Purpose
We aim to examine the preoperative factors associated with increased postoperative length of stay in patients undergoing LLIF in the hospital setting.
Methods
Patient demographics, ...perioperative characteristics, and patient-reported outcome measures (PROMs) were collected from a single-surgeon database. Patients undergoing LLIF in the hospital setting were separated into postoperative LOS <48 h (H) and LOS ≥ 48H. Univariate analysis for preoperative characteristics was utilized to determine covariates for multivariable logistic regression. Multivariable logistic regression was then utilized to determine significant predictors of extended postoperative length of stay. Secondary univariate analysis of inpatient complications, operative, and postoperative characteristics were calculated to determine postoperative factors associated with prolonged hospitalization.
Results
Two-hundred and forty patients were identified with 115 patients’ LOS ≥ 48H. Univariate analysis identified age/Charlson Comorbidity Index (CCI) score/gender/insurance type/number of contiguous fused levels/preoperative PROMs of Visual Analog Scale (VAS) back/VAS leg/Patient-Reported Outcomes Measurement Information System (PROMIS-PF)/Oswestry Disability Index (ODI)/degenerative spondylolisthesis diagnoses/foraminal stenosis/central stenosis for multivariable logistic regression. Multivariable logistic regression calculated significant positive predictors of LOS ≥ 48H to be age/3-level fusion/preoperative ODI scores. Negative predictors of LOS ≥ 48H were the diagnosis of foraminal stenosis/preoperative PROMIS-PF/male gender. The secondary analysis determined that patients with longer operative time/estimated blood loss/transfusion/postoperative day 0 and 1 pain and narcotic consumption/complications of altered mental status/postoperative anemia/fever/ileus/urinary retention were associated with prolonged hospitalization.
Conclusion
Older patients undergoing LLIF with greater preoperative disability and 3-level fusion were more likely to require prolonged hospitalization. Male patients with higher preoperative physical function and who were diagnosed with foraminal stenosis were less likely to require prolonged hospitalization.
Mental health disorders (MHDs) have been linked to worse postoperative outcomes after various surgical procedures. Past studies have also demonstrated a higher prevalence of dysphagia in both acute ...and community mental health settings. Dysphagia is among the most common complications following anterior cervical spine surgery (ACSS); however, current literature describing the association between an established diagnosis of an MHD and the rate of dysphagia after ACSS is sparse.
All patients who underwent ACSS between 2014 and 2020 with a minimum of 6 months of follow-up were retrospectively evaluated at a single institution. Patients were divided into cohorts depending on an established diagnosis of an MHD: the first had no established MHD (non-MHD); the second included patients with a diagnosed MHD. Outcomes were measured using pre- and postoperative patient-reported outcome scores, which included the Swallowing Quality of Life survey for dysphagia, as well as physical and mental health questionnaires. Postoperative dysphagia surveys were obtained at final follow-up for both patient cohorts.
A total of 68 and 124 patients with and without a diagnosis of a MHD were assessed. The MHD group reported significantly worse baseline Patient-Reported Outcomes Measurement Information System depression scale scores (p < 0.001), 12-Item Short-Form Health Survey (p < 0.001), and Veterans RAND 12-Item Health Survey (p = 0.001) mental health components compared to non-MHD group. This group continued to have worse mental health status in the postoperative period, as reported by Patient-Reported Outcomes Measurement Information System depression scale scores (p = 0.024), 12-Item Short-Form Health Survey (p = 0.019), and Veterans RAND 12-Item Health Survey (p = 0.027). Postoperative assessment of Swallowing Quality of Life scores (expressed as the mean ± SD) also showed worse dysphagia outcomes in the MHD cohort (80.1 ± 12.2) than in the non-MHD cohort (86.0 ± 12.1, p = 0.001).
ACSS is associated with significantly higher postoperative dysphagia in patients diagnosed with an MHD when compared to patients without an established mental health diagnosis. Given the high prevalence of MHDs in patients with spinal pathology, it is important for spine surgeons to take note of the increased incidence of dysphagia faced by this patient population.
Radiolucent implants in orthopedic oncology Federico, Vincent P.; Trevino, Noe; Zavras, Athan G. ...
Journal of surgical oncology,
September 2023, 2023-Sep, 2023-09-00, 20230901, Letnik:
128, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Radiolucent implants in have demonstrated promising results for both extremity and spine oncologic procedures. However, questions persist about whether the superiority in surveillance imaging justify ...the increased cost and technical challenges. In this review, we present the current body of literature for the use of radiolucent implants in musculoskeletal oncology, with a focus on implant complications, including screw loosening, breakage, malposition, and loss of reduction. We also discuss clinical outcomes, technical considerations, and postoperative radiotherapy.
We present the 1H, 13C and 15N NMR chemical shifts of bulk ionic liquids based on 1-butyl-3-methylimidazolium (the cation also known as 1-butyl-3-picolinium) halides (Cl-, Br- and I-) and tribromide ...(Br3-) salts. A characterization in solution of the analogous ICl2- and I3- salts is also reported. A series of DFT calculations has been run to predict the features of the NMR spectra of the pure ILs based on a few selected supramolecular ionic aggregates. To test the effect of temperature, and vibrational and conformational motions, only for the chloride salt, we also run first-principles molecular dynamics simulations of the ion pair in the gas phase, using the ADMP scheme (Atom Centered Density Matrix Propagation molecular dynamics model). The aim of our investigation is to test whether a simple DFT based approach of ion-pairing in ionic liquids is capable of providing reliable results and under which conditions the protocol is robust. We obtained a very good agreement between the calculated and experimental spectra for the three halides, where the bulk structure of the ILs is dominated by H-bond interactions between the X- anion (X = Cl, Br and I) and the ortho protons of the pyridinium ring (a structural arrangement not too different from the solid-state structure of pyridinium halides). In contrast, when the H-bond is weak, as in the Br3- case, a number of supramolecular arrangements exist in solution and the simple DFT calculations of a few selected cases cannot exhaustively explore the complete energy landscape. Moreover, the dynamic effects due to thermal motion, evaluated by ADMP MD simulations of the chloride salt, appear to be not very significant.
Recent literature has shown the advantages of outpatient surgery for many shoulder and elbow procedures, including cost savings with equivalent safety in appropriately selected patients. Two common ...settings for outpatient surgeries are ambulatory surgery centers (ASCs), which function as independent financial and administrative entities, or hospital outpatient departments (HOPDs), which are owned and operated by hospital systems. The purpose of this study was to compare shoulder and elbow surgery costs between ASCs and HOPDs.
Publicly available data from 2022 provided by the Centers for Medicare & Medicaid Services (CMS) was accessed via the Medicare Procedure Price Lookup Tool. Current Procedural Terminology (CPT) codes were used to identify shoulder and elbow procedures approved for the outpatient setting by CMS. Procedures were grouped into arthroscopy, fracture, or miscellaneous. Total costs, facility fees, Medicare payments, patient payment (costs not covered by Medicare), and surgeon’s fees were extracted. Descriptive statistics were used to calculate means and standard deviations. Cost differences were analyzed using Mann-Whitney U tests.
Fifty-seven CPT codes were identified. Arthroscopy procedures (n = 16) at ASCs had significantly lower total costs ($2667 ± $989 vs. $4899 ± $1917; P = .009), facility fees ($1974 ± $819 vs. $4206 ± $1753; P = .008), Medicare payments ($2133 ± $791 vs. $3919 ± $1534; P = .009), and patient payments ($533 ± $198 vs. $979 ± $383; P = .009) compared with HOPDs. Fracture procedures (n = 10) at ASCs had lower total costs ($7680 ± $3123 vs. $11,335 ± $3830; P = .049), facility fees ($6851 ± $3033 vs. $10,507 ± $3733; P = .047), and Medicare payments ($6143 ± $2499 vs. $9724 ± $3676; P = .049) compared with HOPDs, although patient payments were not significantly different ($1535 ± $625 vs. $1610 ± $160; P = .449). Miscellaneous procedures (n = 31) at ASCs had lower total costs ($4202 ± $2234 vs. $6985 ± $2917; P < .001), facility fees ($3348 ± $2059 vs. $6132 ± $2736; P < .001), Medicare payments ($3361 ± $1787 vs. $5675 ± $2635; P < .001), and patient payments ($840 ± $447 vs. $1309 ± $350; P < .001) compared with HOPDs. The combined cohort (n = 57) at ASCs had lower total costs ($4381 ± $2703 vs. $7163 ± $3534; P < .001), facility fees ($3577 ± $2570 vs. $6539.1 ± $3391; P < .001), Medicare payments ($3504 ± $2162 vs. $5892 ± $3206; P < .001), and patient payments ($875 ± $540 vs. $1269 ± $393; P < .001) compared with HOPDs.
Shoulder and elbow procedures performed at HOPDs for Medicare recipients were found to have average total cost increase of 164% compared with those performed at ASCs (184% savings for arthroscopy, 148% for fracture, and 166% for miscellaneous). ASC use conferred lower facility fees, patient payments, and Medicare payments. Policy efforts to incentivize migration of surgeries to ASCs may translate into substantial health care cost savings.
Patch infection after carotid endarterectomy (CEA) is a rare but devastating complication. A variety of different treatment options are reported; however, there is currently no consensus on how to ...manage this highly morbid problem. The purpose of this study was to review our experience with management of infectious patch complications after CEA and to highlight utility of femoral vein interposition bypass grafting.
All CEA patch infection operations at the University of Florida from 2002 to 2017 were reviewed retrospectively. Preoperative history, intraoperative details, and postoperative complications were recorded. Bypass patency was verified with duplex ultrasound imaging (1 month, 6 months, annually). The primary end point was 30-day stroke or death; secondary end points included cranial nerve injury, reintervention, reinfection, and survival. Life tables were used to estimate end points.
Twenty-nine patients (mean age, 70 ± 9 years; male, 76%) were identified. The index CEA occurred at a median of 15 months (interquartile range, 1-55 months) preoperatively (39% <2 months after the index procedure). A variety of patch materials were implicated (Dacron, n = 9; unknown/undocumented, n = 8; bovine pericardium, n = 5; expanded polytetrafluoroethylene, n = 3; unidentified nonbiologic prosthetic, n = 3; saphenous vein, n = 1). Carotid reintervention antecedent to the infected patch presentation occurred in 41% (incision and drainage, n = 10; carotid stent, n = 2; vein patch, n = 1). The most common infecting organisms were Staphylococcus and Streptococcus species (52%; n = 15). The most frequent presentation (46%; n = 13) was pericarotid abscess or phlegmon (pulsatile neck mass or pseudoaneurysm, 28% n = 8; carotid-cutaneous fistula, 28% n = 8). Reconstruction strategy included femoral vein interposition bypass in 24 patients (83%; nonreversed configuration, 16/24 67%), saphenous vein patch in 4 patients (14%), and femoral vein patch in 1 patient (3%). Median postoperative length of stay was 5 days (interquartile range, 4-8 days). Twelve patients (41%) experienced a complication, and the 30-day stroke/death rate was 7% (death, n = 1; stroke, n = 1). The single postoperative death occurred in a patient with history of congestive heart failure who developed a pulseless electrical activity arrest on postoperative day 11 that resulted in multiorgan system failure. Cranial nerve injury occurred in 28% (n = 8; cranial nerves X 3, VII 2, XII 2, and IX 1), all of which resolved by last follow-up. In follow-up (mean clinical follow-up, 17 ± 14 months; mean survival time, 108 months 95% confidence interval, 81-135 months), two (7%) complained of limb edema with femoral cutaneous nerve palsy that resolved by 3 months. One interposition bypass occluded at 3 months (asymptomatic); the remaining grafts remained patent with no restenosis, reinfection, or reintervention events. The 1- and 5-year survival was 87% ± 6% and 82% ± 8%, respectively.
CEA patch infection can be successfully managed with femoral vein interposition bypass with acceptable postoperative outcomes. Excellent patency can be anticipated with good long-term survival. This strategy can be considered especially in cases with carotid size mismatch or if there is limited availability of alternative biologic conduits.
Little research has been done to evaluate the prognostic value of short-term postoperative patient-reported outcomes (PROs) on long-term PROs following lumbar decompression (LD). We evaluated the ...prognostic value of short-term PROs on long-term PROs through 2 years after LD.
A single spine surgeon database was retrospectively queried for patients undergoing primary LD with 6-week postoperative PROs reported. The demographics, perioperative traits, and preoperative, 6-month, 1-year, and 2-year PROs were recorded. The PROs included the visual analog scale (VAS) for back pain, VAS for leg pain, PRO measure information system for physical function (PROMIS-PF), and Oswestry disability index. Two-step multivariate linear regression was performed to determine the predictive value of 6-week PROs for the 6-month, 1-year, and 2-year PROs.
A total of 277 patients were included. The 6-week Oswestry disability index, VAS for leg pain, and 9-item patient health questionnaire (PHQ-9) are all positive predictors for their respective outcomes at 6 months. Additionally, the 6-week PROMIS-PF was a negative predictor of the 6-month PHQ-9. The 6-week PROMIS-PF positively predicted the PROMIS-PF through 1 year, and the PHQ-9 was a positive predictor of the PHQ-9 at 1 and 2 years postoperatively.
The 6-week postoperative PROs are predictive of the same outcomes at 6 months, the PROMIS-PF is predictive through 1 year, and the PHQ-9 is predictive through 2 years. Determining the predictive value of early postoperative PROs can be helpful in understanding the likely postoperative trajectory following LD and informing patient expectations.
•This paper studies correlations between anxiety, SD, and PROMs in LD patients.•Anxiety was positively correlated with SD, depression, back pain, and disability.•SD was positively correlated with ...depression, back pain, leg pain, and disability.•Anxiety and SD were negatively correlated with physical function.
Patients with lumbar spinal pathology often suffer from anxiety and sleep disturbance, but correlations between anxiety and sleep disturbance and other patient-reported outcome measures (PROMs) before and after surgical intervention have not been explored. The purpose of this study is to analyze the correlations between patient-reported anxiety, sleep disturbance, and PROMs before and after lumbar decompression.
All patients undergoing elective, primary, lumbar decompression were retrospectively queried from a prospectively-maintained single spine surgeon database. Demographic and perioperative data and pre- and postoperative PROMs were extracted. Patient-Reported Outcome Measure Information System (PROMIS)-Anxiety, PROMIS-Sleep Disturbance (SD), PROMIS-Physical Function (PF), 9-Item Patient Health Questionnaire (PHQ-9), Visual Analog Scale (VAS)-Back, VAS-Leg, Oswestry Disability Index (ODI) were obtained preoperatively and through two years postoperatively. Pearson’s correlation coefficients were calculated between PROMIS-Anxiety, PROMIS-SD, and the other PROMs of interest.
PROMIS-Anxiety was positively correlated with PROMIS-SD (range: r = 0.473–0.828, p ≤ 0.006, all), PHQ-9 (range: r = 0.613––0.890, p ≤ 0.006, all), VAS-Back (range: r = -0.410–0.798, p ≤ 0.039, all), and ODI (range: r = 0.503–0.732, p ≤ 0.033, all) at all timepoints. PROMIS-Anxiety was negatively correlated with PROMIS-PF through 1 year postoperatively (range: r = -0.323– -0.729p ≤ 0.033, all). PROMIS-Anxiety was positively correlated to VAS-Leg at preoperative, 6-week, 12-week, and 2-year postoperative timepoints (range: r = 0.333––0.707, p ≤ 0.022, all). PROMIS-SD was positively correlated with PHQ-9 (range: r = 0.600–0.836), VASBack (range: r = 0.383–0.734), VAS-Leg (range: r = 0.399–0.811), and ODI (range: r = 0.404–0.812) at all timepoints (p ≤ 0.031, all). PROMIS-SD was negatively correlated with PROMIS-PF at all timepoints (range: r = -0.339–0.665, p ≤ 0.035, all).
Patient-reported anxiety and sleep disturbance are significantly correlated with depressive burden, back pain, disability, and physical function, before and after lumbar decompression. Future studies should aim to determine the directionality of the associations and test interventions to improve health-related quality of life following lumbar decompression.
This study sought to quantify radiographic differences in psoas morphology, great vessel anatomy, and lumbar lordosis between supine and prone intraoperative positioning to optimize surgical planning ...and minimize the risk of neurovascular injury.
Measurements on supine magnetic resonance imaging and prone intraoperative computed tomography with O-arm from L2 to L5 levels included the anteroposterior and mediolateral proximity of the psoas, aorta, inferior vena cava (IVC), and anterior iliac vessels to the vertebral body. Psoas transverse and longitudinal diameters, psoas cross-sectional area, total lumbar lordosis, and segmental lordosis were assessed.
Prone position produced significant psoas lateralization, especially at more caudal levels (P < 0.001). The psoas drifted slightly anteriorly when prone, which was non-significant, but the magnitude of anterior translation significantly decreased at more caudal segments (P = 0.038) and was lowest at L5 where in fact posterior retraction was observed (P = 0.032). When prone, the IVC (P < 0.001) and right iliac vein (P = 0.005) migrated significantly anteriorly, however decreased anterior displacement was seen at more caudal levels (P < 0.001). Additionally, the IVC drifted significantly laterally at L5 (P = 0.009). Mean segmental lordosis significantly increased when prone (P < 0.001).
Relative to the vertebral body, the psoas demonstrated substantial lateral mobility when prone, and posterior retraction specifically at L5. IVC and right iliac vein experienced significant anterior mobility—particularly at more cephalad levels. Prone position enhanced segmental lordosis and may be critical to optimizing sagittal restoration.
To determine prognostic value of preoperative Veterans RAND 12-Item Health Survey (VR-12) physical composite score (PCS) on outcomes in patients undergoing anterior cervical discectomy and fusion ...(ACDF).
ACDF patients with preoperative VR-12 PCS formed 2 cohorts: VR-12 PCS <35 and VR-12 PCS ≥35. The following patient-reported outcome measures (PROMs) were gathered preoperatively and postoperatively up to 2 years: VR-12 mental composite score (MCS)/PCS, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System (PROMIS) PF, 9-Item Patient Health Questionnaire (PHQ-9), visual analog scale (VAS) neck/arm pain, and 12-Item Short Form Health Survey (SF-12) PCS/MCS. Comparing PROMs change with established thresholds determined achievement of minimum clinically important difference (MCID). Univariate analysis compared demographics, perioperative characteristics, and preoperative PROMs. Multivariable regression analysis compared postoperative PROMs and MCID achievement.
Of 174 patients, 83 had VR-12 PCS <35. Preoperatively, patients with reduced PF displayed lower patient-reported outcome scores in NDI, PHQ-9, and SF-12 MCS (P ≤ 0.008), but not in VAS arm. At 6 weeks postoperatively, these patients continued to score lower in NDI (P ≤ 0.014) and SF-12 PCS (P ≤ 0.001), among others. By the final check, most scores remained lower (P ≤ 0.002) except for PHQ-9 and VAS arm (P > 0.05). Greater improvements at 6 weeks postoperatively were especially noted in patients with lower initial VR-12 PCS for NDI, PROMIS PF, and SF-12 PCS (P < 0.05). However, by final follow-up, only PROMIS PF showed noteworthy improvement (P = 0.19). Regarding MCID achievement, significant differences were largely absent except in NDI, where patients with reduced PF exhibited more MCID achievement (P = 0.016).
ACDF patients with VR-12 PCS <35 experienced inferior PF, mental health, and disability postoperatively until final follow-up. There were no significant differences in postoperative improvement magnitude and MCID achievement. Results suggest that baseline VR-12 PCS in ACDF patients may indicate poorer PF, mental health, and disability postoperatively. However, VR-12 PCS does not limit extent of postoperative improvement.
PDF
