✓Bis-chlorethyl-nitrosourea (BCNU) is one of the numerous experimental chemotherapeutic agents used to treat recurrent brain tumors. The clinical response and the angiographic changes in tumor vascularity were compared in 32 patients treated with BCNU for recurrent primary brain tumor. In five of 22 initially vascular lesions the tumor vasculature increased, in 11 it decreased, and in six it remained unchanged after treatment. There was no correlation between angiographic changes in the tumor and the clinical course following BCNU therapy.
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Andrew H. Koo, Derek Fewer, Charles B. Wilson, and Thomas H. Newton
Aladine A. Elsamadicy, Andrew B. Koo, Adam J. Kundishora, Fouad Chouairi, Megan Lee, Astrid C. Hengartner, Joaquin Camara-Quintana, Kristopher T. Kahle, and Michael L. DiLuna
OBJECTIVE
Health policy changes have led to increased emphasis on value-based care to improve resource utilization and reduce inpatient hospital length of stay (LOS). Recently, LOS has become a major determinant of quality of care and resource utilization. For adolescent idiopathic scoliosis (AIS), the determinants of extended LOS after elective posterior spinal fusion (PSF) remain relatively unknown. In the present study, the authors investigated the impact of patient and hospital-level risk factors on extended LOS following elective PSF surgery (≥ 4 levels) for AIS.
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The Kids’ Inpatient Database (KID) was queried for the year 2012. Adolescent patients (age range 10–17 years) with AIS undergoing elective PSF (≥ 4 levels) were selected using theInternational Classification of Diseases, Ninth Revision, Clinical Modificationcoding system. Extended hospital LOS was defined as greater than the 75th percentile for the entire cohort (> 6 days), and patients were dichotomized as having normal LOS or extended LOS. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were recorded. A multivariate logistic regression model was used to determine the odds ratio for risk-adjusted LOS. The primary outcome was the degree to which patient comorbidities or postoperative complications correlated with extended LOS.
RESULTS
Comorbidities were overall significantly higher in the extended-LOS cohort than the normal-LOS cohort. Patients with extended LOS had a significantly greater proportion of blood transfusion (p < 0.001) and ≥ 9 vertebral levels fused (p < 0.001). The overall complication rates were greater in the extended-LOS cohort (20.3% [normal-LOS group] vs 43.5% [extended-LOS group]; p < 0.001). On average, the extended-LOS cohort incurred $18,916 more in total cost than the normal-LOS group ($54,697 ± $24,217 vs $73,613 ± $38,689, respectively; p < 0.001) and had more patients discharged to locations other than home (p < 0.001) than did patients in the normal-LOS cohort. On multivariate logistic regression, several risk factors were associated with extended LOS, including female sex, obesity, hypertension, fluid electrolyte disorder, paralysis, blood transfusion, ≥ 9 vertebrae fused, dural injury, and nerve cord injury. The odds ratio for extended LOS was 1.95 (95% CI 1.50–2.52) for patients with 1 complication and 5.43 (95% CI 3.35–8.71) for patients with > 1 complication.
CONCLUSIONS
The authors’ study using the KID demonstrates that patient comorbidities and intra- and postoperative complications all contribute to extended LOS after spinal fusion for AIS. Identifying multimodality interventions focused on reducing LOS, bettering patient outcomes, and lowering healthcare costs are necessary to improve the overall value of care for patients undergoing spinal fusion for AIS.
Aladine A . Elsamadicy安德鲁·b·古梅根Leedam J. Kundishora, Christopher S. Hong, Astrid C. Hengartner, Joaquin Camara-Quintana, Kristopher T. Kahle, and Michael L. DiLuna
OBJECTIVE
In the past decade, a gradual transition of health policy to value-based healthcare has brought increased attention to measuring the quality of care delivered. In spine surgery, adolescents with scoliosis are a population particularly at risk for depression, anxious feelings, and impaired quality of life related to back pain and cosmetic appearance of the deformity. With the rising prevalence of mental health ailments, it is necessary to evaluate the impact of concurrent affective disorders on patient care after spinal surgery in adolescents. The aim of this study was to investigate the impact that affective disorders have on perioperative complication rates, length of stay (LOS), and total costs in adolescents undergoing elective posterior spinal fusion (PSF) (≥ 4 levels) for idiopathic scoliosis.
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A retrospective study of the Kids’ Inpatient Database for the year 2012 was performed. Adolescent patients (age range 10–17 years old) with AIS undergoing elective PSF (≥ 4 levels) were selected using theInternational Classification of Diseases, Ninth Revision, Clinical Modificationcoding system. Patients were categorized into 2 groups at discharge: affective disorder or no affective disorder. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were assessed. The primary outcomes were perioperative complication rates, LOS, total cost, and discharge dispositions.
RESULTS
There were 3759 adolescents included in this study, of whom 164 (4.4%) were identified with an affective disorder (no affective disorder: n = 3595). Adolescents with affective disorders were significantly older than adolescents with no affective disorders (affective disorder: 14.4 ± 1.9 years vs no affective disorder: 13.9 ± 1.8 years, p = 0.001), and had significantly different proportions of race (p = 0.005). Aside from hospital region (p = 0.016), no other patient- or hospital-level factors differed between the cohorts. Patient comorbidities did not differ significantly between cohorts. The number of vertebral levels involved was similar between the cohorts, with the majority of patients having 9 or more levels involved (affective disorder: 76.8% vs no affective disorder: 79.5%, p = 0.403). Postoperative complications were similar between the cohorts, with no significant difference in the proportion of patients experiencing a postoperative complication (p = 0.079) or number of complications (p = 0.124). The mean length of stay and mean total cost were similar between the cohorts. Moreover, the routine and nonroutine discharge dispositions were also similar between the cohorts, with the majority of patients having routine discharges (affective disorder: 93.9% vs no affective disorder: 94.9%, p = 0.591).
CONCLUSIONS
This study suggests that affective disorders may not have a significant impact on surgical outcomes in adolescent patients undergoing surgery for scoliosis in comparison with adults. Further studies are necessary to elucidate how affective disorders affect adolescent patients with idiopathic scoliosis, which may improve provider approach in managing these patients perioperatively and at follow-up in hopes to better the overall patient satisfaction and quality of care delivered.
Aladine A. Elsamadicy, Andrew B. Koo, Benjamin C. Reeves, Zach Pennington, James Yu, C. Rory Goodwin, Luis Kolb, Maxwell Laurans, Sheng-Fu Larry Lo, John H. Shin, and Daniel M. Sciubba
OBJECTIVE
The Hospital Frailty Risk Score (HFRS) was developed utilizing ICD-10 diagnostic codes to identify frailty and predict adverse outcomes in large national databases. While other studies have examined frailty in spine oncology, the HFRS has not been assessed in this patient population. The aim of this study was to examine the association of HFRS-defined frailty with complication rates, length of stay (LOS), total cost of hospital admission, and discharge disposition in patients undergoing spine surgery for metastatic spinal column tumors.
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A retrospective cohort study was performed using the years 2016 to 2019 of the National Inpatient Sample (NIS) database. All adult patients (≥ 18 years old) undergoing surgical intervention for metastatic spinal column tumors were identified using the ICD-10-CM diagnostic codes and Procedural Coding System. Patients were categorized into the following three cohorts based on their HFRS: low frailty (HFRS < 5), intermediate frailty (HFRS 5–15), and high frailty (HFRS > 15). Patient demographics, comorbidities, treatment modality, perioperative complications, LOS, discharge disposition, and total cost of hospital admission were assessed. A multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, nonroutine discharge, and increased cost.
RESULTS
Of the 11,480 patients identified, 7085 (61.7%) were found to have low frailty, 4160 (36.2%) had intermediate frailty, and 235 (2.0%) had high frailty according to HFRS criteria. On average, age increased along with progressively worsening frailty scores (p ≤ 0.001). The proportion of patients in each cohort who experienced ≥ 1 postoperative complication significantly increased along with increasing frailty (low frailty: 29.2%; intermediate frailty: 53.8%; high frailty: 76.6%; p < 0.001). In addition, the mean LOS (low frailty: 7.9 ± 5.0 days; intermediate frailty: 14.4 ± 13.4 days; high frailty: 24.1 ± 18.6 days; p < 0.001), rate of nonroutine discharge (low frailty: 40.4%; intermediate frailty: 60.6%; high frailty: 70.2%; p < 0.001), and mean total cost of hospital admission (low frailty: $48,603 ± $29,979; intermediate frailty: $65,271 ± $43,110; high frailty: $96,116 ± $60,815; p < 0.001) each increased along with progressing frailty. On multivariate regression analysis, intermediate and high frailty were each found to be significant predictors of both prolonged LOS (intermediate: OR 3.75 [95% CI 2.96–4.75], p < 0.001; high: OR 7.33 [95% CI 3.47–15.51]; p < 0.001) and nonroutine discharge (intermediate: OR 2.05 [95% CI 1.68–2.51], p < 0.001; high: OR 5.06 [95% CI 1.93–13.30], p = 0.001).
CONCLUSIONS
This study is the first to use the HFRS to assess the impact of frailty on perioperative outcomes in patients with metastatic bony spinal tumors. Among patients with metastatic bony spinal tumors, frailty assessed using the HFRS was associated with longer hospitalizations, more nonroutine discharges, and higher total hospital costs.
Branden J. Cord, Sreeja Kodali, Sumita Strander, Andrew Silverman, Anson Wang, Fouad Chouairi, Andrew B. Koo, Cindy Khanh Nguyen, Krithika Peshwe, Alexandra Kimmel, Carl M. Porto, Ryan M. Hebert, Guido J. Falcone, Kevin N. Sheth, Lauren H. Sansing, Joseph L. Schindler, Charles C. Matouk, and Nils H. Petersen
OBJECTIVE
While the benefit ofmechanicalthrombectomy(MT)forpatientswithanterior circulationacuteischemicstrokewithlarge-vessel occlusion (AIS-LVO) has been clearly established, difficultvascularaccessmay make the intervention impossible or unduly prolonged.Inthis study, the authors evaluated safety as well as radiographic and functional outcomesinstrokepatientstreatedwith太通过directcarotidpuncture(DCP)forprohibitivevascularaccess.
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The authors retrospectively studiedpatientsfrom their prospective AIS-LVO database who underwent attempted MT between 2015 and 2018.Patientswithprohibitivevascularaccesswere divided into two groups: 1) aborted MT (abMT) after failed transfemoralaccessand 2) attempted MT via DCP. Functional outcome was assessed using the modified Rankin Scale at 3 months. Associationswithoutcome were analyzed using ordinal logistic regression.
RESULTS
Of 352 consecutivepatientswithanterior circulation AIS-LVO who underwent attempted MT, 37patients(10.5%) were deemed to haveprohibitivevascularaccess(mean age [± SD] 82 ± 11 years, mean National Institutes of HealthStrokeScale [NIHSS] score 17 ± 5,withfemales accountingfor75% of thepatients). There were 20patientsinthe DCP group and 17inthe abMT group. The two groups were well matchedforthe known predictors of clinical outcome: age, sex, and admission NIHSS score.Directcarotidaccesswas successfully obtainedin19 of 20patients. Successful reperfusion (thrombolysisincerebral infarction score 2b or 3) was achievedin16 (84%) of 19patientsinthe DCP group.Carotidaccesscomplications included an inability to catheterize thecarotidarteryin1patient, neck hematomasin4patients, non–flow-limiting commoncarotidartery (CCA) dissectionsin2patients, and a delayed, fatalcarotidblowoutin1patient. The neck hematomas and non–flow-limiting CCA dissections did not require any subsequent interventions and remained clinically silent. Comparedwiththe abMT group,patientsinthe DCP group had smaller infarct volumes (11 vs 48 ml, p = 0.04), a greater reductioninNIHSS score (−4 vs +2.9, p = 0.03), and better functional outcome (shift analysisfor3-month modified Rankin Scale score: adjusted OR 5.2, 95% CI 1.02–24.5; p = 0.048).
CONCLUSIONS
DCPforemergency MTinpatientswithanterior circulation AIS-LVO andprohibitivevascularaccessis safe and effective and is associatedwithhigher recanalization rates, smaller infarct volumes, and improved functional outcome comparedwithpatientswithabMT after failed transfemoralaccess. DCP should be consideredinthispatientpopulation.
Mani Ratnesh S. Sandhu, Wyatt B. David, Benjamin C. Reeves, Josiah J. Z. Sherman, Samuel Craft, Christina Jayaraj, Sam Boroumand, Mona Clappier, Alan Gutierrez, Margot Sarkozy, Andrew B. Koo, Dominick A. Tuason, Michael L. DiLuna, and Aladine A. Elsamadicy
OBJECTIVE
Insurance disparities have been suggested to influence the medical and surgical outcomes of adult patients with spinal cord injury (SCI), with a paucity of studies demonstrating their impact on the outcomes of pediatric and adolescent SCI patients. The aim of this study was to assess the impact of insurance status on healthcare utilization and outcomes in adolescent patients presenting with SCI.
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An administrative database study was performed using the 2017 admission year from 753 facilities using the National Trauma Data Bank. Adolescent patients (11–17 years old) with cervical/thoracic SCIs were identified usingInternational Classification of Diseases, Tenth Revision, Clinical Modificationcoding. Patients were categorized by governmental insurance versus private insurance/self-pay. Patient demographics, comorbidities, imaging, procedures, hospital adverse events (AEs), and length of stay (LOS) data were collected. Multivariate regression analyses were used to determine the effect of insurance status on LOS, any imaging or procedure, or any AE.
RESULTS
Of the 488 patients identified, 220 (45.1%) held governmental insurance while 268 (54.9%) were privately insured. Age was similar between the cohorts (p = 0.616), with the governmental insurance cohort (GI cohort) having a significantly lower proportion of non-Hispanic White patients than the private insurance cohort (PI cohort) (GI: 43.2% vs PI: 72.4%, p < 0.001). While transportation accident was the most common mechanism of injury for both cohorts, assault was significantly greater in the GI cohort (GI: 21.8% vs PI: 3.0%, p < 0.001). A significantly greater proportion of patients in the PI cohort received any imaging (GI: 65.9% vs PI: 75.0%, p = 0.028), while there were no significant differences in procedures performed (p = 0.069) or hospital AEs (p = 0.386) between the cohorts. The median (IQR) LOS (p = 0.186) and discharge disposition (p = 0.302) were similar between the cohorts. On multivariate analysis, with respect to governmental insurance, private insurance was not independently associated with obtaining any imaging (OR 1.38, p = 0.139), undergoing any procedure (OR 1.09, p = 0.721), hospital AEs (OR 1.11, p = 0.709), or LOS (adjusted risk ratio −2.56, p = 0.203).
CONCLUSIONS
This study suggests that insurance status may not independently influence healthcare resource utilization and outcomes in adolescent patients presenting with SCIs. Further studies are needed to corroborate these findings.
