Faculty Bibliography

BACKGROUND CONTEXT: Bariatric surgery for morbid obesity helps to address common comorbidity burdens, including decreasing rates of myocardial infarction and stroke. The increased mechanical stresses on the spine caused by morbid obesity predispose patients to various spinal pathologies and are concerning for spinal surgeons, with previous studies suggesting poorer outcomes than the general population. The effects of bariatric surgery on diminishing spinal complaints or symptoms have yet to be elucidated in the literature. PURPOSE: To assess the rate in which various spinal symptoms diminish after bariatric surgery. STUDY DESIGN/SETTING: Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years (2004-2013). PATIENT SAMPLE: A total of 4,351 patients who underwent bariatric surgery with at least one identified spinal diagnosis present before bariatric surgery. OUTCOME MEASURES: Time from bariatric surgery until disappearance of specific spinal complaint, percentage of unresolved spinal complaints with 2-year follow-up.
METHOD(S): Retrospective analysis of the prospectively collected (NYSID) years 2004-2013. Patient linkage codes allow identification of multiple and return inpatient stays within the time frame analyzed (720 days). Inclusion criteria were bariatrics surgery patients with one or more visits prior to and after bariatric procedure (excluding pts with <30 days f/u, spine surgery, or new post-bariatric spine pathology) for one of the following common cervical or lumbar spinal diagnoses, queried with ICD-9CM codes: herniation, stenosis, spondylosis, disc degeneration, and spondylolisthesis. Time from bariatric surgery until the patient's respective spinal diagnosis was no longer present was considered resolution of spinal symptoms. Kaplan-Meier survivorship curves assessed rates of resolution within each spinal diagnosis cohort.
RESULT(S): A total of 4,351 bariatric surgery pts with a preop spinal diagnosis by ICD-9 were analyzed. Lumbar pts: 1,049 had stenosis, 774 spondylosis, 648 degeneration, 249 spondylolisthesis, 72 disc herniation. Cervical pts: 581 disc herniation, 376 had stenosis, 366 spondylosis, 236 degeneration. Cumulative resolution rates at 90-day, 180-day, 360-day, and 720-day follow-up were as follows: lumbar stenosis (48%,67.6%,79%,91%), lumbar herniation (61%,77%,86%,93%), lumbar spondylosis (47%,65%,80%,93%), lumbar spondylolisthesis (37%,58%,70%,87%), lumbar degeneration (37%,56%,72%,86%). By cervical region: cervical stenosis (48%,70%,84%,94%), cervical herniation (39%,58%,74%,87%), cervical spondylosis (46%, 70%,83%, 94%), cervical degeneration (44%,64%,78%,89%). Lumbar herniation pts saw significantly higher 90d-resolution than cervical herniation pts (p<0.001). Cervical vs lumbar degeneration resolution rates did not differ @90d (p=0.058), but did @180d(p=0.034). Cervical and lumbar stenosis resolution was similar @90d & 180d, but cervical showed greater resolution by 1 year (p=0.036).
CONCLUSION(S): Over 50% of bariatric patients diagnosed with a cervical or lumbar pathology before weight-loss surgery no longer sought inpatient care for their respective spinal diagnosis by 180 days postop. Lumbar herniation had significantly higher resolution than cervical herniation by 90d, whereas cervical degeneration and stenosis resolved at higher rates than corresponding lumbar pathologies by 180d and 1-year follow-up, respectively. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Roussouly Classification system of sagittal spinal shape and the SRS-Schwab adult spinal deformity (ASD) classification system have become important indicators of spine deformity. No prior studies have examined the outcomes of matching both Roussouly type and improving in Schwab modifiers postoperatively. PURPOSE: Evaluate outcomes of matching Roussouly Type and improving in Schwab modifier following ASD surgery. STUDY DESIGN/SETTING: Retrospective review of single-center ASD database. PATIENT SAMPLE: A total of 103 ASD patients. OUTCOME MEASURES: Roussouly types, Schwab modifiers, Health Related Quality of Life scores(HRQLs): Minimal Clinical Important Difference for ODI, EQ5D, VAS Leg &Back Pain.
METHOD(S): Surgical ASD patients (SVA>=5cm, PT>=25degree, or TK >=60degree, >3 levels fused) >=18 years old with available baseline (BL) radiographic data at baseline (BL) and 1-year (1Y) were isolated in the single-center Comprehensive Spine Quality Database (Quality). Patients were grouped by two Roussouly types: (1)"theoretical" Roussouly type(Type 1: PI<45degree, LL apex below L4; Type 2: PI<45degree, LL apex above L4 L4-L5 space; Type 3: 45degree60degree); (2) "current" Roussouly type (1: SS<35degree, LL apex below L4; 2: PI<35degree, LL apex above L4-L5 space; 3: 35degree45degree), as previously published. One year (1Y) matched Roussouly: preoperative mismatched (Between 'actual' and 'theoretical' patients that matched at 1Y. Schwab modifiers at BL were identified: non-, moderate and severe deformity (0, +, ++) for PT, SVA, and PI-LL. Schwab improvement was defined as a decrease in a modifier at one year.
RESULT(S): A total of 103 ASD patients (61.8yrs, 63.1%F, 30kg/m2). By surgical approach, 79.6% posterior, 10.7% combined, 2.9% anterior). Average levels fused: 4.6. BL breakdown of 'current; Roussouly type: 28% Type 1, 25.3% Type 2, 32.0% Type 3, 14.7% Type 4. BL Roussouly mismatch: 65.3%. Breakdown BL Schwab modifiers: PT (0: 8.7%, +: 41.7%, ++: 49.5%), SVA (0: 29.7%, +: 20.3%, ++: 50%), PI-LL mismatch (0: 28.2%, +: 25.2%, ++: 46.6%). At one year, 19.2% of patients matched Roussouly target type, while according to Schwab modifiers, 12.6% improved in SVA, 42.7% in PI-LL, and 45.6% in PT. Patients who both met Roussouly type and improved in a Schwab by the modifiers: 9 PT (8.7%), 8 PI-LL (7.8%), 2 SVA (1.9%). There were 2 patients (1.9%) who met their Roussouly type and improved in all 3 Schwab modifiers. One year (1Y) matched Roussouly patients improved more in HRQLs (MCID for ODI, EQ5D, VAS Leg/Back Pain), when compared to mismatched Roussouly, but was not significant(P>0.05). Match Roussouly and improvement in PT Schwab met MCID for EQ5D significantly more (33.3% vs 10.6%, p=0.050). Matched Roussouly and PI-LL Schwab had more patients meet MCID for all HRQLs, yet none were significant, p>0.05. Matched Roussouly and improvement in SVA Schwab met MCID for ODI significantly more (p=0.024).
CONCLUSION(S): Patients who both matched Roussouly sagittal spinal type and improved in SRS-Schwab modifiers had superior patient-reported outcomes at 1-year. Utilizing both classification systems in surgical decision making can optimize postop patient outcomes. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: In the current value-based health care climate where spinal surgery is shifting to the ambulatory setting, factors influencing postoperative patient length of stay (LOS) have significance to both surgeons and hospital administrators. Underlying patient factors including the diagnosis of radiculopathy and myelopathy have not been investigated in this context. PURPOSE: Identify predictors extended LOS(E-LOS) between myelopathy(M), radiculopathy(R), and patients with both (MR). STUDY DESIGN/SETTING: Retrospective review of a single-center stereographic database. PATIENT SAMPLE: A total of 718 surgical cervical spine patients. OUTCOME MEASURES: Postoperative LOS, patient factors, preoperative HRQL, complications, predictors of E-LOS.
METHOD(S): Surgical cervical spine patients >=18yrs diagnosed with M or R primary diagnoses were isolated in the single-center Comprehensive Spine Quality Database (Quality). Patients were stratified by surgical approach: Anterior, Posterior or Combined. Top-quartile LOS values were labeled as extended. M and R patients were compared using chi-squared and independent samples t-tests, as appropriate. Univariate tests assessed differences in baseline patient-related and surgical data between M and R, and extended/non-extended LOS. Univariate/multivariate analyses were run to assess predictive factors of E-LOS in each diagnosis group. Regression with stepwise model selection was employed to explore factors potentially significant in predicting LOS.
RESULT(S): A total of 718 patients (54.5 years, 41.1%F, 29.1kg/m2). Mean CCI score: 1.11. Within the cohort, 177 patients (24.7%) had a diagnosis of myelopathy, 383 (53.3%) radiculopathy, and 22% with a diagnosis of myeloradiculopathy. Patients with M primary diagnosis were significantly older (62.2 vs 49.8yrs, p<0.001) and had a greater CCI score (1.64 vs 0.82, p<0.001) when compared to R patients. By approach: 76.7% anterior (57.6% of M, 90.6%R, 64.6%MR; p<0.001), 16.4% (35%M, 6%R, 20.9%MR; p<0.001) posterior, 6.5% (6.8%M, 3.4%R, 13.9%MR; p<0.001) combined. Average LOS: M(3.8days), R(1.5 days), MR(2.9 days) p<0.001. LOS for anterior approach in each diagnosis was as follows, M: 2.21, R: 1.21, MR: 1.69 days, p<0.001. Meanwhile, posterior approach LOS, M:6.06, R:2.91, MR:5.0, p<0.001; combined approach M: 5.17, R: 6.23, MR: 5.59, P=0.881. A total of 195 patients were categorized as E-LOS (Avg: 5.87 days), 87 M, 43 R, 65 MR. Major surgical approach of E-LOS for M (60.9%) and MR (44.6%) was posterior; whereas R E-LOS patients majorly underwent anterior procedures (53.5%). Generalized linear regression modeling found that the following combination of factors predicted E-LOS in R patients (R2=0.736, p=0.003):BMI, durotomy, CCI, anterior and combined approaches, and cardiac complications. An additional model discovered the predictors of E-LOS in M patients (R2= 0.312, p<0.001): age, hypertension, CCI, anterior and combined approaches, intraoperative complications, neuro complications, ileus, and return to OR in 90 days. Lastly, the model for E-LOS in MR patients consisted of (R2 = 0.267, p=0.001): age, durotomy, BL EQ5D, hypertension, posterior and combined approaches and postoperative complications, specifically neuro.
CONCLUSION(S): Independent of surgical approach, patients with a primary diagnosis of myelopathy, though older aged and higher comorbidity profile, had consistently longer overall postop LOS when compared to radiculopathy or myeloradiculopathy patients. The heightened risk in myelopathy patients for extended LOS should be considered when determining admission status for patients undergoing cervical spine surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Patient-Reported Outcomes Measurement Information System (PROMIS) is a comprehensive self-report measurement tool with patient functions, symptoms, behaviors, and mental health outcomes. Little work has been done correlating PROMIS physical health domain metrics with established adult spinal deformity (ASD) classifications such as SRS-Schwab. PURPOSE: To correlate sagittal alignment components via the SRS-Schwab classification system with established PROMIS domains in a cohort of ASD patients. STUDY DESIGN/SETTING: Retrospective review of a single-center stereoradiographic database. PATIENT SAMPLE: A total of 41 ASD patients with complete baseline radiographic and PROMIS data. OUTCOME MEASURES: PROMIS physical health domain metrics (Pain Intensity [PI], Physical Function [PF], Pain Interference [Interference]), SRS-Schwab modifiers (SVA, PI-LL, PT) METHODS: Surgical ASD patients (SVA>=5cm, PT>=25degree or TK >=60degree) >=18 years old with available baseline (BL) radiographic and PROMIS data were isolated in the single-center comprehensive Spine Quality Database (Quality). Patients were classified according to SRS-Schwab deformity modifiers(0,+,++) for SVA, PI-LL and PT. Descriptives and univariate analyses compared population-weighted PROMIS scores for PI, PF and Interference across ASD deformity modifiers. Conditional Tree Analysis (CTA) with logistic regression sampling established cut-off points for PROMIS scores predicting severe malalignment (++) at BL compared to mild or moderate (0,+).
RESULT(S): A total of 41 patients (58.95 yrs,75.6%F,29.1kg/m2) met inclusion criteria. BL SRS modifiers were as follows: SVA 51.2%, 2.4%, 46.3% (0,+,++); PI-LL 27.3%, 12.1%, 60.6%(0,+,++); PT 18.2%, 36.4%, 45.5% (0,+,++). Mean cohort PI score was 94.2+/-6.0, mean PF score 8.95+/-10.1, mean Inter score 57.84+/-5.46. PF and Interference differed significantly across low and high SVA groups, with low SVA having significantly higher PF (13.50 vs 3.68,p<0.001) and lower Inter (59.62 vs 56.30, p=0.05). PI did not differ across SVA groups (p>0.05). Low PI-LL pts had significantly higher PF than pts with ++PI-LL (19.3 vs 4.15,p=0.001) and trended lower PI and Inter without significance. No significant differences in PI, PF or Inter were found across PT groups (all p>0.05). CTA found a PI score>98 or PF score <6 were independent predictors of Severe (++) SVA as opposed to Mild/Moderate SVA. For example, a PF score<6 increased odds of ++SVA by at least 2.7x compared to 0/+SVA. Similarly, significant thresholds for PI (>98) and PF (<8) scores were found for ++PI-LL, but not ++PT (p>0.05). Pain Interference did not predict SRS metrics to a significant degree (all p>0.05).
CONCLUSION(S): Inferior PROMIS scores of pain intensity and physical function predicted increasingly severe SRS sagittal modifiers at baseline, specifically severe sagittal vertical axis and lumbopelvic mismatch. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Adult Spinal Deformity Frailty Index (ASD-FI), a validated modality for quantifying frailty, stratifies patients into categories not frail (NF), frail (F) and severely frail (SF). However, the cost of treating each frailty state is unknown. PURPOSE: Investigate the cost utility of treating not frail versus frail or severely frail ASD patients. STUDY DESIGN/SETTING: Retrospective review of a prospective single center adult spinal deformity database. PATIENT SAMPLE: A total of 79 operative and non operative ASD patients >=18 years old, with baseline and 2Y ASD-FI and Oswestry Disability Index (ODI) scores. OUTCOME MEASURES: ODI, SF-6D, Cost per quality adjusted life years (QALY), Incremental Cost Effectiveness, Ratio (ICER).
METHOD(S): Inclusion criteria was surgical ASD (scoliosis>=20degree, SVA>=5cm, PT>=25degree, or thoracic kyphosis >=60degree) patients >18 years with available frailty and ODI data at BL and 2-years post op. Independent T-Tests assessed baseline radiographic differences in PT, PI-LL, and Schwab SVA modifier status between NF vs. F/SF patients. Utility data was calculated using the ODI converted to the SF-6D using published conversion methods. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database. After accounting for complications, LOS, revisions, and death, cost per QALY at 2Y and life expectancy were calculated for NF, and F/SF patients. ICER was compared between non op and operative NF and F/SF patients at 2Y and life expectancy.
RESULT(S): Seventy-nine ASD patients met inclusion criteria. Descriptive statistics for the cohort were: age 51.0+/-6.8, 76% women, BMI 26.7+/-6.8, 54% osteotomy, 54% decompression, and 11.6+/-4.2 average levels fused. At BL, there were 48 NF, 26 F, and 4 SF pts. The average BL frailty for NF pts was 0.13+/-0.08, 0.39+/-0.06 for F, and 0.59+/-0.08 for SF pts. There were no differences in PT, PI-LL, or severe SVA Schwab modifier grades between NF or F/SF pts (all p>0.05). At 2-year follow up, there was no difference in the average cost of ASD surgery, $91,068.98 for NF patients and $90,888.53 for F/SF pts (p>0.05). The cost per QALY was higher for NF pts at 2 years vs F/SF pts ($464,239.62 vs. $321,107.89, p<0.05). If the utility gained was sustained to life expectancy, the cost per QALY was $70,796.43 for NF and $48,968.88 for F/SF (p<0.05). When compared to non op ASD pts, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2 years, and $68,311.35 vs. $47,764.61 for NF and F/SF at life expectancy.
CONCLUSION(S): Frail and severely frail patients had lower cost per QALY compared to not frail patients at 3 years and life expectancy. In addition, when compared to a non operative cohort of ASD patients, frail and severely frail patients had lower ICER values. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. In addition, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow-up times, these findings support the cost effectiveness of ASD surgery at all frailty states. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Numerous advances have been made in the field of spine fusion, such as minimally invasive (MIS) or robotic assisted spine surgery. However, it is unknown how these advances have impacted the cost of care. PURPOSE: Compare the economic outcomes of lumbar spine fusion between open, MIS and robotic assisted surgery patients. STUDY DESIGN/SETTING: Retrospective review of a single center spine surgery database. PATIENT SAMPLE: A total of 360 propensity matched patients. OUTCOME MEASURES: Costs, EuroQol-5D (EQ5D), Cost per quality adjusted life years (QALY).
METHOD(S): Inclusion criteria: surgical patients >18 years undergoing lumbar fusion surgery. Patients were categorized into 3 groups based on procedure type: open, MIS or robotic. Open patients undergoing poster spinal fusion were considered as the control group. MIS patients included those undergoing transforaminal or lateral lumbar interbody fusion with percutaneous screws. Robotic patients were those undergoing robot assisted fusion. Propensity score matching was performed between all groups for the number of levels fused. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims for ICD-9 codes. For robot cases, costs were reflective of operational fees and initial purchase cost. Complications and comorbidities (CC) and major complications and comorbidities (MCC) were assessed according to CMS.gov manual definitions. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs per QALY were calculated for both 1 year and life expectancy, assuming no loss of benefit.
RESULT(S): A total of 360 propensity matched patients (120 open, 120 MIS, 120 robot) met inclusion. Descriptive statistics for the cohort were: age 58.8+/-13.5, 50% women, BMI 29.4+/-6.3, op time 294.4+/-119.0, LOS 4.56+/-3.31 days, EBL 515.9+/-670.0 cc, and 2.3+/-2.2 average levels fused. Rates of postop complications were significantly higher in robotic cases versus open and MIS (43% vs. 21% and 22% for open and MIS, p<0.05). However, revision rates were comparable between all groups (3% open, 3% MIS, 5% robotic, p>0.05). After factoring in complications, revisions, and purchasing and operating fees, the costs of robotic cases was significantly higher than both open and MIS surgery ($60,047.01 vs. $42,538.98 open and $41,471.21 MIS). In a sub analysis of 42 patients with BL and 1Y EQ5D data, the cost per QALY at 1Y for open, MIS, and robot assisted cases was $296,624.48, $115,911.69, and $592,734.30. If utility gained was sustained to life expectancy, the cost per QALY was $14,905.75, $5,824.71, $29,785.64 for open, MIS, and robot assisted cases.
CONCLUSION(S): Numerous advances have been made in the field of spine surgery, however, there has been limited discussion of the effect these advances have on economic outcomes. When matched for levels fused, robot assisted surgery patients had significantly higher rates of complications and 30% higher costs of surgery compared to minimally invasive and open spine surgery patients. While 1 year economic outcomes weren't optimal for robotic surgery cases, the projected costs per quality adjusted life years at life expectancy were well below established acceptable thresholds. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. PURPOSE: Investigate the rates of PD in elective orthopedic procedures. STUDY DESIGN/SETTING: Retrospective review of the National Inpatient Database 2007-2013. PATIENT SAMPLE: A total of 15,434,393 weighted hospital discharges. OUTCOME MEASURES: Rates of PD, post-operative complications, length of stay (LOS), cost to charge (CCR), discharge location, and death.
METHOD(S): Inclusion criteria: elective orthopedic surgery procedures from 2007-2013 as defined by ICD-9-CM codes. Exclusion criteria: emergency, trauma, or non-elective surgery. Patients were grouped as shoulder, elbow, hand, spine, hip, knee, or foot/ankle. Descriptive statistics assessed demographics. Rates of DSM-IV PD, as classified by single-level C

BACKGROUND CONTEXT: Although epidural steroid injection (ESI) has been shown to provide adequate pain relief for degenerative spondylolisthesis patients in treatment regimens up to months, it remains unclear whether the use of ESI affects the rate of crossover from nonoperative to operative management. PURPOSE: Investigate the relationship between epidural steroid injections and rates of surgical crossover for degenerative spondylolisthesis patients. STUDY DESIGN/SETTING: Retrospective review of prospectively collected data from 13 spine centers. PATIENT SAMPLE: Degenerative spondylolisthesis patients from both the randomized and concurrent observational cohorts of the Spine Patient Outcomes Research Trial (SPORT). OUTCOME MEASURES: Primary: Surgical crossover rates. Secondary: health related quality of life outcome (HRQL) measures (SF-36, ODI, Sciatica and Leg Pain Bothersomeness Indices), self-reported improvement METHODS: Included: surgical candidates >18yrs with degenerative spondylolisthesis. Excluded: patients receiving ESI before enrollment. Those who received ESI within 3 months of enrollment (ESI) and those who did not (no-ESI) were compared for differences in baseline characteristics. Outcomes at 1-year, 2-year, 3-year, and 4-year intervals following enrollment were assessed within operative and nonoperative groups using longitudinal mixed-effect models with random subject intercept term to account for correlations between repeated measurements. Treatment comparisons were performed at follow-up intervals. Area under the curve analysis for all time points assessed global significance of treatment.
RESULT(S): Included: 266 patients (192 no-ESI, 74 ESI). Patient groups did not differ in age, sex, BMI, or comorbidity burden (all p>0.05). No-ESI had greater baseline SF-36 body-pain scores (38+/-20 vs 30+/-16, p=0.002) and self-reported surgical preference (38% vs 11%, p<0.001). There were no differences in surgical rates within 4-years of enrollment between no-ESI and ESI patients (61% vs 62%, p=0.97). Surgical ESI and no-ESI patients did not differ in op-time, blood loss, rates of decompression, multilevel fusion or levels decompressed (all p>0.05). Surgical ESI and no-ESI patients showed no differences in postoperative HRQL changes at any follow-up interval, or in 4-year average HRQL outcomes. Non-operative no-ESI patients showed greater 4-year average improvement in SF-36 body pain (no-ESI: 17.8, ESI: 7.8, p=0.004) and physical function (no-ESI: 13.1, ESI: 4.3, p=0.005) than non-operative ESI patients. These improvements in SF-36 body pain were greater for non-operative no-ESI patients at 1-year (p=0.002) and 3-years (p=0.005); improvements in SF-36 physical function were greater for non-operative no-ESI patients at 1-year (p=0.030) and 2-years (p=0.002). Of patients that were initially non-operative, there was no difference between ESI and no-ESI groups in surgical crossover rates (ESI: 52%, no-ESI: 39%, p=0.15). For operative patients, crossover rates to non-operative treatment did not differ between ESI and no-ESI groups (ESI: 23%, no-ESI: 16%, p=0.38).
CONCLUSION(S): For surgical degenerative spondylolisthesis patients, there was no relationship between ESI and improved clinical outcomes over a 4-year study. For nonoperative patients, ESI was associated with inferior pain reduction through 3 years of follow-up; however, this was confounded by higher levels of baseline pain. ESI showed little relationship with surgical crossover. FDA DEVICE/DRUG STATUS: Unavailable from authors at time of publication.
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BACKGROUND CONTEXT: As surgery is increasingly recommended for patients with neurologic deterioration secondary to central cord syndrome (CCS), it is important to investigate the relationship between time to surgery and patient outcomes. The merits of early vs delayed surgical treatment remain controversial in the literature. PURPOSE: Investigate associations between time to surgical intervention and surgical outcomes for CCS patients STUDY DESIGN/SETTING: Retrospective review of Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) PATIENT SAMPLE: A total of 9,246 weighted inpatient discharges. OUTCOME MEASURES: Complication rates, discharge destination, length of hospital stay (LOS).
METHOD(S): CCS patients (ICD-9 codes 952.03, 952.08, 952.13, 952.18) were isolated in the NIS database 2005-2013. Operative patients were grouped by time to intervention: same day as admission, 1-day delay, 2-day, 3-day, 4-7 days, 8-14 days, and >14 days. As appropriate, analysis of variance and chi-squared tests compared demographics, Charlson Comorbidity Index (CCI) scores, surgical details, LOS, discharge status, periop complications and total charges across patient groups. Controlling for age, CCI and concurrent traumatic fractures, binary logistic regression assessed surgical timing associated with increased odds of perioperative complication, using same-day patients as a reference group (odds ratio [95% confidence interval]).
RESULT(S): Included: 6,734 CSS patients (59+/-16yrs, 26%F, mean CCI: 1.2+/-1.6). Overall rate of surgical treatment was 64.1%, with rates of surgery increasing from 2005 (50.0%) to 2013 (73.0%, p<0.001). The most common mechanisms of injury were falls (30.3%), pedestrian accidents (6.9%), assault (3.2%) and bicycle-related injury (2.7%). Of the patients that underwent surgery, 52.0% underwent fusion (62.4% 2-3 levels, 33.2% eight-levels, 0.5% 9+ levels), 30.1% discectomy, and 13.8% other exploration/decompression of the spinal canal. Breakdown by time to procedure was: 38.5% same day, 16.1% 1 day, 9.6% 2 days, 7.5% 3 days, 16.2% 4-7 days, 8.3% 8-14 days, and 2.7% >14 days. Timing groups did not differ in trauma status at admission (shock or hemorrhage, p=0.261); however, age differed between groups (min: 1 day [58+/-15 years], max: >14 days [63+/-13 years], p<0.001). Relative to other groups, same-day patients had the lowest LOS (7.7+/-9.8 days vs 9.4-37.3 days, p<0.001) highest rates of home discharge (42.09% vs 30.9%-14.4%, p<0.001). Same-day patients showed a trend of lower perioperative neurologic complications (0.4%) than 1-day (0.6%) and 2-day (1.0%) patients, while patients delayed 3+ days had the lowest (0.1%, p=0.144). Patients delayed >14 days to surgery had increased odds of periop cardiac (7.0 [1.6-30.0]) and infection (6.1 [2.2-16.3]) complications. All timing groups beyond 3 days showed increased odds of VTE: 4-7 days (3.0 [1.6-5.5]), 8-14 days (3.0 [1.4-6.3]), 14+ days (5.6 [2.3-13.6]). Same-day surgery was also associated with lower total hospital charges than delayed surgery ($87,741 vs $118,815-$272,901, p<0.001).
CONCLUSION(S): Patients undergoing surgery for CCS on the same day as admission showed significantly lower odds of complication, hospital charges, and higher rates of discharge to home than patients that experienced a delay to operation. In contrast, patients delayed >14 days to surgery were associated with inferior outcomes, including increased odds of cardiac complication and infection. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Miller et al adult spinal deformity frailty index (ASD-FI) correlates with increased complication risk after surgery; however, its development was not rooted in clinical outcomes, and the 40 factors needed for its calculation limit the index's utility in a clinical setting. PURPOSE: Develop a simplified, weighted frailty index for ASD patients. STUDY DESIGN/SETTING: Retrospective review of prospective ASD database. PATIENT SAMPLE: A total of 50 ASD patients. OUTCOME MEASURES: Health-related quality of life questionnaires: Oswestry Disability Index (ODI), SRS-22r, pain catastrophizing scale, Numerif Rating Scale (NRS) for Leg Pain.
METHOD(S): ASD patients (scoliosis>=20degree, SVA>=5cm, PT>=25degree, or TK >=60degree) with baseline ASD-FI component factors. Component ASD-FI parameters contributing to overall ASD-FI score were assessed via Pearson correlation. Top significant, clinically relevant factors were regressed against ASD-FI score to generate the modified ASD-FI (mASD-FI). Factors comprising the mASD-FI were regressed against the incidence of medical complications; weights for mASD-FI factors were calculated from these regression coefficients via the beta/Sullivan method. Total mASD-FI score was calculated by summing weights of expressed parameters, resulting in a score ranging from 0 to 21. Linear regression correlated ASD-FI and mASD-FI scores, and previously published ASD-FI cutoffs were used to generate corresponding mASD-FI frailty cutoffs: not frail (NF,<7), frail (7-12), severely frail (SF,>12). Analysis of variance assessed the relationship between increasing frailty category and validated baseline measures of patient pain and disability.
RESULT(S): Included: 50 ASD patients (52+/-20yrs, 78% female). All the following preoperative factors correlated with ASD-FI score (all p<0.039), and combined, accounted for 85.0% (p<0.001) of the variation in ASD-FI score: BMI <18.5 kg/m2 or >30 kg/m2 (weight: 5), depression (weight: 5), difficulty climbing stairs (3), presence of >3 medical comorbidities (2), leg weakness (2), difficulty getting dressed (1), bladder incontinence (1), and patient-reported deterioration in health within the past year (1). These factors were used to calculate the overall population's mean mASD-FI score: 5.7+/-5.2. Combined, these factors comprising the mASD-FI showed a trend of predicting the incidence of medical complications (Nagelkerke R2=0.558, Cox & Snell R2=0.399, p=0.065). Overall patient breakdown by mASD-FI frailty category: NF (70%), frail (12%), SF (18%). Increasing frailty category was associated with significant impairments in validated measures of disability, including ODI score (NF: 23.4, frail: 45.0, SF: 49.3, p<0.001), SRS-22r score (NF: 3.5, frail: 2.6, SF: 2.4, p=0.001), pain catastrophizing scale score (NF: 41.9, frail: 32.4, SF: 27.6, p<0.001), and NRS Leg Pain (NF: 2.3, frail: 7.2, SF: 5.6, p=0.001).
CONCLUSION(S): This study modifies an existing ASD frailty index and proposes a weighted, shorter mASD-FI. The mASD-FI relies less on patient-reported variables, and weights component factors by their contribution to adverse outcomes. As increasing mASD-FI score is associated with inferior clinical measures of pain and disability, the mASD-FI may serve as a valuable tool for preoperative risk assessment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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