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OBJECTIVEThe objective of this study was to evaluate the incidence and risk factors for 90-day readmission and reoperation after elective surgery for lumbar spinal stenosis (LSS).METHODSThe authors performed a retrospective consecutive cohort analysis of patients undergoing posterior lumbar decompression with or without fusion for LSS with claudication from January 2014 through December 2015.RESULTSData were collected on 1592 consecutive patients. The mean age at surgery was 67.4 ± 10.1 years and 45% of patients were female. The 90-day reoperation rate was 4.7%, and 69.3% of the reoperations occurred within the first 30 days. The 90-day readmission rate was 7.2%. Multivariable analysis showed that postoperative development of a surgical site infection (SSI; odds ratio [OR] 14.09, 95% confidence interval [CI] 7.86–25.18), acute kidney injury (AKI; OR 6.76, 95% CI 2.39–19.57), and urinary tract infection (UTI; OR 3.96, 95% CI 2.43–6.37), as well as a history of congestive heart failure (CHF; OR 3.03, 95% CI 1.69–5.28), were significant risk factors for readmission within 90 days. Male sex (OR 0.60, 95% CI 0.38–0.92) was associated with decreased odds for readmission. With regards to reoperation, development of SSI (OR 25.06, 95% CI 13.54–46.51), sepsis (OR 7.63, 95% CI 1.52–40.59), UTI (OR 2.54, 95% CI 1.31–4.76), and increased length of stay (LOS; OR 1.25, 95% CI 1.17–1.33) were found to be significant risk factors. A subsequent analysis found that morbid obesity (OR 6.99), history of coronary artery disease (OR 2.263), increased duration of surgery (OR 1.004), and LOS (OR 1.07) were significant risk factors for developing an SSI.CONCLUSIONSOverall, this study found rates of 4.7% and 7.2% for reoperation and readmission, respectively, within 90 days: 30.7% of the reoperations and 44.7% of the readmissions occurred beyond the first 30 days. A diagnosis of SSI, AKI, UTI, and history of CHF were significant factors for readmission, while male sex was associated with decreased odds for readmission. A diagnosis of SSI, sepsis, UTI, and increased LOS were found to be significant predictors for reoperation. Understanding 90-day complication rates is imperative because there has been increased discussion and healthcare policy extending the global postoperative window to 90 days. Current literature supports a readmission rate of 3%–9% after spine surgery. However, this literature either is limited to a 30-day window or does not stratify between different types of spine surgeries.

OBJECTIVE The position of neurosurgery department chair undergoes constant evolution as the health care landscape changes. The authors' aim in this paper was to characterize career attributes of neurosurgery department chairs in order to define temporal trends in qualities being sought in neurosurgical leaders. Specifically, they investigated the hypothesis that increased qualifications in the form of additional advanced degrees and research acumen are becoming more common in recently hired chairs, possibly related to the increased complexity of their role. METHODS The authors performed a retrospective study in which they collected data on 105 neurosurgeons who were neurosurgery department chairs as of December 31, 2016, at accredited academic institutions with a neurosurgery residency program in the United States. Descriptive data on the career of neurosurgery chairs, such as the residency program attended, primary subspecialty focus, and age at which they accepted their position as chair, were collected. RESULTS The median age and number of years in practice postresidency of neurosurgery chairs on acceptance of the position were 47 years (range 36-63 years) and 14 years (range 6-33 years), respectively, and 87% (n = 91) were first-time chairs. The median duration that chairs had been holding their positions as of December 31, 2016, was 10 years (range 1-34 years). The most common subspecialties were vascular (35%) and tumor/skull base (27%), although the tendency to hire from these specialties diminished over time (p = 0.02). More recently hired chairs were more likely to be older (p = 0.02), have more publications (p = 0.007), and have higher h-indices (p < 0.001) at the time of hire. Prior to being named chair, 13% (n = 14) had a PhD, 4% (n = 4) had an MBA, and 23% (n = 24) were awarded a National Institutes of Health R01 grant, tendencies that were stable over time (p = 0.09-0.23), although when additional degrees were analyzed as a binary variable, chairs hired in 2010 or after were more likely to have an MBA and/or PhD versus those hired before 2010 (26% vs 10%, p = 0.04). The 3 most common residency programs attended by the neurosurgery chairs were Massachusetts General Hospital (n = 8, 8%), University of California, San Francisco (n = 8, 8%), and University of Michigan (n = 6, 6%). Most chairs (n = 63, 61%) attended residency at the institution and/or were staff at the institution before they were named chair, a tendency that persisted over time (p = 0.86). CONCLUSIONS Most neurosurgery department chairs matriculated into the position before the age of 50 years and, despite selection processes usually involving a national search, most chairs had a previous affiliation with the department, a phenomenon that has been relatively stable over time. In recent years, a large increase has occurred in the proportion of chairs with additional advanced degrees and more extensive research experience, underscoring how neurosurgical leadership has come to require scientific skills and the ability to procure grants, as...

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Background Necrotizing fasciitis is a rare infection with rapid deterioration and a high mortality rate. Factors associated with in-hospital mortality have not been thoroughly evaluated. Although predictive models identifying the diagnosis of necrotizing fasciitis have been described (such as the Laboratory Risk Indicator for Necrotizing Fasciitis [LRINEC]), their use in predicting mortality is limited. Questions/purposes (1) What demographic factors are associated with in-hospital mortality in patients with necrotizing fasciitis? (2) What clinical factors are associated with in-hospital mortality? (3) What laboratory values are associated with in-hospital mortality? (4) Is the LRINEC score useful in predicting mortality? Methods We retrospectively studied all patients with necrotizing fasciitis at our tertiary care institution during a 10-year period. In all, 134 patients were identified; after filtering out patients with missing data (seven) and those without histologically confirmed necrotizing fasciitis (12), 115 patients remained. These patients were treated with early-initiation antibiotic therapy and aggressive surgical intervention once the diagnosis was suspected. Demographic data, clinical features, laboratory results, and treatment variables were identified. The median age was 56 years and 42% of patients were female. Of the 115 patients analyzed, 15% (17) died in the hospital. Univariate and receiver operating characteristic analyses were performed due to the low number of mortality events seen in this cohort. Results The demographic factors associated with in-hospital mortality were older age (median: 64 years for nonsurvivors [interquartile range (IQR) 57-79] versus 55 years for survivors [IQR 45-63]; p = 0.002), coronary artery disease (odds ratio 4.56 [95% confidence interval (CI) 1.51 to 14]; p = 0.008), chronic kidney disease (OR 4.92 [95% CI 1.62 to 15]; p = 0.006), and transfer from an outside hospital (OR 3.47 [95% CI 1.19 to 10]; p = 0.02). The presenting clinical characteristics associated with in-hospital mortality were positive initial blood culture results (OR 4.76 [95% CI 1.59 to 15]; p = 0.01), lactic acidosis (OR 4.33 [95% CI 1.42 to 16]; p = 0.02), and multiple organ dysfunction syndrome (OR 6.37 [95% CI 2.05 to 20]; p = 0.002). Laboratory values at initial presentation that were associated with in-hospital mortality were platelet count (difference of medians -136 [95% CI -203 to -70]; p < 0.001), serum pH (difference of medians -0.13 [95% CI -0.21 to -0.03]; p = 0.02), serum lactate (difference of medians 0.90 [95% CI 0.40 to 4.80]; p < 0.001), serum creatinine (difference of medians 1.93 [95% CI 0.65 to 3.44]; p < 0.001), partial thromboplastin time (difference of medians 8.30 [95% CI 1.85 to 13]; p = 0.03), and international normalized ratio (difference of medians 0.1 [95% CI 0.0 to 0.5]; p = 0.004). The LRINEC score was a poor predictor of mortality with an area under the receiver operating characteristics curve of 0.56 [95% CI 0.45-0.67]. Conclusions Factors aiding clinical recognition of necrotizing fasciitis are not consistently helpful in predicting mortality of this infection. Identifying patients with potentially compromised organ function should lead to aggressive and expedited measures for diagnosis and treatment. Future multicenter studies with larger populations and a standardized algorithm of treatment triggered by high clinical suspicion can be used to validate these findings to better help prognosticate this potentially fatal diagnosis. Level of Evidence Level III, therapeutic study.

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Study Design. Retrospective cohort study. Objective. The aims of this study were to (1) compare patient and procedure-specific characteristics among those who had short versus long hospital stays and (2) identify independent risk factors that may correlate with extended length of hospital stay (LOS) in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior segmental instrumented fusion (PSIF). Summary of Background Data. Reducing the LOS and identifying risk factors associated with extended admission have become increasingly relevant to healthcare policy makers. There is currently limited research identifying risk factors that correlate with extended stay in patients undergoing PSIF for AIS. Methods. A single-institution, longitudinally maintained database was queried to identify 407 patients who met specific inclusion and exclusion criteria. Based on the distribution and median LOS in the cohort (4 days), patients were divided into those who had long versus short LOS. In both groups, patient demographics, comorbidities, preoperative scoliosis curve measurements, surgery-related characteristics, and complications were analyzed. A univariate and multivariate regression analysis was then conducted to identify independent risk factors associated with extended LOS. Results. Patients who had extended LOS tended to be women (84.6% vs. 75%, P = 0.01), had more levels fused (9 ± 2 vs. 7 ± 2 levels, P < 0.001), had more major postoperative complications (0.8% vs. 7.4%, P = 0.002), had more blood loss during surgery (723 ± 548 vs. 488 ± 341 cm3, P < 0.001), and received less epidural analgesia for pain control (69% vs. 89%, P < 0.001). Except for higher thoracic kyphosis, long LOS patients did not have worse preoperative radiographic curve parameters. Multivariate logistic analysis identified female sex, having ≥9 ± 2 levels of fusion, operative blood loss, major postoperative complications, lack of epidural analgesia, and higher thoracic kyphosis as independent risk factors correlating for extended LOS. Conclusion. Independent risk factors identified by this study may be used to recognize patients with AIS at risk of prolonged hospital stay. Level of Evidence: 3

BACKGROUND Deep brain stimulation (DBS) was first approved by the United States Food and Drug Administration in 1997. Although the fundamentals of DBS remain the same, hardware, software, and imaging have evolved significantly. OBJECTIVE To test our hypothesis that the aggregate complication rate in the medical literature in the past 12 years would be lower than what is often cited based on early experience with DBS surgery. METHODS PubMed, PsycINFO, and EMBASE were queried for studies from 2008 to 2020 that included patients treated with DBS from 2007 to 2019. This yielded 34 articles that evaluated all complications of DBS surgery, totaling 2249 patients. RESULTS The overall complication rate in this study was 16.7% per patient. There was found to be a systemic complication rate of 0.89%, intracranial complication rate of 2.7%, neurological complication rate of 4.6%, hardware complication rate of 2.2%, and surgical site complication rate of 3.4%. The infection and erosion rate was 3.0%. CONCLUSION This review suggests that surgical complication rates have decreased since the first decade after DBS was first FDA approved. Understanding how to minimize complications from the inception of a technique should receive more attention.