Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients

Cerebrovascular Complications in Spinal Fusion Surgery: A Nationwide 8-year Follow-up Study in South Korea

This retrospective study investigated the long-term incidence and risk of postoperative complications following spinal fusion. This study included 640,366 participants from a National Health Examination cohort in the Republic of Korea. Among them, 11,699 individuals underwent spinal fusion, and 56,667 individuals who underwent non-fusion spinal procedures served as controls. Propensity score matching was used to account for patient characteristics including demographic factors, comorbidities, and other relevant variables. The participants were followed for 8 years to assess the occurrence of cerebrovascular disease (CVD), hemorrhagic infarction (HA), ischemic infarction (II), occlusion and stenosis, and ischemic heart disease (IHD). The incidence rates of CVD and IHD were found to be 27.58 and 31.45 per 1,000 person-years in the spinal fusion group compared to 18.68 and 25.73 per 1,000 person-years in the control group (p < .001), respectively. Patients who underwent spinal fusion had a higher risk of CVD, HA, and IHD than those in the control group (all p < .001). In the subgroup analysis, thoracolumbar and noncervical spinal fusion were associated with a higher risk of CVD, II, and IHD (all p < .005). Patients undergoing thoracolumbar fusion may have an increased association with CVD, II in cerebral arteries, and IHD. This suggests a need for careful consideration of vascular risks in such patient populations.

Do TLIF and PLIF Techniques Differ in Perioperative Complications? - Comparison of Complications Rates of Two High Volume Centers

STUDY DESIGN

Retrospective bicentric Cohort Study.

OBJECTIVE

Posterior (PLIF) and transforaminal lumbar interbody fusion (TLIF) have been clinically proven for the surgical treatment of degenerative spinal disorders. Despite many retrospective studies, the superiority of either technique has not been proven to date. In the literature, the complication rate of the conventional PLIF technique is reported to be significantly higher, but with inconsistent complication recording. In this retrospective bicentric study, a less invasive PLIF technique was compared with the conventional TLIF technique and complications were recorded using the validated SAVES V2 classification system.

METHODS

1142 patients underwent PLIF (702) or TLIF (n = 440) up to 3 levels in two specialized centers. Epidemiological data, intra- and postoperative complications during hospitalization and after discharge were analyzed according to SAVES V2.

RESULTS

The overall complication rate was 13.74%. TLIF-patients had slightly significant more complications than PLIF-patients (TLIF = 16.6%/PLIF = 11.9%, P = .0338). Accordingly, complications during revision surgeries were more frequent in the first cohort (TLIF = 20.9%/PLIF = 12.6%; P = .03252). In primary interventions, the surgical technique did not correlate with the complication rate (TLIF = 12.4%/PLIF = 11.7%). There were no significant differences regarding severity of complications.

CONCLUSIONS

An important component of this work is the complication recording according to a uniform classification system (SAVES V2). In contrast to previous literature, we could demonstrate that there is not a significant difference between the two surgical techniques.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Investigating the weekend effect in decompressive thoracolumbar hemilaminectomy for acute intervertebral disc extrusion: An observational cohort study of 460 cases (2018-2023)

OBJECTIVE

To investigate if weekend surgery is associated with poorer outcomes in dogs with acute thoracolumbar intervertebral disc extrusion (IVDE) undergoing decompressive thoracolumbar hemilaminectomy.

STUDY DESIGN

Retrospective observational cohort study.

SAMPLE POPULATION

A total of 460 consecutive cases were reviewed, with 401 dogs undergoing weekday surgery (Cohort WD), and 59 dogs undergoing weekend surgery (Cohort WE).

METHODS

Medical records of a surgical referral center in the UK were reviewed. Preoperative patient demographic and clinical data, and postoperative outcome data were collected with a minimum 28-day follow-up period. Multivariable logistic regression analysis was used to model the odds of a negative outcome.

RESULTS

Cohort WE had a higher preoperative proportion of nonambulatory dogs (p = .0115) but there were no significant differences between the nonambulatory (p = .3762) and deep-pain negative subgroups (p = .6199). Cohort WE had a higher risk of not recovering ambulation compared to Cohort WD [79.2% vs. 91.6% recovery; adjusted OR 3.010 (95% CI: 1.259-7.190); p = .0132] and had a higher risk of postoperative morbidity [32.2% vs. 17.2%; adjusted OR 2.015 (95% CI: 1.089-3.729); p = .0257]. There were no significant differences in other outcome measures between cohorts.

CONCLUSION

Weekend surgery in canine decompressive thoracolumbar hemilaminectomy may be associated with poorer patient outcomes, specifically higher postoperative morbidity and a poorer rate of recovery of ambulation.

CLINICAL SIGNIFICANCE

This study demonstrates a weekend effect in veterinary surgery, which may be important in surgical decision-making in acute thoracolumbar IVDE. Further scrutiny of the patient's journey through the veterinary healthcare system is warranted.

Monthly multidisciplinary complex spine conference: a cost-analysis utilizing time-driven activity-based costing

PURPOSE

To understand costs and provide an initial framework associated with conference implementation as it pertains to complication prevention.

METHODS

Team members' time spent on conference preparation, presentation, and follow-up tasks was recorded and averaged to determine the time required to prepare and present one patient. Using 2022 hourly wage rates based on our urban hospital setting, wage values were calculated for each personnel type and applied to their time spent. The total cost of the conference was annualized and calculated from the time spent in the three phases of the conference multiplied by the wage rate. Published data on complication rates and associated costs before and after conference implementation were used to calculate total cost reduction.

RESULTS

With 3 active spine surgeons and 108 patients per year, the total time investment was 104.04 min per patient, costing $21,791 annually. Total RN equivalent value per patient was 5.25 for all three phases. Using a historical model, this multidisciplinary approach for adult spinal deformity reduced complications by 51% at 30 days, resulting in cost savings of $418,518 per year. Thus, the model demonstrates that implementation of this approach resulted in a potential total savings of $396,726/year.

CONCLUSION

Implementing a cost-saving tool for managing complex spinal disorders is a responsibility of the spine team, who should lead a multidisciplinary conference. The combination of TDABC and lean methodology can effectively demonstrate the variable costs associated with this multidisciplinary effort and models provide evidence of potential cost-savings when applied to a multidisciplinary adult spinal deformity conference. These findings should encourage clinicians and administrators to allocate resources to improve patient care by reducing complications and costs.

Factors associated with increased length of stay and risk of complications in 336 patients submitted to spine surgery. The role of a validated capture system (SAVES v2) as a first-line tool to properly face the problem

PURPOSE

In this study, we analyzed the use of a validated capture system (Spinal Adverse Events Severity system, SAVES V2) as a first non-technical skill to properly face the relevant problem of surgical complications (SCs) and adverse events (AEs) in spinal surgery.

METHODS

We retrospectively collected AEs occurring in a tertiary referral center for spine surgery from January 2017 to January 2018 and classified them according to SAVES V2 system. We compared this collection of AEs with a prospective collection performed without any classification system. Univariate and multivariate logistic regression models were used to determined odds ratio (ORs) for selected potential risk factors of AEs and prolonged length of stay.

RESULTS

Overall a higher number of AEs was retrospectively recorded using SAVES system compared to the prospective recording without the use of any capture system (97/336 vs 210/336, p < 0.001). The length of stay (LOS) increased in the group of complicated patients for all the procedures examined. In the non-oncological group, LOS was significantly higher for complicated patients compared to uncomplicated patients (F = 44.11, p = 0.0000). Similar results have been obtained in the oncological group of patients. In the multivariate regression model surgical time and postoperative AEs emerged as risk factors for prolonged LOS, while only the presence of previous surgeries was confirmed as risk factor for AEs.

CONCLUSION

Considering that the rate of AEs and SCs in spinal surgery is still high despite the improvement of technical skills, we suggest the use of SAVES V2 capture system as a first-line tool to face the problem.

Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors

PURPOSE

To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors.

METHODS

Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant.

RESULTS

Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions.

CONCLUSION

sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.

Local contamination is a major cause of early deep wound infections following open posterior lumbosacral fusions

PURPOSE

Postoperative surgical site infection in patients treated with lumbosacral fusion has usually been thought to be caused by perioperative contamination. With the proximity of these incisions to the perineum, this study sought to determine if contamination by gastrointestinal and/or urogenital flora should be considered as a major cause of this complication.

METHODS

We conducted a retrospective review of adults treated with open posterior lumbosacral fusions between 2014 and 2021 to identify common factors in deep postoperative infection and the nature of the infecting organisms. Cases of tumor, primary infection and minimally invasive surgery were excluded.

RESULTS

489 eligible patients were identified, 20 of which required debridement deep to the fascia (4.1%). Mean age, operative time, estimated blood loss and levels fused were similar between both groups. The infected group had a significantly higher BMI. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth, 3 showed Staphylococcus sp. infection (Perioperative Inside-Out) requiring debridement at 63.5 days. Thirteen showed infection with intestinal or urogenital pathogens (Postoperative Outside-In) requiring debridement at 20.0 days. Postoperative Outside-In infections led to debridement 80.3 days earlier than Perioperative Inside-Out infections (p = 0.007).

CONCLUSIONS

65% of deep infections in patients undergoing open lumbosacral fusion were due to early contamination by pathogens associated with the gastrointestinal and/or urogenital tracts. These required earlier debridement than Staphylococcus sp.

INFECTIONS

There should be renewed focus on keeping these pathogens away from the incision during the early stages of wound healing.

Minimally Invasive Tubular Lumbar Discectomy Versus Conventional Open Lumbar Discectomy: An Observational Study From the Canadian Spine Outcomes and Research Network

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We evaluated the effectiveness of minimally invasive (MIS) tubular discectomy in comparison to conventional open surgery among patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN).

METHODS

We performed an observational analysis of data that was prospectively collected. We implemented Minimum Clinically Important Differences (MCIDs), and we adjusted for potential confounders with multiple logistic regression. Adverse events were collected according to the Spinal Adverse Events Severity (SAVES) protocol.

RESULTS

Three hundred thirty-nine (62%) patients underwent MIS tubular discectomy and 211 (38%) underwent conventional open discectomy. There were no significant differences between groups for improvement of leg pain and disability, but the MIS technique was associated with reduced odds of achieving the MCID for back pain (OR 0.66, 95% CI 0.44 to 0.99, P < 0.05). We identified statistically significant differences in favor of MIS for each of operating time (MIS mean (SD) 72.2 minutes (30.0) vs open 93.5 (40.9)), estimated blood loss (MIS 37.9 mL (36.7) vs open 76.8 (71.4)), length of stay in hospital (MIS 73% same-day discharge vs open 40%), rates of incidental durotomy (MIS 4% vs open 8%), and wound-related complications (MIS 3% vs open 9%); but not for overall rates of reoperation.

CONCLUSIONS

Open and MIS techniques yielded similar improvements of leg pain and disability at up to 12 months of follow-up, but MIS patients were less likely to experience improvement of associated back pain. Small differences favored MIS for operating time, blood loss, and adverse events but may have limited clinical importance.

Factors contributing to a longer length of stay in adults admitted to a quaternary spinal care center

BACKGROUND

Longer hospital length of stay (LOS) has been associated with worse outcomes and increased resource utilization. However, diagnostic and patient-level factors associated with LOS have not been well studied on a large scale. The goal was to identify patient, surgical and organizational factors associated with longer patient LOS for adult patients at a high-volume quaternary spinal care center.

METHODS

We performed a retrospective analysis of 13,493 admissions from January 2006 to December 2019. Factors analyzed included age, sex, admission status (emergent vs scheduled), ASIA grade, operative vs non-operative management, mean blood loss, operative time, and adverse events. Specific adverse events included surgical site infection (SSI), other infection (systemic or UTI), neuropathic pain, delirium, dural tear, pneumonia, and dysphagia. Diagnostic categories included trauma, oncology, deformity, degenerative, and "other". A multivariable linear regression model was fit to log-transformed LOS to determine independent factors associated with patient LOS, with effects expressed as multipliers on mean LOS.

RESULTS

Mean LOS for the population (SD) was 15.8 (34.0) days. Factors significantly (p < 0.05) associated with longer LOS were advanced patient age [multiplier on mean LOS 1.011/year (95% CI: 1.007-1.015)], emergency admission [multiplier on mean LOS 1.615 (95% CI: 1.337-1.951)], ASIA grade [multiplier on mean LOS 1.125/grade (95% CI: 1.051-1.205)], operative management [multiplier on mean LOS 1.211 (95% CI: 1.006-1.459)], and the occurrence of one or more AEs [multiplier on mean LOS 2.613 (95% CI: 2.188-3.121)]. Significant AEs included postoperative SSI [multiplier on mean LOS 1.749 (95% CI: 1.250-2.449)], other infections (systemic infections and UTI combined) [multiplier on mean LOS 1.650 (95% CI: 1.359-2.004)], delirium [multiplier on mean LOS 1.404 (95% CI: 1.103-1.787)], and pneumonia [multiplier on mean LOS 1.883 (95% CI: 1.447-2.451)]. Among the diagnostic categories explored, degenerative patients experienced significantly shorter LOS [multiplier on mean LOS 0.672 (95%CI: 0.535-0.844), p < 0.001] compared to non-degenerative categories.

CONCLUSION

This large-scale study taking into account diagnostic categories identified several factors associated with patient LOS. Future interventions should target modifiable factors to minimize LOS and guide hospital resource allocation thereby improving patient outcomes and quality of care and decreasing healthcare-associated costs.

Addressing Problems in Reporting and Classification of Complications in Neurosurgery

Objective. The purpose of this study was to quantify the rate of adverse events associated to in neurosurgery interventions, to evaluate the differences in reporting of such events among different authors and reviews, and to find the reason behind the occurrence of this differences. Methods. A systematic literature review of scientific publications on existing classifications and reports of frequency on complications in neurosurgery was performed by analysing articles from international databases. Results and conclusion. This current overview is taking an outlook on the existing issues in the classification and reporting of complications in neurosurgery. Complications are common in neurosurgery. Because of nonuniform criteria, unstandardized data gathering procedures, and retrospective data collection, their reporting is inconsistent and varies considerably among authors and reviews. The best way to address this issue is by gathering prospective, multi-institutional outcomes data on neurosurgical patients. The data collection initiatives in the future should be using same terminology and be based on the same universally accepted criteria.

Thoracolumbar Injury Classification and Severity Score Is Predictive of Perioperative Adverse Events in Operatively Treated Thoracic and Lumbar Fractures

STUDY DESIGN

A retrospective cohort study of patients with surgically treated thoracolumbar fractures.

PURPOSE

This study aimed to describe the incidence of adverse events (AEs) after surgical stabilization of thoracolumbar spine injuries and to identify predictive factors for the occurrence of AEs.

OVERVIEW OF LITERATURE

Thoracolumbar spine fractures are frequently present in patients with blunt trauma and are associated with significant morbidity. AEs can occur due to the initial spinal injury or secondary to surgical treatment. There is a lack of emphasis in the literature on the AEs that can occur after operative management of thoracolumbar fractures.

METHODS

We performed a retrospective review of 199 patients with surgically treated thoracolumbar fractures operated between January 2007 and January 2018. The potential risk factors for the development of AEs as well as the development of common complications were evaluated by univariate analysis, and a multivariate logistic regression analysis was performed to identify independent risk factors predictive of the above.

RESULTS

The overall rate of AEs was 46.7%; 83 patients (41.7%) had nonsurgical AEs, whereas 24 (12.1%) had surgical adverse events. The most common AEs were urinary tract infections in 43 patients (21.6%), and hospital-acquired pneumonia in 21 patients (10.6%). On multivariate logistic regression, a Thoracolumbar Injury Classification and Severity (TLICS) score of 8-10 (odds ratio [OR], 6.39; 95% confidence interval [CI], 2.33-17.51), the presence of polytrauma (OR, 2.64; 95% CI, 1.17-5.99), and undergoing open surgery (OR, 2.31; 95% CI, 1.09-4.88) were significant risk factors for AEs. The absence of neurological deficit was associated with a lower rate of AEs (OR, 0.47; 95% CI, 0.31-0.70).

CONCLUSIONS

This study suggests the presence of polytrauma, preoperative American Spinal Injury Association score, and TLICS score are predictive of AEs in patients with surgically treated thoracolumbar fractures. The results might also suggest a role for minimally invasive surgical methods in reducing AEs in these patients.

Augmented Reality Neuronavigation for En Bloc Resection of Spinal Column Lesions

BACKGROUND

Primary tumors involving the spine are relatively rare but represent surgically challenging procedures with high patient morbidity. En bloc resection of these tumors necessitates large exposures, wide tumor margins, and poses risks to functionally relevant anatomical structures. Augmented reality neuronavigation (ARNV) represents a paradigm shift in neuronavigation, allowing on-demand visualization of 3D navigation data in real-time directly in line with the operative field.

METHODS

Here, we describe the first application of ARNV to perform distal sacrococcygectomies for the en bloc removal of sacral and retrorectal lesions involving the coccyx in 2 patients, as well as a thoracic 9-11 laminectomy with costotransversectomy for en bloc removal of a schwannoma in a third patient.

RESULTS

In our experience, ARNV allowed our teams to minimize the length of the incision, reduce the extent of bony resection, and enhanced visualization of critical adjacent anatomy. All tumors were resected en bloc, and the patients recovered well postoperatively, with no known complications. Pathologic analysis confirmed the en bloc removal of these lesions with negative margins.

CONCLUSIONS

We conclude that ARNV is an effective strategy for the precise, en bloc removal of spinal lesions including both sacrococcygeal tumors involving the retrorectal space and thoracic schwannomas.

A comparison between different suture techniques in lumbar spine surgery

As a result of solicited muscles, strong friction, and tensile force on cutaneous tissue, the difference in closure procedure and management strategies and complications of surgical incision healing is a real challenge in lumbar spine surgery. We performed a retrospective study to compare different types of wound closure in lumbar spine surgery. 4383 patients were included in this study. Wound dehiscence was more common in the intracutaneous suture group than in the far- near-near-far suture group. Delayed wound healing occurred more in the far-near near-far suture group than intracutaneous suture group. Also, the far-near near-far interrupted point suture group showed a higher ratio of delayed wound healing compared with crossover suture. The superficial wound infection rate was roughly the same in all types of sutures with an average value of 0.79% with 0.81% SD. This is a preliminary study to compare different types of operative wounds showing the pros and cons related to each option.

Lumbar Fusion Surgery for Patients With Back Pain and Degenerative Disc Disease: An Observational Study From the Canadian Spine Outcomes and Research Network

STUDY DESIGN

Uncontrolled retrospective observational study.

OBJECTIVES

Surgery for patients with back pain and degenerative disc disease is controversial, and studies to date have yielded conflicting results. We evaluated the effects of lumbar fusion surgery for patients with this indication in the Canadian Spine Outcomes and Research Network (CSORN).

METHODS

We analyzed data that were prospectively collected from consecutive patients at 11 centers between 2015 and 2019. Our primary outcome was change in patient-reported back pain at 12 months of follow-up, and our secondary outcomes were satisfaction, disability, health-related quality of life, and rates of adverse events.

RESULTS

Among 84 patients, we observed a statistically significant improvement of back pain at 12 months that exceeded the threshold of Minimum Clinically Important Difference (MCID) (mean change -3.7 points, SD 2.6, p < 0.001, MCID = 1.2; 77% achieved MCID), and 81% reported being "somewhat" or "extremely" satisfied. We also observed improvements of Oswestry Disability Index (-17.3, SD 16.6), Short Form-12 Physical Component Summary (10.3, SD 9.6) and Short Form-12 Mental Component Summary (3.1, SD 8.3); all p < 0.001). The overall rate of adverse events was 19%.

CONCLUSIONS

Among a highly selective group of patients undergoing lumbar fusion surgery for degenerative disc disease, most experienced a clinically significant improvement of back pain as well as significant improvements of disability and health-related quality of life, with high satisfaction at 1 year of follow-up. These findings suggest that surgery for this indication may provide some benefit, and that further research is warranted.

Effect of Ultrasonic Osteotome on Therapeutic Efficacy and Safety of Spinal Surgery: A System Review and Meta-Analysis

Background. A meta-analysis was performed to evaluate the effectiveness and safety of ultrasonic osteotomes in spine surgery to standard spinal surgery procedures. Methods. Using the search keywords “bone curette”, “cutter”, “scalpel”, “bone shaver”, “aspirator”, “osteotome”, “ultrasonic”, “piezosurgery”, and “ ${\text{dent}\hspace{0.17em}\hspace{0.17em}}^{\ast }$ ” in the databases of PubMed (1966-2021.12), Cochrane Library, Embase (1986-2018.12), Web of Science (1978-2021.12), and China Academic Journals Full-Text Database (CNKI, 1979-2021.12). Two researchers reviewed the literature, extracted and extensively assessed the data, and included information on the study quality. RevMan v5.3.5.0 was used for the meta-analysis. Results. A total of 10 trials with a total of 911 patients were included. The meta-analysis findings revealed that, when compared to traditional methods, ultrasonic osteotomes could save operation time ( $\text{OR}=-18.83$ , 95 percent CI (-22.76, -14.99), $P=0.03$ ) and reduce intraoperative bleeding ( $\text{OR}=-66.73$ , 95 percent CI (-75.70, -57.76), $P=0.04$ ) and postoperative complications ( $\text{OR}=0.38$ , 95 percent CI (0.21, 0.69), $P=0.001$ ). There was, however, no significant difference in the hospital stay ( $\text{OR}=-1.34$ , 95 percent CI (-1.90, -0.77), $P=0.23$ ) and symptom improvement rate ( $\text{OR}=1.03$ , 95 percent CI (0.73, 1.45), $P=0.86$ ). Conclusion. There is evidence that using an ultrasonic osteotome in spine surgery is safe and effective and may minimize intraoperative bleeding and save time. However, there is no significant difference in symptom improvement rate, hospital stay length, or postoperative complications compared to standard surgical equipment. Therefore, more high-quality investigations are needed to corroborate the initial results.

Group-based trajectory analysis of acute pain after spine surgery and risk factors for rebound pain

Background

This retrospective study was designed to explore the types of postoperative pain trajectories and their associated factors after spine surgery.

Materials and methods

This study was conducted in a single medical center, and patients undergoing spine surgery with intravenous patient-controlled analgesia (IVPCA) for postoperative pain control between 2016 and 2018 were included in the analysis. Maximal pain scores were recorded daily in the first postoperative week, and group-based trajectory analysis was used to classify the variations in pain intensity over time and investigate predictors of rebound pain after the end of IVPCA. The relationships between the postoperative pain trajectories and the amount of morphine consumption or length of hospital stay (LOS) after surgery were also evaluated.

Results

A total of 3761 pain scores among 547 patients were included in the analyses and two major patterns of postoperative pain trajectories were identified: Group 1 with mild pain trajectory (87.39%) and Group 2 with rebound pain trajectory (12.61%). The identified risk factors of the rebound pain trajectory were age less than 65 years (odds ratio [OR]: 1.89; 95% CI: 1.12–3.20), female sex (OR: 2.28; 95% CI: 1.24–4.19), and moderate to severe pain noted immediately after surgery (OR: 3.44; 95% CI: 1.65–7.15). Group 2 also tended to have more morphine consumption (p < 0.001) and a longer length of hospital stay (p < 0.001) than Group 1.

Conclusion

The group-based trajectory analysis of postoperative pain provides insight into the patterns of pain resolution and helps to identify unusual courses. More aggressive pain management should be considered in patients with a higher risk for rebound pain after the end of IVPCA for spine surgery.

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

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.

Use of demineralized cortical fibers is associated with reduced risk of pseudarthrosis after pedicle subtraction osteotomy for adult spinal deformity

PURPOSE

To assess the effect of demineralized cortical fibers (DCF) on postoperative pseudarthrosis requiring revision surgery in patients undergoing pedicle subtraction osteotomy (PSO) for adult spinal deformity (ASD).

METHODS

The use of DCF was introduced across all procedures in 2017 and subsequent patients undergoing PSO surgery were prospectively and consecutively registered. Following sample-size estimation, a retrospective cohort was also registered undergoing the same procedure immediately prior to the implementation of DCF. The non-DCF group underwent surgery with ABG. Minimum follow-up was 2 years in both groups. The main outcome was postoperative pseudarthrosis, either CT-verified or verified intraoperatively during revision surgery due to rod breakage and assessed using Kaplan-Meier survival analyses.

RESULTS

A total of 48 patients were included in the DCF group and 76 in the non-DCF group. The DCF group had more frequently undergone previous spine surgery (60% vs 36%) and had shorter follow-up (32 ± 2 vs 40 ± 7 months). Pseudarthrosis occurred in 7 (15%) patients in the DCF group and 31 (41%) in the non-DCF group, corresponding to a relative risk increase of 2.6 (95%CI 1.3-2.4, P < 0.01). 1-KM survival analyses, taking time to event into account and thus the difference in follow-up, also showed increased pseudarthrosis in the non-DCF group (log-rank P = 0.022). Similarly, multivariate logistic regression adjusted for age, instrumented levels and sacral fusion was also with significantly increased odds of pseudarthrosis in the non-DCF group (OR: 4.3, 95%CI: 1.7-11.3, P < 0.01).

CONCLUSION

We found considerable and significant reductions in pseudarthrosis following PSO surgery with DCF compared to non-DCF.

LEVEL OF EVIDENCE

III.

Sarcopenia for outcomes in patients undergoing spinal surgery: A protocol for a systematic review and pooled analysis of observational studies

BACKGROUND

Sarcopenia is a progressive age-related skeletal muscle disorder characterized by decreased muscle mass and loss of muscle function. Recent studies have shown that sarcopenia is able to predict a variety of clinical outcomes after spinal surgery. Controversy still exists among previous reports in terms of the definition and measurement of sarcopenia, these findings are heterogeneous so far. Therefore, the aim of the current study is to assess the up-to-date evidence of sarcopenia for postoperative outcomes among people undergoing spinal surgery.

METHODS AND ANALYSIS

This protocol was carried out based on the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) statement. It has been pre-registered in PROSPERO with the registration number of CRD42021260459. Three databases (including Pubmed, EMBASE, and Cochrane Library) will be searched from inception through May 10, 2021 to determine related cohort studies examining sarcopenia on multidimensional outcomes in patients undergoing spinal surgery. Major outcomes will be involved including mortality, morbidity, length of stay, postoperative complications or adverse events. DerSimonian & Laird random-effects meta-analysis will be used to calculate pooled odds ratio (OR) for binary data and pooled weighted mean differences (WMDs) or standardized mean differences (SMDs) for continuous data. The Newcastle-Ottawa Scale (NOS) will be used to assess the risk of bias of included studies. Narrative synthesis will be carried out if a pooled analysis is not possible.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as the data involved are from the published literatures. We intend to disseminate or share the results of the study in a peer-reviewed journal or at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42021260459.

Spine Surgery and Preoperative Hemoglobin, Hematocrit, and Hemoglobin A1c: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Synthesize previous studies evaluating clinical utility of preoperative Hb/Hct and HbA1c in patients undergoing common spinal procedures: anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), posterior lumbar fusion (PLF), and lumbar decompression (LD).

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on preoperative Hb/Hct and HbA1c and post-operative outcomes in adult patients undergoing ACDF, PCF, PLF, or LD surgeries.

RESULTS

Total of 4,307 publications were assessed. Twenty-one articles met inclusion criteria.

PCF AND ACDF

Decreased preoperative Hb/Hct were significant predictors of increased postoperative morbidity, including return to operating room, pulmonary complications, transfusions, and increased length of stay (LOS). For increased HbA1c, there was significant increase in risk of postoperative infection and cost of hospital stay.

PLF

Decreased Hb/Hct was reported to be associated with increased risk of postoperative cardiac events, blood transfusion, and increased LOS. Elevated HbA1c was associated with increased risk of infection as well as higher visual analogue scores (VAS) and Oswestry disability index (ODI) scores.

LD

LOS and total episode of care cost were increased in patients with preoperative HbA1c elevation.

CONCLUSION

In adult patients undergoing spine surgery, preoperative Hb/Hct are clinically useful predictors for postoperative complications, transfusion rates, and LOS, and HbA1c is predictive for postoperative infection and functional outcomes. Using Hct values <35-38% and HbA1c >6.5%-6.9% for identifying patients at higher risk of postoperative complications is most supported by the literature. We recommend obtaining these labs as part of routine pre-operative risk stratification.

LEVEL OF EVIDENCE

III.

Major Surgical Trauma Impairs the Function of Natural Killer Cells but Does Not Affect Monocyte Cytokine Synthesis

Major traumatic and surgical injury increase the risk for infectious complications due to immune dysregulation. Upon stimulation with interleukin (IL) 12 by monocyte/macrophages, natural killer (NK) cells release interferon (IFN) γ that supports the elimination of the pathogen. In the present study, we investigated the impact of invasive spine surgery on the relationship between monocytes and NK cells upon exposure to Staphylococcus aureus. Mononuclear cells and serum were isolated from peripheral blood of patients before and up to 8 d after surgery and stimulated with inactivated S. aureus bacteria. NK cell and monocyte function were determined by flow cytometry. NK cells continuously lost their ability to produce IFN-γ during the first week after surgery independently from monocyte-derived IL-12 secretion. IFN-γ synthesis was minimal on day 8 and was associated with decreased expression of the IL-12 receptor and activation of transcription factors required for IFNG gene transcription. Addition of recombinant IL-12 could at least partially restore NK cell function. Pre-operative levels of growth/differentiation factor (GDF) 15 in the serum correlated with the extent of NK cell suppression and with hospitalization. Thus, NK cell suppression after major surgery might represent a therapeutic target to improve the immune defense against opportunistic infections.

Spine surgery under awake spinal anesthesia: an Egyptian experience during the COVID-19 pandemic

OBJECTIVE

Despite tremendous advancements in biomedical science and surgical technique, spine surgeries are still associated with considerable rates of morbidity and mortality, particularly in the elderly. Multiple novel techniques have been employed in recent years to adequately treat spinal diseases while mitigating the perioperative morbidity associated with traditional spinal surgery. Some of these techniques include minimally invasive methods and novel anesthetic and analgesic methods. In recent years, awake spine surgery with spinal anesthesia has gained attention as an alternative to general anesthesia (GA). In this study, the authors retrospectively reviewed a single-institution Egyptian experience with awake spine surgery using spinal anesthesia during the COVID-19 pandemic.

METHODS

Overall, 149 patients who were admitted to As-Salam International Hospital in Cairo for lumbar and lower thoracic spine surgeries, between 2019 and 2020, were retrospectively reviewed. Patient demographics and comorbidities were collected and analyzed. Visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were assessed at different time intervals including preoperatively, immediately after surgery, and 1 year postoperatively. Patient satisfaction was queried through a questionnaire assessing patient preference for traditional anesthesia or spinal anesthesia.

RESULTS

Of the 149 patients who successfully received spine surgery with spinal anesthesia, there were 49 males and 100 females. The cohort age ranged from 22 to 85 years with a mean of 47.5 years. The operative time ranged from 45 to 300 minutes with a mean estimated blood loss (EBL) of 385 ± 156 mL. No major cardiopulmonary or intraoperative complications occurred, and patients were able to eat immediately after surgery. Patients were able to ambulate without an assistive device 6 to 8 hours after surgery. Decompression and fusion patients were discharged on postoperative days 2 and 3, respectively. VAS and ODI scores demonstrated excellent pain relief, which was maintained at the 1-year postoperative follow-up. No 30- or 90-day readmissions were recorded. Of 149 patients, 124 were satisfied with spinal anesthesia and would recommend spinal anesthesia to other patients. The remaining patients were not satisfied with spinal anesthesia but reported being pleased with their postoperative clinical and functional outcomes. One patient was converted to GA due to the duration of the procedure.

CONCLUSIONS

Patients who received spinal anesthesia for awake spine surgery experienced short stays in the hospital, no readmissions, patient satisfaction, and well-controlled pain. The results of this study have validated the growing body of literature that demonstrates that awake spine surgery with spinal anesthesia is safe and associated with superior outcomes compared with traditional GA. Additionally, the ability to address chronic debilitating conditions, such as spinal conditions, with minimal use of valuable resources, such as ventilators, proved useful during the COVID-19 pandemic and could be a model should other stressors on healthcare systems arise, especially in developing areas of the world.

The Impact of Surgical Site Infection on Patient Outcomes After Open Posterior Instrumented Thoracolumbar Surgery for Degenerative Disorders

BACKGROUND

Few reports in the literature have described the long-term outcome of postoperative infection from the patient perspective. The aim of the present study was to determine if complicated surgical site infection (SSI) affects functional recovery and surgical outcomes up to 2 years after posterior instrumented thoracolumbar surgery for the treatment of degenerative disorders.

METHODS

This retrospective cohort study involved patients who had been enrolled in a previous randomized controlled trial that examined antibiotic use for open posterior multilevel thoracolumbar or lumbar instrumented fusion procedures. In the present study, patients who had SSI (n = 79) were compared with those who did not (n = 456). Patient-reported outcome measures (PROMs) included the Oswestry Disability Index (ODI), leg and back pain scores on a numeric rating scale, Short Form-12 (SF-12) summary scores, and satisfaction with treatment at 1.5, 3, 6, 12, and 24 months. Surgical outcomes included adverse events, readmissions, and additional surgery.

RESULTS

The median time to infection was 15 days. Of the 535 patients, 31 (5.8%) had complicated infections and 48 (9.0%) had superficial infections. Patients with an infection had a higher body mass index (BMI) (p = 0.001), had more commonly received preoperative vancomycin (p = 0.050), were more likely to have had a revision as the index procedure (p = 0.004), had worse preoperative mental functioning (mental component summary score, 40.7 ± 1.6 versus 44.1 ± 0.6), had more operatively treated levels (p = 0.024), and had a higher rate of additional surgery (p = 0.001). At 6 months after surgery, patients who developed an infection scored worse on the ODI by 5.3 points (95% confidence interval [CI], 0.4 to 10.1 points) and had worse physical functioning by -4.0 points (95% CI, -6.8 to -1.2 points). Comparison between the groups at 1 and 2 years showed no difference in functional outcomes, satisfaction with treatment, or the likelihood of achieving the minimum clinically important difference (MCID) for the ODI.

CONCLUSIONS

SSI more than doubled the post-discharge emergency room visit and additional surgery rates. Patients with SSI initially (6 months) had poorer overall physical function representing the delay to recovery; however, the negative impact resolved by the first postoperative year.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Two- and three-year outcomes of minimally invasive and hybrid correction of adult spinal deformity

OBJECTIVE

Previous studies have demonstrated the short-term radiographic and clinical benefits of circumferential minimally invasive surgery (cMIS) and hybrid (i.e., minimally invasive anterior or lateral interbody fusion with an open posterior approach) techniques to correct adult spinal deformity (ASD). However, it is not known if these benefits are maintained over longer periods of time. This study evaluated the 2- and 3-year outcomes of cMIS and hybrid correction of ASD.

METHODS

A multicenter database was retrospectively reviewed for patients undergoing cMIS or hybrid surgery for ASD. Patients were ≥ 18 years of age and had one of the following: maximum coronal Cobb angle (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic incidence-lumbar lordosis mismatch (PI-LL) ≥ 10°, or pelvic tilt (PT) > 20°. Radiographic parameters were evaluated at the latest follow-up. Clinical outcomes were compared at 2- and 3-year time points and adjusted for age, preoperative CC, levels operated, levels with interbody fusion, presence of L5-S1 anterior lumbar interbody fusion, and upper and lower instrumented vertebral level.

RESULTS

Overall, 197 (108 cMIS, 89 hybrid) patients were included with 187 (99 cMIS, 88 hybrid) and 111 (60 cMIS, 51 hybrid) patients evaluated at 2 and 3 years, respectively. The mean (± SD) follow-up duration for cMIS (39.0 ± 13.3 months, range 22-74 months) and hybrid correction (39.9 ± 16.8 months, range 22-94 months) were similar for both cohorts. Hybrid procedures corrected the CC greater than the cMIS technique (adjusted p = 0.022). There were no significant differences in postoperative SVA, PI-LL, PT, and sacral slope (SS). At 2 years, cMIS had lower Oswestry Disability Index (ODI) scores (adjusted p < 0.001), greater ODI change as a percentage of baseline (adjusted p = 0.006), less visual analog scale (VAS) back pain (adjusted p = 0.006), and greater VAS back pain change as a percentage of baseline (adjusted p = 0.001) compared to hybrid techniques. These differences were no longer significant at 3 years. At 3 years, but not 2 years, VAS leg pain was lower for cMIS compared to hybrid techniques (adjusted p = 0.032). Those undergoing cMIS had fewer overall complications compared to hybrid techniques (adjusted p = 0.006), but a higher odds of pseudarthrosis (adjusted p = 0.039).

CONCLUSIONS

In this review of a multicenter database for patients undergoing cMIS and hybrid surgery for ASD, hybrid procedures were associated with a greater CC improvement compared to cMIS techniques. cMIS was associated with superior ODI and back pain at 2 years, but this difference was no longer evident at 3 years. However, cMIS was associated with superior leg pain at 3 years. There were fewer complications following cMIS, with the exception of pseudarthrosis.

Comparison of Total Laminectomy and Pedicle Screw Internal Fixation with Ultrasonic- and Microscopic-Assisted Laminectomy Replantation for Tumors of the Lumbar Spinal Canal: A Retrospective Study of 60 Cases from a Single Center

BACKGROUND Total laminectomy with pedicle screw internal fixation is the most common surgical procedure for patients with primary tumors arising in the spinal canal, but the procedure has several limitations. This study aimed to compare total laminectomy and pedicle screw internal fixation with ultrasound- and microscope-assisted laminectomy replantation surgery in patients with tumors of the lumbar spinal canal. MATERIAL AND METHODS A retrospective study was conducted. Sixty patients with tumor spinal canal were admitted to our hospital. Patients in group A (n=32) underwent total laminectomy and pedicle screw internal fixation; patients in group B (n=28) underwent laminectomy replantation with ultrasonic and microscopic assistance. Operative time, intraoperative blood loss, operative segment, length of hospital stay, postoperative length of bed rest, and visual analog scale (VAS) score after surgery were analyzed. RESULTS Hospital stay and postoperative bed rest time of patients in group B were shorter than those in group A (P=0.004). Intraoperative blood loss, postoperative drainage volume, and postoperative pain relief of group B were significantly lower than those of group A (P=0.000). There was no significant difference in postoperative pathological results between the 2 groups (P=0.901). CONCLUSIONS Ultrasound- and microscope-assisted laminectomy replantation resulted in the reduced intraoperative blood loss, postoperative drainage volume, length of hospital stay, and postoperative VAS pain score, compared with total laminectomy and pedicle screw internal fixation for the surgical removal of tumors of the lumbar spinal canal.

National adverse event profile after lumbar spine surgery for lumbar degenerative disorders and comparison of complication rates between hospitals: a CSORN registry study

OBJECTIVE

Previous works investigating rates of adverse events (AEs) in spine surgery have been retrospective, with data collection from administrative databases, and often from single centers. To date, there have been no prospective reports capturing AEs in spine surgery on a national level, with comparison among centers.

METHODS

The Spine Adverse Events Severity system was used to define the incidence and severity of AEs after spine surgery by using data from the Canadian Spine Outcomes and Research Network (CSORN) prospective registry. Patient data were collected prospectively and during hospital admission for those undergoing elective spine surgery for degenerative conditions. The Spine Adverse Events Severity system defined minor and major AEs as grades 1-2 and 3-6, respectively.

RESULTS

There were 3533 patients enrolled in this cohort. There were 85 (2.4%) individual patients with at least one major AE and 680 (19.2%) individual patients with at least one minor AE. There were 25 individual patients with 28 major intraoperative AEs and 260 patients with 275 minor intraoperative AEs. Postoperatively there were 61 patients with a total of 80 major AEs. Of the 487 patients with minor AEs postoperatively there were 698 total AEs. The average enrollment was 321 patients (range 47-1237 patients) per site. The rate of major AEs was consistent among sites (mean 2.9% ± 2.4%, range 0%-9.1%). However, the rate of minor AEs varied widely among sites-from 7.9% to 42.5%, with a mean of 18.8% ± 9.7%. The rate of minor AEs varied depending on how they were reported, with surgeon reporting associated with the lowest rates (p < 0.01).

CONCLUSIONS

The rate of major AEs after lumbar spine surgery is consistent among different sites but the rate of minor AEs appears to vary substantially. The method by which AEs are reported impacts the rate of minor AEs. These data have implications for the detection and reporting of AEs and the design of strategies aimed at mitigating complications.

The impact of frailty on patient-reported outcomes after elective thoracolumbar degenerative spine surgery

OBJECTIVE

Frailty has been shown to be a risk factor of perioperative adverse events (AEs) in patients undergoing various types of spine surgery. However, the relationship between frailty and patient-reported outcomes (PROs) remains unclear. The primary objective of this study was to determine the impact of frailty on PROs of patients who underwent surgery for thoracolumbar degenerative conditions. The secondary objective was to determine the associations among frailty, baseline PROs, and perioperative AEs.

METHODS

This was a retrospective study of a prospective cohort of patients older than 55 years who underwent surgery between 2012 and 2018. Data and PROs (collected with EQ-5D, Physical Component Summary [PCS] and Mental Component Summary [MCS] of SF-12, Oswestry Disability Index [ODI], and numeric rating scales [NRS] for back pain and leg pain) of patients treated at a single academic center were extracted from the Canadian Spine Outcomes and Research Network registry. Frailty was calculated using the modified frailty index (mFI), and patients were classified as frail, prefrail, and nonfrail. A generalized estimating equation (GEE) regression model was used to assess the association between baseline frailty status and PRO measures at 3 and 12 months.

RESULTS

In total, 293 patients with a mean ± SD age of 67 ± 7 years were included. Of these, 22% (n = 65) were frail, 59% (n = 172) were prefrail, and 19% (n = 56) were nonfrail. At baseline, the three frailty groups had similar PROs, except PCS (p = 0.003) and ODI (p = 0.02) were worse in the frail group. A greater proportion of frail patients experienced major AEs than nonfrail patients (p < 0.0001). However, despite the increased incidence of AEs, there was no association between frailty and postoperative PROs (scores on EQ-5D, PCS and MCS, ODI, and back-pain and leg-pain NRS) at 3 and 12 months (p ≥ 0.05). In general, PROs improved at 3 and 12 months (with most patients reaching the minimum clinically important difference for all PROs).

CONCLUSIONS

Although frailty predicted postoperative AEs, mFI did not predict PROs of patients older than 55 years with degenerative thoracolumbar spine after spine surgery.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

The Effect of Perioperative Adverse Events on Long-Term Patient-Reported Outcomes After Lumbar Spine Surgery

BACKGROUND

Perioperative adverse events (AEs) lead to patient disappointment and greater costs. There is a paucity of data on how AEs affect long-term outcomes.

OBJECTIVE

To examine perioperative AEs and their impact on outcome after lumbar spine surgery.

METHODS

A total of 3556 consecutive patients undergoing surgery for lumbar degenerative disorders enrolled in the Canadian Spine Outcomes and Research Network were analyzed. AEs were defined using the validated Spine AdVerse Events Severity system. Outcomes at 3, 12, and 24 mo postoperatively included the Owestry Disability Index (ODI), 12-Item Short-Form Health Survey (SF-12) Physical (PCS) and Mental (MCS) Component Summary scales, visual analog scale (VAS) leg and back, EuroQol-5D (EQ5D), and satisfaction.

RESULTS

AEs occurred in 767 (21.6%) patients, and 85 (2.4%) patients suffered major AEs. Patients with major AEs had worse ODI scores and did not reach minimum clinically important differences at 2 yr (no AE: 25.7 ± 19.2, major: 36.4 ± 19.1, P < .001). Major AEs were associated with worse ODI scores on multivariable linear regression (P = .011). PCS scores were lower after major AEs (43.8 ± 9.5, vs 37.7 ± 20.3, P = .002). On VAS leg and back and EQ5D, the 2-yr outcomes were significantly different between the major and no AE groups (<0.01), but these differences were small (VAS leg: 3.4 ± 3.0 vs 4.0 ± 3.3; VAS back: 3.5 ± 2.7 vs 4.5 ± 2.6; EQ5D: 0.75 ± 0.2 vs 0.64 ± 0.2). SF12 MCS scores were not different. Rates of satisfaction were lower after major AEs (no AE: 84.6%, major: 72.3%, P < .05).

CONCLUSION

Major AEs after lumbar spine surgery lead to worse functional outcomes and lower satisfaction. This highlights the need to implement strategies aimed at reducing AEs.

The Impact of Frailty on Spine Surgery: Systematic Review on 10 years Clinical Studies

Frailty is a condition characterized by a high vulnerability to low-power stressor. Frailty increases with age and is associated with higher complications and mortality. Several indexes have been used to quantify frailty. Spine diseases, both degenerative and oncologic, frequently require surgery which is related to complications and mortality. Aim of the present systematic review was to collect the most frequently used frailty indexes in clinics to predict surgical outcomes in patients affected by spine diseases, taking into account gender differences. Three databases were employed, and 29 retrospective clinical studies were included in this systematic review. The identified spine pathologies were primary and metastatic spine tumors, adult spine deformity (ASD), degenerative spine disease (DSD), cervical deformity (CD) and other pathologies that affected lumbar spine or multiple spine levels. Eleven indexes were identified: modified Frailty Index (mFI), Adult spinal deformity frailty index (ASD-FI), mFI-5, Metastatic Spinal Tumor Frailty Index (MSTFI), Fried criteria, Cervical deformity frailty index (CD-FI), Spinal tumor frailty index (STFI), Frailty Phenotype criteria (FP), Frailty Index (FI), FRAIL scale and Modified CD-FI (mCD-FI). All these indexes correlated well with minor and major postoperative complications, mortality and length of stay in hospital. Results on gender differences and frailty are still conflicting, although few studies show that women are more likely to develop frailty and more complications in the post-operative period than men. This systematic review could help the surgeon in the adoption of frailty indexes, before the operation, and in preventing complications in frail patients.

A Comparison of Mortality and Morbidity Between Complex and Degenerative Spine Surgery in Prospectively Collected Data From 2280 Procedures

Objective

The reported incidence of complications and/or adverse events (AEs) following spine surgery varies greatly. A validated, systematic, reproducible reporting system to quantify AEs was used in 2 prospective cohorts, from 2 spine surgery centers, conducting either complex or purely degenerative spine surgery; in a comparative fashion. The aim was to highlight the differences between 2 distinctly different prospective cohorts with patients from the same background population.

Methods

AEs were registered according to the predefined AE variables in the SAVES (Spine AdVerse Events Severity) system which was used to record all intra- and perioperative AEs. Additional outcomes, including mortality, length of stay, wound infection requiring revision, readmission, and unplanned revision surgery during the index admission, were also registered.

Results

A total of 593 complex and 1,687 degenerative procedures were consecutively included with 100% data completion. There was a significant difference in morbidity when comparing the total number of AEs between the 2 groups (p < 0.001): with a mean number of 1.42 AEs per patient (n = 845) in the complex cohort, and 0.97 AEs per patient (n = 1,630) in the degenerative cohort.

Conclusion

In this prospective study comparing 2 cohorts, we report the rates of AEs related to spine surgery using a validated reproducible grading system for registration. The rates of morbidity and mortality were significantly higher following complex spine surgery compared to surgery for degenerative spine disease.

Factors Affecting Length of Stay Following 3-Column Spinal Osteotomies in Pediatric Patients

STUDY DESIGN

A retrospective analysis.

OBJECTIVES

Length of stay (LOS) is one of the important indicators for the quality of patient care. Although perioperative complications are known to be associated with longer LOS in general, little has been understood regarding LOS after 3-column spinal osteotomy for the rigid spinal deformity in pediatric population. The main objective of the article is to identify factors affecting the LOS in pediatric patients undergoing 3-column posterior spinal osteotomies.

METHODS

Following research ethics approval, a retrospective review was performed of 35 consecutive posterior 3-column spinal osteotomies performed on pediatric patients in a single academic institution. Patients' demographic data, preoperative comorbidities, details of operative procedures, intraoperative complications, and postoperative complications were investigated, and LOS was compared among the groups.

RESULTS

The mean LOS was 9.0 days, and the median LOS was 7 days (range = 4-23 days). Low body weight and syndromic deformity were associated with longer LOS. Operation time ≥6 hours and total perioperative fluid administration greater than or equal to twice the estimated blood volume were associated with longer LOS. Among postoperative complications, those with respiratory complication had prolonged stay.

CONCLUSIONS

Preoperative low body weight and syndromic scoliosis had longer LOS after 3-column osteotomies. Excessive fluid administration and respiratory complications were associated with longer LOS.

A Multidisciplinary Spine Surgical Indications Conference Leads to Alterations in Surgical Plans in a Significant Number of Cases: A Case Series

STUDY DESIGN

Case series.

OBJECTIVE

To evaluate the impact of a multidisciplinary spine surgery indications conference (MSSIC) on surgical planning for elective spine surgeries.

SUMMARY OF BACKGROUND DATA

Identifying methods for pairing the proper patient with the optimal intervention is of the utmost importance for improving spine care and patient outcomes. Prior studies have evaluated the utility of multidisciplinary spine conferences for patient management, but none have evaluated the impact of a MSSIC on surgical planning and decision making.

METHODS

We implemented a mandatory weekly MSSIC with all spine surgeons at our institution. Each elective spine surgery in the upcoming week is presented. Subsequently, a group consensus decision is achieved regarding the best treatment option based on the expertise and opinions of the participating surgeons. We reviewed cases presented at the MSSIC from September 2019 to December 2019. We compared the surgeon's initial proposed surgery for a patient with the conference attendees' consensus decision on the best treatment and measured compliance rates with the group's recommended treatment.

RESULTS

The conference reviewed 100 patients scheduled for elective spine surgery at our indications conference during the study period. Surgical plans were recommended for alteration in 19 cases (19%) with the proportion statistically significant from zero indicated by a binomial test (P < 0.001). The median absolute change in the invasiveness index of the altered procedures was 3 (interquartile range [IQR] 1-4). Participating surgeons complied with the group's recommendation in 96.5% of cases.

CONCLUSION

In conjunction with other multidisciplinary methods, MSSICs can lead to surgical planning alterations in a significant number of cases. This could potentially result in better selection of surgical candidates and procedures for particular patients. Although long-term patient outcomes remain to be evaluated, this care model will likely play an integral role in optimizing the care spine surgeons provide patients.

LEVEL OF EVIDENCE

4.

Morbidity and mortality following degenerative spine surgery in a prospective cohort of 1687 consecutive surgical procedures

STUDY DESIGN

Prospective, observational cohort study.

OBJECTIVE

To determine the true incidence of adverse events (AEs) in European adults undergoing surgery for degenerative spine diseases. The majority of surgeries performed for degenerative spinal diseases are elective, and the need for adequate estimation of risk-benefit of the intended surgery is imperative. A cumbersome obstacle for adequate estimation of surgery-related risks is that the true incidence of complications or adverse events (AEs) remains unclear.

METHODS

All adult patients (≥ 18 years) undergoing spine surgery at a single center from February 1, 2016, to January 31, 2017, were prospectively and consecutively included. Morbidity and mortality were determined using the Spine AdVerse Events Severity (SAVES) system. Additionally, the correlation between the AEs and length of stay (LOS) and mortality was assessed.

RESULTS

A total of 1687 procedures were performed in the study period, and all were included for analysis. Of these, 1399 (83%) were lumbar procedures and 288 (17%) were cervical. The overall incidence of AEs was 47.4%, with a minor AE incidence of 43.2% and a major of 14.5%. Female sex (OR 1.5 [95% CI 1.2-1.9), p < 0.001) and age > 65 years (OR 1.5 [95% CI 1.1-1.7], p = 0.012) were significantly associated with increased odds of having an AE.

CONCLUSION

Based on prospectively registered AEs in this single-center study, we validated the use of the SAVES system in a European population undergoing spine surgery due to degenerative spine disease. We found a higher incidence of AEs than previously reported in retrospective studies. The major AEs registered occurred significantly more often perioperatively and in patients > 65 years.

Revision surgery and mortality following complex spine surgery: 2-year follow-up in a prospective cohort of 679 patients using the Spine AdVerse Event Severity (SAVES) system

STUDY DESIGN

Prospective study.

OBJECTIVE

To determine the 2-year risk of revision surgery and all-cause mortality after complex spine surgery, and to assess if prospectively registered adverse events (AE) could predict either outcome. Revision surgery and mortality are serious complications to spine surgery. Previous studies of frequency have mainly been retrospective and few studies have employed competing risk survival analyses. In addition, assessment of predictors has focused on preoperative patient characteristics. The effect of perioperative AEs on revision and all-cause mortality risks are not fully understood.

METHODS

Between January 1 and December 31, 2013, we prospectively included all patients undergoing complex spine surgery at a single, tertiary institution. Complex spine surgery was defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment. AEs were registered using the Spine Adverse Event Severity system and patients were followed for minimum 2 years regarding revision surgery and all-cause mortality. Incidences were estimated using competing risk survival analyses and correlation between AEs and either outcome was assessed using proportional odds models.

RESULTS

We included a complete and consecutive cohort of 679 adult and pediatric patients. Demographics, surgical data, AEs, and events of revision or all-cause mortality were registered. The cumulative incidence of 2-year all-cause revision was 19% (16-22%) and all-cause mortality was 15% (12-18%). Deformity surgery was the surgical category with highest incidence of revision and the highest incidence of all-cause mortality was seen in the tumor group. Across surgical categories, cumulative incidences of 2-year revision ranged between 11% (tumor) and 33% (deformity), whilst 2-year all-cause mortality ranged between 3% (deformity) and 33% (tumor). We found that major intraoperative AEs were associated to increased odds of revision. Deep wound infection was associated to increased odds of all-cause mortality.

CONCLUSIONS

We report the cumulative incidences of revision surgery and all-cause mortality following complex spine surgery. We found higher incidences of revision compared to previous retrospective studies. Prospectively registered AEs were correlated to increased odds of revision surgery and all-cause mortality. These results may serve as reference for future interventional studies and aid in identifying at-risk patients.

LEVEL OF EVIDENCE

I.

Predicting postoperative complications in patients undergoing lumbar spinal fusion by using the modified five-item frailty index and nutritional status

Aims

As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion.

Methods

We retrospectively reviewed 584 patients who had undergone lumbar spinal fusion for degenerative lumbar spinal disease. The 'simple' group (SG) consisted of patients who had undergone one- or two-level posterior lumbar fusion. The 'complex' group (CG) consisted of patients who had undergone fusion over three or more levels, or combined anterior and posterior surgery. On admission, the mFI-5 was calculated and nutritional parameters collected.

Results

Complications occurred in 9.3% (37/396) of patients in the SG, and 10.1% (19/167) of patients in the CG. In the SG, the important predictors of complications were age (odds ratio (OR) 1.036; p = 0.002); mFI-5 (OR 1.026 to 2.411, as score increased to 1 ≥ 2 respectively; p = 0.023); albumin (OR 11.348; p < 0.001); vitamin D (OR 2.185; p = 0.032); and total lymphocyte count (OR 1.433; p = 0.011) . In the CG, the predictors of complications were albumin (OR 9.532; p = 0.002) and vitamin D (OR 3.815; p = 0.022).

Conclusion

The mFI-5 and nutritional status were effective predictors of postoperative complications in the SG, but only nutritional status was successful in predicting postoperative complications in the CG. The complexity of the surgery, as well as the preoperative frailty and nutritional status of patients, should be considered when determining if it is safe to proceed with lumbar spinal fusion. Cite this article: Bone Joint J 2020;102-B(12):1717–1722.

Back pain in surgically treated degenerative lumbar spondylolisthesis: what can we tell our patients?

OF BACKGROUND DATA

Surgery for degenerative lumbar spondylolisthesis (DLS) has traditionally been indicated for patients with neurogenic claudication. Surgery improves patients' disability and lower extremity symptoms, but less is known about the impact on back pain.

OBJECTIVE

To evaluate changes in back pain after surgery and identify factors associated with these changes in surgically-treated DLS.

STUDY DESIGN

Retrospective review of prospectively collected data.

METHODS

There were 486 consecutive patients with surgically-treated DLS who were enrolled in the Canadian Spine Outcomes Research Network prospective registry and identified for this study. Patients had demographic data, clinical information, disability (Oswestry Disability Index), and back pain rating scores collected prospectively at baseline, and 12 months follow-up RESULTS: Of the 486 DLS patients, 376 (77.3%) were successfully followed at 12 months. Mean age at baseline was 66.7 (standard deviation [SD] 9.2) years old, and 63% were female. Back pain improved significantly at 12 months, compared with baseline (p<.001). Improvement in Numeric Rating Scale (NRS)-back pain ratings was on average 2.97 (SD 2.5) points at one year and clinically significant improvement in back pain was observed in 75% of patients (minimal clinically important difference (MCID) NRS-Pain 1.2 points). Multivariable logistic regression revealed five factors associated with meeting MCID NRS-back pain at 12 month follow up: higher baseline back pain, better baseline physical function (higher SF-12 Physical Component Score), symptoms duration less than 1 to 2 years, and having no intraoperative adverse events.

CONCLUSIONS

Back pain improved significantly for patients treated surgically for DLS at 1-year follow-up.

Granulocyte-colony stimulating factor improves intervertebral disc degeneration in experimental adult male rats: A microscopic and radiological study

Intervertebral disc degeneration (IVDD) is a major contributor to low back pain (LBP). Granulocyte-colony stimulating factor (GCSF) is known to mobilize hematopoietic stem cells (HSCs) that may be implicated in intervertebral disc (IVD) regeneration. Rats were divided into the following three groups: (i) control group; (ii) IVDD group-the rats underwent Co5/Co6 and Co7/Co8 IVDD operation; and (iii) GCSF-treated group-the rats received daily GCSF subcutaneous injections starting 6 weeks after the IVDD operation and continued for 5 days. All of the rats were euthanized after 8 weeks, and IVDs were assessed by tail X-ray and histopathological, immunohistochemical, and transmission electron microscopy (TEM) analyses. The X-rays showed disc narrowing in the IVDD group that was significantly widened in the GCSF-treated rats. Histologically, the IVDD group showed disarrangement of the annulus fibrosis lamellae, complete degeneration of the nucleus pulposus, and loss of proteoglycan content. These changes were improved after GCSF treatment. Vertebral endplate thickness and cellularity were significantly decreased with IVDD and significantly increased after GCSF treatment. Stromal cell-derived factor-1α (SDF-1α) immune expression was significantly increased in the IVDD group but decreased in the GCSF-treated group. However, the caspase-3 expression percentage showed no significant difference among the studied groups. TEM showed excessive collagen deposits around the notochordal cells in the IVDD group, which were attenuated in the GCSF-treated group. These results indicate that GCSF improves IVDD and promotes its recovery based on radiological, histological and TEM findings.

Use of three-dimensional printing of a lumbar skeletal model for intrathecal administration of nusinersen: a brief technical report

Spinal muscular atrophy (SMA) is an autosomal recessive hereditary neurodegenerative disease causing progressive muscle atrophy, weakness and kyphoscoliosis. Nusinersen is a therapeutic agent for SMA that should be administered intrathecally. However, due to severe kyphoscoliosis, lumbar puncture can be challenging. Here, we present our experience of intrathecal administration of nusinersen in an SMA patient with severe kyphoscoliosis using a life-size three-dimensional printing (3D) skeletal model created with 3D printer. With this strategy, we were able to rapidly and safely perform the lumbar puncture.

Factors affecting postoperative mortality of patients with insufficient union following osteoporotic vertebral fractures and impact of preoperative serum albumin on mortality

Background

Numerous comparative studies of surgical procedures have focused on clinical and radiographical outcomes, as well as the effect of bone fragility on the outcome of spinal surgery; however, insights concerning a risk of mortality or morbidity have been limited. Additionally, the effect of surgical therapy on survival after vertebral compression fractures remains controversial. Our aim was to evaluate the preoperative factors that affected the long-term survival of patients who underwent spinal surgery for an insufficient union following osteoporotic vertebral fractures (OVF) and to determine postoperative mortality.

Methods

We retrospectively reviewed the cases of 105 consecutive patients who underwent spinal surgery for OVF. Mortality was estimated using the Kaplan-Meier method and a log-rank test. The preoperative backgrounds of patients were analyzed to determine which risk factors led to death among the OVF cases. Kaplan-Meier curves were used to estimate survival based on preoperative albumin levels of ≤3.5 g/dL (hypoalbuminemia) versus > 3.5 mg/dL.

Results

The mean follow-up time was 4.1 ± 0.8 years. Two years after surgery, percentage of patients who had died was 15%. The VAS scores and modified Frankel classification were significantly improved one year after surgery. The ratio of male-to-female was significantly higher for patients with OVF who died than for those who were still alive. No significant difference in mortality was observed among surgical procedures for OVF. The univariate analysis showed that male gender, serum albumin < 3.5 g/dl, creatinine clearance< 60 mg/dl, and the American Society of Anesthesiologists classificat0ion ≥3 were significant risk factors for postoperative mortality. Multivariate analysis revealed that only serum albumin ≤3.5 g/dL was a significant risk factor for long-term postoperative mortality of patients with OVF.

Conclusions

Preoperative hypoalbuminemia was associated with postoperative mortality following surgery for OVF.

Level of evidence

Level 3.

Multidisciplinary approaches to complication reduction in complex spine surgery: a systematic review

BACKGROUND CONTEXT

Complex spine surgery carries a high complication rate that can produce suboptimal outcomes for patients undergoing these extensive operations. However, multidisciplinary pathways introduced at multiple institutions have demonstrated a promising potential toward reducing the burden of complications in patients being treated for spinal deformities. To date, there has been no effort to systematically collate the multidisciplinary approaches in use at various institutions.

PURPOSE

The present study aims to determine effective multidisciplinary strategies for reducing the complication rate in complex spine surgery by analyzing existing institutional multidisciplinary approaches and delineating common themes across multiple practice settings.

STUDY DESIGN

Systematic review.

METHODS

We followed guidelines established under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The studies reported on data from PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Cochrane. We included articles that described either approaches to, or results from, the implementation of multidisciplinary paradigms during the preoperative, perioperative, and postoperative phases of care for patients undergoing complex spine surgery. We excluded studies that only targeted one complication unless such an approach was in coordination with more extensive multidisciplinary planning at the same institution.

RESULTS

A total of 406 unique articles were identified. Following an initial determination based on title and abstract, 22 articles met criteria for full-text review, and 10 met the inclusion criteria to be included in the review. Key aspects of multidisciplinary approaches to complex spine surgery included extensive preoperative workup and interdisciplinary conferencing, intraoperative communication and monitoring, and postoperative floor management and discharge planning. These strategies produced decreases in surgical duration and complication rates.

CONCLUSIONS

This study represents the first to systematically analyze multidisciplinary approaches to reduce complications in complex spine surgery. This review provides a roadmap toward reducing the elevated complication rate for patients undergoing complex spine surgery.

Community acquired pressure injuries in a work-related spinal cord injury population: Problem characterization and assessment of a working solution

BACKGROUND

To characterize the problem of community-acquired pressure injuries (CAPIs) in a work-related spinal cord injury (SCI) population in Canada and assess the benefits of a person-centered solution. Characterization of the problem and a solution, albeit in an insured Worker's Compensation Board of British Columbia (WorkSafeBC) cohort, may inform the supply of solutions in the larger SCI population with disparate access to healthcare.

METHODS

For this observational study, data on 244 WorkSafeBC clients, who received an intervention featuring pressure injury (PI) assessment between 2011 and 2015, were used to characterize the problem. Data on observed injuries, risk, referrals, and outcomes were linked to healthcare service claims. Employing an activity-based costing methodology, total expenditures on attributed services were calculated for clients with 1 or more PIs. Intervention cost and benefits from the insurer's perspective are considered.

RESULTS

84 of 244 clients had 1 or more PIs at assessment, with attributed mean cost of $56,092 in 2015 Canadian dollars (CAD). Mean cost by PI severity range from $9580 to $238,736. At an intervention cost of $820,618, detection of less severe injuries provided an opportunity to prevent progression and achieve $3 million in cost avoidance. Follow-up data suggest reasonable returns. Reductions in the incidence, number, and risk of pressure injuries were also observed.

CONCLUSIONS

The analysis establishes the cost of CAPIs in a Canadian-based work-related SCI population and suggests preventative and early intervention is not only feasible but also practical. Results are relevant to decisions regarding the use of proactive prevention-based treatment models as opposed to reactive, solutions in the larger SCI population.

Outcome impact of individualized fluid management during spine surgery: a before-after prospective comparison study

Background

Individualized fluid management (IFM) has been shown to be useful to improve the postoperative outcome of patients undergoing major abdominal surgery. A limited number of clinical studies have been done in orthopaedic patients and have yielded conflicting results. We designed the present study to investigate the clinical impact of IFM in patients undergoing major spine surgery.

Methods

This is a before-after study done in 300 patients undergoing posterior spine arthrodesis. Postoperative outcomes were compared between control group implementing standard fluid management (n = 150) and IFM group (n = 150) guided by fluid protocol based on continuous stroke volume monitoring and optimization. The primary outcome measure was the proportion of patients who developed one or more complications within 30 days following surgery.

Results

During surgery, patients received on average the same volume of crystalloids (7.4 vs 7.2 ml/kg/h) and colloids (1.6 vs 1.6 ml/kg/h) before and after the implementation of IFM. During 30 days following surgery, the proportion of patients who developed one or more complications was lower in the IFM group (32 vs 48%, p < 0.01). This difference was mainly explained by a significant decrease in post-operative nausea and vomiting (from 38 to 19%, p < 0.01), urinary tract infections (from 9 to 1%, p < 0.01) and surgical site infections (from 5 to 1%, p < 0.05). Median hospital length of stay was not affected by the implementation of IFM.

Conclusion

In patients undergoing major spine surgery, the implementation of IFM was associated with a significant decrease in postoperative morbidity.

Trial registration

ClinicalTrials.gov Identifier: NCT02470221. Prospectively registered on June 12, 2015.

Efficacy of a Standalone Microporous Ceramic Versus Autograft in Instrumented Posterolateral Spinal Fusion: A Multicenter, Randomized, Intrapatient Controlled, Noninferiority Trial

STUDY DESIGN

in the rest of the article written as patient- and observer-blinded, multicenter, randomized, intrapatient controlled, noninferiority trial.

OBJECTIVE

The aim of this study was to determine noninferiority of a biphasic calcium-phosphate (AttraX® Putty) as a bone graft substitute for autograft in instrumented posterolateral fusion (PLF).

SUMMARY OF BACKGROUND DATA

Spinal fusion with autologous bone graft is a frequently performed surgical treatment. Several drawbacks of autografting have driven the development of numerous alternatives including synthetic ceramics. However, clinical evidence for the standalone use of these materials is limited.

METHODS

This study included 100 nontraumatic adults who underwent a primary, single- or multilevel, thoracolumbar, instrumented PLF. After instrumentation and preparation for grafting, the randomized allocation side of AttraX® Putty was disclosed. Autograft was applied to the contralateral side of the fusion trajectory, so each patient served as his/her own control. For the primary efficacy outcome, PLF was assessed at 1-year follow-up on computed tomography scans. Each segment and side was scored as fused, doubtful fusion, or nonunion. After correction for multilevel fusions, resulting in a single score per side, the fusion performance of AttraX Putty was tested with a noninferiority margin of 15% using a 90% confidence interval (CI).

RESULTS

There were 49 males and 51 females with a mean age of 55.4 ± 12.0 (range 27-79) years. Two-third of the patients underwent a single-level fusion and 62% an additional interbody fusion procedure. The primary analysis was based on 87 patients, including 146 instrumented segments. The fusion rate of AttraX Putty was 55% versus 52% at the autograft side, with an overall fusion rate of 71%. The 90% CI around the difference in fusion performance excluded the noninferiority margin (difference = 2.3%, 90% CI = -9.1% to +13.7%).

CONCLUSION

The results of this noninferiority trial support the use of AttraX Putty as a standalone bone graft substitute for autograft in instrumented thoracolumbar PLF.

LEVEL OF EVIDENCE

1.

Readmission following complex spine surgery in a prospective cohort of 679 patients - 2-years follow-up using the Spine AdVerse Event Severity (SAVES) system

BACKGROUND CONTEXT

Recent studies suggest that prospective registration more accurately reflects the true incidence of adverse events (AEs). To our knowledge, no previous study has investigated prospectively registered AEs' influence on hospital readmission following spine surgery.

PURPOSE

To determine the frequency and type of unplanned readmissions after complex spine surgery, and to investigate if prospectively registered AEs can predict readmissions.

DESIGN

This is a prospective, consecutive cohort study.

PATIENT SAMPLE

We conducted a single-center study of 679 consecutive patients who underwent complex spine surgery defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment.

OUTCOME MEASURES

The outcomes in this study were (1) readmission to any hospital department within 30 days of discharge and (2) readmission to a surgical spine center at any time in follow-up.

METHODS

All patients undergoing complex spine surgery, at our tertiary referral center, were consecutively, and prospectively, included from January 1 to December 31, 2013. Demographics and perioperative AEs were registered using the Spine AdVerse Events Severity (SAVES) system. Patients were followed for a minimum of two years. A competing risk survival model was used to estimate rates of readmissions with death as a competing risk. Patient characteristics, surgical parameters and perioperative AEs were analyzed to identify factors associated with readmission. Analyses of 30-day readmission were performed using logistic regression models. A proportional odds model, with death as competing risk, was used for readmissions to a spine center at any time in follow-up. Results were reported as odds ratios with 95% confidence intervals (95% CI).

RESULTS

Within 2 years of index discharge, 443 (65%) were readmitted. Only 20% of readmissions were to a spine center. Cumulative incidence (95% CI) of readmission was estimated to 13% (10%-16%) at 30 days, 26% (23%-30%) at 90 days, 50% (46%-54%) at 1 year, and 59% (55%-63%) at 2 years following discharge. Rates were markedly lower for readmissions to a spine center. Increased odds of 30-day readmission were correlated to intraoperative hypotension (p=.02) and major intraoperative blood loss (p<.01). Readmission to a spine center was associated with the number of instrumented vertebrae (p=.047), major intraoperative AE (p=.01), and intraoperative hypotension (p<.01).

CONCLUSIONS

To the best of our knowledge, this is the first study to analyze prospectively registered AEs' association to readmission up to 2 years after complex spine surgery. We found that readmissions were more frequent than previously reported when including readmissions to any department or hospital. Factors related to major intraoperative blood loss were associated to increased odds of readmission. This should be considered during planning of postoperative observation and care.

Incidence, prognosis, and risk factors for bladder and bowel dysfunction due to incidental dural tears in lumbar microendoscopic surgery

BACKGROUND CONTEXT

Despite the common occurrence of incidental dural tears, the incidence and prognosis of bladder and bowel dysfunction (BBD) due to incidental dural tears in lumbar spinal surgery are not well known because of the lack of reported cases.

PURPOSE

To analyze the incidence, prognosis, and risk factors for BBD after lumbar microendoscopic surgery with or without incidental dural tears.

STUDY DESIGN/SETTING

A retrospective cohort study.

PATIENT SAMPLE

We analyzed 2,421 patients who underwent lumbar microendoscopic surgery and investigated patients with BBD after an incidental durotomy during surgery.

OUTCOME MEASURES

Patients were divided into three groups on the basis of dysuria and defecation disorders: severe BBD, mild BBD, and no BBD. The post void residual volumes before and after surgery were compared using an ultrasound bladder scanner or bladder catheterization after confirmation of urination. Bowel dysfunction was evaluated by subjective symptomatic deterioration and the increase in the frequency and duration of postoperative medical care.

METHODS

Risk factors for BBD were analyzed using surgical video documentation to determine the dural tear site and cauda equina exposure from the dural sac. Patients with BBD were prospectively followed up for prognosis determination. The chi-square test was used to compare the incidence of BBD between patients with dural tears and those without. Propensity score-adjusted logistic regression analysis was performed to evaluate the effects of various factors on the incidence of postoperative BBD.

RESULTS

The incidence of dural tears was 6.9% (168/2,421). The overall incidence of BBD was 3.0% (73/2,421), while the incidences of BBD (mild+severe BBD) and severe BBD due to incidental dural tears were 1.2% (30/2,421) and 0.8% (20/2,421), respectively. The incidence of BBD in patients with dural tears and those without tears was 17.9% [30/168] and 1.9% [43/2,253; p<.001]), respectively. BBD rates at 1 week, 1 month, 3 months, 6 months, and 1 year after surgery were 64.0%, 44.0%, 40.0%, 28.0%, and 13.6%, respectively. Logistic regression analysis revealed that the male sex (odds ratio [OR], 4.20), dural tears in the central area (OR, 10.15), and exposure of the cauda equina (OR, 51.04) were significant risk factors.

CONCLUSIONS

The incidence of dural tears in lumbar microendoscopic surgeries are associated with an increased incidence of BBD. The recovery rate for BBD due to incidental dural tears is generally good; however, some patients experience long-term symptoms. Clinicians should be aware that incidental dural tears with cauda equina exposure can increase the risk of BBD.