Faculty Bibliography

Background: The impact of an initially less invasive cardiac intervention on outcomes of future surgical spine procedures has been understudied; therefore, we sought to investigate the effect of coronary stents on postoperative outcomes in an elective spine fusion cohort. Methods: Elective spine fusion patients were isolated with International Classification of Diseases-Ninth Edition and current procedural terminology procedure codes in the PearlDiver database. Patients were stratified by number of coronary stents: (1) 1 to 2 stents (ST12); (2) 3 to 4 stents (ST34); (3) no stents. Mean comparison tests compared differences in demographics, diagnoses, comorbidities, and 30-day and 90-day complication outcomes. Logistic regression assessed the odds of complications associated with coronary stents, controlling for levels fused, age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was P < 0.05. Results: A total of 726,061 elective spine fusion patients were isolated. Of those patients, 707,396 patients had no stent, 17,087 ST12, and 1578 ST34. At baseline (BL), ST12 patients had higher rates of morbid obesity, chronic kidney disease, congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus compared with no stent and ST34 patients (all P < 0.001). Relative to no stent patients, ST12 patients had a longer length of stay and, at 30 days, significantly higher complication rates, including pneumonia, myocardial infarction (MI), sepsis, acute kidney injury, urinary tract infection (UTI), wound complications, transfusions, and 30-day readmissions (P < 0.05). Controlling for age, sex, comorbidities, and levels fused, ST12 was a significant predictor of MI within 30 days (OR 2.15 [95% CI 1.7"“2.7], P < 0.001) and 90 days postoperatively (OR 1.87 [95% CI 1.6"“2.2], P < 0.001). ST34 patients compared with no stent patients at 30 days presented with increased rates of complication, including pneumonia, MI, sepsis, UTI, wound complications, and 30-day readmissions. Regression analysis showed no significant differences in complications between ST12 vs ST34 at 30 days, but at 90 days, ST34 was associated with significantly increased rate and odds of death (1.1% vs 0.3%, P = 0.021; OR 1.94 [95% CI 1.13"“3.13], P = 0.01). Conclusion: Cardiac stents failed to normalize risk profile of patients with coronary artery disease. Postoperatively at 90 days, elective spine fusion patients with 3 or more stents were significantly at risk of mortality compared with patients with fewer or no stents.

INTRODUCTION/BACKGROUND:Osteoporosis affects nearly 200 million individuals worldwide. Given this notable disease burden, there have been increased efforts to investigate complications in patients with osteoporosis undergoing cervical fusion (CF). However, there are limited data regarding long-term outcomes in osteoporotic patients in the setting of ≥4-level cervical fusion. METHODS:The New York State Statewide Planning and Research Cooperative System database was used to identify patients who underwent posterior or combined anterior-posterior ≥4-level CF for cervical radiculopathy or myelopathy from 2009 to 2011, with a minimum follow-up surveillance of 2 years. The following were compared between patients with and without osteoporosis: demographics, hospital-related parameters, medical/surgical complications, readmissions, and revisions. Binary multivariate stepwise logistic regression was used to identify independent predictors of outcomes. RESULTS:A total of 2,604 patients were included (osteoporosis: n = 136 (5.2%); nonosteoporosis: n = 2,468). Patients with osteoporosis were older (66.9 ± 11.2 vs. 60.0 ± 11.4 years, P < 0.001), more often female (75.7% vs. 36.2%, P < 0.001), and White (80.0% vs. 65.3%, P = 0.007). Both cohorts had comparable comorbidity burdens (Charlson/Deyo: 1.1 ± 1.2 vs. 1.0 ± 1.3, P = 0.262), total hospital charges ($100,953 ± 94,933 vs. $91,618 ± 78,327, P = 0.181), and length of stay (9.7 ± 10.4 vs. 8.4 ± 9.6 days, P = 0.109). Patients with osteoporosis incurred higher rates of overall medical complication rates (41.9% vs. 29.4%, P = 0.002) and individual surgical complications, such as nonunion (2.9% vs. 0.7%, P = 0.006). Osteoporosis was associated with medical complications (OR = 1.57, P = 0.021), surgical complications (OR = 1.52, P = 0.030), and readmissions (OR = 1.86, P = 0.003) at 2 years. DISCUSSION/CONCLUSIONS:Among patients who underwent multilevel cervical fusion, those with osteoporosis had higher risk of adverse postoperative outcomes at two years. These data indicate that preoperative screening and management of osteoporosis may be important for optimizing long-term outcomes in patients who require multilevel CF. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS/UNASSIGNED:The data used in this study are available for public use at https://www.health.ny.gov/statistics/sparcs/.

BACKGROUND CONTEXT: Adult spinal deformity (ASD) and cervical deformity (CD) surgery has seen great improvements in increasing perioperative patient safety and decreasing patient mortality. Previous studies have also demonstrated relatively higher risk of death in cervical deformity surgeries, yet there remains a paucity of literature comparing and contrasting the comorbidities and predictive factors associated with death in ASD versus CD surgery. PURPOSE: To assess morbidity and mortality rates and potential correlations with frailty in ASD vs CD patients. STUDY DESIGN/SETTING: Retrospective review of prospective cervical deformity (CD) and adult spinal deformity (ASD) databases. PATIENT SAMPLE: There were 689 ASD patients, 290 CD patients: 979 total. OUTCOME MEASURES: Demographic factors; baseline comorbidities; intra/postoperative complications; mortality.
METHOD(S): Operative CD patients 18yrs with pre-(BL) and up to 5-year (5Y) postoperative radiographic/HRQL data were assessed. Differences in demographics, radiographic alignment, and complication rates were assessed via means comparison analyses. Conditional backstep binary logistic regression analysis identified predictive factors for mortality. Kaplan-Meier curves assessed survivorship of expired patients. Cox regression assessed survivability adjusting for BL frailty status. Logrank analysis determined differences in the survival distribution between ASD and CD patients.
RESULT(S): A total of 625 patients met inclusion criteria (417 ASD, 208 CD). Within 5Y, 12 ASD patients (2.88% of ASD cohort) and 16 CD patients (7.69% of CD cohort) expired (p=.004). At baseline, ASD and CD patients differed significantly in BL Frailty score (0.29 vs 0.41, p.05). No significant differences were noted in BL disability per EQ5D-VAS (p>.05). In terms of baseline self-reported comorbidities in expired patients, the three most common for ASD patients were: arthritis (46%), hypertension (31%) and anemia (23%). In CD patients, the three most common comorbid conditions were: osteoporosis (50%), previous myocardial infarction (17%) and any cancer (17%). Complications analysis revealed no significant differences in major, minor or intraoperative complications between ASD or CD patients, nor between expired vs living patients (all p>.05). Similarly, there were no significant differences in mortality overall within 30 days, between 30 and 90 days, nor >90 days after surgery between ASD or CD patient cohorts (all p>.05). Regression analysis revealed that when accounting for age, BMI and gender, only frailty status remained a significant predictor of death overall (p=.047). Mean survival time for ASD was 84.11 weeks versus 65.17 in CD patients(chi2(1)=.748, p=.387).
CONCLUSION(S): Total 5-year all-cause mortality in adult spinal deformity and cervical deformity patients remains below 3% despite high rates of comorbidities, suggesting rigorous patient selection criteria plays an important role in maintaining the safety of such surgeries. This study demonstrates that while cervical deformity patients demonstrate greater incidence of death postoperatively, significantly increased baseline frailty status may be the principle cause of such results and should be considered when assessing surgical risks versus benefits. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Adolescent idiopathic scoliosis (AIS) affects up to 4% of adolescents. As of yet, the characterization of traumatic injuries in AIS patients is unknown. PURPOSE: To compare the risk of varying fracture locations after blunt trauma between patients with and without AIS. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: The Kid's Inpatient Database (KID) was queried from 2003 to 2009 to identify all patients aged 0-20 with AIS admitted for acute trauma. OUTCOME MEASURES: The rates of various spinal fracture patterns as well as risk factors for vertebral fracture.
METHOD(S): KID was queried for AIS patients aged 0-20 years, from 2003 through 2009. AIS patients admitted for acute trauma were isolated. Mechanisms of injury (MOI), fracture locations and surgical procedures were assessed. Trauma AIS patients were then propensity-score matched to a general (Gen) trauma population of 323,729 KID patients, using age, sex and MOI. Fracture types were compared utilizing Chi-square and t-tests. Logistic regression analysis predicted relative odds of fracture in AIS patients.
RESULT(S): Of 41,142 AIS cases identified, 442 patients suffered acute blunt trauma (2003: 112; 2006: 139; 2009: 186). Of those, the most prevalent MOIs were MVA (37.1%), pedestrian struck (PS) (22.9%), falls (18.3%) and assault (7.6%). Of the 442 acute blunt trauma patients, 99 (22.3%) sustained vertebral fracture. Of those, 25 patients had cervical fractures (MVA 66.52%, PS 24.14%, fall 6.9%), 23 thoracic (MVA 47.8%, PS 21.7%, fall 26.1%), 35 lumbar (MVA 57.1%, PS 20%, fall 25.7%), and 16 sacral/coccygeal (MVA 68.8%, PS 25%, fall 12.5%). Twenty-eight patients underwent spinal fusion (2-3 levels: 35.7%, 4-8 levels: 25.0%, >9 levels: 14.0%) and 14 had vertebral fracture repairs. After propensity-score matching (AIS: 432, Gen: 432), AIS patients had significantly more vertebral fractures (99 vs 52, p<0.001) and exhibited higher rates of thoracic (5.3% vs 2.5%, p=0.035) and lumbar fractures (8.1% vs 2.8%, p<0.001). Logistic regression showed AIS patients had increased odds of overall fracture (OR: 2.1 95% CI [1.4 - 3.1], p<.001), thoracic (OR: 2.2 95% CI [1.0 - 4.5], p=0.039) and lumbar fractures (OR: 3.1 95% CI [1.6 - 6.1], p<0.001).
CONCLUSION(S): AIS trauma patients relative to a normative trauma population were more likely to present with a vertebral fracture; specifically, thoracic and lumbar fractures. Authors acknowledge the limitations of the KID database, such as unavailability of radiographic data. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The impact of neuromuscular disorders such as multiple sclerosis (MS) on outcomes following long segment (4+ level) fusion is underreported. PURPOSE: To identify the impact of MS on two-year (2Y) postoperative complications and revisions following 4 level fusion for ASD. STUDY DESIGN/SETTING: Retrospective cohort. PATIENT SAMPLE: Patients undergoing 4+ level fusion for ASD were identified from the New York State Statewide Planning and Research Cooperative System. OUTCOME MEASURES: Two-year postoperative complications and reoperations.
METHOD(S): Patients undergoing 4-level fusion for ASD were identified from the New York Statewide Planning and Research Cooperative System. Patients with a baseline diagnosis of MS were also identified. Patients with infectious/traumatic/neoplastic indications were excluded. Subjects were 1:1 propensity score-matched (MS to no-MS) by age, sex, and race and compared for rates of 2-year postoperative complications and reoperations. Logistic regression models were utilized to determine risk factors for adverse outcomes at 2 years.
RESULT(S): A total of 86 patients were included (n=43 per group). Age (50.1 vs 50.1 years, p=0.225), sex and race were comparable between groups. MS pts incurred higher charges for their surgical visit ($125,906 vs $84,006, p=0.007) with similar LOS (8.1 vs 5.3 days, p>0.05). MS patients experienced comparable rates of overall medical complications (30.1% vs 25.6%) and surgical complications (34.9% vs 30.2%) all p>0.05. MS pts had similar rates of 2-year revisions (16.3% vs 9.3%, p=0.333). MS was not associated with medical, surgical or overall complications or revisions at minimum 2-year follow-up.
CONCLUSION(S): Patients with MS experienced similar postoperative course compared to those without MS following 4-level fusion for ASD. This data supports the findings of multiple previously published case series' that long segment fusions for ASD can be performed relatively safely in patients with MS. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Despite multiple reports showing favorable long-term functional outcomes following adult spinal deformity (ASD) correction, it is still unclear which patient factors may impact the sustainability of these outcomes. PURPOSE: To assess the sustainability of functional gains following ASD correction and determine predictors for postoperative loss of patient functionality. STUDY DESIGN/SETTING: Retrospective cohort. PATIENT SAMPLE: A total of 689 ASD patients. OUTCOME MEASURES: Sustained clinical benefit, Oswestry Disability Index (ODI), reoperation, mechanical failure, proximal junctional failure (PJF) METHODS: ASD patients with baseline (BL) and three-year (3Y) follow-up data were considered for analysis. Only patients who met the definition of sustained clinical benefit (SCB) at one-year (1Y) were included: 1)Passias et al's threshold for ODI (ODI<31.3), 2) did not develop PJF, and 3) did not have a reoperation for a mechanical failure. Patient groups were created by those who met SCB at 3Y, and those who did not. SCB outcomes were also reported at five-years (5Y) postoperatively. Means comparison tests assessed differences in patient groups. Factors predicting SCB were identified using adjusted regression and conditional inference tree (CIT) analysis.
RESULT(S): A total of 157 patients met inclusion criteria and had SCB at 1Y. Patient breakdown for SCB was 75.0% at 3Y. Gender (78% vs 81%), BMI (25.5 vs 26.4), levels fused (10.6 vs 10.5), operative time (345 vs 362 min), and surgical invasiveness were similar between groups, all P>.05. Following surgery, patient groups were similarly aligned to Lafage et al's age-adjusted PT, PI-LL, and SVA, all P>.05. Regression and CIT analysis adjusting for BL deformity determined that patients who met SCB at 3Y were 95.4% less likely to have an ASD-mFI score > 11 (.046[.005-.420], p=0.006), 73.1% less likely to be older than 55 years at DOS (.269[.091-.798], p=.018), 69.4% less likely to have a CCI score > 0(.306[.116-.811], p=.017), and 86.9% less likely to have a BL EQ5D score <.723 (.131[.029-.585], p=.008). Adjusted for patients without follow-up, sustained clinical benefit at 5Y was 57.9%. Predictors of SCB from 3Y to 5Y included age, CCI and EQ5D, all P <.05.
CONCLUSION(S): Sustained clinical benefit was maintainable for 75.0% of the operative ASD cohort at 3Y. Similarly, a 57.9% maintenance rate of sustained clinical benefit at 5Y reflects the longevity of ASD correction. Independent predictors of sustained clinical benefit included age, frailty, comorbidities and the patient health state. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Dubousset Functional Test (DFT) is a novel functional assessment tool. It has been shown that patients with spinal pathology take significantly longer to complete the DFT than do control patients. There has been a recent focus in the literature on using functional assessment to predict patient outcomes. PURPOSE: To investigate the relationship between patients' performance of the novel four-component functional test proposed by Dubousset, sagittal alignment and patient-reported outcome measures PROMs. STUDY DESIGN/SETTING: Prospective, single center study. PATIENT SAMPLE: Patients presenting to a single institution for lumbar degenerative disease or spinal deformity. OUTCOME MEASURES: The correlation between time to complete DFT, radiographic measures of sagittal alignment and PROMs.
METHOD(S): This is a prospective, single-center study including primary patients who presented for evaluation of lumbar degenerative disease and spinal deformity. DFT is a test which assesses 4 domains: Up and Walking Test (UWT), Steps Test (ST), Down and Sitting Test (DST), Dual Tasking Test (DTT). The UWT asks the patient to sit-to-stand unassisted, walk 5 m, and sit unassisted. ST asks the patient to ascend 3 steps, turn, and descend 3 steps. DST asks the patient to sit from standing, and then stand from sitting, both unassisted. Finally, DTT asks the patient to walk 5 m and back while counting down from 50 by 2. Each test was timed, and performance was scored in seconds required to finish the test. Spinopelvic radiographs and PROMs (EQ5D, ODI, SF12) were collected. DFT performance was stratified by 40th (Fast) and 60th (Slow) percentile cutoffs. Radiographic sagittal parameters were compared between groups. Regression models were built to predict DFT domains performances using alignment parameters.
RESULT(S): A total of 55 patients were included (52y, 66%F, BMI 25.6). Patients in all DFT Slow domains had significantly worse ODI (all above 40), EQ5D (all below 0.5), and worse SF12_PCS (all below 32) except DTT Slow patients who had a comparable PCS to Fast. UWT Slow patients had significantly greater PI-LL (15 vs 2), lower LL (45 vs 60), and greater PT (22 vs 12); DTT Slow had greater PT (22 vs 11); DST Slow had greater PT (23 vs 12), and greater PI-LL (13 vs 1); ST and DTT slow patients had comparable radiographic parameters to ST and DTT Fast; however, they were older (59 vs 43 ys) (all p <0.05). Greater PT correlated with longer time to perform UWT and DST (r=0.451, r=0.488, respectively, p < 0.05). Greater PI-LL correlated with longer UWT (r=0.349) and loss of LL with longer ST (r=0.416), all p <0.05. Notably, loss of L4-S1 correlated with slower UWT (r=0.377, p <0.05). Regression models revealed that PT, PI-LL and SVA together predict UWT with r=0.472, DST with r=0.370, DTT with r=0.310, and ST with r=0.149.
CONCLUSION(S): The Dubousset Functional Test correlates with sagittal radiographic parameters and PROMs. PT, SVA, and PI-LL were able to predict up to 25% of patients' performance on the functional testing. Although radiographic parameters are helpful in guiding ASD treatment, they should be supplemented with other forms of patients' assessment which may include functional testing. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND:There is limited research regarding the association between the mFI-5 and postoperative complications among adult spinal deformity (ASD) patients. METHODS:Using the National Surgical Quality Improvement Project (NSQIP) database, patients with Current Procedural Terminology (CPT) codes for > 7-level fusion or < 7-level fusion with International Classification of Diseases, Ninth Revision (ICD-9) codes for ASD were identified between 2008 and 2016. Univariate analyses with post-hoc Bonferroni correction for demographics and preoperative factors were performed. Logistic regression assessed associations between mFI-5 scores and 30-day post-operative outcomes. RESULTS:2,120 patients met criteria. Patients with an mFI-5 score of 4 or 5 were excluded, given there were<20 patients with those scores. Patients with mFI-5 scores of 1 and 2 had increased 30-day rates of pneumonia (3.5 % and 4.3 % vs 1.6 %), unplanned postoperative ventilation for > 48 h (3.1 % and 4.3 % vs 0.9 %), and UTIs (4.4 % and 7.4 % vs 2.0 %) than patients with a score of 0 (all, p < 0.05). Logistic regression revealed that compared to an mFI-5 of 0, a score of 1 was an independent predictor of 30-day reoperations (OR = 1.4; 95 % CI 1.1-18). A score of 2 was an independent predictor of overall (OR = 2.4; 95 % CI 1.4-4.1) and related (OR = 2.2; 95 % CI 1.2-4.1) 30-day readmissions. A score of 3 was not predictive of any adverse outcome. CONCLUSION/CONCLUSIONS:The mFI-5 score predicted complications and postoperative events in the ASD population. The mFI-5 may effectively predict 30-day readmissions. Further research is needed to identify the benefits and predictive value of mFI-5 as a risk assessment tool.

INTRODUCTION/BACKGROUND:Osteoporosis affects nearly 200 million individuals worldwide. There are little available data regarding outcomes in patients with osteoporosis who undergo short-segment lumbar fusion for degenerative disk disease (DDD). We sought to identify a relationship between osteoporosis and risk of adverse outcomes in patients with DDD undergoing short-segment lumbar fusion. METHODS:Using the New York State Statewide Planning and Research Cooperative System, all patients with DDD who underwent 2- to 3-level lumbar fusion from 2009 through 2011 were identified. Patients with bone mineralization disorders and other systemic and endocrine disorders and surgical indications of trauma, systemic disease(s), and infection were excluded. Patients were stratified by the presence or absence of osteoporosis and compared for demographics, hospital-related parameters, and 2-year complications and revision surgeries. Multivariate binary logistic regression models were used to identify notable predictors of complications. RESULTS:A total of 29,028 patients (osteoporosis = 1,353 [4.7%], nonosteoporosis = 27,675 [95.3%]) were included. Patients with osteoporosis were older (66.9 vs 52.6 years), more often female (85.1% vs 48.4%), and White (82.8% vs 73.5%) (all P < 0.001). The Charlson/Deyo comorbidity index did not significantly differ between groups. Hospital lengths of stay and total charges were higher for patients with osteoporosis (4.9 vs 4.1 days; $74,484 vs $73,724; both P < 0.001). Medical complication rates were higher in patients with osteoporosis, including acute renal failure and deep-vein thrombosis (both P < 0.01). This cohort also had higher rates of implant-related (3.4% vs 1.9%) and wound (9.8% vs 5.9%) complications (both P < 0.01). Preoperative osteoporosis was strongly associated with 2-year medical and surgical complications (odds ratios, 1.6 and 1.7) as well as greater odds of revision surgeries (odds ratio, 1.3) (all P < 0.001). CONCLUSION/CONCLUSIONS:Patients with osteoporosis undergoing 2- to 3-level lumbar fusion for DDD were at higher risk of 2-year medical and surgical complications, especially implant-related and wound complications. These findings highlight the importance of rigorous preoperative metabolic workup and patients' optimization before spinal surgery.

Background:There is limited literature evaluating the impact of isolated cannabis use on outcomes for patients following spinal surgery. This study sought to compare 90-day complication, 90-day readmission, as well as 2-year revision rates between baseline cannabis users and non-users following thoracolumbar spinal fusion (TLF) for adult spinal deformity (ASD). Methods:The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried between January 2009 and September 2013 to identify all patients who underwent TLF for ASD. Inclusion criteria were age ≥18 years and either minimum 90-day (for complications and readmissions) or 2-year (for revisions) follow-up surveillance. Cohorts were created and propensity score-matched based on presence or absence of isolated baseline cannabis use. Baseline demographics, hospital-related parameters, 90-day complications and readmissions, and two-year revisions were retrieved. Multivariate binary stepwise logistic regression identified independent outcome predictors. Results:704 patients were identified (n=352 each), with comparable age, sex, race, primary insurance, Charlson/Deyo scores, surgical approach, and levels fused between cohorts (all, p>0.05). Cannabis users (versus non-users) incurred lower 90-day overall and medical complication rates (2.4% vs. 4.8%, p=0.013; 2.0% vs. 4.1%, p=0.018). Cohorts had otherwise comparable complication, revision, and readmission rates (p>0.05). Baseline cannabis use was associated with a lower risk of 90-day medical complications (OR=0.47, p=0.005). Isolated baseline cannabis use was not associated with 90-day surgical complications and readmissions, or two-year revisions. Conclusion:.