BACKGROUND
Osteoporosis is a metabolic bone disease that commonly affects the elderly. Degenerative spinal disease that may require surgical intervention is also prevalent in this susceptible ...population. If undiagnosed or untreated before spine surgery, osteoporosis may result in an increased risk of postoperative adverse events. Nontreatment of osteoporosis preoperatively may be related to a poor understanding of bone physiology, a lack of standardized treatment algorithms, limited cost-effective interventions, and reluctance by spine surgeons to be the primary provider of osteoporosis management.
OBJECTIVE
The objective of this evidence-based review is to develop guidelines for the preoperative assessment and treatment of osteoporosis in patients undergoing spine surgery.
METHODS
A systematic review of the literature was performed using the National Library of Medicine/PubMed database and Embase for studies relevant to preoperative diagnostic studies that predict increased risk of osteoporosis-related postoperative adverse events and whether the preoperative treatment of low bone mineral density (BMD) in patients with osteoporosis improves outcome.
RESULTS
Out of 281 studies, 17 met the inclusion criteria and were included for systematic review. The task force affirmed a Grade B recommendation that preoperative osteoporosis testing with a dual-energy X-ray absorptiometry scan (T-score < −2.5), a computed tomography scan (Hounsfield units <97.9), and serum vitamin D3 level (<20 ng/mL) predict an increased risk of osteoporosis-related adverse events after spine surgery. The task force determined a Grade B recommendation that preoperative osteoporosis treatment with teriparatide increases BMD, induces earlier and more robust fusion, and may improve select patient outcomes. There is insufficient evidence regarding preoperative treatment with bisphosphonates alone and postoperative outcome.
CONCLUSION
This evidence-based clinical guideline provides a recommendation that patients with suspected osteoporosis undergo preoperative assessment and be appropriately counseled about the risk of postoperative adverse events if osteoporosis is confirmed. In addition, preoperative optimization of BMD with select treatments improves certain patient outcomes.
The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/3-preoperative-osteoporosis-assessment
BACKGROUND
Preoperative malnutrition has been implicated in adverse events after elective surgery, potentially impacting patient outcomes.
OBJECTIVE
As a potentially modifiable risk factor, we sought ...to determine which assessments of nutritional status were associated with specific adverse events after spine surgery. In addition, we explored if a preoperative nutritional improvement intervention may be beneficial in lowering the rates of these adverse events.
METHODS
The literature search yielded 115 abstracts relevant to the PICO (patient/population, intervention, comparison, and outcomes) questions included in this chapter. The task force selected 105 articles for full text review, and 13 met criteria for inclusion in this systematic review.
RESULTS
Malnutrition, assessed preoperatively by a serum albumin <3.5 g/dL or a serum prealbumin <20 mg/dL, is associated with a higher rate of surgical site infections (SSIs), other wound complications, nonunions, hospital readmissions, and other medical complications after spine surgery. A multimodal nutrition management protocol decreases albumin and electrolyte deficiencies in patients with normal preoperative nutritional status. It also improves overall complication rates but does not specifically impact SSIs.
CONCLUSION
It is recommended to assess nutritional status using either serum albumin or prealbumin preoperatively in patients undergoing spine surgery.
The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/4-preoperative-nutritional-assessment.
Prior studies suggest that patient expectations impact postoperative patient-reported outcomes (PROMs). However, no consensus exists on an appropriate expectations tool.
To examine the impact of ...patient expectations using a modified version of the Oswestry Disability Index (ODI) on clinical outcomes and patient satisfaction 1 year after lumbar fusion for degenerative pathologies.
Prospective longitudinal cohort.
Adults undergoing 1 to 2 level lumbar fusion were identified from four tertiaty spine centers.
ODI, EuroQol-5D, Numeric rating scales for back and leg pain.
Preoperatively, patients completed the ODI, as well as a modified ODI reflecting their expected improvement across the 10 ODI items. For example, item 1 in the ODI asks about Pain Intensity at the moment whereas the Expectations ODI asks "One year after surgery, I expect to have…" The difference between this modified ODI score and the baseline ODI score (Baseine ODI minus Expectations ODI) was defined as the Patient Expectation Score. Patients were stratified into tertiles based on their Expectations score into High (HE), Moderate (ME), and Low (LE) Expectations and compared.
There were 30 patients in the HE, 35 in the ME, and 26 in the LE Group, with similar demographics and surgical parameters. Patients in the HE group had worse ODI scores preoperatively (54.96 vs 41.42, p<.001) and were expecting a greater improvement in ODI (43.8 vs 13.5, p<.001). There were fewer patients in the HE group (13, 43%) who reported that they were satisfied with the results compared to either the ME (20, 71%) or LE group (22, 85%, p=.041) despite having similar ODI scores and change in ODI scores 1 year postoperatively.
An expectations tool, linked to a disease-specific measure may provide the clinician with a practical method of assessing a patient's expectation of results after treatment and aid in the shared decision-making during the preoperative surgical process.
Firearm injuries in the U.S. pose a significant public health burden, but data on gunshot wounds (GSWs) specifically involving the spine are scarce. We examined epidemiological trends in GSWs to the ...spine and associated spinal cord injury (SCI) and mortality rates. This was a cross-sectional study of data from level I-III trauma centers in the U.S. participating in the American College of Surgeons National Trauma Data Bank (ACS NTDB) in 2015-2019. We identified adult and pediatric patients presenting with GSW and evaluated those with Abbreviated Injury Scale codes indicating spinal involvement and SCI. We assessed in-hospital mortality and GSW-related SCI. A total of 5,021,316 patients were enrolled in the ACS NTDB. Of the 107,233 patients (2.1% of total) presenting with GSW, 9023 (8.4%) patients had spine involvement. Overall rates of GSW and spinal GSW were similar across years. The most common cause of spinal GSW injury was assault (86.7%). The cervical spine was involved in 24.2% of patients, thoracic spine in 42.8%, and lumbar spine in 39.7%. Cervical SCI was present in 8.7% of all spinal GSW (35.7% of cervical GSW), thoracic SCI in 17.4% (40.6% of thoracic GSW), and lumbar SCI in 8.1% (20.3% of lumbar GSW). The mean patient age was 29.0 ± 12.2 years, 88.5% were male, 62.4% were black, 23.7% were white, and 13.9% were another race. Blood alcohol content was ≥0.08 in 12.1%, and illicit drugs were positive in 24.4%. In-hospital mortality was high in patients with spinal GSWs (8.1%), and mortality was significantly higher with cervical involvement (18.1%), cervical SCI (30.7%), or thoracic incomplete SCI (13.6%) on univariate analysis. On multi-variate analysis of age (excluding patients <16 years of age), sex, Injury Severity Score (ISS), complete SCI, and spinal area of involvement, only greater patient age (age 40-65 years: adjusted odds ratio aOR 1.52, 95% confidence interval CI 1.09-2.11,
= 0.014; age >65 years: aOR 3.90, 95% CI 2.10-7.27,
< 0.001) and higher ISS (ISS 9-15: aOR 6.65, 95% CI 2.38-18.54,
< 0.001; ISS 16-24: aOR 18.13, 95% CI 6.65-49.44,
< 0.001; ISS >24: aOR 68.44, 95% CI 25.39-184.46,
< 0.001) were independently associated with in-hospital mortality risk after spinal GSW. These results demonstrate that spinal GSW is not uncommon and that older patients with more severe systemic injuries have higher in-hospital mortality risk.
Low back pain has an immense impact on the US economy. A significant number of patients undergo surgical management in order to regain meaningful functionality in daily life and in the workplace. ...Return to work (RTW) is a key metric in surgical outcomes, as it has profound implications for both individual patients and the economy at large.
In this study, we investigated the factors associated with RTW in patients who achieved otherwise favorable outcomes after lumbar spine surgery.
This study retrospectively analyzes prospectively collected data from the lumbar module of national spine registry, the Quality Outcomes Database (QOD).
The lumbar module of QOD includes patients undergoing lumbar surgery for primary stenosis, disc herniation, spondylolisthesis (Grade I) and symptomatic mechanical disc collapse or revision surgery for recurrent same-level disc herniation, pseudarthrosis, and adjacent segment disease. Exclusion criteria included age under 18 years and diagnoses of infection, tumor, or trauma as the cause of lumbar-related pain.
The outcome of interest for this study was the return to work 12-month after surgery.
The lumbar module of QOD was queried for patients who were employed at the time of surgery. Good outcomes were defined as patients who had no adverse events (readmissions/complications), had achieved 30% improvement in Oswestry disability index (ODI) and were satisfied (NASS satisfaction) at 3-month post-surgery. Distinct multivariable logistic regression models were fitted with 12-month RTW as outcome for a. overall population and b. the patients with good outcomes. The variables included in the models were age, gender, race, insurance type, education level, occupation type, currently working/on-leave status, workers’ compensation, ambulatory status, smoking status, anxiety, depression, symptom duration, number of spinal levels, diabetes, motor deficit, and preoperative back-pain, leg-pain and ODI score.
Of the total 12,435 patients, 10,604 (85.3%) had successful RTW at 1-year postsurgery. Among patients who achieved good surgical outcomes, 605 (7%) failed to RTW. For both the overall and subgroup analysis, older patients had lower odds of RTW. Females had lower odds of RTW compared with males and patients with higher back pain and baseline ODI had lower odds of RTW. Patients with longer duration of symptoms, more physically demanding occupations, worker's compensation claim and those who had short-term disability leave at the time of surgery had lower odds of RTW independent of their good surgical outcomes.
This study identifies certain risk factors for failure to RTW independent of surgical outcomes. Most of these risk factors are occupational; hence, involving the patient's employer in treatment process and setting realistic expectations may help improve the patients' work-related functionality.
BACKGROUND
Patient factors (increased body mass index BMI, smoking, and diabetes) may impact outcomes after spine surgery. There is a lack of consensus regarding which factors should be screened for ...and potentially modified preoperatively to optimize outcome.
OBJECTIVE
The purpose of this evidence-based clinical practice guideline is to determine if preoperative patient factors of diabetes, smoking, and increased BMI impact surgical outcomes.
METHODS
A systematic review of the literature for studies relevant to spine surgery was performed using the National Library of Medicine PubMed database and the Cochrane Library. Clinical studies evaluating the impact of diabetes or increased BMI with reoperation and/or surgical site infection (SSI) were selected for review. In addition, the impact of preoperative smoking on patients undergoing spinal fusion was reviewed.
RESULTS
A total of 699 articles met inclusion criteria and 64 were included in the systematic review. In patients with diabetes, a preoperative hemoglobin A1c (HbA1c) >7.5 mg/dL is associated with an increased risk of reoperation or infection after spine surgery. The review noted conflicting studies regarding the relationship between increased BMI and SSI or reoperation. Preoperative smoking is associated with increased risk of reoperation (Grade B). There is insufficient evidence that cessation of smoking before spine surgery decreases the risk of reoperation.
CONCLUSION
This evidence-based guideline provides a Grade B recommendation that diabetic individuals undergoing spine surgery should have a preoperative HbA1c test before surgery and should be counseled regarding the increased risk of reoperation or infection if the level is >7.5 mg/dL. There is conflicting evidence that BMI correlates with greater SSI rate or reoperation rate (Grade I). Smoking is associated with increased risk of reoperation (Grade B) in patients undergoing spinal fusion.
The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/2-preoperative-surgical-risk-assessement
STUDY DESIGN.Prospective observational study.
OBJECTIVE.To investigate the association of perioperative vitamin D levels and nonunion rates and time to fusion in patients undergoing elective spine ...fusion.
SUMMARY OF BACKGROUND DATA.Although there is a clear link between bone mineral density and the risk of osteoporosis, it is unclear whether low vitamin D levels affect rates and timing of spinal fusion.
METHODS.Serum 25-OH vitamin D levels were measured perioperatively in adults undergoing elective spinal fusion between 2011 and 2012. Vitamin D levels <20 ng/mL were considered deficient. Univariate and multivariate logistic regression were performed to identify independent predictors of pseudarthrosis/nonunion within a minimum follow-up period of 12 months. Kaplan-Meier analysis was used to compare time to fusion between groups.
RESULTS.Of the 133 patients, 31 (23%) demonstrated vitamin D deficiency. Mean patient age was 57 ± 13 years; 44% were female and 94% were Caucasian. The cervical spine was fused in 49%, the lumbar spine in 47%, and the thoracic spine in 4%. Mean construct length was 2 levels (range 1–16). At 12-month follow-up, 112/133 (84%) patients demonstrated fusion (median time to fusion 8.4 mo). Nonunion at 12 months was associated with vitamin D deficiency (20% of patients with adequate vitamin D level vs. 38% of vitamin D-deficient patients, P = 0.063). Kaplan-Meier survival analysis demonstrated time to fusion was significantly longer in the vitamin D-deficient group (12 vs. 6 mo, P = 0.001). On multivariate analysis, vitamin D deficiency was an independent predictor of nonunion (odds ratio 3.449, P = 0.045) when adjusted for age, sex, obesity, fusion length, location, graft type, smoking, and bone morphogenetic protein use.
CONCLUSION.Vitamin D levels may affect nonunion rate and time to fusion. These results offer insight into the importance of the metabolic milieu for bony fusion as well as a potential avenue for therapeutic intervention.Level of Evidence3
Abstract
BACKGROUND
Lumbar fusion remains the treatment of choice for many degenerative pathologies. Healthcare costs related to the procedure are a concern, and postdischarge needs often contribute ...to greater expenditure. The Quality Outcomes Database (QOD) is a prospective, multicenter clinical registry designed to analyze outcomes after neurosurgical procedures.
OBJECTIVE
To create a simple scoring system to predict discharge needs after lumbar fusion.
METHODS
Institutional QOD data from 2 high-volume neurosurgical centers were collected retrospectively. Univariate and multivariable logistic regression analyses were used to identify factors for our model. A receiver operating characteristic curve was used to set cutoff scores for patients likely to discharge home without ongoing services and those likely to require additional services/alternative placement after discharge.
RESULTS
Two hundred seventeen patients were included. Five variables—osteoporosis, predominant preoperative symptom, need for assistive ambulation device, American Society of Anesthesiologist grade, and age—were included in our final scoring system. Patients with higher scores are less likely to need additional services. In patients with high scores (8-10), our scale correctly predicted discharge needs in 88.7% of cases. In patients with low scores (0-5), our scale predicted discharge needs (additional home services/alternative placement) in 75% of cases. For our final instrument, the area under the receiver operating characteristic curve was 0.809 (95% confidence interval 0.720-0.897).
CONCLUSION
We present a simple scoring system to assist in predicting postdischarge needs for patients undergoing lumbar fusion for degenerative disease. Further validation studies are needed to assess the generalizability of our scale.
The adult spinal cord is typically resistant to hypoxic-ischemic injury because of collateral blood supply; however, congenital or acquired stenosis may result in baseline maximal vasodilation, such ...as superimposed hemodynamic stresses, that cannot be accommodated, leaving the spinal cord vulnerable to ischemic injury. We present a rare case of spinal cord hypoxic-ischemic injury in an adult with underlying cervical spinal stenosis.
A 37-year-old man with a history of morbid obesity, diabetes mellitus, hypertension, and obstructive sleep apnea presented after developing progressive weakness in the extremities. Preoperative computed tomography myelography demonstrated ossification of the posterior longitudinal ligament and severe spinal canal narrowing. Approximately 1 week after posterior decompression, the patient experienced spinal hypoxic-ischemic injury. Imaging revealed cord expansion and abnormal T2 signal intensity. Axial diffusion tensor images of the brain revealed delayed ischemic leukoencephalopathy with restricted diffusion in the cerebral cortex and deep white matter; this led to the decision to withdraw care, and the patient died.
We hypothesize that vascular dysregulation due to cervical stenosis made the cord parenchyma vulnerable to hypoxic and/or hypoperfusion stresses.
Abstract
BACKGROUND
The choice of anterior vs posterior approach for degenerative cervical myelopathy that spans multiple segments remains controversial.
OBJECTIVE
To compare the outcomes following ...the 2 approaches using multicenter prospectively collected data.
METHODS
Quality Outcomes Database (QOD) for patients undergoing surgery for 3 to 5 level degenerative cervical myelopathy was analyzed. The anterior group (anterior cervical discectomy ACDF or corpectomy ACCF with fusion) was compared with posterior cervical fusion. Outcomes included: patient reported outcomes (PROs): neck disability index (NDI), numeric rating scale (NRS) of neck pain and arm pain, EQ-5D, modified Japanese Orthopedic Association score for myelopathy (mJOA), and NASS satisfaction questionnaire; hospital length of stay (LOS), 90-d readmission, and return to work (RTW). Multivariable regression models were fitted for outcomes.
RESULTS
Of total 245 patients analyzed, 163 patients underwent anterior surgery (ACDF-116, ACCF-47) and 82 underwent posterior surgery. Patients undergoing an anterior approach had lower odds of having higher LOS (P < .001, odds ratio 0.16, 95% confidence interval 0.08-0.30). The 12-mo NDI, EQ-5D, NRS, mJOA, and satisfaction scores as well as 90-d readmission and RTW did not differ significantly between anterior and posterior groups.
CONCLUSION
Patients undergoing anterior approaches for 3 to 5 level degenerative cervical myelopathy had shorter hospital LOS compared to those undergoing posterior decompression and fusion. Also, patients in both groups exhibited similar long-term PROs, readmission, and RTW rates. Further investigations are needed to compare the differences in longer term reoperation rates and functional outcomes before the clinical superiority of one approach over the other can be established.
