[Show abstract][Hide abstract] ABSTRACT: STUDY DESIGN:
Retrospective review of a prospectively collected database.
This study compares patient demographics, incidence of comorbidities, procedure-related complications, and mortality following primary vs. revision adult spinal deformity surgerySummary of Background Data. While adult spinal deformity (ASD) surgery has been extensively investigated, no previous study has provided nationwide estimates of patient characteristics and procedure-related complications for primary vs. revision spinal deformity surgery comparatively.
Nationwide Inpatient Sample data collected between 2001 and 2010 was analyzed. Discharges with procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included for patients aged 25+ and 4+ levels fused with any diagnoses specific for scoliosis. Patient demographics, comorbidity and procedure-related complications incidence were determined for primary vs. revision cohorts. Multivariate analysis reported as (OR [95% CI]).
Discharges for 9133 primary and 850 revision cases were identified. Patients differed on the basis of demographic and hospital data. Average comorbidity indices for the cohorts were similar (p = 0.580), as was in-hospital mortality (p = 0.163). The incidence of procedure-related complications was higher for the revision cohort (46.96% vs. 71.97%, p = 0.001). The mean hospital course for the revision cohort was longer (6.37 vs. 7.13 days, p<0.0001). Revisions had an increased risk of complications involving the nervous system (1.34[1.10-1.6]), hematoma/seroma formation (2.31[1.92-2.78]), accidental vessel or nerve puncture (1.44[1.29-1.61]), wound dehiscence (2.18[1.48-3.21]), post-op infection (3.10[2.50-3.85]) and ARDS complications (1.43[1.28-1.60]). The primary cohort had a decreased risk for GI (0.65[0.55-0.76]) and GU complications (0.71[0.51-0.99]).
Relative to primary cases, those undergoing revision correction of spinal deformity have a higher risk of many procedure-related complications with a longer hospital course despite similar baseline comorbidity burden and in-hospital mortality rate. This study provides clinically useful data for surgeons to educate patients at risk for morbidity and mortality and direct future research to improve outcomes.
[Show abstract][Hide abstract] ABSTRACT: Obesity is a significant comorbidity that can increase the risk and technical difficulty of surgery. Previous studies comparing minimally invasive (MIS) to traditional open spinal surgery in the obese have shown similar clinical outcomes but improved perioperative benefits of decreased estimated blood loss (EBL), length of stay (LOS), and complications with MIS approaches. Similar studies have not been performed for obese patients undergoing surgery for adult spinal deformity (ASD). This study's objective was to compare the impact of obesity in the treatment of ASD with MIS compared with open approaches.
Two multicenter databases, one involving MIS surgeries and the other open surgeries, were queried. Inclusion criteria for both databases were diagnosis of ASD, minimum 2-year follow-up, and at least 1 of the following parameters: coronal cobb (CC) = 20°, SVA > 5 cm, PT > 25°, thoracic kyphosis > 60°. Patients with body mass index (BMI) = 30 were identified and then propensity matched for levels fused. Thirty-eight patients with 19 in each group were analyzed.
Patients were well matched with mean ages of 65.4 and 64.3 years and BMI 34.7 and 34.0, respectively, for the MIS and open groups. Table 1 lists outcomes between the groups. Mean levels fused were 4.2 for MIS and 2.7 for open. Statistically significant improvement in Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were noted within each group. Notably, there was no significant difference in radiographic parameters or ODI and VAS scores between groups. A significant decrease in EBL was noted in the MIS group; however, complications and reoperation frequency were not statistically different.
Similar clinical and radiographic improvements were noted for MIS and open treatment of ASD. Although EBL was less in the MIS group, the frequency of complications and reoperations were similar, suggesting the potential benefit of MIS approaches may be mitigated by obesity. Larger comparative studies are needed to clarify the benefit of MIS in the obese undergoing ASD surgery.
[Show abstract][Hide abstract] ABSTRACT: This nationwide study identifies ASD surgical risk factors for morbidity/mortality.
NIS discharges from 2001 to 2010 aged 25+ with scoliosis diagnoses, 4+ levels fused, and procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included. Demographics, comorbidities and procedure-related complications were determined for each subgroup (degenerative, congenital, idiopathic, other). Multivariate analysis reported as [OR (95 % CI)].
11,982 discharges were identified. Morbidity, excluding device-related, and mortality rates were 50.81 and 0.28 %, respectively. Certain comorbidities were associated with increased morbidity/mortality: congestive heart failure (CHF) [1.62 (1.42-1.84)] [5.67 (3.30-9.73)], coagulopathy [3.52 (3.22-3.85)] [2.32 (1.44-3.76)], electrolyte imbalance [2.65 (2.52-2.79)] [4.63 (3.15-6.81)], pulmonary circulation disorders [9.45 (7.45-11.99)] [8.94 (4.43-18.03)], renal failure [1.29 (1.13-1.47)] [5.51 (2.57-11.82)], and pathologic weight loss [2.38 (2.01-2.81)] [7.28 (4.36-12.14)]. Chronic pulmonary disease was associated with higher morbidity [1.08 (1.02-1.14)]; liver disease was linked to increased mortality [36.09 (16.16-80.59)]. 9+ level fusions had increased morbidity vs 4-8 level fusions [1.69 (1.61-1.78)] and refusions [1.08 (1.02-1.14)]. Idiopathic scoliosis was associated with decreased morbidity vs all other subgroups [0.85 (0.80-0.91)]. Age >65 was associated with increased morbidity and mortality vs 25-64 group [1.09 (1.05-1.14)] [3.49 (2.31-5.29)]. Females had increased morbidity [1.18 (1.13-1.23)] and decreased mortality [0.30 (0.21-0.44)]. Mean comorbidity index (0.55) and age (64.38) for degenerative cohort were higher vs all other subgroups (P < 0.0001).
Longer fusions were associated with increased morbidity. Age >65 was associated with increased morbidity/mortality, while females were associated with increased morbidity but decreased mortality. Idiopathic scoliosis had decreased morbidity. Degenerative ASD cases had higher comorbidity indices, potentially due to older age. This study is clinically useful for patient education, surgical decision-making, and optimizing patient outcomes.
European Spine Journal 07/2015; DOI:10.1007/s00586-015-4104-x · 2.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Few studies have provided nationwide estimates of patient characteristics and procedure-related complications, or examined postsurgical outcomes for patients with cervical spondylotic myelopathy (CSM) comparatively with respect to surgical approach. The objective of this study is to identify patients at risk for morbidity and mortality directly related with the selected approach, report an overall nation-wide complication rate for each approach against which surgeons can compare themselves, and direct future research to improve patient outcomes.
Patients surgically treated for CSM were retrospectively identified using ICD-9-CM codes from the Nationwide Inpatient Sample (NIS) database. Four cohorts were compared for demographics and hospital system-related data: anterior (ACDF, ACCF), posterior decompression without fusion, decompression with posterior fusion, and combined anterior-posterior. Multivariate analysis was also used to determine the odds ratio of morbidity and mortality among the cohorts.
54,416 discharges were identified between 2001 and 2010: 34,400 anterior, 9,014 decompression procedures without fusion, 8,741 decompression procedures with posterior fusion, and 2,261 combined anterior-posterior. Groups were statistically different with respect to age, length of hospital stay, mortality, and complications. Groups were statistically different for Deyo score except between posterior decompression only and combined approaches. Using multivariate analysis and adjusting for covariates, the combined (2.74[2.18-3.44]) and laminectomy (1.22[1.04-1.44]) cohorts had an increased risk of mortality when compared to anterior alone.
These findings are the first to determine the rates and odds of perioperative risks directly related to combined anterior-posterior procedures. This study provides clinically useful data for surgeons to educate patients and direct future research to improve patient outcomes.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study is to report and quantify the associated factors for morbidity and mortality following surgical management of cervical spondylotic myelopathy (CSM).
The Nationwide Inpatient Sample (NIS) database was use to retrospectively review all patients over 25 years of age with a diagnosis of CSM who underwent anterior and/or posterior cervical fusion or laminoplasty between 2001 and 2010. The main outcome measures were total procedure-related complications and mortality. Multivariate regression analysis was used to identify demographic, comorbidity, and surgical parameters associated with increased morbidity and mortality risk [reported as: OR (95 % CI)].
A total of 54,348 patients underwent surgical intervention for CSM with an overall morbidity rate of 9.83 % and mortality rate of 0.43 %. Comorbidities found to be associated with an increased complication rate included: pulmonary circulation disorders [6.92 (5.91-8.12)], pathologic weight loss [3.42 (3.00-3.90)], and electrolyte imbalance [2.82 (2.65-3.01)]. Comorbidities found to be associated with an increased mortality rate included: congestive heart failure [4.59 (3.62-5.82)], pulmonary circulation disorders [11.29 (8.24-15.47)], and pathologic weight loss [5.43 (4.07-7.26)]. Alternatively, hypertension [0.56 (0.46-0.67)] and obesity [0.36 (0.22-0.61)] were found to confer a decreased risk of mortality. Increased morbidity and mortality rates were also identified for fusions of 4-8 levels [morbidity: 1.55 (1.48-1.62), mortality: 1.80 (1.48-2.18)] and for age >65 years [morbidity: 1.65 (1.57-1.72), mortality: 2.74 (2.25-3.34)]. An increased morbidity rate was found for posterior-only [1.55 (1.47-1.63)] and combined anterior and posterior fusions [3.20 (2.98-3.43)], and an increased mortality rate was identified for posterior-only fusions [1.87 (1.40-2.49)]. Although revision fusions were associated with an increased morbidity rate [1.81 (1.64-2.00)], they were associated with a decreased rate of mortality [0.24 (0.10-0.59)].
The NIS database was used to provide national estimates of morbidity and mortality following surgical management of CSM in the United States. Several comorbidities, as well as demographic and surgical parameters, were identified as associated factors.
European Spine Journal 05/2015; DOI:10.1007/s00586-015-4010-2 · 2.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECT Alignment changes in the cervical spine that occur following surgical correction for thoracic deformity remain poorly understood. The purpose of this study was to evaluate such changes in a cohort of adults with thoracic deformity treated surgically. METHODS The authors conducted a multicenter retrospective analysis of consecutive patients with thoracic deformity. Inclusion criteria for this study were as follows: corrective osteotomy for thoracic deformity, upper-most instrumented vertebra (UIV) between T-1 and T-4, lower-most instrumented vertebra (LIV) at or above L-5 (LIV ≥ L-5) or at the ilium (LIV-ilium), and a minimum radiographic follow-up of 2 years. Sagittal radiographic parameters were assessed preoperatively as well as at 3 months and 2 years postoperatively, including the C-7 sagittal vertical axis (SVA), C2-7 cervical lordosis (CL), C2-7 SVA, T-1 slope (T1S), T1S minus CL (T1S-CL), T2-12 thoracic kyphosis (TK), apical TK, lumbar lordosis (LL), pelvic incidence (PI), PI-LL, pelvic tilt (PT), and sacral slope (SS). RESULTS Fifty-seven patients with a mean age of 49.1 ± 14.6 years met the study inclusion criteria. The preoperative prevalence of increased CL (CL > 15°) was 48.9%. Both 3-month and 2-year apical TK improved from baseline (p < 0.05, statistically significant). At the 2-year follow-up, only the C2-7 SVA increased significantly from baseline (p = 0.01), whereas LL decreased from baseline (p < 0.01). The prevalence of increased CL was 35.3% at 3 months and 47.8% at 2 years, which did not represent a significant change. Postoperative cervical alignment changes were not significantly different from preoperative values regardless of the LIV (LIV ≥ L-5 or LIV-ilium, p > 0.05 for both). In a subset of patients with a maximum TK ≥ 60° (35 patients) and 3-column osteotomy (38 patients), no significant postoperative cervical changes were seen. CONCLUSION Increased CL is common in adult spinal deformity patients with thoracic deformities and, unlike after lumbar corrective surgery, does not appear to normalize after thoracic corrective surgery. Cervical sagittal malalignment (C2-7 SVA) also increases postoperatively. Surgeons should be aware that spontaneous cervical alignment normalization might not occur following thoracic deformity correction.
[Show abstract][Hide abstract] ABSTRACT: Our clinical understanding of os odontoideum (OO) remains incomplete. Congenital and traumatic causes have been proposed and advocated. Clinical presentations range from asymptomatic to axial pain to myelopathy or vertebral-basilar ischemia. A consensus for surgical management exists for those found to have an unstable atlantoaxial complex or symptomatic cranial-vertebral junction compression.
To evaluate the clinical presentation and surgical outcomes of patients with OO and an unstable atlantoaxial complex or symptomatic cranial-vertebral junction compression.
Patients with a diagnosis of OO who underwent surgical management were included. Patients were excluded on the basis of previous C2 fracture, Fielding diagnostic criteria, and inadequate follow-up. History of trauma and presenting symptoms were assessed. Clinical and neurological improvements were measured with the use of patient satisfaction scores and the Japanese Orthopaedic Association scores. Fusion status was documented with the use of radiographs and computed tomographic imaging.
Of 279 patients, 112 reported a history of cranial-vertebral junction trauma, whereas 28 were diagnosed with congenital malformations. Clinically, 84.9% of patients presented with myelopathy, with pain presented in 42.6%. Atlantoaxial fixation was performed in 240 patients, occiput-to-C2 fixation in 35 patients, and extended occipito-cervical fixation in 4 patients. Mean follow-up was 40.3 months. Complications were reported in 2.4% of patients. Japanese Orthopaedic Association scores improved from a preoperative mean of 12.4 to 14.8. Two hundred thirty-five patients (77.7%) improved, with 30 patients experiencing no change in symptoms and 14 patients deteriorating. Fusion was achieved in 96.8% of patients.
Our data reveal that surgical treatment for OO using the indications and techniques delineated is associated with high satisfaction rates, improved functional scores, and high fusion rates with low complication rates.
AAI, atlantoaxial instabilityJOA, Japanese Orthopaedic AssociationOO, os odontoideum.
[Show abstract][Hide abstract] ABSTRACT: Retrospective review of prospective multicenter database.
Quantify the incidence of new onset cervical deformity (CD) after adult spinal deformity surgery of the thoracolumbar spine, identify predictors of development, and determine the impact on outcomes.
High prevalence of residual CD has been identified after surgical treatment of adult spinal deformity. Development of new onset CD is less understood and its clinical impact unclear.
A total of 215 patients with complete 2-year follow-up and full-length radiographs met inclusion criteria. CD was defined by T1 slope minus Cervical Lordosis (CL) more than 20°, C2-C7 sagittal vertical axis more than 40 mm, or C2-C7 kyphosis more than 10°. Univariate analysis was performed using t tests or tests of proportion. Multivariate logistic regression was used to determine independent predictors of new onset CD. The impact of CD on health-related quality of life and satisfaction was measured using repeated measures mixed models or logistic regression as appropriate, accounting for potential confounders.
The overall rate of CD at 2 years after surgery was 63%. Univariate analysis revealed that patients who developed new onset CD postoperatively had higher incidence of diabetes (7.35% vs. 1.28%, P = 0.05), increased preoperative C2-C7 sagittal vertical axis (P = 0.04) and C2 slope (P = 0.038), and smaller diameter rods used at surgery (P = 0.032). Independent predictors of new onset CD at 2 years included: diabetes (odds ratio, 10.49; P = 0.046) and increased preoperative T1 slope minus cervical lordosis (odds ratio, 1.08/º; P = 0.022). Ending instrumentation below T4 was a negative predictor (odds ratio, 0.31; P = 0.019). Patients with and without CD experienced improvements in 2-year 36-Item Short Form Health Survey (P = 0.0001), Oswestry Disability Index (P = 0.0001), and Scoliosis Research Society (P = 0.0001). Rates and overall improvement were similar. CD was not associated with decreased satisfaction (P = 0.28).
A total of 47.7% of patients without preoperative CD developed new onset postoperative CD after thoracolumbar surgery. Independent predictors of new onset CD at 2 years included diabetes, higher preoperative T1 slope minus cervical lordosis, and ending instrumentation above T4. Significant improvements in health-related quality of life scores occurred despite the development of postoperative CD.
[Show abstract][Hide abstract] ABSTRACT: Study Design Literature review. Objective Atlantoaxial dislocation (AAD) is a rare and potentially fatal disturbance to the normal occipital-cervical anatomy that affects some populations disproportionately, which may cause permanent neurologic deficits or sagittal deformity if not treated in a timely and appropriate manner. Currently, there is a lack of consensus among surgeons on the best approach to diagnose, characterize, and treat this condition. The objective of this review is to provide a comprehensive review of the literature to identify timely and effective diagnostic techniques and treatment modalities of AAD. Methods This review examined all articles published concerning "atlantoaxial dislocation" or "atlantoaxial subluxation" on the PubMed database. We included 112 articles published between 1966 and 2014. Results Results of these studies are summarized primarily as defining AAD, the normal anatomy, etiology of dislocation, clinical presentation, diagnostic techniques, classification, and recommendations for timely treatment modalities. Conclusions The Wang Classification System provides a practical means to diagnose and treat AAD. However, future research is required to identify the most salient intervention component or combination of components that lead to the best outcomes.
[Show abstract][Hide abstract] ABSTRACT: A high prevalence of residual cervical deformity (CD) has been identified following surgical treatment of adult spinal deformity (ASD). Development of new onset CD is less understood and its clinical impact unclear. This study quantifies the incidence of CD after ASD surgery, identifies predictors of development, and determines the impact outcomes.