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Norris ZA, Zabat MA, Patel H, Mottole NA, Ashayeri K, Balouch E, Maglaras C, Protopsaltis TS, Buckland AJ, Fischer CR. Multidisciplinary conference for complex surgery leads to improved quality and safety. Spine Deform 2023; 11:1001-1008. [PMID: 36813882 DOI: 10.1007/s43390-023-00667-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 02/11/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Complex surgery for adult spinal deformity has high rates of complications, reoperations, and readmissions. Preoperative discussions of high-risk operative spine patients at a multidisciplinary conference may contribute to decreased rates of these adverse outcomes through appropriate patient selection and surgical plan optimization. With this goal, we implemented a high-risk case conference involving orthopedic and neurosurgery spine, anesthesia, intraoperative monitoring neurology, and neurological intensive care. METHODS Included in this retrospective review were patients ≥ 18 years old meeting one of the following high-risk criteria: 8 + levels fused, osteoporosis with 4 + levels fused, three column osteotomy, anterior revision of the same lumbar level, or planned significant correction for severe myelopathy, scoliosis (> 75˚), or kyphosis (> 75˚). Patients were categorized as Before Conference (BC): surgery before 2/19/2019 or After Conference (AC): surgery after 2/19/2019. Outcome measures include intraoperative and postoperative complications, readmissions, and reoperations. RESULTS 263 patients were included (96 AC, 167 BC). AC was older than BC (60.0 vs 54.6, p = 0.025) and had lower BMI (27.1 vs 28.9, p = 0.047), but had similar CCI (3.2 vs 2.9 p = 0.312), and ASA Classification (2.5 vs 2.5, p = 0.790). Surgical characteristics, including levels fused (10.6 vs 10.7, p = 0.839), levels decompressed (1.29 vs 1.25, p = 0.863), 3 column osteotomies (10.4% vs 18.6%, p = 0.080), anterior column release (9.4% vs 12.6%, p = 0.432), and revision cases (53.1% vs 52.4%, p = 0.911) were similar between AC and BC. AC had lower EBL (1.1 vs 1.9L, p < 0.001) and fewer total intraoperative complications (16.7% vs 34.1%, p = 0.002), including fewer dural tears (4.2% vs 12.6%, p = 0.025), delayed extubations (8.3% vs 22.8%%, p = 0.003), and massive blood loss (4.2% vs 13.2%, p = 0.018). Length of stay (LOS) was similar between groups (7.2 vs 8.2 days, 0.251). AC had a lower incidence of deep surgical site infections (SSI, 1.0% vs 6.6%, p = 0.038), but a higher rate of hypotension requiring vasopressor therapy (18.8% vs 4.8%, p < 0.001). Other postoperative complications were similar between groups. AC had lower rates of reoperation at 30 (2.1% vs 8.4%, p = 0.040) and 90 days (3.1 vs 12.0%, p = 0.014) and lower readmission rates at 30 (3.1% vs 10.2%, p = 0.038) and 90 days (6.3 vs 15.0%, p = 0.035). On logistic regression, AC patients had higher odds of hypotension requiring vasopressor therapy and lower odds of delayed extubation, intraoperative RBC, and intraoperative salvage blood. CONCLUSIONS Following implementation of a multidisciplinary high-risk case conference, 30- and 90-day reoperation and readmission rates, intraoperative complications, and postoperative deep SSIs decreased. Hypotensive events requiring vasopressors increased, but did not result in longer LOS or greater readmissions. These associations suggest a multidisciplinary conference may help improve quality and safety for high-risk spine patients. particularly through minimizing complications and optimizing outcomes in complex spine surgery.
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Affiliation(s)
- Zoe A Norris
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Michelle A Zabat
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Hershil Patel
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Nicole A Mottole
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Kimberly Ashayeri
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Eaman Balouch
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Constance Maglaras
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Themistocles S Protopsaltis
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Aaron J Buckland
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA
| | - Charla R Fischer
- Spine Research Center, NYU Langone Health Department of Orthopedic Surgery, 306 E. 15th St., New York City, NY, 10003, USA.
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Durand WM, Daniels AH, DiSilvestro K, Lafage R, Diebo BG, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Smith JS, Shaffrey CI, Gupta MC, Klineberg EO, Schwab F, Gum JL, Mundis GM, Eastlack RK, Kebaish K, Soroceanu A, Hostin RA, Burton D, Bess S, Ames CP, Hart RA, Hamilton DK. Patient satisfaction after multiple revision surgeries for adult spinal deformity. J Neurosurg Spine 2023; 38:75-83. [PMID: 36029263 DOI: 10.3171/2022.6.spine2273] [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: 01/16/2022] [Accepted: 06/17/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of health-related quality of life. The authors hypothesized that patients who underwent multiple revision surgeries following ASD correction would exhibit lower self-reported satisfaction scores. METHODS This was a retrospective cohort study of 668 patients who underwent ASD surgery and were eligible for a minimum 2-year follow-up. Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1), after the first revision only (period 2), and after the second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. Scoliosis Research Society-22 (SRS-22r) health-related quality-of-life satisfaction subscore and total satisfaction scores were evaluated at all periods using multiple linear regression and adjustment for age, sex, and Charlson Comorbidity Index. RESULTS In total, 46.6% of the study patients had undergone prior spine surgery before their index surgery. The overall revision rate was 21.3%. Among patients with no spine surgery prior to the index surgery, SRS-22r satisfaction scores increased from period 0 to 1 (from 2.8 to 4.3, p < 0.0001), decreased after one revision from period 1 to 2 (4.3 to 3.9, p = 0.0004), and decreased further after a second revision from period 2 to 3 (3.9 to 3.3, p = 0.0437). Among patients with spine surgery prior to the index procedure, SRS-22r satisfaction increased from period 0 to 1 (2.8 to 4.2, p < 0.0001) and decreased from period 1 to 2 (4.2 to 3.8, p = 0.0011). No differences in follow-up time from last surgery were observed (all p > 0.3). Among patients with multiple revisions, 40% experienced rod fracture, 40% proximal junctional kyphosis, and 33% pseudarthrosis. CONCLUSIONS Among patients undergoing ASD surgery, revision surgery is associated with decreased satisfaction, and multiple revisions are associated with additive detriment to satisfaction among patients initially undergoing primary surgery. These findings have direct implications for preoperative patient counseling and establishment of postoperative expectations.
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Affiliation(s)
- Wesley M Durand
- 1Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alan H Daniels
- 2Department of Orthopaedic Surgery, Brown University, Alpert Medical School, Providence, Rhode Island
| | - Kevin DiSilvestro
- 2Department of Orthopaedic Surgery, Brown University, Alpert Medical School, Providence, Rhode Island
| | - Renaud Lafage
- 3Department of Orthopaedic Surgery, Lenox Hill Hospital, New York
| | - Bassel G Diebo
- 2Department of Orthopaedic Surgery, Brown University, Alpert Medical School, Providence, Rhode Island
| | - Peter G Passias
- 4Department of Orthopaedic Surgery, New York University, Langone Medical Center, New York, New York
| | - Han Jo Kim
- 3Department of Orthopaedic Surgery, Lenox Hill Hospital, New York
| | | | - Virginie Lafage
- 3Department of Orthopaedic Surgery, Lenox Hill Hospital, New York
| | - Justin S Smith
- 5Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Munish C Gupta
- 7Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri
| | - Eric O Klineberg
- 8Department of Orthopaedic Surgery, University of California, UC Davis Medical Center, Sacramento, California
| | - Frank Schwab
- 3Department of Orthopaedic Surgery, Lenox Hill Hospital, New York
| | - Jeffrey L Gum
- 9Department of Orthopaedic Surgery, Leatherman Spine Center, Louisville, Kentucky
| | - Gregory M Mundis
- 10Department of Orthopaedic Surgery, San Diego Spine, La Jolla, California
| | - Robert K Eastlack
- 10Department of Orthopaedic Surgery, San Diego Spine, La Jolla, California
| | - Khaled Kebaish
- 1Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alex Soroceanu
- 11Department of Orthopaedic Surgery, University of Calgary, Alberta, Canada
| | - Richard A Hostin
- 12Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Plano, Texas
| | - Douglas Burton
- 13Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Shay Bess
- 14Department of Orthopaedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Christopher P Ames
- 15Department of Neurosurgery, University of California, San Francisco, California
| | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington; and
| | - D Kojo Hamilton
- 17Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Failure in Adult Spinal Deformity Surgery: A Comprehensive Review of Current Rates, Mechanisms, and Prevention Strategies. Spine (Phila Pa 1976) 2022; 47:1337-1350. [PMID: 36094109 DOI: 10.1097/brs.0000000000004435] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/22/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Literature review. OBJECTIVE The aim of this review is to summarize recent literature on adult spinal deformity (ASD) treatment failure as well as prevention strategies for these failure modes. SUMMARY OF BACKGROUND DATA There is substantial evidence that ASD surgery can provide significant clinical benefits to patients. The volume of ASD surgery is increasing, and significantly more complex procedures are being performed, especially in the aging population with multiple comorbidities. Although there is potential for significant improvements in pain and disability with ASD surgery, these procedures continue to be associated with major complications and even outright failure. METHODS A systematic search of the PubMed database was performed for articles relevant to failure after ASD surgery. Institutional review board approval was not needed. RESULTS Failure and the potential need for revision surgery generally fall into 1 of 4 well-defined phenotypes: clinical failure, radiographic failure, the need for reoperation, and lack of cost-effectiveness. Revision surgery rates remain relatively high, challenging the overall cost-effectiveness of these procedures. CONCLUSION By consolidating the key evidence regarding failure, further research and innovation may be stimulated with the goal of significantly improving the safety and cost-effectiveness of ASD surgery.
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Raad M, Ortiz-Babilonia C, Hassanzadeh H, Puvanesarajah V, Kebaish K, Jain A. Cost-utility Analysis of Neoadjuvant Teriparatide Therapy in Osteopenic Patients Undergoing Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2022; 47:1121-1127. [PMID: 35797582 DOI: 10.1097/brs.0000000000004409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cost-utility analysis study. OBJECTIVE This study aims to evaluate the cost-utility of neoadjuvant teriparatide therapy in osteopenic patients undergoing adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA There is increasing evidence supporting preoperative use of anabolic agents such as teriparatide for preoperative optimization of ASD patients with poor bone density. However, such treatments are associated with added costs. To our knowledge, the cost-utility of teriparatide in osteopenic patients undergoing ASD surgery has not been established. MATERIALS AND METHODS A decision-analysis model was developed for a hypothetical 68-year-old female patient with osteopenia ( T score <-1.0) undergoing a T11 to pelvis instrumented spinal fusion for ASD. A comprehensive literature review was conducted to create estimates for event probabilities, costs, and quality adjusted life years at each node. Key model assumptions were that administration of a 4-month preoperative teriparatide course reduced 2-year postoperative reoperation rates [for pseudarthrosis from 5% to 2.5% and for proximal junctional failure (PJF) from 15% to 5%]. Monte Carlo simulations were used to calculate the mean incremental cost utility ratio and incremental net monetary benefits. One-way sensitivity analysis was used to estimate the contribution of individual parameters to uncertainty in the model. RESULTS Teriparatide was the favored strategy in 82% of the iterations. The mean incremental cost utility ratio for the teriparatide strategy was negative (higher net benefit, lower net cost), and lower than the willingness-to-pay threshold of $50,000 per quality adjusted life year. Teriparatide use was associated with a mean incremental net monetary benefit of $3,948. One-way sensitivity analysis demonstrated that the factors with the greatest impact on the model were the incidence of PJF in the no teriparatide group, the duration and monthly cost of treatment, and the cost of reoperation due to PJF. CONCLUSIONS Neoadjuvant teriparatide is a cost-effective strategy to reduce postoperative complications in patients with osteopenia undergoing ASD surgery.
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Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Carlos Ortiz-Babilonia
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
- Department of Orthopaedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Zuckerman SL, Lai CS, Shen Y, Cerpa M, Lee NJ, Kerolus MG, Ha AS, Buchanan IA, Devin CJ, Lehman RA, Lenke LG. Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative? Global Spine J 2021; 13:1080-1088. [PMID: 34036834 DOI: 10.1177/21925682211019352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Evaluate clinical improvement as measured by patient-reported outcomes (PROs) during the 1 to 2-year interval. STUDY DESIGN Retrospective Cohort. METHODS A single-institution registry of ASD patients undergoing surgery was queried for patients with ≥6 level fusions. Demographics and radiographic variables were collected. PROs collected were the ODI and SRS-22r scores at: preoperative, 1-year and 2-years. Outcome measures of clinical improvement during the 1-2 year time interval were: 1) group medians, 2) percent minimum clinically important difference (MCID), and 3) percent minimal symptom scale (MSS)(ODI < 20 or SRS-pain + function >8). Wilcoxon rank-sum tests, chi-squared tests, Kruskal-Wallis tests, and logistic regression were performed. RESULTS 157 patients undergoing ASD surgery with minimum of 1-year follow-up were included. Mean age was 53.2 and mean instrumented levels was 13.1. Preoperative alignment was: Neutral Alignment (NA) 49%, Coronal Malalignment (CM) 17%, Sagittal Malalignment (SM 17%), and Combined Coronal/Sagittal Malalignment (CCSM) 18%. Preoperative to 1-year, and preoperative to 2-years, all ODI/SRS-22r significantly improved (P < .001). In all patients, the only significant improvement in PROs between 1-and 2-year postoperative were those reaching ODI MCID (69% 1-year vs. 84% 2-years; P < .001). Subgroup analysis: ≥55 years had an improved median ODI (18 vs. 8; P = .047) and an improved percent achieving ODI MCID (73% vs. 84%, P = .048). CCSM patients experienced significant improvement in SRS-appearance score (75% vs. 100%; P = .050), along with those with severe preoperative SM >7.5 cm (73% vs. 100%; P = .032). CONCLUSIONS Most ASD patients experience the majority of PRO improvement by 1-year postoperative. However, subsets of patients that may continue to improve up to 2-years postoperative include patients ≥55 years, combined coronal/sagittal malalignment, and those with severe sagittal malalignment ≥7.5 cm.
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Affiliation(s)
- Scott L Zuckerman
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA.,Department of Neurological Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher S Lai
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Yong Shen
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Mena G Kerolus
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Alex S Ha
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Ian A Buchanan
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Clinton J Devin
- Steamboat Orthopaedic and Spine Institute, Steamboat Springs, CO, USA
| | - Ronald A Lehman
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
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