Abstract
We sought to identify social determinants of health (SDoH) for adult patients undergoing Chiari decompression surgery and to analyze their association with postoperative outcomes, including length of stay (LOS), return to the system within 30 days, and the Chicago Chiari Outcomes Score (CCOS). This is a retrospective study of adult patients who underwent Chiari decompression surgery between June 2021 and January 2023. Data was gathered through electronic medical record review and telephone surveys. Descriptive statistics were used to evaluate demographics of all patients meeting inclusion criteria. Fisher’s exact tests and logistic regression were used for data analysis. A total of 37 patients underwent Chiari decompression (23 CCOS/SDoH survey respondents): 48% bony decompression only, 30% bony decompression plus intradural exploration, and 22% occipitocervical fusion. Seven patients (30%) had a LOS > 2 days, 1 patient (4%) required inpatient rehabilitation postoperatively, 4 patients (17%) returned to the system within 30 days, 10 patients (43%) had an extremely favorable CCOS (15–16), and 11 patients (48%) reported interaction with a Chiari support group. Mean follow-up was 9.5 months. Patients with occipitocervical fusion were more likely to have a LOS > 2 days (p = 0.03), patients who exercised ≥ 3 days per week were more likely to have a favorable CCOS (p = 0.04), and patients who participated in a Chiari support group were less likely to have a favorable CCOS (p = 0.03). Chiari decompression plus occipitocervical fusion may be associated with increased LOS. While more frequent exercise may be associated with better post-surgical outcomes, participation in a Chiari support group may be correlated with worse outcomes.
Keywords: Chiari malformation, Social determinants of health, Adult, Length of stay, Duraplasty, Occipitocervical fusion, Support group
Introduction
The surgical treatment for Chiari malformation may result in improved quality of life for adult patients. In value-based health care, patients, surgeons, and payors are aligned in their goal of maximizing quality while decreasing costs. In addition to biologic and psychological factors, SDoH have been shown to influence surgical outcomes [1, 2].
SDoH were ushered into the vernacular of clinicians by the World Health Organization (WHO) Commission on Social Determinants of Health in 2008 [2–4]. SDoH include conditions in which people are born and their work and living environments, such as safe housing, transportation, and neighborhoods; racism, discrimination, and violence; education, job opportunities, and income; access to nutritious foods and physical activity opportunities; polluted air and water; and language and literacy skills [5]. The US Department of Health and Human Services’ “Healthy People 2030” initiative placed further emphasis on focusing and addressing SDoH as they may contribute to wide health disparities and inequities [5]. SDoH have been shown to influence surgical outcomes, such as postoperative complications and LOS [2, 6–9]. There have been few studies addressing socioeconomic and racial disparities contributing to outcomes after Chiari decompression surgery [10–12]. However, there have been no studies focused on the underlying individual SDoH that may influence outcomes in this patient population. Hence, this study seeks to determine SDoH that are associated with early outcomes after Chiari decompression surgery.
Methods
All subjects participated voluntarily; the study was approved by our institution’s Institutional Review Board (IRB), and the study complied with the Declaration of Helsinki.
Patient population
After obtaining IRB approval, we retrospectively reviewed adult patients (> 18 years of age) who underwent Chiari decompression surgery between June 2021 and January 2023. Surgeries were performed by one of three board-certified or board-eligible pediatric neurosurgeons at a single institution. To be included in the descriptive and univariate analyses, a patient must have responded to at least 1 question on our self-reported SDoH questionnaire in-person or via telephone survey within 2 years of surgery.
SDoH
The SDoH instrument [2] was utilized as a standard tool for gathering SDoH information. The survey includes 12 questions about 10 SDoH. This tool has been used in a study analyzing SDoH and outcomes after lumbar spine surgery and has shown to be effective [2]. The timepoint for completing the survey was not uniform, but it was completed within 2 years of surgery for each patient. The SDoH instrument with questions and response options are included in Fig. 1 [2]. For the final analysis, the responses for the SDoH questions were dichotomized into clinically meaningful groups.
Fig. 1.
A self-reported social determinants of health survey that was used to ask all adult Chiari patients in the study group via telephone call about a variety of health-related factors ©2022 Holbert et al. Originally published in Ochsner Journal. 10.31486/toj.22.0066
Other independent variables
In addition to SDoH, we queried the electronic medical record to gather demographic data, including signs/symptoms at presentation, presence of a syrinx, and index or re-do surgery. We utilized the following simplified classification scheme for procedure type: patients who underwent bony decompression alone, bony decompression plus intradural exploration, or Chiari decompression plus occipitocervical fusion.
Chicago Chiari Outcomes Scale (CCOS)
The CCOS consists of four categories, each scored from 1 to 4: these include pain symptoms, non-pain symptoms, ability to perform daily responsibilities, and surgical complications. The numerical score assigned in each category represents the change from pre-operative baseline to postoperative state at the time of assessment in each category. The total CCOS score ranges from 4 to 16. Reflecting our high standard for a positive result, the CCOS score was dichotomized to “favorable” and “unfavorable” outcomes based on total scores of 15–16 and 4–14, respectively.
Other outcome measures
In addition to CCOS, we examined four commonly used outcome measures to gauge quality after surgery: LOS (measured in days), discharge disposition other than home, and return to the system within 30 days. “Short” LOS was defined as ≤ 2 days. “Long” LOS was defined as > 2 days. Return to the system was defined as return to our institution’s emergency department or re-admission to our health system within 30 days of index surgical intervention. We also evaluated patient involvement with a Chiari support group (online or in person) before or after surgery. Response options included “never,” “monthly or less,” “2–4 times per month,” “2–3 times per week,” “4 or more times per week,” or “decline to answer.” For statistical analysis purposes, responses were dichotomized into “never” and “monthly or more.”
Statistical analysis
Descriptive statistics were used to evaluate the demographics, surgeries performed, outcomes, and prevalence of each SDoH measured on our survey. For descriptive and inferential statistics, the prevalence of each SDoH is presented as a percent of patients responding to questions; nonresponses were not counted for that question. Fisher’s exact tests were used to examine the association between each outcome variable and each categorical predictor. A logistic regression model was used to examine the association between each outcome variable and continuous predictors. Missing values were removed from the analysis. Data was stored on Excel spreadsheets (MS Excel; Microsoft Corporation, Redmond, WA USA). Statistical analysis was performed by using SAS 9.4 (SAS Institute, Cary, North Carolina USA).
Results
Demographics
A total of 37 adult patients underwent Chiari decompression surgery between June 2021 and January 2023. Of these, 23 patients responded to at least part of the survey: 11 (47.8%) underwent bony decompression alone, 7 (30.4%) underwent bony decompression plus intradural exploration, and 5 (21.7%) underwent Chiari decompression plus occipitocervical fusion. In our study population, 82.6% were women and 60.1% were white. The mean age of the patients was 36 years old (range: 18–66) at the time of surgery. Follow-up ranged from 1.4 to 23.0 months (mean: 9.5 months).
We recorded the following signs and symptoms associated with Chiari I malformation at presentation: tussive headaches (91.3%), nausea or vomiting (65.2%), neck pain (65.2%), extremity numbness/paresthesias (65.2%), reported arm weakness (60.9%), and bowel or bladder incontinence (17.4%). Preoperative imaging revealed syringomyelia in 30.4% of cases. Operative intervention was a re-do surgery in 2 (8.7%) cases.
Table 1 Summarizes our findings.
Table 1.
Summary of patient demographics, surgeries, and outcomes
| Variable | |
|---|---|
| Age, years, mean (range) | 36 (18–66) |
| Female gender, n (%) | 19 (82.6) |
| Race, n (%) | |
|
White Black/African American Native American Latino/Hispanic Asian Hawaiian/Pacific Islander |
14 (60.1) 5 (21.7) 3 (13.0) 1 (4.3) 0 0 |
| Symptoms, n (% of total respondents) | |
|
Headache Neck stiffness Nausea/vomiting Urinary incontinence Numbness/paresthesias Reported weakness |
21 (91.3) 15 (65.2) 15 (65.2) 4 (17.4) 15 (65.2) 14 (60.9) |
| Syringomyelia, n (%) | 7 (30.4) |
| Surgery performed, n (%) | |
|
Bony decompression alone Bony decompression + intradural exploration Decompression + occipitocervical fusion |
11 (47.8) 7 (30.4) 5 (21.7) |
| Re-do surgery, n (%) | 2 (8.7) |
| Outcomes | |
|
LOS, days, mean (range) Discharge other than home, n (%) 30-day return to system, n (%) CCOS, mean (range) |
2.3 (1–12) 1 (4.3) 4 (17.4) 13.4 (8–16) |
| Follow-up, months, mean (range) | 9.5 (1.4–23.0) |
Outcomes
Mean length of stay was 2.5 days (range: 1–12 days). The only significant finding on univariate analysis was surgery type, with patients after occipitocervical fusion having a longer length of stay than patients after bone only decompression or bony decompression plus dural exploration (p = 0.03). No social determinants of health were found to be predictive of length of stay.
Only 1 patient had a postoperative disposition other than home (inpatient rehabilitation facility), therefore predictive analysis was not performed for this outcome measure.
During our study period, there were 4 patients (17.4%) who returned to our health system within 30 days. All cases involved return to the emergency department (2 for pain, 2 for cerebrospinal fluid leak rule-out), and none required hospital re-admission or re-operation. There was no demographic or SDoH measure that was significantly correlated with return to system on univariate analysis.
The mean CCOS score was 13.4 (range 8–16), and 10 patients had a “favorable” outcome (CCOS 15–16), while 13 patients had an “unfavorable” outcome (CCOS 4–14). No demographic, surgical, or radiographic factors were found on univariate analysis to correlate with CCOS. The only SDoH measure that was studied to be significantly associated with CCOS was amount of weekly exercise. Exercising ≥ 3 days per week was associated with a favorable CCOS (p = 0.04). Moreover, any interaction with a Chiari support group was found to be significantly correlated with an unfavorable CCOS (p = 0.03).
Tables 2 and 3 summarize our findings.
Table 2.
Responses to the social determinants of health question survey
| SDoH | N (%) |
|---|---|
| Exercise ≥ 3 days/week | 15 (65.2) |
| More than a little stressed | 15 (65.2) |
| Attend church/religious services | 19 (82.6) |
| Married/in relationship | 8 (34.8) |
| Abuse (physical/emotional/verbal) | 2 (8.7) |
| Financial insecurity | 7 (30.4) |
| At least some post-high school education | 14 (60.9) |
| Worried food would run out | 7 (30.4) |
| Insufficient transportation means | 1 (4.3) |
| Drink alcohol ≥ 4 times/week | 1 (4.3) |
Table 3.
Univariate analysis of the effect of multiple predictors on length of stay, 90-day return to system, and CCOS
| Length of stay | Return to system | CCOS | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| ≤ 2 days | > 2 days | p-value | Yes | No | p-value | Unfavorable | Favorable | p-value | ||
| Demographics | Age, years, mean | 33.1 | 40.5 | 0.11 | 32.3 | 36.0 | 0.50 | 33.9 | 37.2 | 0.44 |
| Gender | ||||||||||
|
Female Male |
12 4 |
7 0 |
0.27 |
3 1 |
16 3 |
0.43 |
11 2 |
8 2 |
0.80 | |
| Race | ||||||||||
|
White Non-white |
8 8 |
6 1 |
0.18 |
1 3 |
13 6 |
0.26 |
7 6 |
7 3 |
0.67 | |
| Syrinx | ||||||||||
|
Yes No |
5 11 |
2 5 |
0.37 |
0 4 |
7 12 |
0.27 |
5 8 |
2 8 |
0.40 | |
| Surgery | ||||||||||
|
Bone only Bone + duraplasty OC fusion |
9 6 1 |
2 1 4 |
0.03 |
3 0 1 |
8 7 4 |
0.39 |
6 4 3 |
5 3 2 |
0.14 | |
| SDoH | Exercise | |||||||||
|
≥ 3 days/week < 3 days/week |
11 5 |
4 3 |
0.66 |
1 3 |
14 5 |
0.10 |
6 7 |
9 1 |
0.04 | |
| Stress | ||||||||||
|
More than a little None or little |
12 4 |
3 4 |
0.18 |
4 0 |
11 8 |
0.26 |
8 5 |
7 3 |
0.51 | |
| Religiousness | ||||||||||
|
Attends service Never |
12 4 |
7 0 |
0.27 |
4 0 |
15 4 |
0.43 |
11 2 |
8 2 |
0.40 | |
| Relationship | ||||||||||
|
Yes Single/separated |
6 10 |
2 3 |
0.39 |
1 3 |
7 10 |
0.38 |
4 7 |
4 6 |
0.60 | |
| Abuse (within last year) | ||||||||||
|
Yes No |
1 14 |
1 5 |
0.50 |
1 3 |
1 16 |
0.35 |
2 10 |
0 9 |
0.48 | |
| Paying for basics | ||||||||||
|
Hard/very hard Not hard |
6 9 |
1 5 |
0.61 |
3 1 |
4 13 |
0.09 |
5 7 |
2 7 |
0.64 | |
| Education | ||||||||||
|
More than high school High school or less |
11 4 |
3 3 |
0.35 |
2 2 |
12 5 |
0.57 |
9 3 |
5 4 |
0.40 | |
| Food insecurity | ||||||||||
|
Ever concerned Never concerned |
7 7 |
0 5 |
0.10 |
3 1 |
4 11 |
0.12 |
6 5 |
1 7 |
0.15 | |
| Transportation means | ||||||||||
|
Ever insufficient Never insufficient |
1 14 |
0 6 |
0.71 |
1 3 |
0 17 |
0.19 |
1 11 |
0 9 |
0.57 | |
| Alcohol consumption | ||||||||||
|
≥ 4 times/week < 4 times/week |
1 14 |
0 6 |
0.63 |
0 4 |
1 16 |
0.38 |
1 7 |
0 13 |
0.67 | |
| Participation | ||||||||||
| Chiari support group |
Monthly or more Never |
10 5 |
1 5 |
0.06 |
2 2 |
9 8 |
0.41 |
9 3 |
2 7 |
0.03 |
Factors with p < 0.05 are signified in boldface
Discussion
The relationship between SDoH and neurosurgical outcomes has become increasingly relevant [13]. In a recent review of the literature, studies referencing SDoH were found in 8 subspecialties within neurosurgery, with 40 studies in spine surgery, 4 studies in functional neurosurgery, 14 studies in vascular neurosurgery, 27 studies in cranial oncology, 5 studies in spinal oncology, 5 studies in pediatric neurosurgery, 1 study in trauma, and 3 studies in general/unspecified subspecialties [14]. Research gaps included the remaining neurosurgical subspecialties and numerous other SDoH [14].
Outcomes can be influenced by factors beyond traditionally studied socioeconomic measures, such as household income, education status, insurance status, and racial variables. Some SDoH, such as residence in a food desert, involvement in religious activities, and access to reliable transportation, are not readily available in the electronic medical record. As such, new methods to screen for SDoH must be developed as a dawning of their role in neurosurgical patient outcomes occurs.
Our study confirmed the expected finding that more extensive surgical intervention (OC fusion) is correlated with longer hospital stays. However, there was no evidence in our analysis that SDoH increased length of stay or led to a higher likelihood of returning to the healthcare system. Moreover, patients who exercised more postoperatively were more likely to report better CCOS after surgery. While this may reflect a tendency for patients who have a more active lifestyle preoperatively to also do better in the recovery period, it can also serve to underscore the importance in general of exercise on postoperative healing.
Interestingly, any participation in Chiari support networks, either in person or online, was associated with lower CCOS score. The large majority of these patients reported initiation of their involvement in Chiari support networks at time of diagnosis with Chiari malformation, not postoperatively, which decreases the probability of involvement being confounded by surgical outcome. Support groups have many benefits and can be highly effective for patients coping with mild to severe/refractory disease; however, potential negative effects have been reported in the literature [15, 16]. In this case, participation in a support group may perpetuate the comforting notion of belonging when a chronic disease is present. However, once the disease is treated, fear of isolationism from the rest of the group may take over. Further, any residual symptom is magnified by the rest of the group via in-person and online chat. When an outcome in one patient does not mirror the outcome in another patient, this may sound alarm bells and intensify the perceived burden.
In practice, it is important when screening patients for Chiari decompression to also ask about and address those social factors that may play a role in outcomes and recovery. Employing a wholistic approach to combating this pathology, surgical and otherwise, is most likely to yield a favorable and durable treatment. Further, it may not only be beneficial to council patients about the many benefits of support groups, but also to discuss the occasional negative factors that can be associated with them.
Limitations
This study was limited by its retrospective nature at a single-institution, and therefore, it may not be representative of the larger population of adult patients with Chiari malformation. Moreover, the inclusion criteria only required patients to have responded to a single question on our SDoH survey, resulting in incomplete data from some patients. In addition, because patients answered the survey within 2 years of surgery, a patient’s SDoH status may have changed during the study period, or surgery itself could have influenced SDoH. Furthermore, future studies may need to include standardized SDoH tools with common definitions and standards for SDoH [17, 18]. Low sample size precluded the use of multivariate analysis and may have impeded the capture of statistically significant associations on univariate analysis. Despite these limitations, our study presents a quantitative view of complex SDoH data in a challenging adult-patient population.
Conclusions
Chiari decompression plus occipitocervical fusion may be associated with increased hospital LOS. While more frequent exercise may be associated with better post-surgical outcomes, any participation in a Chiari support group may be correlated with lower CCOS score.
Acknowledgements
Dr. Sixia Chen was supported by the Oklahoma Shared Clinical and Translational Resources (U54GM104938) with an Institutional Development Award (IDeA) from NIGMS. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Abbreviations
- SDoH
Social determinants of health
- LOS
Length of stay
- CCOS
Chicago Chiari Outcomes Score
- WHO
World Health Organization
- IRB
Institutional Review Board
- IDeA
Institutional Development Award
- NIGMS
National Institute of General Medical Sciences
Author contribution
Material preparation and analysis were performed by ST, AJ, and SC. Data collection was performed by ST, KZ, MP, and MO. The first draft of the manuscript was written by ST and AJ, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
Oklahoma Shared Clinical and Translational Resources (U54GM104938) with an Institutional Development Award (IDeA) from NIGMS.
Declarations
Conflict of interest
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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