Perioperative Optimization of Senior Health in Spine Surgery: Impact on Postoperative Delirium

Knowledge mapping and research trends on perioperative neurocognitive disorder from 1990 to 2022: a bibliometric analysis

Introduction

Perioperative neurocognitive disorder (PND) has attracted consistently increasing attention worldwide. However, there are few bibliometric studies that systematically evaluate this field. This study aimed to visualize the knowledge structure and research trends in PND through bibliometrics to help understand the future development of basic and clinical research.

Methods

Literature related to PND in Web of Science and PubMed from 1990 to 2022 were collected through keywords retrospectively. Additionally, the source information, citation information, etc. of these publications were extracted. Finally, bibliometric analysis was performed by visualization software and statistical software.

Results

There were 2837 articles and reviews in total. An exponential rise in PND-related publications was observed. China had the most publication, followed by the US and Germany. The institution with the most output and citations was Harvard University (149 papers, 8966 citations). The most prominent author was Marcantonio Edward R with 66 publications and 5721 citations. The journal with the highest productivity for PND research was Frontiers in Aging Neuroscience followed by Anesthesia and Analgesia. Keywords were identified as six topics, including postoperative delirium, postoperative neurocognitive disorder, cardiac surgery, anaesthesia, orthopedic surgery, and dementia. According to keyword analysis, the most recent popular keywords in PND research were prevention, older patients, emergence delirium, orthopedic surgery, and dexmedetomidine.

Conclusions

Publications on PND are increasing at an alarming rate from 1990 to 2022. Current research and future trends will concentrate on the prevention and treatment of PND, as well as PND associated with orthopedic surgery in older adults.

A Comparison of Short-Term Outcomes after Surgical Treatment of Multilevel Degenerative Cervical Myelopathy in the Geriatric Patient Population: An Analysis of the National Surgical Quality Improvement Program Database 2010-2020

STUDY DESIGN

Retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program database from 2010 to 2020.

PURPOSE

To compare the short-term complication rates of anterior cervical decompression and fusion (ACDF), posterior cervical laminoplasty (LP), and posterior cervical laminectomy and fusion (PCF) in a geriatric population.

OVERVIEW OF LITERATURE

The geriatric population in the United States has increased significantly. Degenerative cervical myelopathy (DCM) is caused by cervical spinal stenosis, and its prevalence increases with age. Therefore, the incidence of multilevel DCM requiring surgical intervention is likely to increase. ACDF, LP, and PCF are the most commonly used surgical techniques for treating multilevel DCM. However, there is uncertainty regarding the optimal surgical technique for the decompression of DCM in geriatric patients.

METHODS

Patients aged 65 years who had undergone either multilevel ACDF, LP, or PCF for the treatment of DCM were analyzed. Additional analysis was performed by standardizing the data for the American Society of Anesthesiologists classification scores and preoperative functional status.

RESULTS

A total of 23,129 patients were identified. Patients with ACDF were younger, more often female, and preoperatively healthier than those in the other two groups. The estimated postoperative mortality and morbidity, mean operation time, and length of hospital stay were the lowest for ACDF, second lowest for LP, and highest for PCF. The readmission and reoperation rates were comparable between ACDF and LP; however, both were significantly lower than PCF.

CONCLUSIONS

PCF is associated with the highest risk of mortality, morbidity, unplanned reoperation, and unplanned readmission in the short-term postoperative period in patients aged 65 years. In contrast, ACDF carries the lowest risk. However, some disease-specific factors may require posterior treatment. For these cases, LP should be included in the preoperative discussion when determining the ideal surgical approach for geriatric patients.

Risk factors of postoperative delirium following spine surgery: A meta-analysis of 50 cohort studies with 1.1 million participants

Objectives

Postoperative delirium (POD) is considered to be a common complication of spine surgery. Although many studies have reported the risk factors associated with POD, the results remain unclear. Therefore, we performed a meta-analysis to identify risk factors for POD among patients following spinal surgery.

Methods

We systematically searched the PubMed, Embase and the Cochrane Library for relevant articles published from 2006 to February 1, 2023 that reported risk factors associated with the incidence of POD among patients undergoing spinal surgery. The Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed, and random effects models were used to estimate pooled odds ratio (OR) estimates with 95 % confidence intervals (CIs) for each factor. The evidence from observational studies was classified according to Egger's P value, total sample size, and heterogeneity between studies.

Results

Of 11,329 citations screened, 50 cohort studies involving 1,182,719 participants met the inclusion criteria. High-quality evidence indicated that POD was associated with hypertension, diabetes mellitus, cardiovascular disease, pulmonary disease, older age (>65 years), patients experiencing substance use disorder (take drug ≥1 month), cerebrovascular disease, kidney disease, neurological disorder, parkinsonism, cervical surgery, surgical site infection, postoperative fever, postoperative urinary tract infection, and admission to the intensive care unit (ICU). Moderate-quality evidence indicated that POD was associated with depression, American Society of Anesthesiologists (ASA) fitness grade (>II), blood transfusion, abnormal potassium, electrolyte disorder, length of stay, inability to ambulate and intravenous fluid volume.

Conclusions

Conspicuous risk factors for POD were mainly patient- and surgery-related. These findings help clinicians identify high-risk patients with POD following spinal surgery and recognize the importance of early intervention.

Comprehensive geriatric assessment to predict adverse events in elderly patients undergoing posterior lumbar fusion surgery

PURPOSE

Although comprehensive geriatric assessment (CGA) has been used widely, its impact on adverse events in elderly patients has not been fully examined. The present study aimed to investigate the relationships between subcomponents of CGA and adverse events (AEs) in elderly patients undergoing posterior lumbar fusion surgery.

METHODS

A total of 242 eligible elderly patients enrolled. Our CGA included activities of daily living, instrumental activities of daily living, nutritional status, cardiac function, pulmonary function, renal function, frailty, cognition, anxiety, depression, delirium, chronic pain score, comorbidity and polypharmacy. Comprehensive complication index was used to summarize postoperative complications and its severity. Logistic regression was performed to determine the relationships between subcomponents of a CGA and postoperative AEs.

RESULTS

Present study found that female were more vulnerable to have AEs. Postoperative major AEs were associated with delirium (odds ratio (OR): 4.302, 95% confidence interval (CI) 1.720-10.761, p = 0.002), nutritional status (OR: 3.030, 95%CI 1.218-7.541, p = 0.017), cognitive impairment (OR: 4.122, 95%CI 1.179-14.407, p = 0.027), Charlson comorbidity index (CCI) (OR: 4.800, 95%CI 1.852-12.440, p = 0.001) and severe dependent (OR: 3.772, 95%CI 1.116-9.841, p = 0.007). Further analysis showed that delirium (OR: 2.824, 95%CI 1.068-7.467, p = 0.036) and CCI (OR: 3.221, 95%CI 1.184-8.766, p = 0.022) were independently related to major AEs.

CONCLUSIONS

These results indicate that preoperative screening preoperative delirium, cognitive, nutrition and CCI are essential to prevent postoperative major AEs of the surgical elderly.

Psoas Muscle Index as a Predictor of Perioperative Outcomes in Geriatric Patients Undergoing Spine Surgery

STUDY DESIGN

Single-center retrospective study.

OBJECTIVE

The objective of this study was to evaluate the association of psoas muscle mass defined sarcopenia with perioperative outcomes in geriatric patients undergoing elective spine surgery.

METHODS

We included geriatric patients undergoing thoracolumbar spinal surgery. Total psoas surface area (TPA) was measured on preoperative axial computerized tomography or magnetic resonance imaging at the L3 vertebra and normalized to the L3 vertebral body area. Patients were divided into quartiles by normalized TPA, and the fourth quartile (Q4) was compared to quartiles 1-3 (Q1-3). Outcomes included perioperative transfusions, length of stay (LOS), delirium, pseudoarthrosis, readmission, discharge disposition, revision surgery, and mortality.

RESULTS

Of the patients who met inclusion criteria (n = 196), the average age was 73.4 y, with 48 patients in Q4 and 148 patients in Q1-3. Q4 normalized TPA cut-off was <1.05. Differences in Q4 preoperative characteristics included significantly lower body mass index, baseline creatinine, and a greater proportion of females (Table 1). Q4 patients received significantly more postoperative red blood cell and platelet transfusions and had longer ICU LOS (P < .05; Table 2). There was no difference in intraoperative transfusion volumes, delirium, initiation of walking, discharge disposition, readmission, pseudoarthrosis, or revision surgery (Tables 2 and 3). Mortality during follow-up was higher in Q4 but was not statistically significant (P = .075).

CONCLUSION

Preoperative TPA in geriatric patients undergoing elective spine surgery is associated with increased need for intensive care and postoperative blood transfusion. Preoperative normalized TPA is a convenient measurement and could be included in geriatric preoperative risk assessment algorithms.

Survey and Interview Findings of an Environmental Scan of Perioperative Geriatric Models of Care in Canada

Background

Best practice recommendations support the implementation of perioperative geriatric care models that tailor to the specific needs of older adults undergoing surgery. The objective of this study was to describe the current proactive perioperative geriatric programs and pathways in Canadian hospitals.

Methods

A survey of geriatricians, surgeons, and anesthesiologists practicing in Canada combined with phone interviews of a subset of participants were used to determine characteristics of perioperative geriatric pathways or programs including eligibility, team composition, and intervention elements.

Results

Analysis of 132 survey respondents and 24 interviews showed 47% (40 out of 85) of hospitals described had elements of a perioperative geriatrics program and 20% had two or more elements. Eleven themes emerged including: how perioperative geriatric care programs built geriatric competencies in other health-care providers; geriatric assessment identified risks not captured in standard perioperative risk assessment; perceived value for patients and the health-care team; delirium prevention was addressed; most programs were reactive; most programs were informal; virtual care may be used to meet demand; successful implementation required system buy-in with collaboration across subspecialties; mechanisms to drive improvement were accountability and data evaluation; few clinicians with geriatric expertise; and other priorities limited program implementation.

Conclusions

There were few hospitals in Canada with perioperative geriatric care models and even fewer with elements spanning the entire perioperative pathway. Strengths, weaknesses, opportunities, and threats to inform the implementation and sustainability of perioperative geriatric care in the Canadian context were identified in this national environmental scan.

Family Presence May Reduce Postoperative Delirium After Spinal Surgery

ABSTRACT

BACKGROUND: Delirium is associated with worse outcomes, but there is a gap in literature identifying nurse-led interventions to reduce delirium in postoperative (postop) surgical spine patients. Because family presence has been associated with a variety of beneficial effects, we aimed to examine whether family presence in the spine intensive care unit (ICU) during the night after surgery was associated with less confusion or delirium on postop day 1. METHODS: This is a prospective nonrandomized pilot clinical trial with pragmatic sampling. Group designation was assigned by natural history. The family-present group was designated as patients for whom a family member remained present during the first night after surgery. The unaccompanied group was designated as patients who did not have a family member stay the night. Data include the Richmond Agitation Sedation Scale, the Confusion Assessment Method for the ICU, the 4AT (Alertness, Attention, Abbreviated mental test, and Acute change) score, and confusion measured with the orientation item on the Glasgow Coma Scale. Baseline data were collected after admission to the spine ICU and compared with the same data collected in the morning of postop day 1. RESULTS: At baseline, 5 of 16 patients in the family-present group (31.3%) had at least 1 incidence of delirium or confusion. Similarly, 6 of 14 patients in the unaccompanied group (42.9%) had at least 1 incidence of delirium or confusion. There was a clinically relevant, but not statistically significant, reduction in postop day 1 delirium or confusion comparing the family-present (6.3%) and unaccompanied (21.4%) groups ( P = .23). CONCLUSION: Family presence may reduce delirium and confusion for patients after spine surgery. The results support continued research into examining nurse-led interventions to reduce delirium and improve outcomes for this population.

Risk for post-operative delirium related to comorbidities in older adult cardiac patients: An integrative review

BACKGROUND

Delirium is defined as a sudden onset of confusion due to disruption in normal brain functioning. Although it is highly prevalent in post-operative patients, most significantly the older adult population, limited information exists explaining why its onset occurs.

PURPOSE

This integrative review aimed to synthesise specific comorbidities that can contribute to the development of post-operative delirium in older adult cardiac surgical patients.

METHODS

PRISMA statement was used to report the identification, selection, appraisal and synthesis of articles and the PRISMA diagram reports the selection process. The Johns Hopkins Evidence-Based Practice Tools were used as guide in literature review, critical analysis, levelling of evidence and quality rating. PubMed, ProQuest, CINAHL plus, EMBASE, MEDLINE, Ovid Nursing Collection and Cochrane databases were searched from 2015 to 2020.

RESULTS

The initial search yielded 1529 articles. Following the removal of duplicates and screening, 14 articles were included for this review. The following comorbidities were identified in the studies: Diabetes mellitus, atrial fibrillation, depression, impaired olfaction, pre-existing cerebrovascular disease, pre-existing cardiovascular disease, insomnia and frailty.

CONCLUSION

There was a strong indication of the development of post-operative delirium among older adult cardiac surgical patients with comorbidities.

RELEVANCE TO CLINICAL PRACTICE

Awareness of the impact of comorbidities in developing post-operative delirium may help healthcare providers to plan and implement proper care management among older adult cardiac surgical patients with comorbidities.

Surgical management of lumbar spinal stenosis in patients over 80: is there an increased risk?

Management of lumbar spinal stenosis (LSS) represents the first cause of spinal surgery for the elderly and will increase with the aging population. Although the surgery improves quality of life, the procedure involves anaesthetic and operative risks. The aim of this study was to assess whether the postoperative complication rate was higher for elderly patients and to find confounding factors. We conducted a retrospective study including all LSS surgeries between 2012 and 2020 at the University Hospital of Caen. We compared two populations opposing patients aged over 80 with others. The primary endpoint was the occurrence of a severe complication (SC). Minor complications were the secondary endpoint. Comorbidities, history of lumbar spine surgery and surgical characteristics were recorded. Nine hundred ninety-six patients undergoing surgery for degenerative LSS were identified. Patients over 80 were significantly affected by additional comorbidities: hypertension, heart diseases, higher age-adjusted comorbidity Charlson score, ASA score and use of anticoagulants. Knee-chest position was preferred for younger patients. Older patients underwent a more extensive decompression and had more incidental durotomies. Of the patients, 5.2% presented SC. Age over 80 did not appear to be a significant risk factor for SC, but minor complications increased. Multivariate analysis showed that heart diseases, history of laminectomy, AA-CCI and accidental durotomies were independent risk factors for SC. Surgical management for lumbar spinal stenosis is not associated to a higher rate of severe complications for patients over 80 years of age. However, preoperative risk factors should be investigated to warn the elderly patients that the complication risk is increased although an optimal preparation is the way to avoid them.