Predictors of Complication Severity Following Adult Spinal Deformity Surgery: Smoking Rate, Diabetes, and Osteotomy Increase Risk of Severe Adverse Events
Bortz, Cole A.; Pierce, Katherine E.; Krol, Oscar; Kummer, Nicholas; Passfall, Lara; Egers, Max; Oh, Cheongeun; Horn, Samantha R.; Segreto, Frank A.; Vasquez-Montes, Dennis; Frangella, Nicholas J.; Buza, John A.; Raman, Tina; Kuprys, Tomas; Lafage, Renaud; Jankowski, Pawel P.; Hassanzadeh, Hamid; Vira, Shaleen N.; Diebo, Bassel G.; Gerling, Michael C.; Passias, Peter G.
Background: Given the physical and economic burden of complications in spine surgery, reducing the prevalence of perioperative adverse events is a primary concern of both patients and health care professionals. This study aims to identify specific perioperative factors predictive of developing varying grades of postoperative complications in adult spinal deformity (ASD) patients, as assessed by the Clavien-Dindo complication classification (Cc) system. Methods: Surgical ASD patients â‰¥18 years were identified in the American College of Surgeons"™ National Surgical Quality Improvement Program from 2005 to 2015. Postoperative complications were stratified by Cc grade severity: minor (I, II, and III) and severe (IV and V). Stepwise regression models generated dataset-specific predictive models for Cc groups. Model internal validation was achieved by bootstrapping and calculating the area under the curve (AUC) of the model. Significance was set at P < 0.05. Results: Included were 3936 patients (59 ± 16 years, 63% women, 29 ± 7 kg/m2) undergoing surgery for ASD (4.4 ± 4.7 levels, 71% posterior approach, 11% anterior, and 18% combined). Overall, 1% of cases were revisions, 39% of procedures involved decompression, 27% osteotomy, and 15% iliac fixation. Additionally, 66% of patients experienced at least 1 complication, 0% of which were Cc grade I, 51% II, 5% III, 43% IV, and 1% V. The final model predicting severe Cc (IV"“V) complications yielded an AUC of 75.6% and included male sex, diabetes, increased operative time, central nervous system tumor, osteotomy, cigarette pack-years, anterior decompression, and anterior lumbar interbody fusion. Final models predicting specific Cc grades were created. Conclusions: Specific predictors of adverse events following ASD-corrective surgery varied for complications of different severities. Multivariate modeling showed smoking rate, osteotomy, diabetes, anterior lumbar interbody fusion, and higher operative time, among other factors, as predictive of severe complications, as classified by the Clavien-Dindo Cc system. These factors can help in the identification of high-risk patients and, consequently, improve preoperative patient counseling. Clinical Relevance: The findings of this study provide a foundation for identifying ASD patients at high risk of postoperative complications .
The Psychological Burden of Disease Among Patients Undergoing Cervical Spine Surgery: Are We Underestimating Our Patients' Inherent Disability?
Passias, Peter; Naessig, Sara; Williamson, Tyler K; Tretiakov, Peter S; Imbo, Bailey; Joujon-Roche, Rachel; Ahmad, Salman; Passfall, Lara; Owusu-Sarpong, Stephane; Krol, Oscar; Ahmad, Waleed; Pierce, Katherine; O'Connell, Brooke; Schoenfeld, Andrew J; Vira, Shaleen; Diebo, Bassel G; Lafage, Renaud; Lafage, Virginie; Cheongeun, Oh; Gerling, Michael; Dinizo, Michael; Protopsaltis, Themistocles; Campello, Marco; Weiser, Sherri
BACKGROUND:Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations. RESEARCH QUESTION/OBJECTIVE:Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease? MATERIALS AND METHODS/METHODS:Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses. RESULTS:). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all p<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs 17.6;p<0.001) and PCS (27.4 vs 19.3;p<0.001). DISCUSSION AND CONCLUSION/CONCLUSIONS:Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated. LEVEL OF EVIDENCE/METHODS:Level III.
Cervical Deformity Correction Fails to Achieve Age-Adjusted Spinopelvic Alignment Targets
Passias, Peter G; Pierce, Katherine E; Horn, Samantha R; Segar, Anand; Passfall, Lara; Kummer, Nicholas; Krol, Oscar; Bortz, Cole; Brown, Avery E; Alas, Haddy; Segreto, Frank A; Ahmad, Waleed; Naessig, Sara; Buckland, Aaron J; Protopsaltis, Themistocles S; Gerling, Michael; Lafage, Renaud; Schwab, Frank J; Lafage, Virginie
OBJECTIVE:To assess whether surgical cervical deformity (CD) patients meet spinopelvic age-adjusted alignment targets, reciprocal, and lower limb compensation changes. STUDY DESIGN/METHODS:Retrospective review. METHODS:CD was defined as C2-C7 lordosis >10Â°, cervical sagittal vertical angle (cSVA) >4 cm, or T1 slope minus cervical lordosis (TS-CL) >20Â°. Inclusion criteria were age >18 years and undergoing surgical correction with complete baseline and postoperative imaging. Published formulas were used to create age-adjusted alignment target for pelvic tilt (PT), pelvic incidence and lumbar lordosis (PI-LL), sagittal vertical angle (SVA), and lumbar lordosis and thoracic kyphosis (LL-TK). Actual alignment was compared with age-adjusted ideal values. Patients who matched Â±10-year thresholds for age-adjusted targets were compared with unmatched cases (under- or overcorrected). RESULTS:= 0.269). CONCLUSIONS:In response to worsening CD postoperatively, patients increased in TK and recruited less lower limb compensation. Almost 75% of CD patients did not meet previously established spinopelvic alignment goals, of whom a subset of patients were actually made worse off in these parameters following surgery. This finding raises the question of whether we should be looking at the entire spine when treating CD. LEVEL OF EVIDENCE: 3/METHODS/:
Predicting 30-Day Perioperative Outcomes in Adult Spinal Deformity Patients With Baseline Paralysis or Functional Dependence
Alas, Haddy; Ihejirika, Rivka C; Kummer, Nicholas; Passfall, Lara; Krol, Oscar; Bortz, Cole; Pierce, Katherine E; Brown, Avery; Vasquez-Montes, Dennis; Diebo, Bassel G; Paulino, Carl B; De la Garza Ramos, Rafael; Janjua, Muhammad B; Gerling, Michael C; Passias, Peter G
BACKGROUND:Patients undergoing surgical treatment of adult spinal deformity (ASD) are often preoperatively risk stratified using standardized instruments to assess for perioperative complications. Many ASD instruments account for medical comorbidity and radiographic parameters, but few consider a patient's ability to independently accomplish necessary activities of daily living (ADLs). METHODS:Patients â‰¥18 years undergoing ASD corrective surgery were identified in National Surgical Quality Improvement Program. Patients were grouped by (1) plegic status and (2) dependence in completing ADLs ("totally dependent" = requires total assistance in ADLs, "partially dependent" = uses prosthetics/devices but still requires help, "independent" = requires no help). Quadriplegics and totally dependent patients comprised "severe functional dependence," paraplegics/hemiplegics who are "partially dependent" comprised "moderate functional dependence," and "independent" nonplegics comprised "independent." Analysis of variance with post hoc testing and Kruskal-Wallis tests compared demographics and perioperative outcomes across groups. Logistic regression found predictors of inferior outcomes, controlling for age, sex, body mass index (BMI), and invasiveness. Subanalysis correlated functional dependence with other established metrics such as the modified Frailty Index (mFI) and Charlson Comorbidity Index (CCI). RESULTS:< 0.001). CONCLUSIONS:Severe functional dependence had significantly longer LOS and more never-event complications than moderate or independent groups. Overall, functional dependence may show superiority to traditional metrics in predicting poor perioperative outcomes, such as increased LOS, readmission rate, and risk of surgical site infection and never events. LEVEL OF EVIDENCE: 3/METHODS/:
Predictive Analytics for Determining Extended Operative Time in Corrective Adult Spinal Deformity Surgery
Passias, Peter G; Poorman, Gregory W; Vasquez-Montes, Dennis; Kummer, Nicholas; Mundis, Gregory; Anand, Neel; Horn, Samantha R; Segreto, Frank A; Passfall, Lara; Krol, Oscar; Diebo, Bassel; Burton, Doug; Buckland, Aaron; Gerling, Michael; Soroceanu, Alex; Eastlack, Robert; Kojo Hamilton, D; Hart, Robert; Schwab, Frank; Lafage, Virginie; Shaffrey, Christopher; Sciubba, Daniel; Bess, Shay; Ames, Christopher; Klineberg, Eric
BACKGROUND:More sophisticated surgical techniques for correcting adult spinal deformity (ASD) have increased operative times, adding to physiologic stress on patients and increased complication incidence. This study aims to determine factors associated with operative time using a statistical learning algorithm. METHODS:Retrospective review of a prospective multicenter database containing 837 patients undergoing long spinal fusions for ASD. Conditional inference decision trees identified factors associated with skin-to-skin operative time and cutoff points at which factors have a global effect. A conditional variable-importance table was constructed based on a nonreplacement sampling set of 2000 conditional inference trees. Means comparison for the top 15 variables at their respective significant cutoffs indicated effect sizes. RESULTS:66 minutes of increased operative time. Increased operative time also correlated with increased hospital length of stay (LOS), increased estimated intraoperative blood loss (EBL), and inferior 2-year Oswestry Disability Index (ODI) scores. CONCLUSIONS:Procedure location and specific surgeon are the most important factors determining operative time, accounting for operative time increases <2 hours. Surgical approach and number of levels fused were also associated with longer operative times, respectively. Extended operative time correlated with longer LOS, higher EBL, and inferior 2-y ODI outcomes. CLINICAL RELEVANCE/CONCLUSIONS:We further identified the poor outcomes associated with extended operative time during surgical correction of ASD, and attributed the useful predictors of time spent in the operating room, including site, surgeon, surgical approach, and the number of levels fused. LEVEL OF EVIDENCE: 3/METHODS/:
A predictive model of perioperative myocardial infarction following elective spine surgery
Passias, Peter G; Pierce, Katherine E; Alas, Haddy; Bortz, Cole; Brown, Avery E; Vasquez-Montes, Dennis; Oh, Cheongeun; Wang, Erik; Jain, Deeptee; O'Connell, Brooke K; Raad, Micheal; Diebo, Bassel G; Soroceanu, Alexandra; Gerling, Michael C
Myocardial infarction (MI), and its predictive factors, has been an understudied complication following spine operations. The objective was to assess the risk factors for perioperative MI in elective spine surgery patients as a retrospective case control study. Elective spine surgery patients with a perioperative MI were isolated in the NSQIP. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests. Univariate/multivariate analyses assessed predictive factors of MI. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. The study included 196,523 elective spine surgery patients (57.1Â yrs, 48%F, 30.4Â kg/m2), and 436 patients with acute MI (Spine-MI). Incidence of MI did not change from 2010 to 2016 (0.2%-0.3%, pÂ =Â 0.298). Spine-MI patients underwent more fusions than patients without MI (73.6% vs 58.4%, pÂ <Â 0.001), with an average of 1.03 levels fused. Spine-MI patients also had significantly more SPO (5.0% vs 1.8%, pÂ <Â 0.001) and 3CO (0.9% vs 0.2%, pÂ <Â 0.001), but less decompression-only procedures (26.4% vs 41.6%, pÂ <Â 0.001). Spine-MI underwent more revisions (5.3% vs 2.9%, pÂ =Â 0.003), had greater invasiveness scores (3.41 vs 2.73, pÂ <Â 0.001) and longer operative times (211.6 vs 147.3Â min, pÂ <Â 0.001). Mortality rate for Spine-MI patients was 4.6% versus 0.05% (pÂ <Â 0.001). Multivariate modeling for Spine-MI predictors yielded an AUC of 83.7%, and included history of diabetes, cardiac arrest and PVD, past blood transfusion, dialysis-dependence, low preoperative platelet count, superficial SSI and days from operation to discharge. A model with good predictive capacity for MI after spine surgery now exists and can aid in risk-stratification of patients, consequently improving preoperative patient counseling and optimization in the peri-operative period.
Validation of the ACS-NSQIP Risk Calculator: A Machine-Learning Risk Tool for Predicting Complications and Mortality Following Adult Spinal Deformity Corrective Surgery
Pierce, Katherine E; Kapadia, Bhaveen H; Naessig, Sara; Ahmad, Waleed; Vira, Shaleen; Paulino, Carl; Gerling, Michael; Passias, Peter G
OBJECTIVE:To calculate the risk for postoperative complications and mortality after corrective surgery of adult spinal deformity (ASD) patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator (SRC). METHODS:axis. RESULTS:) were identified; 36.9% of procedures involved decompression and 100% involved fusion. The means for individual patient characteristics entered into the online risk calculator interface were as follows: functional status (independent: 94.9%, partially dependent: 4.4%, totally dependent: 0.70%), 1.6% emergent cases, wound class (clean: 94.7%, clean/contaminated: 0.8%, contaminated: 0.5%, dirty/infected: 1.4%), American Society of Anesthesiologists class (I: 2.7%, II: 40.7%, III: 52.1%, IV: 4.6%, V: 0%), 5.1% steroid use for chronic condition, 0.04% ascites within 30 days prior to surgery, 1.73% systemic sepsis within 48 hours of surgery, 0.40% ventilator dependent, 3.2% disseminated cancer, 15.6% diabetes mellitus, 52.8% use of hypertensive medications, 0.3% congestive heart failure , 3% dyspnea, 21.4% history of smoking within 1 year, 4.3% chronic obstructive pulmonary disease, 0.7% dialysis, and 0.1% acute renal failure. Predictive of any 30-day postoperative complications ranged from 2.8 to 18.5% across CPT codes, where the actual rate in the cohort was 11.4%, and demonstrated good predictive performance via Brier score (0.000002, maximum: 0.101). The predicted and observed percentages for each of the 13 outcomes were assessed and their associated Brier scores and Brier maximums were calculated. Mean difference between observed and predicted LOS was 2.375 days (95% CI 9.895-5.145). CONCLUSIONS:The ACS-NSQIP SRC predicts surgical risk in patients undergoing ASD corrective surgery. This tool can be used as a resource in preoperative optimization by deformity surgeons. LEVEL OF EVIDENCE/METHODS:3.
Frequency and Implications of Concurrent Complications Following Adult Spinal Deformity Corrective Surgery
Bortz, Cole; Pierce, Katherine E; Brown, Avery; Alas, Haddy; Passfall, Lara; Krol, Oscar; Kummer, Nicholas A; Wang, Erik; O'Connell, Brooke; Wang, Charles; Vasquez-Montes, Dennis; Diebo, Bassel G; Neuman, Brian J; Gerling, Michael C; Passias, Peter G
STUDY DESIGN/METHODS:Retrospective review. OBJECTIVE:Identify co-occurring perioperative complications and associated predictors in a population of patients undergoing surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA/BACKGROUND:Few studies have investigated the development of multiple, co-occurring complications following ASD-corrective surgery. Preoperative risk stratification may benefit from identification of factors associated with multiple, co-occurring complications. METHODS:Elective ASD patients in National Surgical Quality Improvement Program (NSQIP) 2005 to 2016 were isolated; rates of co-occurring complications and affected body systems were assessed via cross tabulation. Random forest analysis identified top patient and surgical factors associated with complication co-occurrence, using conditional inference trees to identify significant cutoff points. Binary logistic regression indicated effect size of top influential factors associated with complication co-occurrence at each factor's respective cutoff point. RESULTS:Included: 6486 ASD patients. The overall perioperative complication rate was 34.8%; 28.5% of patients experienced one complication, 4.5% experienced two, and 1.8% experienced 3+. Overall, 11% of complication co-occurrences were pulmonary/cardiovascular, 9% pulmonary/renal, and 4% integumentary/renal. By complication type, the most common co-occurrences were transfusion/urinary tract infection (UTI) (24.3%) and transfusion/pneumonia (17.7%). Surgical factors of operative time â‰¥400â€Šminutes and fusion â‰¥9 levels were the strongest factors associated with the incidence of co-occurring complications, followed by patient-specific variables like American Society of Anesthesiologists (ASA) physical status classification grade â‰¥2 and age â‰¥65â€Šyears. Regression analysis further showed associations between increasing complication number and longer length of stay (LOS), (R2â€Š=â€Š0.202, Pâ€Š<â€Š0.001), non-home discharge (R2â€Š=â€Š0.111, Pâ€Š=â€Š0.001), and readmission (R2â€Š=â€Š0.010, Pâ€Š<â€Š0.001). CONCLUSION/CONCLUSIONS:For surgical ASD patients, the overall rate of co-occurring perioperative complications was 6.3%. Body systems most commonly affected by complication co-occurrences were pulmonary and cardiovascular, and common co-occurrences included transfusion/UTI (24.3%) and transfusion/pneumonia (17.7%). Increasing number of perioperative complications was associated with greater LOS, non-home discharge, and readmission, highlighting the importance of identifying risk factors for complication co-occurrences.Level of Evidence: 3.
Same Day Surgical Intervention Dramatically Minimizes Complication Occurrence and Optimizes Perioperative Outcomes for Central Cord Syndrome
Bortz, Cole; Dinizio, Mike; Kummer, Nicholas; Brown, Avery; Alas, Haddy; Pierce, Katherine E; Janjua, Muhammad B; Park, Paul; Wang, Charles; Jankowski, Pawel; Hockley, Aaron; Soroceanu, Alex; De la Garza Ramos, Rafael; Sciubba, Daniel M; Frempong-Boadu, Anthony; Vasquez-Montes, Dennis; Diebo, Bassel G; Gerling, Michael C; Passias, Peter G
STUDY DESIGN/METHODS:This was a retrospective cohort study. OBJECTIVE:The aim of this study was to investigate associations between time to surgical intervention and outcomes for central cord syndrome (CCS) patients. BACKGROUND:As surgery is increasingly recommended for patients with neurological deterioration CCS, it is important to investigate the relationship between time to surgery and outcomes. MATERIALS AND METHODS/METHODS:CCS patients were isolated in Nationwide Inpatient Sample database 2005-2013. Patients were grouped by time to surgery: same-day, 1-day delay, 2, 3, 4-7, 8-14, and >14 days. Means comparison tests compared patient factors, perioperative complications, and charges across patient groups. Controlling for age, comorbidities, length of stay, and concurrent traumatic fractures, binary logistic regression assessed surgical timing associated with increased odds of perioperative complication, using same-day as reference group. RESULTS:Included: 6734 CSS patients (64% underwent surgery). The most common injury mechanisms were falls (30%) and pedestrian accidents (7%). Of patients that underwent surgery, 52% underwent fusion, 30% discectomy, and 14% other decompression of the spinal canal. Breakdown by time to procedure was: 39% same-day, 16% 1-day, 10% 2 days, 8% 3 days, 16% 4-7 days, 8% 8-14 days, and 3% >14 days. Timing groups did not differ in trauma status at admission, although age varied: [minimum: 1â€‰d (58Â±15â€‰y), maximum: >14â€‰d (63Â±13â€‰y)]. Relative to other groups, same-day patients had the lowest hospital charges, highest rates of home discharge, and second lowest postoperative length of stay behind 2-day delay patients. Patients delayed >14 days to surgery had increased odds of perioperative cardiac and infection complications. Timing groups beyond 3 days showed increased odds of VTE and nonhome discharge. CONCLUSIONS:CCS patients undergoing surgery on the same day as admission had lower odds of complication, hospital charges, and higher rates of home discharge than patients that experienced a delay to operation. Patients delayed >14 days to surgery were associated with inferior outcomes, including increased odds of cardiac complication and infection.
The Five-item Modified Frailty Index is Predictive of 30-day Postoperative Complications in Patients Undergoing Spine Surgery
Pierce, Katherine E; Naessig, Sara; Kummer, Nicholas; Larsen, Kylan; Ahmad, Waleed; Passfall, Lara; Krol, Oscar; Bortz, Cole; Alas, Haddy; Brown, Avery; Diebo, Bassel; Schoenfeld, Andrew; Raad, Micheal; Gerling, Michael; Vira, Shaleen; Passias, Peter G
STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions. METHODS:Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, <0.3), mildly frail (MF, 0.3-0.5), severely frail (SF, >0.5). Means comparison tests analyzed frailty and clinical outcomes. RESULTS:After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926(Pâ€Š<â€Š0.001). Each index established significant (all Pâ€Š<â€Š0.001) predictive values for unplanned readmission (11 = odds ratio [OR]: 5.65 [2.92-10.94]; 5 = OR: 3.68 [1.85-2.32]), post-op complications (11 = OR: 8.56 [7.12-10.31]; 5 = OR: 13.32 [10.89-16.29]), and mortality (11 = OR: 41.29 [21.92-77.76]; 5 = OR: 114.82 [54.64-241.28]). Frailty categories by mFI-5 were: 83.2% NF, 15.2% MF, and 1.6% SF. From 2005 to 2016, rates of NF decreased (88.8% to 82.2%, Pâ€Š<â€Š0.001), whereas MF increased (9.2% to 16.2%, Pâ€Š<â€Š0.001), and SF remained constant (2% to 1.6%, Pâ€Š>â€Š0.05). With increase in severity, postoperative rates of morbidities and complications increased. CONCLUSION/CONCLUSIONS:The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making.Level of Evidence: 3.