Medical student interested in spine surgery and big data analytics.
Education & Certifications
Bachelor of Science, University of Southern California, Neuroscience (2016)
Medical student interested in spine surgery and big data analytics.
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
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
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
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
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
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
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
Medical malpractice is an important but often underappreciated topic within neurosurgery, particularly for surgeons in the early phases of practice. The practice of spinal neurosurgery involves substantial risk for litigation, as both the natural history of the conditions being treated and the operations being performed almost always carry the risk of permanent damage to the spinal cord or nerve roots, a cardiopulmonary event, death, or other dire outcomes. In this review, the authors discuss important topics related to medical malpractice in spine surgery, including tort reform, trends and frequency of litigation claims in spine surgery, wrong-level and wrong-site surgery, catastrophic outcomes including spinal cord injury and death, and ethical considerations.
View details for DOI 10.3171/2020.8.FOCUS20602
View details for Web of Science ID 000585759900016
View details for PubMedID 33130625
OBJECTIVE: To compare (1) the reoperation rates, (2) risk factors for reoperation, (3) 30-day complication rates, and (4) cost differences between autologous chondrocyte implantation (ACI) and osteochondral allograft transplantation (OCA) of the knee in a large insurance database.DESIGN: Subjects who underwent knee ACI (Current Procedural Terminology [CPT] code 27412) or OCA (CPT code 27415) with minimum 2-year follow-up were queried from a national insurance database. Reoperation was defined by ipsilateral knee procedure after index surgery. Multivariate logistic regression models were built to determine the effect of independent variables (age, sex, tobacco use, obesity, diabetes, and concomitant osteotomy) on reoperation rates. The 30-day complication rates were assessed using ICD-9-CM codes. The cost of the procedures per patient was calculated. Statistical comparisons were made. All P values were reported with significance set at P < 0.05.RESULTS: A total of 909 subjects (315 ACI and 594 OCA) were included (mean follow-up 39.2 months). There was a significantly higher reoperation rate after index ACI compared with OCA (67.6% vs. 40.4%, P < 0.0001). Concomitant osteotomy at the time of index procedure significantly reduced the risk for reoperation in both groups (odds ratio [OR] 0.2, P < 0.0001 and OR 0.2, P = 0.009). The complication rates were similar between ACI (1.6%) and OCA (1.2%) groups (P = 0.24). Day of surgery payments were significantly higher after ACI compared with OCA (P = 0.013).CONCLUSIONS: Autologous chondrocyte implantation had significantly higher reoperation rates and cost with similar complication rates compared with OCA. Concomitant osteotomy significantly reduced the risk for reoperation in both groups.
View details for DOI 10.1177/1947603520967065
View details for PubMedID 33106002
Objective: Endovascular treatment is the mainstay therapy for brain aneurysms. About 15% of patients need re-treatment within six months due to early recanalization. In this study, we investigate risk factors associated with treatment failure.Methods: This retrospective cohort study includes endovascularly treated aneurysm cases between July 2012 and December 2015 at the University of California Davis Medical Center with pre-treatment and early post-treatment imaging. Thin cut 3D aneurysm volume rendering was used for morphologic analyses. Univariate and bivariate analyses were conducted to evaluate differences between patients and clinical factors by treatment failure.Results: Of the 50 patients who met the inclusion criteria, 41 (82.0%) were female, with an average age of 61 years. Most aneurysms were on the anterior communicating artery (40%) or posterior communicating artery (22.0%), and 34 (68%) aneurysms were ruptured. Early treatment failure was observed in 14 (28.0%) of endovascularly treated patients. Raymond-Roy class (RRC) was significantly associated with treatment failure (p = 0.0052), with 10 out of the 14 cases (71.4%) with early recanalization having an RRC of 3. Coil packing density did not associate with aneurysm recanalization (p = 0.61).Conclusion: In our single institution series, patient characteristics, aneurysm characteristics, or coil packing density did not affect early aneurysm recanalization. RRC was the best predictor of early recanalization; however, further confirmation with additional studies are required. Although this study focused on early treatment failure, late recanalization has been shown with longer follow up. Further investigation into factors associated with late treatment failure will need further investigation. New intrasaccular devices and flow diverters will also likely play a role in reducing recurrence in the future as these treatments gain usage.
View details for DOI 10.1016/j.heliyon.2020.e05170
View details for PubMedID 33083618
Purpose: To evaluate the reoperations, complications, and costs up to 5 years following arthroscopic rotator cuff repair (RCR) alone, with acromioplasty (acro), with biceps tenodesis (BT), or with both acro and BT.Methods: We queried the MarketScan database to identify patients who underwent RCR from 2007 to 2016. Patients were stratified into groups based on concomitant procedures (acro and/or BT) performed on the same day as index RCR. Reoperations, complications, and costs were followed for 5 years post-index procedure. Patients without laterality codes were excluded. A multivariate logistic regression analysis was used to control for confounding factors.Results: This study identified 147,838 patients (mean age, 53.1 years; standard deviation, 8.3 years) who underwent primary RCR. Patients were stratified into 4 groups: (1) RCR only, (2) RCR+ acro, (3) RCR+ BT, and (4) RCR+ acro+ BT. Patients in the RCR only group experienced the highest rate of unadjusted overall postoperative complications (17.2%) versus the other groups (RCR+ acro 16.4%, RCR+ BT 15.1%, RCR+ acro+ BT 16.2%, P < .0161). The RCR only group also experienced a significantly greater number of reoperations on the ipsilateral shoulder (P < .0001), whereas the RCR+ acro+ BT had the highest costs at all timepoints. In the regression analysis, there was no significant differences between complications and reoperations between any groups. After adjusting for covariates, the performance of a BT with an RCR and acromioplasty led to increased costs (odds ratio, 1.47, 1.37-1.59, P < .001).Conclusions: Concomitant biceps tenodesis does lead to higher total healthcare costs, both in the shorter and longer terms. When adjusting for confounding factors, the performance of concomitant biceps tenodesis with rotator cuff repair does not lead to a difference in postoperative complication rate or risk for revision surgery.Level of Evidence: Level IV, economic analysis.
View details for DOI 10.1016/j.asmr.2020.05.010
View details for PubMedID 32875302
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
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
Approximately 10% of men and 13% of women older than the age of 60 are affected by symptomatic osteoarthritis of the knee. Anatomic repair or reconstruction after knee injury has been a central tenet of surgical treatment to reduce the risk of osteoarthritis. The purpose of this study was to examine common sports medicine procedures of the knee and determine the proportion of patients who subsequently undergo total knee arthroplasty (TKA).The MarketScan database was queried from the period of January 2007 through December 2016. Patients were identified, who underwent a procedure of the knee, as defined by Current Procedural Terminology codes relating to nonarthroplasty procedures of the knee. Patients in whom laterality could not be confirmed or underwent another ipsilateral knee procedure before TKA were excluded from this study. The primary outcome of this study was the overall rate of TKA after index knee surgery. Time from index procedure to TKA was a secondary outcome. A multivariate regression analysis was used to control for covariates such as age, sex, and comorbidity status.A total of 843,749 patients underwent one of the 13 common sports medicine procedures of the knee. The procedure with the highest unadjusted rate of subsequent TKA was arthroscopic osteochondral allograft (5.81%), whereas anterior cruciate ligament (ACL) reconstruction with meniscus repair demonstrated the lowest rate of subsequent TKA (0.01%). When adjusting for confounding factors, the regression analysis identified meniscal transplantation (odds ratio [OR] = 3.06, P < 0.0001) as having the highest risk of subsequent TKA, followed by osteochondral autograft (OR = 1.74, P = 0.0424) and arthroscopic osteochondral allograft (OR = 1.49, P < 0.0001). ACL reconstruction with meniscus repair (OR = 0.02, P < 0.0001), ACL reconstruction alone (OR = 0.17, P < 0.0001), ACL with meniscectomy (OR = 0.20, P < 0.0001), and meniscal repair (OR = 0.65, P < 0.0001) had the lowest rate of subsequent TKA. ACL reconstruction with meniscus repair had the longest period from index procedure to TKA at 2827 days.ACL reconstruction and meniscus preservation demonstrated an extremely low rate of conversion to TKA when compared with patients who needed salvage interventions such as meniscus and cartilage transplantation. None of the salvage interventions delayed the need for a TKA. Meniscal transplantation had the highest risk of all procedures of going on to a TKA.
View details for DOI 10.5435/JAAOSGlobal-D-20-00125
View details for PubMedID 32852917
The relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis has been reported in multiple studies.To determine the distance from the MPFL central origin on the distal femur to the medial distal femoral physis in skeletally immature participants.Systematic review.A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched for studies investigating the anatomic origin of the MPFL on the distal femur and its relationship to the medial distal femoral physis in skeletally immature participants. Study methodological quality was analyzed with the Anatomical Quality Assessment tool, with studies categorized as low risk, high risk, or unclear risk of bias. Continuous variable data were reported as mean ± SD. Categorical variable data were reported as frequency with percentage.Seven articles were analyzed (298 femurs, 53.7% male patients; mean age, 11.7 ± 3.4 years). There was low risk of bias based on the Anatomical Quality Assessment tool. The distance from the MPFL origin to the distal femoral physis ranged from 3.7 mm proximal to the physis to 10.0 mm distal to the physis in individual studies. Six of 7 studies reported that the MPFL origin on the distal femur lies distal to the medial distal femoral physis in the majority of specimens. The MPFL originated distal to the medial distal femoral physis in 92.8% of participants at a mean distance of 6.9 ± 2.4 mm.The medial patellofemoral ligament originates distal to the medial distal femoral physis in the majority of cases at a mean proximal-to-distal distance of 7 mm distal to the physis. However, this is variable in the literature owing to study design and patient age and sex.
View details for DOI 10.1177/0363546520904685
View details for PubMedID 32109145
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
Meniscal repair leads to improved patient outcomes compared with meniscectomy in small case series.To compare the reoperation rates, 30-day complication rates, and cost differences between meniscectomy and meniscal repair in a large insurance database.Cohort study; Level of evidence, 3.A national insurance database was queried for patients who underwent meniscectomy (Current Procedural Terminology [CPT] code 29880 or 29881) or meniscal repair (CPT code 29882 or 29883) in the outpatient setting and who had a minimum 2-year follow-up. Patients without confirmed laterality and patients who underwent concomitant ligament reconstruction were excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The cost of the procedures per patient was calculated. Propensity score matching was utilized to create matched cohorts with similar characteristics. Statistical comparisons of cohort characteristics, reoperations, postoperative complications, and payments were made. All P values were reported with significance set at P < .05.A total of 27,580 patients (22,064 meniscectomy and 5516 meniscal repair; mean age, 29.9 ± 15.1 years; 41.2% female) were included in this study with a mean follow-up of 45.6 ± 21.0 months. The matched groups were similar with regard to characteristics and comorbidities. There were significantly more patients who required reoperation after index meniscectomy compared with meniscal repair postoperatively (5.3% vs 2.1%; P < .001). Patients undergoing meniscectomy were also significantly more likely to undergo any ipsilateral meniscal surgery (P < .001), meniscal transplantation (P = .005), or total knee arthroplasty (P = .001) postoperatively. There was a significantly higher overall 30-day complication rate after meniscal repair (1.2%) compared with meniscectomy (0.82%; P = .011). The total day-of-surgery payments was significantly higher in the repair group compared with the meniscectomy group ($7094 vs $5423; P < .001).Meniscal repair leads to significantly lower rates of reoperation and higher rates of early complications with a higher total cost compared with meniscectomy in a large database study.
View details for DOI 10.1177/0363546520935453
View details for PubMedID 32667826
The purpose of this study was to determine the (1) reoperation rate and (2) 30-day complication rate in a large insurance database.The Truven Database was queried for subjects that underwent meniscus allograft transplantation (CPT code 29868) in the outpatient setting with minimal two year follow up. Patients without confirmed laterality and patients that underwent concomitant ligament reconstruction were excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using ICD-9-CM codes.284 patients (mean age of 26.2 ± 10.4 years old and 49.6% females) were included in this study with mean follow up of 43.2 ± 19.2 months. One hundred and sixty seven subjects (58.8%) undergoing meniscus allograft transplantation underwent reoperation at an average of 11.9 ± 12.2 months postoperatively. There was a low number of subjects that required ipsilateral unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) postoperatively (0.7% and 1.1%, respectively). The overall 30-day complication rate following meniscus allograft transplantation was 1.4%.Patients undergoing meniscus allograft transplantation have a 58.8% reoperation rate at final follow up with low (1.4%) 30-day complication rates in a large insurance database.
View details for DOI 10.1016/j.arthro.2020.06.031
View details for PubMedID 32645340
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
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
STUDY DESIGN: Technical Report with two illustrative cases.OBJECTIVE: Grade II spondylolisthesis remains a complex surgical pathology for which there is no consensus regarding optimal surgical strategies. Surgical strategies vary regarding extent of reduction, utilization of instrumentation/interbody support, and anterior versus posterior approaches with or without decompression. The objective of this study is to provide the first report on the efficacy of robotic spinal surgery systems in supporting the treatment of grade II spondylolisthesis.METHODS: Utilizing two illustrative cases, we provide a technical report of how a robotic spinal surgery platform can be utilized to treatment grade II spondylolisthesis with a novel instrumentation strategy.RESULTS: We describe how utilization of the "Reverse Bohlman" technique to achieve a large anterior fusion construct spanning the pathologic level and buttressed by the adjacent level above, coupled with a novel, high fidelity posterior fixation scheme with transdiscal S1-L5 and S2Ai screws placed in a minimally invasive fashion with robot guidance allows for the best chance of fusion in situ.CONCLUSIONS: The "Reverse Bohlman" technique coupled with transdiscal S1-L5 and S2Ai screw fixation accomplishes the surgical goals of creating a solid fusion construct, avoiding neurologic injury with aggressive reduction, and halting the progression of anterolisthesis. Utilization of robot guidance allows for efficient placement of these difficult screw trajectories in a minimally invasive fashion.
View details for DOI 10.1016/j.wneu.2019.07.229
View details for PubMedID 31398524
A cell culture platform that enables ex vivo tissue growth from patients or patient-derived xenograft (PDX) models and assesses sensitivity to approved therapies (e.g. Temozolomide, TMZ) in a clinically relevant timeframe would be very useful in translational research and personalized medicine. Here, we present a novel three-dimensional (3D) ECM hydrogel system, VersaGel, for assaying ex vivo growth and therapeutic response with standard image microscopy. Specifically, multicellular spheroids deriving from either five glioblastoma (GBM) patients or a renal cell carcinoma (RCC) PDX model were incorporated into VersaGel and treated with TMZ and several other therapies, guided by the most recent advances in GBM treatment. RCC ex vivo tissue displayed invasive phenotypes in conditioned media. For the GBM patient tumor testing, all 5 clinical responses were predicted by the results of our 3D-TMZ assay. In contrast, the MTT assay found no response to TMZ regardless of the clinical outcome. Finally, one patient was tested with repurposed drugs currently being administered in GBM clinical trials. Interestingly, IC50's were lower than cmax for crizotinib and chloroquine, but higher for sorafenib. In conclusion, a novel hydrogel platform, VersaGel, enables ex vivo tumor growth of patient and PDX tissue and offers insight into patient response to clinically relevant therapies.
View details for PubMedID 30755456
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
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
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
Gangliogliomas (GG) are rare tumors of the nervous system. Patient characteristics and clinical outcomes of low and high-grade GG have been difficult to elucidate in the adult population. This study aims to further elaborate on GG treatment and overall survival utilizing a larger cohort than previously published. The USA National Cancer Database was utilized to evaluate adult (age 18years and older) patients diagnosed with GG between 2004 and 2006. Descriptive statistics and Kaplan-Meier overall survival estimates were provided. A total of 198 adult GG patients were diagnosed between 2004 and 2006. Of these, 181 (91.4%) were low-grade and 17 (8.6%) high-grade GG. Overall, the median age was 36years; approximately 50% of patients were female, and 86.5% Caucasian. Most patients (59%) had near/gross total resection. Radiation and chemotherapy were prescribed in 18 (9.1%) and 11 (5.7%) patients, respectively. Radiation (64.7% versus 3.9%, p<.0001) and chemotherapy (47.1% versus 1.7%, p<.0001) were more frequently given to patients with high-grade tumors than low-grade. The median overall survival of high-grade GG was 44.4months (95% confidence interval [CI]: 10.5-92.5) while the corresponding estimate for low-grade tumors was not reached. Older age (hazard ratio [HR] 1.72, 95% CI: 1.26-2.34) and high tumor grade (HR 3.91, 95% CI: 1.43-10.8) were found to be associated with poor survival. Adult GG have a temporal lobe predilection and overall gross total resection rate of 59%. Older patients with high-grade tumors had an increased hazard of mortality. High-grade GG were significantly more likely to be treated with radiation therapy and chemotherapy.
View details for DOI 10.1016/j.jocn.2015.12.028
View details for Web of Science ID 000379888500011
View details for PubMedID 27083133
Ependymoma is a rare primary brain or spinal cord tumor that arises from the ependyma, a tissue of the central nervous system. This study analyzed a large cohort of adult supratentorial and posterior fossa ependymoma tumors in order to elucidate factors associated with overall survival. We utilized the USA National Cancer Database to study adult World Health Organization grade II/III supratentorial and posterior fossa ependymoma patients treated between 1998 and 2011. Overall survival was estimated by the Kaplan-Meier method and factors associated with survival were determined using a multivariate Cox proportional hazards model. Among 1318 patients, 1055 (80.0%) had grade II and 263 (20.0%) anaplastic tumors located in the posterior fossa (64.3%) and supratentorial region (35.7%). Overall average age was 44.3years, 48.0% of patients were female, 86.5% were Caucasian, and 36.8% underwent near/gross total surgical resection. Radiotherapy was given to 662 patients (50.8%) and 75 (5.9%) received chemotherapy. Older age at diagnosis (hazard ratio [HR] 1.51, p<0.0001), high tumor grade (HR 1.82, p=0.005), and large tumor size (HR 1.66, p=0.008) were associated with poor survival. Females compared to males (HR 0.67, p=0.03) and patients with posterior fossa tumors versus supratentorial (HR 0.64, p=0.04) had a survival advantage. Our study showed that older patients, with supratentorial tumors, and high histological grade had an increased risk of mortality. A survival benefit was captured in females and patients with posterior fossa tumors. Adjuvant radiotherapy and chemotherapy did not confer a survival benefit among all patients, even after stratification by tumor grade or anatomical location.
View details for DOI 10.1016/j.jocn.2015.11.014
View details for Web of Science ID 000376714500006
View details for PubMedID 26810473
OBJECT Head trauma is the leading cause of death in abused children, particularly prior to the age of 2 years. An awareness of factors associated with this condition as well as with a higher risk of mortality is important to improve outcomes and prevent the occurrence of these events. The objective of this study was to evaluate outcomes and factors associated with poor outcomes in infants with diagnosed abusive head trauma (AHT). Patient characteristics, socioeconomic factors, and secondary conditions such as retinal bleeding, contusion, and fractures were considered. METHODS Data were obtained from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. From the Kids' Inpatient Database (KID) sample, the authors identified infants no older than 23 months who had been diagnosed with AHT in 2000, 2003, 2006, and 2009. All statistical analyses were conducted in SAS 9.2. Descriptive statistics were provided, and multivariate logistic regression models were applied to evaluate factors associated with mortality and nonroutine discharge. RESULTS A total of 5195 infants were analyzed in this study. Most infants (85.5%) had ages ranging between 0 and 11 months and were male (61.6%). Overall mortality was 10.8%, with a rate of 9.8% in the 0- to 11-month-old cohort and 16.5% in the 12- to 23-month-olds (p = 0.0003). The overall nonroutine discharge rate of 25.6% increased significantly from 23.3% to 39.0% with increasing age (0-11 vs 12-23 months of age, p < 0.0001). Assuming a multivariate model that adjusted for multiple confounders, the authors found that older infants (12-23 vs 0-11 months, OR 1.81, 95% CI 1.18-2.77) with a secondary diagnosis of retinal bleeding (OR 2.85, 95% CI 2.02-4.00) or shaken baby syndrome (OR 2.09, 95% CI 1.48-2.94) had an increased risk of mortality; these factors were similarly associated with an increased odds of a nonroutine discharge. A higher income ($30,001-$35,000 vs $1-$24,999) was associated with a reduction in the odds of mortality (OR 0.46, 95% CI 0.29-0.72). In the subset of cases (1695 [32.6%]) that specified the perpetrator involved in infant injury, the authors found that the father, stepfather, or boyfriend was most frequently reported (67.4%). A trend for a higher AHT incidence was documented in the early ages (peak at 2 months) compared with older ages. CONCLUSIONS Despite the higher incidence of AHT among infants during the earlier months of life, higher mortality was documented in the 12- to 23-month-olds. Retinal bleeding and shaken baby syndrome were secondary diagnoses associated with higher mortality and nonroutine discharge. Males (67.4%) were overwhelmingly documented as the perpetrators involved in the injury of these infants.
View details for DOI 10.3171/2015.3.PEDS14544
View details for Web of Science ID 000363439700009
View details for PubMedID 26230462
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