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Complications are the chief concern of patients and physicians when considering spine surgery. The authors seek to assess the incidence of complications in patients undergoing spine surgery and identify risk factors for their occurrence. Prospective study of patients undergoing spine surgery from 1 February 2013 to 1 February 2014. Epidemiological characteristics and complications during the surgical hospitalization were recorded and analyzed. The sample comprised 95 patients (mean age, 59 years). Overall, 23% of patients were obese (BMI =30). The mean BMI was 25.9. Approximately 53% of patients had comorbidities. Complications occurred in 23% of cases; surgical site infections were the most common (9%). There were no significant differences between patients who did and did not develop complications in terms of age (60.6 vs 59.9 years, p = 0.71), sex (56% female vs 54% female, p = 0.59), BMI (26.6 vs 27.2, p = 0.40), or presence of comorbidities (52% vs 52.8%, p = 0.87). The risk of complications was higher among patients submitted to spine instrumentation than those submitted to non-instrumented surgery (33% vs 22%), p=0.8. Just over one-quarter of patients in the sample developed complications. In this study, age, BMI, comorbidities were not associated with increased risk of complications after spine surgery. The use of instrumentation increased the absolute risk of complications.
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20 The Open Orthopaedics Journal, 2015, 9, 20-25
1874-3250/15 2015 Bentham Open
Open Access
Risk of Complications in Spine Surgery: A Prospective Study
Rodolfo Casimiro Reis*, Matheus Fernandes de Oliveira, José Marcus Rotta and
Ricardo Vieira Botelho
Spine Surgery Section, Hospital do Servidor Puúblico Estadual de São Paulo, São Paulo-SP, Brazil
Abstract: Purpose: Complications are the chief concern of patients and physicians when considering spine surgery. The
authors seek to assess the incidence of complications in patients undergoing spine surgery and identify risk factors for
their occurrence.
Methods: Prospective study of patients undergoing spine surgery from 1 February 2013 to 1 February 2014.
Epidemiological characteristics and complications during the surgical hospitalization were recorded and analyzed.
Results: The sample comprised 95 patients (mean age, 59 years). Overall, 23% of patients were obese (BMI 30). The
mean BMI was 25.9. Approximately 53% of patients had comorbidities. Complications occurred in 23% of cases; surgical
site infections were the most common (9%). There were no significant differences between patients who did and did not
develop complications in terms of age (60.6 vs 59.9 years, p = 0.71), sex (56% female vs 54% female, p = 0.59), BMI
(26.6 vs 27.2, p = 0.40), or presence of comorbidities (52% vs 52.8%, p = 0.87). The risk of complications was higher
among patients submitted to spine instrumentation than those submitted to non-instrumented surgery (33% vs 22%),
p=0.8.
Conclusion: Just over one-quarter of patients in the sample developed complications. In this study, age, BMI,
comorbidities were not associated with increased risk of complications after spine surgery. The use of instrumentation
increased the absolute risk of complications.
Keywords: Complication, outcome, risk, spine surgery.
INTRODUCTION
Complications are the main concern of patients and
physicians at the time of spine surgery indication, and when
they occur, may have personal and economic consequences,
affecting the quality of life and future independence of
patients [1]. Studies have shown that surgeons and
gynecologists have a lower life expectancy than clinicians,
and emotional stress may be a cause of this difference [2].
Surgical complications are a relevant cause of stress in
surgeons.
Reducing the incidence of these complications is a
constant concern of physicians and health managers.
Reimbursement practices incorporating pay-for-performance
measures seek to link patient outcomes to practitioner
reimbursement. These financial incentives are part of a
policy that aims to reduce hospital-acquired conditions and,
therefore, hospitalization costs [3, 4].
The incidence and prevalence of complications in spine
surgery have varied widely in literature, due to differences in
methodology and patient samples among studies. Few
prospective studies have assessed complications [3-5].
Furthermore, there is no consensus on potential risk factors
for the development of complications in spine surgery [3-9].
*Address correspondence to this author at the Spine Surgery Section,
Hospital do Servidor Puúblico Estadual de São Paulo, Avenida Pedro de
Toledo 1800; 04039-004; São Paulo SP, Brazil; Tel: +55-11-986897473;
E-mail: rodolfocr84@yahoo.com.br
A clear definition of risk of complications in spinal
surgeries, in the setting of different demographics and
comorbidities, is required for adequate therapeutic decision
making, once it can help patients to decide weather submit to
an invasive procedure with provided numeric information.
Therefore, this study sought to assess the incidence of
complications in spine surgery and identify patient-related
risk factors and those related to the use of instrumentation.
METHODS
This study used a prospective observational design
whereby all patients undergoing spine surgery at a tertiary
referral center between 1 February 2013 and 1 February
2014 were observed from surgery to discharge and in
hospital complications were recorded. Hospital do Servidor
Público Estadual de São Paulo, SP, Brazil, covers about 3
million state servers and their relatives throughout São Paulo
state. The Neurosurgery Department provides a 25-bed unit
and offers residency program. Surgeries were indicated in
the Spine clinic (elective cases) and in the emergency
department of the hospital and included a wide range of
procedures (ICD-9CM:01.2, 03.09, 03.32, 03.71, 80.51,
81.00-81.08, 81.30, 81.65, 81.66, 84.51, 84.60, 84.61, 84.62,
84.80, 84.84). No inclusion or exclusion criteria were
applied; all patients undergoing any spine surgery procedure
during the study period were eligible for admission. All
patients received cefuroxime IV 60 minutes before incision
and q 8h post-op, 6 doses total. Regarding deep-vein
thrombosis prophylaxis, graduated compression stockings
Risk of Complications in Spine Surgery The Open Orthopaedics Journal, 2015, Volume 9 21
were used for all patients, and low molecular weight heparin
was prescribed from day 3 post-op for those who could not
walk.
For the purposes of this study, a complication in spinal
surgery was defined as “any untoward event occurring to a
patient while on the neurosurgical service” [10].
Complications were classified as general, specific, or
technical (Table 1), as described by Fritzell, Hagg, and
Nordwall [11], and further divided into two categories:
major (adverse events with sequelae in discharge or
requiring revision surgery during hospitalization) and minor
complications (adverse events with no sequelae in discharge
and not requiring revision surgery), a modified classification
from Lebude B et al. [12].
Table 1. Classification of complications in spine surgery.
General
Specific
Technical
Mortality
Hematoma
Screw placement
Thrombosis
Infection superficial
Instrument-related
Hepatitis
Infection deep
Dislocation of transplant
Gastrointestinal
Nerve root injury/pain
Urinary tract infection
Dural tear
Pulmonary complication
Caudaequine syndrome
Skin problem
Injury to sympathetics
Psychological problems
Sex-related problems
Coping problems
Retrograde ejaculation
Donor site pain
Miscellaneous
Fritzell P, Hagg O, Nordwall A. Complications in lumbar fusion surgery for chronic
low back pain: comparison of three surgical techniques used in a prospective
randomized study. A report from the Swedish Lumbar Spine Study Group. Eur Spine J
2003; 12: 178-189.
The anthropometric variables of interest were age,
gender, and body mass index (BMI), which was stratified in
accordance with WHO guidelines as follows: BMI <18.5,
underweight; 18.524.9, normal range; 25.029.9, over-
weight; 30, obesity [13].
During admission, patients were asked to fill up a
questionnaire with possible comorbidities and ongoing
medications. If any patient had two measures higher than
140x90mmHg (blood pressure) or 126mg/dl (fasting blood
glucose) during hospitalization, he was considered
hypertensive or diabetic, respectively, despite no previous
diagnosis.
Primary spinal diseases were classified etiologically as
degenerative, traumatic, neoplastic, congenital, infectious, or
inflammatory. The operated spinal segment was classified as
cervical, thoracic, or lumbar.
The following variables were tested for correlation with
complications: age, gender, BMI, comorbidities, and
instrumentation.
This study was approved by the institutional Research
Ethics Committee with protocol number 405320.
Statistical Analysis
Numerical variables were expressed by descriptive
statistics (mean, standard deviation, range, and relative
frequency). Student’s t-test was used to compare differences
in age distribution between affected and unaffected patients,
whereas the chi-square method was used to test for
association between the presence of complications and age,
gender, BMI, comorbidities, and instrumentation. The
frequency of complications in relation to the variables
comorbidities and instrumentation was assessed as a
percentage (risk). Absolute risk difference and number
needed to avoid complication related to instrumentation was
calculated.
The significance level was set at p<0.05. All analyses
were carried out in the SPSS for Windows 13.0 software
environment.
RESULTS
Demographic and Surgical Data
Demographic data are shown in Table 2. Ninety-five
patients underwent spine surgery during the study period and
all patients were followed until hospital discharge. The mean
age was 59 ±12.31years, and 46% of patients were >60 years
old. Forty-three patients (45%) were male. The mean BMI
was 25.9;overall, 41 patients were overweight (43.1%) and
22were obese (23.1%).
Table 2. Summary of demographic data.
Variable
N (%)
No. of patients
95
Age (years)
Mean±SD
Range
59 ±12
3188
Sex
Male
Female
43 (45)
52 (55)
BMI
<18.5
18.5-24.9
25-29.9
30
1 (1)
31 (33)
41 (43)
22 (23)
Fifty patients (52.6%) had comorbidities. The most
common comorbid conditions were hypertension, present in
36 patients, and diabetes mellitus, present in 7 (Table 3).
The most common etiology of spinal disease was
degenerative(n=64), followed by neoplastic (n=19) and
trauma (n=11) (Fig. 1). Regarding the affected spinal
segment, 29.4% of procedures were performed on the
cervical spine, 24.3% on the thoracic spine, and 46.3% on
the lumbar spine.
Thirty-six patients (38%) received instrumentation,
whereas 59 (62%) did not.
22 The Open Orthopaedics Journal, 2015, Volume 9 Reis et al.
Table 3. Summary of comorbidities.
Comorbidity
Hypertension
Diabetes mellitus
Depression
Osteoporosis
Smoking
Gout
Alcoholism
Cancer
Stroke
Congestive heart failure
Benign prostatic hypertrophy
Complications
Overall, 25 patients (26%) had 34 complications. Risk of
complication after a cervical procedure was 25% (7 patients
of 28), 17% in thoracic and 32% in lumbar procedures.
Eleven patients (11.6%of the sample) had major
complications, and 14 patients had minor complications (risk
= 15%) (Fig. 2).
Of the 34 complications recorded, 11 (32%) were
general, 18 (53%) were specific, and five (15%) were
technical, as shown in Fig. (3). There were no neurological
complications.
Seven patients (7.3%) underwent revision surgery: five
due to infection, one due to CSF leak, and one due to screw
displacement. Three patients (3.1%) died, all of septic shock
(two secondary to surgical site infection and one due to
underlying spondylodiscitis).
Fig. (1). Etiology of spine diseases.
Fig. (2). Frequency and classification of complications.
2% 2%
7%
12%
20% 67%
Degenerative
Neoplasm
Trauma
Infection
Inflammation
Congenital
None
Minor
Major
74%
15%
11%
Risk of Complications in Spine Surgery The Open Orthopaedics Journal, 2015, Volume 9 23
Association Between Anthropometric Variables and
Complications
There were no significant differences in age (60.6 vs 59.9
years, p= 0.71), sex (56%female vs 54%female, p = 0.59), or
mean BMI (26.6 vs 27.2, p=0.40) between patients who
developed complications and those who did not, respectively
(Table 4).
Table 4. Comparison of demographic data between patients
with and without complications.
Data
Complications
P Value
Present
Absent
Age (years)
59.94
60.64
0.71
Female gender
54.2%
56%
0.59
BMI
27.28
26.62
0.40
Association Between Comorbidities and Complications
Of the 25 patients who developed complications, 52%
had comorbidities; of the 70 patients who did not develop
complications, 52.8% had comorbidities (p = 0.87).
The risk of complications was 24% among patients with
comorbidities (12 of 50) and 26.6% in patients without
comorbidities (12 of 45) (p= 0.31).
The risk of complications between hypertensive and non-
hypertensive patients was the same (40%), p= 1.
Association Between Instrumentation and Complications
The risk of complications among patients who received
instrumentation was 33%(12 of 36), versus 22% (13 of 59)
among those who did not receive instrumentation
(X2;p=0.87). The absolute difference of risk was 11%. At
each 9 patients treated without instrumentation, 1 related
complication could be avoided.
Multivariate Analysis
Since all associations between variables (age, sex, BMI,
comorbidities and instrumentation) and complications did
not reach statistical significance, multivariate analysis could
not be concluded.
DISCUSSION
The postoperative complications of spine surgery have
recently been an object of study due to growing concerns
with reduction of hospital costs and improvement of
healthcare services [3]. From a humanitarian standpoint,
complications are also a major issue, due to their potential to
cause suffering and stress to patients themselves, to their
families, and to their surgeons. Stress has been implicated as
a cause of decreased survival among surgeons as compared
with clinicians [2].
The sample of the present study was similar to those of
previous investigations: demographic characteristics, the
percentage of overweight patients, the higher proportion of
lumbar spine surgeries, and the percentage of patients who
*"Septic"shock"originally"from"preexisting"spondylodiscitis"
Fig. (3). Summary of complications.
Complications
General (11)
Specific (18)
Technical (5)
9
211
31111111113
Wound infection
CSF fistula
Wound dehiscence
Wound serosanguineous
Pneumonia
Heart arrhytmia
Myocardial infarction
Dysautonomia
Syncope
Lung congestion
Pulmonary thromboembolism
Hypertensive Crisis
Septic shock*
Instrument loosening
Urethral bleeding
Burn
6
24 The Open Orthopaedics Journal, 2015, Volume 9 Reis et al.
underwent instrumentation were similar to those of previous
studies on complications in spine surgery [3, 5-7, 14].
The rate of postoperative complications in spine surgery
varies widely in the literature. Campbell et al. recently
reported an incidence of 52%, with a predominance of minor
complications (approximately twice as frequent as major
complications), as seen in the present sample [3]. A
systematic review of the literature revealed that retrospective
studies report a lower incidence of complications than
prospective studies (16% vs 19.9%) [5]. The present study,
which used a prospective design, found an incidence of 26%,
with a predominance of specific complications (53%), which
is also consistent with previous studies [3].
Advanced age and obesity have been associated with
complications, but many of the studies that found this
association reported inconsistent and divergent results, and
most were retrospective [6, 9, 15-19]. Lee et al.
demonstrated an increased incidence of complications
among patients aged >65 years on multivariate analysis of a
prospective database of spine surgery cases [9]. Regarding
obesity, a few retrospective studies have found it to be
associated with an increased complication rate in spine
surgery, but most prospective studies and one nationwide
database study failed to demonstrate such association [6,
20, 21]. In the present study, advanced age and obesity were
not associated with an increased complication rate.
Overall, 52% of patients in the present sample had
presented comorbidities, with a predominance of
cardiovascular diseases. The presence of comorbidities did
not affect the incidence of complications in this sample.
The correlation between comorbidities and complications
in spine surgery is poorly defined in the literature. Most
studies are retrospective or based on population data. Li
et al. and Deyo et al. reported an association between
presence of comorbidities and increased complication rate
[7, 22]. Only one prospective study has assessed the impact
of comorbidities on complications, finding that an increase
in the number of comorbidities was correlated with an
increase in the incidence of complications [3]. The present
study which, as noted above, was prospective in nature
did not find any association between comorbidities and
complications. We did not use any specific comorbidity
score in the analyses, due to the disproportional
predominance of cardiovascular diseases seen in our sample.
In the present sample, the rate of complications was
higher in patients who underwent instrumentation than in
patients who were not instrumented (33% vs 22%
respectively), but the difference did not reach statistical
significance (p=0.8). In the other hand, evaluating the
absolute risk differenceof complication, instrumentation
increased it by 11%. Thus at each 9 patients treated with
instrumentation, one will develop a complication. Several
studies have demonstrated an association between
instrumentation and complications [3, 14, 22].
Although multivariate analysis would be important to
identify independent risk factors for complications, it could
not be concluded, since association between variables and
complications did not reach statistical significance.
Nasser et al. published a systematic review of 105 studies
on complications in spine surgery, most of which were
retrospective [5]. The majority of studies that evaluated
associations between complications and variables studied
only one potential risk factor, such as age, obesity,
comorbidities, or instrumentation. Conversely, our
prospective study evaluated all of these potential
associations. We did not evaluate complications in specific
surgical procedures because this would demand a greater
number of patients.
Some factors may explain the divergence between the
present study and previous investigations regarding the
association between comorbidities, instrumentation and
complications. These elements act as limitations of our study
and should be addressed. Since a consistent definition of
operative complications lacks in literature, we used a wide-
ranging concept of complications herein; our sample was
originated from a high-complexity tertiary referral center,
which for sure does not represent general population
submitted to spine surgery; we presented a small sample
size; we included a broad range of etiologies of spinal
diseases (whereas the literature has largely focused on
degenerative diseases) and a wide range of comorbidities in
this study, such as lifestyle habits (smoking and alcoholism).
As previous mentioned, the study was conducted in a
hospital with residency program; since operator experience
may be a risk factor for complication, residents assistance
may have increased our incidence of complications. Until
large, multicenter studies are conducted, clustered data from
multiple prospective investigations may reveal the true
incidence of complications in spine surgery.
CONCLUSION
Just over one-quarter of patients in the sample developed
complications. Most of these were specific and minor, but
11% of patients experienced major complications, which
caused prolonged hospital stay and increased suffering. The
sample-wide risk of death was 3%.
In the present study, age, BMI and comorbidities were
not associated with an increased risk of complications.
However, the use of instrumentation increases the absolute
risk of complications in 11%.
CONFLICT OF INTEREST
The authors confirm that this article content has no
conflict of interest.
ACKNOWLEDGEMENTS
Declared none.
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Received: August 23, 2014 Revised: December 4, 2014 Accepted: December 11, 2014
© Reis et al.; Licensee Bentham Open.
This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/)
which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.
... One study showed a mortality rate of 3.1% due to sepsis. 17 Another study pertaining to lumbar spine surgeries showed a mortality rate of 0.13% with the highest mortality resulting from shock and pulmonary embolism. 18 All of the mortalities observed in our study from the same consequences. ...
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Background Planning of surgical procedures for spinal fusion is performed on standing radiographs, neglecting the fact that patients are mostly in the sitting position during daily life. The awareness about the differences in the standing and sitting configuration of the spine has increased during the last years. The purpose was to provide an overview of studies related to seated imaging for spinal fusion surgery, identify knowledge gaps and evaluate future research questions. Methods A literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews (PRISMASc) was performed to identify reports related to seated imaging for spinal deformity surgery. A summary of the finding is presented for healthy individuals as well as patients with a spinal disorder and/or surgery. Results The systematic search identified 30 original studies reporting on 1) the pre- and postoperative use of seated imaging of the spine (n=12), 2) seated imaging of the spine for non – surgical evaluation (n=7) and 3) seated imaging of the spine among healthy individuals (12). The summarized evidence illuminates that sitting leads to a straightening of the spine decreasing thoracic kyphosis (TK), lumbar lordosis (LL), the sacral slope (SS). Further, the postural change between standing and sitting is more significant on the lower segments of the spine. Also, the adjacent segment compensates the needed postural change of the lumbar spine while sitting with hyperkyphosis. Conclusions The spine has a different configuration in standing and sitting. This systematic review summarizes the current knowledge about such differences and reveals that there is minimal evidence about their consideration for surgical planning of spinal fusion surgery. Further, it identifies gaps in knowledge and areas of further research.
... 3 Complications can be severely debilitating, although rarely life-threatening, when they occur. 4 Based on the freehand approach to spondylodesis, surgeons found improvement in patient outcomes when they paired the anatomical freehand approaches with fluoroscopy. These early surgical navigation concepts evolved into the various forms of surgical navigation systems used today. ...
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Objective: Several approaches have been studied for internal fixation of the spine using pedicle screws (PSs), including CT navigation, 2D and 3D fluoroscopy, freehand, and robotic assistance. Robot-assisted PS placement has been controversial because training requirements, cost, and previously unclear benefits. This meta-analysis compares screw placement accuracy, operative time, intraoperative blood loss, and overall complications of PS insertion using traditional freehand, navigated, and robot-assisted methods. Methods: A systematic review was performed of peer-reviewed articles indexed in several databases between January 2000 and August 2021 comparing ≥ 2 PS insertion methods with ≥ 10 screws per treatment arm. Data were extracted for patient outcomes, including PS placement, misplacement, and accuracy; operative time, overall complications, intraoperative blood loss, postoperative hospital length of stay, postoperative Oswestry Disability Index (ODI) score, and postoperative visual analog scale (VAS) score for back pain. Risk of bias was assessed using the Newcastle-Ottawa score and Cochrane tool. A network meta-analysis (NMA) was performed to estimate PS placement accuracy as the primary outcome. Results: Overall, 78 studies consisting of 6262 patients and > 31,909 PSs were included. NMA results showed that robot-assisted and 3D-fluoroscopy PS insertion had the greatest accuracy compared with freehand (p < 0.01 and p < 0.001, respectively), CT navigation (p = 0.02 and p = 0.04, respectively), and 2D fluoroscopy (p < 0.01 and p < 0.01, respectively). The surface under the cumulative ranking (SUCRA) curve method further demonstrated that robot-assisted PS insertion accuracy was superior (S = 0.937). Optimal screw placement was greatest in robot-assisted (S = 0.995) placement, and misplacement was greatest with freehand (S = 0.069) approaches. Robot-assisted placement was favorable for minimizing complications (S = 0.876), while freehand placement had greater odds of complication than robot-assisted (OR 2.49, p < 0.01) and CT-navigation (OR 2.15, p = 0.03) placement. Conclusions: The results of this NMA suggest that robot-assisted PS insertion has advantages, including improved accuracy, optimal placement, and minimized surgical complications, compared with other PS insertion methods. Limitations included overgeneralization of categories and time-dependent effects.
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Objective: To investigate the effects of incentive spirometry and deep breathing exercises on forced vital capacity (FVC) and chest expansion in preoperative spine surgery patients. Material & Methods: Fifty-eight patients who were scheduled for spine surgery were recruited from December 2016 to January 2019. Twenty-eight and 30 patients were scheduled for cervical and thoracic/lumbar spine surgery, respectively. All patients were informed of the study protocol, evaluated by a physical therapist, and provided with respiratory training via incentive spirometry and deep breathing exercises. FVC and chest expansion were measured and recorded prior to training, as well as two weeks and four weeks after respiratory training. Results: In preoperative spine patients, FVC and chest expansion were significantly increased (p<0.05) after respiratory training with incentive spirometry and deep breathing exercises. The FVC in a seated position prior to respiratory training, after 2 weeks of training, and after 4 weeks of training is 2,277.9±599, 2,446.6±614.2, and 2,546.5±591.7 milliliters, respectively. The FVC in the supine position prior to respiratory training, after 2 weeks of training, and after 4 weeks of training is 2,080.2±589, 2,268.3±604.3, and 2,365.9±596.1 milliliters, respectively. Chest expansion in a seated position before respiratory training, after 2-week training, and after 4-week training is 4.2±1.3, 4.6±1.2 and 4.7±1.3 centimeters. Chest expansion in supine position before respiratory training, after 2-week training, and after 4-week training is 3.9±1.2, 4.5±1.3 and 4.5±1.2 centimeters respectively. Conclusion: Preoperative respiratory training for 2 weeks and 4 weeks using incentive spirometry and conventional deep breathing exercises significantly increased both FVC and chest expansion in patients undergoing spine surgery.
Article
Study design: A retrospective study at a single academic institution. Objective: The purpose of this study is to utilize machine learning to predict hospital length of stay (LOS) and discharge disposition following adult elective spine surgery, and to compare performance metrics of machine learning models to the American College of Surgeon's National Surgical Quality Improvement Program's (ACS NSQIP) prediction calculator. Summary of background data: A total of 3678 adult patients undergoing elective spine surgery between 2014 and 2019, acquired from the electronic health record. Methods: Patients were divided into three stratified cohorts: cervical degenerative, lumbar degenerative, and adult spinal deformity groups. Predictive variables included demographics, body mass index, surgical region, surgical invasiveness, surgical approach, and comorbidities. Regression, classification trees, and least absolute shrinkage and selection operator (LASSO) were used to build predictive models. Validation of the models was conducted on 16% of patients (N=587), using area under the receiver operator curve (AUROC), sensitivity, specificity, and correlation. Patient data were manually entered into the ACS NSQIP online risk calculator to compare performance. Outcome variables were discharge disposition (home vs. rehabilitation) and LOS (days). Results: Of 3678 patients analyzed, 51.4% were male (n=1890) and 48.6% were female (n=1788). The average LOS was 3.66 days. In all, 78% were discharged home and 22% discharged to rehabilitation. Compared with NSQIP (Pearson R2=0.16), the predictions of poisson regression (R2=0.29) and LASSO (R2=0.29) models were significantly more correlated with observed LOS (P=0.025 and 0.004, respectively). Of the models generated to predict discharge location, logistic regression yielded an AUROC of 0.79, which was statistically equivalent to the AUROC of 0.75 for NSQIP (P=0.135). Conclusion: The predictive models developed in this study can enable accurate preoperative estimation of LOS and risk of rehabilitation discharge for adult patients undergoing elective spine surgery. The demonstrated models exhibited better performance than NSQIP for prediction of LOS and equivalent performance to NSQIP for prediction of discharge location.
Article
Background Context . Post-operative recovery after adult spinal deformity (ASD) operations is arduous, frought with complications, and often requires extended hospital stays. A need exists for a method to rapidly predict patients at risk for eLOS in the preoperative setting. Purpose . To develop a machine learning model to preoperatively estimate the likelihood of extended length of stay (eLOS) following elective multi-level lumbar/thoracolumbar spinal instrumented fusions (≥3 segments) for adult spinal deformity (ASD). Study Design/Setting . Retrospectively from a state-level inpatient database hosted by the Healthcare cost and Utilization Project (HCUP). Patient Sample . 8,866 patients of age≥50 with ASD undergoing elective lumbar or thoracolumbar multi-level instrumented fusions. Outcome Measures . The primary outcome was eLOS (>7 days). Methods . Predictive variables consisted of demographics, comorbidities, and operative information. Significant variables from univariate and multivariate analyses were used to develop a logistic regression-based predictive model that utilized six predictors. Model accuracy was assessed through area under the curve (AUC), sensitivity, and specificity. Results . 8,866 patients met inclusion criteria. A saturated logistic model with all significant variables from multivariate analysis was developed (AUC=0.77), followed by generation of a simplified logistic model through stepwise logistic regression (AUC=0.76). Peak AUC was reached with inclusion of six selected predictors (combined anterior and posterior approach, surgery to both lumbar and thoracic regions, ≥8 level fusion, malnutrition, congestive heart failure, and academic institution). A cutoff of 0.18 for eLOS yielded a sensitivity of 77% and specificity of 68%. Conclusions . This predictive model can facilitate identification of adults at risk for eLOS following elective multi-level lumbar/thoracolumbar spinal instrumented fusions for ASD. With a fair diagnostic accuracy, the predictive calculator will ideally enable clinicians to improve preoperative planning, guide patient expectations, enable optimization of modifiable risk factors, facilitate appropriate discharge planning, stratify financial risk, and accurately identify patients who may represent high-cost outliers. Future prospective studies that validate this risk assessment tool on external datasets would be valuable.
Chapter
The field of spine surgery has evolved appreciably over the past three decades, with many advances in instrumentation and technique. Spine surgery has many common operative procedures to treat radiculopathy, myelopathy, instability caused by degeneration or trauma, infection, and tumors. Surgical techniques include decompression of neural elements and stabilization through an anterior, posterior, or combined approach. The surgical complication rate is reported as 25% after cervical, 17% after thoracic, and 32% after lumbar spine procedures [1]. Deep venous thrombosis and pulmonary embolism are among the possible complications of spinal surgery [1–4].
Article
Study design: Population-based retrospective cohort study.Clinical question: Are patients with a body mass index (BMI) of 35 or more who undergo elective lumbar spine surgery at increased risk of post-surgical complications, as evidenced by reoperation within a 3-month period?Methods: The Alberta Health and Wellness Administrative database was queried to identify patients who underwent elective lumbar spine surgery over a 24-month period. This same database was used to classify subjects as obese (BMI ≥35) and non-obese (BMI <35) and to determine who underwent repeated surgical intervention. The rate of reoperation was determined for both the obese and non-obese groups; further analyses were performed to determine whether certain subjects were at increased risk of reoperation.Results: The point estimate for relative risk for requiring reoperation was 1.73 (95% confidence interval, 1.03-2.90) for obese subjects compared with non-obese subjects. The adjusted point estimate shows that deformity correction surgery is predictive for early reoperation while obesity is not.Conclusions: In obese subjects we observed an increased complication rate after elective lumbar spine surgery, as evidenced by reoperation rates within 3 months. When we considered other possible associations with reoperation, in adjusted analysis, deformity surgery was found to be predictive of early reoperation.Final class of evidence-prognosisStudy designProspective CohortRetrospective Cohort•Case controlCase seriesMethods Patients at similar point in course of treatment•F/U ≥ 85%•Similarity of treatment protocols for patient groups•Patients followed up long enough for outcomes to occur•Control for extraneous risk factorsOverall class of evidenceIIIThe definiton of the different classes of evidence is available on page 55.
Article
Study design: Survey based on complication scenarios. Objective: To assess and compare perceived potential impacts of various perioperative adverse events by both surgeons and patients. Summary of background data: Incidence of adverse events after adult spinal deformity surgery remains substantial. Patient-centered outcomes tools measuring the impact of these events have not been developed. An important first step is to assess the perceptions of surgeons and patients regarding the impact of these events on surgical outcome and quality of life. Methods: Descriptions of 22 potential adverse events of surgery (heart attack, stroke, spinal cord injury, nerve root injury, cauda equina injury, blindness, dural tear, blood transfusion, deep vein thrombosis, pulmonary embolism, superficial infection, deep infection, lung failure, urinary tract infection, nonunion, adjacent segment disease, persistent deformity, implant failure, death, renal failure, gastrointestinal complications, and sexual dysfunction) were presented to 14 spinal surgeons and 16 adult patients with spinal deformity. Impact scores were assigned to each complication on the basis of perceptions of overall severity, satisfaction with surgery, and effect on quality of life. Impact scores were compared between surgeons and patients with a Wilcoxon/Kruskal-Wallis test. Results: Mean impact scores varied from 0.9 (blood transfusion) to 10.0 (death) among surgeons and 2.3 (urinary tract infection) to 9.2 (stroke) among patients. Patients' scores were consistently higher (P < 0.05) than surgeons in all 3 categories for 6 potential adverse events: stroke, lung failure, heart attack, pulmonary embolism, dural tear, and blood transfusion. Three additional complications (renal failure, non-union, and deep vein thrombosis) were rated higher in 1 or 2 categories by patients. Conclusion: There was substantial variation in how both surgeons and patients perceived impacts of various adverse events after spine surgery. Patients generally perceived the impact of adverse events to be greater than surgeons. Patient-centered descriptions of adverse events would provide a more complete description of surgical outcomes.
Article
Background: Cervical spinal cord injury (SCI) has a well-established association with a high risk of respiratory complications. We sought to determine whether high-thoracic (HT) SCI was associated with a similar increased risk of respiratory complications and death. Methods: This was a retrospective cohort study of all adult patients with thoracolumbar injuries entered into the Pennsylvania Trauma System Foundation registry between January 1993 and December 2002. Records were reviewed for the documentation of respiratory complications (intubation, tracheostomy, bronchoscopy, pneumonia) and mortality. The data were then evaluated controlling for age, sex, Glasgow Coma Scale, and Injury Severity Score. Results: In all, 11,080 patients met inclusion criteria: 4,258 patients had thoracic spine fractures and 6,226 patients had lumbar spine fractures, all without SCI; and 596 patients had thoracic SCI (T1 to T6, 231; T7 to T12, 365). Respiratory complications occurred in 51.1% of patients with T1 to T6 SCI (versus 34.5% in T7 to T12 SCI and 27.5% in thoracic fractures). The need for intubation, the risk of pneumonia, and risk of death were significantly greater for patients with T1- to T6-level spinal cord injuries. Among patients with an Injury Severity Score less than 17 (n = 6427), the relative mortality risk was 26.7 times higher among those who developed respiratory complications (9.9% versus 0.4%). Conclusion: Compared with patients with low thoracic SCI or thoracolumbar fractures, patients with HT-SCI have an increased risk of pneumonia and death. Respiratory complications significantly increase the mortality risk in less severely injured patients. The current findings suggest that HT-SCI patients warrant intensive monitoring and aggressive pulmonary care and attention, similar to that given for patients with cervical SCI.
Article
A multicentric retrospective study on primary adult scoliosis patients operated on between 2002 and 2007. A 3-step statistical analysis was performed to describe the incidence of complications, the risk factors, and the reoperation risk with survival curves for the entire cohort. To describe complication rate and risk factors as well as survival curves associated with adult primary scoliosis surgery in patients aged 50 years or older. Adult deformity surgery is classically associated with a high rate of complications. The identification of risk factors for developing such complications is consequently of major interest as well as survival curves that can provide useful information on reoperation risks. Although many reports exist in the literature, the cohorts analyzed are often heterogeneous and the actual prevalence of complications varies widely. This study represents to our knowledge the largest series on adult patients aged 50 years or older operated for the first time for lumbar or thoracolumbar scoliosis and excluding every other possible diagnosis. A retrospective review of prospectively collected data from 6 centers in France. A total of 306 primary lumbar adult or degenerative scoliosis patients older than 50 years undergoing surgery between 2002 and 2007 were included. Demographics, comorbidities, x-ray parameters, surgical data, and complications were analyzed. Statistical analysis was performed to obtain correlations and risk factors for developing complications. Reoperation risk was calculated with Kaplan-Meier survival curves. A total of 306 patients aged 63 years (range, 50-83), with 83% women. Mean follow-up was 54 months. Mean Cumulative Illness Rating Scale score was 5 (range, 0-26). Main curve was 50° (range, 4-96) with apex between T12 and L2. Ten percent of patients had anterior surgery only, 18% had double anteroposterior approach, and 72% had posterior surgery only. Seventy-four percent (226 patients) had long fusions of 3 or more levels and 44% (134 patients) were fused to the sacrum. Forty percent (122 patients) had a decompression performed and 18% had an osteotomy. There were 175 complications for 119 patients (39%). No cases of death or blindness were reported. General complication rate was 13.7%, early infection occurred in 4% (12 patients), and late infection occurred in 1.2%. Neurological complications were present in 7% with 2 cases (0.6%) of late cord-level deficits and 12 reoperations (4%). Prevalence of mechanical complications was 24% (73 patients), with 58 patients (19%) needing a reoperation. Risk factors for mechanical or neurological complications were number of instrumented vertebra (P ≤ 0.01) fusion to the sacrum (P ≤ 0.001), pedicle subtraction osteotomy (PSO) (P = 0.01), and a high preoperative pelvic tilt of 26° or more (P ≤ 0.05). Kaplan-Meier survival curves showed reoperation risk of 44% at 70 months. Long fusion risk was 40% at 50 months and fusions to the sacrum reoperation risk was 48% at 49 months. Overall complication rate was 39%, and 26% of the patients were reoperated for mechanical or neurological complications. Risk factors include number of instrumented vertebra, fusion to the sacrum, PSO, and preoperative pelvic tilt of 26° or more. There is a 44% risk of a new operation in the 6-year-period after the primary procedure.
Article
Several studies have examined the occurrence of medical complication after spine surgery. However, many of these studies have been done using large national databases. Although these allow for analysis of thousands of patients, potentially influential covariates are not accounted for in these retrospective studies. Furthermore, the accuracy of these retrospective data collection in these databases has been called into question. Using multivariate analysis on a prospectively collected data registry to determine significant risk factors for medical complication after spine surgery. Retrospective multivariate analysis of prospectively collected registry data. The registry is a prospectively collected database of all patients who underwent spine surgery in our two institutions from January 1, 2003 to December 31, 2004. Extensive demographic and medical information were prospectively recorded as described previously by Mirza et al. Complications were defined in detail a priori, and they were prospectively recorded for at least 2 years after surgery. We analyzed risk factors for medical complication after spine surgery using univariate and multivariate analyses. We analyzed data from 1,591 patients who met out inclusion criteria. The cumulative incidences of complication after spine surgery per organ system are as follows: cardiac, 8.4%; pulmonary, 13%; gastrointestinal, 3.9%; neurological, 7.35%; hematological, 10.75%; and urological complications, 9.18%. The occurrence of cardiac or respiratory complication after spine surgery was significantly associated with death within 2 years (relative risk, 4.11 and 10.76, respectively). Surgical invasiveness and age were significant risk factors for complications in five of the six organ systems evaluated. Individual organ system-specific elative risk values with 95% confidence intervals and p values are listed in Tables 3 and 4. Risk factors identified in this study can be beneficial to clinicians and patients alike when considering surgical treatment of the spine. Future analyses and models that predict the occurrence of medical complication after spine surgery may be of further benefit for surgical decision making.
Article
Present attempts to control health care costs focus on reducing the incidence of complications and hospital-acquired conditions (HACs). One approach uses restriction or elimination of hospital payments for HACs. Present approaches assume that all HACs are created equal and that payment restrictions should be applied uniformly. Patient factors, and especially patient comorbidities, likely impact complication incidence. The relationship of patient comorbidities and complication incidence in spine surgery has not been prospectively reported. The authors conducted a prospective assessment of complications in spine surgery during a 6-month period; an independent auditor and a validated definition of perioperative complications were used. Initial demographics captured relevant patient comorbidities. The authors constructed a model of relative risk assessment based on the presence of a variety of comorbidities. They examined the impact of specific comorbidities and the cumulative effect of multiple comorbidities on complication incidence. Two hundred forty-nine patients undergoing 259 procedures at a tertiary care facility were evaluated during the 6-month duration of the study. Eighty percent of the patients underwent fusion procedures. One hundred thirty patients (52.2%) experienced at least 1 complication, with major complications occurring in 21.4% and minor complications in 46.4% of the cohort. Major complications doubled the median duration of hospital stay, from 6 to 12 days in cervical spine patients and from 7 to 14 days in thoracolumbar spine patients. At least 1 comorbid condition was present in 86% of the patients. An increasing number of comorbidities strongly correlated with increased risk of major, minor, and any complications (p = 0.017, p < 0.0001, and p < 0.0001, respectively). Patient factors correlating with increased risk of specific complications included systemic malignancy and cardiac conditions other than hypertension. Comorbidities significantly increase the risk of perioperative complications. An increasing number of comorbidities in an individual patient significantly increases the risk of a perioperative adverse event. Patient factors significantly impact the relative risk of HACs and perioperative complications.
Article
There have been few reports with regard to the life spans of medical doctors. The status of the medical doctors graduating from 1926 to 1974, alive or dead as of October 1996, was ascertained on the basis of the list of graduates from the School of Medicine, Hokkaido University. Excluding data on female doctors and those who died in battle during World War II, data on a total of 3,982 doctors were available for study. Their mortality as of October 1996 decreased in parallel with the graduation year. Their mean future life span at graduation was estimated to be about 52.88 years (95% CI, 52.45-53.31) through linear regression (r = 0.992). Their mean age at graduation was 25.17 years. This was not different from the future life expectancy at 25 years of age of the general population (52.35 years). The future life span of surgeons and gynecologists-obstetricians was shorter than that of the doctors of basic medical sciences and internal medicine. This difference might be accounted for by factors peculiar to each speciality (e.g., exposure to blood) or by the degree of stress from work.
Article
large studies of ICD-9-based complication and hospital-acquired condition (HAC) chart reviews have not been validated through a comparison with prospective assessments of perioperative adverse event occurrence. Retrospective chart review, while generally assumed to underreport complication occurrence, has not been subjected to prospective study. It is unclear whether ICD-9-based population studies are more accurate than retrospective reviews or are perhaps equally susceptible to bias. To determine the validity of an ICD-9-based assessment of perioperative complications, the authors compared a prospective independent evaluation of such complications with ICD-9-based HAC data in a cohort of patients who underwent spine surgery. For further comparison, a separate retrospective review of the same cohort of patients was completed as well. a prospective assessment of complications in spine surgery over a 6-month period (May to December 2008) was completed using an independent auditor and a validated definition of perioperative complications. The auditor maintained a prospective database, which included complications occurring in the initial 30 days after surgery. All medical adverse events were included in the assessment. All patients undergoing spine surgery during the study period were eligible for inclusion; the only exclusionary criterion used was the availability of the auditor for patient assessment. From the overall patient database, 100 patients were randomly extracted for further review; in these patients ICD-9-based HAC data were obtained from coder data. Separately, a retrospective assessment of complication incidence was completed using chart and electronic medical record review. The same definition of perioperative adverse events and the inclusion of medical adverse events were applied in the prospective, ICD-9-based, and retrospective assessments. ninety-two patients had adequate records for the ICD-9 assessment, whereas 98 patients had adequate chart information for retrospective review. The overall complication incidence among the groups was similar (major complications: ICD-9 17.4%, retrospective 19.4%, and prospective 22.4%; minor complications: ICD-9 43.8%, retrospective 31.6%, and prospective 42.9%). However, the ICD-9-based assessment included many minor medical events not deemed complications by the auditor. Rates of specific complications were consistently underreported in both the ICD-9 and the retrospective assessments. The ICD-9 assessment underreported infection, the need for reoperation, deep wound infection, deep venous thrombosis, and new neurological deficits (p = 0.003, p < 0.0001, p < 0.0001, p = 0.0025, and p = 0.04, respectively). The retrospective review underestimated incidences of infection, the need for revision, and deep wound infection (p < 0.0001 for each). Only in the capture of new cardiac events was ICD-9-based reporting more accurate than prospective data accrual (p = 0.04). The most sensitive measure for the appreciation of complication occurrence was the prospective review, followed by the ICD-9-based assessment (p = 0.05). an ICD-9-based coding of perioperative adverse events and major complications in a cohort of spine surgery patients revealed an overall complication incidence similar to that in a prospectively executed measure. In contrast, a retrospective review underestimated complication incidence. The ICD-9-based review captured many medical events of limited clinical import, inflating the overall incidence of adverse events demonstrated by this approach. In multiple categories of major, clinically significant perioperative complications, ICD-9-based and retrospective assessments significantly underestimated complication incidence. These findings illustrate a significant potential weakness and source of inaccuracy in the use of population-based ICD-9 and retrospective complication recording.
Article
The overall incidence of complications or adverse events in spinal surgery is unknown. Both prospective and retrospective analyses have been performed, but the results have not been critically assessed. Procedures for different regions of the spine (cervical and thoracolumbar) and the incidence of complications for each have been reported but not compared. Authors of previous reports have concentrated on complications in terms of their incidence relevant to healthcare providers: medical versus surgical etiology and the relevance of perioperative complications to perioperative events. Few authors have assessed complication incidence from the patient's perspective. In this report the authors summarize the spine surgery complications literature and address the effect of study design on reported complication incidence. A systematic evidence-based review was completed to identify within the published literature complication rates in spinal surgery. The MEDLINE database was queried using the key words "spine surgery" and "complications." This initial search revealed more than 700 articles, which were further limited through an exclusion process. Each abstract was reviewed and papers were obtained. The authors gathered 105 relevant articles detailing 80 thoracolumbar and 25 cervical studies. Among the 105 articles were 84 retrospective studies and 21 prospective studies. The authors evaluated the study designs and compared cervical, thoracolumbar, prospective, and retrospective studies as well as the durations of follow-up for each study. In the 105 articles reviewed, there were 79,471 patients with 13,067 reported complications for an overall complication incidence of 16.4% per patient. Complications were more common in thoracolumbar (17.8%) than cervical procedures (8.9%; p < 0.0001, OR 2.23). Prospective studies yielded a higher incidence of complications (19.9%) than retrospective studies (16.1%; p < 0.0001, OR 1.3). The complication incidence for prospective thoracolumbar studies (20.4%) was greater than that for retrospective series (17.5%; p < 0.0001). This difference between prospective and retrospective reviews was not found in the cervical studies. The year of study publication did not correlate with the complication incidence, although the duration of follow-up did correlate with the complication incidence (p = 0.001). Retrospective reviews significantly underestimate the overall incidence of complications in spine surgery. This analysis is the first to critically assess differing complication incidences reported in prospective and retrospective cervical and thoracolumbar spine surgery studies.
Article
The correlation between obesity and incidence of complications in spine surgery is unclear, with some reports suggesting linear relationships between body mass index (BMI) and complication incidence and others noting no relationship. The purpose of this article was to assess the relationship between obesity and occurrence of perioperative complications in an elective thoracolumbar surgery cohort. Prospective observational cohort study at a tertiary care facility. Cohort of 87 consecutive patients undergoing elective surgery for degenerative thoracolumbar pathologies over a 6-month period (May to December 2008). Incidence of perioperative complications (those occurring within 30 days of surgery). A prospective assessment of perioperative spine surgery complications was completed, and data were prospectively entered into a central database. Two independent auditors assessed for the presence and severity of perioperative complications. Previously validated binary definitions of major and minor complications were used. Patient data and early complications (those occurring within 30 days of index surgery) were analyzed using multivariate regression. Mean BMI in this cohort was 31.3; 40.8% of patients were obese (BMI>30) and 10 patients (11.5%) were morbidly obese (BMI>40). The overall complication incidence was 67%. Minor complications occurred in 50% of patients, and major complications occurred in 17.8% of patients. No positioning palsies occurred in this series. Age correlated with an increase in complication risk (p=.006) as did hypertension (p=.004) and performance of a fusion (p<.0001). BMI did not correlate with the incidence of minor, major, or any complications (p=.58). This prospective assessment of perioperative complications in elective degenerative thoracolumbar procedures shows no relationship between patient BMI and the incidence of perioperative minor or major complications. Specific care in perioperative positioning may limit the risk of perioperative positioning palsies in obese patients.