Thirty-day readmission rates in spine surgery: systematic review and meta-analysis

Ropivacaine-epinephrine-clonidine-ketorolac is an effective opioid-sparing local anesthetic for patients undergoing posterior spinal fusion

BACKGROUND CONTEXT

Ropivacaine-Epinephrine-Clonidine-Ketorolac (RECK) cocktail can improve pain control in patients undergoing lumbar decompression. Given the aging population, rising healthcare costs, the opioid epidemic, and associations of acute pain control with long-term opioid use, effective opioid-sparing analgesia following spinal fusion surgery may impart societal benefits.

PURPOSE

We aimed to investigate whether RECK was an effective local anesthetic for patients undergoing posterior spinal fusion.

STUDY DESIGN/SETTING

Single-center retrospective cohort study.

PATIENT SAMPLE

Patients who underwent posterior spinal fusion surgery from June 2019 to June 2021.

OUTCOME MEASURES

Primary outcomes of interest were postoperative pain levels as determined by Visual Analog Scale, in-hospital opioid consumption, length-of-stay <4 days, and long-term opioid utilization at three months postoperatively. Secondary outcomes of interest were rates of discharge to home, complication rates, readmissions within 90 days.

METHODS

We analyzed whether opioid exposure, patient-specific or surgery-specific factors, and administration of RECK (versus another local anesthetic) were associated with postoperative pain levels, in-hospital opioid consumption, length-of-stay, home discharge, long-term opioid utilization, complications, and readmissions within 90 days using multivariable regression.

RESULTS

Of the 162 patients meeting study criteria, 49 (30.2%) received RECK. RECK was significantly associated with decreased pain levels at 2-, 4-, 6-, and 12-hours postoperatively (p≤.001-.01). RECK was associated with decreased total and daily inpatient opioid utilization (as measured by oral morphine equivalents) in multivariable linear regression (B=-159.6, 95% CI:-255.5- -63.6, p=.002 and B=-27.9, 95% CI:-48.9- -7.0, p=.01, respectively). Length-of-stay duration of <4 days was associated with RECK administration (OR 4.1, 95% CI:1.4-13.2, p=.01) and was negatively associated with levels fused (OR 0.4, 95% CI:0.2-0.7, p=.005) and durotomy (OR 0.02, 95% CI:0.0009-0.1, p<.001). Prolonged postoperative opioid utilization was associated with preoperative opioid prescription (OR 3.6, 95% CI:1.7-7.8, p=.001) and was negatively associated with RECK (OR 0.4, 95% CI:0.2-0.9, p=.04). RECK was not associated with readmissions, complications, or home discharge.

CONCLUSIONS

In patients undergoing posterior spinal fusion, RECK was superior to other local anesthetics as it improved pain control, decreased length-of-stay, and decreased opioid utilization. RECK was not associated with increased complications, readmissions, or rates of discharge to home.

The Value of Plastic Surgery Closure in Adults Undergoing Scoliosis Surgery

Introduction: Surgical treatment for scoliosis can be done for functional and esthetic concerns. Surgical intervention may be associated with a complication rate of up to 40% in patients with non-idiopathic scoliosis, and 3% in patients with idiopathic scoliosis. In the present study, the authors sought to evaluate patients undergoing surgery for scoliosis with closure by the plastic and reconstructive surgery service. Methods: A retrospective cohort study was performed by extracting data, including demographics, surgical characteristics, and outcomes, from the electronic medical records of a single, large, tertiary care hospital and from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Data was collected for patients aged 18 to 75 undergoing spinal surgery for scoliosis from 2012 to 2020. Data collected from institutional records included only patients whose incision was closed by plastic and reconstructive surgery, while data from NSQIP was collected from all scoliosis surgery patients regardless of closure type. Results: A total of 98 scoliosis patients were identified who underwent closure by the plastic and reconstructive surgery service. These were compared to 1390 scoliosis patients in NSQIP for whom no specific closure details were noted. At 30-day post-operatively, readmission rates were 2.04% and 7.34% for the institutional and NSQIP cohorts, respectively (P = 0.041), reoperation rates were 1.04% and 5.83% for the institutional and NSQIP cohorts, respectively (P = 0.0384), and overall complication rates were 2.04% and 12.52% for the institutional and NSQIP cohorts, respectively (P = 0.0005). Conclusion: Surgical intervention for scoliosis may benefit from closure by the plastic and reconstructive surgery service, which may yield potential lower rates of readmission, reoperation, and post-operative complication.

Risk Factors for and Prediction of Early Thromboembolic Disease Following Adult Spinal Deformity Surgery: An Analysis of >7,400 Patients with Spinal Deformity

BACKGROUND

The aim of this study was to determine the risk factors associated with deep vein thrombosis (DVT) or pulmonary embolism (PE) within 30 days after multilevel adult spinal deformity (ASD) surgery and to develop risk prediction models.

METHODS

A retrospective observational study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2019. Current Procedural Terminology (CPT) codes 22843 and 22844 were used to query the database and to identify patients who underwent surgical correction of ASD with ≥7 levels of posterior instrumentation. The primary outcomes were the incidences of, and risk factors for, postoperative DVT and PE. Multiple logistic regression was utilized to identify variables associated with an elevated risk of DVT or PE within 30 days after surgery and to develop prediction models for assessing risk.

RESULTS

A total of 7,445 patients (56% female; 73% Caucasian; mean age, 61 years) met the inclusion criteria. Postoperatively, the rate of any venous thromboembolism (VTE; i.e., DVT or PE) was 3.4% (254 patients), the rate of DVT was 2.0% (151 patients), and the rate of PE was 1.7% (127 patients). The following independent predictors of any VTE were identified: weight (odds ratio [OR], 1.054; 95% confidence interval [CI]: 1.027 to 1.081), age per decade of life (OR, 1.106; 95% CI: 1.012 to 1.209), body mass index (BMI; OR, 1.032; 95% CI: 1.015 to 1.049), medicated hypertension (OR, 1.523; 95% CI: 1.168 to 1.987), chronic corticosteroid use (OR, 2.654; 95% CI: 1.848 to 3.812), American Society of Anesthesiologists (ASA) class (OR, 1.768; 95% CI: 1.426 to 2.192), and total operative time (OR, 1.002; 95% CI: 1.002 to 1.003) (p < 0.05 for all). When incorporated into a single model, total operative time, BMI, ASA class, and chronic corticosteroid use were associated with VTE risk.

CONCLUSIONS

Four major risk factors were identified as being associated with postoperative VTE risk in patients undergoing surgery for ASD. Corticosteroid use for a chronic medical condition was the strongest predictor of VTE risk, followed by ASA class, BMI, and operative time. Knowledge of these risk factors can aid in preoperative risk assessment, informed consent, and medical decision-making, such as in determining the clinical thresholds for VTE testing and chemoprophylaxis.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors of 90-Day Unplanned Readmission After Lumbar Spine Surgery for Degenerative Lumbar Disk Disease: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

With the increasing aging population, the number of patients undergoing lumbar spinal surgery for degenerative changes is rising. In the United States, spinal fusion surgery ranked sixth in operating room procedures, accounting for 3.2% of all such procedures, with an aggregate cost for stays amounting to $14.1 billion, making it the most expensive operating room procedure in 2018. The aim of this study was to identify valid risk factors of 90-day unplanned readmissions after lumbar spine surgery through a meta-analysis, with the goal of saving insurance finances and improving patient clinical outcomes.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library databases using the search terms "90-day readmission" and "lumbar spine surgery." Eleven eligible studies were included. Characteristic differences between readmitted and nonreadmitted patients were identified and analyzed using Review Manager software.

RESULTS

This meta-analysis included 11 studies with a total of 648 415 patients; 50 047 were readmitted unplanned after lumbar spine surgery. The incidence of unplanned readmission after lumbar spine surgery was 7.72%. Among demographic risk factors, older age and higher body mass index were significantly associated with unplanned readmission after lumbar spine surgery. Patient characteristics, such as depression, diabetes mellitus, hypertension, renal failure, and an American Society of Anesthesiologists grade greater than 2 were also significantly associated with unplanned readmission after lumbar spine surgery.

CONCLUSION

The meta-analysis revealed a 7.72% incidence of unplanned readmission after lumbar spine surgery. These findings suggest the need for enhanced preoperative optimization and careful patient selection for lumbar spine surgery, particularly in elderly patients and those with multiple comorbidities. Implementation of targeted preventive strategies for high-risk patients may help reduce unplanned readmissions and improve healthcare resource utilization.

Comparison of Outcomes Between Staged and Same-Day Circumferential Spinal Fusion for Adult Spinal Deformity: Systematic Review and Meta-Analysis

BACKGROUND

Adult spinal deformity (ASD) is a prevalent condition often treated with circumferential spinal fusion (CF), which can be performed as staged or same-day procedures. However, evidence guiding the choice between these approaches is lacking.

OBJECTIVE

This study aims to compare patient outcomes following staged and same-day CF for ASD.

METHODS

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted in PubMed, MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus. Eligibility criteria included studies comparing outcomes following staged and same-day CF in adults with ASD. Searches were exported to Covidence, and records were deduplicated automatically. Title and abstract screening, full-text review, and data extraction were performed by two independent reviewers, with all conflicts being resolved by a third reviewer. A meta-analysis was conducted for outcomes reported in 3 or more studies.

RESULTS

Seven studies with 741 patients undergoing CF for ASD were included in the review (staged: n=331, 44.7% and same-day: n=410, 55.3%). Four studies that had comparable outcomes were merged for the quantitative meta-analysis and split based on observed measures. The meta-analysis revealed significantly shorter hospital length of stay (mean difference 3.98, 95% CI 2.23-5.72 days; P<.001) for same-day CF. Three studies compared the operative time between staged and same-day CF, with all reporting a lower mean operative time for same-day CF (mean between 291-479, SD 129 minutes) compared to staged CF (mean between 426-541, SD 124 minutes); however, inconsistent reporting of mean and SD made quantitative analyses unattainable. Of the 4 studies that compared estimated blood loss (EBL) in the relevant groups, 3 presented a lower EBL (mean between 412-1127, SD 954 mL) in same-day surgery compared to staged surgery (mean between 642, SD 550 to 1351, SD 869 mL). Both studies that reported intra- and postoperative adverse events showed more intraoperative adverse events in staged CF (10.9% and 13.6%, respectively) compared to same-day CF (9.1% and 3.6%, respectively). Four studies measuring any perioperative adverse events showed a higher incidence of adverse events in staged CF than all studies combined. However, quantitative analysis of EBL, intraoperative adverse events, and perioperative adverse events found no statistically significant difference. Postoperative adverse events, reoperation, infection rates, and readmission rates showed inconsistent findings between studies. Data quality assessment revealed a moderate degree of bias for all included studies.

CONCLUSIONS

Same-day CF may offer shorter operating time and hospital stay compared to staged CF for ASD. However, there was marked heterogeneity in perioperative outcomes reporting, and continuous variables were inconsistently presented. This underscored the need for standardized reporting of clinical variables and patient-reported outcomes and higher evidence of randomized controlled trials to elucidate the clinical superiority of either approach.

TRIAL REGISTRATION

PROSPERO CRD42022339764; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339764.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/42331.

Preoperative Emergency Department Usage is a Sentinel Marker of Worsened Posterior Lumbar Interbody Fusion Outcome

BACKGROUND

Utilization of the emergency department (ED) is associated with medical and social comorbidities. These factors may also be associated with medical complications after complex surgeries. This study investigated how preoperative ED use increases risk of posterior lumbar interbody fusion (PLIF) complications.

METHODS

We identified adult PLIF patients treated between 2016 and 2019 in the PearlDiver Claims Database. Clinical variables including preoperative ED use within 180 days were collected using International Classification of Disease (ICD-10) codes. Risk difference was calculated, and multivariable regression was performed.

RESULTS

This study included 13,010 (21.1%) patients who went to the ED before surgery and 48,065 (78.9%) who did not. Having a preoperative ED visit significantly increased risk of a postoperative ED visit by 28.7 percentage points, 90-day readmission by 3.8 percentage points, and 30-day major-medical complications by 3.4 percentage points. Risk of these outcomes increased in a dose-dependent fashion. Compared with patients with zero preoperative ED visits, patients who had 6 or more preoperative ED visits had an 82.0 percentage point increase in risk for a postoperative ED visit, a 46.5 percentage point increase for six or more ED visits, a 6.1 percentage point increase for major medical complications, and 10.6% increase for readmission.

CONCLUSIONS

Patients with any preoperative ED visit had an increased risk for postoperative ED use, readmission, and medical complications. The risk difference increased with each additional preoperative visit. Patient counseling and protocols that reduce preventable ED visit in the preoperative period may reduce a patient's risk for costly postoperative complications.

Incidental durotomy in lumbar decompressive surgery: incidence and risk-factors, and the effect of durotomy on hospital and patient metrics

PURPOSE

To evaluate incidental lumbar durotomy incidence and risk-factors, and the association of durotomy with perioperative metrics and patient-reported outcomes.

METHODS

A total 3140 cases of 1-3 level elective decompressive surgery from 2008 to 2023 at a single centre were included. Multivariable analysis was performed on literature derived variables to identify independent risk-factors for durotomy. Absolute difference or absolute risk increase (ARI) between durotomy and non-durotomy perioperative metrics was calculated. The association between durotomy and 3-month or 12-month patient-reported outcome measures was assessed.

RESULTS

All-procedure durotomy incidence was 4.5% (142/3140). Durotomy risk-factors were age (odds ratio (OR) 1.016, 95% confidence intervals (95% CI) 1.011-1.020), female (OR 1.48, 95% CI 1.26-1.74), number of operative levels (two-level OR 1.81, 95% CI 1.48-2.21; three-level OR 3.18, 95% CI 2.14-4.72), multiple versus no previous operation (OR 1.85, 95% CI 1.11-3.07), and fusion with discectomy versus discectomy (OR 2.36, 95% CI 1.90-2.93). Durotomy was associated with longer length of stay (∆2.4 days, p < 0.001), longer operative time (∆21 min, p < 0.001), and higher rate of iatrogenic nerve injury (ARI 4.3%, p < 0.001), 30-day return to theatre (ARI 5.7%, p < 0.001), and 30-day readmission (ARI 4.4%, p = 0.002). Durotomy was not associated with poorer patient-reported outcomes.

CONCLUSION

Dural tears are often under-reported and are associated with longer hospital stay, increased operative time, and rare perioperative complications which increase healthcare costs. Dural tears did not, however, detrimentally affect patient-reported disability or pain outcomes.

Robotic Systems in Spinal Surgery: A Review of Accuracy, Radiation Exposure, Hospital Readmission Rate, Cost, and Adverse Events

BACKGROUND

Recent advances within the last decade have allowed robotics to become commonplace in the operating room. In the field of neurosurgery, robotics assist surgeons in pedicle screw placement and vertebral fusion procedures. The purpose of this review is to look at currently used spinal robots available in the market and compare their overall accuracy, cost, radiation exposure, general adverse events, and hospital readmission rates.

METHODS

The authors searched databases including PubMed and Google Scholar for studies on robotic spine surgery using robotic systems: Mazor X/Mazor Renaissance, Cirq, ExcelsiusGPS, and ROSA ONE Spine. The literature was examined for robot accuracy, hospital readmission rates, adverse events, radiation exposure, and cost of the robots.

RESULTS

In general, many studies recognize that robot-assisted spinal surgery is of equal or greater accuracy compared to freehand surgical techniques. Limited and conflicting data exist regarding radiation exposure and overall adverse events. The upfront cost of robotic spine-based surgery tends to be more than freehand, but minimal data evaluate the cost-effectiveness among robotic systems.

CONCLUSIONS

This review summarizes the findings comparing the individual robotic systems and their comparison to freehand surgery. As robotics become more popular in clinical practice, additional research is needed to assist hospitals and surgeons in making an informed decision about implementing robotics in spinal surgery.

90-Day Emergency Department Utilization and Readmission Rate After Full-Endoscopic Spine Surgery: A Multicenter, Retrospective Analysis of 821 Patients

BACKGROUND AND OBJECTIVES

Emergency department (ED) utilization and readmission rates after spine surgery are common quality of care measures. Limited data exist on the evaluation of quality indicators after full-endoscopic spine surgery (FESS). The objective of this study was to detect rates, causes, and risk factors for unplanned postoperative clinic utilization after FESS.

METHODS

This retrospective multicenter analysis assessed ED utilization and clinic readmission rates after FESS performed between 01/2014 and 04/2023 for degenerative spinal pathologies. Outcome measures were ED utilizations, hospital readmissions, and revision surgeries within 90 days postsurgery.

RESULTS

Our cohort includes 821 patients averaging 59 years of age, who underwent FESS. Most procedures targeted the lumbar or sacral spine (85.75%) while a small fraction involved the cervical spine (10.11%). The most common procedures were lumbar unilateral laminotomies for bilateral decompression (40.56%) and lumbar transforaminal discectomies (25.58%). Within 90 days postsurgery, 8.0% of patients revisited the ED for surgical complications. A total of 2.2% of patients were readmitted to a hospital of which 1.9% required revision surgery. Primary reasons for ED visits and clinic readmissions were postoperative pain exacerbation, transient neurogenic bladder dysfunction, and recurrent disk herniations. Our multivariate regression analysis revealed that female patients had a significantly higher likelihood of using the ED ( P = .046; odds ratio: 1.77, 95% CI 1.01-3.1 5.69% vs 10.33%). Factors such as age, American Society of Anesthesiologists class, body mass index, comorbidities, and spanned spinal levels did not significantly predict postoperative ED utilization.

CONCLUSION

This analysis demonstrates the safety of FESS, as evidenced by acceptable rates of ED utilization, clinic readmission, and revision surgery. Future studies are needed to further elucidate the safety profile of FESS in comparison with traditional spinal procedures.

Baseline American Society of Anesthesiologists classification predicts worse anxiety and pain interference following Lumbar Interbody Fusion

BACKGROUND

The American Society of Anesthesiologists (ASA) classifications allow physicians to briefly assess a patient's risk for general anesthesia and surgical intervention. Although simple to calculate, a patient's ASA score may correlate with differences in outcomes following spinal operations. The purpose of this study is to establish the effect of ASA score on Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes following Lateral Lumbar Interbody Fusion (LLIF).

METHODS

All patient data was collected from a single spinal surgeon database. Patients were separated into cohorts of "Lower ASA" (ASA < 3) and "Higher ASA" (ASA ≥ 3). Demographics, perioperative characteristics, preoperative Patient-Reported Outcomes (PROs), and postoperative PROs at 6 weeks and final postoperative time points were compared statistically. These included Visual Analog Scales for back and leg pain (VAS-B, VAS-L), the Oswestry Disability Index (ODI), the 9-item Patient Health Questionnaire (PHQ-9), and PROMIS measures for Physical Function (PROMIS-PF), Sleep Disturbance (PROMIS-SD), Anxiety (PROMIS-A), and Pain Interference (PROMIS-PI). PRO improvements between preoperative and postoperative time points and Minimum Clinically Important Difference (MCID) were also compared.

RESULTS

In total, 154 patients were included (111 and 43 in the Lower and Higher ASA cohorts, respectively). Patient age, body mass index (BMI), presence of diabetes, and Charlson Comorbidity Index (CCI) score were significantly different between the two cohorts (Table 1, p < 0.004 for all). Primary vs. non-primary surgery, number of spinal levels fused, postoperative length of stay, and rates of isthmic spondylolisthesis and foraminal stenosis also significantly differed (Table 2, p < 0.05 for all). Patients with a higher ASA score were found to have higher PROMIS-A preoperatively (Table 3, p = 0.029). These patients also had higher PROMIS-A and PROMIS-PI at final postoperative evaluation (p values of 0.007 and 0.047, respectively). Score changes over time and MCID achievement did not seem to be impacted by baseline ASA score.

CONCLUSIONS

Patients with a higher preoperative ASA score were found to have worse anxiety pre-operatively and worse anxiety and pain interference at the final postoperative evaluation. Clinical improvement over time was not significantly affected by the ASA score.

The incidence and risk factors for unplanned readmission within 90 days after surgical treatment of spinal fractures

INTRODUCTION

Unplanned readmissions after spine surgery are undesired, and cause significant functional, and financial distress to the patients and healthcare system. Though critical, knowledge about readmissions after surgery for traumatic spinal injuries (TSI) is scarce and under-evaluated.

METHODS

Consecutive patients surgically treated for TSI and who had unplanned readmission within 90 days post-discharge were studied. Peri-operative demographic and surgical variables, surgical treatment, level of injury, delay in surgery, ASIA score, other organ injuries, peri-operative complications, smoking, ICU stay, co-morbidity, and the length of hospital stay were studied and correlated with the causes for readmission.

RESULTS

Among 884 patients, 4.98% (n = 44) had unplanned readmissions within 90 days of discharge. Notably, 50% (n = 22) patients were readmitted within the first 30 days. The common causes of readmissions were urinary tract related problems (27%, n = 12), pressure ulcers (20.4%, n = 9), respiratory problems (13.6%, n = 6), surgical wound related problems (14%, n = 7,) limb injuries (11.4%, n = 5), and others (11%, n = 5). The total beds lost secondary to readmissions was 314 days, and the mean bed-days lost per patient was 7.2 ± 5.1. Thirteen peri-operative risk factors were associated with unplanned readmissions, among which, smoking (OR 2.2), diabetes (OR 2.4), and pressure sore during index admission (OR 16.7) were strong independent predictors.

CONCLUSION

The incidence of unplanned readmissions after TSI was 5%, which was similar to elective spine surgeries but the causes and risk factors are different. Non-surgical complications related to urinary tract, respiratory care and pressure sores were the most common causes. Pre-operative smoking status, diabetes mellitus and pressure sores noted in the index admission were important independent risk factors.

Application of machine learning algorithms to predict 30-day hospital readmission following cement augmentation for osteoporotic vertebral compression fractures

Objective

Osteoporosis is a common skeletal disease that greatly increases the risk of pathologic fractures and accounts for approximately 700,000 vertebral compression fractures (VCFs) annually in the United States. Cement augmentation procedures such as balloon kyphoplasty (KP) and percutaneous vertebroplasty (VP) have demonstrated efficacy in the treatment of VCFs, however, some studies report rates of readmission as high as 10.8% following such procedures. The purpose of this study was to employ Machine Learning (ML) algorithms to predict 30-day hospital readmission following cement augmentation procedures for the treatment of VCFs using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods

ACS-NSQIP was queried to identify patients undergoing either KP or VP from 2011 to 2014. Three ML algorithms were constructed and tasked with predicting post-operative readmissions within this cohort of patients. Results: Postoperative pneumonia, ASA Class 2 designation, age, partially-dependent functional status, and a history of smoking were independently identified as highly predictive of readmission by all ML algorithms. Among these variables postoperative pneumonia (p < 0.01), ASA Class 2 designation (p < 0.01), age (p = 0.002), and partially-dependent functional status (p < 0.01) were found to be statistically significant. Predictions were generated with an average AUC value of 0.757 and an average accuracy of 80.5%.

Conclusions

Postoperative pneumonia, ASA Class 2 designation, partially-dependent functional status, and age are perioperative variables associated with 30-day readmission following cement augmentation procedures. The use of ML allows for quantification of the relative contributions of these variables toward producing readmission.

Optimal time window for initiating cefuroxime surgical antimicrobial prophylaxis in spinal fusion surgery: a nested case-control study

BACKGROUND CONTEXT

Surgical site infections (SSI) are one of the common complications following spinal fusion surgery. Unfortunately, several studies had shown conflicting results regarding optimal timing of surgical antimicrobial prophylaxis (SAP) administration. Due to limitations in population homogeneity and sample size, these studies have not provided significant statistical correlations or clear practical recommendations.

PURPOSE

The purpose of the study was to investigate the impact of timing of cefuroxime SAP on the risk of SSI in patients undergoing spinal fusion surgery, and to determine the optimal timing of administration.

DESIGN

Retrospective nested case-control study.

PATIENT SAMPLE

We retrospectively analyzed consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021.

OUTCOME MEASURE

In the current study, the primary outcome measure was SSI.

METHODS

This was a retrospective nested case-control study. All consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021 formed a retrospective cohort. For each SSI case, 2 controls free of SSI at the time of the index date of their corresponding case were selected, matched by age, sex, and calendar year. Electronic record and radiographic data were reviewed retrospectively in electronic database. SAP related data included timing of administration, preoperative dose, intraoperative second dose, and postoperative use. To examine the effects of mismatched variables, we further adjusted for possible confounding factors using conditional logistic regression models. Subsequently, subgroup analyses were conducted to assess the robustness of the statistical associations.

RESULTS

According to the preplanned statistical scheme and matching factors, we matched 236 controls for these SSI cases, and the subsequent statistical analysis was performed on these 354 patients. After adjusting for confounding factors, the results indicated that the risk of SSI was 70% higher in the group receiving SAP 31 to 60 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=1.732, 95%CI 1.031-2.910, p=.038). Additionally, the risk of SSI was 150% higher in the group receiving SAP 61 to 120 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=2.532, 95%CI 1.250-5.128, p=.010). In subgroup analysis, this statistical trend persisted for both deformity surgeries and different SSI classifications.

CONCLUSION

Administering cefuroxime SAP within 30 minutes before skin incision significantly reduces the risk of SSI, whether they are deep or superficial, in spinal fusion surgery. This pattern remains consistent among spinal deformity patients.

Utilization of Machine Learning to Model Important Features of 30-day Readmissions following Surgery for Metastatic Spinal Column Tumors: The Influence of Frailty

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the relative importance and predicative power of the Hospital Frailty Risk Score (HFRS) on unplanned 30-day readmission after surgical intervention for metastatic spinal column tumors.

METHODS

All adult patients undergoing surgery for metastatic spinal column tumor were identified in the Nationwide Readmission Database from the years 2016 to 2018. Patients were categorized into 3 cohorts based on the criteria of the HFRS: Low(<5), Intermediate(5-14.9), and High(≥ 15). Random Forest (RF) classification was used to construct predictive models for 30-day patient readmission. Model performance was examined using the area under the receiver operating curve (AUC), and the Mean Decrease Gini (MDG) metric was used to quantify and rank features by relative importance.

RESULTS

There were 4346 patients included. The proportion of patients who required any readmission were higher among the Intermediate and High frailty cohorts when compared to the Low frailty cohort (Low:33.9% vs. Intermediate:39.3% vs. High:39.2%, P < .001). An RF classifier was trained to predict 30-day readmission on all features (AUC = .60) and architecturally equivalent model trained using only ten features with highest MDG (AUC = .59). Both models found frailty to have the highest importance in predicting risk of readmission. On multivariate regression analysis, Intermediate frailty [OR:1.32, CI(1.06,1.64), P = .012] was found to be an independent predictor of unplanned 30-day readmission.

CONCLUSION

Our study utilizes machine learning approaches and predictive modeling to identify frailty as a significant risk-factor that contributes to unplanned 30-day readmission after spine surgery for metastatic spinal column metastases.

Implant and construct decision-making in metastatic spine tumour surgery: a review of current concepts with a decision-making algorithm

STUDY DESIGN

Narrative Review.

OBJECTIVE

Metastatic spine tumour surgery (MSTS) is an important treatment modality of metastatic spinal disease (MSD). Increase in MSTS has been due to improvements in our oncological treatment, as patients have increased longevity and even those with poorer comorbidities are now being considered for surgery. However, there is currently no guideline on how MSTS surgeons should select the appropriate levels to instrument, and which type of implants should be utilised.

METHODS

The current literature on MSTS was reviewed to study implant and construct decision making factors, with a view to write this narrative review. All studies that were related to instrumentation in MSTS were included.

RESULTS

A total of 58 studies were included in this review. We discuss novel decision-making models that should be taken into account when planning for surgery in patients undergoing MSTS. These factors include the quality of bone for instrumentation, the extent of the construct required for MSTS patients, the use of cement augmentation and the choice of implant. Various studies have advocated for the use of these modalities and demonstrated better outcomes in MSTS patients when used appropriately.

CONCLUSION

We have established a new instrumentation algorithm that should be taken into consideration for patients undergoing MSTS. It serves as an important guide for surgeons treating MSTS, with the continuous evolvement of our treatment capacity in MSD.

LEVEL OF EVIDENCE IV

Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter?

For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.

Improvement of operating room air quality and sustained reduction of surgical site infections in an orthopedic specialty hospital

INTRODUCTION

Surgical site infection (SSI) rates can be impacted by air quality, and a high-efficiency particulate air and ultraviolet air recirculation system (HUAIRS) has been shown to improve operating room air quality. This study examined the impact of HUAIRS devices on SSI rates when used at an orthopedic specialty hospital.

METHODS

HUAIRS devices were used intraoperatively at the facility. Total particle counts before and after HUAIRS implementation were compared. SSI rates for nervous system procedures or for all procedures at the facility were also compared for the 2.5-year periods before and after implementing HUAIRS devices.

RESULTS

Over 30,000 consecutive procedures were performed from 2017 to 2022. The overall SSI rate at the facility was 0.45% before implementing HUAIRS devices compared to 0.22% (P < 0.001) after. The SSI rate following nervous system procedures was 2.06% before implementing HUAIRS devices versus 0.29% (P < .001) after. Total particle counts were also significantly lower after implementing HUAIRS devices.

DISCUSSION AND CONCLUSIONS

Implementation of HUAIRS devices at an orthopedic specialty hospital is associated with significant reductions in SSI rates and intraoperative air contamination levels. These data support the need to further investigate intraoperative air quality interventions for the reduction in SSI rates.

Developing an Automated Registry (Autoregistry) of Spine Surgery Using Natural Language Processing and Health System Scale Databases

BACKGROUND AND OBJECTIVES

Clinical registries are critical for modern surgery and underpin outcomes research, device monitoring, and trial development. However, existing approaches to registry construction are labor-intensive, costly, and prone to manual error. Natural language processing techniques combined with electronic health record (EHR) data sets can theoretically automate the construction and maintenance of registries. Our aim was to automate the generation of a spine surgery registry at an academic medical center using regular expression (regex) classifiers developed by neurosurgeons to combine domain expertise with interpretable algorithms.

METHODS

We used a Hadoop data lake consisting of all the information generated by an academic medical center. Using this database and structured query language queries, we retrieved every operative note written in the department of neurosurgery since our transition to EHR. Notes were parsed using regex classifiers and compared with a random subset of 100 manually reviewed notes.

RESULTS

A total of 31 502 operative cases were downloaded and processed using regex classifiers. The codebase required 5 days of development, 3 weeks of validation, and less than 1 hour for the software to generate the autoregistry. Regex classifiers had an average accuracy of 98.86% at identifying both spinal procedures and the relevant vertebral levels, and it correctly identified the entire list of defined surgical procedures in 89% of patients. We were able to identify patients who required additional operations within 30 days to monitor outcomes and quality metrics.

CONCLUSION

This study demonstrates the feasibility of automatically generating a spine registry using the EHR and an interpretable, customizable natural language processing algorithm which may reduce pitfalls associated with manual registry development and facilitate rapid clinical research.

Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors

BACKGROUND CONTEXT

Although outpatient spine surgery is becoming increasingly popular in the United States, unplanned readmission following outpatient surgery remains a significant postoperative concern.

PURPOSE

This study aimed to (1) describe the incidence and timing of 30-day unplanned readmission after ambulatory lumbar and cervical spine surgery (2) evaluate the common reasons for readmission, and (3) identify factors associated with readmission in this population.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database.

OUTCOME MEASURES

Hospital readmission within 30 postoperative days.

METHODS

Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Reasons for and timing of unplanned readmissions were recorded. Multivariable poisson regressions were employed to determine any independent predictors of readmission.

RESULTS

A total of 33,092 ambulatory cervical and 68,115 ambulatory lumbar spine surgery patients were identified. Incidences of 30-day readmission were 3.37% and 3.07% among cervical and lumbar patients, respectively. The most common surgical site-related reasons for readmission included uncontrolled pain, recurrence of disc herniation or major symptom, and postoperative hematoma/seroma. Common nonsurgical site-related reasons included gastrointestinal, neurological, and cardiovascular complications. Factors associated with readmission among cervical patients included age ≥55, BMI ≥35, functional dependence, diabetes, smoking, COPD, and steroid use, whereas factors associated with readmission following lumbar spine surgery included age ≥65, female sex, BMI ≥35, functional dependence, ASA ≥3, diabetes, smoking, COPD, and hypertension (p<.05 for all).

CONCLUSION

This study highlights the common reasons and factors associated with unplanned readmission following ambulatory spine surgery. Consideration of these factors may be critical to ensuring appropriate patient selection for ambulatory spine surgery.

30-and 90-day readmissions in lumbar spine surgery. Differences in prevalence and causes

BACKGROUND

The morbidity associated with surgical treatment of lumbar degenerative conditions has attracted increasing interest due to the economic impact on society, especially postoperative readmission. Limited studies have assessed this risk in a prospective, single-center consecutive fashion.

OBJECTIVE

To assess the incidence and causes of 30- and 90-day unplanned readmission and revision surgery following surgical treatment for lumbar degenerative spine conditions at a tertiary treatment center.

STUDY DESIGN

Prospective, single-center cohort study.

METHODS

All patients undergoing degenerative lumbar spine surgery in a 1-year period from February 1st, 2016, were prospectively included. Patient characteristics, surgical information and information regarding postoperative complications, including readmission (30- and 90-days) and revision surgery were recorded. Readmissions were classified according to whether they were due to the surgical intervention specifically, or a medical complication.

RESULTS

A total of 1399 patients underwent surgery for various lumbar degenerative pathologies in the study period and all were included. Of these, 9.4% (n = 132) were readmitted within 30 days of surgery and in some cases, multiple readmissions occurred (up to 3). The total 90-day readmission rate was 17.6%. Of these, 15% were related to the surgical procedure. The predominant medical related causes were systemic infection (30-day: 14.4%, 90-day: 10.7%), neurological symptoms (30-day: 6.3%, 90-day: 5.0%) and cardiovascular events (30-day: 8.1%, 90-day: 12.9%). The surgical related causes for readmission were pain (30-day: 13.1%, 90-day: 2.9%), wound complications (30-day: 11.3%, 90-day: 5.0% and re-herniation (30-day: 13.1%, 90-day: 2.9%). Age was the only factor with significant influence on readmission.

CONCLUSION

The incidence of medical conditions causing unplanned 30-day readmissions following surgery for lumbar degenerative conditions, is significantly higher compared to readmissions related specifically to the surgical procedure. Examples of medical treatment included antibiotics, analgesics, laxatives, anticoagulants and beta blockers. The difference is even more pronounced for the 90-day readmissions. The predominant medical causes were systemic infections, neurological and cardiovascular events. Predominant causes related to the surgery were pain, wound complications and re-herniations. Readmissions may be reduced by optimizing the medical treatment and the pain management before discharge of the patient.

Association of preoperative hypoprotein malnutrition with spinal postoperative complications and other conditions: A systematic review and meta-analysis

BACKGROUND

Postoperative complications of spinal surgery are a common clinical problem, which impose significant economic and clinical burdens on patients and medical staff. Previous studies have suggested a close relationship between low-protein malnutrition and postoperative complications of surgery. However, the relationship between preoperative malnutrition and various orthopedic postoperative complications remains unclear.

PURPOSE

To investigate the association between protein malnutrition and postoperative complications and outcomes.

METHODS

We conducted a systematic search of the PubMed, Embase, Cochrane Library, and Web of Science databases for published research articles between the database inception and February 28th, 2023, that evaluated the association between malnutrition and the risk of postoperative complications and death in spinal surgery patients. Malnutrition was defined as low pre-albumin and albumin levels before surgery. Two evaluators independently extracted study data and assessed the risk of bias in each study. Fixed- or random-effect models were used to calculate the pooled effect estimates. Funnel plots and Egger's tests were used to detect publication bias, and the Trim-and -Fill method was conducted to evaluate the impact of publication bias on the results.

RESULTS

A total of 26 studies were included in this meta-analysis, comprising 17 retrospective cohort studies and 9 case-control studies. The study included more than 86,000 participants. Analysis of postoperative complications revealed that the overall incidence of malnutrition-related complications after surgery was 3.17 times higher (OR = 3.17, 95% CI 2.69-3.75, z = 13.57, P < 0.05). The incidence of surgical site infections was 2.08 times higher (OR = 2.08, 95% CI 1.66-2.62, z = 6.307, P < 0.05), and the incidence of postoperative urinary tract infections was 2.55 times higher (OR = 2.55, 95% CI 1.80-3.60, z = 5.30, P < 0.05). The incidence of postoperative sepsis was 3.31 times higher (OR = 3.31, 95% CI 2.31-4.75, z = 6.51, P < 0.05), and the incidence of postoperative pneumonia was 3.02 times higher (OR = 3.02, 95% CI 1.331-6.857, z = 2.64, P = 0.008 < 0.05). The incidence of postoperative cardiac complications was 4.24 times higher (OR = 4.24, 95% CI 2.45-7.35, z = 5.15, P < 0.05), and the incidence of postoperative renal complications was 4.04 times higher (OR = 4.04, 95% CI 2.06-7.93, z = 4.05, P < 0.05). The incidence of postoperative pulmonary complications was 2.38 times higher (OR = 2.38, 95% CI 1.46-3.87, z = 6.98, P < 0.05), while the incidence of postoperative thrombotic complications was 2.76 times higher (OR = 2.76, 95% CI 1.756-4.345, z = 4.40, P < 0.05). Furthermore, the incidence of transfusion during and after surgery was 1.33 times higher (OR = 1.33, 95% CI 1.13-1.56, z = 3.40, P = 0.001 < 0.05), the incidence of postoperative readmission was 1.67 times higher (OR = 1.67, 95% CI 1.24-2.27, z = 3.33, P = 0.001 < 0.05), and the risk of postoperative death was 6.01 times higher (OR = 6.01, 95% CI 4.51-8.01, z = 12.27, P < 0.05). After conducting a publication bias test and Trim-and -Fill method analysis, we found no evidence of publication bias, and the results remained stable.

CONCLUSION

Preoperative low protein malnutrition is closely related to the incidence of postoperative complications and postoperative status. More prospective multicenter studies should be conducted to validate this conclusion. Furthermore, more effective assessment and intervention of preoperative nutritional status should be carried out to prevent the occurrence of postoperative complications and mortality risk.

Geographic Distribution in Training and Practice of Academic Neurological and Orthopedic Spine Surgeons in the United States

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

This study aimed to stratify the geographic distribution of academic spine surgeons in the United States, analyzing how this distribution highlights differences in academic, demographic, professional metrics, and gaps in access to spine care.

METHODS

Spine surgeons were identified using American Association of Neurological Surgeons and American Academy of Orthopedic Surgeons databases, categorizing into geographic regions of training and practice. Departmental websites, National Institutes of Health (NIH) RePort Expenditures and Results, Google Patent, and NIH icite databases were queried for demographic and professional metrics.

RESULTS

Academic spine surgeons (347 neurological; 314 orthopedic) are predominantly male (95%) and few have patents (23%) or NIH funding (4%). Regionally, the Northeast has the highest proportion per capita (3.28 surgeons per million), but California is the state with the highest proportion (13%). The Northeast has the greatest regional retention post-residency at 74%, followed by the Midwest (59%). The West and South are more associated with additional degrees. Neurosurgery-trained surgeons hold more additional degrees (17%) than orthopedic surgeons (8%), whereas more orthopedic surgeons hold leadership positions (34%) than neurosurgeons (20%).

CONCLUSIONS

Academic spine surgeons are found at the highest proportion in the Northeast and California; the Northeast has the greatest regional retention. Spine neurosurgeons have more additional degrees, whereas spine orthopedic surgeons have more leadership positions. These results are relevant to training programs looking to correct geographic disparities, surgeons in search of training programs, or students in pursuit of spine surgery.

Retrospective Analysis of Causes and Risk Factors of 30-Day Readmission After Spine Surgery for Thoracolumbar Trauma

STUDY DESIGN

Retrospective Case Series.

OBJECTIVE

This study aims to evaluate readmission rates, risk factors, and reason for unplanned 30-day readmissions after thoracolumbar spine trauma surgery.

METHODS

A retrospective chart review was conducted for patients undergoing operative treatment for thoracic or lumbar trauma with open or minimally invasive surgical approach at a Level 1 urban trauma center. Patients were divided into two groups based on 30-day readmission status. Reason for readmission, reoperation rates, injury type, trauma severity, and incidence of polytrauma were compared between the two groups.

RESULTS

A total of 312 patients, 69.9% male with an average age of 47 ± 19 years were included. The readmitted group included 16 patients (5.1%) of which 9 (56%) were readmitted for medical complications and 7 for surgical complications. Wound complications (31.3% of readmissions) were the most common cause of readmission, followed by non-wound related sepsis (18.9% of readmissions). A total of 6 patients (37.5%) required reoperation; 2 instrumentation failures underwent revision surgery, and 4 wound complications underwent irrigation and debridement. Patients with higher Injury Severity Scale (ISS) were more likely to be readmitted (27.8% vs 22.1%, P = .045). Concomitant lower limb surgery increased odds of readmission (OR, 4.40; 95% CI, 1.10-17.83; P = .037).

CONCLUSION

Spine trauma 30-day readmission rate was 5.1%, comparable to those reported in the elective spine surgery literature. Readmitted patients were more likely to sustain concomitant operative lower limb trauma. Wound complications were the most common cause of readmission, and almost half of the patients were readmitted due to surgery-related complications.

Clinical Outcomes and Cost Differences Between Patients Undergoing Primary Anterior Cervical Discectomy and Fusion Procedures with Private or Medicare Insurance: A Propensity Score-Matched Study

OBJECTIVE

We assessed whether the insurance type reflects a patient's quality of care after an anterior discectomy and fusion (ACDF) procedure by comparing differences in the postoperative complications, readmission rates, reoperation rates, lengths of hospital stay, and cost of treatment between patients with Medicare versus private insurance.

METHODS

Propensity score matching was used to match patient cohorts insured by Medicare and private insurance in the MarketScan Commercial Claims and Encounters Database (2007-2016). Age, sex, year of operation, geographic region, comorbidities, and operative factors were used to match cohorts of patients who had undergone an ACDF procedure.

RESULTS

A total of 110,911 patients met the inclusion criteria. Of these patients, 97,543 patients (87.9%) were privately insured and 13,368 patients (12.1%) were insured by Medicare. The propensity score matching algorithm matched 7026 privately insured patients to 7026 Medicare patients. After matching, no significant differences were found in the 90-day postoperative complication rates, lengths of stay, or reoperation rates between the Medicare and privately insured cohorts. The Medicare group had had lower postoperative readmission rates for all time points: 30 days (1.8% vs. 4.6%; P < 0.001), 60 days (2.5% vs. 6.3%; P < 0.001), and 90 days (4.2% vs. 7.7%; P < 0.001). The median payment to physicians was significantly lower for the Medicare group ($3885 vs. $5601; P < 0.001).

CONCLUSIONS

In the present study, propensity score matched patients covered by Medicare and private insurance who had undergone an ACDF procedure had had similar treatment outcomes.

Risk Factors for Thirty-Day Readmission Following Lumbar Surgery: A Meta-Analysis

OBJECTIVE

Thirty-day readmission is one of the common complications after lumbar surgery. More 30-day readmission increases the total hospitalization, economic burden, and physical pain of patients, delays the progress of postoperative rehabilitation, and even lead to die. Therefore, it is necessary to analyze the risk factors of 30-day readmission following lumbar surgery.

METHODS

We searched for all the clinical trials published from the establishment of the database to May 1, 2022 through the Cochrane Library, Web of Science, Embase, and PubMed. Data including age, American Society of Anesthesiology physical status class, preoperative hematocrit (Hct), diabetes mellitus (DM), current smoker, chronic obstructive pulmonary disease (COPD), length of hospital stay (LHS), operation time, and surgical site infection (SSI) were extracted. We used Review Manager 5.4 for data analysis.

RESULTS

Six studies with 30,989 participants were eligible for this meta-analysis. The analysis revealed that there were statistically significant differences in the age (95% confidence interval [CI]: -3.35-2.90, P < 0.001), preoperative Hct (95% CI: 0.75-1.33, P < 0.001), DM (95% CI: 0.56-0.74, P < 0.001), COPD (95% CI: 0.38-0.58, P < 0.001), operation time (95% CI: -35.54-16.18, P < 0.001), LHS (95% CI: -0.54-0.50, P < 0.001), and SSI (95% CI: 0.02-0.03, P < 0.001) between no readmission and readmission groups. In terms of the American Society of Anesthesiology physical status class and current smoker, there was no significant effect on the 30-day readmission (P = 0.16 and P = 0.35 respectively).

CONCLUSIONS

Age, preoperative Hct, DM, COPD, operation time, LHS, and SSI are the danger factors of 30-day readmission following lumbar surgery.

Risk Factors for 30-day Unplanned Readmission following Surgery for Lumbar Degenerative Diseases: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Surgical procedures for lumbar degenerative diseases (LDD), which have emerged in the 21-century, are commonly practiced worldwide. Regarding financial burdens and health costs, readmissions within 30days following surgery are inconvenient. We performed a systematic review to integrate real-world evidence and report the current risk factors associated with 30-day readmission following surgery for LDD.

METHODS

The Cochrane Library, Embase, and Medline electronic databases were searched from inception to April 2022 to identify relevant studies reporting risk factors for 30-day readmission following surgery for LDD.

RESULTS

Thirty-six studies were included in the review. Potential risk factors were identified in the included studies that reported multivariate analysis results, including age, race, obesity, higher American Society of Anesthesiologists score, anemia, bleeding disorder, chronic pulmonary disease, heart failure, dependent status, depression, diabetes, frailty, malnutrition, chronic steroid use, surgeries with anterior approach, multilevel spinal surgeries, perioperative transfusion, presence of postoperative complications, prolonged operative time, and prolonged length of stay.

CONCLUSIONS

There are several potential perioperative risk factors associated with unplanned readmission following surgery for LDD. Preoperatively identifying patients that are at increased risk of readmission is critical for achieving the best possible outcomes.

Use of prophylactic perioperative antibiotics for lumbar spinal fusions: A nationwide population-based cohort study

BACKGROUND

Perioperative prophylactic antibiotic (PPA) use in spine surgery is known to reduce the rate of surgical site infections. In the past decade, several evidence-based guidelines have been published and surveillance systems to monitor the proper use of antimicrobials had been adapted by many institutes.

OBJECTIVE

To report the trends of PPA prescription in lumbar fusion surgeries nationwide in the Republic of Korea.

METHODS

This is a nationwide registry study. Using the population-based data from the Republic of Korea provided by the Korean Health Insurance Review and Assessment Service, data of all lumbar spinal fusion surgeries performed between 2010 and 2018 in adult patients (age ≥19 years) were reviewed.

RESULTS

The most frequently used antibiotics were first-generation cephalosporins, which accounted for 38.2 % of total PPA prescriptions and were prescribed in 58.96 % of lumbar fusion surgeries. A gradual increase in prescription trends was observed. The second most frequently used PPAs were second-generation cephalosporins, which showed decrease in use from 2016. The frequency of vancomycin prescriptions gradually increased over the observation period and showed an almost four-fold increase in 2018 compared to 2010. First- and second-generation cephalosporins were prescribed less frequently to patients with renal disease.

CONCLUSION

The pattern of PPA use has changed remarkably over the observation period. Furthermore, specific differences in PPA prescriptions were observed among patients with certain co-morbidities.

Surgical site infection in thoracic and lumbar fractures: incidence and risk factors in 11,401 patients from a nationwide administrative database

BACKGROUND CONTEXT

The rate of surgical site infection (SSI) following elective spine surgery ranges from 0.5%‒10%. Published reports suggest a higher SSI rate in non-elective spine surgery such as spine trauma; however, there is a paucity of large database studies examining this issue.

PURPOSE

The objective of this study was to investigate the incidence and risk factors of SSI in patients undergoing spine surgery for thoracic and lumbar fractures in a large population database.

STUDY DESIGN/SETTING

This is a retrospective study utilizing the PearlDiver Patient Claims Database.

PATIENT SAMPLE

Patients undergoing spine surgery for thoracic and lumbar fractures between 2015-2020 were identified in the PearlDiver Patient Claims Database using ICD-10 codes. Patients were excluded who had another surgery either 14 days before or 21 days after the index spine surgery, or pathologic fracture.

OUTCOME MEASURES

Rate of surgical site infection.

METHODS

Clinical data collected from the PearlDiver database based on ICD-10 codes included gender, age, diabetes, smoking status, obesity, Elixhauser Comorbidity Index (ECI), Charlson Comorbidity Index (CCI), and SSI. Univariate analysis was used to assess the association of potential risk factors and SSI. Multivariable analysis was used to identify independent risk factors of SSI. The authors have no conflicts of interest or funding sources to declare.

RESULTS

A total of 11,401 patients undergoing spine surgery for thoracic and lumbar fractures met inclusion criteria, and 1,065 patients were excluded. 860 patients developed SSI (7.5%). Risk factors significantly associated with SSI in univariate analysis included diabetes (OR 1.50; 95% CI, 1.30‒1.73; p<.001), obesity (OR 1.66; 95% CI, 1.44‒1.92; p<.001), increased age (p<.001), ECI (p<.001), and CCI (p<.001). On multivariable analysis, obesity and ECI were independently associated with SSI (p<.001 and p<.001, respectively).

CONCLUSIONS

Non-elective surgery for thoracic and lumbar fractures is associated with a 7.5% risk of SSI. Obesity and ECI are independent predictors of SSI in this population. Limitations include the reliance on accurate insurance coding which may not fully capture all SSI, and in particular superficial SSI. These findings provide a broad overview of the risk of SSI in this population at a national level and may also help counsel patients regarding risk.

Continuous Relationship of Operative Duration with Risk of Adverse Perioperative Outcomes and Early Discharge Undergoing Thoracoscopic Lung Cancer Surgery

Background: For thoracoscopic lung cancer surgery, the continuous relationship and the trigger point of operative duration with a risk of adverse perioperative outcomes (APOs) and early discharge remain unknown. Methods: This study enrolled 12,392 patients who underwent this surgical treatment. Five groups were stratified by operative duration: <60 min, 60−120 min, 120−180 min, 180−240 min, and ≥240 min. APOs included intraoperative hypoxemia, delayed extubation, postoperative pulmonary complications (PPCs), prolonged air leakage (PAL), postoperative atrial fibrillation (POAF), and transfusion. A restricted cubic spline (RCS) plot was used to characterize the continuous relationship of operative duration with the risk of APOs and early discharge. Results: The risks of the aforementioned APOs increased with each additional hour after the first hour. A J-shaped association with APOs was observed, with a higher risk in those with prolonged operative duration compared with those with shorter values. However, the probability of early discharge decreased from 0.465 to 0.350, 0.217, and 0.227 for each additional hour of operative duration compared with counterparts (<60 min), showing an inverse J-shaped association. The 90 min procedure appears to be a tipping point for a sharp increase in APOs and a significant reduction in early discharge. Conclusions: Our findings have important and meaningful implications for risk predictions and clinical interventions, and early rehabilitation, for APOs.

Rates and reasons for reoperation within 30 and 90 days following cervical spine surgery: a retrospective cohort analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry

BACKGROUND CONTEXT

Reoperation following cervical spinal surgery negatively impacts patient outcomes and increases health care system burden. To date, most studies have evaluated reoperations within 30 days after spine surgery and have been limited in scope and focus. Evaluation within the 90-day period, however, allows a more comprehensive assessment of factors associated with reoperation.

PURPOSE

The purpose of this study is to assess the rates and reasons for reoperations after cervical spine surgery within 30 and 90 days.

DESIGN

We performed a retrospective analysis of a state-wide prospective, multi-center, spine-specific database of patients surgically treated for degenerative disease.

PATIENT SAMPLE

Patients 18 years of age or older who underwent cervical spine surgery for degenerative pathologies from February 2014 to May 2019. Operative criteria included all degenerative cervical spine procedures, including those with cervical fusions with contiguous extension down to T3.

OUTCOME MEASURES

We determined causes for reoperation and independent surgical and demographic risk factors impacting reoperation.

METHODS

Patient-specific and surgery-specific data was extracted from the registry using ICD-10-DM codes. Reoperations data was obtained through abstraction of medical records through 90 days. Univariate analysis was done using chi-square tests for categorical variables, t-tests for normally distributed variables, and Wilcoxon rank-sum tests for variables with skewed distributions. Odds ratios for return to the operating room (OR) were evaluated in multivariate analysis.

RESULTS

A total of 13,435 and 13,440 patients underwent cervical spine surgery and were included in the 30 and 90-day analysis, respectively. The overall reoperation rate was 1.24% and 3.30% within 30 and 90 days, respectively. Multivariate analysis showed within 30 days, procedures involving four or more levels, posterior only approach, and longer length of stay had increased odds of returning to the OR (p<.05), whereas private insurance had a decreased odds of return to OR (p<.05). Within 90 days, male sex, coronary artery disease (CAD), previous spine surgery, procedures with 4 or more levels, and longer length of stay had significantly increased odds of returning to the OR (p<.05). Non-white race, independent ambulatory status pre-operatively, and having private insurance had decreased odds of return to the OR (p<.05). The most common specified reasons for return to the OR within 30 days was hematoma (19%), infection (17%), and wound dehiscence (11%). Within 90 days, reoperation reasons were pain (10%), infection (9%), and hematoma (8%).

CONCLUSION

Reoperation rates after elective cervical spine surgery are 1.24% and 3.30% within 30 and 90 days, respectively. Within 30 days, four or more levels, posterior approach, and longer length of stay were risk factors for reoperation. Within 90 days, male sex, CAD, four or more levels, and longer length of hospital stay were risk factors for reoperation. Non-white demographic and independent preoperative ambulatory status were associated with decreased reoperation rates.

Does Operative Duration of Lobectomy for Early Lung Cancer Increase Perioperative Morbidity?

BACKGROUND

Longer bariatric, colorectal, plastic, spine, and urologic operations increase complications and lengths of stay. We aimed to determine whether this is a risk factor for lung lobectomy morbidity.

METHODS

The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for early-stage non-small cell lung cancer lobectomy with surgical duration treated as a continuous variable. Univariate and multivariate analyses compared patient and clinical characteristics with perioperative outcomes and procedure durations. Robotic cases were combined with thoracoscopic cases for duration analyses into a minimally invasive group. All analyses were conducted in SAS v9.4 (SAS Institute, Cary, NC) at a significance level of .05.

RESULTS

In 17,852 patients mean duration of thoracotomy, thoracoscopy, and robotic lobectomies were 178 ± 84, 185 ± 73, and 214 ± 82 minutes, respectively (P < .001). The most common complications were prolonged air leak (12.3%), atrial fibrillation (12%), pneumonia (4.4%), and atelectasis requiring bronchoscopy (4.1%). Procedure duration was associated with increased odds of intraoperative packed red blood cell transfusion (P < .001) and length of stay > 5 days (P < .001) for both thoracotomy and minimally invasive lobectomy. Increased odds of pneumonia (P < .001), atelectasis (P < .001), and unexpected intensive care unit admission (P = .006) for thoracotomy lobectomy were associated with longer procedure duration. Increased lobectomy duration was not associated with readmission (P = .549) or 30-day mortality (P = .208).

CONCLUSIONS

Longer early-stage lung cancer lobectomy durations are associated with postoperative morbidity and increased length of stay. Although the effects of protracted operation times on long-term survival are unknown, short-term mortality differences were not detected. Measures that decrease operative durations without sacrificing safety and oncologic outcome should be undertaken by surgeons and hospital systems.

Operative Time Less Than 1.5 Hours, Male Sex, Dependent Functional Status, Presence of Dyspnea, and Reoperations Within 30 days Are Independent Risk Factors for Readmission After ACLR

Purpose

The purposes of this study are to use a large, patient-centered database to describe the 30-day readmission rate and to identify predictive risk factors for readmission after elective isolated ACLR.

Methods

The National Surgical Quality Improvement Program Database was retrospectively queried for isolated ACLR procedures between 2011 and 2017. Current Procedural Terminology (CPT) codes were used to identify isolated ACLR patients. Those undergoing additional procedures such as meniscectomy or multi-ligamentous reconstruction were excluded. Readmissions were analyzed against demographic variables with bivariate analysis. Multivariate logistic regression was used to find independent risk factors for 30-day readmissions after ACLR.

Results

A total of 11,060 patients (37.2% female) were included with an average age of 32.2 ± 10.6 years and mean body mass index (BMI) of 27.9 ± 6.5 kg/m² (29.2% were >30). The overall readmission rate was 0.59%. The most reported reason for readmission was infection 0.22 (24 out of 11,060). The following variables were associated with significantly higher readmission rates: male sex (P = .001), history of severe chronic obstructive pulmonary disease (COPD) (P = .025), cardiac comorbidity (P = .034), operative time >1.5 hours (P <.001), partially dependent functional health status (P = .002), high preoperative creatinine (P = .009), normal preoperative albumin (P = .020), hypertension (P = .034), and reoperations (P < .001). Operative time >1.5 hours, male sex, dependent functional status, the presence of dyspnea, and undergoing a reoperation were identified as independent risk factors for 30-day readmissions (P < .05 for all).

Conclusions

Isolated ACLR is associated with low 30-day readmission rates. Operative time >1.5 hours, male sex, dependent functional status, the presence of dyspnea, and 30-day reoperations are independent risk factors for readmission that should be considered in patient selection and addressed with preoperative counseling.

Level of Evidence

Level III, retrospective cohort study.

Clinical Outcomes at One-year Follow-up for Patients With Surgical Site Infection After Spinal Fusion

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To compare health-related quality of life outcomes at one-year follow-up between patients who did and did not develop surgical site infection (SSI) after thoracolumbar spinal fusion.

SUMMARY OF BACKGROUND DATA

SSI is among the most common healthcare-associated complications. As healthcare systems increasingly emphasize the value of delivered care, there is an increased need to understand the clinical impact of SSIs.

MATERIALS AND METHODS

A retrospective 3:1 (control:SSI) propensity-matched case-control study was conducted for adult patients who underwent thoracolumbar fusion from March 2014 to January 2020 at a single academic institution. Exclusion criteria included less than 18 years of age, incomplete preoperative and one-year postoperative patient-reported outcome measures, and revision surgery. Continuous and categorical data were compared via independent t tests and χ 2 tests, respectively. Intragroup analysis was performed using paired t tests. Regression analysis for ∆ patient-reported outcome measures (postoperative minus preoperative scores) controlled for demographics. The α was set at 0.05.

RESULTS

A total of 140 patients (105 control, 35 SSI) were included in final analysis. The infections group had a higher rate of readmission (100% vs. 0.95%, P <0.001) and revision surgery (28.6% vs. 12.4%, P =0.048). Both groups improved significantly in Physical Component Score (control: P =0.013, SSI: P =0.039), Oswestry Disability Index (control: P <0.001, SSI: P =0.001), Visual Analog Scale (VAS) Back (both, P <0.001), and VAS Leg (control: P <0.001, SSI: P =0.030). Only the control group improved in Mental Component Score ( P <0.001 vs. SSI: P =0.228), but history of a SSI did not affect one-year improvement in ∆MCS-12 ( P =0.455) on regression analysis. VAS Leg improved significantly less in the infection group (-1.87 vs. -3.59, P =0.039), which was not significant after regression analysis (β=1.75, P =0.050).

CONCLUSION

Development of SSI after thoracolumbar fusion resulted in increased revision rates but did not influence patient improvement in one-year pain, functional disability, or physical and mental health status.

The Impact of Isolated Baseline Cannabis Use on Outcomes Following Thoracolumbar Spinal Fusion: A Propensity Score-Matched Analysis

BACKGROUND

There is limited literature evaluating the impact of isolated cannabis use on outcomes for patients following spinal surgery. This study sought to compare 90-day complication, 90-day readmission, as well as 2-year revision rates between baseline cannabis users and non-users following thoracolumbar spinal fusion (TLF) for adult spinal deformity (ASD).

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried between January 2009 and September 2013 to identify all patients who underwent TLF for ASD. Inclusion criteria were age ≥18 years and either minimum 90-day (for complications and readmissions) or 2-year (for revisions) follow-up surveillance. Cohorts were created and propensity score-matched based on presence or absence of isolated baseline cannabis use. Baseline demographics, hospital-related parameters, 90-day complications and readmissions, and two-year revisions were retrieved. Multivariate binary stepwise logistic regression identified independent outcome predictors.

RESULTS

704 patients were identified (n=352 each), with comparable age, sex, race, primary insurance, Charlson/Deyo scores, surgical approach, and levels fused between cohorts (all, p>0.05). Cannabis users (versus non-users) incurred lower 90-day overall and medical complication rates (2.4% vs. 4.8%, p=0.013; 2.0% vs. 4.1%, p=0.018). Cohorts had otherwise comparable complication, revision, and readmission rates (p>0.05). Baseline cannabis use was associated with a lower risk of 90-day medical complications (OR=0.47, p=0.005). Isolated baseline cannabis use was not associated with 90-day surgical complications and readmissions, or two-year revisions.

CONCLUSION

Isolated baseline cannabis use, in the absence of any other diagnosed substance abuse disorders, was not associated with increased odds of 90-day surgical complications or readmissions or two-year revisions, though its use was associated with reduced odds of 90-day medical complications when compared to non-users undergoing TLF for ASD. Further investigations are warranted to identify the physiologic mechanisms underlying these findings. Level of Evidence: III.

Rates and risk factors associated with 30- and 90-day readmissions and reoperations after spinal fusions for adult lumbar degenerative pathology and spinal deformity

PURPOSE

Analyze state databases to determine variables associated with of short-term readmissions and reoperations following thoracolumbar spine fusions for degenerative pathology and spinal deformity.

METHODS

Retrospective study of State Inpatient Database (2005-13, CA, NE, NY, FL, NC, UT).

INCLUSION CRITERIA

age > 45 years, diagnosis of degenerative spinal deformity, ≥ 3 level posterolateral lumbar spine fusion.

EXCLUSION CRITERIA

revision surgery, cervical fusions, trauma, and cancer. Univariate and step-wise multivariate logistic regression analyses were performed to identify independent variables associated with of 30- and 90-day readmissions and reoperations.

RESULTS

12,641 patients were included. All-cause 30- and 90-day readmission rates were 14.6% and 21.1%, respectively. 90-day readmissions were associated with: age > 80 (OR: 1.42), 8 + level fusions (OR: 1.19), hospital length of stay (LOS) > 7 days (OR: 1.43), obesity (OR: 1.29), morbid obesity (OR: 1.66), academic hospital (OR: 1.13), cancer history (OR:1.21), drug abuse (OR: 1.31), increased Charlson Comorbidity index (OR: 1.12), and depression (OR: 1.20). Private insurance (OR: 0.64) and lumbar-only fusions (OR: 0.87) were not associated with 90-day readmissions. All-cause 30- and 90-day reoperation rates were 1.8% and 4.2%, respectively. Variables associated with 90-day reoperations were 8 + level fusions (OR: 1.28), LOS > 7 days (OR: 1.43), drug abuse (OR: 1.68), osteoporosis (OR: 1.26), and depression (OR: 1.23). Circumferential fusion (OR: 0.58) and lumbar-only fusions (OR: 0.68) were not associated with 90-day reoperations.

CONCLUSIONS

30- and 90-day readmission and reoperation rates in thoracolumbar fusions for adult degenerative pathology and spinal deformity may have been underreported in previously published smaller studies. Identification of modifiable risk factors is important for improving quality of care through preoperative optimization.

The Relation of Surgical Procedures and Diagnosis Groups to Unplanned Readmission in Spinal Neurosurgery: A Retrospective Single Center Study

Background: Unplanned readmission has gained increasing interest as a quality marker for inpatient care, as it is associated with patient mortality and higher economic costs. Spinal neurosurgery is characterized by a lack of epidemiologic readmission data. The aim of this study was to identify causes and predictors for unplanned readmissions related to index diagnoses and surgical procedures. Methods: In this study, from 2015 to 2017, spinal neurosurgical procedures were recorded for surgical and non-surgical treated patients. The main reasons for an unplanned readmission within 30 days following discharge were identified. Multivariate logarithmic regression revealed predictors of unplanned readmission. Results: A total of 1172 patient records were examined, of which 4.27% disclosed unplanned readmissions. Among the surgical patients, the readmission rate was 4.06%, mainly attributable to surgical site infections, while it was 5.06% for the non-surgical patients, attributable to uncontrolled pain. A night-time surgery presented as the independent predictive factor. Conclusion: In the heterogeneous group of spinal neurosurgical patients, stratification into diagnostic groups is necessary for statistical analysis. Degenerative lumbar spinal stenosis and spinal abscesses are mainly affected by unplanned readmission. The surgical procedure dorsal root ganglion stimulation is an independent predictor of unplanned re-hospitalizations, as is the timing of surgery.

Do In-Hospital Rothman Index Scores Predict Postdischarge Adverse Events and Discharge Location After Total Knee Arthroplasty?

BACKGROUND

There have been efforts to reduce adverse events and unplanned readmissions after total joint arthroplasty. The Rothman Index (RI) is a real-time, composite measure of medical acuity for hospitalized patients. We aimed to examine the association among in-hospital RI scores and complications, readmissions, and discharge location after total knee arthroplasty (TKA). We hypothesized that RI scores could be used to predict the outcomes of interest.

METHODS

This is a retrospective study of an institutional database of elective, primary TKA from July 2018 until December 2019. Complications and readmissions were defined per Centers for Medicare and Medicaid Services. Analysis included multivariate regression, computation of the area under the curve (AUC), and the Youden Index to set RI thresholds.

RESULTS

The study cohort's (n = 957) complications (2.4%), readmissions (3.6%), and nonhome discharge (13.7%) were reported. All RI metrics (minimum, maximum, last, mean, range, 25th%, and 75th%) were significantly associated with increased odds of readmission and home discharge (all P < .05). RI scores were not significantly associated with complications. The optimal RI thresholds for increased risk of readmission were last ≤ 71 (AUC = 0.65), mean ≤ 67 (AUC = 0.66), or maximum ≤ 80 (AUC = 0.63). The optimal RI thresholds for increased risk of home discharge were minimum ≥ 53 (AUC = 0.65), mean ≥ 69 (AUC = 0.65), or maximum ≥ 81 (AUC = 0.60).

CONCLUSION

RI values may be used to predict readmission or home discharge after TKA.

Increased Surgical Site Subcutaneous Fat Thickness Is Associated with Infection after Posterior Cervical Fusion

Background: Previous literature has associated increased body mass index (BMI) with risk of surgical site infection (SSI) after posterior cervical fusion (PCF) surgery. However, few studies have examined the association between local adiposity and risk of SSI, re-admission, and re-operation after PCF. Local adiposity is easily measured on pre-operative magnetic resonance imaging (MRI) and may act as a more accurate predictor compared with BMI. Patients and Methods: Subjects undergoing PCF from 2013-2018 at a single institution were identified retrospectively. Posterior cervical subcutaneous fat thickness, paraspinal muscle thickness, and lamina-to-skin distance measurements were obtained from computed tomography (CT) or MRI scans. Subjects with active infection, malignancy, or revision procedures were excluded. Results: Two hundred five patients were included with 20 developing SSIs. Subjects with SSIs had a longer fusion construct (4.90 vs. 3.71 levels; p = 0.001), higher Elixhauser comorbidity index (ECI; 2.05 vs. 1.34; p = 0.045), had a history of diabetes mellitus (30% vs. 10.8%; p = 0.026), higher subcutaneous fat thickness (30.5 vs. 23.6 mm; p = 0.013), and higher lamina-to-skin distance (66.4 vs. 57.9 mm; p = 0.027). Subcutaneous fat thickness (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.10]; p = 0.026) and lamina-to-skin distance (OR, 1.05; 95% CI, 1.01-1.09]; p = 0.014) were associated with SSI in multivariable analysis. A subcutaneous fat thickness cutoff value of 23.2 mm had 90% sensitivity and 54.1% specificity for prediction of SSI. There was no association need for re-admission or re-operation. Conclusions: Increased posterior cervical fat may increase the risk of SSI after PCF. Pre-operative advanced imaging may be a valuable tool for assisting with patient counseling, optimization, and risk stratification.

Natural language processing for prediction of readmission in posterior lumbar fusion patients: which free-text notes have the most utility?

BACKGROUND CONTEXT

The increasing volume of free-text notes available in electronic health records has created an opportunity for natural language processing (NLP) algorithms to mine this unstructured data in order to detect and predict adverse outcomes. Given the volume and diversity of documentation available in spine surgery, it remains unclear which types of documentation offer the greatest value for prediction of adverse outcomes.

STUDY DESIGN/SETTING

Retrospective review of medical records at two academic and three community hospitals.

PURPOSE

The purpose of this study was to conduct an exploratory analysis in order to examine the utility of free-text notes generated during the index hospitalization for lumbar spine fusion for prediction of 90-day unplanned readmission.

PATIENT SAMPLE

Adult patients 18 years or older undergoing lumbar spine fusion for lumbar spondylolisthesis or lumbar spinal stenosis between January 1, 2016 and December 31, 2020.

OUTCOME MEASURES

The primary outcome was inpatient admission within 90-days of discharge from the index hospitalization.

METHODS

The predictive performance of NLP algorithms developed by using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, medical doctor (MD) (resident or attending), and allied practice professional (APP) (nurse practitioner or physician assistant) notes were assessed by discrimination, calibration, overall performance.

RESULTS

Overall, 708 patients were included in the study and 83 (11.7%) had 90-day inpatient readmission. In the independent testing set of patients (n=141) not used for model development, the area under the receiver operating curve of NLP algorithms for prediction of 90-day readmission using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, MD/APP notes was 0.70, 0.57, 0.57, 0.60, 0.60, and 0.49 respectively.

CONCLUSION

In this exploratory analysis, discharge summary, physical therapy, and case management notes had the most utility and daily MD/APP progress notes had the least utility for prediction of 90-day inpatient readmission in lumbar fusion patients among the free-text documentation generated during the index hospitalization.

IDENTIFICATION OF RISK FACTORS ASSOCIATED WITH 30-DAY READMISSION OF PATIENTS SUBMITTED TO ANTERIOR OR POSTERIOR ACCESS CERVICAL SPINE SURGERY

ABSTRACT Aim: To conduct a systematic review of the literature to identify risk factors associated with 30-day readmission of patients submitted to anterior or posterior access cervical spine surgery. Methods: The databases used to select the papers were PubMed, Web of Science, and Cochrane, using the following search strategy: patient AND readmission AND (30 day OR “thirty day” OR 30-day OR thirty-day) AND (spine AND cervical). Results: Initially, 179 papers that satisfied the established search stringwere selected. After reading the titles and abstracts, 46 were excluded from the sample for not effectively discussing the theme proposed for this review. Of the 133 remaining papers, 109 were also excluded after a detailed reading of their content, leaving 24 that were included in the sample for the meta-analysis. Conclusions: The average readmission rate in the studies evaluated was 4.85%. Only the occurrence of infections, as well as the presence of patients classified by the American Society of Anesthesiology (ASA) assessment system with scores greater than III, were causal factors that influenced the readmission of patients. No significant differences were noted when comparing the anterior and posterior surgical access routes. Level of evidence II; Systematic Review of Level II or Level I Studies with discrepant results.

Readmissions after elective orthopedic surgery in a comprehensive co-management care system-a retrospective analysis

Background

No surgical intervention is without risk. Readmissions and reoperations after elective orthopedic surgery are common and are also stressful for the patient. It has been shown that a comprehensive ortho-medical co-management model decreases readmission rates in older patients suffering from hip fracture; but it is still unclear if this also applies to elective orthopedic surgery. The aim of the current study was to determine the proportion of unplanned readmissions or returns to operating room (for any reason) across a broad elective orthopedic population within 90 days after elective surgery. All cases took place in a tertiary care center using co-management care and were also assessed for risk factors leading to readmission or unplanned return to operating room (UROR).

Methods

In this observational study, 1295 patients undergoing elective orthopedic surgery between 2015 and 2017 at a tertiary care center in Switzerland were investigated. The proportion of reoperations and readmissions within 90 days was measured, and possible risk factors for reoperation or readmission were identified using logistic regression.

Results

In our cohort, 3.2% (42 of 1295 patients) had an UROR or readmission. Sixteen patients were readmitted without requiring further surgery—nine of which due to medical and seven to surgical reasons. Patient-related factors associated with UROR and readmission were older age (67 vs. 60 years; p = 0.014), and American Society of Anesthesiologists physical status (ASA PS) score ≥ 3 (43% vs. 18%; p < 0.001). Surgery-related factors were: implantation of foreign material (62% vs. 33%; p < 0.001), duration of operation (76 min. vs. 60 min; p < 0.001), and spine surgery (57% vs. 17%; p < 0.001). Notably, only spine surgery was also found to be independent risk factor.

Conclusion

Rates of UROR during initial hospitalization and readmission were lower in the current study than described in the literature. However, several comorbidities and surgery-related risk factors were found to be associated with these events. Although no surgery is without risk, known threats should be reduced and every effort undertaken to minimize complications in high-risk populations. Further prospective controlled research is needed to investigate the potential benefits of a co-management model in elective orthopedic surgery.

Neurosurgical Care during the COVID-19 Pandemic in Central Germany: A Retrospective Single Center Study of the Second Wave

The healthcare system has been placed under an enormous burden by the SARS-CoV-2 (COVID-19) pandemic. In addition to the challenge of providing sufficient care for COVID-19 patients, there is also a need to ensure adequate care for non-COVID-19 patients. We investigated neurosurgical care in a university hospital during the pandemic. We examined the second wave of the pandemic from 1 October 2020 to 15 March 2021 in this retrospective single-center study and compared it to a pre-pandemic period from 1 October 2019 to 15 March 2020. Any neurosurgical intervention, along with patient- and treatment-dependent factors, were recorded. We also examined perioperative complications and unplanned readmissions. A statistical comparison of the study groups was performed. We treated 535 patients with a total of 602 neurosurgical surgeries during the pandemic. This compares to 602 patients with 717 surgeries during the pre-pandemic period. There were 67 fewer patients (reduction to 88.87%) admitted and 115 fewer surgeries (reduction to 83.96%) performed, which were essentially highly elective procedures, such as cervical spinal stenosis, intracranial neurinomas, and peripheral nerve lesions. Regarding complication rates and unplanned readmissions, there was no significant difference between the COVID-19 pandemic and the non-pandemic patient group. Operative capacities were slightly reduced to 88% due to the pandemic. Nevertheless, comprehensive emergency and elective care was guaranteed in our university hospital. This speaks for the sufficient resources and high-quality processes that existed even before the pandemic.

First American College of Surgeons National Surgical Quality Improvement Program Report from a Low-Middle-Income Country: A 1-Year Outcome Analysis of Neurosurgical Cases

BACKGROUND

Low-middle-income countries (LMICs) share a substantial proportion of global surgical complications. This is compounded by the seemingly deficient documentation of postsurgical complications and the lack of a national average for comparison. In this context, the implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) that compares hospital performance based on postsurgical complication data provided by a wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of the NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To our knowledge, this report is the first from an LMIC to report its postoperative neurosurgical complications in comparison with international benchmarks.

METHODS

Our hospital joined the NSQIP in 2019. Through a standardized ACS protocol, ACS-trained surgical clinical reviewers (SCRs) reviewed and extracted data from randomly assigned neurosurgical patients' medical records from preoperative to postoperative (30-day) data using validated, standardized data definitions. SCRs entered deidentified data in an online Health Insurance Portability and Accountability Act web-based secure platform. The validated data were then consigned to the ACS NSQIP head office in the United States where the data were analyzed and compared with similar data from other centers registered with the NSQIP. In this way, our hospital was rated for each of the variables related to postsurgical complications after both spinal and cranial procedures, and the results were sent back to us in the form of text, tables, and graphs.

RESULTS

Our initial report suggested a relatively higher odds ratio for sepsis and readmissions after spinal procedures at our hospital, and a similarly higher odds ratio for morbidity, sepsis, urinary tract infection, and surgical site infection for cranial procedures. For these variables, our hospital fell in the needs improvement category of the NSQIP. For the rest of the variables studied for both spinal and cranial procedures, the hospital fell in the as expected category of the NSQIP.

CONCLUSIONS

Implementation of the NSQIP is an important first step in creating a culture of transparency, safety, and quality. This is the first report of NSQIP implementation in an LMIC, and we have shown comparable results to developed countries.

Risk Factors Associated with 90-day Readmissions Following Odontoid Fractures: A Nationwide Readmissions Database Study

STUDY DESIGN

Nationwide Readmissions Database Study.

OBJECTIVE

The aim of this study was to investigate readmission rates and factors related to readmission after surgical and nonsurgical management of odontoid fractures.

SUMMARY OF BACKGROUND DATA

Management of odontoid fractures, which are the most common isolated spine fracture in the elderly, continues to be debated. The choice between surgical or nonsurgical treatment has been reported to impact mortality and might influence readmission rates. Hospital readmissions represent a large financial burden upon our healthcare system. Factors surrounding hospital readmissions would benefit from a better understanding of their associated causes to lower health care costs.

METHODS

A retrospective study was performed using the 2016 Healthcare Utilization Project (HCUP) Nationwide Readmission Database (NRD). Demographic information and factors associated with readmission were collected. Readmission rates, complications, length of hospital stay were collected. Patients treated operatively, nonoperatively, and patients who were readmitted or not readmitted were compared. Statistical analysis was performed using open source software SciPy (Python v1.3.0) for all analyses.

RESULTS

We identified 2921 patients who presented with Type II dens fractures from January 1, 2016 to September 30, 2016, 555 of which underwent surgical intervention. The readmission rate in patients who underwent surgery was 16.4% (91/555) and 29.4% (696/2366) in the nonoperative group. Hospital costs for readmitted and nonreadmitted patients were $353,704 and $174,922, and $197,099 and $80,715 for nonoperatively managed patients, respectively. Medicaid and Medicare patients had the highest readmission rate in both groups. Charlson and Elixhauser comorbidity indices were significantly higher in patients who were readmitted (P < 0.0001).

CONCLUSION

We report an overall 90-day readmission rate of 16.4% and 29.4%, in operative and nonoperative management of type II odontoid fractures, respectively. In the face of a rising incidence of this fracture in the elderly population, an understanding of the comorbidities and age-related demographics associated with 90-day readmissions following both surgical and nonsurgical treatment are critical.Level of Evidence: 3.

Risk Factors Associated with ICU-Specific Care in Patients Undergoing Endovascular Treatment of Unruptured Intracranial Aneurysms

BACKGROUND

Multiple studies suggest routine postoperative intensive care unit (ICUs) stays in presumed high-risk neurosurgical procedures may be unnecessary. Our objective was to evaluate the risk factors associated with ICU-specific needs in patients undergoing elective endovascular treatment of unruptured intracranial aneurysms.

METHODS

A retrospective review of consecutive patients undergoing elective endovascular treatment of unruptured aneurysms was performed between January 2010 and January 2020 in a single academic medical center. Patient demographic information, aneurysm and treatment characteristics, intraoperative and postoperative complications, as well as ICU-specific needs, were abstracted. The primary outcome was ICU-specific needs.

RESULTS

A total of 382 patient encounters in 344 unique patients were abstracted. 13.6% (52 of 382) of patient encounters had an ICU-specific need. Multivariate analysis revealed that age [adjusted odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, p = 0.03], procedure duration greater 200 min (adjusted OR 2.75, 95% CI 1.34-5.88, p = 0.007), and any intraoperative complication (adjusted OR 20.41, CI 7.97-56.57, p < 0.001) were independent predictors of postoperative ICU-specific needs. The majority of ICU-specific needs (94%, 49 of 52) occurred within 6 h of surgery.

CONCLUSIONS

Our results show that age, procedure duration greater than or equal to 200 min, and intraoperative complication were independent predictors of postoperative ICU-specific needs in patients presenting for elective endovascular treatment of unruptured intracranial aneurysms. The majority of ICU-specific needs and associated complications occurred in the immediate postoperative period. This data can be used to help decide the appropriate postoperative level of care in this patient population.

Using a national surgical database to predict complications following posterior lumbar surgery and comparing the area under the curve and F1-score for the assessment of prognostic capability

BACKGROUND

With spinal surgery rates increasing in North America, models that are able to accurately predict which patients are at greater risk of developing complications are highly warranted. However, the previously published methods which have used large, multi-centre databases to develop their prediction models have relied on the receiver operator characteristics curve with the associated area under the curve (AUC) to assess their model's performance. Recently, it has been found that a precision-recall curve with the associated F1-score could provide a more realistic analysis for these models.

PURPOSE

To develop a logistic regression (LR) model for the prediction of complications following posterior lumbar spine surgery and to then assess for any difference in performance of the model when using the AUC versus the F1-score.

STUDY DESIGN

Retrospective review of a prospective cohort.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was used. All patients that underwent posterior lumbar spine surgery between 2005 to 2016 with appropriate data were included.

OUTCOME MEASURES

Both the AUC and F1-score were utilized to assess the prognostic performance of the prediction model.

METHODS

In order to develop the LR model used to predict a complication during or following spine surgery, 19 variables were selected by three orthopedic spine surgeons from the NSQIP registry. Two datasets were developed for this analysis: (1) an imbalanced dataset, which was taken directly from the NSQIP registry, and (2) a down-sampled set. The purpose of the down-sampled set was to balance the data in order to evaluate whether balancing the data had an effect on model performance. The AUC and F1-score were applied to both of these datasets.

RESULTS

Within the NSQIP database, 52,787 spine surgery cases were identified of which only 10% of these cases had complications during surgery. Applying the LR model showed a large difference between the AUC (0.69) and the F1 score (0.075) on the imbalanced dataset. However, no major differences existed between the AUC and F1-score when the data was balanced and the LR model was reapplied (0.69 and 0.62, AUC and F1-score, respectively).

CONCLUSIONS

The F1-score detected a drastically lower performance for the prediction of complications when using the imbalanced data, but detected a performance similar to the AUC level when balancing techniques were utilized for the dataset. This difference is due to a low precision score when many false positive classifications are present, which is not identified when using the AUC value. This lowers the utility of the AUC score, as many of the datasets used in medicine are imbalanced. Therefore, we recommend using the F1-score on large, prospective databases when the data is imbalanced with a large amount of true negative classifications.

Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery

Surgical site infection (SSI) is a potentially devastating complication of spinal surgery that increases patient morbidity and healthcare costs. SSIs have complex and multifactorial etiologies; therefore, there are numerous opportunities for prevention and risk mitigation. The aim of this narrative review was to describe the incidence, risk factors, and outcomes of SSIs in spine surgery with an emphasis on postoperative wound care. We list and describe the preoperative, intraoperative, and postoperative evidence-based interventions that can be applied to potentially prevent SSI after spinal surgery.

Interleukin-6 as inflammatory marker of surgical site infection following spinal surgery

BACKGROUND

In order to elucidate whether serum inflammatory markers identify patients with local surgical site infection(SSI) as underlying disease for recurrent or new symptomatology following spine surgery, we evaluated the diagnostic potential of interleukin-6(IL-6) as a marker of SSI. The diagnostic significance of IL-6 was compared to the standard serum inflammatory markers C-reactive protein(CRP) and white blood cell count (WBCC).

METHOD

Ninety-eight consecutive patients with readmission due to recurrent or new symptomology after spinal surgery of degenerative spine disorders entered the study. Baseline patients' characteristics and the abovementioned inflammatory markers were collected, and arithmetical means with standard deviation, area under the curve (AUC), thresholds, sensitivity, specificity, positive(+)likelihood ratio (LR), and negative(-)LR with corresponding 95% confidence interval(95%CI) were calculated and correlated with presence or absence of SSI.

RESULTS

Nine patients suffered from a SSI, whereas the remaining 89 patients had a recurrent/adjacent-segment degenerative disorder without evidence of infection. The most significant parameter for diagnosing a SSI was serum IL-6 (cut-off value > 15.3 pg/ml, AUC = 0.954, SE = 85.7%, SP = 97.3%), followed by CRP (cut-off value = 0.8 mg/dl, AUC = 0.916, SE = 88.9%, SP = 84.5%) CONCLUSIONS: In the case of recurrent or new symptomatology following spinal surgery, serum IL-6 has the highest diagnostic potential for diagnosing spinal SSI.

Outcomes Following Discectomy for Far Lateral Disc Herniation Are Not Predicted by Obstructive Sleep Apnea

Introduction

Previous studies have demonstrated that obstructive sleep apnea (OSA) is associated with adverse postoperative outcomes, but few studies have examined OSA in a purely spine surgery population. This study investigates the association of the STOP-Bang questionnaire, a screening tool for undiagnosed OSA, with adverse events following discectomy for far lateral disc herniation (FLDH).

Methods

All adult patients (n = 144) who underwent FLDH surgery at a single, multihospital, academic medical center (2013-2020) were retrospectively enrolled. Univariate logistic regression was performed to evaluate the relationship between risk of OSA (low- or high-risk) according to STOP-Bang score and postsurgical outcomes, including unplanned hospital readmissions, ED visits, and reoperations.

Results

Ninety-two patients underwent open FLDH surgery, while 52 underwent endoscopic procedures. High risk of OSA according to STOP-Bang score did not predict risk of readmission, ED visit, outpatient office visit, or reoperation of any kind within either 30 days or 30-90 days of surgery. High risk of OSA also did not predict risk of reoperation of any kind or repeat neurosurgical intervention within 30 days or 90 days of the index admission (either during the same admission or after discharge).

Conclusion

The STOP-Bang questionnaire is not a reliable tool for predicting post-operative morbidity and mortality for FLDH patients undergoing discectomy. Additional studies are needed to assess the impact of OSA on morbidity and mortality in other spine surgery populations.