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Background: There exists a lack of comparison between large national healthcare databases reporting surgical morbidity and mortality. Prior authors have expressed concern that the Scoliosis Research Society (SRS) membership may have underreported complications in spinal surgery. Thus, the purpose of the present study was to compare the incidence of morbidity between the SRS and National Surgical Quality Improvement Program (NSQIP) databases., Methods: We reviewed patients enrolled between 2012 and 2013, with a total of 96,875 patients identified in the SRS dataset and 15,909 in the combined adult and pediatric NSQIP dataset. Patients were matched based on diagnostic category,and a univariate analysis was used to compare reported complication rates in the categories of perioperative infection, neurologic injury, and mortality. The SRS database only requires detailed demographic data reporting on patients that have had a complication event. We compared the demographics and comorbidities of this subgroup, and used this as a surrogate to assess the potential magnitude of confounders., Results: Small differences existed between the SRS and NSQIP databases in terms of mortality (0.1% v. 0.2%), infection (1.2% v. 2%), and neurologic injury (0.8% v. 0.1%) (p<0.001 for each comparison). Infection rates were consistently lower across multiple diagnostic sub-categories in the SRS database, whereas neurologic injury rates were consistently lower in the NSQIP database. These differences reached statistical significance across several diagnostic subcategories, but the clinical magnitude of the differences was small. Amongst the patients with a complication, modest differences in comorbidities existed between the two cohorts., Conclusion: Overall, the incidence of short-term morbidity and mortality was similar between the two databases. There were modest differences in comorbidities, which may explain the small differences observed in morbidity. Concerns regarding possible under-reporting of morbidity and mortality data by the SRS membership seem largely unfounded. This study may be useful for future investigators using the NSQIP and SRS datasets.

Background: Risk factors for complication after single-level anterior cervical discectomy and fusion remain poorly defined. The purpose of this study was to identify the incidence and risk factors for complication from a large, prospectively collected database, with a separate emphasis on the safety of outpatient procedures., Methods: The American College of Surgeons National Surgical Quality Improvement Program prospectively collects thirty-day morbidity and mortality data from more than 480 hospitals around the United States. We retrospectively queried this database to identify cases of single-level elective anterior cervical discectomy and fusion. Univariate and multivariate analyses were used to identify risk factors for complication, and a propensity score model was used to create matched inpatient and outpatient cohorts., Results: Of 2914 cases identified, 597 (20.5%) received outpatient treatment and 2317 (79.5%) received inpatient treatment. The overall incidence of any systemic morbidity was 3.2%. There were five mortalities (0.2%), four in the inpatient cohort and one in the outpatient cohort. Patient age over sixty-five years, body mass index of >30 kg/m 2 , American Society of Anesthesiologists class of 3 or 4, current dialysis, current corticosteroid use, recent sepsis, and operative times longer than 120 minutes were each independent risk factors for complication in the multivariate analysis. After propensity score matching to control for comorbidities, there were no significant differences in complication rates between inpatients and outpatients, and outpatient treatment was not a risk factor for complication in the multivariate analysis., Conclusions: Single-level elective anterior cervical discectomy and fusion had low complication rates, with no additional risk seen with outpatient as compared with inpatient procedures. It seems reasonable to consider inpatient admission for any patient with the risk factors identified here, particularly difficult airways. This information may be useful to surgeons performing informed consents for medical optimization and for selecting patients most appropriate for outpatient treatment., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was searched to identify patients who underwent primary total knee arthroplasty between 2005 and 2010. Complications that occurred within thirty days after the procedure in patients who had been managed with either general or spinal anesthesia were identified. Patient characteristics, thirty-day complication rates, and mortality were compared. Multivariate logistic regression identified predictors of thirty-day morbidity, and stratified propensity scores were used to adjust for selection bias., Results: The database search identified 14,052 cases of primary total knee arthroplasty; 6030 (42.9%) were performed with the patient under spinal anesthesia and 8022 (57.1%) were performed with the patient under general anesthesia. The spinal anesthesia group had a lower unadjusted frequency of superficial wound infections (0.68% versus 0.92%; p = 0.0003), blood transfusions (5.02% versus 6.07%; p = 0.0086), and overall complications (10.72% versus 12.34%; p = 0.0032). The length of surgery (ninety-six versus 100 minutes; p < 0.0001) and the length of hospital stay (3.45 versus 3.77 days; p < 0.0001) were shorter in the spinal anesthesia group. After adjustment for potential confounders, the overall likelihood of complications was significantly higher in association with general anesthesia (odds ratio, 1.129; 95% confidence interval, 1.004 to 1.269). Patients with the highest number of preoperative comorbidities, as defined by propensity score-matched quintiles, demonstrated a significant difference between the groups with regard to the short-term complication rate (11.63% versus 15.28%; p = 0.0152). Age, female sex, black race, elevated creatinine, American Society of Anesthesiologists class, operative time, and anesthetic choice were all independent risk factors of short-term complication after total knee arthroplasty., Conclusions: Patients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities.

Background: PROXIMAL JUNCTIONAL KYPHOSIS (PJK) IS DEFINED AS: 1) Proximal junction sagittal Cobb angle >≥10°, and 2) Proximal junction sagittal Cobb angle of at least 10° greater than the pre-operative measurement PJK is a common complication which develops in 39% of adults following surgery for spinal deformity. The pathogenesis, risk factors and prevention of this complication are unclear., Methods: Of 54 consecutive adults treated with spinal deformity surgery (age≥59.3±10.1 years), 19 of 54 (35%) developed PJK. The average follow-up was 26.8 months (range 12 - 42). Radiographic parameters were measured at the pre-operative, early postoperative (4-6 weeks), and final follow-up visits. Sagittal alignment was measured by the ratio between the C7-plumbline and the sacral-femoral distance. Binary logistic regression model with predictor variables included: Age, BMI, C7-plumbline, and whether lumbar lordosis, thoracic kyphosis and sacral slope were present, Results: Patients who developed PJK and those without PJK presented with comparable age, BMI, pelvic incidence and sagittal imbalance before surgery. They also presented with comparable sacral slope and lumbar lordosis. The average magnitude of thoracic kyphosis was significantly larger than the lumbar lordosis in the proximal junctional kyphosis group, both at baseline and in the early postoperative period, as represented by [(-lumbar )lordosis - (thoracic kyphosis)]; no- PJK versus PJK; 6.6°±23.2° versus -6.6°±14.2°; p≥0.012. This was not effectively addressed with surgery in the PJK group [(-LL-TK): 6.2°±13.1° vs. -5.2°±9.6°; p≥0.004]. This group also presented with signs of pelvic retroversion with a sacral slope of 29.3°±8.2° pre-operatively that was unchanged after surgery (30.4°±8.5° postoperatively). Logistic regression determined that the magnitude of thoracic kyphosis and sagittal balance (C7-plumbline) was the most important predictor of proximal junctional kyphosis., Conclusions: Proximal junctional kyphosis developed in those patients where the thoracic kyphosis remained greater in magnitude relative to the lumbar lordosis, and where the sagittal balance seemed corrected, but part of thise correction was secondary to pelvic retroversion., Level of Evidence: Prognostic case-control study - Level III.