Alcoholism as a predictor for pseudarthrosis in primary spine fusion: An analysis of risk factors and 30-day outcomes for 52,402 patients from 2005 to 2013

Nomogram for predicting surgical site infections in elderly patients after open lumbar spine surgery: A retrospective study

The aim of this study is to develop a nomogram to assess the risk of surgical site infection in elderly patients undergoing open lumbar spine surgery and explore related risk factors. We reviewed the records of 578 elderly patients who had undergone open lumbar spine surgery. The clinical parameters were subjected to lasso regression and logistic regression analyses. Subsequently, a nomogram was constructed to predict the risk of postoperative surgical site infection and validated using bootstrap resampling. A total of 578 patients were included in the analysis, of which 17 were diagnosed as postoperative surgical site infection. Following the final logistic regression analysis, obesity, hypoalbuminemia and drinking history were identified as independent risk factors and subsequently incorporated into the nomogram. The nomogram demonstrated excellent discrimination, with an area under the receiver-operating characteristic curve of 0.879 (95% CI 0.769 ~ 0.989) after internal validation. The calibration curve exhibited a high level of consistency. Decision curve analysis revealed that this nomogram had greater clinical value when the risk threshold for surgical site infection occurrence was >1% and <89%. We had developed a nomogram for predicting the risk of postoperative surgical site infection in elderly patients who had undergone open lumbar spine surgery. Validation using bootstrap resampling demonstrated excellent discrimination and calibration, indicating that the nomogram may hold potential clinical utility as a simple predictive tool for healthcare professionals.

The incidence of reoperation for pseudarthrosis after cervical spine surgery

INTRODUCTION

Pseudarthrosis after cervical spine surgery represents an underreported and challenging complication. Using a large multi-center surgical database, we sought to: (1) report the incidence of cervical pseudarthrosis, (2) evaluate changes in rates of cervical pseudarthrosis, and (3) describe risk factors for suboptimal outcomes after cervical pseudarthrosis surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019 was used. The primary outcome was occurrence of a cervical fusion procedure with a prior diagnosis of pseudarthrosis. Fusion for pseudarthrosis was divided into anterior and posterior approaches. Post-operative complications were classified as major or minor. Prolonged LOS was defined as exceeding the 75th percentile for total hospital stay.

RESULTS

A total of 780 patients underwent cervical fusion for pseudarthrosis, and a significant increase in rates of surgery for pseudarthrosis was seen (0.25-1.2%, p < 0.001). The majority of cervical pseudarthrosis was treated with a posterior approach (66.5%). Postoperatively, 38 (4.9%) patients suffered a complication and 247 (31.7%) had a prolonged LOS. The three strongest risk factors for complications and extended LOS were > 10% weight loss preoperatively, congestive heart failure, and pre-operative bleeding disorder.

CONCLUSION

Results from a large multi-center national database revealed that surgery to treat cervical pseudarthrosis has increased from 2012 to 2019. Most pseudarthrosis was treated with a posterior approach. Reoperation to treat cervical pseudarthrosis carried risk, with 5% having complications and 32% having an extended LOS. These results lay the groundwork for a future prospective study to discern the true incidence of cervical pseudarthrosis and how to best avoid its occurrence.

Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

Risk factors for reoperation after lumbar spine surgery in a 10-year Korean national health insurance service health examinee cohort

Degenerative lumbar spine disease is becoming increasingly prevalent in the aging population. Surgical treatment is the standard treatment modality for intractable cases, but the reoperation rate remains high. We conducted this study to longitudinally evaluate the impact of health risk factors on the risk of lumbar spine reoperation in Koreans aged over 40 years. Subjects aged > 40 years who underwent their first lumbar spinal surgery between January 2005 and December 2008 were selected and followed up until 2015. A total of 6300 people were included. The reoperation rate during the 10-year follow-up period was 13.2% (831/6300 patients). The reoperation rate was the highest in patients in their 60 s (15.4%, P < 0.05). The reoperation rates were also significantly higher in men (vs. women: 14.7% vs. 11.7%, P < 0.05), smokers (vs. non-smokers: 15.2% vs. 12.7%, P < 0.05), alcohol drinkers (vs. non-drinkers: 14.7% vs. 12.4%, P < 0.05), and those with a higher Charlson Comorbidity Index (CCI) score (CCI 0, 11.6%; 1–2, 13.2%; and ≥ 3, 15%; P < 0.05). Among patients undergoing lumbar spine surgery, reoperation is performed in 13.2% of patients within 10 years. Male sex, age in the 60 s, alcohol use, smoking, higher Hgb and a high CCI score increased the risk of reoperation after lumbar spine operation.

The Association of Alcohol Use Disorder with Perioperative Complications following Primary Total Hip Arthroplasty

Purpose

Alcohol use disorder is a leading mental health disorder in the United States. Few studies evaluating the association of alcohol use disorder following primary total hip arthroplasty (THA) have been reported. Therefore, the purpose of this study was to determine whether patients with alcohol use disorder undergoing primary THA have higher rates of: 1) in-hospital lengths of stay (LOS); 2) complications (medical/implant-related); and 3) costs.

Materials and Methods

Using a nationwide claims database from January 1st, 2005 to March 31st, 2014, patients with alcohol use disorder undergoing primary THA were identified and matched to a comparison group according to age, sex, and various comorbidities, resulting in 230,467 patients who were included in the study (n=38,416) and a matched-cohort (n=192,051). Outcomes of interest included comparison of LOS, 90-day medical and 2-year implant-related complications, and costs. A P-value less than 0.002 was considered statistically significant.

Results

Patients with alcohol use disorder had longer in-hospital LOS (4 days vs 3 days; P<0.0001) as well as higher frequency and odds ratio (OR) of 90-day medical (45.94% vs 12.25%; OR, 2.89; P<0.0001) and 2-year implant-related complications (17.71% vs 8.46%; OR, 1.97; P<0.0001). Patients in the study group incurred higher 90-day costs of care ($17,492.63 vs $14,921.88; P<0.0001).

Conclusion

With the growing prevalence of alcohol use disorder in the United States, the current investigation can be utilized to evaluate the need for interventions prior to THA which can potentially minimize the rates of morbidity and mortality within this population.

The influence of modifiable risk factors on short-term postoperative outcomes following cervical spine surgery: A retrospective propensity score matched analysis

BACKGROUND

Modifiable risk factors (MRFs) represent patient variables associated with increased complication rates that may be prevented. There exists a paucity of studies that comprehensively analyze MRF subgroups and their independent association with postoperative complications in patients undergoing cervical spine surgery. Therefore, the purpose of this study is to compare outcomes between patients receiving cervical spine surgery with reported MRFs.

METHODS

Retrospective analysis of the Nationwide Readmissions Database (NRD) from the years 2016 and 2017, a publicly available and purchasable data source, to include adult patients undergoing cervical fusion. MRF cohorts were separated into three categories: substance abuse (alcohol, tobacco/nicotine, opioid abuse); vascular disease (hypertension, dyslipidemia); and dietary factors (malnutrition, obesity). Three-way nearest-neighbor propensity score matching for demographics, hospital, and surgical characteristics was implemented.

FINDINGS

We identified 9601 with dietary MRFs (D-MRF), 9654 with substance abuse MRFs (SA-MRF), and 9503 with vascular MRFs (V-MRF). Those with d-MRFs had significantly higher rates of medical complications (9.3%), surgical complications (8.1%), and higher adjusted hospital costs compared to patients with SA-MRFs and V-MRFs. Patients with d-MRFs (16.3%) and V-MRFs (14.0%) were independently non-routinely discharged at a significantly higher rate compared to patients with SA-MRFs (12.6%) (p<0.0001 and p = 0.0037). However, those with substance abuse had the highest readmission rate and were more commonly readmitted for delayed procedure-related infections.

INTERPRETATION

A large proportion of patients who receive cervical spine surgery have potential MRFs that uniquely influence their postoperative outcomes. A thorough understanding of patient-specific MRF subgroups allows for improved preoperative risk stratification, tailored patient counseling, and postoperative management planning.

FUNDING

None.

Identifying risks factors in thoracolumbar anterior fusion surgery through predictive analytics in a nationally representative inpatient sample

PURPOSE

Anterior thoracolumbar (TL) surgical approaches provide more direct trajectories compared to posterior approaches. Proper patient selection is key in identifying populations that may benefit from anterior TL fusion. Here, we utilize predictive analytics to identify risk factors in anterior TL fusion in patients with trauma and deformity.

METHODS

In this retrospective cohort study of patients receiving anterior TL fusion (between and including T12/L1), population-based regression models were developed to identify risk factors using the National Readmission Database 2016-2017. Readmissions were analyzed at 30- and 90-day intervals. Risk factors included hypertension, obesity, malnutrition, smoking, alcohol use, long-term opioid use, and frailty. Multivariate regression models were developed to determine the influence of each risk factor on complication rates.

RESULTS

A total of 265 and 375 patients were identified for the scoliosis and burst fracture cohorts, respectively. In patients with scoliosis, alcohol use was found to increase the length of stay (LOS) (p = 0.00061) and all-payer inpatient cost following surgery (p = 0.014), and frailty was found to increase the inpatient LOS (p = 0.0045). In patients with burst fractures, malnutrition was found to increase the LOS (p < 0.0001) and all-payer cost (p < 0.0001), obesity was found to increase the all-payer cost (p = 0.012), and frailty was found to increase the all-payer cost (p = 0.031) and LOS (p < 0.0001).

DISCUSSION

Patient-specific risk factors in anterior TL fusion surgery significantly influence complication rates. An understanding of relevant risk factors before surgery may facilitate preoperative patient selection and postoperative patient triage and risk categorization.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

Intoxication by hand sanitizer due to delirium after infectious spondylitis surgery during the COVID-19 pandemic: A case report and literature review

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Alcohol-containing hand sanitizers are being utilized during the COVID-19 pandemic.

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These are relatively safe for use, but abuse should be avoided.

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Postoperative spinal surgery delirium can cause an altered mental state.

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This is the first case of hand sanitizer intoxication after spinal surgery.

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Caution should be exercised when treating patients with postoperative delirium.

Introduction

Alcohol-containing hand sanitizers are part of the strategy to prevent person-to-person transmission during the COVID-19 pandemic. The purpose of this report was to present a case of ethanol-induced hand sanitizer intoxication after spine surgery in a patient with a postoperative delirious state.

Presentation of case

A 63-year-old man was admitted to the spine department with intractable back pain as the main symptom and diagnosed with infectious spondylitis with discitis. The patient suddenly showed mental changes, resulting in a semi-comatose mental state the first day after surgery, without seizure-like activity and asphyxia. We subsequently discovered the patient had consumed half of an ethanol hand sanitizer bottle (about 300–400 mL) which was placed at the foot of the bed to prevent infection transmission during the COVID-19 pandemic. The patient did not tend to depend on alcohol or psychiatric medication in the past, and had no addiction. After seven months, the patient had complete bone union and independent ambulation.

Discussion

Acute ethanol intoxication can result in life-threatening clinical effects. One of the major problems after orthopedic surgery is delirium, with the largest number appearing after spine surgery.

Conclusion

Hand sanitizer, mainly composed of ethanol, did not cause abnormal findings or interfere with the course of treatment of infectious spondylitis. However, it is expected that such accidents will increase, due to the increase in the use of hand sanitizers caused by COVID-19. It is, therefore, necessary to avoid potential patient abuse, especially after spinal surgery in patients at risk of delirium.

Development of a Risk Prediction Model With Improved Clinical Utility in Elective Cervical and Lumbar Spine Surgery

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

We present a universal model of risk prediction for patients undergoing elective cervical and lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Previous studies illustrate predictive risk models as possible tools to identify individuals at increased risk for postoperative complications and high resource utilization following spine surgery. Many are specific to one condition or procedure, cumbersome to calculate, or include subjective variables limiting applicability and utility.

METHODS

A retrospective cohort of 177,928 spine surgeries (lumbar (L) Ln = 129,800; cervical (C) Cn = 48,128) was constructed from the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Cases were identified by Current Procedural Terminology (CPT) codes for cervical fusion, lumbar fusion, and lumbar decompression laminectomy. Significant preoperative risk factors for postoperative complications were identified and included in logistic regression. Sum of odds ratios from each factor was used to develop the Universal Spine Surgery (USS) score. Model performance was assessed using receiver-operating characteristic (ROC) curves and tested on 20% of the total sample.

RESULTS

Eighteen risk factors were identified, including sixteen found to be significant outcomes predictors. At least one complication was present among 11.1% of patients, the most common of which included bleeding requiring transfusion (4.86%), surgical site infection (1.54%), and urinary tract infection (1.08%). Complication rate increased as a function of the model score and ROC area under the curve analyses demonstrated fair predictive accuracy (lumbar = 0.741; cervical = 0.776). There were no significant deviations between score development and testing datasets.

CONCLUSION

We present the Universal Spine Surgery score as a robust, easily administered, and cross-validated instrument to quickly identify spine surgery candidates at increased risk for postoperative complications and high resource utilization without need for algorithmic software. This may serve as a useful adjunct in preoperative patient counseling and perioperative resource allocation.

LEVEL OF EVIDENCE

3.