The prevalence of malnutrition in patients undergoing lumbar spine surgery ranges from 5% to 50% and is associated with higher rates of surgical site infections, medical complications, longer lengths ...of stay, and mortality.
To determine if perioperative nutritional intervention decreases wound healing complications in patients undergoing lumbar spine surgery.
A prospective randomized controlled trial.
Patients aged 55+ undergoing elective primary lumbar surgery were included. Patients with a preoperative albumin<3.5 g/dL were defined as malnourished. Intervention group received nutritional supplementation (protein shake) twice daily from postoperative day 0 to two weeks postdischarge. Control group was instructed to continue regular daily diets. Primary outcomes included minor in-hospital complications (wound drainage, electrolyte abnormalities, hypotension, ileus, deep venous thrombus) and wound healing complications within 90 days. Secondary outcomes included 90-day emergency room visits, readmissions, and return to the operating room. Baseline data were compared between groups using means comparison tests. Multivariable analysis evaluated association of outcomes with nutritional supplementation. Subanalysis of malnourished patients assessed effects of nutritional supplementation on outcomes.
One hundred three patients were included. Thirty-seven (35.9%) were considered malnourished preoperatively. Forty-six (44.7%) received nutritional intervention and 57 (55.3%) served as controls. Adjusted analysis found patients receiving supplementation had lower rates of in-hospital minor complications (2.1% vs. 23.2%, P <0.01), and perioperative wound healing complications (3.4% vs. 17.9%, P <0.05). Subgroup analysis of 37 malnourished patients demonstrated that malnourished patients who received perioperative nutritional supplementation had lower rates of minor complications during admission (0.0% vs. 34.4%, P =0.01) and return to the operating room within 90 days (0.0% vs. 12.4%, P =0.04).
Over one third of patients undergoing lumbar surgery were malnourished. Nutritional supplementation during the two-week perioperative period decreased rates of minor complications during admission and wound complications within 90 days. Malnourished patients receiving supplementation less often returned to the operating room. To our knowledge, this is the first study to investigate the effects of perioperative nutritional intervention on wound healing complications for patients undergoing elective lumbar spine surgery.
I.
Study Design. Retrospective cohort study. Objective. This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery. Summary of ...Background Data. The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions. Methods. Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, <0.3), mildly frail (MF, 0.3–0.5), severely frail (SF, >0.5). Means comparison tests analyzed frailty and clinical outcomes. Results. After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926( P < 0.001). Each index established significant (all P < 0.001) predictive values for unplanned readmission (11 = odds ratio OR: 5.65 2.92–10.94; 5 = OR: 3.68 1.85–2.32), post-op complications (11 = OR: 8.56 7.12–10.31; 5 = OR: 13.32 10.89–16.29), and mortality (11 = OR: 41.29 21.92–77.76; 5 = OR: 114.82 54.64–241.28). Frailty categories by mFI-5 were: 83.2% NF, 15.2% MF, and 1.6% SF. From 2005 to 2016, rates of NF decreased (88.8% to 82.2%, P < 0.001), whereas MF increased (9.2% to 16.2%, P < 0.001), and SF remained constant (2% to 1.6%, P > 0.05). With increase in severity, postoperative rates of morbidities and complications increased. Conclusion. The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making. Level of Evidence: 3
Adult spinal deformity (ASD) represents a major cause of disability in the elderly population in the United States. Surgical intervention has been shown to reduce disability and pain in properly ...indicated patients. However, there is a small subset of patients in whom nonoperative treatment is also able to durably maintain or improve symptoms.
To examine the factors associated with successful nonoperative management in patients with ASD.
We retrospectively evaluated a cohort of 207 patients with nonoperative ASD, stratified into 3 groups: (1) success, (2) no change, and (3) failure. Success was defined as a gain in minimal clinically importance difference in both Oswestry Disability Index and Scoliosis Research Society-Pain. Logistic regression model and conditional inference decision trees established cutoffs for success according to baseline (BL) frailty and sagittal vertical axis.
In our cohort, 44.9% of patients experienced successful nonoperative treatment, 22.7% exhibited no change, and 32.4% failed. Successful nonoperative patients at BL were significantly younger, had a lower body mass index, decreased Charlson Comorbidity Index, lower frailty scores, lower rates of hypertension, obesity, depression, and neurological dysfunction (all P < .05) and significantly higher rates of grade 0 deformity for all Schwab modifiers (all P < .05). Conditional inference decision tree analysis determined that patients with a BL ASD-frailty index ≤ 1.579 (odds ratio: 8.3 4.0-17.5, P < .001) were significantly more likely to achieve nonoperative success.
Success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty the most important determinant factor. The factors presented here may be useful in informing preoperative discussion and clinical decision-making regarding treatment strategies.
Retrospective analysis of a prospectively collected multicenter database.
The objective of this study was to assess the radiographic and health-related quality of life (HRQoL) impact of a short-term ...(<1 y) return to the operating room (OR) after adult cervical spine deformity (ACSD) surgery.
Returns to the OR within a year of ACSD correction can be particularly devastating to these vulnerable hosts as they often involve compromise of the soft tissue envelope, neurological deficits, or hardware failure. This work sought to assess the impact of a short-term reoperation on 1-year radiographic and HRQoL outcomes.
Patients operated on from January 1, 2013, to January 1, 2019, with at least 1 year of follow-up were included. The primary outcome was a short-term return to the OR. Variables of interest included patient demographics, Charlson Comorbidity Index, HRQoL measured with the modified Japanese Orthopaedic Association), Neck Disability Index, and EuroQuol-5D Visual Analog Scale (EQ-5D VAS) and radiographic outcomes, including T1 slope, C2-C7 sagittal Cobb angle, T1 slope-Cobb angle, and cervical sagittal vertical axis. Comparisons between those who did versus did not require a 1-year reoperation were performed using paired t tests. A Kaplan-Meier survival curve was used to estimate reoperation-free survival up to 2 years postoperatively.
A total of 121 patients were included in this work (age: 61.9±10.1 yr, body mass index: 28.4±6.9, Charlson Comorbidity Index: 1.0±1.4, 62.8% female). A 1-year unplanned return to the OR was required for 28 (23.1%) patients, of whom 19 followed up for at least 1 year. Indications for a return to the OR were most commonly for neurological complications (5%), infectious/wound complications (5.8%), and junctional failure (6.6%) No differences in demographics, comorbidities, preoperative or 1-year postoperative HRQoL, or radiographic outcomes were seen between operative groups.
Reoperation <1 year after ACSD surgery did not influence 1-year radiographic outcomes or HRQoL.
Abstract Background Context Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin ...trigger—defined as an intraoperative hemoglobin level of ≥10 g/dL, a postoperative level of ≥8 g/dL, or a whole hospital nadir between 8-10 g/dL—and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study. Purpose To describe the perioperative outcomes and economic cost associated with liberal hemoglobin trigger transfusion among spine surgery patients. Study Design/Setting Retrospective study. Patient Sample The surgical billing database at our institution was queried for inpatients discharged between 2008 and 2015 after the following procedures: atlantoaxial fusion, anterior cervical fusion, posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, other procedures, and tumor-related surgeries. In total, 6931 patients were included for analysis. Outcome Measures The primary outcome was composite morbidity which was comprised of: (1) infection (sepsis, surgical-site infection, Clostridium dificile, or drug-resistant infection), (2) thrombotic event (pulmonary embolus, deep venous thrombosis, or disseminated intravascular coagulation), (3) kidney injury, (4) respiratory event, and/or (5) ischemic event (transient ischemic attack, myocardial infarction, or cerebrovascular accident). Methods Data on intraoperative transfusion were obtained from an automated prospectively collected anesthesia data management system. Data on postoperative hospital transfusion was obtained through a Web-based intelligence portal. Based on previous research, we analyzed the data using three definitions of a liberal transfusion trigger in patients who received an RBC transfusion: a liberal intraoperative Hb trigger as a nadir Hb level of 10 g/dL or greater, a liberal postoperative Hb trigger as a nadir Hb level of 8 g/dL or greater, or a whole hospital nadir Hb level of 8-10 g/dL. Variables analyzed included in-hospital morbidity, mortality, length of stay, and total costs associated with a liberal transfusion strategy. Results Among patients with a whole hospital stay nadir hemoglobin between 8 to 10 g/dL, transfused patients demonstrated a longer in-hospital stay (median IQR, 6 5-9 vs. 4 3-6 days; P<0.0001) and a higher perioperative morbidity (n=145, 11.5% vs. n=74, 6.1%; P<0.0001) than those not transfused. Even after adjusting for age, gender, race, ASA class, CCI score, estimated blood loss, baseline hemoglobin value, number of operated levels, and surgery type, logistic regression analysis revealed that patients with a nadir hemoglobin of 8-10 g/dL who were transfused had an independently higher risk of perioperative morbidity (odds ratio OR = 2.12; 95% confidence interval CI, 1.24-3.64; P=0.006). Estimated additional costs associated with liberal trigger use, defined as a transfusion occurring in patients with a whole hospital stay nadir Hb of 8-10 g/dL, ranged from $202,675 to $700,151 annually. Conclusions Transfusion using a liberal trigger is associated with increased morbidity, even after controlling for possible confounders. Our results suggest that modification of transfusion practice may be a potential area for improving patient outcomes and reducing costs.
STUDY DESIGN.Retrospective case series of atlantoaxial rotatory fixed dislocation (AARFD).
OBJECTIVE.To describe clinical features and the surgical treatment of AARFD.
SUMMARY OF BACKGROUND DATA.The ...classification and treatment strategy for atlantoaxial rotatory fixation (AARF) were previously described and remained controversial. AARF concomitant with atlantoaxial dislocation has different clinical features and treatment strategy with the most AARF. Due to deficiency of the transverse ligament or odontoid, the atlantoaxial remains unstable even after the torticollis relieved or cured. Because of the rarity, treatment strategy for this special condition has not been specialized and fully explored in the literatures.
METHODS.Thirty-two children with AARFD (sustained torticollis more than 6 weeks and atlanto-dental internal more than 5 mm) were retrospectively reviewed. Treatment methodology, pearls, and pitfalls of the treatment were discussed.
RESULTS.Thirty-two cases had sustained torticollis for an average of 5.7 months. ADI of them ranged from 8 to 22 mm, with a mean of 11.3 mm. Eight cases presented with signs and symptoms of spinal cord dysfunction. All 32 cases underwent surgery and had no spinal cord or vertebral artery injury. The surgery included posterior reduction and fusion (reducible dislocation and torticollis, 16 cases), and transoral release followed by posterior reduction and fusion (irreducible dislocation and torticollis, 16 cases). The average follow-up time was 42 months. Solid fusion and torticollis healing were achieved in 31 patients (96.9%) as detected radiologically. Two cases (6.3%, 2/32) suffered complications (cerebrospinal fluid leakage and recurred torticollis followed by revision).
CONCLUSION.AARFD had distinct clinical features relative to common presentations of AARF. Because of deficiency of the transverse ligament or odontoid and subsequent atlantoaxial dislocation, surgical treatments are applied for this condition, including transoral release and posterior C1–2 reduction and fusion. AARFD cases were successfully managed surgically without preoperative traction, with few complications seen.Level of Evidence4
A retrospective cohort review.
To develop a scoring system for predicting increased risk of postoperative complications in adult spinal deformity (ASD) surgery based on baseline nutritional and ...metabolic factors.
Endocrine and metabolic conditions have been shown to adversely influence patient outcomes and may increase the likelihood of postoperative complications. The impact of these conditions has not been effectively evaluated in patients undergoing ASD surgery.
ASD patients 18 years or above with baseline and two-year data were included. An internally cross-validated weighted equation using preoperative laboratory and comorbidity data correlating to increased perioperative complications was developed via Poisson regression. Body mass index (BMI) categorization (normal, over/underweight, and obese) and diabetes classification (normal, prediabetic, and diabetic) were used per the Centers for Disease Control and Prevention and the American Diabetes Associates parameters. A novel ASD-specific nutritional and metabolic burden score (ASD-NMBS) was calculated via Beta-Sullivan adjustment, and Conditional Inference Tree determined the score threshold for experiencing ≥1 complication. Cohorts were stratified into low-risk and high-risk groups for comparison. Logistic regression assessed correlations between increasing burden score and complications.
Two hundred one ASD patients were included (mean age: 58.60±15.4, sex: 48% female, BMI: 29.95±14.31, Charlson Comorbidity Index: 3.75±2.40). Significant factors were determined to be age (+1/yr), hypertension (+18), peripheral vascular disease (+37), smoking status (+21), anemia (+1), VitD hydroxyl (+1/ng/mL), BMI (+13/cat), and diabetes (+4/cat) (model: P <0.001, area under the curve: 92.9%). Conditional Inference Tree determined scores above 175 correlated with ≥1 post-op complication ( P <0.001). Furthermore, HIGH patients reported higher rates of postoperative cardiac complications ( P =0.045) and were more likely to require reoperation ( P =0.024) compared with low patients.
The development of a validated novel nutritional and metabolic burden score (ASD-NMBS) demonstrated that patients with higher scores are at greater risk of increased postoperative complications and course. As such, surgeons should consider the reduction of nutritional and metabolic burden preoperatively to enhance outcomes and reduce complications in ASD patients.
Purpose
This nationwide study identifies ASD surgical risk factors for morbidity/mortality.
Methods
NIS discharges from 2001 to 2010 aged 25+ with scoliosis diagnoses, 4+ levels fused, and procedural ...codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included. Demographics, comorbidities and procedure-related complications were determined for each subgroup (degenerative, congenital, idiopathic, other). Multivariate analysis reported as OR (95 % CI).
Results
11,982 discharges were identified. Morbidity, excluding device-related, and mortality rates were 50.81 and 0.28 %, respectively. Certain comorbidities were associated with increased morbidity/mortality: congestive heart failure (CHF) 1.62 (1.42–1.84) 5.67 (3.30–9.73), coagulopathy 3.52 (3.22–3.85) 2.32 (1.44–3.76), electrolyte imbalance 2.65 (2.52–2.79) 4.63 (3.15–6.81), pulmonary circulation disorders 9.45 (7.45–11.99) 8.94 (4.43–18.03), renal failure 1.29 (1.13–1.47) 5.51 (2.57–11.82), and pathologic weight loss 2.38 (2.01–2.81) 7.28 (4.36–12.14). Chronic pulmonary disease was associated with higher morbidity 1.08 (1.02–1.14); liver disease was linked to increased mortality 36.09 (16.16–80.59). 9+ level fusions had increased morbidity vs 4–8 level fusions 1.69 (1.61–1.78) and refusions 1.08 (1.02–1.14). Idiopathic scoliosis was associated with decreased morbidity vs all other subgroups 0.85 (0.80–0.91). Age >65 was associated with increased morbidity and mortality vs 25–64 group 1.09 (1.05–1.14) 3.49 (2.31–5.29). Females had increased morbidity 1.18 (1.13–1.23) and decreased mortality 0.30 (0.21–0.44). Mean comorbidity index (0.55) and age (64.38) for degenerative cohort were higher vs all other subgroups (
P
< 0.0001).
Conclusions
Longer fusions were associated with increased morbidity. Age >65 was associated with increased morbidity/mortality, while females were associated with increased morbidity but decreased mortality. Idiopathic scoliosis had decreased morbidity. Degenerative ASD cases had higher comorbidity indices, potentially due to older age. This study is clinically useful for patient education, surgical decision-making, and optimizing patient outcomes.
Recent debate has arisen between whether to use a three-column osteotomy (3CO) or multilevel low-grade (MLG) techniques to treat severe sagittal malalignment in adult spinal deformity (ASD) surgery. ...The goal of this study was to compare the outcomes of 3CO and MLG techniques performed in corrective surgeries for ASD.
ASD patients who had a baseline PI-LL > 30° and 2-year follow-up data were included. Patients underwent either 3CO or MLG (thoracolumbar posterior column osteotomies at ≥ 3 levels or anterior lumbar interbody fusion at ≥ 3 levels with no 3CO). The segmental utility ratio was used to assess relative segmental correction (segmental correction divided by overall correction in lordosis divided by the number of thoracolumbar interventions interbody fusion, thoracolumbar posterior column osteotomies, and 3CO). The paired t-test was used to assess lordotic distribution by differences in lordosis between adjacent lumbar disc spaces (e.g., L1-2 to L2-3). Multivariate analysis, controlling for age, sex, BMI, osteoporosis, baseline pelvic incidence, and T1 pelvic angle, was used to evaluate the complication rates and radiographic and patient-reported outcomes between the groups.
A total of 93 patients were included, 53% of whom underwent MLG and 47% of whom underwent 3CO. The MLG group had a lower BMI (p < 0.05). MLG patients received fewer previous fusions than 3CO patients (31% vs 80%, p < 0.001). MLG patients had 24% less blood loss but a 22% longer operative time (565 vs 419 minutes, p = 0.008). Using adjusted analysis, the 3CO group had greater segmental and relative correction at each level (segmental utility ratio mean 69% for 3CO vs 23% for MLG, p < 0.001). However, the 3CO group had lordotic differences between two adjacent lumbar disc pairs (range -0.5° to 9.0°, p = 0.009), while MLG was more harmonious (range 2.2°-6.5°, p > 0.4). MLG patients were more likely to undergo realignment to age-adjusted standards (OR 5.6, 95% CI 1.2-46.4; p = 0.033). MLG patients were less likely to develop neurological complications or undergo reoperation (OR 0.4, 95% CI 0.1-0.9; p = 0.041). Adjusted analysis revealed that MLG patients more often met a substantial clinical benefit in the Oswestry Disability Index score (OR 5.3, 95% CI 1.1-26.8; p = 0.043).
MLG techniques showed better utility in lumbar distribution and age-adjusted global correction while minimizing neurological complications and reoperation rates by 2 years postoperatively. In selected instances, these techniques may offer the spine deformity surgeon a safer alternative when correcting severe adult spinal deformity.
