Meic H. Schmidt

BACKGROUND AND OBJECTIVES: Type II odontoid fractures (T2OF) are the most prevalent cervical spine injuries among the elderly. Nonetheless, there are insufficient data regarding the influence of frailty on outcomes for both nonoperative and operative treatment approaches. We sought to evaluate the influence of frailty on outcomes using 5-factor modified frailty index. METHODS: We performed a retrospective review of the American College of Surgeons Trauma Quality Improvement Program database from 2015 to 2020. We analyzed nonoperative and operative traumatic T2OF cases. Outcomes included major complications, hospital length of stay (LOS), nonhome discharge (NHD), mortality rates, and survival probabilities. We used unmatched and propensity score–matched risk-adjusted models to assess the association between frailty and all outcomes. Survival probabilities were examined using Kaplan–Meier plots, stratified by frailty strata. RESULTS: A total of 22 440 patients comprising 7138 (31.8%) robust, 7913 (35.2%) normal, 5158 (22.9%) frail, and 2231 (9.9%) very frail patients were included. Results from unmatched multivariable analyses revealed a dose-dependent relationship between frailty and all outcomes, in both cohorts ( P < .05). Propensity score–matched resulted in 3942 nonoperative and operative matched pairs. Preoperative characteristics were similar between cohorts, except for age: 75 years (IQR: 60-83) for nonoperative and 70 years (IQR: 56-78) for operative, and male sex: 1799 (55.8%) for nonoperative and 439 (61.1%) for operative cohorts. Significant mortality reductions (43%-77%; P < .05) were observed in the operative cohort compared with the nonoperative cohort across all frailty strata. As expected, the operative cohort had longer LOS and increased NHD risk ranging from 64% to 97%, P < .001. In Kaplan–Meier analyses, survival declined significantly across increasing frailty strata P < .001. CONCLUSION: Increasing frailty was independently associated with major complications, LOS, NHD, and decreased survival. Operative patients exhibited improved survival compared with nonoperative patients across all frailty strata. These findings highlight the importance of frailty in T2OF management and care coordination.

BACKGROUND AND OBJECTIVES: Organized neurosurgery offers innumerable opportunities for scientific exchange, networking, and continuing medical education (CME). National, regional, and state societies and meetings have rapidly proliferated across neurosurgery, as have neurosurgical-associated publications and journals. This study sought to review individual costs incurred by neurosurgeons seeking engagement in organized neurosurgery to illustrate the costs associated with participation. METHODS: National, regional, and state neurosurgery societies were identified, and associated annual meetings were recorded. Leading neurosurgery journals, as determined by reputation and impact factor, were selected. Data unavailable online were acquired through direct communication with the respective organization. American Board of Neurological Surgeons board-certification costs were acquired and compared with board-certification costs in comparable specialties (orthopedic surgery (Ortho), plastic surgery (PS), general surgery (GS), neurology). Baseline academic engagement was defined as two general society memberships, two annual meeting registrations, and respective board certification. A CME credit-per-dollar value was created to measure the relative financial value of CME. RESULTS: A total of 31 societies, 23 meetings, and 18 journals were identified. Society membership costs included American Association of Neurological Surgeons ($1100), Congress of Neurological Surgeons ($990), Society of NeuroInterventional Surgery ($775), and Cervical Spine Research Society ($950). Meetings with the greatest registration fees included the Society of Neurological Surgeons ($1800) and the American Society of Pediatric Neurosurgeons ($1675) annual meetings. Individual journal subscription costs included Journal of Neurosurgery ($636), Neurosurgery ($643), Spine ($1188), and World Neurosurgery ($909). In our limited comparison, the specialty of neurosurgery had the greatest baseline academic engagement cost ($11,588; PS: $8105; Ortho: $7013; GS: $5570; neurology: $4640). Costs of nontraditional CME are significantly less compared with traditional, meeting-driven CME opportunities. CONCLUSION: Organized neurosurgery incurs major individual costs by way of society membership, meeting registration, and journal subscriptions. Rising costs for engagement are substantial and may not be sustainable when contrasted with unchanged CME reimbursement, prompting dialog to identify sources of subsidization.

BACKGROUND AND OBJECTIVES: Neurosurgery is a world leader in disseminating neurosurgical science. Although the literature has seen significant increases in academic collaboration, data science, and authorship diversity, the bibliometric evolution of Neurosurgery remains unknown. This study sought to elucidate bibliometric trends in Neurosurgery from 1977 to 2023. METHODS: Wolters Kluwer and Web of Science were used to identify all publications in Neurosurgery from 1977 to 2023. Database utilization was analyzed from 2007 to 2023 using abstract keywords. The BERTopic tool analyzed prevailing subspecialty themes. Publication types including clinical/case report/review were analyzed. Statistical analysis included exponential and linear regression. RESULTS: From 1977 to 2023, 29 755 publications containing 127 171 authors were published in Neurosurgery. From 1977 to 2023, the mean authorship count per publication exponentially increased (2.4 to 8.4, 2.0% annually) (R ² = 0.76), small authorship groups (≤ 5 authors) linearly decreased (90% to 37%) (R = 0.93), multinational authorship groups linearly increased (0% to 21.2%) (R = 0.95), and authorship affiliations per publication exponentially increased (1.3 to 4.6, 3.2% annually) (R ² = 0.65). From 1990 to 2023, female first authorship linearly increased (7.5% to 15.7%) (R = 0.93), Bachelor degree first authorship increased (0.6% to 12.5%), and MD/PhD senior authorship increased (6.2% to 24.7%), with more review articles and less case reports. Cerebrovascular topics dominated from 1980 to 2020, with spine topics most represented in the 2020s. Database utilization demonstrated an exponential, 4.6-fold increase from 2007 (0.38%) to 2023 (2.14%) (R = 0.63). CONCLUSION: Neurosurgery publications have demonstrated increasing authorship counts, authorship diversity, collaboration, and database utilization since the journal's 1977 inception, prominently publishing on topics in cerebrovascular and spine research.

Objective: To evaluate the prognostic utility of baseline frailty, measured by the Risk Analysis Index (RAI), for prediction of postoperative mortality among patients with spinal malignancy (SM) undergoing resection.Methods: SM surgery cases were queried from the American College of Surgeons – National Surgical Quality Improvement Program database (2011–2020). The relationship between preoperative RAI frailty score and increasing rate of primary endpoint (mortality or discharge to hospice within 30 days, “mortality/hospice”) were assessed. Discriminatory accuracy was assessed by computation of C-statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis.Results: A total of 2,235 cases were stratified by RAI score: 0–20, 22.7%; 21–30, 11.9%; 31–40, 54.7%; and ≥ 41, 10.7%. The rate of mortality/hospice was 6.5%, which increased linearly with increasing RAI score (p < 0.001). RAI was also associated with increasing rates of major complication, extended length of stay, and nonhome discharge (all p < 0.05). The RAI demonstrated acceptable discriminatory accuracy for prediction of primary endpoint (C-statistic, 0.717; 95% CI, 0.697–0.735). In pairwise ROC comparison, RAI demonstrated superiority versus modified frailty index-5 and chronological age (p < 0.001).Conclusion: Preoperative frailty, as measured by RAI, is a robust predictor of mortality/ hospice after SM surgery. The frailty score may be applied in clinical settings using a user-friendly calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spinalMalignancyRAI/.

OBJECTIVE: The objective of this paper was to compare the predictive ability of the recalibrated Risk Analysis Index (RAI-rev) with the 5-item modified frailty index-5 (mFI-5) for postoperative outcomes of anterior cervical discectomy and fusion (ACDF). METHODS: This study was performed using data of adult (age > 18 years) ACDF patients obtained from the National Surgical Quality Improvement Program database during the years 2015–2019. Multivariate modeling and receiver operating characteristic (ROC) curve analysis, including area under the curve/C-statistic calculation with the DeLong test, were performed to evaluate the comparative discriminative ability of the RAI-rev and mFI-5 for 5 postoperative outcomes. RESULTS: Both the RAI-rev and mFI-5 were independent predictors of increased postoperative mortality and morbidity in a cohort of 61,441 ACDF patients. In the ROC analysis for 30-day mortality prediction, C-statistics indicated a significantly better performance of the RAI-rev (C-statistic = 0.855, 95% CI 0.852–0.858) compared with the mFI-5 (C-statistic = 0.684, 95% CI 0.680–0.688) (p < 0.001, DeLong test). The results were similar for postoperative ACDF morbidity, Clavien-Dindo grade IV complications, nonhome discharge, and reoperation, demonstrating the superior discriminative ability of the RAI-rev compared with the mFI-5. CONCLUSIONS: The RAI-rev demonstrates superior discrimination to the mFI-5 in predicting postoperative ACDF mortality and morbidity. To the authors’ knowledge, this is the first study to document frailty as an independent risk factor for postoperative mortality after ACDF. The RAI-rev has conceptual fidelity to the frailty phenotype and may be more useful than the mFI-5 in preoperative ACDF risk stratification. Prospective validation of these findings is necessary, but patients with high RAI-rev scores may benefit from knowing that they might have an increased surgical risk for ACDF morbidity and mortality.