Morbidity and mortality after spinal deformity surgery in patients 75 years and older: complications and predictive factors

Clinical Outcomes and Complication Profile of Spine Surgery in Septuagenarians and Octogenarians: Case Series

OBJECTIVE

The aging global population presents an increasing challenge for spine surgeons. Advancements in spine surgery, including minimally invasive techniques, have broadened treatment options, potentially benefiting older patients. This study aims to explore the clinical outcomes of spine surgery in septuagenarians and octogenarians.

METHODS

This retrospective analysis, conducted at a US tertiary center, included patients aged 70 and older who underwent elective spine surgery for degenerative conditions. Data included the Charlson Comorbidity Index (CCI), ASA classification, surgical procedures, intraoperative and postoperative complications, and reoperation rates. The objective of this study was to describe the outcomes of our cohort of older patients and discern whether differences existed between septuagenarians and octogenarians.

RESULTS

Among the 120 patients meeting the inclusion criteria, there were no significant differences in preoperative factors between the age groups (P > 0.05). Notably, the septuagenarian group had a higher average number of fused levels (2.36 vs. 0.38, P = 0.001), while the octogenarian group underwent a higher proportion of minimally invasive procedures (P = 0.012), resulting in lower overall bleeding in the oldest group(P < 0.001). Mobility outcomes were more favorable in septuagenarians, whereas octogenarians tended to maintain or experience a decline in mobility(P = 0.012). A total of 6 (5%) intraoperative complications and 12 (10%) postoperative complications were documented, with no statistically significant differences observed between the groups.

CONCLUSIONS

This case series demonstrates that septuagenarians and octogenarians can achieve favorable clinical outcomes with elective spine surgery. Spine surgeons should be well-versed in the clinical and surgical care of older adults, providing optimal management that considers their increased comorbidity burden and heightened fragility.

Body Mass Index, Sex, and Age Are Predictors of Discharge to a Post-acute Care Facility Following Total Ankle Arthroplasty

BACKGROUND

The utilization of total ankle arthroplasty (TAA) continues to increase. Discharge to a post-acute care (PAC) facility can increase patient morbidity and postoperative costs. The purpose of this study is to investigate the effects of age and body mass index (BMI) on discharge to a PAC facility and hospital length of stay (LOS) following TAA.

METHODS

A retrospective review of patients who underwent TAA from the National Surgical Quality Improvement Program (NSQIP) database was performed. Using overweight patients as the reference BMI group, sex- and age-adjusted log-binomial regression models were utilized to estimate risk ratios of BMI categories for being discharged to a PAC facility. A linear regression was utilized to estimate the effect of BMI category on hospital LOS.

RESULTS

Obese patients had 1.36 times the risk of overweight patients (P = .040), and morbidly obese patients had 2 times risk of overweight patients (P = .001) of being discharged to a PAC facility after TAA. Men had 0.48 times the risk of women (P < .001). Compared with patients aged 18 to 44 years, patients aged ≥65 years had 4.13 times the risk (P = .012) of being discharged to a PAC facility after TAA. Relative to overweight patients, on average there was no difference in hospital LOS for underweight patients, but healthy weight patients stayed an additional 0.30 days (P=.003), obese patients stayed an additional 0.18 days (P = .011), and morbidly obese patients stayed an additional 0.33 days (P = .009). Men stayed 0.29 fewer hospital days than women (P < .001) on average.

CONCLUSION

Women and patients who are obese or morbidly obese have a longer hospital LOS and an increased chance of being discharged to a PAC facility. Increasing age is also associated with an increased risk of being discharged to a PAC. These may be important factors when developing and discussing the postoperative plan with patients prior to TAA.

LEVELS OF EVIDENCE

Level III.

Comparative efficacy of robotic-assisted and freehand techniques for pedicle screw placement in spinal disorders: a meta-analysis and systematic review

The efficacy and safety of robotic-assisted pedicle screw placement compared to traditional fluoroscopy-guided techniques are of great interest in the field of spinal surgery. This systematic review and meta-analysis aimed to compare the outcomes of these two methods in patients with spinal diseases. Following the PRISMA guidelines, we conducted a systematic search across PubMed, Embase, Web of Science, and Cochrane Library. We included randomized controlled trials comparing robotic-assisted and fluoroscopy-guided pedicle screw placement in patients with spinal diseases. Outcome measures included the accuracy of pedicle screw placement, postoperative complication rates, intraoperative radiation exposure time, and duration of surgery. Data were analyzed using Stata software. Our analysis included 12 studies. It revealed significantly higher accuracy in pedicle screw placement with robotic assistance (odds ratio [OR] = 2.83, 95% confidence interval [CI] = 2.20-3.64, P < 0.01). Postoperative complication rates, intraoperative radiation exposure time, and duration of surgery were similar between the two techniques (OR = 0.72, 95% CI = 0.31 to 1.68, P = 0.56 for complication rates; weighted mean difference [WMD] = - 0.13, 95% CI = - 0.93 to 0.68, P = 0.86 for radiation exposure time; WMD = 0.30, 95% CI = - 0.06 to 0.66, P = 0.06 for duration of surgery). Robotic-assisted pedicle screw placement offers superior placement accuracy compared to fluoroscopy-guided techniques. Postoperative complication rates, intraoperative radiation exposure time, and duration of surgery were comparable for both methods. Future studies should explore the potential for fewer complications with the robotic-assisted approach as suggested by the lower point estimate.

Use of Dynamic Spinal Instruments (Dynesys) in Adult Spinal Deformities According to Silva-Lenke and Berjano-Lamartina Classifications

BACKGROUND

Adult spinal deformities (ASD) present complex challenges in spine surgery. The diverse nature of these deformities requires a comprehensive understanding of their classification and treatment options. Traditional approaches, such as fusion and rigid stabilization are associated with complications, including screw loosening, breakage, proximal junctional kyphosis (PJK), and pseudoarthrosis. Dynamic stabilization techniques have emerged as promising alternatives, to reduce these complications and preserve spinal motion.

OBJECTIVE

This study investigated the effectiveness of dynamic stabilization using the Dynesys system in the surgical treatment of adult degenerative spinal deformities, with a particular emphasis on their classification.

METHODS

ASDs were classified according to the Berjano-Lamartina (BL) and Silva-Lenke (SL) classifications. We analyzed the efficacy of the Dynesys system in enhancing sagittal balance, radiological parameters, and clinical outcomes in this context.

RESULTS

Dynamic stabilization of patients with ASDs using the Dynesys system significantly improved the visual analog scale and Oswestry Disability Index scores and decreased the complication rates. Patients with BL types 2, 3, and 4 experienced a significant improvement in sagittal balance followed by sagittal vertical axis measurements (p = 0.045, p = 0.015, and p < 0.0001, respectively).

CONCLUSION

The SL and BL classifications, which were originally developed for rigid spinal stabilization, can be applied in dynamic stabilization. Furthermore, dynamic stabilization using the Dynesys system can be used as an alternative to rigid stabilization in SL levels 2 and 3, and BL types 1, 2, and 3, and in some patients with type 4 ASDs.

Transforaminal endoscopic lumbar foraminotomy for octogenarian patients

Background

Radiculopathy caused by lumbar foraminal stenosis in older people has become more common in the aging general population. However, patients aged ≥80 years rarely undergo conventional open surgery under general anesthesia because of the high risk of peri-operative morbidity and adverse events. Therefore, less invasive surgical alternatives are needed for older or medically handicapped patients. Transforaminal endoscopic lumbar foraminotomy (TELF) under local anesthesia may be helpful in at-risk patients, although only limited information is available regarding the clinical outcomes of this procedure in octogenarians. Therefore, this study aimed to investigate the safety and efficacy of TELF for treating radiculopathy induced by foraminal stenosis in octogenarian patients.

Methods

Overall, 32 consecutive octogenarian patients with lumbar foraminal stenosis underwent TELF between January 2019 and January 2021. The inclusion criterion was unilateral radiculopathy secondary to lumbar foraminal stenosis. The pain focus was confirmed using imaging studies and selective nerve blocks. Full-scale foraminal decompression was performed using a percutaneous transforaminal endoscopic approach under local anesthesia. Surgical outcomes were assessed using the visual analog pain score, Oswestry Disability Index, and modified MacNab criteria.

Results

The pain scores and functional outcomes improved significantly during the 24-month follow-up period, and the rate of clinical improvement was 93.75% in 30 of the 32 patients. None of the patients experienced systemic complications.

Conclusion

TELF under local anesthesia is an effective and safe treatment for foraminal stenosis in octogenarian or medically compromised patients. The mid-term follow-up did not reveal any significant progression in spinal stability. Therefore, this endoscopic procedure can be an effective alternative to aggressive surgery for managing lumbar foraminal stenosis in octogenarian patients with intractable radiculopathy.

Transforaminal Endoscopic Lumbar Lateral Recess Decompression for Octogenarian Patients

The incidence of radiculopathy due to lumbar spinal stenosis has been on the increase in the aging population. However, patients aged ≥ 80 years hesitate to undergo conventional open surgery under general anesthesia because of the risk of postoperative morbidity and adverse events. Therefore, less invasive surgical alternatives are required for the elderly or medically handicapped patients. Transforaminal endoscopic lumbar lateral recess decompression (TELLRD) may be helpful for those patients. This study aimed to demonstrate the efficacy of TELLRD for treating radiculopathy in octogenarian patients. A total of 21 consecutive octogenarian patients with lumbar foraminal stenosis underwent TELLRD between January 2017 and January 2021. The inclusion criterion was unilateral radiculopathy, which stemmed from lumbar lateral recess stenosis. The pain source was verified using imaging studies and selective nerve blocks. Full-scale lateral canal decompression was performed using a percutaneous transforaminal endoscopic approach under local anesthesia. We found the pain scores and functional status improved significantly during the 24-month follow-up period. The clinical improvement rate was 95.24% (20 of 21 patients) with no systemic complication. In conclusion, endoscopic lateral recess decompression via the transforaminal approach is practical for octogenarian patients.

Risk of spinal surgery among individuals who have been re-vascularized for coronary artery disease

HYPOTHESIS

Revascularization is a more effective intervention to reduce future postop complications.

METHODS

Patients undergoing elective spine fusion surgery were isolated in the PearlDiver database. Patients were stratified by having previous history of vascular stenting (Stent), coronary artery bypass graft (CABG), and no previous heart procedure (No-HP). Means comparison tests (chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, and comorbidities. Binary logistic regression assessed the odds of 30-day and 90-day postoperative (postop) complications associated with each heart procedure (Odds Ratio [95 % confidence interval]). Statistical significance was set p < 0.05.

RESULTS

731,173 elective spine fusion patients included. Overall, 8,401 pts underwent a CABG, 24,037 pts Stent, and 698,735 had No-HP prior to spine fusion surgery. Compared to Stent and No-HP patients, CABG patients had higher rates of morbid obesity, chronic kidney disease, and diabetes (p < 0.001 for all). Meanwhile, stent patients had higher rates of PVD, hypertension, and hyperlipidemia (all p < 0.001). 30-days post-op, CABG patients had significantly higher complication rates including pneumonia, CVA, MI, sepsis, and death compared to No-HP (all p < 0.001). Stent patients vs. No-HF had higher 30-day post-op complication rates including pneumonia, CVA, MI, sepsis, and death. Furthermore, adjusting for age, comorbidities, and sex Stent was significantly predictive of a MI 30-days post-op (OR: 1.90 [1.53-2.34], P < 0.001). Additionally, controlling for levels fused, stent patients compared to CABG patients had 1.99x greater odds of a MI within 30-days (OR: 1.99 [1.26-3.31], p = 0.005) and 2.02x odds within 90-days postop (OR: 2.2 [1.53-2.71, p < 0.001).

CONCLUSION

With regards to spine surgery, coronary artery bypass graft remains the gold standard for risk reduction. Stenting does not appear to minimize risk of experiencing a post-procedure cardiac event as dramatically as CABG.

Advances and Evolving Challenges in Spinal Deformity Surgery

BACKGROUND

Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes.

METHODS

We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases.

RESULTS

Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed.

CONCLUSIONS

The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients.

The ISSG-AO Complication Intervention Score, but Not Major/Minor Designation, is Correlated With Length of Stay Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

The International Spine Study Group-AO (ISSG-AO) Adult Spinal Deformity (ASD) Complication Classification System was developed to improve classification, reporting, and study of complications among patients undergoing ASD surgery. The ISSG-AO system classifies interventions to address complications by level of invasiveness: grade zero (none); grade 1, mild (e.g., medication change); grade 2, moderate (e.g., ICU admission); grade 3, severe (e.g., reoperation related to surgery of interest). To evaluate the efficacy of the ISSG-AO ASD Complication Classification System, we aimed to compare correlations between postoperative length of stay (LOS) and complication severity as classified by the ISSG-AO ASD and traditional major/minor complication classification systems.

METHODS

Patients age ≥18 in a multicenter ASD database who sustained in-hospital complications were identified. Complications were classified with the major/minor and ISSG-AO systems and correlated with LOS using an ensemble-based machine learning algorithm (conditional random forest) and a generalized linear mixed model.

RESULTS

490 patients at 19 sites were included. 64.9% of complications were major, and 35.1% were minor. By ISSG-AO classification, 20.4%, 66.1%, 6.7%, and 6.7% were grades 0-3, respectively. ISSG-AO complication grading demonstrated significant correlation with LOS, whereas major/minor complication classification demonstrated inverse correlation with LOS. In conditional random forest analysis, ISSG-AO classification had the greatest relative importance when assessing correlations across multiple variables with LOS.

CONCLUSIONS

The ISSG-AO system may help identify specific complications associated with prolonged LOS. Targeted interventions to avoid or reduce these complications may improve ASD surgical quality and resource utilization.

Persistent Orthostatic Hypotension Following Surgery for Adult Spinal Deformity: Prevalence, Risk Factors, and Cardiovascular Evaluation

STUDY DESIGN

Retrospective case-control study.

PURPOSE

To understand the prevalence of persistent orthostatic hypotension (POH), as well as its risk factors and cardiovascular pathology, in patients receiving surgery for the adult spinal deformity (ASD).

OVERVIEW OF LITERATURE

Although reports of the incidence of and risk factors for POH in different spinal disorders have recently been published, we are not aware of the comprehensive evaluation of POH following surgery for ASD.

METHODS

We examined medical records from a single central database for 65 patients receiving surgical treatment for ASD. Statistical comparisons were made between patients who experienced postoperative POH and those who did not, by examining patient and operative characteristics, such as age, sex, comorbidities, functional status, preoperative neurological function, vertebral fractures, three-column osteotomy, total operative time, estimated blood loss, length of stay, and radiographic parameters. The determinants of POH were assessed using multiple logistic regression.

RESULTS

We showed that postoperative POH was a complication of ASD surgery, with a 9% incidence rate. Patients with POH were statistically considerably more likely to require supported walkers due to partial paralysis and to have comorbidities including diabetes and neurodegenerative disease (ND). Furthermore, ND was an independent risk factor for postoperative POH (odds ratio, 4.073; 95% confidence interval, 1.094-8.362; p =0.020). Moreover, perioperative evaluation of the inferior vena cava showed that patients with postoperative POH had preoperative congestive heart failure and had hypovolemia lower postoperative diameter of the inferior vena cava than patients without POH.

CONCLUSIONS

Postoperative POH is a potential complication of ASD surgery. The most pertinent risk factor is having an ND. According to our study, patients who have surgery for ASD may experience alterations in their hemodynamics.

Multidisciplinary conference for complex surgery leads to improved quality and safety

INTRODUCTION

Complex surgery for adult spinal deformity has high rates of complications, reoperations, and readmissions. Preoperative discussions of high-risk operative spine patients at a multidisciplinary conference may contribute to decreased rates of these adverse outcomes through appropriate patient selection and surgical plan optimization. With this goal, we implemented a high-risk case conference involving orthopedic and neurosurgery spine, anesthesia, intraoperative monitoring neurology, and neurological intensive care.

METHODS

Included in this retrospective review were patients ≥ 18 years old meeting one of the following high-risk criteria: 8 + levels fused, osteoporosis with 4 + levels fused, three column osteotomy, anterior revision of the same lumbar level, or planned significant correction for severe myelopathy, scoliosis (> 75˚), or kyphosis (> 75˚). Patients were categorized as Before Conference (BC): surgery before 2/19/2019 or After Conference (AC): surgery after 2/19/2019. Outcome measures include intraoperative and postoperative complications, readmissions, and reoperations.

RESULTS

263 patients were included (96 AC, 167 BC). AC was older than BC (60.0 vs 54.6, p = 0.025) and had lower BMI (27.1 vs 28.9, p = 0.047), but had similar CCI (3.2 vs 2.9 p = 0.312), and ASA Classification (2.5 vs 2.5, p = 0.790). Surgical characteristics, including levels fused (10.6 vs 10.7, p = 0.839), levels decompressed (1.29 vs 1.25, p = 0.863), 3 column osteotomies (10.4% vs 18.6%, p = 0.080), anterior column release (9.4% vs 12.6%, p = 0.432), and revision cases (53.1% vs 52.4%, p = 0.911) were similar between AC and BC. AC had lower EBL (1.1 vs 1.9L, p < 0.001) and fewer total intraoperative complications (16.7% vs 34.1%, p = 0.002), including fewer dural tears (4.2% vs 12.6%, p = 0.025), delayed extubations (8.3% vs 22.8%%, p = 0.003), and massive blood loss (4.2% vs 13.2%, p = 0.018). Length of stay (LOS) was similar between groups (7.2 vs 8.2 days, 0.251). AC had a lower incidence of deep surgical site infections (SSI, 1.0% vs 6.6%, p = 0.038), but a higher rate of hypotension requiring vasopressor therapy (18.8% vs 4.8%, p < 0.001). Other postoperative complications were similar between groups. AC had lower rates of reoperation at 30 (2.1% vs 8.4%, p = 0.040) and 90 days (3.1 vs 12.0%, p = 0.014) and lower readmission rates at 30 (3.1% vs 10.2%, p = 0.038) and 90 days (6.3 vs 15.0%, p = 0.035). On logistic regression, AC patients had higher odds of hypotension requiring vasopressor therapy and lower odds of delayed extubation, intraoperative RBC, and intraoperative salvage blood.

CONCLUSIONS

Following implementation of a multidisciplinary high-risk case conference, 30- and 90-day reoperation and readmission rates, intraoperative complications, and postoperative deep SSIs decreased. Hypotensive events requiring vasopressors increased, but did not result in longer LOS or greater readmissions. These associations suggest a multidisciplinary conference may help improve quality and safety for high-risk spine patients. particularly through minimizing complications and optimizing outcomes in complex spine surgery.

Clinical Results of 10-mm Endoscopic Minimally Invasive Interlaminar Decompression in the Treatment of Lumbar Spinal Stenosis with Degenerative Lumbar Scoliosis and Simple Lumbar Spinal Stenosis

Purpose

The number of patients with lumbar spinal stenosis (LSS) with degenerative lumbar scoliosis (DLS) is gradually increasing as the population ages. The purpose of this study was to evaluate the clinical outcomes of 10-mm endoscopic minimally invasive interlaminar decompression for LSS with DLS and simple LSS.

Material and Methods

The clinical data of 175 consecutive elderly patients with LSS were retrospectively analyzed. They were divided into LSS group and LSS with DLS group based on whether they were accompanied by DLS. Patient demographics, perioperative indicators, and clinical outcomes were recorded. Lumbar spine stability was assessed by imaging data. Meanwhile, visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified Macnab criteria were used to assess clinical outcomes.

Results

There were 129 patients in the LSS group and 46 patients in the LSS with DLS group. Both groups had similar VAS and ODI scores preoperatively, and both were significantly lower postoperatively (P < 0.05). However, patients combined with DLS showed higher VAS scores for low back pain at 3 months and 1 year postoperatively (P < 0.05). In addition, postoperative LL and PI-LL were significantly improved in both groups (P < 0.05). However, patients in LSS with DLS group showed higher PT, PI and PI-LL before and after surgery. According to the modified Macnab criteria, the excellent and good rates were 92.25% and 89.13% in the LSS group and LSS with DLS group at the last follow-up, respectively.

Conclusion

10-mm endoscopic minimally invasive interlaminar decompression for LSS with or without DLS has shown satisfactory clinical outcomes. However, patients with DLS may have higher residual low back pain after surgery.

A Nationwide Study Characterizing the Risk and Outcome Profiles of Multilevel Fusion Procedures in Neuromuscular Scoliosis Patients with Neurofibromatosis Type 1

BACKGROUND

Spine abnormalities are a common manifestation of Neurofibromatosis Type 1 (NF1); however, the outcomes of surgical treatment for NF1-associated spinal deformity are not well explored. The purpose of this study was to investigate the outcome and risk profiles of multilevel fusion surgery for NF1 patients.

METHODS

The National Inpatient Sample was queried for NF1 and non-NF1 patient populations with neuromuscular scoliosis who underwent multilevel fusion surgery involving eight or more vertebral levels between 2004 and 2017. Multivariate regression modeling was used to explore the relationship between perioperative variables and pertinent outcomes.

RESULTS

Of the 55,485 patients with scoliosis, 533 patients (0.96%) had NF1. Patients with NF1 were more likely to have comorbid solid tumors (P < 0.0001), clinical depression (P < 0.0001), peripheral vascular disease (P < 0.0001), and hypertension (P < 0.001). Following surgery, NF1 patients had a higher incidence of hydrocephalus (0.6% vs. 1.9% P = 0.002), seizures (4.9% vs. 5.7% P = 0.006), and accidental vessel laceration (0.3% vs.1.9% P = 0.011). Although there were no differences in overall complication rates or in-hospital mortality, multivariate regression revealed NF1 patients had an increased probability of pulmonary (OR 0.5, 95%CI 0.3-0.8, P = 0.004) complications. There were no significant differences in utilization, including nonhome discharge or extended hospitalization; however, patients with NF1 had higher total hospital charges (mean -$18739, SE 3384, P < 0.0001).

CONCLUSIONS

These findings indicate that NF1 is associated with certain complications following multilevel fusion surgery but does not appear to be associated with differences in quality or cost outcomes. These results provide some guidance to surgeons and other healthcare professionals in their perioperative decision making by raising awareness about risk factors for NF1 patients undergoing multilevel fusion surgery. We intend for this study to set the national baseline for complications after multilevel fusion in the NF1 population.

Timing of inpatient medical complications after adult spinal deformity surgery: early ambulation matters

BACKGROUND

The substantial risk for medical complication after adult spinal deformity (ASD) surgery is well known. However, the timing of medical complications during the inpatient stay have not been previously described. Accurate anticipation of complications and adverse events may improve patient counseling and postoperative management.

PURPOSE

(1) Describe the rate of medical complication and adverse events by postoperative day after ASD surgery and (2) determine whether early ambulation is protective for complications.

STUDY DESIGN/SETTING

Single institution retrospective cohort study.

PATIENT SAMPLE

Two hundred thirty-five patients with ASD who underwent posterior-only fusion of the lumbar spine (≥5 levels to the pelvis) between 2013 and 2020.

OUTCOME MEASURES

Medical complications, categorized per the International Spine Study Group-AO system (cardiopulmonary [CP], gastrointestinal [GI], central nervous system [CNS], infectious [nonsurgical site], and renal) and adverse events (postoperative blood transfusion, urinary retention, and electrolyte abnormalities).

METHODS

Patients were identified from an institutional ASD database. Outcome measures were classified by the first postoperative day the event was recognized. Demographics, year of surgery, surgical factors, radiographic parameters, surgical invasiveness (ASD-S Index), frailty (Modified Frailty Index-5 [mFI-5]), Charlson Comorbidity Index (CCI), obstructive sleep apnea (OSA), smoking, preoperative opioid use, depression, and post-operative day of ambulation were assessed as risk factors for inpatient medical complications.

RESULTS

After exclusions of patients with incomplete medical chart data, 191 patients were available for analysis, mean age 66±10 y, BMI 28±5 kg/m2, PI-LL 24±20°, T1PA 28±13°. Inpatient medical complications occurred in 55 (28.8%) patients; adverse events occurred in 137 (71.7%). Length of stay was higher in patients with medical complications (mean 8.5±3.8 vs. 5.8±2.3 days, p<.001). However, for patients who had an adverse event, but no medical complication, LOS was comparable (p>.05). Most medical complications occurred by POD3 (58% of all complications). Risk (defined as the proportion of patients with that complication out of all inpatients that day) of CNS, CP, and GI complication peaked early in the postoperative course (CNS on POD1 [2.1% risk]; GI on POD2 [3.7%]; CP on POD3 [2.7%]). Risk for infectious and renal complications (infectious POD8 [2.7%]; renal POD7 [0.9%]) peaked later (Figure 1). On univariate analysis, patients with medical complications had higher rates of OSA (9.1% vs. 2.2%, p=.045), ASD-S (45.9 vs. 40.8, p=.04), max coronal cobb (46.9 vs. 36.7°, p=.003), ASA class (2.5 vs. 2.3, p=.01), and POD of ambulation (1.9 vs. 1.3, p=.01). On multivariate logistic regression (c-statistic 0.78), larger coronal cobb and later POD of ambulation were independent risk factors for complications (OR 1.04, 95% CI 1.01-1.07 and OR 2.3, 95% CI 1.2-4.7, respectively).

CONCLUSIONS

Our data may inform peri-operative management and patient expectations for hospitalization after ASD surgery. Early ambulation may reduce the risk of complications.

Importance of physiological age in determining indications for adult spinal deformity surgery in patients over 75 years of age: a propensity score matching analysis

PURPOSE

Physiologically, people age at different rates, which leads to a discrepancy between physiological and chronological age. Physiological age should be a priority when considering the indications for adult spinal deformity (ASD) surgery. The primary objective of this study was to determine the characteristics of the postoperative course, surgical outcomes, and complication rates to extend the healthy life expectancy of older ASD patients (≥ 75 years). The secondary objective was to clarify the importance of physiological age in the surgical treatment of older ASD patients, considering frailty.

METHODS

A retrospective review of 109 consecutive patients aged ≥ 65 years with symptomatic ASD who underwent a corrective long fusion with lateral interbody fusion from the lower thoracic spine to the pelvis from 2015 to 2019 was conducted. Patients were classified into two groups according to age (group Y [65-74 years], group O [≥ 75 years]) and further divided into four groups according to the ASD-frailty index score (Y-F, Y-NF, O-F, and O-NF groups). To account for potential risk factors for perioperative course characteristics, complication rates, and surgical outcomes, patients from the database were subjected to propensity score matching based on sex, BMI, and preoperative sagittal spinal alignment (C7 sagittal vertical axis, pelvic incidence-lumbar lordosis, and pelvic tilt). Clinical outcomes were evaluated 2 years postoperatively, using three patient-reported outcome measures of health-related quality of life: the Oswestry Disability Index, Scoliosis Research Society questionnaire (SRS-22), and Short Form 36 (SF-36). Additionally, the postoperative time-to-first ambulation, as well as minor, major, and mechanical complications, were evaluated.

RESULTS

In the comparison between Y and O groups, patients in group O were at a higher risk of minor complications (delirium and urinary tract infection). In contrast, other surgical outcomes of group O were comparable to those of group Y, except for SRS-22 (satisfaction) and time to ambulation after surgery, with better outcomes in Group O. Patients in the O-NF group had better postoperative outcomes (time to ambulation after surgery, SRS-22 (function, self-image, satisfaction), SF-36 [PCS]) than those in the Y-F group.

CONCLUSIONS

Older age warrants monitoring of minor complications in the postoperative management of patients. However, the outcomes of ASD surgery depended more on frailty than on chronological age. Older ASD patients without frailty might tolerate corrective surgery and have satisfactory outcomes when minimally invasive techniques are used. Physiological age is more important than chronological age when determining the indications for surgery in older patients with ASD.

Incidence of New Onset Dementia and Health Care Utilization Following Spine Fusions: A Propensity Score Matching Analysis

BACKGROUND

Dementia following spine fusions is not described in the literature. Also, the impact of new onset dementia on long-term health care utilization is not described. The aim of our study was to define the incidence of new onset dementia and its long-term health care utilization in elderly patients.

MATERIALS AND METHODS

MarketScan database were queried using the ICD-9/10 and CPT 4^th edition, from 2001 to 2019. We included patients ≥ 55 of age who underwent spine fusions with at least 5 years follow-up. Outcomes were new onset dementia (> 6 months after the procedure) length of stay (LOS), discharge disposition, hospital re-admissions, outpatient services, and medication refills.

RESULTS

Of 45,129 patients who underwent spine fusions, 1283 patients (2.84%) were diagnosed to have new-onset dementia. There was no difference in the re-operation rates among the dementia and non-dementia cohort at 1-, 2- and 5-years following the index procedure. Patients in the dementia cohort incurred higher number of hospital re-admissions up to 5-years after the index procedure. In terms of combined index procedure and post-discharge utilization payments, significant differences were noted among the dementia vs. non-dementia cohorts at 5-years ($126,628 vs. $ 77,098), following the index procedure.

CONCLUSION

Elderly age, higher comorbidities, Medicare insurance, multi-level lumbosacral fusions were identified as risk markers for developing dementia following spine fusions. Dementia resulted in significantly higher health care utilization with no increased rate of re-operations for up to 5-years following the index procedure.

Comprehensive Perioperative Approach to Complex Spine Deformity Management

OBJECTIVE

Study perioperative strategies for optimizing neuroprotection in complex spine deformity correction surgery.

METHODS

We report the case of a patient with severe lumbar dextroscoliosis, thoracolumbar junction hyperkyphosis with a 40-degree Cobb angle levoconvex scoliosis who underwent spinal deformity correction with loss of neuromonitoring during surgery. We performed a literature review on perioperative management of complex spine deformity.

RESULTS

A 50-year-old man presented with lumbar pain and right L4 radiculopathy. Surgical intervention for deformity correction and decompression was indicated with T4-L4 posterior instrumentation L2/L3 and L3/L4 transforaminal lumbar interbody fusion. Surgery was aborted due to the loss of neuromonitoring. Postsurgery, the patient had left sensory deficit and the neurocritical care team clinically suspected and deduced the anatomic location of the spinal cord compression. Magnetic resonance imaging confirmed a T10-T11 hyperintensity suggestive of cord ischemia due to osteophyte compressing the spinal cord. The patient underwent a second corrective surgery with no intraoperative events and has no long-term neurological sequela.

CONCLUSIONS

This case illustrates that a comprehensive perioperative approach and individualized risk factor assessment is useful in complex spine deformity surgery. Further research is needed to determine how this individualized comprehensive approach can lead to intraoperative and postoperative countermeasures that improved spine surgery outcomes.

LEVEL OF EVIDENCE

Level V.

Hospital frailty risk score predicts adverse events in spine surgery

PURPOSE

The Hospital Frailty Risk Score (HFRS) is derived from routinely collected data and validated as a geriatric risk stratification tool. This study aimed to evaluate the utility of the HFRS as a predictor for postoperative adverse events in spine surgery.

METHODS

In this retrospective analysis of 2042 patients undergoing spine surgery at a university spine center between 2011 and 2019, HFRS was calculated for each patient. Multivariable logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events. Adverse events were compared between patients with high or low frailty risk.

RESULTS

Patients with intermediate or high frailty risk showed a higher rate of reoperation (19.7% vs. 12.2%, p < 0.01), surgical site infection (3.4% vs. 0.4%, p < 0.001), internal complications (4.1% vs. 1.1%, p < 0.01), Clavien-Dindo IV complications (8.8% vs. 3.4%, p < 0.001) and transfusion (10.9% vs. 1.5%, p < 0.001). Multivariable logistic regression analyses revealed a high HFRS as independent risk factor for reoperation [odds ratio (OR) = 1.1; 95% confidence interval (CI) 1.0-1.2], transfusion (OR = 1.3; 95% CI 1.2-1.4), internal complications (OR = 1.2; 95% CI 1.1-1.3), surgical site infections (OR = 1.3; 95% CI 1.2-1.5) and other complications (OR = 1.3; 95% CI 1.2-1.4).

CONCLUSION

The HFRS can predict adverse events and is an easy instrument, fed from routine hospital data. By identifying risk patients at an early stage, the individual patient risk could be minimized, which leads to less complications and lower costs.

LEVEL OF EVIDENCE

Level III - retrospective cohort study TRIAL REGISTRATION: The study was approved by the local ethics committee (20-1821-104) of the University of Regensburg in February 2020.

Preoperative Polypharmacy in Geriatric Patients is Associated with Increased 90-Day All-Cause Hospital Readmission After Surgery for Adult Spinal Deformity Patients

OBJECTIVE

To investigate the effect of preoperative polypharmacy (PP) on 90-day all-cause readmission rate in older adults undergoing corrective surgery for ASD.

METHODS

Older adults with a diagnosis of ASD undergoing spinal surgery at a quaternary medical center from January 2016 to March 2019 were enrolled in this study. Patients were dichotomized into two groups stratified by the number of preoperative prescription medications; with PP defined as 5 or more prescription medications. The primary outcome measure was 90-day all-cause readmission rate. Secondary outcomes included postoperative changes in health-related quality of life measures.

RESULTS

Among 161 patients (mean [SD], 69.59[8.79] years), 97 patients were included in PP cohort and 64 in non-polypharmacy (non-PP) cohort. Both groups were balanced at baseline. The duration of hospital (5.82[1.93] vs. 6.50[4.00] days), mean number of fusion levels, and duration of surgery was statistically similar between both groups (p>0.05). There was no difference in the proportion of patients discharged directly home (31.25% vs. 40.42%, p=0.36). 90-day all-cause readmission rate was 3-fold higher in the PP cohort compared with the non-PP cohort. After adjusting for preoperative patient optimization, ASA grade, surgical invasiveness, smoking, depression and baseline functional disability, older adults with PP had a 9.79 increased odds of 90-day all-cause hospital readmission (p=0.04). Change in HRQOL measures were similar between both groups.

CONCLUSION

This study's findings indicate that despite preoperative optimization, older adults exposed to polypharmacy are at a significantly increased risk of hospital readmission within 90-days of surgery.

Assessment of Adult Spinal Deformity Complication Timing and Impact on 2-Year Outcomes Using a Comprehensive Adult Spinal Deformity Classification System

STUDY DESIGN

Retrospective review of prospectively collected multicenter registry data.

OBJECTIVE

To identify rates and timing of postoperative complications in adult spinal deformity (ASD) patients, the impact of complication type and timing on health related quality of life (HRQoL) outcomes, and the impact of complication timing on readmission and reoperation rates. Better understanding of complication timing and impact on HRQoL may improve patient selection, preoperative counseling, and postoperative complication surveillance.

SUMMARY OF BACKGROUND DATA

ASD is common and associated with significant disability. Surgical correction is often pursued, but is associated with high complication rates. The International Spine Study Group, AO Spinal Deformity Forum, and European Spine Study Group have developed a new complication classification system for ASD (ISSG-AO spine complications classification system).

METHODS

The ISSG-AO spine complications classification system was utilized to assess complications occurring over the 2-year postoperative time period amongst a multicenter, prospectively enrolled cohort of patients who underwent surgery for ASD. Kaplan-Meier survival curves were established for each complication type. Propensity score matching was performed to adjust for baseline disability and comorbidities. Associations between each complication type and HRQoL, and reoperation/readmission and complication timing, were assessed.

RESULTS

Of 584 patients meeting inclusion criteria, cardiopulmonary, gastrointestinal, infection, early adverse events, and operative complications contributed to a rapid initial decrease in complication-free survival. Implant-related, radiographic, and neurologic complications substantially decreased long-term complication-free survival. Only radiographic and implant-related complications were significantly associated with worse 2-year HRQoL outcomes. Need for readmission and/or reoperation was most frequent among those experiencing complications after postoperative day 90.

CONCLUSION

Surgeons should recognize that long-term complications have a substantial negative impact on HRQoL, and should carefully monitor for implant-related and radiographic complications over long-term follow-up.Level of Evidence: 4.

How old is too old?: Matched analysis of geriatric patients undergoing anterior lumbar interbody fusion

STUDY DESIGN

Retrospective Review INTRODUCTION/OBJECTIVE: The aim of this study is to utilize a national database to identify how age affects patient outcomes following anterior lumbar interbody fusion (ALIF). There are no established age guidelines for the geriatric population within the spine specialty, which makes patient selection challenging. Furthermore, there are conflicting studies for the risks of performing spine surgeries in the elderly.

METHODS

A retrospective review of the Mariner Claims Database was conducted on patients who underwent a single level ALIF (CPT 22558) between 2010 and 2018. Patients were separated into three groups by age: 50-64, 65-74, and 75-84 and matched with respect to gender, smoking, and comorbidity burden. Multivariable logistic regression was used to determine the independent effect of outpatient surgery on the postoperative outcomes after adjusting for demographic factors and pertinent comorbidities. Statistical significance was set at p < 0.05.

RESULTS

The study identified 8459 matched patients (3350 50-64; 3350 65-74; and 1759 75-84). Compared with patients aged 50-64, patients aged 65-74 and 75-84 had significantly increased risks of pneumonia (65-74: OR 1.53, 95% CI 1.06-2.24, p = 0.025; 75-84: OR 1.62, 95% CI 1.07-2.42, p = 0.022), sepsis (65-74: OR 2.20, 95% CI 1.36-3.76, p = 0.002; 75-84: OR 2.42, 95% CI 1.43-4.13, p = 0.001), and major complications (65-74: OR 1.35, 95% CI 1.05-1.74, p = 0.021; 75-84: OR 1.48, 95% CI 1.11-1.95, p = 0.006) (Table 2). There were no significant differences between patients aged 65-74 and 75-84 for risks of postoperative pneumonia, sepsis, and major complications (p > 0.05). There were no differences between any groups in terms of long-term outcomes such as pseudoarthrosis, implant related complications, or reoperation (p > 0.05) (Table 3).

DISCUSSION/CONCLUSION

The study showed that those older than 65 had a significant increase in risk of pneumonia, sepsis, and major complications following ALIF. In the two cohorts above the age of 65 (65-74 and 75-84) there was no significant differences in postoperative outcomes.

LEVEL OF EVIDENCE

3.

Comparison of percutaneous transforaminal endoscopic decompression and short-segment fusion in the treatment of elderly degenerative lumbar scoliosis with spinal stenosis

Background

Degenerative lumbar scoliosis (DLS) combined with spinal stenosis is increasingly being diagnosed in the elderly. However, the appropriate surgical approach remains somewhat controversial. The aim of this study was to compare the results of percutaneous transforaminal endoscopic decompression (PTED) and short-segment fusion for the treatment of mild degenerative lumbar scoliosis combined with spinal stenosis in older adults over 60 years of age.

Methods

Of the 54 consecutive patients included, 30 were treated with PTED and 24 were treated with short-segment open fusion. All patients were followed up for at least 12 months (12–24 months). Patient demographics, and perioperative and clinical outcomes were recorded. Visual analog scale (VAS) scores, Oswestry disability index (ODI) scores, and modified Macnab criteria were used to assess clinical outcomes. At the same time, changes in disc height, segmental lordosis, coronal Cobb angle, and lumbar lordosis were compared.

Results

The mean age was 68.7 ± 6.5 years in the PTED group and 66.6 ± 5.1 years in the short-segment fusion group. At 1 year postoperatively, both groups showed significant improvement in VAS and ODI scores compared with preoperative scores (p < 0.05), with no statistically significant difference between groups. However, VAS-Back and ODI were lower in the PTED group at 1 week postoperatively (p < 0.05). According to the modified Macnab criteria, the excellent rates were 90.0 and 91.6% in the PTED and short-segment fusion groups, respectively. However, the PTED group had a significantly shorter operative time, blood loss, postoperative hospital stay, postoperative bed rest, and complication rate. There was no significant difference in radiological parameters between the two groups preoperatively. At the last follow-up, there were significant differences in disc height, segmental lordosis at the L4–5 and L5–S1 levels, and Cobb angle between the two groups.

Conclusion

Both PTED and short-segment fusion for mild degenerative lumbar scoliosis combined with spinal stenosis have shown good clinical results. PTED under local anesthesia may be an effective supplement to conventional fusion surgery in elderly patients with DLS combined with spinal stenosis.

The effect of patient age on discharge destination and complications after lumbar spinal fusion

Age is an important patient characteristic that has been correlated with specific outcomes after lumbar spine surgery. We performed a retrospective cohort study to model the effect of age on discharge destination and complications after a 1-level or multi-level lumbar spine fusion surgery. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent lumbar spinal fusion surgery from 2013 through 2017. Perioperative outcomes were compared across ages 18 to 90 using multivariable nonlinear logistic regressioncontrolling for preoperative characteristics. A total of 61,315 patients were analyzed, with patients over 70 having a higher risk of being discharged to an inpatient rehabilitation center and receiving an intraoperative or postoperative blood transfusion. However, the rates of the other complications and outcomes analyzed in this study were not significantly different as patients age. In conclusion, advanced-age affects the discharge destination after a one- or multi-level fusion and intraoperative/postoperative blood transfusion after a one-level fusion. However, age alone does not significantly affect the risk of the other complications and outcomes assessed in this study. This study will help guide preoperative discussion with advanced-aged patients who are considering a 1-level or multi-level lumbar spine fusion surgery.

The complication trends of adult spinal deformity surgery in Japan - The Japanese Scoliosis Society Morbidity and Mortality survey from 2012 to 2017

BACKGROUND

The Japanese Scoliosis Society Morbidity & Mortality Committee performed a longitudinal nationwide complication survey of spinal deformity surgery from 2012 to 2017. The present study aimed to analyze the survey results and report the complication trends of adult spinal deformity surgery in Japan.

METHODS

All Japanese Scoliosis Society members were invited to participate in the survey. Adult spinal deformity was categorized into three groups by age: 20-39 years, 40-64 years and ≥65 years. Complications were grouped into death, blindness, neurological deficits (motor/sensory), infection, massive bleeding, hematoma, pneumonia, cardiac failure, deep vein thrombosis/pulmonary embolism, gastrointestinal perforation, and instrumentation failure.

RESULTS

The surveys were performed in 2012, 2014, and 2017. The overall complication rates were 21.6%, 26.0%, and 25.4%, respectively. The complication rates differed significantly by age group in all years such that older patients had a higher complication rate than younger patients. The rate of neurological deficits, particularly motor deficits, significantly increased in 2014 (3.1%-5.5%), and decreased in 2017 (4.3%). Massive bleeding and postoperative hematoma decreased significantly year by year (8.0%, 4.8%, 2.5% and 1.3%, 0.5%, 0.3%, respectively). The complication rate of instrumentation failure remained high, increasing without significant difference (5.2%, 5.8%, 6.5%, respectively), and was more common in the middle-aged and older patients.

CONCLUSIONS

Surgical complication rates in patients with adult spinal deformity remain high, especially neurological deficits and instrumentation failure in patients aged over 40 years. However, the complication rates of massive bleeding and postoperative hematoma decreased over this period.

Kitchen elbow sign predicts surgical outcomes in adults with spinal deformity: a retrospective cohort study

Kitchen elbow sign (KE-Sign) is a skin abnormality on the extensor side of the elbow and forearm that is often observed in patients with adult spinal deformity (ASD). The significance of KE-Sign in surgical cases was investigated. Overall, 114 patients with ASD treated with long spinal fusion were reviewed and divided into KE-Sign positive and negative groups. The preoperative and 1-year follow-up evaluations included radiographic parameters [C7 sagittal vertical axis (SVA), pelvic incidence (PI) and lumbar lordosis (LL)], the Oswestry Disability Index (ODI), visual analogue scales (VASs) for low back pain, leg pain, and satisfaction, and Short Form 36 questionnaire (SF-36). Multi-regression analysis was performed to identify patient satisfaction predictors and improvement in the ODI as dependent variables and preoperative background factors as independent variables. Preoperative characteristics showed no significant difference between both groups. Improvement in the ODI and VAS for satisfaction were significantly superior in the KE-Sign positive group. In multiple regression analysis, KE-Sign and preoperative ODI were significantly associated with improvement in the ODI; age, KE-Sign, preoperative low back pain VAS, and leg pain VAS were significantly associated with satisfaction. KE-Sign can be a predictor of better surgical outcomes in ASD patients.

Spine Surgery in the Octogenarian Population: A Comparison of Demographics, Surgical Approach, and Healthcare Utilization With the PearlDiver Database

Background

With the recent advances in technology and healthcare, increasing numbers of individuals over the age of 80 will require surgical intervention for spinal pathology. Given the risk of increased complications in the elderly, a limited number of spinal surgeries are performed on octogenarians every year. This makes it difficult to generalize the trends and outcomes of these surgeries to a greater population. This study attempts to understand the trends in the safety profile and healthcare utilization across the United States for octogenarians undergoing spinal fusion and/or decompression surgery for spinal stenosis and/or degenerative disease using the PearlDiver database.

Methodology

Patients who underwent fusion and/or decompression for stenosis and/or degenerative diseases were extracted using International Classification of Disease ninth and tenth revisions (ICD-9 prior to October 2015, ICD-10 after) from 2007 to 2016 in the PearlDiver database. Three comparative groups were considered: (1) primary fusion without concurrent decompression, (2) primary decompression with concurrent fusion, and (3) fusion with concurrent decompression. Outcomes of interest were patient characteristics, demographics, length of stay, surgery hospitalization payments, and discharge disposition. These outcomes were compared to patients over the age of 20 who also underwent spinal surgery.

Results

A total of 9,715 patients who underwent spinal surgery were identified in the search. Of the 9,139 patients, 503 were octogenarians and 73 were nonagenarians. Octogenarians and nonagenarians diagnosed with spinal stenosis were more likely to undergo decompression alone rather than fusion or both fusion and decompression (21 for both fusion and decompression; p < 0.0001). Patients diagnosed with both spinal stenosis and degeneration were more likely to undergo both fusion and decompression than fusion or decompression alone (239 for both, 208 for decompression alone, and 23 for fusion alone; p < 0.0001). No statistically significant difference was found in the percentage of patients discharged home following either fusion or decompression or both surgeries (p = 0.0737). The mean length of stay for patients in the 20-79-year age group was 2.79 days, whereas for the octogenarian and nonagenarian cohort it was 3.85 days. The index hospitalization pay for patients in the 20-79-year age group was $19,220, whereas for the octogenarians and nonagenarians cohort it was $15,091.

Conclusions

Patients over the age of 80 were more likely to undergo either a fusion procedure or a decompression procedure alone rather than both unless they were diagnosed with spinal degeneration. The PearlDiver database analysis indicates that the length of stay for octogenarians and nonagenarians is longer than that for patients in the 20-79-year age group, and that younger patients are more likely to be discharged earlier than patients over the age of 80. Moreover, we observed that the index hospitalization pay was higher for patients over the age of 20 than for octogenarians and nonagenarians in all cases except for a fusion procedure.

Risk factors of unintended return to the operating room in adult spinal deformity

Background

To evaluate the incidence and risk factors associated with unintended return to the operating room in adult spinal deformity after spinal deformity corrective surgery.

Methods

Retrospect of 141 adult spinal deformity patients in a single institution between January 2017 and December 2019. Inclusion criteria enrolled 18 to 80 years old patients who diagnosed with congenital/idiopathic/syndromic/acquired spinal deformity underwent posterior corrective spinal surgery. The surgical details and complications were recorded. The rate of unintended return to the operating room (UIROR) during hospitalization was examined, and the risk factors of unintended return to the operating room were investigated via multivariate analysis.

Results

This is a retrospective study. One hundred and forty-one patients who underwent spinal deformity surgery with a mean age of 31.8 years (range 18-69 years) were studied. The rate of unintended return to the operating room was 10.64% (15/141). Two of 15 patients had twice unintended surgery during hospitalization (13.33%). The most principal complication was neurologic deficit (73.3%); six of 15 postoperative present implants deviation causes severe lower limbs radiating pain (40%). The multivariate analysis shows higher apical vertebral rotation (AVR>grade II, odds ratio [OR] = 9.362; 95% CI= 1.930-45.420; P= .006), obesity (OR = 11.448; 95% CI= 1.320-99.263; P= .027), and previous neurological symptom (OR = 7.358; 95% CI= 1.798-30.108; P= .006) were independent predictors of unintended return to the operating room.

Conclusion

Postoperative neurologic deficit and short-term implant malposition are essential causes of unintended return to the operating room in adult spinal deformity patients. Preoperative factors such as higher AVR (> grade II), obesity, and previous neurological symptom may significantly increase the risk of morbidity in UIROR. Spine surgeons should be alert to these risk factors and require adequate preoperative evaluations to reduce the incidence of unintended return to the operating room.

Impact of New Motor Deficit on HRQOL After Adult Spinal Deformity Surgery: Subanalysis From Scoli Risk 1 Prospective Study

STUDY DESIGN

International, multicenter, prospective, longitudinal observational cohort.

OBJECTIVE

To assess how new motor deficits affect patient reported quality of life scores after adult deformity surgery.

SUMMARY OF BACKGROUND DATA

Adult spinal deformity surgery is associated with high morbidity, including risk of new postoperative motor deficit. It is unclear what effect new motor deficit has on Health-related Quality of Life scores (HRQOL) scores.

METHODS

Adult spinal deformity patients were enrolled prospectively at 15 sites worldwide. Other inclusion criteria included major Cobb more than 80°, C7-L2 curve apex, and any patient undergoing three column osteotomy. American Spinal Injury Association (ASIA) scores and standard HRQOL scores were recorded pre-op, 6 weeks, 6 months, and 2 years.

RESULTS

Two hundred seventy two complex adult spinal deformity (ASD) patients enrolled. HRQOL scores were worse for patients with lower extremity motor score (LEMS). Mean HRQOL changes at 6 weeks and 2 years compared with pre-op for patients with motor worsening were: ODI (+12.4 at 6 weeks and -4.7 at 2 years), SF-36v2 physical (-4.5 at 6 weeks and +2.3 at 2 years), SRS-22r (0.0 at 6 weeks and +0.4 at 2 years). Mean HRQOL changes for motor-neutral patients were: ODI (+0.6 at 6 weeks and -12.1 at 2 years), SF-36v2 physical (-1.6 at 6 weeks and +5.9 at 2 years), and SRS-22r (+0.4 at 6 weeks and +0.7 at 2 years). For patients with LEMS improvement, mean HRQOL changes were: ODI (-0.6 at 6 weeks and -16.3 at 2 years), SF-36v2 physical (+1.0 at 6 weeks and +7.0 at 2 years), and SRS-22r (+0.5 at 6 weeks and +0.9 at 2 years).

CONCLUSION

In the subgroup of deformity patients who developed a new motor deficit, total HRQOLs and HRQOL changes were negatively impacted. Patients with more than 2 points of LEMS worsening had the worst changes, but still showed overall HRQOL improvement at 6 months and 2 years compared with pre-op baseline.Level of Evidence: 3.

Development of a Preoperative Adult Spinal Deformity Comorbidity Score That Correlates With Common Quality and Value Metrics: Length of Stay, Major Complications, and Patient-Reported Outcomes

STUDY DESIGN

Retrospective review of a multicenter prospective registry.

OBJECTIVES

Our goal was to develop a method to risk-stratify adult spinal deformity (ASD) patients on the basis of their accumulated health deficits. We developed a novel comorbidity score (CS) specific to patients with ASD based on their preoperative health state and investigated whether it was associated with major complications, length of hospital stay (LOS), and self-reported outcomes after ASD surgery.

METHODS

We identified 273 operatively treated ASD patients with 2-year follow-up. We assessed associations between major complications and age, comorbidities, Charlson Comorbidity Index score, and Oswestry Disability Index score. Significant factors were used to construct the ASD-CS. Associations of ASD-CS with major complications, LOS, and patient-reported outcomes were analyzed.

RESULTS

Major complications increased significantly with ASD-CS (P < .01). Compared with patients with ASD-CS of 0, the odds of major complications were 2.8-fold higher (P = .068) in patients with ASD-CS of 1 through 3; 4.5-fold higher (P < .01) in patients with ASD-CS of 4 through 6; and 7.5-fold higher (P < .01) in patients with ASD-CS of 7 or 8. Patients with ASD-CS of 7 or 8 had the longest mean LOS (10.7 days) and worst mean Scoliosis Research Society-22r total score at baseline; however, they experienced the greatest mean improvement (0.98 points) over 2 years.

CONCLUSIONS

The ASD-CS is significantly associated with major complications, LOS, and patient-reported outcomes in operatively treated ASD patients.

Development and Validation of a Multidomain Surgical Complication Classification System for Adult Spinal Deformity

STUDY DESIGN

Prospective analysis of example cases.

OBJECTIVE

The aim of this study was to analyze the accuracy and repeatability of a new comprehensive classification system for capturing complications data in adult spinal deformity.

SUMMARY OF BACKGROUND DATA

Complications are common in adult spinal deformity surgery. However, no consensus exists on the definition or classification of complications in adult spinal deformity surgery. The lack of consensus significantly limits understanding of complications' effects on outcomes in surgery for adult spinal deformity.

METHODS

Using a Delphi method, members of the International Spine Study Group, AO Spine, and the European Spine Study Group collaborated to develop an adult spinal deformity classification system. The multidomain classification system accounts for medical complications (cancer, cardiopulmonary, central nervous system, gastrointestinal, infectious, musculoskeletal, renal) and surgical complications (implant complications, radiographic complications, neurologic events, intraoperative events, and wound complications). Seventeen individuals ("event readers"), including spine surgeons, trainees, and research coordinators, used the new classification system two separate times to analyze complications in ten example cases. The accuracy and repeatability of the classification system were subsequently calculated based on the providers' responses for the example cases.

RESULTS

The 10 example cases included 22 complications. Nearly 95% of complications were captured by >95% of the event readers. The system demonstrated good repeatability of 86.9% between the first and second set of responses provided by event readers.

CONCLUSION

The ISSG-AO Multi-Domain Spinal Deformity Complication Classification System for Adult Spinal Deformity demonstrated good accuracy and repeatability among both surgeons and research coordinators in capturing complications in adult spinal deformity surgery. The ISSG-AO system may be applied to help better understand the impact of complications on outcomes and costs in adult spinal deformity surgery.Level of Evidence: 5.

Anterior Column Realignment: Analysis of Neurological Risk and Radiographic Outcomes

BACKGROUND

Anterior column realignment (ACR) is a less invasive alternative to 3-column osteotomy for the correction of sagittal imbalance. We hypothesized that ACR would correct sagittal imbalance with an acceptable neurological risk.

OBJECTIVE

To assess long-term neurological and radiographic outcomes after ACR.

METHODS

Patients ≥18 yr who underwent ACR from 2005 to 2013 were eligible. Standing scoliosis radiographs were studied at preoperation, postoperation (≤6 wk), and at minimum 2 yr of follow-up. Clinical/radiographic data were collected through a retrospective chart review, with thoracic 1 spino-pelvic inclination (T1SPi) used as the angular surrogate for sagittal vertical axis.

RESULTS

A total of 26 patients had complete data, with a mean follow-up of 2.8 yr (1.8-7.4). Preoperative, sagittal parameters were lumbar lordosis (LL) of -16.1°, pelvic incidence (PI)-LL of 41.7°, T1SPi of 3.6°, and pelvis tilt (PT) of 32.4°. LL improved by 30.6° (P < .001) postoperation. Mean changes in PT (-8.3), sacral slope (8.9), T1SPi (-4.9), and PI-LL (-33.5) were all significant. The motion segment angle improved by 26.6°, from 5.2° to -21.4° (P < .001). Neurological complications occurred in 32% patients postoperation (n = 8; 1 patient with both sensory and motor). New thigh numbness/paresthesia developed in 3 (13%) patients postoperation; only 1 (4%) persisted at latest follow-up. A total of 6 (24%) patients developed a new lower extremity motor deficit postoperation, with 4 (8%) having persistent new weakness at last follow-up. Out of 8 patients with preoperative motor deficit, half saw improvement postoperation and 75% improved by last follow-up.

CONCLUSION

There was net motor improvement, with 24% of patients improving and 16% having persistent new weakness at latest follow-up; 60% were unchanged. Radiographic results demonstrate that ACR is a useful tool to treat severe sagittal plane deformity.

Multidisciplinary approaches to complication reduction in complex spine surgery: a systematic review

BACKGROUND CONTEXT

Complex spine surgery carries a high complication rate that can produce suboptimal outcomes for patients undergoing these extensive operations. However, multidisciplinary pathways introduced at multiple institutions have demonstrated a promising potential toward reducing the burden of complications in patients being treated for spinal deformities. To date, there has been no effort to systematically collate the multidisciplinary approaches in use at various institutions.

PURPOSE

The present study aims to determine effective multidisciplinary strategies for reducing the complication rate in complex spine surgery by analyzing existing institutional multidisciplinary approaches and delineating common themes across multiple practice settings.

STUDY DESIGN

Systematic review.

METHODS

We followed guidelines established under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The studies reported on data from PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Cochrane. We included articles that described either approaches to, or results from, the implementation of multidisciplinary paradigms during the preoperative, perioperative, and postoperative phases of care for patients undergoing complex spine surgery. We excluded studies that only targeted one complication unless such an approach was in coordination with more extensive multidisciplinary planning at the same institution.

RESULTS

A total of 406 unique articles were identified. Following an initial determination based on title and abstract, 22 articles met criteria for full-text review, and 10 met the inclusion criteria to be included in the review. Key aspects of multidisciplinary approaches to complex spine surgery included extensive preoperative workup and interdisciplinary conferencing, intraoperative communication and monitoring, and postoperative floor management and discharge planning. These strategies produced decreases in surgical duration and complication rates.

CONCLUSIONS

This study represents the first to systematically analyze multidisciplinary approaches to reduce complications in complex spine surgery. This review provides a roadmap toward reducing the elevated complication rate for patients undergoing complex spine surgery.

The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve

OBJECTIVE

Posterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.

METHODS

A retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.

RESULTS

A total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.

CONCLUSIONS

Surgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon's experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

Team Approach: Safety and Value in the Practice of Complex Adult Spinal Surgery

Surgical management of complex adult spinal deformities is of high risk, with a substantial risk of operative mortality. Current evidence shows that potential risk and morbidity resulting from surgery for complex spinal deformity may be minimized through risk-factor optimization. The multidisciplinary team care model includes neurosurgeons, orthopaedic surgeons, physiatrists, anesthesiologists, hospitalists, psychologists, physical therapists, specialized physician assistants, and nurses. The multidisciplinary care model mimics previously described integrated care pathways designed to offer a structured means of providing a comprehensive preoperative medical evaluation and evidence-based multimodal perioperative care. The role of each team member is illustrated in the case of a 66-year-old male patient with previous incomplete spinal cord injury, now presenting with Charcot spinal arthropathy and progressive vertebral-body destruction resulting in lumbar kyphosis.

Surgeon-specific risk stratification model for early complications after complex adult spinal deformity surgery

STUDY DESIGN

Retrospective outcome analysis of a prospectively collected single-surgeon cases OBJECTIVES: Identify risk factors for complications in adult surgical spine deformity patients, develop a surgeon-specific risk stratification model, and predict the likelihood of 6-week postoperative complications based on prospectively collected preoperative measures. Adult spinal deformity surgery is challenging technically as well as economically. Although many risk factors are well known for spine surgery, complications after complex spine deformity surgery remain a significant problem worldwide.

METHODS

We reviewed 124 consecutive adult patients who have undergone instrumented spinal fusion with nine or more levels over a 21-month period in a single institution. We extracted data from patient medical records. Complications within the 6 weeks after surgery were identified. Univariate and logistic regression analyses (LRAs) were implemented. We generated a formula based on the LRA predictive algorithm-a numeric probabilistic likelihood statistic representing an individual patient's risk of developing a complication.

RESULTS

A total of 34 (27%) patients had complications that were categorized into either 21 (17%) medical or 17 (13.7%) surgical complications, including 3 (2.4%) proximal junctional kyphosis, 8 (6.4%) neurologic deficit, and 9 (6.5%) any wound issue. The predictive model was significant and calibrated using area under the receiver operating characteristics curve analysis. The model correctly classified 83.1% cases. Patients with a three-column osteotomy or history of deep vein thrombosis have 6 and 19 times higher overall complications, respectively, compared with patients without. Patients with a three-column osteotomy or body mass index > 30, respectively, are 24 and 11 times more likely to develop a wound complication. Patients with a three-column osteotomy have 10 times higher rates of surgical complication.

CONCLUSIONS

Complex spine deformity is often associated with complications. No single variable effectively predicts postoperative complications for such a complicated situation. However, when all risk factors are considered, patients with three-column osteotomy have a significantly higher chance to develop early complications.

LEVEL OF EVIDENCE

Level IV.

Perioperative Complications And Risk Factors In Degenerative Lumbar Scoliosis Surgery For Patients Older Than 70 Years Of Age

Study design

Multivariate analysis of retrospective registry data.

Objective

To report the perioperative complication in a large cohort of surgery for elderly degenerative lumbar scoliosis (DLS) patients and to analyze the risk factors.

Summary of background data

The perioperative complication rate and risk factors for patients with DLS remain unclear, especially in elderly population.

Methods

Between November 2015 and June 2018, 98 patients aged 70 or older with DLS received decompression and intervertebral fusion by one spine surgeon at Beijing Xuanwu Hospital. The medical history and comorbidities of all patients were recorded.

Results

The perioperative complication rate was 34.7% in all patients, 11.2% of all patients had major complications, and 31.6% had minor complications. The major complication most commonly seen was wound infection, and the most common minor complication was hypoproteinemia. Elderly patients (>75) had longer hospital stays (17.5 ± 7.9) when compared to younger patients. Two risk factors of perioperative complications were chosen after binary logistic regression analysis: lower BMI and longer instrumented segments. The only risk factor for major complications was longer instrumented level (≥3), and the only risk factor for minor complications was lower BMI.

Conclusion

Our findings indicate that in elderly patients with DLS, lower BMI is a risk factor for minor perioperative complication. Obesity is not a major problem in this population, on the contrary, BMI is a protective factor for perioperative complications. The risk factors for major perioperative complications in elderly patients with DLS are longer instrumented segments but not related to the number of decompression and intervertebral fusion levels. Preoperative comorbidities and advanced age were not associated to a higher perioperative complication rate in elderly patients. The perioperative complication rate in patients with DLS over 70 years of age is found to be acceptable with appropriate perioperative management.

Epidemiology and Socioeconomic Trends in Adult Spinal Deformity Care

Adult spinal deformity (ASD) has gained significant attention over the past decade with improvements in diagnostic tools, classification schemes, and surgical technique. The demographics of the aging population in the United States are undergoing a fundamental shift as medical care advances and life expectancy increases. The “baby boomers” represent the fastest growing demographic in the United States and by 2050, the number of individuals 65 yr and older is projected to reach 89 million, more than double its current size. Based on current prevalence estimates there are approximately 27.5 million elderly individuals with some form of spinal deformity, which will place a significant burden on our health care systems. Rates of surgery for ASD and case complexity are both increasing, with concomitant increase in the cost of deformity care. At the same time, patients are more medically complex with increasing number of comorbidities that result in increased surgical risk and complication profiles. This review aims to highlight recent trends in the epidemiology and socioeconomic patterns in surgery for ASD.

Predictors of Hospital-Acquired Conditions Are Predominately Similar for Spine Surgery and Other Common Elective Surgical Procedures, With Some Key Exceptions

STUDY DESIGN

Retrospective review of a prospectively collected database.

OBJECTIVE

To predict the occurrence of hospital-acquired conditions (HACs) 30-days postoperatively and to compare predictors of HACs for spine surgery with other common elective surgeries.

METHODS

Patients ≥18 years undergoing elective spine surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Outcome measures included any HACs: superficial or deep surgical site infection (SSI), venous thromboembolism (VTE), urinary tract infection (UTI). Spine surgery patients were compared with those undergoing other common procedures. Random forest followed by multivariable regression analysis was used to determine risk factors for the occurrence of HACs.

RESULTS

A total of 90 551 elective spine surgery patients, of whom 3021 (3.3%) developed at least 1 HAC, 1.4% SSI, 1.3% UTI, and 0.8% VTE. The occurrence of HACs for spine patients was predicted with high accuracy (area under the curve [AUC] 77.7%) with the following variables: female sex, baseline functional status, hypertension, history of transient ischemic attack (TIA), quadriplegia, steroid use, preoperative bleeding disorders, American Society of Anesthesiologists (ASA) class, operating room duration, operative time, and level of residency supervision. Functional status and hypertension were HAC predictors for total knee arthroplasty (TKA), bariatric, and cardiothoracic patients. ASA class and operative time were predictors for most surgery cohorts. History of TIA, preoperative bleeding disorders, and steroid use were less predictive for most other common surgical cohorts.

CONCLUSIONS

Occurrence of HACs after spine surgery can be predicted with demographic, clinical, and surgical factors. Predictors for HACs in surgical spine patients, also common across other surgical groups, include functional status, hypertension, and operative time. Understanding the baseline patient risks for HACs will allow surgeons to become more effective in their patient selection for surgery.

[What is actually adult spinal deformity? : Development, classification, and indications for surgical treatment]

BACKGROUND

Adult spinal deformity (ASD) is a complex entity that has had emerging significance for spine surgeons in the last decade. Sagittal and/or coronary deformities can have a high impact (disability, pain) on the quality of patients' life. Radiologic diagnostics determine the common spinopelvic parameters as the basis for classification of ASD.

TREATMENT

Conservative treatment options may be sufficient in mild cases. The deformity's complexity frequently demands the entire spectrum of methods and techniques in spinal surgery. This article gives an overview on the development of the ASD, the correct classification as well as the indication for surgical therapy.

Complications of Spine Surgery in Elderly Japanese Patients: Implications for Future of World Population Aging

Objective

To analyze the relationship between age and perioperative complications of spine surgery in a Japanese cohort with the longest average life expectancy in the world.

Methods

Patients with spinal stenosis who underwent standard spine surgery without instrumented fusion were divided into 4 groups: adults (20–64 years), the young-old (65–74), the middle old (75–84), and the oldest-old (≥85). Data on medical complications, surgical complications, and deaths within 30 days of index surgery were compared across the groups. Risk factors for complications were identified through multivariate analysis.

Results

A total of 584 patients underwent 673 operations: 35% were performed on adult patients, 33% on the young-old, 27% on the middle old, and 5% on the oldest-old. The rates of total or [major] medical complications significantly increased with age (8% [0.8%], 11% [0.9%], 27% [3.9%], 45% [9.1%], respectively; p<0.001 [p=0.003]), whereas those of surgical complications did not differ (11%, 8.1%, 14%, 9.1%, respectively; p=0.25). Independent risk factors for medical complications were an age of 75 years or older (75–84: odds ratio [OR], 5.1; ≥85: OR, 6.2) and American Society of Anesthesiologists (ASA) physical status classification III (OR, 5.4). Two patients older than 85 years died from medical complications.

Conclusion

The complications of spine surgery increased in the middle and oldest-old patients because of medical complications; however, most were minor and treatable. Major complications were associated with preoperative medical comorbidities and their severities; therefore, most elderly patients with low ASA physical status classification (≤II) may benefit from spine surgery.

Percutaneous Endoscopic Lumbar Foraminotomy for Foraminal Stenosis with Postlaminectomy Syndrome in Geriatric Patients

INTRODUCTION

Postlaminectomy syndrome (PLS) or failed back surgery syndrome is a condition characterized by persistent pain following a back surgery. Degenerative processes may result in foraminal stenosis development over time, even after a successful surgery. Percutaneous endoscopic lumbar foraminotomy (PELF) offers a minimally invasive means of treating foraminal stenosis after a back surgery. The objective of this study was to evaluate the outcomes of PELF for foraminal stenosis with PLS in geriatric patients.

METHODS

Two-year follow-up data were collected from 21 consecutive patients aged 65 years or older (mean age, 72.4 years) who underwent PELF for foraminal stenosis with PLS. Transforaminal endoscopic foraminal decompression was performed under local anesthesia. Outcomes were assessed using visual analog scale pain score, Oswestry Disability Index, and modified Macnab criteria.

RESULTS

Mean visual analog scale for leg pain improved from 8.48 at baseline to 3.33 at 6 weeks, 2.10 at 1 year, and 2.19 at 2 years after PELF (P < 0.01). Mean Oswestry Disability Index improved from 67.29 at baseline to 30.69 at 6 weeks, 22.50 at 1 year, and 20.81 at 2 years after PELF (P < 0.01). Based on the modified Macnab criteria, excellent or good results were obtained in 81.0% of patients and symptomatic improvements were obtained in 95.2% of patients.

CONCLUSIONS

The transforaminal endoscopic approach can provide a better access angle to achieve a sophisticated foraminal decompression with less facet and dural injury. Therefore, PELF under local anesthesia can be useful for PLS or postoperative foraminal stenosis in elderly patients.

The prevalence of complications associated with lumbar and thoracic spinal deformity surgery in the elderly population: a meta-analysis

Background

The prevalence of spinal deformities increases with age, affecting between 30% and 68% of the elderly population (ages ≥65). The reported prevalence of complications associated with surgery for spinal deformities in this population ranges between 37% and 71%. Given the wide range of reported complication rates, the decision to perform surgery remains controversial.

Methods

A comprehensive search was conducted using PubMed, Embase, and Cochrane to identify studies reporting complications for spinal deformity surgery in the elderly population. Pooled prevalence estimates for individual complication types were calculated using the random-effects model.

Results

Of 5,586 articles, 14 met inclusion criteria. Fourteen complication types were reported, with at least 2 studies for each complication with the following pooled prevalence: reoperation (prevalence 19%; 95% CI, 9-36%; 107 patients); hardware failure (11%; 95% CI, 5-25%; 52 patients); infection (7%; 95% CI, 4-12%; 262 patients); pseudarthrosis (6%; 95% CI, 3-12%; 149 patients); radiculopathy (6%; 95% CI, 1-33%; 116 patients); cardiovascular event (5%; 95% CI, 1-32%; 121 patients); neurological deficit (5%; 95% CI, 2-15%; 248 patients); deep vein thrombosis (3%; 95% CI, 1-7%; 230 patients); pulmonary embolism (3%; 95% CI, 1-7%; 210 patients); pneumonia (3%; 95% CI, 1-11%; 210 patients); cerebrovascular or stroke event (2%; 95% CI, 0-9%; 85 patients); death (2%; 95% CI, 1-9%; 113 patients); myocardial infarction (2%; 95% CI, 1-6%; 210 patients); and postoperative hemorrhage (1%; 95% CI, 0-10%; 85 patients).

Conclusions

Most complication types following spinal deformity surgery in the elderly had prevalence point estimates of <6%, while all were at least ≤19%. Additional studies are needed to further explore composite prevalence estimates and prevalence associated with traditional surgical approaches as compared to minimally-invasive procedures in the elderly.

The prevalence of complications associated with lumbar and thoracic spinal deformity surgery in the elderly population: a meta-analysis

BACKGROUND

The prevalence of spinal deformities increases with age, affecting between 30% and 68% of the elderly population (ages ≥65). The reported prevalence of complications associated with surgery for spinal deformities in this population ranges between 37% and 71%. Given the wide range of reported complication rates, the decision to perform surgery remains controversial.

METHODS

A comprehensive search was conducted using PubMed, Embase, and Cochrane to identify studies reporting complications for spinal deformity surgery in the elderly population. Pooled prevalence estimates for individual complication types were calculated using the random-effects model.

RESULTS

Of 5,586 articles, 14 met inclusion criteria. Fourteen complication types were reported, with at least 2 studies for each complication with the following pooled prevalence: reoperation (prevalence 19%; 95% CI, 9-36%; 107 patients); hardware failure (11%; 95% CI, 5-25%; 52 patients); infection (7%; 95% CI, 4-12%; 262 patients); pseudarthrosis (6%; 95% CI, 3-12%; 149 patients); radiculopathy (6%; 95% CI, 1-33%; 116 patients); cardiovascular event (5%; 95% CI, 1-32%; 121 patients); neurological deficit (5%; 95% CI, 2-15%; 248 patients); deep vein thrombosis (3%; 95% CI, 1-7%; 230 patients); pulmonary embolism (3%; 95% CI, 1-7%; 210 patients); pneumonia (3%; 95% CI, 1-11%; 210 patients); cerebrovascular or stroke event (2%; 95% CI, 0-9%; 85 patients); death (2%; 95% CI, 1-9%; 113 patients); myocardial infarction (2%; 95% CI, 1-6%; 210 patients); and postoperative hemorrhage (1%; 95% CI, 0-10%; 85 patients).

CONCLUSIONS

Most complication types following spinal deformity surgery in the elderly had prevalence point estimates of <6%, while all were at least ≤19%. Additional studies are needed to further explore composite prevalence estimates and prevalence associated with traditional surgical approaches as compared to minimally-invasive procedures in the elderly.

Surgical Risk Assessment and Prevention in Elderly Spinal Deformity Patients

Introduction:

Prevalence of adult deformity surgery in the elderly individuals continues to increase. These patients have additional considerations for the spine surgeon during surgical planning. We perform an informative review of the spinal and geriatric literature to assess preoperative and intraoperative factors that impact surgical complication occurrences in this population.

Significance:

There is a need to understand surgical risk assessment and prevention in geriatric patients who undergo thoracolumbar adult deformity surgery in order to prevent complications.

Methods:

Searches of relevant biomedical databases were conducted by a medical librarian. Databases searched included MEDLINE, Web of Science, CINAHL, IPA, Cochrane, PQ Health and Medical, SocINDEX, and WHO’s Global Health Library. Search strategies utilized Medical Subject Headings plus text words for extensive coverage of scoliosis and surgical technique concepts.

Results:

Degenerative scoliosis affects 68% of the geriatric population, and the rate of surgical interventions for this pathology continues to increase. Complications following spinal deformity surgery in this patient population range from 37% to 62%. Factors that impact outcomes include age, comorbidities, blood loss, and bone quality. Using these data, we summarize multimodal risk prevention strategies that can be easily implemented by spine surgeons.

Conclusions:

After evaluation of the latest literature on the complications associated with adult deformity surgery in geriatric patients, comprehensive perioperative management is necessary for improved outcomes. Preoperative strategies include assessing physiological age via frailty score, nutritional status, bone quality, dementia/delirium risk, and social activity support. Intraoperative strategies include methods to reduce blood loss and procedural time. Postoperatively, development of a multidisciplinary team approach that encourages early ambulation, decreases opiate use, and ensures supportive discharge planning is imperative for better outcomes for this patient population.

Laser-assisted endoscopic lumbar foraminotomy for failed back surgery syndrome in elderly patients

Elderly patients with failed back surgery syndrome (FBSS) or post-laminectomy foraminal stenosis have a higher risk of perioperative morbidity with extensive revision surgery. Thus, there is a need for safer and less invasive surgical options, such as laser-assisted endoscopic lumbar foraminotomy (ELF). A pin-point laser beam can allow precise tissue ablation and dissection in fibrotic adhesion tissues while preventing normal tissue injury. The present study aimed to describe the surgical technique of laser-assisted ELF and to evaluate the clinical outcomes of elderly patients with FBSS. Two-year follow-up data were collected from 26 consecutive patients aged 65 years or older who were treated with laser-assisted ELF for FBSS. Full-endoscopic foraminal decompression was performed using a side-firing laser and mechanical instruments. The average age of the patients was 70.2 years (range, 65-83 years). The mean visual analog pain score for leg pain improved from 8.58 at baseline to 3.35 at 6 weeks, 2.19 at 1 year, and 2.35 at 2 years after ELF (P < 0.001). The mean Oswestry disability index improved from 65.93 at baseline to 31.41 at 6 weeks, 21.77 at 1 year, and 20.64 at 2 years after ELF (P < 0.001). Based on the modified Macnab criteria, excellent or good results were obtained in 84.6% patients and symptomatic improvements were obtained in 92.3%. Extensive revision surgery in elderly patients might cause significant surgical morbidities. Laser-assisted ELF under local anesthesia could be a safe and effective surgical alternative for such patients at risk.