Faculty Bibliography

BACKGROUND CONTEXT: Traditional iliac (IS) and S2-alar-iliac (S2AI) pelvic fixation methods have unique technical characteristics in their application, and result in varied biomechanical and anatomic impact. These differences may lead to variance in lumbopelvic fixation failure types and rates. PURPOSE: We intended to evaluate the influence of type of iliac fixation utilized for adult spinal deformity (ASD) correction on the frequency and manner of lumbopelvic fixation failure. STUDY DESIGN/SETTING: Retrospective review of prospective, multicenter ASD database. PATIENT SAMPLE: This study included 410 patients. OUTCOME MEASURES: HRQL (ODI, SF-36, NRS), rod fracture, screw fracture, screw loosening, revision surgery, pseudarthrosis METHODS: Inclusion criteria included ASD (coronal Cobb>=20degree, sagittal vertical axis (SVA) >=5cm, pelvic tilt >=25degree and/or thoracic kyphosis >60degree) >= 18 years old, 2yr follow-up, and >5 level fusion with pelvic fixation. Cohort subdivided by type of pelvic fixation (IS vs S2AI). Loosening was defined by lucency around the screw shank on radiographs. Univariate testing was performed using t-tests and chi-squared tests. Multivariate logistic regression, accounting for significant confounders, was used to examine differences between the two groups for screw loosening/fracture, rod fracture, and revision surgery. Level of significance = p<0.05.
RESULT(S): Of the total of 1422 patients, 410 met inclusion criteria (IS=287, S2AI=131). The two groups had similar age, BMI, baseline co-morbidities, and number of levels fused (p>0.05), as well as similar baseline HRQLs (SF-36, ODI, SRS-22, NRS leg and back, p>0.05) and deformity (PT, PI-LL, SVA, p>0.05). Patients in the IS group had a higher proportion of unilateral fixation compared to S2AI group (12.9% vs 5.6%; p=0.001). The overall pelvic fixation failure rate (screw loosening/screw fracture/rod fracture) was 29.4%. Loosening of pelvic fixation occurred in 13.4% of patients, and was more prevalent in the S2AI fixation group (OR 2.74, p=0.001). The rate of S1 screw loosening was 2.9%, and more likely to occur in the S2AI group (OR 4.17, p=0.045). The rate of pelvic fixation fracture in the overall cohort was 2.3%, with no difference between groups (p=0.37). Rod fracture occurred in 14.1% below L4, with a trend toward less occurrence in the S2AI group (OR 0.47, p=0.06). Revision surgery was required in 22.7% of our cohort, with no difference between groups (p=0.449). Patients with failure of the pelvic fixation had less improvement in their HRQL at 2years (PCS 7.69 vs 10.46 p=0.028; SRS 0.83 vs 1.03 p=0.019; ODI 12.91 vs 19.77 p=0.0016).
CONCLUSION(S): Pelvic fixation is commonly used in long segment adult spinal deformity surgery to improve the rate of L5-S1 fusion and protect from construct failure at the lumbosacral junction. Our results demonstrate a substantial rate of pelvic fixation hardware issues following ASD correction. Lumbopelvic fixation failure occurred at a rate of 29.4% following surgical correction of ASD that involved iliac fixation and was associated with diminished clinical outcomes. Additionally, S2AI screws were more likely to demonstrate loosening, but less commonly associated with rod fractures. Patients who experienced failure of their pelvic fixation had less improvement in their HRQL two years postoperatively. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Following cervical deformity (CD) corrective surgery, durability remains a challenge and distal junctional kyphosis (DJK) is an important risk for a surgeon to consider. DJK is the result from fixation failure, adjacent level fracture or spondylolisthesis. The timing of DJK onset has yet to be investigated. PURPOSE: To determine the timing of DJK development following CD corrective surgery. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: A total of 139 CD patients. OUTCOME MEASURES: Early/Late DJK Development, Severe DJK, Symptomatic DJK.
METHOD(S): Included: surgical CD patients (C2-C7 Cobb>10degree, CL>10degree, cSVA>4cm, or CBVA>25degree) without preop DJK. DJK angle was defined as the change in kyphosis between lower-most instrumented vertebra (LIV) and LIV-2 from preop to postop (<-10). X2 analysis and post-hoc testing assessed annual and overall incidence of early (3M follow-u) and late (DJK development at 6M, 1Y, 2Y) DJK development among operative patients. Differences between early and late DJK (development after 3 months) were assessed. Pearson correlations determined significant variables associated with development of early versus late DJK. Severe DJK was defined as DJK angle <-20degree. DJK was considered symptomatic if associated with reoperation or the previously published thresholds of NDI>24 or mJOA<14. The natural progression of the disease was predicted with the use of a Kaplan-Meier survivorship analysis.
RESULT(S): A total of 139 patients without preop DJK were included (16 re-op) (61.8yrs, 62.3%F, 29.1kg/m2). Surgical characteristics: 20.1% anterior approach, 42.4% posterior, 36.7% combined (levels fused: 7.6). Incidence of DJK from 2013-2018: 23%. Early: 9.4%, late: 10.1% (6M delayed: 3.6%, 1Y delayed: 6.5%, 2Y delayed: 2.2%). No differences were observed between op and reop for development of early or late DJK at all f/u (p>0.050). Presence of upgoing plantar response at baseline neuro exam, C2-C7 angle, T1-C2 angle, CBVA and combined approach correlated with development of early DJK. For late DJK: history of tumor and pulmonary disease, pelvic incidence, T10-L2 angle, and L4 pelvic angle. Apex of the secondary driver was significantly lower in the Late group (mean early: T2/3; late: T10; p=0.023). 3M radiographically, Early DJK patients had greater TK (-57.9degree vs -40degree, p=0.024, while L4PA remained larger in the late DJK group (14.5degree, p=0.009). Between early and late groups, 41.7% of early DJK patients met criteria for severe DJK, while 0% of Late DJK patient were severe(p=0.010); symptomatic DJK between the two groups was not significant (p=0.941). Kaplan-Meier survivorship analysis determined patients within the cohort to have a 91.1% cumulative probability of maintaining non-DJK status by 3-month follow-up, 85.9% at 6-month, 80% at 1-year, and 77.0% by 2-year follow-up.
CONCLUSION(S): Patients undergoing CD corrective surgery have incidence of early and incidence of late DJK. While the majority of DJK development occurs within the first 6 months, late DJK occurs and differs in presentation and etiologic factors. Early DJK occurrence is more likely to be severe radiographically, associated with neurological decline, and is more strongly related to biomechanical factors such as use of a combined approach at the time of surgery. Contrarily, although equally likely to be symptomatic as reflected in loss of clinical gains from surgery, late DJK is more likely mild radiographically and associated with suboptimal cervical realignment and lack of addressing secondary drivers, likely related to negative compensatory mechanisms. Customized prophylactic approaches for both occurrences is mandated. 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: Chiari malformations (CM) are congenital or acquired hind brain anomalies with resultant cerebellar tonsillar herniation through the foramen magnum. Chiari I malformation consists of herniation of the cerebellar tonsils into the foramen magnum thus crowding the craniocervcial junction. Surgical management is variable among these type 1 patients(pts) based on their presenting symptoms. PURPOSE: Identify complication rates following CM surgery. STUDY DESIGN/SETTING: Retrospective cohort study of (Kids' Inpatient Database) KID. PATIENT SAMPLE: Chiari Malformation Type I. OUTCOME MEASURES: Complication rates, fusion, decompression, duroplasty, laminectomy, LOS, Readmission.
METHOD(S): The KID database was queried for diagnoses of operative Chiari Malformation from 2003-2012 by ICD-9 codes (348.4). Differences in preoperative demographics (age/BMI) and perioperative complication rates between patient cohorts were assessed using Pearson's chi-squared tests and T-tests when necessary. Binary logistic regression were utilized to find significant factors associated with complication rate. Decision tree analysis was utilized for continuous variables predictive of complication rate. Certain surgical procedures were analyzed for their relationship with post-operative outcomes.
RESULT(S): A total of 13,812 CM-1 patients were isolated (10.12 yrs, 0.62 CCI). Of these pts, 8.2% (1,128) received a complication. From 2003 to 2012, the rate of complications for CM-1 pts decreased significantly (9.6%-5.1%) along with surgical rate (33.3%-28.6%), despite the increase in CM diagnosis (36.3%-42.3%; all p<0.05). CM-1 pts who had a complication were younger (9.73+/-6.8 yrs vs 10.2+/-6.3 yrs) and had a lower invasiveness score (0.35+/-1.0 vs 0.41+/-1.0), however; they had a larger CCI (1.10+/-1.6 vs 0.6+/-1.3) than those who did not have a complication (all p<0.05). The most prevalent comorbidities for these pts were cerebrovascular (16.67%), malignancy (11.6%), pulmonary (9.6%), and renal (7.1%; all p<0.05). CM-1 pts who experienced complications had a concurrent diagnosis of syringomyelia (7.1%) and also Scoliosis (3.2%; all p<0.05). CM-1 pts who did not have a complication had a greater surgical rate than those that had a complication (76.4% vs 23.6% p<0.05). Having an interbody instrument, having an invasiveness score>4.25 and receiving a fusion greater than 4 levels were all significant factors associated with receiving a complication postoperatively (p<0.05). The most common complication was nervous system related (2.8%), anemia (2.4%), and acute respiratory distress (2.1%). CM-1 pts that underwent a fusion (3.4% vs 2.1%) had greater complication rates as well as those that underwent a craniotomy (23.2% vs 19.1%; all p<0.05). However, CM-1 pts who underwent a decompression had lower postop complications (21.3% vs 28.9%; all p<0.05). A total of 13,812 CM-1 patients isolated (10.12 yrs, 0.62 CCI). Of these pts, 8.2% (1,128) received a complication. From 2003 to 2012, the rate of complications for CM-1 pts decreased significantly (9.6%-5.1%) along with surgical rate (33.3%-28.6%), despite the increase in CM diagnosis (36.3%-42.3%; all p<0.05). CM-1 pts who had a complication were younger (9.73+/-6.8yrs vs 10.2+/-6.3yrs) and had a lower invasiveness score (0.35+/-1.0 vs 0.41+/-1.0), however; they had a larger CCI (1.10+/-1.6 vs 0.6+/-1.3) than those who did not have a complication (all p<0.05). The most prevalent comorbidities for these pts were cerebrovascular (16.67%), malignancy (11.6%), pulmonary (9.6%), and renal (7.1%; all p<0.05). CM-1 pts who experienced complications had a concurrent diagnosis of syringomyelia (7.1%) and also Scoliosis (3.2%; all p<0.05). CM-1 pts who did not have a complication had a greater surgical rate than those that had a complication (76.4% vs 23.6% p<0.05). Having an interbody instrument, having an invasiveness score>4.25 and receiving a fusion greater than 4 levels were all significant factors associated with receiving a complication postoperatively (p<0.05). The most common complication was nervous system related (2.8%), anemia (2.4%), and acute respiratory distress (2.1%). CM-1 pts that underwent a fusion (3.4% vs 2.1%) had greater complication rates as well as those that underwent a craniotomy (23.2% vs 19.1%; all p<0.05). However, CM-1 pts that underwent a decompression had lower postop complications (21.3% vs 28.9%; all p<0.05).
CONCLUSION(S): Treatment of Chiari malformation has been identified to have improved from 2003 to 2012 with increased identification of diagnosis and decreased complications. Chiari patients undergoing fusions and craniotomies are at a greater risk of postoperative complications especially when the instrumented fusions are performed on >4 levels. 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 anterior cervical discectomy and fusion (ACDF) is underreported. PURPOSE: Identify the impact of MS on two-year (2Y) postoperative complications and revisions following 2-3-level ACDF for cervical radiculopathy (CR) or myelopathy (CM). STUDY DESIGN/SETTING: Retrospective review of the New York State Statewide Planning and Research Cooperative System (SPARCS) database. PATIENT SAMPLE: Patients undergoing 2-3 level ACDF for CR/CM. OUTCOME MEASURES: Two-year postoperative complications and reoperations.
METHOD(S): Patients undergoing 2-3 level ACDF for CR/CM were identified from SPARCS. Patients with a baseline diagnosis of MS were also identified. Patients with infectious/traumatic/neoplastic were excluded. The remaining patients were 1:1 propensity score-matched (MS to no-MS) for age, sex, race, Deyo index and compared for rates of 2Y postoperative complications and reoperations. Logistic regression models were utilized to determine significant predictors of these outcomes.
RESULT(S): A total of 302 total patients were identified (MS, n=151; non-MS, n=151). MS patients were more frequently female (72.8% vs 27.2%, p<0.001). Age was comparable (50.1 vs 50.1 years, p=0.225). MS patients incurred higher charges for their surgical visit ($41,029 vs $31,654) and higher LOS (2.8 vs 2.2 days), both p<=0.016. They experienced higher rates of deep vein thrombosis (DVT) (3.3% vs 0%, p=0.02), with similar overall medical (19.2% vs 21.2%), surgical (7.9% vs 10.6%), and total complications (21.9% vs 25.8%), all p>0.05. MS patients had similar rates of 2Y revisions (6.6% vs 5.3%, p=0.627). MS was not associated with medical, surgical, or overall complications or revisions at minimum 2Y follow-up.
CONCLUSION(S): Despite differences in demographics and higher rates of postoperative DVT, MS patients experienced comparable postoperative course with respect to other individual and overall complications and revisions following 2-3-level CF for degenerative spinal pathologies. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Adult spinal deformity (ASD) corrective surgery is often associated with high rates of adverse outcomes during the recovery course. With the growth of predictive analytics in the medical field, it is important to utilize the developing machine-learning resources to consider the risks associated with major operations. PURPOSE: To assess the validity of the ACS-NSQIP risk index for postop complications and mortality in a prospective multicenter ASD database. STUDY DESIGN/SETTING: Retrospective cohort study of a prospective multicenter ASD database PATIENT SAMPLE: A total of 1,281 ASD patients. OUTCOME MEASURES: Predictive performance of the ACS-NSQIP calculator in an ASD database.
METHOD(S): Patients>18yrs undergoing surgery for ASD (scoliosis>=20degree, SVA>=5cm, PT>=25degree or TK>=60degree). Calculated perioperative complication risk averages via the ACS-NSQIP surgical calculator with CPT codes were compared with 30-day complication rates in the ASD database. Outcomes assessed (as defined by NSQIP): serious complication, any complication, pneumonia, cardiac complication, SSI, UTI, VTE, renal failure, return to OR, death, sepsis and length of hospital stay. Predictive performance of the calculator was analyzed by Brier score (sum of squared differences between the binary outcome and the predicted risk). It ranges from 0 to a maximum Brier score [(mean observed outcome)*(1-[mean observed outcome])]. Values closer to 0 are suggestive of better predictive performance (>0.05 considered poor). Length of stay was assessed with a Bland-Altman plot, observed LOS on the x-axis and the difference between the observed and predicted LOS on the y-axis. Performance of the calculator for serious/any complications for surgeries indicated as 'Risk significantly higher than estimate' was assessed by comparing means of patients who were in the top quartile for their ISSG-invasiveness scores.
RESULT(S): A total of 1,281 ASD patients (60.2 yrs, 73.5% F, 28 kg/m2) were included. A total of 49.4% of procedures involved decompression and 100% involved fusion, with a mean number of levels fused of 10.98. The means for individual patient characteristics that coincide with the variables entered into the online risk calculator interface are as follows: functional status through baseline ODI scores (Independent [0-40]: 35.6%, Partially Dependent [41-80]: 61.8%, Totally Dependent [81+]: 2.6%), 0% emergent cases, ASA Class (I: 5.6%, II: 46.8%, III: 41.7%, IV: 1.4%, V: 0%), 11.9% disseminated cancer, 9.1% diabetes mellitus, 36.5% use of hypertensive medications, 10.8% CHF, 5.9% current smoker, 5.2% COPD, and 4.4% acute renal failure. Predictive of any 30-day postoperative complications ranged from 2.8-18.5% across CPT codes, where the actual rate in the cohort was 9.0%, and demonstrated good predictive performance via Brier Score (0.00064516, Max: 0.00819), as well as pneumonia, SSI, UTI, VTE, renal failure, death and sepsis (Brier Max: 0-0.01458096). Serious and cardiac complications, as well as return to OR were poorly predicted via the NSQIP risk index (Brier Max > 0.05). Mean difference between observed and predicted LOS was 4.276 days with a 95% confidence interval of 9.484 - -0.932. When indicated for significantly high risk, the calculator poorly predicted overall and serious complications (Brier Max >0.1).
CONCLUSION(S): While the ACS-NSQIP risk index had acceptable predictive performance in regards to the occurrence of overall post-operative complications, notable exceptions were detected. Specifically, deficiencies in assessing serious complications, cardiac complication and return to OR were seen, and performance was noted to diminish with procedures of greater invasiveness. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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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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