STUDY DESIGN.Retrospective analysis of a population-based database.
OBJECTIVE.To investigate national epidemiological trends of cervical spine surgical procedures from 2002–2009.
SUMMARY OF ...BACKGROUND DATA.Anterior cervical fusion (ACF), posterior cervical fusion (PCF), and posterior cervical decompression (PCD) are procedures routinely performed for cervical degenerative pathology. Studies regarding epidemiological trends of these procedures is currently lacking in the literature.
METHODS.Data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project was obtained for each year between 2002 and 2009. Patients undergoing ACF, PCF, and PCD for the diagnosis of cervical radiculopathy and myelopathy were identified. Demographics, costs, and mortality were assessed in the surgical subgroups. A P value of 0.001 was used to denote significance.
RESULTS.An estimated 1,323,979 cervical spine surgical procedures were performed between 2002 and 2009. There was a significant upward trend in the mean age of patients undergoing cervical spine surgery during this time period. ACF and PCF cohorts demonstrated statistically significant increases in comorbidities and costs from 2002–2009. The PCF group had the greatest mortality, comorbidities, costs, and longest hospitalizations compared with ACF and PCF cohorts across all time periods.
CONCLUSION.Our study demonstrates that cervical spine surgical procedures have increased between 2002 and 2009 (P = 0.001). The primary increase in volume is due to the increasing number of ACFs. Despite older patients with more comorbidities undergoing ACF and PCF procedures, mortality has not changed. However, this patient population trended significant increases in costs during this time period. We hypothesize that these increased costs are due to an increased comorbidity burden in patients undergoing ACF or PCF. Results of this study can be used to set benchmarks for future epidemiological investigations in cervical spine surgery.Level of Evidence4
STUDY DESIGN.Retrospective analysis.
OBJECTIVE.A national population-based database was analyzed to characterize the risks of postoperative complications and mortality associated with the patientʼs ...body mass index (BMI) after lumbar spinal surgery.
SUMMARY OF BACKGROUND DATA.Obesity has been associated with greater perioperative complications and worsened surgical outcomes after lumbar spinal surgery. However, the stratified BMI risks of postoperative complications relative to normal weight patients have not been well characterized.
METHODS.The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who underwent lumbar spinal surgery between 2006 and 2011. Patients were stratified into BMI cohortsnormal (18.5–24.99 kg/m), overweight (25.00–29.99 kg/m), class 1 (30.00–34.99 kg/m), class 2 (35.00–39.99 kg/m), and class 3 (≥40 kg/m) obesity. Preoperative patient characteristics and perioperative outcomes were assessed. The relative risks of 30-day postoperative complications and mortality for each BMI cohort were calculated in reference to the normal weight cohort using a 95% confidence interval.
RESULTS.A total of 24,196 patients underwent lumbar spine surgery between 2006 and 2011 of which 19,195 (79.3%) were overweight or obese. The risk for deep vein thrombosis increased beginning with overweight patients and compounded for the subsequent obesity classes. The risk for superficial wound infection and pulmonary embolism increased beginning with the class 1 obesity cohort. Furthermore, the relative risk increase for urinary tract infection, acute renal failure, and sepsis was significantly increased only among class 3 obesity patients. Lastly, there was no relative risk increase in 30-day mortality in any cohort after lumbar spine surgery.
CONCLUSION.Overweight and obese patients demonstrated an increased risk of postoperative complications relative to normal weight patients. Despite these findings, a BMI 25 kg/m or more was not associated with a greater risk of mortality. Further studies are warranted to characterize the impact of postoperative complications associated with overweight and obese patients on hospital resource utilization and costs after lumbar spine surgery.Level of Evidence4
A unique, visually appealing, and easy-to-read guide on spinal anatomy, pathology, and management
The management of patients with spinal conditions involves a team-based approach, with professionals ...and trainees contributing through their respective roles. As such, medical trainees need resources that enable them to quickly and adeptly learn spine "basics," such as performing spinal examinations. This handbook is a concise, compact guide on key principles of spine surgical knowledge - from the atlanto-occipital joint to the coccyx. It provides both professionals and medical trainees with user-friendly, insightful text gleaned from the hands-on insights of seasoned spinal surgeons.
Core fundamentals cover spine anatomy, clinical evaluations, spine imaging, diagnostic spine tests, and select spine procedures. Common surgical approaches are delineated in succinct bulleted text, accompanied by case studies and radiographic pathology. This format is conducive to learning and provides an ideal spine surgery review for medical students, postgraduate trainees participating in spine rotations, and residents.
Key HighlightsThe only book on spinal pathology and management created with contributions from medical students and residentsHigh-impact citations and questions at the end of each chapter highlight key topicsDetailed drawings, diagrams, radiographic images, and MRIs elucidate and expand upon chapter topicsTables provide a quick reference, with concise information including impacted anatomy, nerves, and procedural maneuvers utilized in exams
Spine Essentials Handbook: A Bulleted Review of Anatomy, Evaluation, Imaging, Tests, and Procedures is a must-have resource for orthopaedic and neurosurgery residents and medical students. It will also benefit physiatrists, spine practitioners, orthopaedic and neurosurgical trainees and nurses, and chiropractors.
This book includes complimentary access to a digital copy on https://medone.thieme.com.
Structured Abstract Background Context Lateral lumbar interbody fusion (LLIF) is a frequently utilized technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been ...associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach. Purpose To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF. Study Design Systematic Review Patient Sample 6819 patients who underwent LLIF reported in clinical studies through June 2016. Outcome Measures Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and musculoskeletal/spine (MSK) categories. Methods This systematic review was performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and musculoskeletal/spine (MSK) categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work. Results A total of 2232 articles were identified. Following screening of title, abstract, and full text availability, 63 articles were included in the review. There were a total 6819 patients with 11325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval CI=1.00-1.85%), cardiac (1.86%; CI=1.33-2.52%), vascular (0.81%; CI=0.44-1.36%), pulmonary (1.47; CI=0.95-2.16%), gastrointestinal (1.38%; CI=1.00-1.87%), urologic (0.93%; CI=0.55-1.47%), transient neurologic (36.07%; CI=34.74-37.41%), persistent neurologic (3.98%; CI=3.42-4.60%), and MSK/Spine (9.22%; CI=8.28-10.23%). Concluson The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks and expectations for patients following LLIF procedures.
STUDY DESIGN.A retrospective review of data collected prospectively by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).
OBJECTIVE.The aim of this study was ...to investigate the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days following posterior lumbar fusion surgery.
SUMMARY OF BACKGROUND DATA.Malnutrition is a potentially modifiable risk factor that may contribute to complications following spinal surgery. Although prior studies have identified associations between malnutrition, delayed wound healing, and surgical site infection (SSI), the evidence for such a relationship within spine surgery is mixed.
METHODS.Patients who underwent posterior lumbar spinal fusion of one to three levels as part of the ACS-NSQIP were identified. Patients without preoperative serum albumin concentration were excluded. Outcomes were compared between patients with and without hypoalbuminemia (defined as serum albumin concentration <3.5 g/dL). All comparisons were adjusted for baseline differences between populations.
RESULTS.Four thousand three hundred ten patients were included. The prevalence of hypoalbuminemia was 4.8%. In comparison to patients with normal albumin concentration, patients with hypoalbuminemia had a higher risk for occurrence of wound dehiscence 1.5% vs. 0.2%, adjusted relative risk (RR) = 5.8, P = 0.006, SSI (5.4% vs. 1.7%, adjusted RR = 2.3, P = 0.010), and urinary tract infection (5.4% vs. 1.5%, adjusted RR = 2.5, P = 0.005). Similarly, patients with hypoalbuminemia had a higher risk for unplanned hospital readmission within 30 days of surgery (11.7% vs. 5.4%, RR = 1.8, P < 0.001). Finally, patients with hypoalbuminemia had a longer mean inpatient stay (5.2 vs. 3.7 days, RR = 1.2, P < 0.001).
CONCLUSION.The present study suggests that malnutrition is an independent risk factor for infectious and wound complications following posterior lumbar fusion. Malnutrition was also associated with an increased length of stay and readmission. Future studies should evaluate methods of correcting malnutrition before lumbar spinal surgery. Such efforts have the potential to meaningfully decrease the rates of adverse events following this procedure.Level of Evidence3
STUDY DESIGN.Retrospective database analysis.
OBJECTIVE.A population-based database was analyzed to characterize the incidence, hospital costs, mortality, and risk factors associated with ...postoperative delirium after lumbar decompression (LD) and lumbar fusion (LF) surgical procedures.
SUMMARY OF BACKGROUND DATA.Postoperative delirium is a common complication after surgery in the elderly that leads to increased hospitalization, cost, and other adverse outcomes. The incidence of delirium after lumbar spine surgery has not been discussed in this literature.
METHODS.Data from the Nationwide Inpatient Sample were obtained from 2002–2009. Patients undergoing LD or LF for degenerative pathologies were identified. Patient demographics, comorbidities, length of stay, discharge disposition, costs, and mortality were assessed. SPSS version 20 was used for statistical analysis using independent T tests for discrete variables and χ tests for categorical data. Logistic regression was performed to identify independent predictors of delirium. A P value of less than 0.001 was used to denote significance.
RESULTS.A total of 578,457 LDs and LFs were identified in the United States from 2002–2009. Of these, 292,177 were LDs and 286,280 were LFs. The overall incidence of delirium was 8.4 events per 1000 cases. Patients undergoing LF had a statistically greater incidence of delirium than patients undergoing LD (11.8 vs. 5.0 per 1000; P < 0.001). Patients experiencing delirium were significantly older and more likely to be female than nonaffected patients (P < 0.001). Patients with delirium in both cohorts demonstrated significantly greater comorbidities, length of stay, greater costs, and more frequent discharge to skilled nursing facilities (P < 0.001). The presence of delirium in LD-treated patients was associated with an increased mortality rate (6.1 vs. 0.8 per 1000; P < 0.001). Logistic regression demonstrated that independent predictors of delirium included older age (≥65 yr), alcohol/drug abuse, depression, psychotic disorders, neurological disorders, deficiency anemia, fluid/electrolyte disorders, and weight loss.
CONCLUSION.The results of our study demonstrated an overall incidence of 8.4 events per 1000 lumbar spine surgical procedures. Overall analysis demonstrated an increased incidence of delirium in older females with greater comorbid conditions. Delirium was found to be associated with increased length of stay, costs, and mortality in all patients undergoing lumbar spine surgery. We recommend that physicians put greater effort into recognizing risk factors of delirium and diagnosing it in a timely manner to mitigate its effects.Level of Evidence3
STUDY DESIGN.Retrospective review of prospectively collected data.
OBJECTIVE.To investigate if zero profile devices offer an advantage over traditional plate/cage constructs for dysphagia rates in ...single level anterior cervical discectomy and fusion (ACDF).
SUMMARY OF BACKGROUND DATA.Dysphagia rates following ACDF have been reported to be as high as 83%, most cases are self-limiting, but chronic dysphagia can continue in up to 35% of patients. Zero profile devices were developed to limit dysphagia, and other plate specific complications, however the literature is currently divided regarding their efficacy.
METHODS.Dysphagia was assessed by swallowing quality of life (SWAL-QOL) scores preoperatively, at 6 weeks and 12 weeks. Patient reported outcome measures (PROMs) including visual analog scale (VAS) and Neck Disability Index (NDI) were collected preoperatively, at 6 weeks and at 6 months. Univariate and multivariate regression analysis was conducted with SWAL-QOL score as the dependent variable.
RESULTS.Sixty-four patients were included, 41 received a zero profile device, and 23 received plate-graft construct. Both groups were similar regarding patient demographics, except operative time, with the zero-profile group having a shorter procedure time than the cage-plate group (44.88 ± 6.54 vs. 54.43 ± 14.71 min, P = 0.001). At all timepoints dysphagia rates were similar between the groups. Regression analysis confirmed preoperative SWAL-QOL and operative time were the only significant variables. PROMs were also similar between groups at all time points, except VAS neck at 6 months, which was lower in the plate-graft group (1.05 ± 1.48 vs. 3.43 ± 3.21, P = 0.007).
CONCLUSION.Operative time and preoperative SWAL-QOL scores are predictive of dysphagia in single level ACDF. Zero profile devices had a significantly shorter operative time, and may provide a benefit in dysphagia rates in this regard.Level of Evidence3
Independent, retrospective clinical record review with a concurrent control.
To identify whether rhBMP-2 is associated with an increased incidence of clinically relevant postoperative prevertebral ...swelling problems in patients undergoing anterior cervical fusions.
Bone Morphogenetic Protein-2 (rhBMP-2) is FDA approved as a bone graft substitute in anterior lumbar interbody fusions. rhBMP-2 has also been used "off-label" in anterior cervical fusions. We suspected that rhBMP-2 might increase the incidence of adverse swelling events.
A total of 234 consecutive patients (ages 12-82 years) undergoing anterior cervical fusion with and without rhBMP-2 over a 2-year period at one institution comprised the study population. The incidence of clinically relevant prevertebral swelling was calculated. The populations were compared and statistical significance was determined.
A total of 234 patients met the study criteria, 69 of whom underwent anterior cervical spine fusions using rhBMP-2; 27.5% of those patients in the rhBMP-2 group had a clinically significant swelling event versus only 3.6% of patients in the non-rhBMP-2 group. This difference was statistically significant (P < 0.0001) and remained so after controlling for other significant predictors of swelling.
Off-label use of rhBMP-2 in the anterior cervical spine is associated with an increased rate of clinically relevant swelling events.
Abstract Background context Postoperative ileus is a known complication of surgery. The incidence and risk factors for ileus after lumbar fusion surgery is not well characterized. Purpose To ...determine rates of postoperative ileus, a population-based database was analyzed to identify incidence, mortality, and risk factors associated with anterior (ALF), posterior (PLF), and combined anterior/posterior (APLF) lumbar fusions. Study design This was a retrospective database analysis. Patient sample The sample consisted of 220,522 patients from the Nationwide Inpatient Sample (NIS) database. Outcome measures Outcome measures were incidence of postoperative ileus, length of stay (LOS), in-hospital costs, and mortality. Methods Data from the NIS were obtained from 2002 to 2009. Patients undergoing ALF, PLF, and APLF for degenerative pathologies were identified and the incidence of postoperative ileus was assessed. Patient demographics, Charlson comorbidity index (CCI), LOS, costs, and mortality were assessed. SPSS v.20 was used to detect statistical differences between groups and perform logistic regression analyses to identify independent predictors of postoperative ileus. A p value less than .001 denoted significance. Results A total of 220,522 lumbar fusions were identified in the United States from 2002 to 2009. There were 19,762 ALFs, 182,801 PLFs, and 17,959 APLFs. The incidence of postoperative ileus was increased in ALFs over PLFs (74.9 vs. 26.0 per 1,000; p<.001). Within PLF and APLF groups, CCI scores were increased in the presence of postoperative ileus (p<.001). Across cohorts, patients with postoperative ileus demonstrated greater LOS and costs (p<.001). PLF-treated patients with postoperative ileus demonstrated increased mortality (p<.001). Independent predictors of postoperative ileus included male gender, 3+ fusion levels, alcohol abuse, anemia, fluid/electrolyte disorders, and weight loss (p<.001). Conclusions The results of our study demonstrate increased incidence of postoperative ileus associated with anterior approaches for lumbar fusion. Across cohorts, postoperative ileus was associated with increased LOS and costs. To determine the mortality and resource use associated with postoperative ileus, we recommend preoperatively identifying and treating modifiable risk factors, especially when an anterior approach is used.
A nonrandomized, nonblinded prospective review.
To analyze intraoperative, immediate postoperative, and financial outcomes in worker's compensation (WC) and non-WC patients undergoing either an open ...or a minimally invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF).
Few studies have analyzed outcomes in a WC population of MIS TLIFs.
A total of 66 consecutive patients undergoing a single-level TLIF (open/MIS) were analyzed (33 open and 33 MIS). Twenty-four total WC patients were identified (11 MIS and 13 open). Patients in either cohort (MIS/open) were matched according to insurance status (WC) and medical comorbidities (Charleston disability index). Every patient in this study had a diagnosis of either degenerative disc disease or spondylolisthesis and stenosis. Operative time (min), length of stay (d), estimated blood loss (mL), anesthesia time (min), visual analogue scale scores, and hospital cost/payment amount were assessed (MIS/open and work-comp versus non-work comp).
There were no statistically significant differences between MIS WC and non-WC TLIFs with respect to surgical time, length of stay, estimated blood loss, visual analogue scale scores, and anesthesia time. There were no statistically significant differences between open WC and non-WC TLIF patients in all of the same above-mentioned parameters. There were significant differences between MIS (WC and non-WC) and open (WC and non-WC) TLIFs in clinical outcomes. There were statistically significant differences in total costs amounts between WC MIS TLIF and WC open TLIF ($28,060 vs. $33,862, respectively; P = 0.0311) and non-WC MIS TLIF versus non-WC open TLIF groups ($29,429 vs. $32,998, respectively; P = 0.0001).
Contrary to popular belief, immediate outcomes and hospitalizations between non-WC and WC populations did not differ regardless of surgical technique (MIS/open). Differences occurred in improved outcomes with an MIS TLIF versus an open TLIF even in a WC environment. MIS TLIF WC and non-WC patient hospital costs were lower than their open TLIF counterparts.
