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Raisch P, Pflästerer J, Kreinest M, Vetter SY, Grützner PA, Jung MK. Adverse events after surgery for injuries to the subaxial cervical spine: analysis of incidence and risk factors. Eur J Trauma Emerg Surg 2024; 50:1153-1164. [PMID: 38363327 PMCID: PMC11249423 DOI: 10.1007/s00068-024-02458-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/22/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE To determine the incidence of severe surgical adverse events (sSAE) after surgery of patients with subaxial cervical spine injury (sCS-Fx) and to identify patient, treatment, and injury-related risk factors. METHODS Retrospective analysis of clinical and radiological data of sCS-Fx patients treated surgically between 2010 and 2020 at a single national trauma center. Baseline characteristics of demographic data, preexisting conditions, treatment, and injury morphology were extracted. Incidences of sSAEs within 60 days after surgery were analyzed. Univariate analysis and binary logistic regression for the occurrence of one or more sSAEs were performed to identify risk factors. P-values < .05 were considered statistically significant. RESULTS Two hundred and ninety-two patients were included. At least one sSAE occurred in 49 patients (16.8%). Most frequent were sSAEs of the surgical site (wound healing disorder, infection, etc.) affecting 29 patients (9.9%). Independent potential risk factors in logistic regression were higher age (OR 1.02 [1.003-1.04], p = .022), the presence of one or more modifiers in the AO Spine Subaxial Injury Classification (OR 2.02 [1.03-3.96], p = .041), and potentially unstable or unstable facet injury (OR 2.49 [1.24-4.99], p = .010). Other suspected risk factors were not statistically significant, among these Injury Severity Score, the need for surgery for concomitant injuries, the primary injury type according to AO Spine, and preexisting medical conditions. CONCLUSION sSAE rates after treatment of sCS-Fx are high. The identified risk factors are not perioperatively modifiable, but their knowledge should guide intra and postoperative care and surgical technique.
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Affiliation(s)
- Philipp Raisch
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Jan Pflästerer
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Michael Kreinest
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Sven Y Vetter
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Paul A Grützner
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany
| | - Matthias K Jung
- Clinic for Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen On the Rhine, Germany.
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Lee MJ, Weaver DJ, El Dafrawy MH. Extracranial Vertebral Artery Injuries. J Am Acad Orthop Surg 2024:00124635-990000000-01007. [PMID: 38810231 DOI: 10.5435/jaaos-d-24-00244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/28/2024] [Indexed: 05/31/2024] Open
Abstract
Paired vertebral arteries (VAs) travel from the subclavian artery through the cervical spine and into the intracranial space where they contribute to posterior cerebral circulation. Blunt and penetrating injuries to the cervical spine risk injury to the VA. Among the most feared complications of vertebral artery injury (VAI) is posterior circulation stroke. Appropriate screening and treatment of these injuries in the trauma setting remain vitally important to aid in the prevention of devastating neurologic sequelae. A robust knowledge of the VA anatomy is required for spine surgeons to avoid VAI during cervical spine approaches and instrumentation. Both anterior and posterior cervical spine surgeries can place the VA at risk. Careful preoperative assessment with the appropriate advanced imaging studies is necessary to verify the course of the VA in the cervical spine and thus prevent iatrogenic injury because anatomic variations along the course of the artery can prove hazardous if not properly anticipated. Iatrogenic VAI can be treated successfully with tamponade. However, in some cases, ligation, repair, or endovascular procedures may be indicated.
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Affiliation(s)
- Michael J Lee
- From the Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
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Baker SC, Lucasti C, Graham BC, Scott MM, Vallee EK, Kowalski D, Patel DV, Hamill CL. Predicting Complications in 153 Lumbar Pedicle Subtraction Osteotomies by a Single Surgeon Over a 6-Year Period. J Am Acad Orthop Surg 2024:00124635-990000000-01000. [PMID: 38787893 DOI: 10.5435/jaaos-d-23-01263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
INTRODUCTION Pedicle subtraction osteotomy (PSO) is a complex surgical procedure that provides correction of moderate sagittal imbalance. Surgical complications have adverse effects on patient outcomes and healthcare costs, making it imperative for clinical researchers to focus on minimizing complications. However, when it comes to risk modeling of PSO surgery, there is currently no consensus on which patient characteristics or measures should be used. This study aimed to describe complications and compare the performance of various sociodemographic characteristics, surgical variables, and established risk indices in predicting postoperative complications, infections, and readmissions after lumbar PSO surgeries. METHODS A review was conducted on 191 patients who underwent PSO surgery at a single institution by a single fellowship-trained orthopaedic spine surgeon between January 1, 2018, and December 31, 2021. Demographic, intraoperative, and postoperative data within 30 days, 1 year, and 2 years of the index procedure were evaluated. Descriptive statistics, t-test, chi-squared analysis, and logistic regression models were used. RESULTS Intraoperative complications were significantly associated with coronary artery disease (odds ratios [OR] 3.95, P = 0.03) and operating room time (OR 1.01, P = 0.006). 30-day complications were significantly cardiovascular disease (OR 2.68, P = 0.04) and levels fused (OR 1.10, P = 0.04). 2-year complications were significantly associated with cardiovascular disease (OR 2.85, P = 0.02). 30-day readmissions were significantly associated with sex (4.47, 0.04) and length of hospital stay (χ2 = 0.07, P = 0.04). 2-year readmissions were significantly associated with age (χ2 = 0.50, P = 0.03), hypertension (χ2 = 4.64, P = 0.03), revision surgeries (χ2 = 5.46, P = 0.02), and length of hospital stay (χ2 = 0.07, P = 0.03). DISCUSSION This study found that patients with coronary vascular disease and longer fusions were at higher risk of postoperative complications and patients with notable intraoperative blood loss were at higher risk of postoperative infections. In addition, physicians should closely follow patients with extended postoperative hospital stays, with advanced age, and undergoing revision surgery because these patients were more likely to be readmitted to the hospital.
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Affiliation(s)
- Seth C Baker
- From the Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY (Baker, Graham, Scott, and Vallee), and the UBMD Orthopaedics and Sports Medicine Doctors, Buffalo, NY (Lucasti, Kowalski, Patel, and Hamill)
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Lenga P, Dao Trong P, Papakonstantinou V, Unterberg AW, Ishak B. A Comprehensive Prospective Analysis of Surgical Outcomes and Adverse Events in Spinal Procedures Among Octogenarians: A Detailed Analysis From a German Tertiary Center. Global Spine J 2024:21925682241250328. [PMID: 38679888 DOI: 10.1177/21925682241250328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
STUDY DESIGN Prospective case series. OBJECTIVES Drawing from prospective data, this study delves into the frequency and nature of adverse events (AEs) following spinal surgery specifically in octogenarians, shedding light on the challenges and implications of treating this specific cohort as well as on risk factors for their occurrence. METHODS Octogenarians who received spinal surgery and were discharged between January 2019 and December 2022 were proactively included in our study. An AE was characterized as any incident transpiring within the initial 30 days after surgery that led to an unfavorable outcome. RESULTS From January 2020 to December 2022, 184 octogenarian patients (average age: 83.1 ± 2.8 years) underwent spinal surgeries. Of these, 81.5% were elective and 18.5% were emergencies, with 69.0% addressing degenerative pathologies. Using the Charlson Comorbidity Index, the mean score was 8.1 ± 2.2, highlighting cardiac diseases as predominant. Surgical details show 71.2% had decompression, with 28.8% receiving instrumentation. AEs included wound infections 3.1% for degenerative, 13.3% for tumor and dural leaks. The overall incidence of dural leaks was found to be 2.7% (5/184 cases), and each case underwent surgical revision. Pulmonary embolism resulted in two fatalities post-trauma. Wound infections (26.7%) were prevalent in infected spine cases. Significant AE risk factors were comorbidities, extended surgery durations, and instrumentation procedures. CONCLUSIONS In octogenarian spinal surgeries, AEs occurred in 15.8% of cases, influenced by comorbidities and surgical complexities. The 2.2% mortality rate wasn't linked to surgeries. Accurate documentation remains crucial for assessing outcomes in this age group.
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Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Philip Dao Trong
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Tan H, Yamamoto EA, Smith S, Yoo J, Kark J, Lin C, Orina J, Philipp T, Ross DA, Wright C, Wright J, Ryu WHA. Characterizing utilization patterns and reoperation risk factors of interspinous process devices: analysis of a national claims database. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:283-290. [PMID: 38065695 DOI: 10.1093/pm/pnad159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Interspinous process devices (IPDs) were developed as minimally invasive alternatives to open decompression surgery for spinal stenosis. However, given high treatment failure and reoperation rates, there has been minimal adoption by spine surgeons. This study leveraged a national claims database to characterize national IPD usage patterns and postoperative outcomes after IPD implantation. METHOD Using the PearlDiver database, we identified all patients who underwent 1- or 2-level IPD implantation between 2010 and 2018. Univariate and multivariable logistic regression was performed to identify predictors of the number of IPD levels implanted and reoperation up to 3 years after the index surgery. Right-censored Kaplan-Meier curves were plotted for duration of reoperation-free survival and compared with log-rank tests. RESULTS Patients (n = 4865) received 1-level (n = 3246) or 2-level (n = 1619) IPDs. Patients who were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.01-1.03, P < .001), male (aOR 1.31, 95% CI 116-1.50, P < .001), and obese (aOR 1.19, 95% CI 1.05-1.36, P < .01) were significantly more likely to receive a 2-level IPD than to receive a 1-level IPD. The 3-year reoperation rate was 9.3% of patients when mortality was accounted for during the follow-up period. Older age decreased (aOR 0.97, 95% CI 0.97-0.99, P = .0039) likelihood of reoperation, whereas 1-level IPD (aOR 1.37, 95% CI 1.01-1.89, P = .048), Charlson Comorbidity Index (aOR 1.07, 95% CI 1.01-1.14, P = .018), and performing concomitant open decompression increased the likelihood of reoperation (aOR 1.68, 95% CI 1.35-2.09, P = .0014). CONCLUSION Compared with 1-level IPDs, 2-level IPDs were implanted more frequently in older, male, and obese patients. The 3-year reoperation rate was 9.3%. Concomitant open decompression with IPD placement was identified as a significant risk factor for subsequent reoperation and warrants future investigation.
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Affiliation(s)
- Hao Tan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, United States
| | - Erin A Yamamoto
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, United States
| | - Spencer Smith
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, Portland, OR 97239, United States
| | - Jung Yoo
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, Portland, OR 97239, United States
| | - Jonathan Kark
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, Portland, OR 97239, United States
| | - Clifford Lin
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, Portland, OR 97239, United States
| | - Josiah Orina
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, United States
| | - Travis Philipp
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, Portland, OR 97239, United States
| | - Donald A Ross
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, United States
| | - Christina Wright
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, United States
| | - James Wright
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, United States
| | - Won Hyung A Ryu
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, United States
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Cottone C, Kim D, Lucasti C, Scott MM, Graham BC, Aronoff N, Hasanspahic B, Kowalski D, Bird J, Patel D. Causes of Intraoperative Neuromonitoring Events in Adult Spine Deformity Surgery: A Systematic Review. Global Spine J 2024:21925682241242693. [PMID: 38532704 DOI: 10.1177/21925682241242693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Intraoperative neuromonitoring (IOMN) has become a standard practice in the detection and prevention of nerve damage and postoperative deficit. While multicenter studies have addressed this inquiry, there have been no systematic reviews to date. This systematic review identifies the leading causes of IONM alerts during adult spinal deformity (ASD) surgeries. METHODS Following PRISMA guidelines, a literature search was performed in PubMed and Embase. IONM alert causes were grouped by equivalent terms used across different studies and binned into larger categories, including surgical maneuver, Changes in blood pressure/temperature, Oxygenation, Anesthesia, Patient position, and Unknown. RESULTS Inclusion criteria were studies on adult patients receiving ASD correction surgery using IONM with documented alert causes. 1544 references were included in abstract review, 128 in full text review, and 16 studies qualified for data extraction. From those studies, there was a total of 3945 adult patients with 299 IONM alerts. Surgical maneuver led the alert causes (258 alerts/86.3%), with signal loss most commonly occurring at correction or osteotomy (101/33.8% and 95/31.8% respectively). Pedicle screw placement caused 35 alerts (11.7%). Changes in temperature and blood pressure were the third largest category (34/11.4%). CONCLUSIONS The most frequent causes of IONM alerts in ASD surgery were surgical maneuvers such as correction, osteotomy, and pedicle screw placement. This information provides spine surgeons with a quantitative perspective on the causes of IONM changes and show that most occur at predictable times during ASD surgery.
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Affiliation(s)
- Chloe Cottone
- Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
| | - David Kim
- Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
| | - Christopher Lucasti
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
| | - Maxwell M Scott
- Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
| | - Benjamin C Graham
- Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
| | - Nell Aronoff
- University Libraries, University at Buffalo, Buffalo, NY, USA
| | - Bilal Hasanspahic
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
| | - David Kowalski
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
| | - Justin Bird
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
| | - Dil Patel
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, USA
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Naqeeb MR, Naser AY. Postprocedural Disorders of Eye and Adnexa Admissions Profile. CLINICAL OPTOMETRY 2023; 15:261-270. [PMID: 37937276 PMCID: PMC10627053 DOI: 10.2147/opto.s437044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023]
Abstract
Purpose The aim of this study was to examine hospitalisation profiles related to postprocedural disorders of eye and adnexa in England and Wales. Patients and Methods This was an ecological study using publicly available data extracted from the "Hospital Episode Statistics (HES) database" in England and the "Patient Episode Database for Wales (PEDW)" for the period between April 1999 and April 2020. Diagnostic code for postprocedural disorders of eye and adnexa (H59) was used to identify hospital admission. We used the chi-squared test to assess the difference between the hospital admission rates between 1999 and 2020. Results Hospital admission rate decreased by 6.3% [from 4.98 (95% CI 4.79-5.17) in 1999 to 4.67 (95% CI 4.50-4.84) in 2020 per 100,000 persons, trend test, p<0.05]. The most common hospital admissions causes were other postprocedural disorders of eye and adnexa "Chorioretinal scars after surgery for detachment." The age group 75 years and above accounted for 44.3% of the total number of admissions. Hospital admission rate among females decreased by 30.2% [from 5.90 (95% CI 5.61-6.19) in 1999 to 4.12 (95% CI 3.89-4.35) in 2020 per 100,000 persons]. Hospital admission rate among males increased by 30.2% [from 4.02 (95% CI 3.77-4.26) in 1999 to 5.23 (95% CI 4.97-5.49) in 2020 per 100,000 persons]. Conclusion This study revealed that hospital admission rates for postprocedural disorders of the eye and adnexa decreased over the course of the study period. Eye and adnexa disorders accounted for the preponderance of hospital admissions among the elderly. Further research is required to identify risk factors that can be avoided.
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Affiliation(s)
| | - Abdallah Y Naser
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
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Sarwahi V, Hasan S, Rao H, Visahan K, Grunfeld M, Dzaugis P, Wendolowski S, Vora R, Galina J, Lo Y, Moguilevitch M, Thornhill B, Amaral T, DiMauro JP. Does a dedicated "Scoliosis Team" and surgical standardization improve outcomes in adolescent idiopathic scoliosis surgery and is it reproducible? Spine Deform 2023; 11:1409-1418. [PMID: 37507585 DOI: 10.1007/s43390-023-00728-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE The objective of this study was to determine if standardization improves adolescent idiopathic scoliosis (AIS) surgery outcomes and whether it is transferrable between institutions. METHODS A retrospective review was conducted of AIS patients operated between 2009 and 2021 at two institutions (IA and IB). Each institution consisted of a non-standardized (NST) and standardized group (ST). In 2015, surgeons changed institutions (IA- > IB). Reproducibility was determined between institutions. Median and interquartile ranges (IQR), Kruskal-Wallis, and χ2 tests were used. RESULTS 500 consecutive AIS patients were included. Age (p = 0.06), body mass index (p = 0.74), preoperative Cobb angle (p = 0.53), and levels fused (p = 0.94) were similar between institutions. IA-ST and IB-ST had lower blood loss (p < 0.001) and shorter surgical time (p < 0.001). IB-ST had significantly shorter hospital stay (p < 0.001) and transfusion rate (p = 0.007) than IB-NST. Standardized protocols in IB-ST reduced costs by 18.7%, significantly lowering hospital costs from $74,794.05 in IB-NST to $60,778.60 for IB-ST (p < 0.001). Annual analysis of surgical time revealed while implementation of standardized protocols decreased operative time within IA, when surgeons transitioned to IB, and upon standardization, IB operative time values decreased once again, and continued to decrease annually. Additions to standardized protocol in IB temporarily affected the operative time, before stabilizing. CONCLUSION Surgeon-led standardized AIS approach and streamlined surgical steps improve outcomes and efficiency, is transferrable between institutions, and adjusts to additional protocol changes.
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Affiliation(s)
- Vishal Sarwahi
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA.
| | - Sayyida Hasan
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Himanshu Rao
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Keshin Visahan
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | | | - Peter Dzaugis
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Stephen Wendolowski
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Rushabh Vora
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Jesse Galina
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Yungtai Lo
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | - Terry Amaral
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
| | - Jon-Paul DiMauro
- Billie and George Ross Center for Advanced Pediatric Orthopaedics and Minimally Invasive Spinal Surgery, Cohen Children's Medical Center, Northwell Hofstra School of Medicine, 7 Vermont Drive, Lake Success, New Hyde Park, NY, 11042, USA
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Rampersaud YR, Sundararajan K, Docter S, Perruccio AV, Gandhi R, Adams D, Briggs N, Davey JR, Fehlings M, Lewis SJ, Magtoto R, Massicotte E, Sarro A, Syed K, Mahomed NN, Veillette C. Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study. BMC Health Serv Res 2023; 23:1150. [PMID: 37880706 PMCID: PMC10598977 DOI: 10.1186/s12913-023-10055-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 09/23/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries. METHODS Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors. RESULTS The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs. CONCLUSIONS This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.
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Affiliation(s)
- Y Raja Rampersaud
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada.
- Krembil Research Institute, University Health Network, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada.
| | - Kala Sundararajan
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Shgufta Docter
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - Anthony V Perruccio
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Rajiv Gandhi
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Diana Adams
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - Natasha Briggs
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - J Rod Davey
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael Fehlings
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Stephen J Lewis
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Rosalie Magtoto
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Eric Massicotte
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Angela Sarro
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Khalid Syed
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nizar N Mahomed
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christian Veillette
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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10
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Drexler R, Ricklefs FL, Pantel T, Göttsche J, Nitzschke R, Zöllner C, Westphal M, Dührsen L. Association of the classification of intraoperative adverse events (ClassIntra) with complications and neurological outcome after neurosurgical procedures: a prospective cohort study. Acta Neurochir (Wien) 2023; 165:2015-2027. [PMID: 37407852 PMCID: PMC10409660 DOI: 10.1007/s00701-023-05672-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE To analyze the reliability of the classification of intraoperative adverse events (ClassIntra) to reflect intraoperative complications of neurosurgical procedures and the potential to predict the postoperative outcome including the neurological performance. The ClassIntra classification was recently introduced and found to be reliable for assessing intraoperative adverse events and predicting postoperative complications across different surgical disciplines. Nevertheless, its potential role for neurosurgical procedures remains elusive. METHODS This is a prospective, monocentric cohort study assessing the ClassIntra in 422 adult patients who underwent a neurosurgical procedure and were hospitalized between July 1, 2021, to December 31, 2021. The primary outcome was the occurrence of intraoperative complications graded according to ClassIntra and the association with postoperative outcome reflected by the Clavien-Dindo classification and comprehensive complication index (CCI). The ClassIntra is defined as intraoperative adverse events as any deviation from the ideal course on a grading scale from grade 0 (no deviation) to grade V (intraoperative death) and was set at sign-out in agreement between neurosurgeon and anesthesiologist. Secondary outcomes were the neurological outcome after surgery as defined by Glasgow Coma Scale (GCS), modified Rankin scale (mRS), Neurologic Assessment in Neuro-Oncology (NANO) scale, National Institute Health of Strokes Scale (NIHSS), and Karnofsky Performance Score (KPS), and need for unscheduled brain scan. RESULTS Of 442 patients (mean [SD] age, 56.1 [16.2]; 235 [55.7%] women and 187 [44.3%] men) who underwent a neurosurgical procedure, 169 (40.0%) patients had an intraoperative adverse event (iAE) classified as ClassIntra I or higher. The NIHSS score at admission (OR, 1.29; 95% CI, 1.03-1.63, female gender (OR, 0.44; 95% CI, 0.23-0.84), extracranial procedures (OR, 0.17; 95% CI, 0.08-0.61), and emergency cases (OR, 2.84; 95% CI, 1.53-3.78) were independent risk factors for a more severe iAE. A ClassIntra ≥ II was associated with increased odds of postoperative complications classified as Clavien-Dindo (p < 0.01), neurological deterioration at discharge (p < 0.01), prolonged hospital (p < 0.01), and ICU stay (p < 0.01). For elective craniotomies, severity of ClassIntra was associated with the CCI (p < 0.01) and need for unscheduled CT or MRI scan (p < 0.01). The proportion of a ClassIntra ≥ II was significantly higher for emergent craniotomies (56.2%) and associated with in-hospital mortality, and an unfavorable neurological outcome (p < 0.01). CONCLUSION Findings of this study suggest that the ClassIntra is sensitive for assessing intraoperative adverse events and sufficient to identify patients with a higher risk for developing postoperative complications after a neurosurgical procedure.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Nitzschke
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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11
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Yearley AG, Chalif JI, Zaidi HA. Utility of Expandable Interbody Cages in Open Transforaminal Interbody Fusions: A Comparison With Static Cages. Cureus 2023; 15:e40262. [PMID: 37440805 PMCID: PMC10335839 DOI: 10.7759/cureus.40262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/15/2023] Open
Abstract
Background Expandable interbody cages, while popular in minimally invasive fusions due to their slim profile and increased ease of insertion, have not been widely explored in open surgery. The benefits of expandable cages may also extend to open fusions through their potential to achieve a greater restoration of lumbar lordosis while minimizing intraoperative complications. To highlight these benefits, we present a case series of adult spinal deformity (ASD) patients treated with an open transforaminal lumbar interbody fusion (TLIF) using expandable cages and compare outcomes to those of patients treated with static cages from the literature. Methods A retrospective cohort study of patients who underwent a deformity correction procedure and TLIF with expandable interbody cages at Brigham and Women's Hospital between 2018 and 2022 was conducted. Patient demographics, complications, and pre- and postoperative radiographic parameters of spinopelvic alignment were collected. A literature search was completed to identify studies employing static cages. T-tests were performed to compare postoperative changes in radiographic parameters by cage type. Results Forty-five patients (mean age of 62.6 years) with an average of 2.1 cages placed met the inclusion criteria. Patients experienced five intraoperative complications and 23 neurologic deficits (from minor to major), while nine patients required a revision operation. Lumbar lordosis increased by 9.8° ± 14.5° (p < 0.0001), the sagittal vertical axis (SVA) decreased by 25.5 mm ± 56.7 mm (p = 0.0048), and pelvic incidence-lumbar lordosis mismatch decreased by 13.3° ± 17.5° (p < 0.0001) with the use of expandable cages. Expandable cages yielded similar changes in lumbar lordosis to 15° and 8° cages but improved the lumbar lordosis generated from rectangular and 4° cages. When compared to static cages, expandable cages mildly reduced intraoperative complications. Conclusions Expandable interbody cages are an effective means of restoring spinopelvic alignment in ASD that have the potential to improve patient outcomes in open fusions compared to standard static cages. Especially when compared to rectangular and 4° static cages, expandable cages provide a clear benefit in the correction of lumbar lordosis. The impact of open spinal fusions with expandable cages on outcomes should continue to be explored in other cohorts.
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Affiliation(s)
- Alexander G Yearley
- Department of Neurological Surgery, Harvard Medical School, Boston, USA
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, USA
| | - Joshua I Chalif
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, USA
| | - Hasan A Zaidi
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, USA
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Risk factors of early complications after thoracic and lumbar spinal deformity surgery: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:899-913. [PMID: 36611078 DOI: 10.1007/s00586-022-07486-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/07/2022] [Accepted: 12/04/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE To determine risk factors increasing susceptibility to early complications (intraoperative and postoperative within 6 weeks) associated with surgery to correct thoracic and lumbar spinal deformity. METHODS We systematically searched the PubMed and EMBASE databases for studies published between January 1990 and September 2021. Observational studies evaluating predictors of early complications of thoracic and lumbar spinal deformity surgery were included. Pooled odds ratio (OR) or standardized mean difference (SMD) with 95% confidence intervals (CI) was calculated via the random effects model. RESULTS Fifty-two studies representing 102,432 patients met the inclusion criteria. Statistically significant patient-related risk factors for early complications included neurological comorbidity (OR = 3.45, 95% CI 1.83-6.50), non-ambulatory status (OR = 3.37, 95% CI 1.96-5.77), kidney disease (OR = 2.80, 95% CI 1.80-4.36), American Society of Anesthesiologists score > 2 (OR = 2.23, 95% CI 1.76-2.84), previous spine surgery (OR = 1.98, 95% CI 1.41-2.77), pulmonary comorbidity (OR = 1.94, 95% CI 1.21-3.09), osteoporosis (OR = 1.60, 95% CI 1.17-2.20), cardiovascular diseases (OR = 1.46, 95% CI 1.20-1.78), hypertension (OR = 1.37, 95% CI 1.23-1.52), diabetes mellitus (OR = 1.84, 95% CI 1.30-2.60), preoperative Cobb angle (SMD = 0.43, 95% CI 0.29, 0.57), number of comorbidities (SMD = 0.41, 95% CI 0.12, 0.70), and preoperative lumbar lordotic angle (SMD = - 0.20, 95% CI - 0.35, - 0.06). Statistically significant procedure-related factors were fusion extending to the sacrum or pelvis (OR = 2.53, 95% CI 1.53-4.16), use of osteotomy (OR = 1.60, 95% CI 1.12-2.29), longer operation duration (SMD = 0.72, 95% CI 0.05, 1.40), estimated blood loss (SMD = 0.46, 95% CI 0.07, 0.85), and number of levels fused (SMD = 0.37, 95% CI 0.03, 0.70). CONCLUSION These data may contribute to development of a systematic approach aimed at improving quality-of-life and reducing complications in high-risk patients.
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13
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Najjar E, Hassanin MA, Komaitis S, Karouni F, Quraishi N. Complications after early versus late mobilization after an incidental durotomy: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:778-786. [PMID: 36609888 DOI: 10.1007/s00586-023-07526-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/02/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND An incidental durotomy (IDT) is a frequent complication of spinal surgery. The conventional management involving a period of flat bed rest is highly debatable. Indeed, there are scanty data and no consensus regarding the need or ideal duration of post-operative bed rest following IDT. OBJECTIVE To systematically evaluate the literature regarding the outcomes of mobilization within 24 h and after 24 h following IDT in open lumbar or thoracic surgery with respect to the length of hospital stay, minor and major complications. METHODS A systematic review of the literature using PubMed, Embase and Cochrane and dating up until September 2022 was undertaken following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. RESULTS Out of 532 articles, 6 studies met the inclusion criteria (1 Level-I, 4 level-III and 1 Level-IV evidence) and were analyzed. Overall, 398 patients of mean age 59.9 years were mobilized within 24 h. The average length of stay (LOS) for this group was 5.7 days. Thirty-four patients (8.5%) required reoperation while the rate of minor complications was 25.4%. Additionally, 265 patients of mean age 63 years with IDT were mobilized after 24 h. The average LOS was 7.8 days. Twenty patients (7.54%) required reoperation while the rate of minor complications was 55%. Meta-analysis comparing early to late mobilization, showed a significant reduction in the risk of minor complications and shorter overall LOS due to early mobilization, but no significant difference in major complications and reoperation rates. CONCLUSIONS Although early mobilization after repaired incidental dural tears in open lumbar and thoracic spinal surgery has a similar major complication/ reoperation rates compared to late mobilization, it significantly decreases the risk of minor complications and length of hospitalization.
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Affiliation(s)
- Elie Najjar
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Mohamed A Hassanin
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.,Department of Orthopedic Surgery, Assiut University, Asyut, Egypt
| | - Spyridon Komaitis
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - Faris Karouni
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Nasir Quraishi
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
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14
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Timon C, Lee M, Feeley I, Quinlan J. Recording adverse events following orthopaedic trauma: Financial implications and validation of an adverse event assessment form in an Irish regional trauma unit. Injury 2023; 54:508-512. [PMID: 36414501 DOI: 10.1016/j.injury.2022.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/27/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND In Ireland, funding of orthopaedic trauma is based on an activity-based funding (ABF) model. Clinically similar cases are split into diagnostic-related groups (DRG), with base funding per DRG provided. Increased complexity of cases (length of stay; complications incurred; occurrence of adverse events) attracts additional remuneration to the base funding. In our institution these adverse events are recorded via retrospective chart-abstraction methods by administrative staff. Incidences which are not included from this review affect both follow up with family physicians and patient care; as well as skewing budgetary decisions that impact fiscal viability of the service. The aim of this study was to compare a prospectively implemented adverse events form with the current national retrospective chart abstraction method. Our outcomes in terms of pay-by-results financial implications. METHODS An adverse events database adapted from a similar validated model was used to prospectively record complications in 216 patients admitted via the orthopaedic trauma service. Data was contemporaneously collected via a GDPR compliant secure medical messaging platform. Results were compared with the same cohort using an existing data abstraction method. Both data sets were coded in accordance with current standards for case funding. RESULTS Overall, 49 adverse events were recorded during the study through prospective charting of adverse events, compared with 26 events documented by customary method (p<0.01).Anaemia requiring blood transfusion n = 11 22.4%) was the most common complication, followed by delirium n = 6 (12%), acute kidney injury n = 6 (12%), and pneumonia n = 5 (10.2%). Missed appropriate funding through conventional methods totalled €40,293 . CONCLUSION This pilot study demonstrates the ability to improve capture of adverse events through use of a well-designed assessment form. Proper perioperative data handling is a critical aspect of financial subsidies, enabling optimal allocation of funds.
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Affiliation(s)
- Charlie Timon
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - Matthew Lee
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland
| | - Iain Feeley
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland
| | - John Quinlan
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland
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15
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Yamanouchi K, Takano S, Mima Y, Matsunaga T, Ohnishi K, Matsumoto M, Nakamura M, Shimono T, Yagi M. Validation of a surgical drill with a haptic interface in spine surgery. Sci Rep 2023; 13:598. [PMID: 36635361 PMCID: PMC9837054 DOI: 10.1038/s41598-023-27467-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 01/02/2023] [Indexed: 01/14/2023] Open
Abstract
Real haptics is a technology that reproduces the sense of force and touch by transmitting contact information with real objects by converting human movements and the feel of the objects into data. In recent years, real haptics technology has been installed in several surgical devices. A custom-made surgical drill was used to drill into the posterior lamina to verify the time required for penetration detection and the distance the drill advanced after penetration. A surgeon operated with the drill and the same aspects were measured and verified. All experiments were performed on female miniature pigs at 9 months of age with a mean body weight of 23.6 kg (range 9-10 months and 22.5-25.8 kg, n = 12). There were statistically significant differences in the average reaction time and the distance travelled after penetration between a handheld drill and the drill with the penetration detection function (p < 0.001). The reaction time to detect penetration and the distance after penetration were both significantly improved when compared with those of the handheld surgical drill without the penetration detection function, with mean differences of 0.049 ± 0.019 s [95% CI 0.012, 0.086 s] and 2.511 ± 0.537 mm [95% CI 1.505, 3.516 mm]. In this study, we successfully conducted a performance evaluation test of a custom-made haptic interface surgical drill. A prototype high-speed drill with a haptic interface accurately detected the penetration of the porcine posterior lamina.
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Affiliation(s)
- Kento Yamanouchi
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, Japan
| | - Shunya Takano
- Kanagawa Institute of Industrial Science and Technology, Kawasaki, Japan
| | - Yuichiro Mima
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, Japan
| | - Takuya Matsunaga
- Kanagawa Institute of Industrial Science and Technology, Kawasaki, Japan
| | - Kouhei Ohnishi
- Keio Frontier Research and Education Collaborative Square, Keio University, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, Japan
| | - Tomoyuki Shimono
- Kanagawa Institute of Industrial Science and Technology, Kawasaki, Japan.
- Faculty of Engineering, Yokohama National University, 79-5 Tokiwadai, Hodogaya-Ku, Yokohama, 240-8501, Japan.
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, Japan.
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16
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Broggi M, Ferroli P, Schiavolin S, Zattra C, Schiariti M, Acerbi F, Caldiroli D, Raggi A, Vetrano I, Falco J, de Laurentis C, Broggi G. Surgical Complexity and Complications: The Need for a Common Language. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:1-12. [PMID: 37548717 DOI: 10.1007/978-3-030-12887-6_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Quality measurement and outcome assessment have recently caught an attention of the neurosurgical community, but lack of standardized definitions and methodology significantly complicates these tasks. OBJECTIVE To identify a uniform definition of neurosurgical complications, to classify them according to etiology, and to evaluate them comprehensively in cases of intracranial tumor removal in order to establish a new, easy, and practical grading system capable of predicting the risk of postoperative clinical worsening of the patient condition. METHODS A retrospective analysis was conducted on all elective surgeries directed at removal of intracranial tumor in the authors' institution during 2-year study period. All sociodemographic, clinical, and surgical factors were extracted from prospectively compiled comprehensive patient registry. Data on all complications, defined as any deviation from the ideal postoperative course occurring within 30 days of the procedure, were collected with consideration of the required treatment and etiology. A logistic regression model was created for identification of independent factors associated with worsening of the Karnofsky Performance Scale (KPS) score at discharge after surgery in comparison with preoperative period. For each identified statistically significant independent predictor of the postoperative worsening, corresponding score was defined, and grading system, subsequently named Milan Complexity Scale (MCS), was formed. RESULTS Overall, 746 cases of surgeries for removal of intracranial tumor were analyzed. Postoperative complications of any kind were observed in 311 patients (41.7%). In 223 cases (29.9%), worsening of the KPS score at the time of discharge in comparison with preoperative period was noted. It was independently associated with 5 predictive factors-major brain vessel manipulation, surgery in the posterior fossa, cranial nerve manipulation, surgery in the eloquent area, tumor size >4 cm-which comprised MCS with a range of the total score from 0 to 8 (higher score indicates more complex clinical situations). Patients who demonstrated KPS worsening after surgery had significantly higher total MCS scores in comparison with individuals whose clinical status at discharge was improved or unchanged (3.24 ± 1.55 versus 1.47 ± 1.58; P < 0.001). CONCLUSION It is reasonable to define neurosurgical complication as any deviation from the ideal postoperative course occurring within 30 days of the procedure. Suggested MCS allows for standardized assessment of surgical complexity before intervention and for estimating the risk of clinical worsening after removal of intracranial tumor. Collection of data on surgical complexity, occurrence of complications, and postoperative outcomes, using standardized prospectively maintained comprehensive patient registries seems very important for quality measurement and should be attained in all neurosurgical centers.
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Affiliation(s)
- Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvia Schiavolin
- Neurology, Public Health and Disability Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Costanza Zattra
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Dario Caldiroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alberto Raggi
- Neurology, Public Health and Disability Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ignazio Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Camilla de Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanni Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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17
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Garg B, Bansal T, Mehta N. Three-column osteotomy by single-stage posterior approach in congenital and post-tubercular kyphosis: a comparison of outcomes. Spine Deform 2022; 10:883-892. [PMID: 35277838 DOI: 10.1007/s43390-022-00491-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/19/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK). METHODS The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24 months. RESULTS Patients in Group CK (median: 13 years, range: 4-30 years) presented earlier than those in Group PTK (median: 16 years, range: 6-45 years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5 min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2 ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24 months (p < 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group. CONCLUSION Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Tungish Bansal
- Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India. .,Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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18
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González-Vargas PM, Calero Félix L, Martín-Gallego Á, Thenier-Villa JL, de la Lama Zaragoza AR, Conde Alonso C. Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:71-81. [PMID: 35248301 DOI: 10.1016/j.neucie.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/10/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control. METHODS The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification. RESULTS 92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05). CONCLUSION The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.
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Affiliation(s)
- Pedro Miguel González-Vargas
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain.
| | - Lourdes Calero Félix
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Álvaro Martín-Gallego
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - José Luis Thenier-Villa
- Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain; Department of Neurosurgery, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Adolfo Ramón de la Lama Zaragoza
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
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Le HV, Wick JB, Lafage R, Kelly MP, Kim HJ, Gupta MC, Bess S, Burton DC, Ames CP, Smith JS, Shaffrey CI, Schwab FJ, Passias PG, Protopsaltis TS, Lafage V, Klineberg EO. Surgical Factors and Treatment Severity for Perioperative Complications Predict Hospital Length of Stay in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2022; 47:136-143. [PMID: 34889884 DOI: 10.1097/brs.0000000000004122] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected multicenter registry data. OBJECTIVE The aim of this study was to determine whether surgical variables and complications as graded by treatment severity impact postoperative hospital length of stay (LOS). SUMMARY OF BACKGROUND DATA Surgical treatment can substantially improve quality of life for patients with adult spinal deformity (ASD). However, surgical treatment is associated with high complication rates, which may impact hospital LOS. Classifying complications by severity of subsequent treatment may allow surgeons to better understand complications and predict their impact on important outcome metrics, including LOS. METHODS Patients enrolled in a multicenter, prospectively enrolled database for ASD were assessed for study inclusion. Complications were graded based on intervention severity. Associations between LOS, complication intervention severity, and surgical variables (fusion length, use of interbody fusion, use of major osteotomy, primary versus revision surgery, same day vs. staged surgery, and surgical approach), were assessed. Two multivariate regression models were constructed to assess for independent associations with LOS. RESULTS Of 1183 patients meeting inclusion criteria, 708 did not and 475 did experience a perioperative complication during their index hospitalization, with 660 and 436 included in the final cohorts, respectively. Among those with complications, intervention severities included 14.9% with no intervention, 68.6% with minor, 8.9% with moderate, and 7.6% with severe interventions. Multivariate regression modeling demonstrated that length of posterior fusion, use of major osteotomy, staged surgery, and severity of intervention for complications were significantly associated with LOS. CONCLUSION Careful selection of surgical factors may help reduce hospital LOS following surgery for ASD. Classification of complications by treatment severity can help surgeons better understand and predict the implications of complications, in turn assisting with surgical planning and patient counseling.Level of Evidence: 4.
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Affiliation(s)
- Hai V Le
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA
| | - Joseph B Wick
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA
| | | | - Michael P Kelly
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/ Rocky Mountain Hospital for Children, Denver, CO
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, KS
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | | | | | - Peter G Passias
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | | | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA
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20
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Ayling OGS, Charest-Morin R, Eagles ME, Ailon T, Street JT, Dea N, McIntosh G, Christie SD, Abraham E, Jacobs WB, Bailey CS, Johnson MG, Attabib N, Jarzem P, Weber M, Paquet J, Finkelstein J, Stratton A, Hall H, Manson N, Rampersaud YR, Thomas K, Fisher CG. National adverse event profile after lumbar spine surgery for lumbar degenerative disorders and comparison of complication rates between hospitals: a CSORN registry study. J Neurosurg Spine 2021; 35:698-703. [PMID: 34416721 DOI: 10.3171/2021.2.spine202150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous works investigating rates of adverse events (AEs) in spine surgery have been retrospective, with data collection from administrative databases, and often from single centers. To date, there have been no prospective reports capturing AEs in spine surgery on a national level, with comparison among centers. METHODS The Spine Adverse Events Severity system was used to define the incidence and severity of AEs after spine surgery by using data from the Canadian Spine Outcomes and Research Network (CSORN) prospective registry. Patient data were collected prospectively and during hospital admission for those undergoing elective spine surgery for degenerative conditions. The Spine Adverse Events Severity system defined minor and major AEs as grades 1-2 and 3-6, respectively. RESULTS There were 3533 patients enrolled in this cohort. There were 85 (2.4%) individual patients with at least one major AE and 680 (19.2%) individual patients with at least one minor AE. There were 25 individual patients with 28 major intraoperative AEs and 260 patients with 275 minor intraoperative AEs. Postoperatively there were 61 patients with a total of 80 major AEs. Of the 487 patients with minor AEs postoperatively there were 698 total AEs. The average enrollment was 321 patients (range 47-1237 patients) per site. The rate of major AEs was consistent among sites (mean 2.9% ± 2.4%, range 0%-9.1%). However, the rate of minor AEs varied widely among sites-from 7.9% to 42.5%, with a mean of 18.8% ± 9.7%. The rate of minor AEs varied depending on how they were reported, with surgeon reporting associated with the lowest rates (p < 0.01). CONCLUSIONS The rate of major AEs after lumbar spine surgery is consistent among different sites but the rate of minor AEs appears to vary substantially. The method by which AEs are reported impacts the rate of minor AEs. These data have implications for the detection and reporting of AEs and the design of strategies aimed at mitigating complications.
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Affiliation(s)
- Oliver G S Ayling
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | - Raphaele Charest-Morin
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | | | - Tamir Ailon
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | - John T Street
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | - Nicolas Dea
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
| | | | - Sean D Christie
- 10Department of Surgery, Dalhousie University, Halifax, Nova Scotia; and
| | - Edward Abraham
- 3Department of Surgery, Canada East Spine Centre, Saint John, New Brunswick
| | | | | | - Michael G Johnson
- 5Departments of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Manitoba
| | - Najmedden Attabib
- 10Department of Surgery, Dalhousie University, Halifax, Nova Scotia; and
| | - Peter Jarzem
- 11Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Michael Weber
- 11Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Jerome Paquet
- 6Department of Surgery, Laval University, Quebec City, Quebec
| | | | | | - Hamilton Hall
- 9Department of Surgery, University of Toronto, Ontario
| | - Neil Manson
- 3Department of Surgery, Canada East Spine Centre, Saint John, New Brunswick
| | | | | | - Charles G Fisher
- 1Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia
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21
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Garg B, Bansal T, Mehta N, Sharma D. Clinical, radiological and functional outcome of posterior-only three-column osteotomy in healed, post-tubercular kyphotic deformity: a minimum of 2-year follow-up. Spine Deform 2021; 9:1669-1678. [PMID: 33978945 DOI: 10.1007/s43390-021-00361-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy. METHODS The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded. RESULTS The median age of the study population was 16 years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9 mm v/s postoperative: 5.5 ± 16.3 mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient. CONCLUSION Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.
| | - Tungish Bansal
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruv Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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22
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Racca F, Longhitano Y, Wolfler A, Carfagna F, Grattarola C, Serio P, Sbaraglia F, Amigoni A, Savron F, Caramelli F, Montagnini L, Astuto M, Gallo E, Zanza C, Vaschetto R, Conti G. Perioperative management of children with neuromuscular disorders based on a common protocol: A prospective, national study in Italy. Acta Anaesthesiol Scand 2021; 65:1195-1204. [PMID: 33963537 DOI: 10.1111/aas.13844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared perioperative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped). METHOD We conducted a multicentre, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals. RESULTS We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs, and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 (2-14) days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher intensive care unit (ICU) admission rate and longer hospital LOS. CONCLUSION Disease severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs.
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Affiliation(s)
- Fabrizio Racca
- Department of Anaesthesiology and Intensive Care Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo Alessandria Italy
| | - Yaroslava Longhitano
- Department of Anaesthesiology and Intensive Care Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo Alessandria Italy
| | - Andrea Wolfler
- Department of Anaesthesiology and Intensive Care Vittore Buzzi Children's Hospital Milan Italy
| | - Fabio Carfagna
- Department of Translational Medicine University of Eastern Piedmont Amedeo Avogadro School of Medicine Novara Italy
| | - Claudia Grattarola
- Department of Anaesthesiology and Intensive Care Unit Istituto Giannina Gaslini Genova Italy
| | - Paola Serio
- Department of Paediatric Anaesthesia and Intensive Care Meyer Children Hospital Florence Italy
| | - Fabio Sbaraglia
- Department of Emergency Medicine, Anaesthesia and Intensive Care University Hospital Agostino Gemelli IRCCS Rome Italy
| | - Angela Amigoni
- Paediatric Intensive Care Unit Department of Woman's and Child's Health University Hospital of Padova Padua Italy
| | - Fabio Savron
- Department of Anaesthesia and Intensive Care Institute for Maternal and Child Health – IRCCS “Burlo Garofolo” Trieste Italy
| | - Fabio Caramelli
- Department of Anaesthesia and Intensive Care University of Bologna Hospital of Bologna Sant'Orsola‐Malpighi Polyclinic Bologna Italy
| | - Luigi Montagnini
- Department of Anaesthesiology and Intensive Care Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo Alessandria Italy
| | - Marinella Astuto
- Dipartimento Chirurgia Generale e Specialità Medico Chirurgiche A.O.Universitaria “Policlinico‐Vittorio Emanuele”Università degli Studi di Catania Catania Italy
| | - Elisa Gallo
- Department of Translational Medicine University of Eastern Piedmont Amedeo Avogadro School of Medicine Novara Italy
| | - Christian Zanza
- Department of Anaesthesiology and Intensive Care Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo Alessandria Italy
- Foundation of “Nuovo Ospedale Alba‐Bra” Department of Emergency Medicine, Anaesthesia and Critical Care Medicine Michele and Pietro Ferrero Hospital Verduno Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine University of Eastern Piedmont Amedeo Avogadro School of Medicine Novara Italy
| | - Giorgio Conti
- Department of Emergency Medicine, Anaesthesia and Intensive Care University Hospital Agostino Gemelli IRCCS Rome Italy
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Bayissa BB, Mummud M, Miressa F, Fekadu G. Postoperative Complications and Associated Factors Among Surgical Patients Treated at a Tertiary Hospital, Eastern Ethiopia: A Prospective Cohort Study. OPEN ACCESS SURGERY 2021. [DOI: 10.2147/oas.s320506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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24
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Anzuatégui PR, Mello GJP, Rigolino AVB. Lymphopenia predicts 30-day morbidity and mortality following spinal metastasis surgery. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 6:100062. [PMID: 35141627 PMCID: PMC8820028 DOI: 10.1016/j.xnsj.2021.100062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 01/11/2023]
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25
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Kulkarni AG, Patel JY, Asati S, Mewara N. "Spine Surgery Checklist": A Step towards Perfection through Protocols. Asian Spine J 2021; 16:38-46. [PMID: 34015208 PMCID: PMC8873991 DOI: 10.31616/asj.2020.0432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/19/2020] [Indexed: 11/23/2022] Open
Abstract
Study Design This was a retrospective study. Purpose This study aimed to evaluate the effectiveness of a novel checklist that was designed specifically for the "spine-surgerysubspecialty" to reduce the incidence of some common preventable human errors and major perioperative complications in spine surgery. Overview of Literature We proposed a unique spine surgery-specific checklist that recognizes the risk factors, anticipates the possible human errors, and thus helps in preventing these errors. This checklist is associated with increased patient safety awareness, improved communication (keeps everyone updated regarding their responsibilities), reduction in the surgical claims, and reduction in the number of postoperative complications, including mortality. Methods This retrospective pilot study was performed at single center on 858 spine surgery patients. The patients were divided into the following two groups: the study group (after implementation of the checklist [2016-2017]) and the control group (before the implementation of the checklist [2015-2016]). The incidence of common preventable human errors and major perioperative complications in spine surgeries were recorded and compared between the two groups. Results The prevalence of wrong-level surgeries was 0%, and the overall prevalence of the preventable errors was 1.22% (5/410). The rate of adverse, near-miss, and no-harm events was 0%, 0.73% (3/410), and 0.48% (2/410), respectively. The preoperative, intraoperative, and postoperative errors were 0.48% (2/410), 0.24% (1/410), and 0.48% (2/410), respectively. The reoperation rate related to preventable errors reduced after the checklist was used. There were significant differences in the total preventable errors related to complications, such as infections, prolonged hospital stays, and unplanned hospital readmission/revision surgeries (p=0.001). Conclusions The authors proposed the first-of-its kind spine surgery-specific checklist that is comprehensive and involves perioperative parameters. The checklist is easy to use, safe, and effective for reducing the unforgiving errors and perioperative complications. However, its broader implementation would require validation in large, multi-center, randomized control studies.
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Affiliation(s)
- Arvind Gopalrao Kulkarni
- Mumbai Spine Scoliosis & Disc Replacement Centre, Bombay Hospital and Medical Research Center, Mumbai, India
| | - Jwalant Yogeshkumar Patel
- Mumbai Spine Scoliosis & Disc Replacement Centre, Bombay Hospital and Medical Research Center, Mumbai, India
| | - Sanjeev Asati
- Mumbai Spine Scoliosis & Disc Replacement Centre, Bombay Hospital and Medical Research Center, Mumbai, India
| | - Navin Mewara
- Mumbai Spine Scoliosis & Disc Replacement Centre, Bombay Hospital and Medical Research Center, Mumbai, India
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26
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Ashraf M, Kamboh UA, Ashraf N. Intraoperative Computed Tomography Scanner-Guided Craniovertebral Junction Surgery in a Patient with an Occipitalized C1. J Neurosci Rural Pract 2021; 12:603-607. [PMID: 34295121 PMCID: PMC8289552 DOI: 10.1055/s-0041-1730088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Craniovertebral junction surgery is associated with unique difficulties. Type 2 odontoid fractures (Anderson and D Alonzo) have a great potential for nonunion and malunion. These fracture patients may require a circumferential decompression and fixation. The addition of intraoperative CT with neuronavigation greatly aids in craniovertebral junction surgery. We operated on a 59-year-old-male with a type 2 fracture with posterior subluxation of C1 anterior arch and a cranially displaced odontoid peg. First, a transoral odontoidectomy was performed followed by a craniocervical fixation. Occipital plates and C3-C4 lateral mass screws were used as C1 was discovered to be occipitalized intraoperatively and atlantoaxial facet joints could not be reduced as discovered by intraoperative CT resconstruction. Intraoperative CT scan was crucial to this circumferential decompression and fixation, allowed us to resect the odontoid peg safely and completely and to confirm adequate screw trajectory making this complex surgery easier for us and safer for the patient. The patient was discharged 4 months after admission with stable neurology. Intraoperative CT was fundamental to correct decision making.
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Affiliation(s)
- Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom.,Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Pakistan
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Pakistan
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Jo HR, Noh EJ, Oh SH, Choi SK, Sung WS, Choi SJ, Kim DI, Hong SU, Kim EJ. The effectiveness of different acupuncture therapies for neck pain: A protocol for systematic review and/or network meta-analysis. Medicine (Baltimore) 2021; 100:e25379. [PMID: 33879667 PMCID: PMC8078380 DOI: 10.1097/md.0000000000025379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Neck pain is common musculoskeletal disorders in adult population. Acupuncture treatment has been widely used for treating neck pain. Nevertheless, previous systematic reviews (SRs) on acupuncture for neck pain remain controversial, and there is no SR for the comparative efficacy and safety of various types of acupuncture. Therefore, this study aims to evaluate and rank the effectiveness and safety of different types of acupuncture for neck pain by SR and network meta-analysis. METHODS Nine databases will be searched, including Ovid-MEDLINE, EMBASE, Cochrane library, China National Knowledge Infrastructure (CNKI), KoreaMed, Korean medical database (KMBASE), Korean Studies Information Service System (KISS), ScienceON, and Oriental Medicine Advanced Searching Integrated System (OASIS) from their inception to July 2021. The primary outcome is the change of pain intensity. A frequentist network meta-analysis will be performed to compare all relative outcomes of different acupuncture methods, using R software. The quality of included randomized controlled trials will be assessed by Cochrane Collaboration "risk of bias" tools and the evidence will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation instrument. RESULTS The final findings of this network meta-analysis will be published in a recognized journal. CONCLUSIONS Our study will evaluate and compare the effectiveness of various types of acupuncture for neck pain and provide clinicians with best option for what types of acupuncture treatments are effective. TRIAL REGISTRATION NUMBER INPLASY202120041.
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Affiliation(s)
| | - Eun-Ji Noh
- Department of Obstetrics & Gynecology, College of Korean Medicine, Dongguk University Graduate School
| | - Se-Hee Oh
- Department of Ophthalmology, Otolaryngology and Dermatology, Dongguk University Ilsan Oriental Hospital, Gyeongi-do
| | | | - Won-Suk Sung
- Department of Acupuncture & Moxibustion, Dongguk University Bundang Oriental Hospital, Seongnam-si
| | - Su-Ji Choi
- Department of Obstetrics & Gynecology, Dongguk University Ilsan Oriental Hospital, Gyeonggi-do
| | - Dong-Il Kim
- Department of Obstetrics & Gynecology, Dongguk University Ilsan Oriental Hospital, Gyeonggi-do
| | - Seung-Ug Hong
- Department of Ophthalmology, Otolaryngology and Dermatology, Dongguk University Ilsan Oriental Hospital, Gyeongi-do
| | - Eun-Jung Kim
- Department of Acupuncture & Moxibustion, Dongguk University, Seoul, Republic of Korea
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Ayling OGS, Ailon T, Street JT, Dea N, McIntosh G, Abraham E, Jacobs WB, Soroceanu A, Johnson MG, Paquet J, Rasoulinejad P, Phan P, Yee A, Christie S, Nataraj A, Glennie RA, Hall H, Manson N, Rampersaud YR, Thomas K, Fisher CG. The Effect of Perioperative Adverse Events on Long-Term Patient-Reported Outcomes After Lumbar Spine Surgery. Neurosurgery 2021; 88:420-427. [PMID: 33009559 DOI: 10.1093/neuros/nyaa427] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 06/28/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Perioperative adverse events (AEs) lead to patient disappointment and greater costs. There is a paucity of data on how AEs affect long-term outcomes. OBJECTIVE To examine perioperative AEs and their impact on outcome after lumbar spine surgery. METHODS A total of 3556 consecutive patients undergoing surgery for lumbar degenerative disorders enrolled in the Canadian Spine Outcomes and Research Network were analyzed. AEs were defined using the validated Spine AdVerse Events Severity system. Outcomes at 3, 12, and 24 mo postoperatively included the Owestry Disability Index (ODI), 12-Item Short-Form Health Survey (SF-12) Physical (PCS) and Mental (MCS) Component Summary scales, visual analog scale (VAS) leg and back, EuroQol-5D (EQ5D), and satisfaction. RESULTS AEs occurred in 767 (21.6%) patients, and 85 (2.4%) patients suffered major AEs. Patients with major AEs had worse ODI scores and did not reach minimum clinically important differences at 2 yr (no AE: 25.7 ± 19.2, major: 36.4 ± 19.1, P < .001). Major AEs were associated with worse ODI scores on multivariable linear regression (P = .011). PCS scores were lower after major AEs (43.8 ± 9.5, vs 37.7 ± 20.3, P = .002). On VAS leg and back and EQ5D, the 2-yr outcomes were significantly different between the major and no AE groups (<0.01), but these differences were small (VAS leg: 3.4 ± 3.0 vs 4.0 ± 3.3; VAS back: 3.5 ± 2.7 vs 4.5 ± 2.6; EQ5D: 0.75 ± 0.2 vs 0.64 ± 0.2). SF12 MCS scores were not different. Rates of satisfaction were lower after major AEs (no AE: 84.6%, major: 72.3%, P < .05). CONCLUSION Major AEs after lumbar spine surgery lead to worse functional outcomes and lower satisfaction. This highlights the need to implement strategies aimed at reducing AEs.
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Affiliation(s)
- Oliver G S Ayling
- Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, Canada
| | - Tamir Ailon
- Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, Canada
| | - John T Street
- Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, Canada
| | - Nicolas Dea
- Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, Canada
| | | | - Edward Abraham
- Department of Surgery, Canada East Spine Centre, Saint John, Canada
| | - W Bradly Jacobs
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Alex Soroceanu
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Michael G Johnson
- Departments of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Canada
| | - Jerome Paquet
- Department of Surgery, Laval University, Quebec City, Canada
| | | | - Phillipe Phan
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Albert Yee
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Sean Christie
- Department of Surgery, Dalhousie University, Halifax, Canada
| | - Andrew Nataraj
- Department of Surgery, University of Alberta, Edmonton, Canada
| | | | - Hamilton Hall
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Neil Manson
- Department of Surgery, Canada East Spine Centre, Saint John, Canada
| | | | - Kenneth Thomas
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Charles G Fisher
- Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, Canada
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Chandra Venkata Vemula R, Prasad BCM, Kumar K. Prospective study of complications in neurosurgery and their impact on the health related quality of life (HRQOL) – Proposal of a new complication grading in neurosurgery based on HRQOL. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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González-Vargas PM, Calero Félix L, Martín-Gallego Á, Thenier-Villa JL, de la Lama Zaragoza AR, Conde Alonso C. Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00010-5. [PMID: 33663907 DOI: 10.1016/j.neucir.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control. METHODS The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification. RESULTS 92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05). CONCLUSION The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.
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Affiliation(s)
- Pedro Miguel González-Vargas
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain.
| | - Lourdes Calero Félix
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Álvaro Martín-Gallego
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - José Luis Thenier-Villa
- Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain; Department of Neurosurgery, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Adolfo Ramón de la Lama Zaragoza
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo, Pontevedra, Spain; Neuroscience Research Group, Galicia Sur Health Research Institute, Vigo, Pontevedra, Spain
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31
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Kato S, Dear T, Lewis SJ. Factors Affecting Length of Stay Following 3-Column Spinal Osteotomies in Pediatric Patients. Global Spine J 2021; 11:154-160. [PMID: 32875845 PMCID: PMC7882824 DOI: 10.1177/2192568219895225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN A retrospective analysis. OBJECTIVES Length of stay (LOS) is one of the important indicators for the quality of patient care. Although perioperative complications are known to be associated with longer LOS in general, little has been understood regarding LOS after 3-column spinal osteotomy for the rigid spinal deformity in pediatric population. The main objective of the article is to identify factors affecting the LOS in pediatric patients undergoing 3-column posterior spinal osteotomies. METHODS Following research ethics approval, a retrospective review was performed of 35 consecutive posterior 3-column spinal osteotomies performed on pediatric patients in a single academic institution. Patients' demographic data, preoperative comorbidities, details of operative procedures, intraoperative complications, and postoperative complications were investigated, and LOS was compared among the groups. RESULTS The mean LOS was 9.0 days, and the median LOS was 7 days (range = 4-23 days). Low body weight and syndromic deformity were associated with longer LOS. Operation time ≥6 hours and total perioperative fluid administration greater than or equal to twice the estimated blood volume were associated with longer LOS. Among postoperative complications, those with respiratory complication had prolonged stay. CONCLUSIONS Preoperative low body weight and syndromic scoliosis had longer LOS after 3-column osteotomies. Excessive fluid administration and respiratory complications were associated with longer LOS.
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Affiliation(s)
- So Kato
- The Hospital for Sick Children, Toronto, Ontario, Canada,University of Tokyo, Tokyo, Japan
| | - Taylor Dear
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen J. Lewis
- The Hospital for Sick Children, Toronto, Ontario, Canada,Stephen J Lewis, Division of Orthopaedics Surgery, Hospital for Sick Children, 555 University Ave, Room S107, Service Floor, Burton Wing, Toronto, Ontario M5G 1X8, Canada.
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Kwan KYH, Lenke LG, Shaffrey CI, Carreon LY, Dahl BT, Fehlings MG, Ames CP, Boachie-Adjei O, Dekutoski MB, Kebaish KM, Lewis SJ, Matsuyama Y, Mehdian H, Qiu Y, Schwab FJ, Cheung KMC. Are Higher Global Alignment and Proportion Scores Associated With Increased Risks of Mechanical Complications After Adult Spinal Deformity Surgery? An External Validation. Clin Orthop Relat Res 2021; 479:312-320. [PMID: 33079774 PMCID: PMC7899533 DOI: 10.1097/corr.0000000000001521] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 09/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Global Alignment and Proportion (GAP) score, based on pelvic incidence-based proportional parameters, was recently developed to predict mechanical complications after surgery for spinal deformities in adults. However, this score has not been validated in an independent external dataset. QUESTIONS/PURPOSES After adult spinal deformity surgery, is a higher GAP score associated with (1) an increased risk of mechanical complications, defined as rod fractures, implant-related complications, proximal or distal junctional kyphosis or failure; (2) a higher likelihood of undergoing revision surgery to treat a mechanical complication; and (3) is a lower (more proportioned) GAP score category associated with better validated outcomes scores using the Oswestry Disability Index (ODI), Scoliosis Research Society-22 (SRS-22) and the Short Form-36 questionnaires? METHODS A total of 272 patients who had undergone corrective surgeries for complex spinal deformities were enrolled in the Scoli-RISK-1 prospective trial. Patients were included in this secondary analysis if they fulfilled the original inclusion criteria by Yilgor et al. From the original 272 patients, 14% (39) did not satisfy the radiographic inclusion criteria, the GAP score could not be calculated in 14% (37), and 24% (64) did not have radiographic assessment at postoperative 2 years, leaving 59% (159) for analysis in this review of data from the original trial. A total of 159 patients were included in this study,with a mean age of 58 ± 14 years at the time of surgery. Most patients were female (72%, 115 of 159), the mean number of levels involved in surgery was 12 ± 4, and three-column osteotomy was performed in 76% (120 of 159) of patients. The GAP score was calculated using parameters from early postoperative radiographs (between 3 and 12 weeks) including pelvic incidence, sacral slope, lumbar lordosis, lower arc lordosis and global tilt, which were independently obtained from a computer software based on centralized patient radiographs. The GAP score was categorized as proportional (scores of 0 to 2), moderately disproportional (scores of 3 to 6), or severely disproportional (scores higher than 7 to 13). Receiver operating characteristic area under curve (AUC) was used to assess associations between GAP score and risk of mechanical complications and risk of revision surgery. An AUC of 0.5 to 0.7 was classified as "no or low associative power", 0.7 to 0.9 as "moderate" and greater than 0.9 as "high". We analyzed differences in validated outcome scores between the GAP categories using Wilcoxon rank sum test. RESULTS At a minimum of 2 years' follow-up, a higher GAP score was not associated with increased risks of mechanical complications (AUC = 0.60 [95% CI 0.50 to 0.70]). A higher GAP score was not associated with a higher likelihood of undergoing a revision surgery to treat a mechanical complication (AUC = 0.66 [95% 0.53 to 0.78]). However, a moderately disproportioned GAP score category was associated with better SF-36 physical component summary score (36 ± 10 versus 40 ± 11; p = 0.047), better SF-36 mental component summary score (46 ± 13 versus 51 ± 12; p = 0.01), better SRS-22 total score (3.4 ± 0.8 versus 3.7 ± 0.7, p = 0.02) and better ODI score (35 ± 21 versus 25 ± 20; p = 0.003) than severely disproportioned GAP score category. CONCLUSION Based on the findings of this external validation study, we found that alignment targets based on the GAP score alone were not associated with increased risks of mechanical complications and mechanical revisions in patients with complex adult spinal disorders. Parameters not included in the original GAP score needed to be considered to reduce the likelihood of mechanical complications. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Kenny Yat Hong Kwan
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Lawrence G Lenke
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Christopher I Shaffrey
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Leah Y Carreon
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Benny T Dahl
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Michael G Fehlings
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Christopher P Ames
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Oheneba Boachie-Adjei
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Mark B Dekutoski
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Khaled M Kebaish
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Stephen J Lewis
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Yukihiro Matsuyama
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Hossein Mehdian
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Yong Qiu
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Frank J Schwab
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Kenneth Man Chee Cheung
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
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Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE The aim of this study was to compare the utility and cost-effectiveness of multilevel lateral interbody fusion (LIF) combined with posterior spinal fusion (PSF) (L group) and conventional PSF (with transforaminal lumbar interbody fusion) (P group) in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA The clinical and radiographic outcomes of multilevel LIF for ASD have been reported favorable; however, the cost benefit of LIF in conjunction with PSF is still controversial. METHODS Retrospective comparisons of 88 surgically treated ASD patients with minimum 2-year follow-up from a multicenter database (L group [n = 39] and P group [n = 49]) were performed. Demographic and radiographic data, health-related quality of life (HRQoL), and the direct hospitalization cost for the initial surgery and 2-year total hospitalization cost were analyzed. RESULTS Analyses of sagittal spinal alignment showed no significant difference between the two groups at baseline and 2 years post-operation. Surgical time was longer in the L group (L vs. P: 354 vs. 268 minutes, P < 0.01), whereas the amount of blood loss was greater in the P group (494 vs. 678 mL, P = 0.03). The HRQoL was improved similarly at 2 years post-operation (L vs. P: SRS-22 total score, 3.86 vs. 3.80, P = 0.54), with comparable revision rates (L vs. P: 18% vs. 10%, P = 0.29). The total direct cost of index surgery was significantly higher in the L group (65,937 vs. 49,849 USD, P < 0.01), which was mainly due to the operating room cost, including implant cost (54,466 vs. 41,328 USD, P < 0.01). In addition, the 2-year total hospitalization cost, including revision surgery, was also significantly higher in the L group (70,847 vs. 52,560 USD, P < 0.01). CONCLUSION LIF with PSF is a similarly effective surgery for ASD when compared with conventional PSF. However, due to the significantly higher cost, additional studies on the cost-effectiveness of LIF in different ASD patient cohorts are warranted. LEVEL OF EVIDENCE 3.
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Solumsmoen S, Bari TJ, Woldu S, Zielinski OB, Gehrchen M, Dahl B, Bech-Azeddine R. Morbidity and mortality following degenerative spine surgery in a prospective cohort of 1687 consecutive surgical procedures. Acta Neurochir (Wien) 2021; 163:281-287. [PMID: 33230624 DOI: 10.1007/s00701-020-04655-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
STUDY DESIGN Prospective, observational cohort study. OBJECTIVE To determine the true incidence of adverse events (AEs) in European adults undergoing surgery for degenerative spine diseases. The majority of surgeries performed for degenerative spinal diseases are elective, and the need for adequate estimation of risk-benefit of the intended surgery is imperative. A cumbersome obstacle for adequate estimation of surgery-related risks is that the true incidence of complications or adverse events (AEs) remains unclear. METHODS All adult patients (≥ 18 years) undergoing spine surgery at a single center from February 1, 2016, to January 31, 2017, were prospectively and consecutively included. Morbidity and mortality were determined using the Spine AdVerse Events Severity (SAVES) system. Additionally, the correlation between the AEs and length of stay (LOS) and mortality was assessed. RESULTS A total of 1687 procedures were performed in the study period, and all were included for analysis. Of these, 1399 (83%) were lumbar procedures and 288 (17%) were cervical. The overall incidence of AEs was 47.4%, with a minor AE incidence of 43.2% and a major of 14.5%. Female sex (OR 1.5 [95% CI 1.2-1.9), p < 0.001) and age > 65 years (OR 1.5 [95% CI 1.1-1.7], p = 0.012) were significantly associated with increased odds of having an AE. CONCLUSION Based on prospectively registered AEs in this single-center study, we validated the use of the SAVES system in a European population undergoing spine surgery due to degenerative spine disease. We found a higher incidence of AEs than previously reported in retrospective studies. The major AEs registered occurred significantly more often perioperatively and in patients > 65 years.
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Dural Leak: Is It Deterrent to Outcomes in Spine Surgery?: 10 Years Retrospective Analysis of Incidence, Management Protocol, and Surgical Outcomes. Spine (Phila Pa 1976) 2020; 45:E1615-E1621. [PMID: 32833929 DOI: 10.1097/brs.0000000000003662] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVES To review the incidence of dural leaks, evaluate the efficacy of primary closure of durotomy and to study its effect on clinical outcome. The secondary aim is to classify the dural leaks and proposing a treatment algorithm for dural leaks. SUMMARY OF BACKGROUND DATA Dural leaks are described as one of the fearful complications in spine surgery. Literature evaluating the actual incidence, ideal treatment protocol, efficacy of primary repair techniques and its effects on long-term surgical outcomes are scanty. METHODS It was a retrospective analysis of 5390 consecutively operated spine cases over a period of 10 years. All cases were divided into two groups-study group (with dural leak-255) and control group (without dural leak-5135). Dural leaks were managed with the proposed treatment algorithm. Blood loss, surgical time, hospital stay, time for return to mobilization, pain free status, and clinical outcome score (ODI, VAS, NDI, and Wang criteria) were assessed in both groups at regular intervals. The statistical comparison between two groups was established with chi-square and t-tests. RESULTS The overall incidence of dural leaks was 4.73% with highest incidence in revision cases (27.61%). There was significant difference noted in mean surgical blood loss (P 0.001), mean hospital stay (P 0.001), time to achieve pain-free status after surgery, and return to mobilization between two groups. However, no significant difference was noted in operative time (P 0.372) and clinical outcome scores at final follow-up between the two groups. CONCLUSION Primary closure should be undertaken in all amenable major dural leak cases. Dural leaks managed as proposed by the author's treatment algorithm have shown a comparable clinical outcome as in patients without dural leaks. Dural leak is a friendly adverse event that does not prove a deterrent to long-term clinical outcome in spine surgeries. LEVEL OF EVIDENCE 4.
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Klineberg EO, Passias PG, Poorman GW, Jalai CM, Atanda A, Worley N, Horn S, Sciubba DM, Hamilton DK, Burton DC, Gupta MC, Smith JS, Soroceanu A, Hart RA, Neuman B, Ames CP, Schwab FJ, Lafage V. Classifying Complications: Assessing Adult Spinal Deformity 2-Year Surgical Outcomes. Global Spine J 2020; 10:896-907. [PMID: 32730730 PMCID: PMC7485066 DOI: 10.1177/2192568220937473] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
STUDY DESIGN Retrospective review of prospective database. OBJECTIVE Complication rates for adult spinal deformity (ASD) surgery vary widely because there is no accepted system for categorization. Our objective was to identify the impact of complication occurrence, minor-major complication, and Clavien-Dindo complication classification (Cc) on clinical variables and patient-reported outcomes. METHODS Complications in surgical ASD patients with complete baseline and 2-year data were considered intraoperatively, perioperatively (<6 weeks), and postoperatively (>6 weeks). Primary outcome measures were complication timing and severity according to 3 scales: complication presence (yes/no), minor-major, and Cc score. Secondary outcomes were surgical outcomes (estimated blood loss [EBL], length of stay [LOS], reoperation) and health-related quality of life (HRQL) scores. Univariate analyses determined complication presence, type, and Cc grade impact on operative variables and on HRQL scores. RESULTS Of 167 patients, 30.5% (n = 51) had intraoperative, 48.5% (n = 81) had perioperative, and 58.7% (n = 98) had postoperative complications. Major intraoperative complications were associated with increased EBL (P < .001) and LOS (P = .0092). Postoperative complication presence and major postoperative complication were associated with reoperation (P < .001). At 2 years, major perioperative complications were associated with worse ODI, SF-36, and SRS activity and appearance scores (P < .02). Increasing perioperative Cc score and postoperative complication presence were the best predictors of worse HRQL outcomes (P < .05). CONCLUSION The Cc Scale was most useful in predicting changes in patient outcomes; at 2 years, patients with raised perioperative Cc scores and postoperative complications saw reduced HRQL improvement. Intraoperative and perioperative complications were associated with worse short-term surgical and inpatient outcomes.
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Affiliation(s)
| | - Peter G. Passias
- NYU Hospital for Joint Diseases, New York, NY, USA,Peter G. Passias, Department of Orthopaedic Surgery, NYU Medical Center—Hospital for Joint Diseases, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA.
| | | | | | | | - Nancy Worley
- NYU Hospital for Joint Diseases, New York, NY, USA
| | | | | | | | | | - Munish Chandra Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Justin S. Smith
- University of Virginia Health System, Charlottesville, VA, USA
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Implementation of enhanced recovery after surgery (ERAS) protocol for anterior cervical discectomy and fusion: a propensity score-matched analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:560-567. [PMID: 32409887 DOI: 10.1007/s00586-020-06445-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 03/21/2020] [Accepted: 05/02/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS), still emerging for the spine, proposes a multimodal approach of perioperative care involving the optimization of every procedural step, with the patient in a proactive position regarding his/her management. We aimed to demonstrate a reduction in the length of hospital stay for ACDF without increasing the risk for patients by comparing 2 groups before and after ERAS implementation using propensity score (PS)-matched analysis. METHODS We selected 2 periods of 1 year, before (n = 268 patients) and after ERAS implementation (n = 271 patients). Data were collected on patient demographics, operative and perioperative details, 90-day readmissions and morbidity. ERAS-trained nurses were involved to support patients at each pre/per/postoperative step with the help of a mobile app. A satisfaction survey was included. PS analyses were used for dealing with confounding bias in this retrospective observational study. RESULTS After PS matching, the outcomes of 202 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was reduced from 2.96 ± 1.35 to 1.40 ± 0.6 days (Student, p < 0.001). All 90-day surgical morbidity was similar between the 2 groups, including 30-day readmission (0.5% vs 0%; p = 1), 30- to 90-day readmission (0.5% vs 0.0%; p = 1), 90-day reoperation (0% vs 1%; p = 0.49), major complications (3.0% vs 3.5%; p = 1) and minor complications (2.0% vs 3.5%; p = 0.54). There was no significant difference concerning the satisfaction survey. CONCLUSIONS The introduction of ERAS for ACDF in our institution has resulted in a significant decrease in LOS, without causing an increase in postoperative complications and has maintained patients' satisfaction.
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Rybkin I, Azizkhanian I, Gary J, Cole C, Schmidt M, Gandhi C, Al-Mufti F, Anderson P, Santarelli J, Bowers C. Unique Neurosurgical Morbidity and Mortality Conference Characteristics: A Comprehensive Literature Review of Neurosurgical Morbidity and Mortality Conference Practices with Proposed Recommendations. World Neurosurg 2020; 135:48-57. [DOI: 10.1016/j.wneu.2019.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022]
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König A, Joseph F, Janse van Rensburg C, Myburgh J, Keough N. Kambin's triangle and the position of the dorsal nerve root in the lumbar neural foramen. Clin Anat 2020; 33:1204-1213. [DOI: 10.1002/ca.23565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Anya König
- Department of Anatomy University of Pretoria Pretoria Gauteng South Africa
| | - Febin Joseph
- Department of Radiology Steve Biko Academic Hospital Pretoria Gauteng South Africa
| | | | - Jolandie Myburgh
- Department of Anatomy University of Pretoria Pretoria Gauteng South Africa
| | - Natalie Keough
- Department of Anatomy University of Pretoria Pretoria Gauteng South Africa
- Department of Anatomy and Cellular Biology College of Medicine and Health Sciences (CMHS), Khalifa University Abu Dhabi United Arab Emirates
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Jiang F, Wilson JRF, Badhiwala JH, Santaguida C, Weber MH, Wilson JR, Fehlings MG. Quality and Safety Improvement in Spine Surgery. Global Spine J 2020; 10:17S-28S. [PMID: 31934516 PMCID: PMC6947676 DOI: 10.1177/2192568219839699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Review article. OBJECTIVES A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery. METHODS A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review. RESULTS Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature. CONCLUSION Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.
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Affiliation(s)
- Fan Jiang
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jamie R. F. Wilson
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jetan H. Badhiwala
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,St Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T2S8, Canada.
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Gozal YM, Aktüre E, Ravindra VM, Scoville JP, Jensen RL, Couldwell WT, Taussky P. Defining a new neurosurgical complication classification: lessons learned from a monthly Morbidity and Mortality conference. J Neurosurg 2020; 132:272-276. [PMID: 30660128 DOI: 10.3171/2018.9.jns181004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/20/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The absence of a commonly accepted standardized classification system for complication reporting confounds the recognition, objective reporting, management, and avoidance of perioperative adverse events. In the past decade, several classification systems have been proposed for use in neurosurgery, but these generally focus on tallying specific complications and grading their effect on patient morbidity. Herein, the authors propose and prospectively validate a new neurosurgical complication classification based on understanding the underlying causes of the adverse events. METHODS A new complication classification system was devised based on the authors' previous work on morbidity in endovascular surgery. Adverse events were prospectively compiled for all neurosurgical procedures performed at their tertiary care academic medical center over the course of 1 year into 5 subgroups: 1) indication errors; 2) procedural errors; 3) technical errors; 4) judgment errors; and 5) critical events. The complications were presented at the monthly institutional Morbidity and Mortality conference where, following extensive discussion, they were assigned to one of the 5 subgroups. Additional subgroup analyses by neurosurgical subspecialty were also performed. RESULTS A total of 115 neurosurgical complications were observed and analyzed during the study period. Of these, nearly half were critical events, while technical errors accounted for approximately one-third of all complications. Within neurosurgical subspecialties, vascular neurosurgery (36.5%) had the most complications, followed by spine & peripheral nerve (21.7%), neuro-oncology (14.8%), cranial trauma (13.9%), general neurosurgery (12.2%), and functional neurosurgery (0.9%). CONCLUSIONS The authors' novel neurosurgical complication classification system was successfully implemented in a prospective manner at their high-volume tertiary medical center. By employing the well-established Morbidity and Mortality conference mechanism, this simple system may be easily applied at other neurosurgical centers and may allow for uniform analyses of perioperative morbidity and the introduction of corrective initiatives.
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Anzuatégui PR, Cunha LAMD, Mello GJP, Stieven Filho E, Graells XS. Spinal Metastasis Surgery: A Proposal for a Predictive Model of Morbidity and Mortality. Rev Bras Ortop 2019; 54:665-672. [PMID: 31875065 PMCID: PMC6923646 DOI: 10.1055/s-0039-1697018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022] Open
Abstract
Objective
To develop a predictive model of early postoperative morbidity and mortality with the purpose of assisting in the selection of the candidates for spinal metastasis surgery.
Methods
A retrospective analysis of consecutive patients operated for metastatic spinal disease. The possible prognostic preoperative characteristics were gender, age, comorbidities, tumor growth rate, and leukocyte and lymphocyte count in the peripheral blood. The postoperative outcomes were 30-day mortality, 90-day mortality and presence of complications. A predictive model was developed based on factors independently associated with these three outcomes. The final model was then tested for the tendency to predict adverse events, discrimination capacity and calibration.
Results
A total of 205 patients were surgically treated between 2002 and 2015. The rates of the 30-day mortality, 90-day mortality and presence of complications were of 17%, 42% and 31% respectively. The factors independently associated with these three outcomes, which constituted the predictive model, were presence of comorbidities, no slow-growing primary tumor, and lymphocyte count below 1,000 cells/µL. Exposure to none, one, two or three factors was the criterion for the definition of the following categories of the predictive model: low, moderate, high and extreme risk respectively. Comparing the risk categories, there was a progressive increase in the occurrence of outcomes, following a linear trend. The discrimination capacity was of 72%, 73% and 70% for 30-day mortality, 90-day mortality and complications respectively. No lack of calibration occurred.
Conclusion
The predictive model estimates morbidity and mortality after spinal metastasis surgery and hierarchizes risks as low, moderate, high and extreme.
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Affiliation(s)
- Pedro Reggiani Anzuatégui
- Serviço de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil.,Serviço de Ortopedia Oncológica, Hospital Erasto Gaertner, Curitiba, PR, Brasil
| | - Luiz Antônio Munhoz da Cunha
- Serviço de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil.,Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil
| | | | - Edmar Stieven Filho
- Serviço de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil.,Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil
| | - Xavier Soler Graells
- Serviço de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil
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Barbanti-Brodano G, Griffoni C, Halme J, Tedesco G, Terzi S, Bandiera S, Ghermandi R, Evangelisti G, Girolami M, Pipola V, Gasbarrini A, Falavigna A. Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:927-936. [PMID: 31696338 DOI: 10.1007/s00586-019-06203-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 09/10/2019] [Accepted: 10/04/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate whether the World Health Organization Safety Surgical Checklist (SSC) is an effective tool to reduce complications in spinal surgery. METHODS We retrospectively evaluated the clinical and radiological charts prospectively collected from patients who underwent a spinal surgery procedure from January 2010 to December 2012. The aim of this study was to compare the incidence of complications between two periods, from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist's effectiveness. RESULTS The sample size was 917 patients with an average of 30-month follow-up. The mean age was 52.88 years. The majority of procedures were performed for oncological diseases (54.4%) and degenerative diseases (39.8%). In total, 159 complications were detected (17.3%). The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. No correlation was observed between the type of pathology and the complication incidence. We observed a reduction in the overall incidence of complications following the introduction of the SSC: In 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%). CONCLUSIONS The SSC seems to be an effective tool to reduce complications in spinal surgery. We propose to extend the use of checklist system also to the preoperative and postoperative phases in order to further reduce the incidence of complications. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Giovanni Barbanti-Brodano
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy.
| | - Cristiana Griffoni
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Jarkko Halme
- Department of Orthopaedic Trauma and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Giuseppe Tedesco
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Silvia Terzi
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Stefano Bandiera
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Riccardo Ghermandi
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Gisberto Evangelisti
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Marco Girolami
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Valerio Pipola
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Asdrubal Falavigna
- Department of Neurosurgery, University of Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil
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Won D, Lee JM, Park IS, Lee CH, Lee K, Kim JY, Lee YS. Posterior Inferior Cerebellar Artery Infarction Originating at C1-2 after C1-2 Fusion. Korean J Neurotrauma 2019; 15:192-198. [PMID: 31720276 PMCID: PMC6826101 DOI: 10.13004/kjnt.2019.15.e27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 11/15/2022] Open
Abstract
Vertebral artery injuries associated with C1 lateral mass screw insertion rarely occur during C1-2 fusion. The posterior inferior cerebellar artery (PICA) is uncommonly located at the C1 lateral mass insertion position. A 71-year-old woman with atlanto-axial subluxation and cord compression underwent C1-2 fusion. Sixth nerve palsy and diplopia were detected postoperatively, and decreased consciousness occurred on postoperative day 4. Brain magnetic resonance image (MRI) and computed tomography (CT) revealed PICA infarction. In the preoperative CT angiography, the PICA originated between the C1 and C2 level. In the postoperative CT scan, the PICA was not visible. The patient was treated conservatively for two weeks and recovered. PICA originating between the C1 and C2 level comprises 1.1–1.3% of cases. Therefore, vertebral artery anomalies should be evaluated prior to C1-2 fusion to prevent vessel injuries.
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Affiliation(s)
- Donghyun Won
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ja Myoung Lee
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - In Sung Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chul Hee Lee
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Kwangho Lee
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji-yoon Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young Seok Lee
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
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Raman T, Varlotta C, Vasquez-Montes D, Buckland AJ, Errico TJ. The use of tranexamic acid in adult spinal deformity: is there an optimal dosing strategy? Spine J 2019; 19:1690-1697. [PMID: 31202836 DOI: 10.1016/j.spinee.2019.06.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/20/2019] [Accepted: 06/11/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT ASD (Adult spinal deformity) surgery often entails complex osteotomies and realignment procedures, particularly in the setting of rigid deformities. Although previous studies have established the efficacy of tranexamic acid (TXA), data evaluating the widely variable dosing regimens remains sparse. PURPOSE To improve understanding of blood loss and transfusion requirements for low-dose and high-dose TXA regimens for adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING This is a retrospective cohort study of 318 ASD patients who received TXA. Outcome measures include estimated blood loss (EBL), perioperative transfusion requirement, and complications. METHODS A retrospective review was conducted on 318 ASD patients: 258 patients received a low-dose regimen of TXA (10 or 20 mg/kg loading dose with a 1 or 2 mg/kg/h maintenance dose) and 60 patients received a high-dose regimen of TXA (40 mg/kg loading dose with a 1 mg/kg/h maintenance dose, 30 mg/kg loading dose with a 10 mg/kg/h maintenance dose, or 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose). RESULTS Compared with the low-dose TXA group, the high-dose TXA group had significantly decreased EBL (1402 vs. 1793 mL, p=.009), blood volume lost (30.3 vs. 39.4%, p=.01), intraoperative packed red blood cell (pRBC) transfusion (0.9 vs. 1.6 U, p<.0001), and intraoperative platelet transfusion (0 vs. 0.1 U, p<.0001). High-dose TXA was predictive of 515 cc less EBL (p=.002), 11.4% less blood volume lost (p=.004), and 1 U pRBC less transfused intraoperatively (p<.0001) than the low-dose TXA group. The high-dose TXA group had a higher incidence of postop atrial fibrillation (5 vs. 0%, p<.0001) and myocardial infarction (1.7 vs. 0%, p=.04). CONCLUSIONS Varying dosing regimens of TXA are utilized for ASD surgery, with a prevailing theme of dosing ambiguity. These data demonstrate that high-dose TXA is more effective than low-dose TXA in reducing blood loss and blood product transfusion requirement in ASD surgery. Importantly, rates of MI and postop AF were higher in the high-dose TXA group.
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Affiliation(s)
- Tina Raman
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.
| | - Chris Varlotta
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Dennis Vasquez-Montes
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Aaron J Buckland
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Thomas J Errico
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
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Kalidindi KKV, Bhat MR, Mannem A, Chhabra HS. Conservative Management for Late Presenting Dural Tears After Spine Surgery: An Institutional Experience and Literature Review. World Neurosurg 2019; 134:e82-e92. [PMID: 31542441 DOI: 10.1016/j.wneu.2019.09.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Symptoms and evidence of cerebrospinal fluid (CSF) leak after an uneventful intraoperative and immediate postoperative course are a rare entity in spine surgery. The literature is sparse on the description of such late presenting dural tears (LPDTs). They may need further admissions, wound management, and additional surgical procedures that add to the morbidity of the patient. METHODS A retrospective review of spine surgeries done at our institute for degenerative spinal conditions between January 2017 and January 2018 was conducted. A mini meta-analysis was performed on studies comparing conservative and surgical management of LPDTs. RESULTS Among 1929 patients, 6 cases (5 lumbar and 1 cervical) had an LPDT. Five of them had a CSF fistula and 1 patient had a pseudomeningocele. Two patients with CSF fistula were complicated by superficial surgical site infection (SSI). There was additional evidence of pneumocephalus and pneumorachis in 1 case. The SSI was managed by bedside debridement, regular dressing, and culture-sensitive antibiotics. CSF fistulas were managed by deep suturing, and pseudomeningocele was managed by excision of the sac and plication of the neck. All the patients had a good to an excellent outcome at the end of a 1-year follow-up. CONCLUSIONS One should be aware of the possibility of LPDTs. A combination of history, clinical examination, and imaging may aid in the diagnosis. It can be associated with complications like CSF fistula, pseudomeningocele, SSI, pneumocephalus, or pneumorachis. Conservative trial can have good to excellent outcomes in the management of such cases though there is insufficient evidence to establish it.
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Affiliation(s)
| | - Mohd Rafiq Bhat
- Department of Spine Service, Indian Spinal Injuries Center, Vasant Kunj, New Delhi, India
| | - Abhishek Mannem
- Department of Spine Service, Indian Spinal Injuries Center, Vasant Kunj, New Delhi, India
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Sethi R, Bohl M, Vitale M. State-of-the-Art Reviews: Safety in Complex Spine Surgery. Spine Deform 2019; 7:657-668. [PMID: 31495465 DOI: 10.1016/j.jspd.2019.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 04/03/2019] [Accepted: 04/12/2019] [Indexed: 12/16/2022]
Abstract
The surgical correction of spinal deformities carries a high risk of perioperative morbidity. As the incidence of debilitating spinal deformities continues to increase, so too does our obligation to search for ways to enhance safety in our delivery of surgical care. Standardized work processes and other lean manufacturing methodologies have the potential to improve efficiency, safety, and hence value in our delivery of surgical care to patients with complex spine pathologies by reducing variability in our work processes. These principles can be applied to patient care from the initial preoperative assessment to long-term postoperative follow-up in the creation of comprehensive protocols that guide the management of these complex patients. Early evidence suggests that short-term outcomes can be improved by implementing packages of systems reform aimed at reducing variability in our work processes; however, contradicting evidence exists on the utility of several specific components of these systems-reform packages.
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Affiliation(s)
- Rajiv Sethi
- Department of Health Services Research, Neuroscience Institute, Virginia Mason Medical Center, University of Washington, Seattle, WA, USA.
| | - Michael Bohl
- Department of Health Services Research, Neuroscience Institute, Virginia Mason Medical Center, University of Washington, Seattle, WA, USA; Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael Vitale
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
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Yoo JS, Ahn J, Karmarkar SS, Lamoutte EH, Singh K. The use of tranexamic acid in spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S172. [PMID: 31624738 PMCID: PMC6778277 DOI: 10.21037/atm.2019.05.36] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/13/2019] [Indexed: 11/06/2022]
Abstract
Patients undergoing surgical procedures of the spine with associated large volume blood loss often require perioperative blood conservation strategies. Synthetic antifibrinolytic medications such as tranexamic acid (TXA) may reduce blood transfusion requirements and postoperative complications following spinal procedures. Studies investigating the role of TXA in spine surgery have presented promising results and have proven its safety and efficacy. However, further investigation is needed to determine the optimal dosing regimen of TXA. In this article, we provide an overview of the basic science and pharmacology of TXA. A comprehensive summary of the findings from clinical trials and a review of the literature that demonstrate the risks and benefits of TXA in spine surgery are also presented.
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Affiliation(s)
- Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sailee S Karmarkar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Eric H Lamoutte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Han DG, Koh W, Shin JS, Lee J, Lee YJ, Kim MR, Kang K, Shin BC, Cho JH, Kim NK, Ha IH. Cervical surgery rate in neck pain patients with and without acupuncture treatment: a retrospective cohort study. Acupunct Med 2019; 37:268-276. [PMID: 31429587 DOI: 10.1136/acupmed-2018-011724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Surgical treatment of neck pain often entails high costs and adverse events. The present cohort study investigated whether utilisation of acupuncture in neck pain patients is associated with a reduced rate of cervical surgery. METHODS The Korean National Health Insurance Service National Sample Cohort (NHIS-NSC) database was retrospectively analysed to identify the 2 year incidence of cervical surgery in Korean patients suffering neck pain from 2004 to 2010. The incidence was calculated and compared between patients receiving and not receiving acupuncture treatment using Cox proportional hazards models. Cumulative survival rates were compared using Kaplan-Meier survival analysis. RESULTS The acupuncture and control groups included 50 171 and 128 556 neck pain patients, respectively. A total of 50 161 patients were selected in each group following propensity score matching with regard to sex, age, income and Charlson comorbidity index. The hazard ratio (HR) for surgery within 2 years was significantly lower in the acupuncture group compared with the control group (HR 0.397, 95% CI 0.299 to 0.527). In addition, subgroup analyses according to gender, age and income revealed consistent results for both men (HR 0.337, 95% CI 0.234 to 0.485) and women (HR 0.529, 95% CI 0.334 to 0.836); the results were consistently observed across all age and income strata. Sensitivity analysis with varying numbers of acupuncture treatments and treatment course duration also consistently indicated lower HRs for surgery within 2 years in the acupuncture group compared with the control group. CONCLUSIONS A significantly lower HR for cervical surgery was observed in neck pain patients following acupuncture treatment. Acupuncture treatment may therefore be an effective method for managing neck pain, and has the potential to mitigate unnecessary surgery. These findings need to be confirmed by prospective studies.
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Affiliation(s)
- Dong-Geun Han
- Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Wonil Koh
- Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Joon-Shik Shin
- Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Jinho Lee
- Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Yoon Jae Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Me-Riong Kim
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Kyungwon Kang
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Byung-Cheul Shin
- Spine and Joint Center, Pusan National University Korean Medicine Hospital, Yangsan, Republic of Korea
| | - Jae-Heung Cho
- Department of Rehabilitation Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Nam-Kwen Kim
- Monitoring Center for Korean Medicine and Western Medicine Collaboration, Pusan National University Korean Medicine Hospital, Yangsan, Republic of Korea
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
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Barber SM, Fridley JS, Konakondla S, Nakhla J, Oyelese AA, Telfeian AE, Gokaslan ZL. Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:217. [PMID: 31297382 DOI: 10.21037/atm.2019.01.04] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.
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Affiliation(s)
- Sean M Barber
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jared S Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jonathan Nakhla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
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