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Nunna RS, Ansari D, Ostrov PB, Dettori JR, Godolias P, Ortiz-Torres M, Elias E, Gruber M, Oskouian RJ, Chapman JR. The Risk of Adverse Events in Smokers Undergoing Spinal Fusion: A Systematic Review and Meta-Analysis. Global Spine J 2023; 13:242-253. [PMID: 36367824 PMCID: PMC9837502 DOI: 10.1177/21925682221110127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES Determine if tobacco use is associated with increased risk of postoperative adverse events within 90 days in patients undergoing spinal fusion surgery. METHODS Databases were queried to identify cohort studies that directly compared smokers with non-smokers and provided the absolute number of adverse events and the population at risk. Data quality was evaluated using the Quality in Prognosis Studies tool. Risk ratios (RR) and 95% confidence intervals were calculated and compared between studies. The grading of recommendation, assessment, development and evaluation (GRADE) criteria were used to assess the strength of the evidence. RESULTS Seventeen studies assessing 37 897 participants met the inclusion criteria. Of these, 10 031 (26.5%) were smokers and 27 866 (73.5%) were nonsmokers. The mean age for the study population was 58 years, and 45% were males. Smoking was not associated with increased risk of one or more major adverse events within 90 days following spine surgery (seven studies, pooled RR 1.13, 95% CI [.75-1.71], I2 = 41%). However, smoking was significantly associated with one or more major adverse events in ≤2 level fusion (three studies, pooled RR 2.46, 95% CI [1.18-5.12], I2 = 0%), but not in fusions of ≥3 levels (four studies, pooled RR .87, 95% CI [.70-1.08], I2 = 0%). Additionally, there was no statistically significant association between smoking and any adverse event, nor increased reoperation risk due to adverse events. CONCLUSIONS In this meta-analysis, tobacco use was not associated with a statistically significant increased risk of adverse events within 90 days in patients undergoing spinal fusion surgery. Our results are limited by the variable reporting methodology for both complication rates as well as smoking incidence between the included individual studies.
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Affiliation(s)
- Ravi S. Nunna
- Department of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Darius Ansari
- Department of Neurosurgery, University of Illinois at
Chicago, Chicago, IL, USA
| | - Philip B. Ostrov
- Department of Neurosurgery, University of Illinois at
Chicago, Chicago, IL, USA
| | | | | | | | - Elias Elias
- Department of Neurosurgery, University of
Texas-Southwestern, Dallas, TX, USA
| | - Max Gruber
- Elson S. Floyd College of
Medicine, Spokane, WA, USA
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Lee YJ, Cho PG, Kim KN, Kim SH, Noh SH. Risk Factors of Unplanned Readmission after Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis. Yonsei Med J 2022; 63:842-849. [PMID: 36031784 PMCID: PMC9424775 DOI: 10.3349/ymj.2022.63.9.842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 12/02/2022] Open
Abstract
PURPOSE With an increasing number of anterior cervical discectomy and fusion (ACDF) being conducted for degenerative cervical disc disease, there is a rising interest in the related quality of management and healthcare costs. Unplanned readmission after ACDF affects both the quality of management and medical expenses. This meta-analysis was performed to evaluate the risk factors of unplanned readmission after ACDF to improve the quality of management and prevent increase in healthcare costs. MATERIALS AND METHODS We searched the databases of PubMed, EMBASE, Web of Science, and Cochrane Library to identify eligible studies using the searching terms, "readmission" and "ACDF." A total of 10 studies were included. RESULTS Among the demographic risk factors, older age [weighted mean difference (WMD), 3.93; 95% confidence interval (CI), 2.30-5.56; p<0.001], male [odds ratio (OR), 1.23; 95% CI, 1.10-1.36; p<0.001], and private insurance (OR, 0.34; 95% CI, 0.17-0.69; p<0.001) were significantly associated with unplanned readmission. Among patient characteristics, hypertension (HTN) (OR, 2.14; 95% CI, 1.41-3.25; p<0.001), diabetes mellitus (DM) (OR, 1.59; 95% CI, 1.20-2.11; p=0.001), coronary artery disease (CAD) (OR, 2.87; 95% CI, 2.13-3.86; p<0.001), American Society of Anesthesiologists (ASA) physical status grade >2 (OR, 2.13; 95% CI, 1.68-2.72; p<0.001), and anxiety and depression (OR, 1.39; 95% CI, 1.29-1.51; p<0.001) were significantly associated with unplanned readmission. Among the perioperative factors, pulmonary complications (OR, 22.52; 95% CI, 7.21-70.41; p<0.001) was significantly associated with unplanned readmission. CONCLUSION Male, older age, HTN, DM, CAD, ASA grade >2, anxiety and depression, pulmonary complications were significantly associated with an increased occurrence of unplanned readmission after ACDF.
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Affiliation(s)
- Young Ju Lee
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
| | - Pyung Goo Cho
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyun Kim
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea.
| | - Sung Hyun Noh
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.
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Connor M, Briggs RG, Bonney PA, Lamorie-Foote K, Shkirkova K, Min E, Ding L, Mack WJ, Attenello FJ, Liu JC. Tobacco Use Is Associated With Increased 90-Day Readmission Among Patients Undergoing Surgery for Degenerative Spine Disease. Global Spine J 2022; 12:787-794. [PMID: 33030060 PMCID: PMC9344509 DOI: 10.1177/2192568220964032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
STUDY DESIGN Retrospective database study. OBJECTIVE Tobacco use is associated with complications after surgical procedures, including poor wound healing, surgical site infections, and cardiovascular events. We used the Nationwide Readmissions Database (NRD) to determine if tobacco use is associated with increased 30- and 90-day readmission among patients undergoing surgery for degenerative spine disorders. METHODS Patients who underwent elective spine surgery were identified in the NRD from 2010 to 2014. The study population included patients with degenerative spine disorders treated with discectomy, fusion, or decompression. Descriptive and multivariate logistic regression analyses were performed to identify patient and hospital factors associated with 30- and 90-day readmission, with significance set at P value <.001. RESULTS Within 30 days, 4.8% of patients were readmitted at a median time of 9 days. The most common reasons for 30-day readmission were postoperative infection (12.5%), septicemia (3.5%), and postoperative pain (3.0%). Within 90 days, 7.3% were readmitted at a median time of 18 days. The most common reasons for 90-day readmission were postoperative infection (9.6%), septicemia (3.5%), and pneumonia (2.3%). After adjustment for patient and hospital characteristics, tobacco use was independently associated with readmission at 90 days (odds ratio 1.05, 95% confidence interval 1.03-1.07, P < .0001) but not 30 days (odds ratio 1.02, 95% confidence interval 1.00-1.05, P = .045). CONCLUSIONS Tobacco use is associated with readmission within 90 days after cervical and thoracolumbar spine surgery for degenerative disease. Tobacco use is a known risk factor for adverse health events and therefore should be considered when selecting patients for spine surgery.
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Affiliation(s)
| | | | - Phillip A. Bonney
- University of Southern
California, Los Angeles, CA, USA,Phillip A. Bonney, MD, Department of
Neurosurgery, University of Southern California, 1200 N State St., Ste. 3300,
Los Angeles, CA 90033, USA.
| | | | | | - Elliot Min
- University of Southern
California, Los Angeles, CA, USA
| | - Li Ding
- University of Southern
California, Los Angeles, CA, USA
| | | | | | - John C. Liu
- University of Southern
California, Los Angeles, CA, USA
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Liu G, Tan JH, Tan J, Ng JH, Chua J, Chan YH, Riew KD. Does Cigarette Smoking Affect Cervical Laminoplasty Clinical and Radiologic Outcomes? Clin Spine Surg 2022; 35:E473-E477. [PMID: 34907932 DOI: 10.1097/bsd.0000000000001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/11/2021] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE This study aimed to investigate if smokers have both poorer early clinical and radiologic outcomes in cervical laminoplasty when compared with nonsmokers. SUMMARY OF BACKGROUND DATA Cigarette smoking had been reported to increase rates of pseudoarthrosis following spinal instrumentation with fusion. METHODOLOGY A retrospective review of all patients who underwent open-door cervical laminoplasty was performed. Nurick, neck pain visual analog scale, and neck disability index scores were reviewed. Cervical lordosis, range of motion (ROM), and intervertebral disc height were measured. The rates and reasons for revision surgery were recorded and classified according to the etiology of laminoplasty revision surgery. RESULTS Sixty patients were recruited, of which 20 patients (18 males, 2 females) were smokers and 40 patients (27 males, 13 females) were nonsmokers. There was no statistically significant difference between smokers and nonsmokers in preoperative and postoperative visual analog scale, neck disability index, and Nurick scores. A trend was noted toward a greater postoperative reduction in cervical lordosis (13±8 vs. 11±11 degrees). Furthermore, 41% of smokers versus 30% in nonsmokers had >10% loss of postoperative ROM, and 59% smokers versus 50% nonsmokers had >5% loss of postoperative ROM.Postoperative complications and intervertebral disc deterioration were similar in both groups. A higher reoperation rate was noted in smokers with 6 smokers (30%) as compared with 4 nonsmokers (10%), although this did not reach statistical significance. Among the smokers, 4 (20%) were because of cervical disease progression while 2 were technique related. In nonsmokers, all 4 (10%) were because of cervical disease progression. CONCLUSION This study showed that while there was a nonstatistically significant trend noted toward higher rates of revision surgery in smokers, the laminoplasty outcomes were not significantly poorer in smokers. In heavy smokers with multilevel cervical myelopathy, laminoplasty may be the treatment of choice over anterior spinal decompression and fusion where a high risk of pseudoarthrosis is anticipated.
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Affiliation(s)
- Gabriel Liu
- Department of Orthopaedic Surgery, University Spine Centre
| | - Jun-Hao Tan
- Department of Orthopaedic Surgery, University Spine Centre
| | - Joshua Tan
- Department of Orthopaedic Surgery, National University Hospital, National University Health System
| | - Jing Han Ng
- Department of Orthopaedic Surgery, National University Hospital, National University Health System
| | - Jasline Chua
- Department of Orthopaedic Surgery, National University Hospital, National University Health System
| | - Yiong Huak Chan
- Medicine Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - K Daniel Riew
- Columbia University Medical Center, Spine Division, Adult and Pediatric Comprehensive Spine Fellowship, Columbia University, New York, NY
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Hoang H, Sharfman Z, Gelfand Y, Ramos RLG, Gomez J, Krystal J, Kramer D, Yassari R. Cigarette smoking and complications in elective thoracolumbar fusions surgery: An analysis of 58,304 procedures. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:169-174. [PMID: 35837438 PMCID: PMC9274679 DOI: 10.4103/jcvjs.jcvjs_15_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/01/2022] [Indexed: 11/04/2022] Open
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Trends in national utilization of posterior lumbar fusion and 30-day reoperation and readmission rates from 2006–2016. Clin Neurol Neurosurg 2020; 199:106310. [DOI: 10.1016/j.clineuro.2020.106310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 02/04/2023]
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Abstract
STUDY DESIGN Invited narrative review. OBJECTIVES The aim of this review was to summarize current literature regarding risk factors that surgeons can optimize in the preoperative setting in the spinal surgery patient, in order to reduce complications and improve patient-reported outcomes. METHODS Review of the relevant literature by the authors. RESULTS Modifiable risk factors identified relative to the patient include obesity, malnutrition/nutrient deficiency, diabetes/hyperglycemia, preoperative anemia, vitamin D/DEXA (dual-energy radiograph absorptiometry), nicotine use/smoking, and opioid use/psychosocial factors. CONCLUSION By maximizing a patient's physiological and psychological status prior to elective spine surgery, we may move closer to achieving the goals of value-based care: improving patient-reported outcomes while decreasing the cost of care.
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Affiliation(s)
- Sukanta Maitra
- Department of Orthopaedic Surgery, UNLV School of Medicine, Las Vegas, NV, USA,Sukanta Maitra, Department of Orthopaedic Surgery, UNLV School of Medicine, Las Vegas, NV 89102, USA.
| | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael D. Daubs
- Department of Orthopaedic Surgery, UNLV School of Medicine, Las Vegas, NV, USA
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Ranson WA, Neifert SN, Cheung ZB, Mikhail CM, Caridi JM, Cho SK. Predicting In-Hospital Complications After Anterior Cervical Discectomy and Fusion: A Comparison of the Elixhauser and Charlson Comorbidity Indices. World Neurosurg 2019; 134:e487-e496. [PMID: 31669536 DOI: 10.1016/j.wneu.2019.10.102] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to determine the ability of the Elixhauser Comorbidity Index (ECI) and Charlson Comorbidity Index (CCI) to predict postoperative complications after anterior cervical discectomy and fusion (ACDF). METHODS This was a retrospective study of ACDF hospitalizations in the National Inpatient Sample from 2013 to 2014. The ECI and CCI were calculated, and patients who experienced postoperative complications were identified. The ability of these indexes to predict complications was compared using the c statistic (area under the receiver operating characteristic curve [AUC]). In addition, the CCI and ECI were compared with a base model that included age, sex, race, and primary payer. RESULTS A total of 261,780 patients were included. Patients who experienced a complication were more often male (P < 0.0001) and older (P < 0.0001). They also had a higher comorbidity burden as assessed by both the ECI (P < 0.0001) and the CCI (P < 0.0001). The ECI was superior in predicting airway complications (AUC, 0.81 vs. 0.75; P < 0.0001), hemorrhagic anemia (AUC, 0.67 vs. 0.63; P = 0.0015), pulmonary embolism (AUC, 0.91 vs. 0.77; P < 0.0001), wound dehiscence (AUC, 0.80 vs. 0.55; P = 0.0080), sepsis (AUC, 0.87 vs. 0.82; P = 0.0001), and septic shock (AUC, 0.94 vs. 0.83; P < 0.0001). The CCI was not found to be superior to the ECI for predicting any complications. Both were excellent for predicting mortality (ECI AUC, 0.87; CCI AUC, 0.90). CONCLUSIONS The ECI was superior to the CCI in predicting 6 of 15 complications in this study. Both are excellent tools for predicting mortality after ACDF.
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Affiliation(s)
- William A Ranson
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA
| | - Sean N Neifert
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA
| | | | - John M Caridi
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedics, Mount Sinai Hospital, New York, New York, USA.
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9
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Epstein NE. Preoperative measures to prevent/minimize risk of surgical site infection in spinal surgery. Surg Neurol Int 2018; 9:251. [PMID: 30637169 PMCID: PMC6302553 DOI: 10.4103/sni.sni_372_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 01/29/2023] Open
Abstract
Background: Multiple measures prior to spine surgery may reduce the risks of postoperative surgical site infections (SSIs). Methods: The incidence of SSI following spinal surgery (including reoperations and readmissions) may be markedly reduced by performing less extensive procedures and avoiding fusion where feasible. Preoperative testing up to 3 weeks postoperatively should include other studies to limit the perioperative SSI risk; cardiac stress tests (e.g., older patients/cardiac comorbidities), starting tamsulosin in males over 60 (e.g. avoid urinary retention due to benign prostatic hypertrophy), albumin/prealbumin levels (e.g., low levels increase SSI risk), and HBA1C levels to identify new/treat known diabetics (normalize/reduce preoperative levels). Results: Other measures include the timely administration of preoperative antibiotics (e.g., cefazolin 2 g nonpenicillin allergic), one dose of gentamicin (adjusted dose/weight), nasal cultures for methicillin-resistant Staphylococcus aureus (patients/health-care workers), and bathing 2 weeks preoperatively with chlorhexidine gluconate 4% (not just night before/morning of surgery). Additionally, prior to surgery, the following medications that increase the bleeding risk should be stopped (e.g. for varying periods); anticoagulants, antiplatelet therapies (e.g., aspirin for at least 7–10 days), nonsteroidal anti-inflammatories (NSAIDS: timing depends on the drug), vitamin E, and herbal supplements. Additionally, avoiding elective spinal surgery in morbidly obese patients and recognizing other major medical contraindications to spinal surgery should help reduce infection, morbidity, and mortality rates. Conclusions: Appropriate preoperative and intraoperative prophylactic maneuvers may reduce the risk of postoperative spinal SSI. Specific attention to these details may avoid infections and improve outcomes.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurological Surgery, School of Medicine, State University of N.Y. at Stony Brook, and Chief of Neurosurgical Spine/Education at NYU Winthrop Hospital, Mineola, NY 11501, USA
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