Lumbar Spine Fusion Surgery in Solid Organ Transplant Recipients Is Associated With Increased Medical Complications and Mortality

Complication, Readmission, Intensive Care Unit Admission, and Revision Incidence Following Anterior Cervical Discectomy and Fusion Surgery in End-stage Renal Disease and Renal Transplant Patients

STUDY DESIGN

Retrospective cross-sectional study aimed to investigate the postoperative outcomes following anterior cervical discectomy and fusion (ACDF) surgery in patients with end-stage renal disease (ESRD) and renal transplant recipients, using data from a large national database. Three patient groups were analyzed: control group, ESRD group, and renal transplant group.

OBJECTIVE

To investigate the postoperative outcomes following ACDF surgery in patients with ESRD and renal transplant recipients, utilizing data from a large national database.

BACKGROUND

Patients with ESRD and renal transplant recipients face unique health challenges, and there is a paucity of comprehensive research examining their postoperative surgical experiences, especially in the context of spine surgery.

MATERIALS AND METHODS

Data from 158,101 ACDF procedures performed between 2016 and 2019 were analyzed. Patients were stratified into 3 groups: control, end-stage renal failure, and renal transplant. The primary outcomes included 30-day medical complications, 30-day intensive care unit admissions, 90-day readmissions, and 1-year revision surgery. Multivariable logistic regression was employed for analysis.

RESULTS

Patients with ESRD had significantly higher rates of 30-day medical complications (56%) and 90-day readmissions (38%) compared with the control patients (3% and 3%, respectively). Renal transplant patients also showed elevated rates of medical complications and readmissions, 12% and 10%, respectively, but lower than patients with ESRD. Patients with ESRD had significantly higher odds of intensive care unit admission. There were no significant differences in revision rates among the groups.

CONCLUSIONS

Patients with ESRD and renal transplant recipients undergoing ACDF surgery face increased risks of medical complications and readmissions, with patients with ESRD showing surprisingly high rates. Tailored care strategies and close monitoring are crucial for these patient cohorts, emphasizing the need for specialized postoperative care. The study's findings highlight the multifaceted nature of surgical outcomes in medically complex populations and the importance of holistic assessment.

Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review

OBJECTIVE

The objective of this study was to investigate the perioperative management and outcomes of patients with a prior history of successful transplantation undergoing spine surgery.

METHODS

We searched Medline, Embase, and Cochrane Central Register of Controlled Trials for matching reports in July 2021. We included case reports, cohort studies, and retrospective analyses, including terms for various transplant types and an exhaustive list of key words for various forms of spine surgery.

RESULTS

We included 45 studies consisting of 34 case reports (published 1982-2021), 3 cohort analyses (published 2005-2006), and 8 retrospective analyses (published 2006-2020). The total number of patients included in the case reports, cohort studies, and retrospective analysis was 35, 48, and 9695, respectively. The mean 1-year mortality rate from retrospective analyses was 4.6% ± 1.93%, while the prevalence of perioperative complications was 24%. Cohort studies demonstrated an 8.5% ± 12.03% 30-day readmission rate. The most common procedure performed was laminectomy (38.9%) among the case reports. Mortality after spine surgery was noted for 4 of 35 case report patients (11.4%).

CONCLUSIONS

This is the first systematic scoping review examining the population of transplant patients with subsequent unrelated spine surgery. There is significant heterogeneity in the outcomes of post-transplant spine surgery patients. Given the inherent complexity of managing this group and elevated mortality and complications compared to the general spine surgery population, further investigation into their clinical care is warranted.

Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review Protocol

Spine surgery patients with a history of organ transplantation are a complex population due to their unique anesthetic considerations, immunologic profiles, drug interactions, and potential organ dysfunction. It is common for these patients to develop neck/back pain and pathology that warrants surgical intervention. However, there is a relative dearth of literature examining their outcomes and clinical considerations. The purpose of this protocol is to investigate their clinical outcomes following spine surgery and medical management. We perform a systematic literature search using PRISMA-ScR guidelines to include case reports, cohort studies, and retrospective analyses. The search terms include kidney, liver, heart, pancreas, lung, and bone marrow for transplants of interest and contain an extensive list of terms covering spine surgery. The search is conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials. A thorough examination of titles and abstracts is performed followed by data extraction. The data points include patient demographics, past medical history, spine procedural information, and clinical outcomes. This systematic review will aid clinicians in identifying demographics, medical management, and clinical outcomes for spine surgery patients with a previous organ transplant. These findings will highlight the gaps in the knowledge of this complex population and stimulate further research.

Management of Cervical Kyphotic Deformity Associated With Loeys-Dietz Vasculopathy and Cardiac Transplantation: Case Report, Literature Review, and Strategies for Complex Skeletal Dysplasias

Seventy-six percent of pediatric patients with Loeys-Dietz syndrome (LDS), a connective tissue disorder driven by a transforming growth factor-beta (TGF-B) pathway mutation, manifest cervical spine malformations. A prior series showed that 16% required surgical stabilization. Spine surgery in LDS is associated with an 88% complication rate due to poor bone quality and cerebrovascular ectasia.

Of 77 patients with LDS, one patient who required spine surgery was identified in an institutional database from 2010 to 2020. A 15-year-old with LDS presented with symptomatic cervical myelopathy from a rapidly progressive and unstable cervical deformity. We performed a C5-6 corpectomy and an O-T2 posterior spinal fusion with recombinant human bone morphogenetic protein-2 (rhBMP-2). We achieved correction of her kyphosis and normalization of her neurologic status. She is neurologically well one year postoperatively with bony fusion.

The management of a pediatric patient with LDS, orthotopic heart transplantation (OHT), and craniocervical deformity with instability is a novel challenge. Long-segment constructs are beneficial, rather than sparing the occiput or cervicothoracic junction. Off-label BMP may aid an LDS patient with TGF-B mutation and sternotomy. Surgeons should continue immunomodulatory and antiplatelet medications when required for OHT.

Complications and safety of the transplanted organ after upper extremity surgery in patients receiving immunosuppressant therapy after solid organ transplantation

PURPOSE

The purpose of this study was to evaluate the complications and safety of transplanted organs after upper extremity surgery in patients taking immunosuppressants after solid organ transplantation (SOT).

METHODS

Seventy-two transplant recipients underwent 99 upper extremity surgeries while on immunosuppressants after SOT at our institution between January 2009 and December 2018. We retrospectively reviewed the clinical data of these patients, including their demographic information and data related to the SOT and upper extremity surgery.

RESULTS

Trigger/tendon release (n = 31, 31.3%) was the most frequently performed upper extremity surgery, followed by incision and drainage for an infection (n = 16, 16.2%). Post-operative complications occurred after ten upper extremity operative procedures (10.1%), among which uncontrolled infection after surgery for an infection (n = 4) was the most common. According to the Clavien-Dindo classification, the complications of three surgical procedures were grade I, three were grade II, and four were grade III, and all were treatable. The occurrence rate of the complications was not significantly different between emergent and elective surgery. All transplanted organ-specific indicators did not worsen significantly after emergent or elective upper extremity surgery.

CONCLUSIONS

Since the function of the transplanted organ was well-preserved after emergent or elective upper extremity surgery, common upper extremity procedures do not seem to be a worrisome practice for SOT patients. However, when treating hand and upper extremity infections in SOT patients, surgeons should explain the possible need for multiple operations  and the high complication rate.

Renal Transplantation Is Associated with Increased Complications Following Spinal Fusion Operations: Analysis of a National Database

BACKGROUND

Improved postoperative care for renal transplant recipients has advanced both duration and overall quality of life. However, degenerative spinal pathology is increasingly prevalent after transplant. Outcomes following spinal fusion among the renal transplant population in the United States are rarely addressed.

METHODS

The Healthcare Cost and Utilization Project National Inpatient Sample database was employed. Cases in years 2008-2014 for patients ≥18 years old receiving spinal fusion, exploration/decompression, and/or spinal revision/re-fusion surgeries were included. Cases were divided into kidney transplant recipients (KTR) and non-kidney transplant recipients. Complications, demographics, and socioeconomic outcomes were compared between cohorts.

RESULTS

Of 579,726 patients who met inclusion criteria, 685 (0.1%) were KTRs. The KTR population was older and included more men compared with the non-kidney transplant recipient population (60.1 years vs. 56.6 years, P < 0.001; 58% male vs. 45.5% male, P < 0.001). KTRs experienced higher total complication rates (29.8% vs. 18.9%, P < 0.001). Prevalence of acute posthemorrhagic anemia and need for transfusion was markedly higher for KTRs (15.8% vs. 9.1%, P < 0.001; 13.6% vs. 6.2%, P < 0.001). Multivariate analysis revealed longer length of stay (median 1.23 days, interquartile range 0.94-1.53, P < 0.001), lower routine discharge (odds ratio = 0.57, 95% confidence interval 0.48-0.69, P < 0.001), and higher discharge to alternative care facilities (odds ratio = 1.91, 95% confidence interval 1.57-2.33, P < 0.001) for KTRs. The inpatient course for KTRs undergoing spinal operations was significantly costlier ($87,445 vs. $71,589, P < 0.001).

CONCLUSIONS

History of renal transplant was associated with increased inpatient medical and socioeconomic complications following spinal fusion. Physicians and patients must understand and respect the potentially increased perioperative challenges facing KTRs.

Solid Organ Transplant Is Associated With Increased Morbidity and Mortality in Patients Undergoing One or Two-level Anterior Cervical Decompression and Fusion

STUDY DESIGN

Retrospective database review OBJECTIVE.: The aim of this study was to analyze the implications of solid organ transplant (SOT) on postoperative outcomes following elective one or two-level anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Although SOTs have been associated with increased morbidity, postoperative outcomes in SOT recipients undergoing cervical spinal surgery are not well studied.

METHODS

A retrospective database review of Medicare patients younger than 85 years who underwent an elective one to two-level ACDF from 2006-2013 was conducted. Following our exclusion criteria, patients were then divided into the following groups: those with a prior history of kidney, liver, heart or lung transplant (SOT group) and non-SOT patients. Both groups were compared for hospital length of stay, 90-day major medical complications, 90-day hospital readmission, 1-year surgical site infection (SSI), 1-year revision ACDF, and 1-year mortality.

RESULTS

A total of 992 (0.5%) SOT recipients (1,144 organs) were identified out of 199,288 ACDF patients. SOT recipients had a significantly longer length of stay (2.32 vs. 5.22 days, p<0.001), higher rate of major medical complications (8.2% vs. 4.5%; OR 1.85, 95% CI 1.45-2.33, p<0.001) and hospital readmission (19.5% vs. 7.5%, OR 2.05, 95% CI 1.74-2.41, p<0.001). In addition, SOT patients had increased mortality within one year of surgery (5.8% vs. 1.3%; OR 3.01, 95% CI 2.26-3.94, p<0.001) compared to non-SOT patients. SOT was not independently associated with SSI (OR 1.25, 95% CI 0.85-1.75, p=0.230), and there was no significant difference in revision rate (0.9% vs. 0.5%; OR 1.54, 95% CI 0.73-2.82, p=0.202) between both groups.

CONCLUSION

SOT is independently associated with longer hospital stay, increased rate of major medical complications, hospital readmission and mortality. Spine surgeons should be aware of the higher rates of morbidity and mortality in these patients and take it into consideration when developing patient-specific treatment plans.

LEVEL OF EVIDENCE

3.

Revision Joint Arthroplasty and Renal Transplant: A Matched Control Cohort Study

BACKGROUND

There is little literature concerning clinical outcomes following revision joint arthroplasty in solid organ transplant recipients. The aims of this study are to (1) analyze postoperative outcomes and mortality following revision hip and knee arthroplasty in renal transplant recipients (RTRs) compared to non-RTRs and (2) characterize common indications and types of revision procedures among RTRs.

METHODS

A retrospective Medicare database review identified 1020 RTRs who underwent revision joint arthroplasty (359 revision total knee arthroplasty [TKA] and 661 revision total hip arthroplasty [THA]) from 2005 to 2014. RTRs were compared to their respective matched control groups of nontransplant revision arthroplasty patients for hospital length of stay, readmission, major medical complications, infections, septicemia, and mortality following revision.

RESULTS

Renal transplantation was significantly associated with increased length of stay (6.12 ± 7.86 vs 4.33 ± 4.29, P < .001), septicemia (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.83-3.46; P < .001), and 1-year mortality (OR, 2.71; 95% CI, 1.51-4.53; P < .001) following revision TKA. Among revision THA patients, RTR status was associated with increased hospital readmission (OR, 1.23; 95% CI, 1.03-1.47; P = .023), septicemia (OR, 1.82; 95% CI, 1.41-2.34; P < .001), and 1-year mortality (OR, 2.65; 95% CI, 1.88-3.66; P < .001). The most frequent primary diagnoses associated with revision TKA and THA among RTRs were mechanical complications of prosthetic implant.

CONCLUSION

Prior renal transplantation among revision joint arthroplasty patients is associated with increased morbidity and mortality when compared to nontransplant recipients.

Outcomes Following Posterior Lumbar Fusion in Patients with Polycythemia Vera

BACKGROUND

Polycythemia vera (PV) is a chronic myeloproliferative neoplasm that is associated with increased risk for venous and arterial thromboembolism. The aim of this study was to evaluate outcomes following elective posterior lumbar fusion (PLF) and/or posterior interbody fusion (PLIF) among patients with PV.

METHODS

Using PearlDiver retrospective national database, Medicare patients <85 years old who underwent elective primary PLF (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 81.07) and/or PLIF (ICD-9-CM code 81.08) for degenerative lumbar spine pathologies during 2006-2013 were identified. Patients included in the PLF and/or PLIF cohort were separated into patients with a prior diagnosis of PV (ICD-9-CM code 238.4) and a control cohort of patients without PV. Comparisons of postoperative outcomes were made between the PV patient group and matched control group. Significance was set at 0.05.

RESULTS

Selected study participants included 1491 patients with PV and 29,056 patients in the matched control group. Patients with PV had a significantly increased rate of 90-day acute pulmonary embolism (1.9% vs. 1.2%, odds ratio [OR] 1.65, 95% confidence interval [CI] 1.10-2.38, P = 0.010), 90-day lower extremity deep vein thrombosis (3.4% vs. 1.9%, OR 1.81, 95% CI 1.33-2.40, P < 0.001), and 1-year diagnosis of surgical site infection (5.4% vs. 4.2%, OR 1.30, 95% CI 1.02-1.63, P = 0.027) compared with patients without PV. Nonetheless, PV was not associated with other major medical complications, including stroke, myocardial infarction, and mortality, following PLF and/or PLIF.

CONCLUSIONS

Patients with PV undergoing elective PLF and/or PLIF have a significantly increased risk for pulmonary embolism, lower extremity deep vein thrombosis, and surgical site infection.