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Higginbotham DO, El-Othmani MM, Nham FH, Alsoof D, Diebo BG, McCarty SA, Daniels AH. Perioperative Nutritional, Functional, and Bone Health Optimization in Spine Surgery: A National Investigation of Spine Surgeons' Perceptions and Practices. J Am Acad Orthop Surg 2024:00124635-990000000-00995. [PMID: 38773840 DOI: 10.5435/jaaos-d-23-00582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION While perioperative nutritional, functional, and bone health status optimization in spine surgery is supported with ample evidence, the implementation and surgeon perception regarding such efforts in clinical practice remain largely unexplored. This study sought to assess the current perception of spine surgeons and implementation regarding the nutritional, functional status, and bone health perioperative optimization. METHODS An anonymous 30-question survey was distributed to orthopaedic spine fellowship and neurosurgery program directors identified through the North American Spine Society and American Association of Neurological Surgeons contact databases. RESULTS The questionnaire was completed by 51 surgeon survey respondents. Among those, 62% reported no current formal nutritional optimization protocols with 14% not recommending an optimization plan, despite only 10% doubting benefits of nutritional optimization. While 5% of respondents perceived functional status optimization as nonbeneficial, 68% of respondents reported no protocol in place and 46% noted a functional status assessment relying on patient dependency. Among the respondents, 85% routinely ordered DEXA scan if there was suspicion of osteoporosis and 85% usually rescheduled surgery if bone health optimization goals were not achieved while 6% reported being suspicious of benefit from such interventions. CONCLUSION While most responding spine surgeons believe in the benefit of perioperative nutritional and functional optimization, logistical and patient compliance challenges were noted as critical barriers toward optimization. Understanding surgeon perception and current practices may guide future efforts toward advancement of optimization protocols.
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Affiliation(s)
- Devan O Higginbotham
- From the Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI (Higginbotham, Nham, and McCarty), the Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY (El-Othmani), and the Department of Orthopedics, Warren Alpert Medical School, Brown University, Providence, RI (Alsoof, Diebo, and Daniels)
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McDonald CL, Berreta RAS, Alsoof D, Homer A, Molino J, Ames CP, Shaffrey CI, Hamilton DK, Diebo BG, Kuris EO, Hart RA, Daniels AH. Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty. Spine J 2023; 23:1365-1374. [PMID: 37236366 DOI: 10.1016/j.spinee.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/16/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND CONTEXT Surgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality. PURPOSE The purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample. STUDY DESIGN/SETTING Retrospective cohort study using an administrative claims database. PATIENT SAMPLE A total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons. OUTCOME MEASURES The primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total). METHODS The PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521. RESULTS A total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (orthopedic surgeons: $17,971.66 vs neurological surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery. CONCLUSIONS This investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.
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Affiliation(s)
- Christopher L McDonald
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Rodrigo A Saad Berreta
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Daniel Alsoof
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Alex Homer
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Janine Molino
- Department of Orthopedics, Biostatistics Division, Brown University Warren Alpert Medical School, Grads Dorm Building 3rd Floor, Rhode Island Hospital 593 Eddy St, 02903, Providence, RI, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, Eighth Floor, 400 Parnassus Ave, CA 94143, San Francisco, California
| | - Christopher I Shaffrey
- Department of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, 200 Lothrop Street, A402 UPMC Presbyterian, PA 15213, Pittsburgh, Pennsylvania
| | - Bassel G Diebo
- Swedish Neuroscience Institute, 550 17th Avenue, James Tower, Suite 500, 98122, Seattle, WA
| | - Eren O Kuris
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Robert A Hart
- Swedish Neuroscience Institute, 550 17th Avenue, James Tower, Suite 500, 98122, Seattle, WA
| | - Alan H Daniels
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA.
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Arora A, Cummins DD, Wague A, Mendelis J, Samtani R, McNeill I, Theologis AA, Mummaneni PV, Berven S. Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review. Spine Deform 2023; 11:773-785. [PMID: 36811703 PMCID: PMC10261200 DOI: 10.1007/s43390-023-00654-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/21/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery. METHODS Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009). RESULTS Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization. CONCLUSIONS Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.
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Affiliation(s)
- Ayush Arora
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Daniel D Cummins
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Aboubacar Wague
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Joseph Mendelis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Rahul Samtani
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Ian McNeill
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University California, San Francisco, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA.
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Risk factors of early complications after thoracic and lumbar spinal deformity surgery: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:899-913. [PMID: 36611078 DOI: 10.1007/s00586-022-07486-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/07/2022] [Accepted: 12/04/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE To determine risk factors increasing susceptibility to early complications (intraoperative and postoperative within 6 weeks) associated with surgery to correct thoracic and lumbar spinal deformity. METHODS We systematically searched the PubMed and EMBASE databases for studies published between January 1990 and September 2021. Observational studies evaluating predictors of early complications of thoracic and lumbar spinal deformity surgery were included. Pooled odds ratio (OR) or standardized mean difference (SMD) with 95% confidence intervals (CI) was calculated via the random effects model. RESULTS Fifty-two studies representing 102,432 patients met the inclusion criteria. Statistically significant patient-related risk factors for early complications included neurological comorbidity (OR = 3.45, 95% CI 1.83-6.50), non-ambulatory status (OR = 3.37, 95% CI 1.96-5.77), kidney disease (OR = 2.80, 95% CI 1.80-4.36), American Society of Anesthesiologists score > 2 (OR = 2.23, 95% CI 1.76-2.84), previous spine surgery (OR = 1.98, 95% CI 1.41-2.77), pulmonary comorbidity (OR = 1.94, 95% CI 1.21-3.09), osteoporosis (OR = 1.60, 95% CI 1.17-2.20), cardiovascular diseases (OR = 1.46, 95% CI 1.20-1.78), hypertension (OR = 1.37, 95% CI 1.23-1.52), diabetes mellitus (OR = 1.84, 95% CI 1.30-2.60), preoperative Cobb angle (SMD = 0.43, 95% CI 0.29, 0.57), number of comorbidities (SMD = 0.41, 95% CI 0.12, 0.70), and preoperative lumbar lordotic angle (SMD = - 0.20, 95% CI - 0.35, - 0.06). Statistically significant procedure-related factors were fusion extending to the sacrum or pelvis (OR = 2.53, 95% CI 1.53-4.16), use of osteotomy (OR = 1.60, 95% CI 1.12-2.29), longer operation duration (SMD = 0.72, 95% CI 0.05, 1.40), estimated blood loss (SMD = 0.46, 95% CI 0.07, 0.85), and number of levels fused (SMD = 0.37, 95% CI 0.03, 0.70). CONCLUSION These data may contribute to development of a systematic approach aimed at improving quality-of-life and reducing complications in high-risk patients.
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Gehrchen ML, Bari TJ, Dahl B, Andersen TB, Gehrchen M. Is preoperative S-albumin associated to postoperative complications and readmission in patients with adult spinal deformity: a prospective analysis of 128 patients using the Spine AdVerse Event Severity (SAVES) system. Spine Deform 2022; 10:893-900. [PMID: 34982418 DOI: 10.1007/s43390-021-00467-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/19/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the association between preoperative S-albumin and postoperative outcome following adult spinal deformity (ASD) surgery. METHODS All patients undergoing ASD surgery from February 1, 2017 and January 31, 2018 at a single quaternary referral center were prospectively included. Adverse events (AE) during admission were assessed using the Spine AdVerse Events Severity (SAVES) system. Based on preoperative S-albumin, patients were categorized as "normal" or "abnormal" and compared regarding postoperative outcome, adverse events (AEs), 30- and 90-day readmission, revision surgery, and mortality. RESULTS A total of 128 patients aged ≥ 18 years were included, and S-albumin was available in 88%. Of these, 73% (n = 93) were classified as "normal", 16% (n = 20) as "abnormal", and 12% (n = 15) as "missing". The "normal" albumin group had less comorbidity burden [ASA score 2 (2, 3) vs 3 (2, 3), p = 0.011], higher hemoglobin levels (8.4 (± 0.9) mmol/L vs 7.4 (± 1.1) mmol/L, p < 0.001), and higher S-albumin (38.9 (± 2.7) g/L vs 31.9 (± 4.4) g/L, < 0.001). The rate of 90-day readmission was significantly increased in the "abnormal" group (65% vs 36%), corresponding to a relative risk increase of 1.25 (95% CI 1.02-1.52, p = 0.029). Similar increased risks were found in subsequent logistic regression analyses, although results were not significant in multivariable analysis (p = 0.102). Comparing remaining outcome parameters, point estimates revealed increased AEs, 30-day readmission, and revision in the "abnormal" albumin group, although effects did not reach statistical significance. CONCLUSIONS In a prospective, consecutive, single-center cohort of 128 patients undergoing ASD surgery, we found a significant association between "abnormal" preoperative S-albumin and increased 90-day readmission. Furthermore, although the findings were not statistically significant, we did find that AEs, 30-day readmission, and revision were numerically more frequent in the "abnormal" group, suggesting an expected tendency that should be further investigated. We conclude that nutritional status prior to ASD surgery could be important to consider and suggest validation in larger prospective cohorts. LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Mathilde Louise Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin St., Houston, TX, 77030, USA
| | - Thomas Borbjerg Andersen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Lee NJ, Lenke LG, Cerpa M, Lombardi J, Ha A, Park P, Leung E, Sardar ZM, Lehman RA. The 90-Day Reoperations and Readmissions in Complex Adult Spinal Deformity Surgery. Global Spine J 2022; 12:415-422. [PMID: 32878483 PMCID: PMC9121151 DOI: 10.1177/2192568220953391] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE Identify surgical complex adult spine deformity patients who are at increased risk for an unplanned postoperative 90-day readmission and/or reoperation. METHODS A total of 227 consecutive records of complex adult (≥18 years old) spine deformity surgeries from 2015 to 2018 were reviewed. Demographics, comorbidities, operative details, and postoperative complication data was collected. Chi-square/Fisher's exact test and t tests were used for bivariate analysis. To determine independent predictors for readmissions/reoperations, stepwise multivariate logistic regressions were employed. The C-statistic and Hosmer-Lemeshow (HL) value was used to measure concordance and goodness of fit. RESULTS Average age was 50.5 ± 17.8 years and 67.8% were female. Ninety-day readmission and reoperation rates were 7.0% and 5.3%, respectively. Median number of days after index discharge date resulting in readmission and reoperation were 16.5 and 28, respectively. The multivariate regression for 90-day readmissions included pulmonary comorbidity, depression, history of deep vein thrombosis/pulmonary embolism (DVT/PE), and gastrointestinal comorbidity (C-statistic = 0.82; HL = 0.79). Pulmonary comorbidity, depression, and history of DVT/PE increased risk for 90-day readmission by 5-, 3.5-, and 10.2-fold, respectively. The multivariate regression for 90-day reoperations was similar to readmissions (C-statistic = 0.89; HL = 0.31). Operative time>7 hours and history of DVT/PE increased risk for early reoperation by 5.8- and 8.7-fold, respectively. CONCLUSIONS An emphasis on medically optimizing patients with preexisting pulmonary comorbidities, depression, and history of DVT/PE may have a substantial impact on improving short-term outcomes in this population. The present study provides benchmark data and may serve as an initial model to predict unplanned reoperations and readmissions.
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Affiliation(s)
- Nathan J. Lee
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Lawrence G. Lenke
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Meghan Cerpa
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA,Meghan Cerpa, Columbia University Medical Center, 5141 Broadway, New York, NY 10034, USA.
| | - Joseph Lombardi
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Alex Ha
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Paul Park
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Eric Leung
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Zeeshan M. Sardar
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ronald A. Lehman
- Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, NY, USA
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Effect of Bone Health Optimization on Osteoporosis Screening and Treatment Before Thoracolumbar Fusion. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202203000-00014. [PMID: 35290252 PMCID: PMC8926033 DOI: 10.5435/jaaosglobal-d-21-00253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/23/2022] [Indexed: 11/18/2022]
Abstract
Objective: Osteoporosis is not rare in thoracolumbar spine fusion patients and may portend poorer surgical outcomes. Implementation of a bone health optimization (BHO) clinic improves osteoporosis screening and treatment in the total joint arthroplasty population. We hypothesize that preoperative osteoporosis is common, under-recognized, and undertreated in thoracolumbar fusion patients and that a BHO clinic will increase preoperative osteoporosis screening rates and pharmacologic osteoporosis treatment in this population. Methods: This retrospective case series includes adults older than 30 years who underwent elective thoracolumbar spine fusion at a single tertiary care center before and after creation of a BHO referral clinic. Data collected included preoperative osteoporosis risk factors, prior dual-energy radiograph absorptiometry testing, and prior osteoporosis pharmacotherapy. Fracture risk was estimated using the fracture risk assessment tool with and without bone mineral density (BMD), and the US National Osteoporosis Foundation criteria for screening and treatment were applied. Results: Ninety patients were included in the pre-BHO group; 53 patients met criteria for BMD measurement, but only 10 were tested within 2 years preoperatively. Sixteen patients (18%) met criteria for osteoporosis pharmacotherapy, but only 5 of the 16 (31%) received osteoporosis medication within 6 months of surgery. There were 87 patients in the post-BHO group, and 19 were referred to the BHO clinic. BMD measurement was done in 17 of the patients (89%) referred to the BHO clinic compared with 10% for those not referred. All patients (n = 7) referred to the BHO clinic meeting treatment criteria received treatment within 6 months before surgery, whereas only 25% of the patients not referred received treatment. Discussion: Osteoporosis is not rare in adults undergoing thoracolumbar spine fusion with ∼13% to 18% meeting criteria for pharmacotherapy. Preoperative BHO referral increases screening and treatment.
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The role of the fractional lumbosacral curve in persistent coronal malalignment following adult thoracolumbar deformity surgery: a radiographic analysis. Spine Deform 2021; 9:721-731. [PMID: 33651338 DOI: 10.1007/s43390-020-00228-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/10/2020] [Indexed: 10/22/2022]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE Assess radiographically the effect of an all-posterior approach on correction of coronal balance in primary adult thoracolumbar spinal deformities based on Bao's classification of coronal imbalance with a focus on lumbosacral curve correction. Achieving appropriate coronal alignment is difficult in adults with coronal malalignment due to trunk shift ipsilateral to degenerated thoracolumbar scoliosis' apex. METHODS Review of adults who underwent posterior spinal fusions to pelvis (≥ 5 levels) for thoracolumbar scoliosis. Exclusion: revisions, no coronal deformity, thoracic Cobb > 30°, and anterior operations. Patients were divided into three groups, as proposed by Bao et al.: type A: CSVL < 3 cm; type B: CSVL > 3 cm and C7 plumb shifted to scoliosis' concavity; type C: CSVL > 3 cm and C7 plumb shifted to scoliosis' convexity. Radiographic parameters and surgical techniques were compared. RESULTS 124 patients (male-6; female-118; avg. age 58 ± 10 years; type A-87; type B-19; type C-18). Type C had significantly greater lumbosacral fractional curves. 28% of type C were treated with fractional curve TLIFs, while all, but one, type B had TLIFs of the fractional curve. Deformity parameters after surgery were similar, except type C had persistently greater fractional curves/coronal malalignment. All preop type B were appropriately corrected postop. For preop type C, 67% remained type C and 33% became type A postop. Compared to those who became type A, persistently undercorrected and malaligned (type C) patients had significantly greater preop lumbosacral fractional curves, greater preop coronal Cobb angles, and more commonly involved TLIFs of lumbosacral fractional curves. Compared to no interbody support, use of TLIFs provided better correction of the lumbosacral curve. CONCLUSIONS In adults with primary, posterior-only operations for thoracolumbar spinal deformity, 67% of type C coronal deformities and 20% of type A deformities remained or had worse coronal malalignment postop. While the use of TLIFs improved correction of the lumbosacral curve compared to no interbody support, alternative surgical strategies should be considered to more adequately correct lumbosacral fractional curves and balance correction of lumbosacral and major thoracolumbar curves so as to maintain and/or restore coronal balance. LEVEL OF EVIDENCE III.
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Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To identify gaps in opioid prescription immediately prior to spinal fusion and to study the effect of such simulated "opioid weaning/elimination" on risk of long-term postoperative opioid use. SUMMARY OF BACKGROUND DATA Numerous studies have described preoperative opioid duration and dose thresholds associated with sustained postoperative opioid use. However, the benefit and duration of preoperative opioid weaning before spinal fusion has not been elaborated. METHODS Humana commercial insurance data (2007-Q1 2017) was used to study primary cervical and lumbar/thoracolumbar fusions. More than 5000 total morphine equivalents in the year before spinal fusion were classified as chronic preoperative opioid use. Based on time between last opioid prescription (<14-days' supply) and spinal fusion, chronic opioid users were divided as; no gap, >2-months gap (2G) and >3-months gap (3G). Primary outcome measure was long-term postoperative opioid use (>5000 total morphine equivalents between 3 and 12-mo postoperatively). The effect of "opioid gap" on risk of long-term postoperative opioid use was studied using multiple-variable logistic regression analyses. RESULTS 17,643 patients were included, of whom 3590 (20.3%) had chronic preoperative opioid use. Of these patients, 41 (1.1%) were in the 3G group and 106 (3.0%) were in the 2G group. In the 2G group, 53.8% patients ceased to have long-term postoperative use as compared with 27.8% in NG group. This association was significant on logistic regression analysis (OR 0.30, 95% CI: 0.20-0.46, P < 0.001). CONCLUSIONS Chronic opioid users whose last opioid prescription was >2-months prior to spinal fusion and less than 14-days' supply had significantly lower risk of long-term postoperative opioid use. We have simulated "opioid weaning" in chronic opioid users undergoing major spinal fusion and our analysis provides an initial reference point for current clinical practice and future clinical studies.Level of Evidence: 3.
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Mechanical revision following pedicle subtraction osteotomy: a competing risk survival analysis in 171 consecutive adult spinal deformity patients. Spine Deform 2021; 9:191-205. [PMID: 32875546 DOI: 10.1007/s43390-020-00195-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 08/25/2020] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To report the incidence of revision surgery due to mechanical failure following pedicle subtraction osteotomy (PSO) in adult spinal deformity (ASD) patients. PSO allow major surgical correction of ASD, although; the risk of mechanical complications remains considerable. Previous reports have been based on smaller cohorts or multicenter databases and none have utilized competing risk (CR) survival analysis. METHODS All ASD patients undergoing PSO surgery from 2010 to 2015 at a single, tertiary institution were included. Demographics, long standing radiographs as well as intra- and postoperative complications were registered for all. A CR-model was used to estimate the incidence of revision surgery due to mechanical failure and two predefined multivariable models were used to assess radiographic prediction of failure and reported as odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS A total of 171 patients were included with 2-year follow-up available for 91% (mean [IQR]: 35 [24-50] months). Mechanical failure occurred in 111 cases (65%) at any time in follow-up, the most frequent being rod breakage affecting 81 patients (47%). Cumulative incidence of revision surgery due to mechanical failure was estimated to 34% at 2 years and 58% at 5 years. A multivariable proportional odds model with death as competing risk showed significantly increased odds of revision with fusion to the sacrum (OR: 5.42; 95% CI 1.89-15.49) and preoperative pelvic tilt (PT) > 20° (OR: 2.41; 95% CI 1.13-5.16). History of previous surgery, number of instrumented vertebra, as well as postoperative SRS-Schwab modifiers and Global Alignment and Proportion score were not associated with significant effects on odds of revision. CONCLUSIONS In a consecutive single-center cohort of patients undergoing PSO for ASD, we found an estimated incidence of revision surgery due to mechanical failure of 34% 2 years postoperatively. Fusion to the sacrum and preoperative PT > 20° were associated with elevated risks of revision. LEVEL OF EVIDENCE Prognostic III.
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Machine Learning for Predictive Modeling of 90-day Readmission, Major Medical Complication, and Discharge to a Facility in Patients Undergoing Long Segment Posterior Lumbar Spine Fusion. Spine (Phila Pa 1976) 2020; 45:1151-1160. [PMID: 32706568 DOI: 10.1097/brs.0000000000003475] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case control study. OBJECTIVE To develop predictive models for postoperative outcomes after long segment lumbar posterior spine fusion (LSLPSF). SUMMARY OF BACKGROUND DATA Surgery for adult spinal deformity is effective for treating spine-related disability; however, it has high complication and readmission rates. METHODS Patients who underwent LSLPSF (three or more levels) were identified in State Inpatient Database. Data was queried for discharge-to-facility (DTF), 90-day readmission, and 90-day major medical complications, and demographic, comorbid, and surgical data. Data was partitioned into training and testing sets. Multivariate logistic regression, random forest, and elastic net regression were performed on the training set. Models were applied to the testing set to generate AUCs. AUCs between models were compared using the method by DeLong et al. RESULTS.: 37,852 patients were analyzed. The DTF, 90-day readmission, and 90-day major medical complication rates were 35.4%, 19.0%, and 13.0% respectively. For DTF, the logistic regression AUC was 0.77 versus 0.75 for random forest and 0.76 for elastic net (P < 0.05 for all comparisons). For 90-day readmission, the logistic regression AUC was 0.65, versus 0.63 for both random forest and elastic net (P < 0.05 for all comparisons). For 90-day major medical complications, the logistic regression AUC was 0.70, versus 0.69 for random forest and 0.68 for elastic net (P < 0.05 for all comparisons). CONCLUSION This study created comprehensive models to predict discharge to facility, 90-day readmissions, and 90-day major medical complications after LSLPSF. This information can be used to guide decision making between the surgeon and patient, as well as inform value-based payment models. LEVEL OF EVIDENCE 3.
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