is unclear if the 6WT may further help to detect differences in well performing patients that reach a ceiling effect in PROMs after surgery.PURPOSE: To evaluate changes and timing of change in objective functional impairment (OFI) as measured with the smartphone-based 6WT in relation to patient-reported outcome measures (PROMs) after surgery for degenerative lumbar disorders (DLD) STUDY DESIGN: Prospective observational cohort study PATIENT SAMPLE: 50 consecutive patients undergoing surgery for degenerative lumbar disorders OUTCOME MEASURES: Patients self-determined their objective functional impairment using the 6-minute Walking Test application (6WT-app) and completed a set of paper-based patient-reported outcome measures (PROMs) before, six weeks and 3 months after surgery.METHODS: 50 patients undergoing surgery for DLD were assessed preoperatively (baseline), 6 weeks (6W) and 3 months (3M) postoperatively. Paired sample t-tests were used to establish significant changes in raw 6-minute walking distance (6WD) and standardised z-scores, as well as PROMs. Pearson correlation coefficient was used to define the relationship between 6WT and PROMs. Floor and ceiling effects were assessed for each PROM (Visual Analogue Scale - VAS, Core Outcome Measure Index - COMI, Zurich Claudication Questionnaire - ZCQ).RESULTS: Mean 6WT results improved from 377m (standard deviation - SD 137; z-score: 1.8, SD 1.8) to 490m (SD 126; -0.7, SD 1.5) and 518m (SD 112; -0.4, SD 1.41; all p < 0.05) at 6W and 3M follow-up. No significant improvement was observed between 6W and 3M for the ZCQ, VAS back and leg pain. While correlation between 6WT and all PROMs were weak at baseline, correlation coefficient increased to moderate at 3M. A considerable ceiling effect (best possible score) was observed, most notably for the ZCQ Physical Performance, VAS back and leg pain in 24%, 20% and 16% of patient at 6W and in 30%, 24% and 28% at 3M.CONCLUSION: Objective functional tests can describe the continued change in the physical recovery of a patient and may help to detect differences in well performing groups as well as in cases where patients' PROM results cannot further improve because of a ceiling effect.

    View details for DOI 10.1016/j.spinee.2023.05.002

    View details for PubMedID 37182704

  • Representativeness of the American Spine Registry: a comparison of patient characteristics with the National Inpatient Sample. Journal of neurosurgery. Spine Bydon, M., Sardar, Z. M., Michalopoulos, G. D., El Sammak, S., Chan, A. K., Carreon, L. Y., Norheim, E., Park, P., Ratliff, J. K., Tumialan, L., Pugely, A. J., Steinmetz, M. P., Hsu, W., Knightly, J. J., Ziegenhorn, D. M., Donnelly, P. C., Mullen, K. J., Rykowsky, S., De, A., Potts, E. A., Coric, D., Wang, M. Y., Qureshi, S., Sethi, R. K., Fu, K., Patel, A. A., Yoon, S. T., Brodke, D., Stroink, A. R., Bisson, E. F., Haid, R. W., Asher, A. L., Burton, D., Mummaneni, P. V., Glassman, S. D. 2023: 1-10

    Abstract

    OBJECTIVE: The American Spine Registry (ASR) is a collaborative effort between the American Academy of Orthopaedic Surgeons and the American Association of Neurological Surgeons. The goal of this study was to evaluate how representative the ASR is of the national practice with spinal procedures, as recorded in the National Inpatient Sample (NIS).METHODS: The authors queried the NIS and the ASR for cervical and lumbar arthrodesis cases performed during 2017-2019. International Classification of Diseases, 10th Revision and Current Procedural Terminology codes were used to identify patients undergoing cervical and lumbar procedures. The two groups were compared for the overall proportion of cervical and lumbar procedures, age distribution, sex, surgical approach features, race, and hospital volume. Outcomes available in the ASR, such as patient-reported outcomes and reoperations, were not analyzed due to nonavailability in the NIS. The representativeness of the ASR compared to the NIS was assessed via Cohen's d effect sizes, and absolute standardized mean differences (SMDs) of < 0.2 were considered trivial, whereas > 0.5 were considered moderately large.RESULTS: A total of 24,800 arthrodesis procedures were identified in the ASR for the period between January 1, 2017, and December 31, 2019. During the same time period, 1,305,360 cases were recorded in the NIS. Cervical fusions comprised 35.9% of the ASR cohort (8911 cases) and 36.0% of the NIS cohort (469,287 cases). The two databases presented trivial differences in terms of patient age and sex for all years of interest across both cervical and lumbar arthrodeses (SMD < 0.2). Trivial differences were also noted in the distribution of open versus percutaneous procedures of the cervical and lumbar spine (SMD < 0.2). Among lumbar cases, anterior approaches were more common in the ASR than in the NIS (32.1% vs 22.3%, SMD = 0.22), but the discrepancy among cervical cases in the two databases was trivial (SMD = 0.03). Small differences were illustrated in terms of race, with SMDs < 0.5, and a more significant discrepancy was identified in the geographic distribution of participating sites (SMDs of 0.7 and 0.74 for cervical and lumbar cases, respectively). For both of these measures, SMDs in 2019 were smaller than those in 2018 and 2017.CONCLUSIONS: The ASR and NIS databases presented a very high similarity in proportions of cervical and lumbar spine surgeries, as well as similar distributions of age and sex, and distribution of open versus endoscopic approach. Slight discrepancies in anterior versus posterior approach among lumbar cases and patient race, and more significant discrepancies in geographic representation were also identified, yet decreasing trends in differences suggested the improving representativeness of the ASR over the course of time and its progressive growth. These conclusions are important to underline the external validity of quality investigations and research conclusions to be drawn from analyses in which the ASR is used.

    View details for DOI 10.3171/2023.3.SPINE221264

    View details for PubMedID 37148235

  • Identification of Factors Associated With 30-Day Readmissions After Posterior Lumbar Fusion Using Machine Learning and Traditional Models: A National Longitudinal Database Study. Spine Rezaii, P. G., Herrick, D., Ratliff, J. K., Rusu, M., Scheinker, D., Desai, A. M. 2023

    Abstract

    STUDY DESIGN: Retrospective cohort study.OBJECTIVE: To identify factors associated with readmissions after PLF using machine learning and logistic regression (LR) models.SUMMARY OF BACKGROUND DATA: Readmissions following posterior lumbar fusion (PLF) place significant health and financial burden on the patient and overall healthcare system.METHODS: The Optum Clinformatics Data Mart database was used to identify patients who underwent posterior lumbar laminectomy, fusion, and instrumentation between 2004 and 2017. Four machine learning models and a multivariable LR model were used to assess factors most closely associated with 30-day readmission. These models were also evaluated in terms of ability to predict unplanned 30-day readmissions. The top performing model (Gradient Boosting Machine; GBM) was then compared to the validated LACE index in terms of potential cost savings associated with implementation of the model.RESULTS: A total of 18,981 patients were included, of which 3,080 (16.2%) were readmitted within 30 days of initial admission. Discharge status, prior admission, and geographic division were most influential for the LR model, while discharge status, length of stay, and prior admissions had greatest relevance for the GBM model. GBM outperformed LR in predicting unplanned 30-day readmission (mean AUC 0.865 vs. 0.850, P<0.0001). Use of GBM also achieved a projected 80% decrease in readmission-associated costs relative to those achieved by the LACE index model.CONCLUSIONS: Factors associated with readmission vary in terms of predictive influence based on standard logistic regression and machine learning models used, highlighting the complementary roles these models have in identifying relevant factors for prediction of 30-day readmissions. For posterior lumbar fusion procedures, Gradient Boosting Machine yielded greatest predictive ability and associated cost savings for readmission.LEVEL OF EVIDENCE: 3.

    View details for DOI 10.1097/BRS.0000000000004664

    View details for PubMedID 37027190

  • A Stepwise Replicable Approach to Negotiating Value-driven Supply Chain Contracts for Orthobiologics. The Journal of the American Academy of Orthopaedic Surgeons Gupta, A., Lee, J., Chawla, A., Rajagopalan, V., Kohler, M., Moelling, B., McFarlane, K. H., Sheth, K. R., Ratliff, J. K., Hu, S. S., Wall, J. K., Shea, K. G. 2023

    Abstract

    Orthobiologics are increasingly used to augment healing of tissues. Despite growing demand for orthobiologic products, many health systems do not enjoy substantial savings expected with high-volume purchases. The primary goal of this study was to evaluate an institutional program designed to (1) prioritize high-value orthobiologics and (2) incentivize vendor participation in value-driven contractual programs.A three-step approach was used to reduce costs through optimization of orthobiologics supply chain. First, surgeons with orthobiologics expertise were engaged in key supply chain purchasing decisions. Second, eight orthobiologics formulary categories were defined. Capitated pricing expectations were established for each product category. Capitated pricing expectations were established for each product using institutional invoice data and market pricing data. In comparison with similar institutions, products offered by multiple vendors were priced at a lower benchmark (10th percentile of market price) than more rare products priced at the 25th percentile of the market price. Pricing expectations were transparent to vendors. Third, a competitive bidding process required vendors to submit pricing proposals for products. Clinicians and supply chain leaders jointly awarded contracts to vendors that met pricing expectations.Compared with our projected estimate of $423,946 savings using capitated product prices, our actual annual savings was $542,216. Seventy-nine percent of savings came from allograft products. Although the number of total vendors decreased from 14 to 11, each of the nine returning vendors received a larger, three-year institutional contract. Average pricing decreased across seven of the eight formulary categories.This study demonstrates a three-step replicable approach to increase institutional savings for orthobiologic products, engaging clinician experts, and strengthening relationships with select vendors. Vendor consolidation permits a symbiotic win-win relationship: Health systems achieve increased value by reducing unnecessary complexity of multiple contracts, and vendors obtain larger contracts with increased market share.Level IV study.

    View details for DOI 10.5435/JAAOS-D-21-01008

    View details for PubMedID 36801893

  • Opioid usage in lumbar disc herniation patients with nonsurgical, early, and late surgical treatments. World neurosurgery Zhou, Z., Jin, M. C., Jensen, M. R., Barros Guinle, M. I., Ren, A., Agarwal, A. A., Leaston, J., Ratliff, J. K. 2023

    Abstract

    Assess opioid usage in surgical and non-surgical patients with lumbar disc herniation receiving different treatment approaches and timing.Individuals with newly diagnosed lumbar intervertebral disc without myelopathy were queried from Optum Clinformatics DataMart. Patients were categorized into 3 cohorts: nonsurgical, early surgery, and late surgery. Early surgery cohort patients had surgery within 30-days post-diagnosis; late surgery cohort patients had surgery after 30 days but before 1-year post-diagnosis. The index date was defined as the diagnosis date for nonsurgical patients, and the initial surgery date for surgical patients. The primary outcome was the average daily opioid morphine milligram equivalent (MME) prescribed. Additional outcomes included the percentage of opioid-using patients and cumulative opioid burden.A total of 573,082 patients met inclusion criteria: 533,226 patients received nonsurgical treatments, 22,312 patients received early surgery, and 17,544 patients received late surgery. Both surgical cohorts experienced a "post-surgical hump" of opioid usage, which then sharply declined and gradually plateaued, with daily opioid MME consistently lower in the early as opposed to late surgery cohort. The early surgery cohort also consistently had a lower prevalence of opioid-using patients than the late surgery cohort. Patients receiving nonsurgical demonstrated the highest one-year post-index cumulative opioid burden, and the early surgery cohort consistently had lower cumulative opioid MME than the late surgery cohort.Early surgery in lumbar disc herniation patients is associated with lower long-term average daily MME, incidence of opioid use, and one-year cumulative MME burden compared to nonsurgical and late surgery treatment approaches.

    View details for DOI 10.1016/j.wneu.2023.02.029

    View details for PubMedID 36775237

  • Trends, Payments, and Costs Associated with BMP Use in Medicare Beneficiaries Undergoing Spinal Fusion. The spine journal : official journal of the North American Spine Society Wadhwa, H., Wu, J. Y., Malacon, K., Ames, C., Ratliff, J., Zygourakis, C. 2023

    Abstract

    Bone morphogenic protein (BMP) promotes bony fusion but increases costs. Recent trends in BMP use among Medicare patients have not been well-characterized.To assess utilization trends, complication, payments, and costs associated with BMP use in spinal fusion in a Medicare-insured population.Retrospective cohort study PATIENT SAMPLE: : 316,070 patients who underwent spinal fusion in a 20% sample of Medicare-insured patients, 2006-2015 OUTCOME MEASURES: : Utilization trends across time and geography, complications, payments, and costs.Patients were stratified by fusion type and diagnosis. Multivariable logistic and linear regression were used to adjust for the effect of baseline characteristics on complications and total payments or cost, respectively.BMP was used in 60,249 cases (19.1%). BMP utilization rates decreased from 23.1% in 2006 to 12.0% in 2015, most significantly in anterior cervical (7.5% to 3.1%), posterior cervical (17.0% to 8.3%), and posterior lumbar fusions (31.5% to 15.8%). There are significant state- and region-level geographic differences in BMP utilization. Across all years, states with the highest BMP use were Indiana (28.5%), Colorado (26.6%), and Nevada (25.7%). States with the lowest BMP use were Maine (2.3%), Vermont (8.2%), and Mississippi (10.4%). After multivariate risk adjustment, BMP use was associated with decreased overall complications in thoracic (OR (95% CI): 0.89 (0.81-0.99) and anterior lumbar fusions (OR (95% CI): 0.89 (0.84-0.95)), as well as increased reoperation rates in anterior cervical (OR (95% CI): 1.11 (1.04-1.19)), posterior cervical (OR (95% CI): 1.14 (1.04-1.25)), thoracic (OR (95% CI): 1.32 (1.23-1.41)), and posterior lumbar fusions (OR (95% CI): 1.11 (1.06-1.16)). BMP use was also associated with greater total costs, independent of fusion type, after multivariate risk adjustment (p < 0.0001). Payments, however, were comparable between groups in anterior and posterior cervical fusion with or without BMP. BMP use was associated with greater total payments in thoracic, anterior lumbar, and posterior lumbar fusions. Notably, the difference in payments was smaller than the associated cost increase in all fusion types.BMP use has declined across all fusion types over the last decade, after a peak in 2007. While BMP is associated with greater costs, reimbursement does not increase proportionally with BMP cost.

    View details for DOI 10.1016/j.spinee.2023.01.012

    View details for PubMedID 36709918

  • Quality and patient safety research in pediatric neurosurgery: a review. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery Ruiz Colón, G. D., Wu, A., Ratliff, J. K., Prolo, L. M. 2023

    Abstract

    In 2001, the National Academy of Medicine, formerly known as the Institute of Medicine (IOM), published their seminal work, Crossing the Quality Chasm: A New Health System for the 21st Century. In this work, the authors called for improved safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity in the United States' healthcare system. Two decades after the publication of this work, healthcare costs continue to rise, but outcomes lag other nations. The objective of this narrative review is to describe research efforts in pediatric neurosurgery with respect to the six quality aims proposed by the IOM, and highlight additional research opportunities.PubMed, Google Scholar, and EBSCOhost were queried to identify studies in pediatric neurosurgery that have addressed the aims proposed by the IOM. Studies were summarized and synthesized to develop a set of research opportunities to advance quality of care.Twenty-three studies were reviewed which focused on the six quality aims proposed by the IOM. Out of these studies, five research opportunities emerged: (1) To examine performance of tools of care, (2) To understand processes surrounding care delivery, (3) To conduct cost-effectiveness analyses for a broader range of neurosurgical conditions, (4) To identify barriers driving healthcare disparities, and (5) To understand patients' and caregivers' experiences receiving care, and subsequently develop tools and programs to address their needs and preferences.There is a growing body of literature examining quality in pediatric neurosurgical care across all aims proposed by the IOM. However, there remains important gaps in the literature that, if addressed, will advance the quality of pediatric neurosurgical care delivery.

    View details for DOI 10.1007/s00381-022-05821-z

    View details for PubMedID 36695845

  • A Protocol for Reducing Intensive Care Utilization After Craniotomy: A 3-Year Assessment. Neurosurgery Ruiz Colón, G. D., Ohkuma, R., Pendharkar, A. V., Heifets, B. D., Li, G., Lu, A., Gephart, M. H., Ratliff, J. K. 2023

    Abstract

    Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the "Non-Intensive CarE" (NICE) protocol to identify craniotomy patients who did not require postoperative ICU care.To determine the longitudinal impact of the NICE protocol on postoperative length of stay (LOS), ICU utilization, readmissions, and complications.In this retrospective cohort study, our institution's electronic medical record was queried to identify craniotomies before protocol deployment (May 2014-May 2018) and after deployment (May 2018-December 2021). The primary end points were average postoperative LOS and ICU utilization; secondary end points included readmissions, reoperation, and postoperative complications rate. End points were compared between pre- and postintervention cohorts.Four thousand eight hundred thirty-seven craniotomies were performed from May 2014 to December 2021 (2302 preprotocol and 2535 postprotocol). Twenty-one percent of postprotocol craniotomies were enrolled in the NICE protocol. After protocol deployment, the overall postoperative LOS decreased from 4.0 to 3.5 days (P = .0031), which was driven by deceased postoperative LOS among protocol patients (average 2.4 days). ICU utilization decreased from 57% of patients to 42% (P < .0001), generating ∼$760 000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within 30 days; none could have been prevented through ICU stay.The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

    View details for DOI 10.1227/neu.0000000000002337

    View details for PubMedID 36639854

  • Neurosurgical Utilization, Charges, and Reimbursement After the Affordable Care Act: Trends From 2011 to 2019. Neurosurgery Hersh, A. M., Dedrickson, T., Gong, J. H., Jimenez, A. E., Materi, J., Veeravagu, A., Ratliff, J. K., Azad, T. D. 2023

    Abstract

    BACKGROUND: An estimated 50 million Americans receive Medicare health care coverage. Prior studies have established a downward trend in Medicare reimbursement for commonly billed surgical procedures, but it is unclear whether these trends hold true across all neurosurgical procedures.OBJECTIVE: To assess trends in utilization, charges, and reimbursement by Medicare for neurosurgical procedures after passage of the Affordable Care Act in 2010.METHODS: We review yearly Physician/Supplier Procedure Summary datasets from the Centers for Medicare and Medicaid Services for all procedures billed by neurosurgeons to Medicare Part B between 2011 and 2019. Procedural coding was categorized into cranial, spine, vascular, peripheral nerve, and radiosurgery cases. Weighted averages for charges and reimbursements adjusted for inflation were calculated. The ratio of the weighted mean reimbursement to weighted mean charge was calculated as the reimbursement-to-charge ratio, representing the proportion of charges reimbursed by Medicare.RESULTS: Overall enrollment-adjusted utilization decreased by 12.1%. Utilization decreased by 24.0% in the inpatient setting but increased by 639% at ambulatory surgery centers and 80.2% in the outpatient setting. Inflation-adjusted, weighted mean charges decreased by 4.0% while reimbursement decreased by 4.6%. Procedure groups that saw increases in reimbursement included cervical spine surgery, cranial functional and epilepsy procedures, cranial pain procedures, and endovascular procedures. Ambulatory surgery centers saw the greatest increase in charges and reimbursements.CONCLUSION: Although overall reimbursement declined across the study period, substantial differences emerged across procedural categories. We further find a notable shift in utilization and reimbursement for neurosurgical procedures done in non-inpatient care settings.

    View details for DOI 10.1227/neu.0000000000002306

    View details for PubMedID 36700751

  • Utilization Trends, Cost, and Payments for Adult Spinal Deformity Surgery in Commercial and Medicare-Insured Populations. Neurosurgery Wadhwa, H., Leung, C., Sklar, M., Ames, C. P., Veeravagu, A., Desai, A., Ratliff, J., Zygourakis, C. C. 2022

    Abstract

    BACKGROUND: Previous studies have characterized utilization rates and cost of adult spinal deformity (ASD) surgery, but the differences between these factors in commercially insured and Medicare populations are not well studied.OBJECTIVE: To identify predictors of increased payments for ASD surgery in commercially insured and Medicare populations.METHODS: We identified adult patients who underwent fusion for ASD, 2007 to 2015, in 20% Medicare inpatient file (n = 21614) and MarketScan commercial insurance database (n = 38789). Patient age, sex, race, insurance type, geographical region, Charlson Comorbidity Index, and length of stay were collected. Outcomes included predictors of increased payments, surgical utilization rates, total cost (calculated using Medicare charges and hospital-specific charge-to-cost ratios), and total Medicare and commercial payments for ASD.RESULTS: Rates of fusion increased from 9.0 to 8.4 per 10000 in 2007 to 20.7 and 18.2 per 10000 in 2015 in commercial and Medicare populations, respectively. The Medicare median total charges increased from $88106 to $144367 (compound annual growth rate, CAGR: 5.6%), and the median total cost increased from $31846 to $39852 (CAGR: 2.5%). Commercial median total payments increased from $58164 in 2007 to $64634 in 2015 (CAGR: 1.2%) while Medicare median total payments decreased from $31415 in 2007 to $25959 in 2015 (CAGR: -2.1%). The Northeast and Western regions were associated with higher payments in both populations, but there is substantial state-level variation.CONCLUSION: Rate of ASD surgery increased from 2007 to 2015 among commercial and Medicare beneficiaries. Despite increasing costs, Medicare payments decreased. Age, length of stay, and BMP usage were associated with increased payments for ASD surgery in both populations.

    View details for DOI 10.1227/neu.0000000000002140

    View details for PubMedID 36136402

  • Modifiers of and Disparities in Palliative and Supportive Care Timing and Utilization among Neurosurgical Patients with Malignant Central Nervous System Tumors. Cancers Jin, M. C., Hsin, G., Ratliff, J., Thomas, R., Zygourakis, C. C., Li, G., Wu, A. 2022; 14 (10)

    Abstract

    Patients with primary or secondary central nervous system (CNS) malignancies benefit from utilization of palliative care (PC) in addition to other supportive services, such as home health and social work. Guidelines propose early initiation of PC for patients with advanced cancers. We analyzed a cohort of privately insured patients with malignant brain or spinal tumors derived from the Optum Clinformatics Datamart Database to investigate health disparities in access to and utilization of supportive services. We introduce a novel construct, "provider patient racial diversity index" (provider pRDI), which is a measure of the proportion of non-white minority patients a provider encounters to approximate a provider's patient demographics and suggest a provider's cultural sensitivity and exposure to diversity. Our analysis demonstrates low rates of PC, home health, and social work services among racial minority patients. Notably, Hispanic patients had low likelihood of engaging with all three categories of supportive services. However, patients who saw providers categorized into high provider pRDI (categories II and III) were increasingly more likely to interface with supportive care services and at an earlier point in their disease courses. This study suggests that prospective studies that examine potential interventions at the provider level, including diversity training, are needed.

    View details for DOI 10.3390/cancers14102567

    View details for PubMedID 35626171

  • An integrated risk model stratifying seizure risk following brain tumor resection among seizure-naive patients without antiepileptic prophylaxis. Neurosurgical focus Jin, M. C., Parker, J. J., Prolo, L. M., Wu, A., Halpern, C. H., Li, G., Ratliff, J. K., Han, S. S., Skirboll, S. L., Grant, G. A. 2022; 52 (4): E3

    Abstract

    The natural history of seizure risk after brain tumor resection is not well understood. Identifying seizure-naive patients at highest risk for postoperative seizure events remains a clinical need. In this study, the authors sought to develop a predictive modeling strategy for anticipating postcraniotomy seizures after brain tumor resection.The IBM Watson Health MarketScan Claims Database was canvassed for antiepileptic drug (AED)- and seizure-naive patients who underwent brain tumor resection (2007-2016). The primary event of interest was short-term seizure risk (within 90 days postdischarge). The secondary event of interest was long-term seizure risk during the follow-up period. To model early-onset and long-term postdischarge seizure risk, a penalized logistic regression classifier and multivariable Cox regression model, respectively, were built, which integrated patient-, tumor-, and hospitalization-specific features. To compare empirical seizure rates, equally sized cohort tertiles were created and labeled as low risk, medium risk, and high risk.Of 5470 patients, 983 (18.0%) had a postdischarge-coded seizure event. The integrated binary classification approach for predicting early-onset seizures outperformed models using feature subsets (area under the curve [AUC] = 0.751, hospitalization features only AUC = 0.667, patient features only AUC = 0.603, and tumor features only AUC = 0.694). Held-out validation patient cases that were predicted by the integrated model to have elevated short-term risk more frequently developed seizures within 90 days of discharge (24.1% high risk vs 3.8% low risk, p < 0.001). Compared with those in the low-risk tertile by the long-term seizure risk model, patients in the medium-risk and high-risk tertiles had 2.13 (95% CI 1.45-3.11) and 6.24 (95% CI 4.40-8.84) times higher long-term risk for postdischarge seizures. Only patients predicted as high risk developed status epilepticus within 90 days of discharge (1.7% high risk vs 0% low risk, p = 0.003).The authors have presented a risk-stratified model that accurately predicted short- and long-term seizure risk in patients who underwent brain tumor resection, which may be used to stratify future study of postoperative AED prophylaxis in highest-risk patient subpopulations.

    View details for DOI 10.3171/2022.1.FOCUS21751

    View details for PubMedID 35364580

  • Prediction of Discharge Status and Readmissions after Resection of Intradural Spinal Tumors. Neurospine Jin, M. C., Ho, A. L., Feng, A. Y., Medress, Z. A., Pendharkar, A. V., Rezaii, P., Ratliff, J. K., Desai, A. M. 2022; 19 (1): 133-145

    Abstract

    OBJECTIVE: Intradural spinal tumors are uncommon and while associations between clinical characteristics and surgical outcomes have been explored, there remains a paucity of literature unifying diverse predictors into an integrated risk model. To predict postresection outcomes for patients with spinal tumors.METHODS: IBM MarketScan Claims Database was queried for adult patients receiving surgery for intradural tumors between 2007 and 2016. Primary outcomes-of-interest were nonhome discharge and 90-day postdischarge readmissions. Secondary outcomes included hospitalization duration and postoperative complications. Risk modeling was developed using a regularized logistic regression framework (LASSO, least absolute shrinkage and selection operator) and validated in a withheld subset.RESULTS: A total of 5,060 adult patients were included. Most surgeries utilized a posterior approach (n = 5,023, 99.3%) and tumors were most commonly found in the thoracic region (n = 1,941, 38.4%), followed by the lumbar (n = 1,781, 35.2%) and cervical (n = 1,294, 25.6%) regions. Compared to models using only tumor-specific or patient-specific features, our integrated models demonstrated better discrimination (area under the curve [AUC] [nonhome discharge] = 0.786; AUC [90-day readmissions] = 0.693) and accuracy (Brier score [nonhome discharge] = 0.155; Brier score [90-day readmissions] = 0.093). Compared to those predicted to be lowest risk, patients predicted to be highest-risk for nonhome discharge required continued care 16.3 times more frequently (64.5% vs. 3.9%). Similarly, patients predicted to be at highest risk for postdischarge readmissions were readmitted 7.3 times as often as those predicted to be at lowest risk (32.6% vs. 4.4%).CONCLUSION: Using a diverse set of clinical characteristics spanning tumor-, patient-, and hospitalization-derived data, we developed and validated risk models integrating diverse clinical data for predicting nonhome discharge and postdischarge readmissions.

    View details for DOI 10.14245/ns.2143244.622

    View details for PubMedID 35378587

  • Commentary: Loss of Relativity: The Physician Fee Schedule, the Neurosurgeon, and the Trojan Horse NEUROSURGERY Tumialan, L. M., Veeravagu, A., Ratliff, J. K. 2021; 89 (6): E323-E324
  • The impact of osteoporosis on adult deformity surgery outcomes in Medicare patients. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Varshneya, K., Bhattacharjya, A., Jokhai, R. T., Fatemi, P., Medress, Z. A., Stienen, M. N., Ho, A. L., Ratliff, J. K., Veeravagu, A. 2021

    Abstract

    OBJECTIVE: To identify the impact of osteoporosis (OS) on postoperative outcomes in Medicare patients undergoing ASD surgery.BACKGROUND: Patients with OP and advanced age experience higher than average rates of ASD. However, poor bone density could undermine the durability of a deformity correction.METHODS: We queried the MarketScan Medicare Supplemental database to identify patients Medicare patients who underwent ASD surgery from 2007 to 2016.RESULTS: A total of 2564 patients met the inclusion criteria of this study, of whom n=971 (61.0%) were diagnosed with osteoporosis. Patients with OP had a similar 90-day postoperative complication rates (OP: 54.6% vs. non-OP: 49.2%, p=0.0076, not significant after multivariate regression correction). This was primarily driven by posthemorrhagic anemia (37.6% in OP, vs. 33.1% in non-OP). Rates of revision surgery were similar at 90days (non-OP 15.0%, OP 16.8%), but by 2years, OP patients had a significantly higher reoperation rate (30.4% vs. 22.9%, p<0.0001). In multivariate regression analysis, OP increased odds for revision surgery at 1year (OR 1.4) and 2years (OR 1.5) following surgery (all p<0.05). OP was also an independent predictor of readmission at all time points (90days, OR 1.3, p<0.005).CONCLUSION: Medicare patients with OP had elevated rates of complications, reoperations, and outpatient costs after undergoing primary ASD surgery.

    View details for DOI 10.1007/s00586-021-06985-z

    View details for PubMedID 34655336

  • Commentary: Loss of Relativity: The Physician Fee Schedule, the Neurosurgeon, and the Trojan Horse. Neurosurgery Tumialan, L. M., Veeravagu, A., Ratliff, J. K. 2021

    View details for DOI 10.1093/neuros/nyab339

    View details for PubMedID 34498695

  • Outcome Measures of Medicare Patients With Diabetes Mellitus Undergoing Thoracolumbar Deformity Surgery. Clinical spine surgery Varshneya, K., Bhattacharjya, A., Sharma, J., Stienen, M. N., Medress, Z. A., Ratliff, J. K., Veeravagu, A. 2021

    Abstract

    STUDY DESIGN: This was a retrospective study.OBJECTIVE: The objective of this study was to identify the impact of diabetes on postoperative outcomes in Medicare patients undergoing adult spinal deformity (ASD) surgery.METHODS: We queried the MarketScan Medicare database to identify patients who underwent ASD surgery from 2007 to 2016. Patients were then stratified based on diabetes status at the time of the index operation. Patients not enrolled in the Medicare dataset and those with any prior history of trauma or tumor were excluded from this study.RESULTS: A total of 2564 patients met the inclusion criteria of this study, of which n=746 (29.1.%) were diabetic. Patients with diabetes had a higher rate of postoperative infection than nondiabetic patients (3.1% vs. 1.7%, P<0.05) within 90 days. Renal complications were also more elevated in the diabetic cohort (3.2% vs. 1.3%, P<0.05). Readmission rates were significantly higher in the diabetes cohort through of 60 days (15.2% vs. 11.8%, P<0.05) and 90 days (17.0% vs. 13.4%, P<0.05). When looking specifically at the outpatient payments, patients with diabetes did have a higher financial burden at 60 days ($8147 vs. $6956, P<0.05) and 90 days ($10,126 vs. $8376, P<0.05).CONCLUSIONS: In this study, diabetic patients who underwent ASD surgery had elevated rates of postoperative infection, outpatient costs, and rates of readmissions within 90 days. Further research should investigate the role of poor glycemic control on spine surgery outcomes.

    View details for DOI 10.1097/BSD.0000000000001229

    View details for PubMedID 34183547

  • Surgical Outcomes of Human Immunodeficiency Virus-positive Patients Undergoing Lumbar Degenerative Surgery. Clinical spine surgery Varshneya, K., Wadhwa, H., Ho, A. L., Medress, Z. A., Stienen, M. N., Desai, A., Ratliff, J. K., Veeravagu, A. 2021

    Abstract

    STUDY DESIGN: This was a retrospective cohort studying using a national administrative database.OBJECTIVE: The objective of this study was to determine the postoperative complications and quality outcomes of the human immunodeficiency virus (HIV)-positive patients undergoing surgical management for lumbar degenerative disease (LDD).METHODS: This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether they were HIV positive at the time of surgery. Multivariate regression was utilized to reduce the confounding of baseline covariates. Patients who underwent 3 or more levels of surgical correction were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined.RESULTS: A total of 120,167 patients underwent primary lumbar degenerative surgery, of which 309 (0.26%) were HIV positive. In multivariate regression analysis, the HIV-positive cohort was more likely to be readmitted at 30 days [odds ratio (OR)=1.9, 95% confidence interval (CI): 1.2-2.8], 60 days (OR=1.7, 95% CI: 1.2-2.5), and 90 days (OR=1.5, 95% CI: 1.0-2.2). The HIV-positive cohort was also more likely to experience any postoperative complication (OR=1.7, 95% CI: 1.2-2.3). Of the major drivers identified, HIV-positive patients had significantly greater odds of cerebrovascular disease and postoperative neurological complications (OR=3.8, 95% CI: 1.8-6.9) and acute kidney injury (OR=3.4, 95% CI: 1.3-7.1). Costs of index hospitalization were not significantly different between the 2 cohorts ($30,056 vs. $29,720, P=0.6853). The total costs were also similar throughout the 2-year follow-up period.CONCLUSION: Patients who are HIV positive at the time of LDD surgery are at a higher risk for postoperative central nervous system and renal complications and unplanned readmissions.

    View details for DOI 10.1097/BSD.0000000000001221

    View details for PubMedID 34183544

  • Hemorrhage risk of direct oral anticoagulants in real-world venous thromboembolism patients. Thrombosis research Jin, M. C., Sussman, E. S., Feng, A. Y., Han, S. S., Skirboll, S. L., Berube, C., Ratliff, J. K. 2021; 204: 126-133

    Abstract

    INTRODUCTION: Venous thromboembolism (VTE) management increasingly involves anticoagulation with direct oral anticoagulants (DOACs). Few studies have used competing-risks analyses to ascertain the mortality-adjusted hemorrhage and recurrent VTE (rVTE) risk of individual DOACs. Furthermore, hemorrhage risk factors in patients treated with apixaban remain underexplored.MATERIALS AND METHODS: Patients diagnosed with VTE receiving anticoagulation were identified from the Optum Clinformatics Data Mart (2003-2019). Study endpoints included readmissions for intracranial hemorrhage (ICH), non-intracranial hemorrhage (non-ICH hemorrhage), and rVTE. Coarsened exact matching was used to balance baseline clinical characteristics. Complication incidence was evaluated using a competing-risks framework. We additionally modeled hemorrhage risk in apixaban-treated patients.RESULTS: Overall, 225,559 patients were included, of whom 34,201 received apixaban and 46,007 received rivaroxaban. Compared to rivaroxaban, apixaban was associated with decreased non-ICH hemorrhage (sHR=0.560, 95%CI=0.423-0.741), but not ICH, and rVTE (sHR=0.802, 95%CI=0.651-0.988) risk. This was primarily in emergent readmissions (sHR[emergent hemorrhage]=0.515, 95%CI=0.372-0.711; sHR[emergent rVTE]=0.636, 95%CI=0.488-0.830). Contributors to emergent hemorrhage in apixaban-treated patients include older age (sHR=1.025, 95%CI=1.011-1.039), female sex (sHR=1.662, 95%CI=1.252-2.207), prior prescription antiplatelet therapy (sHR=1.591, 95%CI=1.130-2.241), and complicated hypertension (sHR=1.936, 95%CI=1.134-3.307). Patients anticipated to be "high-risk" experienced elevated ICH (sHR=3.396, 95%CI=1.375-8.388) and non-ICH hemorrhage (sHR=3.683, 95%CI=2.957-4.588) incidence.CONCLUSIONS: In patients with VTE receiving anticoagulation, apixaban was associated with reduced non-ICH hemorrhage and rVTE risk, compared to rivaroxaban. Risk reduction was restricted to emergent readmissions. We present a risk-stratification approach to predict hemorrhage in patients receiving apixaban, potentially guiding future clinical decision-making.

    View details for DOI 10.1016/j.thromres.2021.06.015

    View details for PubMedID 34198049

  • External validation of a predictive model of adverse events following spine surgery. The spine journal : official journal of the North American Spine Society Fatemi, P., Zhang, Y., Han, S. S., Purington, N., Zygourakis, C. C., Veeravagu, A., Desai, A., Park, J., Shuer, L. M., Ratliff, J. K. 2021

    Abstract

    BACKGROUND CONTEXT: We lack models that reliably predict 30-day postoperative adverse events (AEs) following spine surgery.PURPOSE: We externally validated a previously developed predictive model for common 30-day adverse events (AEs) after spine surgery.STUDY DESIGN/SETTING: This prospective cohort study utilizes inpatient and outpatient data from a tertiary academic medical center.PATIENT SAMPLE: We assessed a prospective cohort of all 276 adult patients undergoing spine surgery in the Department of Neurosurgery at a tertiary academic institution between April 1, 2018 and October 31, 2018. No exclusion criteria were applied.OUTCOME MEASURES: Incidence of observed AEs was compared with predicted incidence of AEs. Fifteen assessed AEs included: pulmonary complications, congestive heart failure, neurological complications, pneumonia, cardiac dysrhythmia, renal failure, myocardial infarction, wound infection, pulmonary embolus, deep venous thrombosis, wound hematoma, other wound complication, urinary tract infection, delirium, and other infection.METHODS: Our group previously developed the Risk Assessment Tool for Adverse Events after Spine Surgery (RAT-Spine), a predictive model of AEs within 30 days following spine surgery using a cohort of approximately one million patients from combined Medicare and MarketScan databases. We applied RAT-Spine to the single academic institution prospective cohort by entering each patient's preoperative medical and demographic characteristics and surgical type. The model generated a patient-specific overall risk score ranging from 0 to 1 representing the probability of occurrence of any AE. The predicted risks are presented as absolute percent risk and divided into low (<17%), medium (17-28%), and high (>28%).RESULTS: Among the 276 patients followed prospectively, 76 experienced at least one 30-day postoperative AE. Slightly more than half of the cohort were women (53.3%). The median age was slightly lower in the non-AE cohort (63 vs 66.5 years old). Patients with Medicaid comprised 2.5% of the non-AE cohort and 6.6% of the AE cohort. Spinal fusion was performed in 59.1% of cases, which was comparable across cohorts. There was good agreement between the predicted AE and observed AE rates, Area Under the Curve (AUC) 0.64 (95% CI 0.56-0.710). The incidence of observed AEs in the prospective cohort was 17.8% among the low-risk group, 23.0% in the medium-risk group, and 38.4% in the high risk group (p = 0.003).CONCLUSIONS: We externally validated a model for postoperative AEs following spine surgery (RAT-Spine). The results are presented as low-, moderate-, and high-risk designations.

    View details for DOI 10.1016/j.spinee.2021.06.006

    View details for PubMedID 34116215

  • Radiolucent carbon fiber-reinforced implants for treatment of spinal tumors- clinical, radiographic, and dosimetric considerations. World neurosurgery Takayanagi, A., Siddiqi, I., Ghanchi, H., Lischalk, J., Vrionis, F., Ratliff, J., Bilsky, M., Hariri, O. R. 2021

    Abstract

    The management of spine tumors is multimodal and personalized to each individual patient. Patients often require radiation therapy after surgical fixation. While titanium implants are used most commonly, they produce significant artifact, leading to decreased confidence in target-volume coverage and normal tissue sparing. Carbon-based materials have been found to have minimal effects on dose-perturbation in postoperative radiation therapy while demonstrating biostability and biocompatibility that is comparable to titanium implants. We conducted a systematic review on carbon-based screw and rod fixation systems in the treatment of spinal tumors utilizing Pubmed and Web of Sciences databases. We reviewed clinical studies with regards to safety of spine fixation with carbon fiber reinforced (CFR) implants, biomechanical studies, as well as radiation and dosimetric studies. The radiolucency of CFR-PEEK implants has potential to benefit spine tumor patients. Clinical studies have demonstrated no increase in complications with implementation of CFR-PEEK implants, and these devices appear to have sufficient stiffness and pullout strength. However, further trials will be necessary in order to determine if there is a clinically significant impact on local tumor control.

    View details for DOI 10.1016/j.wneu.2021.05.100

    View details for PubMedID 34062294

  • Factors which predict adverse events following surgery in adults with cervical spinal deformity BONE & JOINT JOURNAL Varshneya, K., Jokhai, R., Medress, Z. A., Stienen, M. N., Ho, A., Fatemi, P., Ratliff, J. K., Veeravagu, A. 2021; 103B (4): 734–38
  • Factors which predict adverse events following surgery in adults with cervical spinal deformity. The bone & joint journal Varshneya, K., Jokhai, R., Medress, Z. A., Stienen, M. N., Ho, A., Fatemi, P., Ratliff, J. K., Veeravagu, A. 2021; 103-B (4): 734–38

    Abstract

    AIMS: The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults.METHODS: We identified adult patients who underwent corrective cervical spinal surgery between 1 January 2007 and 31 December 2015 from the MarketScan database. The baseline comorbidities and characteristics of the operation were recorded. Adverse events were defined as the development of a complication, an unanticipated deleterious postoperative event, or further surgery. Patients aged < 18 years and those with a previous history of tumour or trauma were excluded from the study.RESULTS: A total of 13,549 adults in the database underwent primary corrective surgery for a cervical spinal deformity during the study period. A total of 3,785 (27.9%) had a complication within 90 days of the procedure, and 3,893 (28.7%) required further surgery within two years. In multivariate analysis, male sex (odds ratio (OR) 0.90 (95% confidence interval (CI) 0.8 to 0.9); p = 0.019) and a posterior approach (compared with a combined surgical approach, OR 0.66 (95% CI 0.5 to 0.8); p < 0.001) significantly decreased the risk of complications. Osteoporosis (OR 1.41 (95% CI 1.3 to 1.6); p < 0.001), dyspnoea (OR 1.48 (95% CI 1.3 to 1.6); p < 0.001), cerebrovascular accident (OR 1.81 (95% CI 1.6 to 2.0); p < 0.001), a posterior approach (compared with an anterior approach, OR 1.23 (95% CI 1.1 to 1.4); p < 0.001), and the use of bone morphogenic protein (BMP) (OR 1.22 (95% CI 1.1 to 1.4); p = 0.003) significantly increased the risks of 90-day complications. In multivariate regression analysis, preoperative dyspnoea (OR 1.50 (95% CI 1.3 to 1.7); p < 0.001), a posterior approach (compared with an anterior approach, OR 2.80 (95% CI 2.4 to 3.2; p < 0.001), and postoperative dysphagia (OR 2.50 (95% CI 1.8 to 3.4); p < 0.001) were associated with a significantly increased risk of further surgery two years postoperatively. A posterior approach (compared with a combined approach, OR 0.32 (95% CI 0.3 to 0.4); p < 0.001), the use of BMP (OR 0.48 (95% CI 0.4 to 0.5); p < 0.001) were associated with a significantly decreased risk of further surgery at this time.CONCLUSION: The surgical approach and intraoperative use of BMP strongly influence the risk of further surgery, whereas the comorbidity burden and the characteristics of the operation influence the rates of early complications in adult patients undergoing corrective cervical spinal surgery. These data may aid surgeons in patient selection and surgical planning. Cite this article: Bone Joint J2021;103-B(4):734-738.

    View details for DOI 10.1302/0301-620X.103B4.BJJ-2020-0845.R2

    View details for PubMedID 33789479

  • Telehealth Adoption Across Neurosurgical Subspecialties at a Single Academic Institution During the COVID-19 Pandemic. World neurosurgery Leung, C., Wadhwa, H., Sklar, M., Sheth, K., Loo, S., Ratliff, J., Zygourakis, C. C. 2021

    Abstract

    OBJECTIVE: The COVID-19 pandemic has dramatically changed healthcare, forcing providers to adopt and implement telehealth technology to provide continuous care for their patients. Amid this rapid transition from in-person to remote visits, differences in telehealth utilization have arisen among neurosurgical subspecialties. In this study, we analyze the impact of telehealth on neurosurgical healthcare delivery during the COVID-19 pandemic at our institution and highlight differences in telehealth utilization across different neurosurgical subspecialties.METHODS: To quantify differences in telehealth utilization, we analyzed all outpatient neurosurgery visits at a single academic institution. Internal surveys were administered to neurosurgeons and to patients to determine both physician and patient satisfaction with telehealth visits. Patient Likelihood-to-Recommend Press Ganey scores were also evaluated.RESULTS: There was a decrease in outpatient visits during the COVID-19 pandemic in all neurosurgical subspecialties. Telehealth adoption was higher in spine, tumor, and interventional pain than in functional, peripheral nerve, or vascular neurosurgery. Neurosurgeons agreed that telehealth was an efficient (92%) and effective (85%) methodology; however, they noted it was more difficult to evaluate and bond with patients. The majority of patients were satisfied with their video visits and would recommend video visits over in-person visits.CONCLUSIONS: During the COVID-19 pandemic, neurosurgical subspecialties varied in adoption of telehealth, which may be due to the specific nature of each subspecialty and their necessity to perform in-person evaluations. Telehealth visits will likely continue after the pandemic as they can improve clinical efficiency; overall both patients and physicians are satisfied with healthcare delivery over video.

    View details for DOI 10.1016/j.wneu.2021.03.062

    View details for PubMedID 33746106

  • Risk Factors for Revision Surgery After Primary Adult Thoracolumbar Deformity Surgery. Clinical spine surgery Varshneya, K., Stienen, M. N., Medress, Z. A., Fatemi, P., Pendharkar, A. V., Ratliff, J. K., Veeravagu, A. 2021

    Abstract

    STUDY DESIGN: This is a retrospective cohort study.OBJECTIVE: The aim was to identify the risk factors for revision surgery within 2 years of patients undergoing primary adult spinal deformity (ASD) surgery.SUMMARY OF BACKGROUND DATA: Previous literature reports estimate 20% of patients undergoing thoracolumbar ASD correction undergo reoperation within 2 years. There is limited published data regarding specific risk factors for reoperation in ASD surgery in the short term and long term.METHODS: The authors queried the MarketScan database in order to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2015. Patient-level factors and revision risk were investigated during 2 years after primary ASD surgery. Patients under the age of 18 years and those with any prior history of trauma or tumor were excluded from this study.RESULTS: A total 7422 patients underwent ASD surgery during 2007-2015 in the data set. Revision rates were 13.1% at 90 days, 14.5% at 6 months, 16.7% at 1 year, and 19.3% at 2 years. In multivariate multiple logistic regression analysis, obesity [adjusted odds ratio (OR): 1.58, P<0.001] and tobacco use (adjusted OR: 1.38, P=0.0011) were associated with increased odds of reoperation within 2 years. Patients with a combined anterior-posterior approach had lower odds of reoperation compared with those with posterior only approach (adjusted OR: 0.66, P=0.0117).CONCLUSIONS: Obesity and tobacco are associated with increased odds of revision surgery within 2 years of index ASD surgery. Male sex and combined surgical approach are associated with decreased odds of revision surgery.

    View details for DOI 10.1097/BSD.0000000000001124

    View details for PubMedID 33443943

  • An Analysis of Public Interest in Elective Neurosurgical Procedures during the COVID-19 Pandemic through Online Search Engine Trends. World neurosurgery Feng, A. Y., Garcia, C. A., Jin, M. C., Ho, A. L., Li, G. n., Grant, G. n., Ratliff, J. n., Skirboll, S. L. 2021

    Abstract

    In the wake of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) has recommended the temporary cessation of all elective surgeries. The effects on patients' interest of elective neurosurgical procedures are currently unexplored.Using Google Trends (GT), search terms of seven different neurosurgical procedure categories (Trauma, Spine, Tumor, Movement Disorder, Epilepsy, Endovascular, and Miscellaneous) were assessed in terms of relative search volume (RSV) between January 2015 and September 2020. Analyses of search terms were performed for over the short-term (Feb 18th, 2020-Apr 18th, 2020), intermediate-term (Jan 1st, 2020-May 31st, 2020) and long-term (Jan 2015-Sept 2020). State-level interest during phase I re-opening (Apr 28th, 2020-May 31st, 2020) was also evaluated.In the short-term, RSV of four categories (epilepsy, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. In the intermediate-term, RSV of five categories (miscellaneous, epilepsy, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. In the long-term, RSV of nearly all categories (endovascular, epilepsy, miscellaneous, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. Only the movement disorder procedure category had significantly higher RSV in states that reopened early.With the recommendation for cessation of elective surgeries, patient interest in overall elective neurosurgical procedures have dropped significantly. With gradual reopening, there has been a resurgence in some procedure types. GT has proven to be a useful tracker of patient interest and may be utilized by neurosurgical departments to facilitate outreach strategies.

    View details for DOI 10.1016/j.wneu.2020.12.143

    View details for PubMedID 33412316

  • Defining and Describing Treatment Heterogeneity in New-Onset Idiopathic Lower Back and Extremity Pain Through Reconstruction of Longitudinal Care Sequences. The spine journal : official journal of the North American Spine Society Jin, M. C., Azad, T. D., Fatemi, P., Ho, A. L., Vail, D., Zhang, Y., Feng, A. Y., Kim, L. H., Bentley, J. P., Stienen, M. N., Li, G., Desai, A. M., Veeravagu, A., Ratliff, J. K. 2021

    Abstract

    Despite established guidelines, long-term management of surgically-treated low back pain (LBP) and lower extremity pain (LEP) remains heterogeneous. Understanding care heterogeneity could inform future approaches for standardization of practices.To describe treatment heterogeneity in surgically-managed LBP and LEP.Retrospective study of a nationwide commercial database spanning inpatient and outpatient encounters for enrollees of eligible employer-supplied healthcare plans (2007-2016).A population-based sample of opioid-naïve adult patients with newly-diagnosed LBP or LEP were identified. Inclusion required at least 12-months of pre-diagnosis and post-diagnosis continuous follow-up.Included treatments/evaluations include conservative management (chiropractic manipulative therapy, physical therapy, epidural steroid injections), imaging (x-ray, MRI, CT), pharmaceuticals (opioids, benzodiazepines), and spine surgery (decompression, fusion).Primary outcomes-of-interest were 12-month net healthcare expenditures (inpatient and outpatient) and 12-month opioid usage.Analyses include interrogation of care sequence heterogeneity and temporal trends in sequence-initiating services. Comparisons were conducted in the framework of sequence-specific treatment sequences, which reflect the personalized order of healthcare services pursued by each patient. Outlier sequences characterized by high opioid use and costs were identified from frequently observed surgical treatment sequences using Mahalanobis distance.A total of 2,496,908 opioid-naïve adult patients with newly-diagnosed LBP or LEP were included (29,519 surgical). In the matched setting, increased care sequence heterogeneity was observed in surgical patients (0.51 vs 0.12 previously-unused interventions/studies pursued per month). Early opioid and MRI use has decreased between 2008 and 2015 but is matched by increases in early benzodiazepine and x-ray use. Outlier sequences, characterized by increased opioid use and costs, were found in 5.8% of surgical patients. Use of imaging prior to conservative management was common in patients pursuing outlier sequences compared to non-outlier sequences (96.5% vs 63.8%, p<0.001). Non-outlier sequences were more frequently characterized by early conservative interventions (31.9% vs 7.4%, p<0.001).Surgically-managed LBP and LEP care sequences demonstrate high heterogeneity despite established practice guidelines. Outlier sequences associated with high opioid usage and costs can be identified and are characterized by increased early imaging and decreased early conservative management. Elements that may portend suboptimal longitudinal management could provide opportunities for standardization of patient care.

    View details for DOI 10.1016/j.spinee.2021.05.019

    View details for PubMedID 34033933

  • Anterior Cervical Discectomy and Fusion vs. Laminoplasty for Multilevel Cervical Spondylotic Myelopathy: A National Administrative Database Analysis. World neurosurgery Wadhwa, H., Sharma, J., Varshneya, K., Fatemi, P., Nathan, J., Medress, Z. A., Stienen, M. N., Ratliff, J. K., Veeravagu, A. 2021

    Abstract

    Anterior cervical discectomy and fusion (ACDF) is effective for treatment of single level cervical spondylotic myelopathy (CSM), but data surrounding multilevel CSM remains controversial. One alternative is laminoplasty, though evidence comparing these strategies remains sparce. In this paper, we retrospectively review readmission and reoperation rates among patients undergoing ACDF or laminoplasty for multilevel CSM from a national longitudinal administrative claims database.We queried the MarketScan Commercial Claims and Encounters database to identify patients who underwent ACDF or laminoplasty for multilevel CSM from 2007-2016. Patients were stratified by operation type. Patients younger than 18 years of age, with a history of tumor or trauma, or underwent an anterior-posterior approach were excluded from this study.A total of 5,445 patients were included, of which 1,521 underwent laminoplasty. A matched cohort who underwent ACDF was identified. The overall 90-day postoperative complication rate was higher in the laminoplasty cohort (OR 1.48 (95% CI 1.18 - 1.86); p < 0.0001). Mean length of stay and 90-day rates of readmission were higher in the laminoplasty cohort. Hospital and total costs of the index hospitalization were higher in the ACDF cohort, as were total payments up to 2 years after the index hospitalization.In this administrative claims database study, there was no difference in reoperation rate between ACDF and laminoplasty. ACDF had fewer complications and readmissions than laminoplasty but was associated with higher costs. Further, prospective research should investigate the factors driving the higher cost of ACDF in this population, and long-term clinical outcomes.

    View details for DOI 10.1016/j.wneu.2021.06.064

    View details for PubMedID 34153482

  • Obesity in Patients Undergoing Lumbar Degenerative Surgery-A Retrospective Cohort Study of Postoperative Outcomes. Spine Varshneya, K., Wadhwa, H., Stienen, M. N., Ho, A. L., Medress, Z. A., Aikin, J., Li, G., Desai, A., Ratliff, J. K., Veeravagu, A. 2021; 46 (17): 1191-1196

    Abstract

    Retrospective cohort studying using a national, administrative database.The aim of this study was to determine the postoperative complications and quality outcomes of patients with and without obesity undergoing surgical management for lumbar degenerative disease (LDD).Obesity is a global epidemic that negatively impacts health outcomes. Characterizing the effect of obesity on LDD surgery is important given the growing elderly obese population.This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether the patient had a concurrent diagnosis of obesity at time of surgery. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between patients with and without obesity. Patients who underwent three or more levels surgical correction, were under the age of 18 years, or those with any previous history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined.A total of 67,215 patients underwent primary lumbar degenerative surgery, of which 22,405 (33%) were obese. After propensity score matching, baseline covariates of the two cohorts were similar. The complication rate was 8.3% in the nonobese cohort and 10.4% in the obese cohort (P < 0.0001). Patients with obesity also had longer lengths of stay (2.7 days vs. 2.4 days, P < 0.05), and higher rates of reoperation and readmission at all time-points through the study follow-up period to their nonobese counterparts (P < 0.05). Including payments after discharge, lumbar degenerative surgery in patients with obesity was associated with higher payments throughout the 2-year follow-up period ($68,061 vs. $59,068 P < 0.05).Patients with a diagnosis of obesity at time of LDD surgery are at a higher risk for postoperative complications, reoperation, and readmission.Level of Evidence: 4.

    View details for DOI 10.1097/BRS.0000000000004001

    View details for PubMedID 34384097

  • Single vs Multistage Surgical Management of Single and Two-Level Lumbar Degenerative Disease. World neurosurgery Varshneya, K., Wadhwa, H., Stienen, M. N., Ho, A. L., Medress, Z. A., Herrick, D. B., Desai, A., Ratliff, J. K., Veeravagu, A. 2021

    Abstract

    Retrospective cohort studying using a national, administrative database.To determine the postoperative complications and quality outcomes of single and multi-stage surgical management for lumbar degenerative disease (LDD).This study identified patients with who underwent surgery for LDD between 2007 - 2016. Patients were stratified based on whether their surgeon choose to correct their LDD in a single or multistage manner, and these cohorts were mutually exclusive. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between single and multi-stage patients. Patients who underwent three or more levels surgical correction, were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined.A total of 47,190 patients underwent primary surgery for LDD, of which 9,438 (20%) underwent multi-stage surgery. After propensity score matching, baseline covariates of the two cohorts were similar. The complication rate was 6.1% in the single stage cohort and 11.0% in the multistage cohort. Rates of post-hemorrhagic anemia, infection, wound complication, DVT, and hematoma were all higher in the multistage cohort. Lengths of stay, revision, and readmission rates were also significantly higher in the multi-stage cohort. Through 2-years of follow up, multi-stage surgery was associated with higher payments throughout the 2-year follow-up period ($57,036 vs $39,318, p < 0.05).Single stage surgery for lumbar degenerative disc disease demonstrates improved outcomes and lower healthcare utilization. Spine surgeons should carefully consider single-stage surgery when treating patients with less than three-level LDD.

    View details for DOI 10.1016/j.wneu.2021.05.115

    View details for PubMedID 34087456

  • Advanced Age Does Not Impact Outcomes After 1-level or 2-level Lateral Lumbar Interbody Fusion. Clinical spine surgery Wadhwa, H., Oquendo, Y. A., Tigchelaar, S. S., Warren, S. I., Koltsov, J. C., Desai, A., Veeravagu, A., Alamin, T. F., Ratliff, J. K., Hu, S. S., Cheng, I. 2021

    Abstract

    This was a retrospective comparative study.The objective of this study was to assess the effect of increased age on perioperative and postoperative complication rates, reoperation rates, and patient-reported pain and disability scores after lateral lumbar interbody fusion (LLIF).LLIF was developed to minimize soft tissue trauma and reduce the risk of vascular injury; however, there is little evidence regarding the effect of advanced age on outcomes of LLIF.Patients who underwent LLIF from 2009 to 2019 at one institution with a minimum 6-month follow-up were retrospectively reviewed. Patients less than 18 years old with musculoskeletal tumor or trauma were excluded. The primary outcome was the preoperative to postoperative change in the Numeric Pain Rating Scale (NPRS) for back pain. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and change in Oswestry Disability Index were also evaluated. Relationships with age were assessed both with age as a continuous variable and segmenting by age below 70 versus 70+.In total, 279 patients were included. The median age was 65±13 years and 159 (57%) were female. Age was not related to improvements in back NPRS and Oswestry Disability Index. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and radiographic fusion rate also were not related to age. After multivariable risk adjustment, increasing age was associated with greater improvements in back NPRS. The decrease in back NPRS was 0.68 (95% confidence interval: 0.14, 1.22; P=0.014) points greater for every 10-year increase in age. Age was not associated with rates of complication, readmission, or reoperation.LLIF is a safe and effective procedure in the elderly population. Advanced age is associated with larger improvements in preoperative back pain. Surgeons should consider the benefits of LLIF and other minimally invasive techniques when evaluating elderly candidates for lumbar fusion.Level III.

    View details for DOI 10.1097/BSD.0000000000001270

    View details for PubMedID 34724454

  • Status epilepticus after intracranial neurosurgery: incidence and risk stratification by perioperative clinical features. Journal of neurosurgery Jin, M. C., Parker, J. J., Zhang, M. n., Medress, Z. A., Halpern, C. H., Li, G. n., Ratliff, J. K., Grant, G. A., Fisher, R. S., Skirboll, S. n. 2021: 1–13

    Abstract

    Status epilepticus (SE) is associated with significant mortality, cost, and risk of future seizures. In one of the first studies of SE after neurosurgery, the authors assess the incidence, risk factors, and outcome of postneurosurgical SE (PNSE).Neurosurgical admissions from the MarketScan Claims and Encounters database (2007 through 2015) were assessed in a longitudinal cross-sectional sample of privately insured patients who underwent qualifying cranial procedures in the US and were older than 18 years of age. The incidence of early (in-hospital) and late (postdischarge readmission) SE and associated mortality was assessed. Procedural, pathological, demographic, and anatomical covariates parameterized multivariable logistic regression and Cox models. Multivariable logistic regression and Cox proportional hazards models were used to study the incidence of early and late PNSE. A risk-stratification simulation was performed, combining individual predictors into singular risk estimates.A total of 197,218 admissions (218,217 procedures) were identified. Early PNSE occurred during 637 (0.32%) of 197,218 admissions for cranial neurosurgical procedures. A total of 1045 (0.56%) cases of late PNSE were identified after 187,771 procedure admissions with nonhospice postdischarge follow-up. After correction for comorbidities, craniotomy for trauma, hematoma, or elevated intracranial pressure was associated with increased risk of early PNSE (adjusted OR [aOR] 1.538, 95% CI 1.183-1.999). Craniotomy for meningioma resection was associated with an increased risk of early PNSE compared with resection of metastases and parenchymal primary brain tumors (aOR 2.701, 95% CI 1.388-5.255). Craniotomies for infection or abscess (aHR 1.447, 95% CI 1.016-2.061) and CSF diversion (aHR 1.307, 95% CI 1.076-1.587) were associated with highest risk of late PNSE. Use of continuous electroencephalography in patients with early (p < 0.005) and late (p < 0.001) PNSE rose significantly over the study time period. The simulation regression model predicted that patients at high risk for early PNSE experienced a 1.10% event rate compared with those at low risk (0.07%). Similarly, patients predicted to be at highest risk for late PNSE were significantly more likely to eventually develop late PNSE than those at lowest risk (HR 54.16, 95% CI 24.99-104.80).Occurrence of early and late PNSE was associated with discrete neurosurgical pathologies and increased mortality. These data provide a framework for prospective validation of clinical and perioperative risk factors and indicate patients for heightened diagnostic suspicion of PNSE.

    View details for DOI 10.3171/2020.10.JNS202895

    View details for PubMedID 33990087

  • Rod-Screw Constructs Composed of Dissimilar Metals Do Not Affect Complication Rates in Posterior Fusion Surgery Performed for Adult Spinal Deformity. Clinical spine surgery Denduluri, S. K., Koltsov, J. C., Ziino, C. n., Segovia, N. n., McMains, C. n., Falakassa, J. n., Ratliff, J. n., Wood, K. B., Alamin, T. n., Cheng, I. n., Hu, S. S. 2021; 34 (2): E121–E125

    Abstract

    This was a retrospective cohort study.The objective of this study was to compare implant-related complications between mixed-metal and same-metal rod-screw constructs in patients who underwent posterior fusion for adult spinal deformity.Contact between dissimilar metals is discouraged due to potential for galvanic corrosion, increasing the risk for metal toxicity, infection, and implant failure. In spine surgery, titanium (Ti) screws are most commonly used, but Ti rods are notch sensitive and likely more susceptible to fracture after contouring for deformity constructs. Cobalt chrome (CC) and stainless steel (SS) rods may be suitable alternatives. No studies have yet evaluated implant-related complications among mixed-metal constructs (SS or CC rods with Ti screws).Adults with spinal deformity who underwent at least 5-level thoracic and/or lumbar posterior fusion or 3-column osteotomy between January 2013 and May 2015 were reviewed, excluding neuromuscular deformity, tumor, acute trauma or infection. Implant-related complications included pseudarthrosis, proximal junctional kyphosis, hardware failure (rod fracture, screw pullout or haloing), symptomatic hardware, and infection.A total of 61 cases met inclusion criteria: 24 patients received Ti rods with Ti screws (Ti-Ti, 39%), 31 SS rods (SS-Ti, 51%), and 6 CC rods (CC-Ti, 9.8%). Median follow-up was 37-42 months for all groups. Because of the limited number of cases, the CC-Ti group was not included in statistical analyses. There were no differences between Ti-Ti and SS-Ti groups with regard to age, body mass index, or smokers. Implant-related complications did not differ between the Ti-Ti and SS-Ti groups (P=0.080). Among the Ti-Ti group, there were 15 implant-related complications (63%). In the SS-Ti group, there were 12 implant-related complications (39%). There were 3 implant-related complications in the CC-Ti group (50%).We found no evidence that combining Ti screws with SS rods increases the risk for implant-related complications.

    View details for DOI 10.1097/BSD.0000000000001058

    View details for PubMedID 33633069

  • Commentary: The Enforceability of Noncompete Clauses in the Medical Profession: A Review by the Workforce Committee and the Medico-legal Committee of the Council of State Neurosurgical Societies. Neurosurgery Veeravagu, A., Medress, Z. A., Ratliff, J. 2020

    View details for DOI 10.1093/neuros/nyaa481

    View details for PubMedID 33231255

  • Fostering Reproducibility and Generalizability in Machine Learning for Clinical Prediction Modeling in Spine Surgery. The spine journal : official journal of the North American Spine Society Azad, T. D., Ehresman, J., Ahmed, A. K., Staartjes, V. E., Lubelski, D., Stienen, M. N., Veeravagu, A., Ratliff, J. K. 2020

    Abstract

    As the use of machine learning algorithms in the development of clinical prediction models has increased, researchers are becoming more aware of the deleterious that stem from the lack of reporting standards. One of the most obvious consequences is the insufficient reproducibility found in current prediction models. In an attempt to characterize methods to improve reproducibility and to allow for better clinical performance, we utilize a previously proposed taxonomy that separates reproducibility into three components: technical, statistical, and conceptual reproducibility. By following this framework, we discuss common errors that lead to poor reproducibility, highlight the importance of generalizability when evaluating a ML model's performance, and provide suggestions to optimize generalizability to ensure adequate performance. These efforts are a necessity before such models are applied to patient care.

    View details for DOI 10.1016/j.spinee.2020.10.006

    View details for PubMedID 33065274

  • Predictive Modeling of Long-Term Opioid and Benzodiazepine Use after Intradural Tumor Resection. The spine journal : official journal of the North American Spine Society Jin, M. C., Ho, A. L., Feng, A. Y., Zhang, Y., Staartjes, V. E., Stienen, M. N., Han, S. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2020

    Abstract

    INTRODUCTION: Despite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection.METHODS: The IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6-months of continuous pre-admission baseline data and 12-months of continuous post-discharge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%.RESULTS: A total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with post-discharge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% CI 1.1 to 38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3 to 32.9). Pre- and peri-operative use of prescribed NSAIDs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased post-discharge opioid and benzodiazepine use. Intramedullary location was associated with longer duration post-discharge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5 to 19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (AUC=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients.CONCLUSIONS: We developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies.

    View details for DOI 10.1016/j.spinee.2020.10.010

    View details for PubMedID 33065272

  • Can the Charlson Comorbidity Index be used to predict the ASA grade in patients undergoing spine surgery? European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society Mannion, A. F., Bianchi, G., Mariaux, F., Fekete, T. F., Reitmeir, R., Moser, B., Whitmore, R. G., Ratliff, J., Haschtmann, D. 2020

    Abstract

    BACKGROUND: The American Society of Anaesthesiologists' Physical Status Score (ASA) is a key variable in predictor models of surgical outcome and "appropriate use criteria". However, at the time when such tools are being used in decision-making, the ASA rating is typically unknown. We evaluated whether the ASA class could be predicted statistically from Charlson Comorbidy Index (CCI) scores and simple demographic variables.METHODS: Using established algorithms, the CCI was calculated from the ICD-10 comorbidity codes of 11'523 spine surgery patients (62.3±14.6y) who also had anaesthetist-assigned ASA scores. These were randomly split into training (N=8078) and test (N=3445) samples. A logistic regression model was built based on the training sample and used to predict ASA scores for the test sample and for temporal (N=341) and external validation (N=171) samples.RESULTS: In a simple model with just CCI predicting ASA, receiver operating characteristics (ROC) analysis revealed a cut-off of CCI≥1 discriminated best between being ASA≥3 versus<3 (area under the curve (AUC), 0.70±0.01, 95%CI,0.82-0.84). Multiple logistic regression analyses including age, sex, smoking, and BMI in addition to CCI gave better predictions of ASA (Nagelkerke's pseudo-R2 for predicting ASA class 1 to 4, 46.6%; for predicting ASA≥3 vs. <3, 37.5%). AUCs for discriminating ASA≥3 versus<3 from multiple logistic regression were 0.83±0.01 (95%CI, 0.82-0.84) for the training sample and 0.82±0.01 (95%CI, 0.81-0.84), 0.85±0.02 (95%CI, 0.80-0.89), and 0.77±0.04 (95%CI,0.69-0.84) for the test, temporal and external validation samples, respectively. Calibration was adequate in all validation samples.CONCLUSIONS: It was possible to predict ASA from CCI. In a simple model, CCI≥1 best distinguished between ASA≥3 and<3. For a more precise prediction, regression algorithms were created based on CCI and simple demographic variables obtainable from patient interview. The availability of such algorithms may widen the utility of decision aids that rely on the ASA, where the latter is not readily available.

    View details for DOI 10.1007/s00586-020-06595-1

    View details for PubMedID 32945963

  • Rod-Screw Constructs Composed of Dissimilar Metals Do Not Affect Complication Rates in Posterior Fusion Surgery Performed for Adult Spinal Deformity. Clinical spine surgery Denduluri, S. K., Koltsov, J. C., Ziino, C., Segovia, N., McMains, C., Falakassa, J., Ratliff, J., Wood, K. B., Alamin, T., Cheng, I., Hu, S. S. 2020

    Abstract

    STUDY DESIGN: This was a retrospective cohort study.OBJECTIVE: The objective of this study was to compare implant-related complications between mixed-metal and same-metal rod-screw constructs in patients who underwent posterior fusion for adult spinal deformity.SUMMARY OF BACKGROUND DATA: Contact between dissimilar metals is discouraged due to potential for galvanic corrosion, increasing the risk for metal toxicity, infection, and implant failure. In spine surgery, titanium (Ti) screws are most commonly used, but Ti rods are notch sensitive and likely more susceptible to fracture after contouring for deformity constructs. Cobalt chrome (CC) and stainless steel (SS) rods may be suitable alternatives. No studies have yet evaluated implant-related complications among mixed-metal constructs (SS or CC rods with Ti screws).METHODS: Adults with spinal deformity who underwent at least 5-level thoracic and/or lumbar posterior fusion or 3-column osteotomy between January 2013 and May 2015 were reviewed, excluding neuromuscular deformity, tumor, acute trauma or infection. Implant-related complications included pseudarthrosis, proximal junctional kyphosis, hardware failure (rod fracture, screw pullout or haloing), symptomatic hardware, and infection.RESULTS: A total of 61 cases met inclusion criteria: 24 patients received Ti rods with Ti screws (Ti-Ti, 39%), 31 SS rods (SS-Ti, 51%), and 6 CC rods (CC-Ti, 9.8%). Median follow-up was 37-42 months for all groups. Because of the limited number of cases, the CC-Ti group was not included in statistical analyses. There were no differences between Ti-Ti and SS-Ti groups with regard to age, body mass index, or smokers. Implant-related complications did not differ between the Ti-Ti and SS-Ti groups (P=0.080). Among the Ti-Ti group, there were 15 implant-related complications (63%). In the SS-Ti group, there were 12 implant-related complications (39%). There were 3 implant-related complications in the CC-Ti group (50%).CONCLUSION: We found no evidence that combining Ti screws with SS rods increases the risk for implant-related complications.

    View details for DOI 10.1097/BSD.0000000000001058

    View details for PubMedID 32925188

  • The Effect of Socioeconomic Status on Age at Diagnosis and Overall Survival in Patients with Intracranial Meningioma. The International journal of neuroscience Brewster, R., Deb, S., Pendharkar, A. V., Ratliff, J., Li, G., Desai, A. 2020: 1–12

    Abstract

    Background: Intracranial meningiomas are the most common primary tumors of the central nervous system. How socioeconomic status (SES) impacts treatment access and outcomes for brain tumor subtypes is an emerging area of research. Few studies have examined the relationship between SES and meningioma survival and management with reference to relevant clinical factors, including age at diagnosis. We studied the independent effects of SES on receiving surgery and survival probability in patients with intracranial meningiomaMethods: 54,282 patients diagnosed with intracranial meningioma between 2003-2012 from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute database were included. Patient SES was divided into tertiles. Patient age groups included "older" (>65, the median patient age) and "younger". Multivariable linear regression and Cox proportional hazards model were used with SAS v9.4. Results were adjusted for race, sex, and tumor grade. Kaplan Meier survival curves were constructed according to SES tertiles and age groups.Results: Meningioma prevalence increased with higher SES tertile. Higher SES tertile was also associated with younger age at diagnosis (OR= 0.890, p <0.05), an increased likelihood of undergoing gross total resection (GTR) (OR =1.112, p<0.05), and a trend towards greater 5-year survival probability (HR =1.773, p=0.0531). Survival probability correlated with younger age at diagnosis (HR =2.597, p<0.001), but not with GTR receipt.Conclusion: The findings from this national longitudinal study on patients with meningioma suggest that SES affects age at diagnosis and treatment access for intracranial meningiomas patients. Further studies are required to understand and address the mechanisms underlying these disparities.

    View details for DOI 10.1080/00207454.2020.1818742

    View details for PubMedID 32878534

  • Aneurysmal subarachnoid hemorrhage in patients with migraine and tension headache: A cohort comparison study. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia Lamsam, L., Bhambhvani, H. P., Thomas, A., Ratliff, J. K., Moore, J. M. 2020; 79: 90–94

    Abstract

    Migraine headache is a common condition with an estimated lifetime prevalence of greater than 20%. While it is a well-established risk factor for cardiovascular disease and ischemic stroke, its association with subarachnoid hemorrhage is largely unexplored. We sought to compare the incidence of aneurysmal subarachnoid hemorrhage in a cohort of migraine patients with a cohort of patients with tension headache. A cohort comparison study utilizing the MarketScan insurance claims database compared patients diagnosed with migraine who were undergoing treatment with abortive or prophylactic pharmacotherapy (treatment cohort) and patients diagnosed with tension headache who had never been diagnosed with a migraine and who were naive to migraine pharmacotherapy (control cohort). Patients with major pre-existing risk factors for aSAH were excluded from the study, and minor risk factors such as smoking status and hypertension were accounted for using coarsened exact matching (CEM) and subsequent cox proportional-hazards (CPH) regression. More than 679,000 patients (~125,000 treatment and~550,000 control) with an average follow-up of more than three years were analyzed for aneurysmal subarachnoid hemorrhage. CPH regression on matched data showed that treated migraine patients had a significantly lower hazard of aneurysmal subarachnoid hemorrhage compared with tension headache patients (HR=0.40, 95% CI: 0.19 - 0.86, p=0.02). This large cohort comparison study, analyzing more than 679,000 patients, demonstrated that migraine patients undergoing pharmacologic treatment had a lower hazard of aneurysmal subarachnoid hemorrhage than patients diagnosed with tension headaches. Future work specifically focusing on migraine medications may identify the mechanisms underlying this association.

    View details for DOI 10.1016/j.jocn.2020.07.017

    View details for PubMedID 33070926

  • Predictors of 2-year reoperation in Medicare patients undergoing primary thoracolumbar deformity surgery. Journal of neurosurgery. Spine Varshneya, K., Jokhai, R. T., Fatemi, P., Stienen, M. N., Medress, Z. A., Ho, A. L., Ratliff, J. K., Veeravagu, A. 2020: 1–5

    Abstract

    OBJECTIVE: This was a retrospective cohort study in which the authors used a nationally representative administrative database. Their goal was to identify the risk factors for reoperation in Medicare patients undergoing primary thoracolumbar adult spinal deformity (ASD) surgery. Previous literature reports estimate that 20% of patients undergoing thoracolumbar ASD correction undergo revision surgery within 2 years. Most published data discuss risk factors for revision surgery in the general population, but these have not been explored specifically in the Medicare population.METHODS: Using the MarketScan Medicare Supplemental database, the authors identified patients who were diagnosed with a spinal deformity and underwent ASD surgery between 2007 and 2015. The interactions of patient demographics, surgical factors, and medical factors with revision surgery were investigated during the 2 years following primary ASD surgery. The authors excluded patients without Medicare insurance and those with any prior history of trauma or tumor.RESULTS: Included in the data set were 2564 patients enrolled in Medicare who underwent ASD surgery between 2007 and 2015. The mean age at diagnosis with spinal deformity was 71.5 years. A majority of patients (68.5%) were female. Within 2 years of follow-up, 661 (25.8%) patients underwent reoperation. Preoperative osteoporosis (OR 1.58, p < 0.0001), congestive heart failure (OR 1.35, p = 0.0161), and paraplegia (OR 2.41, p < 0.0001) independently increased odds of revision surgery. The use of intraoperative bone morphogenetic protein was protective against reoperation (OR 0.71, p = 0.0371). Among 90-day postoperative complications, a wound complication was the strongest predictor of undergoing repeat surgery (OR 2.85, p = 0.0061). The development of a pulmonary embolism also increased the odds of repeat surgery (OR 1.84, p = 0.0435).CONCLUSIONS: Approximately one-quarter of Medicare patients with ASD who underwent surgery required an additional spinal surgery within 2 years. Baseline comorbidities such as osteoporosis, congestive heart failure, and paraplegia, as well as short-term complications such as pulmonary embolism and wound complications significantly increased the odds of repeat surgery.

    View details for DOI 10.3171/2020.5.SPINE191425

    View details for PubMedID 32707541

  • A Comparative Analysis of Patients Undergoing Fusion for Adult Cervical Deformity by Approach Type. Global spine journal Varshneya, K., Medress, Z. A., Stienen, M. N., Nathan, J., Ho, A., Pendharkar, A. V., Loo, S., Aikin, J., Li, G., Desai, A., Ratliff, J. K., Veeravagu, A. 2020: 2192568220915717

    Abstract

    Retrospective cohort study.To provide insight into postoperative complications, short-term quality outcomes, and costs of the surgical approaches of adult cervical deformity (ACD).A national database was queried from 2007 to 2016 to identify patients who underwent cervical fusion for ACD. Patients were stratified by approach type-anterior, posterior, or circumferential. Patients undergoing anterior and posterior approach surgeries were additionally compared using propensity score matching.A total of 6575 patients underwent multilevel cervical fusion for ACD correction. Circumferential fusion had the highest postoperative complication rate (46.9% vs posterior: 36.7% vs anterior: 18.5%, P < .0001). Anterior fusion patients more commonly required reoperation compared with posterior fusion patients (P < .0001), and 90-day readmission rate was highest for patients undergoing circumferential fusion (P < .0001). After propensity score matching, the complication rate remained higher in the posterior, as compared to the anterior fusion group (P < .0001). Readmission rate also remained higher in the posterior fusion group; however, anterior fusion patients were more likely to require reoperation. At index hospitalization, posterior fusion led to 1.5× higher costs, and total payments at 90 days were 1.6× higher than their anterior fusion counterparts.Patients who undergo posterior fusion for ACD have higher complication rates, readmission rates, and higher cost burden than patients who undergo anterior fusion; however, posterior correction of ACD is associated with a lower rate of reoperation.

    View details for DOI 10.1177/2192568220915717

    View details for PubMedID 32875897

  • A Comparative Analysis of Patients Undergoing Fusion for Adult Cervical Deformity by Approach Type GLOBAL SPINE JOURNAL Varshneya, K., Medress, Z. A., Stienen, M. N., Nathan, J., Ho, A., Pendharkar, A. V., Loo, S., Aikin, J., Li, G., Desai, A., Ratliff, J. K., Veeravagu, A. 2020
  • Objective activity tracking in spine surgery: a prospective feasibility study with a low-cost consumer grade wearable accelerometer. Scientific reports Stienen, M. N., Rezaii, P. G., Ho, A. L., Veeravagu, A., Zygourakis, C. C., Tomkins-Lane, C., Park, J., Ratliff, J. K., Desai, A. M. 2020; 10 (1): 4939

    Abstract

    Patient-reported outcome measures (PROMs) are commonly used to estimate disability of patients with spinal degenerative disease. Emerging technological advances present an opportunity to provide objective measurements of activity. In a prospective, observational study we utilized a low-cost consumer grade wearable accelerometer (LCA) to determine patient activity (steps per day) preoperatively (baseline) and up to one year (Y1) after cervical and lumbar spine surgery. We studied 30 patients (46.7% male; mean age 57 years; 70% Caucasian) with a baseline activity level of 5624 steps per day. The activity level decreased by 71% in the 1st postoperative week (p<0.001) and remained 37% lower in the 2nd (p<0.001) and 23% lower in the 4th week (p=0.015). At no time point until Y1 did patients increase their activity level, compared to baseline. Activity was greater in patients with cervical, as compared to patients with lumbar spine disease. Age, sex, ethnic group, anesthesia risk score and fusion were variables associated with activity. There was no correlation between activity and PROMs, but a strong correlation with depression. Determining activity using LCAs provides real-time and longitudinal information about patient mobility and return of function. Recovery took place over the first eight postoperative weeks, with subtle improvement afterwards.

    View details for DOI 10.1038/s41598-020-61893-4

    View details for PubMedID 32188895

  • Postoperative Complication Burden, Revision Risk, and Health Care Use in Obese Patients Undergoing Primary Adult Thoracolumbar Deformity Surgery GLOBAL SPINE JOURNAL Varshneya, K., Pangal, D. J., Stienen, M. N., Ho, A. L., Fatemi, P., Medress, Z. A., Herrick, D. B., Desai, A., Ratliff, J. K., Veeravagu, A. 2020
  • Postoperative Complication Burden, Revision Risk, and Health Care Use in Obese Patients Undergoing Primary Adult Thoracolumbar Deformity Surgery. Global spine journal Varshneya, K., Pangal, D. J., Stienen, M. N., Ho, A. L., Fatemi, P., Medress, Z. A., Herrick, D. B., Desai, A., Ratliff, J. K., Veeravagu, A. 2020: 2192568220904341

    Abstract

    This is a retrospective cohort study using a nationally representative administrative database.To identify the impact of obesity on postoperative outcomes in patients undergoing thoracolumbar adult spinal deformity (ASD) surgery.The obesity rate in the United States remains staggering, with approximately one-third of all Americans being overweight or obese. However, the impact of elevated body mass index on spine surgery outcomes remains unclear.We queried the MarketScan database to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2016. Patients were then stratified by whether or not they were diagnosed as obese at index surgical admission. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between obese and nonobese patients. Patients <18 years and those with any prior history of trauma or tumor were excluded from this study. Baseline demographics and comorbidities, postoperative complication rates, and short- and long-term reoperation rates were determined.A total of 7423 patients met the inclusion criteria of this study, of whom 597 (8.0%) were obese. Initially, patients with obesity had a higher 90-day postoperative complication rate than nonobese patients (46.1% vs 40.8%, P < .05); however, this difference did not remain after PSM. Revision surgery rates after 2 years were similar across the 2 groups following primary surgery (obese, 21.4%, vs nonobese, 22.0%; P = .7588). Health care use occurred at a higher rate among obese patients through 2 years of long-term follow-up (obese, $152 930, vs nonobese, $140 550; P < .05).Patients diagnosed with obesity who underwent ASD surgery did not demonstrate increased rates of complications, reoperations, or readmissions. However, overall health care use through 2 years of follow-up after index surgery was higher in the obesity cohort.

    View details for DOI 10.1177/2192568220904341

    View details for PubMedID 32875891

  • Lumboperitoneal and Ventriculoperitoneal Shunting for Idiopathic Intracranial Hypertension Demonstrate Comparable Failure and Complication Rates NEUROSURGERY Azad, T. D., Zhang, Y., Varshneya, K., Veeravagu, A., Ratliff, J. K., Li, G. 2020; 86 (2): 272–80
  • Evaluating Shunt Survival Following Ventriculoperitoneal Shunting with and without Stereotactic Navigation in Previously Shunt-Naïve Patients. World neurosurgery Jin, M. C., Wu, A. n., Azad, T. D., Feng, A. n., Prolo, L. M., Veeravagu, A. n., Grant, G. A., Ratliff, J. n., Li, G. n. 2020

    View details for DOI 10.1016/j.wneu.2020.01.138

    View details for PubMedID 31996335

  • A Predictive-Modeling Based Screening Tool for Prolonged Opioid Use after Surgical Management of Low Back and Lower Extremity Pain. The spine journal : official journal of the North American Spine Society Zhang, Y. n., Fatemi, P. n., Medress, Z. n., Azad, T. D., Veeravagu, A. n., Desai, A. n., Ratliff, J. K. 2020

    Abstract

    Outpatient postoperative pain management in spine patients, specifically involving the use of opioids, demonstrates significant variability.Using preoperative risk factors and 30-day postoperative opioid prescribing patterns, we developed models for predicting long-term opioid use in patients after elective spine surgery.This retrospective cohort study utilizes inpatient, outpatient, and pharmaceutical data from MarketScan databases (Truven Health).In all, 19,317 patients who were newly diagnosed with low back or lower extremity pain (LBP or LEP) between 2008 and 2015 and underwent thoracic or lumbar surgery within one year after diagnosis were enrolled. Some patients initiated opioids after diagnosis but all patients were opioid-naïve prior to the diagnosis.Long-term opioid use was defined as filling ≥180 days of opioids within one year after surgery.Using demographic variables, medical and psychiatric comorbidities, preoperative opioid use, and 30-day postoperative opioid use, we generated seven models on 80% of the dataset and tested the models on the remaining 20%. We used three regression-based models (full logistic regression, stepwise logistic regression, least absolute shrinkage and selection operator [LASSO]), support vector machine, two tree-based models (random forest, stochastic gradient boosting), and time-varying convolutional neural network. Area under the curve (AUC), Brier index, sensitivity, and calibration curves were used to assess the discrimination and calibration of the models.We identified 903 (4.6%) of patients who met criteria for long-term opioid use. The regression-based models demonstrated the highest AUC, ranging from 0.835 to 0.847, and relatively high sensitivities, predicting between 74.9-76.5% of the long-term opioid use patients in the test dataset. The three strongest positive predictors of long-term opioid use were high preoperative opioid use (OR 2.70; 95% CI 2.27-3.22), number of days with active opioid prescription between postoperative days 15-30 (OR 1.10; 95% CI 1.07-1.12), and number of dosage increases between postoperative day 15-30 (OR 1.71, 95% CI 1.41-2.08). The strongest negative predictors were number of dosage decreases in the 30-day postoperative period.We evaluated several predictive models for postoperative long-term opioid use in a large cohort of patients with LBP or LEP who underwent surgery. A regression-based model with high sensitivity and AUC is provided online to screen patients for high risk of long-term opioid use based on preoperative risk factors and opioid prescription patterns in the first 30 days after surgery. It is hoped that this work will improve identification of patients at high risk of prolonged opioid use and enable early intervention and counseling.

    View details for DOI 10.1016/j.spinee.2020.05.098

    View details for PubMedID 32445803

  • Costs and Complications Associated with Resection of Supratentorial Tumors with and without the Operative Microscope in the United States. World neurosurgery Zhang, Y. n., Zhang, M. n., Lin, M. n., Gephart, M. H., Veeravagu, A. n., Ratliff, J. K., Li, G. n. 2020

    Abstract

    The operative microscope, a commonly used tool in neurosurgery, is critical in many supratentorial tumor cases. However, use of operating microscope for supratentorial tumor varies by surgeon.To assess complication rates, readmissions, and costs associated with operative microscope use in supratentorial resections.A retrospective analysis was conducted using a national administrative database to identify patients with glioma or brain metastases who underwent supratentorial resection between 2007 and 2016. Univariate and multivariate analyses were used to assess 30-day complications, readmissions and costs between patients who underwent resection with and without use of microscope.The cohort included 12058 glioma patients and 5433 metastasis patients. Rates of microscope use varied by state from 19.0% to 68.6%. Microscope use was associated with $5228.9 in additional costs of index hospitalization among glioma patients (p < 0.001), and $2824.0 among metastasis patients (p < 0.001). Rates of intraoperative cerebral edema were lower among the microscope cohort than among the non-microscope cohort (p < 0.027). Microscope use was associated with a slight reduction in 30-day rates of neurological complications (14.7% vs. 16.7%, p = 0.048), specifically in nonspecific cerebrovascular complications. There were no differences in rates of other complications, readmissions, or 30-day postoperative costs.Use of operative microscope for supratentorial resections varies by state and is associated with higher cost of surgery. Microscope use may be associated with lower rates of intraoperative cerebral edema and some cerebrovascular complications, but is not associated with significant differences in other complications, readmissions, or 30-day costs.

    View details for DOI 10.1016/j.wneu.2020.03.021

    View details for PubMedID 32171932

  • Complications, Costs, and Quality Outcomes of Patients Undergoing Cervical Deformity Surgery with Intraoperative BMP Use. Spine Varshneya, K. n., Wadhwa, H. n., Pendharkar, A. V., Medress, Z. A., Stienen, M. N., Ratliff, J. K., Veeravagu, A. n. 2020

    Abstract

    An epidemiological study using national administrative data from the MarketScan database.To identify the impact of bone morphogenetic protein (BMP) on postoperative outcomes in patients undergoing adult cervical deformity (ACD) surgery.BMP has been shown to stimulate bone growth and improve fusion rates in spine surgery. However, the impact of BMP on reoperation rates and postoperative complication rate is controversial.We queried the MarketScan database to identify patients who underwent ACD surgery from 2007-2015. Patients were stratified by BMP use in the index operation. Patients under 18 and those with any history of tumor or trauma were excluded. Baseline demographics and comorbidities, postoperative complication rates and reoperation rates were analyzed.A total of 13,549 patients underwent primary ACD surgery, of which 1155 (8.5%) had intraoperative BMP use. The overall 90-day complication rate was 27.6% in the non-BMP cohort and 31.1% in the BMP cohort (p < 0.05). Patients in the BMP cohort had longer average length of stay (4.0 days vs 3.7 days, p < 0.05) but lower revision surgery rates at 90-days (14.5% vs 28.3%, p < 0.05), 6 months (14.9% vs 28.6%, p < 0.05), 1 year (15.7% vs 29.2%, p < 0.05), and 2 years (16.5% vs 29.9%, p < 0.05) postoperatively. BMP use was associated with higher payments throughout the 2-year follow-up period ($107,975 vs $97,620, p < 0.05). When controlling for baseline group differences, BMP use independently increased the odds of postoperative complication (OR 1.22, 95% CI 1.1 - 1.4) and reduced the odds of reoperation throughout 2-years of follow-up (OR 0.49, 95% CI 0.4 - 0.6).Intraoperative BMP use has benefits for fusion integrity in ACD surgery but is associated with increased postoperative complication rate. Spine surgeons should weigh these benefits and drawbacks to identify optimal candidates for BMP use in ACD surgery.3.

    View details for DOI 10.1097/BRS.0000000000003629

    View details for PubMedID 32756275

  • Opioid Prescribing Patterns for Low Back Pain Among Commercially-Insured Children. Spine Azad, T. D., Harries, M. D., Veeravagu, A. n., Ratliff, J. K. 2020

    View details for DOI 10.1097/BRS.0000000000003657

    View details for PubMedID 32858745

  • Adult Spinal Deformity Surgery in Patients With Movement Disorders: A Propensity-matched Analysis of Outcomes and Cost. Spine Varshneya, K. n., Azad, T. D., Pendharkar, A. V., Desai, A. n., Cheng, I. n., Karikari, I. n., Ratliff, J. K., Veeravagu, A. n. 2020; 45 (5): E288–E295

    Abstract

    This was a retrospective study using national administrative data from the MarketScan database.To investigate the complication rates, quality outcomes, and costs in a nationwide cohort of patients with movement disorders (MD) who undergo spinal deformity surgery.Patients with MD often present with spinal deformities, but their tolerance for surgical intervention is unknown.The MarketScan administrative claims database was queried to identify adult patients with MD who underwent spinal deformity surgery. A propensity-score match was conducted to create two uniform cohorts and mitigate interpopulation confounders. Perioperative complication rates, 90-day postoperative outcomes, and total costs were compared between patients with MD and controls.A total of 316 patients with MD (1.7%) were identified from the 18,970 undergoing spinal deformity surgery. The complication rate for MD patients was 44.6% and for the controls 35.6% (P = 0.009). The two most common perioperative complications were more likely to occur in MD patients, acute-posthemorrhagic anemia (26.9% vs. 20.8%, P < 0.05) and deficiency anemia (15.5% vs. 8.5%, P < 0.05). At 90 days, MD patients were more likely to be readmitted (17.4% vs. 13.2%, P < 0.05) and have a higher total cost ($94,672 vs. $85,190, P < 0.05). After propensity-score match, the overall complication rate remained higher in the MD group (44.6% vs. 37.6%, P < 0.05). 90-day readmissions and costs also remained significantly higher in the MD cohort. Multivariate modeling revealed MD was an independent predictor of postoperative complication and inpatient readmission. Subgroup analysis revealed that Parkinson disease was an independent predictor of inpatient readmission, reoperation, and increased length of stay.Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of perioperative complications and 90-day readmissions compared with patients without these disorders.3.

    View details for DOI 10.1097/BRS.0000000000003251

    View details for PubMedID 32045403

  • Conventional Versus Stereotactic Image Guided Pedicle Screw Placement During Spinal Deformity Correction: A Retrospective Propensity Score-Matched Study of a National Longitudinal Database. The International journal of neuroscience Rezaii, P. G., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Veeravagu, A. n., Ratliff, J. K., Desai, A. M. 2020: 1–13

    Abstract

    Purpose/aim: To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity.Methods: The Thomson Reuters MarketScan national longitudinal database was used to identify patients undergoing osteotomy, posterior instrumentation, and fusion for treatment of spinal deformity with or without image-guided navigation between 2007-2016. Conventional and navigated groups were propensity-matched (1:1) to normalize differences between demographics, comorbidities, and surgical characteristics. Clinical outcomes and charges were compared between matched groups using bivariate analyses.Results: A total of 4,604 patients were identified as having undergone deformity correction, of which 286 (6.2%) were navigated. Propensity-matching resulted in a total of 572 well-matched patients for subsequent analyses, of which half were navigated. Rate of mechanical instrumentation-related complications was found to be significantly lower for navigated procedures (p = 0.0371). Navigation was also associated with lower rates of 90-day unplanned readmissions (p = 0.0295), as well as 30- and 90-day postoperative revisions (30-day: p = 0.0304, 90-day: p = 0.0059). Hospital, physician, and total payments favored the conventional group for initial admission (p = 0.0481, 0.0001, 0.0019, respectively); however, when taking into account costs of readmissions, hospital payments became insignificantly different between the two groups.Conclusions: Procedures involving image-guided navigation resulted in decreased instrumentation-related complications, unplanned readmissions, and postoperative revisions, highlighting its potential utility for the treatment of spine deformity. Future advances in navigation technologies and methodologies can continue to improve clinical outcomes, decrease costs, and facilitate widespread adoption of navigation for deformity correction.

    View details for DOI 10.1080/00207454.2020.1763343

    View details for PubMedID 32364414

  • Association between Physician Industry Payments and Cost of Anterior Cervical Discectomy and Fusion in Medicare Beneficiaries. World neurosurgery Liu, C. n., Ahmed, K. n., Chen, C. L., Dudley, R. A., Gonzales, R. n., Orrico, K. n., Yerneni, K. n., Stienen, M. N., Veeravagu, A. n., Desai, A. n., Park, J. n., Ratliff, J. K., Zygourakis, C. C. 2020

    Abstract

    Neurosurgical spine specialists receive considerable amounts of industry support which may impact the cost of care. The aim of this study was to evaluate the association between industry payments received by spine surgeons and the total hospital and operating room (OR) costs of an anterior cervical discectomy and fusion (ACDF) procedure among Medicare beneficiaries.All ACDF cases were identified among the Medicare Carrier Files, from January 1, 2013, to December 31, 2014, and matched to the Medicare Inpatient Baseline File. The total hospital and OR charges were obtained for these cases. Charges were converted to cost using year-specific cost-to-charge ratios. Surgeons were identified among Open Payments database, which is used to quantify industry support. Analyses was performed to examine the association between industry payments received and ACDF costs.Matching resulting in the inclusion of 2,209 ACDF claims from 2013-2014. In 2013 and 2014, the mean total cost for an ACDF was $21,798 and $21,008, respectively; mean OR cost was $5,878 and $6,064, respectively. Mann-Whitney U test demonstrated no significant differences in the mean total or OR cost for an ACDF based on quartile of general industry payment received (p=0.21 and p=0.54), and linear regression found no association between industry general payments, research support, or investments on the total hospital cost (p=0.41, p=0.13, and p=0.25), or OR cost for an ACDF (p=0.35, p=0.24, and p=0.40).This study suggests that spine surgeons performing ACDF surgeries may receive industry support without impacting the cost of care.

    View details for DOI 10.1016/j.wneu.2020.08.023

    View details for PubMedID 32791230

  • Emergent neuroimaging for seizures in epilepsy: A population study. Epilepsy & behavior : E&B Lamsam, L. n., Bhambhvani, H. P., Ratliff, J. K., Kvam, K. A. 2020; 112: 107339

    Abstract

    We determined how often patients with epilepsy presented to the emergency department (ED) for seizure and the frequency and predictors for undergoing emergent neuroimaging during those visits. We conducted a retrospective population-based cohort study using administrative claims' data from 2007 to 2015. Adults with epilepsy were identified based on a diagnosis of epilepsy and an outpatient prescription for an antiepileptic medication. The Bonferroni corrected significance level was 0.0018. We identified 381,362 patients with a mean follow-up period of 1.99 years, of whom 35,015 (9.2%) patients presented to the ED for seizure at least once. Patients with at least one ED visit were younger, more likely to be male, had fewer comorbidities, and had longer follow-up as compared with those with no ED visit (all p < 0.001). Among the 35,015 patients presenting to the ED, 13.6% had neuroimaging, mostly commonly head computed tomography (CT; 95.5%). Patients undergoing neuroimaging were younger (46 versus 48 years) and with higher rates of psychosis (17.4% versus 13.8%) and depression (16.1% versus 12.2%; p < 0.001). This helps to quantify the burden of ED and emergent neuroimaging utilization for patients with epilepsy and can help inform efforts to curtail unnecessary neuroimaging.

    View details for DOI 10.1016/j.yebeh.2020.107339

    View details for PubMedID 32911297

  • Adverse Events and Bundled Costs after Cranial Neurosurgical Procedures: Validation of the LACE Index Across 40,431 Admissions and Development of the LACE-Cranial Index. World neurosurgery Jin, M. C., Wu, A. n., Medress, Z. A., Parker, J. J., Desai, A. n., Veeravagu, A. n., Grant, G. A., Li, G. n., Ratliff, J. K. 2020

    Abstract

    Anticipating post-discharge complications following neurosurgery remains difficult. The LACE index, based on four hospitalization descriptors, stratifies patients by risk of 30-day post-discharge adverse events but has not been validated in a procedure-specific manner in neurosurgery. Our study sought to explore the utility of the LACE index in cranial neurosurgery population and to develop an enhanced model, LACE-Cranial.The Optum Clinformatics Database was used to identify cranial neurosurgery admissions (2004-2017). Procedures were grouped as trauma/hematoma/ICP, open vascular, functional/pain, skull base, tumor, or endovascular. Adverse events were defined as post-discharge death/readmission. LACE-Cranial was developed using a logistic regression framework incorporating an expanded feature set in addition to the original LACE components.A total of 40,431 admissions were included. Predictions of 30-day readmissions was best for skull-base (AUC=0.636) and tumor (AUC=0.63) admissions but was generally poor. Predictive ability of 30-day mortality was best for functional/pain admissions (AUC=0.957) and poorest for trauma/hematoma/ICP admissions (AUC=0.613). Across procedure types except for functional/pain, a high-risk LACE score was associated with higher post-discharge bundled payment costs. Incorporating features identified to contribute independent predictive value, the LACE-Cranial model achieved procedure-specific 30-day mortality AUCs ranging from 0.904 to 0.98. Prediction of 30-day and 90-day readmissions was also improved, with tumor and skull base cases achieving 90-day readmission AUCs of 0.718 and 0.717, respectively.While the unmodified LACE index demonstrates inconsistent classification performance, the enhanced LACE-Cranial model offers excellent prediction of short-term post-discharge mortality across procedure groups and significantly improved anticipation of short-term post-discharge readmissions.

    View details for DOI 10.1016/j.wneu.2020.10.103

    View details for PubMedID 33127572

  • Opioid Use in Adults with Low Back or Lower Extremity Pain who Undergo Spine Surgical Treatment within One Year of Diagnosis. Spine Fatemi, P. n., Zhang, Y. n., Ho, A. n., Lama, R. n., Jin, M. n., Veeravagu, A. n., Desai, A. n., Ratliff, J. K. 2020

    Abstract

    Retrospective longitudinal cohort.We investigated opioid prescribing patterns amongst adults in the United States diagnosed with low back or lower extremity pain (LBP/LEP) who underwent spine surgery.Opioid-based treatment of LBP/LEP and postsurgical pain have separately been associated with chronic opioid use, but a combined and large-scale cohort study is missing.This study utilizes commercial inpatient, outpatient, and pharmaceutical insurance claims. Between 2008 and 2015, patients without prior prescription opioids with a new diagnosis of LBP/LEP who underwent surgery within one year after diagnosis were enrolled. Opioid prescribing patterns after LBP/LEP diagnosis and after surgery were evaluated. All patients had one-year postoperative follow-up. Low and high frequency (≥6 refills in 12 months) opioid prescription groups were identified.25,506 patients without prior prescription opioids were diagnosed with LBP/LEP and underwent surgery within one year of diagnosis. After LBP/LEP diagnosis, 18,219 (71.4%) were prescribed opioids while 7,287 (28.6%) were not. After surgery, 2,952 (11.6%) were prescribed opioids with high frequency and 22,554 (88.4%) with low frequency. Among patients prescribed opioids prior to surgery, those with high frequency prescriptions were more likely to continue this pattern postoperatively than those with low frequency prescriptions preoperatively (OR:2.15, 95% CI:1.97-2.34). For those prescribed opioids preoperatively, average daily morphine milligram equivalent (MME) decreased after surgery (by 2.62 in decompression alone cohort and 0.25 in arthrodesis cohort, p < 0.001). Postoperative low-frequency patients were more likely than high-frequency patients to discontinue opioids one-year after surgery (OR:3.78, 95% CI:3.59-3.99). Postoperative high-frequency patients incurred higher cost than low-frequency patients. Postoperative high-frequency prescribing varied widely across states (4.3%-20%).A stepwise association exists between opioid use after LEP or LBP diagnosis and frequency and duration of opioid prescriptions after surgery. Simultaneously, the strength of prescriptions as measured by MME decreased following surgery.3.

    View details for DOI 10.1097/BRS.0000000000003663

    View details for PubMedID 32833930

  • Evaluating the Impact of Spinal Osteotomy on Surgical Outcomes of Thoracolumbar Deformity Correction. World neurosurgery Varshneya, K. n., Stienen, M. N., Ho, A. L., Medress, Z. A., Fatemi, P. n., Pendharkar, A. V., Ratliff, J. K., Veeravagu, A. n. 2020

    Abstract

    In cases of adult spinal deformity (ASD) with severe sagittal malalignment, the use of osteotomies may be necessary in addition to posterior fusion. However, little data exists describing the impact of osteotomies on complications and quality outcomes during ASD surgery.We queried the MarketScan database to identify patients who underwent ASD surgery from 2007-2016. Patients were stratified into whether or not an osteotomy was used in the index operation. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between osteotomy and non-osteotomy patients. Patients under the age of 18 years and those with any prior history of trauma or tumor were excluded from this study.7423 patients met the inclusion criteria of this study, of which n = 2700 (36.4%) received an osteotomy. After PSM, baseline comorbidities and approach type were similar between cohorts. The overall 90-day complication rate was 43.2% in non-osteotomy patients and 52.8% in osteotomy patients (p < 0.0001). The osteotomy cohort also had significantly higher rates of revision surgeries through 2 years (21.1% vs 18.0%, p < 0.05) following index surgery. Three-column osteotomy patients had the highest procedural payments, costing $155,885 through 90-days and $167,161 through 1 year following surgery.This analysis confirms high costs as well as complication, readmission and reoperation rates until two years after ASD surgery in general, which are even higher in cases where an osteotomy is required. Further research should explore strategies for optimizing patient outcomes following osteotomy.

    View details for DOI 10.1016/j.wneu.2020.09.072

    View details for PubMedID 32956883

  • Single- versus dual-attending strategy for spinal deformity surgery: 2-year experience and systematic review of the literature. Journal of neurosurgery. Spine Cheng, I. n., Stienen, M. N., Medress, Z. A., Varshneya, K. n., Ho, A. L., Ratliff, J. K., Veeravagu, A. n. 2020: 1–12

    Abstract

    Adult spinal deformity (ASD) surgery is complex and associated with high morbidity and complication rates. There is growing evidence in the literature for the beneficial effects of an approach to surgery in which two attending physicians rather than a single attending physician perform surgery for and oversee the surgical care of a single patient in a dual-attending care model. The authors developed a dual-attending care collaboration in August 2017 in which a neurosurgeon and an orthopedic surgeon mutually operated on patients with ASD.The authors recorded data for 2 years of experience with ASD patients operated on by dual attending surgeons. Analyses included estimated blood loss (EBL), transfusions, length of stay (LOS), discharge disposition, complication rates, emergency room visits and readmissions, subjective health status improvement, and disability (Oswestry Disability Index [ODI] score) and pain (visual analog scale [VAS] score) at last follow-up. In addition, the pertinent literature for dual-attending spinal deformity correction was systematically reviewed.The study group comprised 19 of 254 (7.5%) consecutively operated patients who underwent thoracolumbar fusion during the period from January 2017 to June 2019 (68.4% female; mean patient age 65.1 years, ODI score 44.5, VAS pain score 6.8). The study patients were matched by age, sex, anesthesia risk, BMI, smoking status, ODI score, VAS pain score, prior spine surgeries, and basic operative characteristics (type of interbody implants, instrumented segments, pelvic fixation) to 19 control patients (all p > 0.05). There was a trend toward less EBL (mean 763 vs 1524 ml, p = 0.059), fewer intraoperative red blood cell transfusions (mean 0.5 vs 2.3, p = 0.079), and fewer 90-day readmissions (0% vs 15.8%, p = 0.071) in the dual-attending group. LOS and discharge disposition were similar, as were the rates of any < 30-day postsurgery complications, < 90-day postsurgery emergency room visits, and reoperations, and ODI and VAS pain scores at last follow-up (all p > 0.05). At last follow-up, 94.7% vs 68.4% of patients in the dual- versus single-attending group stated their health status had improved (p = 0.036). In the authors' literature search of prior articles on spinal deformity correction, 5 of 8 (62.5%) articles reported lower EBL and 6 of 8 (75%) articles reported significantly lower operation duration in dual-attending cases. The literature contained differing results with regard to complication- or reoperation-sparing effects associated with dual-attending cases. Similar clinical outcomes of dual- versus single-attending cases were reported.Establishing a dual-attending care management platform for ASD correction was feasible at the authors' institution. Results of the use of a dual-attending strategy at the authors' institution were favorable. Positive safety and outcome profiles were found in articles on this topic identified by a systematic literature review.

    View details for DOI 10.3171/2020.3.SPINE2016

    View details for PubMedID 32650315

  • Improving the Patient-Physician Relationship in the Digital Era - Transformation From Subjective Questionnaires Into Objective Real-Time and Patient-Specific Data Reporting Tools. Neurospine Maldaner, N., Desai, A., Gautschi, O. P., Regli, L., Ratliff, J. K., Park, J., Stienen, M. N. 2019; 16 (4): 712–14

    View details for DOI 10.14245/ns.1938400.200

    View details for PubMedID 31905462

  • Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease. Global spine journal Azad, T. D., Varshneya, K., Herrick, D. B., Pendharkar, A. V., Ho, A. L., Stienen, M., Zygourakis, C., Bagshaw, H. P., Veeravagu, A., Ratliff, J. K., Desai, A. 2019: 2192568219889363

    Abstract

    This was an epidemiological study using national administrative data from the MarketScan database.To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease.We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into "Early RT" if they received RT within 4 weeks of surgery and as "Late RT" if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes.A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications (P = .574).When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.

    View details for DOI 10.1177/2192568219889363

    View details for PubMedID 32875859

  • Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease GLOBAL SPINE JOURNAL Azad, T. D., Varshneya, K., Herrick, D. B., Pendharkar, A., Ho, A. L., Stienen, M., Zygourakis, C., Bagshaw, H. P., Veeravagu, A., Ratliff, J. K., Desai, A. 2019
  • Letter: Antibiotic Stewardship and Single-Dose Antibiotic Prophylaxis: A Word of Caution. Neurosurgery Ho, A. L., Stienen, M. N., Ratliff, J. K. 2019

    View details for DOI 10.1093/neuros/nyz477

    View details for PubMedID 31748799

  • Patterns of Opioid and Benzodiazepine Use in Opioid-Naive Patients with Newly Diagnosed Low Back and Lower Extremity Pain. Journal of general internal medicine Azad, T. D., Zhang, Y., Stienen, M. N., Vail, D., Bentley, J. P., Ho, A. L., Fatemi, P., Herrick, D., Kim, L. H., Feng, A., Varshneya, K., Jin, M., Veeravagu, A., Bhattacharya, J., Desai, M., Lembke, A., Ratliff, J. K. 2019

    Abstract

    BACKGROUND: The morbidity and mortality associated with opioid and benzodiazepine co-prescription is a pressing national concern. Little is known about patterns of opioid and benzodiazepine use in patients with acute low back pain or lower extremity pain.OBJECTIVE: To characterize patterns of opioid and benzodiazepine prescribing among opioid-naive, newly diagnosed low back pain (LBP) or lower extremity pain (LEP) patients and to investigate the relationship between benzodiazepine prescribing and long-term opioid use.DESIGN/SETTING: We performed a retrospective analysis of a commercial database containing claims for more than 75 million enrollees in the USA.PARTICIPANTS: Participants were adult patients newly diagnosed with LBP or LEP between 2008 and 2015 who did not have a red flag diagnosis, had not received an opioid prescription in the 6months prior to diagnosis, and had 12months of continuous enrollment after diagnosis.MAIN OUTCOMES AND MEASURES: Among patients receiving at least one opioid prescription within 12months of diagnosis, we defined discrete patterns of benzodiazepine prescribing-continued use, new use, stopped use, and never use. We tested the association of these prescription patterns with long-term opioid use, defined as six or more fills within 12months.RESULTS: We identified 2,497,653 opioid-naive patients with newly diagnosed LBP or LEP. Between 2008 and 2015, 31.9% and 11.5% of these patients received opioid and benzodiazepine prescriptions, respectively, within 12months of diagnosis. Rates of opioid prescription decreased from 34.8% in 2008 to 27.0% in 2015 (P<0.001); however, prescribing of benzodiazepines only decreased from 11.6% in 2008 to 10.8% in 2015. Patients with continued or new benzodiazepine use consistently used more opioids than patients who never used or stopped using benzodiazepines during the study period (one-way ANOVA, P<0.001). For patients with continued and new benzodiazepine use, the odds ratio of long-term opioid use compared with those never prescribed a benzodiazepine was 2.99 (95% CI, 2.89-3.08) and 2.68 (95% CI, 2.62-2.75), respectively.LIMITATIONS: This study used administrative claims analyses, which rely on accuracy and completeness of diagnostic, procedural, and prescription codes.CONCLUSION: Overall opioid prescribing for low back pain or lower extremity pain decreased substantially during the study period, indicating a shift in management within the medical community. Rates of benzodiazepine prescribing, however, remained at approximately 11%. Concurrent prescriptions of benzodiazepines and opioids after LBP or LEP diagnosis were associated with increased risk of long-term opioid use.

    View details for DOI 10.1007/s11606-019-05549-8

    View details for PubMedID 31720966

  • Propensity-matched Comparison of Outcomes and Costs After Macroscopic and Microscopic Anterior Cervical Corpectomy Using a National Longitudinal Database. Spine Ho, A. L., Rezaii, P. G., Pendharkar, A. V., Sussman, E. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2019; 44 (21): E1281–E1288

    Abstract

    STUDY DESIGN: A retrospective analysis of national longitudinal database.OBJECTIVE: The aim of this study was to examine the outcomes and cost-effectiveness of operating microscope utilization in anterior cervical corpectomy (ACC).SUMMARY OF BACKGROUND DATA: The operating microscope allows for superior visualization and facilitates ACC with less manipulation of tissue and improved decompression of neural elements. However, many groups report no difference in outcomes with increased cost associated with microscope utilization.METHODS: A longitudinal database (MarketScan) was utilized to identify patients undergoing ACC with or without microscope between 2007 and 2016. Propensity matching was performed to normalize differences between the two cohorts. Outcomes and costs were subsequently compared.RESULTS: A total of 11,590 patients were identified for the "macroscopic" group, while 4299 patients were identified for the "microscopic" group. For the propensity-matched analysis, 4298 patients in either cohort were successfully matched according to preoperative characteristics. Hospital length of stay was found to be significantly longer in the macroscopic group than the microscopic group (1.86 nights vs. 1.56 nights, P < 0.0001). Macroscopic ACC patients had an overall higher rate of readmissions [30-day: 4.2% vs. 3.2%, odds ratio (OR) = 0.76 (0.61-0.96), P = 0.0223; 90-day: 7.0% vs. 5.9%, OR = 0.82 (0.69-0.98), P = 0.0223]. Microscopic ACC patients had a higher rate of discharge to home [86.6% vs. 92.5%, OR = 1.91 (1.65-2.21), P < 0.0001] and lower rates of new referrals to pain management [1.0% vs. 0.4%, OR = 0.42 (0.23-0.74), P = 0.0018] compared with macroscopic ACC. Postoperative complication rate was not found to be significantly different between the groups. Finally, total initial admission charges were not significantly different between the macroscopic and microscopic groups ($30,175 vs. $29,827, P = 0.9880).CONCLUSION: The present study suggests that the use of the operating microscope for ACC is associated with decreased length of stay, readmissions, and new referrals to pain management, as well as higher rate of discharge to home.LEVEL OF EVIDENCE: 3.

    View details for DOI 10.1097/BRS.0000000000003147

    View details for PubMedID 31634304

  • Long-Term Update of Stereotactic Radiosurgery for Benign Spinal Tumors NEUROSURGERY Chin, A. L., Fujimoto, D., Kumar, K. A., Tupper, L., Mansour, S., Chang, S. D., Adler, J. R., Gibbs, I. C., Hancock, S. L., Dodd, R., Li, G., Gephart, M., Ratliff, J. K., Tse, V., Usoz, M., Sachdev, S., Soltys, S. G. 2019; 85 (5): 708–16
  • Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015 NEUROSURGICAL FOCUS Varshneya, K., Rodrigues, A. J., Medress, Z. A., Stienen, M. N., Grant, G. A., Ratliff, J. K., Veeravagu, A. 2019; 47 (5): E10

    Abstract

    Skull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.The authors queried the MarketScan database (2007-2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.The authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non-CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6-13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2-44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7-5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5-4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).The authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

    View details for DOI 10.3171/2019.8.FOCUS19543

    View details for Web of Science ID 000493985900010

    View details for PubMedID 31675705

  • Conventional Versus Stereotactic Image-guided Pedicle Screw Placement During Posterior Lumbar Fusions: A Retrospective Propensity Score-matched Study of a National Longitudinal Database. Spine Pendharkar, A. V., Rezaii, P. G., Ho, A. L., Sussman, E. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2019; 44 (21): E1272–E1280

    Abstract

    STUDY DESIGN: Retrospective 1:1 propensity score-matched analysis on a national longitudinal database between 2007 and 2016.OBJECTIVE: The aim of this study was to compare complication rates, revision rates, and payment differences between navigated and conventional posterior lumbar fusion (PLF) procedures with instrumentation.SUMMARY OF BACKGROUND DATA: Stereotactic navigation techniques for spinal instrumentation have been widely demonstrated to improve screw placement accuracies and decrease perforation rates when compared to conventional fluoroscopic and free-hand techniques. However, the clinical utility of navigation for instrumented PLF remains controversial.METHODS: Patients who underwent elective laminectomy and instrumented PLF were stratified into "single level" and "3- to 6-level" cohorts. Navigation and conventional groups within each cohort were balanced using 1:1 propensity score matching, resulting in 1786 navigated and conventional patients in the single-level cohort and 2060 in the 3 to 6 level cohort. Outcomes were compared using bivariate analysis.RESULTS: For the single-level cohort, there were no significant differences in rates of complications, readmissions, revisions, and length of stay between the navigation and conventional groups. For the 3- to 6-level cohort, length of stay was significantly longer in the navigation group (P < 0.0001). Rates of readmissions were, however, greater for the conventional group (30-day: P = 0.0239; 90-day: P = 0.0449). Overall complications were also greater for the conventional group (P = 0.0338), whereas revision rate was not significantly different between the 2 groups. Total payments were significantly greater for the navigation group in both the single level and 3- to 6-level cohorts (P < 0.0001).CONCLUSION: Although use of navigation for 3- to 6-level instrumented PLF was associated with increased length of stay and payments, the concurrent decreased overall complication and readmission rates alluded to its potential clinical utility. However, for single-level instrumented PLF, no differences in outcomes were found between groups, suggesting that the value in navigation may lie in more complex procedures.LEVEL OF EVIDENCE: 3.

    View details for DOI 10.1097/BRS.0000000000003130

    View details for PubMedID 31634303

  • Trends in Anterior Lumbar Interbody Fusion in the United States: A MarketScan Study From 2007 to 2014. Clinical spine surgery Varshneya, K., Medress, Z. A., Jensen, M., Azad, T. D., Rodrigues, A., Stienen, M. N., Desai, A., Ratliff, J. K., Veeravagu, A. 2019

    Abstract

    BACKGROUND: Although the incidence of spinal fusions has increased significantly in the United States over the last quarter century, national trends of anterior lumbar interbody fusion (ALIF) utilization are not known.PURPOSE: The objective of this study was to characterize trends, clinical characteristics, risk factors associated with, and outcomes of ALIF in the United States.STUDY DESIGN: This was an epidemiological study using national administrative data from the MarketScan database.METHODS: Using a large administrative database, we identified adults who underwent ALIF in the United States from 2007 to 2014. The incidence of ALIF was studied longitudinally over time and across geographic regions in the United States. Data related to postoperative complications, length of stay, readmission, and cost were collected.RESULTS: We identified 49,945 patients that underwent ALIF in the United States between 2007 and 2014. The total number of ALIF procedures increased from 3650 in 2007 to 6151 in 2014, accounting for an average increase of 24.07% annually. The Southern United States performed the highest number of ALIFs. The most common conditions treated were degenerative disc disease and spondylolisthesis. Over one third of patients (34.6%) underwent multilevel fusion. The most common complications were iron deficiency anemia, urinary tract infections, and pulmonary complications. Hospital and physician pay increased significantly during the study period.CONCLUSIONS: For the first time in our knowledge, we identified national trends in ALIF utilization, outcomes, and cost using a large administrative database. Our study reaffirms prior work that has demonstrated low rates of complications, mortality, and readmission following ALIF.LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1097/BSD.0000000000000904

    View details for PubMedID 31609798

  • TO THE EDITOR. Spine Azad, T. D., Vail, D., Ratliff, J. K. 2019; 44 (18): E1109–E1110

    View details for DOI 10.1097/BRS.0000000000003143

    View details for PubMedID 31479040

  • A Descriptive Analysis of Spinal Cord Arteriovenous Malformations: Clinical Features, Outcomes, and Trends in Management. World neurosurgery Varshneya, K., Pendharkar, A. V., Azad, T. D., Ratliff, J. K., Veeravagu, A. 2019

    Abstract

    BACKGROUND: Spinal arteriovenous malformations (AVM) are an abnormal interconnection of vasculature in the spine than can lead to significant neurological deficit if left untreated.OBJECTIVE: The objective of this study was to characterize how spinal AVM patients initially presented, what treatment options were utilized, and their overall outcomes on a national scale.METHODS: The MarketScan database was queried to identify adult patients diagnosed with a spinal AVM from 2007 - 2015. Trends in management, postoperative complication rates, and costs were determined.RESULTS: 976 patients were identified with having a diagnosis of a spinal AVM. Patients were more commonly treated with an open incision than an embolization (40.1% vs 15.4%). The overall complication rate was 33.61%. Spinal AVM admissions have been stable over the past decade and mean cost of hospitalization has risen from of $48,700 in 2007 to $71,292 in 2015. Patients who underwent open surgery had a higher complication rate than those treated with embolization (31.15% vs 18.25%, p < 0.005); however, this may be strongly influenced by complexity of spinal AVM pathology and not treatment modality.CONCLUSIONS: Costs of spinal AVM management continue to rise, even when treatment modalities have reduced length of stay significantly. Open surgery may lead to more postoperative complications and a higher length of stay than endovascular approaches. Further studies should look to identify the efficacy of endovascular approaches for spinal cord AVMs, particularly in complex spinal AVM traditionally treated with open surgery and to isolate factors leading to the elevated hospitalization costs.LEVEL OF EVIDENCE: III.

    View details for DOI 10.1016/j.wneu.2019.08.010

    View details for PubMedID 31404690

  • Laminectomy versus Corpectomy for Spinal Metastatic Disease-Complications, Costs, and Quality Outcomes. World neurosurgery Azad, T. D., Varshneya, K., Ho, A. L., Veeravagu, A., Sciubba, D. M., Ratliff, J. K. 2019

    View details for DOI 10.1016/j.wneu.2019.07.206

    View details for PubMedID 31404695

  • Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature SPINE JOURNAL Stienen, M. N., Ho, A. L., Staartjes, V. E., Maldaner, N., Veeravagu, A., Desai, A., Gautschi, O. P., Bellut, D., Regli, L., Ratliff, J. K., Park, J. 2019; 19 (7): 1276–93
  • Patient Satisfaction and Press Ganey Scores for Spine Versus Nonspine Neurosurgery Clinics. Clinical spine surgery Chen, Y., Johnson, E., Montalvo, C., Stratford, S., Veeravagu, A., Tharin, S., Desai, A., Ratliff, J., Shuer, L., Park, J. 2019

    Abstract

    STUDY DESIGN: Retrospective survey review.OBJECTIVE: We seek to evaluate satisfaction scores in patients seen in neurosurgical spine versus neurosurgical nonspine clinics.SUMMARY OF BACKGROUND DATA: The Press Ganey survey is a well-established metric for measuring hospital performance and patient satisfaction. These measures have important implications in setting hospital policy and guiding interventions to improve patient perceptions of care.METHODS: Retrospective Press Ganey survey review was performed to identify patient demographics and patient visit characteristics from January 1st, 2012 to October 10th, 2017 at Stanford Medical Center. A total of 40 questions from the Press Ganey survey were investigated and grouped in categories addressing physician and nursing care, personal concerns, admission, room, meal, operating room, treatment and discharge conditions, visitor accommodations and overall clinic assessment. Raw ordinal scores were converted to continuous scores of 100 for unpaired student t test analysis. We identified 578 neurosurgical spine clinic patients and 1048 neurosurgical nonspine clinic patients.RESULTS: Spine clinic patients reported lower satisfaction scores in aggregate (88.2 vs. 90.1; P=0.0014), physician (89.5 vs. 92.6; P=0.0002) and nurse care (91.3 vs. 93.4; P=0.0038), personal concerns (88.2 vs. 90.9; P=0.0009), room (81.0 vs. 83.1; P=0.0164), admission (90.8 vs. 92.6; P=0.0154) and visitor conditions (87.0 vs. 89.2; P=0.0148), and overall clinic assessment (92.9 vs. 95.5; P=0.005).CONCLUSIONS: This study is the first to evaluate the relationship between neurosurgical spine versus nonspine clinic with regards to patient satisfaction. The spine clinic cohort reported less satisfaction than the nonspine cohort in all significant questions on the Press Ganey survey. Our findings suggest that efforts should be made to further study and improve patient satisfaction in spine clinics.LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1097/BSD.0000000000000825

    View details for PubMedID 30969193

  • Socioeconomic Predictors of Surgical Resection and Survival for Patients With Osseous Spinal Neoplasms CLINICAL SPINE SURGERY Deb, S., Brewster, R., Pendharkar, A., Veeravagu, A., Ratliff, J., Desai, A. 2019; 32 (3): 125–31
  • Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature. The spine journal : official journal of the North American Spine Society Stienen, M. N., Ho, A. L., Staartjes, V. E., Maldaner, N., Veeravagu, A., Desai, A., Gautschi, O. P., Bellut, D., Regli, L., Ratliff, J. K., Park, J. 2019

    Abstract

    BACKGROUND CONTEXT: The accurate determination of a patient's functional status is necessary for therapeutic decision-making and to critically appraise treatment efficacy. Current subjective patient-reported outcome measure (PROM)-based assessments have limitations and can be complimented by objective measures of function.PURPOSE: To systematically review the literature and provide an overview on the available objective measures of function for patients with degenerative diseases of the lumbar spine.STUDY DESIGN/SETTING: Systematic review of the literature.METHODS: The PRISMA guidelines were followed. Two reviewers independently searched the PubMed, Web of Science, EMBASE and SCOPUS databases for permutations of the words "objective", "assessment", "function", "lumbar" and "spine", including articles on human subjects with degenerative diseases of the lumbar spine that reported on objective measures of function, published until September 2018. No funding was received. The authors report no conflicts of interest.RESULTS: Of 2389 identified articles, 82 were included in the final analysis. There was a significant increase of 0.12 per year in the number of publications dealing with objective measures of function since 1989 (95% CI 0.08-0.16, p<0.001). Some publications studied multiple diagnoses and objective measures. The US was the leading nation in terms of scientific output for objective outcome measures (n=21; 25.6%), followed by Switzerland (n=17; 20.7%), Canada, Germany and the United Kingdom (each n=6; 7.3%). Our search revealed 21 different types of objective measures, predominantly applied to patients with lumbar spinal stenosis (n=67 publications; 81.7%), chronic/unspecific low back pain (n=28; 34.2%) and lumbar disc herniation (n=22; 26.8%). The Timed-Up-and-Go (TUG) test was the most frequently applied measure (n=26 publications; 31.7%; cumulative number of reported subjects: 5181), followed by the Motorized Treadmill Test (MTT; n=25 publications; 30.5%, 1499 subjects) and with each n=9 publications (11.0%) the Five-Repetition Sit-To-Stand test (5R-STS; 955 subjects), as well as accelerometry analyses (336 subjects). The reliability and validity of many of the less-applied objective measures was uncertain. There was profound heterogeneity in their application and interpretation of results. Risk of bias was not assessed.CONCLUSIONS: Clinical studies on patients with lumbar degenerative diseases increasingly employ objective measures of function, which offer high potential for improving the quality of outcome measurement in patient-care and research. This review provides an overview on available options. Our findings call for an agreement and standardization in terms of test selection, conduction and analysis to facilitate comparison of results across cohorts.

    View details for PubMedID 30831316

  • Commentary: The Anatomy of Disvalued Codes: The 63047 and the 22633. Neurosurgery Tumialan, L. M., Ratliff, J. K., Cheng, J. 2019; 84 (2): E122–E126

    View details for PubMedID 30649486

  • Commentary: The Anatomy of Disvalued Codes: The 63047 and the 22633 NEUROSURGERY Tumialan, L. M., Ratliff, J. K., Cheng, J. 2019; 84 (2): E122-E126
  • Quality Reporting in Neurological Surgery: Practice Adherence to Quality Payment Program Guidelines NEUROSURGERY Agarwal, N., Kashkoush, A., Baucom, E. T., Ratliff, J. K., Stroink, A. R., Council State Neurosurgical Soc 2019; 84 (2): 537–42

    Abstract

    Recent legislation has changed quality reporting in neurological surgery. The present study summarizes the reporting of objectives and measures outlined by the Quality Payment Program (QPP) and assesses how practices are preparing to comply. In February 2017, 220 neurosurgical practices were surveyed regarding their adherence to quality reporting objectives and measures. Survey responders were asked to report infrastructure-level data including practice type and number of providers. Furthermore, we evaluated the reporting of quality and advancing care measures outlined by the QPP. Assessment of quality measures was focused on those related to neurosurgical patient management. A total of 27 responses were obtained. Practices consisted of 8 academic (30%), 16 physician-owned (59%), and 3 hospital-owned (11%) neurosurgical practices. Of the 27 total responders, 18 indicated their adherence to a host of quality and advancing care measures. Practice type was strongly associated with the number of quality measures performed (P = .020, Wilcoxon rank-sum test). Physician-owned practices reported performing a median of 5 quality measures (interquartile range, 4.5-9.5), while practices in academic and hospital-owned groups reported performing 12 quality measures (interquartile range, 9.5-13.5). Forty-five percent of physician-owned practices reported performing at least 6 quality measures, whereas 100% of academic and hospital-owned practices reported the same benchmark (P = .038, Fisher's exact test). Performance of advancing care measures was not associated with practice type. Compared to other practice types, the rate of quality reporting among physician-owned neurosurgical practices appears to be modest thus far, which may influence future reimbursement adjustments.

    View details for PubMedID 29566181

  • Initial Provider Specialty Is Associated With Long-term Opiate Use in Patients With Newly Diagnosed Low Back and Lower Extremity Pain SPINE Azad, T. D., Vail, D., Bentley, J., Han, S. S., Suarez, P., Varshneya, K., Mittal, V., Veeravagu, A., Desai, M., Bhattacharya, J., Ratliff, J. K. 2019; 44 (3): 211–18
  • Outcomes and costs following Ommaya placement with thrombocytopenia among US cancer patients. World neurosurgery Zhang, M. n., Zhang, Y. n., Zheng, E. n., Gephart, M. H., Veeravagu, A. n., Desai, A. n., Ratliff, J. K., Li, G. n. 2019

    Abstract

    Placement of Ommaya reservoirs for administration of intrathecal chemotherapy may be complicated by comorbid thrombocytopenia among patients with hematologic or leptomeningeal disease. Aggregated data on risks of Ommaya placement among thrombocytopenic patients is lacking. This study assesses complications, revision rates, and costs associated with Ommaya placement among patients with thrombocytopenia in a large population sample.Using a national administrative database, this retrospective study identifies a cohort of adult cancer patients who underwent Ommaya placement between 2007 and 2016. Preoperative thrombocytopenia was defined as diagnosis of secondary thrombocytopenia, bleeding event, procedure to control bleeding, or platelet transfusion, within 30 days prior to index admission. Univariate and multivariate analyses were performed to assess costs, 30-day complications, readmissions, and revisions among patients with and without preoperative thrombocytopenia.The analytic cohort included 1652 patients, of whom 29.3% met criteria for preoperative thrombocytopenia. In-hospital mortality rates were 7.7% among thrombocytopenic patients vs. 1.2% among non-thrombocytopenic patients (p < 0.001). Preoperative thrombocytopenia was associated with 14.5 times greater hazard of intracranial hemorrhage within 30 days following Ommaya placement, occurring in 25.6% vs. 2.0% of thrombocytopenic and non-thrombocytopenic patients, respectively (p < 0.014). Revision rates did not differ significantly between thrombocytopenic and non-thrombocytopenic patients. Thrombocytopenia was associated with longer length of stay (7.4 vs 13.9 days, p < 0.001) and additional $10,000 per patient in costs of index hospitalization (p < 0.001).This is the largest study to date documenting costs and complication rates of Ommaya placement in patients with and without thrombocytopenia.

    View details for DOI 10.1016/j.wneu.2019.12.063

    View details for PubMedID 31866457

  • Reliability of the 6-minute walking test smartphone application. Journal of neurosurgery. Spine Stienen, M. N., Gautschi, O. P., Staartjes, V. E., Maldaner, N. n., Sosnova, M. n., Ho, A. L., Veeravagu, A. n., Desai, A. n., Zygourakis, C. C., Park, J. n., Regli, L. n., Ratliff, J. K. 2019: 1–8

    Abstract

    Objective functional measures such as the 6-minute walking test (6WT) are increasingly applied to evaluate patients with degenerative diseases of the lumbar spine before and after (surgical) treatment. However, the traditional 6WT is cumbersome to apply, as it requires specialized in-hospital infrastructure and personnel. The authors set out to compare 6-minute walking distance (6WD) measurements obtained with a newly developed smartphone application (app) and those obtained with the gold-standard distance wheel (DW).The authors developed a free iOS- and Android-based smartphone app that allows patients to measure the 6WD in their home environment using global positioning system (GPS) coordinates. In a laboratory setting, the authors obtained 6WD measurements over a range of smartphone models, testing environments, and walking patterns and speeds. The main outcome was the relative measurement error (rME; in percent of 6WD), with |rME| < 7.5% defined as reliable. The intraclass correlation coefficient (ICC) for agreement between app- and DW-based 6WD was calculated.Measurements (n = 406) were reliable with all smartphone types in neighborhood, nature, and city environments (without high buildings), as well as with unspecified, straight, continuous, and stop-and-go walking patterns (ICC = 0.97, 95% CI 0.97-0.98, p < 0.001). Measurements were unreliable indoors, in city areas with high buildings, and for predominantly rectangular walking courses. Walking speed had an influence on the ME, with worse accuracy (2% higher rME) for every kilometer per hour slower walking pace (95% CI 1.4%-2.5%, p < 0.001). Mathematical adjustment of the app-based 6WD for velocity-dependent error mitigated the rME (p < 0.011), attenuated velocity dependence (p = 0.362), and had a positive effect on accuracy (ICC = 0.98, 95% CI 0.98-0.99, p < 0.001).The new, free, spine-specific 6WT smartphone app measures the 6WD conveniently by using GPS coordinates, empowering patients to independently determine their functional status before and after (surgical) treatment. Measurements of 6WD obtained for the target population under the recommended circumstances are highly reliable.

    View details for DOI 10.3171/2019.6.SPINE19559

    View details for PubMedID 31518975

  • Effect of Electronic Clinical Decision Support on Imaging for the Evaluation of Acute Low Back Pain in the Ambulatory Care Setting. World neurosurgery Chen, D. n., Bhambhvani, H. P., Hom, J. n., Mahoney, M. n., Wintermark, M. n., Sharp, C. n., Ratliff, J. n., Chen, Y. R. 2019

    Abstract

    To assess the effectiveness of a clinical decision support tool consisting of an electronic medical record Best Practice Alert (BPA) on the frequency of lumbar imaging in patients with acute low back pain (LBP) in the ambulatory care setting. To understand why providers order imaging outside of clinical guidelines.We implemented a BPA pop-up alert on 3/23/16 that informed the ordering physician of the Choosing Wisely recommendation to not order imaging within the first 6 weeks of low back pain in the absence of red flags. We measured imaging rates 1 year before and after implementation of the BPA. To override the BPA, providers could ignore the alert or explain their rationale for ordering imaging using either pre-set options or free-text submission. We tracked pre-set options and manually reviewed 125 free-text submissions.Significant decreases in both total imaging rate (9.6% decrease, p = 0.02) and MRI rate (14.9% decrease, p < 0.01) were observed after implementation of the BPA. No change was found in the rates of x-ray or CT ordering. 64% of providers used pre-set options in overriding the BPA, while 36% of providers entered a free-text submission. Among those providers using a free-text submission, 56% entered a non-guideline supported rationale.The present study demonstrates the effectiveness of a simple, low-cost clinical decision support tool in reducing imaging rates for patients with acute low back pain. We additionally identify reasons providers order imaging outside of clinical guidelines.

    View details for DOI 10.1016/j.wneu.2019.11.031

    View details for PubMedID 31733384

  • Lumboperitoneal and Ventriculoperitoneal Shunting for Idiopathic Intracranial Hypertension Demonstrate Comparable Failure and Complication Rates. Neurosurgery Azad, T. D., Zhang, Y. n., Varshneya, K. n., Veeravagu, A. n., Ratliff, J. K., Li, G. n. 2019

    Abstract

    Idiopathic intracranial hypertension results in increased intracranial pressure leading to headache and visual loss. This disease frequently requires surgical intervention through lumboperitoneal (LP) or ventriculoperitoneal (VP) shunting.To compare postoperative outcomes between LP and VP shunts, including failure and complication rates.A retrospective analysis was conducted using a national administrative database (MarketScan) to identify idiopathic intracranial hypertension (IIH) patients who underwent LP or VP shunting from 2007 to 2014. Multivariate logistic and Cox regressions were performed to compare rates of shunt failure and time to shunt failure between LP and VP shunts while controlling for demographics and comorbidities.The analytic cohort included 1082 IIH patients, 347 of whom underwent LP shunt placement at index hospitalization and 735 of whom underwent VP shunt placement. Rates of shunt failure were similar among patients with LP and VP shunt (34.6% vs 31.7%; P = .382). Among patients who experienced shunt failure, the mean number of shunt failures was 2.1 ± 1.6 and was similar between LP and VP cohorts. Ninety-day readmission rates, complication rates, and costs did not differ significantly between LP and VP shunts. Patients who experienced more than two shunt failures tended to have an earlier time to first shunt failure (hazard ratio 1.41; 95% confidence interval 1.08-1.85; P = .013).These findings suggest that LP and VP shunts may have comparable rates of shunt failure and complication. Regardless of shunt type, earlier time to first shunt failure may be associated with multiple shunt failures.

    View details for PubMedID 30937428

  • Analysis of Outcomes and Cost of Inpatient and Ambulatory Anterior Cervical Disk Replacement Using a State-level Database. Clinical spine surgery Purger, D. A., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Veeravagu, A. n., Ratliff, J. K., Desai, A. M. 2019

    Abstract

    Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures.The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR.Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group ($11,059 vs. 17,033; P<0.001). The 90-day cumulative charges were significantly lower in the outpatient ADR group (mean $46,404.03 vs. $80,055; P<0.0001).ADR can be performed in an ambulatory setting with comparable morbidity, readmission rates, and lower costs, to inpatient ADR.

    View details for DOI 10.1097/BSD.0000000000000840

    View details for PubMedID 31180992

  • Socioeconomic Predictors of Surgical Resection and Survival for Patients With Osseous Spinal Neoplasms. Clinical spine surgery Deb, S., Brewster, R., Pendharkar, A. V., Veeravagu, A., Ratliff, J., Desai, A. 2018

    Abstract

    OF BACKGROUND DATA: Primary osseous spinal neoplasms (POSNs) include locally aggressive tumors such as osteosarcoma, chondrosarcoma, Ewing sarcoma, and chordoma. For such tumors, surgical resection is associated with improved survival for patients. Socioeconomic predictors of receiving surgery, however, have not been studied.OBJECTIVE: To examine the independent effect of race on receiving surgery and survival probability in patients with POSN.STUDY DESIGN: A total of 1904 patients from the SEER program at the National Cancer Institute database, all diagnosed with POSN of the spinal cord, vertebral column, pelvis, or sacrum from 2003 through 2012 were included in the study. Race was reported as white or nonwhite. Treatment included receiving surgery and no surgery.MATERIALS AND METHODS: Multivariable logistic regression was used to determine odds of receiving surgery based on race. Survival probability based on and race and surgery status was analyzed by Cox proportional hazards model and Kaplan-Meir curves. Results were adjusted for age at diagnosis, sex, socioeconomic status (composite index), tumor size, and tumor grade. Data were analyzed with SAS version 9.4.RESULTS: The study found that white patients were significantly more likely to receive surgery (odds ratio=3.076, P<0.01). Furthermore, nonwhite race was associated with significantly shorter survival time [hazard ratio (HR)=1.744, P<0.05]. Receiving surgery was associated with improved overall survival (HR=2.486, P<0.01). After adjusting for receiving surgery, white race remained significantly associated with higher survival probability (HR=2.061, P<0.05).CONCLUSIONS: This national study of patients with typically aggressive POSN found a significant correlation between race and the likelihood of receiving surgery. The study also found race to be a significant predictor of overall survival, regardless of receiving surgical treatment. These findings suggest an effect of race on receiving treatment and survival in patients with POSN, regardless of socioeconomic status. Further studies are required to understand reasons underlying these findings, and how they may be addressed.

    View details for PubMedID 30531357

  • Geographic variation in the surgical management of lumbar spondylolisthesis: characterizing practice patterns and outcomes SPINE JOURNAL Azad, T. D., Vail, D., O'Connell, C., Han, S. S., Veeravagu, A., Ratliff, J. K. 2018; 18 (12): 2232–38
  • Radiographic Rate and Clinical Impact of Pseudarthrosis in Spine Radiosurgery for Metastatic Spinal Disease. Cureus Zhang, M., Appelboom, G., Ratliff, J. K., Soltys, S. G., Adler, J. R., Park, J., Chang, S. D. 2018; 10 (11): e3631

    Abstract

    Purpose Pseudarthrosis within the spine tumor population is increased from perioperative radiation and complex stabilization for invasive and recurrent pathology. We report the radiographic and clinical rates of pseudarthrosis following multiple courses of instrumented fusion and perioperative stereotactic radiosurgery (SRS). Methods We performed a single institution review of 418 patients treated with non-isocentric SRS for spine between October 2002 and January 2013, identifying those with spinal instrumentation and greater than six months of follow-up. Surgical history, radiation planning, and radiographic outcomes were documented. Results Eleven patients whomet criteria for inclusion underwent 21 sessions of spinal SRS and 16 instrumented operations. Radiographic follow-up was 48.9 months; 3/11 (27%) were with radiographic hardware failure, and one (9%) separate case ultimately warranted externalization due to tumor recurrence. SRS was administered to treat progression of disease in 12/21 (57%) procedures, and residual lesions in 7/11 (64%) procedures. Following first and second SRS, 8/11 (73%) and 2/7 (29%) patients were with symptomatic improvement, respectively. Conclusion Risk of pseudarthrosis following SRS for patients with oncologic spinal lesions will become increasingly apparent with the optimized management of and survival from spinal pathologies. We highlight how the need for local control outpaces the risk of instrumentation failure.

    View details for PubMedID 30705790

  • Radiographic Rate and Clinical Impact of Pseudarthrosis in Spine Radiosurgery for Metastatic Spinal Disease CUREUS Zhang, M., Appelboom, G., Ratliff, J. K., Soltys, S. G., Adler, J. R., Park, J., Chang, S. D. 2018; 10 (11)
  • Conus Medullaris Dural Arteriovenous Fistula Arising From the Artery of the Filum Terminale: 2-Dimensional Operative Video OPERATIVE NEUROSURGERY Lamsam, L., Quon, J., Fischbein, N., Iv, M., Dodd, R., Ratliff, J. 2018; 15 (4): 471

    View details for DOI 10.1093/ons/opx297

    View details for Web of Science ID 000449384100034

  • Intraoperative analgesic regimens and surgical duration after spine surgery Response NEUROSURGICAL FOCUS O'Connell, C., Sun, E., Ratliff, J. K., Veeravagu, A. 2018; 45 (3)
  • Intracranial Hemorrhage in Deep Vein Thrombosis/Pulmonary Embolus Patients Without Atrial Fibrillation: Direct Oral Anticoagulants Versus Warfarin STROKE Lamsam, L., Sussman, E. S., Iyer, A. K., Bhambhvani, H. P., Han, S. S., Skirboll, S., Ratliff, J. K. 2018; 49 (8): 1866–71
  • Postoperative Opioid Use, Complications, and Costs in Surgical Management of Lumbar Spondylolisthesis SPINE Vail, D., Azad, T. D., O'Connell, C., Han, S. S., Veeravagu, A., Ratliff, J. K. 2018; 43 (15): 1080–88
  • Outpatient spine surgery: defining the outcomes, value, and barriers to implementation. Neurosurgical focus Pendharkar, A. V., Shahin, M. N., Ho, A. L., Sussman, E. S., Purger, D. A., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2018; 44 (5): E11

    Abstract

    Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

    View details for PubMedID 29712520

  • Outpatient spine surgery: defining the outcomes, value, and barriers to implementation NEUROSURGICAL FOCUS Pendharkar, A., Shahin, M., Ho, A., Sussman, E., Purger, D., Veeravagu, A., Ratliff, J., Desai, A. 2018; 44 (5)
  • Propensity-matched comparison of outcomes and cost after macroscopic and microscopic lumbar discectomy using a national longitudinal database NEUROSURGICAL FOCUS Pendharkar, A., Rezaii, P., Ho, A., Sussman, E., Purger, D., Veeravagu, A., Ratliff, J., Desai, A. 2018; 44 (5)
  • Propensity-matched comparison of outcomes and cost after macroscopic and microscopic lumbar discectomy using a national longitudinal database. Neurosurgical focus Pendharkar, A. V., Rezaii, P. G., Ho, A. L., Sussman, E. S., Purger, D. A., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2018; 44 (5): E12

    Abstract

    OBJECTIVE There has been considerable debate about the utility of the operating microscope in lumbar discectomy and its effect on outcomes and cost. METHODS A commercially available longitudinal database was used to identify patients undergoing discectomy with or without use of a microscope between 2007 and 2015. Propensity matching was performed to normalize differences between demographics and comorbidities in the 2 cohorts. Outcomes, complications, and cost were subsequently analyzed using bivariate analysis. RESULTS A total of 42,025 patients were identified for the "macroscopic" group, while 11,172 patients were identified for the "microscopic" group. For the propensity-matched analysis, the 11,172 patients in the microscopic discectomy group were compared with a group of 22,340 matched patients who underwent macroscopic discectomy. There were no significant differences in postoperative complications between the groups other than a higher proportion of deep vein thrombosis (DVT) in the macroscopic discectomy cohort versus the microscopic discectomy group (0.4% vs 0.2%, matched OR 0.48 [95% CI 0.26-0.82], p = 0.0045). Length of stay was significantly longer in the macroscopic group compared to the microscopic group (mean 2.13 vs 1.83 days, p < 0.0001). Macroscopic discectomy patients had a higher rate of revision surgery when compared to microscopic discectomy patients (OR 0.92 [95% CI 0.84-1.00], p = 0.0366). Hospital charges were higher in the macroscopic discectomy group (mean $19,490 vs $14,921, p < 0.0001). CONCLUSIONS The present study suggests that the use of the operating microscope in lumbar discectomy is associated with decreased length of stay, lower DVT rate, lower reoperation rate, and decreased overall hospital costs.

    View details for PubMedID 29712527

  • Outpatient vs Inpatient Anterior Cervical Discectomy and Fusion: A Population-Level Analysis of Outcomes and Cost NEUROSURGERY Purger, D. A., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Yang, L., Desai, M., Veeravagu, A., Ratliff, J. K., Desai, A. 2018; 82 (4): 454–63
  • Analysis of National Rates, Cost, and Sources of Cost Variation in Adult Spinal Deformity NEUROSURGERY Zygourakis, C. C., Liu, C. Y., Keefe, M., Moriates, C., Ratliff, J., Dudley, R., Gonzales, R., Mummaneni, P. V., Ames, C. P. 2018; 82 (3): 378–87

    Abstract

    Several studies suggest significant variation in cost for spine surgery, but there has been little research in this area for spinal deformity.To determine the utilization, cost, and factors contributing to cost for spinal deformity surgery.The cohort comprised 55 599 adults who underwent spinal deformity fusion in the 2001 to 2013 National Inpatient Sample database. Patient variables included age, gender, insurance, median income of zip code, county population, severity of illness, mortality risk, number of comorbidities, length of stay, elective vs nonelective case. Hospital variables included bed size, wage index, hospital type (rural, urban nonteaching, urban teaching), and geographical region. The outcome was total hospital cost for deformity surgery. Statistics included univariate and multivariate regression analyses.The number of spinal deformity cases increased from 1803 in 2001 (rate: 4.16 per 100 000 adults) to 6728 in 2013 (rate: 13.9 per 100 000). Utilization of interbody fusion devices increased steadily during this time period, while bone morphogenic protein usage peaked in 2010 and declined thereafter. The mean inflation-adjusted case cost rose from $32 671 to $43 433 over the same time period. Multivariate analyses showed the following patient factors were associated with cost: age, race, insurance, severity of illness, length of stay, and elective admission (P < .01). Hospitals in the western United States and those with higher wage indices or smaller bed sizes were significantly more expensive (P < .05).The rate of adult spinal deformity surgery and the mean case cost increased from 2001 to 2013, exceeding the rate of inflation. Both patient and hospital factors are important contributors to cost variation for spinal deformity surgery.

    View details for PubMedID 28486687

  • Geographic variation in the surgical management of lumbar spondylolisthesis: characterizing practice patterns and outcomes. The spine journal : official journal of the North American Spine Society Azad, T. D., Vail, D. n., O'Connell, C. n., Han, S. S., Veeravagu, A. n., Ratliff, J. K. 2018

    Abstract

    The role of arthrodesis in the surgical management of lumbar spondylolisthesis remains controversial. We hypothesized that practice patterns and outcomes for this patient population may vary widely.To characterize geographic variation in surgical practices and outcomes for patients with lumbar spondylolisthesis.Retrospective analysis on a national longitudinal database between 2007 and 2014.We calculated arthrodesis rates, inpatient and long term costs, and key quality indicators (e.g. reoperation rates). Using linear and logistic regression models, we then calculated expected quality indicator values, adjusting for patient-level demographic factors, and compared these values to the observed values, to assess quality variation apart from differences in patient populations.We identified a cohort of 67,077 patients (60.7% female, mean age of 59.8 years (SD, 12.0) with lumbar spondylolisthesis who received either laminectomy or laminectomy with arthrodesis. The majority of patients received arthrodesis (91.8%). Actual rates of arthrodesis varied from 97.5% in South Dakota to 81.5% in Oregon. Geography remained a significant predictor of arthrodesis even after adjusting for demographic factors (p<0.001). Marked geographic variation was also observed in initial costs ($32,485 in Alabama to $78,433 in Colorado), two-year post-operative costs ($15,612 in Arkansas to $34,096 in New Jersey), length of hospital stay (2.6 days in Arkansas to 4.5 in Washington, D.C.), 30-day complication rates (9.5% in South Dakota to 22.4% in Maryland), 30-day readmission rates (2.5% in South Dakota to 13.6% in Connecticut), and reoperation rates (1.8% in Maine to 12.7% in Alabama).There is marked geographic variation in the rates of arthrodesis in treatment of spondylolisthesis within the United States. This variation remains pronounced after accounting for patient-level demographic differences. Costs of surgery and quality outcomes also vary widely. Further study is necessary to understand the drivers of this variation.

    View details for PubMedID 29746964

  • Long-Term Update of Stereotactic Radiosurgery for Benign Spinal Tumors. Neurosurgery Chin, A. L., Fujimoto, D. n., Kumar, K. A., Tupper, L. n., Mansour, S. n., Chang, S. D., Adler, J. R., Gibbs, I. C., Hancock, S. L., Dodd, R. n., Li, G. n., Gephart, M. H., Ratliff, J. K., Tse, V. n., Usoz, M. n., Sachdev, S. n., Soltys, S. G. 2018

    Abstract

    Stereotactic radiosurgery (SRS) for benign intracranial tumors is an established standard of care. The widespread implementation of SRS for benign spinal tumors has been limited by lack of long-term data.To update our institutional experience of safety and efficacy outcomes after SRS for benign spinal tumors.We performed a retrospective cohort study of 120 patients with 149 benign spinal tumors (39 meningiomas, 26 neurofibromas, and 84 schwannomas) treated with SRS between 1999 and 2016, with follow-up magnetic resonance imaging available for review. The primary endpoint was the cumulative incidence of local failure (LF), with death as a competing risk. Secondary endpoints included tumor shrinkage, symptom response, toxicity, and secondary malignancy.Median follow-up was 49 mo (interquartile range: 25-103 mo, range: 3-216 mo), including 61 courses with >5 yr and 24 courses with >10 yr of follow-up. We observed 9 LF for a cumulative incidence of LF of 2%, 5%, and 12% at 3, 5, and 10 yr, respectively. Excluding 10 tumors that were previously irradiated or that arose within a previously irradiated field, the 3-, 5-, and 10-yr cumulative incidence rates of LF were 1%, 2%, and 8%, respectively. At last follow-up, 35% of all lesions had decreased in size. With a total of 776 patient-years of follow-up, no SRS-related secondary malignancies were observed.Comparable to SRS for benign intracranial tumors, SRS provides longer term local control of benign spinal tumors and is a standard-of-care alternative to surgical resection.

    View details for PubMedID 30445557

  • Stabilization of the Craniocervical Junction Following Resection of Chordomas and Chondrosarcomas of the Skull Base and Spine CHORDOMAS AND CHONDROSARCOMAS OF THE SKULL BASE AND SPINE, 2ND EDITION Azad, T. D., Veeravagu, A., Ravikumar, V., Ratliff, J. K., Harsh, G. R., VazGuimaraes, F. 2018: 271–78
  • Conus Medullaris Dural Arteriovenous Fistula Arising From the Artery of the Filum Terminale: 2-Dimensional Operative Video. Operative neurosurgery (Hagerstown, Md.) Lamsam, L. n., Quon, J. n., Fischbein, N. n., Iv, M. n., Dodd, R. n., Ratliff, J. n. 2018

    View details for PubMedID 29444295

  • Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes. Neurosurgical focus O'Connell, C. n., Azad, T. D., Mittal, V. n., Vail, D. n., Johnson, E. n., Desai, A. n., Sun, E. n., Ratliff, J. K., Veeravagu, A. n. 2018; 44 (1): E5

    Abstract

    OBJECTIVE Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs. METHODS A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug-use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs. RESULTS The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17-1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95-0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03-1.25), revision fusions (OR 1.15, 95% CI 1.05-1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04-1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84-1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively. CONCLUSIONS Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.

    View details for DOI 10.3171/2017.10.FOCUS17563

    View details for PubMedID 29290135

  • Impact of Inpatient Venous Thromboembolism Continues After Discharge: Retrospective Propensity Scored Analysis in a Longitudinal Database CLINICAL SPINE SURGERY Li, A. Y., Azad, T. D., Veeravagu, A., Bhatti, I., Li, A., Cole, T., Desai, A., Ratliff, J. K. 2017; 30 (10): E1392–E1398
  • Stereotactic Radiosurgery for Benign Neurogenic Spinal Tumors Chin, A. L., Fujimoto, D. K., Tse, V., Chang, S. D., Adler, J. R., Gibbs, I. C., Dodd, R. L., Li, G., Gephart, M. H., Desai, A., Ratliff, J., Sachdev, S., Soltys, S. G. ELSEVIER SCIENCE INC. 2017: S186
  • Spine Stereotactic Radiosurgery: Outcomes and Predictors of Local Recurrence Kumar, K. A., Fujimoto, D. K., White, E. C., Ho, C. K., Azoulay, M., Gibbs, I. C., Adler, J. R., Chang, S. D., Hancock, S. L., Desai, A., Ratliff, J., Soltys, S. G., Choi, C. H. ELSEVIER SCIENCE INC. 2017: E86
  • A pilot study on the use of cerebrospinal fluid cell-free DNA in intramedullary spinal ependymoma JOURNAL OF NEURO-ONCOLOGY Connolly, I., Li, Y., Pan, W., Johnson, E., You, L., Vogel, H., Ratliff, J., Gephart, M. 2017; 135 (1): 29–36

    Abstract

    Cerebrospinal fluid (CSF) represents a promising source of cell-free DNA (cfDNA) for tumors of the central nervous system. A CSF-based liquid biopsy may obviate the need for riskier tissue biopsies and serve as a means for monitoring tumor recurrence or response to therapy. Spinal ependymomas most commonly occur in adults, and aggressive resection must be delicately balanced with the risk of injury to adjacent normal tissue. In patients with subtotal resection, recurrence commonly occurs. A CSF-based liquid biopsy matched to the patient's spinal ependymoma mutation profile has potential to be more sensitive then surveillance MRI, but the utility has not been well characterized for tumors of the spinal cord. In this study, we collected matched blood, tumor, and CSF samples from three adult patients with WHO grade II intramedullary spinal ependymoma. We performed whole exome sequencing on matched tumor and normal DNA to design Droplet Digital™ PCR (ddPCR) probes for tumor and wild-type mutations. We then interrogated CSF samples for tumor-derived cfDNA by performing ddPCR on extracted cfDNA. Tumor cfDNA was not reliably detected in the CSF of our cohort. Anatomic sequestration and low grade of intramedullary spinal cord tumors likely limits the role of CSF liquid biopsy.

    View details for PubMedID 28900844

  • Trends in Utilization and Cost of Cervical Spine Surgery Using the National Inpatient Sample Database, 2001 to 2013 SPINE Liu, C. Y., Zygourakis, C. C., Yoon, S., Kliot, T., Moriates, C., Ratliff, J., Dudley, R., Gonzales, R., Mummaneni, P. V., Ames, C. P. 2017; 42 (15): E906–E913

    Abstract

    A retrospective review.The aim of this study was to determine national rates of cervical spine surgery and to examine factors that underlie cost variation.There has been an increase in the rate and cost of spinal surgery over the past decades, but there is little understanding of the drivers of cost variation at the national level.We analyzed 419,830 patients who underwent cervical spine surgery (anterior cervical fusion, posterior cervical fusion, posterior cervical decompression, combined anterior/posterior cervical fusion) for degenerative conditions in the 2001 to 2013 NIS database. We determined the rates of surgery by time and geographic region, and then created univariate and multivariate models to evaluate the effect of these factors on total hospital costs: patient age, gender, race, insurance, income, county of residence, elective versus nonelective case, length of stay, risk of mortality, severity of illness, hospital bed size, wage index, hospital type, and geographic region.The most common type of cervical spine surgery was anterior fusion (80.6% of all surgeries). The national rates of all cervical spine surgery decreased slightly from 2001 to 2013 (75.34 to 72.20 per 100,000 adults), while the mean inflation-adjusted cost increased 64%, from $11,799 to $19,379, during this time period. Multivariate analyses showed that older age, male gender, black/other race, private insurance, greater risk of mortality/severity of illness, and longer length of stay were associated with higher costs. The wage index was positively correlated with cost, and hospitals in the western U.S. were 27% more expensive than those in the Northeast.The rate of cervical spine surgery decreased slightly, while the mean case cost increased at a rate double that of inflation from 2001 to 2013. Even after controlling for patient and hospital factors including wage index, there was significant geographic variation in the cost for cervical spine surgery.3.

    View details for PubMedID 28562473

  • Geographic and Hospital Variation in Cost of Lumbar Laminectomy and Lumbar Fusion for Degenerative Conditions NEUROSURGERY Zygourakis, C. C., Liu, C. Y., Wakam, G., Moriates, C., Boscardin, C., Ames, C. P., Mummaneni, P. V., Ratliff, J., Dudley, R., Gonzales, R. 2017; 81 (2): 331–40

    Abstract

    Spinal surgery costs vary significantly across hospitals and regions, but there is insufficient understanding of what drives this variation.To examine the factors underlying the cost variation for lumbar laminectomy/discectomy and lumbar fusions.We obtained patient information (age, gender, race, severity of illness, risk of mortality, population of county of residence, median zipcode income, insurance status, elective vs nonelective admission, length of stay) and hospital data (region, hospital type, bed size, wage index) for all patients who underwent lumbar laminectomy/discectomy (n = 181 267) or lumbar fusions (n = 433 364) for degenerative conditions in the 2001 to 2013 National Inpatient Sample database. We performed unadjusted and adjusted analyses to determine which factors affect cost.Mean costs for lumbar laminectomy/discectomy and lumbar fusion increased from $8316 and $21 473 in 2001 (in inflation-adjusted 2013 dollars), to $11 405 and $29 438, respectively, in 2013. There was significant regional variation in cost, with the West being the most expensive region across all years and showing the steepest increase in cost over time. After adjusting for patient and hospital factors, the West was 23% more expensive than the Northeast for lumbar laminectomy/discectomy, and 25% more expensive than the Northeast for lumbar fusion ( P < .01). Higher wage index, smaller hospital bed size, and rural/urban nonteaching hospital type were also associated with higher cost for lumbar laminectomy/discectomy and fusion ( P < .01).After adjusting for patient factors and wage index, the Western region, hospitals with smaller bed sizes, and rural/urban nonteaching hospitals were associated with higher costs for lumbar laminectomy/discectomy and lumbar fusion.

    View details for PubMedID 28327960

  • Surgeon Procedure Volume and Complication Rates in Anterior Cervical Discectomy and Fusions: Analysis of a National Longitudinal Database. Clinical spine surgery Cole, T., Veeravagu, A., Zhang, M., Ratliff, J. K. 2017; 30 (5): E633-E639

    Abstract

    Retrospective study using the MarketScan longitudinal database (2006-2010).Compare complication rates between groups of patients undergoing anterior cervical discectomy and fusion (ACDF) procedures performed by surgeons with high versus low mean annual ACDF volume.Over the past decade the volume of ACDFs performed has increased, concurrent with greater appreciation of potential for associated complications. The effect of surgeon procedure volume on adverse events occurrence in the postoperative period has not been described.We evaluated the relationship between surgeon procedure volume and postoperative incidence of any complication using a multivariate logistic regression model. A total of 24,461 patients undergoing single and multiple level ACDFs were identified in the MarketScan database by Current Procedural Terminology coding. Annual surgeon volume was determined by tracking of anonymized surgeon identification numbers, with high-volume surgeons defined as those performing an average of at least 30 ACDF procedures annually.Over 50% of unique surgeon identifiers reported <9 ACDF operations per year, whereas the highest decile reported a range of 44-101. High surgeon volume was protective for any complication [odds ratio (OR), 72; 95% confidence interval, 0.65-0.81; P<0.0001], with an adjusted number needed to harm of 44. Patients treated by high-volume physicians specifically had lower odds of dysphagia (2.22% vs. 3.08%; OR, 0.71; P<0.0013), neurological complications (0.33% vs. 0.64%; OR, 0.52; P<0.0107), new diagnosis of chronic pain (0.48% vs. 0.82%; OR, 0.58; P<0.0119), pulmonary complications (1.10% vs. 1.58%; OR, 0.69; P<0.0138), and other wound complications (0.06% vs. 0.22%; OR, 0.28; P<0.0242).We demonstrate a possible association between higher surgeon procedure volume and decreased postoperative complications after ACDF. There was no difference observed in need for revision surgery or readmission rates.

    View details for DOI 10.1097/BSD.0000000000000238

    View details for PubMedID 28525490

  • Cranioplasty Complications and Costs: A National Population-Level Analysis Using the MarketScan Longitudinal Database. World neurosurgery Li, A., Azad, T. D., Veeravagu, A., Bhatti, I., Long, C., Ratliff, J. K., Li, G. 2017; 102: 209-220

    Abstract

    To characterize cranioplasty complications and costs at a population level using a longitudinal national claims database.We identified cranioplasty patients between 2007-2014 in the MarketScan national database. We evaluated age, autograft usage, cranioplasty size, and cranioplasty timing on postoperative outcomes. We further analyzed associated costs. A subset analysis of adult cranioplasty patients with emergent indications, including stroke and trauma, was also performed.We identified 8,275 patients (mean 44.0±20.0 years, 45.2% male) consisting of 13.8% pediatric (<18 years), 76.0% adults (18-64 years), and 10.2% elderly adults (>65 years). Overall complication rate was 36.6%, mortality rate 0.5%, and 30-day readmission rate 12.0%. Elderly patients had the highest complication rate (p<0.0001). Overall, large cranioplasties (>5 cm) saw higher complication rates than small cranioplasties (≤5 cm, p=0.047). In those with emergent indications only(N=1,282), size did not influence complications-though large cranioplasties showed higher infection risk (p=0.02). Overall, autograft use did not affect outcomes, but was associated with higher complication risk-including infections-in the subset with only emergent indications (p<0.001, p=0.001). Late (>90 days) cranioplasty timing had higher complication rates in both the overall cohort and subset with emergent indications (p<0.001, p<0.001). Index costs of care were mainly driven by hospital payments in both the overall cohort and those with emergent indications.We found a high complication rate associated with cranioplasty in the U.S.A. Older age, large cranioplasties, and delayed cranioplasties increased complication risk overall. Among those with only emergent indications, complications were associated with a delayed time to cranioplasty and autograft usage.

    View details for DOI 10.1016/j.wneu.2017.03.022

    View details for PubMedID 28315803

  • Outpatient vs Inpatient Anterior Cervical Discectomy and Fusion: A Population-Level Analysis of Outcomes and Cost. Neurosurgery Purger, D. A., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Yang, L., Desai, M., Veeravagu, A., Ratliff, J. K., Desai, A. 2017

    Abstract

    Outpatient anterior cervical discectomy and fusion (ACDF) is a promising candidate for US healthcare cost reduction as several studies have demonstrated that overall complications are relatively low and early discharge can preserve high patient satisfaction, low morbidity, and minimal readmission.To compare clinical outcomes and associated costs between inpatient and ambulatory setting ACDF.Demographics, comorbidities, emergency department (ED) visits, readmissions, reoperation rates, and 90-d charges were retrospectively analyzed for patients undergoing elective ACDF in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.A total of 3135 ambulatory and 46 996 inpatient ACDFs were performed. Mean Charlson comorbidity index, length of stay, and mortality were 0.2, 0.4 d, and 0% in the ambulatory cohort and 0.4, 1.8 d, and 0.04% for inpatients ( P < .0001). Ambulatory patients were younger (48.0 vs 53.1) and more likely to be Caucasian. One hundred sixty-eight ambulatory patients (5.4%) presented to the ED within 30 d (mean 11.3 d), 51 (1.6%) were readmitted, and 5 (0.2%) underwent reoperation. Among inpatient surgeries, 2607 patients (5.5%) presented to the ED within 30 d (mean 9.7 d), 1778 (3.8%) were readmitted (mean 6.3 d), and 200 (0.4%) underwent reoperation. Higher Charlson comorbidity index increased rate of ED visits (ambulatory operating room [OR] 1.285, P < .05; inpatient OR 1.289, P < .0001) and readmission (ambulatory OR 1.746, P < .0001; inpatient OR 1.685, P < .0001). Overall charges were significantly lower for ambulatory ACDFs ($33 362.51 vs $74 667.04; P < .0001).ACDF can be performed in an ambulatory setting with comparable morbidity and readmission rates, and lower costs, to those performed in an inpatient setting.

    View details for DOI 10.1093/neuros/nyx215

    View details for PubMedID 28498922

  • The effect of socioeconomic status on gross total resection, radiation therapy and overall survival in patients with gliomas. Journal of neuro-oncology Deb, S., Pendharkar, A. V., Schoen, M. K., Altekruse, S., Ratliff, J., Desai, A. 2017

    Abstract

    Socioeconomic status (SES) is associated with survival in many cancers but the effect of socioeconomic status on survival and access to care for patients with gliomas has not been well studied. This study included 50,170 patients from the Surveillance, Epidemiology, and End Results Program at the National Cancer Institute database diagnosed with gliomas of the brain from 2003 to 2012. Patient SES was divided into tertiles and quintiles. Treatment options included radiation, surgery (gross total resection (GTR)/other surgery), and radiation with surgery. Multivariable logistic regression and Cox proportional hazards model were used to analyze data with SAS v9.4. The results were adjusted for age at diagnosis, race, sex, tumor type, and tumor grade. Kaplan-Meier survival curves were constructed according to SES tertiles and quintiles. Patients from a higher SES tertile were significantly more likely to receive surgery, radiation, GTR, and radiation with surgery (OR 1.092, 1.116, 1.103, 1.150 respectively, all p < 0.0001). This correlation was also true when patients were divided into quintiles (OR 1.054, 1.072, 1.062, 1.089 respectively, all p < 0.0001). Furthermore, the lowest SES tertiles (HR 1.258, 1.146) and the lowest SES quintiles (HR 1.301, 1.273, 1.194, 1.119) were associated with significantly shorter survival times (all p for trend <0.0001). Surgery, radiation therapy, surgery with radiation therapy, and GTR were also found to be associated with improved overall survival in glioma patients (HR 0.553, 0.849, 0.666, 0.491 respectively, all p < 0.0001). The findings from this national study suggest an effect of SES on access to treatment, and survival in patients with gliomas.

    View details for DOI 10.1007/s11060-017-2391-2

    View details for PubMedID 28258423

  • Diagnostic Utility of Intraoperative Neurophysiological Monitoring for Intramedullary Spinal Cord Tumors: Systematic Review and Meta-Analysis. Clinical spine surgery Azad, T. D., Pendharkar, A. V., Nguyen, V. n., Pan, J. n., Connolly, I. D., Veeravagu, A. n., Popat, R. n., Ratliff, J. K., Grant, G. A. 2017

    Abstract

    Systematic review and meta-analysis.The aim of this study was to systematically evaluate the diagnostic utility of intraoperative neurophysiological monitoring (IONM) for detecting postoperative injury in resection of intramedullary spinal cord tumors (IMSCT).Surgical management of IMSCT can involve key neurological and vascular structures. IONM aims to assess the functional integrity of susceptible elements in real time. The diagnostic value of IONM for ISMCT has not been systematically evaluated.We performed a systematic review of the PubMed and MEDLINE databases for studies investigating the use of IONM for IMSCT and conducted a meta-analysis of diagnostic capability.Our search produced 257 citations. After application of exclusion criteria, 21 studies remained, 10 American Academy of Neurology grade III and 11 American Academy of Neurology grade IV. We found that a strong pooled mean sensitivity of 90% [95% confidence interval (CI), 84-94] and a weaker pooled mean specificity of 82% (95% CI, 70-90) for motor-evoked potential (MEP) recording changes. Somatosensory-evoked potential (SSEP) recording changes yielded pooled sensitivity of 85% (95% CI, 75-91) and pooled specificity of 72% (95% CI, 57-83). The pooled diagnostic odds ratio for MEP was 55.7 (95% CI, 26.3-119.1) and 14.3 (95% CI, 5.47-37.3) for SSEP. Bivariate analysis yielded summary receiver operative characteristic curves with area under the curve of 91.8% for MEPs and 86.3% for SSEPs.MEPs and SSEPs appear to be more sensitive than specific for detection of postoperative injury. Patients with perioperative neurological deficits are 56 times more likely to have had changes in MEPs during the procedure. We observed considerable variability in alarm criteria and interventions in response to IONM changes, indicating the need for prospective studies capable of defining standardized alarm criteria and responses.

    View details for PubMedID 28650882

  • Endoscopic vs. Microscopic Resection of Sellar Lesions-A Matched Analysis of Clinical and Socioeconomic Outcomes. Frontiers in surgery Azad, T. D., Lee, Y. J., Vail, D. n., Veeravagu, A. n., Hwang, P. H., Ratliff, J. K., Li, G. n. 2017; 4: 33

    Abstract

    Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce, with conflicting reports of cost and clinical outcome advantages.To determine if the proposed benefits of endoscopic resection are realized on a population level.We performed a matched cohort study of 9,670 adult patients in the MarketScan database who underwent either endoscopic or microscopic surgery for sellar lesions. Coarsened matching was applied to estimate the effects of surgical approach on complication rates, length of stay (LOS), costs, and likelihood of postoperative radiation.We found that LOS, readmission, and revision rates did not differ significantly between approaches. The overall complication rate was higher for endoscopy (47% compared to 39%, OR 1.37, 95% CI 1.22-1.53). Endoscopic approach was associated with greater risk of neurological complications (OR 1.32, 95% CI 1.11-1.55), diabetes insipidus (OR 1.65, 95% CI 1.37-2.00), and cerebrospinal fluid rhinorrhea (OR 1.83, 95% CI 1.07-3.13) compared to the microscopic approach. Although the total index payment was higher for patients receiving endoscopic resection ($32,959 compared to $29,977 for microscopic resection), there was no difference in long-term payments. Endoscopic surgery was associated with decreased likelihood of receiving post-resection stereotactic radiosurgery (OR 0.67, 95% CI 0.49-0.90) and intensity-modulated radiation therapy (OR 0.78, 95% CI 0.65-0.93).Our results suggest that the transition from a microscopic to endoscopic approach to sellar lesions must be subject to careful evaluation. Although there are evident advantages to transsphenoidal endoscopy, our analysis suggests that the benefits of the endoscopic approach are yet to be materialized.

    View details for PubMedID 28691009

  • Microsurgical vs. Endoscopic Excision of Colloid Cysts: An Analysis of Complications and Costs Using a Longitudinal Administrative Database. Frontiers in neurology Connolly, I. D., Johnson, E. n., Lamsam, L. n., Veeravagu, A. n., Ratliff, J. n., Li, G. n. 2017; 8: 259

    Abstract

    Open microsurgical and endoscopic approaches are the two main surgical options for excision of colloid cysts. Controversy remains as to which is superior. Previous studies consist of small cohort sizes. This topic has not been investigated using national administrative claims data which benefits from larger patient numbers.Current Procedural Terminology (CPT) and International Classification of Disease version 9 (ICD-9) coding at inpatient visit was used to select for index surgical procedures corresponding to microsurgical or endoscopic excision of colloid cysts. Comorbidities, costs, and complications were collected.We identified a total of 483 patients. In all, 240 were from the microsurgical cohort and 243 were from the endoscopic cohort. The two groups displayed similar demographic and comorbidity profiles. Thirty-day post-operative complications were also similar between groups with the exception of seizures and thirty-day readmissions, both higher in the open surgical cohort. The seizure rates were 14.7 and 5.4% in the microsurgical and endoscopic cohorts, respectively (p = 0.0011). The thirty-day readmission rates were 17.3 and 9.6% in the microsurgical and endoscopic cohorts, respectively (p = 0.0149). Index admission costs and 90-day post discharge payments were higher in patients receiving microsurgical excision.An analysis of administrative claims data revealed few differences in surgical complications following colloid cyst excision via microsurgical and endoscopic approaches. Post-operative seizures and thirty-day readmissions were seen at higher frequency in patients who underwent microsurgical resection. Despite similar complication profiles, patients undergoing microsurgical excision experienced higher index admission costs and 90-day aggregated costs suggesting that complications may have been more severe in this group.

    View details for PubMedID 28649225

  • Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesthesia and analgesia Hah, J. M., Bateman, B. T., Ratliff, J. n., Curtin, C. n., Sun, E. n. 2017; 125 (5): 1733–40

    Abstract

    Physicians, policymakers, and researchers are increasingly focused on finding ways to decrease opioid use and overdose in the United States both of which have sharply increased over the past decade. While many efforts are focused on the management of chronic pain, the use of opioids in surgical patients presents a particularly challenging problem requiring clinicians to balance 2 competing interests: managing acute pain in the immediate postoperative period and minimizing the risks of persistent opioid use after the surgery. Finding ways to minimize this risk is particularly salient in light of a growing literature suggesting that postsurgical patients are at increased risk for chronic opioid use. The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical- and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term. In this paper, we discuss the consequences of chronic opioid use after surgery and present an analysis of the extent to which surgery has been associated with chronic opioid use. We follow with a discussion of the risk factors that are associated with chronic opioid use after surgery and proceed with an analysis of the extent to which opioid-sparing perioperative interventions (eg, nerve blockade) have been shown to reduce the risk of chronic opioid use after surgery. We then conclude with a discussion of future research directions.

    View details for PubMedID 29049117

  • Outcomes of cervical laminoplasty-Population-level analysis of a national longitudinal database. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia Veeravagu, A. n., Azad, T. D., Zhang, M. n., Li, A. n., Pendharkar, A. V., Ratliff, J. K., Shuer, L. M. 2017

    Abstract

    Cervical laminoplasty is an important alternative to laminectomy in decompressing of the cervical spine. Further evidence to assess the utility of laminoplasty is required. We examine outcomes of cervical laminoplasty via a population level analysis in the United States.We performed a population-level analysis using the national MarketScan longitudinal database to analyze outcomes and costs of cervical laminoplasty between 2007 and 2014. Outcomes included postoperative complications, revision rates, and functional outcomes.Using a national administrative database, we identified 2613 patients (65.6% male, mean 58.5 years) who underwent cervical laminoplasty. Mean length of stay was 3.1 ± 2.8 days and mean follow-up was 795.5 ± 670.6 days. The overall complication rate was 22.5% (N = 587), 30-day readmission rate was 7.5% (N = 195), and mortality rate was 0.08% (N = 2, elderly patients only). The complication rate was significantly increased in elderly patients (age >65 years) compared to non-elderly patients (OR 0.751, p < .01). The use of intraoperative neuromonitoring (IONM) during the cervical laminoplasty procedure did not significantly impact outcomes. The overall re-operation rate after the initial procedure was 10.9%. Total costs of cervical laminoplasty were mainly driven by hospital charges with physician-related payments comprising a small amount.Our national analysis of cervical laminoplasty found the procedure to be clinically effective with low complication rates and postoperative symptomatic improvement.

    View details for PubMedID 29153782

  • Postoperative Opioid Use, Complications, and Costs in Surgical Management of Lumbar Spondylolisthesis. Spine Vail, D. n., Azad, T. D., O'Connell, C. n., Han, S. S., Veeravagu, A. n., Ratliff, J. K. 2017

    Abstract

    Retrospective analysis on a national longitudinal database (2007-2014).To determine the association between arthrodesis and complication rates, costs, surgical revision, and postoperative opioid prescription.Arthrodesis in patients receiving laminectomy for lumbar spondylolisthesis remains controversial. However, population-level evidence to support the use of arthrodesis remains limited.We identified 73,176 patient records and used coarsened exact matching to create comparable populations of patients who received laminectomy or laminectomy with arthrodesis. We use linear and logistic regression models to analyze the relationship between arthrodesis and postoperative complications, length of stay, costs, readmissions, surgical revisions, and postoperative opioid prescribing.Patients who underwent arthrodesis spent one more day in the hospital on average (p < 0.01), and had higher costs of care at their index visit ($24,126, p < 0.01), which were partially offset by lower costs of care over the two years following their procedure ($14,667 less in arthrodesis patients, p = 0.01). Patients with arthrodesis were less likely to have a surgical revision (OR = 0.66, p < 0.01). Patients with arthrodesis used more opioids in the first two months following their procedure, but had comparable opioid use to patients undergoing laminectomy without arthrodesis in all other post-operative months over the next two years, and were not more or less likely to convert to chronic opioid use. Postoperative opioid prescription varied dramatically across states (p < 0.01); geographic variation in opioid use is substantially greater than differences in opioid use based on procedure performed.Arthrodesis is associated with reduced likelihood of surgical revision and increased use of opioids in the first two months following surgery, but not associated with greater or lesser opioid use beyond the initial two postoperative months. Geographic variation in opioid use is substantial even after accounting for patient characteristics and for whether patients underwent arthrodesis.3.

    View details for PubMedID 29215492

  • Impact of Inpatient Venous Thromboembolism Continues After Discharge: Retrospective Propensity Scored Analysis in a Longitudinal Database. Clinical spine surgery Li, A. Y., Azad, T. D., Veeravagu, A., Bhatti, I., Li, A., Cole, T., Desai, A., Ratliff, J. K. 2016: -?

    Abstract

    Propensity score matched retrospective study using a nationwide longitudinal database.To quantify the longitudinal economic impact of venous thromboembolism (VTE) complications in spinal fusion patients.VTE is a rare and serious complication that may occur after spine surgery. The long-term socioeconomic impact understanding of these events has been limited by small sample sizes and a lack of longitudinal follow-up. We provide a comparative economic outcomes analysis of these complications.We identified 204,308 patients undergoing spinal fusion procedures in a national billing claims database (MarketScan) between 2006 and 2010. Cohorts were balanced using 50:1 propensity score matching and outcome measures compared at 6, 12, and 18 months postoperation.A total of 1196 (0.6%) patients developed postoperative VTE, predominantly occurring following lumbar fusion (69.7%). Postoperative VTE patients demonstrated an increase in hospital length of stay (7.8 vs. 3.3 d, P<0.001) and a decreased likelihood of being discharged home (71% vs. 85%, P<0.001). A $26,306 increase in total hospital payments (P<0.001) was observed, with a disproportionate increase seen in hospital payments ($22,103, P<0.001), relative to physician payments ($1766, P=0.001).At 6, 12, and 18 months postfusion, increased rates of readmission and follow-up clinic visits were observed. Delayed readmissions were associated with decreased length of stay (3.6 vs. 4.6 d, P<0.001), but increased total payments, averaging at $21,270 per readmission. VTE patients generated greater cumulative outpatient service payments, costing $8075, $11,134, and $13,202 more at 6, 12, and 18 months (P<0.001).VTEs are associated with longer hospitalizations, a decreased likelihood of being discharged home, and overall increases of hospital resource utilization and cost in inpatient and outpatient settings. VTE patients generate greater charges in the outpatient setting and are more likely to become readmitted at 6, 12, and 18 months after surgery, demonstrating a significant socioeconomic impact long after occurrence.Level III-therapeutic.

    View details for PubMedID 27750270

  • An assessment of data and methodology of online surgeon scorecards. Journal of neurosurgery. Spine Xu, L. W., Li, A., Swinney, C., Babu, M., Veeravagu, A., Wolfe, S. Q., Nahed, B. V., Ratliff, J. K. 2016: 1-8

    Abstract

    OBJECTIVE Recently, 2 surgeon rating websites (Consumers' Checkbook and ProPublica) were published to allow the public to compare surgeons through identifying surgeon volume and complication rates. Among neurosurgeons and orthopedic surgeons, only cervical and lumbar spine, hip, and knee procedures were included in this assessment. METHODS The authors examined the methodology of each website to assess potential sources of inaccuracy. Each online tool was queried for reports on neurosurgeons specializing in spine surgery and orthopedic surgeons specializing in spine, hip, or knee surgery. Surgeons were chosen from top-ranked hospitals in the US, as recorded by a national consumer publication ranking system, within the fields of neurosurgery and orthopedic surgery. The results were compared for accuracy and surgeon representation, and the results of the 2 websites were also compared. RESULTS The methodology of each site was found to have opportunities for bias and limited risk adjustment. The end points assessed by each site were actually not complications, but proxies of complication occurrence. A search of 510 surgeons (401 orthopedic surgeons [79%] and 109 neurosurgeons [21%]) showed that only 28% and 56% of surgeons had data represented on Consumers' Checkbook and ProPublica, respectively. There was a significantly higher chance of finding surgeon data on ProPublica (p < 0.001). Of the surgeons from top-ranked programs with data available, 17% were quoted to have high complication rates, 13% with lower volume than other surgeons, and 79% had a 3-star out of 5-star rating. There was no significant correlation found between the number of stars a surgeon received on Consumers' Checkbook and his or her adjusted complication rate on ProPublica. CONCLUSIONS Both the Consumers' Checkbook and ProPublica websites have significant methodological issues. Neither site assessed complication occurrence, but rather readmissions or prolonged length of stay. Risk adjustment was limited or nonexistent. A substantial number of neurosurgeons and orthopedic surgeons from top-ranked hospitals have no ratings on either site, or have data that suggests they are low-volume surgeons or have higher complication rates. Consumers' Checkbook and ProPublica produced different results with little correlation between the 2 websites in how surgeons were graded. Given the significant methodological issues, incomplete data, and lack of appropriate risk stratification of patients, the featured websites may provide erroneous information to the public.

    View details for PubMedID 27661563

  • Complications, Readmissions, and Revisions for Spine Procedures Performed by Orthopedic Surgeons Versus Neurosurgeons: A Retrospective, Longitudinal Study. Clinical spine surgery Mabud, T., Norden, J., Veeravagu, A., Swinney, C., Cole, T., McCutcheon, B. A., Ratliff, J. 2016: -?

    Abstract

    Retrospective database analysis.To examine the impact of training pathway, either neurosurgical or orthopedic, on complications, readmissions, and revisions in spine surgery.Training pathway has been shown to have an impact on outcomes in various surgical subspecialties. Although training pathway has not been shown to have a significant impact on spine surgery outcomes in the perioperative period, long-term results are unknown.A retrospective analysis of 197,682 patients receiving 1 of 3 common spine surgeries [lumbar laminectomy, lumbar fusion, and anterior cervical discectomy and fusion (ACDF)] between 2006 and 2010 was conducted. Patient data were obtained from a large claims database. Postoperative adverse effects, all-cause readmission, revision surgery rates, and intermediary payments in these cohorts of patients were compared between spine surgeons with either neurosurgical or orthopedic backgrounds.Patient demographics, hospital-stay characteristics, and medical comorbidities were similar between neurosurgeons and orthopedic surgeons. The risks of surgical complications, all-cause readmission, and revision surgery were also similar between neurosurgeons and orthopedic surgeons across all procedure types assessed, with several minor exceptions: neurosurgeons had marginally higher odds of any complication for lumbar fusions [odds ratio (OR) 1.14; 95% confidence interval (CI), 1.09-1.20] and ACDFs (OR, 1.09; 95% CI, 1.04-1.15). Neurosurgeons also had slightly higher rates of revision surgery for concurrent lumbar laminectomy with fusion (OR, 1.14; 95% CI, 1.08-1.22), and ACDFs (OR, 1.20; 95% CI, 1.14-1.28). No associations between surgeon type and any particular complication were consistently observed for all procedure groups. There were also no associations between surgeon type and 30-day all-cause readmission. Median total intermediary payments were somewhat higher for neurosurgery patients for all procedure groups assessed.Few significant associations between surgeon type and patient outcomes exist in the context of spine surgery. Those which do are small and unlikely to be clinically meaningful.Level 3.

    View details for PubMedID 27623297

  • 105 The Effect of Socioeconomic Status on Gross Total Resection, Radiation Therapy, and Overall Survival in Patients With Gliomas. Neurosurgery Deb, S., Pendharkar, A. V., Altekruse, S., Ratliff, J. K., Desai, A. 2016; 63: 144-145

    Abstract

    Socioeconomic status (SES) is associated with survival in many cancers but the effect of SES on survival and access to care for patients with gliomas has not been studied.50 170 patients from the SEER Program at the National Cancer Institute database were included in this study. All patients were diagnosed with gliomas of the brain from 2003 to 2012. Patient SES was divided into tertiles and quintiles. Treatment options included radiation (yes/no), surgery (gross total resection [GTR]/other surgery/no surgery), and radiation with surgery (yes/no). Multivariable logistic regression and Cox proportional hazards model were used to analyze data with SAS v9.4. The results were adjusted for age at diagnosis, race, and sex. Kaplan-Meier survival curves were constructed according to SES tertiles and quintiles.Patients from a higher SES tertile were significantly more likely to receive surgery, radiation, GTR, and radiation with surgery (odds ratio [OR] = 1.101, 1.12, 1.108, 1.153, respectively, all P < .0001). This correlation was also true when patients were divided into quintiles (OR = 1.06, 1.074, 1.065, 1.092, respectively, all P < .0001). Furthermore, the lowest SES tertiles (hazards ratio [HR] = 1.226, 1.129) and the lowest SES quintiles (HR = 1.264, 1.232, 1.178, 1.108) were associated with significantly shorter survival times (all P for trend <.0001). Surgery, surgery with radiation therapy, and GTR were also found to be associated with improved overall survival in glioma patients (HR = 0.649, 0.782, 0.753, respectively, all P < .0001). When adjusted for treatment received (radiation, surgery, or radiation with surgery), the effect of SES on survival reduced (HR = 1.204, 1.11 for tertiles; HR = 1.239, 1.198, 1.153, 1.091 for quintiles), but was still significant (all P for trend <.0001).The findings from this national study on patients with gliomas suggest an effect of SES on access to treatment and survival in patients with gliomas. Further studies are required to understand reasons underlying these disparities and how they may be addressed.

    View details for DOI 10.1227/01.neu.0000489676.60475.df

    View details for PubMedID 27399385

  • Surgeon Procedure Volume and Complication Rates in Anterior Cervical Discectomy and Fusions: Analysis of a National Longitudinal Database. Clinical spine surgery Cole, T., Veeravagu, A., Zhang, M., Ratliff, J. K. 2016: -?

    Abstract

    Retrospective study using the MarketScan longitudinal database (2006-2010).Compare complication rates between groups of patients undergoing anterior cervical discectomy and fusion (ACDF) procedures performed by surgeons with high versus low mean annual ACDF volume.Over the past decade the volume of ACDFs performed has increased, concurrent with greater appreciation of potential for associated complications. The effect of surgeon procedure volume on adverse events occurrence in the post-operative period has not been described.We evaluated the relationship between surgeon procedure volume and post-operative incidence of any complication using a multivariate logistic regression model. 24,461 patients undergoing single and multiple level ACDFs were identified in the MarketScan database by Current Procedural Terminology coding. Annual surgeon volume was determined by tracking of anonymized surgeon identification numbers, with high-volume surgeons defined as those performing an average of at least 30 ACDF procedures annually.Over 50% of unique surgeon identifiers reported less than 9 ACDF operations per year, while the highest decile reported a range of 44 to 101. High surgeon volume was protective for any complication (OR.72, 95% CI 0.65-0.81 P<0.0001), with an adjusted number needed to harm of 44. Patients treated by high-volume physicians specifically had lower odds of dysphagia (2.22% vs. 3.08%, OR 0.71, P<0.0013), neurological complications (0.33% vs. 0.64%, OR 0.52, P<0.0107), new diagnosis of chronic pain (0.48% vs. 0.82%, OR 0.58, P<0.0119), pulmonary complications (1.10% vs. 1.58%, OR 0.69, P<0.0138), and other wound complications (0.06% vs. 0.22%, OR 0.28, P<0.0242).We demonstrate a possible association between higher surgeon procedure volume and decreased post-operative complications following anterior cervical discectomy and fusion. There was no difference observed in need for revision surgery or readmission rates.

    View details for PubMedID 25551324

  • Delayed Presentation of Sciatic Nerve Injury after Total Hip Arthroplasty: Neurosurgical Considerations, Diagnosis, and Management. Journal of neurological surgery reports Xu, L. W., Veeravagu, A., Azad, T. D., Harraher, C., Ratliff, J. K. 2016; 77 (3): e134-8

    Abstract

    Total hip arthroplasty (THA) is an established treatment for end-stage arthritis, congenital deformity, and trauma with good long-term clinical and functional outcomes. Delayed sciatic nerve injury is a rare complication after THA that requires prompt diagnosis and management.We present a case of sciatic nerve motor and sensory deficit in a 52-year-old patient 2 years after index left THA. Electromyography (EMG) results and imaging with radiographs and CT of the affected hip demonstrated an aberrant acetabular cup screw in the posterior-inferior quadrant adjacent to the sciatic nerve.The patient underwent surgical exploration that revealed injury to the peroneal division of the sciatic nerve due to direct injury from screw impingement. A literature review identified 11 patients with late-onset neuropathy after THA. Ten patients underwent surgical exploration and pain often resolved after surgery with 56% of patients recovering sensory function and 25% experiencing full recovery of motor function.Delayed neuropathy of the sciatic nerve is a rare complication after THA that is most often due to hardware irritation, component failure, or wear-related pseudotumor formation. Operative intervention is often pursued to explore and directly visualize the nerve with limited results in the literature showing modest relief of pain and sensory symptoms and poor restoration of motor function.

    View details for DOI 10.1055/s-0035-1568134

    View details for PubMedID 27602309

    View details for PubMedCentralID PMC5011454

  • Surgical outcomes of cervical spondylotic myelopathy: an analysis of a national, administrative, longitudinal database. Neurosurgical focus Veeravagu, A., Connolly, I. D., Lamsam, L., Li, A., Swinney, C., Azad, T. D., Desai, A., Ratliff, J. K. 2016; 40 (6): E11-?

    Abstract

    OBJECTIVE The authors performed a population-based analysis of national trends, costs, and outcomes associated with cervical spondylotic myelopathy (CSM) in the United States. They assessed postoperative complications, resource utilization, and predictors of costs, in this surgically treated CSM population. METHODS MarketScan data (2006-2010) were used to retrospectively analyze the complications and costs of different spine surgeries for CSM. The authors determined outcomes following anterior cervical discectomy and fusion (ACDF), posterior fusion, combined anterior/posterior fusion, and laminoplasty procedures. RESULTS The authors identified 35,962 CSM patients, comprising 5154 elderly (age ≥ 65 years) patients (mean 72.2 years, 54.9% male) and 30,808 nonelderly patients (mean 51.1 years, 49.3% male). They found an overall complication rate of 15.6% after ACDF, 29.2% after posterior fusion, 41.1% after combined anterior and posterior fusion, and 22.4% after laminoplasty. Following ACDF and posterior fusion, a significantly higher risk of complication was seen in the elderly compared with the nonelderly (reference group). The fusion level and comorbidity-adjusted ORs with 95% CIs for these groups were 1.54 (1.40-1.68) and 1.25 (1.06-1.46), respectively. In contrast, the elderly population had lower 30-day readmission rates in all 4 surgical cohorts (ACDF, 2.6%; posterior fusion, 5.3%; anterior/posterior fusion, 3.4%; and laminoplasty, 3.6%). The fusion level and comorbidity-adjusted odds ratios for 30-day readmissions for ACDF, posterior fusion, combined anterior and posterior fusion, and laminoplasty were 0.54 (0.44-0.68), 0.32 (0.24-0.44), 0.17 (0.08-0.38), and 0.39 (0.18-0.85), respectively. CONCLUSIONS The authors' analysis of the MarketScan database suggests a higher complication rate in the surgical treatment of CSM than previous national estimates. They found that elderly age (≥ 65 years) significantly increased complication risk following ACDF and posterior fusion. Elderly patients were less likely to experience a readmission within 30 days of surgery. Postoperative complication occurrence, and 30-day readmission were significant drivers of total cost within 90 days of the index surgical procedure.

    View details for DOI 10.3171/2016.3.FOCUS1669

    View details for PubMedID 27246481

  • Performance Measures in Neurosurgical Patient Care Differing Applications of Patient Safety Indicators MEDICAL CARE Moghavem, N., McDonald, K., Ratliff, J. K., Hernandez-Boussard, T. 2016; 54 (4): 359-364

    Abstract

    Patient Safety Indicators (PSIs) are administratively coded identifiers of potentially preventable adverse events. These indicators are used for multiple purposes, including benchmarking and quality improvement efforts. Baseline PSI evaluation in high-risk surgeries is fundamental to both purposes.Determine PSI rates and their impact on other outcomes in patients undergoing cranial neurosurgery compared with other surgeries.The Agency for Healthcare Research and Quality (AHRQ) PSI software was used to flag adverse events and determine risk-adjusted rates (RAR). Regression models were built to assess the association between PSIs and important patient outcomes.We identified cranial neurosurgeries based on International Classification of Diseases, Ninth Revision, Clinical Modification codes in California, Florida, New York, Arkansas, and Mississippi State Inpatient Databases, AHRQ, 2010-2011.PSI development, 30-day all-cause readmission, length of stay, hospital costs, and inpatient mortality.A total of 48,424 neurosurgical patients were identified. Procedure indication was strongly associated with PSI development. The neurosurgical population had significantly higher RAR of most PSIs evaluated compared with other surgical patients. Development of a PSI was strongly associated with increased length of stay and hospital cost and, in certain PSIs, increased inpatient mortality and 30-day readmission.In this population-based study, certain accountability measures proposed for use as value-based payment modifiers show higher RAR in neurosurgery patients compared with other surgical patients and were subsequently associated with poor outcomes. Our results indicate that for quality improvement efforts, the current AHRQ risk-adjustment models should be viewed in clinically meaningful stratified subgroups: for profiling and pay-for-performance applications, additional factors should be included in the risk-adjustment models. Further evaluation of PSIs in additional high-risk surgeries is needed to better inform the use of these metrics.

    View details for DOI 10.1097/MLR.0000000000000490

    View details for Web of Science ID 000372935200004

  • Performance Measures in Neurosurgical Patient Care: Differing Applications of Patient Safety Indicators. Medical care Moghavem, N., McDonald, K., Ratliff, J. K., Hernandez-Boussard, T. 2016; 54 (4): 359-64

    Abstract

    Patient Safety Indicators (PSIs) are administratively coded identifiers of potentially preventable adverse events. These indicators are used for multiple purposes, including benchmarking and quality improvement efforts. Baseline PSI evaluation in high-risk surgeries is fundamental to both purposes.Determine PSI rates and their impact on other outcomes in patients undergoing cranial neurosurgery compared with other surgeries.The Agency for Healthcare Research and Quality (AHRQ) PSI software was used to flag adverse events and determine risk-adjusted rates (RAR). Regression models were built to assess the association between PSIs and important patient outcomes.We identified cranial neurosurgeries based on International Classification of Diseases, Ninth Revision, Clinical Modification codes in California, Florida, New York, Arkansas, and Mississippi State Inpatient Databases, AHRQ, 2010-2011.PSI development, 30-day all-cause readmission, length of stay, hospital costs, and inpatient mortality.A total of 48,424 neurosurgical patients were identified. Procedure indication was strongly associated with PSI development. The neurosurgical population had significantly higher RAR of most PSIs evaluated compared with other surgical patients. Development of a PSI was strongly associated with increased length of stay and hospital cost and, in certain PSIs, increased inpatient mortality and 30-day readmission.In this population-based study, certain accountability measures proposed for use as value-based payment modifiers show higher RAR in neurosurgery patients compared with other surgical patients and were subsequently associated with poor outcomes. Our results indicate that for quality improvement efforts, the current AHRQ risk-adjustment models should be viewed in clinically meaningful stratified subgroups: for profiling and pay-for-performance applications, additional factors should be included in the risk-adjustment models. Further evaluation of PSIs in additional high-risk surgeries is needed to better inform the use of these metrics.

    View details for DOI 10.1097/MLR.0000000000000490

    View details for PubMedID 26759981

  • Piriformis Syndrome With Variant Sciatic Nerve Anatomy: A Case Report. PM & R : the journal of injury, function, and rehabilitation Kraus, E., Tenforde, A. S., Beaulieu, C. F., Ratliff, J., Fredericson, M. 2016; 8 (2): 176-179

    Abstract

    A 68-year-old male long distance runner presented with low back and left buttock pain, which eventually progressed to severe and debilitating pain, intermittently radiating to the posterior thigh and foot. A comprehensive workup ruled out possible spine or hip causes of his symptoms. A pelvic magnetic resonance imaging neurogram with complex oblique planes through the piriformis demonstrated variant anatomy of the left sciatic nerve consistent with the clinical diagnosis of piriformis syndrome. The patient ultimately underwent neurolysis with release of the sciatic nerve and partial resection of the piriformis muscle. After surgery the patient reported significant pain reduction and resumed running 3 months later. Piriformis syndrome is uncommon but should be considered in the differential diagnosis for buttock pain. Advanced imaging was essential to guide management.

    View details for DOI 10.1016/j.pmrj.2015.09.005

    View details for PubMedID 26377629

  • Postoperative Visual Loss Following Lumbar Spine Surgery: A Review of Risk Factors by Diagnosis WORLD NEUROSURGERY Li, A., Swinney, C., Veeravagu, A., Bhatti, I., Ratliff, J. 2015; 84 (6): 2010-2021

    Abstract

    Postoperative visual loss (POVL) is a potentially devastating complication of lumbar spine surgery that may lead to significant functional impairment. Although POVL is rare, a review of the literature shows that it is being reported with increasing frequency. A systematic analysis detailing the etiology and prognosis of the 3 main types of POVL has yet to be published. We reviewed potential preoperative and intraoperative risk factors for ischemic optic neuropathy (ION), central retinal artery occlusion (CRAO), and cortical blindness (CB) after lumbar spine surgery.A PubMed and Google literature search was completed in the absence of time constraints. Relevant articles on POVL after spine surgery were identified and reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.We identified 4 large-scale studies that statistically analyzed risk factors for POVL. ION, CRAO, and CB were the most frequently reported POVL types in the literature. Data were abstracted from 19 ION case reports, 3 CRAO case reports, and 5 CB case reports.We reviewed the preoperative and intraoperative risk factors for each of the 3 main POVL types, using several published case reports to supplement the limited large-scale studies available. ION risks may be influenced by a longer operative time in the prone position with anemia, hypotension, and blood transfusion. The risk for CRAO is usually due to improper positioning during the surgery. Prone positioning and obesity were found to be most commonly associated with CB development. The prognosis, prevention techniques, and treatment of each POVL type can vary considerably.

    View details for DOI 10.1016/j.wneu.2015.08.030

    View details for Web of Science ID 000366286300087

    View details for PubMedID 26341434

  • Identification of complications that have a significant effect on length of stay after spine surgery and predictive value of 90-day readmission rate JOURNAL OF NEUROSURGERY-SPINE Yadla, S., Ghobrial, G. M., Campbell, P. G., Maltenfort, M. G., Harrop, J. S., Ratliff, J. K., Sharan, A. D. 2015; 23 (6): 807-811

    Abstract

    Complications after spine surgery have an impact on overall outcome and health care expenditures. The increased cost of complications is due in part to associated prolonged hospital stays. The authors propose that certain complications have a greater impact on length of stay (LOS) than others and that those complications should be the focus of future targeted prevention efforts. They conducted a retrospective analysis of a prospectively maintained database to identify complications with the greatest impact on LOS as well as the predictive value of these complications with respect to 90-day readmission rates.Data on 249 patients undergoing spine surgery at Thomas Jefferson University from May to December 2008 were collected by a study auditor. Any complications occurring within 30 days of surgery were recorded as was overall LOS for each patient. Stepwise regression analysis was performed to determine whether specific complications had a statistically significant effect on LOS. For correlation, all readmissions within 90 days were recorded and organized by complication for comparison with those complications affecting LOS.The mean LOS for patients without postoperative complications was 6.9 days. Patients who developed pulmonary complications had an associated increase in LOS of 11.1 days (p < 0.005). The development of a urinary tract infection (UTI) was associated with an increase in LOS of 3.4 days (p = 0.002). A new neurological deficit was associated with an increase in LOS of 8.2 days (p = 0.004). Complications requiring return to the operating room (OR) showed a trend toward an increase in LOS of 4.7 days (p = 0.09), as did deep wound infections (3.3 days, p = 0.08). The most common reason for readmission was for wound drainage (n = 21; surgical drainage was required in 10 [4.01%] of these 21 cases). The most common diagnoses for readmission, in decreasing order of incidence, were categorized as hardware malpositioning (n = 4), fever (n = 4), pulmonary (n = 2), UTI (n = 2), and neurological deficit (n = 1). Complications affecting LOS were not found to be predictive of readmission (p = 0.029).Postoperative complications in patients who have undergone spine surgery are not uncommon and are associated with prolonged hospital stays. In the current cohort, the occurrence of pulmonary complications, UTI, and new neurological deficit had the greatest effect on overall LOS. Further study is required to determine the causative factors affecting readmission. These specific complications may be high-yield targets for cost reduction and/or prevention efforts.

    View details for DOI 10.3171/2015.3.SPINE14318

    View details for Web of Science ID 000365371900018

    View details for PubMedID 26315951

  • Craniotomy for Resection of Meningioma: An Age-Stratified Analysis of the MarketScan Longitudinal Database WORLD NEUROSURGERY Connolly, I. D., Cole, T., Veeravagu, A., Popat, R., Ratliff, J., Li, G. 2015; 84 (6): 1864-1870

    Abstract

    We sought to describe complications after resection for meningioma with the use of longitudinal administrative data, which our group has shown recently to be superior to nonlongitudinal administrative data.We identified patients who underwent resection for meningioma between 2010 and 2012 in the Thomson Reuters MarketScan database. Current Procedural Terminology coding at inpatient visit was used to select for meningioma resection procedure. Comorbidities and complications were obtained by use of the International Classification of Diseases, Ninth Revision or Current Procedural Terminology coding. Associations between complications and demographic and clinical factors were evaluated with logistic regression.We identified a total of 2216 patients. Approximately 41% developed 1 or more perioperative complications. Approximately 15% were readmitted within 30 days of their procedure. The most frequent complications that occurred in our cohort were new postoperative seizures (11.8%), postoperative dysrhythmia (7.9%), intracranial hemorrhage (5.9%), and cerebral artery occlusion (5.4%). General neurosurgical complications and general neurologic complications occurred in 4.4% and 16.1% of patients, respectively. Nearly 55% of elderly patients (≥ 70 years) developed 1 or more perioperative complication (vs. 39% of nonelderly patients). After we adjusted for comorbidities, elderly status and male sex were found to be significantly associated with increased odds for a variety of complications.In this study, we report complication rates in patients undergoing resection for meningioma. Because of the longitudinal nature of the MarketScan database, we were able to capture a wide array of specific postoperative complications associated with meningioma resection procedures. Care should be taken in the selection of candidates for meningioma resection.

    View details for DOI 10.1016/j.wneu.2015.08.018

    View details for PubMedID 26318633

  • Clavicle pain and reduction of incisional and fascial pain after posterior cervical surgery. Journal of neurosurgery. Spine Duetzmann, S., Cole, T., Senft, C., Seifert, V., Ratliff, J. K., Park, J. 2015; 23 (6): 684-689

    Abstract

    Incisional pain after posterior cervical spine surgery can be severe and very unpleasant to the patient. Ongoing incisional pain is one of the key disadvantages of posterior over anterior surgical approaches to the cervical spine. It prolongs hospital stays and delays return to work. In this study, the hypothesized that incisional pain in the immediate postoperative period is caused partially by tension on the skin as well as on the deep cervical fascia and the fascia overlying the trapezius, which are usually sewn together during closure. Reduction of this tension through retraction of the shoulders should therefore reduce pain as well as the amount of pain medication used in the early postoperative period.In this prospective randomized controlled study, 30 patients who had undergone posterior cervical spine surgery were randomized into 2 groups who either wore or did not wear a clavicle brace to retract the shoulders. Patients in the brace group began wearing the brace on postoperative day (POD) 4 and wore it continuously throughout the 30-day study period. Outcome was assessed by two measures: 1) the daily level of self reported pain according to the visual analog scale (VAS) and 2) the number of pain pills taken during the 30-day postoperative period.Wearing a clavicle brace in the immediate postoperative period significantly reduced incisional pain and the amount of pain medication that patients took. Beginning on POD 4 and continuing until day POD 13, the mean daily VAS score for pain was significantly lower in the brace group than in the control group. Furthermore, patients who wore the clavicle brace took less pain medication from POD 4 to POD 12. At this point the difference lost significance until the end of the study period. Four patients were randomized but did not tolerate wearing the brace.Patients who tolerated wearing the clavicle brace after posterior cervical spine surgery had reduced pain and used less pain medication.

    View details for DOI 10.3171/2015.2.SPINE141118

    View details for PubMedID 26296190

  • Giant Prolactinoma Presenting with Neck Pain and Structural Compromise of the Occipital Condyles. Journal of neurological surgery reports Yecies, D., Ajlan, A., Ratliff, J., Ziskin, J., Hwang, P., Vogel, H., Katznelson, L., Harsh, G. 2015; 76 (2): e297-301

    Abstract

    Prolactinomas are the most common form of endocrinologically active pituitary adenoma; they account for ∼ 45% of pituitary adenomas encountered in clinical practice. Giant adenomas are those > 4 cm in diameter. Less than 0.5% of pituitary adenomas encountered in neurosurgical practice are giant prolactinomas. Patients with giant prolactinomas typically present with highly elevated prolactin levels, endocrinologic disturbances, and neurologic symptoms from mass-induced pressure. Described here is an unusual case of a giant prolactinoma presenting with neck pain and structural compromise of the occipital condyles. Transnasal biopsy of the nasopharyngeal portion of the mass obtained tissue consistent with an atypical prolactinoma with p53 reactivity and a high Ki-67 index of 5%. Despite the size and invasiveness of the tumor, the patient had resolution of his clinical symptoms, dramatic reduction of his hyperprolactinemia, and near-complete disappearance of his tumor following medical treatment.

    View details for DOI 10.1055/s-0035-1566124

    View details for PubMedID 26623246

  • Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database CUREUS Cole, T., Veeravagu, A., Zhang, M., Azad, T., Swinney, C., Li, G. H., Ratliff, J. K., Giannotta, S. L. 2015; 7 (10)

    View details for DOI 10.7759/cureus.369

    View details for Web of Science ID 000453606600030

  • Improved capture of adverse events after spinal surgery procedures with a longitudinal administrative database JOURNAL OF NEUROSURGERY-SPINE Veeravagu, A., Cole, T. S., Azad, T. D., Ratliff, J. K. 2015; 23 (3): 374-382

    Abstract

    The significant medical and economic tolls of spinal disorders, increasing volume of spine surgeries, and focus on quality metrics have made it imperative to understand postoperative complications. This study demonstrates the utility of a longitudinal administrative database for capturing overall and procedure-specific complication rates after various spine surgery procedures.The Thomson Reuters MarketScan Commercial Claims and Encounters and the Medicare Supplemental and Coordination of Benefits database was used to conduct a retrospective analysis of longitudinal administrative data from a sample of approximately 189,000 patients. Overall and procedure-specific complication rates at 5 time points ranging from immediately postoperatively (index) to 30 days postoperatively were computed.The results indicated that the frequency of individual complication types increased at different rates. The overall complication rate including all spine surgeries was 13.6% at the index time point and increased to 22.8% at 30 days postoperatively. The frequencies of wound dehiscence, infection, and other wound complications exhibited large increases between 10 and 20 days postoperatively, while complication rates for new chronic pain, delirium, and dysrhythmia increased more gradually over the 30-day period studied. When specific surgical procedures were considered, 30-day complication rates ranged from 8.6% in single-level anterior cervical fusions to 27.3% in multilevel combined anterior and posterior lumbar spine fusions.This study demonstrates the usefulness of a longitudinal administrative database in assessing postoperative complication rates after spine surgery. Use of this database gave results that were comparable to those in prospective studies and superior to those obtained with nonlongitudinal administrative databases. Longitudinal administrative data may improve the understanding of overall and procedure-specific complication rates after spine surgery.

    View details for DOI 10.3171/2014.12.SPINE14659

    View details for Web of Science ID 000360027300017

  • Cervical laminoplasty developments and trends, 2003-2013: a systematic review JOURNAL OF NEUROSURGERY-SPINE Duetzmann, S., Cole, T., Ratliff, J. K. 2015; 23 (1): 24-34

    Abstract

    OBJECT Despite extensive clinical experience with laminoplasty, the efficacy of the procedure and its advantages over laminectomy remain unclear. Specific clinical elements, such as incidence or progression of kyphosis, incidence of axial neck pain, postoperative cervical range of motion, and incidence of postoperative C-5 palsies, are of concern. The authors sought to comprehensively review the laminoplasty literature over the past 10 years while focusing on these clinical elements. METHODS The authors conducted a literature search of articles in the Medline database published between 2003 and 2013, in which the terms "laminoplasty," "laminectomy," and "posterior cervical spine procedures" were used as key words. Included was every single case series in which patient outcomes after a laminoplasty procedure were reported. Excluded were studies that did not report on at least one of the above-mentioned items. RESULTS A total of 103 studies, the results of which contained at least 1 of the prespecified outcome variables, were identified. These studies reported 130 patient groups comprising 8949 patients. There were 3 prospective randomized studies, 1 prospective nonrandomized alternating study, 15 prospective nonrandomized data collections, and 84 retrospective reviews. The review revealed a trend for the use of miniplates or hydroxyapatite spacers on the open side in Hirabayashi-type laminoplasty or on the open side in a Kurokawa-type laminoplasty. Japanese Orthopaedic Association (JOA) scoring was reported most commonly; in the 4949 patients for whom a JOA score was reported, there was improvement from a mean (± SD) score of 9.91 (± 1.65) to a score of 13.68 (± 1.05) after a mean follow-up of 44.18 months (± 35.1 months). The mean preoperative and postoperative C2-7 angles (available for 2470 patients) remained stable from 14.17° (± 0.19°) to 13.98° (± 0.19°) of lordosis (average follow-up 39 months). The authors found significantly decreased kyphosis when muscle/posterior element-sparing techniques were used (p = 0.02). The use of hardware in the form of hydroxyapatite spacers or miniplates did not influence the progression of deformity (p = 0.889). An overall mean (calculated from 2390 patients) of 47.3% loss of range of motion was reported. For the studies that used a visual analog scale score (totaling 986 patients), the mean (cohort size-adjusted) postoperative pain level at a mean follow-up of 29 months was 2.78. For the studies that used percentages of patients who complained of postoperative axial neck pain (totaling 1249 patients), the mean patient number-adjusted percentage was 30% at a mean follow-up of 51 months. The authors found that 16% of the studies that were published in the last 10 years reported a C-5 palsy rate of more than 10% (534 patients), 41% of the studies reported a rate of 5%-10% (n = 1006), 23% of the studies reported a rate of 1%-5% (n = 857), and 12.5% reported a rate of 0% (n = 168). CONCLUSIONS Laminoplasty remains a valid option for decompression of the spinal cord. An understanding of the importance of the muscle-ligament complex, plus the introduction of hardware, has led to progress in this type of surgery. Reporting of outcome metrics remains variable, which makes comparisons among the techniques difficult.

    View details for DOI 10.3171/2014.11.SPINE14427

    View details for Web of Science ID 000356980800004

    View details for PubMedID 25909270

  • Cranial neurosurgical 30-day readmissions by clinical indication JOURNAL OF NEUROSURGERY Moghavem, N., Morrison, D., Ratliff, J. K., Hernandez-Boussard, T. 2015; 123 (1): 189-197

    Abstract

    Postsurgical readmissions are common and vary by procedure. They are significant drivers of increased expenditures in the health care system. Reducing readmissions is a national priority that has summoned significant effort and resources. Before the impact of quality improvement efforts can be measured, baseline procedure-related 30-day all-cause readmission rates are needed. The objects of this study were to determine population-level, 30-day, all-cause readmission rates for cranial neurosurgery and identify factors associated with readmission.The authors identified patient discharge records for cranial neurosurgery and their 30-day all-cause readmissions using the Agency for Healthcare Research and Quality (AHRQ) State Inpatient Databases for California, Florida, and New York. Patients were categorized into 4 groups representing procedure indication based on ICD-9-CM diagnosis codes. Logistic regression models were developed to identify patient characteristics associated with readmissions. The main outcome measure was unplanned inpatient admission within 30 days of discharge.A total of 43,356 patients underwent cranial neurosurgery for neoplasm (44.23%), seizure (2.80%), vascular conditions (26.04%), and trauma (26.93%). Inpatient mortality was highest for vascular admissions (19.30%) and lowest for neoplasm admissions (1.87%; p < 0.001). Thirty-day readmissions were 17.27% for the neoplasm group, 13.89% for the seizure group, 23.89% for the vascular group, and 19.82% for the trauma group (p < 0.001). Significant predictors of 30-day readmission for neoplasm were Medicaid payer (OR 1.33, 95% CI 1.15-1.54) and fluid/electrolyte disorder (OR 1.44, 95% CI 1.29-1.62); for seizure, male sex (OR 1.74, 95% CI 1.17-2.60) and index admission through the emergency department (OR 2.22, 95% CI 1.45-3.43); for vascular, Medicare payer (OR 1.21, 95% CI 1.05-1.39) and renal failure (OR 1.52, 95% CI 1.29-1.80); and for trauma, congestive heart failure (OR 1.44, 95% CI 1.16-1.80) and coagulopathy (OR 1.51, 95% CI 1.25-1.84). Many readmissions had primary diagnoses identified by the AHRQ as potentially preventable.The frequency of 30-day readmission rates for patients undergoing cranial neurosurgery varied by diagnosis between 14% and 24%. Important patient characteristics and comorbidities that were associated with an increased readmission risk were identified. Some hospital-level characteristics appeared to be associated with a decreased readmission risk. These baseline readmission rates can be used to inform future efforts in quality improvement and readmission reduction.

    View details for DOI 10.3171/2014.12.JNS14447

    View details for Web of Science ID 000356981200025

    View details for PubMedID 25658784

  • Sacral Peak Pressure in Healthy Volunteers and Patients With Spinal Cord Injury With and Without Liquid-Based Pad NURSING RESEARCH Duetzmann, S., Forsey, L. M., Senft, C., Seifert, V., Ratliff, J., Park, J. 2015; 64 (4): 300-305

    Abstract

    The prevalence of sacral pressure ulcers in patients with spinal cord injuries is high. The sacral area is vulnerable to compressive pressure because of immobility and because the sacrum and posterior superior iliac prominence lie closely under the skin with no muscle layer in between.The aim of this study was to assess peak sacral pressure before and after use of PURAP, a liquid-based pad that covers only the sacral area and can be applied on any bed surface.Healthy volunteers (n = 12) and patients with spinal cord injuries (n = 10) took part; the patients had undergone spine surgery within 7 days before data collection. Participants were in bed, pretest pressure maps were generated, PURAP was placed for 15 minutes, and then posttest pressure maps were generated. Peak pressure was obtained every second and averaged over the entire period. Patients rated whether their comfort had improved when PURAP was in use.For healthy volunteers, mean pretest peak sacral pressure was 74.7 (SD = 16.2) mmHg; the posttest mean was 49.1 (SD = 7.5) mmHg (p < .001, Wilcoxon signed-rank test). For patients with spinal cord injuries, mean pretest peak sacral pressure was 105.7 (SD = 22.4) mmHg; the posttest mean was 81.4 (SD = 18.3) mmHg (p < .001, Wilcoxon signed-rank test). The pad reduced the peak sacral pressure in the patient group by 23% (range = 11%-42%) and in the volunteers by 32% (range = 19%-46%). Overall, 70% of the patients reported increased comfort with PURAP.Peak sacral pressure was reduced when PURAP was used. It covers only the sacral area but could help many patients with spinal cord injury because the prevalence of sacral pressure ulcers is high in this group. PURAP may be economically advantageous in countries and hospitals with limited financial resources needed for more expensive mattresses and cushions.

    View details for DOI 10.1097/NNR.0000000000000100

    View details for Web of Science ID 000357940700009

  • Anterior Versus Posterior Approach for Multilevel Degenerative Cervical Disease A Retrospective Propensity Score-Matched Study of the MarketScan Database SPINE Cole, T., Veeravagu, A., Zhang, M., Azad, T. D., Desai, A., Ratliff, J. K. 2015; 40 (13): 1033-1038

    Abstract

    Retrospective 2:1 propensity score-matched analysis on a national longitudinal database between 2006 and 2010.To compare rates of adverse events, revisions procedure rates, and payment differences in anterior cervical fusion procedures compared with posterior laminectomy and fusion procedures with at least 3 levels of instrumentation.The comparative benefits of anterior versus posterior approach to multilevel degenerative cervical disease remain controversial. Recent systematic reviews have reached conflicting conclusions. We demonstrate the comparative economic and clinical outcomes of anterior and posterior approaches for multilevel cervical degenerative disk disease.We identified 13,662 patients in a national billing claims database who underwent anterior or posterior cervical fusion procedures with 3 or more levels of instrumentation. Cohorts were balanced using 2:1 propensity score matching and outcomes were compared using bivariate analysis.With the exception of dysphagia (6.4% in anterior and 1.4% in posterior), overall 30-day complication rates were lower in the anterior approach group. The rate of any complication excluding dysphagia with anterior approaches was 12.3%, significantly lower (P < 0.0001) than that of posterior approaches, 17.8%. Anterior approaches resulted in lower hospital ($18,346 vs. $23,638) and total payments ($28,963 vs. $33,526). Patients receiving an anterior surgical approach demonstrated significantly lower rate of 30-day readmission (5.1% vs. 9.9%, P < 0.0001), were less likely to require revision surgery (12.8% vs. 18.1%, P < 0.0001), and had a shorter length of stay by 1.5 nights (P < 0.0001).Anterior approaches in the surgical management of multilevel degenerative cervical disease provide clinical advantages over posterior approaches, including lower overall complication rates, revision procedure rates, and decreased length of stay. Anterior approach procedures are also associated with decreased overall payments. These findings must be interpreted in light of limitations inherent to retrospective longitudinal studies including absence of subjective and radiographical outcomes.3.

    View details for DOI 10.1097/BRS.0000000000000872

    View details for Web of Science ID 000357946000009

  • International Classification of Disease Clinical Modification 9 Modeling of a Patient Comorbidity Score Predicts Incidence of Perioperative Complications in a Nationwide Inpatient Sample Assessment of Complications in Spine Surgery JOURNAL OF SPINAL DISORDERS & TECHNIQUES Chitale, R., Campbell, P. G., Yadla, S., Whitmore, R. G., Maltenfort, M. G., Ratliff, J. K. 2015; 28 (4): 126-133

    Abstract

    SUMMARY OF BACKGROUND DATA:: A patient comorbidity score (RCS) was developed from a prospective study of complications occurring in spine surgery patients. OBJECTIVE:: To validate the RCS, we present an ICD-CM-9 model of the score and correlate the score with complication incidence in a group of patients from the Nationwide Inpatient Sample (NIS) database. We compare the predictive value of the score to the Charlson index. STUDY DESIGN:: We conducted a retrospective assessment of NIS patients undergoing cervical or thoracolumbar spine surgery for degenerative pathology from 2002 to 2009. METHODS:: We generated an ICD-9-CM coding-based model of our prospectively derived RCS, categorizing diagnostic codes to represent relevant comorbidities. Multivariate models were performed to eliminate the least significant variables. ICD-9-CM coding was also used to calculate a Charlson comorbidity score for each patient. The accuracy of the RCS was compared with the Charlson index through use of a receiver operating curve (ROC). RESULTS:: A total of 352,535 patients undergoing 369,454 spine procedures for degenerative disease were gathered. Hypertension and hyperlipidemia were the most common comorbidities. Cervical procedures resulted in 8286 complications (4.50%) while thoracolumbar procedures produced 25,118 complications (13.55%). Increasing RCS correlated linearly with increasing complication incidence (OR 1.11, 95% CI 1.10-1.13, P<0.0001). Logistic regression revealed that neurological deficit, cardiac conditions, and drug or alcohol use had greatest association with complication occurrence. The Charlson index also correlated with complication occurrence in both cervical (OR 1.25, 95% CI 1.23-1.27) and thoracolumbar (1.11, 95% CI 1.10-1.12) patient groups. ROC analysis allowed a comparison of accuracy of the indices by comparing predictive values. The RCS performed as well as the Charlson index in predicting complication occurrence in both cervical and thoracic spine patients. CONCLUSIONS:: ICD-9 based modeling validated that RCS correlates with complication occurrence. The RCS performed as well as the Charlson index in predicting risk of complication in spine patients.

    View details for Web of Science ID 000353682900012

    View details for PubMedID 22960417

  • Letter. Spine Cole, T., Ratliff, J. 2015; 40 (9): 668-?

    View details for DOI 10.1097/BRS.0000000000000858

    View details for PubMedID 26030219

  • National trends in burn and inhalation injury in burn patients: results of analysis of the nationwide inpatient sample database. Journal of burn care & research Veeravagu, A., Yoon, B. C., Jiang, B., Carvalho, C. M., Rincon, F., Maltenfort, M., Jallo, J., Ratliff, J. K. 2015; 36 (2): 258-265

    Abstract

    The aim of this study was describe national trends in prevalence, demographics, hospital length of stay (LOS), hospital charges, and mortality for burn patients with and without inhalational injury and to compare to the National Burn Repository. Burns and inhalation injury cause considerable mortality and morbidity in the United States. There remains insufficient reporting of the demographics and outcomes surrounding such injuries. The National Inpatient Sample database, the nation's largest all-payer inpatient care data repository, was utilized to select 506,628 admissions for burns from 1988 to 2008 based on ICD-9-CM recording. The data were stratified based on the extent of injury (%TBSA) and presence or absence of inhalational injury. Inhalation injury was observed in only 2.2% of burns with <20% TBSA but 14% of burns with 80 to 99% TBSA. Burn patients with inhalation injury were more likely to expire in-hospital compared to those without (odds ratio, 3.6; 95% confidence interval, 2.7-5.0; P < .001). Other factors associated with higher mortality were African-American race, female sex, and urban practice setting. Patients treated at rural facilities and patients with hyperglycemia had lower mortality rates. Each increase in percent of TBSA of burns increased LOS by 2.5%. Patients with burns covering 50 to 59% of TBSA had the longest hospital stay at a median of 24 days (range, 17-55). The median in-hospital charge for a burn patient with inhalation injury was US$32,070, compared to US$17,600 for those without. Overall, patients who expired from burn injury accrued higher in-hospital charges (median, US$50,690 vs US$17,510). Geographically, California and New Jersey were the states with the highest charges, whereas Vermont and Maryland were states with the lowest charges. The study analysis provides a broad sampling of nationwide demographics, LOS, and in-hospital charges for patients with burns and inhalation injury.

    View details for DOI 10.1097/BCR.0000000000000064

    View details for PubMedID 24918946

  • Adding insult to injury: discontinuous insurance following spine trauma. journal of bone and joint surgery. American volume Kastenberg, Z. J., Hurley, M. P., Weiser, T. G., Cole, T. S., Staudenmayer, K. L., Spain, D. A., Ratliff, J. K. 2015; 97 (2): 141-146

    Abstract

    Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.

    View details for DOI 10.2106/JBJS.N.00148

    View details for PubMedID 25609441

  • Adding Insult to Injury: Discontinuous Insurance Following Spine Trauma JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Kastenberg, Z. J., Hurley, M. P., Weiser, T. G., Cole, T. S., Staudenmayer, K. L., Spain, D. A., Ratliff, J. K. 2015; 97A (2): 141-146

    Abstract

    Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.

    View details for DOI 10.2106/JBJS.N.00148

    View details for Web of Science ID 000348217200012

  • Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database. Cure¯us Cole, T., Veeravagu, A., Zhang, M., Azad, T., Swinney, C., Li, G. H., Ratliff, J. K., Giannotta, S. L. 2015; 7 (10)

    Abstract

    Object Retrosigmoid (RS) and translabyrinthine (TL) surgery remain essential treatment approaches for symptomatic or enlarging acoustic neuromas (ANs). We compared nationwide complication rates and payments, independent of tumor characteristics, for these two strategies. Methods We identified 346 and 130 patients who underwent RS and TL approaches, respectively, for AN resection in the 2010-2012 MarketScan database, which characterizes primarily privately-insured patients from multiple institutions nationwide. Results Although we found no difference in 30-day general neurological or neurosurgical complication rates, in TL procedures there was a decreased risk for postoperative cranial nerve (CN) VII injury (20.2% vs 10.0%, CI 0.23-0.82), dysphagia (10.4% vs 3.1%, CI 0.10-0.78), and dysrhythmia (8.4% vs 2.3%, CI 0.08-0.86). Overall, there was no difference in surgical repair rates of CSF leak; however, intraoperative fat grafting was significantly higher in TL approaches (19.8% vs 60.2%, CI 3.95-9.43). In patients receiving grafts, there was a trend towards a higher repair rate after RS approach, while in those without grafts, there was a trend towards a higher repair rate after TL approach. Median total payments were $16,856 higher after RS approaches ($67,774 vs $50,918, p < 0.0001), without differences in physician or 90-day postoperative payments. Conclusions  Using a nationwide longitudinal database, we observed that the TL, compared to RS, approach for AN resection experienced lower risks of CN VII injury, dysphagia, and dysrhythmia. There was no significant difference in CSF leak repair rates. The payments for RS procedures exceed payments for TL procedures by approximately $17,000. Data from additional years and non-private sources will further clarify these trends.

    View details for DOI 10.7759/cureus.369

    View details for PubMedID 26623224

    View details for PubMedCentralID PMC4659577

  • The use of bone morphogenetic protein in thoracolumbar spine procedures: analysis of the MarketScan longitudinal database SPINE JOURNAL Veeravagu, A., Cole, T. S., Jiang, B., Ratliff, J. K., Gidwani, R. A. 2014; 14 (12): 2929-2937

    Abstract

    The use of recombinant human bone morphogenetic protein (BMP) in the thoracolumbar spine remains controversial, with many questioning the risks and benefits of this new biologic.To describe national trends, incidence of complications, and revision rates associated with BMP use in thoracolumbar spine procedures.Administrative database study.A matched cohort of 52,259 patients undergoing thoracolumbar fusion surgery from 2006 to 2010 were identified in the MarketScan database. Patients without BMP treatment were matched 2:1 to patients receiving intraoperative BMP.Revision rates and postoperative complications.The MarketScan database was used to select patients undergoing thoracolumbar fusion procedures, with and without intraoperative BMP. We ascertained outcome measures using either International Classification of Disease, ninth revision, or Current Procedural Terminology coding, and matched groups were evaluated using a bivariate and multivariate analyses. Kaplan-Meier estimates of fusions failure rates were also calculated.Patients receiving intraoperative BMP underwent fewer refusions, decompressions, posterior and anterior revisions, or any revision procedure (single level 4.53% vs. 5.85%, p<.0001; multilevel 5.02% vs. 6.83%, p<.0001; overall cohort 4.73% vs. 6.09%, p<.0001). After adjusting for comorbidities, demographics, and levels of procedure, BMP was not associated with the postoperative development of cancer (odds ratio 0.92). Bone morphogenetic protein use was associated with an increase in any complication at 30 days (15.8% vs. 14.9%, p=.0065), which is only statistically significant among multilevel procedures (19.74% vs. 18.02%, p=.0013). Thirty-day complications in multilevel procedures associated with BMP use included new dysrhythmia (4.68% vs. 4.01%, p=.0161) and delirium (1.08% vs. 0.69%, p=.0024). A new diagnosis of chronic pain was associated with BMP use in both single-level (2.74% vs. 2.15%, p=.0019) and multilevel (3.7% vs. 2.52%, p<.0001) procedures. Bone morphogenetic protein was negatively associated with infection in single-level procedures (2.12% vs. 2.64%, p=.0067) and wound dehiscence in multilevel procedures (0.84% vs. 1.18%, p=.0167).In national data analysis of thoracolumbar procedures, we found that BMP was associated with decreased incidence of revision spinal surgery and with a slight increased risk of overall complications at 30 days. Although no BMP-associated increased risk of malignancy was found, lack of long-term follow-up precludes detection of between-group differences in malignancies and other rare events that may not appear until later.

    View details for DOI 10.1016/j.spinee.2014.05.010

    View details for Web of Science ID 000345429500023

  • The Prevalence and Impact of Mortality of the Acute Respiratory Distress Syndrome on Admissions of Patients With Ischemic Stroke in the United States JOURNAL OF INTENSIVE CARE MEDICINE Rincon, F., Maltenfort, M., Dey, S., Ghosh, S., Vibbert, M., Urtecho, J., Jallo, J., Ratliff, J. K., McBride, J. W., Bell, R. 2014; 29 (6): 357-364

    Abstract

    PURPOSE: To determine the epidemiology of the acute respiratory distress syndrome (ARDS) and impact on in-hospital mortality in admissions of patients with acute ischemic stroke (AIS) in the United States. METHODS: Retrospective cohort study of admissions with a diagnosis of AIS and ARDS from 1994 to 2008 identified through the Nationwide Inpatient Sample. RESULTS: During the 15-year study period, we found 55 58 091 admissions of patients with AIS. The prevalence of ARDS in admissions of patients with AIS increased from 3% in 1994 to 4% in 2008 (P < .001). The ARDS was more common among younger men, nonwhites, and associated with history of congestive heart failure, hypertension, chronic obstructive pulmonary disease, renal failure, chronic liver disease, systemic tissue plasminogen activator, craniotomy, angioplasty or stent, sepsis, and multiorgan failures. Mortality due to AIS and ARDS decreased from 8% in 1994 to 6% in 2008 (P < .001) and 55% in 1994 to 45% in 2008 (P < .001), respectively. The ARDS in AIS increased in-hospital mortality (odds ratio, 14; 95% confidence interval, 13.5-14.3). A significantly higher length of stay was seen in admissions of patients with AIS having ARDS. CONCLUSION: Our analysis demonstrates that ARDS is rare after AIS. Despite an overall significant reduction in mortality after AIS, ARDS carries a higher risk of death in this patient population.

    View details for DOI 10.1177/0885066613491919

    View details for Web of Science ID 000344375600006

  • Usage of Recombinant Human Bone Morphogenetic Protein in Cervical Spine Procedures JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Cole, T., Veeravagu, A., Jiang, B., Ratliff, J. K. 2014; 96A (17): 1409-1416

    Abstract

    Usage of recombinant human bone morphogenetic protein (rhBMP) in anterior cervical discectomy and fusion (ACDF) procedures is controversial. Studies suggest increased rates of dysphagia, hematoma or seroma, and severe airway compromise in anterior cervical spine procedures using rhBMP. The purpose of the present study was to determine and describe national utilization trends and complication rates associated with rhBMP usage in anterior cervical spine procedures.The MarketScan database from 2006 to 2010 was retrospectively queried to identify 91,543 patients who underwent ACDF with or without cervical corpectomy. Patient selection and outcomes were ascertained with use of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) and CPT (Current Procedural Terminology) coding. A total of 3197 patients were treated with rhBMP intraoperatively. Mean follow-up was 588 days (interquartile range [IQR], 205 to 886 days) in the non-treated cohort and 591 days (IQR, 203 to 925 days) in the rhBMP-treated cohort. Multivariate logistic regression as well as propensity score analysis were used to evaluate the association of rhBMP usage with postoperative complications.In propensity score-adjusted models, rhBMP usage was associated with an increased risk of any complication (odds ratio [OR] = 1.34, 95% confidence interval [CI] = 1.2 to 1.5) and specific complications such as hematoma or seroma (OR = 1.8, 95% CI = 1.4 to 2.3), dysphagia (OR = 1.3, 95% CI = 1.1 to 1.5), and any pulmonary complication (OR = 1.5, 95% CI = 1.2 to 1.8) within thirty days postoperatively. There were no significant differences in the rates of readmission, in-hospital mortality, referral to pain management, new malignancy, or reoperation between the two cohorts. Usage of rhBMP was associated with a mean increase of $5545 (19%) in total payments to the hospital and primary physician (p < 0.001).We found an increased overall rate of postoperative complications in patients receiving rhBMP for cervical spinal fusion procedures compared with patients not receiving rhBMP. Hematoma or seroma, pulmonary complications, and dysphagia were also more common in the rhBMP cohort. Usage of rhBMP in a case was associated with $311 greater payments to the surgeon and $4213 greater payments to the hospital.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.M.01016

    View details for Web of Science ID 000343799600010

  • Longitudinal incidence and concurrence rates for traumatic brain injury and spine injury - A twenty year analysis. Clinical neurology and neurosurgery Ghobrial, G. M., Amenta, P. S., Maltenfort, M., Williams, K. A., Harrop, J. S., Sharan, A., Jallo, J., Heller, J., Ratliff, J., Prasad, S. 2014; 123: 174-180

    Abstract

    The reported incidence of concurrent traumatic brain (TBI) and spine or spinal cord injuries (SCI) is poorly defined, with widely variable literature rates from 16 to 74%.To define the incidence of concurrent TBI and SCI, and compare the incidence over a twenty-year time period.To define the longitudinal incidence and concurrent rate of TBI and SCI via a retrospective review of the Nationwide Inpatient Sample (NIS) database over a twenty year period.Over the study period, the incidence of TBI declined from 143 patients/100k admissions to 95 patients/100k. However, there was a concurrent increase in SCI from 61 patients/100k admissions to 75 patients/100k admissions (P<0.0001). Regional variations in SCI trends were noted, with specific regions demonstrating an increasing trend. Cervical fractures had the greatest increase by nearly a three-fold rise (1988: 4562-2008: 12,418). There was an increase in the incidence of TBI among SCI admission from 3.7% (1988) to 12.5% (2008) (OR=1.067 per year; 95% CI=1.065-1.069 per year; P<0.0001). Concurrently, SCI patients had an increase in TBI (9.1% (1988)-15.9% (2008) (OR=1.038 per year (95% CI 1.036-1.040; P<0.001))).A retrospective review of the NIS demonstrates a rising trend in the incidence of concurrent TBI and SCI. More investigative work is necessary to examine causative factors for this trend.

    View details for DOI 10.1016/j.clineuro.2014.05.013

    View details for PubMedID 24973569

  • Gender differences in compensation in academic medicine: the results from four neurological specialties within the University of California Healthcare System SCIENTOMETRICS Henderson, M. T., Fijalkowski, N., Wang, S. K., Maltenfort, M., Zheng, L. L., Ratliff, J., Moshfeghi, A. A., Moshfeghi, D. M. 2014; 100 (1): 297-306
  • Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study SPINE JOURNAL Veeravagu, A., Cole, T., Jiang, B., Ratliff, J. K. 2014; 14 (7): 1125-1131

    Abstract

    The natural history of cervical degenerative disease with operative management has not been well described. Even with symptomatic and radiographic evidence of multilevel cervical disease, it is unclear whether single- or multilevel anterior cervical discectomy and fusion (ACDF) procedures produce superior long-term outcomes.To describe national trends in revision rates, complications, and readmission for patients undergoing single and multilevel ACDF.Administrative database study.Between 2006 and 2010, 92,867 patients were recorded for ACDF procedures in the Thomson Reuters MarketScan database. Restricting to patients with >24 months follow-up, 28,777 patients fulfilled our inclusion criteria, of which 12,744 (44%) underwent single-level and 16,033 (56%) underwent multilevel ACDFs.Revision rates and postoperative complications.We used the MarketScan database from 2006 to 2010 to select ACDF procedures based on Current Procedural Terminology coding at inpatient visit. Outcome measures were ascertained using either International Classification of Disease version 9 or Current Procedural Terminology coding.Perioperative complications were more common in multilevel procedures (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.6; p<.0001). Single-level ACDF patients had higher rates of postoperative cervical epidural steroid injections (OR, 0.88; 95% CI, 0.8-1.0; p=.01). Within 30 days after index procedure, the multilevel ACDF cohort was 1.6 times more likely to have undergone revision (OR, 1.6; 95% CI, 1.1-2.4; p=.02). At 2 years follow-up, revision rates were 9.13% in the single-level ACDF cohort and 10.7% for multilevel ACDFs (OR, 1.2; 95% CI, 1.1-1.3; p<.0001). In a multivariate analysis at 2 years follow-up, patients from the multilevel cohort were more likely to have received a surgical revision (OR, 1.1; 95% CI, 1.0-1.2; p=.001), to be readmitted into the hospital for any cause (OR, 1.2; 95% CI, 1.1-1.4; p=.007), and to have suffered complications (OR, 1.3; 95% CI, 1.1-1.5; p=.0003).In this study, we report rates of adverse events and the need for revision surgery in patients undergoing single versus multilevel ACDFs. Increasing number of levels fused at the time of index surgery correlated with increased rate of reoperations. Multilevel ACDF patients requiring additional surgery more often underwent more extensive revision surgeries.

    View details for DOI 10.1016/j.spinee.2013.07.474

    View details for Web of Science ID 000338467000008

  • Acute Lung Injury in Patients with Subarachnoid Hemorrhage: A Nationwide Inpatient Sample Study WORLD NEUROSURGERY Veeravagu, A., Chen, Y., Ludwig, C., Rincon, F., Maltenfort, M., Jallo, J., Choudhri, O., Steinberg, G. K., Ratliff, J. K. 2014; 82 (1-2): E235-E241

    Abstract

    Subarachnoid hemorrhage (SAH) causes significant morbidity and mortality. Pulmonary complications may be particularly frequent, but national data is lacking on the outcomes associated with acute respiratory distress syndrome (ARDS) in SAH patients. The aim of this study is to determine national trends for SAH patients with ARDS.The Nationwide Inpatient Sample Database (NIS) was utilized to sample 193,209 admissions for SAH with and without ARDS from 1993 to 2008 using ICD-9-CM coding. A multivariate stepwise regression analysis was performed.The incidence of ARDS in SAH has increased from 35.51% in 1993 to 37.60% in 2008. However, the overall mortality in SAH patients and in SAH patients with ARDS has decreased in the same period, from 42.30% to 31.99% and from 75.13% to 60.76% respectively. Multivariate analysis showed that the predictors of developing ARDS in SAH patients include older age, larger hospital size, and comorbidities such as epilepsy, cardiac arrest, sepsis, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and hematologic, renal, or neurological dysfunction. Predictors of mortality in SAH patients include age and hospital complications such as coronary artery disease, ARDS, cancer, and hematologic, or renal dysfunction.SAH patients are at increased risk of developing ARDS and the identification of certain risk factors may alert and aid the practitioner in preventing worsening disease.

    View details for DOI 10.1016/j.wneu.2014.02.030

    View details for Web of Science ID 000342911400067

  • Minding the stroke business. World neurosurgery Gonzalez, L. F., Jabbour, P., Ratliff, J., Tjoumakaris, S., Dumont, A., Rosenwasser, R. H. 2013; 80 (3-4): 228-229

    View details for DOI 10.1016/j.wneu.2012.05.028

    View details for PubMedID 22633840

  • Acute respiratory distress syndrome and acute lung injury in patients with vertebral column fracture(s) and spinal cord injury: a nationwide inpatient sample study SPINAL CORD Veeravagu, A., Jiang, B., Rincon, F., Maltenfort, M., Jallo, J., Ratliff, J. K. 2013; 51 (6): 461-465

    Abstract

    Study design:Retrospective Nationwide Inpatient Sample (NIS) study.Objectives:To determine national trends in prevalence, risk factors and mortality for vertebral column fracture (VCF) and spinal cord injury (SCI) patients with and without acute respiratory distress syndrome/acute lung injury (ARDS/ALI).Setting:United States of America, 1988 to 2008.Methods:The NIS was utilized to select 284 612 admissions for VCF with and without acute SCI from 1988 to 2008 based on ICD-9-CM. The data were stratified for in-hospital complications of ARDS/ALI.Results:Patients with SCI were more likely to develop ARDS/ALI compared with those without (odds ratio (OR): 4.9, 95% confidence interval (CI) 4.7-5.2, P<0.001). Compared with patients with lumbar fractures, those with cervical, thoracic and sacral fractures were more likely to develop ARDS/ALI (P<0.001). ARDS/ALI was statistically more prevalent (P<0.01) in VCF/SCI patients with epilepsy, sepsis, cardiac arrest, congestive heart failure (CHF), hypertension, chronic obstructive pulmonary disease and metabolic disorders. Patients with female gender, surgery at rural practice setting, and coronary artery disease and diabetes were less likely to develop ARDS/ALI (P<0.001). VCF/SCI patients who developed ARDS/ALI were more likely to die in-hospital than those without ARDS/ALI (OR 6.5, 95% CI 6.0-7.1, P<0.001). Predictors of in-hospital mortality after VCF/SCI include: older age, male sex, epilepsy, sepsis, hypertension, CHF, chronic obstructive pulmonary disease and liver disease. Patients who developed ARDS/ALI stayed a mean of 25 hospital days (30-440 days) while patients without ARDS/ALI stayed a mean of 6 days (7-868 days, P<0.001).Conclusion:Our analysis demonstrates that SCI patients are more at risk for ARDS/ALI, which carries a significantly higher risk of mortality.Spinal Cord advance online publication, 12 March 2013; doi:10.1038/sc.2013.16.

    View details for DOI 10.1038/sc.2013.16

    View details for Web of Science ID 000320224100007

    View details for PubMedID 23478670

  • Considering the diagnosis of occipitocervical dissociation. spine journal Kalani, M. A., Ratliff, J. K. 2013; 13 (5): 520-522

    Abstract

    COMMENTARY ON: Gire JD, Roberto RF, Bobinski M, et al. The utility and accuracy of computed tomography in the diagnosis of occipitocervical dissociation. Spine J 2013;13:510-9 (in this issue).

    View details for DOI 10.1016/j.spinee.2013.02.030

    View details for PubMedID 23664556

  • A biologic without guidelines: the YODA project and the future of bone morphogenetic protein-2 research SPINE JOURNAL Carragee, E. J., Baker, R. M., Benzel, E. C., Bigos, S. J., Cheng, I., Corbin, T. P., Deyo, R. A., Hurwitz, E. L., Jarvik, J. G., Kang, J. D., Lurie, J. D., Mroz, T. E., Oener, F. C., Peul, W. C., Rainville, J., Ratliff, J. K., Rihn, J. A., Rothman, D. J., Schoene, M. L., Spengler, D. M., Weiner, B. K. 2012; 12 (10): 877-880

    View details for DOI 10.1016/j.spinee.2012.11.002

    View details for Web of Science ID 000311684600004

    View details for PubMedID 23199819

  • Impact of Acute Lung Injury and Acute Respiratory Distress Syndrome After Traumatic Brain Injury in the United States NEUROSURGERY Rincon, F., Ghosh, S., Dey, S., Maltenfort, M., Vibbert, M., Urtecho, J., McBride, W., Moussouttas, M., Bell, R., Ratliff, J. K., Jallo, J. 2012; 71 (4): 795-803

    Abstract

    Traumatic brain injury (TBI) is a major cause of disability, morbidity, and mortality. The effect of the acute respiratory distress syndrome and acute lung injury (ARDS/ALI) on in-hospital mortality after TBI remains controversial.To determine the epidemiology of ARDS/ALI, the prevalence of risk factors, and impact on in-hospital mortality after TBI in the United States.Retrospective cohort study of admissions of adult patients>18 years with a diagnosis of TBI and ARDS/ALI from 1988 to 2008 identified through the Nationwide Inpatient Sample.During the 20-year study period, the prevalence of ARDS/ALI increased from 2% (95% confidence interval [CI], 2.1%-2.4%) in 1988 to 22% (95% CI, 21%-22%) in 2008 (P<.001). ARDS/ALI was more common in younger age; males; white race; later year of admission; in conjunction with comorbidities such as congestive heart failure, hypertension, chronic obstructive pulmonary disease, chronic renal and liver failure, sepsis, multiorgan dysfunction; and nonrural, medium/large hospitals, located in the Midwest, South, and West continental US location. Mortality after TBI decreased from 13% (95% CI, 12%-14%) in 1988 to 9% (95% CI, 9%-10%) in 2008 (P<.001). ARDS/ALI-related mortality after TBI decreased from 33% (95% CI, 33%-34%) in 1988 to 28% (95% CI, 28%-29%) in 2008 (P<.001). Predictors of in-hospital mortality after TBI were older age, male sex, white race, cancer, chronic kidney disease, hypertension, chronic liver disease, congestive heart failure, ARDS/ALI, and organ dysfunctions.Our analysis demonstrates that ARDS/ALI is common after TBI. Despite an overall reduction of in-hospital mortality, ARDS/ALI carries a higher risk of in-hospital death after TBI.

    View details for DOI 10.1227/NEU.0b013e3182672ae5

    View details for Web of Science ID 000309117200027

    View details for PubMedID 22855028

  • The incidence of pulmonary embolism (PE) after spinal fusions CLINICAL NEUROLOGY AND NEUROSURGERY Senders, Z. J., Zussman, B. M., Maltenfort, M. G., Sharan, A. D., Ratliff, J. K., Harrop, J. S. 2012; 114 (7): 897-901

    Abstract

    Pulmonary embolism (PE) is a rare but serious event that may occur after spinal surgery.To correlate PE incidence after spinal arthrodesis with surgical approach, region of spine operated, and primary spinal pathology. To identify PE incidence trends in this population.The Nationwide Inpatient Sample was queried using ICD-9 codes (81.01-81.08) for spinal fusion procedures over a 21-year period (1988-2008). Other data points included PE occurrence, surgical approach, spinal region, surgical indication, and mortality. Multivariate and relational analyses were performed.4,505,556 patients were identified and 9530 had PE (incidence=0.2%). PE patients had higher odds of combined A/P surgical approaches than posterior approaches (OR=1.97; 95% CI=1.66-2.33), and PE incidence was higher in thoracic versus cervical or lumbar fusions (OR=2.54; 95% CI=2.14-3.02). PE was more likely with vertebral fracture (OR=1.85; 95% CI=1.53-2.23) and SCI with vertebral fracture (OR=4.59; 95% CI=3.72-5.70) than without trauma. Between 1988 and 2008, the PE incidence remained stable for patients with intervertebral disk degeneration and scoliosis, but increased for patients with vertebral fracture, and SCI with vertebral fracture. There was greater inpatient mortality with occurrence of a PE (OR=12.92; 95% CI=10.55-14.41).Although the incidence of PE in spinal arthrodesis patients is only 0.2%, there is a higher incidence after combined A/P approaches, thoracic procedures, and trauma surgical procedures. Despite the overall PE incidence remaining stable since 1988, incidence steadily increased among trauma patients. Further research is needed to explain these trends, given the context of changing patient populations and improving surgical techniques and prophylaxis measures. Greater caution and prophylaxis among trauma patients may be warranted.

    View details for DOI 10.1016/j.clineuro.2012.01.044

    View details for Web of Science ID 000307855800013

    View details for PubMedID 22386262

  • Anatomical relationships of the anterior blood vessels to the lower lumbar intervertebral discs: analysis based on magnetic resonance imaging of patients in the prone position. journal of bone and joint surgery. American volume Vaccaro, A. R., Kepler, C. K., Rihn, J. A., Suzuki, H., Ratliff, J. K., Harrop, J. S., Morrison, W. B., Limthongkul, W., Albert, T. J. 2012; 94 (12): 1088-1094

    Abstract

    Intra-abdominal vascular injuries are rare during posterior lumbar spinal surgery, but they can result in major morbidity or mortality when they do occur. We are aware of no prior studies that have used prone patient positioning during magnetic resonance imaging for the purpose of characterizing the retroperitoneal iliac vasculature with respect to the intervertebral disc. The purpose of this study was to define the vascular anatomy adjacent to the lower lumbar spine with use of supine and prone magnetic resonance imaging.A prospective observational study included thirty patients without spinal abnormality who underwent supine and prone magnetic resonance imaging without abdominal compression. The spinal levels of the aortic bifurcation and confluence of the common iliac veins were identified. The proximity of the anterior iliac vessels to the anterior and posterior aspects of the anulus fibrosus in sagittal and coronal planes was measured by two observers, and interobserver reliability was calculated.The aortic bifurcation and confluence of the common iliac veins were most commonly at the level of the L4 vertebral body and migrated cranially with prone positioning. The common iliac vessels were closer to the anterior aspect of the intervertebral disc and to the midline at L4-L5 as compared with L5-S1, consistent with the bifurcation at the L4 vertebral body. Prone positioning resulted in greater distances between the disc and iliac vessels at L4-L5 and L5-S1 by an average of 3 mm. The position of the anterior aspect of the anulus with respect to each iliac vessel demonstrated substantial variation between subjects. The intraclass correlation coefficient for measurement of vessel position exceeded 0.9, demonstrating excellent interobserver reliability.This study confirmed the L4 level of the aortic bifurcation and iliac vein coalescence but also demonstrated substantial mobility of the great vessels with positioning. Supine magnetic resonance imaging will underestimate the proximity of the vessels to the intervertebral disc. Large interindividual variation in the location of vasculature was noted, emphasizing the importance of careful study of the location of the retroperitoneal vessels on a case-by-case basis.

    View details for DOI 10.2106/JBJS.K.00671

    View details for PubMedID 22717827

  • Anatomical Relationships of the Anterior Blood Vessels to the Lower Lumbar Intervertebral Discs Analysis Based on Magnetic Resonance Imaging of Patients in the Prone Position JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Vaccaro, A. R., Kepler, C. K., Rihn, J. A., Suzuki, H., Ratliff, J. K., Harrop, J. S., Morrison, W. B., Limthongkul, W., Albert, T. J. 2012; 94A (12): 1088-1094
  • Patient Comorbidities and Complications After Spinal Surgery A Societal-Based Cost Analysis SPINE Whitmore, R. G., Stephen, J., Stein, S. C., Campbell, P. G., Yadla, S., Harrop, J. S., Sharan, A. D., Maltenfort, M. G., Ratliff, J. K. 2012; 37 (12): 1065-1071

    Abstract

    Prospective observational study.To determine how patient comorbidities and perioperative complications after spinal surgery affect the health care costs to society.Despite efforts to reduce adverse events related to spinal surgery, complications are common and significantly increased by patient comorbidities.Patients who underwent spinal surgery at a tertiary academic center during a 6-month period (May 2008 to December 2008) were prospectively followed. All demographic data, comorbidities, procedural information, and complications to 30-day follow-up were recorded. Diagnosis-Related Group codes and Current Procedural Terminology codes were captured for each patient. Direct costs were estimated from a societal perspective, using 2008 Medicare rates of reimbursement. A multivariable analysis was performed to assess the impact of specific patient comorbidities and complications on total health care costs.A total of 226 cases were analyzed. The mean cost of care for cases with complications was greater than that for cases without complications ($13,518.35 [95% confidence interval (CI), $9378.80-$17,657.90]; P < 0.0001). These results were consistent across degenerative, traumatic, and tumor/infection preoperative diagnoses. Cases with major complications were more costly than those with minor complications ($13,714.88 [CI, $6353.02-$21,076.74]; P = 0.0001). Systemic malignancy and preoperative neurological comorbidity were each associated with an increase in the cost of care ($7919 [CI, $2073-$15,225]; P = 0.006] and $5508 [CI, $814-$11,198; P = 0.02]), respectively, when compared with a baseline cost of care derived from all cases in the database. The cost of care was increased by pulmonary complications ($7233 [CI, $3982.53-$11,152.88]; P < 0.0001), instrumentation malposition ($6968 [CI, $1705.90-$14,277.16]; P = 0.0062), new neurological deficit ($4537 [CI, $863.95-$9274.30]; P = 0.013), and by wound infection ($4067 [CI, $1682.79-$6872.39]; P = 0.0004), after adjustment for covariates.Both minor and major complications were found to increase the cost of care in a prospective assessment of spine surgery complications. Specific patient comorbidities and perioperative complications are associated with significant increases in the total cost of care to society.

    View details for DOI 10.1097/BRS.0b013e31823da22d

    View details for Web of Science ID 000304364800019

    View details for PubMedID 22045005

  • The influence of medical school and residency training program upon choice of an academic career and academic productivity among otolaryngology faculty in the United States of America: Our experience of 1433 academic otolaryngologists CLINICAL OTOLARYNGOLOGY Leng, T., Jaben, K. A., Zheng, L., Yang, J., Paulus, Y. M., Moshfeghi, A. A., Maltenfort, M. G., Campbell, P. G., Ratliff, J. K., Moshfeghi, D. M. 2012; 37 (1): 58-62
  • Complications related to instrumentation in spine surgery: a prospective analysis NEUROSURGICAL FOCUS Campbell, P. G., Yadla, S., Malone, J., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Ratliff, J. K. 2011; 31 (4)

    Abstract

    Prospective examination of perioperative complications in spine surgery is limited in the literature. The authors prospectively collected data on patients who underwent spinal fusion at a tertiary care center and evaluated the effect of spinal fusion and comorbidities on perioperative complications.Between May and December 2008 data were collected prospectively in 248 patients admitted to the authors' institution for spine surgery. The 202 patients undergoing spine surgery with instrumentation were further analyzed in this report. Perioperative complications occurring within the initial 30 days after surgery were included. All adverse occurrences, whether directly related to surgery, were included in the analysis.Overall, 114 (56.4%) of 202 patients experienced at least one perioperative complication. Instrumented fusions were associated with more minor complications (p = 0.001) and more overall complications (0.0024). Furthermore, in the thoracic and lumbar spine, complications increased based on the number of levels fused. Advanced patient age and certain comorbidities such as diabetes, cardiac disease, or a history of malignancy were also associated with an increased incidence of complications.Using a prospective methodology with a broad definition of complications, the authors report a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery.

    View details for DOI 10.3171/2011.7.FOCUS1134

    View details for Web of Science ID 000295406500011

    View details for PubMedID 21961854

  • Medical School and Residency Influence on Choice of an Academic Career and Academic Productivity Among US Neurology Faculty ARCHIVES OF NEUROLOGY Campbell, P. G., Lee, Y. H., Bell, R. D., Maltenfort, M. G., Moshfeghi, D. M., Leng, T., Moshfeghi, A. A., Ratliff, J. K. 2011; 68 (8): 999-1004

    Abstract

    To evaluate the effectiveness of medical schools and neurology training programs in the United States by determining their contribution to academic neurology in terms of how many graduates choose academic careers and their respective influence on current medical knowledge through bibliometric analysis.Biographical information from current faculty members of neurology training programs in the United States was obtained through an Internet-based search of departmental Web sites. Collected variables included medical school attended, residency program completed, and current academic rank. For each faculty member, ISI Web of Science and Scopus h -indices were also collected.Data from academic neurologists from 120 training programs with 3249 faculty members were collected. All data regarding training program and medical school education were compiled and analyzed by the institution from which each individual graduated. The 20 medical schools and neurology residency training programs producing the greatest number of graduates remaining in academic practice and the mean h -indices are reported. More medical school graduates of the Columbia University College of Physicians and Surgeons chose to enter academic neurology practice than the graduates of any other institution. Analyzed by residency training program attended, New York Presbyterian Hospital (Columbia University), Mayo Clinic (Rochester, Minnesota), and Mount Sinai Medical Center (New York, New York) produced the most graduates remaining in academics.This retrospective, longitudinal cohort study examines through quantitative measures the academic productivity and rank of academic neurologists. The results demonstrate that several training programs excel in producing a significantly higher proportion of academically active neurologists.

    View details for DOI 10.1001/archneurol.2011.67

    View details for Web of Science ID 000293647500005

    View details for PubMedID 21482917

  • Medical school and residency influence on choice of an academic career and academic productivity among neurosurgery faculty in the United States Clinical article JOURNAL OF NEUROSURGERY Campbell, P. G., Awe, O. O., Maltenfort, M. G., Moshfeghi, D. M., Leng, T., Moshfeghi, A. A., Ratliff, J. K. 2011; 115 (2): 380-386

    Abstract

    Factors determining choice of an academic career in neurological surgery are unclear. This study seeks to evaluate the graduates of medical schools and US residency programs to determine those programs that produce a high number of graduates remaining within academic programs and the contribution of these graduates to academic neurosurgery as determined by h-index valuation.Biographical information from current faculty members of all accredited neurosurgery training programs in the US with departmental websites was obtained. Any individual who did not have an American Board of Neurological Surgery certificate (or was not board eligible) was excluded. The variables collected included medical school attended, residency program completed, and current academic rank. For each faculty member, Web of Science and Scopus h-indices were also collected.Ninety-seven academic neurosurgery departments with 986 faculty members were analyzed. All data regarding training program and medical school education were compiled and analyzed by center from which each faculty member graduated. The 20 medical schools and neurosurgical residency training programs producing the greatest number of graduates remaining in academic practice, and the respective individuals' h-indices, are reported. Medical school graduates of the Columbia University College of Physicians and Surgeons chose to enter academics the most frequently. The neurosurgery training program at the University of Pittsburgh produced the highest number of academic neurosurgeons in this sample.The use of quantitative measures to evaluate the academic productivity of medical school and residency graduates may provide objective measurements by which the subjective influence of training experiences on choice of an academic career may be inferred. The top 3 residency training programs were responsible for 10% of all academic neurosurgeons. The influence of medical school and residency experiences on choice of an academic career may be significant.

    View details for DOI 10.3171/2011.3.JNS101176

    View details for Web of Science ID 000293145100037

    View details for PubMedID 21495810

  • Preoperative Diagnosis and Early Complications in Thoracolumbar Spine Surgery A Single Center Prospective Study JOURNAL OF SPINAL DISORDERS & TECHNIQUES Yadla, S., Malone, J., Campbell, P. G., Maltenfort, M. G., Sharan, A. D., Harrop, J. S., Ratliff, J. K. 2011; 24 (2): E16-E20

    Abstract

    Prospective observational cohort study.To determine the incidence of early complications with thoracolumbar spine surgery and its correlation with preoperative diagnosis.The reported incidence of early complications associated with thoracolumbar surgery is highly variable. Varying definitions of what constitutes a "complication" and varying study methodologies make evaluation and comparison of the literature difficult. No large study has investigated the effect of preoperative diagnosis and patient comorbidities on early postoperative complications in thoracolumbar surgery.One-hundred twenty-eight consecutive patients who underwent thoracolumbar surgery by the neurosurgical service at the Thomas Jefferson University Hospital were prospectively entered into a central database from May to December 2008. An earlier-described, binary definition of major and minor complication was used. Data on preoperative diagnosis, comorbidities, body mass index, surgical procedure, length of stay (LOS), and early complication was examined using χ and time-to-discharge survival analysis.The overall complication incidence was 59.4%, with a minor complication incidence of 52.3% and a major complication incidence of 24.2%. The highest incidences of complications occurred in patients with the diagnosis of infection and tumor, where incidence exceeded 70%; this difference did not achieve statistical significance. The overall median LOS was 7 days; LOS was longer in patients with traumatic pathology (17 d) and patients with neoplastic pathology (14 d) (P<0.05).A higher incidence of complications than earlier studies was noted. A trend toward higher complication incidence in patients with infectious or neoplastic disease was observed. The severity of patient pathology, the broader definitions of complication used, and the elimination of recall bias by the use of a prospective study design accounts for the higher incidence of complications reported in this series. However, a large, prospective study using clear definitions is needed to elucidate the true incidence of early complications in thoracolumbar surgery.

    View details for DOI 10.1097/BSD.0b013e3181e12403

    View details for Web of Science ID 000288740200013

    View details for PubMedID 21445020

  • Lumbar Decompression Using a Traditional Midline Approach Versus a Tubular Retractor System Comparison of Patient-Based Clinical Outcomes SPINE Anderson, D. G., Patel, A., Maltenfort, M., Vaccaro, A. R., Ratliff, J., Hilibrand, A., Harrop, J. S., Sharan, A. D., Ponnappan, R. K., Rihn, J., Albert, T. J. 2011; 36 (5): E320-E325

    View details for DOI 10.1097/BRS.0b013e3181db1dfb

    View details for Web of Science ID 000287446300005

    View details for PubMedID 21178844

  • Incidence of Early Complications in Cervical Spine Surgery and Relation to Preoperative Diagnosis A Single-center Prospective Study JOURNAL OF SPINAL DISORDERS & TECHNIQUES Yadla, S., Malone, J., Campbell, P. G., Nasser, R., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Ratliff, J. K. 2011; 24 (1): 50-54

    Abstract

    Prospective observational cohort study.To determine the incidence of early postoperative complications in patients undergoing cervical spine surgery and its correlation with preoperative diagnosis.The reported incidence of complications and adverse events in cervical spine surgery is highly variable. Inconsistent definitions and varying methodologies have made the interpretation of earlier reports difficult. No large study has analyzed the overall early morbidity of cervical spine surgery in a prospective fashion or attempted to correlate preoperative diagnosis and comorbidities with perioperative complications.Data on 121 consecutive patients, who underwent cervical spine surgery at the Thomas Jefferson University Hospital from May to December 2008, was prospectively collected. Complication definition and gradations of complication severity were validated by a survey of spine surgeons and spine surgery patients. An independent assessor prospectively audited complication incidence in the patient cohort. Data on diagnosis, comorbidities, BMI, complications, and length of stay were prospectively collected and assessed using stepwise multivariate analysis.The overall incidence of early complications was 47.1% with a 40.5% incidence of minor complications and an 18.2% incidence of major complications. Major complication incidence was greater in cases of infection (20.0%) and spinal oncologic procedures (30.0%), although this difference was not of statistical significance (P=0.07). Total number of complications recorded was greater in cases of infection and neoplasm (P=0.05).Complications in cervical spine procedures occurred most frequently in cases involving trauma and spinal oncologic procedures. This study illustrates that the incidence of early complications in cervical spine procedures is greater than appreciated earlier. This difference likely arises owing to the use of a broad definition of perioperative complications, elimination of recall bias through use of a prospective assessment, and overall case complexity. Accurate assessment of the incidence of early complications in cervical spine surgery is important for patient counseling and in design of prospective quality improvement programs.

    View details for DOI 10.1097/BSD.0b013e3181d0d0e8

    View details for Web of Science ID 000286622500012

    View details for PubMedID 20124909

  • High-resolution ultrasonography in the diagnosis and intraoperative management of peripheral nerve lesions Clinical article JOURNAL OF NEUROSURGERY Lee, F. C., Singh, H., Nazarian, L. N., Ratliff, J. K. 2011; 114 (1): 206-211

    Abstract

    The diagnosis of peripheral nerve lesions relies on clinical history, physical examination, electrodiagnostic studies, and radiography. Magnetic resonance neurography offers high-resolution visualization of structural peripheral nerve lesions. The availability of MR neurography may be limited, and the costs can be significant. By comparison, ultrasonography is a portable, dynamic, and economic technology. The authors explored the clinical applicability of high-resolution ultrasonography in the preoperative and intraoperative management of peripheral nerve lesions.The authors completed a retrospective analysis of 13 patients undergoing ultrasonographic evaluation and surgical treatment of nerve lesions at their institution (nerve entrapment [5], trauma [6], and tumor [2]). Ultrasonography was used for diagnostic (12 of 13 cases) and intraoperative management (6 of 13 cases). The authors examine the initial impact of ultrasonography on clinical management.Ultrasonography was an effective imaging modality that augmented electrophysiological and other neuroimaging studies. The modality provided immediate visualization of a sutured peroneal nerve after a basal cell excision, prompting urgent surgical exploration. Ultrasonography was used intraoperatively in 2 cases to identify postoperative neuromas after mastectomy, facilitating focused excision. Ultrasonography correctly diagnosed an inflamed lymph node in a patient in whom MR imaging studies had detected a schwannoma, and the modality correctly diagnosed a tendinopathy in another patient referred for ulnar neuropathy. Ultrasonography was used in 6 patients to guide the surgical approach and to aid in intraoperative localization; it was invaluable in localizing the proximal segment of a radial nerve sectioned by a humerus fracture. In all cases, ultrasonography demonstrated the correct lesion diagnosis and location (100%); in 7 (58%) of 12 cases, ultrasonography provided the correct diagnosis when other imaging and electrophysiological studies were inconclusive or inadequate.High-resolution ultrasonography may provide an economical and accurate imaging modality with utility in diagnosis and management of peripheral nerve lesions. Further research is required to assess the role of ultrasonography in evaluation of peripheral nerve pathology.

    View details for DOI 10.3171/2010.2.JNS091324

    View details for Web of Science ID 000285669500041

    View details for PubMedID 20225925

  • Neurologic Improvement After Thoracic, Thoracolumbar, and Lumbar Spinal Cord (Conus Medullaris) Injuries SPINE Harrop, J. S., Naroji, S., Maltenfort, M. G., Ratliff, J. K., Tjoumakaris, S. I., Frank, B., Anderson, D. G., Albert, T., Vaccaro, A. R. 2011; 36 (1): 21-25

    Abstract

    Retrospective.With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord.Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients meeting the criteria of T4 to S5 injury, excluding gunshot wounds. One-year follow-up data were available on 95 of these patients.Contingency table analyses (chi-squared statistics) and multivariate logistic regression. Variables of interest included level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology.A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with 22.4% of thoracic or thoracolumbar spinal cord-injured patients. Only 7.7% of ASIA A patients showed neurologic improvement, compared with 95.2% of ASIA D patients; ASIA B patients demonstrated a 66.7% improvement rate, whereas ASIA C had a 84.6% improvement rate. When the two effects were considered jointly in a multivariate analysis, ASIA A and thoracic/thoracolumbar patients had only a 4.1% rate of improvement, compared with 96% for lumbar (conus) and incomplete patients (ASIA B-D) and 66.7% to 72.2% for the rest of the patients. All of these relationships were significant to P < 0.001 (chi-square test). There was no link to age or gender, and race and etiology were secondary to region and severity of injury.Thoracic (T4-T9) SCIs have the least potential for neurologic improvement. Thoracolumbar (T10-T12) and lumbar (conus) spinal cord have a greater neurologic improvement rate, which might be related to a greater proportion of lower motor neurons. Thus, defining the exact region of injury and potential for neurologic improvement should be considered in future clinical trial design. Combining all anatomic regions of the spine in SCI trials may be misleading if different regions have neurologic improvement at different rates. Over a ten-year period, 95 complete thoracic/thoracolumbar SCI patients had only a 4.1% rate of neurologic improvement, compared with 96.0% for incomplete lumbar (conus) patients and 66.7% to 72.2% for all others.

    View details for DOI 10.1097/BRS.0b013e3181fd6b36

    View details for Web of Science ID 000285778700016

    View details for PubMedID 21192220

  • Impact of total disc arthroplasty on the surgical management of lumbar degenerative disc disease: Analysis of the Nationwide Inpatient Sample from 2000 to 2008. Surgical neurology international Awe, O. O., Maltenfort, M. G., Prasad, S., Harrop, J. S., Ratliff, J. K. 2011; 2: 139-?

    Abstract

    Spinal fusion is the most rapidly increasing type of lumbar spine surgery for various lumbar degenerative pathologies. The surgical treatment of lumbar spine degenerative disc disease may involve decompression, stabilization, or arthroplasty procedures. Lumbar disc athroplasty is a recent technological advance in the field of lumbar surgery. This study seeks to determine the clinical impact of anterior lumbar disc replacement on the surgical treatment of lumbar spine degenerative pathology. This is a retrospective assessment of the Nationwide Inpatient Sample (NIS).The NIS was searched for ICD-9 codes for lumbar and lumbosacral fusion (81.06), anterior lumbar interbody fusion (81.07), and posterolateral lumbar fusion (81.08), as well as for procedure codes for revision fusion surgery in the lumbar and lumbosacral spine (81.36, 81.37, and 81.38). To assess lumbar arthroplasty, procedure codes for the insertion or replacement of lumbar artificial discs (84.60, 84.65, and 84.68) were queried. Results were assayed from 2000 through 2008, the last year with available data. Analysis was done using the lme4 package in the R programming language for statistical computing.A total of nearly 300,000 lumbar spine fusion procedures were reported in the NIS database from 2000 to 2008; assuming a representative cross-section of the US health care market, this models approximately 1.5 million procedures performed over this time period. In 2005, the first year of its widespread use, there were 911 lumbar arthroplasty procedures performed, representing 3% of posterolateral fusions performed in this year. Since introduction, the number of lumbar spine arthroplasty procedures has consistently declined, to 653 total procedures recorded in the NIS in 2008. From 2005 to 2008, lumbar arthroplasties comprised approximately 2% of lumbar posterolateral fusions. Arthroplasty patients were younger than posterior lumbar fusion patients (42.8 ± 11.5 vs. 55.9 ± 15.1 years, P < 0.0000001). The distribution of arthroplasty procedures was even between academic and private urban facilities (48.5% and 48.9%, respectively). While rates of posterolateral lumbar spine fusion steadily grew during the period (OR 1.06, 95% CI: 1.05-1.06, P < 0.0000001), rates of revision surgery and anterior spinal fusion remained static.The impact of lumbar arthroplasty procedures has been minimal. Measured as a percentage of more common lumbar posterior arthrodesis procedures, lumbar arthroplasty comprises only approximately 2% of lumbar spine surgeries performed in the United States. Over the first 4 years following the Food and Drug Administration (FDA) approval, the frequency of lumbar disc arthroplasty has decreased while the number of all lumbar spinal fusions has increased.

    View details for DOI 10.4103/2152-7806.85980

    View details for PubMedID 22059134

  • Defining "Complications'' in Spine Surgery Neurosurgery and Orthopedic Spine Surgeons' Survey JOURNAL OF SPINAL DISORDERS & TECHNIQUES Lebude, B., Yadla, S., Albert, T., Anderson, D. G., Harrop, J. S., Hilibrand, A., Maltenfort, M., Sharan, A., Vaccaro, A. R., Ratliff, J. K. 2010; 23 (8): 493-500

    Abstract

    Survey of neurosurgical and orthopedic spine surgeons.To define the "complications of spinal surgery," we surveyed a large group of practicing spine surgeons to establish a preliminary definition of perioperative complications.Although the risk of complications following spinal procedures plays an important role in determining the appropriateness of surgical intervention, there is little consensus among spine surgeons regarding the definition of complications in spine surgery. The relevance of medical complications is also not clearly defined.We surveyed a cohort of practicing spine surgeons via email and a commercially maintained website. Surgeons were presented with various complication scenarios, and asked to assess the presence or absence of a complication, as well as complication severity, with responses limited to "major complication" and "minor complication/adverse event."The survey was sent to approximately 2000 practicing surgeons; complete responses were received from 229, giving a response rate of 11.4%. Orthopedic surgeons comprised the majority of respondents (73%); most surgeons reported being in practice for greater than 5 years (83%). Greater than 75% of surgeons agreed on complication presence or absence in 10 of 11 scenarios assessed (91%, P<0.05). Consensus (≥70% agreement, P<0.05) as to type of complication was found in 7 of 11 scenarios presented (64%). Events deemed major complications involved either severe medical adverse events with permanent sequela or events requiring return to the operating room. Surgeons consistently considered medical adverse events, whether or not directly related to surgery, relevant to complication assessment.We present a practical binary definition of complications in spine surgery based upon a survey of over 200 practicing spine surgeons. Further work is required in critically assessing spine surgery complications.

    View details for DOI 10.1097/BSD.0b013e3181c11f89

    View details for Web of Science ID 000284942700009

    View details for PubMedID 20124913

  • Early complications in spine surgery and relation to preoperative diagnosis: a single-center prospective study Clinical article JOURNAL OF NEUROSURGERY-SPINE Yadla, S., Malone, J., Campbell, P. G., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Ratliff, J. K. 2010; 13 (3): 360-366

    Abstract

    The reported incidence of complications in spine surgery varies widely. Variable study methodologies may open differing avenues for potential bias, and unclear definitions of perioperative complication make analysis of the literature challenging. Although numerous studies have examined the morbidity associated with specific procedures or diagnoses, no prospective analysis has evaluated the impact of preoperative diagnosis on overall early morbidity in spine surgery. To accurately assess perioperative morbidity in patients undergoing spine surgery, a prospective analysis of all patients who underwent spine surgery by the neurosurgical service at a large tertiary care center over a 6-month period was conducted. The correlation between preoperative diagnosis and the incidence of postoperative complications was assessed.Data were prospectively collected on 248 consecutive patients undergoing spine surgery performed by the neurosurgical service at the Thomas Jefferson University Hospital from May to December 2008. A standardized definition of minor and major complications was applied to all adverse events occurring within 30 days of surgery. Data on diagnosis, complications, and length of stay were retrospectively assessed using stepwise multivariate analysis. Patients were analyzed by preoperative diagnosis (neoplasm, infection, degenerative disease, trauma) and level of surgery (cervical or thoracolumbar).Total early complication incidence was 53.2%, with a minor complication incidence of 46.4% and a major complication incidence of 21.3%. Preoperative diagnosis correlated only with the occurrence of minor complications in the overall cohort (p = 0.02). In patients undergoing surgery of the thoracolumbar spine, preoperative diagnosis correlated with presence of a complication and the number of complications (p = 0.003). Within this group, patients with preoperative diagnoses of infection and neoplasm were more often affected by isolated and multiple complications (p = 0.05 and p = 0.02, respectively). Surgeries across the cervicothoracic and thoracolumbar junctions were associated with higher incidences of overall complication than cervical or lumbar surgery alone (p = 0.04 and p = 0.03, respectively). Median length of stay was 5 days for patients without a complication. Length of stay was significantly greater for patients with a minor complication (10 days, p < 0.0001) and even greater for patients with a major complication (14 days, p < 0.0001).The incidence of complications found in this prospective analysis is higher than that reported in previous studies. This association may be due to a greater accuracy of record-keeping, absence of recall bias via prospective data collection, high complexity of pathology and surgical approaches, or application of a more liberal definition of what constitutes a complication. Further large-scale prospective studies using clear definitions of complication are necessary to ascertain the true incidence of early postoperative complications in spine surgery.

    View details for DOI 10.3171/2010.3.SPINE09806

    View details for Web of Science ID 000281110800013

    View details for PubMedID 20809731

  • Early Complications Related to Approach in Cervical Spine Surgery: Single-Center Prospective Study WORLD NEUROSURGERY Campbell, P. G., Yadla, S., Malone, J., Zussman, B., Maltenfort, M. G., Sharan, A. D., Harrop, J. S., Ratliff, J. K. 2010; 74 (2-3): 363-368

    Abstract

    Surgical intervention is performed on the cervical spine in a heterogeneous number of pathologic conditions in a diverse patient population. Several authors have examined complication prevalence in cervical spine surgery using retrospective analysis. However, few prospective studies have directly examined perioperative complications. Most prospective studies in the spine literature have assessed only specific spinal implants in carefully selected surgical patients, and complication incidence in broader patient populations is limited.To prospectively collect data on all patients who underwent cervical spine surgery at a large tertiary care center and to evaluate the effect of the approach and the incidence of early complications.Data were collected prospectively on 119 patients admitted to the neurosurgical service at Thomas Jefferson University hospital from May to December 2008. Data collected consisted of preoperative diagnosis, medical comorbidities, body mass index, surgical approach, length of stay, and complications, and were analyzed using multivariate regression analysis. Complications occurring within 30 days after each operative procedure were included. Medical adverse events, regardless of their relationship to the operative intervention, were also included as complications. A previously validated binary definition of major and minor complications was used to stratify the data.Overall, 53 of 119 patients (44.5%) experienced at least one complication. Eleven of 41 patients (26.8%) undergoing only an anterior cervical procedure had a perioperative complication, compared with 26 of 53 patients (49.0%) undergoing only a posterior cervical procedure (P = .01). In patients undergoing a combined anterior and posterior surgical procedure, 16 of 25 (66%) experienced a complication, a significant difference in comparison with solitary anterior procedures (P = .004). Anterior procedures were associated with postoperative dysphagia and vocal cord paresis, whereas wound infection and C5 palsy was more frequently recorded in the group undergoing surgery via an isolated posterior approach.The incidence of complications or adverse events is not definitely known for most spinal procedures because of the complexity of defining complications and obtaining accurate data. Therefore, to obtain a more accurate assessment of spinal procedures, a prospective algorithm was designed to collect and record complications during the acute perioperative period. Using this technique, a significantly higher complication rate was documented than had been previously reported for cervical spine operative interventions. In addition, use of a broad definition of perioperative complications likely increased the recorded incidence of perioperative adverse events and complications. Complications were more common in patients undergoing posterior and anteroposterior procedures.

    View details for DOI 10.1016/j.wneu.2010.05.034

    View details for Web of Science ID 000292781100041

    View details for PubMedID 21492571

  • Complications in spine surgery A review JOURNAL OF NEUROSURGERY-SPINE Nasser, R., Yadla, S., Maltenfort, M. G., Harrop, J. S., Anderson, D. G., Vaccaro, A. R., Sharan, A. D., Ratliff, J. K. 2010; 13 (2): 144-157

    Abstract

    The overall incidence of complications or adverse events in spinal surgery is unknown. Both prospective and retrospective analyses have been performed, but the results have not been critically assessed. Procedures for different regions of the spine (cervical and thoracolumbar) and the incidence of complications for each have been reported but not compared. Authors of previous reports have concentrated on complications in terms of their incidence relevant to healthcare providers: medical versus surgical etiology and the relevance of perioperative complications to perioperative events. Few authors have assessed complication incidence from the patient's perspective. In this report the authors summarize the spine surgery complications literature and address the effect of study design on reported complication incidence.A systematic evidence-based review was completed to identify within the published literature complication rates in spinal surgery. The MEDLINE database was queried using the key words "spine surgery" and "complications." This initial search revealed more than 700 articles, which were further limited through an exclusion process. Each abstract was reviewed and papers were obtained. The authors gathered 105 relevant articles detailing 80 thoracolumbar and 25 cervical studies. Among the 105 articles were 84 retrospective studies and 21 prospective studies. The authors evaluated the study designs and compared cervical, thoracolumbar, prospective, and retrospective studies as well as the durations of follow-up for each study.In the 105 articles reviewed, there were 79,471 patients with 13,067 reported complications for an overall complication incidence of 16.4% per patient. Complications were more common in thoracolumbar (17.8%) than cervical procedures (8.9%; p < 0.0001, OR 2.23). Prospective studies yielded a higher incidence of complications (19.9%) than retrospective studies (16.1%; p < 0.0001, OR 1.3). The complication incidence for prospective thoracolumbar studies (20.4%) was greater than that for retrospective series (17.5%; p < 0.0001). This difference between prospective and retrospective reviews was not found in the cervical studies. The year of study publication did not correlate with the complication incidence, although the duration of follow-up did correlate with the complication incidence (p = 0.001).Retrospective reviews significantly underestimate the overall incidence of complications in spine surgery. This analysis is the first to critically assess differing complication incidences reported in prospective and retrospective cervical and thoracolumbar spine surgery studies.

    View details for DOI 10.3171/2010.3.SPINE09369

    View details for Web of Science ID 000280405000003

    View details for PubMedID 20672949

  • Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures SPINE JOURNAL Yadla, S., Malone, J., Campbell, P. G., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Vaccaro, A. R., Ratliff, J. K. 2010; 10 (7): 581-587

    Abstract

    The correlation between obesity and incidence of complications in spine surgery is unclear, with some reports suggesting linear relationships between body mass index (BMI) and complication incidence and others noting no relationship.The purpose of this article was to assess the relationship between obesity and occurrence of perioperative complications in an elective thoracolumbar surgery cohort.Prospective observational cohort study at a tertiary care facility.Cohort of 87 consecutive patients undergoing elective surgery for degenerative thoracolumbar pathologies over a 6-month period (May to December 2008).Incidence of perioperative complications (those occurring within 30 days of surgery).A prospective assessment of perioperative spine surgery complications was completed, and data were prospectively entered into a central database. Two independent auditors assessed for the presence and severity of perioperative complications. Previously validated binary definitions of major and minor complications were used. Patient data and early complications (those occurring within 30 days of index surgery) were analyzed using multivariate regression.Mean BMI in this cohort was 31.3; 40.8% of patients were obese (BMI>30) and 10 patients (11.5%) were morbidly obese (BMI>40). The overall complication incidence was 67%. Minor complications occurred in 50% of patients, and major complications occurred in 17.8% of patients. No positioning palsies occurred in this series. Age correlated with an increase in complication risk (p=.006) as did hypertension (p=.004) and performance of a fusion (p<.0001). BMI did not correlate with the incidence of minor, major, or any complications (p=.58).This prospective assessment of perioperative complications in elective degenerative thoracolumbar procedures shows no relationship between patient BMI and the incidence of perioperative minor or major complications. Specific care in perioperative positioning may limit the risk of perioperative positioning palsies in obese patients.

    View details for DOI 10.1016/j.spinee.2010.03.001

    View details for Web of Science ID 000279858800002

    View details for PubMedID 20409758

  • Impact of a Standardized Protocol and Antibiotic-Impregnated Catheters on Ventriculostomy Infection Rates in Cerebrovascular Patients NEUROSURGERY Harrop, J. S., Sharan, A. D., Ratliff, J., Prasad, S., Jabbour, P., Evans, J. J., Veznedaroglu, E., Andrews, D. W., Maltenfort, M., Liebman, K., Flomenberg, P., Sell, B., Baranoski, A. S., Fonshell, C., Reiter, D., Rosenwasser, R. H. 2010; 67 (1): 187-191

    Abstract

    Ventriculostomy infections create significant morbidity. To reduce infection rates, a standardized evidence-based catheter insertion protocol was implemented. A prospective observational study analyzed the effects of this protocol alone and with antibiotic-impregnated ventriculostomy catheters.To compare infection rates after implementing a standardized protocol for ventriculostomy catheter insertion with and without the use of antibiotic-impregnated catheters.Between 2003 and 2008, 1961 ventriculostomies and infections were documented. A ventriculostomy infection was defined as 2 positive CSF cultures from ventriculostomy catheters with a concurrent increase in cerebrospinal fluid white blood cell count. A baseline (preprotocol) infection rate was established (period 1). Infection rates were monitored after adoption of the standardized protocol (period 2), institution of antibiotic-impregnated catheter A (period 3), discontinuation of antibiotic-impregnated catheter A (period 4), and institution of antibiotic-impregnated catheter B (period 5).The baseline infection rate (period 1) was 6.7% (22/327 devices). Standardized protocol (period 2) implementation did not change the infection rate (8.2%; 23/281 devices). Introduction of catheter A (period 3) reduced infections to 1.0% (2/195 devices, P=.0005). Because of technical difficulties, this catheter was discontinued (period 4), resulting in an increase in infection rate (7.6%; 12/157 devices). Catheter B (period 5) significantly decreased infections to 0.9% (9 of 1001 devices, P=.0001). The Staphylococcus infection rate for periods 1, 2, and 4 was 6.1% (47/765) compared with 0.2% (1/577) during use of antibiotic-impregnated catheters (periods 3 and 5).The use of antibiotic-impregnated catheters resulted in a significant reduction of ventriculostomy infections and is recommended in the adult neurosurgical population.

    View details for DOI 10.1227/01.NEU.0000370247.11479.B6

    View details for Web of Science ID 000278875400048

    View details for PubMedID 20559105

  • Dorsal Epidural Intervertebral Disk Herniation With Atypical Radiographic Findings: Case Report and Literature Review JOURNAL OF SPINAL CORD MEDICINE Teufack, S. G., Singh, H., Harrop, J., Ratliff, J. 2010; 33 (3): 268-271

    Abstract

    Intervertebral disk herniation is relatively common. Migration usually occurs in the ventral epidural space; rarely, disks migrate to the dorsal epidural space due to the natural anatomical barriers of the thecal sac.Case report.A 49-year-old man presented with 1 week of severe back pain with bilateral radiculopathy to the lateral aspect of his lower extremities and weakness of the ankle dorsiflexors and toe extensors. Lumbar spine magnetic resonance imaging with gadolinium revealed a peripheral enhancing dorsal epidural lesion with severe compression of the thecal sac. Initial differential diagnosis included spontaneous hematoma, synovial cyst, and epidural abscess. Posterior lumbar decompression was performed; intraoperatively, the lesion was identified as a large herniated disk fragment.Dorsal migration of a herniated intervertebral disk is rare and may be difficult to definitively diagnose preoperatively. Dorsal disk migration may present in a variety of clinical scenarios and, as in this case, may mimic other epidural lesions on magnetic resonance imaging.

    View details for Web of Science ID 000281007700011

    View details for PubMedID 20737802

  • Pilomatrix Carcinoma of the Thoracic Spine: Case Report and Review of the Literature JOURNAL OF SPINAL CORD MEDICINE Yadia, S., Randazzo, C. G., Malik, S., Gressen, E., Chasky, M., Kenyon, L. C., Ratliff, J. K. 2010; 33 (3): 272-277

    Abstract

    Pilomatrixoma is a common head and neck neoplasm in children. Its malignant counterpart, pilomatrix carcinoma, is rare and found more often in men.Case report of a 21-year-old man with pilomatrixoma of the thoracic spine that underwent malignant degeneration to pilomatrix carcinoma.The appearance of a painless mobile axillary mass was followed by severe back pain 1 year later. Imaging revealed a compression fracture at the T5 level. The patient underwent resection of the axillary mass and spinal reconstruction of the fracture; the pathology was consistent with synchronous benign pilomatrixomas. Three months later he presented with a recurrence of the spinal lesion and underwent further surgical resection; the pathology was consistent with pilomatrix carcinoma. He received adjuvant radiotherapy and at his 1-year follow-up examination had no sign of recurrence.Pilomatrix carcinoma involving the spine is a rare occurrence. It has a high incidence of local recurrence, and wide excision may be necessary to reduce this risk. Radiotherapy may be a helpful adjuvant therapy. Clinicians should be aware of this entity because of its potential for distant metastasis.

    View details for Web of Science ID 000281007700012

    View details for PubMedID 20737803

  • Correlation of C2 Fractures and Vertebral Artery Injury SPINE Ding, T., Maltenfort, M., Yang, H., Smith, H., Ratliff, J., Vaccaro, A., Anderson, D. G., Harrop, J. 2010; 35 (12): E520-E524

    Abstract

    Retrospective review of prospectively collected data.Vertebral artery injuries (VAI) occur commonly after cervical spine trauma. No study has yet examined the association between VAI and specific variants of C2 fractures.To evaluate the incidence of VAI (as defined by magnetic resonance imaging/angiography [MRI/A]) in subtypes of C2 fractures. To define the association between the incidence, morphology, and severity of C2 fractures, based on fracture angulation and comminution, and the occurrence of VAI.Patients admitted to the hospital with C2 fractures between October 2006 and December 2008 to a tertiary care referral center were identified through a prospectively maintained database. Computed tomography (CT) and MRI/A studies were individually reviewed to evaluate the specific C2 fracture type and the occurrence of VAI. Fracture displacement and angulation were measured. Incidence of VAI was compared between different types and subtypes of C2 fractures. The effects of displacement and angulation of the fracture, morphology of foramen transversarium fracture, patient age, and patient gender on VAI were also analyzed.One hundred one patients were identified with C2 fractures that met inclusion criteria, and 18 (17.8%) had VAI by MRI/A. There was no correlation between fracture types and VAI. However, in subtype analysis, there was a correlation of VAI with traumatic spondylolisthesis of axis (TSA) and greater degree of angulation (P = 0.0023), communition fracture (P = 0.0341), and presence of bone fragment(s) within the foramen transversarium (P = 0.0075). Multivariate logistic regression indicated that age, gender and the presence of fragments within foramen transversarium were associated with greater risk of VAI.Vertebral artery injuries are more likely to occur in C2 fractures with comminuted fractures involving the foramen transversarium, with fractures manifesting bony fragment(s) within the foramen transversarium, or with fractures having greater angulation. These risk factors should be considered when a patient presents with isolated axis fracture.

    View details for DOI 10.1097/BRS.0b013e3181cd98b6

    View details for Web of Science ID 000278074400006

    View details for PubMedID 20445475

  • Early Complications Related to Approach in Thoracic and Lumbar Spine Surgery: A Single Center Prospective Study WORLD NEUROSURGERY Campbell, P. G., Malone, J., Yadla, S., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Ratliff, J. K. 2010; 73 (4): 395-401

    Abstract

    Thoracic and lumbar spine surgical procedures are performed for a variety of pathologies. The literature consists of multiple retrospective reviews examining complication prevalence with the surgical treatment of these disorders. However, there is limited direct examination of perioperative complications through a prospective approach. Of the prospective assessments, the majority focuses on specific surgical procedures or provides a limited assessment of certain spinal implants. Prospective assessments of complication incidence in broad patient populations are limited. This article analyzes a prospectively collected database of patients who underwent a thoracic and/or lumbar spine surgery at a large tertiary care center and the effect of surgical approach (anterior or posterior) on the incidence of early complications.Data collection was performed prospectively on 128 patients on the neurosurgical spine service at Thomas Jefferson University hospital from May to December 2008. Data on preoperative diagnosis, medical comorbidities, body mass index, surgical approach and procedure, length of stay, and complication occurrence was recorded and analyzed. Acute complications or adverse events occurring within the initial 30 days after each operative procedure were included. All medical adverse events were included as complications. A previously circumstantiated binary definition of major and minor complications was used to stratify the data.Overall, 76 of 128 patients (59.4%) in this cohort experienced at least one complication. Anterior thoracic and lumbar procedures had an 83.3% (5/6) incidence of complications. Of those patients having solely a posterior thoracic and lumbar procedures, 37 of 75 (49.3%) experienced at least one complication. Combined anterior and posterior surgical procedure had a complication incidence of 34 of 47 (72.3%). The mean number of complications reached significance for the minor and overall complications groups (P = .0076 and .0172, respectively, Poisson regression). Comparing the incidence of complications reveals the overall complications in the posterior alone group compared with the anterior/posterior combined group was significantly lower (P = .0134). Those undergoing instrumented fusions were statistically more likely to encounter complications (P < .001).There is a considerably higher complication incidence than previously reported for thoracic, thoracolumbar, and lumbar spine operations. A prospective approach and a broad definition of perioperative complications increased the recorded incidence of perioperative adverse events and complications. The case complexity of a tertiary referral center may also have escalated the increased incidence. Complications were more common in patients undergoing anterior and anterior/posterior procedures.

    View details for DOI 10.1016/j.wneu.2010.01.024

    View details for Web of Science ID 000292775600059

    View details for PubMedID 20849799

  • Cervical Myelopathy A Clinical and Radiographic Evaluation and Correlation to Cervical Spondylotic Myelopathy SPINE Harrop, J. S., Naroji, S., Maltenfort, M., Anderson, D. G., Albert, T., Ratliff, J. K., Ponnappan, R. K., Rihn, J. A., Smith, H. E., Hilibrand, A., Sharan, A. D., Vaccaro, A. 2010; 35 (6): 620-624
  • Adult scoliosis surgery outcomes: a systematic review NEUROSURGICAL FOCUS Yadla, S., Maltenfort, M. G., Ratliff, J. K., Harrop, J. S. 2010; 28 (3)

    Abstract

    Appreciation of the optimal management of skeletally mature patients with spinal deformities requires understanding of the natural history of the disease relative to expected outcomes of surgical intervention. Appropriate outcome measures are necessary to define the surgical treatment. Unfortunately, the literature lacks prospective randomized data. The majority of published series report outcomes of a particular surgical approach, procedure, or surgeon. The purpose of the current study was to systematically review the present spine deformity literature and assess the available data on clinical and radiographic outcome measurements.A systematic review of MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: "adult scoliosis surgery," "adult spine deformity surgery," "outcomes," and "complications." Exclusion criteria included follow-up shorter than 2 years and mean patient age younger than 18 years. Data on major curve (coronal scoliosis or lumbar lordosis Cobb angle as reported), major curve correction, Oswestry Disability Index (ODI) scores, Scoliosis Research Society (SRS) instrument scores, complications, and pseudarthroses were recorded.Forty-nine articles were obtained and included in this review; 3299 patient data points were analyzed. The mean age was 47.7 years, and the mean follow-up period was 3.6 years. The average major curve correction was 26.6 degrees (for 2188 patients); for 2129 patients, it was possible to calculate average curve reduction as a percentage (40.7%). The mean total ODI was 41.2 (for 1289 patients), and the mean postoperative reduction in ODI was 15.7 (for 911 patients). The mean SRS-30 equivalent score was 97.1 (for 1700 patients) with a mean postoperative decrease of 23.1 (for 999 patients). There were 897 reported complications for 2175 patients (41.2%) and 319 pseudarthroses for 2469 patients (12.9%).Surgery for adult scoliosis is associated with improvement in radiographic and clinical outcomes at a minimum 2-year follow-up. Perioperative morbidity includes an approximately 13% risk of pseudarthrosis and a greater than 40% incidence of perioperative adverse events. Incidence of perioperative complications is substantial and must be considered when deciding optimal disease management. Although the quality of published studies in this area has improved, particularly in the last few years, the current review highlights the lack of routine use of standardized outcomes measures and assessment in the adult scoliosis literature.

    View details for DOI 10.3171/2009.12.FOCUS09254

    View details for Web of Science ID 000275048800004

    View details for PubMedID 20192664

  • Cervical Myelopathy: A Clinical and Radiographic Evaluation and Correlation to Cervical Spondylotic Myelopathy. Spine Harrop, J. S., Naroji, S., Maltenfort, M., Anderson, D. G., Albert, T., Ratliff, J. K., Ponnappan, R. K., Rihn, J. A., Smith, H. E., Hilibrand, A., Sharan, A. D., Vaccaro, A. 2010

    Abstract

    STUDY DESIGN.: Retrospective analysis of a cohort of patients treated between April 2006 and January 2008, and diagnosed with cervical degenerative disease. OBJECTIVE.: To determine the correlation of the clinical findings associated with cervical myelopathy to the presence of spinal cord compression or cord signal abnormalities on magnetic resonance imaging (MRI). BACKGROUND.: There are numerous reports describing the radiographic features of cervical spondylosis, however, no publication specifically describes the association between the physical signs of cervical myelopathy and the presenting imaging findings. METHODS.: Myelopathy was defined as the presence of greater than one long-tract sign localized to the cervical spinal cord (Hoffman or Babinski signs, clonus, hyper-reflexia, crossed abductor sign, and/or gait dysfunction) on physical examination in the absence of other neurologic condition(s). The presence of these signs, MRI imaging features of spinal cord compression and hyperintense T2 intraparenchymal cord signal abnormality, and patient demographics were recorded. RESULTS.: One hundred three patients met inclusion criteria (age >18, symptomatic cervical degenerative disease and complete neurologic assessment). Of these, 54 had clinical findings of cervical myelopathy. Radiographic features of cord compression were present in 62% of patients, and 84% had myelopathy on examination. No patients without cord compression presented with myelopathy (P < 0.0001). Thirty-five percent of the patients presented with hyperintense signal on T2 MRI within the spinal cord parenchyma. This finding correlated with the presence of myelopathy (P < 0.0001). Multivariate analysis on the subset with cord compression indicates that the likelihood of myelopathy increased with the presence of cord signal hyperintensity (odds ratio [OR], 11.4), sensory loss (OR, 16.9), and age (OR, 1.10 per year). CONCLUSION.: The diagnosis of cervical myelopathy is based on presenting symptoms and physical examination. This analysis illustrates that radiographic cervical spinal cord compression and hyperintense T2 intraparenchymal signal abnormalities correlate with the presence of myelopathic findings on physical examination.

    View details for DOI 10.1097/BRS.0b013e3181b723af

    View details for PubMedID 20150835

  • Potential financial impact of restriction in "never event" and periprocedural hospital-acquired condition reimbursement at a tertiary neurosurgical center: a single-institution prospective study Clinical article JOURNAL OF NEUROSURGERY Teufack, S. G., Campbell, P., Jabbour, P., Maltenfort, M., Evans, J., Ratliff, J. K. 2010; 112 (2): 249-256

    Abstract

    The Centers for Medicare and Medicaid Services (CMS) have moved to limit hospital augmentation of diagnosis-related group billing for "never events" (adverse events that are serious, largely preventable, and of concern to the public and health care providers for the purpose of public accountability) and certain hospital-acquired conditions (HACs). Similar restrictions may be applied to physician billing. The financial impact of these restrictions may fall on academic medical centers, which commonly have populations of complex patients with a higher risk of HACs. The authors sought to quantify the potential financial impact of restrictions in never events and periprocedural HAC billing on a tertiary neurosurgery facility.Operative cases treated between January 2008 and June 2008 were reviewed after searching a prospectively maintained database of perioperative complications. The authors assessed cases in which there was a 6-month lag time to allow for completion of hospital and physician billing. They speculated that other payers would soon adopt the present CMS restrictions and that procedure-related HACs would be expanded to cover common neurosurgery procedures. To evaluate the impact on physician billing and to directly contrast physician and hospital billing impact, the authors focused on periprocedural HACs, as opposed to entire admission HACs. Billing records were compiled and a comparison was made between individual event data and simultaneous cumulative net revenue and net receipts. The authors assessed the impact of the present regulations, expansion of CMS restrictions to other payers, and expansion to rehospitalization and entire hospitalization case billing due to HACs and never events.A total of 1289 procedures were completed during the examined period. Twenty-five procedures (2%) involved patients in whom HACs developed; all were wound infections. Twenty-nine secondary procedures were required for this cohort. Length of stay was significantly higher in patients with HACs than in those without (11.6 +/- 11.5 vs 5.9 +/- 7.0 days, respectively). Fifteen patients required readmission due to HACs. Following present never event and HAC restrictions, hospital and physician billing was minimally affected (never event billing as percent total receipts was 0.007% for hospitals and 0% for physicians). Nonpayment for rehospitalization and reoperation for HACs by CMS and private payers yielded greater financial impact (CMS only, percentage of total receipts: 0.14% hospital, 0.2% physician; all payers: 1.56% hospital, 3.0% physician). Eliminating reimbursement for index procedures yielded profound reductions (CMS only as percentage of total receipts: 0.62% hospital, 0.8% physician; all payers: 5.73% hospital, 8.9% physician).The authors found potentially significant reductions in physician and facility billing. The expansion of never event and HACs reimbursement nonpayment may have a substantial financial impact on tertiary care facilities. The elimination of never events and reduction in HACs in current medical practices are worthy goals. However, overzealous application of HACs restrictions may remove from tertiary centers the incentive to treat high-risk patients.

    View details for DOI 10.3171/2009.7.JNS09753

    View details for Web of Science ID 000274107000008

    View details for PubMedID 19681681

  • Iliac Bolt Fixation An Anatomic Approach JOURNAL OF SPINAL DISORDERS & TECHNIQUES Harrop, J. S., Jeyamohan, S. B., Sharan, A., Ratliff, J., Vaccaro, A. R. 2009; 22 (8): 541-544

    Abstract

    An illustrative technique display and discussions.Review of traditional and new "anatomic" techniques for placement of iliac-spinal fixation.Placement of iliac fixation traditionally has been performed using offset connectors, devascularizing the iliac muscles, in addition to the posterior iliac spine. The technique reviewed provides for the screw heads to be placed in a more anatomic position, allowing rods to be laid parallel without the detachment of the erector spinous muscles.Utilization of anatomic models and discussion of present surgical technique for iliac bolt fixation (traditional) compared and contrasted to newer technique using the anatomic landmarks and structures of the iliac crest.The anatomic models illustrate and support the utilization of an anatomic technique for fixation due to the lessening of muscle trauma, alignment of the rod systems, and preservation of the cortical surfaces.The anatomic placement of iliac bolts provides for improved alignment of constructs while addressing spinal deformities. It may also increase screw pullout and construct strength.

    View details for DOI 10.1097/BSD.0b013e31818da3e2

    View details for Web of Science ID 000279665500001

    View details for PubMedID 19956026

  • Complications in spinal surgery: comparative survey of spine surgeons and patients who underwent spinal surgery Clinical article JOURNAL OF NEUROSURGERY-SPINE Ratliff, J. K., Lebude, B., Albert, T., Anene-Maidoh, T., Anderson, G., Dagostino, P., Maltenfort, M., Hilibrand, A., Sharan, A., Vaccaro, A. R. 2009; 10 (6): 578-584

    Abstract

    Definitions of complications in spinal surgery are not clear. Therefore, the authors assessed a group of practicing spine surgeons and, through the surgeons' responses to an online and emailed survey, developed a simple definition of operative complications due to spinal surgery. To validate this assessment, the authors revised their survey to make it appropriate for a lay audience and repeated the assessment with a cohort of patients who underwent spine surgery.The authors surveyed a cohort of practicing spine surgeons via email and a web-based survey. Surgeons were presented with various complication scenarios and were asked to grade the presence or absence of a complication as well as complication severity, with responses limited to "major complication" and "minor complication/adverse event." The authors administered a similar assessment, modified for lay persons, to patients in a spinal surgery clinic.Complete responses were obtained from 229 surgeons; orthopedic surgeons comprised the majority of respondents (73%). The authors obtained completed surveys from 197 patients. Overall, there was consistent agreement between physicians and patients regarding the presence or absence of a complication in the majority of scenarios (8 [73%] of 11 scenarios with agreement that a complication was present). The overall kappa value, evaluating major versus minor complication, and presence or absence of a complication over the entire cohort, was fair (kappa = 0.21). The authors found greater variation between the cohorts when evaluating complication severity. Patients were consistently more critical than physicians in the majority of scenarios in which a difference was evident. In 4 scenarios, patients were more likely than surgeons to deem the scenario a complication and to grade the complication as major versus minor (p < 0.01). In 3 additional scenarios, patients were more likely than physicians to grade a major complication as opposed to minor complication (p < 0.01). In only 1 scenario were patients less likely than physicians to report a complication (p < 0.001).Comparing responses of spine surgeons and patients who underwent spinal surgery in assessing a group of common postoperative events, the authors found significant agreement on perception of presence of a complication in the majority of scenarios reviewed. However, patients were consistently more critical than surgeons when differences in reporting were found. The authors' data underscore the importance of reconciling differing opinions regarding complications through open discussions between physicians and patients to ensure accurate patient expectations of planned medical or surgical interventions.

    View details for DOI 10.3171/2009.2.SPINE0935

    View details for Web of Science ID 000266461000010

    View details for PubMedID 19558291

  • Clinical survey: patterns of utilization of lumbar epidural steroid injections by a cohort of spinal surgeons. PM & R : the journal of injury, function, and rehabilitation Lebude, B., Wang, D., Harrop, J. S., Maltenfort, M., Anderson, D. G., Vaccaro, A. R., Ratliff, J. K. 2009; 1 (4): 329-334

    Abstract

    There are few data on responses to conservative therapy in the management of lumbar degenerative diseases. To understand the use of epidural steroid injections (ESIs) by spine surgeons in the treatment of 2 distinct lumbar spinal conditions-herniated nucleus pulposus (HNP) and degenerative disk disease (DDD)-a survey of orthopedic and neurosurgical spine surgeons was conducted.Participants were surveyed via posting of a survey on a commercially maintained Web site. Respondents were queried on individual preferences regarding epidural steroid injections for HNP and DDD.N/A.The survey was completed by 61 surgeons; not all surgeons completed the entire survey. There was equal representation between orthopedic and neurosurgical spine surgeons; most surgeons reported being in practice for greater than 10 years (41%) and most surgeons reported completing between either 50 and 100 or 100 and 200 spine surgeries each year (26% and 31%).Results were tabulated and assessed for variance. Both individual responses to the different ESI treatment protocols offered and difference in use of lumbar epidural steroids between diagnoses were analyzed.In treatment of lumbar HNP, the majority of respondents considered ESIs after 6 weeks of noninterventional care (69%). In lumbar DDD, there was no consensus as to overall use, timing, number of ESIs constituting a treatment regimen, number of treatment cycles recommended, and length of treatment before considering other intervention. In comparing treatment of lumbar HNP or DDD, there was no agreement with regard to timing of ESIs, with regard to duration of treatment, nor with regard to number of injections comprising a treatment regimen (kappa = -0.01, 0.03, and -0.02, respectively).No consensus was found as to timing, frequency, and duration of ESI treatment in lumbar HNP and DDD patients in a survey of practicing spine surgeons. These results illustrate one example of lack of consensus in conservative treatment protocols.

    View details for DOI 10.1016/j.pmrj.2008.11.013

    View details for PubMedID 19627915

  • Clinical Survey: Patterns of Utilization of Lumbar Epidural Steroid Injections by a Cohort of Spinal Surgeons PM&R Lebude, B., Wang, D., Harrop, J. S., Maltenfort, M., Anderson, D. G., Vaccaro, A. R., Ratliff, J. K. 2009; 1 (4): 329-334
  • Pseudarthrosis Following Lumbar Interbody Fusion Using Bone Morphogenetic Protein-2: Intraoperative and Histopathologic Findings ORTHOPEDICS Whang, P. G., O'Hara, B. J., Ratliff, J., Sharan, A., Brown, Z., Vaccaro, A. R. 2008; 31 (10): 1031-1034

    View details for Web of Science ID 000259984000018

    View details for PubMedID 19226004

  • Traumatic spondyloptosis of the thoracolumbar spine JOURNAL OF NEUROSURGERY-SPINE Yadla, S., Lebude, B., Tender, G. C., Sharan, A. D., Harrop, J. S., Hilibrand, A. S., Vaccaro, A. R., Ratliff, J. K. 2008; 9 (2): 145-151

    Abstract

    Traumatic Grade V thoracolumbar spondylolisthesis, or traumatic spondyloptosis (severe translation injuries), are uncommon spinal injuries. To the best of the authors' knowledge, this article represents the first reported case series of these unique spinal lesions.The authors undertook a retrospective review of a tertiary care regional spinal cord injury patient population treated over a 10-year period (1997-2007). They analyzed data regarding age, sex, mechanism of injury, neurological status, and treatment.Five patients were identified (3 men and 2 women) with ages ranging from 17 to 44 years. All patients had sustained high-energy closed spinal injuries: 3 motor vehicle accidents, 1 injured in a building collapse, and 1 hurt by a fallen steel beam. Four patients, all with sagittal-plane spondyloptosis, had a complete neurological deficit (American Spinal Injury Association [ASIA] Grade A), and 1, with coronal-plane spondyloptosis, presented with an incomplete neurological deficit (ASIA Grade C). Four patients had sustained concurrent multisystem trauma. All patients underwent surgery: an isolated posterior fusion in 2 and combined posterior-anterior fusion in 3. Only the patient with an incomplete neurological deficit (coronal-plane spondyloptosis) recovered neurological function postoperatively.Traumatic thoracolumbar junction spondyloptosis is rare. Surgical reconstruction and stabilization allow for early mobilization and rehabilitation. In the present series, a patient with coronal-plane spondyloptosis presented with preserved neurological function. This may be due to the result of differences in resultant neurological compression due to displacement mechanics compared with sagittally displaced injuries.

    View details for DOI 10.3171/SPI/2008/9/8/145

    View details for Web of Science ID 000257958200005

    View details for PubMedID 18764746

  • Spine-related expenditures and self-reported health status JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Ratliff, J., Hilibrand, A., Vaccaro, A. R. 2008; 299 (22): 2627-2627

    View details for Web of Science ID 000256586200014

    View details for PubMedID 18544720

  • Spinal injuries after falls from hunting tree stands SPINE JOURNAL Fayssoux, R. S., TALLY, W., SANFILIPPO, J. A., Stock, G., Ratliff, J. K., Anderson, G., Hilibrand, A. S., Albert, T. J., Vaccaro, A. R. 2008; 8 (3): 522-528

    Abstract

    Spinal injuries are common sequelae of falls from hunting tree stands. Significant neurological injury is not uncommon and can result in significant morbidity as well as enormous expenditure of health care dollars. Recent literature on the subject is limited.The purpose of this study was to identify precipitating causes, characterize the spectrum of spinal injury, and determine potential interventional safety and prevention recommendations.A retrospective study.Medical record review of 22 patients admitted either directly or via referral to a level I spinal cord injury referral center over a 10-year period (1995-2005) after a fall from a hunting tree stand.All patients were men with a mean age of 46 years (range, 27-80 years). Initial acute care hospitalization averaged 10 days (range, 2-28 days). The average height of fall was 18 feet (range, 10-30 feet). Four of 19 falls (21%) occurred during the morning hours, 2 of 19 falls occurred during the afternoon, and 13 of 19 falls (68%) occurred during the evening hours. Time lapse from injury to presentation to an emergency department ranged from 30 minutes to 14 hours. Alcohol use was a factor in 2 of 20 falls (10%). Hypothermia complicated 3 of 21 cases (14%). Associated injuries were present in 12 of 21 patients (57%) and included fractures to the axial and appendicular skeleton, pneumothoraces, a retroperitoneal bleed, and a brachial plexopathy. Eight of 22 patients (37%) sustained injury to the cervical spine. Five of these 8 patients (63%) had neurological deficits (3 complete and 2 incomplete spinal cord injuries). Thirteen of 22 (59%) patients sustained injury to the thoracic or lumbar spine. Ten of these 13 (77%) had neurologic deficits (3 complete and 7 incomplete). Nine of 22 (41%) patients were treated nonoperatively; the remaining 13 (59%) underwent operative intervention.Falls from hunting tree stands remain a significant cause of spinal injury and subsequent disability. The best intervention for these injuries is prevention. There is a continued need for hunter safety education to reduce the incidence of these injuries with emphasis on safety harness usage, proper installation and annual inspection of tree stands, hunting in groups with periodic contact, the use of communication devices, and abstinence from alcohol consumption while hunting.

    View details for DOI 10.1016/j.spinee.2006.11.005

    View details for Web of Science ID 000256181300014

    View details for PubMedID 18023620

  • Whiplash: diagnosis, treatment, and associated injuries. Current reviews in musculoskeletal medicine Yadla, S., Ratliff, J. K., Harrop, J. S. 2008; 1 (1): 65-68

    Abstract

    Focused review of the current literature.To identify and synthesize the most current data pertaining to the diagnosis and treatment of whiplash and whiplash-associated disorders (WAD), and to report on whiplash-related injuries.A search of OVID Medline (1996-January 2007) and the Cochrane database of systematic reviews was performed using the keywords whiplash and WAD. Articles under subheadings for pathology, diagnosis, treatment, and epidemiology were chosen for review after identification by the authors.A total of 485 articles in the English language literature were identified. Thirty-six articles pertained to the diagnosis, treatment, epidemiology of whiplash, and WAD, and were eligible for focused review. From these, 21 primary and 15 secondary sources were identified for full review. In addition, five articles were found that focused on whiplash associated cervical injuries. These five articles were also primary sources.Whiplash is a common injury associated most often with motor vehicle accidents. It may present with a variety of clinical manifestations, collectively termed WAD. Whiplash is an important cause of chronic disability. Many controversies exist regarding the diagnosis and treatment of whiplash injuries. The multifactorial etiology, believed to underly whiplash injuries, make management highly variable between patients. Radiographic evidence of injury often cannot be identified in the acute phase. Recent studies suggest early mobilization may lead to improved outcomes. Ligamentous and bony injuries may go undetected at initial presentation leading to delayed diagnosis and inappropriate therapies.

    View details for DOI 10.1007/s12178-007-9008-x

    View details for PubMedID 19468901

  • Acute cervical fracture or congenital spinal deformity? JOURNAL OF SPINAL CORD MEDICINE Harrop, J. S., Jeyamohan, S., Sharan, A., Ratliff, J., Flanders, A., Maltenfort, M., Falowski, S., Vaccaro, A. 2008; 31 (1): 83-87

    Abstract

    There are few reports of developmental or congenital cervical spinal deformities. Such cases may be mistaken for traumatically induced fractures, and additional treatment may ensue.A retrospective analysis was performed to identify patients with congenital cervical spine deformities. These patients were matched with a confirmed traumatic spinal fracture population with similar demographic features. Patients were analyzed for age, gender, imaging findings (plain roentgenograms including dynamic flexion and extension views, computed tomography scan, and MRI), neurologic status, and subjective complaints of pain.Thirty-six individuals were included in the final analysis, 7 with congenital abnormalities and 29 with radiographically confirmed traumatic injuries. Patients with congenital abnormalities had significantly less soft-tissue swelling compared with the population with traumatic fractures (P < 0.001). Furthermore, those with congenital defects presented with lesser degrees of vertebral subluxation (0.29 mm vs 7.24 mm) (P < 0.0001) and without neurologic deficits (P < 0.0001).Congenital abnormalities, though rare, can be mistaken for traumatic fractures of the spine. Physicians should note any evidence of soft-tissue swelling, neurologic deficits, degree of subluxation, and radiographic evidence of pedicle absence because these characteristics often provide insight into the specific etiology of the observed spinal deformity (congenital vs traumatic).

    View details for Web of Science ID 000256163400013

    View details for PubMedID 18533417

  • Cervical extradural meningioma: Case report and literature review JOURNAL OF SPINAL CORD MEDICINE Frank, B. L., Harrop, J. S., Hanna, A., Ratliff, J. 2008; 31 (3): 302-305

    Abstract

    Extradural lesions are most commonly metastatic neoplasms. Extradural meningioma accounts for 2.7 to 10% of spinal neoplasms and most commonly is found in the thoracic spine.Case report.A 45-year-old woman presented with posterior cervicothoracic pain for 8 months following a motor vehicle crash. Magnetic resonance imaging of the cervical spine revealed an enhancing epidural mass. Computerized tomography of the chest, abdomen, and pelvis revealed no systemic disease. Due to the lesion's unusual signal characteristics and location, an open surgical biopsy was completed, which revealed a psammomatous meningioma. Surgical decompression of the spinal cord and nerve roots was then performed. The resection was subtotal due to the extension of the tumor around the vertebral artery.Meningiomas should be considered in the differential diagnosis of contrast-enhancing lesions in the cervical spine.

    View details for Web of Science ID 000258146700009

    View details for PubMedID 18795481

  • Perioperative complications of minimally invasive surgery (MIS): comparison of MIS and open interbody fusion techniques. Surgical technology international Bagan, B., Patel, N., Deutsch, H., Harrop, J., Sharan, A., Vaccaro, A. R., Ratliff, J. K. 2008; 17: 281-286

    Abstract

    The risk of perioperative complications while adopting minimally invasive spine surgery techniques may slow the acceptance of this technology. We assess the perioperative complication rate with minimally invasive single- and two-level interbody fusions and compare this incidence with a contemporaneous cohort of open single- and two-level open interbody fusions, with all procedures completed by a single surgeon in a single practice group. We compiled all open and MIS interbody fusion cases completed during the study period. Sofamor-Danek X-Tube and Stryker Luxor minimally invasive systems were used on all patients. Medical records were reviewed to assess any adverse events occurring in the perioperative period. Care was taken to include all medical and surgical adverse events and complications occurring within 30 days of surgery. Over the study period, 28 minimally invasive lumbar fusions were identified: 24 single- and 4 two-level cases. Both TLIF and PLIF techniques were used. This cohort was compared with a group of 19 single- and two-level open interbody fusion cases completed over the same period. The complication rate for the MIS cohort was 18%, with 7 complications occurring in 5 patients. In the open group, 8 complications occurred in 7 patients, an incidence of 37%. A standard distribution of complications occurred, and the difference between the two groups was not statistically significant. Limiting our analysis to severe complications yielded rates of 7% and 21% for the two groups, also not significantly divergent. Perioperative complications are not more common in well-selected MIS patients. Allowing for proper patient selection, MIS techniques have a favorable complication profile.

    View details for PubMedID 18802914

  • Mortality rates in geriatric patients with spinal cord injuries JOURNAL OF NEUROSURGERY-SPINE Fassett, D. R., Harrop, J. S., Maltenfort, M., Jeyamohan, S. B., Ratliff, J. D., Anderson, D. G., Hilibrand, A. S., Albert, T. J., Vaccaro, A. R., Sraran, A. D. 2007; 7 (3): 277-281

    Abstract

    The authors undertook this study to evaluate the incidence of spinal cord injury (SCI) in geriatric patients (> or = 70 years of age) and examine the impact of patient age, extent of neurological injury, and spinal level of injury on the mortality rate associated with traumatic SCI.A prospectively maintained SCI database (3481 patients) at a single institution was retrospectively studied for the period from 1978 through 2005. Parameters analyzed included patient age, admission American Spinal Injury Association (ASIA) motor score, level of SCI, mechanism of injury, and mortality data. The data pertaining to the 412 patients 70 years of age and older were compared with those pertaining to the younger cohort using a chi-square analysis.Since 1980, the number of SCI-related hospital admissions per year have increased fivefold in geriatric patients and the percentage of geriatric patients within the SCI population has increased from 4.2 to 15.4%. In comparison with younger patients, geriatric patients were found to be less likely to have severe neurological deficits (greater percentage of ASIA Grades C and D injuries), but the mortality rates were higher in the older age group both for the period of hospitalization (27.7% compared with 3.2%, p < 0.001) and during 1-year follow-up. The mortality rates in this older population directly correlate with the severity of neurological injury (1-year mortality rate, ASIA Grade A 66%, Grade D 23%, p < 0.001). The mortality rate in elderly patients with SCI has not changed significantly over the last two decades, and the 1-year mortality rate was greater than 40% in all periods analyzed.Spinal cord injuries in older patients are becoming more prevalent. The mortality rate in this patient group is much greater than in younger patients and should be taken into account when aggressive interventions are considered and in counseling families regarding prognosis.

    View details for Web of Science ID 000249219700003

    View details for PubMedID 17877260

  • The influence of fracture mechanism and morphology on the reliability and validity of two novel thoracolumbar injury classification systems SPINE Whang, P. G., Vaccaro, A. R., Poelstra, K. A., Patel, A. A., Anderson, D. G., Albert, T. J., Hilibrand, A. S., Harrop, J. S., Sharan, A. D., Ratliff, J. K., Hurlbert, R. J., Anderson, P., Aarabi, B., Sekhon, L. H., Gahr, R., Carrino, J. A. 2007; 32 (7): 791-795

    Abstract

    The Thoracolumbar Injury Severity Score (TLISS) and the Thoracolumbar Injury Classification and Severity Score (TLICS) were prospectively evaluated.To compare the reliability and validity of the TLISS and TLICS schemes to determine the importance of injury mechanism and morphology to the identification and treatment of thoracolumbar fractures.Two novel algorithms have been developed for the categorization and management of thoracolumbar injuries: the TLISS system emphasizing injury mechanism and the TLICS scheme involving injury morphology.The clinical and radiographic findings of 25 patients with thoracolumbar fractures were prospectively presented to 5 groups of surgeons with disparate levels of training and experience with spinal trauma. These injuries were consecutively scored, first using the TLISS and then 3 months later with the TLICS. The recommended treatments proposed by the 2 schemes were compared with the actual management of each patient.For both algorithms, the interrater kappa statistics of all subgroups (mechanism/morphology, status of the posterior ligaments, total score, predicted management) were within the range of moderate to substantial reproducibility (0.45-0.74), and there were no statistically significant differences noted between the respective kappa values. Interrater correlation was higher for the TLISS paradigm on mechanism/morphology, integrity of the posterior ligaments, and proposed management (P < or = 0.01). The TLISS and TLICS schemes both exhibited excellent overall validity.Although both schemes were noted to have substantial reproducibility and validity, our results indicate the TLISS is more reliable than the TLICS, suggesting that the mechanism of trauma may be a more valuable parameter than fracture morphology for the classification and treatment thoracolumbar injuries. Since these injury characteristics are interrelated and are critical to the maintenance of spinal stability, we think that both concepts should be considered during the assessment and management of these patients.

    View details for Web of Science ID 000245470100014

    View details for PubMedID 17414915

  • Minimally invasive lumbar laminectomy via a dual-tube technique: evaluation in a cadaver model SURGICAL NEUROLOGY Musacchio, M., Patel, N., Bagan, B., Deutsch, H., Vaccaro, A. R., Ratliff, J. 2007; 67 (4): 348-352

    Abstract

    Minimally invasive surgery is a promising new tool in treatment of spinal disorders. Minimally invasive laminectomy provides an efficacious means of achieving lumbar decompression. Present single-tube approaches may entail significant facet injury. We explore the feasibility of a dual-tube minimally invasive laminectomy approach in a cadaver model.We performed minimally invasive lumbar laminectomies in 8 adult cadavers. Twenty-three levels were treated. We used a dual-tube technique, undercutting the facet joints bilaterally while attempting to minimize facet injury. Crossed-tube rongeuring of individual facet joints and neural foramina mirrored open techniques. Pre- and postoperative CT scans of the cadavers were obtained; we measured the cross-sectional area of the spinal canal and neural foramina in each specimen using a CT workstation. Facet damage was assessed. We used the Medtronic Sofamor-Danek (Memphis, Tenn) X-Tube and Quadrant systems to complete individual procedures.Increases in canal cross-sectional area were achieved in each specimen: L3-4 increased from 238.3 to 354.4 mm(2) (125.1%); L4-5, 274 to 390.9 mm(2) (142.7%); and L5-S1, 349.9 mm(2) to 458.8 mm(2) (131%). Neural foraminal diameter also increased in each specimen (L3-4 right increased 123%; left, 136.8%; L4-5, 143.5% and 145.6%; L5-S1, 124% and 116% respectively). Incidental facet injury was noted in 5 (10.9%) of a potential 46 joints.We demonstrate that a dual-tube MIS technique can effectively complete lumbar decompressive laminectomy and foraminotomy procedures in a cadaver model, without significant facet injury. Minimally invasive surgery laminectomy techniques hold significant clinical promise.

    View details for DOI 10.1016/j.surneu.2006.08.075

    View details for Web of Science ID 000245661900005

    View details for PubMedID 17350398

  • Obesity and spine surgery: relation to perioperative complications JOURNAL OF NEUROSURGERY-SPINE Patel, N., Bagan, B., Vadera, S., Maltenfort, M. G., Deutsch, H., Vaccaro, A. R., Harrop, J., Sharan, A., Ratliff, J. K. 2007; 6 (4): 291-297

    Abstract

    Many patients undergoing elective thoracic or lumbar fusion procedures are obese, but the contribution of obesity to complications in spine surgery has not been defined. The authors retrospectively assessed the prevalence of obesity in a cohort of patients undergoing thoracic and lumbar fusion and correlate the presence of obesity with the incidence of operative complications.A retrospective review of consecutive patients treated by a single surgeon (J.K.R.) over a 36-month period at either Rush University Medical Center or the Neurological and Orthopedic Institute of Chicago was performed. The authors identified 332 elective thoracic and lumbar spine surgery cases; the cohort was restricted to include only patients with symptomatic degenerative conditions in need of an anterior, posterior, or combined anterior-posterior fusion. Cases of trauma, tumor, and infection and any case in which the procedure was performed for emergency indications were excluded. A total of 97 cases were identified; of these 86 procedures performed in 84 patients had adequate follow-up material for inclusion in the present study. A broad definition of complications was used. Complications were divided into adverse events (minor) and significant complications (major) based on their impact on patient outcome. Stepwise multivariate logistic regression was used to identify which variables had a significant effect on the risk of complications. Variables considered were body mass index (BMI), height, weight, age, sex, presence or absence of diabetes mellitus (DM) and/or hypertension, number of levels fused (single compared with multiple), and type of surgery performed. The mean BMI for the cohort was 28.8 (95% confidence interval 24.4-30.3); 60 patients (71.4%) were considered overweight or obese (BMI > or = 25). There were 42 complications in 31 patients (36.9%); this included 19 significant complications in 17 patients (20.2%). Logistic regression revealed that the probability of a significant complication was related to BMI (p < 0.04); the chance of a significant complication was 14% with a BMI of 25, 20% with a BMI of 30, and 36% with a BMI of 40. Positioning-related palsies were only found in extremely obese patients (BMI > or = 40). The probability of minor complication occurrence increased with age (p < 0.02), not BMI. The rate of complications was independent of sex as well as the presence of DM or hypertension. A standard collection of complications occurred, including wound infection (three cases), cerebrospinal fluid leakage (eight cases, one requiring reoperation), deep vein thrombosis (two cases), cardiac events (four cases), symptomatic pseudarthrosis (one case), pneumonia (three cases), prolonged intubation (two cases), urological issues (eight cases), positioning-related palsy (two cases), and neuropathic pain (two cases).Obesity is a prevalent condition in patients undergoing elective fusion for degenerative spinal conditions and may increase the prevalence and incidence of perioperative complications. In their analysis, the authors correlated increasing BMI and increased risk of significant postoperative complications. The correlation of obesity and perioperative complications may assist in the preoperative evaluation and selection of patients for surgery.

    View details for Web of Science ID 000245341900001

    View details for PubMedID 17436915

  • Evaluation of neurologic deficit without apparent cause: the importance of a multidisciplinary approach. journal of spinal cord medicine Smith, H. E., Rynning, R. E., Okafor, C., Zaslavsky, J., Tracy, J. I., Ratliff, J., Harrop, J., Albert, T., Hilibrand, A., Anderson, G., Sharan, A., Brown, Z., Vaccaro, A. R. 2007; 30 (5): 509-517

    Abstract

    A patient presenting with an acute neurologic deficit with no apparent etiology presents a diagnostic dilemma. A broad differential diagnosis must be entertained, considering both organic and psychiatric causes.A case report and thorough literature review of acute paraplegia after a low-energy trauma without a discernible organic etiology.Diagnostic imaging excluded any bony malalignment or fracture and any abnormality on magnetic resonance imaging. When no organic etiology was identified, a multidisciplinary approach using neurology, psychiatry, and physical medicine and rehabilitation services was applied. Neurophysiologic testing confirmed the absence of an organic disorder, and at this juncture, diagnostic efforts focused on identifying any psychiatric disorder to facilitate appropriate treatment for this individual. The final diagnosis was malingering.The full psychiatric differential diagnosis should be considered in the evaluation of any patient with an atypical presentation of paralysis. A thorough clinical examination in combination with the appropriate diagnostic studies can confidently exclude an organic disorder. When considering a psychiatric disorder, the differential diagnosis should include conversion disorder and malingering, although each must remain a diagnosis of exclusion. Maintaining a broad differential diagnosis and involving multiple disciplines (neurology, psychiatry, social work, medical specialists) early in the evaluation of atypical paralysis may facilitate earlier diagnosis and initiation of treatment for the underlying etiology.

    View details for PubMedID 18092568

  • Clinical notes - Evaluation of neurologic deficit without apparent cause: The importance of a multidisciplinary approach JOURNAL OF SPINAL CORD MEDICINE Smith, H. E., Rynning, R. E., Okafor, C., Zaslavsky, J., Tracy, J. I., Ratliff, J., Harrop, J., Albert, T., Hilibrand, A., Anderson, G., Sharan, A., Brown, Z., Vaccaro, A. R. 2007; 30 (5): 509-517
  • Regional variability in use of a novel assessment of thoracolumbar spine fractures: United States versus international surgeons. World journal of emergency surgery : WJES Ratliff, J., Anand, N., Vaccaro, A. R., Lim, M. R., Lee, J. Y., Arnold, P., Harrop, J. S., Rampersaud, R., Bono, C. M., Gahr, R. H. 2007; 2: 24-?

    Abstract

    Considerable variability exists in clinical approaches to thoracolumbar fractures. Controversy in evaluation and nomenclature contribute to this confusion, with significant differences found between physicians, between different specialties, and in different geographic regions. A new classification system for thoracolumbar injuries, the Thoracolumbar Injury Severity Score (TLISS), was recently described by Vaccaro. No assessment of regional differences has been described. We report regional variability in use of the TLISS system between United States and non-US surgeons.Twenty-eight spine surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 clinical thoracolumbar injury case histories, which included pertinent imaging studies. Cases were classified and scored using the TLISS system. After a three month period, the case histories were re-ordered and the physicians repeated the exercise; 22 physicians completed both surveys and were used to assess intra-rater reliability. The reliability and treatment validity of the TLISS was assessed. Surgeons were grouped into US (n = 15) and non-US (n = 13) cohorts. Inter-rater (both within and between different geographic groups) and intra-rater reliability was assessed by percent agreement, Cohen's kappa, kappa with linear weighting, and Spearman's rank-order correlation.Non-US surgeons were found to have greater inter-rater reliability in injury mechanism, while agreement on neurological status and posterior ligamentous complex integrity tended to be higher among US surgeons. Inter-rater agreement on management was moderate, although it tended to be higher in US-surgeons. Inter-rater agreement between US and non-US surgeons was similar to within group inter-rater agreement for all categories. While intra-rater agreement for mechanism tended to be higher among US surgeons, intra-rater reliability for neurological status and PLC was slightly higher among non-US surgeons. Intra-rater reliability for management was substantial in both US and non-US surgeons. The TLISS incorporates generally accepted features of spinal injury assessment into a simple patient evaluation tool. The management recommendation of the treatment algorithm component of the TLISS shows good inter-rater and substantial intra-rater reliability in both non-US and US based spine surgeons. The TLISS may improve communication between health providers and may contribute to more efficient management of thoracolumbar injuries.

    View details for PubMedID 17825106

  • Minimally invasive thoracolumbar costotransversectomy and corpectomy via a dual-tube technique: evaluation in a cadaver model. Surgical technology international Musacchio, M., Patel, N., Bagan, B., Deutsch, H., Vaccaro, A. R., Ratliff, J. 2007; 16: 221-225

    Abstract

    Minimally invasive surgery (MIS) is a promising new tool in the treatment of a variety of spinal disorders. MIS laminectomy techniques provide an effective means of achieving lumbar decompression. MIS corpectomy techniques have not been described. If feasible, such a technique would be optimal in the treatment of spinal metastatic disease, where traditional open techniques can result in a significant burden to a compromised patient. In this study, we explored the feasibility of a dual-tube minimally invasive thoracic corpectomy approach in a cadaver model. A minimally invasive thoracolumbar costotransversectomy and corpectomy were perfumed in eight adult cadavers. A dual-tube technique was used to perform a costotransversectomy followed by a corpectomy on one side, and through the opposite tube a transpedicular approach on the contralateral side. Pre- and postoperative CT scans of all cadavers were obtained to measure the cross-sectional area of the vertebral bodies in each specimen via a CT workstation. Reconstruction of the anterior column was attempted in some cadavers using polymethylmethacrylate (PMMA) cement. A successful costotransversectomy and corpectomy were completed in each cadaver. A percutaneous delivery system was successful in allowing an anterior column reconstruction using PMMA as a strut graft in selected cadavers. We demonstrated that a dual-tube MIS approach to thoracic corpectomy is technically feasible. Additionally, spinal stabilization can be achieved via percutaneous PMMA administration. This approach may provide a minimally invasive option in the treatment of select spinal metastases.

    View details for PubMedID 17429793

  • Central cord injury: pathophysiology, management, and outcomes. spine journal Harrop, J. S., Sharan, A., Ratliff, J. 2006; 6 (6): 198S-206S

    Abstract

    Cervical spinal trauma can result in a heterogeneous collection of spinal cord injury syndromes. Acute traumatic central cord syndrome is a common category of which no uniform consensus on the etiology, pathophysiology, and treatment exists.To evaluate and review potential pathophysiology, current treatment options, and management of central cord injuries.Comprehensive literature review and clinical experience.A systematic review of Medline for articles related to central cord and spinal cord injury was conducted up to and including journal articles published in September 2005.Central cord injuries is a clinical definition which is composed of a heterogeneous population for which medical management and surgical decompression and stabilization provide improved neurologic recovery.

    View details for PubMedID 17097539

  • An aneurysmal bone cyst in the cervical spine of a 10-year-old girl: A case report SPINE Beiner, J. M., Sastry, A., Berchuck, M., Grauer, J. N., Kwon, B. K., Ratliff, J. K., Stock, G. H., Brown, A. K., Vaccaro, A. R. 2006; 31 (14): E475-E479

    Abstract

    An aneurysmal bone cyst in the neural arch of the fourth cervical vertebra of a 10-year-old girl is reported, along with a brief review of the literature on the topic.To report the presentation and diagnosis of this disorder along with a discussion of the major pitfalls of treatment.An aneurysmal bone cyst occurs commonly in the second decade, with a predilection for the lumbar spine. With occurrence in the neural arch of a cervical vertebra, the potential for instability following surgical excision is high.A 10-year-old white female presented with neck pain of 3 months' duration. Diagnostic imaging revealed an expansile lytic lesion in the spinous process and lamina of the fourth cervical vertebra. Surgical treatment consisted of excisional biopsy and a segmental instrumented posterior fusion from C3-C5. The histopathology was consistent with an aneurysmal bone cyst.Surgical excision consisting of laminectomy and instrumented segmental fusion provided a good clinical result, and minimized the risk and degree of the 2 most common complications: recurrence of the tumor; and postlaminectomy kyphosis, a frequent occurrence in the pediatric population.In pediatric patients who develop a bone tumor of the posterior elements of the cervical spine, careful clinical and radiologic evaluation is necessary to narrow the differential diagnosis. In most cases, a complete excision should be performed if possible. The risk of postlaminectomy kyphosis is high in the pediatric age population. As such, a fusion should be considered whenever a laminectomy is performed in the immature cervical spine. Risk factors for kyphosis include a high cervical level, multiple laminectomy levels, and postoperative irradiation.

    View details for Web of Science ID 000238323700035

    View details for PubMedID 16778679

  • Palsies of the fifth cervical nerve root after cervical decompression: prevention using continuous intraoperative electromyography monitoring JOURNAL OF NEUROSURGERY-SPINE Jimenez, J. C., Sani, S., Braverman, B., DEUTSCH, H., Ratliff, J. K. 2005; 3 (2): 92-97

    Abstract

    A desire to prevent complications resulting from spinal surgery led to the development of intraoperative monitoring. Intraoperative electromyography (EMG) provides useful diagnostic information regarding nerve root function during spinal and peripheral nerve surgeries. The C-5 nerve root is considered particularly vulnerable to injury during cervical surgery. Despite advances in techniques, the incidence of postoperative C-5 palsy has not changed.The authors reviewed prospectively collected data obtained in 161 patients who underwent 171 cervical procedures. In 116 procedures, operative monitoring was modified to include continuous C-5 EMG from the deltoid muscle. In cases in which spontaneous C-5 activity occurred, an appropriate change in operative manipulation was made. A historical control group consisted of a retrospective review of 55 procedures that were monitored using conventional techniques. In the retrospective cohort, four (7.3%) of 55 patients presented after undergoing surgery for C-5 nerve root palsy. In each patient conventional monitoring revealed unremarkable findings. In the prospective cohort, intraoperative spontaneous EMG activity necessitated a change in either positioning or operative technique in three cases. Only one patient (0.9%) experienced postoperative C-5 palsy. Postoperative C-5 palsy occurred in no patient in whom there was no intra-operative evidence of root irritation (p < 0.03, chi-square test).The incidence of postoperative C-5 palsies was reduced from 7.3% to 0.9% due to intraoperative continuous EMG monitoring. No patient suffered a postoperative C-5 palsy when intraoperative evidence of root irritation was absent.

    View details for Web of Science ID 000231368400003

    View details for PubMedID 16370297

  • Metastatic spine tumors SOUTHERN MEDICAL JOURNAL Ratliff, J. K., Cooper, P. R. 2004; 97 (3): 246-253

    Abstract

    Cancer is the second leading cause of death in the United States, and vertebral body metastases often occur in systemic malignancy. Metastatic spinal tumors may present with pain or neurologic deficit, or may be detected during screening examinations in patients with known malignancy. Management of spinal metastases remains controversial. The role of surgery, especially decompressive laminectomy without stabilization, has been questioned. Recent series attest to the beneficial role of surgery, emphasizing anterior and combined decompression and stabilization procedures. We review the relevant literature on metastatic spinal tumors, assessing imaging strategies, adjuvant treatment, patient selection, and results and complications. Operative decompression and stabilization is an important tool in the management of spinal metastatic disease. Patient selection and appropriate use of anterior and/or posterior decompression and stabilization are necessary to optimize surgical results.

    View details for Web of Science ID 000222171900008

    View details for PubMedID 15043331

  • A critical review of cervical laminoplasty NEUROSURGERY QUARTERLY Sani, S., Ratliff, J. K., Cooper, P. R. 2004; 14 (1): 5-16
  • Cervical laminoplasty: a critical review JOURNAL OF NEUROSURGERY Ratliff, J. K., Cooper, P. R. 2003; 98 (3): 230-238

    Abstract

    The technique of cervical laminoplasty was developed to decompress the spinal canal in patients with multi-level anterior compression caused by ossification of the posterior longitudinal ligament or cervical spondylosis. There is a paucity of data confirming its superiority to laminectomy with regard to neurological outcome, preserving spinal stability, preventing postlaminectomy kyphosis, and the development of the "postlaminectomy membrane."The authors conducted a metaanalysis of the English-language laminoplasty literature, assessing neurological outcome, change in range of motion (ROM), development of spinal deformity, and complications. Seventy-one series were reviewed, comprising more than 2000 patients. All studies were retrospective, uncontrolled, nonrandomized case series. Forty-one series provided postoperative recovery rate data in which the Japanese Orthopaedic Association Scale was used for assessing myelopathy. The mean recovery rate was 55% (range 20-80%). The authors of 23 papers provided data on the percentage of patients improving (mean approximately 80%). There was no difference in neurological outcome based on the different laminoplasty techniques or when laminoplasty was compared with laminectomy. There was postlaminoplasty worsening of cervical alignment in approximately 35% and with development of postoperative kyphosis in approximately 10% of patients who underwent long-term follow-up review. Cervical ROM decreased substantially after laminoplasty (mean decrease 50%, range 17-80%). The authors of studies with long-term follow up found that there was progressive loss of cervical ROM, and final ROM similar to that seen in patients who had undergone laminectomy and fusion. In their review of the laminectomy literature the authors could not confirm the occurrence of postlaminectomy membrane causing clinically significant deterioration of neurological function. Postoperative complications differed substantially among series. In only seven articles did the writers quantify the rates of postoperative axial neck pain, noting an incidence between 6 and 60%. In approximately 8% of patients, C-5 nerve root dysfunction developed based on the 12 articles in which this complication was reported.The literature has yet to support the purported benefits of laminoplasty. Neurological outcome and change in spinal alignment are similar after laminectomy and laminoplasty. Patients treated with laminoplasty develop progressive limitation of cervical ROM similar to that seen after laminectomy and fusion.

    View details for Web of Science ID 000181993200001

    View details for PubMedID 12691377

  • Convection-enhanced delivery in intact and lesioned peripheral nerve JOURNAL OF NEUROSURGERY Ratliff, J. K., Oldfield, E. H. 2001; 95 (6): 1001-1011

    Abstract

    Although the use of multiple agents is efficacious in animal models of peripheral nerve injury, translation to clinical applications remains wanting. Previous agents used in trials in humans either engendered severe side effects or were ineffective. Because the blood-central nervous system barrier exists in nerves as it does in the brain, limited drug delivery poses a problem for translation of basic science advances into clinical applications. Convection-enhanced delivery (CED) is a promising adjunct to current therapies for peripheral nerve injury. In the present study the authors assessed the capacity of convection to ferry macromolecules across sites of nerve injury in rat and primate models, examined the functional effects of convection on the intact nerve, and investigated the possibility of delivering a macromolecule to the spinal cord via retrograde convection from a peripherally introduced catheter.The authors developed a rodent model of convective delivery to lesioned sciatic nerves (injury due to crush or laceration in 76 nerves) and compared the results to a smaller series of five primates with similar injuries. In the intact nerve, convective delivery of vehicle generated only a transient neurapraxic deficit. Early after injury (postinjury Days 1, 3, 7, and 10), infusion failed to cross the site of injury in crushed or lacerated nerves. Fourteen days after crush injury, CED of radioactively-labeled albumin resulted in perfusion through the site of injury to distal growing neurites. In primates, successful convection through the site of crush injury occurred by postinjury Day 28. In contrast, in laceration models there was complete occlusion of the extracellular space to convective distribution at the site of laceration and repair, and convective distribution in the extracellular space crossed the site of injury only after there was histological evidence of completion of nerve regeneration. Finally, in two primates, retrograde infusion into the spinal cord through a peripheral nerve was achieved.Convection provides a safe and effective means to deliver macromolecules to regenerating neurites in crush-injured peripheral nerves. Convection block in lacerated and suture-repaired nerves indicates a significant intraneural obstruction of the extracellular space. a disruption that suggests an anatomical obstruction to extracellular and, possibly, intraaxonal flow, which may impair nerve regeneration. Through peripheral retrograde infusion, convection can be used for delivery to spinal cord gray matter. Convection-enhanced delivery provides a promising approach to distribute therapeutic agents to targeted sites for treatment of disorders of the nerve and spinal cord.

    View details for Web of Science ID 000172564600014

    View details for PubMedID 11765815

  • Gunshot wounds to the neck SOUTHERN MEDICAL JOURNAL Tender, G. C., Ratliff, J., Awasthi, D., Buechter, K. 2001; 94 (8): 830-832

    Abstract

    Gunshot wounds to the neck are diagnostically and therapeutically challenging cases. We report such a case with vascular and neurologic injuries and describe the therapeutic options. Initial treatment is aimed at hemodynamic stabilization. Zone II neck injuries are managed selectively, and physical examination alone may dictate emergency surgical exploration. Spinal cord injury must be suspected and assessed clinically, as well as by computed tomography and angiography. Deteriorating or stable neurologic status and cord compression by bullet or bone fragments require surgical decompression. Improving neurologic status may be managed conservatively. In gunshot wounds to the neck, treatment should be individualized and multidisciplinary.

    View details for Web of Science ID 000170847600015

    View details for PubMedID 11549197

  • Root and spinal cord compression from methylmethacrylate vertebroplasty. Spine Ratliff, J., Nguyen, T., Heiss, J. 2001; 26 (13): E300-2

    Abstract

    Case report and literature review.Clinicians use methylmethacrylate vertebroplasty to treat vertebral hemangiomas, metastases, and osteoporotic fractures. Cement may leak out of the vertebral body and compress the adjacent spinal cord and nerve roots. We review a case of nerve-root and cord compression from methylmethacrylate extrusion during vertebroplasty.A 50-year-old female presented with disabling thoracic back pain. A metastasis to T1 was discovered, with collapse of the vertebral body but without cord compression. Methylmethacrylate vertebroplasty was performed. After injection, portable computed tomography (CT) showed a leakage of methylmethacrylate into the C8 and T1 foramina and spinal canal. Radiculopathy and myelopathy developed. Surgical decompression using the anterior approach was necessary.Case report.Early surgical intervention decompressed the neural elements and relieved the neurological deficits.Neurologic complications of methylmethacrylate vertebroplasty necessitate active involvement of spine surgeons in patient evaluation and management.

    View details for PubMedID 11458170

  • Outcome study of surgical treatment for axial neck pain SOUTHERN MEDICAL JOURNAL Ratliff, J., Voorhies, R. M. 2001; 94 (6): 595-602

    Abstract

    We reviewed our surgical treatment of chronic axial cervical pain over a 4-year period to determine whether surgery in selected cases was associated with favorable outcomes.We retrospectively studied 27 consecutive cases (20 patients with follow-up) of longstanding axial cervical spine pain treated surgically by a single surgeon from June 1994 through August 1998. Diagnostic workup included the following when appropriate: Minnesota Multiphasic Personality Inventory (MMPI) with interview, provocative diskography (with a nonpainful control level), single photon emission computed tomography (SPECT), and diagnostic facet injection. Twenty patients (74%) responded to a postoperative telephone survey.For general outcome measures, 85% of patients reported satisfaction with pain relief and surgical result. Ninety-five percent stated they would repeat the procedure; 85% manifested improvement in Prolo score.Surgical treatment of chronic axial neck pain, when preceded by thorough evaluation, can yield excellent clinical results.

    View details for Web of Science ID 000169600400004

    View details for PubMedID 11440327

  • Multiple pituitary adenomas in Cushing's disease JOURNAL OF NEUROSURGERY Ratliff, J. K., Oldfield, E. H. 2000; 93 (5): 753-761

    Abstract

    Clinically evident multiple pituitary adenomas rarely occur. The authors assess the incidence and clinical relevance of multiple adenomas in Cushing's disease.A prospective clinical database of 660 pituitary surgeries was analyzed to assess the incidence of multiple pituitary adenomas in Cushing's disease. Relevant radiographic scans, medical records, and histopathological reports were reviewed. Thirteen patients with at least two separate histopathologically confirmed pituitary adenomas were identified. Prolactinomas (nine patients) were the most common incidental tumors. Other incidental tumors included secretors of growth hormone ([GH], one patient) and GH and prolactin (two patients), and a null-cell tumor (one patient). In two patients, early repeated surgery was performed because the initial operation failed to correct hypercortisolism, in one instance because the tumor excised at the initial surgery was a prolactinoma, not an adrenocorticotropic hormone-secreting tumor. One patient had three distinct tumors.Multiple pituitary adenomas are rare, but may complicate management of patients with pituitary disease.

    View details for Web of Science ID 000090033800004

    View details for PubMedID 11059654

  • Osteochondroma of the C5 lamina with cord compression - Case report and review of the literature SPINE Ratliff, J., Voorhies, R. 2000; 25 (10): 1293-1295

    Abstract

    Case report of a solitary osteochondroma of the cervical spine causing myelopathy in a 66-year-old woman.To review the relevant literature and describe a highly unusual clinical manifestation of solitary osteochondroma.Osteochondromas are common benign bony lesions that seldom occur in the axial skeleton. These lesions are more commonly reported with neural compression in cases of hereditary multiple exostoses (Bessel-Hagel syndrome, diaphyseal aclasis).Chart review, review of relevant radiographic examinations and histopathologic specimens, clinical follow-up with examination, and literature review.Manifestation with new neurologic deficit in a 66-year-old patient was singular.Osteochondromas are unusual in the axial skeleton, and are rarely signaled by neural compression. Occurrence is generally in young adults in the second and third decades. Initial manifestation with a new neurologic deficit in a 66-year-old patient was highly unusual.

    View details for Web of Science ID 000087146200019

    View details for PubMedID 10806510

  • Increased MRI signal intensity in association with myelopathy and cervical instability: Case report and review of the literature SURGICAL NEUROLOGY Ratliff, J., Voorhies, R. 2000; 53 (1): 8-13

    Abstract

    Increased T2-weighted signal intensity in patients with cervical myelopathy has been extensively reviewed in the literature. A variety of etiologies with similar MRI appearances have been described; attempt at correlation of MRI findings with clinical presentation and outcomes after treatment has led to a limited consensus.We present a case of cervical myelopathy with associated hyperintense T2-weighted signal characteristics, secondary to cervical spondylosis and instability.Rapid resolution of radiographic abnormalities after surgical decompression and fusion was noted. Clinical improvement did not parallel radiographic resolution.These findings are important in considering the pathophysiology of MRI changes in cervical myelopathy.

    View details for Web of Science ID 000085420000005

    View details for PubMedID 10697228

  • Tethered cord syndrome in adults SOUTHERN MEDICAL JOURNAL Ratliff, J., Mahoney, P. S., Kline, D. G. 1999; 92 (12): 1199-1203

    Abstract

    Adult onset of tethered cord syndrome is a rare pathologic entity. Its treatable nature makes early diagnosis and timely surgical intervention important goals. Because of present referral patterns, adult patients with tethered cord syndrome may present initially to their primary care physician. We present a recent representative case of adult-onset tethered cord syndrome, with emphasis on initial complaints and the symptom constellation relevant to the primary care physician. Thorough clinical history and physical examination should direct investigators to include tethered cord syndrome in the differential diagnosis of select patients.

    View details for Web of Science ID 000084425200013

    View details for PubMedID 10624914

  • Arteriovenous fistula with associated aneurysms coexisting with dural arteriovenous malformation of the anterior inferior fair - Case report and review of the literature JOURNAL OF NEUROSURGERY Ratliff, J., Voorhies, R. M. 1999; 91 (2): 303-307

    Abstract

    This 24-year-old man presented with an unusual case of a high-flow arteriovenous fistula (AVF). This lesion was similar to giant AVFs in children that have been previously described in the literature. In patients in whom abnormalities of the vein of Galen have been excluded and in whom presentation occurs after 20 years of age, a diagnosis of congenital AVF is quite unusual. The fistula in this case originated in an enlarged callosomarginal artery and drained into the superior sagittal sinus via a saccular vascular abnormality. Two giant aneurysmal dilations of the fistula were present. In an associated finding, a small falcine dural arteriovenous malformation (AVM) was also present. Arterial supply to the AVM arose from both external carotid arteries and the left vertebral artery, with drainage through an aberrant vein in the region of the inferior sagittal sinus into the vein of Galen. Craniotomy with exposure and trapping of the AVF was performed, with subsequent radiosurgical (linear accelerator) treatment of the dural AVM. Through this combination of microsurgical trapping of the AVF and radiotherapy of the dural AVM, an excellent clinical outcome was achieved.

    View details for Web of Science ID 000081681800017

    View details for PubMedID 10433319

  • Intramedullary tuberculoma of the spinal cord - Case report and review of the literature JOURNAL OF NEUROSURGERY Ratliff, J. K., Connolly, E. S. 1999; 90 (1): 125-128

    Abstract

    Intramedullary spinal tuberculosis infection remains an extremely rare disease entity. In the most recent reviews only 148 cases have been reported in the world literature, although numerous recent reports from developing countries and on human immunodeficiency virus (HIV)-positive patients have increased this number. The authors present an unusual case of intramedullary tuberculoma in an HIV-negative patient from the southern United States who demonstrated no other signs or symptoms of tuberculosis infection. The authors believe that this is the first case of its kind to be presented in recent literature. The presentation of miliary disease via an isolated intramedullary spinal mass in a patient with no evident risk factors for tuberculosis infection emphasizes the importance of including tuberculosis in the differential diagnosis of spinal cord masses.

    View details for Web of Science ID 000078774400020

    View details for PubMedID 10413137

  • Management of lumbar instability NEUROSURGERY QUARTERLY Connolly, E. S., Ratliff, J. 1997; 7 (1): 1-10
  • Cholesterol levels in 1,084 healthy New Orleans males. journal of the Louisiana State Medical Society Simopoulos, D. N., Ratliff, J., Elahi, P., Brown, M., Waters, M., McMahon, F. G. 1993; 145 (8): 346-351

    Abstract

    It is widely recognized that elevated cholesterol levels constitute a major risk factor for the development of atherosclerosis and coronary heart disease. Most of the previous surveys conducted in an effort to learn more about incidence of hypercholesterolemia involved patients who had other concurrent risk factors such as hypertension, obesity, diabetes mellitus, cigarette smoking, or a history of myocardial infarction. Relatively few studies have been conducted in younger populations or in healthy individuals. Because we had access to baseline cholesterol data on 1,084 relatively young, otherwise completely healthy, nonobese males, we elected to determine the prevalence of hypercholesterolemia in this population. Elevated cholesterol levels (> 200 mg/dL) were found in 25.2% of our healthy subjects. These findings help to confirm the presence of a potentially serious public health problem existing among otherwise healthy, relatively young men in our community.

    View details for PubMedID 8228545