Faculty Bibliography

BACKGROUND CONTEXT: Hospital acquired conditions (HACs) were established in the Affordable Care Act, and are defined as reasonably preventable complications that are nonreimbursable. In high risk patient populations for HACs, such as frail surgical spine patients, preoperative evaluation should consider modifiable factors. PURPOSE: To identify if optimizing the modifiable factors in the frailty index reduce the risk of developing HACs in population of surgical spine patients. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: This study included 196,523 elective spine surgery patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). OUTCOME MEASURES: Modifiable patient frailty factors: hypertension and diabetes mellitus; rates of HACs, superficial or deep surgical site infection (SSI), deep venous thromboembolism (VTE) and urinary tract infection (UTI), across frailty scores.
METHOD(S): Patients >18 years who underwent elective spine surgery were identified in ACS-NSQIP database from 2005-2016. HACs identified: SSI, VTE, and UTI. Patient frailty was assessed utilizing the modified NSQIP 5-factor frailty index. The modified frailty score (mFI-5) is assessed on a scale between 0 and 1 (no frailty [NF] <0.3, mild frailty [MF] 0.3-0.5, severe frailty [SF] >0.5). Descriptive analysis quantified rates of patient characteristics, operative details, and HAC prevalence. Stepwise linear regression models determined significant predictors of baseline frailty using controllable patient factors. HACs were compared between 'optimized' and 'non-optimized' frailty status in the cohort. Level of significance was set to P<0.05.
RESULT(S): A total of 196,523 patients (57+/-14.2 years, 30.4 kg/m², 48%F) met inclusion criteria. Overall, 5,720 (2.9%) of patients developed an HAC, the most common was an SSI (1.3%), followed by UTI (1.1%). When stratified by the mFI-5 frailty severity groups at baseline, 83.6% of patients were categorized NF, 15.1% MF and 1.3% SF. Within the frailty severity groups, prevalence of overall HACs increased significantly (NF: 2.64%, MF: 4.17%, 5.93%, p<0.001). Rates of all individual postoperative HACs assessed also increased with greater baseline frailty severity: SSI (NF: 1.14%, MF: 1.93%, SF: 2.39%, p<0.001), UTI (NF: 0.91%, MF: 1.66%, SF: 2.85%, p<0.001), VTE (NF: 0.68%, MF: 0.80%, SF: 1.16%, p=0.002). Stepwise linear regression models determined that diabetes mellitus (beta = 0.493) and hypertension (beta = 0.679) were the most significant predictors for increased baseline frailty by way of the mFI-5 NSQIP index (Final model: R2= 0.897). Of total patients, 47.2% had the optimal modifiable frailty factors (no history of diabetes or hypertension). The optimal frailty patients had significantly less overall incidence of SSI (2.03% vs 2.5%, p<0.001), UTI (0.65% vs 1.4%, p<0.001), DVT (0.56% vs 0.84%, p<0.001), and any overall HAC (2.18% vs 3.56%, p<0.001).
CONCLUSION(S): Stepwise linear regression models determined that hypertension and diabetes account for 89.7% of variance in baseline mFI-5 score. Patients with these optimal controllable factors had reduced incidence of all hospital acquired conditions. In order to optimize hospital resources and treatment outcomes, physicians and patients should be aware of the modifiable factors that contribute to a patient's frailty that can ultimately impact acquiring HACs. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of HRQOL. PURPOSE: We hypothesized that patients who underwent multiple revision surgeries following adult spinal deformity correction would exhibit lower satisfaction scores. STUDY DESIGN/SETTING: Retrospective cohort study of a prospectively collected multicenter database of ASD patients. PATIENT SAMPLE: A total of 668 patients undergoing ASD surgery and eligible for minimum 2-year follow-up were included. OUTCOME MEASURES: SRS-22r satisfaction score.
METHOD(S): Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1) (ie, never underwent revision or had not yet undergone revision), after first revision only (period 2), and after second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. SRS-22r satisfaction scores were evaluated at all periods using multiple linear regression adjusting for age, gender, and CCI.
RESULT(S): In total, 46.6% had prior spine surgery before their index surgery. The overall revision rate was 21.3%. among patients with no spine surgery prior to the index surgery, satisfaction increased from period 0 to 1 (2.8 to 4.3, p<0.0001), decreased after one revision from period 1 to 2 (4.3 to 3.9, p=0.0004), and decreased after a second revision from period 2 to 3 (3.9 to 3.3, p=0.0437). Among patients with spine surgery prior to the index procedure, satisfaction increased from period 0 to 1 (2.8 to 4.2, p<0.0001), and decreased from period 1 to 2 (4.2 to 3.8, p=0.0011). No differences in follow-up time from last surgery were observed between visits in periods 1, 2, and 3 (all p>0.3). among patients with multiple revisions, 40% experienced rod fracture, 40% PJK, and 33% pseudarthrosis.
CONCLUSION(S): ASD patients exhibit decreased satisfaction with subsequent revision. Among patients undergoing primary surgery in our database, this effect is additive for multiple revisions. These results have important implications for surgeons, patients, insurers, hospital administrators, and policymakers. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Vascular stenting is a common intervention for patients afflicted with coronary artery disease. For elective spine fusion patients with a history of coronary artery disease, a stent provides a less invasive surgical intervention allowing patients to move forward with spinal surgery. However, the impact of an initially less invasive cardiac intervention on outcomes of future surgical spine procedures has been understudied. PURPOSE: Investigate effect of coronary stents on postoperative outcomes in an elective spine fusion cohort. STUDY DESIGN/SETTING: Retrospective review of the PearlDiver database between the years 2006-2013. PATIENT SAMPLE: A total of 726,061 elective spine fusion patients. OUTCOME MEASURES: Comorbidity burden, 30-day and 90-day complications (myocardial infarction, pneumonia, sepsis, death, would complications, transfusions), length of stay.
METHOD(S): Elective spine fusion patients were isolated with ICD-9 and CPT procedures codes in the PearlDiver database. Patients were stratified by number of coronary stents: (1) 1-2 stents (ST12); (2) 3-4 stents (ST34); (3) no stents. Means comparison tests compared differences in demographics, diagnoses, comorbidities, 30-day and 90-day complication outcomes. Logistic regression assessed the odds of complication associated with coronary stents, controlling for levels fused, age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was set p<0.05.
RESULT(S): A total of 726,061 elective spine fusion patients were isolated; 707,396 patients had no stent, 17,087 ST12 and 1,578 ST34. At BL, ST12 patients had higher rates of morbid obesity, chronic kidney disease, CHF, COPD, and diabetes mellitus compared to no stent and ST34 (all p<0.001). Relative to no stent patients, ST12 patients had a greater LOS and at 30 days, significantly higher complication rates including pneumonia, myocardial infarction, sepsis, AKI, UTI, wound complications, transfusions, and 30-day readmission (p<0.05). Controlling for age, sex, comorbidities, and levels fused ST12 was a significant predictor of MI within 30 days (OR: 2.15[1.7-2.7], p<0.001) and 90-days postop (OR:1.87[1.6-2.2], p<0.001). ST34 patients compared to no stent at 30 days presented with increased complication rates such as pneumonia, MI, sepsis, UTI, wound complications, and 30-day readmissions. Regression analysis show 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 [1.13-3.13],p=0.01).
CONCLUSION(S): 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 to patients with fewer or no stents. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Prior studies have demonstrated potential benefits of adult spinal deformity (ASD) surgery, but less outcomes data exist for operative ASD patients with severe scoliotic curves (thoracic [TH] curve >=75degree, thoracolumbar [TL] curve >=50degree, or lumbar [LL] curve >=50degree). Also, the surgical complication profile is less clear for this subset of patients with severe scoliotic deformity and warrants focused investigation. PURPOSE: The objective of the current study was to assess treatment outcomes and complication rates associated with ASD surgery in patients with severe scoliosis. STUDY DESIGN/SETTING: Retrospective review of a prospectively collected multicenter consecutive case registry PATIENT SAMPLE: Enrollment required: age >=18 yrs, scoliosis >=20degree, sagittal vertical axis (SVA) >=5cm, pelvic tilt >=25degree, and/or thoracic kyphosis >=60degree. OUTCOME MEASURES: Standard coronal and sagittal spinopelvic deformity measurements and health-related quality of life (HRQL) outcomes, which included Oswestry Disability Index (ODI), Short Form-36 (SF-36) scores, and Scoliosis Research Society-22 (SRS-22) scores.
METHOD(S): Using a prospective multicenter database, we identified surgically treated ASD patients with severe scoliosis (TH Cobb >=75degree or TL/LL Cobb >=50degree) and minimum 2-yr follow-up. Demographic data, surgical characteristics, radiographic alignment measurements, HRQL outcomes and associated complications were analyzed.
RESULT(S): Of 178 patients, 146 (82%, mean age 54 yrs, 92% women, 88 TL, 50 LL, 8 TH) had minimum 2-yr follow-up (mean=3.1 yrs). Almost 30% had prior spine fusion, 6% were active or past smokers, 16% had osteoporosis and 77% had at least 1 comorbidity. Surgical details included: posterior-only (58%) or anterior-posterior approach (42%), SPO (65%), 3CO (14%), TLIF (23%), ALIF (37%), sacropelvic fixation (76%), upper thoracic UIV (64%) and mean posterior fusion length of 13.2 levels. Postoperative coronal alignment improved significantly for all patients (global coronal alignment 3.8 to 2.8 cm, p< 0.001; TH Cobb 38degree to 24degree, p<0.001; TL Cobb 61degree to 30degree, p<0.001; LL Cobb 50degree to 24degree, p<0.001; Fractional Cobb 20degree to 7degree, p<0.001). Overall sagittal alignment also improved significantly (p<0.05), most notably for severe lumbar curves (C7-S1 SVA 6.7 to 2.5 cm, p<0.001; PI-LL 18degreeto 3degree, p<0.001). Overall HRQL improved significantly, including ODI (39 to 26, p<0.001), SF-36 PCS (35 to 41, p<0.001) and SRS-22r (2.9 to 3.8, p<0.001). A total of 191 complications were reported (92 minor/99 major), and 94 (64%) patients had at least one complication. The most common complications included dural tear (12%), pleural effusion (12%), rod fracture (11%), radiculopathy (8%) and proximal junctional kyphosis (7%). 34 reoperations were performed in 27 (18%) patients, with most common indications of rod fracture/pseudarthrosis (8), deep wound infection (6) and neurological deficit (5).
CONCLUSION(S): Surgery for severe adult scoliosis is associated with significant improvement in radiographic alignment and HRQL measures. Although associated complication rates are high, these appear to be comparable to reports of less severe scoliosis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Navigation assisted and robotics systems are becoming more widespread in their utilization and can be invaluable intraoperative adjuncts during spine surgery. These systems are utilized in hopes of improving surgical accuracy and clinical outcomes. However, there is a lack in specificity of which type of procedures benefit the most from use of navigation versus robotics. PURPOSE: Identify Trends of Navigation and Robotic assisted elective spine surgeries from the onset of inception. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Elective spine patients from (2007-2016). OUTCOME MEASURES: Complications, procedures, levels fused.
METHOD(S): Patients(pts) between 2007-2016 in Nationwide Inpatient Sample (NIS) were isolated by ICD9 codes for Navigation [Nav] or Robotic [Rob]-Assisted surgery. Basic demographics and surgical variables were identified between each group via chi-squared and t-tests. Each system was analyzed from 2009-2015 for trends in usage with specific procedures and specific diagnoses.
RESULT(S): Included 3,759,751 elective spine patients (56.9 yrs, 52.7% F) with 100,488 Nav and 4,724 Rob pts. Nav pts were younger (56.7 vs 62.7) and had a lower comorbidity index (1.8 vs 6.2; all p<0.05). Nav pts also had more decompressions (65% vs 42%), fusions (71% vs 50.5%), anterior (17% vs 16.7%), posterior (58.3% vs 36.8%), and combined approach (7.1%vs 5%) than Rob pts. Overall, complication rates increased for Nav (5.8%-21.7%) and Rob pts (3.3%-18.4%) as well as for 2-3 level fusions (50.4%-52.5%) and (1.3%-3.2%); respectively. Concomitantly, Rob and Nav systems have been used on increasingly invasive spinal procedures (Rob:1.7-2.2; Nav: 3.7-4.6). During this time, the rate of posterior approaches (27.4%-41.3%) increased as well as osteotomies (4%-7%) and spinal fusions (40.9%-54.2%) for Rob pts. However, the rates for anterior approach for Rob procedures has since decreased (14.9%-14.4%). Nav increased for posterior (51.5%-63.9%) and anterior approaches (16.4%-19.2%) despite the decrease rate of osteotomies (2.1%-2.1%) and decompressions (73.6%-63.2%).
CONCLUSION(S): From 2007 to 2016 Robotic and Nav systems have been performed on increasing invasive spine procedures. Robotic systems have shifted from anterior to posterior approaches especially for spinal fusions. While, Navigation computer-assisted procedures have been increasingly used for different approaches, but have decreased in rates of usage for decompression procedures. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: With the increasing emphasis on value-based outcomes in healthcare, there has been an increased focus on the cost of surgical intervention in patients with adult spinal deformity (ASD). However, there is paucity in the literature on the economic impact of an initial nonoperative approach for patients that eventually require surgical intervention. PURPOSE: Investigate the cost utility of nonoperative treatment for ASD STUDY DESIGN/SETTING: Retrospective cohort study of a prospective multicenter adult spinal deformity database. PATIENT SAMPLE: A total of 824 operative (Op) and Nonoperative (N-Op) ASD patients. OUTCOME MEASURES: ODI, SF-6D, Cost per quality adjusted life years (QALY).
METHOD(S): N-Op and Op patients who met database criteria for ASD with complete radiographic and HRQL data at baseline and 2Y were included. A cost analysis was completed on the PearlDiver database assessing average cost of nonoperative treatment prior to surgical intervention based on previously published treatments (NSAID, narcotics, muscle relaxants, epidural steroid injections, physical therapy and chiropractor). Utility data was calculated using ODI converted to SF-6D with published conversion methods. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Complications, comorbidities (CC), major complications, and comorbidities (MCC) were assessed according to CMS.gov manual definitions. Successful N-Op treatment was defined as a gain in MCID in both ODI and SRS-Pain and failure as a loss in MCID or conversion to operative treatment. Patients with BL ODI <=20 and continued ODI at 2Y <= 20 were considered N-Op successful maintenance. Average utilization of non-operative treatment and cost were applied to our ASD cohort.
RESULT(S): A total of 824 patients were included (58.24yrs, 81% F, 27.1 kg/m2). Overall, 75.5% of patients were operative and 24.5% nonoperative. At baseline operative patients were significantly older, had a greater BMI, increased pelvic tilt, and increased PI-LL (all p<0.05). With respect to deformity, operative patients had higher rates of severe ++ sagittal deformity according to SRS-Schwab modifiers for PT, SVA, and PI-LL (p<0.05). At 2Y, operative patients showed significantly increased rates of a gain in MCID for PCS, ODI, and SRS Activity, Pain, Appearance, and Mental. Virtual Cost-Analysis showed average cost of non-operative treatment 2Y prior to surgical intervention to be $2,041. Overall, nonoperative patients at 2Y had an overall gain in ODI of 0.36, did not show gain in QALY, and nonoperative treatment was determined to be cost ineffective. A subset of N-Op patients however underwent successful maintenance treatment and had a decrease in ODI of -1.1 and a gain in utility of 0.006 at 2Y. If utility gained for this cohort was sustained to life expectancy, patients' cost per QALY was $18,934 compared to a cost per QALY gained of $70,690.79 for posterior-only and $48,273.49 for combined approach operative patients.
CONCLUSION(S): ASD patients undergoing operative treatment at baseline had greater sagittal deformity and greater improvement in HRQL postoperatively compared to nonoperative patients. Additionally, nonoperative patients overall had an increase in ODI and did not show improvement in utility gained. Nonoperative patients with low disability and sagittal deformity underwent successful maintenance and cost-effective treatment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: There have been few investigations into national trends in outcomes and costs associated with the assimilation of robotic assisted surgery. In order to improve cost efficiency, further research is needed into the drivers of higher charge ratios. PURPOSE: To evaluate if incorporation of robotic assisted spine surgeries will lead to a rise in cost without a significant improvement in outcomes. STUDY DESIGN/SETTING: Retrospective review of a national patient database between 2010-2016. PATIENT SAMPLE: A total of 4,185 discharges. OUTCOME MEASURES: Cost-to-Charge ratio, length of stay, invasiveness.
METHOD(S): Included: elective spine surgery procedures from 2010-2016 as defined by ICD-9/10-CM codes. Descriptive statistics assessed demographics for the cohort. Rates of open and MIS robot assisted procedures, trends in postoperative complications, length of stay, total charges, CCR and hospital location were assessed. PSM was performed between robotic and nonrobotic spine surgery patients for levels fused. Regression analysis was used to evaluate robot assisted procedures as a predictor of postop complications, extended LOS (LOS above 75th percentile), higher total charges (charges above 75th percentile), higher cost to charge ratio (CCR above 75th percentile), unfavorable discharge and death.
RESULT(S): A total of 4,185 discharges were included (age 59.7 +/- 16.2, 55% female, average severity of illness score 1.87 +/- 0.83). Overall, there has been a significant increase in robot assisted surgeries from 2010 to 2016 increasing from 11 recorded cases to 1,535 in 2016 (p<0.001). There has been a significant increase in total charges from 2010-2016, with a mean high of $455,210.91 in 2011 (p<0.001). However, there has been a decrease in CCR from 2012 to 2016 (0.33 compared to 0.24. p<0.001). Average length of stay has significantly decreased from 9.5 days in 2010 to 4.4 days in 2016 (p<0.001), while 50% of patients have been unfavorably discharged since 2012. When compared to 4,185 invasiveness match non-robotic patients, robot assistance was not significantly associated with higher total charges, however it was significantly associated with higher CCR (OR: 2.4 [2.15-2.69], p<0.001).
CONCLUSION(S): Compared to invasiveness matched nonrobotic patients, robot assisted patients had significantly higher odds of having a high cost to charge ratio for their hospital encounter, despite having similar total charges. Cost to charge increase due to technology may represent an added financial burden that is developing so clinical benefit of new technology is warranted. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Many patients are unable to undergo a major adult spinal deformity (ASD) corrective surgery due to deformity severity, age, comorbidities, and overall frailty status. In order to optimize quality of life in patients with ASD there may be alignment ratios to be prioritized across different presentations of spinal shape. PURPOSE: To prioritize radiographic alignment ratios for alignment. STUDY DESIGN/SETTING: Retrospective review of a single surgeon adult spinal deformity database. PATIENT SAMPLE: A total of 165 patients undergoing ASD corrective surgery OUTCOME MEASURES: Minimal clinically important difference (MCID) for SRS-22r and Oswestry Disability Index (ODI); proximal junctional kyphosis (PJK).
METHOD(S): Included: patients >18yrs undergoing surgery for ASD (scoliosis >=20degree, SVA >=5cm, PT >=25degree, or TK >=60degree) with full baseline (BL) and 2-year (2Y) radiographic parameters and HRQL scores. Patients were stratified by baseline pelvic incidence: low PI (<45), high PI (>=45). Ratios of SRS-Schwab radiographic parameters (PI-LL, SVA, PT) were assessed for quartiles of correction: minimal (<0%), 0-25%, 25-50%, 50-75%, and 75-100%. Target quartiles of correction were assessed within the PI severity groups for achievement of 2Y best clinical outcome as defined by Smith et al: SRS-22 scores >=4.5 and ODI <=15 [BCO] through correlations and stepwise linear regression analysis.
RESULT(S): A total of 165 ASD patients included (56.7+/-16.3yrs, 80.3% female, 25.8+/-5.3kg/m2). By approach, anterior: 0.6%, posterior: 91.2%, and combined approach: 8.2%. Average levels fused: 11.3+/-4.1, operative time: 332 min, estimated blood loss: 1,968 ccs. By baseline PI: 24.3% low PI, 75.7% high PI. (47 patients) of patients met the criteria for BCO, which was evenly distributed among the Roussouly types (p=0.115). For low PI patients, a combination of correcting the PI-LL from 0-25%, SVA 75-100%, and PT 0-25% significantly predicting acquiring the BCO (R2 =0.622, p=0.002). For BCO in high PI patients, a 25-50% correction in PI-LL, SVA minimal, and PT 75-100% (R2 =0.297, p=0.021). Low PI patents who met the three ratios of correction (PI-LL, SVA and PT) had less major complications (11.1% vs 23.1%) compared to other low PI patients. High PI patients who were corrected to the Schwab quartile of ratios underwent less reoperations (6.1% vs 23.3%) and had less PJK occurrence by 2-years postop (20.4% vs 40%), all p<0.05.
CONCLUSION(S): Certain ratios of correction of the SRS-Schwab modifiers contribute to improving clinical outcomes and vary by preoperative spinal shape. Prioritization of global realignment relative lumbo-pelvic mismatch depends on the theoretical contour of the individual patient. Importantly, certain subgroups experience the most clinical benefit from the initial percentages of realignment, which may obviate more aggressive corrections on an individual basis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Scoliosis Research Society established appropriateness criteria for surgery for degenerative lumbar scoliosis (DLS) in order to improve and unify clinical decision making. Though utilized and validated in various cohorts, an appropriateness criteria has yet to be developed in a cervical deformity (CD) population. PURPOSE: To modify the DLS Appropriateness criteria to be utilized in a CD cohort. STUDY DESIGN/SETTING: Retrospective review of a single-surgeon CD database PATIENT SAMPLE: A total of 100 CD patients. OUTCOME MEASURES: Appropriateness criteria.
METHOD(S): CD patients>18yrs were included. Each patient was scored based upon the SRS-appropriateness criteria, comprised of clinical or radiographic characteristics and was modified for a cervical deformity cohort: (1) Severity of Symptoms [NDI], (2) Severity of Myelopathy[mJOA.], (3) Progression of Deformity, (4) Global Sagittal Malalignment [Schwab modifiers], (5) Severity of Risk Factors, (6) Degree of the T1S-CL curvature. For the category 'progression', radiographs were only available at one preoperative time point, and we were unable to include this in the total score. Based upon certain combinations of criteria, patients were stratified into Appropriate and Not Appropriate.
RESULT(S): A total of 100 patients were included (61yrs, 62% F, 29.5kg/m²). Assessment of the categories of Appropriateness of CD surgery: (1) Symptoms: 6% None to Mild, 94% Moderate to Severe; (2) Myelopathy: 16% None to Mild, 45% Moderate, 39% Severe; (3) All were grouped No Progression in the present study; (4) 19% demonstrated Global Malalignment (+/++Schwab), 81% did not; (5) Risk Factors: 27% had None to Mild, 63% Moderate, 10% Severe; (6) Curvature TS-CL demonstrated 88.6% of patients Severe (>20degree). Not Appropriate: None to Mild (NDI <28), with (1) None to Moderate myelopathy (mJOA >12) and Severe Risk Factors (2) None to Mild myelopathy (15-18) and No Progression or Imbalance (3) Moderate myelopathy (mJOA 12-15) and None to Moderate Risk Factors and no Progression, or imbalance and TSCL <25degree. Appropriate: Moderate to Severe Symptoms (NDI >=30), with (1) Severe myelopathy (mJOA<12) and Any Risk Factors (2) Moderate myelopathy and None to Moderate Risk Factors (3) Moderate myelopathy with Severe Risk Factors, Progression AND Imbalance (4) None to Mild myelopathy and None to Moderate Risk Factors and Progression OR imbalance (5) None to Mild myelopathy with None to Moderate Risk Factors and TSCL >25degree. In the present cohort, 94% were deemed Appropriate for surgery, 6% Not Appropriate. Less Appropriate patients demonstrated higher rates of postop dysphagia complications (17% vs 2%), met MCID for NDI less (0% vs 30.9%), and had more occurrences of DJK (16.7% vs 6.4%) by 2 years, p<0.05.
CONCLUSION(S): In light of the heterogeneity and uncertainty surrounding CD, this study developed CD appropriateness criteria, using established methodology, for surgeons to consider in the preoperative decision-making that correlate well with major postop occurrences. Application of the appropriateness criteria for CD may optimize patient selection and reduce the incidence of unwarranted surgery, although future validation is necessary. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Spinal fusion is increasingly considered for management of patients with osteoporosis (OP) and degenerative disc disease (DDD). Little data is available regarding long-term outcomes in OP patients undergoing short-segment, lumbar fusion for DDD. PURPOSE: Analyze the impact of OP on long-term outcomes in patients who have had 2-3-level lumbar fusions for degenerative disc disease. STUDY DESIGN/SETTING: Retrospective review of the New York State Statewide Planning and Research Cooperative System (NYS SPARCS) database. PATIENT SAMPLE: Patients with DDD undergoing 2-3-level lumbar fusion. OUTCOME MEASURES: Frequency of 2-year medical and surgical complications and reoperations.
METHOD(S): Utilizing SPARCS, all patients from 2009-2011 with ICD-9 codes for DDD who underwent 2-3-level lumbar fusion were identified. Patients with bone mineralization disorders, systemic and endocrine disorders affecting bone quality were excluded. Surgical indications of trauma, systemic disease(s), and infection were excluded. Patients with and without OP were compared for demographics, hospital-related parameters, and 2-year complications and reoperations. Logistic regression models were utilized to identify predictors of complications.
RESULT(S): A total of 29,028 patients (OP=1,353 (4.7%), No-OP=27,675) were included. OP patients were older (66.9 vs 52.6 years) as well as more often female (85.1% vs 48.4%) and white (82.8% vs 73.5%), all p<0.001. Deyo index did not differ between groups. LOS and total charges were higher for OP patients (4.9 vs 4.1 days; $74,484 vs $73,724), all p<0.001. Medical complications were higher for OP patients: acute renal failure (8.9% vs 4.7%), and deep vein thromboses (3.4% vs 1.6%), all p<0.01. OP patients also had higher rates of implant-related (3.4% vs 1.9%) and wound complications (9.8% vs 5.9%) (p<0.01). Preoperative OP was associated with 2-year medical and surgical complications (OR=1.62, 1.66; p<0.001). Patients with OP had greater odds of reoperations (OR=1.34).
CONCLUSION(S): Patients with OP undergoing 2-3-level lumbar fusion for DDD were at higher risk of 2-year medical and surgical complications, and 3.4% of OP patients experienced implant-related complication. These findings highlight the importance of rigorous preoperative metabolic workup prior to spinal surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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