Predicting critical care unit-level complications after long-segment fusion procedures for adult spinal deformity

Surgical Factors and Treatment Severity for Perioperative Complications Predict Hospital Length of Stay in Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review of prospectively collected multicenter registry data.

OBJECTIVE

The aim of this study was to determine whether surgical variables and complications as graded by treatment severity impact postoperative hospital length of stay (LOS).

SUMMARY OF BACKGROUND DATA

Surgical treatment can substantially improve quality of life for patients with adult spinal deformity (ASD). However, surgical treatment is associated with high complication rates, which may impact hospital LOS. Classifying complications by severity of subsequent treatment may allow surgeons to better understand complications and predict their impact on important outcome metrics, including LOS.

METHODS

Patients enrolled in a multicenter, prospectively enrolled database for ASD were assessed for study inclusion. Complications were graded based on intervention severity. Associations between LOS, complication intervention severity, and surgical variables (fusion length, use of interbody fusion, use of major osteotomy, primary versus revision surgery, same day vs. staged surgery, and surgical approach), were assessed. Two multivariate regression models were constructed to assess for independent associations with LOS.

RESULTS

Of 1183 patients meeting inclusion criteria, 708 did not and 475 did experience a perioperative complication during their index hospitalization, with 660 and 436 included in the final cohorts, respectively. Among those with complications, intervention severities included 14.9% with no intervention, 68.6% with minor, 8.9% with moderate, and 7.6% with severe interventions. Multivariate regression modeling demonstrated that length of posterior fusion, use of major osteotomy, staged surgery, and severity of intervention for complications were significantly associated with LOS.

CONCLUSION

Careful selection of surgical factors may help reduce hospital LOS following surgery for ASD. Classification of complications by treatment severity can help surgeons better understand and predict the implications of complications, in turn assisting with surgical planning and patient counseling.Level of Evidence: 4.

The use of tranexamic acid in adult spinal deformity: is there an optimal dosing strategy?

BACKGROUND CONTEXT

ASD (Adult spinal deformity) surgery often entails complex osteotomies and realignment procedures, particularly in the setting of rigid deformities. Although previous studies have established the efficacy of tranexamic acid (TXA), data evaluating the widely variable dosing regimens remains sparse.

PURPOSE

To improve understanding of blood loss and transfusion requirements for low-dose and high-dose TXA regimens for adult spinal deformity (ASD) surgery.

STUDY DESIGN/SETTING

This is a retrospective cohort study of 318 ASD patients who received TXA. Outcome measures include estimated blood loss (EBL), perioperative transfusion requirement, and complications.

METHODS

A retrospective review was conducted on 318 ASD patients: 258 patients received a low-dose regimen of TXA (10 or 20 mg/kg loading dose with a 1 or 2 mg/kg/h maintenance dose) and 60 patients received a high-dose regimen of TXA (40 mg/kg loading dose with a 1 mg/kg/h maintenance dose, 30 mg/kg loading dose with a 10 mg/kg/h maintenance dose, or 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose).

RESULTS

Compared with the low-dose TXA group, the high-dose TXA group had significantly decreased EBL (1402 vs. 1793 mL, p=.009), blood volume lost (30.3 vs. 39.4%, p=.01), intraoperative packed red blood cell (pRBC) transfusion (0.9 vs. 1.6 U, p<.0001), and intraoperative platelet transfusion (0 vs. 0.1 U, p<.0001). High-dose TXA was predictive of 515 cc less EBL (p=.002), 11.4% less blood volume lost (p=.004), and 1 U pRBC less transfused intraoperatively (p<.0001) than the low-dose TXA group. The high-dose TXA group had a higher incidence of postop atrial fibrillation (5 vs. 0%, p<.0001) and myocardial infarction (1.7 vs. 0%, p=.04).

CONCLUSIONS

Varying dosing regimens of TXA are utilized for ASD surgery, with a prevailing theme of dosing ambiguity. These data demonstrate that high-dose TXA is more effective than low-dose TXA in reducing blood loss and blood product transfusion requirement in ASD surgery. Importantly, rates of MI and postop AF were higher in the high-dose TXA group.