Michigan Spine Surgery Improvement Collaborative

Michigan Spine Surgery Improvement Collaborative

https://mssic.org/

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide quality improvement collaborative involving orthopedic surgeons and neurosurgeons with the aim of improving the quality of care of spine surgery. The objective of this collaborative is to heighten patient care outcomes while consequently increasing the efficiency of treatment.

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospectivelongitudinalmulticenterquality-improvement collaborative.

Michigan Spine Surgery Improvement Collaborative (MSSIC) prospectively collects data on all patients undergoing operations for degenerative and/or deformity indications.


In 2013, Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) established the Michigan Spine Surgery Improvement Collaborative (MSSIC) as a Collaborative Quality Initiative (CQI). MSSIC is one of the newest of 21 other CQIs that have significantly improved and continue to improve the quality of patient care throughout the state of Michigan. METHODS MSSIC focuses on lumbar and cervical spine surgery, specifically indications such as stenosis, disk herniation, and degenerative disease. Surgery for tumors, traumatic fractures, deformity, scoliosis, and acute spinal cord injury are currently not within the scope of MSSIC. Starting in 2014, MSSIC consisted of 7 hospitals and in 2015 included another 15 hospitals, for a total of 22 hospitals statewide. A standardized data set is obtained by data abstractors, who are funded by BCBSM/BCN. Variables of interest include indications for surgery, baseline patient-reported outcome measures, and medical history. These are obtained within 30 days of surgery. Outcome instruments used include the EQ-5D general health state score (0 being worst and 100 being the best health one can imagine) and EQ-5D-3 L. For patients undergoing lumbar surgery, a 0 to 10 numeric rating scale for leg and back pain and the Oswestry Disability Index for back pain are collected. For patients undergoing cervical surgery, a 0 to 10 numeric rating scale for arm and neck pain, Neck Disability Index, and the modified Japanese Orthopaedic Association score are collected. Surgical details, postoperative hospital course, and patient-reported outcome measures are collected at 90-day, 1-year, and 2-year intervals. RESULTS As of July 1, 2015, a total of 6397 cases have been entered into the registry. This number reflects 4824 eligible cases with confirmed surgery dates. Of these 4824 eligible cases, 3338 cases went beyond the 120-day window and were considered eligible for the extraction of surgical details, 90-day outcomes, and adverse events. Among these 3338 patients, there are a total of 2469 lumbar cases, 862 cervical cases, and 7 combined procedures that were entered into the registry.

In addition to functioning as a registry, MSSIC is also meant to be a platform for quality improvement with the potential for future initiatives and best practices to be implemented statewide in order to improve quality and lower costs. With its current rate of recruitment and expansion, MSSIC will provide a robust platform as a regional prospective registry. Its unique funding model, which is supported by BCBSM/BCN, will help ensure its longevity and viability, as has been observed in other CQIs that have been active for several years 1).


Macki et al. aimed to identify which factors are significantly associated with return-to-work after lumbar surgery at long-term follow-up.

Summary of background data: Prior publications have created a clinically relevant predictive model for return-to-work, wherein educationgenderrace, comorbidities, and preoperative symptoms increased the likelihood of return-to-work at 3 months after lumbar surgery. They sought to determine if these trends 1) persisted at 1 year and 2 years postoperatively, or 2) differed among preoperatively employed versus unemployed patients.

MSSIC was queried for all patients undergoing lumbar operations (2014-2019). All patients intended to return to work postoperatively. Patients were followed for up to 2 years postoperatively. Measures of association were calculated with multivariable generalized estimating equations (GEE).

Return-to-work increased from 63% (3542/5591) at 90 days postoperatively to 75% (3143/4147) at 1 year and 74% (2133/2866) at 2 years postoperatively. Following GEE, neither clinical nor surgical variables predicted return-to-work at all three-time intervals: 90 days, 1 year, and 2 years postoperatively. Only socioeconomic factors reached statistical significance at all follow-up points. Preoperative employment followed by insurance status had the greatest associations with return-to-work. In a sub-analysis of patients who were preoperatively employed, insurance was the only factor with significant associations with return-to-work at all three follow-up intervals. The return-to-work rates among unemployed patients at baseline increased from 29% (455/1100) at 90 days, 44% (495/608) at 1 year, and 46% (366/426) at 2 years postoperatively. The only two significant factors associated with return-to-work at all three follow-up intervals were Medicaid, as compared to private insurance, and male gender.

In patients inquiring about long-term return-to-work after lumbar surgery, health insurance status represents the important determinant of employment status.Level of Evidence: 2 2).


While a complex myriad of socio-economic factors interplay between race and surgical success, they identified modifiable risk factors, specifically depression, that may improve patient-reported outcomes (PROs) among African American patients after elective lumbar spine surgery 3).


Correction of sagittal balance is associated with greater odds of discharge to home. These findings, coupled with the recognized implications of admission to a rehabilitation facility, will emphasize the importance of spine surgeons accounting for the sagittal vertical axis (SVA) in their surgical planning of MIS lumbar interbody fusions 4)


Using MSSIC, Zakaria et al. sought to identify the relationship between a positive Patient Health Questionnaire-2 (PHQ-2) screening, which is predictive of depression, and patient satisfactionreturn to work, and achieving Oswestry Disability Index (ODI) minimal clinically important difference (MCID) scores up to 2 years after lumbar fusion.

Data from a total of 8585 lumbar fusion patients were analyzed. Patient satisfaction was measured by the North American Spine Society patient satisfaction index. A positive PHQ-2 score is one that is ≥ 3, which has an 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. Generalized estimating equation models were constructed; variables tested include age, sex, race, past medical history, severity of surgery, and preoperative opioid usage.

Multivariate analysis was performed. Patients with a positive PHQ-2 score (i.e., ≥ 3) were less likely to be satisfied after lumbar fusion at 90 days (relative risk [RR] 0.93, p < 0.001), 1 year (RR 0.92, p = 0.001), and 2 years (RR 0.92, p = 0.028). A positive PHQ-2 score was also associated with decreased likelihood of returning to work at 90 days (RR 0.76, p < 0.001), 1 year (RR 0.85, p = 0.001), and 2 years (RR 0.82, p = 0.031). A positive PHQ-2 score was predictive of failure to achieve an ODI MCID at 90 days (RR 1.07, p = 0.005) but not at 1 year or 2 years after lumbar fusion.

A multivariate analysis based on information from a large, multicenter, prospective database on lumbar fusion patients was performed. The authors found that a positive score (≥ 3) on the PHQ-2, which is a simple and accurate screening tool for depression, predicts an inability to return to work and worse satisfaction up to 2 years after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes 5).


Ninety-day readmission occurred in 9.0% of patients, mainly for painwound infection, and radicular symptoms. Increased focus on postoperative pain may decrease readmissions. Among factors impacting the likelihood of 90-d readmission, early postoperative ambulation may be most easily modifiable. Optimization of preexisting medical conditions could also potentially decrease readmission risk 6).


Multivariate analysis identified the common adverse events after cervical spine surgery, along with their associated risk factors. They found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events 7).


1)

Chang V, Schwalb JM, Nerenz DR, Pietrantoni L, Jones S, Jankowski M, Oja-Tebbe N, Bartol S, Abdulhak M. The Michigan Spine Surgery Improvement Collaborative: a statewide Collaborative Quality Initiative. Neurosurg Focus. 2015 Dec;39(6):E7. doi: 10.3171/2015.10.FOCUS15370. PMID: 26621421.
2)

Macki M, Anand SK, Hamilton T, Lim S, Mansour T, Bazydlo M, Schultz L, Abdulhak MM, Khalil JG, Park P, Aleem I, Easton R, Schwalb JM, Nerenz D, Chang V. Analysis of Factors associated with Return to Work After Lumbar Surgery up to 2-years follow-up: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study. Spine (Phila Pa 1976). 2021 Jul 7. doi: 10.1097/BRS.0000000000004163. Epub ahead of print. PMID: 34265812.
3)

Macki M, Hamilton T, Lim S, Telemi E, Bazydlo M, Nerenz DR, Zakaria HM, Schultz L, Khalil JG, Perez-Cruet MJ, Aleem IS, Park P, Schwalb JM, Abdulhak MM, Chang V. Disparities in outcomes after spine surgery: a Michigan Spine Surgery Improvement Collaborative study. J Neurosurg Spine. 2021 May 7:1-9. doi: 10.3171/2020.10.SPINE20914. Epub ahead of print. PMID: 33962387.
4)

Macki M, Fadel HA, Hamilton T, Lim S, Massie LW, Zakaria HM, Pawloski J, Chang V. The influence of sagittal spinopelvic alignment on patient discharge disposition following minimally invasive lumbar interbody fusion. J Spine Surg. 2021 Mar;7(1):8-18. doi: 10.21037/jss-20-596. PMID: 33834123; PMCID: PMC8024762.
5)

Zakaria HM, Mansour TR, Telemi E, Asmaro K, Macki M, Bazydlo M, Schultz L, Nerenz DR, Abdulhak M, Schwalb JM, Park P, Chang V. Use of Patient Health Questionnaire-2 scoring to predict patient satisfaction and return to work up to 1 year after lumbar fusion: a 2-year analysis from the Michigan Spine Surgery Improvement Collaborative. J Neurosurg Spine. 2019 Aug 23:1-8. doi: 10.3171/2019.6.SPINE1963. [Epub ahead of print] PubMed PMID: 31443085.
6)

Park P, Nerenz DR, Aleem IS, Schultz LR, Bazydlo M, Xiao S, Zakaria HM, Schwalb JM, Abdulhak MM, Oppenlander ME, Chang VW. Risk Factors Associated With 90-Day Readmissions After Degenerative Lumbar Fusion: An Examination of the Michigan Spine Surgery Improvement Collaborative (MSSIC) Registry. Neurosurgery. 2019 Sep 1;85(3):402-408. doi: 10.1093/neuros/nyy358. PMID: 30113686.
7)

Zakaria HM, Bazydlo M, Schultz L, Pahuta MA, Schwalb JM, Park P, Aleem I, Nerenz DR, Chang V; MSSIC Investigators. Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative. J Neurosurg Spine. 2019 Feb 15:1-13. doi: 10.3171/2018.10.SPINE18666. Epub ahead of print. PMID: 30771759.

Electrical stimulation for peripheral nerve injury treatment

Electrical stimulation for peripheral nerve injury treatment

Peripheral nerve injury afflicts individuals from all walks of life. Despite the peripheral nervous system’s intrinsic ability to regenerate, many patients experience incomplete functional recovery. Surgical repair aims to expedite this recovery process in the most thorough manner possible. However, full recovery is still rarely seen especially when nerve injury is compounded with polytrauma where surgical repair is delayed. Pharmaceutical strategies supplementary to nerve microsurgery have been investigated but surgery remains the only viable option 1).


Electrical stimulation is regarded pivotal to promote repair of nerve injury, however, failed to get extensive application in vivo due to the challenges in noninvasive electrical loading accompanying with construction of biomimetic cell niche.

Building on decades of experimental evidence in animal models, several recent, prospective, randomized clinical trials have affirmed electrical stimulation as a clinically translatable technique to enhance functional recovery in patients with peripheral nerve injuries requiring surgical treatment 2).


Implantable wireless stimulators can deliver therapeutic electrical stimulation to injured peripheral nerve tissue. Implantable wireless nerve stimulators might represent a novel means of facilitating therapeutic electrical stimulation in both intraoperative and postoperative settings 3).


Zhang et al. demonstrated a new concept of magneto responsive electric 3D matrix for remote and wireless electrical stimulation. By the preparation of magnetoelectric core/shell structured Fe3 O4 @BaTiO3 NPs-loaded hyaluronan/collagen hydrogels, which recapitulate considerable magneto-electricity and vital features of native neural extracellular matrix, the enhancement of neurogenesis both in cellular level and spinal cord injury in vivo with external pulsed magnetic field applied is proved. The findings pave the way for a novel class of remote controlling and delivering electricity through extracellular niches-mimicked hydrogel network, arising prospects not only in neurogenesis but also in human-computer interaction with higher resolution 4).


The frequency of stimulation is an important factor in the success of both quality and quantity of axon regeneration as well as growth of the surrounding myelin and blood vessels that support the axon. Histological analysis and measurement of regeneration showed that low frequency stimulation had a more successful outcome than high frequency stimulation on regeneration of damaged sciatic nerves.

The use of autologous nerve grafting procedures that involve redirection of regenerative donor nerve fibers into the graft conduit has been successful in restoring target muscle function. Localized delivery of soluble neurotrophic factors may help promote the rate of axon regeneration observed within these graft conduits.

An expanding area of nerve regeneration research deals with the development of scaffolding and bio-conduits. Scaffolding developed from biomaterial would be useful in nerve regeneration if they successfully exhibit essentially the same role as the endoneurial tubes and Schwann cell do in guiding regrowing axons.

The surgeon, who treats nerve injuries, should have knowledge about how peripheral nerves react to trauma, particularly an understanding about the extensive pathophysiological alterations that occur both in the peripheral and in the central nervous system. A large number of factors influence the functional outcome, where the surgeon only can affect a few of them. In view of the new knowledge about the delicate intracellular signaling pathways that are rapidly initiated in neurons and in nonneuronal cells with the purpose to induce nerve regeneration, the timing of nerve repair and reconstruction after injury has gained more interest. It is crucial to understand and to utilize the inborn mechanisms for survival and regeneration of neurons and for activation, survival, and proliferation of the Schwann cells and other cells that are acting after a nerve injury. Thus, experimental and clinical data clearly point toward the advantage of early nerve repair and reconstruction of injuries. Following an appropriate diagnosis of a nerve injury, the nerve should be promptly repaired or reconstructed, and new rehabilitation strategies should early be initiated. Considering nerve transfers in the treatment arsenal can shorten the time of nerve reinnervation of muscle targets. Timing of nerve repair and reconstruction is crucial after nerve injury 5).


1)

Willand MP, Nguyen MA, Borschel GH, Gordon T. Electrical Stimulation to Promote Peripheral Nerve Regeneration. Neurorehabil Neural Repair. 2016 Jun;30(5):490-6. doi: 10.1177/1545968315604399. Epub 2015 Sep 10. PMID: 26359343.
2)

Zuo KJ, Gordon T, Chan KM, Borschel GH. Electrical stimulation to enhance peripheral nerve regeneration: Update in molecular investigations and clinical translation. Exp Neurol. 2020 Oct;332:113397. doi: 10.1016/j.expneurol.2020.113397. Epub 2020 Jul 3. PMID: 32628968.
3)

MacEwan MR, Gamble P, Stephen M, Ray WZ. Therapeutic electrical stimulation of injured peripheral nerve tissue using implantable thin-film wireless nerve stimulators. J Neurosurg. 2018 Feb 9:1-10. doi: 10.3171/2017.8.JNS163020. Epub ahead of print. PMID: 29424647.
4)

Zhang Y, Chen S, Xiao Z, Liu X, Wu C, Wu K, Liu A, Wei D, Sun J, Zhou L, Fan H. Magnetoelectric Nanoparticles Incorporated Biomimetic Matrix for Wireless Electrical Stimulation and Nerve Regeneration. Adv Healthc Mater. 2021 Jun 27:e2100695. doi: 10.1002/adhm.202100695. Epub ahead of print. PMID: 34176235.
5)

Dahlin LB. The role of timing in nerve reconstruction. Int Rev Neurobiol. 2013;109:151-64. doi: 10.1016/B978-0-12-420045-6.00007-9. Review. PubMed PMID: 24093611.

Malignant middle cerebral artery territory infarction

Malignant middle cerebral artery territory infarction

The malignant middle cerebral artery territory infarction is a distinct syndrome that occurs in up to 10% of stroke patients, 1) 2) which carries a mortality of up to 80% (mostly due to severe postischemic cerebral edema → increased ICP → herniation 3)

Patients usually present with findings of severe hemispheric stroke (hemiplegia, forced eye and head deviation) often with CT findings of major infarct within the first 12 hours. Most develop drowsiness shortly after admission. There is progressive deterioration during the first 2 days, and subsequent transtentorial herniation usually within 2–4 days of stroke. Fatalities are often associated with: severe drowsiness, dense hemiplegia, age > 45–50 yrs, 4) early parenchymal hypodensity involving > 50% of the MCA distribution on CT scan,23 midline shift > 8–10 mm, early sulci effacement, and hyperdense artery sign (p. 1354) 5) in MCA. Neurosurgeons may become involved in caring for these patients because aggressive therapies in these patients may reduce morbidity and mortality. Options include:

  1. conventional measures to control ICP (with or without ICP monitor): mortality is still high in this group and elevated ICP is not a common cause of initial neurologic deterioration in large hemispheric stroke

2. hemicraniectomy (decompressive craniectomy):

  1. ✖ to date, the following treatments have not improved outcome: agents to lyse clot, hyperventilationmannitol, or barbiturate coma.

In patients with severe middle cerebral artery (MCA), intracranial atherosclerotic disease (ICAD), the mechanism of stroke is multifactorial, but hemodynamic insufficiency plays a significant role. This finding is important in selecting a subgroup of patients who may benefit from revascularization 6).

see Malignant middle cerebral artery syndrome.

Malignant middle cerebral artery territory infarction diagnosis.

Malignant middle cerebral artery territory infarction treatment.

Malignant middle cerebral artery territory infarction outcome.

A case of a child with serological evidence of SARS-CoV-2 infection whose onset was a massive right cerebral artery ischemia that led to a malignant cerebral infarction. The patient underwent a life-saving decompressive hemicraniectomy, with good functional recovery, except for residual hemiplegia. During rehabilitation, the patient also developed a lower extremity peripheral nerve neuropathy, likely related to a long-Covid syndrome 7).


A 39-year-old woman in the 24th week of pregnancy who suffered a right malignant MCA infarction that eventually required DC. The patient delivered a healthy baby and underwent a second surgery for cranioplasty 7 months later. 8).


1)

Moulin DE, Lo R, Chiang J, et al. Prognosis in Middle Cerebral Artery Occlusion. Stroke. 1985;16:282–284
2) , 3)

Hacke W, Schwab S, Horn M, et al. Malignant Middle Cerebral Artery Territory Infarction: Clinical Course and Prognostic Signs. Arch Neurol. 1996; 53:309–315
4) , 5)

Wijdicks EFM, Diringer MN. Middle Cerebral Artery Territory Infarction and Early Brain Swelling: Progression and Effect of Age on Outcome. Mayo Clin Proc. 1998; 73:829–836
6)

Dubow JS, Salamon E, Greenberg E, Patsalides A. Mechanism of Acute Ischemic Stroke in Patients with Severe Middle Cerebral Artery Atherosclerotic Disease. J Stroke Cerebrovasc Dis. 2014 Jan 11. pii: S1052-3057(13)00425-4. doi: 10.1016/j.jstrokecerebrovasdis.2013.10.015. [Epub ahead of print] PubMed PMID: 24424333.
7)

Scala MR, Spennato P, Cicala D, Piccolo V, Varone A, Cinalli G. Malignant cerebral infarction associated with COVID-19 in a child. Childs Nerv Syst. 2021 Jun 26. doi: 10.1007/s00381-021-05273-x. Epub ahead of print. PMID: 34175976.
8)

Fernández García A, Jiménez Zapata HD, de Lera Alfonso MC, Sánchez Fernández C, Jiménez Arribas P, Rodríguez Arias CA. Decompressive Craniectomy in Pregnant Women. J Neurol Surg A Cent Eur Neurosurg. 2021 Jun 2. doi: 10.1055/s-0041-1726108. Epub ahead of print. PMID: 34077979.
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