Ibrahim, Sufyan

Background Although regional anesthesia (RA) is associated with improved pain control, reduced opioid use, and accelerated recovery after arthroplasty, racial and geographic differences have been identified in hip and knee arthroplasty, with limited data for shoulder and ankle arthroplasty. We examined differences in RA utilization for shoulder, hip, knee, and ankle arthroplasty, based on patient-level and hospital-level characteristics. Methods Using the National Inpatient Sample, we conducted a cross-sectional study of adults who underwent shoulder, hip, knee, and ankle arthroplasties from 2016 to 2020. RA was defined using procedure codes for neuraxial anesthesia and peripheral nerve blocks. Weighted descriptive statistics summarized RA utilization and compared patient-level and hospital-level characteristics using standardized mean differences (SMDs), with ≥0.10 indicating meaningful differences. Results We identified 1132 011 unweighted admissions, representing approximately 5.7 million weighted arthroplasties. RA was used in 7.0% of cases. RA utilization varied by procedure type, with the highest rates in shoulder (11.4%) and ankle arthroplasty (11.4%), followed by knee (9.1%) and hip arthroplasty (2.4%). Variation in RA utilization was observed in ankle arthroplasty based on race (SMD=0.11) and primary payer (SMD=0.12). RA use also varied by hospital size for shoulder (SMD=0.13), hip (SMD=0.29), and knee arthroplasty (SMD=0.22), by hospital location and teaching status for shoulder (SMD=0.17), hip (SMD=0.18), knee (SMD=0.19), and ankle arthroplasty (SMD=0.12), and by geographic region for shoulder (SMD=0.26), hip (SMD=0.45), knee (SMD=0.24), and ankle arthroplasty (SMD=0.17). Conclusions There is notable variation in RA use for inpatient arthroplasty across hospitals and geographic regions, with limited variation based on patient characteristics. These findings highlight the presence of system-level variation in RA use and underscore the need for further research to better understand the drivers of these patterns.

OBJECTIVE Isthmic spondylolisthesis impacts up to 11.5% of the general population. For patients who have failed conservative therapy, decompression and fusion or decompression alone are options for surgical management. However, there remains debate as to whether reduction of mobile spondylolisthesis is integral to good patient outcomes. The present systematic review and meta-analysis aimed to address this by comparing clinical and radiological outcomes between patients treated with fusion in situ and those undergoing fusion with reduction of isthmic spondylolisthesis. METHODS The Scopus, EMBASE, Medline, and Cochrane databases were systematically queried on the basis of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies comparing treatment outcomes in patients with isthmic spondylolisthesis after in situ fusion or fusion with spondylolisthesis reduction. Endpoints of interest included Oswestry Disability Index (ODI) score, hospitalization duration, operative morbidity, and rates of surgical revision. Data from individual studies were aggregated using random-effects models to assess combined effects. RESULTS Of 277 identified studies, 7 studies were included with an aggregate 308 patients (143 underwent fusion in situ and 165 underwent reduction). Patients who underwent reduction for isthmic lumbar spondylolisthesis had significantly lower rates of pseudarthrosis at last follow-up (OR 0.22, p = 0.03). Estimated blood loss, operative time, hospitalization duration, change in ODI score, change in back pain (visual analog scale [VAS]), and reoperation rate did not differ significantly between groups. CONCLUSIONS For patients with isthmic spondylolisthesis, the present data suggest that fusion with reduction of spondylolisthesis may lower rates of pseudarthrosis as compared to in situ fusion. However, operative morbidity and improvement in patient-reported outcomes were similar between strategies.

Background: Estimating operative time with low accuracy and precision leads to suboptimal scheduling of available operating rooms (ORs) and waste of healthcare resources. We aimed to develop a predictive machine learning (ML) model for operative time using our institutional data to improve the scheduling of neurosurgical ORs, minimize waste, and maximize resource utilization. Methods: We developed a predictive model using our institution’s multicenter registry, which included diverse neurosurgical cases across three tertiary hospitals. We applied multiple ML techniques, including linear regression, support vector regression, deep neural networks, and extreme gradient boosting regression (XGBR). The best model was combined with the first fit decreasing bin-packing algorithm to create a practical OR scheduling system based on prior data. Results: The XGBR model exhibited the best performance, with lower mean absolute errors (MAEs) (root mean squared error: 52.24, MAE: 37.25) and higher R2 (0.76) values than other models. Implementing this model in a simulated OR scheduling scenario using institutional data, we successfully scheduled 30 random procedures with minimal residual time, such that the model ran out of procedures for the week with 86 and 171 min remaining in the cranial and spinal ORs, respectively, demonstrating potential efficiency gains. The cranial procedures were scheduled over 4 days and spinal procedures over 6 days, optimizing available OR time. Conclusion: Integrating ML models into operative time prediction can significantly improve the accuracy and efficiency of surgical schedules. This approach minimizes wasted OR time and enhances resource allocation, potentially improving patient outcomes and satisfaction by reducing waiting times.

Background: Postoperative failure to wean from ventilator support is associated with poor outcomes. This study characterizes patients requiring prolonged ventilation after head-and-neck reconstructive surgery and their outcomes. Methods : Patients who underwent head-and-neck reconstructive surgery were identified in the National Surgical Quality Improvement Program (NSQIP) database using CPT codes, ICD-10 codes, and free-text search. Hypothesis testing and regression analysis was utilized to compare patient characteristics and peri/postoperative complication rates between those with and without extended ventilation. Results : NSQIP contained 4661 patients who underwent free flap surgery; 180 experienced prolonged ventilation. Patients with primary oral cavity/sinonasal malignancy, preoperative ventilator dependence, and preoperative open wound/wound infection were more likely to experience prolonged ventilation. Prolonged ventilation patients experienced double the overall hospital stay, and increased rates of wound disruption, reoperation, and mortality. (p<0.05). Conclusion : Prolonged mechanical ventilation can significantly affect outcomes of free flap patients, including longer hospital stays, and higher 30-day mortality.

BACKGROUND AND OBJECTIVES: Cervical spinal cord injury (SCI) can occur in the absence of easily identifiable osseoligamentous abnormalities, such as fractures and dislocations. The role of surgery in the management of this condition remains to be elucidated. METHODS: A comprehensive literature search was conducted to identify studies investigating outcomes after surgical management of cervical SCI without fracture and dislocation. Random-effects model meta-analysis was performed, with neurological improvement and time to surgery as primary end points. Subgroup analysis by time to surgery was performed to assess neurological improvement between patients undergoing surgery within 72 hours of injury vs later than 72 hours after injury. RESULTS: A total of 16 studies yielding 398 surgically treated patients with this condition were analyzed. The mean age at the time of injury was 52 ± 33.8 years, and male patients comprised 86.4% (95% CI: 76.6%-94.4%). The mean number of spinal cord segments affected was 2.5 ± 4. Injury was most commonly inflicted by falls (58.4%, 95% CI: 46.6%-69.9%), followed by motor vehicle accidents (30.5%, 95% CI: 23.4%-38%). Preoperatively, abnormal magnetic resonance imaging findings were observed in 125 patients (31.4%), and included: Intervertebral disk injury in 33 patients (26.4%); Cord edema in 23 patients (18.4%); Cord contusion in 22 patients (17.6%); Ligamentous injury in 6 patients (4.8%); and MRI abnormalities not specified in 41 patients (32.8%). Postoperatively, neurological improvement was noted in 62% (95% CI: 21.4%-95.2%) of patients who underwent surgery within 72 hours after injury, and in 71.1% (95% CI: 33%-98.1%) of the patients who underwent surgery later than 72 hours after injury ( P = .8). CONCLUSION: This meta-analysis demonstrated high rates of neurological improvement in patients treated surgically for cervical SCI without fracture and dislocation. No significant differences were noted between patients undergoing surgery acutely, within 72 hours after injury, and patients being treated surgically later in the course of cervical SCI without fracture and dislocation.

BACKGROUND AND OBJECTIVES: There has been limited assessment between anterior cervical diskectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) on patient-reported outcome measures (PROMs) in the treatment of cervical spondylotic myelopathy. We sought to compare PROMs from two-level ACDF with single-level ACCF procedures. We evaluate these results in the context of minimum clinically important difference (MCID) thresholds, which have not been performed previously. METHODS: This retrospective analysis of prospectively collected data from the Quality Outcomes Database Spine Collaborative Research Study Group compared two-level ACDF and single-level ACCF at 3-, 12-, and 24 months postoperatively. PROMs included arm pain Numeric Rating Scale, neck pain Numeric Rating Scale, Neck Disability Index, and North American Spine Society Patient Satisfaction Index. Multivariate logistic regression was used to determine differences in perioperative outcomes, as well as the impact of two-level ACDF vs one-level ACCF on PROMs. MCID thresholds were based off previously established limits. RESULTS: Three hundred and thirty patients were included (236 ACDF, 94 ACCF), and the follow-up rate was 82% at 2 years. There was a significantly higher baseline age, American Society of Anesthesiologists grade, proportion of diabetes, osteoarthritis, ambulation dependence, and myelopathy severity in the ACCF cohort. On multivariable analysis, the ACCF group had greater average length of stay and estimated blood loss. There were no significant differences between reoperation rates or nonroutine discharge. There were similar rates of MCID achievement for PROMs at all time points. CONCLUSION: This study suggests that both ACDF and ACCF procedures for cervical spondylotic myelopathy are able to achieve similar, clinically meaningful improvements in PROMs by 2 years. Patients undergoing single-level ACCF have more estimated blood loss and longer length of stay, as well as worse baseline myelopathy. Both procedures have efficacious, durable outcomes. It is reasonable that other factors, such as radiographic characteristics and patient symptoms, may influence patient selection for ACDF vs ACCF.

OBJECTIVE Cervical spondylotic myelopathy (CSM) shows varying levels of improvement after surgical treatment. While some patients improve soon after surgery, others may take months to years to show any signs of improvement. The goal of this study was to evaluate postoperative improvement, patient-reported outcomes, and patient satisfaction up to 2 years after surgical treatment for CSM, which will help optimize the current treatment strategies and effectively manage patient expectations. METHODS This was a retrospective study of prospectively collected data using the Quality Outcomes Database. The primary outcomes of interest were achievement of the minimal clinically important difference (MCID) for the numeric rating scale for neck and arm pain, modified Japanese Orthopaedic Association, Neck Disability Index, and EQ-5D scores and postoperative satisfaction (North American Spine Society scale). Early and sustained improvement was defined as MCID achievement in at least one patient-reported outcome measure (PROM) at the 3-, 12-, and 24-month follow-ups. Transient improvement was defined as MCID achievement only at the 3-month and/or 12-month follow-up but not at the 24-month follow-up. Late improvement was defined as MCID achievement in at least one PROM only at the 24-month follow-up. RESULTS There were 630 patients included in the comparative analysis. A total of 463 (73.5%) patients achieved early and sustained improvement, 105 (16.7%) patients experienced transient improvement with subsequent decline, 25 (4.0%) patients reported late improvement, and 37 (5.9%) patients did not report any clinically meaningful improvement after surgery. Patients with an anterior approach were more likely to be in the early and sustained improvement group. African American patients (OR 2.98, 95% CI 1.14–7.76; p = 0.03) were more likely to report late improvement when compared with White patients. The overall satisfaction rate at the 24-month follow-up was 87.8%. CONCLUSIONS These findings indicate that 73.5% of patients achieve early and sustained improvement, and 87.8% of patients are satisfied with surgery 24 months postoperatively.

OBJECTIVE Primary rod fracture after surgery for adult spinal deformity (ASD) is a leading cause of revision, with recent prospective multicenter fracture rates reported at 11%–14% by 2 years. Consequently, the addition of supplemental rods has been explored to reduce fractures. Here the authors describe their experience with a novel iliac accessory rod technique in which each accessory rod anchors to an independent iliac bolt caudally via lateral connector, and attaches to the primary rod rostrally via side-to-side connector. METHODS This retrospective, single-center case series included patients who underwent thoracolumbar/lumbar fusion for ASD between March 2019 and August 2023. Data on baseline demographics, radiographic parameters, surgical characteristics, complications, rod fracture, and revision rates were collected. Paired, 2-tailed t-tests were used to compare pre- and postoperative radiographic outcomes. Rod fracture rates were compared to prior investigations via chi-square goodness of fit testing. The technique for iliac accessory rod placement is described. RESULTS The study consisted of 82 patients (mean age 66 years, 51% female, 26% with prior fusion) with a median follow-up of 2 years (IQR 28–104 weeks). A total of 50 patients (61%) had ≥ 2-year follow-up. Each surgery involved an average of 4 posterior column osteotomies and 8 segments. Iliac accessory rods were cobalt chromium and were placed bilaterally in 87% of constructs. Postoperative alignment improved significantly in the following parameters: maximum coronal Cobb angle, fractional curve, sagittal vertical axis, lumbar lordosis, thoracic kyphosis, and pelvic incidence to lumbar lordosis mismatch (p < 0.001 for all comparisons). Of 50 patients with ≥ 2-year follow-up, rod fracture occurred in 1 (2.0%), which was incidentally found and required no intervention. The present rod fracture rate was significantly lower than the authors’ historically reported institutional rate of 21% for traditional dual-rod constructs, and the 11%–14% reported in recent prospective multicenter studies that used traditional and supplemental rod constructs (p < 0.05 for all comparisons). Reoperation occurred in 12 patients (14.6%); 7 (8.5%) for proximal junctional kyphosis and 5 (6.1%) for wound complication. CONCLUSIONS Here the authors describe their experience with a novel iliac accessory rod technique to prevent rod fracture in patients undergoing surgery for ASD. The 2-year rod fracture rate (2.0%) in this study is significantly lower than the authors’ historical dual-rod fracture rate, and other prospective multicenter investigations. Future studies with longer follow-up are needed to determine the durability of this technique.

OBJECTIVE Deficiency in patient education has been correlated with increased disease-related morbidity and decreased access to care. However, the associations between educational level, preoperative disease severity, and postoperative outcomes in patients with lumbar spondylolisthesis have yet to be explored. METHODS The spondylolisthesis dataset of the Quality Outcomes Database (QOD)—a cohort with prospectively collected data by the SpineCORe study team of the 12 highest enrolling sites with an 81% follow-up at 5 years —was utilized and stratified for educational level. Patients were classified into three categories (high school or less, graduate, or postgraduate). Patient-reported outcome measures (PROMs) documented at baseline and follow-up included Oswestry Disability Index (ODI) score, EQ-5D in quality-adjusted life years, and numeric rating scale (NRS) scores for back and leg pain. Disease severity was measured with PROMs. Postoperatively, patients also completed the North American Spine Society assessment to measure their satisfaction with surgery. Multivariable regression analysis was used to compare education level with disease severity and postoperative outcomes. RESULTS A total of 608 patients underwent analysis, with 260 individuals (42.8%) at an educational level of high school or less. On univariate analysis, baseline disease severity was worse among patients with lower levels of education. On multivariable regression analysis, patients with postgraduate level of education had significantly lower ODI scores (β = −3.75, 95% CI −7.31 to −0.2, p = 0.039) compared to graduates, while the other PROMs were not associated with significant differences at baseline. Five years postoperatively, patients from various educational backgrounds exhibited similar rates of minimal clinically important differences in PROMs. Nevertheless, patients with the lowest educational level had higher ODI scores (27.1, p < 0.01), lower EQ-5D scores (0.701, p < 0.01), and higher NRS leg pain (3.0, p < 0.01) and back pain (4.0, p < 0.01) scores compared to those with graduate or postgraduate levels of education. The odds for postoperative satisfaction were also comparable between cohorts at 5 years (reference, graduate level; high school or less, OR 0.87, 95% CI 0.46–1.64, p = 0.659; postgraduate, OR 1.6, 95% CI 0.7–3.65, p = 0.262). CONCLUSIONS Lower patient education level was associated with a greater baseline disease severity in patients with lumbar spondylolisthesis. Surgery demonstrated similar benefits irrespective of educational background; however, individuals with lower educational level reported lower outcomes overall. This emphasizes the need for enhanced health literacy to mitigate disparities for reported outcomes.