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Nerve root retraction time during lumbar endoscopic discectomy: association with new onset radiculitis, a post-operative neurologic complication

Gerling, Michael C; Baker, Melissa; Stanton, Eloise; Chaladoff, Evan; Buser, Zorica
PURPOSE/OBJECTIVE:To evaluate the relationship between nerve root retraction time, post-operative radiculitis and patient reported outcomes. METHODS:Patients who underwent single- or multi-level lumbar discectomy between 2020 and 2022 for lumbar disk herniations were prospectively followed with pre-operative, interoperative and post-operative variables including radiculitis and patient reported outcomes including VAS, ODI and CAT domains Pain interference, Pain intensity and Physical function. Intraoperative nerve root retraction time was recorded. Paired sample two-tailed t-test and multivariate regression were utilized with p < 0.05 being significant. RESULTS:A total of 157 patients who underwent single- or multi-level endoscopic lumbar discectomy. Average patient age was 44 years, and 64% were male patients. Nerve retraction time ranged from 4 to 15 min. Eighteen percent reported new radiculitis at 2-weeks post-operatively. In patients with new-onset radiculitis 79.2% reported significantly worse VAS leg at 2 weeks post-operative (4.2 vs. 8.3, p < 0.001) compared to 12.5% who had improved VAS leg (9.3 vs. 7, p = 0.1181). Patients with radiculitis and worse VAS scores had substantially longer nerve retraction time (13.8 ± 7.5 min) than patients with improved VAS leg (6.7 ± 1.2 min). At 6 months, patients with longer nerve retraction time had no significant improvement in the ODI or CAT compared to the baseline. CONCLUSIONS:This is the first study in discectomy literature to show that new onset radiculitis and poorer outcomes in VAS leg correlate with longer nerve retraction time at early and later time points.
PMID: 37747545
ISSN: 1432-0932
CID: 5627852

External Validation of the National Surgical Quality Improvement Program Calculator Utilizing a Single Institutional Experience for Adult Spinal Deformity Corrective Surgery

Naessig, Sara; Pierce, Katherine; Ahmad, Waleed; Passfall, Lara; Krol, Oscar; Kummer, Nicholas A.; Williamson, Tyler; Imbo, Bailey; Tretiakov, Peter; Moattari, Kevin; Joujon-Roche, Rachel; Zhong, Jack; Balouch, Eaman; O"™Connell, Brooke; Maglaras, Constance; Diebo, Bassel; Lafage, Renaud; Lafage, Virginie; Vira, Shaleen; Hale, Steven; Gerling, Michael; Protopsaltis, Themistocles; Buckland, Aaron; Passias, Peter G.
Background: Identify the external applicability of the American College of Surgeons"™ National Surgical Quality Improvement Program (NSQIP) risk calculator in the setting of adult spinal deformity (ASD) and subsets of patients based on deformity and frailty status. Methods: ASD patients were isolated in our single-center database and analyzed for the shared predictive variables displayed in the NSQIP calculator. Patients were stratified by frailty (not frail <0.03, frail 0.3"“0.5, severely frail >0.5), deformity [T1 pelvic angle (TPA) > 30, pelvic incidence minus lumbar lordosis (PI-LL) > 20], and reoperation status. Brier scores were calculated for each variable to validate the calculator"™s predictability in a single center"™s database (Quality). External validity of the calculator in our ASD patients was assessed via Hosmer-Lemeshow test, which identified whether the differences between observed and expected proportions are significant. Results: A total of 1606 ASD patients were isolated from the Quality database (48.7 years, 63.8% women, 25.8 kg/m2); 33.4% received decompressions, and 100% received a fusion. For each subset of ASD patients, the calculator predicted lower outcome rates than what was identified in the Quality database. The calculator showed poor predictability for frail, deformed, and reoperation patients for the category "any complication" because they had Brier scores closer to 1. External validity of the calculator in each stratified patient group identified that the calculator was not valid, displaying P values >0.05. Conclusion: The NSQIP calculator was not a valid calculator in our single institutional database. It is unable to comment on surgical complications such as return to operating room, surgical site infection, urinary tract infection, and cardiac complications that are typically associated with poor patient outcomes. Physicians should not base their surgical plan solely on the NSQIP calculator but should consider multiple preoperative risk assessment tools.
ISSN: 2211-4599
CID: 5500202

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 ≥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 .
ISSN: 2211-4599
CID: 5460082

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.
PMID: 36502878
ISSN: 1773-0619
CID: 5381802

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 >10°, cervical sagittal vertical angle (cSVA) >4 cm, or T1 slope minus cervical lordosis (TS-CL) >20°. 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 ±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/:
PMID: 35772976
ISSN: 2211-4599
CID: 5281352

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 ≥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/:
PMID: 35728828
ISSN: 2211-4599
CID: 5281942

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/:
PMID: 35444038
ISSN: 2211-4599
CID: 5218372

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 (57.1 yrs, 48%F, 30.4 kg/m2), and 436 patients with acute MI (Spine-MI). Incidence of MI did not change from 2010 to 2016 (0.2%-0.3%, p = 0.298). Spine-MI patients underwent more fusions than patients without MI (73.6% vs 58.4%, p < 0.001), with an average of 1.03 levels fused. Spine-MI patients also had significantly more SPO (5.0% vs 1.8%, p < 0.001) and 3CO (0.9% vs 0.2%, p < 0.001), but less decompression-only procedures (26.4% vs 41.6%, p < 0.001). Spine-MI underwent more revisions (5.3% vs 2.9%, p = 0.003), had greater invasiveness scores (3.41 vs 2.73, p < 0.001) and longer operative times (211.6 vs 147.3 min, p < 0.001). Mortality rate for Spine-MI patients was 4.6% versus 0.05% (p < 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.
PMID: 34929633
ISSN: 1532-2653
CID: 5099612

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.
PMID: 35078894
ISSN: 2211-4599
CID: 5154462

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 ≥400 minutes and fusion ≥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 ≥2 and age ≥65 years. Regression analysis further showed associations between increasing complication number and longer length of stay (LOS), (R2 = 0.202, P < 0.001), non-home discharge (R2 = 0.111, P = 0.001), and readmission (R2 = 0.010, P < 0.001). 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.
PMID: 34618707
ISSN: 1528-1159
CID: 5043472