Ischemic stroke after cervical spine injury: analysis of 11,005 patients using the Japanese Diagnosis Procedure Combination database

A Study on Interobserver and Intraobserver Reliability of the Huashan Radiologic Classification System for Cervical Spinal Cord Injury Without Fracture and Dislocation

STUDY DESIGN

Observational study.

OBJECTIVE

To assess the reproducibility and reliability of the system.

BACKGROUND

The Huashan radiologic classification system for cervical spinal cord injury without fracture and dislocation (CSCIWFD) was recently proposed and found useful for clinical practice.

PATIENTS AND METHODS

Patients diagnosed with CSCIWFD between 2015 and 2021 were recruited. Six spine surgeons from different institutions, three experienced and other inexperienced respectively, were trained as observers of the system, and these surgeons classified the recruited patients using the system. Then, 8 weeks later, they repeated the classification on the same patients in a different order. The interobserver and intraobserver agreement between the results was analyzed using percentage agreement, weighted kappa, and Cohen kappa ( κ ) statistics.

RESULTS

A total of 60 patients were included in the analysis. Type I was the most frequent type (29 cases, 48.3%), followed by type II (13 cases, 21.7%), type III (12 cases, 20%), and type IV (6 cases, 10%). For all the observers, experienced observers, and inexperienced observers, the overall agreement percentages were 77.6% ( κ = 0.78), 84.4% ( κ = 0.84), and 72.8% ( κ = 0.74), respectively, indicating substantial to nearly perfect interobserver reproducibility. A higher level of agreement was found for differentiating type I from other types, with the percentage agreement ranging from 87.8% to 94.4% ( κ = 0.74-0.88). For distinguishing compression on the spinal cord (types I and II vs types III and IV) among the different groups of observers, the percentage agreement was 97.8% ( κ = 0.94), indicating nearly perfect reproducibility. As for intraobserver agreement, the percentage agreement ranged from 86.7% to 96.7% ( κ = 0.78-0.95), indicating at least substantial reliability.

CONCLUSIONS

The Huashan radiologic classification system for CSCIWFD was easy to learn and apply in a clinical environment, showing excellent reproducibility and reliability. Therefore, it would be promising to apply and promote this system for the precise evaluation and personalized treatment strategy.

Effect of Intraoperative Tranexamic Acid on Perioperative Major Hemorrhage Requiring Transfusion in Patients Undergoing Elective Spine Surgery: A Propensity Score-Matched Analysis Using a National Inpatient Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aimed to examine whether the use of intravenous TXA in elective spine surgery is associated with reduced perioperative massive hemorrhage requiring transfusion.

METHODS

We extracted all patients who underwent decompression with or without fusion surgery for the cervical, thoracic, and lumbar spine between April 2012 and March 2019. The primary outcome was the occurrence of massive hemorrhage requiring transfusion, defined as at least 560 mL of blood transfusion within 2 days of spine surgery or the requirement of additional blood transfusion from 3-7 days postoperatively. Secondary outcomes were the occurrence of thrombotic complications (pulmonary embolism, acute coronary syndrome, and stroke) and postoperative hematoma requiring additional surgery.

RESULTS

We identified 83,821 eligible patients, with 9747 (12%) patients in the TXA group. Overall, massive hemorrhage requiring transfusion occurred in 781 (.9%) patients. Propensity score matching yielded 8394 pairs. In the matched cohort, the TXA group had a lower proportion of massive hemorrhage requiring transfusion than the control group (.7% vs 1.1%; P = .002). There was no significant difference in the occurrence of thrombotic complications and postoperative hematoma requiring additional surgery between both groups. The multivariable regression analysis also showed that the use of TXA was associated with significantly lower proportions of massive hemorrhage requiring transfusion (odds ratio, .62; 95% confidence interval, .43-.90; P = .012).

CONCLUSIONS

In this analysis using real-world data, TXA use in elective spinal surgery was associated with reduced perioperative massive hemorrhage requiring transfusion without increasing thrombotic complications.

LEVEL OF EVIDENCE

Prognostic Level Ⅲ.

Perioperative Cerebrovascular Accidents in Spine Surgery: A Retrospective Descriptive Study and A Systematic Review with Meta-Analysis

Introduction

Perioperative cerebrovascular accidents (CVAs) related to spine surgery, although rare, can lead to significant disabilities. More studies on spine surgeries are required to identify those at risk of perioperative CVAs. The characteristics and outcomes of patients that experienced CVAs during spine surgery were assessed through a retrospective descriptive study and meta-analysis.

Methods

Patients aged ≥18 years who underwent spine surgery under general anesthesia at a hospital between April 2011 and March 2023 were examined. Of the 2,391 initially identified patients, 2,346 were included after excluding 45 who underwent debridement for surgical site infections. Subsequently, a meta-analysis including the present retrospective descriptive study was conducted. Databases such as PubMed and Google Scholar were searched for original peer-reviewed articles written in English.

Results

Of the 2,346 patients, 4 (0.17%) (three men, one woman) exhibited perioperative CVAs associated with spine surgery. The CVAs were diverse in nature: one case of cerebral hemorrhage resulting from dural injury during posterior occipitocervical fusion, two cases of cerebral infarctions after lumbar laminectomy and anterior thoracic fusion due to anticoagulant discontinuation, and one case of posterior reversible encephalopathy syndrome following microscopic lumbar discectomy due to gestational hypertension. The subsequent meta-analysis included three studies (n=186,860). It showed several risk factors for perioperative CVAs, including cervical level (pooled odds ratio [OR]=1.33), hypertension (pooled OR=2.27), atrial fibrillation (pooled OR=8.78), history of heart disease (pooled OR=2.47), and diabetes (pooled OR=2.13).

Conclusions

It was speculated that the potential risk factors for the four perioperative CVA cases of spine surgery in this retrospective descriptive study were intraoperative dural injury, preoperative anticoagulant discontinuation, and gestational hypertension history. The meta-analysis revealed that cervical spine surgery, hypertension, atrial fibrillation, heart disease, and diabetes increased the CVA risk. This highlights the need for risk assessment, preoperative optimization, and postoperative care to reduce spine surgery-associated perioperative CVAs.

Perioperative stroke in patients undergoing spinal surgery: a retrospective cohort study

BACKGROUND

The incidence of perioperative stroke following spinal surgery, including ischemic and hemorrhagic stroke, has not been fully investigated in the Chinese population. Whether specific spinal or emergency/elective procedures are associated with perioperative stroke remains controversial. This study aimed to investigate the incidence of perioperative stroke, health economic burden, clinical outcomes, and associated risk factors.

METHOD

A retrospective cohort study using an electronic hospital information system database was conducted from Jan 1, 2015, to Jan 1, 2021, in a tertiary hospital in China. Patients aged ≥18 years who had undergone spinal surgery were included in the study. We recorded patient demographics, comorbidities, and health economics data. Clinical outcomes included perioperative stroke during hospitalization and associated risk factors. The patients' operative data, anesthetic data, and clinical manifestations were recorded.

RESULT

A total of 17,408 patients who had undergone spinal surgery were included in this study. Twelve patients had perioperative stroke, including seven ischemic stroke (58.3%) and five hemorrhagic stroke (41.7%). The incidence of perioperative stroke was 0.07% (12/17,408). In total, 12 stroke patients underwent spinal fusion. Patients with perioperative stroke were associated with longer hospital stay (38.33 days vs. 9.78 days, p < 0.001) and higher hospital expenses (RMB 175,642 vs. RMB 81,114, p < 0.001). On discharge, 50% of perioperative patients had severe outcomes. The average onset time of perioperative stroke was 1.3 days after surgery. Stroke history (OR 146.046, 95% CI: 28.102-759.006, p < 0.001) and hyperlipidemia (OR 4.490, 95% CI: 1.182-17.060, p = 0.027) were associated with perioperative stroke.

CONCLUSION

The incidence of perioperative stroke of spinal surgery in a tertiary hospital in China was 0.07%, with a high proportion of hemorrhagic stroke. Perioperative stroke patients experienced a heavy financial burden and severe outcomes. A previous stroke history and hyperlipidemia were associated with perioperative stroke.

Risk factors for severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation: an analysis using a nationwide inpatient database

Objectives

Venoarterial extracorporeal membrane oxygenation is increasingly being used as a life-saving modality in critically ill patients. Despite its necessity, severe lower extremity ischemia associated with venoarterial extracorporeal membrane oxygenation remains a potentially devastating complication. We aimed to investigate the incidence and risk factors for severe lower extremity ischemia requiring fasciotomy or amputation following venoarterial extracorporeal membrane oxygenation.

Methods

All patients who received venoarterial extracorporeal membrane oxygenation during hospitalization were identified in a Japanese national inpatient database from July 1, 2010 to March 31, 2018. The primary outcome was occurrence of severe lower extremity ischemia that required fasciotomy or amputation. We used cause-specific proportional hazard models to examine the associations between potential risk factors and outcomes. We also performed a competing-risk analysis to estimate the cause-specific HR for severe lower extremity ischemia using a multivariable competing-risk Cox proportional hazard model with adjustment for potential risk factors.

Results

A total of 29 231 patients who underwent venoarterial extracorporeal membrane oxygenation during hospitalization were identified. Of these, 98 patients (0.3%) had lower extremity ischemia requiring fasciotomy or amputation. The young group (≤18 years) had a significantly higher proportion of severe lower extremity ischemia cases than the adult (19-59 years) and elderly (≥60 years) groups (1.4%, 0.5%, and 0.2%, respectively; p<0.001). In a multivariable competing-risk Cox proportional hazards regression model, younger age (HR 3.06; 95% CI 1.33 to 7.02; p<0.008) and consciousness disturbance on admission (HR 2.53; 95% CI 1.60 to 3.99; p<0.001) were significantly associated with higher likelihood of severe lower extremity ischemia.

Conclusion

In this study using a nationwide database, younger age and consciousness disturbance on admission were associated with higher risk of severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation.

Level of evidence

Level Ⅲ-prognostic and epidemiological.

Impact of orthogeriatric care management by orthopedic surgeons and physicians on in-hospital clinical outcomes: A difference-in-difference analysis

AIM

The orthopedic surgery unit in our suburb serves a large elderly trauma population in addition to providing elective surgeries. As patients with hip fractures have become older and at higher risk of medical complications, our hospital has initiated integrated co-management of these patients by orthopedic surgeons and geriatricians from the point of hospital admission. The aim of this study was to evaluate the impact of the hospital policy change on hip fracture management and clinical outcome indicators.

METHODS

Using the difference-in-difference approach, in total, 288 consecutive patients with hip fractures treated during the 1 year before and 2 years after transition to orthogeriatric care from a geriatric consultation model to integrated orthogeriatric care model were compared with 576 patients from other local hospitals.

RESULTS

Despite a seasonal trend toward increased length of hospital stay in winter, the intervention significantly reduced the change in mean length of stay (mean difference [95% confidence interval], -12.9 days [-21.5 to -4.3]; P = 0.007) and discharge to home tended to change less frequently (-12.6%; P = 0.10). There was no significant reduction in mean time to surgery (-0.2 days; P = 0.83), mortality (-0.8%; P = 0.62), or complications (-1.0%; P = 0.85).

CONCLUSIONS

Changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly reduced length of hospital stay probably due to a lower chance of discharge to home. To our knowledge, this is the first study in Japan to compare two orthogeriatric care models considering the nationwide improvement in hip fracture management.

AUTHOR

Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

Diabetes Mellitus Does Not Impact Achievement of a Minimum Clinically Important Difference Following Anterior Cervical Discectomy and Fusion

BACKGROUND

Diabetes mellitus (DM) has been identified as a risk factor for poorer outcomes following anterior cervical discectomy and fusion (ACDF). This study aims to evaluate the impact DM has on achievement of MCID (minimum clinically important difference) following ACDF.

METHODS

A surgical database was reviewed for patients who underwent primary, single-level ACDF procedures with posterior instrumentation. Visual analog scales (VAS) Arm and Neck, Neck Disability Index (NDI), and Patient-Reported Outcomes Measurement Information System (PROMIS) and 12-item Short Form (SF-12) scores for physical function (PF) were recorded. MCID achievement was calculated using pre-established values from the literature. Intergroup differences in demographic, perioperative characteristics, mean outcome scores and rates of MCID achievement were calculated.

RESULTS

There were 43 patients with diabetes and 320 patients without diabetes. DM status was significantly associated with age, ethnicity, hypertension, American Society of Anesthesiologists physical classification score, Charlson Comorbidity Index, and insurance type (all P ≤ 0.041). Postoperative length of stay was significantly greater for the DM group (P = 0.011). Mean VAS Arm and NDI differed at 6 months (P ≤ 0.049, both) and PROMIS-PF differed from 6 weeks through 6 months (P ≤ 0.039, all). Patients without diabetes significantly improved in all PROMs by 1 year postoperatively (P < 0.01, all). Patients with diabetes significantly improved in VAS Neck and Arm, SF-12 physical component score, and PROMIS-PF by 1 year (all P ≤ 0.013) but NDI significantly improved only at 12 weeks (P = 0.038). Intergroup differences for MCID achievement were demonstrated at 6 months for NDI and SF-12 physical component score (P ≤ 0.008).

CONCLUSIONS

Although moderate intergroup differences in MCID achievement were demonstrated, the results of this study suggest that patients may realize similar benefits of ACDF surgery regardless of DM status.

Clinical features and early post-operative complications of isolated C2 odontoid fractures: a retrospective analysis using a national inpatient database in Japan

PURPOSE

To examine the clinical features and post-treatment complications in patients with isolated C2 odontoid fractures.

METHODS

We extracted data for all patients who were admitted with C2 odontoid fractures from the Japanese Diagnosis Procedure Combination database between July 2010 and March 2017. We then compared the post-treatment complications during hospitalization according to treatment types: conservative treatment (with or without use of halo-vest) and surgery (anterior or posterior spinal fixation).

RESULTS

A total of 3167 patients (1533 men, 1634 women; mean age, 70 years) with isolated C2 odontoid fractures were identified, including 1124 patients (35%) aged ≥ 80 years. Among the total patients, 2476 (78%) received conservative treatment (with halo-vest, 728; without halo-vest, 1748). The remaining 691 patients (22%) underwent surgery (anterior surgery, 129; posterior surgery, 556; combined surgery, 6). There were no differences between the conservative treatment and surgery groups in baseline characteristics and preexisting comorbid conditions except for age (71 vs. 69 years, p = 0.042). In-hospital death occurred in 136 patients (4.3%). There was no significant difference in in-hospital mortality between the two groups (overall, conservative treatment 4.6% vs. surgery 3.0%, p = 0.066; age ≥ 80 years, conservative treatment 7.2% vs. surgery 5.4%, p = 0.34). Use of halo-vest was not associated with increased mortality (with halo-vest 3.7% vs. without halo-vest 5.0%, p = 0.15).

CONCLUSION

The great majority of isolated odontoid fractures occurred in elderly patients. Conservative treatment and surgery had similarly low in-hospital mortality. Use of halo-vest was not associated with an increase in mortality.

Comparison of Perioperative Complications Between Anterior Fusion and Posterior Fusion for Osteoporotic Vertebral Fractures in Elderly Patients: Propensity Score-Matching Analysis Using Nationwide Inpatient Database

STUDY DESIGN

This was a retrospective cohort study using a nationwide inpatient database.

OBJECTIVE

The objective of this study was to evaluate the perioperative complications post-anterior fusion (AF) and posterior fusion (PF) for osteoporotic vertebral fractures (OVFs) with a large National Inpatient Database.

SUMMARY OF BACKGROUND DATA

OVF of the thoracolumbar spine often occur because of bone fragility and low-energy trauma in elderly patients. Though AF and PF are 2 representative surgical methods, there have been few studies focusing on perioperative complications of each method.

MATERIALS AND METHODS

The total 2446 (AF: 435 cases, PF: 2011 cases) patients who diagnosed thoracic or lumbar OVF and received either AF or PF were included from 2012 to 2016 with the Diagnosis Procedure Combination (DPC) database. After one-to-one propensity score-matching, total 866 cases were analyzed to evaluate systemic and local complication rates, reoperation rates, costs, and mortality.

RESULTS

A total of 433 pairs were made between the surgical procedures after matching. At least 1 systemic complication was seen in 26.6% of the AF group compared with 16.9% of the PF group (P=0.001). Specifically, the incidence of pulmonary embolism (P=0.045), urinary tract infection (P=0.012), and pleurisy (P=0.004) were significantly higher in the AF group. Blood transfusion (P=0.007) and the operation for systemic complications (P=0.020) were required more often in the AF group. The cost for hospitalization was also higher in the AF group (P<0.001). There were no differences in the mortality rates between the 2 groups.

CONCLUSIONS

More systemic complications were observed in the AF group. Surgeons need to take careful consideration of the merits and demerits described in this study when deciding the surgical method for OVF.

LEVEL OF EVIDENCE

Level 3.

Comparison of Perioperative Complications in Anterior Decompression With Fusion and Posterior Decompression With Fusion for Cervical Ossification of the Posterior Longitudinal Ligament: Propensity Score Matching Analysis Using a Nation-Wide Inpatient Database

STUDY DESIGN

A retrospective comparative study.

OBJECTIVE

To compare the perioperative complications and costs of anterior decompression with fusion (ADF) and posterior decompression with fusion (PDF) for patients with cervical ossification of the posterior longitudinal ligament (OPLL).

SUMMARY OF BACKGROUND DATA

Surgical treatment of cervical OPLL has a high risk of various complications. ADF and PDF are effective for the treatment of cervical OPLL; however, few studies have compared the two procedures in terms of the perioperative surgical complications.

METHODS

Patients undergoing ADF and PDF for cervical OPLL from 2010 to 2016 were identified in a nation-wide inpatient database. We investigated systemic and local complications, length of hospital stay, costs for hospitalization, reoperation, and mortality. Propensity score was calculated from patients' characteristics and preoperative comorbidities, and one to one matching was performed.

RESULTS

Propensity score-matching produced 854 pairs of patients who underwent ADF and PDF. The rate of at least one systemic complication was significantly higher in the ADF group (P = 0.004). The incidence rates of postoperative respiratory failure (P = 0.034) and dysphagia (P = 0.008) were significantly higher in the ADF group. The rates of pneumonia (P = 0.06) and hoarseness (P = 0.08) also tended to be higher in the ADF group. However, no difference was found in the mortality rate (P = 0.22). In the local complications, spinal fluid leakage was significantly higher in the ADF group (P < 0.001). However, blood transfusion rate was significantly higher in the PDF group (P = 0.001). Hospital stay was significantly longer in the PDF group (P < 0.001) and the cost for hospitalization was greater in the PDF group (P < 0.001).

CONCLUSION

The present study demonstrated that perioperative complications, such as respiratory failure, dysphagia, and spinal fluid leakage, were more common in the ADF group. However, hospital stay was longer in the PDF group, and the cost for hospitalization was greater in the PDF group.

LEVEL OF EVIDENCE

3.

Comparison of Perioperative Complications Between Anterior Decompression With Fusion and Laminoplasty For Cervical Spondylotic Myelopathy: Propensity Score-matching Analysis Using Japanese Diagnosis Procedure Combination Database

STUDY DESIGN

A retrospective comparative study with a large national database.

OBJECTIVE

The objective of this study was to compare the perioperative complications and costs of anterior decompression with fusion (ADF) and laminoplasty (LAMP) for patients who had cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

CSM is the most common spinal cord disorder in the upper middle-aged people in Japan. ADF and LAMP represent 2 major treatments; however, few studies have reported large-scale investigations for perioperative complications with CSM. Thus, it is controversial which surgical approach will lead to the best clinical outcome in CSM.

MATERIALS AND METHODS

All data in this study were collected from the Japanese Diagnosis Procedure Combination database for patients diagnosed with CSM. We adjusted for known confounding biases with propensity score matching. One-to-one matched pairs between each surgical procedure were analyzed for the purposes of comparing systemic complication rates, local complication rates, medical costs, and mortality.

RESULTS

After propensity score matching, 1638 pairs of patients undergoing ADF and LAMP were made. More perioperative systemic complications were observed in the ADF group, such as atrial fibrillation (ADF/LAMP=0.7%/0.2%, P=0.032), respiratory failure (1.4%/0.1%, P<0.001), dysphagia (2.2%/0.2%, P<0.001), and sepsis (0.5%/0.1%, P=0.019). In contrast, a high rate of pulmonary embolism was observed with LAMP groups (ADF/LAMP=0%/0.2%, P=0.045). Local complications, such as infection (ADF/LAMP=0.8%/1.7%, P=0.026) and meningitis (0%/0.2%, P<0.045), were more common in the LAMP group. Conversely, spinal fluid leakage (ADF/LAMP=0.6%/0%, P=0.003) was more common in the ADF group. The costs (P<0.001) were higher in the ADF group.

CONCLUSIONS

More systemic complications, such as respiratory disease, cardiovascular events, and sepsis, were observed in the ADF group, although local infection was more frequently seen in the LAMP group. Medical costs were higher in the ADF group. The findings in this study will contribute to each CSM patient by allowing suitable adaptation of cervical surgeries.

LEVEL OF EVIDENCE

Level III.

Perioperative complications of anterior decompression with fusion versus laminoplasty for the treatment of cervical ossification of the posterior longitudinal ligament: propensity score matching analysis using a nation-wide inpatient database

BACKGROUND CONTEXT

Surgical treatment of cervical ossification of the posterior longitudinal ligament (OPLL) has a high risk of various complications. Anterior decompression with fusion (ADF) and laminoplasty (LAMP) are the most representative surgical procedures. However, few studies have compared the two procedures in terms of perioperative surgical complications.

PURPOSE

To compare the perioperative complications post-ADF and LAMP for cervical OPLL using a large national inpatient database.

STUDY DESIGN

A retrospective cohort study with propensity score matching analysis.

PATIENT SAMPLE

Overall, 8,718 (ADF/LAMP:1,333/7,485) patients who underwent surgery for cervical OPLL from April 1, 2010 to March 31, 2016 in hospitals using the diagnosis procedure combination were analyzed.

OUTCOME MEASURES

The occurrence of postoperative complications during hospitalization.

METHODS

We compared the perioperative systemic and local complications, reoperation rates, and costs between ADF and LAMP using propensity score matching analysis.

RESULTS

One-to-one matching resulted in 1,192 pairs of patients who underwent ADF and LAMP. The postoperative cardiovascular event rate was significantly higher (ADF/LAMP=1.9/0.8%, p=.013) in the ADF group. The incidence rates of dysphagia (similarly, 2.4/0.2%, p<.001), pneumonia (1.0/0.3%, p=.045), and spinal fluid leakage (2.4/0.4%, p<.001) were also higher in the ADF group, even after matching. The costs were also higher in the ADF group. However, surgical site infection (2.0/3.4%, p=.033) was significantly lower in the ADF group. No significant difference in the reoperation rates was found between the groups.

CONCLUSION

The present study, using a large nationwide database, demonstrated that perioperative complications were more common in the ADF group, but that surgical site infection (SSI) was more frequently observed in the LAMP group.

Can Elective Spine Surgery Be Performed Safely Among Nonagenarians?: Analysis of a National Inpatient Database in Japan

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare morbidity and mortality between nonagenarians and other older adult patients who underwent elective spine surgery.

SUMMARY OF BACKGROUND DATA

There is a lack of information of the perioperative risks of nonagenarians undergoing spine surgery.

METHODS

Data of patients aged ≥65 years who underwent elective spine surgery from July 2010 to March 2013 were extracted from the Diagnosis Procedure Combination database, a nationwide administrative inpatient database in Japan. Clinical outcomes included mortality, occurrence of major complications (cardiac events, respiratory complications, pulmonary embolism, stroke, and acute renal failure), urinary tract infection, and postoperative delirium. These clinical outcomes in nonagenarians were compared with those in patients aged 65 to 79 years and octogenarians. A multivariate logistic regression model fitted with a generalized estimation equation was used to evaluate the influence of advanced age on 90-day mortality and postoperative major complications.

RESULTS

Of 88,370 patients identified in the database, 418 were nonagenarians. Compared with patients aged 65 to 79 years and octogenarians, nonagenarians had the highest rates of 90-day mortality (0.2%, 0.3%, and 1.7%, respectively; P < 0.001) and at least one major complication (3.7%, 5.0%, and 7.4%, respectively; P < 0.001). Nonagenarians had the highest proportions of cardiac events, respiratory complications, urinary tract infections, and delirium. The multivariable logistic regression analyses revealed that nonagenarians had increased risks of both 90-day mortality (odds ratio, 8.65; 95% confidence interval, 3.62-20.6) and postoperative major complications (odds ratio, 2.32; 95% confidence interval, 1.61-3.36) compared with patients aged 65 to 79 years.

CONCLUSION

Nonagenarians had increased morbidity and mortality following elective spine surgery compared with other older adult patients. Among the complications, cardiac events, respiratory complications, urinary tract infection, and delirium were more likely to occur in nonagenarians.

LEVEL OF EVIDENCE

3.

Progress in research into spinal cord injury repair: Tissue engineering scaffolds and cell transdifferentiation

As with all tissues of the central nervous system, the low regeneration ability of spinal cord tissue after injury decreases the potential for repair and recovery. Initially, in spinal cord injuries (SCI), often the surgeon can only limit further damage by early surgical decompression. However, with the development of basic science, especially the development of genetic engineering, molecular biology, tissue engineering, and materials science, some promising progress has been made in promoting the repair of central nervous system injuries. For example, transplantation of neural stem cells (NSCs), olfactory ensheathing cells (OECs), and gene- mediated transdifferentiation to repair central nervous system injury. This paper summarizes the progress and prospects of SCI repair with tissue engineering scaffold and cell transdifferentiation from an extensive literatures.

Atopic dermatitis is a novel demographic risk factor for surgical site infection after anterior cruciate ligament reconstruction

PURPOSE

Although various risk factors for surgical site infection after anterior cruciate ligament reconstruction (ACLR) have been reported, the number of studies with large sample sizes on this topic is limited. The aim of the present study was to clarify the risk factors for early surgical site infection after ACLR in a large cohort using a national database in Japan.

METHODS

The data of patients who underwent ACLR from 2010 to 2015 were obtained from the Diagnosis Procedure Combination database, which covers approximately half of all hospital admissions in Japan. The outcome measures were the prevalences of surgical site infection and deep surgical site infection after ACLR during hospitalization. The association between the occurrence of surgical site infection and patients' demographic data, including sex, age, body mass index (BMI), smoking status, preoperative steroid use, and comorbidities such as diabetes, hepatic dysfunction, renal dysfunction, and atopic dermatitis, were examined using a multivariable logistic regression model.

RESULTS

Among 30,536 patients who underwent ACLR, 288 patients with surgical site infection (0.94%) and 86 with deep surgical site infection (0.28%) were identified. The univariate analysis showed that higher prevalences of surgical site infection and deep surgical site infection were associated with male sex, a higher BMI, atopic dermatitis, and preoperative steroid use. Patients with diabetes or hepatic dysfunction had a significantly higher prevalence of surgical site infection. The multivariable analysis showed that surgical site infection was significantly associated with male sex vs. female sex; odds ratio (OR), 2.90; 95% confidence interval (CI), 2.17-3.89, age of ≤ 19 vs. 20-29 years; OR, 1.56; 95% CI 1.13-2.15, BMI of ≥ 30.0 vs. 18.5-22.9 kg/m²; OR, 1.72; 95% CI 1.16-2.54, diabetes (OR, 2.70; 95% CI 1.28-5.71), atopic dermatitis (OR, 7.19; 95% CI 2.94-17.57), and preoperative steroid use (OR, 6.18; 95% CI 2.32-16.52).

CONCLUSION

Atopic dermatitis, preoperative steroid use, young age (≤ 19 years), obesity (BMI of ≥ 30.0 kg/m²), male sex, and diabetes were independent demographic risk factors for surgical site infection after ACLR. The present study will be useful when surgeons evaluate the risk of SSI after ACLR in terms of demographic aspects.

LEVEL OF EVIDENCE

III.

In-hospital complication rate following microendoscopic versus open lumbar laminectomy: a propensity score-matched analysis

BACKGROUND CONTEXT

The incidence of postoperative complications after microendoscopic laminectomy (MEL) has not been compared with that after open laminectomy in a large study, so it is not clear whether MEL is a safer procedure.

PURPOSE

The objective of this study was to compare postoperative morbidity and mortality following lumbar laminectomy between patients treated with MEL and with open laminectomy.

STUDY DESIGN

This is a retrospective cohort study with propensity score-matched analysis.

PATIENT SAMPLE

Data of patients who underwent elective spinal surgery between July 2010 and March 2013 were extracted from the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan.

OUTCOME MEASURES

Clinical outcomes included length of hospital stay, occurrence of major complications (cardiac events, respiratory complications, pulmonary embolism, stroke, and acute renal failure), surgical site infection (SSI), postoperative delirium, and in-hospital death.

MATERIALS AND METHODS

Propensity score matching was performed to adjust for measured confounding factors, including patient age, sex, Charlson Comorbidity Index, body mass index, smoking status, blood transfusion, duration of anesthesia, number of operated disc levels, and type of hospital and hospital volumes. The clinical outcomes of one-to-one propensity-matched pairs of the MEL and the open laminectomy groups were compared.

RESULTS

Of 23,317 patients identified in the database, 1,536 underwent MEL (6.6%). By one-to-one propensity score matching, 1,536 pairs were selected. The distributions of patient backgrounds were closely balanced between the MEL and the open laminectomy groups. An analysis of 1,536 pairs revealed that there was a significantly lower incidence of major postoperative complications in those who underwent MEL (1.0% vs. 2.8% for open laminectomy, risk difference 1.8%, 95% confidence interval [CI] 0.9%-2.9%), SSI (0.5% vs. 1.6% for open laminectomy, risk difference 1.1%, 95% CI 0.4%-1.9%), and postoperative delirium (1.1% vs. 2.3% for open laminectomy, risk difference1.2%, 95% CI 0.3%-2.1%). The length of hospital stay was significantly shorter in those treated with MEL (12 days vs. 16 days for open laminectomy, p<.001). There was no significant difference in in-hospital mortality between the groups.

CONCLUSIONS

Patients who underwent MEL were significantly less likely to experience major postoperative complications and were less likely to develop SSI and postoperative delirium than those who underwent open laminectomy.

Annual trends in arthroscopic meniscus surgery: Analysis of a national database in Japan

Background

The importance of meniscus preservation is widely recognized. There have been a few studies describing trends in meniscectomy and meniscus repair in the United States; however, they presented differing results. We reported annual trends in meniscus surgery, using a national database in Japan.

Methods

We interrogated the Diagnosis Procedure Combination database, which represents approximately half of all hospital admissions in Japan. We included the patients who underwent meniscectomy and meniscus repair between July 2007 and March 2015. The diagnosis, age and sex of each patient were recorded.

Results

We identified 83,105 patients: 69,310 underwent meniscectomy; 13,416 underwent meniscus repair and 379 underwent both in a single admission. The proportion of patients undergoing meniscus repair rose from 7.0% in 2007 to 25.9% in 2014 (p < 0.001), while the proportion undergoing meniscectomy fell from 92.8% in 2007 to 73.3% in 2014 (p < 0.001). Among patients under 30 years old, the proportions undergoing meniscus repair or meniscectomy in 2014 were 50.3% versus 48.3%, respectively. A bimodal age distribution was observed for meniscectomy, with peaks at 10–19 years of age and 60–69 years of age, whereas most patients undergoing meniscus repair were 10–19 years of age.

Conclusions

We found characteristic trends where the popularity of meniscus repair increased rapidly at the expense of meniscectomy in Japan during the study period. In the last survey year, the proportion of meniscus repair exceeded that of meniscectomy in those younger than 30 years. Meniscectomy was undertaken most often in adolescents and early old age, while meniscus repair was undertaken most often in adolescents.

Method of Decompression by durotomy and duroplasty for cervical spinal cord injury in patients without fracture or dislocation

Introduction:

We developed the method of cervical spinal cord decompression through durotomy followed by duroplasty and analyzed its efficacy.

Purpose:

To develop a tactic of decompression durotomy and duroplasty for the treatment of severe spinal cord injury(SCI) with extensive edema of the spinal cord and without intramedullary hematoma, and to demonstrate the effectiveness of this method.

Methods:

From October 2016 to January 2018, 17 decompression operations were performed in the cervical spine in patients with SCI. Decompression laminectomy was done without durotomy in the first group of patients. In the second group, duroplasty of the spinal cord was performed after decompression durotomy. A total of 17 patients, 16 males (94%) and 1 female (6%), were operated on (ages from 32 to 66 years). The patients were divided into two groups: a control group and an experimental group. We used the ASIA scale for assessing the patients. The mean follow up time is 12 months (8−24 months).

Results:

The first group, i.e., the control group consisted of 10 patients who underwent decompression laminectomy without durotomy. The second group, i.e., the experimental group consisted of 7 patients who underwent durotomy followed by duroplasty. In this group, the positive dynamics were observed in 6 patients. Out of 2 patients with ASIA grade “A”, one showed improvement to ASIA grade “C”, and one improved to ASIA “D”. Two patients with ASIA grade “B” showed recovery to ASIA “D”. Two patients with ASIA grade “C” improved to grade “D” while one patient showed no change from ASIA “C”. Durotomy and duroplasty was effective in the experimental group.

Conclusion:

The performance of durotomy and duroplasty is an efficient method for the full-scale decompression of the spinal cord and the prevention of edema. This method aims at decreasing intraspinal pressure, as well as preventing ischemia and apoptosis, which is possible for the prevention and treatment of the spinal cord compartment syndrome or spinal cord intramedullary hypertension.

Annual trends in knee arthroplasty and tibial osteotomy: Analysis of a national database in Japan

BACKGROUND

Various nationwide studies have reported differing annual trends in utilization of knee arthroplasty and tibial osteotomy. Using the Diagnosis Procedure Combination database in Japan, the present series examined annual trends and demographics in total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA) and tibial osteotomy.

METHODS

All patients were identified who underwent TKA, UKA or tibial osteotomy for osteoarthritis, osteonecrosis or rheumatoid arthritis of the knee between July 2007 and March 2015.

RESULTS

A total of 170,433 cases of TKA, 13,209 cases of UKA and 8760 cases of tibial osteotomy were identified. The proportion of patients undergoing UKA rose from 4.0% in 2007 to 8.1% in 2014 (P<0.001), and that of tibial osteotomy from 2.6% in 2007 to 5.5% in 2014 (P<0.001); the proportion undergoing TKA fell from 93.4% in 2007 to 86.3% in 2014 (P<0.001). Between 2007 and 2014 the proportions of patients with osteonecrosis who underwent UKA and tibial osteotomy increased from 34.7% and 11.6% to 38.6% and 16.2%, respectively (P=0.001 for UKA and P=0.004 for tibial osteotomy). The proportions of patients with osteonecrosis undergoing UKA or tibial osteotomy were significantly greater than those with other diagnoses (P<0.001 for both).

CONCLUSIONS

The popularity of UKA and tibial osteotomy in Japan increased during the period 2007-2014 at the expense of TKA. The proportions of UKA and tibial osteotomy in patients with osteonecrosis also increased, and were larger than those in patients with other causative diseases.

Seasonal Variations in the Risk of Reoperation for Surgical Site Infection Following Elective Spinal Fusion Surgery: A Retrospective Study Using the Japanese Diagnosis Procedure Combination Database

STUDY DESIGN

A retrospective study of data abstracted from the Diagnosis Procedure Combination (DPC) database, a national representative database in Japan.

OBJECTIVE

The aim of this study was to examine seasonal variations in the risk of reoperation for surgical site infection (SSI) following spinal fusion surgery.

SUMMARY OF BACKGROUND DATA

Although higher rates of infection in the summer than in other seasons were thought to be caused by increasing inexperience of new staff, high temperature, and high humidity, no studies have examined seasonal variations in the risk of SSI following spinal fusion surgery in the country where medical staff rotation timing is not in summer season. In Japan, medical staff rotation starts in April.

METHODS

We retrospectively extracted the data of patients who were admitted between July 2010 and March 2013 from the DPC database. Patients were included if they were aged 20 years or older and underwent elective spinal fusion surgery. The primary outcome was reoperation for SSI during hospitalization. We performed multivariate analysis to clarify the risk factors of primary outcome with adjustment for patient background characteristics.

RESULTS

We identified 47,252 eligible patients (23,659 male, 23,593 female). The mean age of the patients was 65.4 years (range, 20-101 yrs). Overall, reoperation for SSI occurred in 0.93% of the patients during hospitalization. The risk of reoperation for SSI was significantly higher in April (vs. February; odds ratio, 1.93; 95% confidence interval, 1.09-3.43, P = 0.03) as well as other known risk factors. In subgroup analysis with stratification for type of hospital, month of surgery was identified as an independent risk factor of reoperation for SSI among cases in an academic hospital, although there was no seasonal variation among those in a nonacademic hospital.

CONCLUSION

This study showed that month of surgery is a risk factor of reoperation for SSI following elective spinal fusion surgery, nevertheless, in the country where medical staff rotation timing is not in summer season.

LEVEL OF EVIDENCE

3.

Predominantly negative impact of diabetes on spinal surgery: A review and recommendation for better preoperative screening

BACKGROUND

For patients undergoing spine surgery, the literature attributes significant increased perioperative risks/adverse events (AE) complications, longer length of stay (LOS), and higher 30-day readmission/reoperation rates to those with diabetes. Diabetics are often divided into those with insulin dependent diabetes (IDDM), and non-insulin dependent diabetes (NIDD). However, other series also compare those with uncontrolled diabetes (UCDM) vs. those with controlled DM (CDM).

METHODS

We found a marked variation in the size and quality of studies identified in PubMed regarding the impact of diabetes on spinal surgery (e.g., focusing on complications, AE, outcomes, morbidity, and mortality).

RESULTS

Of the 197,461 lumbar fusions in one NIS (Nationwide Inpatient Sample 1988-2003), 11,000 (5.6%) diabetics (DM) had higher infection rates, transfusion rates, more pneumonias, higher in-hospital mortality rates, greater costs, and longer LOS than those undergoing similar procedures without DM. For 3726 ACS-NSQIP patients undergoing anterior cervical fusions, 270 NIDDM had more urinary tract infections and returns to the operating room; the 171 IDDM required more reoperations, 30 day readmission, and longer LOS (by 5 days) vs. 3285 non DM. Of the 5627 patients undergoing posterior cervical fusions (ACS-NSQIP), 2029 (36.1%) had AE directly related to DM. In another NSQUIP study of 51277 patients undergoing lumbar spine surgery, IDDM and NIDDM demonstrated longer LOS, plus IDDM showed more surgical AE and 30 day readmissions vs. those with no DM.

CONCLUSIONS

Patients with IDDM or NIDDM undergoing spine surgery exhibited more perioperative complications/AE/morbidity, longer LOS, and higher readmission/reoperation rates vs. non DM.

Mortality and morbidity after spinal surgery in patients with Parkinson's disease: a retrospective matched-pair cohort study

BACKGROUND CONTEXT

There is a lack of information about postoperative outcomes and related risk factors associated with spinal surgery in patients with Parkinson's disease (PD).

PURPOSE

This study aimed to investigate the postoperative morbidity and mortality associated with spinal surgery for patients with PD, and the risk factors for poor outcomes.

STUDY DESIGN

This is a retrospective matched-pair cohort study.

PATIENT SAMPLE

Data of patients who underwent elective spinal surgery between July 2010 and March 2013 were extracted from the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan.

OUTCOME MEASURES

In-hospital mortality and occurrence of postoperative complications.

METHODS

For each patient with PD, we randomly selected up to four age- and sex-matched controls in the same hospital in the same year. The differences in in-hospital mortality and occurrence of postoperative complications were compared between patients with PD and controls. A multivariable logistic regression model fitted with a generalized estimation equation was used to identify significant predictors of major complications (surgical site infection, sepsis, pulmonary embolism, respiratory complications, cardiac events, stroke, and renal failure). Multiple imputation was used for missing data.

RESULTS

Among 154,278 patients undergoing spinal surgery, 1,423 patients with PD and 5,498 matched controls were identified. Crude in-hospital mortality was higher in patients with PD than in controls (0.8% vs. 0.3%, respectively). The crude proportion of major complications was also higher in patients with PD (9.8% vs. 5.1% in controls). Postoperative delirium was more common in patients with PD (30.3%) than in controls (4.3%). Parkinson's disease was a significant predictor of major postoperative complications, even after adjusting for other risk factors (odds ratio, 1.74; 95% confidence intervals, 1.37-2.22; p<.001).

CONCLUSIONS

Patients with PD had a significantly increased risk of postoperative complications following spinal surgery. Postoperative delirium was the most frequently observed complication.

Complications in the Management of Patients with Spine Trauma

More than 50% of patients diagnosed with acute, traumatic spinal cord injury will experience at least 1 complication during their hospitalization. Age, severity of neurological injury, concurrent traumatic brain injury, comorbid illness, and mechanism of injury are all associated with increasing risk of complication. More than 75% of complications will occur within 2 weeks of injury. The complications associated with SCI carry a significant risk of morbidity and mortality; their early identification and management is critical in the care of the SCI patient.

Does the microendoscopic technique reduce mortality and major complications in patients undergoing lumbar discectomy? A propensity score-matched analysis using a nationwide administrative database

OBJECTIVE Although minimally invasive spinal surgery has recently gained popularity, few nationwide studies have compared the adverse events that occur during endoscopic versus open spinal surgery. The purpose of this study was to compare perioperative complications associated with microendoscopic discectomy (MED) and open discectomy for patients with lumbar disc herniation. METHODS The authors retrospectively extracted from the Diagnosis Procedure Combination database, a national inpatient database in Japan, data for patients admitted between July 2010 and March 2013. Patients who underwent lumbar discectomy without fusion surgery were included in the analysis, and those with an urgent admission were excluded. The authors examined patient age, sex, Charlson Comorbidity Index, body mass index, smoking status, blood transfusion, duration of anesthesia, type of hospital, and hospital volume (number of patients undergoing discectomy at each hospital). One-to-one propensity score matching between the MED and open discectomy groups was performed to compare the proportions of in-hospital deaths, surgical site infections (SSIs), and major complications, including stroke, acute coronary events, pulmonary embolism, respiratory complications, urinary tract infection, and sepsis. The authors also compared the hospital length of stay between the 2 groups. RESULTS A total of 26,612 patients were identified in the database. The mean age was 49.6 years (SD 17.7 years). Among all patients, 17,406 (65.4%) were male and 6422 (24.1%) underwent MED. A propensity score-matched analysis with 6040 pairs of patients showed significant decreases in the occurrence of major complications (0.8% vs 1.3%, p = 0.01) and SSI (0.1% vs 0.2%, p = 0.02) in patients treated with MED compared with those who underwent open discectomy. Overall, MED was associated with significantly lower risks of major complications (OR 0.62, 95% CI 0.43-0.89, p = 0.01) and SSI (OR 0.29, 95% CI 0.09-0.87, p = 0.03) than open discectomy. There was a significant difference in length of hospital stay (11 vs 15 days, p < 0.001) between the groups. There was no significant difference in in-hospital mortality between MED and open discectomy. CONCLUSIONS The microendoscopic technique was associated with lower risks for SSI and major complications following discectomy in patients with lumbar disc herniation.

Risk of infectious complications associated with blood transfusion in elective spinal surgery-a propensity score matched analysis

BACKGROUND CONTEXT

Although the negative aspects of blood transfusion are increasingly recognized, less is known about transfusion-related risks in spinal surgery.

PURPOSE

This study was designed to determine whether perioperative allogeneic blood transfusion is associated with increased risk of infectious complications after elective spinal surgery.

STUDY DESIGN

A retrospective cohort study with propensity score matched analysis was carried out.

PATIENT SAMPLE

Data of patients with spinal canal stenosis and spondylolisthesis who underwent elective lumbar surgeries (decompression or fusion) were obtained from the Diagnosis Procedure Combination database, a nationwide administrative inpatient database in Japan.

OUTCOME MEASURES

Clinical outcomes included in-hospital death and the occurrence of infectious complications (surgical site infection [SSI], respiratory tract infection, urinary tract infection, and sepsis).

METHODS

Patients' clinical information, including sex, age, type of hospital, preoperative comorbidities, duration of anesthesia, cell saver use, and volume of allogeneic blood transfused, were investigated. Patients transfused with >840 mL (6 units) were excluded. Propensity scores for receiving transfusion were calculated, with one-to-one matching based on estimated propensity scores to adjust for patients' baseline characteristics. The proportions of complications were compared in patients with and without transfusions. This study was funded by grants from the Ministry of Health, Labour and Welfare, Japan.

RESULTS

Of the 84,650 patients identified, 5,289 patients (6.1%) received transfusions, with 4,436 (5.2%) receiving up to 840 mL. One-to-one propensity score matching resulted in 4,275 pairs with and without transfusion. Patients transfused were at increased risk of SSI (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.5; p<.001) and urinary tract infection (OR, 2.5; 95% CI, 1.5-4.2; p<.001) than those not transfused.

CONCLUSIONS

Allogeneic blood transfusion after elective lumbar surgery was associated with increased risks of SSI and urinary tract infection.

Perioperative stroke in patients undergoing elective spinal surgery: a retrospective analysis using the Japanese diagnosis procedure combination database

BACKGROUND

Although a few studies on perioperative stroke following spinal surgery have been reported, differences in the incidence of perioperative stroke among various surgical procedures have not been determined. The purpose of this retrospective analysis was to investigate the incidence of perioperative stroke during hospitalization in patients undergoing elective spinal surgery, and to examine whether the incidence varied according to the surgical procedure.

METHODS

A retrospective analysis of data from the Diagnosis Procedure Combination database, a nationwide administrative impatient database in Japan, identified 167,106 patients who underwent elective spinal surgery during 2007-2012. Patient information extracted included age, sex, preoperative comorbidity, administration of blood transfusion, length of hospitalization, and type of hospital. Clinical outcomes included perioperative stroke during hospitalization, and in-hospital death.

RESULTS

The overall incidence of perioperative stroke was 0.22 % (371/167,106) during hospitalization. A logistic regression model fitted with a generalized estimating equation showed perioperative stroke was associated with advanced age, a history of cardiac disease, an academic institution, and resection of a spinal tumor. Patients who underwent resection of a spinal cord tumor (reference) had a higher risk of stroke compared with those undergoing discectomy (odds ratio (OR), 0.29; 95 % confidence interval (CI), 0.14-0.58; p = 0.001), decompression surgery (OR, 0.44; 95 % CI, 0.26-0.73; p = 0.001), or arthrodesis surgery (OR, 0.55; 95 % CI, 0.34-0.90); p = 0.02). Advanced age (≥80 years; OR, 5.66; 95 % CI, 3.10-10.34; p ≤ 0.001), history of cardiac disease (OR, 1.58; 95 % CI, 1.10-2.26; p = 0.01), diabetes (OR, 1.73; 95 % CI, 1.36-2.20; p ≤ 0.001), hypertension (OR, 1.53; 95 % CI, 1.18-1.98; p = 0.001), cervical spine surgery (OR, 1.44; 95 % CI, 1.09-1.90; p = 0.01), a teaching hospital (OR, 1.36; 95 % CI, 1.01-1.82; p = 0.04), and length of stay (OR, 1.008; 95 % CI, 1.005-1.010; p ≤ 0.001) were also risk factors for perioperative stroke.

CONCLUSIONS

Perioperative stroke occurred in 0.22 % of patients undergoing spinal surgery. Resection of a spinal cord tumor was associated with increased risk of perioperative stroke as well as advanced age, comorbidities at admission, cervical spine surgery, surgery in a teaching hospital, and length of stay.

Corrective spinal surgery may be protective against stroke in patients with blunt traumatic vertebral artery occlusion

OBJECT Approximately 10% of patients with blunt traumatic extracranial cerebrovascular injury have a complete occlusion of the vertebral artery (VA). Ischemic stroke due to embolization of thrombus from an occluded VA following cervical spine surgery has been observed. The risk of ischemic stroke with cervical spine surgery in the presence of an occluded VA, however, has never been determined. METHODS A retrospective chart review of 52 patients with a VA occlusion following a blunt trauma was performed. Clinical and radiographic characteristics were collected and analyzed. RESULTS Ten patients (19.2%) suffered an ischemic stroke attributable to a traumatic VA occlusion. Univariate analysis demonstrated that patients with ischemic stroke were significantly older (p = 0.042) and had a lower rate of cervical spine surgery (p < 0.005). Multivariate analysis found cervical spine surgery to be protective against ischemic stroke (OR 0.049 [95% CI 0.014-0.167], p = 0.014); increasing age and bilateral VA injury (bilateral occlusion or unilateral occlusion with contralateral dissection) were risk factors for ischemic stroke (OR 1.05 [95% CI1.02-1.07], p = 0.065 and OR 13.2 [95% CI 2.98-58.9], p = 0.084, respectively). CONCLUSIONS Traumatic VA occlusion is associated with a risk of ischemic stroke and mortality. Corrective cervical spine surgery potentially decreases the risk of ischemic stroke by stabilizing the spine and thereby reducing motion across the occluded segment of the VA and preventing embolization of thrombus. While a high stoke risk may be inherent to the disease, novel therapies should be investigated.