Descriptive analysis of unplanned readmission and reoperation rates after intradural spinal tumor resection

Cerebrospinal fluid leaks following intradural spinal surgery—Risk factors and clinical management

Background

Cerebrospinal fluid leakage (CSFL) following spinal durotomy can lead to severe sequelae. However, while several studies have investigated accidental spinal durotomies, the risk factors and influence of clinical management in planned durotomies remain unclear.

Methods

We performed a retrospective analysis of all patients who underwent planned intradural spinal surgery at our institution between 2010 and 2020. Depending on the occurrence of a CSFL, patients were dichotomized and compared with respect to patient and case-related variables as well as dural closure technique, epidural drainage placement, and timing of mobilization.

Results

A total of 351 patients were included. CSFL occurred in 4.8% of all cases. Surgical indication, tumor histology, location within the spine, previous intradural surgery, and medical comorbidities were not associated with an increased risk of CSFL development (all p > 0.1). Age [odds ratio (OR), 0.335; 95% confidence interval (CI), 0.105–1.066] and gender (OR, 0.350; 95% CI, 0.110–1.115) were not independently associated with CSFL development. There was no significant association between CSFL development and the dural closure technique (p = 0.251), timing of mobilization (p = 0.332), or placement of an epidural drainage (p = 0.321).

Conclusion

CSFL following planned durotomy pose a relevant and quantifiable complication risk of surgery that should be factored in during preoperative patient counseling. Our data could not demonstrate superiority of any particular dural closure technique but support the safety of both early mobilization within 24 h postoperatively and epidural drainage with reduced or no force of suction.

Reliability of Early Ambulation after Intradural Spine Surgery : Risk Factors and a Preventive Method for Cerebrospinal Fluid Leak Related Complications

Objective

Cerebrospinal fluid leakage related complications (CLC) occasionally occur after intradural spinal surgery. We sought to investigate the effectiveness of early ambulation after intradural spinal surgery and analyze the risk factors for CLC.

Methods

For this retrospective cohort study, we enrolled 314 patients who underwent intradural spinal surgery at a single institution. The early group contained 79 patients who started ambulation after 1 day of bedrest without position restrictions, while the late group consisted of 235 patients who started ambulation after at least 3 days of bed rest and were limited to the prone position after surgery. In the early group, Prolene 6–0 was used as the dura suture material, while black silk 5–0 was used as the dura suture material in the late group.

Results

The overall incidence rate of CLC was 10.8%. Significant differences between the early and late groups were identified in the rate of CLC (2.5% vs. 13.6%), surgical repair required (1.3% vs. 7.7%), and length of hospital stay (2.99 vs. 9.29 days) (p<0.05). Logistic regression analysis revealed that CLC was associated with practices specific to the late group (p=0.011) and the revision surgery (p=0.022).

Conclusion

Using Prolene 6–0 as a dura suture material for intradural spinal surgery resulted in lower CLC rates compared to black silk 5–0 sutures despite a shorter bed rest period. Our findings revealed that suture - needle ratio related to dura defect was the most critical factor for CLC. One-day ambulation after primary dura closure using Prolene 6–0 sutures appears to be a cost-effective and safe strategy for intradural spinal surgery.

Readmission following complex spine surgery in a prospective cohort of 679 patients - 2-years follow-up using the Spine AdVerse Event Severity (SAVES) system

BACKGROUND CONTEXT

Recent studies suggest that prospective registration more accurately reflects the true incidence of adverse events (AEs). To our knowledge, no previous study has investigated prospectively registered AEs' influence on hospital readmission following spine surgery.

PURPOSE

To determine the frequency and type of unplanned readmissions after complex spine surgery, and to investigate if prospectively registered AEs can predict readmissions.

DESIGN

This is a prospective, consecutive cohort study.

PATIENT SAMPLE

We conducted a single-center study of 679 consecutive patients who underwent complex spine surgery defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment.

OUTCOME MEASURES

The outcomes in this study were (1) readmission to any hospital department within 30 days of discharge and (2) readmission to a surgical spine center at any time in follow-up.

METHODS

All patients undergoing complex spine surgery, at our tertiary referral center, were consecutively, and prospectively, included from January 1 to December 31, 2013. Demographics and perioperative AEs were registered using the Spine AdVerse Events Severity (SAVES) system. Patients were followed for a minimum of two years. A competing risk survival model was used to estimate rates of readmissions with death as a competing risk. Patient characteristics, surgical parameters and perioperative AEs were analyzed to identify factors associated with readmission. Analyses of 30-day readmission were performed using logistic regression models. A proportional odds model, with death as competing risk, was used for readmissions to a spine center at any time in follow-up. Results were reported as odds ratios with 95% confidence intervals (95% CI).

RESULTS

Within 2 years of index discharge, 443 (65%) were readmitted. Only 20% of readmissions were to a spine center. Cumulative incidence (95% CI) of readmission was estimated to 13% (10%-16%) at 30 days, 26% (23%-30%) at 90 days, 50% (46%-54%) at 1 year, and 59% (55%-63%) at 2 years following discharge. Rates were markedly lower for readmissions to a spine center. Increased odds of 30-day readmission were correlated to intraoperative hypotension (p=.02) and major intraoperative blood loss (p<.01). Readmission to a spine center was associated with the number of instrumented vertebrae (p=.047), major intraoperative AE (p=.01), and intraoperative hypotension (p<.01).

CONCLUSIONS

To the best of our knowledge, this is the first study to analyze prospectively registered AEs' association to readmission up to 2 years after complex spine surgery. We found that readmissions were more frequent than previously reported when including readmissions to any department or hospital. Factors related to major intraoperative blood loss were associated to increased odds of readmission. This should be considered during planning of postoperative observation and care.

Postoperative Venous Thromboembolism in Extramedullary Spinal Tumors

Context:

Venous thromboembolism (VTE), including deep-vein thrombosis (DVT) and pulmonary embolism (PE), is the fatal complication following spine surgery and the appropriate perioperative prophylaxis is still debated.

Aims:

The aim of this study is to evaluate the incidence of along with risk factors for postoperative VTE in surgically treated extramedullary spinal tumor patients.

Setting and Designs:

The study design involves single institute and retrospective cohort study.

Subjects and Methods:

The cohort database was reviewed between the periods of January 2014 and June 2019. Patients undergoing surgery for spine tumor, extradural tumor, and intradural extramedullary were consecutively collected.

Statistical Analysis Used:

The incidence of VTE and clinical factors reported to be associated with VTE were identified, and then analyzed with an appropriate Cox regression model.

Results:

The study identified 103 extramedullary spinal tumor patients. Three patients (2.9%) were diagnosed with a proximal leg DVT, while symptomatic PE did not identify. Risk factors associated with DVT occurrence were as follows: operative time ≥8 h (Hazard ratio [HR] 13.98, P = 0.03) and plasma transfusion (HR 16.38, P = 0.02), whereas plasma transfusion was the only significant factor, after multivariate analysis (HR 11.77, P = 0.05).

Conclusions:

Patients who underwent surgery for extramedullary spinal tumors showed a 2.9% incidence of DVT. The highest rate of DVT was found in patients who received plasma transfusion. More attention should be paid on perioperative associated factors for intensive prevention coupled with early screening in this group.

Adult Spinal Ependymomas: An Epidemiologic Study

OBJECTIVE

In adults, spinal ependymomas constitute only 3% to 6% of central nervous system tumors. Because of their rarity and poor prognosis, large population-based studies are needed to assess the epidemiology and survival risk factors associated with these tumors in the hope of improving outcome. The authors undertook this retrospective study to explore factors that may influence survival in adult patients with spinal ependymomas.

METHODS

Using the Surveillance, Epidemiology, and End Results database, a prospective cancer registry, the authors retrospectively assessed survival in histologically confirmed spinal ependymomas in patients 18 years of age and older. Survival was described with Kaplan-Meier curves, and a multivariate regression analysis was used to assess the association of several variables with survival while controlling for confounding variables.

RESULTS

Overall survival at 1 year, 3 years, and 5 years after diagnosis was 97.0%, 94.3%, and 93.3%, respectively. Patient age at diagnosis (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.04-1.07, P < 0.001), tumor grade IV (HR 11.11, 95% CI 1.27-97.02, P = 0.032), and the use of radiation therapy during the course of treatment (HR 4.42, 95% CI 1.69-11.57, P = 0.003) were each associated with decreased survival. Gross total resection (HR 0.42, 95% CI 0.20-1.10, P = 0.026) was associated with improved overall survival. Gender, tumor size, and tumor extension were not found to impact survival.

CONCLUSIONS

High-grade ependymomas occurring in the spine have a much worse prognosis than do those with lower grades. Early diagnosis and surgery appear to be associated with improved survival and outcomes, whereas radiation therapy has an unclear role.