Jonathan N Grauer

Yale University, New Haven, Connecticut, United States

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Publications (211)409.51 Total impact

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    ABSTRACT: OBJECT Surgery for subdural hematoma (SDH) is a commonly performed neurosurgical procedure. This study identifies patient characteristics associated with adverse outcomes and prolonged length of stay (LOS) in patients who underwent surgical treatment for SDH. METHODS All patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) who were treated via craniotomy or craniectomy for SDH between 2005 and 2012 were identified. Patient demographics, comorbidities, and 30-day outcomes were described. Multivariate regression was used to identify predictors of adverse events. RESULTS A total of 746 surgical procedures performed for SDH were identified and analyzed. Patients undergoing this procedure were 64% male with an average age (± SD) of 70.9 ± 14.1 years. The most common individual adverse events were death (17%) and intubation for more than 48 hours (19%). In total, 34% experienced a serious adverse event other than death, 8% of patients returned to the operating room (OR), and the average hospital LOS was 9.8 ± 9.9 days. In multivariate analysis, reduced mortality was associated with age less than 60 years (relative risk [RR] = 0.47, p = 0.017). Increased mortality was associated with gangrene (RR = 3.5, p = 0.044), ascites (RR = 3.00, p = 0.006), American Society of Anesthesiologists (ASA) Class 4 or higher (RR = 2.34, p = 0.002), coma (RR = 2.25, p < 0.001), and bleeding disorders (RR = 1.87, p = 0.003). Return to the OR was associated with pneumonia (RR = 3.86, p = 0.044), male sex (RR = 1.85, p = 0.015), and delirium (RR = 1.75, p = 0.016). Serious adverse events were associated with ventilator dependence preoperatively (RR = 1.86, p < 0.001), dialysis (RR = 1.44, p = 0.028), delirium (RR = 1.40, p = 0.005), ASA Class 4 or higher (RR = 1.36, p = 0.035), and male sex (RR = 1.29, p = 0.037). Similarly, LOS was increased in ventilator dependent patients by 1.56-fold (p = 0.002), in patients with ASA Class 4 or higher by 1.30-fold (p = 0.006), and in delirious patients by 1.29-fold (p = 0.008). CONCLUSIONS Adverse outcomes are common after surgery for SDH. In this study, 18% of the patients died within 30 days of surgery. Factors associated with adverse outcomes were identified. Patients and families should be counseled about the serious risks of morbidity and death associated with acute traumatic SDH requiring surgery.
    Journal of Neurosurgery 08/2015; DOI:10.3171/2015.2.JNS142721 · 3.74 Impact Factor
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    ABSTRACT: Magnetic resonance imaging (MRI) is often used in the evaluation of degenerative conditions of the cervical spine. However, the agreement of interpreting and reporting varying degenerative findings on cervical MRI has not been well assessed. To compare the inter-rater and intra-rater agreement of MRI findings between common degenerative findings of the cervical spine. Retrospective diagnostic study. Forty-eight patients who underwent routine cervical spine MRI at our institution between January 2011 and June 2012. Reviewers evaluated each MRI study at each vertebral level for disc hydration, disc space height, central stenosis, foraminal stenosis, endplate changes, spondylolithesis, and cord signal change. A panel of two orthopaedic spine surgeons and four musculoskeletal radiologists independently reviewed 48 sets of T2-weighted axial and sagittal MRI sequences for a series of pre-selected criteria, and their findings were compared with those of the other panelists to determine inter-rater agreement. Each panelist also re-reviewed the first ten studies to determine intra-rater agreement. Absolute inter-rater and intra-rater agreements were then calculated and compared for different findings. A modified analysis ignored disagreements between the least severe grades of findings in order to determine the inter-rater and intra-rater agreements of the most clinically important severity grades. There were no sources of funding or conflicts of interest related to this study. Absolute inter-rater agreement ranged from 54.6% to 95.0%. Disc hydration (54.6%), central stenosis (72.7%), and foraminal stenosis (73.1%) demonstrated the lowest inter-rater agreement, while spondylolisthesis (95.0%) and cord signal change (92.9%) demonstrated the highest agreement. The modified analysis found better inter-rater agreement, ranging from 80.9%-95.0%. Absolute intra-rater agreement ranged from 74.2% to 94.7%. The modified analysis again found better agreement, ranging from 85.0%-94.7%. As would be expected, overall intra-rater agreement (81.6%, 95% C.I., 78.9%-84.3%) was higher than inter-rater agreement (75.7%, 95% C.I., 74.4%-77.0%). The clinical specialty of the reviewer had no significant impact on inter- or intra-rater agreement. MRI findings play an important role in the management of patients with cervical spine conditions. For this reason, consistent descriptions of these findings are essential and physicians should be aware of the relative reliability of these findings. This systematic study developed standardized grading criteria and nomenclature for common clinically significant MRI findings in the cervical spine. Even in this optimized research setting, we found significant ranges in agreement across these MRI findings. In the clinical setting inter- and intra-rater agreements may be lower and the range of agreements between findings may be greater. Physicians should be aware of inconsistencies inherent in the interpretation of cervical MRI findings and should be aware that some findings demonstrate lower agreement than others. Copyright © 2015. Published by Elsevier Inc.
    The spine journal: official journal of the North American Spine Society 08/2015; DOI:10.1016/j.spinee.2015.08.026 · 2.43 Impact Factor
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    ABSTRACT: Retrospective cohort study. To determine the incidence and risk factors for short-term morbidity following posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS). NMS is a challenging spinal deformity for which PSF is often recommended. There is a lack of information on risk factors for short-term adverse outcomes after PSF for NMS. Patients who underwent PSF for NMS during 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Patient characteristics were tested for association with adverse events, infectious complications, extended length of stay (LOS), and readmission using multivariate regression. Of the 940 NMS patients identified, 133 (14.1%) had an adverse event and 99 (10.5%) had a severe adverse event. American Society of Anesthesiologists (ASA) classification ≥3 was found to be the only independent risk factor for any adverse event (relative risk [RR] 2.2, p = 0.012) and severe adverse events (RR 2.5, p = 0.008). Infectious complications were associated with body mass index (BMI)-for-age ≥95 percentile (RR 2.8, p = 0.005), ASA classification ≥3 (RR 5.9, p = 0.003), and instrumentation to the pelvis (RR 1.8, p = 0.039).A total of 254 patients (27%) spent longer than a week in the hospital postoperatively, and ASA classification ≥3 (RR 2.3, p<0.001), preoperative seizure disorder (RR 1.4, p = 0.002), previous cardiac surgery (RR 1.6, p = 0.004), operative time ≥470 minutes (RR 1.8, p<0.001), and ≥13 levels instrumented (RR 1.9, p = 0.001) were associated with extended LOS.Seventy-six patients (8.1%) were readmitted, and BMI-for-age ≥ 95 percentile (RR 1.8, p = 0.033) was the only risk factor found for readmission. The identified factors associated with poor short-term outcomes after PSF for NMS can be used as benchmark data, be useful for optimizing patient care, and can inform future studies in these patients.
    Spine 08/2015; 15(10). DOI:10.1097/BRS.0000000000001093 · 2.30 Impact Factor
  • Orthopaedic Surgery 08/2015; 7(3):281-5. DOI:10.1111/os.12187
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    ABSTRACT: We conducted a study to characterize the risk factors for extended length of stay (LOS) and readmission after primary total shoulder arthroplasty (TSA). Patients who were 60 years or older and underwent TSA between 2011 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were used to test patient characteristics for association with extended LOS and readmission within 30 days. Extended LOS was defined as LOS of more than 3 days (90th percentile LOS). Of the 1505 TSA patients identified, 49 (3.3%) were readmitted. Multivariate analysis revealed that extended LOS was independently associated with age 70 years or older and history of diabetes. Readmission was independently associated with history of heart disease and history of hypertension. The identified risk factors may be useful for preoperative discussions, surgical decision-making, and postoperative planning for THA patients.
    American journal of orthopedics (Belle Mead, N.J.) 08/2015; 44(8):E268-71.
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    ABSTRACT: Retrospective cohort study. To characterize the timing of complications following spinal fusion procedures. Despite many publications on risk factors for complications following spine surgery, there are few publications on the timing at which such complications occur. Patients undergoing anterior cervical decompression and fusion (ACDF) or posterior lumbar fusion (PLF; with or without interbody) procedures during 2011-2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. For each of eight different complications, the median time from surgery until complication was determined, along with the interquartile range and middle 80%. 12,067 patients undergoing ACDF and 11,807 patients undergoing PLF were identified. For ACDF, the median day of diagnosis (and interquartile range; middle 80%) for anemia requiring transfusion was 0 (0-1; 0-2), myocardial infarction 2 (1-5; 0-15), pneumonia 4 (2-9; 1-14), pulmonary embolism 5 (2-9; 1-10), deep vein thrombosis 10.5 (7-16.5; 5-21), sepsis 10.5 (4-18; 1-23), surgical site infection 13 (8-19; 5-25), and urinary tract infection 17 (8-22; 4-26). For PLF, the median day of diagnosis (and interquartile range; middle 80%) for anemia requiring transfusion was 0 (0-1; 0-2), myocardial infarction 2 (1-4; 1-8), pneumonia 4 (2-9; 1-17), pulmonary embolism 5 (3-11; 2-17), urinary tract infection 7 (4-14; 2-23), deep vein thrombosis 8 (5-16; 3-20), sepsis 9 (4-16; 2-22), and surgical site infection 17 (13-22; 9-27). These precisely described postoperative time periods enable heightened clinical awareness amongst spine surgeons. Spine surgeons should have the lowest threshold for testing for each complication during the time period of greatest risk. Authors, reviewers, and surgeons utilizing research on postoperative complications should carefully consider the impact that the duration of follow-up has on study results.
    Spine 07/2015; DOI:10.1097/BRS.0000000000001073 · 2.30 Impact Factor
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    ABSTRACT: Retrospective cohort study. To identify factors associated with blood transfusion for primary posterior lumbar fusion surgery, and to identify associations between blood transfusion and other postoperative complications. Blood transfusion is a relatively common occurrence for patients undergoing primary posterior lumbar fusion. There is limited information available describing which patients are at increased risk for blood transfusion, and the relationship between blood transfusion and short-term postoperative outcomes is poorly characterized. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing primary posterior lumbar fusion from 2011 to 2013. Multivariate analysis was used to find associations between patient characteristics and blood transfusion, along with associations between blood transfusion and postoperative outcomes. Out of 4,223 patients, 704 (16.7%) had a blood transfusion. Age 60-69 (relative risk [RR] 1.6), age ≥ 70 (RR 1.7), ASA class ≥ 3 (RR 1.1), female sex (RR 1.1), pulmonary disease (RR 1.2), preoperative hematocrit < 36.0 (RR 2.0), operative time ≥ 310 minutes (RR 2.9), two levels (RR 1.6), and three or more levels (RR 2.1) were independently associated with blood transfusion. Interbody fusion (RR 0.9) was associated with decreased rates of blood transfusion.Receiving a blood transfusion was significantly associated with any complication (RR 1.7), sepsis (RR 2.6), return to the operating room (RR 1.7), deep surgical site infection (RR 2.6), and pulmonary embolism (RR 5.1). Blood transfusion was also associated with an increase in postoperative length of stay of 1.4 days (p < 0.001). One in six patients received a blood transfusion while undergoing primary posterior lumbar fusion, and risk factors for these occurrences were characterized. Strategies to minimize blood loss might be considered in these patients to avoid the associated complications.
    Spine 07/2015; 15(10). DOI:10.1097/BRS.0000000000001047 · 2.30 Impact Factor
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    ABSTRACT: We conducted a retrospective national-cohort study to determine the incidence of and independent risk factors for venous thromboembolic events (VTEs) after open reduction and internal fixation (ORIF) of ankle fractures. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent ORIF for ankle fracture between 2005 and 2012. VTE was defined as the occurrence of a deep vein thrombosis or a pulmonary embolism within the first 30 postoperative days. Of the 4412 ankle fracture patients who met the inclusion criteria, 33 (0.8%) had a VTE. Multivariate analysis revealed that body mass index (BMI) of 30 to 35 kg/m2 (odds ratio [OR], 4.77; 95% confidence interval [CI], 1.05-21.72; P = .044), BMI of 35 kg/m2 or higher (OR, 4.71; 95% CI, 1.03-21.68; P = .046), heart disease (OR, 3.28; 95% CI, 1.20-8.97; P = .020), and dependent functional status (OR, 2.59; 95% CI, 1.11-6.04; P = .028) were independently associated with occurrence of VTE after ankle fracture ORIF. Patients with higher BMI and patients with heart disease or dependent functional status may be considered for VTE prophylaxis.
    American journal of orthopedics (Belle Mead, N.J.) 07/2015; 44(7):E220-E224.
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    ABSTRACT: Retrospective cohort study. To compare the infection rates in the Scoliosis Research Society (SRS) morbidity and mortality database to those in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Surgical databases have demonstrated value in orthopaedic surgery. However, few studies in the literature have used the SRS database relative to other available databases. In order to validate the surgeon-reported data of the SRS database, we compared the rate of postoperative infection in this database to that of the chart-abstracted ACS-NSQIP database. International Classification of Disease, ninth revision (ICD-9) codes were used to group patients from the 2012 and 2013 ACS-NSQIP database into groups corresponding to spinal deformity diagnoses delineated by SRS. Postoperative infection rates after surgical correction of these deformities compared to those reported in the 2012 and 2013 SRS database using chi-square tests. The overall rate of acute postoperative infection was slightly lower in the SRS database than in the ACS-NSQIP database (1.21% compared to 2.05% in ACS-NSQIP, a difference of only 0.84% was statistically significant, p<0.001).The infection rates of most diagnoses did not differ; these included scoliosis (idiopathic < 10 years of age / congenital / neuromuscular / other scoliosis), spondylolisthesis (isthmic / dysplastic), and kyphosis (congenital and other). The only differences noted were in Scheuermann kyphosis (difference of 5.49%, p = 0.003), degenerative spondylolithesis (deference of 0.69%, p = 0.003), and idiopathic scoliosis in the age 10-18 year and adult age ranges (differences of 1.10% and 1.28%, p<0.001 for both). Although some statistical differences were found in infection rates between the surgeon-reported SRS database and the chart-abstracted ACS-NSQIP database, these small differences likely reflect differences in surgical cases and data collection methods. This finding supports the validity of the surgeon-reported SRS morbidity and morality database.
    Spine 06/2015; DOI:10.1097/BRS.0000000000001033 · 2.30 Impact Factor
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    ABSTRACT: Industry payments made to physicians by drug and device manufacturers or group purchasing organizations are now reported to the Centers for Medicare and Medicaid Services (CMS) as a part of the Physician Payments Sunshine Act. Initial reports from the program show that orthopaedic surgeons lead all physician specialties in total and average industry payments. However, before further discussion of these payments and their implications can take place, it remains to be seen whether these figures are a true reflection of the field of orthopaedic surgery in general, rather than the result of a few outlier physicians in the field. In addition, the nature and sources of these funds should be determined to better inform the national dialogue surrounding these payments. We asked: (1) How do industry payments to orthopaedic surgeons compare with payments to physicians and surgeons in other fields, in terms of median payments and the Gini index of disparity? (2) How much do payments to the highest-receiving orthopaedic surgeons contribute to total payments? (3) What kind of industry payments are orthopaedic surgeons receiving? (4) How much do the highest-paying manufacturers contribute to total payments to orthopaedic surgeons? We reviewed the most recent version of the CMS Sunshine Act Open Payments database released on December 19, 2014, containing data on payments made between August 1, 2013 and December 31, 2013. Data on total payments to individual physicians, physician specialty, the types of payments made, and the manufacturers making payments were reviewed. The Gini index of statistical dispersion was calculated for payments made to orthopaedic surgeons and compared with payments made to physicians and surgeons in all other medical specialties. A Gini index of 0 indicates complete equality of payments to everyone in the population, whereas an index of 1 indicates complete inequality, or all income going to one individual. A total of 15,376 orthopaedic surgeons receiving payments during the 5-month period were identified, accounting for USD 109,846,482. The median payment to orthopaedic surgeons receiving payments was USD 121 (interquartile range, USD 34-619). The top 10% of orthopaedic surgeons receiving payments (1538 surgeons) received at least USD 4160 and accounted for 95% of total payments. Royalties and patent licenses accounted for 69% of all industry payments to orthopaedic surgeons. Even as a relatively small specialty, orthopaedic surgeons received substantial payments from industry (more than USD 110 million) during the 5-month study period. Whether there is a true return of value from these payments remains to be seen; however, future ethical and policy discussions regarding industry payments to orthopaedic surgeons should take into account the large disparities in payments that are present and also the nature of the payments being made. It is possible that patients and policymakers may view industry payments to orthopaedic surgeons more positively in light of these new findings. Level III, Economic and Decision Analysis.
    Clinical Orthopaedics and Related Research 06/2015; 473(10). DOI:10.1007/s11999-015-4413-8 · 2.77 Impact Factor
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    ABSTRACT: Cervical spine fractures can lead to many devastating consequences. However, mortality rates of older individuals with odontoid or subaxial spine fractures have not been definitively established. We conducted a retrospective review of all patients who underwent computed tomography of the cervical spine in the emergency department of a level I trauma center over 9 years to compare mortality rates after odontoid and subaxial fractures in elderly persons with those of the general population. We searched the National Death Index for patient death records, and compared mortality rates at 3 months, 1 year, and 2 years to sex- and age-matched data from the general population. Odontoid fracture survival was 84.4% at 3 months, 82.2% at 1 year, and 72.9% at 2 years. Male survival was significantly worse compared with age- and sex-matched counterparts (P < .001), but female survival was not (P = .568). In subaxial fractures, survival was 87.9% at 3 months and 85.7% at 1 and 2 years. Male survival was decreased compared with age- and sex-matched counterparts (P < .0001), whereas female survival was not (P = .554). In conclusion, the mortality of men with either fracture was greater compared with age-matched men initially, but this normalized. Female survival was not affected by either fracture.
    American journal of orthopedics (Belle Mead, N.J.) 06/2015; 44(6):E173-E179.
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    ABSTRACT: Retrospective review of prospectively collected data. To determine the incidence and risk factors for development of a urinary tract infection (UTI) following a posterior lumbar fusion procedure. UTI following surgery is common and has important clinical consequences for both patients and the healthcare system. Few studies have examined UTI following spinal fusion procedures. Patients undergoing posterior lumbar fusion procedures during 2011-2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Statistical comparisons were made using multivariate regression with adjustment for demographic, comorbidity, and operative characteristics. 10,825 patients met inclusion criteria. The incidence of a UTI was 1.77% (95% confidence interval [CI] = 1.52-2.02%). Independent risk factors for a UTI were greater age (for 50-59 years, RR = 1.0; 60-69 years, RR = 2.1; ≥70 years, RR = 3.5; p<0.001), female sex (RR = 2.2, p<0.001), dependent functional status (RR = 2.1, p = 0.010), malnutrition (RR = 2.3, p = 0.004), diabetic status (for non-insulin-dependent diabetes, RR = 1.5; for insulin-dependent diabetes, RR = 1.9; p = 0.011), and increased operative duration (for 120-179 minutes, RR = 1.4; 180-239 minutes, RR = 2.3; ≥240 minutes, RR = 2.7; p<0.001).Patients who developed a UTI had a greater risk for systemic sepsis than other patients (11.5% versus 0.63%; adjusted RR = 14.4, p<0.001). Patients who developed a UTI had a greater risk for readmission than other patients (36.7% versus 5.0%; adjusted RR = 6.1, p<0.001). UTIs occur in nearly 1 in 50 patients undergoing posterior lumbar fusion procedures. Patients who are older, female, dependent, malnourished, or diabetic are at greater risk and should be counseled and monitored accordingly. In addition, morbidity associated with a UTI in this population is substantial, as demonstrated by a 14-fold increase in the risk for systemic sepsis and a 6-fold increase in the risk for readmission. As such, increased preventative measures should be targeted to the patients identified here to be at greatest risk.
    Spine 05/2015; DOI:10.1097/BRS.0000000000001003 · 2.30 Impact Factor
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    ABSTRACT: Survey of spine surgeons and biomechanical comparison of screw pullout forces. To investigate what may be a suboptimal practice regularly occurring in spine surgery. In order for a tap to function in its intended manner, the pitch of the tap should be the same as the pitch of the screw. Under-tapping has been shown to increase the pullout force of pedicle screws compared to line-to-line tapping. However, given the way current commercial lumbar pedicle screw systems are designed, under-tapping may result in a tap being used that has a different pitch from that of the screw (incongruent pitch). A survey asked participants questions to estimate the proportion of cases each participant performed in the prior year using various hole preparation techniques. Participant responses were interpreted in the context of manufacturing specifications of specific instrumentation systems. Screw pullout forces were compared between under-tapping with incongruent pitch and under-tapping with congruent pitch using 0.16g/cm polyurethane foam block and 6.5mm screws. Of the 3,679 cases in which participants reported tapping, participants reported line-to-line tapping in 209 cases (5%), under-tapping with incongruent pitch in 1,156 cases (32%), and under-tapping with congruent pitch in 2,314 cases (63%). The mean pullout force for under-tapping with incongruent pitch was 56N (8%) less than the mean pullout force for under-tapping with congruent pitch. This is equivalent to 13 pounds. This study estimates that for about 1 out of every 3 surgical cases with tapping of lumbar pedicle screws in the United States, hole preparation is being performed by under-tapping with incongruent pitch. This study also shows that under-tapping with incongruent pitch results in a decrease in pullout force by 8% compared to under-tapping with congruent pitch. Steps should be taken to correct this suboptimal practice.
    Spine 04/2015; 40(12). DOI:10.1097/BRS.0000000000000922 · 2.30 Impact Factor
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    ABSTRACT: Total hip arthroplasty may be performed under general or spinal anesthesia. The purpose of the current study was to compare perioperative outcomes between anesthetic types for patients undergoing primary elective total hip arthroplasty. Patients who had undergone primary elective total hip arthroplasty from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Operating room times, length of stay, thirty-day adverse events, and readmission were compared between patients who had received general anesthesia and those who had received spinal anesthesia. Propensity-adjusted multivariate analysis was used to control for selection bias and baseline patient characteristics. A total of 20,936 patients who had undergone total hip arthroplasty met inclusion criteria for this study. Of these, 12,752 patients (60.9%) had received general anesthesia and 8184 patients (39.1%) had received spinal anesthesia. On propensity-adjusted multivariate analyses, general anesthesia for total hip arthroplasty was associated with increased operative time (+12 minutes [95% confidence interval, +11 to +13 minutes]; p < 0.001) and postoperative room time (+5 minutes [95% confidence interval, +4 to +6 minutes]; p < 0.001). General anesthesia was also associated with the occurrence of any adverse event (odds ratio, 1.31 [95% confidence interval, 1.23 to 1.41]; p < 0.001), prolonged postoperative ventilator use (odds ratio, 5.81 [95% confidence interval, 1.35 to 25.06]; p = 0.018), unplanned intubation (odds ratio, 2.17 [95% confidence interval, 1.11 to 4.29]; p = 0.024), stroke (odds ratio, 2.51 [95% confidence interval, 1.02 to 6.20]; p = 0.046), cardiac arrest (odds ratio, 5.04 [95% confidence interval, 1.15 to 22.07]; p = 0.032), any minor adverse event (odds ratio, 1.35 [95% confidence interval, 1.25 to 1.45]; p = 0.001), and blood transfusion (odds ratio, 1.34 [95% confidence interval, 1.25 to 1.45]; p < 0.001). General anesthesia was not associated with any difference in preoperative room time, postoperative length of stay, or readmission. General anesthesia was associated with an increased rate of adverse events and mildly increased operating room times. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
    The Journal of Bone and Joint Surgery 03/2015; 97(6):455-61. DOI:10.2106/JBJS.N.00662 · 5.28 Impact Factor
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    ABSTRACT: Study Design. A retrospective study of surgically treated cervical spinal cord injury (SCI) patients from the National Trauma Data Bank Research Data Set (NTDB RDS). To determine how time to surgery differs between SCI subtypes, where delays before surgery occur, and what factors are associated with delays. Studies have shown that cervical SCI patients receiving surgery within 24 hours after injury have superior neurological outcomes to patients receiving later surgery, with most evidence coming from the incomplete SCI subpopulation. Surgically treated cervical SCI patients from 2011 and 2012 were identified in NTDB RDS and divided into subpopulations of complete, central, and other incomplete SCIs. Relationships between surgical timing and patient and injury characteristics were analyzed using multivariate regression. A total of 2,636 cervical SCI patients were identified: 803 with complete SCI, 950 with incomplete SCI, and 883 with central SCI. The average time to surgery was 51.1 hours for complete SCI patients, 55.3 hours for incomplete SCI patients, and 83.1 hours for central SCI patients. Only 44% of SCI patients underwent surgery within the first 24 hours after injury, including only 49% of patients with incomplete SCI.The vast majority of time between injury and surgery was after admission, rather than in the emergency department or in the field. Upper cervical injuries and greater Charlson comorbidity index were associated with later surgery in all three SCI subpopulations. The majority of SCI patients do not receive surgery within the first 24 hours after injury, and the majority of delays occur after inpatient admission. Factors associated with these delays highlight areas of focus for expediting care in these patient populations.
    Spine 03/2015; 40(13). DOI:10.1097/BRS.0000000000000883 · 2.30 Impact Factor
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    ABSTRACT: A retrospective study of surgically treated patients with acute traumatic central cord syndrome (ATCCS) from the National Trauma Data Bank Research Data Set. To determine the association of time to surgery, pre-existing comorbidities, and injury severity on mortality and adverse events in surgically treated patients with ATCCS. Although earlier surgery has been shown to be beneficial for other spinal cord injuries, the literature is mixed regarding the appropriate timing of surgery after ATCCS. Traditionally, this older population has been treated with delayed surgery because medical optimization is often indicated preoperatively. Surgically treated patients with ATCCS in the National Trauma Data Bank Research Data Set from 2011 and 2012 were identified. Time to surgery, Charlson Comorbidity Index, and injury severity scores were tested for association with mortality, serious adverse events, and minor adverse events using multivariate logistic regression. A total of 1060 patients with ATCCS met inclusion criteria. After controlling for pre-existing comorbidity and injury severity, delayed surgery was associated with a decreased odds of inpatient mortality (odds ratio = 0.81, P = 0.04), or a 19% decrease in odds of mortality with each 24-hour increase in time until surgery. The association of time to surgery with serious adverse events was not statistically significant (P = 0.09), whereas time to surgery was associated with increased odds of minor adverse events (odds ratio = 1.06, P < 0.001). Although the potential neurological effect of surgical timing for patients with ATCCS remains controversial, the decreased mortality with delayed surgery suggests that waiting to optimize general health and potentially allow for some spinal cord recovery in these patients may be advantageous. 3.
    Spine 03/2015; 40(5):349-356. DOI:10.1097/BRS.0000000000000756 · 2.30 Impact Factor
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    Jonathan N Grauer · Seth S Leopold
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    ABSTRACT: Most clinicians have come to imagine that scientific evidence has levels, and at the top of the pyramid are randomized clinical trials (RCTs) and meta-analyses [12]. But we all have read some poorly designed randomized trials, and sometimes a humble case series can substantially influence thought about a technique or implant, particularly if it describes failures of treatment. Nevertheless, as the Centre for Evidence-Based Medicine analogizes [6], if clinical evidence were stored in boxes marked “randomized trial,” “cohort study,” “case series,” and the like, and we needed to answer an important question, we might first open the box stamped “randomized trial” to see if there is anything inside.All the same, there are some important kinds of questions that RCTs and meta-analyses will never answer. Surgical RCTs generally are small to medium-sized, and as such, are tooled to assess efficacy more than safety. Randomized trials have almost no ability to detect rare events, evaluate resourc ...
    Clinical Orthopaedics and Related Research 02/2015; 473(5). DOI:10.1007/s11999-015-4223-z · 2.77 Impact Factor
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    ABSTRACT: To test the hypothesis that clinical assessment reliably identifies patients with radiographic changes (including loss of reduction, hardware failure, and hardware migration) at the initial visit following operative repair of distal radius fractures. We identified 102 patients undergoing operative repair of distal radius fractures. Radiographs and clinical notes were reviewed. At the initial postoperative visit, 11 patients had more than normal postoperative pain, 0 had deformity, 0 had crepitus with gentle motion, and 0 had instability at the fracture site on examination. These 11 patients were considered to have positive clinical assessments, but none had radiographic changes on x-rays taken that day. Three patients had negative clinical assessments but had radiographic changes noted at the initial postoperative visit. There were no additional radiographic changes between the series taken at the initial postoperative visit and series taken at later postoperative visits. These data suggest that for purposes of detecting radiographic changes, radiography at the initial visit is helpful, whereas radiography at subsequent visits may not be. Radiography at subsequent visits may be useful to monitor bony healing, which we did not investigate. Diagnostic IV. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
    The Journal Of Hand Surgery 01/2015; 40(1):49-56. DOI:10.1016/j.jhsa.2014.08.038 · 1.67 Impact Factor
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    ABSTRACT: Study Design. Retrospective cohort.Objective. To evaluate whether myelopathy is associated with increased morbidity and mortality after anterior cervical discectomy and fusion (ACDF) compared to other indications for this procedure.Summary of Background Data. ACDF is the most common surgical procedure for the management of a spectrum of cervical spine pathologies. As a more advanced condition, myelopathy is generally believed to be associated with higher morbidity and mortality after this procedure, but there is limited evidence to support this supposition. The current study compares outcomes of ACDF procedures performed for myelopathy to those performed for other indications, controlling for other patient factors.Methods. Patients who underwent ACDF between 2010 and 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Myelopathic patients were identified by diagnosis codes for cervical myelopathy. Bivariate and multivariate logistic regressions were performed to compare 30-day adverse events and readmission between groups. Multivariate analyses controlled for patient and surgical characteristics.Results. A total of 5,256 ACDF procedures met inclusion criteria, of which 1,425 (27.3%) were performed for cervical myelopathy. Myelopathic patients were older and were less healthy compared to non-myelopathic patients. Multivariate analysis controlling for baseline patient characteristics found that myelopathic patients were at significantly increased risk of any adverse event (odds ratio [OR] = 1.5), any severe adverse event (OR = 1.8), and death (OR = 8.9) compared to non-myelopathic patients.Conclusion. After adjusting for baseline patient characteristics, not only were any adverse events and serious adverse events more common following ACDF for myelopathic patients compared to non-myelopathic patients, but mortality was approximately nine times more likely. It is important for surgical planning and patient counselling to keep this significant difference in mind for this common procedure that has different morbidities based on the pathology for which it is performed.
    Spine 01/2015; DOI:10.1097/BRS.0000000000000785 · 2.30 Impact Factor
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    ABSTRACT: The Spine Patient Outcomes Research Trial (SPORT) is a highly referenced clinical trial that randomized patients with lumbar pathology to receive surgery or continued conservative treatment. Compare the SPORT lumbar disc herniation cohort and an analogous cohort from the National Surgical Quality Improvement Program (NSQIP) database. Study Design/Setting: Retrospective cohort study comparing a national database population to a randomized clinical trial. Elective lumbar discectomies from NSQIP between 2010 and 2012. Demographics were compared between the randomized SPORT cohorts (surgical and nonoperative) and NSQIP. Perioperative factors and complications were then compared between SPORT discectomy patients and NSQIP. No funding sources or potential conflicts of interest exist. Using current procedural terminology (CPT) and International Classification of Diseases, 9(th) revision (ICD-9) codes, all elective lumbar discectomies from NSQIP between 2010 and 2012 were identified. Where possible based on published data and variables available in each cohort, the two populations were compared. 6,846 NSQIP discectomy patients were compared to the randomized SPORT surgical and nonoperative cohorts. Demographic comparisons showed NSQIP patients were older (average age 48.2 ± 14.5 years [mean ± standard deviation], versus 41.7 ± 11.8 and 43.0 ± 11.3 years, respectively [p<0.001]) and had higher BMI (29.6 ± 6.2 kg/m(2), versus 27.8 ± 5.6 and 28.2 ± 5.4 kg/m(2), respectively [p<0.001]). No statistical differences existed for gender or race. Smoking status was not different between the SPORT nonoperative group and NSQIP, but was higher in NSQIP compared to SPORT surgical patients (p=0.020 by 7%). Perioperative factors and complications comparisons between the SPORT surgical cohort and NSQIP showed no statistical difference in average operative time, length of stay, deep wound infections, wound dehiscence, total wound complications, or blood transfusions. SPORT superficial wound infection rates were higher than NSQIP (p=0.029 by 1.4%). As expected, SPORT one-year reoperation rates were higher than NSQIP 30-day rates (7% versus 2%, p<0.001). SPORT lumbar disc herniation results are similar to those from a large national patient sample. Even statistically significant differences would be considered clinically similar. These findings support the generalizability of the SPORT lumbar disc herniation results. Copyright © 2014 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 12/2014; 15(4). DOI:10.1016/j.spinee.2014.12.008 · 2.43 Impact Factor

Publication Stats

3k Citations
409.51 Total Impact Points


  • 1998–2015
    • Yale University
      • Department of Orthopaedics and Rehabilitation
      New Haven, Connecticut, United States
  • 1997–2015
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 2012
    • Duke University
      Durham, North Carolina, United States
  • 2011
    • Columbia University
      New York, New York, United States
  • 2009
    • Kansas City VA Medical Center
      Kansas City, Missouri, United States
  • 2008
    • University of New Haven
      New Haven, Connecticut, United States
  • 2003–2007
    • Thomas Jefferson University
      • • Rothman Institute
      • • Department of Orthopaedic Surgery
      Philadelphia, Pennsylvania, United States
  • 2006
    • University of Pittsburgh
      • Department of Orthopaedic Surgery
      Pittsburgh, Pennsylvania, United States
  • 2003–2005
    • Rothman Institute
      Philadelphia, Pennsylvania, United States
  • 2004
    • Boston University
      • Division of Orthopaedic Surgery
      Boston, Massachusetts, United States
    • Keio University
      • Department of Orthopedic Surgery
      Edo, Tōkyō, Japan