Differences in primary and revision deformity surgeries: following 1,063 primary thoracolumbar adult spinal deformity fusions over time

Fusion Mass Screws in Revision Spinal Deformity Surgery: A Simple and Safe Alternative Fixation

BACKGROUND

Revision spinal deformity surgery has a high rate of complications. Fixation may be challenging due to altered anatomy. Screws through a fusion mass are an alternative to pedicle screw fixation.

OBJECTIVE

The purpose of this retrospective study was to further elucidate the safety and efficacy of fusion mass screws (FMSs) in revision spinal deformity surgery.

DESIGN

Retrospective case series.

METHODS

Fifteen freehand FMSs were placed in 6 patients with adult spinal deformity between 2016 and 2018 by the senior author. FMSs were combined with pedicle screws, at times at the same level. FMSs were used to save distal levels from fusion, assist in closing a 3-column osteotomy and provide additional fixation in cases of severe instability. Computed tomography (CT) was used to assess bone mineral density (BMD) and thickness of each fusion mass preoperatively along with accuracy of FMS placement postoperatively.

RESULTS

The mean BMD of the fusion mass was 397 Hounsfield units (HU; range: 156-628 HU). The mean AP thickness of the fusion mass was 15.5 ± 4.8 mm (range: 8.6-24.4 mm). The mean FMS length was 35.3 ± 5.5 mm (range: 25-40 mm). There was no evidence of FMS loosening, breakage, or pseudarthrosis at latest follow-up (mean: 2.2 years, range: 1.4-3.1 years). No neurologic deficits were observed. 1/15 screws had a low-grade breach into the canal (<2 mm). No patients required revision surgery.

CONCLUSION

FMSs may be used to augment fixation in revision spinal deformity cases when pedicle screw placement may be challenging. FMSs may also provide an additional anchor at levels with pedicular fixation.

LEVEL OF EVIDENCE: 3

Patient satisfaction after multiple revision surgeries for adult spinal deformity

OBJECTIVE

Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of health-related quality of life. The authors hypothesized that patients who underwent multiple revision surgeries following ASD correction would exhibit lower self-reported satisfaction scores.

METHODS

This was a retrospective cohort study of 668 patients who underwent ASD surgery and were eligible for a minimum 2-year follow-up. Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1), after the first revision only (period 2), and after the second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. Scoliosis Research Society-22 (SRS-22r) health-related quality-of-life satisfaction subscore and total satisfaction scores were evaluated at all periods using multiple linear regression and adjustment for age, sex, and Charlson Comorbidity Index.

RESULTS

In total, 46.6% of the study patients had undergone prior spine surgery before their index surgery. The overall revision rate was 21.3%. Among patients with no spine surgery prior to the index surgery, SRS-22r satisfaction scores increased from period 0 to 1 (from 2.8 to 4.3, p < 0.0001), decreased after one revision from period 1 to 2 (4.3 to 3.9, p = 0.0004), and decreased further after a second revision from period 2 to 3 (3.9 to 3.3, p = 0.0437). Among patients with spine surgery prior to the index procedure, SRS-22r satisfaction increased from period 0 to 1 (2.8 to 4.2, p < 0.0001) and decreased from period 1 to 2 (4.2 to 3.8, p = 0.0011). No differences in follow-up time from last surgery were observed (all p > 0.3). Among patients with multiple revisions, 40% experienced rod fracture, 40% proximal junctional kyphosis, and 33% pseudarthrosis.

CONCLUSIONS

Among patients undergoing ASD surgery, revision surgery is associated with decreased satisfaction, and multiple revisions are associated with additive detriment to satisfaction among patients initially undergoing primary surgery. These findings have direct implications for preoperative patient counseling and establishment of postoperative expectations.

Risk Factors for Revision Surgery After Primary Adult Thoracolumbar Deformity Surgery

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

The aim was to identify the risk factors for revision surgery within 2 years of patients undergoing primary adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

Previous literature reports estimate 20% of patients undergoing thoracolumbar ASD correction undergo reoperation within 2 years. There is limited published data regarding specific risk factors for reoperation in ASD surgery in the short term and long term.

METHODS

The authors queried the MarketScan database in order to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2015. Patient-level factors and revision risk were investigated during 2 years after primary ASD surgery. Patients under the age of 18 years and those with any prior history of trauma or tumor were excluded from this study.

RESULTS

A total 7422 patients underwent ASD surgery during 2007-2015 in the data set. Revision rates were 13.1% at 90 days, 14.5% at 6 months, 16.7% at 1 year, and 19.3% at 2 years. In multivariate multiple logistic regression analysis, obesity [adjusted odds ratio (OR): 1.58, P<0.001] and tobacco use (adjusted OR: 1.38, P=0.0011) were associated with increased odds of reoperation within 2 years. Patients with a combined anterior-posterior approach had lower odds of reoperation compared with those with posterior only approach (adjusted OR: 0.66, P=0.0117).

CONCLUSIONS

Obesity and tobacco are associated with increased odds of revision surgery within 2 years of index ASD surgery. Male sex and combined surgical approach are associated with decreased odds of revision surgery.

Independent Predictors of Revision Lumbar Fusion Outcomes and the Impact of Spine Surgeon Variability: Does It Matter Whether the Primary Surgeon Revises?

BACKGROUND

There is a paucity of information regarding treatment strategies and variables affecting outcomes of revision lumbar fusions.

OBJECTIVE

To evaluate the influence of primary vs different surgeon on functional outcomes of revisions.

METHODS

All elective lumbar fusion revisions, March 2018 to August 2019, were retrospectively categorized as performed by the same or different surgeon who performed the primary surgery. Oswestry Disability Index (ODI) and clinical variables were collected. Multiple logistic regression identified multivariable-adjusted odds ratio (OR) of independent variables analyzed.

RESULTS

Of the 130 cases, 117 (90%) had complete data. There was a slight difference in age in the same (median: 59; interquartile range [IQR], 54-66) and different surgeon (median: 67; IQR, 56-72) groups (P = .02); all other demographic variables were not significantly different (P > .05). Revision surgery with a different surgeon had an ODI improvement (median: 8; IQR, 2-14) greater than revisions performed by the same surgeon (median: 1.5; IQR, -3 to 10) (P < .01). Revisions who achieved minimum clinically important difference (MCID) performed by different surgeon (59.7%) were also significantly greater than the ones performed by the same surgeon (40%) (P = .042). Multivariate analysis demonstrated that a different surgeon revising (OR, 2.37; [CI]: 1.007-5.575, P = .04) was an independent predictor of MCID achievement, each additional 2 years beyond the last surgery conferred a 2.38 ([CI]: 1.36-4.14, P < .01) times greater odds of MCID achievement, and the anterior lumbar interbody fusion approach decreased the chance of achieving MCID (OR, 0.19; [CI]: 0.04-0.861, P = .03).

CONCLUSION

All revision lumbar spinal fusion approaches may not achieve the same outcomes. This analysis suggests that revision surgeries may have better outcomes when performed by a different surgeon.

True Differences in Poor Outcome Risks Between Revision and Primary Lumbar Spine Surgeries

Background: Previous studies have shown that the rates of complications associated with revision spine surgery are higher than those of primary spine surgery. However, there is a lack of research exploring the difference in magnitude of risk of poor outcomes between primary and revision lumbar spine surgeries. Purposes: We sought to compare the risks of poor outcomes for primary and revision lumbar spine surgeries and to analyze different measures of risk to better understand the true differences between the 2 forms of surgery. Methods: This retrospective observational study used data from the Quality Outcomes Database Lumbar Spine Surgical Registry from 2012 to 2018. We included individuals who received primary or revision surgery due to degenerative lumbar disorders. Outcome variables collected were complications within 30 days of surgery and 3 destination variables, specifically, (1) 30-day hospital readmission, (2) 30-day return to operating room, and (3) revision surgery within 3 months. Measures of risk considered were odds ratio (OR), relative risk (RR), relative risk increase (RRI), and absolute risk increase (ARI). Results: There were 31,843 individuals who received primary surgery and 7889 who received revision surgery. After controlling for baseline descriptive variables and comorbidities, revision surgery increased the odds of 4 complications and all 3 destination variables. Risk ratios reflected smaller magnitudes but similar findings as the statistically significant ORs. Conclusion: Revision surgery is related to higher overall risks than primary surgery, but the true magnitudes of these risks are very small. RRI and ARI should be included when reporting ORs to better clarify the significance.

Predictors of 2-year reoperation in Medicare patients undergoing primary thoracolumbar deformity surgery

OBJECTIVE

This was a retrospective cohort study in which the authors used a nationally representative administrative database. Their goal was to identify the risk factors for reoperation in Medicare patients undergoing primary thoracolumbar adult spinal deformity (ASD) surgery. Previous literature reports estimate that 20% of patients undergoing thoracolumbar ASD correction undergo revision surgery within 2 years. Most published data discuss risk factors for revision surgery in the general population, but these have not been explored specifically in the Medicare population.

METHODS

Using the MarketScan Medicare Supplemental database, the authors identified patients who were diagnosed with a spinal deformity and underwent ASD surgery between 2007 and 2015. The interactions of patient demographics, surgical factors, and medical factors with revision surgery were investigated during the 2 years following primary ASD surgery. The authors excluded patients without Medicare insurance and those with any prior history of trauma or tumor.

RESULTS

Included in the data set were 2564 patients enrolled in Medicare who underwent ASD surgery between 2007 and 2015. The mean age at diagnosis with spinal deformity was 71.5 years. A majority of patients (68.5%) were female. Within 2 years of follow-up, 661 (25.8%) patients underwent reoperation. Preoperative osteoporosis (OR 1.58, p < 0.0001), congestive heart failure (OR 1.35, p = 0.0161), and paraplegia (OR 2.41, p < 0.0001) independently increased odds of revision surgery. The use of intraoperative bone morphogenetic protein was protective against reoperation (OR 0.71, p = 0.0371). Among 90-day postoperative complications, a wound complication was the strongest predictor of undergoing repeat surgery (OR 2.85, p = 0.0061). The development of a pulmonary embolism also increased the odds of repeat surgery (OR 1.84, p = 0.0435).

CONCLUSIONS

Approximately one-quarter of Medicare patients with ASD who underwent surgery required an additional spinal surgery within 2 years. Baseline comorbidities such as osteoporosis, congestive heart failure, and paraplegia, as well as short-term complications such as pulmonary embolism and wound complications significantly increased the odds of repeat surgery.

Black Race as a Social Determinant of Health and Outcomes After Lumbar Spinal Fusion Surgery: A Multistate Analysis, 2007 to 2014

STUDY DESIGN

A retrospective analysis of patient hospitalization and discharge records.

OBJECTIVE

To examine the association between race and inpatient postoperative complications following lumbar spinal fusion surgery.

SUMMARY OF BACKGROUND DATA

Racial disparities in healthcare have been demonstrated across a range of surgical procedures. Previous research has identified race as a social determinant of health that impacts outcomes after lumbar spinal fusion surgery. However, these studies are limited in that they are outdated, contain data from a single institution, analyze small limited samples, and report limited outcomes. Our study aims to expand and update the literature examining the association between race and inpatient postoperative complications following lumbar spine surgery.

METHODS

We analyzed 267,976 patient discharge records for inpatient lumbar spine surgery using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We used unadjusted bivariate analysis, adjusted multivariable, and stratified analysis to compare patient demographics, present-on-admission comorbidities, hospital characteristics, and complications by categories of race/ethnicity.

RESULTS

Black patients were 8% and 14% more likely than white patients to experience spine surgery specific complications (adjusted odds ratios [aOR]: 1.08, 95% confidence interval [CI]: 1.03-1.13) and general postoperative complications (aOR: 1.14, 95% CI: 1.07-1.20), respectively. Black patients, compared with white patients, also had increased adjusted odds of 30-day readmissions (aOR: 1.13, 95% CI: 1.07-1.20), 90-day readmissions (aOR: 1.07, 95% CI: 1.02-1.13), longer length of stay (LOS) (adjusted Incidence Rate Ratio: 1.15, 95% CI: 1.14-1.16), and higher total charges (adjusted Incidence Rate Ratio: 1.08, 95% CI: 1.07-1.09).

CONCLUSION

Our findings demonstrate that black patients, as compared with white patients, are more likely to have postoperative complications, longer postoperative lengths of stay, higher total hospital charges, and increased odds of 30- and 90-day readmissions following lumbar spinal fusion surgery.

LEVEL OF EVIDENCE

4.