Impact of resolved early major complications on 2-year follow-up outcome following adult spinal deformity surgery

Highest Achievable Outcomes for Adult Spinal Deformity Corrective Surgery: Does Frailty Severity Exert a Ceiling Effect?

STUDY DESIGN

Retrospective single-center study.

OBJECTIVE

To assess the influence of frailty on optimal outcome following ASD corrective surgery.

SUMMARY OF BACKGROUND DATA

Frailty is a determining factor in outcomes after ASD surgery and may exert a ceiling effect on the best possible outcome.

METHODS

ASD patients with frailty measures, baseline, and 2-year ODI included. Frailty was classified as Not Frail (NF), Frail (F) and Severely Frail (SF) based on the modified Frailty Index, then stratified into quartiles based on two-year ODI improvement (most improved designated "Highest"). Logistic regression analyzed relationships between frailty and ODI score and improvement, maintenance, or deterioration. A Kaplan-Meier survival curve was used to analyze differences in time to complication or reoperation.

RESULTS

A total of 393 ASD patients were isolated (55.2% NF, 31.0% F, and 13.7% SF), then classified as 12.5% NF-Highest, 17.8% F-Highest, and 3.1% SF-Highest. The SF group had the highest rate of deterioration (16.7%, P =0.025) in the second postoperative year, but the groups were similar in improvement (NF: 10.1%, F: 11.5%, SF: 9.3%, P =0.886). Improvement of SF patients was greatest at six months (ΔODI of -22.6±18.0, P <0.001), but NF and F patients reached maximal ODI at 2 years (ΔODI of -15.7±17.9 and -20.5±18.4, respectively). SF patients initially showed the greatest improvement in ODI (NF: -4.8±19.0, F: -12.4±19.3, SF: -22.6±18.0 at six months, P <0.001). A Kaplan-Meier survival curve showed a trend of less time to major complication or reoperation by 2 years with increasing frailty (NF: 7.5±0.381 yr, F: 6.7±0.511 yr, SF: 5.8±0.757 yr; P =0.113).

CONCLUSIONS

Increasing frailty had a negative effect on maximal improvement, where severely frail patients exhibited a parabolic effect with greater initial improvement due to higher baseline disability, but reached a ceiling effect with less overall maximal improvement. Severe frailty may exert a ceiling effect on improvement and impair maintenance of improvement following surgery.

LEVEL OF EVIDENCE

Level III.

Risk factors of early complications after thoracic and lumbar spinal deformity surgery: a systematic review and meta-analysis

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.

Unplanned Readmission Following Early Postoperative Complications After Fusion Surgery in Adult Spine Deformity: A Multicentric Study

STUDY DESIGN

Multicentric retrospective study, Level of evidence III.

OBJECTIVE

The objective of this multicentric study was to analyze the prevalence and risk factors of early postoperative complications in adult spinal deformity patients treated with fusion. Additionally, we studied the impact of complications on unplanned readmission and hospital length of stay.

METHODS

Eight spine centers from 6 countries in Latin America were involved in this study. Patients with adult spinal deformity treated with fusion surgery from 2017 to 2019 were included. Baseline and surgical characteristics such as age, sex, comorbidities, smoking, number of levels fused, number of surgical approaches were analyzed. Postoperative complications at 30 days were recorded according to Clavien-Dindo and Glassman classifications.

RESULTS

172 patients (120 females/52 males, mean age 59.4 ± 17.6) were included in our study. 78 patients suffered complications (45%) at 30 days, 43% of these complications were considered major. Unplanned readmission was observed in 35 patients (20,3%). Risk factors for complications were: Smoking, previous comorbidities, number of levels fused, two or more surgical approaches and excessive bleeding. Hospital length of stay in patients without and with complications was of 7.8 ± 13.7 and 17 ± 31.1 days, respectively (P 0.0001).

CONCLUSION

The prevalence of early postoperative complications in adult spinal deformity patients treated with fusion was of 45% in our study with 20% of unplanned readmissions at 30 days. Presence of complications significantly increased hospital length of stay.

Combined anterior-posterior versus all-posterior approaches for adult spinal deformity correction: a matched control study

PURPOSE

Anterior approaches are gaining popularity for adult spinal deformity (ASD) surgeries especially with the introduction of hyperlordotic cages and improvement in MIS techniques. Combined Approaches provide powerful segmental sagittal correction potential and increase the surface area available for fusion in ASD surgery, both of which would improve overall. This is the first study directly comparing surgical outcomes between combined anterior-posterior approaches and all-posterior approach in a matched ASD population.

METHODS

This is a retrospective matched control cohort analysis with substitution using a multicenter prospectively collected ASD data of patients with > 2 year FU. Matching criteria include: age, American Society of Anesthesiologists Score, Lumbar Cobb angle, sagittal deformity (Global tilt) and ODI.

RESULTS

In total, 1024 ASD patients were available for analysis. 29 Combined Approaches patients met inclusion criteria, and only 22 could be matched (1:2 ratio). Preoperative non-matched demographical, clinical, surgical and radiological parameters were comparable between both groups. Combined approaches had longer surgeries (548 mns vs 283) with more blood loss (2850 ml vs 1471) and needed longer ICU stays (74 h vs 27). Despite added morbidity, they had comparable complication rates but with significantly less readmissions (9.1% vs 38.1%) and reoperations (18.2% vs 43.2%) at 2 years. Combined Approaches achieved more individualised and harmonious deformity correction initially. At the 2 years control, Combined Approaches patients reported better outcomes as measured by COMI and SRS scores. This trend was maintained at 3 years.

CONCLUSION

Despite an increased initial surgical invasiveness, combined approaches seem to achieve more harmonious correction with superior sagittal deformity control; they need fewer revisions and have improved long-term functional outcomes when compared to all-posterior approaches for ASD deformity correction.

Surgeons' risk perception in ASD surgery: The value of objective risk assessment on decision making and patient counselling

BACKGROUND

Surgeons often rely on their intuition, experience and published data for surgical decision making and informed consent. Literature provides average values that do not allow for individualized assessments. Accurate validated machine learning (ML) risk calculators for adult spinal deformity (ASD) patients, based on 10 year multicentric prospective data, are currently available. The objective of this study is to assess surgeon ASD risk perception and compare it to validated risk calculator estimates.

METHODS

Nine ASD complete (demographics, HRQL, radiology, surgical plan) preoperative cases were distributed online to 100 surgeons from 22 countries. Surgeons were asked to determine the risk of major complications and reoperations at 72 h, 90 d and 2 years postop, using a 0-100% risk scale. The same preoperative parameters circulated to surgeons were used to obtain ML risk calculator estimates. Concordance between surgeons' responses was analyzed using intraclass correlation coefficients (ICC) (poor < 0.5/excellent > 0.85). Distance between surgeons' and risk calculator predictions was assessed using the mean index of agreement (MIA) (poor < 0.5/excellent > 0.85).

RESULTS

Thirty-nine surgeons (74.4% with > 10 years' experience), from 12 countries answered the survey. Surgeons' risk perception concordance was very low and heterogeneous. ICC ranged from 0.104 (reintervention risk at 72 h) to 0.316 (reintervention risk at 2 years). Distance between calculator and surgeon prediction was very large. MIA ranged from 0.122 to 0.416. Surgeons tended to overestimate the risk of major complications and reintervention in the first 72 h and underestimated the same risks at 2 years postop.

CONCLUSIONS

This study shows that expert surgeon ASD risk perception is heterogeneous and highly discordant. Available validated ML ASD risk calculators can enable surgeons to provide more accurate and objective prognosis to adjust patient expectations, in real time, at the point of care.

Quality metrics in adult spinal deformity surgery over the last decade: a combined analysis of the largest prospective multicenter data sets

OBJECTIVE

The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010.

METHODS

This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR).

RESULTS

Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010-2011 vs 2015-2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence-lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01).

CONCLUSIONS

The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.

Complications of adult spinal deformity surgery: A literature review

Purpose:

Adult spinal deformity incidence increases accordingly as the population ages. Even though surgery is the best option for the treatment, the complications due to surgery are pretty challenging. This study aims to review the complication rates of adult spinal deformity surgery.

Methods:

A literature review of the last decade was performed searching for the query “Adult spine deformity and complication.” This search yielded 2781 results, where 79 articles were chosen to investigate the complications of adult spinal deformity surgery. In addition, the demographic data, surgical interventions, and complications were extracted from the publications.

Results:

A total of 26,207 patients were analyzed, and 9138 complications were found (34.5%). Implant failure, including screw loosening, breakage, distal and proximal junctional kyphosis, were the most common complications. The neurologic complications were about 10.8%, and the infection rate was 3.6%. Cardiac and pulmonary complications were about 4.8%.

Discussion:

Age, body mass index, smoking, osteoporosis, and other comorbidities are the significant risk factors affecting adult spinal deformity surgery. Presurgical planning and preoperative risk factor assessment must be done to avoid complications. Furthermore, intra and postoperative complications affect the patients’ quality of life and length of stay, and hospital readmissions. Revision surgery also increases the risk of complications.

Conclusion:

Good patient evaluation before surgery and careful planning of the surgery are essential in avoiding complications of adult spinal deformity.

The impact of severe postoperative complications on outcomes of bariatric surgery-multicenter case-matched study

BACKGROUND

Bariatric surgery has relatively low complication rates, especially severe postoperative complications (defined by Clavien-Dindo classification as types 3 and 4), but these rates cannot be ignored. In other than bariatric surgical disciplines, complications affect not only short-term but also long-term results. In the field of bariatric surgery, this topic has not been extensively studied.

OBJECTIVES

The aim of the study was to assess the outcomes of bariatric treatment in patients with obesity and severe postoperative complications in comparison to patients with a noneventful perioperative course.

SETTING

Six surgical units at Polish public hospitals.

METHODS

We performed a multicenter propensity score matched analysis of 206 patients from 6 Polish surgical units and assessed the outcomes of bariatric procedures. A total of 103 patients with severe postoperative complications (70 laparoscopic sleeve gastrectomy [SG] and 33 with laparoscopic Roux en Y gastric bypass [RYGB]) were compared to 103 patients with no severe complications in terms of peri- and postoperative outcomes.

RESULTS

The outcomes of bariatric treatment did not differ between compared groups. Median percentage of total weight loss 12 months after the surgery was 28.8% in the group with complications and 27.9% in patients with no severe complications (P = 0.993). Remission rates of both type 2 diabetes mellitus and arterial hypertension showed no significant difference between SG and RYGB (36% versus 42%, P = 0.927, and 41% versus 46%, P = 0.575. respectively).

CONCLUSIONS

The study suggests that severe postoperative complications had no significant influence either on weight loss effects or obesity-related diseases remission.

The dynamics of satisfaction in surgical and non-surgical adult spinal deformity patients

PURPOSE

For adult spinal deformity (ASD) patients receiving operative (op) and non-operative (non-op) treatment, the relationship between HRQoL measures, complications and self-reported satisfaction remains unclear. The objective of this analysis is to study nonlinear association dynamics between ASD patient satisfaction, HRQoL, and complications over a two-year follow-up period.

METHODS

From a prospective multicenter international adult spinal deformity database, all patients with 2-year follow-up data on satisfaction (21st question of SRS-22r) were identified and included. A total of 12 LOESS (local polynomial fit) regressions were performed between patient satisfaction (SRS22 item 21) and HRQoL measures (ODI, SF36PCS and SRS22 subtotal) interacting with surgery at baseline, 6 months and 1 and 2 years of follow-up.

RESULTS

A total of 856 patients (527 op and 329 non-op) were included. At baseline, satisfaction was lower for patients scheduled for surgery even when HRQL was similar to those elected for conservative treatment. The nonlinear correlations showed that for similar PROMs, op patients reached higher satisfaction levels during follow-up, especially at six months. In fact, at six months operated patients with a deterioration of their initial PROMs had some improvement in their satisfaction, which could not be further observed at the end of follow-up.

CONCLUSIONS

Satisfaction does not correlate well with other PROMs, and it might be subject to other external factors not directly related to treatment. Even if patient satisfaction is important in evaluating well-being and patient's experience with medical care, it should not be considered as an isolated proxy to measure quality of treatment.