Incidence, risk factors, and mortality associated with aspiration in cervical spine surgery

Development and validation of a prediction model for postoperative pneumonia in patients who received spinal surgery: A retrospective study

Objectives

To develop and validate a risk prediction model by identifying the preoperative factors associated with an increased risk of pneumonia after spinal surgery.

Methods

This study included patients with spinal disease from two hospitals between January 2021 and June 2023. The patients were divided into the training and validation sets, which were categorized as postoperative pneumonia (POP) or non-POP, respectively. This study identified the independent risk variables for POP using a multivariate logistic regression analysis. A nomogram prediction model was developed and validated using risk factors, receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) to assess predictive performance.

Results

Following exclusion, 2223 patients from Changzheng Hospital were enrolled in the training set and 357 patients from the No. 905 Hospital of PLA Navy were enrolled in the validation set. Univariate and multivariate logistic regression analyses revealed that operation time, American Society of Anesthesiologists (ASA) grade, smoking, non-wearing of medical masks, lack of preoperative respiratory training, chronic obstructive pulmonary disease (COPD), underlying diseases, and spinal section were risk factors for POP development in patients with spinal diseases. The area under the ROC curve of the training set was 0.950, whereas that of the validation set was 0.879. The model calibration curves demonstrated good agreement, and the DCA indicated a high expected net benefit value.

Conclusion

The POP risk prediction model has high accuracy and efficiency in predicting POP in patients with spinal diseases. POP development is influenced by factors such as operation length, ASA grade, smoking, non-wearing of medical masks, lack of preoperative respiratory training, COPD, underlying diseases, and lumbar surgery.

The significance of metabolic disease in degenerative cervical myelopathy: a systematic review

Introduction

Degenerative cervical myelopathy (DCM) is a form of chronic spinal cord injury, with a natural history of potential for progression over time. Whilst driven by mechanical stress on the spinal cord from degenerative and congenital pathology, the neurological phenotype of DCM is likely to be modified by multiple systemic factors. The role of metabolic factors is therefore of interest, particularly given that ischaemia is considered a key pathological mechanism of spinal cord injury. The objective was therefore to synthesise current evidence on the effect of metabolism on DCM susceptibility, severity, and surgical outcomes.

Methods

A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English, with a focus on DCM and metabolism, including diabetes, cardiovascular disease, anaemia, and lipid profile, were eligible for inclusion. Risk of methodological bias was assessed using the Joanna Briggs Institute (JBI) critical assessment tools. Quality assessments were performed using the GRADE assessment tool. Patient demographics, metabolic factors and the relationships between metabolism and spinal cord disease, spinal column disease and post-operative outcomes were assessed.

Results

In total, 8,523 papers were identified, of which 57 met criteria for inclusion in the final analysis. A total of 91% (52/57) of included papers assessed the effects of diabetes in relation to DCM, of which 85% (44/52) reported an association with poor surgical outcomes; 42% of papers (24/57) discussed the association between cardiovascular health and DCM, of which 88% (21/24) reported a significant association. Overall, DCM patients with diabetes or cardiovascular disease experienced greater perioperative morbidity and poorer neurological recovery. They were also more likely to have comorbidities such as obesity and hyperlipidaemia.

Conclusion

Metabolic factors appear to be associated with surgical outcomes in DCM. However, evidence for a more specific role in DCM susceptibility and severity is uncertain. The pathophysiology and natural history of DCM are critical research priorities; the role of metabolism is therefore a key area for future research focus.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021268814.

Risk factors for in-hospital mortality in geriatric patients aged 80 and older with axis fractures: a nationwide, cross-sectional analysis of concomitant injuries, comorbidities, and treatment strategies in 10,077 cases

PURPOSE

To investigate the association between treatment, comorbidities, concomitant injuries, and procedures with in-hospital mortality in patients aged 80 years or older with axis fractures.

METHODS

Data were extracted from the German InEK (Institut für das Entgeltsystem im Krankenhaus) GmbH database (2019-2021) for patients aged 80 years or older with axis fractures and the in-hospital mortality rate was calculated. Differences in comorbidities and concomitant diseases and injuries were analyzed using the Chi-square test. In surgically treated patients, odds ratios (OR) with 95% confidence intervals (95% CI) were used to analyze potential risk factors for in-hospital mortality.

RESULTS

Among 10,077 patients, the in-hospital mortality rate was 8.4%, with no significant difference between surgically (9.4%) and non-surgically treated patients (7.9%; p = 0.103). The most common comorbidities were essential hypertension (67.3%), atrial fibrillation (28.2%), and chronic kidney disease (23.3%), while the most common concomitant injuries were head and face wounds (25.9%), concussions (12.8%), and atlas fractures (11.6%). In surgically treated patients, spinal cord injury (OR = 4.62, 95% CI: 2.23-9.58), acute renal failure (OR = 3.20, 95% CI: 2.26-4.53), and acute bleeding anemia (OR = 2.06, 95% CI: 1.64-2.59) were associated with increased in-hospital mortality (all p < 0.01). Screw-rod-system fixation of one segment (OR = 0.74, 95% CI: 0.56-0.97) and intraoperative navigation (OR = 0.45, 95% CI: 0.16-0.71) were identified as potential protective factors (both p < 0.05).

CONCLUSION

Comprehensive geriatric assessment and optimization of comorbidities during treatment are crucial. The indication for surgical treatment must be carefully individualized. Future studies should focus on the choice of surgical technique, perioperative blood management, and intraoperative navigation as potential protective factors.

Ultrasonographic Evaluation of Upper Esophageal Sphincter for Dysphagia During the Acute Postoperative Phase of Anterior Cervical Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

To verify the pathophysiology of dysphagia during the acute postoperative phase of anterior cervical surgery and to identify its predictive features, using ultrasonographic (US) examination for upper esophageal sphincter (UES).

SUMMARY OF BACKGROUND DATA

There are no clinical studies investigating dysphagia after anterior cervical surgery, using US examination for UES.

MATERIALS AND METHODS

We enrolled patients who underwent anterior cervical spine surgery between August 2018 and March 2022. Dysphagia was evaluated using the Eating Assessment Tool-10 (EAT-10) questionnaires. The US examination was performed preoperatively and 2 weeks postoperatively. Three US parameters for morphologic measurements (outer diameter, inner diameter, and muscle thickness) and 4 for functional measurements (displacement, time to relax, passing duration, and time to contract) were assessed. To verify the pathophysiology of postoperative dysphagia, we examined the change in the ratios of US parameters (=US parameter2 weeks postoperatively/US parameterat baseline) and the existence of significant correlations with change in the EAT-10 score (=EAT-102 weeks postoperatively-EAT-10at baseline). To identify the predictive features, the baseline US parameters were compared between dysphagia (+) and dysphagia (-) groups.

RESULTS

A total of 46 patients (mean age, 61.3 y; 78.3% male) were included for analysis. A greater increase of the EAT-10 score after surgery was positively correlated with change ratios of the muscle thickness and time to contract and negatively with change ratio of the inner diameter. The dysphagia (+) group exhibited significantly greater inner diameter and smaller muscle thickness at baseline than the dysphagia (-) group.

CONCLUSION

Dysphagia during the acute postoperative phase of anterior cervical surgery is caused by the physical narrowing of the inner lumen due to muscle thickening of the UES and sphincter contractile dysfunction. In addition, a baseline UES morphology characterized by a greater inner diameter and a thinner muscle layer is predictive of postoperative dysphagia.

Pulmonary Function in Patients with Solitary Spinal Metastases: A Hospital-Based Cross-Sectional Study

Background

This study aimed to evaluate the pulmonary function of patients with solitary spinal metastases with the intention of providing a data-driven basis to evaluate cardiopulmonary function in patients with spinal metastases in the future.

Methods

This was a retrospective analysis of 157 patients with solitary spinal metastases in our hospital from January 2010 to December 2018. This study analyzed the influence of different stages of solitary spinal involvement on respiratory function, based on the spinal segment invaded by the metastases.

Results

The highest proportion of solitary spinal metastases occurred at the thoracic level (49.7%), with the lowest proportion at the sacral level (3.9%). The largest number of patients were in the 60-69-year age group (34.6%). There was no significant difference in pulmonary function among patients with spinal metastases at different segments (all P > 0.05). The highest vital capacity (VC), forced expiratory volume in one second (FEV₁), and forced vital capacity (FVC) were observed in patients who were overweight (all P < 0.05). There were no significant relationships between pulmonary respiratory function and body mass index (BMI) groups in male patient with spinal metastases. In female patients, the highest VC, FEV₁, FVC, and maximum voluntary ventilation were observed in patients who were overweight (all P < 0.05).

Conclusion

Thoracic vertebral metastasis was the main type of solitary spinal metastatic tumor. Spinal metastases were more common at ages 60-69 years. There was no significant difference in pulmonary function among patients with spinal metastasis at different segments. Lung function was better in patients with spinal metastases who were overweight, especially in female patients.

Aspiration pneumonia and anesthesia techniques in hip fracture surgery in elderly patients: A retrospective cohort study using administrative data

Purpose: Aspiration pneumonia is a critical issue. General anesthesia may suppress the airway's protective reflex. However, aspiration pneumonia is also observed in patients who undergo hip fracture surgery under spinal anesthesia. The aim of this study was to investigate the relationship between anesthesia methods and aspiration pneumonia as well as the predictive factors of aspiration pneumonia in elderly patients undergoing hip fracture surgery. Methods: The medical records of 19,809 patients aged ≥60 years who underwent hip fracture surgery under general or spinal anesthesia were reviewed. After propensity score matching, the anesthesia methods affecting the occurrences of aspiration pneumonia and other complications were investigated via logistic regression and instrumental variable analyses. Predictive factors of aspiration pneumonia were also investigated in all subjects using a multivariable logistic regression analysis. Results: Among the 11,673 general anesthesia patients and 8136 spinal anesthesia patients, aspiration pneumonia occurred in 356 patients (1.8%). Post-propensity score matching the incidences of aspiration pneumonia with general and spinal anesthesia were 1.8% and 1.5%, respectively (p = 0.158); other pulmonary complications were 1.5% and 1.5%, respectively (p = 0.893); and the mortality rates were 1.4% and 1.2%, respectively (p = 0.219). The predictive factors of aspiration pneumonia were advanced age, male sex, lean body, cerebrovascular disease, dementia, and dependency for activities of daily living (eating). Conclusion: Spinal and general anesthesia showed similar incidences of aspiration pneumonia in elderly hip fracture surgery. Regardless of the anesthesia method, great care should be taken, especially in elderly patients with the identified predictive factors.

The Role of Nutrition in Degenerative Cervical Myelopathy: A Systematic Review

Introduction

Degenerative cervical myelopathy (DCM) is the commonest cause of adult spinal cord impairment worldwide, encompassing chronic compression of the spinal cord, neurological disability and diminished quality of life. Evidence on the contribution of environmental factors is sparse; in particular, the role of nutrition in DCM is unknown. The objective of this review was to assess the effect of nutrition on DCM susceptibility, severity and surgical outcome.

Methods

A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English papers, focussing on cervical myelopathy and nutrition, published before January 2020 were considered eligible. Quality assessments were performed using the GRADE assessment tool. Patient demographics, nutritional factor and DCM outcomes measures were recorded. Relationships between nutritional factors, interventions and disease prognosis were assessed.

Results

In total, 5835 papers were identified of which 44 were included in the final analysis. DCM patients with pathological weight pre-operatively were more likely to see poorer improvements post-surgically. These patients experienced poorer physical and mental health improvements from surgery compared to normal weight patients and were more likely to suffer from post-operative complications such as infection, DVT, PE and hospital readmissions. Two trials reporting benefits of nutritional supplements were identified, with 1 suggesting Cerebrolysin to be significant in functional improvement. An unbalanced diet, history of alcohol abuse and malnourishment were associated with poorer post-operative outcome.

Conclusion

Although the overall strength of recommendation is low, current evidence suggests nutrition may have a significant role in optimising surgical outcome in DCM patients. Although it may have a role in onset and severity of DCM, this is a preliminary suggestion. Further work needs to be done on how nutrition is defined and measured, however, the beneficial results from studies with nutritional interventions suggest nutrition could be a treatment target in DCM.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Pulmonary Evaluation and Optimization

BACKGROUND

There are no current recommendations for preoperative pulmonary evaluation and management of patients undergoing elective spine surgery.

OBJECTIVE

The aim of this guideline is to determine preoperative risk factors for perioperative and postoperative pulmonary adverse events and to determine the optimal preoperative evaluation and management of at-risk patients.

METHODS

A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to postoperative pulmonary adverse events in patients undergoing spine surgery. Clinical studies evaluating preoperative patient risk factors and preoperative diagnostic and treatment interventions were selected for review.

RESULTS

The literature search yielded 152 abstracts relevant to the PICO (patient/population, intervention, comparison, and outcomes) questions included in this chapter. The task force selected 65 articles for full-text review, and 24 were selected for inclusion in this systematic review. Twenty-three articles addressed preoperative patient risk factors. One article addressed preoperative diagnostic studies of pulmonary function. There were no studies meeting the inclusion criteria for preoperative pulmonary treatment.

CONCLUSION

There is substantial evidence for multiple preoperative patient factors that predict an increased risk of a postoperative pulmonary adverse event. Individuals with these risk factors (functional dependence, advanced age [≥65 yr], chronic obstructive pulmonary disease, congestive heart failure, weight loss, and obstructive sleep apnea) who are undergoing spine surgery should be counseled regarding the potential increased risk of a perioperative and postoperative pulmonary adverse events. There is insufficient evidence to support any specific preoperative diagnostic test for predicting the risk of postoperative pulmonary adverse events or any treatment intervention that reduces risk. It is suggested, however, to consider appropriate preoperative pulmonary diagnostic testing and treatment to address active pulmonary symptoms of existing or suspected disease.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/5-preoperative-pulmonary-evaluation-optimization.

Frailty as Tested by Gait Speed Is a Risk Factor for Liver Transplant Respiratory Complications

OBJECTIVES

Frailty and sarcopenia are known risk factors for adverse liver transplant outcomes and mortality. We hypothesized that frailty or sarcopenia could identify the risk for common serious transplant-related adverse respiratory events.

METHODS

For 107 patients (74 men, 33 women) transplanted over 1 year, we measured frailty with gait speed, chair stands, and Karnofsky Performance Scale (KPS) and sarcopenia with Skeletal Muscle Index on computed tomography at L3. We recorded the stress-tested cardiac double product as an index of cardiac work capacity. Outcomes included days of intubation, aspiration, clinical pneumonia, reintubation/tracheostomy, days to discharge, and survival. We modeled the outcomes using unadjusted regression and multivariable analyses controlled for (i) age, sex, and either Model for End-Stage Liver Disease-Na (MELDNa) or Child-Turcotte-Pugh scores, (ii) hepatocellular carcinoma status, and (iii) chronic obstructive pulmonary disease and smoking history. Subgroup analysis was performed for living donor liver transplant and deceased donor liver transplant recipients.

RESULTS

Gait speed was negatively associated with aspiration and pulmonary infection, both in unadjusted and MELDNa-adjusted models (adjusted odds ratio for aspiration 0.10 [95% confidence interval [CI] 0.02-0.67] and adjusted odds ratio for pulmonary infection 0.12 [95% CI 0.02-0.75]). Unadjusted and MELDNa-adjusted models for gait speed (coefficient -1.47, 95% CI -2.39 to -0.56) and KPS (coefficient -3.17, 95% CI -5.02 to -1.32) were significantly associated with shorter intubation times. No test was associated with length of stay or need for either reintubation or tracheostomy.

DISCUSSION

Slow gait speed, an index of general frailty, indicates significant risk for post-transplant respiratory complications. Intervention to arrest or reverse frailty merits exploration as a potentially modifiable risk factor for improving transplant respiratory outcomes.

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.

Risk Factors of Pulmonary Complications After Minimally Invasive Surgery for Elderly Patients with Vertebral Compression Fractures

Purpose

To determine the risk factors for pulmonary complications after minimally invasive surgery in elderly patients with vertebral compression fractures (VCFs).

Methods

A total of 233 elderly patients (age ≥ 65 years) with VCFs, who underwent percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) surgery at Hebei General Hospital from January 2011 to December 2016, were retrospectively analyzed. Risk factors and the effects of the model were determined by univariate logistic regression analyses and the receiver operating characteristic (ROC) curve, respectively. A risk assessment scale was established based on the risk factors, as well as physiological and surgical scores for mortality and morbidity. The risk assessment scale prospectively evaluated risk factors of pulmonary complications after minimally invasive surgery for elderly patients with VCFs from January to June 2017.

Results

27 patients were diagnosed with pulmonary complications (27/233, 11.59%). There were statistically significant differences between patients with and without pulmonary complications in terms of age, body mass index (BMI), smoking, cardiovascular diseases and old fractures between patients with and without pulmonary complications (P < 0.05). Logistic regression analysis showed that smoking, cardiovascular diseases and old fractures were risk factors (P < 0.05) and area under the curve was 0.738 (95% confidence intervals (CI): 0.648–0.828). 53 elderly patients with VCFs were assessed, 5 of them occurred pulmonary complications. Areas under the curve of preoperative and total risk assessment values were all 0.925.

Conclusion

Significant risk factors of pulmonary complications were BMI, cardiovascular diseases and old fractures for patients aged 65 years or elderly with VCFs after minimally invasive surgery. The risk assessment scale gained high accuracy.

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.

Predictors of 30-Day Outcomes in Octogenarians with Traumatic C2 Fractures Undergoing Surgery

BACKGROUND

Predictors of surgical outcomes following traumatic axis (C2) fractures in octogenarians remain undercharacterized.

METHODS

Patients age ≥80 years undergoing cervical spine surgery following traumatic C2 fractures were extracted from the National Sample Program of the National Trauma Data Bank (2003-2012). Outcomes include overall inpatient complications, individual complications with an incidence >1%, hospital length of stay (HLOS), discharge disposition, and mortality. Demographics, comorbidities, and injury predictors were analyzed using multivariable regression. Odds ratios (OR), mean differences, and 95% confidence intervals (CIs) were calculated. Statistical significance was assessed at P < 0.05.

RESULTS

The cohort of 442 patients was 48.6% male and had a mean age of 84.3 ± 2.7 years. The distribution of admissions was 42.3% to the hospital floor, 40.3% to the intensive care unit (ICU), 7.7% to telemetry, 2.0% to the operating room, and 7.7% to other/unknown. Mortality was 9.7%, mean HLOS was 13.1 ± 9.2 days, the rate of complications was 38.5%, and 81.5% of survivors were discharged to a nonhome facility. Injury severity was predictive of mortality and overall complications. History of bleeding disorder/coagulopathy predicted mortality (OR, 4.02; 95% CI, 1.07-15.05), overall complications (OR, 3.01; 95% CI, 1.09-8.32), cardiac arrest (OR, 8.19; 95% CI, 1.06-63.54), and renal complications (OR, 10.36; 95% CI, 2.13-50.38). History of congestive heart failure predicted mortality (OR, 3.10; 95% CI, 1.10-8.69). ICU admission (vs. floor) predicted overall complications (OR, 2.01; 95% CI, 1.23-3.27) and pneumonia (OR, 4.65; 95% CI, 1.91-11.30). Telemetry admission (vs. floor) predicted unplanned intubation (OR, 7.76; 95% CI, 1.24-48.49).

CONCLUSIONS

In this cohort of octogenarians undergoing surgery for traumatic C2 fracture, injury severity and a history of bleeding disorder/coagulopathy were identified as risk factors for inpatient complications and mortality. Heightened surveillance should be considered for ICU and/or telemetry admissions for the development of complications. These findings warrant consideration by the clinician, patient, and family to inform clinical decisions and goals of care.

Coagulation Profile as a Risk Factor for 30-day Morbidity Following Cervical Laminectomy and Fusion

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

The aim of this study was to determine the ability of abnormal coagulation profile to predict adverse events following posterior cervical laminectomy and fusion (PCLF).

SUMMARY OF BACKGROUND DATA

PCLF is an increasingly common procedure used to treat a variety of traumatic and degenerative spinal conditions. Abnormal coagulation profile is associated with postoperative adverse events, including blood transfusion. There is a paucity of literature that specifically addresses the relationship between coagulation profile and complications following PCLF.

METHODS

ACS-NSQIP was utilized to identify patients undergoing PCLF between 2006 and 2013. A total of 3546 patients met inclusion criteria. Multivariate analysis was utilized to identify associations between abnormal coagulation profile and postoperative complications.

RESULTS

Membership in the low-platelet cohort was an independent risk factor for myocardial infarction (Odds Ratio (OR) = 5.4 [1.0, 29.1], P = 0.049) and bleeding transfusion (OR = 2.0 [1.2, 3.4], P = 0.011). Membership in the high international normalized ratio group was an independent risk factor for pneumonia (OR = 6.3 [2.5, 16.1], P < 0.001), ventilation >48 hours (OR = 6.5 [2.3, 18.4], P < 0.001), organ space surgical site infection (OR = 11.1 [2.1, 57.3], P = 0.004), urinary tract infection (OR = 3.0 [1.2, 8.0], P = 0.024), bleeding transfusion (OR = 6.0 [3.4, 10.7], P < 0.001), sepsis (OR = 5.1 [1.6, 16.4], P = 0.006), and septic shock (OR = 6.8 [1.7, 27.4], P = 0.007). Membership in the bleeding disorders cohort was an independent predictor of unplanned intubation (OR = 3.2 [1.1, 9.5], P = 0.041), pneumonia (OR = 2.9 [1.2, 7.2], P = 0.023), ventilation >48 hours (OR = 4.8 [1.9, 12.4], P = 0.001), cerebrovascular accident/stroke with neurological deficit (OR = 24.8 [2.9, 210.6], P = 0.003), bleeding transfusion (OR = 2.1 [1.1, 4.1], P = 0.032), reoperation (OR = 3.6 [1.4, 9.3], P = 0.008), and sepsis (OR = 3.4 [1.1, 10.4], P = 0.031).

CONCLUSION

This is the first large study to document abnormal coagulation profile as an independent predictor of outcomes following PCLF. Abnormal coagulation profile represents a predictor of complications that can be medically mitigated, and is therefore a valuable parameter to assess preoperatively. Coagulation profile should continue to play a role in targeting patients for risk stratification, preoperative optimization, and quality improvement initiatives.

LEVEL OF EVIDENCE

3.

Medical complications and mortality in octogenarians undergoing elective spinal fusion surgeries

BACKGROUND

The consequences of suffering postoperative complications in elderly undergoing spinal surgeries may be different compared to younger patients. The primary objective of this study was to identify the types and frequency of medical complications and mortality rates in patients 80 years of age or older undergoing elective spinal fusion surgeries for degenerative spinal disease.

METHODS

A prospective observational study with a retrospective chart review was performed, which included all consecutive patients ≥80 years old undergoing elective spinal fusion surgeries from May 2012 to August 2015. We identified a total of 95 patients, of which 39 cervical and 56 lumbar surgeries were performed. There were 41 female and 54 male patients with the mean age of 82.8 years (range, 80-91). The perioperative complications were allocated into the following categories: infection, pulmonary, cardiac, gastrointestinal, hematologic, urologic, neurovascular, thromboembolic, and other. Baseline and postoperative clinical outcome scores were compared to evaluate efficacy.

RESULTS

The mean follow-up time was 14.8 months (range, 5 days to 37 months) with an overall mortality rate of 8.4%. The 30-day, 90-day, and 1-year mortality rates were 2.1, 2.1, and 4.2%, respectively. There were 53.9 and 71.4% patients with complications in the cervical and lumbar patient groups, respectively. The presence of general comorbidities and the number of intervertebral levels predicted the occurrence of perioperative complications. Also, longer OR times were associated with a higher number of complications per patient and the occurrence of a UTI. Dysphagia was a significant predictor in developing pneumonia and atelectasis.

CONCLUSIONS

The incidence of perioperative medical complications and mortality rates in octogenarians undergoing elective spinal surgeries are quite high. The benefits of having surgery must be weighed against the risks of not only surgical but also adverse medical events. An informed decision-making process should include discussion of potential postoperative morbidity specific to this patient population in order to guide patient's acceptance of higher risks and expectations postoperatively. It is also important to identify potential complications and adapt preventive measures in order to help minimize them in this patient population.

Spinal Fusion for Pediatric Spondylolisthesis: National Trends, Complications, and Short-Term Outcomes

BACKGROUND

Current surgical management guidelines for pediatric spondylolisthesis (PS) are reliant on data from single-center cohorts.

OBJECTIVE

To analyze national trends and predictors of short-term outcomes in spinal fusion surgery for PS by performing a retrospective cross-sectional analysis of the Kids’ Inpatient Database (KID).

METHODS

The KID (sampled every 3 yr) was queried from 2003 to 2012 to identify all cases (age 5-17) of spinal fusion for PS (n = 2646). We analyzed trends in patient characteristics, surgical management, and short-term outcomes. Both univariate and multivariable analyses were utilized.

RESULTS

The 2646 spinal fusions for PS included posterior-only fusions (86.8%, PSF), anterior lumbar interbody fusions (4.8%, ALIF), and combined anterior and posterior fusions (8.4%, APLF) procedures. The utilization of APLF decreased over time (9.9%-6.4%, P = .023), whereas the number of total spinal fusions and the proportion of PSF and ALIF procedures have not changed significantly. Uptrends in Medicaid insured individuals (1.2%-18.9%), recombinant human bone morphogenetic protein-2 insertion (8.8%-16.6%), decompression (34.7%-42.8%), and mean inflation-adjusted hospital costs ($21 855-$32 085) were identified (all P &lt; .001). In multivariable analysis, Medicaid status (odds ratio [OR] = 1.93, P = .004), teaching hospitals (OR = 1.94, P = .01), decompression (OR = 1.78, P = .004), and the APLF procedure (OR = 2.47, P = .001) increased the likelihood of complication occurrence (all P &lt; .001).

CONCLUSION

The addition of decompression during fusion and the APLF procedure were associated with more in-hospital complications, though this may have been indicative of greater surgical complexity. The utilization of the APLF procedure has decreased significantly, while costs associated with the treatment of PS have increased over time.

Complications and Mortality Following One to Two-Level Anterior Cervical Fusion for Cervical Spondylosis in Patients Above 80 Years of Age

STUDY DESIGN

A retrospective database review.

OBJECTIVE

The aim of this study was to determine the complication and mortality rates in patients 80 years of age and older who were treated with anterior cervical fusion surgery and to compare these rates against those of other elderly patients.

SUMMARY OF BACKGROUND DATA

Cervical spondylosis is frequently observed in the elderly and is the most common cause of myelopathy in older adults. With increasing life expectancies, a greater proportion of patients are being treated with spine surgery at a later age. Limited information is available regarding outcomes following anterior cervical fusion surgery in patients 80 years of age or older.

METHODS

Medicare data from the PearlDiver Database (2005-2012) were queried for patients who underwent primary one to two-level anterior cervical spine fusion surgeries for cervical spondylosis. After excluding patients with prior spine metastasis, bone cancer, spine trauma, or spine infection, this cohort was divided into two study groups: patients 65 to 79 (51,808) and ≥80 years old (5515) were selected. A cohort of matched control patients was selected from the 65 to 79-year-old and 90-day complication rates and 90-day and 1-year mortality rates were compared between cohorts.

RESULTS

The proportion of patients experiencing at least one major medical complication was relatively increased by 53.4% in patients aged ≥80 years [odds ratio (OR) 1.63]. Patients 80 years of age or older were more likely to experience dysphagia (OR 2.16), reintubation (OR 2.34), and aspiration pneumonitis (OR 3.17). Both 90-day (OR: 4.34) and 1-year (OR 3.68) mortality were significantly higher in the ≥80 year cohort.

CONCLUSION

Patients 80 years of age or older are more likely to experience a major medical complication or mortality following anterior cervical fusion for cervical spondylosis than patients 65 to 79 years old. Dysphagia, aspiration pneumonitis, and reintubation rates are also significantly higher in patients 80 years of age or older. Although complication rates may be higher in this patient population, carefully selected patients could potentially derive much benefit from surgery and should not be screened out solely on the basis of age.

LEVEL OF EVIDENCE

4.

Intraoperative Death During Cervical Spinal Surgery: A Retrospective Multicenter Study

STUDY DESIGN

A retrospective multicenter study.

OBJECTIVE

Routine cervical spine surgeries are typically associated with low complication rates, but serious complications can occur. Intraoperative death is a very rare complication and there is no literature on its incidence. The purpose of this study was to determine the intraoperative mortality rates and associated risk factors in patients undergoing cervical spine surgery.

METHODS

Twenty-one surgical centers from the AOSpine North America Clinical Research Network participated in the study. Medical records of patients who received cervical spine surgery from January 1, 2005, to December 31, 2011, were reviewed to identify occurrence of intraoperative death.

RESULTS

A total of 258 patients across 21 centers met the inclusion criteria. Most of the surgeries were done using the anterior approach (53.9%), followed by posterior (39.1%) and circumferential (7%). Average patient age was 57.1 ± 13.2 years, and there were more male patients (54.7% male and 45.3% female). There was no case of intraoperative death.

CONCLUSIONS

Death during cervical spine surgery is a very rare complication. In our multicenter study, there was a 0% mortality rate. Using an adequate surgical approach for patient diagnosis and comorbidities may be the reason how the occurrence of this catastrophic adverse event was prevented in our patient population.

Does Patient Sex Affect the Rate of Mortality and Complications After Spine Surgery? A Systematic Review

BACKGROUND

Available studies disagree regarding the influence of patient sex on mortality and complications after spine surgery. We sought to conduct a systematic review and pool the results of existing research to better understand this issue.

QUESTIONS/PURPOSES

We performed a systematic review to address two questions: (1) Does sex (male versus female) influence mortality after spine surgery? (2) Does sex impact the development of postoperative complications after spine surgery?

METHODS

This systematic review was performed through a query of PubMed using a structured search algorithm. Additional queries of Embase, SCOPUS, Web of Science, and the tables of contents of orthopaedic and neurosurgical journals were also conducted using search terms such as "sex factors", "male or female", "risk factors", and "spine surgery". Selected papers were independently abstracted by three of the authors (AJS, ENR, EIW) and pooling was performed. Our literature search returned 720 studies, of which 99 underwent full review. Of these, 50 were selected for final abstraction. The Cochrane Q test was used to assess study heterogeneity; significant study heterogeneity was present and so a random-effects model was used. A Harbord test was used to evaluate for the presence of publication bias; this analysis found no statistically significant evidence of publication bias.

RESULTS

Males were at increased odds of mortality after spine surgery (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.35-1.97; p<0.001). No differences between the sexes were identified for the odds of complications (OR, 1.04; 95% CI, 0.95-1.13; p=0.42).

CONCLUSIONS

Our results determined that males were at elevated odds of mortality but not of complications after spine surgery. These results should be used to inform preoperative discussion and decision-making at the time of surgical consent. Future work should be directed at determining the underlying factors responsible for increased mortality among males and prospective studies specifically designed to evaluate sex-based differences in outcomes after spine surgery.

LEVEL OF EVIDENCE

Level III, therapeutic study.