Search

Background: For cervical deformity (CD) surgery, goals include realignment, improved patient quality of life, and improved clinical outcomes. There is limited research identifying patients most likely to achieve all three. Objective: The objective is to create a model predicting good 1-year postoperative realignment, quality of life, and clinical outcomes following CD surgery using baseline demographic, clinical, and radiographic factors. Methods: Retrospective review of a multicenter CD database. CD patients were defined as having one of the following radiographic criteria: Cervical sagittal vertical axis (cSVA) >4 cm, cervical kyphosis/scoliosis >10°° or chin-brow vertical angle >25°. The outcome assessed was whether a patient achieved both a good radiographic and clinical outcome. The primary analysis was stepwise regression models which generated a dataset-specific prediction model for achieving a good radiographic and clinical outcome. Model internal validation was achieved by bootstrapping and calculating the area under the curve (AUC) of the final model with 95% confidence intervals. Results: Seventy-three CD patients were included (61.8 years, 58.9% F). The final model predicting the achievement of a good overall outcome (radiographic and clinical) yielded an AUC of 73.5% and included the following baseline demographic, clinical, and radiographic factors: mild-moderate myelopathy (Modified Japanese Orthopedic Association >12), no pedicle subtraction osteotomy, no prior cervical spine surgery, posterior lowest instrumented vertebra (LIV) at T1 or above, thoracic kyphosis >33°°, T1 slope <16 and cSVA <20 mm. Conclusions: Achievement of a positive outcome in radiographic and clinical outcomes following surgical correction of CD can be predicted with high accuracy using a combination of demographic, clinical, radiographic, and surgical factors, with the top factors being baseline cSVA <20 mm, no prior cervical surgery, and posterior LIV at T1 or above. [ABSTRACT FROM AUTHOR]

The AHRQ (Agency for Healthcare Research and Quality) has requested the correction of the result Tables 1–3 of this study: All stated numbers below 10 shall be modified to read "<10" instead. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery (BS) is an increasingly common treatment for morbid obesity that has the potential to effect bone and mineral metabolism. The effect of prior BS on spine surgery outcomes has not been well established. The aim of this study was to assess differences in complication rates following spinal surgery for patients with and without a history of BS.Methods: Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years 2004-2013. BS patients and morbidly obese patients (non-BS) were divided into cervical and thoracolumbar surgical groups and propensity score matched for age, gender, and invasiveness and complications compared.Results: One thousand nine hundred thirty-nine spine surgery patients with a history of BS were compared to 1625 non-BS spine surgery patients. The average time from bariatric surgery to spine surgery is 2.95 years. After propensity score matching, 740 BS patients were compared to 740 non-BS patients undergoing thoracolumbar surgery, with similar comorbidity rates. The overall complication rate for BS thoracolumbar patients was lower than non-BS (45.8% vs 58.1%, P < 0.001), with lower rates of device-related (6.1% vs 23.2%, P < 0.001), DVT (1.2% vs 2.7%, P = 0.039), and hematomas (1.5% vs 4.5%, P < 0.001). Neurologic complications were similar between BS patients and non-BS patients (2.3% vs 2.7%, P = 0.62). For patients undergoing cervical spine surgery, BS patients experienced lower rates of bowel issues, device-related, and overall complication than non-BS patients (P < 0.05).Conclusions: Bariatric surgery patients undergoing spine surgery experience lower overall complication rates than morbidly obese patients. This study warrants further investigation into these populations to mitigate risks associated with spine surgery for bariatric patients. [ABSTRACT FROM AUTHOR]

Background Context: With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount.Purpose: Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges.Study Design/setting: This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database.Patient Sample: Patients undergoing thoracolumbar surgery for correction of ASD were included in the study.Outcome Measures: Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups.Methods: Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion.Results: A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio [OR]: 0.28, confidence interval [CI]: 0.22-0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35-0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40-0.64), interbody device placement (OR: 0.80, CI: 0.64-0.98), and fixation to the iliac (OR: 0.54, CI: 0.41-0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21-0.57) and blood transfusions (OR: 0.42, CI: 0.34-0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p<.001), but again not different from skilled nursing facility discharges (+$6,091, p=.212).Conclusions: Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective analysis of three prospectively collected databases.Objective: To compare perioperative outcomes in Adult Spinal Deformity (ASD) surgeries in a surgeon-run (SR-ASD) and two national databases: the Nationwide Inpatient Sample (NIS) and the National Surgical Quality Improvement Program (NSQIP).Summary Of Background Data: Much has been learned on the treatment of ASD in the last decade with prospective multicenter collaborative research focusing on this specific condition. Nondisease specific national databases are being used for hypothesis and quality control testing on a large number of ASD patients. Their accuracy and applicability remains unevaluated.Methods: Patients were identified on each respective database undergoing lumbar spine fusion for ASD. Propensity score matching established cohorts of patients on each database with similar procedures being performed. Complication prevalence and relative risk was compared on the NIS and NSQIP against SR-ASD. Secondary outcome measures included hospital-stay characteristics, surgical invasiveness, patient demographics, and patient comorbidities.Results: Two hundred fifty-five patients were identified on each database 1:1:1 with similar overall surgical intensity. Querying the databases using ICD-9 codes, CPT codes, and surgeon-reports resulted in different complication incidences: overall complication rates were 17.65% on NIS, 24.31% on NSQIP, and 68.24% on SR-ASD. The relative risk of a medical complication in SR-ASD was 1.87 (1.42-2.48) relative to NIS and 1.91 (1.44-2.54) relative to NSQIP. The relative risk of a surgical complication was 5.45 (2.69-11.05) compared with NIS and 12.05 (3.98-36.49) compared with NSQIP.Conclusion: After selecting patients using the same criteria and diagnosis, NIS, NSQIP, and SR-ASD databases captured different patient populations and different complication incidences. There were total absences of certain complications contrary to usual literature rates in all three databases. Faithful reporting necessitates understanding database limitations, and careful evaluation of database strengths and weaknesses is paramount to accurate reports.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background Context: Adult spinal deformity (ASD) represents a constellation of complex malalignments affecting the spinal column. Corrective surgical procedures aimed at improving ASD can be equally challenging, and commonly require multiple index procedures and potential revisions before definitive management. There is a paucity of data comparing the outcomes of same-day(simultaneous [SIM]) and 2-day (staged [STA]) procedures for long spinal fusions for ASD. Using a large patient cohort with surgeon- and patient-reported outcomes will be particularly useful in determining the utility and effect of staging long spinal fusions for ASD.Purpose: This study aimed to compare intraoperative, perioperative, and 2-year outcomes of STA and SIM procedures correcting ASD.Study Design: This is a retrospective analysis of a prospective multicenter database.Patient Sample: A total of 142 patients (71 STA, 71 SIM) were included.Outcome Measures: Primary outcome measures were intra- and perioperative (6 weeks) complication rates. Secondary outcome measures were 2-year thoracolumbar and spinopelvic radiographic parameters, 2-year health-related quality of life (HRQoL) changes (Oswestry Disability Index [ODI] and Short Form-36 [SF-36]), and 2-year complication rates.Methods: Inclusion criteria included patients with ASD ≥18 years with 6-week and 2-year follow-up. Propensity score matching identified similar patients undergoing STA or SIM long spinal fusions based on surgical invasiveness, pelvic tilt, and sagittal vertical axis (SVA). Complications, HRQoL scores (Scoliosis Research Society-22 Patient Questionnaire [SRS-22r], SF-36, ODI), and patient characteristics were compared across and within treatment groups at follow-up with analysis of variance (ANOVA) and paired t tests at three surgical stages: intraoperatively, perioperatively (6 weeks), and postoperatively (>6 weeks).Results: A total of 142 patients were included (71 STA, 71 SIM). Matching STA and SIM groups based on degree of deformity and surgical invasiveness created two groups similar in overall correction of the surgery. Patients undergoing STA underwent more anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) procedures, whereas patients undergoing SIM had longer fusions. Charlson comorbidity index and revision status were similar between groups (p>.05). Staging procedures had significantly more complications causing reoperation (STA: 47% vs. SIM: 8%, p=.021), and had a greater number of perioperative complications requiring a return to the operating room (OR) (STA: 9.9% vs. SIM: 1.4%, p=.029). There was no difference in intraoperative complications, mortality, or perioperative infection or wound complications (p>.05) between the two procedures. At 2-year follow-up, incidence of revision surgery was higher in STA (STA: 21.1% vs. SIM: 8.5%, p=.033).Conclusion: Staged spinal fusions, which add ALIFs and LLIFs to the procedure, compared with similar-correction SIM procedures, result in similar intraoperative complication incidence, but significantly higher rates of peri- and postoperative complications leading to revision. Functional outcomes, radiographic parameters, and mortality were similar. This will aid surgeons in their determination of the optimal treatment for such complex procedures. [ABSTRACT FROM AUTHOR]

Introduction: Since its introduction BMP has been utilized in populations with higher rates of malunion, such as adult spinal deformity (ASD) patients. Contradictory conclusions exist in spinal literature regarding the safety and efficacy of the use of BMP in this setting. Previous studies, however, did not distinguish deformity cases from spondylolisthesis or stenosis. The purpose of this study is to evaluate the safety and efficacy of BMP use in spinal fusion surgery for ASD.Methods: 166 papers were screened after database search. 40 full texts were assessed for eligibility. Five studies were included for meta-analysis. Three were comparative studies between a BMP and non-BMP group, and the other was used to supplement dose-effect analysis.Results: The current meta-analysis found increased odds of developing radiculitis or neurological complications (OR = 2.18, 95% CI, p = 0.02, i 2 = 0), but no other significant relationship between complications commonly attributed to BMP use (tumorigenesis, infections, seroma formation, or osteolysis) and BMP use. BMP patients had decreased rates of pseudarthrosis (OR = 0.23, 95% CI, p = 0.002, i 2 = 0). There was an average dose of 8.75 mg/level in the 417 patients studied, lower than the advised dosage of 12 mg/level.Conclusions: The current literature shows BMP to be a safe and effective grafting technique in the treatment of ASD. Spine surgeons may currently be using sub-optimal doses of BMP. The benefit of increasing the rate of fusion must be weighed against the increased risk of radiculitis and neurologic complications in this patient population. [ABSTRACT FROM AUTHOR]

Background Context: Non-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings.Purpose: This study aimed to identify deformity and disability characteristics of patients with ASD who ultimately convert to operative treatment compared with those who remain non-operative and those who initially choose surgery.Study Design/setting: A retrospective review was carried out.Patient Sample: A total of 510 patients with ASD (189 non-operative, 321 operative) with minimum 2-year follow-up comprised the patient sample.Outcome Measures: Oswestry Disability Index (ODI), Short-Form 36 Health Assessment (SF-36), Scoliosis Research Society questionnaire (SRS-22r), and spinopelvic radiographic alignment were the outcome measures.Methods: Demographic, radiographic, and patient-reported outcome measures (PROMs) from a cohort of patients with ASD prospectively enrolled into a multicenter database were evaluated. Patients were divided into three treatment cohorts: Non-operative (NON=initial non-operative treatment and remained non-operative), Operative (OP=initial operative treatment), and Crossover (CROSS=initial non-operative treatment with subsequent conversion to operative treatment). NON and OP groups were propensity score-matched (PSM) to CROSS for baseline demographics (age, body mass index, Charlson Comorbidity Index). Time to crossover was divided into early (<1 year) and late (>1 year). Outcome measures were compared across and within treatment groups at four time points (baseline, 6 weeks, 1 year, and 2 years).Results: Following PSM, 118 patients were included (NON=39, OP=38, CROSS=41). Crossover rate was 21.7% (41/189). Mean time to crossover was 394 days. All groups had similar baseline sagittal alignment, but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9° vs. 3.1°, p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds-Non with Schwab T/L/D curves and ODI≥40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades ("+"/'++') and ODI≥40 (OR: 5.57, p=.007) were at increased crossover risk.Conclusions: High baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective review of prospective multicenter database.Objective: The aim of this study was to identify factors influencing readmission, reoperation, and the impact on health-related quality of life outcomes (HRQoLs) in adult spinal deformity (ASD) surgery.Summary Of Background Data: Many ASD patients experience complications requiring readmission. It is important to identify baseline/operative factors leading to rehospitalizations and reoperation, which may impact outcomes.Methods: Inclusion Criteria: ASD surgical patients (age >18 yrs, major coronal Cobb ≥20°, sagittal vertical axis ≥5 cm, pelvic tilt ≥25°, and/or thoracic kyphosis >60°) with complete baseline, 1-, and 2-year follow-up. Patients were grouped on the basis of readmission occurrence (yes/no) and type [medical (no reoperation) vs. surgical (revision surgery)]. Readmissions caused by infections requiring surgical treatment (e.g., deep infections) were considered reoperations. Univariate and multivariate analyses determined readmission and reoperation predictors. Repeated measures mixed models evaluated readmission impact on HRQoLs at 1 and 2 years.Results: Three hundred thirty-four patients were included: 76 (22.8%) readmissions, involving 65 (85.5% of 76) reoperations (surgical readmission) and 11 (14.5% of 76) medical readmissions. The most common surgical readmission indication (n = 65) was implant complications (36.9%; rod breakage n = 13); the most common medical readmission indication was infection (36.4%, n = 4), treated with antibiotics. Noninfectious medical readmission (n = 7) included pleural effusion, deep vein thrombosis (DVT), intraoperative blood loss, neurologic, and unspecified. Readmission predictors: increased number of major peri-operative complications [odds ratio (OR) 5.13, P = 0.014], infection presence (OR 25.02, P = 0.001), implant complications (OR 6.12, P < 0.001), and radiographic complications (DJK, proximal junctional kyphosis, pseudoarthrosis, sagittal/coronal imbalance) (OR 16.94, P < 0.001). HRQoL analysis revealed overall improvement of the full cohort (P < 0.01), though the 76 readmitted improved less overall and at each time point P < 0.001) except in 6-week MCS (P = 0.14).Conclusion: Major peri-operative, implant, radiographic, and infection complications during index were associated with increased readmission odds. Implant complications most frequently caused surgical readmissions. Readmitted patients improved in outcome scores, although less compared with the nonreadmitted cohort, yet displayed reduced 6-week SF-36 Mental Component Summary.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Bariatric surgery is an increasingly common treatment for morbid obesity that has the potential to effect bone and mineral metabolism. The effect of prior bariatric surgery on outcomes following spinal surgery has not been well-established. PURPOSE To assess differences in complication rates following spinal surgery for patients with and without a history of bariatric surgery. STUDY DESIGN/SETTING Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years (2004–2013). PATIENT SAMPLE A total of 1,939 patients with prior bariatric surgery now undergoing spine surgery, 1,625 overweight or obese spine surgery patients (no bariatric procedures), and 28,304 spine surgery patients who are not obese or overweight. OUTCOME MEASURES Complications following spine surgery. METHODS Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years 2004-2013. Patient linkage codes allow identification of multiple and return inpatient stays within the time-frame analyzed. Complication rates were compared between bariatric surgery patients now undergoing spine surgery versus morbidly obese patients having spine surgery. Bariatric surgery (BS) patients and morbidly obese patients (non-BS) were divided into cervical and thoracolumbar surgical groups and were propensity score matched for age, gender and degree of invasiveness. Nonobese spine surgery patients were used as a standard. RESULTS A total of 1,939 spine surgery patients with a history of BS were compared to 1,625 non-BS spine surgery patients in the NYSID database. A total of 89% of normal weight spine surgery patients had a decompression and the overall complication rate for these patients is 45%. The average time from bariatric surgery to spine surgery is 2.95 years. BS patients had primarily two-three level fusions and decompressions, which is similar to non-BS patients. After propensity score matching for age, gender and invasiveness, 740 BS patients were compared to 740 non-BS patients undergoing thoracolumbar surgery, with similar comorbidity rates between cohorts. The overall complication rate for BS patients undergoing thoracolumbar surgery was significantly lower than non-BS patients (45.8% vs. 58.1%, P<.001). The most common complications following thoracolumbar surgery for BS patients were anemia (20.3%), bowel issues (12.3%), device-related complications (6.1%), and digestive problems (5.0%). BS patients undergoing a thoracolumbar procedure experienced lower rates of device-related complications (6.1% vs. 23.2%, P<.001), DVT (1.2% vs. 2.7%, P=.039), and hematomas (1.5% vs. 4.5%, P<.001) than non-BS patients undergoing thoracolumbar surgery. Neurologic complications were similar between BS patients and non-BS patients (2.3% vs. 2.7%, P=.62) and this rate was similar to normal weight patients undergoing spine procedures (1.65%). Spine surgery revision rates for BS patients was 14.9% and the average length of stay for BS patients undergoing spine surgery was higher than non-BS patients undergoing thoracolumbar surgery (5.95 days vs. 5.14 days, P=.007). For patients undergoing cervical spine surgery, BS patients experienced lower rates of bowel issues, device-related, and overall complication rates than non-BS patients (all P>.05). CONCLUSIONS Bariatric surgery patients undergoing spine surgery experience lower overall complication rates than morbidly obese patients. This study warrants further investigation into these populations to mitigate risks associated with spine surgery for bariatric patients. [ABSTRACT FROM AUTHOR]