Timing of inpatient medical complications after adult spinal deformity surgery: early ambulation matters

Incremental Increase in Hospital Length of Stay Due to Complications of Surgery for Adult Spinal Deformity

Study DesignRetrospective Cohort Study.ObjectivesLength of Stay (LOS) and resource utilization are of primary importance for hospital administration. This study aimed to understand the incremental effect of having a specific complication on LOS among ASD patients.MethodsA retrospective examination of prospective multicenter data utilized patients without a complication prior to discharge to develop a patient-adjusted and surgery-adjusted predictive model of LOS among ASD patients. The model was later applied to patients with at least 1 complication prior to discharge to investigate incremental effect of each identified complication on LOS vs the expected LOS.Results571/1494 (38.2%) patients experienced at least 1 complication before discharge with a median LOS of 7 [IQR 5 to 9]. Univariate analysis demonstrated that LOS was significantly affected by patients' demographics (age, CCI, sex, disability, deformity) and surgical strategy (invasiveness, fusion length, posterior MIS fusion, direct decompression, osteotomy severity, IBF use, EBL, ASA, ICU stay, day between stages, Date of Sx). Using patients with at least 1 complication prior discharge and compared to the patient-and-surgery adjusted prediction, having a minor complication increased the expected LOS by 0.9 day(s), a major complication by 3.9 days, and a major complication with reoperation by 6.3 days.ConclusionComplications following surgery for ASD correction have different, but predictable impact on LOS. Some complications requiring minimal intervention are associated with significant and substantial increases in LOS, while complications with significant impact on patient quality of life may have no influence on LOS.

The combined effect of nutritional status and body mass index on 90-day adverse events following long-segments fusion for adult spinal deformity: a propensity score-matched analysis

OBJECTIVE

The aim of this study was to investigate the individual and combined effects of PNI (prognostic nutritional index) and BMI (body mass index) on 90-day adverse events (AEs) following adult spinal deformity (ASD) surgery.

METHODS

A retrospective analysis was conducted on prospectively collected data from patients who underwent open long-segment fusion surgery for ASD. Patients were stratified into four groups based on BMI and PNI: low BMI with low PNI (LBLP), high BMI with low PNI (HBLP), low BMI with high PNI (LBHP), and high BMI with high PNI (HBHP). The primary outcome was the incidence of postoperative AEs within 90 days of ASD surgery.

RESULTS

The LBLP group had a significantly higher risk of overall AEs (58.7% vs. 33.3%, p = 0.004) and infectious complications (20.6% vs. 7.9%, p = 0.042) compared to the LBHP group. The HBHP group exhibited a higher rate of major AEs (28.1% vs. 12.3%, p = 0.036) and infectious complications (15.6% vs. 3.5%, p = 0.026) within 90 days postoperatively than the LBHP group. Multivariate logistic regression analysis identified male, higher American Society of Anesthesiologists class, increased intraoperative blood loss, and HBHP status (compared to LBHP) as independent predictors of 90-day major AEs.

CONCLUSION

In patients with low PNI, those with low BMI had a significantly higher risk of overall adverse events and infectious complications. Conversely, among patients with high PNI, those with high BMI were more prone to major adverse events and infectious complications within 90 days postoperatively.

Incidence of and Risk Factors for Ileus Following Spine Surgery

BACKGROUND

The purpose of this study was to determine the incidence of postoperative ileus (POI) after spine surgery and to identify risk factors for its development.

METHODS

A retrospective database study was performed between 2019 and 2021. A database of all patients who underwent spine surgery was searched, and patients who developed clinical and radiographic evidence of POI were identified. Demographic characteristics, perioperative data including opioid consumption, ambulation through postoperative day 1, surgical positioning, medical history, and surgical history were obtained and compared to examine risk factors for developing POI.

RESULTS

A total of 10,666 consecutive patients were identified who underwent cervical, thoracic, thoracolumbar, lumbar, or lumbosacral surgery with or without fusion. No patients were excluded from this study. The overall incidence of POI after spine surgery was 1.63%. POI was associated with a significantly greater mean length of stay of 7.6 ± 5.0 days compared with 2.9 ± 2.9 days in the overall cohort (p < 0.001). A history of ileus (odds ratio [OR], 21.13; p < 0.001) and a history of constipation (OR, 33.19; p < 0.001) were also associated with an increased rate of POI compared with patients without these conditions. Postoperatively, patients who developed POI had decreased early ambulation distance through postoperative day 1 at 14.8 m compared with patients who did not develop POI at 31.4 m (p < 0.001). Total postoperative opioid consumption was significantly higher (p < 0.001) in the POI group (330.3 morphine equivalent dose [MED]) than in the group without POI (174.5 MED). Lastly, patients who underwent fusion (p < 0.001), were positioned in a supine or lateral position (p = 0.03) (indicators of anterior or lateral approaches), had thoracolumbar or lumbar surgery (p = 0.01), or had multiple positions during the surgical procedure (p < 0.001) had a significantly higher risk of POI than those who did not.

CONCLUSIONS

The overall incidence of POI after all spine surgery is low. Several nonmodifiable predictors of POI include prior ileus, constipation, hepatitis, and prostatectomy. Multiple surgical factors increased the risk of POI, including supine positioning, surgery with the patient in multiple positions, and fusion. POI was associated with decreased early ambulation and increased opioid usage. Strategies should be implemented to maximize early ambulation and decrease opioid usage perioperatively.

LEVEL OF EVIDENCE

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

Why Didn't You Walk Yesterday? Factors Associated With Slow Early Recovery After Adult Spinal Deformity Surgery

STUDY DESIGN

This is a retrospective case-control study.

OBJECTIVES

The objectives of this study are to identify (1) risk factors for delayed ambulation following adult spinal deformity (ASD) surgery and (2) complications associated with delayed ambulation.

METHODS

One-hundred and ninety-one patients with ASD who underwent posterior-only fusion (≥5 levels, LIV pelvis) were reviewed. Patients who ambulated with physical therapy (PT) on POD2 or later (LateAmb, n = 49) were propensity matched 1:1 to patients who ambulated on POD0-1 (NmlAmb, n = 49) based on the extent of fusion and surgical invasiveness score (ASD-S). Risk factors, as well as inpatient medical complications were compared. Logistic regressions were used to identify risk factors for late ambulation.

RESULTS

Of the patients who did not ambulate on POD0-1, 32% declined participation secondary to pain or dizziness/fatigue, while 68% were restricted from participation by PT/nursing due to fatigue, inability to follow commands, nausea/dizziness, pain, or hypotension. Logistic regression showed that intraoperative estimated blood loss (EBL) >2L (OR = 5.57 [1.51-20.55], P = .010) was independently associated with an increased risk of delayed ambulation, with a 1.25 times higher risk for every 250 mL increase in EBL (P = .014). Modified 5-Item Frailty Index (mFI-5) was also independently associated with delayed ambulation (OR = 2.53 [1.14-5.63], P = .023). LateAmb demonstrated a higher hospital LOS (8.4 ± 4.0 vs 6.2 ± 2.6, P < .001). The LateAmb group trended toward an increase in medical complications on POD3+ (14.3% vs 26.5%, P = .210).

CONCLUSIONS

EBL demonstrates a dose-response relationship with risk for delayed ambulation. Delayed ambulation increases LOS and may impact medical complications.

Evaluating the Association Between Physical Therapy Variables and Outcomes After Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to investigate how inpatient physical therapy variables impact (1) inpatient complications, (2) 90-day readmissions, (3) 1-year reoperation rates, and (4) length of stay after posterior lumbar decompression and fusion.

SUMMARY OF BACKGROUND DATA

Previous studies have emphasized the role of early ambulation in postoperative spine patients as an effective method for improving pain and decreasing length of stay, but few studies have evaluated the efficacy of inpatient physical therapy.

METHODS

Patients 18 years of age or older who underwent primary 1-level or 2-level posterior lumbar decompression and fusion from 2019 to 2020 were retrospectively identified. Physical therapy data, including time to first inpatient PT session, gait trial distance achieved, post-treatment pain rating, and Activity Measure for Post-Acute Care (Activity Measure for Post-Acute Care [AM-PAC]) scores were collected using manual chart review. Surgical outcome variables included length of stay, inpatient complications, 90-day readmissions, and reoperations within 1 year of primary surgery.

RESULTS

Overall, 425 patients were identified. There was no difference in hours to PT or total gait trial distance achieved between patients who experienced a complication and those that did not. Patients in the noncomplication group had higher AM-PAC scores than patients in the complication group. There was no difference with regards to time to PT, AM-PAC score, or gait trial distance achieved between readmitted patients and nonreadmitted patients or revision patients and nonrevision patients. Stepwise logistic regression showed that having a physical therapy session within 6 hours of surgery was predictive of a decreased length of stay both in all patients.

CONCLUSIONS

While inpatient physical therapy within 6 hours of surgery does not appear to impact readmissions, complications, or reoperations, surgeons should encourage early ambulation postoperatively to decrease extended hospital stays. Future investigation should seek to identify factors that delay inpatient PT in the 6 hours after surgery.

Full-Percutaneous Trans-Kambin Lumbar Interbody Fusion With a Large-Footprint Interbody Cage

STUDY DESIGN

Exploratory prospective observational cohort.

OBJECTIVES

Aim of this study was to evaluate clinical and radiologic outcome, and surgical efficiency of a novel universal delivery system that allows full-percutaneous extraforaminal, trans-Kambin lumbar interbody fusion with a large-footprint lumbar interbody cage using only fluoroscopic imaging and open-surgery instrumentation.

METHODS

We prospectively evaluated patients that underwent elective trans-Kambin TLIF surgery with a large-footprint interbody cage using a novel universal delivery system. Clinical follow-up was evaluated pre-and post-operatively with Visual Analogic Scale (VAS) and Oswestry Disability Index (ODI) scores, while radiologic follow-up was performed with a computed tomography scan and standing films post-operatively at hospital discharge and 1 year follow-up.

RESULTS

A total of 47 patients were evaluated. Clinically, post-operative VAS and ODI scores significantly (P < 0.001) improved compared to pre-operative scores and 29.4 months mean follow-up. Radiologic evaluation yielded an intervertebral fusion rate of 90% of the operated levels and a significant increase in segmental lordosis by 3.7°. Median surgical time for interbody cage insertion per level was 28 minutes. Complications included 14 (29%) cases with transitory post-operative radiculitis, 4 (8%) cases with partial muscle weakness and 2 (4%) cases that required revision surgery. Post-operative ambulation started at a median 5 hours and median hospital length of stay was 28 hours.

CONCLUSIONS

A new universal delivery system allows overcoming most limitations of current full-endoscopic trans-Kambin fusion as it allows a time- efficient full-percutaneous insertion of a large-footprint interbody cage under fluoroscopy imaging only, with standard open-surgery instruments and optional endoscopic visualization.

Enhanced recovery pathway in adult patients with spinal deformity undergoing open thoracolumbar surgery

PURPOSE

The poor prognosis of adult patients with spinal deformity following long-segment spinal fusion surgery remains a major concern. Our study aims to investigate the impact of an Enhanced Recovery After Surgery (ERAS) protocol on the prognosis of adult patients with spinal deformity.

METHODS

This study focused on a retrospective review of a database of previous adult spinal deformity. Adult patients with spinal deformity who underwent long-segment fusion surgery from July 2016 to July 2022 were evaluated, from July 2016 to July 2019 for the pre-ERAS patient group and from July 2019 to July 2022 for the ERAS group. Demographic data, radiological sagittal parameters, and intraoperative data were collected from all patients. The length of hospital stay, postoperative complications, and 90-day readmission rates were compared between the two groups. Additionally, multivariate regression models were used to analyze the predictors of postoperative length of stay, postoperative complications, and 90-day readmission rates.

RESULTS

A total of 215 patients were included in this study, 102 patients in the pre-ERAS group and 113 patients in the ERAS group. Postoperative outcomes in the ERAS group included significantly lower postoperative length of stay (LOS) (13.09 ± 4.57 vs. 11.13 ± 4.16, P = 0.001); significantly lower rate of postoperative complications (52.0% vs. 29.2%, P < 0.001) and significantly lower 90-day readmission rates (14.7% vs. 6.19%, P = 0.040). Multivariate linear regression showed that fewer ERAS (P = 0.022), later drain placement (P = 0.027), and more complications (P = 0.002) were significantly associated with longer postoperative LOS. Multivariate logistic regression showed that fewer ERAS (P = 0.015) and later drain removal (P = 0.041) were significantly associated with more complications, and more ERAS (P = 0.009), earlier postoperative LOS (P = 0.020), and earlier urinary catheter removal (P = 0.034) were significantly associated with the 90-day readmission rates.

CONCLUSIONS

According to the results of our study, it is necessary to implement an ERAS protocol for adult patients with spinal deformity undergoing long-segment fusion surgery. The ERAS protocol is effective in reducing postoperative hospital length of stay, incidence of surgical complications, and 90-day readmission rates.

Risk Factors for Postoperative Urinary Retention After Lumbar Fusion Surgery: Anesthetics and Surgical Approach

INTRODUCTION

Postoperative urinary retention (POUR) after lumbar fusion surgery can lead to longer hospital stays and thus increased risk of developing other postoperative complications. Therefore, we aimed to determine the relationship between POUR and (1) surgical approach and (2) anesthetic agents, including sugammadex and glycopyrrolate.

METHODS

After institutional review board approval, L4-S1 single-level lumbar fusion surgeries between 2018 and 2021 were identified. A 3:1 propensity match of patients with POUR to those without was conducted, controlling for patient age, sex, diabetes status, body mass index, smoking status, history of benign prostatic hyperplasia, and the number of levels decompressed. POUR was defined as documented straight catheterization yielding >400 mL. We compared patient demographic, surgical, anesthetic, and postoperative characteristics. A bivariant analysis and backward multivariable stepwise logistic regression analysis ( P -value < 0.200) were performed. Significance was set to P < 0.05.

RESULTS

Of the 899 patients identified, 51 met the criteria for POUR and were matched to 153 patients. No notable differences were observed between groups based on demographic or surgical characteristics. On bivariant analysis, patients who developed POUR were more likely to have been given succinylcholine (13.7% vs. 3.92%, P = 0.020) as an induction agent. The independent predictors of POUR identified by multivariable analysis included the use of succinylcholine {odds ratio (OR), 4.37 (confidence interval [CI], 1.26 to 16.46), P = 0.022} and reduced postoperative activity (OR, 0.99 [CI, 0.993 to 0.999], P = 0.049). Factors protective against POUR included using sugammadex as a reversal agent (OR, 0.38 [CI, 0.17 to 0.82], P = 0.017). The stepwise regression did not identify an anterior surgical approach as a notable predictor of POUR.

CONCLUSION

We demonstrate that sugammadex for anesthesia reversal was protective against POUR while succinylcholine and reduced postoperative activity were associated with the development of POUR. In addition, we found no difference between the anterior or posterior approach to spinal fusion in the development of POUR.