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Bortz CA, Pierce KE, Krol O, Kummer N, Passfall L, Egers M, Oh C, Horn SR, Segreto FA, Vasquez-Montes D, Frangella NJ, Buza JA, Raman T, Kuprys T, Lafage R, Jankowski PP, Hassanzadeh H, Vira SN, Diebo BG, Gerling MC, Passias PG. Predictors of Complication Severity Following Adult Spinal Deformity Surgery: Smoking Rate, Diabetes, and Osteotomy Increase Risk of Severe Adverse Events. Int J Spine Surg 2023; 17:103-111. [PMID: 36750312 PMCID: PMC10025845 DOI: 10.14444/8393] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Given the physical and economic burden of complications in spine surgery, reducing the prevalence of perioperative adverse events is a primary concern of both patients and health care professionals. This study aims to identify specific perioperative factors predictive of developing varying grades of postoperative complications in adult spinal deformity (ASD) patients, as assessed by the Clavien-Dindo complication classification (Cc) system. METHODS Surgical ASD patients ≥18 years were identified in the American College of Surgeons' National Surgical Quality Improvement Program from 2005 to 2015. Postoperative complications were stratified by Cc grade severity: minor (I, II, and III) and severe (IV and V). Stepwise regression models generated dataset-specific predictive models for Cc groups. Model internal validation was achieved by bootstrapping and calculating the area under the curve (AUC) of the model. Significance was set at P < 0.05. RESULTS Included were 3936 patients (59 ± 16 years, 63% women, 29 ± 7 kg/m2) undergoing surgery for ASD (4.4 ± 4.7 levels, 71% posterior approach, 11% anterior, and 18% combined). Overall, 1% of cases were revisions, 39% of procedures involved decompression, 27% osteotomy, and 15% iliac fixation. Additionally, 66% of patients experienced at least 1 complication, 0% of which were Cc grade I, 51% II, 5% III, 43% IV, and 1% V. The final model predicting severe Cc (IV-V) complications yielded an AUC of 75.6% and included male sex, diabetes, increased operative time, central nervous system tumor, osteotomy, cigarette pack-years, anterior decompression, and anterior lumbar interbody fusion. Final models predicting specific Cc grades were created. CONCLUSIONS Specific predictors of adverse events following ASD-corrective surgery varied for complications of different severities. Multivariate modeling showed smoking rate, osteotomy, diabetes, anterior lumbar interbody fusion, and higher operative time, among other factors, as predictive of severe complications, as classified by the Clavien-Dindo Cc system. These factors can help in the identification of high-risk patients and, consequently, improve preoperative patient counseling. CLINICAL RELEVANCE The findings of this study provide a foundation for identifying ASD patients at high risk of postoperative complications . LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Cole A Bortz
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Katherine E Pierce
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Oscar Krol
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Nicholas Kummer
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Lara Passfall
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Max Egers
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Cheongeun Oh
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Samantha R Horn
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Frank A Segreto
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Dennis Vasquez-Montes
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Nicholas J Frangella
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - John A Buza
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Tina Raman
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Tomas Kuprys
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Pawel P Jankowski
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Shaleen N Vira
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Michael C Gerling
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
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2
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Passias PG, Bortz CA, Lafage V, Lafage R, Smith JS, Line B, Eastlack R, Gupta MC, Hostin RA, Horn SR, Segreto FA, Egers M, Sciubba DM, Gum JL, Kebaish KM, Klineberg EO, Burton DC, Schwab FJ, Shaffrey CI, Ames CP, Bess S. Durability of Satisfactory Functional Outcomes Following Surgical Adult Spinal Deformity Correction: A 3-Year Survivorship Analysis. Oper Neurosurg (Hagerstown) 2021; 18:118-125. [PMID: 31149719 DOI: 10.1093/ons/opz093] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 01/13/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite reports showing positive long-term functional outcomes following adult spinal deformity (ASD)-corrective surgery, it is unclear which factors affect the durability of these outcomes. OBJECTIVE To assess durability of functional gains following ASD-corrective surgery; determine predictors for postoperative loss of functionality. METHODS Surgical ASD patients > 18 yr with 3-yr Oswestry Disability Index (ODI) follow-up, and 1-yr postoperative (1Y) ODI scores reaching substantial clinical benefit (SCB) threshold (SCB < 31.3 points). Patients were grouped: those sustaining ODI at SCB threshold beyond 1Y (sustained functionality) and those not (functional decline). Kaplan-Meier survival analysis determined postoperative durability of functionality. Multivariate Cox regression assessed the relationship between patient/surgical factors and functional decline, accounting for age, sex, and levels fused. RESULTS All 166 included patients showed baseline to 1Y functional improvement (mean ODI: 35.3 ± 16.5-13.6 ± 9.2, P < .001). Durability of satisfactory functional outcomes following the 1Y postoperative interval was 88.6% at 2-yr postoperative, and 71.1% at 3-yr postoperative (3Y). Those sustaining functionality after 1Y had lower baseline C2-S1 sagittal vertical axis (SVA) and T1 slope (both P < .05), and lower 1Y thoracic kyphosis (P = .035). From 1Y to 3Y, patients who sustained functionality showed smaller changes in alignment: pelvic incidence minus lumbar lordosis, SVA, T1 slope minus cervical lordosis, and C2-C7 SVA (all P < .05). Those sustaining functionality beyond 1Y were also younger, less frail at 1Y, and had lower rates of baseline osteoporosis, hypertension, and lung disease (all P < .05). Lung disease (Hazard Ratio:4.8 [1.4-16.4]), 1Y frailty (HR:1.4 [1.1-1.9]), and posterior approach (HR:2.6 [1.2-5.8]) were associated with more rapid decline. CONCLUSION Seventy-one percent of ASD patients maintained satisfactory functional outcomes by 3Y. Of those who failed to sustain functionality, the largest functional decline occurred 3-yr postoperatively. Frailty, preoperative comorbidities, and surgical approach affected durability of functional gains following surgery.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Cole A Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton Line
- Rocky Mountain Scoliosis and Spine, Denver, Colorado
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Richard A Hostin
- Southwest Scoliosis Institute, Baylor Scott and White Medical Center, Plano, Texas
| | - Samantha R Horn
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Frank A Segreto
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Max Egers
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, California
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, Denver, Colorado
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3
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Varlotta CG, Manning JH, Ayres EW, Wang E, Woo D, Vasquez-Montes D, Alas H, Brown A, Egers M, Kim Y, Bendo JA, Fischer CR, Protopsaltis TS, Stieber JR, Buckland AJ. Preoperative MRI predictors of health-related quality of life improvement after microscopic lumbar discectomy. Spine J 2020; 20:391-398. [PMID: 31580903 DOI: 10.1016/j.spinee.2019.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Lumbar herniated nucleus pulposus (HNP) is a common spinal pathology often treated by microscopic lumbar discectomy (MLD), though prior reports have not demonstrated which preoperative MRI factors may contribute to significant clinical improvement after MLD. PURPOSE To analyze the MRI characteristics in patients with HNP that predict meaningful clinical improvement in health-related quality of life scores (HRQoL) after MLD. STUDY DESIGN/SETTING Retrospective clinical and radiological study of patients undergoing MLD for HNP at a single institution over a 2-year period. PATIENT SAMPLE Eighty-eight patients receiving MLD treatment for HNP. OUTCOME MEASURES Cephalocaudal Canal Migration; Canal & HNP Anterior-Posterior (AP) Lengths and Ratio; Canal & HNP Axial Areas and Ratio; Hemi-Canal & Hemi-HNP Axial Areas and Ratio; Disc appearance (black, gray, or mixed); Baseline (BL); and 3-month (3M) postoperative HRQoL scores. METHODS Patients >18 years old who received MLD for HNP with BL and 3M HRQoL scores of PROMIS (Physical Function, Pain Interference, and Pain Intensity), ODI, VAS Back, and VAS Leg scores were included. HNP and spinal canal measurements of cephalocaudal migration, AP length, area, hemi-area, and disc appearance were performed using T2 axial and sagittal MRI. HNP measurements were divided by corresponding canal measurements to calculate AP, Area, and Hemi-Area ratios. Using known minimal clinically important differences (MCID) for each ΔHRQoL score, patients were separated into two groups based on whether they reached MCID (MCID+) or did not reach MCID (MCID-). The MCID for PROMIS pain intensity was calculated using a decision tree. A linear regression illustrated correlations between PROMIS vs ODI and VAS Back/Leg scores. Independent t-tests and chi-squared tests were utilized to investigate significant differences in HNP measurements between the MCID+ and MCID- groups. RESULTS There were 88 MLD patients included in the study (Age=44.6±14.9, 38.6% female). PROMIS pain interference and pain intensity were strongly correlated with ODI and VAS Back/Leg (R≥0.505), and physical function correlated with ODI and VAS Back/Leg (R=-0.349) (all p<.01). The strongest MRI predictors of meeting HRQoL MCID were gray disc appearance, HNP area (>116.6 mm2), and Hemi-Area Ratio (>51.8%). MCID+ patients were 2.7 times more likely to have a gray HNP MRI signal than a mixed or black HNP MRI signal in five out of six HRQoL score comparisons (p<.025). MCID+ patients had larger HNP areas than MCID- patients had in five out of six HRQoL score comparisons (116.6 mm2±46.4 vs 90.0 mm2±43.2, p<.04). MCID+ patients had a greater Hemi-Area Ratio than MCID- patients had in four out of six HRQoL score comparisons (51.8%±14.7 vs 43.9%±14.9, p<.05). CONCLUSIONS Patients who met MCID after MLD had larger HNP areas and larger Hemi-HNP Areas than those who did not meet MCID. These patients were also 2.7× more likely to have a gray MRI signal than a mixed or black MRI signal. When accounting for HNP area relative to canal area, patients who met MCID had greater Hemi-HNP canal occupation than patients who did not meet MCID. The results of this study suggest that preoperative MRI parameters can be useful in predicting patient-reported improvement after MLD.
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Affiliation(s)
- Christopher G Varlotta
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Jordan H Manning
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Ethan W Ayres
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Erik Wang
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Dainn Woo
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Dennis Vasquez-Montes
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Haddy Alas
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Avery Brown
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Max Egers
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Yong Kim
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - John A Bendo
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Charla R Fischer
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | | | - Jonathan R Stieber
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA
| | - Aaron J Buckland
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Health, New York, NY, USA.
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4
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Horn SR, Pierce KE, Oh C, Segreto FA, Egers M, Bortz C, Vasquez-Montes D, Lafage R, Lafage V, Vira S, Steinmetz L, Ge DH, Buza JA, Moon J, Diebo BG, Alas H, Brown AE, Shepard NA, Hassanzadeh H, Passias PG. Predictors of Hospital-Acquired Conditions Are Predominately Similar for Spine Surgery and Other Common Elective Surgical Procedures, With Some Key Exceptions. Global Spine J 2019; 9:717-723. [PMID: 31552152 PMCID: PMC6745634 DOI: 10.1177/2192568219826083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
STUDY DESIGN Retrospective review of a prospectively collected database. OBJECTIVE To predict the occurrence of hospital-acquired conditions (HACs) 30-days postoperatively and to compare predictors of HACs for spine surgery with other common elective surgeries. METHODS Patients ≥18 years undergoing elective spine surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Outcome measures included any HACs: superficial or deep surgical site infection (SSI), venous thromboembolism (VTE), urinary tract infection (UTI). Spine surgery patients were compared with those undergoing other common procedures. Random forest followed by multivariable regression analysis was used to determine risk factors for the occurrence of HACs. RESULTS A total of 90 551 elective spine surgery patients, of whom 3021 (3.3%) developed at least 1 HAC, 1.4% SSI, 1.3% UTI, and 0.8% VTE. The occurrence of HACs for spine patients was predicted with high accuracy (area under the curve [AUC] 77.7%) with the following variables: female sex, baseline functional status, hypertension, history of transient ischemic attack (TIA), quadriplegia, steroid use, preoperative bleeding disorders, American Society of Anesthesiologists (ASA) class, operating room duration, operative time, and level of residency supervision. Functional status and hypertension were HAC predictors for total knee arthroplasty (TKA), bariatric, and cardiothoracic patients. ASA class and operative time were predictors for most surgery cohorts. History of TIA, preoperative bleeding disorders, and steroid use were less predictive for most other common surgical cohorts. CONCLUSIONS Occurrence of HACs after spine surgery can be predicted with demographic, clinical, and surgical factors. Predictors for HACs in surgical spine patients, also common across other surgical groups, include functional status, hypertension, and operative time. Understanding the baseline patient risks for HACs will allow surgeons to become more effective in their patient selection for surgery.
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Affiliation(s)
| | | | - Cheongeun Oh
- NYU Langone Orthopaedic Hospital, New York, NY, USA
| | | | - Max Egers
- NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Cole Bortz
- NYU Medical Center, NY Spine Institute, New York, NY, USA
| | | | | | | | - Shaleen Vira
- NYU Langone Orthopaedic Hospital, New York, NY, USA
| | | | - David H. Ge
- NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - John A. Buza
- NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - John Moon
- NYU Langone Orthopaedic Hospital, New York, NY, USA
| | | | - Haddy Alas
- NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Avery E. Brown
- NYU Medical Center, NY Spine Institute, New York, NY, USA
| | | | | | - Peter G. Passias
- NYU Medical Center, NY Spine Institute, New York, NY, USA,Peter G. Passias, Division of Spinal Surgery,
Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301
East 17th Street, New York, NY 10003, USA.
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