1
|
Patel Y, Ramachandran K, Shetty AP, Chelliah S, Subramanian B, Kanna RM, Shanmuganathan R. Comparison Between Relative Efficacy of Erector Spinae Plane Block and Caudal Epidural Block for Postoperative Analgesia in Lumbar Fusion Surgery- A Prospective Randomized Controlled Study. Global Spine J 2023:21925682231203653. [PMID: 37737097 DOI: 10.1177/21925682231203653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
STUDY DESIGN Prospective, randomized controlled double-blinded study. OBJECTIVE To compare the relative efficacy of ultrasound-guided ESPB and CEB for postoperative analgesia after a single-level lumbar fusion surgery and compared it with conventional multimodal analgesia. METHODS 81 patients requiring single-level lumbar fusion surgery were randomly allocated into 3 groups (ESPB group, CEB group, and the control group). Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization, and complications were recorded. RESULTS The total opioid consumption in the first 24 hours was significantly lower in both the block groups than in the control group (103.70 ± 13.34 vs 105 ± 16.01 vs 142.59 ± 40.91mcg; P < .001). The total muscle relaxant consumption was also significantly less in block groups compared to controls (50.93 ± 1.98 vs 52.04 ± 3.47 vs 55.00 ± 5.29 mg; P < .001). The intraoperative blood loss was significantly less in both the block group (327.78 ± 40.03 mL, 380.74 ± 77.80 mL) than the control group (498.89 ± 71.22 mL) (P < .001). Among the block groups, the immediate postoperative pain relief was better in the CEB group, however, the ESPB group had a longer duration of postoperative pain relief. CONCLUSION Both ESPB and CEB produce adequate postoperative analgesia after lumbar fusion however the duration of action was significantly longer in the ESPB group with relatively shorter surgical time and lesser blood loss compared to the CEB group.
Collapse
Affiliation(s)
- Yogin Patel
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Karthik Ramachandran
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Sekar Chelliah
- Department of Anesthesia, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Balavenkat Subramanian
- Department of Anesthesia, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | | |
Collapse
|
2
|
Effects of tizanidine and clonidine on postoperative pain after lumbar fusion surgery. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
3
|
Fritsche T, Schnetz M, Klug A, Fischer S, Ruckes C, Hunfeld KP, Hoffmann R, Gramlich Y. Tissue sampling is non-inferior in comparison to sonication in orthopedic revision surgery. Arch Orthop Trauma Surg 2022; 143:2901-2911. [PMID: 35612616 DOI: 10.1007/s00402-022-04469-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to assess the role of sonication fluid cultures in detecting musculoskeletal infections in orthopedic revision surgery in patients suspected of having peri-prosthetic joint infection (PJI), fracture-related infections (FRI), or postoperative spinal implant infections (PSII). METHODS Between 2016 and 2019, 149 cases with a data set including sonication fluid cultures and tissue specimen and histological analysis were included. Accuracy of each diagnostic tool as well as the influence of antibiotic therapy was analyzed. Pathogens identified in the sonication cultures and in the associated tissue samples were compared based on the matching of the antibiograms. Therapeutic benefits were then assessed. RESULTS Of 149 cases, 43.6% (n = 65) were identified as PJI, 2.7% (n = 4) as FRI, 12.8% (n = 19) as PSII, 6.7% (n = 10) as aseptic non-union, and 34.2% (n = 51) as aseptic implant loosening. The sensitivity and specificity of tissue and synovial specimens showed no significant difference with respect to sonication fluid cultures (sensitivity/specificity: tissue: 68.2%/96.7%; sonication fluid cultures: 60.2%/98.4%). The administration of antibiotics over 14 days prior to microbiological sampling (n = 40) resulted in a lower sensitivity of 42.9% each. Histological analysis showed a sensitivity 86.3% and specificity of 97.4%. In 83.9% (n = 125) of the cases, the results of sonication fluid cultures and tissue specimens were identical. Different microorganisms were found in only four cases. In 17 cases, tissue samples (n = 5) or sonication (n = 12) were false-negatives. CONCLUSION Sonication fluid culture showed no additional benefit compared to conventional microbiological diagnostics of tissue and synovial fluid cultures. Preoperative administration of antibiotics had a clearly negative effect on microbiologic test accuracy. In over 83.9% of the cases, sonication fluid and tissue cultures showed identical results. In the other cases, sonication fluid culture did not further contribute to the therapy decision, whereas other factors, such as fistulas, cell counts, or histological analysis, were decisive in determining therapy.
Collapse
Affiliation(s)
- Theresa Fritsche
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Matthias Schnetz
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Sebastian Fischer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Studies, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, Mainz, Germany
| | - K P Hunfeld
- Institute of Laboratory Medicine, Microbiology and Infection Control, Northwest Medical Center, Medical Faculty Goethe University Frankfurt, Steinbacher Hohl 2-26, 60488, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - Yves Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
| |
Collapse
|
4
|
Arena PJ, Mo J, Liu Q, Zhou X, Gong R, Wentworth C, Murugesan S, Huang K. The incidence of acute myocardial infarction after elective spinal fusions or joint replacement surgery in the United States: a large-scale retrospective observational cohort study in 322,585 patients : Post-surgical myocardial infarction data. Patient Saf Surg 2021; 15:30. [PMID: 34537067 PMCID: PMC8449870 DOI: 10.1186/s13037-021-00305-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background Acute myocardial infarction (AMI) is an uncommon but fatal complication among patients undergoing elective spinal fusion surgery (SF), total hip arthroplasty (THA), and total knee arthroplasty (TKA). Our objective was to estimate the incidence of AMI among adults undergoing elective SF, THA, and TKA in different post-operative risk windows and characterize high-risk sub-populations in the United States. Methods A retrospective cohort study was conducted using data from a longitudinal electronic healthcare record (EHR) database from January 1, 2007 to June 30, 2018. ICD codes were used to identify SF, THA, TKA, AMI, and selected clinical characteristics. Incidence proportions (IPs) and 95% confidence intervals were estimated in the following risk windows: index hospitalization, ≤ 30, ≤ 90, ≤ 180, and ≤ 365 days post-operation. Results A total of 67,533 SF patients, 87,572 THA patients, and 167,480 TKA patients were eligible for the study. The IP of AMI after SF, THA, and TKA ranged from 0.36, 0.28, and 0.25% during index hospitalization to 1.05, 0.93, and 0.85% ≤ 365 days post-operation, respectively. The IP of AMI was higher among patients who were older, male, with longer hospital stays, had a history of AMI, and had a history of diabetes. Conclusion The IP of post-operative AMI was generally highest among the SF cohort compared to the THA and TKA cohorts. Additionally, potential high-risk populations were identified. Future studies in this area are warranted to confirm these findings via improved confounder control and to identify effect measure modifiers. Supplementary Information The online version contains supplementary material available at 10.1186/s13037-021-00305-6.
Collapse
Affiliation(s)
- Patrick J Arena
- Global Medical Epidemiology & Big Data Analysis, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA
| | - Jingping Mo
- Safety Surveillance Research, Pfizer Inc., New York, NY, USA
| | - Qing Liu
- Global Medical Epidemiology & Big Data Analysis, Pfizer Inc., Collegeville, PA, USA
| | - Xiaofeng Zhou
- Global Medical Epidemiology & Big Data Analysis, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA
| | - Richard Gong
- Real World Evidence Center of Excellence, Pfizer Inc., New York, NY, USA
| | - Charles Wentworth
- Global Medical Epidemiology & Big Data Analysis, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA
| | | | - Kui Huang
- Global Medical Epidemiology & Big Data Analysis, Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA.
| |
Collapse
|
5
|
Kurosu K, Oe S, Hasegawa T, Shimizu S, Yoshida G, Kobayashi S, Fujita T, Yamada T, Ide K, Watanabe Y, Nakai K, Yamato Y, Yasuda T, Banno T, Arima H, Mihara Y, Ushirozako H, Matsuyama Y. Preoperative prognostic nutritional index as a predictive factor for medical complication after cervical posterior decompression surgery: A multicenter study. J Orthop Surg (Hong Kong) 2021; 29:23094990211006869. [PMID: 33832377 DOI: 10.1177/23094990211006869] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective longitudinal cohort study. OBJECTIVE To investigate postoperative medical complications in patients with malnutrition after cervical posterior surgery. METHODS A total of 256 patients were participated and divided into PNI < 50 group (group L) or PNI ≥ 50 (group H). Patient data, preoperative laboratory data, surgical data, hospitalization data, JOA score, complication data were measured. RESULTS Group L and group H were 127 and 129 patients, each PNI was L: 44.8 ± 4.3, H: 54.6 ± 4.0, P < 0.01. There was significant difference in mean age (L: 72.2 years vs H: 64.8 years, P < 0.01), BMI (23.1 vs 24.7, P < 0.01), serum albumin (L: 3.9 ± 0.4 g/dl vs H: 4.4 ± 0.3 g/dl, P < 0.01), total lymphocyte count (L: 1.3 ± 0.5 103/µL vs H: 2.1 ± 0.7 103/μL, P < 0.01), hospital stay (L: 25.0 days vs H: 18.8 days, P < 0.05), discharge to home (87.5% vs 57.5%, P < 0.01), delirium (L: 15.9% vs H: 3.9%, P < 0.01), medical complications (L: 25.2% vs H: 7.0%, P < 0.01), pre- and post- operative JOA score (L: 11.3 ± 2.8 vs H: 12.4 ± 2.6, P < 0.01; L: 13.3 ± 3.0 vs H: 14.1 ± 2.4, P = 0.02). Multiple logistic regression analysis showed that significant risk factors for medical complications were PNI<50 (P = 0.024, odds ratio [OR] 2.746, 95% confidence interval [CI] 1.143-6.600) and age (P = 0.005, odds ratio [OR] 1.064, 95% confidence interval [CI] 1.020-1.111). CONCLUSION Medical complications are significantly higher in patients with PNI < 50 and higher age. The results showed that PNI is a good indicator for perioperative medical complications in cervical posterior surgery. Improvement of preoperative nutritional status is important to avoid medical complications. LEVEL OF EVIDENCE 3.
Collapse
Affiliation(s)
- Kenta Kurosu
- Department of Orthopedic Surgery, Shizuoka City Hospital, Shizuoka City, Japan.,Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shin Oe
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Orthopedic Surgery and Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Orthopedic Surgery, Haibara General Hospital, Haibara, Japan
| | - Tomohiko Hasegawa
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Orthopedic Surgery, Japanese Red Cross Hamamatsu Hospital, Hamamatsu, Japan
| | - Satoshi Shimizu
- Department of Orthopedic Surgery, 13698Narita Memorial Hospital, Toyohashi, Japan
| | - Go Yoshida
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Orthopedic Surgery, Aoyama Hospital, Toyokawa, Japan
| | - Sho Kobayashi
- Department of Orthopedic Surgery, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Tomotada Fujita
- Department of Orthopedic Surgery, Enshu Hospital, Hamamatsu, Japan
| | - Tomohiro Yamada
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Orthopedic Surgery, Kikugawa General Hospital, Kikugawa, Japan
| | - Koichiro Ide
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuh Watanabe
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Keiichi Nakai
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Orthopedic Surgery, 13773Iwata City Hospital, Iwata, Japan
| | - Yu Yamato
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Orthopedic Surgery and Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tatsuya Yasuda
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan.,Department of Orthopedic Surgery, 13773Iwata City Hospital, Iwata, Japan
| | - Tomohiro Banno
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hideyuki Arima
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuki Mihara
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroki Ushirozako
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, 12793Hamamatsu University School of Medicine, Hamamatsu, Japan
| |
Collapse
|
6
|
Schömig F, Bürger J, Hu Z, Pruß A, Klotz E, Pumberger M, Hipfl C. Intraoperative blood loss as indicated by haemoglobin trend is a predictor for the development of postoperative spinal implant infection-a matched-pair analysis. J Orthop Surg Res 2021; 16:393. [PMID: 34144708 PMCID: PMC8212517 DOI: 10.1186/s13018-021-02537-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background With a reported rate of 0.7–20%, postoperative spinal implant infection (PSII) is one of the most common complications after spine surgery. While in arthroplasty both haematoma formation and perioperative blood loss have been identified as risk factors for developing periprosthetic joint infections and preoperative anaemia has been associated with increased complication rates, literature on the aetiology of PSII remains limited. Methods We performed a matched-pair analysis of perioperative haemoglobin (Hb) and haematocrit (Hct) levels in aseptic and septic spine revision surgeries. 317 patients were included, 94 of which were classified as septic according to previously defined criteria. Patients were matched according to age, body mass index, diabetes, American Society of Anesthesiologists score and smoking habits. Descriptive summaries for septic and aseptic groups were analysed using Pearson chi-squared for categorical or Student t test for continuous variables. Results Fifty patients were matched and did not differ significantly in their reason for revision, mean length of hospital stay, blood transfusion, operating time, or number of levels operated on. While there was no significant difference in preoperative Hb or Hct levels, the mean difference between pre- and postoperative Hb was higher in the septic group (3.45 ± 1.25 vs. 2.82 ± 1.48 g/dL, p = 0.034). Conclusions We therefore show that the intraoperative Hb-trend is a predictor for the development of PSII independent of the amount of blood transfusions, operation time, number of spinal levels operated on and hospital length of stay, which is why strategies to reduce intraoperative blood loss in spine surgery need to be further studied.
Collapse
Affiliation(s)
- Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Justus Bürger
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Zhouyang Hu
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Axel Pruß
- Institute of Transfusion Medicine, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Edda Klotz
- Department of Anesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Christian Hipfl
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| |
Collapse
|
7
|
Farias FAC, Dagostini CM, Falavigna A. HIV and Surgery for Degenerative Spine Disease: A Systematic Review. J Neurol Surg A Cent Eur Neurosurg 2021; 82:468-474. [PMID: 33845512 DOI: 10.1055/s-0041-1724111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND STUDY AIMS The objective of this review is to evaluate the incidence of operative treatment, outcomes, and complications of surgery for degenerative spine disease (DSD) on human immunodeficiency virus (HIV) positive patients. Combined antiretroviral treatment led HIV patients to live long enough to develop many chronic conditions common in the uninfected population. Surgery for DSD is one of the most commonly performed neurosurgical procedures. However, the incidence of spine surgery for DSD in HIV-positive patients seems to be lower than that in uninfected individuals, although this has not been clearly determined. METHODS A systematic search of the Medline, Web of Science, Embase, and SciElo databases was conducted. Only primary studies addressing DSD surgery on HIV-positive patients were included. Evaluated variables were rates of surgical treatment, surgical outcomes and complications, year of publication, country where study was conducted, type of study, and level of evidence. RESULTS Six articles were included in the review from 1,108 records. Significantly lower rates of DSD surgery were identified in HIV-infected patients (0.86 per 1,000 patient-years) when compared with uninfected patients (1.41 per 1,000 patient-years). There was a significant increase in spinal surgery in HIV-positive patients over time, with a 0.094 incidence per 100,000 in the year 2000 and 0.303 in 2009. HIV-positive patients had very similar outcomes when compared with controls, with 66.6% presenting pain relief at a 3-month follow-up. Higher incidences of hospital mortality (1.6 vs. 0.3%; p < 0.001) and complications (12.2 vs. 9.5%, p < 0.001) were observed in HIV carriers. CONCLUSIONS HIV-positive individuals appear to undergo less surgery for DSD than HIV-negative individuals. Improvement rates appear to be similar in both groups, even though some complications appear to be more prevalent in HIV carriers. Larger studies are needed for decisive evidence on the subject.
Collapse
Affiliation(s)
| | | | - Asdrubal Falavigna
- Health Sciences Postgraduate Program, University of Caxias do Sul, Caxias do Sul, RS, Brazil
| |
Collapse
|
8
|
Prevalence of Occult Infections in Posterior Instrumented Spinal Fusion. Clin Spine Surg 2021; 34:25-31. [PMID: 32453165 DOI: 10.1097/bsd.0000000000001014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
STUDY DESIGN This is a prospective observational study. OBJECTIVE The aim of this study is to determine the rate of occult infection after instrumented spine surgery in presumed aseptic patients. SUMMARY OF BACKGROUND DATA The reported incidence rate of delayed/occult infection determined by positive culture swabs after instrumented spine surgery in prospective studies is 0.2%-6.9%. However, this rate may be higher as delayed infections are challenging to diagnose. Fever can be absent and inflammatory markers are often normal. If indolent organisms exist in low concentrations surrounding the instrumentation, these organisms can possibly avoid detection and disrupt bone formation leading to instrumentation loosening, pain generation, and/or failure of a solid fusion. MATERIALS AND METHODS This study included 50 consecutive presumed aseptic patients undergoing a posterior revision requiring removal of instrumentation at least 6 months following their index procedure. Common markers of infection were examined preoperatively. Multiple culture swabs were taken directly from the removed instrumentation and cultured for 14 days. RESULTS Of the 50 patients, 19 (38%) were culture-positive (CP) for bacteria upon removal of their instrumentation, with 14 patients (28%) having ≥2 positive specimens of the same organism. The average length of time between the index procedure and the revision surgery was 4.55 years (range: 0.53-21 y). Polymicrobial infections were found in 26% (5/19) of CP patients. The most prevalent microorganism found was Propionibacterium acnes, in 63% (12/19) of CP patients. There was no significant difference between CP and culture-negative patients regarding preoperative markers for infection, age, or length between index and revision procedures. CONCLUSIONS The results of this study indicate a positive culture rate of 38% in presumed aseptic patients who had previously undergone instrumented spine surgery. These results are consistent with other retrospective studies and are >6 times greater than any previous prospective study utilizing culture swabs. LEVEL OF EVIDENCE Level-III.
Collapse
|
9
|
Schömig F, Gogia J, Caridi J. Epidemiology of postoperative spinal implant infections. JOURNAL OF SPINE SURGERY 2020; 6:762-764. [PMID: 33447680 DOI: 10.21037/jss-20-498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - Jaspaul Gogia
- Department of Orthopedics, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA
| | - John Caridi
- Departments of Neurosurgery and Orthopedics, Mount Sinai Hospital, New York, NY, USA
| |
Collapse
|
10
|
Bürger J, Palmowski Y, Pumberger M. Comprehensive treatment algorithm of postoperative spinal implant infection. JOURNAL OF SPINE SURGERY 2020; 6:793-799. [PMID: 33447685 DOI: 10.21037/jss-20-497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Postoperative spinal implant infection (PSII) is a commonly found and serious complication after instrumented spinal surgery. Whereas early-onset PSII usually can be diagnosed by clinical symptoms, the diagnosis of late-onset PSII can be often made only by examination of intraoperatively collected samples. The treatment of PSII consists of surgical and antibiotic therapy schemes. In case of early PSII, the retention of spinal implants is a feasible option, whereas late PSII is usually treated by one-staged exchange of the spinal implants. Radical debridement of surrounding tissue should be performed in any case of PSII. The antibiotic treatment depends on either the implants can be removed or need to be retained or exchanged, respectively. If the causative pathogens are sensitive for biofilm-active antibiotic agents, the duration of antibiotic treatment amounts to 12 weeks with retention of spinal implants. In case of problematic pathogens, the application of antibiotics needs to be prolonged for an individual duration. Antibiotic treatment should always be initiated with an intravenous application for at least 2 weeks.
Collapse
Affiliation(s)
- Justus Bürger
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Yannick Palmowski
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| |
Collapse
|
11
|
Daniels CJ, Cupler ZA, Gliedt JA, Walters S, Schielke AL, Hinkeldey NA, Golley DJ, Hawk C. Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review. Complement Ther Clin Pract 2020; 42:101261. [PMID: 33276229 DOI: 10.1016/j.ctcp.2020.101261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events. METHODS Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events. RESULTS Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria. CONCLUSION There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Cheryl Hawk
- Texas Chiropractic College, Pasadena, TX, USA
| |
Collapse
|
12
|
Schömig F, Perka C, Pumberger M, Ascherl R. Implant contamination as a cause of surgical site infection in spinal surgery: are single-use implants a reasonable solution? - a systematic review. BMC Musculoskelet Disord 2020; 21:634. [PMID: 32977778 PMCID: PMC7519515 DOI: 10.1186/s12891-020-03653-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/16/2020] [Indexed: 01/03/2023] Open
Abstract
Background In spine surgery, surgical site infection (SSI) is one of the main perioperative complications and is associated with a higher patient morbidity and longer patient hospitalization. Most factors associated with SSI are connected with asepsis during the surgical procedure and thus with contamination of implants and instruments used which can be caused by pre- and intraoperative factors. In this systematic review we evaluate the current literature on these causes and discuss possible solutions to avoid implant and instrument contamination. Methods A systematic literature search of PubMed addressing implant, instrument and tray contamination in orthopaedic and spinal surgery from 2001 to 2019 was conducted following the PRISMA guidelines. All studies regarding implant and instrument contamination in orthopaedic surgery published in English language were included. Results Thirty-five studies were eligible for inclusion and were divided into pre- and intraoperative causes for implant and instrument contamination. Multiple studies showed that reprocessing of medical devices for surgery may be insufficient and lead to surgical site contamination. Regarding intraoperative causes, contamination of gloves and gowns as well as contamination via air are the most striking factors contributing to microbial contamination. Conclusions Our systematic literature review shows that multiple factors can lead to instrument or implant contamination. Intraoperative causes of contamination can be avoided by implementing behavior such as changing gloves right before handling an implant and reducing the instruments’ intraoperative exposure to air. In avoidance of preoperative contamination, there still is a lack of convincing evidence for the use of single-use implants in orthopaedic surgery.
Collapse
Affiliation(s)
- Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Rudolf Ascherl
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| |
Collapse
|
13
|
Abstract
STUDY DESIGN Retrospective database study. OBJECTIVE We sought to identify trends in demographics, comorbidities, and postoperative complications among patients undergoing ACDF and PLF. SUMMARY OF BACKGROUND DATA As demand for anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) surgery continues to increase, it is important to understand changes in the healthcare system and patient populations undergoing these procedures. METHODS We identified 220,520 ACDF and 151,547 PLF surgeries (2006-2016; Premier Healthcare database). Annual proportions or medians were calculated for patient and hospital characteristics, and (Elixhauser) comorbidities. Postoperative complications, including blood transfusions, cardiovascular, pulmonary, renal, or wound complications, hemorrhage, stroke, sepsis, thromboembolism, delirium, inpatient falls, and mortality, were reported per 1000 inpatient days. Trends were assessed by Cochran-Armitage tests and linear regression for binary and continuous variables, respectively. RESULTS The median age of patients undergoing ACDF and PLF increased significantly from 2006 to 2016 (50 to 57 yr and 58 to 61 yr, respectively; P < 0.001) coinciding with an increasing comorbidity burden (30.2% to 47.9% and 44.9% to 55.7%, respectively representing the share of patients with ≥2 Elixhauser comorbidities; P < 0.001). Overall rate of any complication experienced a significant decline after both ACDF (24.5 to 20.8 per 1000 inpatient days; P = 0.002) and PLF (30.5 to 23.1 per 1000 inpatient days; P < 0.001). CONCLUSIONS The comorbidity burden of patients undergoing ACDF and PLF increased substantially from 2006 to 2016, however without a corresponding increase in overall complication rate. Understanding these changes can help guide future practice, advise in the allocation of resources, and inform future areas of research. LEVEL OF EVIDENCE 3.
Collapse
|
14
|
El-Monajjed K, Driscoll M. Analysis of Surgical Forces Required to Gain Access Using a Probe for Minimally Invasive Spine Surgery via Cadaveric-Based Experiments Towards Use in Training Simulators. IEEE Trans Biomed Eng 2020; 68:330-339. [PMID: 32746011 DOI: 10.1109/tbme.2020.2996980] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Virtual Reality haptic-based surgical simulators for training purposes have recently been receiving increased traction within the medical field. However, its future adoption is contingent on the accuracy and reliability of the haptic feedback. GOAL This study describes and analyzes the implementation of a set of haptic-tailored experiments to extract the force feedback of a medical probe used in minimally invasive spinal lumbar interbody fusion surgeries. METHODS Experiments to extract linear, lateral and rotational insertion, relaxation and extraction of the tool within the spinal muscles, intervertebral discs and lumbar nerve on two cadaveric torsos were conducted. RESULTS Notably, mean force-displacement and torque-angular displacement curves describing the different tool-tissue responses were reported with a maximum force of 6.87 (±1.79) N at 40 mm in the muscle and an initial rupture force through the Annulus Fibrosis of 20.550 (±7.841) N at 6.441 mm in the L4/L5 disc. CONCLUSION The analysis showed that increasing the velocity of the probe slightly reduced and delayed depth of the muscle punctures but significantly lowered the force reduction due to relaxation. Decreasing probe depth resulted with a reduction to the force relaxation drop. However, varying the puncturing angle of attack resulted with a significant effect on increasing force intensities. Finally, not resecting the thoracolumbar fascia prior to puncturing the muscle resulted with a significant increase in the force intensities. SIGNIFICANCE These results present a complete characterization of the input required for probe access for spinal surgeries to provide an accurate haptic response in training simulators.
Collapse
|
15
|
Bürger J, Palmowski Y, Strube P, Perka C, Putzier M, Pumberger M. Low sensitivity of histopathological examination of peri-implant tissue samples in diagnosing postoperative spinal implant infection. Bone Joint J 2020; 102-B:899-903. [PMID: 32600139 DOI: 10.1302/0301-620x.102b7.bjj-2019-1725.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIMS To evaluate the histopathological examination of peri-implant tissue samples as a technique in the diagnosis of postoperative spinal implant infection (PSII). METHODS This was a retrospective analysis. Patients who underwent revision spinal surgery at our institution were recruited for this study. PSII was diagnosed by clinical signs, histopathology, and microbiological examination of intraoperatively collected samples. Histopathology was defined as the gold standard. The sensitivity for histopathology was calculated. A total of 47 patients with PSII and at least one microbiological and histopathological sample were included in the study. RESULTS PSII occurred in approximately 28% of the study population. Histopathology showed a sensitivity of 51.1% in the diagnosis of PSII. The most commonly found pathogens were Cutibacterium acnes and gram-positive staphylococci. CONCLUSION Histopathology has low sensitivity for detecting PSII. In particular, infections caused by low-virulence microorganisms are insufficiently detected by histopathology. Cite this article: Bone Joint J 2020;102-B(7):899-903.
Collapse
Affiliation(s)
- Justus Bürger
- Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Patrick Strube
- Orthopaedic Department, University Hospital Jena, Eisenberg, Germany
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | | |
Collapse
|
16
|
Abstract
Background
Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion.
Methods
A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein).
Results
The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (−3 h; 95% CI, −6, −0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (−11 h; 95% CI, −19, −6; P < 0.001) were shorter; opioid consumption was lower at day 1 (−57 mg; 95% CI, −130, −5; P = 0.030) without adversely affecting pain scores (−2; 95% CI, −3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037).
Conclusions
Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Collapse
|
17
|
Multimodal Pain Management and Postoperative Outcomes in Lumbar Spine Fusion Surgery: A Population-based Cohort Study. Spine (Phila Pa 1976) 2020; 45:580-589. [PMID: 31770340 DOI: 10.1097/brs.0000000000003320] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective population-based cohort analysis. OBJECTIVE Given the lack of large-scale data on the use and efficacy of multimodal analgesia in spine fusion surgery, we conducted a population-based analysis utilizing the nationwide claims-based Premier Healthcare database. SUMMARY OF BACKGROUND DATA Multimodal analgesia, combining different pain signaling pathways to achieve additive and synergistic effects, is increasingly emerging as the standard of care. METHODS Cases of posterior lumbar fusion surgery were extracted (2006-2016). Opioid-only analgesia was compared to multimodal analgesia, that is, systemic opioid analgesia + either acetaminophen, steroids, gabapentinoids, ketamine, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, or neuraxial anesthesia (categorized into 1, 2, or >2 additional analgesic modes). Mixed-effects models measured associations between multimodal analgesia categories and outcomes, including opioid prescription dose, cost/length of hospitalization, and opioid-related complications. Odds ratios (ORs, or % change) and 95% confidence intervals (CIs) are reported. RESULTS Among 265,538 patients the incidence of multimodal analgesia was 61.1% (162,156); multimodal pain management-specifically when adding NSAIDs/COX-2 inhibitors to opioids-was associated with reduced opioid prescription (-13.3% CI -16.7 to -9.7%), cost (-2.9% CI -3.9 to -1.8%) and length of hospitalization (-7.3% CI -8.5 to -6.1%). Multimodal analgesia in general was associated with stepwise decreased odds for gastrointestinal complications (OR 0.95, 95% CI 0.88-1.04; OR 0.84, CI 0.75-0.95; OR 0.78, 95% CI 0.64-0.96), whereas odds were increased for postoperative delirium (OR 1.14, 95% CI 1.00-1.32; OR 1.33, 95% CI 1.11-1.59; OR 1.31, 95% CI 0.99-1.74), and counterintuitively- naloxone administration (OR 1.25, 95% CI 1.13-1.38; OR 1.56, 95% CI 1.37-1.77; OR 1.84, 95% CI 1.52-2.23) with increasing analgesic modes used: one, two, or more additional analgesic modes, respectively. Post-hoc analysis revealed that specifically gabapentinoid use increased odds of naloxone requirement by about 50%, regardless of concurrent opioid dose (P < 0.001). CONCLUSION Although multimodal analgesia was not consistently implemented in spine fusion surgery, particularly NSAIDs and COX-2 inhibitors demonstrated opioid sparing effects. Moreover, results suggest a synergistic interaction between gabapentinoids and opioids, the former potentiating opioid effects resulting in greater naloxone requirement. LEVEL OF EVIDENCE 3.
Collapse
|
18
|
Does increasing age impact clinical and radiographic outcomes following lumbar spinal fusion? Spine J 2020; 20:563-571. [PMID: 31731010 DOI: 10.1016/j.spinee.2019.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 11/04/2019] [Accepted: 11/08/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite the growing senior population within the United States, there is a lack of consensus regarding the safety and efficacy of performing lumbar spinal fusion for this population. PURPOSE To evaluate the clinical and radiographic outcomes in different age cohorts following lumbar spinal fusion. STUDY DESIGN Retrospective cohort analysis. PATIENT SAMPLE Analysis of 1,184 patients who underwent posterolateral lumbar fusion from 2011 to 2018. Surgery was indicated after failure of conservative treatment to address radiculopathy and/or neurogenic claudication. Patients were excluded if they were under 18 years of age at the time of surgery, had a lumbar fracture, tumor, or infection, or had fusions involving the thoracic spine, high-grade spondylolisthesis, or concomitant deformity. Of the 1,184 patients, 850 patients were included. Patients were divided into three roughly equal groups for analysis: young (18-54 years), middle-aged (55-69 years), and senior (≥70 years). OUTCOME MEASURES Visual Analog Scale Back/Leg pain, and Oswestry Disability Index (ODI) were collected, and achievement of minimal clinically important difference was evaluated. Lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), and PI-LL difference were measured on radiographs. Rates of postoperative complications were analyzed. METHODS Several radiographic parameters were measured using plain radiographs obtained at preoperative, immediately postoperative (standing radiographs performed on postoperative day 1), and most recent follow-up visits. Preoperative and final patient-reported outcomes, along with demographic information, were obtained all patients. Binary outcome variables were compared between groups with multivariate logistic regression, and continuous outcome variables were compared using multivariate linear regression, with age 18 to 54 years used as the reference. Multivariate regressions were used to compare outcomes between cohorts while controlling baseline characteristics. RESULTS A total of 850 patients were included; 330 young (38.80%), 317 middle-aged (37.30%), and 203 senior (23.90%). Seniors had higher postoperative length of stay compared to younger patients (p<.001). Younger patients had worse final ODI scores compared to middle-aged patients (p=.002). Seniors had higher rates of proximal ASD (p=.002) compared to young patients. There was no difference in achievement of minimal clinically important differences (MCID) between all three groups. CONCLUSIONS Senior patients have significant improvement in patient-reported clinical outcomes, despite having greater comorbidities, and longer length of stay. However, given a general lack of achievement of MCID across all cohorts, these findings suggest the need for a critical re-evaluation of the role of lumbar spinal fusion in the management of patients with refractory radiculopathic and/or neurogenic claudication symptoms.
Collapse
|
19
|
Cancelliere C, Wong JJ, Yu H, Nordin M, Mior S, Pereira P, Brunton G, Shearer H, Connell G, Verville L, Taylor-Vaisey A, Côté P. Postsurgical rehabilitation for adults with low back pain with or without radiculopathy who were treated surgically: protocol for a mixed studies systematic review. BMJ Open 2020; 10:e036817. [PMID: 32229527 PMCID: PMC7170616 DOI: 10.1136/bmjopen-2020-036817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Surgical rates for low back pain (LBP) have been increasing in Europe, North America and Asia. Many patients treated surgically will require postsurgical rehabilitation. Little is known about the effectiveness of postsurgical rehabilitation interventions on health outcomes or about patients' experiences with these interventions. OBJECTIVES To conduct a mixed studies systematic review of quantitative and qualitative studies regarding: (1) the effectiveness and safety of postsurgical rehabilitation interventions for adults with LBP treated surgically and (2) the experiences of patients, healthcare providers, caregivers or others involved with the rehabilitation. METHODS AND ANALYSIS We will search MEDLINE, Embase, PsycINFO, CINAHL, the Index to Chiropractic Literature, the Cochrane Controlled Register of Trials and the Rehabilitation & Sports Medicine Source for peer-reviewed empirical studies published from inception in any language. Studies using quantitative, qualitative and mixed methodologies will be included. We will also search reference lists of all eligible articles. Data extraction will include type of presurgical pathology, indication for surgery, surgical procedure, how the intervention was delivered and by whom, context and setting. We will conduct a quality assessment of each study and consider study quality in our evidence synthesis. We will use a sequential approach at the review level to synthesise and integrate data. First, we will synthesise the quantitative and qualitative studies independently, conducting a meta-analysis of the quantitative studies if appropriate and thematic synthesis of the qualitative studies. Then, we will integrate the quantitative and qualitative evidence by juxtaposing the findings in a matrix. ETHICS AND DISSEMINATION Ethical approval is not required for this knowledge synthesis. Findings will be disseminated through knowledge translation activities including: (1) presentations at national and international conferences and scientific meetings; (2) presentations to local and international stakeholders; (3) publications in peer-reviewed journals and (4) posts on organisational websites. PROSPERO REGISTRATION NUMBER CRD42019134607.
Collapse
Affiliation(s)
- Carol Cancelliere
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
| | - Jessica J Wong
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hainan Yu
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
| | - Margareta Nordin
- Department of Orthopedic Surgery and Environmental Medicine, NYU School of Medicine, Occupational and Industrial Orthopedic Center, New York University, New York, New York, USA
| | - Silvano Mior
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
- Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Paulo Pereira
- Spine Unit, Department of Neurosurgery, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ginny Brunton
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- EPPI-Centre, UCL Institute of Education, University College London, London, UK
| | - Heather Shearer
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gaelan Connell
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
- Rehabilitation Sciences, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Leslie Verville
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
| | - Anne Taylor-Vaisey
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
| | - Pierre Côté
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, Oshawa, Ontario, Canada
| |
Collapse
|
20
|
Gornet MF, Burkus JK, Dryer RF, Peloza JH, Schranck FW, Copay AG. Lumbar disc arthroplasty versus anterior lumbar interbody fusion: 5-year outcomes for patients in the Maverick disc investigational device exemption study. J Neurosurg Spine 2020; 31:347-356. [PMID: 31100723 DOI: 10.3171/2019.2.spine181037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite evidence of its safety and effectiveness, the use of lumbar disc arthroplasty has been slow to expand due in part to concerns about late complications and the risks of revision surgery associated with early devices. More recently, FDA approval of newer devices and improving reimbursements have reversed this trend in the United States. Additional long-term data on lumbar disc arthroplasty are still needed. This study reports the 5-year results of the FDA investigational device exemption clinical trial of the Medtronic Spinal and Biologics' Maverick total disc replacement. METHODS Patients with single-level degenerative disc disease from L4 to S1 were randomized 2:1 at 31 investigational sites. In the period from April 2003 to August 2004, 405 patients received the investigational device and 172 patients underwent the control procedure of anterior lumbar interbody fusion. Outcome measures included the Oswestry Disability Index (ODI), numeric rating scales (NRSs) for back and leg pain, the SF-36, disc height, interbody motion, heterotopic ossification (investigational device), adverse events (AEs), additional surgeries, and neurological status. Treatment was considered an overall success when all of the following criteria were met: 1) ODI score improvement ≥ 15 points over the preoperative score; 2) maintenance or improvement in neurological status compared with preoperatively; 3) disc height success, that is, no more than a 2-mm reduction in anterior or posterior height; 4) no serious AEs caused by the implant or by the implant and the surgical procedure; and 5) no additional surgery classified as a failure. RESULTS Compared to that in the control group, improvement in the investigational group was statistically greater according to the ODI and SF-36 Physical Component Summary (PCS) at 1, 2, and 5 years; the NRS for back pain at 1 and 2 years; and the NRS for leg pain at 1 year. The rates of heterotopic ossification increased over time: 1.0% (4/382) at 1 year, 2.6% (9/345) at 2 years, and 5.9% (11/187) at 5 years. Investigational patients had fewer device-related AEs and serious device-related AEs than the control patients at both 2 and 5 years postoperatively. Noninferiority of the composite measure overall success was demonstrated at all follow-up intervals; superiority was demonstrated at 1 and 2 years. CONCLUSIONS Lumbar disc arthroplasty is a safe and effective treatment for single-level lumbar degenerative disc disease, resulting in improved physical function and reduced pain up to 5 years after surgery.Clinical trial registration no.: NCT00635843 (clinicaltrials.gov).
Collapse
|
21
|
Non-medical factors significantly influence the length of hospital stay after surgery for degenerative spine disorders. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:203-212. [PMID: 31734806 DOI: 10.1007/s00586-019-06209-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Unnecessarily long hospital stays are costly and inefficient. Studies have shown that the length of hospital stay (LOS) for spine surgical procedures is influenced by various disease-related or medical factors, but few have examined the role of socio-demographic/socio-economic (SDE) factors. METHODS This was a retrospective analysis of data from 10,770 patients (5056 men, 5714 women; 62 ± 15 years) with degenerative spinal disorders, collected prospectively in an in-house database within the framework of EUROSPINE's Spine Tango Registry. Surgeons completed the Tango surgery form (clinical history, demographics, surgical measures, complications), and patients, a baseline Core Outcome Measures Index. Stepwise linear regression analyses examined SDE predictors of LOS, controlling for potential medical/biological factors. RESULTS The mean LOS was 7.9 ± 5.2 days. The final model accounted for 42% of variance in LOS, with SDE variables explaining 13% variance and medical/surgical predictors, 29%. In the final model, the SDE factors age and being female were significant independent predictors of LOS, whereas others were either non-significant (insurance status, being of Swiss nationality, being a smoker) or reached only borderline significance (p < 0.1) (BMI). Controlling for all other SDE and medical/surgical confounders, being female was associated with 1.11-day longer LOS (95% CI 0.96-1.27; p < 0.0001). CONCLUSIONS Patients of advanced age and female gender are at increased risk of longer hospital stay after surgery for degenerative spinal disorders. Further studies should seek to understand the reasoning behind the gender disparity, in order to minimise potentially unnecessary costs of prolonged LOS. Targeted preoperative discharge planning may improve the utilisation of hospital resources. These slides can be retrieved under Electronic Supplementary Material.
Collapse
|
22
|
Haffner M, Saiz AM, Nathe R, Hwang J, Migdal C, Klineberg E, Roberto R. Preoperative multimodal analgesia decreases 24-hour postoperative narcotic consumption in elective spinal fusion patients. Spine J 2019; 19:1753-1763. [PMID: 31325627 DOI: 10.1016/j.spinee.2019.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/19/2019] [Accepted: 07/10/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Effective postoperative pain management in patients undergoing elective spinal fusion surgery has been associated with shorter hospital stays, reduced rates of hospital readmissions due to pain, and decreased cost of care. Furthermore, preoperative multimodal analgesia regimens have been shown to decrease postoperative subjective pain measurements and narcotic consumption in patients undergoing spinal fusion and total arthroplasty surgeries. PURPOSE Compare the difference in effects on 24-hour postoperative narcotic consumption, reported pain, and early mobility with administration of preoperative celecoxib plus gabapentin, gabapentin alone, and a nonstandardized analgesia regimen in patients undergoing elective spinal fusion surgery involving ≤5 levels. STUDY DESIGN Retrospective review, Level of Evidence III. PATIENT SAMPLE A total of 185 adult patients undergoing elective spinal fusion surgery involving ≤5 levels from 2013 to 2017 at one academic institution. Patients were excluded if the surgery was nonelective, for oncological purposes, or the patient was younger than 17 years old. OUTCOME MEASURES Twenty-four-hour postoperative morphine equivalent consumption, 24-hour postoperative visual analogue scale (VAS) pain scores, postoperative day to ambulate, and postoperative day to clear physical therapy. METHODS A single-institution retrospective chart review was conducted. Patients meeting inclusion criteria were grouped by whether they had received preoperative celecoxib plus gabapentin, gabapentin alone, or neither of these medications. Opioid medication intake for the first 24 hours after the surgery end time was tabulated and converted to morphine equivalents. Visual analogue scale (VAS) pain scores were also averaged over the first 24 hours. Finally, physical therapy notes were reviewed to determine the time taken for the patient to first ambulate and to clear physical therapy. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work. RESULTS Twenty-four-hour postoperative morphine equivalent consumption was significantly lower in the celecoxib plus gabapentin group compared with control (p=.004). Patients in the celecoxib plus gabapentin group had significantly lower mean VAS scores (p=.002) and had earlier mobility postoperatively (p=.012) than those in the control group. Early mobility and time to physical therapy clearance did differ between the celecoxib + gabapentin group compared with the gabapentin alone group. The gabapentin group had a significantly higher 24-hour morphine dose equivalent (p=.013) and a significantly higher VAS average (p=.009) compared with the celecoxib + gabapentin group. Gabapentin given alone compared with control did not show statistically significant improved outcomes in postoperative morphine equivalent consumption, pain scores or physical therapy goals. CONCLUSIONS This study demonstrates that administering a selective COX-2 inhibitor and GABA-analogue preoperatively can significantly decrease 24-hour postoperative opioid consumption, VAS pain scores, and elapsed time to postoperative mobility in patients undergoing elective spine fusion surgery of ≤5 levels. Optimal standardized dosing and drug combination for preoperative multimodal analgesia remains to be elucidated.
Collapse
Affiliation(s)
- Max Haffner
- Department of Orthopedic Surgery, University of California, Davis Health, Sacramento, CA 95817, USA
| | - Augustine M Saiz
- Department of Orthopedic Surgery, University of California, Davis Health, Sacramento, CA 95817, USA.
| | - Ryan Nathe
- Department of Orthopedic Surgery, University of California, Davis Health, Sacramento, CA 95817, USA
| | - Joshua Hwang
- University of California, Davis School of Medicine, Sacramento, CA 95817, USA
| | - Christopher Migdal
- University of California, Davis School of Medicine, Sacramento, CA 95817, USA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis Health, Sacramento, CA 95817, USA
| | - Rolando Roberto
- Department of Orthopedic Surgery, University of California, Davis Health, Sacramento, CA 95817, USA
| |
Collapse
|
23
|
Multimodal Nutritional Management in Primary Lumbar Spine Surgery: A Randomized Controlled Trial. Spine (Phila Pa 1976) 2019; 44:967-974. [PMID: 30817733 DOI: 10.1097/brs.0000000000002992] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized controlled trial. OBJECTIVE The purpose of this study was to evaluate the clinical effect and safety of a new multimodal nutritional management (MNM) protocol for patients receiving primary lumbar spine surgery. SUMMARY OF BACKGROUND DATA Poor nutritional status is common in the perioperative period in primary lumbar spine surgery, and may impede recovery after surgery. METHODS A total of 187 patients were included in this prospective randomized controlled trial. They were randomly assigned to the MNM group or the control group. Albumin (ALB) infusion, postoperative ALB level, electrolyte disorders, postoperative electrolyte levels, transfusion rate, postoperative hemoglobin level, length of stay (LOS), and complications were compared between the groups. RESULTS Compared with the control group, the rate and the total amount of ALB infusion were lower in the MNM group, and the postoperative level of ALB in the MNM group was higher on the first postoperative day, and the third postoperative day. The incidence of hypokalemia, hyponatremia, and hypocalcemia were lower in the MNM group. In the MNM group, the postoperative levels of sodium, potassium, and calcium were higher than the control group. The transfusion rate was similar between the two groups. The hemoglobin level was similar between the two groups on first postoperative day, but was higher in the MNM group on third postoperative day. LOS in the MNM group was shorter than in the control group. The incidence of wound drainage was lower in the MNM group. No statistical differences were observed regarding surgical complications between the two groups. CONCLUSION The MNM protocol effectively reduced ALB infusion, the incidence of electrolyte disorders, and wound drainage, increased the postoperative levels of ALB, sodium, potassium, and calcium, and reduced the LOS without increasing the rate of postoperative complications. LEVEL OF EVIDENCE 2.
Collapse
|
24
|
Discharge to inpatient facilities after lumbar fusion surgery is associated with increased postoperative venous thromboembolism and readmissions. Spine J 2019; 19:430-436. [PMID: 29864544 DOI: 10.1016/j.spinee.2018.05.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 05/06/2018] [Accepted: 05/30/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postdischarge care is a significant source of cost variability after posterior lumbar fusion surgery. However, there remains limited evidence associating postdischarge inpatient services and improved postoperative outcomes, despite the high cost of these services. PURPOSE To determine the association between posthospital discharge to inpatient care facilities and postoperative complications. STUDY DESIGN A retrospective review of all 1- to 3-level primary posterior lumbar fusion cases in the 2010-2014 National Surgical Quality Improvement Program registry was conducted. Propensity scores for discharge destination were determined based on observable baseline patient characteristics. Multivariable propensity-adjusted logistic regressions were performed to determine associations between discharge destination and postdischarge complications, with adjusted odds ratios (OR) and 95% confidence intervals (CI). RESULTS A total of 18,652 posterior lumbar fusion cases were identified, 15,234 (82%) were discharged home, and 3,418 (18%) were discharged to continued inpatient care. Multivariable propensity-adjusted analysis demonstrated that being discharged to inpatient facilities was independently associated with higher risk of thromboembolic complications (OR [95% CI]: 1.79 [1.13-2.85]), urinary complications, (1.79 [1.27-2.51]), and unplanned readmissions (1.43 [1.22-1.68]). CONCLUSIONS Discharge to continued inpatient care versus home after primary posterior lumbar fusion is independently associated with higher odds of certain major complications. To optimize clinical outcomes as well as cost savings in an era of value-based reimbursements, clinicians and hospitals should consider further investigation into carefully investigating which patients might be better served by home discharge after surgery.
Collapse
|
25
|
Bürger J, Akgün D, Strube P, Putzier M, Pumberger M. Sonication of removed implants improves microbiological diagnosis of postoperative spinal infections. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:768-774. [DOI: 10.1007/s00586-019-05881-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/06/2019] [Indexed: 12/17/2022]
|
26
|
Ye I, Tang R, White SJ, Cheung ZB, Cho SK. Predictors of 30-Day Postoperative Pulmonary Complications After Open Reduction and Internal Fixation of Vertebral Fractures. World Neurosurg 2018; 123:e288-e293. [PMID: 30496929 DOI: 10.1016/j.wneu.2018.11.153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 11/18/2018] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The purpose of this study was to identify predictors of 30-day postoperative pulmonary complications after open reduction and internal fixation (ORIF) of vertebral fractures. METHODS We performed a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014. Adult patients who underwent ORIF of vertebral fractures were included and divided into 2 groups based on the occurrence of 30-day postoperative pulmonary complications. Baseline patient and operative characteristics were compared between the 2 groups. Multivariate regression (MVR) analysis was performed to identify independent risk factors for pulmonary complications. RESULTS A total of 900 patients were included in our cohort. The overall 30-day pulmonary complication rate was 5.67%. Patients who had a pulmonary complication after vertebral ORIF were more often men and more often had diabetes, functional dependence, American Society of Anesthesiologists score classification of 3 or higher, pulmonary comorbidity, renal comorbidity, and preoperative anemia. The pulmonary complication group also had a higher incidence of 30-day mortality, prolonged hospitalization, pneumonia, cardiac complications, urinary tract infection, blood transfusion, and sepsis. The MVR analysis found that pulmonary comorbidity (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.5-11.5; P < 0.001), diabetes (OR, 2.1; 95% CI, 1.0-4.2; P = 0.037), partial or dependent functional status (OR, 4.7; 95% CI, 2.2-10.2; P < 0.001), and cervical spine involvement (OR, 3.6; 95% CI, 1.7-8.0; P = 0.001) were independent predictors of pulmonary complications. CONCLUSIONS Early identification of risk factors for postoperative pulmonary complications is important in the evaluation of patients with vertebral fractures for surgical decision-making, preoperative optimization, and subsequent postoperative care to improve patient outcomes and minimize morbidity.
Collapse
Affiliation(s)
- Ivan Ye
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ray Tang
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel J White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
27
|
Moonla R, Threetipayarak A, Panpaisarn C, Pattayaruk N, Kaewkam U, Jumpalee N, Panwilai J. Comparison of Preoperative and Postoperative Parecoxib Administration for Pain Control Following Major Spine Surgery. Asian Spine J 2018; 12:893-901. [PMID: 30213173 PMCID: PMC6147878 DOI: 10.31616/asj.2018.12.5.893] [Citation(s) in RCA: 3] [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] [Received: 08/31/2017] [Accepted: 02/18/2018] [Indexed: 11/23/2022] Open
Abstract
Study Design Prospective randomized, double-blind controlled trial. Purpose Here, we aim to compare the efficacy and safety of pain control between pre- and postoperative parecoxib administration in patients who have undergone major spine surgery. Overview of Literature Several studies have compared the efficacy of pre- and postoperative administration of parecoxib, which led to inconclusive results owing to variation in operative time. Preincisional parecoxib administration reduces inflammatory response in major spine surgery requiring longer operative time; however, it may not reduce pain as much as parecoxib administration immediately after surgery would. Methods Totally, 127 patients who underwent major spine surgery were randomly divided into three groups: pre-group, which received 40 mg parecoxib before skin incision and at 12 and 24 hours after the first dose; post-group, which received the same dose at wound closure and at 12 and 24 hours after the first dose; and control group, which did not receive any parecoxib. Efficacy and safety of parecoxib were measured based on pain score, morphine consumption, and side effects from both morphine and parecoxib at 24 hours after surgery. Results Initial postoperative pain score, postoperative pain score at rest, and accumulative morphine consumption at 24 hours after surgery were similar between the pre- and post-groups. Despite the significantly lower pain score and morphine consumption in both pre- and post-groups compared with the control group, cumulative morphine consumption at 24 hours after surgery was reduced by approximately 50% in the pre-group and 46% in the post-group compared. Analgesic-related complication incidence was similar in all groups. Conclusions The timing of parecoxib administration, either before or after major spinal surgery, did not affect the safety and analgesic efficacy of pain management.
Collapse
Affiliation(s)
- Rayakorn Moonla
- Department of Anesthesiology, Chiangmai Neurological Hospital, Chiangmai, Thailand
| | | | | | - Nida Pattayaruk
- Department of Nurse Anesthesia, Chiangmai Neurological Hospital, Chiangmai, Thailand
| | - Unchana Kaewkam
- Department of Nurse Anesthesia, Chiangmai Neurological Hospital, Chiangmai, Thailand
| | - Nipawan Jumpalee
- Department of Nurse Anesthesia, Chiangmai Neurological Hospital, Chiangmai, Thailand
| | - Jatupong Panwilai
- Department of Nurse Anesthesia, Chiangmai Neurological Hospital, Chiangmai, Thailand
| |
Collapse
|
28
|
Koh W, Kang K, Lee YJ, Kim MR, Shin JS, Lee J, Lee JH, Shin KM, Ha IH. Impact of acupuncture treatment on the lumbar surgery rate for low back pain in Korea: A nationwide matched retrospective cohort study. PLoS One 2018; 13:e0199042. [PMID: 29894499 PMCID: PMC5997340 DOI: 10.1371/journal.pone.0199042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Low back pain (LBP) is a globally prevalent disorder with high social significance. Invasive surgical procedures are increasingly being used to treat LBP despite a lack of solid evidence supporting their long-term benefits. This nationwide retrospective cohort study investigated the association between acupuncture treatment and lumbar surgery rate in patients with LBP. METHODS Using the National Health Insurance Service Sample Cohort Database for 2002-2013, we identified newly diagnosed LBP patients in Korea between 2004 and 2010 and divided them into an acupuncture group and control group according to whether or not they received acupuncture. Propensity scores based on age, sex, income, and Charlson Comorbidity Index were matched between the two study groups. The lumbar surgery rate in the two years following the first visit (control group) or the first acupuncture session (acupuncture group) was calculated. In addition to the overall analysis, stratified analyses were also conducted in different age, sex, and income strata. Sensitivity analyses were further performed using varying definitions of acupuncture treatment. RESULTS After matching, 130,089 subjects were included in each study group. The lumbar surgery rate was significantly lower in the acupuncture group than in the control group (hazard ratio [HR] 0.633, 95% confidence interval [CI] 0.576-0.696). Decrease in HR was consistently observed in the acupuncture group for all age strata, except for patients in their 20s (HR 1.031, 95% CI 0.804-1.323). HR for lumbar surgery tended to be further reduced in the older age groups upon acupuncture treatment, with no apparent sex-related differences. Lowered HR in the acupuncture group was continuously observed across all income groups; the higher income group showed a tendency of greater decrease. Sensitivity analyses showed that the number of acupuncture sessions had no major impact on the likelihood of lumbar surgery, but also that more intensive acupuncture treatment was associated with further reduction in lumbar surgery rates. CONCLUSION The present results found that administration of acupuncture treatment is associated with lower lumbar surgery rates for LBP patients in Korea. Prospective studies are warranted in the future to further investigate the effect of acupuncture treatment on lumbar surgery incidence.
Collapse
Affiliation(s)
- Wonil Koh
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Kyungwon Kang
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Yoon Jae Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Me-riong Kim
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Joon-Shik Shin
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Jinho Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Jun-Hwan Lee
- Clinical Research Division, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
- University of Science & Technology (UST), Korean Medicine Life Science, Campus of Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
| | - Kyung-Min Shin
- Clinical Research Division, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| |
Collapse
|
29
|
Heckmann ND, Sivasundaram L, Stefl MD, Kang HP, Basler ET, Lieberman JR. Total Hip Arthroplasty Bearing Surface Trends in the United States From 2007 to 2014: The Rise of Ceramic on Polyethylene. J Arthroplasty 2018; 33:1757-1763.e1. [PMID: 29429883 DOI: 10.1016/j.arth.2017.12.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/23/2017] [Accepted: 12/28/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Wear of the bearing surface is a critical element in determining the longevity of a total hip arthroplasty (THA). Over the past decade, concerns related to modern metal-on-metal (MoM) bearings and corrosion at the femoral head-neck interface have influenced surgeon selection of bearing surfaces. The purpose of this study is to analyze trends in THA bearing surface selection from 2007 through 2014 using a large national database. METHODS The Nationwide Inpatient Sample database was used to extract bearing surface data from patients who underwent a primary THA between 2007 and 2014. Patients were grouped by bearing surface type: metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), MoM, and ceramic-on-ceramic (CoC) bearings. Descriptive statistics were employed to describe trends. Univariate and multivariate analyses were performed to identify differences between bearing surface groups. RESULTS During the study period, 2,460,640 THA discharges were identified, of which 1,059,825 (43.1%) had bearing surface data. A total of 496,713 (46.9%) MoP, 307,907 (29.1%) CoP, 210,381 (19.9%) MoM, and 44,823 (4.2%) CoC cases were identified. MoM utilization peaked in 2008 representing 40.1% of THAs implanted that year and steadily declined to 4.0% in 2014. From 2007 to 2014, the use of CoP bearing surfaces increased from 11.1% of cases in 2007 to 50.8% of cases in 2014. In 2014, CoP utilization surpassed MoP which represented 42.1% of bearing surfaces that year. CONCLUSION During the study period, MoM bearing surfaces decreased precipitously, while CoP surpassed MoP as the most popular bearing surface used in a THA.
Collapse
Affiliation(s)
- Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | | | - Michael D Stefl
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Hyunwoo Paco Kang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Eric T Basler
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| |
Collapse
|
30
|
Hsu HW, Bashkuev M, Pumberger M, Schmidt H. Differences in 3D vs. 2D analysis in lumbar spinal fusion simulations. J Biomech 2018; 72:262-267. [PMID: 29559240 DOI: 10.1016/j.jbiomech.2018.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 02/26/2018] [Accepted: 03/03/2018] [Indexed: 10/17/2022]
Abstract
Lumbar interbody fusion is currently the gold standard in treating patients with disc degeneration or segmental instability. Despite it having been used for several decades, the non-union rate remains high. A failed fusion is frequently attributed to an inadequate mechanical environment after instrumentation. Finite element (FE) models can provide insights into the mechanics of the fusion process. Previous fusion simulations using FE models showed that the geometries and material of the cage can greatly influence the fusion outcome. However, these studies used axisymmetric models which lacked realistic spinal geometries. Therefore, different modeling approaches were evaluated to understand the bone-formation process. Three FE models of the lumbar motion segment (L4-L5) were developed: 2D, Sym-3D and Nonsym-3D. The fusion process based on existing mechano-regulation algorithms using the FE simulations to evaluate the mechanical environment was then integrated into these models. In addition, the influence of different lordotic angles (5, 10 and 15°) was investigated. The volume of newly formed bone, the axial stiffness of the whole segment and bone distribution inside and surrounding the cage were evaluated. In contrast to the Nonsym-3D, the 2D and Sym-3D models predicted excessive bone formation prior to bridging (peak values with 36 and 9% higher than in equilibrium, respectively). The 3D models predicted a more uniform bone distribution compared to the 2D model. The current results demonstrate the crucial role of the realistic 3D geometry of the lumbar motion segment in predicting bone formation after lumbar spinal fusion.
Collapse
Affiliation(s)
- Hung-Wei Hsu
- Julius Wolff Institut, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maxim Bashkuev
- Julius Wolff Institut, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Pumberger
- Spine Department, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Hendrik Schmidt
- Julius Wolff Institut, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| |
Collapse
|
31
|
Abstract
Soft tissue trauma of skeletal muscle is one of the most common side effects in surgery. Muscle injuries are not only caused by accident-related injuries but can also be of an iatrogenic nature as they occur during surgical interventions when the anatomical region of interest is exposed. If the extent of trauma surpasses the intrinsic regenerative capacities, signs of fatty degeneration and formation of fibrotic scar tissue can occur, and, consequentially, muscle function deteriorates or is diminished. Despite research efforts to investigate the physiological healing cascade following trauma, our understanding of the early onset of healing and how it potentially determines success or failure is still only fragmentary. This review focuses on the initial physiological pathways following skeletal muscle trauma in comparison to bone and tendon trauma and what conclusions can be drawn from new scientific insights for the development of novel therapeutic strategies. Strategies to support regeneration of muscle tissue after injury are scarce, even though muscle trauma has a high incidence. Based on tissue specific differences, possible clinical treatment options such as local immune-modulatory and cell therapeutic approaches are suggested that aim to support the endogenous regenerative potential of injured muscle tissues.
Collapse
|
32
|
Ninety-Day Reimbursements for Primary Single-Level Posterior Lumbar Interbody Fusion From Commercial and Medicare Data. Spine (Phila Pa 1976) 2018; 43:193-200. [PMID: 29252824 DOI: 10.1097/brs.0000000000002283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, economic analysis. OBJECTIVE To analyze the distribution of 90-day payments for a primary single-level posterior lumbar interbody fusion from Commercial payers and Medicare. SUMMARY OF BACKGROUND DATA Episode-based bundled payments aim to align incentives of all health care providers toward the common goal of high quality and economic health care. Understanding the evolving reimbursement models for spine surgery will require knowledge on existing payments, distribution, and variation. Also, it will help identify areas for cost reduction. This is currently not known for a primary single-level posterior lumbar interbody fusion. METHODS Administrative claims data were used to study reimbursements from Commercial payers (2007-Q3 2015), Medicare Advantage (2007-Q3 2015), and Medicare (2005-2012) for a primary single-level posterior lumbar interbody fusion. Distribution of payments among various service providers was studied. In addition to descriptive analysis, variation between regions and payers was studied by a one-way analysis of variance and post hoc Tukey test. RESULTS Average hospital costs comprise 74.2% to 77% of the total payments, followed by surgeon's fees which accounted for 12.8% to 13.7%. Overall burden of readmissions/revisions was 2.1% to 2.7%, but for the readmitted patient it constitutes 25% to 54% of the 90-day payment. Inpatient surgery had significantly higher facility costs than outpatient surgery (P = 0.02). The average 90-day payment amount was $51,465, $26,234, and $25,501 for Commercial payers, Medicare Advantage, and Medicare, respectively. There was some regional variation, however not consistent among different payers. CONCLUSION Hospital costs constitute the majority share of 90-day payments, which can be reduced by performing surgery in the outpatient setting. Reducing hospital costs and readmissions can lower the financial burden associated with this common spine procedure. LEVEL OF EVIDENCE 3.
Collapse
|
33
|
Drazin D, Lagman C, Bhargava S, Nuño M, Kim TT, Johnson JP. National trends following decompression, discectomy, and fusion in octogenarians and nonagenarians. Acta Neurochir (Wien) 2017; 159:517-525. [PMID: 28050718 DOI: 10.1007/s00701-016-3056-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 12/12/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND The National Inpatient Sample (NIS) database is used to evaluate a wide variety of surgical procedures across a range of specialties. The authors of this study assess national trends of the three commonest spine procedures performed (decompression, fusion, and discectomy) in patients between the ages of 80 and 100 years (octogenarians and nonagenarians). METHODS The NIS database was queried to identify patients between the ages of 80 and 100 with a primary diagnosis of spinal stenosis, disk herniation without myelopathy, or protrusion due to degeneration of spine/disk disorders and who have undergone spinal decompression, fusion, or discectomy between the years 1998 and 2011. Variables of concern included length-of-stay (LOS), non-routine discharge, average total charges, in-hospital complications, and mortality rate. RESULTS Decompression was the most common procedure performed (n = 113,267, 50.5%). Fusion (n = 60,345, 26.9%) was associated with the longest LOS (5.1 days), highest in-hospital complication and mortality rates (n = 13,170, 21.8% and n = 449, 0.7%, respectively), most non-routine discharges (n = 42,662, 70.7%), and highest mean for average total charges ($69,295) (p < 0.001). Discectomy (n = 50,740, 22.6%), had the shortest LOS (3.7 days), lowest complication and mortality rates (n = 6823, 13.4% and n = 102, 0.2%, respectively), fewest non-routine discharges (n = 22,861, 45.1%), and lowest mean for average total charges ($22,787) (p < 0.001). CONCLUSIONS Decompression was most common. Fusion had the longest LOS, highest complication and mortality rates, most non-routine discharges, and was most expensive. Discectomy was least commonly performed, had the shortest LOS, lowest complication and mortality rates, fewest non-routine discharges, and was least expensive.
Collapse
Affiliation(s)
- Doniel Drazin
- Department of Neurosurgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
| | - Carlito Lagman
- Department of Neurosurgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Siddharth Bhargava
- Department of Neurosurgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Miriam Nuño
- Department of Neurosurgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Terrence T Kim
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| |
Collapse
|
34
|
Ilangovan V, Vivakaran TTR, Gunasekaran D, Devikala D. Epidural tramadol via intraoperatively placed catheter as a standalone analgesic after spinal fusion procedure: An analysis of efficacy and cost. J Neurosci Rural Pract 2017; 8:55-59. [PMID: 28149082 PMCID: PMC5225723 DOI: 10.4103/0976-3147.193535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This was a prospective analysis of epidural tramadol as a single analgesic agent delivered through intraoperatively placed epidural catheter for postoperative pain relief after spinal fusion procedures in terms of efficacy and cost. MATERIALS AND METHODS Twenty patients who underwent spinal fusion procedures were included in the study. After completion of the procedure, an epidural catheter was placed at the highest level of exposed dura and brought out through a separate tract. Postoperatively, tramadol was infused into the epidural space via the catheter at a dose of 1 mg/kg diluted in 10 ml of saline. The dosage frequency was arbitrarily fixed at every 6 h during the first 2 days and thereafter reduced to every 8 h after the first 2 days till day 5. Conventional intravenous analgesics were used only if additional analgesia was required as assessed by visual analog scale (VAS). RESULTS Patients' VAS score was assessed every 4 h from the day of surgery. Patients with a VAS score of 6 or more were given additional analgesia in the form of intravenous paracetamol. Of the twenty patients, eight patients needed additional analgesia during the first 24 h and none required additional analgesia after the first 24 h. The median VAS score was 7 within the first 24 h and progressively declined thereafter. Epidural tramadol was noted to be many times cheaper than conventional parenteral analgesics. CONCLUSION Epidural tramadol infusion is safe and effective as a standalone analgesic after open spinal fusion surgery, especially after the 1st postoperative day. Intraoperative placement of the epidural catheter is a simple way of delivering tramadol to the epidural space. The cost of analgesia after spinal fusion surgery can be reduced significantly using epidural tramadol alone.
Collapse
Affiliation(s)
- Vijaysundar Ilangovan
- Department of Neurosurgery, Saveetha Medical College and Hospital, Kanchipuram, Tamil Nadu, India
| | | | - D Gunasekaran
- Department of Anaesthesiology, Saveetha Medical College and Hospital, Kanchipuram, Tamil Nadu, India
| | - D Devikala
- Department of Anaesthesiology, Saveetha Medical College and Hospital, Kanchipuram, Tamil Nadu, India
| |
Collapse
|
35
|
De la Garza-Ramos R, Abt NB, Kerezoudis P, McCutcheon BA, Bydon A, Gokaslan Z, Bydon M. Deep-wound and organ-space infection after surgery for degenerative spine disease: an analysis from 2006 to 2012. Neurol Res 2017; 38:117-23. [PMID: 27118607 DOI: 10.1080/01616412.2016.1138669] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To study the incidence and risk factors of deep-wound and organ-space surgical site infection (SSI) following surgery for degenerative spine disease. METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program were obtained for the years 2006-2012. All adult patients over 40 years of age who underwent elective cervical or lumbar spine surgery for degenerative spine disease were identified. Rates of deep-wound and organ-space SSI were calculated for each procedure. A multivariate logistic regression analysis was conducted to identify independent risk factors for SSI development. RESULTS A total of 36,440 patients were identified, with 7,627 patients (20.93%) undergoing cervical spine surgery and 28,813 patients (79.07%) undergoing lumbar spine surgery. The overall rate of SSI was 0.72% (n = 264); there were 189 deep-wound infections (0.52%) and 75 organ-space infections (0.21%). The highest rates of SSI were for patients undergoing a posterolateral fusion of the lumbar spine (1.04%), followed by patients undergoing a posterior cervical decompression (1.02%); the lowest rates were for patients undergoing cervical disc replacement (0.00%). The multivariate analysis revealed that chronic steroid use (OR 3.66) and increasing operative time (OR 1.002) were the strongest independent risk factors for SSI development in the cervical spine, and renal morbidity (OR 3.93), hemato-oncological morbidity (OR 2.55), and chronic steroid use (2.04) were the strongest risk factors for lumbar SSI. Additionally, patients with a SSI had longer lengths of stay and higher mortality rates (0.76%) when compared to patients without a SSI (0.09%). CONCLUSION Deep-wound and organ-space infections are severe complications in patients undergoing spine surgery. In this study of a multi-centre and prospectively collected database, the rate of SSI was 0.72%. Patients with renal disorders, chronic steroid use, hemato-oncological disease, and diabetes, among others, had significantly higher odds of SSI development.
Collapse
Affiliation(s)
- Rafael De la Garza-Ramos
- a Department of Neurosurgery , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Nicholas B Abt
- a Department of Neurosurgery , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | | | | | - Ali Bydon
- a Department of Neurosurgery , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Ziya Gokaslan
- c Department of Neurosurgery , Warren Alpert Medical School, Brown University , Providence , RI , USA
| | - Mohamad Bydon
- b Department of Neurosurgery , Mayo Clinic , Rochester , MN , USA
| |
Collapse
|
36
|
Daniels CJ, Wakefield PJ, Bub GA, Toombs JD. A Narrative Review of Lumbar Fusion Surgery With Relevance to Chiropractic Practice. J Chiropr Med 2016; 15:259-271. [PMID: 27857634 PMCID: PMC5106443 DOI: 10.1016/j.jcm.2016.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 06/23/2016] [Accepted: 08/05/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE The purpose of this narrative review was to describe the most common spinal fusion surgical procedures, address the clinical indications for lumbar fusion in degeneration cases, identify potential complications, and discuss their relevance to chiropractic management of patients after surgical fusion. METHODS The PubMed database was searched from the beginning of the record through March 31, 2015, for English language articles related to lumbar fusion or arthrodesis or both and their incidence, procedures, complications, and postoperative chiropractic cases. Articles were retrieved and evaluated for relevance. The bibliographies of selected articles were also reviewed. RESULTS The most typical lumbar fusion procedures are posterior lumbar interbody fusion, anterior lumbar interbody fusion, transforaminal interbody fusion, and lateral lumbar interbody fusion. Fair level evidence supports lumbar fusion procedures for degenerative spondylolisthesis with instability and for intractable low back pain that has failed conservative care. Complications and development of chronic pain after surgery is common, and these patients frequently present to chiropractic physicians. Several reports describe the potential benefit of chiropractic management with spinal manipulation, flexion-distraction manipulation, and manipulation under anesthesia for postfusion low back pain. There are no published experimental studies related specifically to chiropractic care of postfusion low back pain. CONCLUSIONS This article describes the indications for fusion, common surgical practice, potential complications, and relevant published chiropractic literature. This review includes 10 cases that showed positive benefits from chiropractic manipulation, flexion-distraction, and/or manipulation under anesthesia for postfusion lumbar pain. Chiropractic care may have a role in helping patients in pain who have undergone lumbar fusion surgery.
Collapse
Affiliation(s)
- Clinton J. Daniels
- Corresponding author: Clinton J. Daniels, DC, MS, 811 Rowell St, Steilacoom, WA 98388.811 Rowell St., SteilacoomWA98388
| | | | | | | |
Collapse
|
37
|
Incremental Hospital Cost and Length-of-Stay Associated With Treating Adverse Events Among Medicare Beneficiaries Undergoing Lumbar Spinal Fusion During Fiscal Year 2013. Spine (Phila Pa 1976) 2016; 41:1613-1620. [PMID: 27105464 DOI: 10.1097/brs.0000000000001641] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVES To report the incremental hospital resource consumption associated with treating selected adverse events experienced by Medicare beneficiaries undergoing a two- or three-level lumbar spinal fusion. SUMMARY OF BACKGROUND DATA Hospitals are increasingly at financial risk for the incremental resources consumed in treating patients experiencing adverse events because of public and private third-party payers' efforts to base hospital reimbursement on "pay for performance" measures. However, little is known about average incremental resources consumed in treating patients experiencing adverse events following lumbar spinal fusions. METHODS The 2013 fiscal year Medicare Provider Analysis and Review file was used to identify 83,658 Medicare beneficiaries who underwent two- or three vertebrae-level lumbar spinal fusion. International Classification of Diseases-9th-Clinical Modification diagnostic and procedure codes were used to identify the frequencies of nine adverse events. This study estimated both the observed and risk-adjusted incremental hospital resources consumed (cost and length of stay [LOS]) in treating Medicare beneficiaries experiencing each adverse event. RESULTS Overall, 17.7% of Medicare beneficiaries undergoing lumbar spinal fusion experienced at least one of the study's adverse events. Medicare beneficiaries experiencing any complication consumed significantly more hospital resources (incremental cost of $8911) and had longer LOS (incremental stays of 5.7 days). After adjusting for patient demographics and comorbid conditions, incremental cost of treating adverse events ranged from a high of $32,049 (infection) to a low of $9976 (transfusion). CONCLUSION Adverse events frequently occur and add substantially to the hospital resource costs of patients undergoing spinal fusion. Shared decision-making instruments should clearly provide these risk estimates to the patient before surgical consideration. Investment in activities that have been shown to reduce specific adverse events is warranted, and this project may allow health systems to prioritize performance improvement areas. LEVEL OF EVIDENCE 3.
Collapse
|
38
|
Comer GC, Behn A, Ravi S, Cheng I. A Biomechanical Comparison of Shape Design and Positioning of Transforaminal Lumbar Interbody Fusion Cages. Global Spine J 2016; 6:432-8. [PMID: 27433426 PMCID: PMC4947403 DOI: 10.1055/s-0035-1564568] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 08/12/2015] [Indexed: 10/24/2022] Open
Abstract
STUDY DESIGN Cadaveric biomechanical analysis. OBJECTIVE The aim of this study was to compare three interbody cage shapes and their position within the interbody space with regards to construct stability for transforaminal lumbar interbody fusion. METHODS Twenty L2-L3 and L4-L5 lumbar motion segments from fresh cadavers were potted in polymethyl methacrylate and subjected to testing with a materials testing machine before and after unilateral facetectomy, diskectomy, and interbody cage insertion. The three cage types were kidney-shaped, articulated, and straight bullet-shaped. Each cage type was placed in a common anatomic area within the interbody space before testing: kidney, center; kidney, anterior; articulated, center; articulated, anterior; bullet, center; bullet, lateral. Load-deformation curves were generated for axial compression, flexion, extension, right bending, left bending, right torsion, and left torsion. Finally, load to failure was tested. RESULTS For all applied loads, there was a statistically significant decrease in the slope of the load-displacement curves for instrumented specimens compared with the intact state (p < 0.05) with the exception of right axial torsion (p = 0.062). Among all instrumented groups, there was no statistically significant difference in stiffness for any of the loading conditions or load to failure. CONCLUSIONS Our results failed to show a clearly superior cage shape design or location within the interbody space for use in transforaminal lumbar interbody fusion.
Collapse
Affiliation(s)
- Garet C. Comer
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, United States
| | - Anthony Behn
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, United States
| | - Shashank Ravi
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, United States,Address for correspondence Ivan Cheng, MD Department of Orthopaedic Surgery, Stanford University450 Broadway Street, Redwood City, CA 94063United States
| |
Collapse
|
39
|
Affiliation(s)
- N. Birch
- The Chris Moody Centre, East Midlands
Spine Limited, Gate 4, Moulton
College, Pitsford Road, Moulton, Northants, NN3 7QL, UK
| |
Collapse
|
40
|
Sivasubramaniam V, Patel HC, Ozdemir BA, Papadopoulos MC. Trends in hospital admissions and surgical procedures for degenerative lumbar spine disease in England: a 15-year time-series study. BMJ Open 2015; 5:e009011. [PMID: 26671956 PMCID: PMC4679892 DOI: 10.1136/bmjopen-2015-009011] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Low back pain (LBP), from degenerative lumbar spine disease, represents a significant burden on healthcare resources. Studies worldwide report trends attributable to their country's specific demographics and healthcare system. Considering England's specific medico-socioeconomic conditions, we investigate recent trends in hospital admissions and procedures for LBP, and discuss the implications for the allocation of healthcare resources. DESIGN Retrospective cohort study using Hospital Episode Statistics data relating to degenerative lumbar spine disease in England, between 1999 and 2013. Regression models were used to analyse trends. OUTCOME MEASURES Trends in the number of admissions and procedures for LBP, mean patient age, gender and length of stay. RESULTS Hospital admissions and procedures have increased significantly over the study period, from 127.09 to 216.16 and from 24.5 to 48.83 per 100,000, respectively, (p<0.001). The increase was most marked in the oldest age groups with a 1.9 and 2.33-fold increase in admissions for patients aged 60-74 and ≥ 75 years, respectively, and a 2.8-fold increase in procedures for those aged ≥ 60 years. Trends in hospital admissions were characterised by a widening gender gap, increasing mean patient age, and decreasing mean hospital stay (p<0.001). Trends in procedures were characterised by a narrowing gender gap, increasing mean patient age (p=0.014) and decreasing mean hospital stay (p<0.001). Linear regression models estimate that each hospital admission translates to 0.27 procedures, per 100,000 (95% CI 0.25 to 0.30, r 0.99, p<0.001; r, Pearson's correlation coefficient). Hospital admissions are increasing at 3.5 times the rate of surgical procedures (regression gradient 7.63 vs 2.18 per 100,000/year). CONCLUSIONS LBP represents a significant and increasing workload for hospitals in England. These trends demonstrate an increasing demand for specialists involved in the surgical and non-surgical management of this disease, and highlight the need for services capable of dealing with the increased comorbidity burden associated with an ageing patient group.
Collapse
Affiliation(s)
| | - Hitesh C Patel
- Department of Cardiology, The Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Baris A Ozdemir
- Department of Vascular Surgery, St George's Hospital, London, UK
- London Deanery Surgical Rotation, UK
| | | |
Collapse
|
41
|
Oren J, Hutzler LH, Hunter T, Errico T, Zuckerman J, Bosco J. Decreasing spine implant costs and inter-physician cost variation. Bone Joint J 2015. [DOI: 10.1302/0301-620x.97b8.35333] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre. Cite this article: 2015; 97-B:1102–5.
Collapse
Affiliation(s)
- J. Oren
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, 10003, USA
| | - L. H. Hutzler
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| | - T. Hunter
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| | - T. Errico
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| | - J. Zuckerman
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| | - J. Bosco
- NYU Hospital for Joint Diseases, 301
East 17th Street, Suite 1402, New
York, New York, 10003, USA
| |
Collapse
|
42
|
Abstract
STUDY DESIGN Bibliometric review of the literature. OBJECTIVE To analyze and quantify the most frequently cited papers in lumbar spine surgery and to measure their impact on the entire lumbar spine literature. SUMMARY OF BACKGROUND DATA Lumbar spine surgery is a dynamic and complex field. Basic science and clinical research remain paramount in understanding and advancing the field. While new literature is published at increasing rates, few studies make long-lasting impacts. METHODS The Thomson Reuters Web of Knowledge was searched for citations of all papers relevant to lumbar spine surgery. The number of citations, authorship, year of publication, journal of publication, country of publication, and institution were recorded for each paper. RESULTS The most cited paper was found to be the classic paper from 1990 by Boden et al that described magnetic resonance imaging findings in individuals without back pain, sciatica, and neurogenic claudication showing that spinal stenosis and herniated discs can be incidentally found when scanning patients. The second most cited study similarly showed that asymptomatic patients who underwent lumbar spine magnetic resonance imaging frequently had lumbar pathology. The third most cited paper was the 2000 publication of Fairbank and Pynsent reviewing the Oswestry Disability Index, the outcome-measure questionnaire most commonly used to evaluate low back pain. The majority of the papers originate in the United States (n=58), and most were published in Spine (n=63). Most papers were published in the 1990s (n=49), and the 3 most common topics were low back pain, biomechanics, and disc degeneration. CONCLUSION This report identifies the top 100 papers in lumbar spine surgery and acknowledges those individuals who have contributed the most to the advancement of the study of the lumbar spine and the body of knowledge used to guide evidence-based clinical decision making in lumbar spine surgery today. LEVEL OF EVIDENCE 3.
Collapse
|
43
|
Abstract
PURPOSE OF REVIEW Recent investigations have substantially improved our understanding of myocardial injury after noncardiac surgery (MINS). RECENT FINDINGS MINS is defined as a prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. MINS occurs in 8% of adults undergoing major noncardiac surgery and is diagnosed with an elevated postoperative troponin measurement. MINS is associated with significant morbidity, and approximately 10% of patients experiencing MINS will die within 30 days. There is a dose-graded response in mortality and time to death with increasing levels of postoperative troponin elevations. Most patients (>80%) suffering from MINS will not experience an ischemic symptom. Without troponin monitoring, the majority of MINS events would go undetected. To avoid missing these prognostically relevant events, guidelines now recommend perioperative troponin monitoring in high-risk patients having noncardiac surgery. In patients who suffer MINS, risk-adjusted observational data suggest that aspirin and a statin can reduce the risk of 30-day mortality. SUMMARY Among adults, MINS is the most common cardiovascular complication that occurs after noncardiac surgery. Given that worldwide 200 million adult patients undergo major noncardiac surgery each year, at least 8 million of these patients will suffer MINS making this a substantial public health problem.
Collapse
|
44
|
Inpatient mortality after orthopaedic surgery. INTERNATIONAL ORTHOPAEDICS 2015; 39:1307-14. [DOI: 10.1007/s00264-015-2702-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/30/2015] [Indexed: 10/23/2022]
|
45
|
Deyo RA. Fusion surgery for lumbar degenerative disc disease: still more questions than answers. Spine J 2015; 15:272-4. [PMID: 25598279 DOI: 10.1016/j.spinee.2014.11.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 11/08/2014] [Indexed: 02/03/2023]
Abstract
Yoshihara H, Yoneoka D. National trends in the surgical treatment for lumbar degenerative disc disease: United States, 2000 to 2009. Spine J 2015;15:265-71 (in this issue).
Collapse
Affiliation(s)
- Richard A Deyo
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA; Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USA; Kaiser Northwest Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227-1098, USA.
| |
Collapse
|
46
|
Number of recent inpatient admissions as a risk factor for increased complications, length of stay, and cost in patients undergoing posterior lumbar fusion. Spine (Phila Pa 1976) 2014; 39:2148-56. [PMID: 25271515 DOI: 10.1097/brs.0000000000000639] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To identify risk factors for increased complication rate, hospital charges, and length of stay in patients undergoing posterior lumbar fusion. SUMMARY OF BACKGROUND DATA A better understanding of risk factors for perioperative complications in patients undergoing posterior lumbar fusion can aid with patient selection and postoperative monitoring. Previous studies have assessed the impact of factors such as body mass index, age, and American Society of Anesthesiologists physical status classification on complication rate. METHODS Data were acquired from the institution's quality improvement data set. Preoperative demographic factors included sex, age, number of inpatient admissions in the prior year, body mass index, Charlson comorbidity score, American Society of Anesthesiologists physical status classification, number of levels fused, operative duration, and medications on admission. Complications recorded included pneumonia, myocardial infarction, venous thromboembolic event, hardware failure, readmission, or unplanned return to the operating room. Multivariate regression was used to identify predictors of increased complication rate, hospital charges, and length of stay. RESULTS A total of 462 patients were included. A history of more than 1 admission in the prior year was the only variable significantly associated with increased complication rate (odds ratio 10.56, P < 0.0001). History of more than 1 admission in the prior year (+1.92 d, P < 0.0001), operative duration more than 5 hours (+0.81 d, P = 0.008), and American Society of Anesthesiologists physical status classification 3 or greater (+0.75 d, P = 0.01) were associated with increased length of stay, whereas history of more than 1 admission in the prior year (+$27,798, P < 0.0001), fusion of 4 or more levels (+$38,043, P < 0.0001), and operative duration more than 5 hours (+$40,298, P < 0.0001) were associated with increased total charges. CONCLUSION The number of inpatient admissions in the prior year was found to be a more powerful predictor of perioperative risk after lumbar fusion than metrics evaluated in prior studies, such as age, body mass index, and comorbidities. LEVEL OF EVIDENCE 3.
Collapse
|
47
|
Stundner O, Chiu YL, Sun X, Ramachandran SK, Gerner P, Vougioukas V, Mazumdar M, Memtsoudis SG. Sleep apnoea adversely affects the outcome in patients who undergo posterior lumbar fusion: a population-based study. Bone Joint J 2014; 96-B:242-8. [PMID: 24493191 DOI: 10.1302/0301-620x.96b2.31842] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite the increasing prevalence of sleep apnoea, little information is available regarding its impact on the peri-operative outcome of patients undergoing posterior lumbar fusion. Using a national database, patients who underwent lumbar fusion between 2006 and 2010 were identified, sub-grouped by diagnosis of sleep apnoea and compared. The impact of sleep apnoea on various outcome measures was assessed by regression analysis. The records of 84,655 patients undergoing posterior lumbar fusion were identified and 7.28% (n = 6163) also had a diagnostic code for sleep apnoea. Compared with patients without sleep apnoea, these patients were older, more frequently female, had a higher comorbidity burden and higher rates of peri-operative complications, post-operative mechanical ventilation, blood product transfusion and intensive care. Patients with sleep apnoea also had longer and more costly periods of hospitalisation. In the regression analysis, sleep apnoea emerged as an independent risk factor for the development of peri-operative complications (odds ratio (OR) 1.50, confidence interval (CI) 1.38;1.62), blood product transfusions (OR 1.12, CI 1.03;1.23), mechanical ventilation (OR 6.97, CI 5.90;8.23), critical care services (OR 1.86, CI 1.71;2.03), prolonged hospitalisation and increased cost (OR 1.28, CI 1.19;1.37; OR 1.10, CI 1.03;1.18). Patients with sleep apnoea who undergo posterior lumbar fusion pose significant challenges to clinicians.
Collapse
Affiliation(s)
- O Stundner
- Paracelsus Medical University, Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Sullivan MP, Baldwin KD, Donegan DJ, Mehta S, Ahn J. Geriatric fractures about the hip: divergent patterns in the proximal femur, acetabulum, and pelvis. Orthopedics 2014; 37:151-7. [PMID: 24762143 DOI: 10.3928/01477447-20140225-50] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 10/09/2013] [Indexed: 02/03/2023]
Abstract
Geriatric acetabular, pelvis, and subtrochanteric femur fractures are poorly understood and rapidly growing clinical problems. The purpose of this study was to describe the epidemiologic trends of these injuries as compared with traditional fragility fractures about the hip. From 1993 to 2010, the Nationwide Inpatient Sample (NIS) recorded more than 600 million Medicare-paid hospital discharges. This retrospective study used the NIS to compare patients with acetabular fractures (n=87,771), pelvic fractures (n=522,831), and subtrochanteric fractures (n=170,872) with patients with traditional hip fractures (intertrochanteric and femoral neck, n=3,495,742) with regard to annual trends over an 18-year period in incidence, length of hospital stay, hospital mortality, transfers from acute care institutions, and hospital charges. Traditional hip fractures peaked in 1996 and declined by 25.7% by 2010. During the same 18-year period, geriatric acetabular fractures increased by 67%, subtrochanteric femur fractures increased by 42%, and pelvic fractures increased by 24%. Hospital charges, when controlling for inflation, increased roughly 50% for all fracture types. Furthermore, transfers from outside acute care hospitals for definitive management stayed elevated for acetabular fractures as compared with traditional hip fractures, suggesting a greater need for tertiary care of acetabular fractures. Geriatric acetabular fractures are rapidly increasing, whereas traditional hip fractures continue to decline. Patients with these injuries are more likely to be transferred from their hospital of presentation to another acute care institution, possibly increasing costs and complications. This is likely related to their complexity and the lack of consensus regarding optimal management.
Collapse
|
49
|
Andrade NS, Flynn JP, Bartanusz V. Twenty-year perspective of randomized controlled trials for surgery of chronic nonspecific low back pain: citation bias and tangential knowledge. Spine J 2013; 13:1698-704. [PMID: 24012430 DOI: 10.1016/j.spinee.2013.06.071] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 05/27/2013] [Accepted: 06/24/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT After decades of clinical research, the role of surgery for chronic nonspecific low back pain (CNLBP) remains equivocal. Despite significant intellectual, human, and economic investments into randomized controlled trials (RCTs) in the past two decades, the role of surgery in the treatment for CNLBP has not been clarified. PURPOSE To delineate the historical research agenda of surgical RCTs for CNLBP performed between 1993 and 2012 investigating whether conclusions from earlier published trials influenced the choice of research questions of subsequent RCTs on elucidating the role of surgery in the management of CNLBP. STUDY DESIGN Literature review. METHODS We searched the literature for all RCTs involving surgery for CNLBP. We reviewed relevant studies to identify the study question, comparator arms, and sample size. Randomized controlled trials were classified as "indication" trials if they evaluated the effectiveness of surgical therapy versus nonoperative care or as "technical" if they compared different surgical techniques, adjuncts, or procedures. We used citation analysis to determine the impact of trials on subsequent research in the field. RESULTS Altogether 33 technical RCTs (3,790 patients) and 6 indication RCTs (981 patients) have been performed. Since 2007, despite the unclear benefits of surgery reported by the first four indication trials published in 2001 to 2006, technical trials have continued to predominate (16 vs. 2). Of the technical trials, types of instrumentation (13 trials, 1,332 patients), bone graft materials and substitutes (11 trials, 833 patients), and disc arthroplasty versus fusion (5 trials, 1,337 patients) were the most common comparisons made. Surgeon authors have predominantly cited one of the indication trials that reported more favorable results for surgery, despite a lack of superior methodology or sample size. Trials evaluating bone morphogenic protein, instrumentation, and disc arthroplasty were all cited more frequently than the largest trial of surgical versus nonsurgical therapy. CONCLUSIONS The research agenda of RCTs for surgery of CNLBP has not changed substantially in the last 20 years. Technical trials evaluating nuances of surgical techniques significantly predominate. Despite the publication of four RCTs reporting equivocal benefits of surgery for CNLBP between 2001 and 2006, there was no change in the research agenda of subsequent RCTs, and technical trials continued to outnumber indication trials. Rather than clarifying what, if any, indications for surgery exist, investigators in the field continue to analyze variations in surgical technique, which will probably have relatively little impact on patient outcomes. As a result, clinicians unfortunately have little evidence to advise patients regarding surgical intervention for CNLBP.
Collapse
Affiliation(s)
- Nicholas S Andrade
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229-3900, USA
| | | | | |
Collapse
|
50
|
Perioperative complications and mortality after spinal fusions: analysis of trends and risk factors. Spine (Phila Pa 1976) 2013; 38:1970-6. [PMID: 23928714 DOI: 10.1097/brs.0b013e3182a62527] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To analyze the trends in complications and mortality after spinal fusions. SUMMARY OF BACKGROUND DATA Utilization of spinal fusions has been increasing during the past decade. It is essential to evaluate surgical outcomes to better identify patients who benefit most from surgical intervention. Integration of empiric evidence from large administrative databases into clinical decision making is instrumental in providing higher-quality, evidence-based, patient-centered care. METHODS This study used Nationwide Inpatient Sample data from 2001 through 2010. Patients who underwent spinal fusions were identified using the CCS (Clinical Classifications Software) and ICD-9 (International Classification of Diseases, 9th Revision) codes. Data on patient comorbidities, primary diagnosis, and postoperative complications were obtained via ICD-9 diagnosis codes and via CCS categories. National estimates were calculated using weights provided as part of the database. Time trend analysis for average length of stay, total charges, mortality, and comorbidity burden was performed. Univariate and multivariate models were constructed to identify predictors of mortality and postoperative complications. RESULTS An estimated 3,552,873 spinal fusions were performed in the United States between 2001 and 2010. The national bill for spinal fusions increased from $10 billion to $46.8 billion. Today, patients are older and have a greater comorbidity burden than 10 years ago. Mortality remained relatively constant at 0.46%, 1.2%, and 0.14% for cervical, thoracic, and lumbar fusions, respectively. Morbidity rates showed an increasing trend at all levels. Multivariate analysis of 19 procedures and patient-related risk factors and 9 perioperative complications identified 85 statistically significant (P< 0.01) interactions. CONCLUSION The data on perioperative risks and risk factors for postoperative complications of spinal fusions presented in this study is pivotal to appropriate surgical patient selection and well-informed risk-benefit evaluation of surgical intervention. LEVEL OF EVIDENCE N/A.
Collapse
|