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Ton A, Wishart D, Ball JR, Shah I, Murakami K, Ordon MP, Alluri RK, Hah R, Safaee MM. The Evolution of Risk Assessment in Spine Surgery: A Narrative Review. World Neurosurg 2024; 188:1-14. [PMID: 38677646 DOI: 10.1016/j.wneu.2024.04.117] [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: 03/17/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Risk assessment is critically important in elective and high-risk interventions, particularly spine surgery. This narrative review describes the evolution of risk assessment from the earliest instruments focused on general surgical risk stratification, to more accurate and spine-specific risk calculators that quantified risk, to the current era of big data. METHODS The PubMed and SCOPUS databases were queried on October 11, 2023 using search terms to identify risk assessment tools (RATs) in spine surgery. A total of 108 manuscripts were included after screening with full-text review using the following inclusion criteria: 1) study population of adult spine surgical patients, 2) studies describing validation and subsequent performance of preoperative RATs, and 3) studies published in English. RESULTS Early RATs provided stratified patients into broad categories and allowed for improved communication between physicians. Subsequent risk calculators attempted to quantify risk by estimating general outcomes such as mortality, but then evolved to estimate spine-specific surgical complications. The integration of novel concepts such as invasiveness, frailty, genetic biomarkers, and sarcopenia led to the development of more sophisticated predictive models that estimate the risk of spine-specific complications and long-term outcomes. CONCLUSIONS RATs have undergone a transformative shift from generalized risk stratification to quantitative predictive models. The next generation of tools will likely involve integration of radiographic and genetic biomarkers, machine learning, and artificial intelligence to improve the accuracy of these models and better inform patients, surgeons, and payers.
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Affiliation(s)
- Andy Ton
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Danielle Wishart
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jacob R Ball
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ishan Shah
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kiley Murakami
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Matthew P Ordon
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - R Kiran Alluri
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Raymond Hah
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Michael M Safaee
- Department of Neurological Surgery, Keck School of MedicineUniversity of Southern California, Los Angeles, California, USA.
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Levy HA, Pumford A, Kelley B, Allen TG, Pinter ZW, Girdler SJ, Bydon M, Fogelson JL, Elder BD, Currier B, Nassr AN, Karamian BA, Freedman BA, Sebastian AS. Unilateral versus bilateral pedicle screw fixation with anterior lumbar interbody fusion: a comparison of postoperative outcomes. 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 2024:10.1007/s00586-024-08412-5. [PMID: 39014077 DOI: 10.1007/s00586-024-08412-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 05/09/2024] [Accepted: 07/09/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE To determine of the impact of ALIF with minimally invasive unilateral pedicle screw fixation (UPSF) versus bilateral pedicle screw fixation (BPSF) on perioperative outcomes, radiographic outcomes, and the rates of fusion, subsidence, and adjacent segment stenosis. METHODS All adult patients who underwent one-level ALIF with UPSF or BPSF at an academic institution between 2015 and 2022 were retrospectively identified. Postoperative outcomes including length of hospital stay (LOS), wound complications, readmissions, and revisions were determined. The rates of fusion, screw loosening, adjacent segment stenosis, and subsidence were assessed on one-year postoperative CT. Lumbar alignment including lumbar lordosis, L4-S1 lordosis, regional lordosis, pelvic tilt, pelvic incidence, and sacral slope were assessed on standing x-rays at preoperative, immediate postoperative, and final postoperative follow-up. Univariate and multivariate analysis compared outcomes across posterior fixation groups. RESULTS A total of 60 patients were included (27 UPSF, 33 BPSF). Patients with UPSF were significantly younger (p = 0.011). Operative time was significantly greater in the BPSF group in univariate (p < 0.001) and multivariate analysis (ß=104.1, p < 0.001). Intraoperative blood loss, LOS, lordosis, pelvic parameters, fusion rate, subsidence, screw loosening, adjacent segment stenosis, and revision rate did not differ significantly between fixation groups. Though sacral slope (p = 0.037) was significantly greater in the BPSF group, fixation type was not a significant predictor on regression. CONCLUSIONS ALIF with UPSF relative to BPSF predicted decreased operative time but was not a significant predictor of postoperative outcomes. ALIF with UPSF can be considered to increase operative efficiency without compromising construct stability.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA.
| | - Andrew Pumford
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Brian Kelley
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Tyler G Allen
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Zachariah W Pinter
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Steven J Girdler
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Benjamin D Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bradford Currier
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Ahmad N Nassr
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Arjun S Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
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Rumalla KC, Covell MM, Skandalakis GP, Rumalla K, Kassicieh AJ, Roy JM, Kazim SF, Segura A, Bowers CA. The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011-2020). Spine J 2024; 24:582-589. [PMID: 38103740 DOI: 10.1016/j.spinee.2023.12.003] [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: 08/31/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND CONTEXT Preoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making. PURPOSE This study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication. STUDY DESIGN/SETTING Cross-sectional retrospective analysis of retrospective and nationally-representative data. PATIENT SAMPLE The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020. OUTCOME MEASURES CDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication. METHODS Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis. RESULTS There were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919). CONCLUSION Preoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.
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Affiliation(s)
- Kranti C Rumalla
- Feinberg School of Medicine, Northwestern University, 420 E Superior St., Chicago, IL, 60611, USA
| | - Michael M Covell
- School of Medicine, Georgetown University, 3900 Reservoir Road NW, Washington, DC, 20007, USA
| | - Georgios P Skandalakis
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Alexander J Kassicieh
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Joanna M Roy
- Topiwala National Medical College, Mumbai Central, Mumbai, Maharashtra 400008, India
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Aaron Segura
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 8342 S Levine Ln, Sandy, UT, 84070, USA.
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Zaidat B, Shrestha N, Rosenberg AM, Ahmed W, Rajjoub R, Hoang T, Mejia MR, Duey AH, Tang JE, Kim JS, Cho SK. Performance of a Large Language Model in the Generation of Clinical Guidelines for Antibiotic Prophylaxis in Spine Surgery. Neurospine 2024; 21:128-146. [PMID: 38569639 PMCID: PMC10992653 DOI: 10.14245/ns.2347310.655] [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: 12/10/2023] [Revised: 01/29/2024] [Accepted: 02/17/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Large language models, such as chat generative pre-trained transformer (ChatGPT), have great potential for streamlining medical processes and assisting physicians in clinical decision-making. This study aimed to assess the potential of ChatGPT's 2 models (GPT-3.5 and GPT-4.0) to support clinical decision-making by comparing its responses for antibiotic prophylaxis in spine surgery to accepted clinical guidelines. METHODS ChatGPT models were prompted with questions from the North American Spine Society (NASS) Evidence-based Clinical Guidelines for Multidisciplinary Spine Care for Antibiotic Prophylaxis in Spine Surgery (2013). Its responses were then compared and assessed for accuracy. RESULTS Of the 16 NASS guideline questions concerning antibiotic prophylaxis, 10 responses (62.5%) were accurate in ChatGPT's GPT-3.5 model and 13 (81%) were accurate in GPT-4.0. Twenty-five percent of GPT-3.5 answers were deemed as overly confident while 62.5% of GPT-4.0 answers directly used the NASS guideline as evidence for its response. CONCLUSION ChatGPT demonstrated an impressive ability to accurately answer clinical questions. GPT-3.5 model's performance was limited by its tendency to give overly confident responses and its inability to identify the most significant elements in its responses. GPT-4.0 model's responses had higher accuracy and cited the NASS guideline as direct evidence many times. While GPT-4.0 is still far from perfect, it has shown an exceptional ability to extract the most relevant research available compared to GPT-3.5. Thus, while ChatGPT has shown far-reaching potential, scrutiny should still be exercised regarding its clinical use at this time.
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Affiliation(s)
- Bashar Zaidat
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nancy Shrestha
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashley M. Rosenberg
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Wasil Ahmed
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami Rajjoub
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy Hoang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mateo Restrepo Mejia
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akiro H. Duey
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin E. Tang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Stoltzfus MT, Nguyen K, Freedman Z, Hallan DR, Hong J, Rizk E. Effects of Preoperative Glucocorticoid Use on Patients Undergoing Single-Level Lumbar Fusions: A Retrospective Propensity Score-Matched Registry Study. Cureus 2024; 16:e57197. [PMID: 38681464 PMCID: PMC11056191 DOI: 10.7759/cureus.57197] [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: 01/14/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
Objective Spinal fusions are gaining popularity as a means of treating spinal deformity and instability from a range of pathologies. The prevalence of glucocorticoid use has also increased in recent decades, and their systemic effects are well-documented. Although commonly used in the preoperative period, the effects of steroids on outcomes among patients undergoing spinal fusions are inadequately described. This study compares the odds of developing complications among patients who underwent single-level lumbar fusions with and without preoperative glucocorticoid use in hopes of establishing more evidence-based parameters for guiding preoperative steroid use. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective, propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent posterior or posterolateral single-level lumbar fusions with and without interbody fusion, those who used glucocorticoids for at least one week within a year of fusion and those who did not. The outcomes of interest were examined within 30 days of the operation and included death, reoperation, deep or superficial surgical site infection (SSI), pneumonia, reintubation, ventilator dependence, tracheostomy, acute kidney injury (AKI), renal insufficiency, pulmonary embolism (PE) or deep venous thrombosis (DVT), urinary tract infection (UTI), emergency department (ED) visit, sepsis, and myocardial infarction (MI). Results The odds of developing pneumonia within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.67 (p≤0.001, 95% CI: 0.59-0.69). The odds of requiring a tracheostomy within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.39 (p≤0.001, 95% CI: 0.26-0.60). The odds of reoperation, deep and superficial SSI, and ED visits within 30 days of operation were significantly higher for the same glucocorticoid-receiving cohort, with odds ratios of 1.4 (p=0.003, 95% CI: 1.11-1.65), 1.86 (p≤0.001, 95% CI: 1.31-2.63), 2.28 (p≤0.001, 95% CI: 1.57-3.31), and 1.25 (p≤0.001, 95% CI: 1.17-1.33), respectively. After propensity score-matching, there was no significant difference between the odds of death, DVT, PE, MI, UTI, AKI, sepsis, reintubation, and ventilator dependence between the two cohorts. Conclusion In support of much of the current literature regarding preoperative glucocorticoid use and rates of complications, patients who underwent a single-level lumbar fusion and have used glucocorticoids for at least a week within a year of operation experienced significantly higher odds of reoperation, deep and superficial SSI, and ED visits. However, these patients using glucocorticoids were also found to have lower odds of developing pneumonia, renal insufficiency, and tracheostomy requirement than those who did not use steroids within a year of surgery.
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Affiliation(s)
- Mason T Stoltzfus
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Kenny Nguyen
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Zachary Freedman
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - David R Hallan
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Jinpyo Hong
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
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Jo J, Lakomkin N, Zuckerman SL, Chanbour H, Riew KD. The incidence of reoperation for pseudarthrosis after cervical spine surgery. 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 2024; 33:1275-1282. [PMID: 38091104 DOI: 10.1007/s00586-023-08058-9] [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: 05/04/2023] [Revised: 10/16/2023] [Accepted: 11/19/2023] [Indexed: 03/19/2024]
Abstract
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.
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Affiliation(s)
- Jacob Jo
- Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN, USA
| | - Nikita Lakomkin
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN, USA.
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN, USA
| | - K Daniel Riew
- Department of Neurological Surgery, Cornell University Medical Center, New York, NY, USA
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
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Lu J, Guan F, Zhang Z, Gao Q, Li Q, Yu Z, Gu J. Comparison between gravity drainage group and suction drainage group after cervical laminoplasty: a retrospective STROBE-compliant cohort study. Br J Neurosurg 2024; 38:68-71. [PMID: 34608847 DOI: 10.1080/02688697.2021.1900538] [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: 02/19/2019] [Accepted: 03/03/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES A retrospective study was conducted to compare gravity drainage and suction drainage after cervical laminoplasty. PATIENTS AND METHODS A total of 375 patients who underwent laminoplasty between January 2011 and December 2015 were engaged in this analysis. We investigated the patients' basic characteristics, drainage characteristics and postoperative complications. RESULTS During the initial 24 h after laminoplasty, the drainage volume in the suction drainage group was 177.31 ± 92.02 mL, and the drainage volume in the gravity drainage group was 133.33 ± 92.40 mL. The drainage volume showed significant difference (p < 0.01). The total drainage volume was 357.49 ± 195.16 mL and 250.16 ± 27.44 mL in the suction drainage group and gravity drainage group, respectively. The total drainage volume between the two groups was statistically different (p = 0.03). The postoperative Hb was significantly different between the gravity group and suction group on the first day after the operation (108.37 ± 23.92 mL vs. 87.32 ± 21.53 mL, p = 0.02). The number of patients required blood transfusion was significantly different between the two groups as well (p = 0.04). Two cases had symptomatic epidural hematomas (SEH) after laminoplaty. However, the occurrence of SEH among the two groups was not different significantly. Twelve patients had surgical site infection (SSI). Of these 12, nine had applied gravity drainage and three suction drainage. The rate of SSI was similar between the two groups (p = 0.71). CONCLUSION The initial 24 h' drainage volume and the total drainage volume increased significantly in the suction drainage group. The postoperative Hb was lower in the suction group than the gravity drainage group the first postoperative day. More patients needed blood transfusion if suction drainage was performed. The application of suction drainage cannot decrease the incidence of SSI and SEH after laminoplasty. Gravity drainage is recommended for laminoplasty.
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Affiliation(s)
- Juncheng Lu
- Hospital of Harbin Medical University, Harbin, China
| | - Fulin Guan
- Hospital of Harbin Medical University, Harbin, China
| | | | - Qichang Gao
- Hospital of Harbin Medical University, Harbin, China
| | - Qingsong Li
- Hospital of Harbin Medical University, Harbin, China
| | - Zhange Yu
- Hospital of Harbin Medical University, Harbin, China
| | - Jiaao Gu
- Hospital of Harbin Medical University, Harbin, China
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Xie J, Du Y, Tan Z, Tang H. Association between malnutrition and surgical site wound infection among spinal surgery patients: A meta-analysis. Int Wound J 2023; 20:4061-4068. [PMID: 37391942 PMCID: PMC10681542 DOI: 10.1111/iwj.14297] [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: 06/11/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 07/02/2023] Open
Abstract
A surgical site infection (SSI) is one of the most common complications of spinal surgery. Malnutrition has also been linked to SSI after other surgical procedures. However, whether malnutrition is a risk factor for SSI after spinal surgery remains controversial. Therefore, we performed a meta-analysis to comprehensively evaluate the relationship between malnutrition and SSI. Relevant studies of the correlation between malnutrition and SSI were retrieved from the Cochrane Library, EMBASE, PubMed, Web of Science, China National Knowledge Infrastructure and Wanfang Data from database inception to 21 May 2023. Two reviewers independently assessed the included studies, and a meta-analysis was performed using STATA 17.0 software. A total of 24 articles with 179 388 patients were included: 3919 and 175 469 cases comprised the SSI and control groups, respectively. The meta-analysis results showed that malnutrition significantly increased the SSI incidence (odds ratio, 1.811; 95% confidence interval, 1.512-2.111; p < 0.001). These results suggest that patients with malnutrition are at higher risk for SSI after surgery. However, because of significant differences in sample sizes among studies, and because some studies had limitations to their methodological quality, further validation of these results by additional high-quality studies with larger sample sizes is necessary.
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Affiliation(s)
- Jiang Xie
- Department of Spine Surgery and Orthopaedics, Xiangya HospitalCentral South UniversityChangshaChina
- National Clinical Research Center for Geriatric Disorders, Xiangya HospitalCentral South UniversityChangshaChina
| | - Yuxuan Du
- Department of Spine Surgery and Orthopaedics, Xiangya HospitalCentral South UniversityChangshaChina
- National Clinical Research Center for Geriatric Disorders, Xiangya HospitalCentral South UniversityChangshaChina
| | - Zejiu Tan
- Department of Spine Surgery and Orthopaedics, Xiangya HospitalCentral South UniversityChangshaChina
- National Clinical Research Center for Geriatric Disorders, Xiangya HospitalCentral South UniversityChangshaChina
| | - Hao Tang
- Department of Spine Surgery and Orthopaedics, Xiangya HospitalCentral South UniversityChangshaChina
- National Clinical Research Center for Geriatric Disorders, Xiangya HospitalCentral South UniversityChangshaChina
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Amen TB, Song J, Mai E, Rudisill SS, Bovonratwet P, Subramanian T, Kaidi AK, Maayan O, Qureshi SA, Iyer S. Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors. Spine J 2023; 23:1848-1857. [PMID: 37716549 DOI: 10.1016/j.spinee.2023.09.005] [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: 05/30/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND CONTEXT Although outpatient spine surgery is becoming increasingly popular in the United States, unplanned readmission following outpatient surgery remains a significant postoperative concern. PURPOSE This study aimed to (1) describe the incidence and timing of 30-day unplanned readmission after ambulatory lumbar and cervical spine surgery (2) evaluate the common reasons for readmission, and (3) identify factors associated with readmission in this population. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. OUTCOME MEASURES Hospital readmission within 30 postoperative days. METHODS Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Reasons for and timing of unplanned readmissions were recorded. Multivariable poisson regressions were employed to determine any independent predictors of readmission. RESULTS A total of 33,092 ambulatory cervical and 68,115 ambulatory lumbar spine surgery patients were identified. Incidences of 30-day readmission were 3.37% and 3.07% among cervical and lumbar patients, respectively. The most common surgical site-related reasons for readmission included uncontrolled pain, recurrence of disc herniation or major symptom, and postoperative hematoma/seroma. Common nonsurgical site-related reasons included gastrointestinal, neurological, and cardiovascular complications. Factors associated with readmission among cervical patients included age ≥55, BMI ≥35, functional dependence, diabetes, smoking, COPD, and steroid use, whereas factors associated with readmission following lumbar spine surgery included age ≥65, female sex, BMI ≥35, functional dependence, ASA ≥3, diabetes, smoking, COPD, and hypertension (p<.05 for all). CONCLUSION This study highlights the common reasons and factors associated with unplanned readmission following ambulatory spine surgery. Consideration of these factors may be critical to ensuring appropriate patient selection for ambulatory spine surgery.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA.
| | - Junho Song
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Eric Mai
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Samuel S Rudisill
- Rush Medical College, Rush University Medical Center, Chicago, IL, USA
| | - Patawut Bovonratwet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Tejas Subramanian
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Austin K Kaidi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Omri Maayan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Sheeraz A Qureshi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Sravisht Iyer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
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10
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Wang J, Chang Y, Suo M, Huang H, Liu X, Li Z. Incidence and risk factors of surgical site infection following cervical laminoplasty: A retrospective clinical study. Int Wound J 2023; 21:e14450. [PMID: 37859579 PMCID: PMC10828128 DOI: 10.1111/iwj.14450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023] Open
Abstract
There are many debates regarding the risk factors of surgical site infection (SSI) following posterior cervical surgery in previous studies. And, till now there is no such a study to examine cervical laminoplasty surgery. From January 2011 through October 2021, a total of 405 patients who were treated with unilateral open-door laminoplasty surgeries were enrolled in this study. We divided the patients into the SSI group and the non-SSI group and compared their patient-specific and procedure-specific factors. Univariate and multiple logistic regression analysis were performed to determine the risk factors. Of the 405 patients, 20 patients had SSI. The rate of SSI found to be 4.93%. There were significant differences between groups in the thicker subcutaneous fat thickness (FT) (p < 0.001), the higher ratio of subcutaneous FT to muscle thickness (MT) (p < 0.001), the higher preoperative Japanese Orthopaedic Association (JOA) Scores (p < 0.003), the decreased preoperative serum albumin (p < 0.001), the more postoperative drainage (p < 0.05) and the longer time of draining (p < 0.001). Logistic regression analysis of these differences showed that the higher ratio of subcutaneous FT/MT, the higher preoperative JOA scores, the decreased preoperative serum albumin and the longer time of draining were significantly related to SSI (p < 0.05). The higher ratio of subcutaneous FT/MT, the higher preoperative JOA scores, the decreased preoperative serum albumin and the longer time of draining are identified as the independent risk factors of SSI in cervical laminoplasty. Identification of these risk factors could be useful in reducing the SSI incidence and patients counselling.
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Affiliation(s)
- Jinzuo Wang
- Department of OrthopaedicsFirst Affiliated Hospital of Dalian Medical UniversityDalianPeople's Republic of China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic DiseasesDalianPeople's Republic of China
| | - Yvang Chang
- Department of ThyroidFirst Affiliated Hospital of China Medical UniversityShenyangPeople's Republic of China
| | - Moran Suo
- Department of OrthopaedicsFirst Affiliated Hospital of Dalian Medical UniversityDalianPeople's Republic of China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic DiseasesDalianPeople's Republic of China
| | - Huagui Huang
- Department of OrthopaedicsFirst Affiliated Hospital of Dalian Medical UniversityDalianPeople's Republic of China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic DiseasesDalianPeople's Republic of China
| | - Xin Liu
- Department of OrthopaedicsFirst Affiliated Hospital of Dalian Medical UniversityDalianPeople's Republic of China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic DiseasesDalianPeople's Republic of China
| | - Zhonghai Li
- Department of OrthopaedicsFirst Affiliated Hospital of Dalian Medical UniversityDalianPeople's Republic of China
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopaedic DiseasesDalianPeople's Republic of China
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11
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Hu Y, Wang L, Liu H, Yang K, Wang S, Zhang X, Qu B, Yang H. Association of preoperative hypoprotein malnutrition with spinal postoperative complications and other conditions: A systematic review and meta-analysis. Clin Nutr ESPEN 2023; 57:448-458. [PMID: 37739691 DOI: 10.1016/j.clnesp.2023.07.083] [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: 04/10/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Postoperative complications of spinal surgery are a common clinical problem, which impose significant economic and clinical burdens on patients and medical staff. Previous studies have suggested a close relationship between low-protein malnutrition and postoperative complications of surgery. However, the relationship between preoperative malnutrition and various orthopedic postoperative complications remains unclear. PURPOSE To investigate the association between protein malnutrition and postoperative complications and outcomes. METHODS We conducted a systematic search of the PubMed, Embase, Cochrane Library, and Web of Science databases for published research articles between the database inception and February 28th, 2023, that evaluated the association between malnutrition and the risk of postoperative complications and death in spinal surgery patients. Malnutrition was defined as low pre-albumin and albumin levels before surgery. Two evaluators independently extracted study data and assessed the risk of bias in each study. Fixed- or random-effect models were used to calculate the pooled effect estimates. Funnel plots and Egger's tests were used to detect publication bias, and the Trim-and -Fill method was conducted to evaluate the impact of publication bias on the results. RESULTS A total of 26 studies were included in this meta-analysis, comprising 17 retrospective cohort studies and 9 case-control studies. The study included more than 86,000 participants. Analysis of postoperative complications revealed that the overall incidence of malnutrition-related complications after surgery was 3.17 times higher (OR = 3.17, 95% CI 2.69-3.75, z = 13.57, P < 0.05). The incidence of surgical site infections was 2.08 times higher (OR = 2.08, 95% CI 1.66-2.62, z = 6.307, P < 0.05), and the incidence of postoperative urinary tract infections was 2.55 times higher (OR = 2.55, 95% CI 1.80-3.60, z = 5.30, P < 0.05). The incidence of postoperative sepsis was 3.31 times higher (OR = 3.31, 95% CI 2.31-4.75, z = 6.51, P < 0.05), and the incidence of postoperative pneumonia was 3.02 times higher (OR = 3.02, 95% CI 1.331-6.857, z = 2.64, P = 0.008 < 0.05). The incidence of postoperative cardiac complications was 4.24 times higher (OR = 4.24, 95% CI 2.45-7.35, z = 5.15, P < 0.05), and the incidence of postoperative renal complications was 4.04 times higher (OR = 4.04, 95% CI 2.06-7.93, z = 4.05, P < 0.05). The incidence of postoperative pulmonary complications was 2.38 times higher (OR = 2.38, 95% CI 1.46-3.87, z = 6.98, P < 0.05), while the incidence of postoperative thrombotic complications was 2.76 times higher (OR = 2.76, 95% CI 1.756-4.345, z = 4.40, P < 0.05). Furthermore, the incidence of transfusion during and after surgery was 1.33 times higher (OR = 1.33, 95% CI 1.13-1.56, z = 3.40, P = 0.001 < 0.05), the incidence of postoperative readmission was 1.67 times higher (OR = 1.67, 95% CI 1.24-2.27, z = 3.33, P = 0.001 < 0.05), and the risk of postoperative death was 6.01 times higher (OR = 6.01, 95% CI 4.51-8.01, z = 12.27, P < 0.05). After conducting a publication bias test and Trim-and -Fill method analysis, we found no evidence of publication bias, and the results remained stable. CONCLUSION Preoperative low protein malnutrition is closely related to the incidence of postoperative complications and postoperative status. More prospective multicenter studies should be conducted to validate this conclusion. Furthermore, more effective assessment and intervention of preoperative nutritional status should be carried out to prevent the occurrence of postoperative complications and mortality risk.
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Affiliation(s)
- Yongrong Hu
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610000, China
| | - Liping Wang
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610000, China
| | - Hao Liu
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610000, China
| | - Kunhai Yang
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610000, China
| | - Song Wang
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610000, China
| | - Xiang Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610000, China
| | - Bo Qu
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610000, China.
| | - Hongsheng Yang
- Department of Orthopedics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610000, China.
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Stewart KE, Terada R, Windrix C, Ma L, Gomes M, Butt A, Tanaka KA. Trends and Prediction of Surgical Site Infection After Elective Spine Surgery: An Analysis of the American College of Surgeons National Surgical Quality Improvement Project Database. Surg Infect (Larchmt) 2023. [PMID: 37311216 DOI: 10.1089/sur.2023.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
Background: Surgical site infection (SSI) is an infrequent but costly complication after elective spine surgery. Identification of important temporal changes and predictive factors may inform targeted prevention efforts. Patients and Methods: A retrospective study of elective spine surgery patients was performed using the National Surgical Quality Improvement Programs (NSQIP) database from 2011 and 2019. Temporal changes in SSI and related factors were examined descriptively. Recursive partitioning and bootstrap forest techniques were used to inform the development of predictive models for SSI. Results: A total of 6,038 (1.66%) of 363,754 patients had an SSI recorded. Peri-operative transfusion and preoperative anemia decreased over the nine-year period, however, obesity and diabetes mellitus increased, whereas the SSI rate remained essentially unchanged. A full model including 15 variables had an area under the curve (AUC) of 0.693 (95% confidence interval [CI], 0.686-0.700) whereas a reduced model with just nine variables had an AUC of 0.690 (95% CI, 0.683-0.697). Adjusted odd ratios (aOR) greater than two were noted for only three variables; a posterior approach (aOR, 2.32; 95% CI, 2.14-2.50), body mass index (BMI) >40 kg/m2 (aOR, 2.63; 95% CI, 2.39-2.90), and surgical duration longer than 350 minutes (aOR, 2.39; 95% CI, 2.14-2.67). Remaining retained variables included albumin <3.5 g/dL, inpatient procedure, peri-operative transfusion, diabetes mellitus (both insulin/non-insulin), anemia, and smoking. Conclusions: Surgical site infection rate remained unchanged over a nine-year period despite the lower rates of allogeneic blood transfusion. Class 3 obesity, long operative times, and a posterior approach mainly for thoracic/lumbar spine procedures seemed more pragmatic, but their predictive performance was only modest in our prediction models for SSI.
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Affiliation(s)
- Kenneth E Stewart
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Rui Terada
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Casey Windrix
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Louis Ma
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Marcos Gomes
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amir Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Chan RWY, Chiang YH, Lin HC, Chang CY, Tsou YS. Postoperative 30-Day Comparative Complications of Multilevel Anterior Cervical Discectomy and Fusion and Laminoplasty for Cervical Spondylotic Myelopathy: An Evidence in Reaching Consensus. Diagnostics (Basel) 2023; 13:2024. [PMID: 37370919 DOI: 10.3390/diagnostics13122024] [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: 04/20/2023] [Revised: 05/25/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Although a few large-scale studies have investigated multilevel anterior cervical discectomy and fusion (ACDF) and laminoplasty (LAMP) and their related complications for cervical spondylotic myelopathy (CSM), the optimal surgical intervention remains controversial. Therefore, we compared their 30 days of postoperative complications. Through the 2010-2019 ACS NSQIP Participant Use Data Files, we estimated the risk of serious morbidity, reoperation, readmission, mortality, and other postoperative complications. Initially, propensity score matching (PSM) of the preoperative characteristics of both groups was performed for further analysis. Multivariable logistic regression analysis provided OR and 95% CI for comparative complications. After PSM, 621 pairs of cohorts were generated for both groups. Increased frequency of postoperative complications was observed in the LAMP group, especially for surgical wound infection, no matter whether superficial (ACDF/LAMP = 0%/1.13%, p = 0.0154) or deep wound infection (ACDF/LAMP = 0%/0.97%, p = 0.0309). The mean length of total hospital stays (ACDF/LAMP = 2.25/3.11, p < 0.0001) and days from operation to discharge (ACDF/LAMP = 2.12/3.08, p < 0.0001) were longer, while the hospitalization rate for over 30 days (ACDF/LAMP = 4.67%/7.41%, p = 0.0429) and unplanned reoperation (ACDF/LAMP = 6.12%/9.34%, p = 0.0336) were higher in LAMP. Results also indicated congestive heart failure as a risk factor (adjusted OR = 123.402, p = 0.0002). Conclusively, multilevel ACDF may be a safer surgical approach than LAMP for CSM in terms of perioperative morbidities, including surgical wound infection, prolonged hospitalization, and unplanned reoperation. However, these approaches showed no significant differences in systemic complications and perioperative mortality.
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Affiliation(s)
- Ryan Wing-Yuk Chan
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Yung-Hsiao Chiang
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
- Department of Surgery, School of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsiu-Chen Lin
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Department of Clinical Pathology, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Chih-Yau Chang
- Department of Quality Management, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Yi-Syue Tsou
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
- Ph.D. Program in Medical Neuroscience, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan
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14
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Huang X, Guo Y, Fu R, Li H. A nomogram to predict postoperative surgical site infection of adult patients who received orthopaedic surgery: a retrospective study. Sci Rep 2023; 13:8129. [PMID: 37208366 DOI: 10.1038/s41598-023-34926-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
Surgical site infection is a common postoperative complication with serious consequences. This study developed a nomogram to estimate the probability of postoperative surgical site infection for orthopaedic patients. Adult patients following orthopaedic surgery during hospitalization were included in this study. We used univariate and multivariate logistic regression analyses to establish the predictive model, which was also visualized by nomogram. To evaluate the model performance, we applied the receiver operating characteristic curve, calibration curve, and decision curve analysis, which were utilized in external validation and internal validation. From January 2021 to June 2022, a total of 787 patients were enrolled in this study. After statistical analysis, five variables were enrolled in the predictive model, including age, operation time, diabetes, WBC, and HGB. The mathematical formula has been established as follows: Logit (SSI) = - 6.301 + 1.104 * (Age) + 0.669 * (Operation time) + 2.009 * (Diabetes) + 1.520 * (WBC) - 1.119 * (HGB). The receiver Operating Characteristic curve, calibration curve, and decision curve analysis presented a good performance of this predictive model. Our nomogram showed great discriminative ability, calibration, and clinical practicability in the training set, external validation, and internal validation.
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Affiliation(s)
- Xu'an Huang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Graduate School of Peking Union Medical College, Beijing, People's Republic of China
| | - Yang Guo
- The School of Clinical Medicine, Fujian Medical University, The First Affiliated Hospital of Xiamen University, 55 Zhenhai Road, Xiamen, 361001, Fujian Province, People's Republic of China.
| | - Ribin Fu
- The School of Clinical Medicine, Fujian Medical University, Zhongshan Hospital Xiamen University, No.201-209, Hubinnan Road, Siming District, Xiamen, 361001, Fujian Province, People's Republic of China.
| | - Hongwei Li
- Zhongshan Hospital Xiamen University, Xiamen, China
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15
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Saleh H, Williamson TK, Passias PG. Perioperative Nutritional Supplementation Decreases Wound Healing Complications Following Elective Lumbar Spine Surgery: A Randomized Controlled Trial. Spine (Phila Pa 1976) 2023; 48:376-383. [PMID: 36730860 DOI: 10.1097/brs.0000000000004522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prevalence of malnutrition in patients undergoing lumbar spine surgery ranges from 5% to 50% and is associated with higher rates of surgical site infections, medical complications, longer lengths of stay, and mortality. PURPOSE To determine if perioperative nutritional intervention decreases wound healing complications in patients undergoing lumbar spine surgery. STUDY DESIGN/SETTING A prospective randomized controlled trial. MATERIALS AND METHODS Patients aged 55+ undergoing elective primary lumbar surgery were included. Patients with a preoperative albumin<3.5 g/dL were defined as malnourished. Intervention group received nutritional supplementation (protein shake) twice daily from postoperative day 0 to two weeks postdischarge. Control group was instructed to continue regular daily diets. Primary outcomes included minor in-hospital complications (wound drainage, electrolyte abnormalities, hypotension, ileus, deep venous thrombus) and wound healing complications within 90 days. Secondary outcomes included 90-day emergency room visits, readmissions, and return to the operating room. Baseline data were compared between groups using means comparison tests. Multivariable analysis evaluated association of outcomes with nutritional supplementation. Subanalysis of malnourished patients assessed effects of nutritional supplementation on outcomes. RESULTS One hundred three patients were included. Thirty-seven (35.9%) were considered malnourished preoperatively. Forty-six (44.7%) received nutritional intervention and 57 (55.3%) served as controls. Adjusted analysis found patients receiving supplementation had lower rates of in-hospital minor complications (2.1% vs. 23.2%, P <0.01), and perioperative wound healing complications (3.4% vs. 17.9%, P <0.05). Subgroup analysis of 37 malnourished patients demonstrated that malnourished patients who received perioperative nutritional supplementation had lower rates of minor complications during admission (0.0% vs. 34.4%, P =0.01) and return to the operating room within 90 days (0.0% vs. 12.4%, P =0.04). CONCLUSIONS Over one third of patients undergoing lumbar surgery were malnourished. Nutritional supplementation during the two-week perioperative period decreased rates of minor complications during admission and wound complications within 90 days. Malnourished patients receiving supplementation less often returned to the operating room. To our knowledge, this is the first study to investigate the effects of perioperative nutritional intervention on wound healing complications for patients undergoing elective lumbar spine surgery. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Hesham Saleh
- Department of Orthopedic Surgery, NYU Langone Medical Center, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center, New York Spine Institute, New York, NY
| | - Peter G Passias
- Division of Spinal Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center, New York Spine Institute, New York, NY
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16
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Shu L, Muheremu A, Shoukeer K, Ji Y. Prophylactic Application of Vancomycin Powder in Preventing Surgical Site Infections After Spinal Surgery. World Neurosurg 2023; 171:e542-e553. [PMID: 36529431 DOI: 10.1016/j.wneu.2022.12.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We sought to analyze the preventive effect of local vancomycin powder application on surgical site infection (SSI) in spinal surgeries and provide the basis for future clinical practice. METHODS Through PubMed, Medline, Elsevier, and the Cochrane Library, with MeSH words "vancomycin powder," "local/intraoperative/topical/intra-wound," "spine/spinal/lumbar/cervical/thoracolumbar," "surgery," "infection," and "SSI," we searched for case-control research papers on the impact of prophylactic application of vancomycin powder on the incidence of SSI and compared the rate of infection using RevMan 5.3 meta-analysis software. RESULTS A total of 1950 publications were found using the mesh words, and 50 of those studies were selected for final analysis. There were 34,301 cases in total, including 14,793 cases in vancomycin group and 19,508 cases in the control group. Results of meta-analysis showed that the incidence of SSI was significantly lower in the prophylactic vancomycin powder group than the control group (P < 0.001). Further subgroup analysis showed that the incidence of SSI was significantly lower in the prophylactic vancomycin powder group than the control group in spine surgeries with internal fixation, deformity correction, and deep tissue infections (P < 0.001). Meanwhile, there were no significant differences between the 2 groups concerning patients undergoing noninstrumented spine surgeries and the incidence of superficial tissue infection. CONCLUSIONS Overall, prophylactic application of vancomycin powder in spinal surgery can significantly reduce the incidence of SSI in deep tissues, and this effect is more prominent in patients undergoing internal fixation and deformity correction surgeries.
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Affiliation(s)
- Li Shu
- Orthopedic Research Center, Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Aikeremujiang Muheremu
- Orthopedic Research Center, Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
| | - Kutiluke Shoukeer
- Orthopedic Research Center, Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yuchen Ji
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Piche JD, Rodoni B, Muralidharan A, Yang D, Gagnier J, Patel R, Aleem I. Investigating the Association of Patient Body Mass Index With Posterior Subcutaneous Fat Thickness in the Cervical Spine: A Retrospective Radiographic Study. Cureus 2023; 15:e34739. [PMID: 36909100 PMCID: PMC9997731 DOI: 10.7759/cureus.34739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION Although BMI is often used as a surrogate for posterior cervical subcutaneous fat thickness (SFT), the association of BMI with cervical SFT is unknown. We performed a retrospective radiographic study to analyze the relationship between BMI and cervical SFT. METHODS This was a retrospective cohort study of patients with cervical CT scans. SFT was assessed by measuring the distance (mm) from the spinous processes of C2-C7 to the skin edge. Pearson correlations and linear regression were used to analyze the relationship between BMI and SFT. One-way ANOVA was used to analyze differences in C2-C7 distances while stratifying by BMI. RESULTS A total of 96 patients were included. BMI had a moderate correlation with average C2-C7 (r=0.546, p < 0.05) SFT, and a weak to moderate correlation with each individual C2-C7 distance. The strongest correlation was at the C7 level (r= 0.583, p < 0.05). These analyses remained significant controlling for potential confounders of patient age, sex, and diabetes. No difference was found in the average C2-C7 distance in patients with BMIs of 25-30 compared to those with BMIs of 30-40 (p=0.996), whereas in patients with BMI <25 and BMI >40, differences were significant (p < 0.05). CONCLUSIONS BMI is not strongly correlated with SFT in the cervical spine. Although BMI less than 25 or greater than 40 is correlated with respectively decreased or increased cervical SFT, BMI of 25-40 is not correlated with cervical SFT. This is clinically important information for surgeons counseling patients on perioperative risk before undergoing cervical spine procedures, namely infection. Further research delineating the relationship between posterior SFT and surgical site infection in the cervical spine is warranted.
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Affiliation(s)
- Joshua D Piche
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, USA
| | - Bridger Rodoni
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, USA
| | | | - Daniel Yang
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, USA
| | - Joel Gagnier
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, USA
| | - Rakesh Patel
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, USA
| | - Ilyas Aleem
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, USA
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Incidence and local risk factors of infection after anterior sub-axial cervical spine surgery: retrospective database analysis of 4897 consecutive procedures. Arch Orthop Trauma Surg 2023; 143:717-727. [PMID: 34432096 DOI: 10.1007/s00402-021-04133-2] [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: 04/29/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The anterior cervical spine approach is safe and effective in many cervical spine pathologies. It is considered one of the most common approaches in spine surgery. Postoperative infections after anterior cervical surgery are rare but serious. MATERIALS AND METHODS This study is a retrospective database analysis. In this study, the incidence, and the local risk factors of postoperative infection after anterior-only sub-axial cervical spine surgery in a high-volume spine center were analyzed. The data of patients operated in a teaching hospital is electronically stored in a comprehensive medical database program. Postoperative infection after anterior cervical surgery from C2 to C7 was calculated and analyzed. In the study period, 4897 patients were operated. Twenty-four infections after a primary aseptic operation were detected. Independent local risk factors were estimated. RESULTS Postoperative infection occurred in 24/4897 patients (0.49%). The incidence of infection after cervical trauma was 3% (7/229), after spinal cord injury 4.3% (2/46), with myelopathy 1.98% (11/556), and after revision surgery 1.25% (7/560). The incidence showed a significant increase (p = 0.00, 0.01, 0.02). In 14 of the postoperatively infected patients (58.3%) an oesophageal injury was diagnosed. Odds ratios (OR) with a confidence interval (CI) of 95% was calculated. Independent risk factors for the postoperative infections were: Cervical trauma (OR 8.59, 95% CI 3.52-20.93), revision surgery (OR 3.22, 95% CI 1.33-7.82), The presence of cervical myelopathy (OR 6.71, 95% CI 2.99-15.06), and spinal cord injury (OR 9.33, 95% CI 2.13-40.83). CONCLUSIONS Postoperative infection after anterior cervical surgery is low (0.49%). In addition to the general risk factor for infection, the local risk factors are trauma, myelopathy, spinal cord injury, and revision surgeries. In the case of postoperative infection, an oesophageal injury should be excluded.
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Li X, Li H, Huang S, Pan Y. Association between hypoalbuminemia and complications after degenerative and deformity-correcting spinal surgeries: A systematic review and meta-analysis. Front Surg 2023; 9:1030539. [PMID: 36684211 PMCID: PMC9852605 DOI: 10.3389/fsurg.2022.1030539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/14/2022] [Indexed: 01/07/2023] Open
Abstract
Objective The current review was designed to explore if hypoalbuminemia is associated with increased complications in patients undergoing spinal degenerative and deformities surgeries. Methods The search for eligible studies was conducted on the databases of PubMed, Embase, Web of Science, and CENTRAL up to 20th June 2022. Complication rates were pooled to obtain odds ratio (OR) and 95% confidence intervals. Results Thirteen studies were included. We found that hypoalbuminemia was significantly associated with increased risk of all complications (OR: 2.72 95% CI: 2.04, 3.63 I 2 = 58% p < 0.00001), mortality (OR: 7.73 95% CI: 3.81, 15.72 I 2 = 0% p < 0.00001), revision surgery (OR: 3.15 95% CI: 1.53, 6.48 I 2 = 87% p = 0.002), readmissions (OR: 1.96 95% CI: 1.29, 2.98 I 2 = 23% p = 0.02), surgical site infections (OR: 2.97 95% CI: 1.90, 4.63 I 2 = 38% p < 0.00001), wound complications (OR: 2.31 95% CI: 1.17, 4.56 I 2 = 48% p = 0.02), pulmonary complications (OR: 3.74 95% CI: 2.66, 5.26 I 2 = 0% p < 0.00001), renal complications (OR: 3.04 95% CI: 1.22, 7.54 I 2 = 0% p = 0.02), cardiac complications (OR: 4.33 95% CI: 2.14, 8.77 I 2 = 0% p < 0.0001), urinary tract infections (OR: 2.08 95% CI: 1.80, 2.41 I 2 = 0% p < 0.00001), and sepsis (OR: 4.95 95% CI: 1.87, 13.08 I 2 = 64% p = 0.01) as compared to those with normal albumin. Conclusion Hypoalbuminemia is a significant risk factor for complications after spinal degenerative and deformity surgeries. Research is also needed on the role of nutritional support in improving outcomes after spinal degenerative and deformity surgeries. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42022340024.
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Affiliation(s)
- Xia Li
- Department of Orthopedics Nursing, First Affiliated Hospital of Huzhou University, Huzhou, China
| | - Haidong Li
- Department of Orthopedics, First Affiliated Hospital of Huzhou University, Huzhou, China
| | - Shufeng Huang
- Department of Orthopedics, First Affiliated Hospital of Huzhou University, Huzhou, China
| | - Yiping Pan
- Department of Orthopedics Nursing, First Affiliated Hospital of Huzhou University, Huzhou, China,Correspondence: Yiping Pan
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Gupta A, Shin J, Oliver D, Vives M, Lin S. Incidence and risk factors for surgical site infection (SSI) after primary hip hemiarthroplasty: an analysis of the ACS-NSQIP hip fracture procedure targeted database. ARTHROPLASTY (LONDON, ENGLAND) 2023; 5:1. [PMID: 36593517 PMCID: PMC9808930 DOI: 10.1186/s42836-022-00155-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/16/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Primary hip hemiarthroplasty (HHA) is frequently utilized to treat geriatric hip fractures, which are associated with significantly higher morbidity and mortality. While not particularly common, surgical site infection (SSI) is a major complication that frequently requires revision surgery in a frail population. The objective of this study was to determine the incidence of and risk factors for SSI after HHA in hip fracture patients. MATERIALS AND METHODS This retrospective cohort study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Geriatric patients (65+) who underwent HHA for non-pathologic, traumatic hip fractures between 2016-2017 were included. Demographic variables, comorbidities, operative variables, and complications were compared between "SSI" and "non-SSI" groups. Multivariate regression identified independent risk factors for postoperative SSI. Significance was set at P = 0.05. RESULTS A total of 6169 patients were included. The overall incidence of SSI was 1.3%. SSI was significantly associated with body mass index (BMI), preoperative functional status, congestive heart failure, chronic corticosteroid use, intraoperative time, sepsis, wound dehiscence, readmission within 30-days, and reoperation. On multivariate analysis, chronic steroid use (OR: 2.30, 95% CI: 1.13-4.70), BMI ≥ 35 kg/m2 (OR: 3.59, 95% CI: 1.57-8.18), and intraoperative time ≥120 mins (OR: 2.15, 95% CI: 1.08-4.27) were found to be independent risk factors. CONCLUSIONS Postoperative SSI is a serious complication that is responsible for prolonged hospital stays, increased mortality, and greater healthcare costs. Here, we identified multiple risk factors for SSI after primary HHA in the US elderly population.
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Affiliation(s)
- Arjun Gupta
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
| | - John Shin
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
| | - Dylan Oliver
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
| | - Michael Vives
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
| | - Sheldon Lin
- grid.430387.b0000 0004 1936 8796Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite D-1610, Newark, NJ 07103 USA
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21
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Lantz JM, Roberts C, Formanek B, Michener LA, Hah RJ, Wang JC, Buser Z. Incidence of complications associated with cervical spine surgery and post-operative physical therapy and implications for timing of initiation of post-operative physical therapy: a retrospective database study. 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; 32:382-388. [PMID: 36401668 DOI: 10.1007/s00586-022-07466-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/19/2022] [Accepted: 11/11/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe the incidence of complications associated with cervical spine surgery and post-operative physical therapy (PT), and to identify if the timing of initiation of post-operative PT impacts the incidence rates. METHODS MOrtho PearlDiver database was queried using billing codes to identify patients who had undergone Anterior Cervical Discectomy and Fusion (ACDF), Posterior Cervical Fusion (PCF), or Cervical Foraminotomy and post-operative PT from 2010-2019. For each surgical procedure, patients were divided into three 12-week increments for post-operative PT (starting at post-operative weeks 2, 8, 12) and then matched based upon age, gender, and Charlson Comorbidity Index score. Each group was queried to determine complication rates and chi-square analysis with adjusted odds ratios, 95% confidence intervals, and p-values were used. RESULTS Following matching, 3,609 patients who underwent cervical spine surgery at one or more levels and had post-operative PT (ACDF:1784, PCF:1593, and cervical foraminotomy:232). The most frequent complications were new onset cervicalgia (2-14 weeks, 8-20 weeks, 12-24 weeks): ACDF (15.0%, 14.0%, 13.0%), PCF (18.8%, 18.0%, 19.9%), cervical foraminotomy (16.8%, 16.4%, 19.4%); revision: ADCF (7.9%, 8.2%, 7.4%), PCF (9.3%, 10.6%, 10.2%), cervical foraminotomy (11.6%, 10.8% and 13.4%); wound infection: ACDF (3.3%, 3.4%, 3.1%), PCF (8.3%, 8.0%,7.7%), cervical foraminotomy (5.2%, 6.5%, < 4.7%). None of the comparisons were statistically significant. CONCLUSION The most common post-operative complications included new onset cervicalgia, revision and wound infection. Complications rates were not impacted by the timing of initiation of PT whether at 2, 8, or 12 weeks post-operatively.
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Affiliation(s)
- Justin M Lantz
- Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern California, 1640 Marengo St, HRA 102, Los Angeles, CA, 90033, USA. .,USC Spine Physical Therapy Fellowship Program, University of Southern California, Los Angeles, CA, USA.
| | - Callie Roberts
- Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern California, 1640 Marengo St, HRA 102, Los Angeles, CA, 90033, USA
| | - Blake Formanek
- Department of Orthopaedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, CA, USA
| | - Lori A Michener
- Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern California, 1640 Marengo St, HRA 102, Los Angeles, CA, 90033, USA
| | - Raymond J Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, CA, USA
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, CA, USA
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22
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Lener S, Abramovic A, Lang A, Thomé C, Hartmann S. Minimally Invasive Instrumentation of the Cervical Spine: Past, Present, and Future. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:247-251. [PMID: 38153477 DOI: 10.1007/978-3-031-36084-8_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Posterior cervical instrumentation and fusion procedures are becoming more and more common with the aging population and rising numbers of multisegmental and revision procedures. The instrumentation of the cervical spine has so far been performed almost exclusively via open approaches. Over the past two decades, minimally invasive surgery (MIS) techniques have gained increasing popularity. To date, only a few attempts to instrument the cervical spine in a minimally invasive fashion have been reported. The following article, after a detailed review of the currently available literature, overviews MIS in dorsal cervical instrumentation and past, present and future techniques, and it discusses the current limitations. Nevertheless, and because of the multiple advantages of MIS instrumentation, a lot of work remains to be carried out to fully establish MIS procedures for posterior cervical instrumentation.
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Affiliation(s)
- Sara Lener
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria.
| | - Anto Abramovic
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Anna Lang
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Sebastian Hartmann
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
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23
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Muacevic A, Adler JR, Page PS, Josiah DT. Predictors of 30-Day Readmission Following Cervical Laminoplasty in 3,085 Patients: An American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database Study. Cureus 2022; 14:e32480. [PMID: 36644040 PMCID: PMC9835871 DOI: 10.7759/cureus.32480] [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: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
Background Cervical laminoplasty is a surgical alternative to laminectomy and fusion for treating multi-level cervical spondylotic myelopathy. There is limited evidence evaluating readmission incidence and risk factors following cervical laminoplasty. Here, we provide a retrospective review evaluating preoperative risk for 30-day readmission following cervical laminoplasty. Methodology The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing laminoplasty as defined by Current Procedural Terminology codes 63050 and 63051. Patients were then categorized based on whether 30-day readmission occurred, and preoperative risk factors were examined. Continuous and categorical variables were analyzed using Student's t-test or Fisher's exact test. Multivariate regression analysis was performed for each variable, with p-values of <0.05 considered significant. Results In total, 3,085 patients were identified as undergoing posterior cervical laminoplasty. Of these, 2,938 patients did not require readmission, and 147 patients were readmitted, representing a 4.77% 30-day readmission rate. For all patients, sepsis (odds ratio (OR) = 5.58, p = 0.03), dialysis (OR = 3.46, p = 0.01), American Society of Anesthesiologists class >2 (OR = 1.69, p = 0.011), and hypertension (OR = 1.51, p = 0.04) were predictive of readmission. A subgroup analysis was performed for all geriatric patients (aged >65). In total, 1,353 patients were identified, of whom 76 were readmitted, demonstrating a readmission rate of 5.62%. For the elderly patients, hypertension (OR = 1.98, confidence interval (CI) = 1.04-3.75, p = 0.04) and independent status (OR = 0.39, CI = 0.21-0.74, p = 0.004) were predictive of readmission. Conclusions Assessment of predictors for readmission is important for patient education and setting appropriate clinical expectations for surgeons and providers. Preoperative hypertension, dialysis, and sepsis were risk factors for 30-day readmission following cervical laminoplasty, with functional status being a unique risk factor for elderly patients.
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Prospective Investigation of Surgical Outcomes after Anterior Decompression with Fusion and Laminoplasty for the Cervical Ossification of the Posterior Longitudinal Ligament: A Propensity Score Matching Analysis. J Clin Med 2022; 11:jcm11237012. [PMID: 36498586 PMCID: PMC9736093 DOI: 10.3390/jcm11237012] [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: 10/18/2022] [Revised: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
The ideal surgical strategy for cervical ossification of the posterior longitudinal ligament (OPLL) remains controversial due to the lack of high-quality evidence. Herein, we prospectively investigated the surgical outcomes of anterior cervical decompression with fusion (ADF) and laminoplasty (LAMP) with cervical OPLL. Three hundred patients were included in this study (ADF: n = 89; LAMP: n = 211 patients), and propensity score matching yielded 67 pairs of patients with ADF and LAMP, in which clinical outcomes were compared. Crude analysis revealed that the ADF group showed greater neurological recovery in cervical Japanese Orthopedic Association scores at two years, compared with that in the LAMP group (53.1% vs. 44.3%, p = 0.037). The ratio of minimum clinically important difference (MCID) success was significantly greater in the ADF group (59.6% vs. 43.6%, p = 0.016). Multivariate analysis showed that the factors affecting MCID success were age, body mass index, duration of symptoms, and choice of ADF. In the 1:1 matched analysis, neurological improvement was more favorable in the ADF group (57.2%) compared to the LAMP group (46.8%) at two years (p = 0.049). However, perioperative complications, such as dysphagia and graft-related complications, were more common in the ADF group.
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25
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Habermann EB, Harris AHS, Giori NJ. Large Surgical Databases with Direct Data Abstraction: VASQIP and ACS-NSQIP. J Bone Joint Surg Am 2022; 104:9-14. [PMID: 36260037 DOI: 10.2106/jbjs.22.00596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Direct data abstraction from a patient's chart by experienced medical professional data abstractors has been the historical gold standard for quality and accuracy in clinical medical research. The limiting challenge to population-wide studies for quality and public health purposes is the high personnel costs associated with very large-scale efforts of this type. Two historically related programs that are at least partially able to successfully circumvent this problem and provide high-quality data relating to surgical procedures and the early postoperative period are reviewed in this article. Both utilize similar data abstraction efforts by specially trained and qualified medical abstractors of a sample subset of the total procedures performed at participating hospitals.The Veterans Affairs Surgical Quality Improvement Program (VASQIP), detailed by Nicholas J. Giori, MD, PhD, in the first section of this article, makes use of trained abstractors and has undergone recent additions and updates, including the development of an associated total hip registry for the VA system. The data elements and data integrity provided by both of these programs establish important benchmarks for other "big data" efforts, which often attempt to use alternative less-expensive methods of data collection in order to achieve more widespread or even nationwide data collection.In the second section, Elizabeth B. Habermann, PhD, MPH, provides a detailed review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the data elements collected, and examples of the range of quality improvement and outcomes studies in orthopaedic surgery that it has made possible, along with information on data that have not been collected and the resulting limitations. The ACS NSQIP was actually modeled after the very similar earlier effort started by the United States Department of Veterans Affairs (VA).
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Affiliation(s)
- Elizabeth B Habermann
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Alex H S Harris
- VA Palo Alto Health Care System, Palo Alto, California.,Department of Surgery, Stanford University, Stanford, California
| | - Nicholas J Giori
- VA Palo Alto Health Care System, Palo Alto, California.,Department of Orthopedic Surgery, Stanford University, Stanford, California
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26
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Chen F, Wang J, Zhao X, Lv XQ. Interaction of basic diseases and low red blood cell count as critical murderer of wound infection after osteosarcoma resection: Wound infection after osteosarcoma resection. Medicine (Baltimore) 2022; 101:e31074. [PMID: 36221384 PMCID: PMC9542657 DOI: 10.1097/md.0000000000031074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Surgical wound infection is one of the common complications in patients after osteosarcoma resection. It is imperative to grasp the risk factors comprehensively. Therefore, this study aimed to explore the risk factors of wound infection and deeply analyze the correlation between risk factors and wound infection. METHODS The study subjects were 101 patients who underwent osteosarcoma resection between April 2018 and August 2021. The diagnosis of postoperative wound infection was confirmed by postoperative observation of the incision, ultrasound imaging, and pathogenic examination. This study included a series of potential factors, mainly laboratory examination indicators and patients' general information. The statistical methods had Pearson Chi-square test, Spearman-rho correlation test, multifactorial linear regression model, logistic regression analysis, and receiver operating characteristic (ROC) curve. RESULTS Pearson Chi-square test and Spearman correlation test showed that red blood cell (RBC) count (P = .033) and basic diseases (P = .020) were significantly correlated with a surgical wound infection after osteosarcoma resection. Logistic regression analysis manifested that basic disease (OR = 0.121, 95% CI: 0.015-0.960, P = .046) and RBC (OR = 0.296, 95% CI: 0.093-0.944, P = .040) have a clear correlation with whether the patients have surgical wound infection after osteosarcoma resection. And the interaction of basic diseases and RBC could diagnose the surgical wound infection sensitively and accurately (AUC = 0.700, P = .014, 95% CI = 0.564-0.836) via the ROC analysis. CONCLUSION Patients with basic diseases and low RBC were risk factors for surgical wound infection after osteosarcoma resection.
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Affiliation(s)
- Fei Chen
- The Second Department of Orthopedics, Hangzhou Fuyang District First People’s Hospital, Hangzhou, PR China
- * Correspondence: Fei Chen, The Second Department of Orthopedics, Hangzhou Fuyang District First People’s Hospital, No. 429 Beihuan Road, Fuyang District, Hangzhou 311499, PR China (e-mail: )
| | - Jie Wang
- Department of Orthopedics, The Fourth Hospital of Hebei Medical University, Hebei Province, PR China
| | - Xin Zhao
- Department of Orthopedics, The Fourth Hospital of Hebei Medical University, Hebei Province, PR China
| | - Xian-qiang Lv
- Department of Urology, The Fourth Hospital of Hebei Medical University, Hebei Province, PR China
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27
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Shah AA, Devana SK, Lee C, Bugarin A, Hong MK, Upfill-Brown A, Blumstein G, Lord EL, Shamie AN, van der Schaar M, SooHoo NF, Park DY. A Risk Calculator for the Prediction of C5 Nerve Root Palsy After Instrumented Cervical Fusion. World Neurosurg 2022; 166:e703-e710. [PMID: 35872129 PMCID: PMC10410645 DOI: 10.1016/j.wneu.2022.07.082] [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: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND C5 palsy is a common postoperative complication after cervical fusion and is associated with increased health care costs and diminished quality of life. Accurate prediction of C5 palsy may allow for appropriate preoperative counseling and risk stratification. We primarily aim to develop an algorithm for the prediction of C5 palsy after instrumented cervical fusion and identify novel features for risk prediction. Additionally, we aim to build a risk calculator to provide the risk of C5 palsy. METHODS We identified adult patients who underwent instrumented cervical fusion at a tertiary care medical center between 2013 and 2020. The primary outcome was postoperative C5 palsy. We developed ensemble machine learning, standard machine learning, and logistic regression models predicting the risk of C5 palsy-assessing discrimination and calibration. Additionally, a web-based risk calculator was built with the best-performing model. RESULTS A total of 1024 patients were included, with 52 cases of C5 palsy. The ensemble model was well-calibrated and demonstrated excellent discrimination with an area under the receiver-operating characteristic curve of 0.773. The following features were the most important for ensemble model performance: diabetes mellitus, bipolar disorder, C5 or C4 level, surgical approach, preoperative non-motor neurologic symptoms, degenerative disease, number of fused levels, and age. CONCLUSIONS We report a risk calculator that generates patient-specific C5 palsy risk after instrumented cervical fusion. Individualized risk prediction for patients may facilitate improved preoperative patient counseling and risk stratification as well as potential intraoperative mitigating measures. This tool may also aid in addressing potentially modifiable risk factors such as diabetes and obesity.
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Affiliation(s)
- Akash A Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
| | - Sai K Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Changhee Lee
- Department of Artificial Intelligence, Chung-Ang University, Seoul, South Korea
| | - Amador Bugarin
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Michelle K Hong
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Alexander Upfill-Brown
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gideon Blumstein
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Elizabeth L Lord
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Arya N Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mihaela van der Schaar
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, United Kingdom; Department of Electrical & Computer Engineering, UCLA, Los Angeles, California, USA
| | - Nelson F SooHoo
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Effect of Fellow Involvement and Experience on Patient Outcomes in Spine Surgery. J Am Acad Orthop Surg 2022; 30:831-840. [PMID: 35421018 DOI: 10.5435/jaaos-d-21-01019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 03/06/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Investigations in spine surgery have demonstrated that trainee involvement correlates with increased surgical time, readmissions, and revision surgeries; however, the specific effects of spine fellow involvement remain unelucidated. This study aims to investigate the isolated effect of fellow involvement on surgical timing and patient-reported outcomes measures (PROMs) after spine surgery and evaluate how surgical outcomes differ by fellow experience. METHODS All patients aged 18 years or older who underwent primary or revision decompression or fusion for degenerative diseases and/or spinal deformity between 2017 and 2019 at a single academic institution were retrospectively identified. Patient demographics, surgical factors, intraoperative timing, transfusion status, length of stay (LOS), readmissions, revision rate, and preoperative and postoperative PROMs were recorded. Surgeries were divided based on spine fellow participation status and occurrence in the start or end of fellowship training. Univariate and multivariate analyses compared outcomes across fellow involvement and fellow experience groups. RESULTS A total of 1,108 patients were included. Age, preoperative diagnoses, number of fusion levels, and surgical approach differed markedly by fellow involvement. Fellow training experience groups differed by patient smoking status, preoperative diagnosis, and surgical approach. On univariate analysis, spine fellow involvement was associated with extended total theater time, induction start to cut time, cut to close time, and LOS. Increased spine fellow training was associated with reduced cut to close time and LOS. On regression, fellow involvement predicted cut to close extension while increased fellow training experience predicted reduction in cut to close time, both independent of surgical factors and assisting residents or physician assistants. Transfusions, readmissions, revision rate, and PROMs did not differ markedly by fellow involvement or experience. CONCLUSION Spine fellow participation predicted extended procedural duration. However, the presence of a spine fellow did not affect long-term postoperative outcomes. Furthermore, increased fellow training experience predicted decreased procedural time, underscoring a learning effect. AVAILABILITY OF DATA AND MATERIAL The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. LEVEL OF EVIDENCE Level 3.
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Cefazolin prophylaxis in spine surgery: patients are frequently underdosed and at increased risk for infection. Spine J 2022; 22:1442-1450. [PMID: 35680016 DOI: 10.1016/j.spinee.2022.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/03/2022] [Accepted: 05/25/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Perioperative antibiotics are critical in reducing the risk of postoperative spine infections. However, the efficacy and optimal weight-based prophylactic cefazolin dosing is unclear. PURPOSE To determine (1) if inadequate weight-based prophylactic dosing of cefazolin affects infection rates after spinal fusions, and (2) identify the optimal dosing of cefazolin. STUDY DESIGN/SETTING Single center retrospective cohort PATIENT SAMPLE: Patients undergoing posterior cervical or lumbar spinal fusion between January 2000 and October 2020 OUTCOME MEASURES: Postoperative surgical site infection status METHODS: Patients were grouped based on our institutionally derived dosing adequacy standards, 1 g for <60 kg, 2 g for 60 to 120 kg, and 3 g for >120 kg. Univariate comparisons and multivariate regressions identified the effect of inadequate dosing on infection rate. Patients were subsequently regrouped into cefazolin dose (grams) administered and logistic regression and receiver operating characteristic curves were compiled to determine the probability of infection based on cefazolin dose and patient weight. Alpha was set at 0.05. RESULTS A total of 2,643 patients met inclusion criteria and 95 infections (3.6%) were identified. The infection rate was higher in the inadequate dosing group (5.86% vs. 2.58%, p<.001). Adequate dosing was a predictor of decreased infections after lumbar fusion (OR: 0.43, p<.001), but not posterior cervical fusions (OR: 0.47, p=.065). Patients were subsequently regrouped into 1 g or 2 g of cefazolin administered resulting in a 5.01% and 2.77% infection rate, respectively (p=.005). The area under the curve (AUC) and 95% confidence interval for one (0.850 [0.777-0.924]) and two (0.575 [0.493-0.657]) g of cefazolin demonstrated lower infection rates for patients given 2 g cefazolin. CONCLUSIONS Patients receiving an inadequate weight-based dose of preoperative cefazolin had an increased risk of infection following spinal fusion surgery. Two grams prophylactic cefazolin significantly reduces the likelihood of infection.
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Weinberg DS, Eoh JH, Manz WJ, Fakunle OP, Dawes AM, Park ET, Rhee JM. Off-label usage of RhBMP-2 in posterior cervical fusion is not associated with early increased complication rate and has similar clinical outcomes. Spine J 2022; 22:1079-1088. [PMID: 35181539 DOI: 10.1016/j.spinee.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Arthrodesis is important for the success of posterior cervical fusion (PCF), however, there exists limited data regarding the safety and efficacy of bone morphogenic protein (BMP) in PCF. PURPOSE The primary objective was to evaluate early postoperative complications associated with BMP in PCF and determine whether BMP leads to adverse early clinical outcomes. A secondary objective was to determine the optimal location for BMP sponge placement, within the facet joint (IF) or elsewhere, and the optimal dosage/level. DESIGN Retrospective, consecutive case-control study. PATIENT SAMPLE Seven hundred sixty-five patients who underwent PCF OUTCOME MEASURES: Patient-reported outcomes (PROs), complications, arthrodesis, optimum dose/level of BMP METHODS: Surgical data, including preoperative diagnosis, levels fused, type of bone graft, BMP dose (when used), and fusion technique were recorded. Complications were assessed by reviewing the medical record encompassing the first 6-weeks postoperative. These included medical, neurological, and wound-related complications and reoperation. Neurological complications were defined as any new weakness, radicular pain, or numbness. PROs were collected, including SF36, VAS, EQ-5D, and NDI scores. To determine the optimal dosage and location for BMP placement, a sub-analysis was performed. RESULTS There were no significant differences between the BMP and no BMP group with regards to wound complications, neurological complications, or reoperation. There were no differences in PROs between BMP and no BMP. Placement of BMP for IF and at a dose of 0.87 mg/level minimized wound-related complications. The BMP group had a higher fusion rate compared to the no BMP group (96% vs. 91%, p=.02) when assessed 1 year post-operatively. CONCLUSION BMP was not associated with a higher rate of early complications after PCF when the dose was minimized. Complications thought to be associated with BMP, such as compressive seroma, radiculitis, and wound-related complications were not seen at a higher rate. PROs at early follow-up were similar. Placement of BMP for IF and at lower doses than previously reported may minimize complications.
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Affiliation(s)
- Douglas S Weinberg
- Department of Orthopedic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jae Hyung Eoh
- Department of Orthopedics, Pohang Semyeong Christianity Hospital, Pohang, Korea
| | - Wesley J Manz
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Eric T Park
- Emory University School of Medicine, Atlanta, GA, USA
| | - John M Rhee
- Department of Orthopedic Surgery and Neurosurgery, The Emory Spine Center, Emory University School of Medicine, 59 Executive Park South, Atlanta, GA, USA.
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Levy HA, Karamian BA, Vijayakumar G, Gilmore G, Canseco JA, Radcliff KE, Kurd MF, Rihn JA, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The impact of case order and intraoperative staff changes on spine surgical efficiency. Spine J 2022; 22:1089-1099. [PMID: 35121151 DOI: 10.1016/j.spinee.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 01/04/2022] [Accepted: 01/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency. PURPOSE This study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases. STUDY DESIGN/ SETTING Retrospective cohort analysis PATIENT SAMPLE: All patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy. OUTCOME MEASURES Intraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions. METHODS Surgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups. RESULTS A total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time. CONCLUSIONS Intraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brian A Karamian
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Gayathri Vijayakumar
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Griffin Gilmore
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose A Canseco
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kris E Radcliff
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark F Kurd
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeffrey A Rihn
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher K Kepler
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
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Mo K, Gupta A, Al Farii H, Raad M, Musharbash F, Tran B, Zheng M, Lee SH. 30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:204-213. [PMID: 35875628 PMCID: PMC9263737 DOI: 10.21037/jss-22-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy. METHODS The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected. RESULTS Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037). CONCLUSIONS These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.
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Affiliation(s)
- Kevin Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Arjun Gupta
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Humaid Al Farii
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Farah Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Britni Tran
- Western University of Health Sciences, Pomona, CA, USA
| | - Ming Zheng
- Western University of Health Sciences, Pomona, CA, USA
| | - Sang Hun Lee
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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Miller EM, McAllister BD. Increased risk of postoperative wound complications among obesity classes II & III after ALIF in 10-year ACS-NSQIP analysis of 10,934 cases. Spine J 2022; 22:587-594. [PMID: 34813958 DOI: 10.1016/j.spinee.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/11/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior lumbar interbody fusion (ALIF) procedures for lumbar spine disease have been increasing amid a growing obese patient population with limited studies available focusing exclusively on risk-factors for post-operative ALIF complications. PURPOSE The objective of this study was to compare 30-day post-operative complications among different obesity World Health Organization classes according to body mass index (BMI) in comparison to non-obese patients who underwent an ALIF procedure. STUDY DESIGN/SETTING Retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2009 to 2019. PATIENT SAMPLE A total of 10,934 patients undergoing an ALIF. OUTCOME MEASURES Primary outcome measures include 30 day cardiac, pulmonary, urinary, infectious, and wound complications. Secondary outcomes included rates of blood transfusion, reintubation, deep vein thrombosis, pulmonary embolism, 30-day return to the operating room (OR), and 30 day mortality. METHODS Patients were identified by use of the current procedural terminology codes 22558 and 22585 from 2009 to 2019. Patients were divided into the following groups: non-obese (BMI 18.5-29.9 kg/m2), Obese I (BMI 30-34.9 kg/m2), Obese II (BMI 35-39.9 kg/m2), and Obese III (BMI ≥40 kg/m2). Age, gender, race, American Society of Anesthesiologists status, smoking status, hypertension requiring medication, steroid used, chronic obstructive pulmonary disease, history of a bleeding disorder, and diabetes was identified as risk factors after a univariate analysis conducted for demographic variables and pre-operative comorbidities. A multivariate logistic regression analysis was then performed to adjust for these preoperative risk factors and compare obesity classes I-III to non-obese patients. RESULTS Obesity classes II and III had a significant odds ratio (OR) for superficial infection (OR:2.7, 95%CI(1.7-4.5); OR:2.8, 95%CI(1.5-5.2) respectively), organ space infection (OR:3.8, 95%CI(1.6-7.4); OR:3.2, 95%CI(1.1-9.9) respectively), wound disruption (OR:2.8, 95%CI(1.1-7.4); OR:4.6, 95%CI(1.6-13.6) respectively), and total wound complication (OR:2.6, 95%CI(1.8-3.9); OR:3.4, 95%CI(2.2-5.4) respectively) following a multivariate logistic regression analysis. CONCLUSIONS Risk for post-operative wound complications following an ALIF were found to be significantly higher for obesity classes II-III in comparison to non-obese patients. These findings can further support the use of additional wound care in the perioperative setting for certain levels of obesity.
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Affiliation(s)
- Evan M Miller
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
| | - Beck D McAllister
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
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Reier L, Fowler JB, Arshad M, Siddiqi J. Drains in Spine Surgery for Degenerative Disc Diseases: A Literature Review to Determine Its Usage. Cureus 2022; 14:e23129. [PMID: 35464540 PMCID: PMC9001810 DOI: 10.7759/cureus.23129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/13/2022] [Indexed: 11/21/2022] Open
Abstract
No guidelines currently exist for surgeons to follow regarding drain use after spine surgery for degenerative disc disease. Therefore, we conducted a literature review to determine what situations warrant drain placement versus those which do not. When placed, we further investigate optimal drain duration. The goal of this article is to provide spine surgeons insight into the current literature and guidance when deciding if a drain should be used or discontinued. We performed a PubMed search and analyzed 44peer-reviewed journal articles. Only studies that had the full article available were included. The highest-quality studies that were reviewed, demonstrated that in most situations using a drain is not associated with superior outcomes. It revealed that when drains are retained for a longer duration they run a greater risk of surgical site infection (SSI). Additionally, drains are associated with increased blood loss, a greater chance of requiring blood transfusions, and longer hospital stays. We conclude that drains are currently being overused in spine surgery for cases of degenerative disc disease, which exposes patients to unnecessary complications while providing minimal benefit.
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Donnally CJ, Henstenburg JM, Pezzulo JD, Farronato D, Patel PD, Sherman M, Canseco JA, Kepler CK, Vaccaro AR. Increased Surgical Site Subcutaneous Fat Thickness Is Associated with Infection after Posterior Cervical Fusion. Surg Infect (Larchmt) 2022; 23:364-371. [PMID: 35262398 DOI: 10.1089/sur.2021.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Previous literature has associated increased body mass index (BMI) with risk of surgical site infection (SSI) after posterior cervical fusion (PCF) surgery. However, few studies have examined the association between local adiposity and risk of SSI, re-admission, and re-operation after PCF. Local adiposity is easily measured on pre-operative magnetic resonance imaging (MRI) and may act as a more accurate predictor compared with BMI. Patients and Methods: Subjects undergoing PCF from 2013-2018 at a single institution were identified retrospectively. Posterior cervical subcutaneous fat thickness, paraspinal muscle thickness, and lamina-to-skin distance measurements were obtained from computed tomography (CT) or MRI scans. Subjects with active infection, malignancy, or revision procedures were excluded. Results: Two hundred five patients were included with 20 developing SSIs. Subjects with SSIs had a longer fusion construct (4.90 vs. 3.71 levels; p = 0.001), higher Elixhauser comorbidity index (ECI; 2.05 vs. 1.34; p = 0.045), had a history of diabetes mellitus (30% vs. 10.8%; p = 0.026), higher subcutaneous fat thickness (30.5 vs. 23.6 mm; p = 0.013), and higher lamina-to-skin distance (66.4 vs. 57.9 mm; p = 0.027). Subcutaneous fat thickness (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.10]; p = 0.026) and lamina-to-skin distance (OR, 1.05; 95% CI, 1.01-1.09]; p = 0.014) were associated with SSI in multivariable analysis. A subcutaneous fat thickness cutoff value of 23.2 mm had 90% sensitivity and 54.1% specificity for prediction of SSI. There was no association need for re-admission or re-operation. Conclusions: Increased posterior cervical fat may increase the risk of SSI after PCF. Pre-operative advanced imaging may be a valuable tool for assisting with patient counseling, optimization, and risk stratification.
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Affiliation(s)
- Chester J Donnally
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jeffery M Henstenburg
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joshua D Pezzulo
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dominic Farronato
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Parthik D Patel
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthew Sherman
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Fried TB, Schroeder GD, Anderson DG, Donnally CJ. Minimally Invasive Surgery (MIS) Versus Traditional Open Approach: Transforaminal Interbody Lumbar Fusion. Clin Spine Surg 2022; 35:59-62. [PMID: 33496467 DOI: 10.1097/bsd.0000000000001125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/07/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Tristan B Fried
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Nunna RS, Khalid S, Chiu RG, Parola R, Fessler RG, Adogwa O, Mehta AI. Anterior vs Posterior Approach in Multilevel Cervical Spondylotic Myelopathy: A Nationwide Propensity-Matched Analysis of Complications, Outcomes, and Narcotic Use. Int J Spine Surg 2022; 16:88-94. [PMID: 35314510 PMCID: PMC9519084 DOI: 10.14444/8198] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND There is unclear evidence regarding the optimal surgical approach for multilevel cervical spondylotic myelopathy (CSM). The objective of this study was to compare complications, outcomes, and narcotic use in anterior discectomy and fusion (ACDF) vs posterior decompression and fusion (PCDF) in CSM patients. STUDY DESIGN Registry-based retrospective cohort analysis. METHODS Patients undergoing 3-level ACDF or PCDF for CSM between 2007 and 2017 were identified from the Humana Claims Database using relevant procedure codes. Propensity score-matched groups were compared in regards to complications, outcomes, and narcotic use. RESULTS Propensity score matching generated equal cohorts of 6124 patients. The posterior fusion group had a higher rate of urinary tract infection (OR 2.47, P < 0.0001), deep vein thrombosis (OR 1.90, P < 0.0001), and pulmonary embolism (OR 1.75, P < 0.0001). In regards to 30-day outcomes, the posterior approach demonstrated higher rates of stroke (OR 1.68, P < 0.0001), wound dehiscence (OR 5.59, P < 0.0001), Surgical site infection (SSI) (OR 4.76, P < 0.0001), wound revision surgery (OR 3.02, P < 0.0001), and all-cause readmission (OR 2.01, P < 0.0001). One-year outcomes revealed higher rates of pseudarthrosis (4.7% vs 2.0%, OR 2.43, P < 0.0001) and revision or extension surgery (OR 2.33, P < 0.0001) in the posterior fusion cohort. These patients also demonstrated significantly higher mean morphine milligram equivalent used at 30 days (OR 1.19, P < 0.0001), as well as 60 (OR 1.20, P < 0.0001), 90 (OR 1.21, P < 0.0001), and 120 (OR 1.21, P < 0.0001) days. CONCLUSIONS This nationwide propensity-matched analysis of multilevel CSM patients found the posterior approach to be associated with increased rates of inpatient complications, wound complications, 30-day readmission, 1-year pseudarthrosis, and 1-year revision or extension surgery. These patients also demonstrated higher levels of narcotic use up to 120 days after surgery. CLINICAL RELEVANCE The posterior approach for treatment of CSM may be associated with increased rates of short- and long-term complications in addition to increased narcotic consumption in comparison to the anterior approach.
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Affiliation(s)
- Ravi S Nunna
- Department of Neurosurgery, Swedish Medical Center, Seattle, WA, USA
| | - Syed Khalid
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Ryan G Chiu
- Department of Neurosurgery, University of Illinois-Chicago Medical Center, Chicago, IL, USA
| | - Rown Parola
- Department of Neurosurgery, University of Illinois-Chicago Medical Center, Chicago, IL, USA
| | - Richard G Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois-Chicago Medical Center, Chicago, IL, USA
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Koizumi M, Kato Y, Yoneda A, Okamura K, Tsukada N, Mui T, Hyakuda Y, Shoji H, Nakayama S, Tanaka Y. Severe complication subsequent to surgical site infection after cervical laminoplasty: a case report. Spinal Cord Ser Cases 2022; 8:5. [PMID: 35027550 PMCID: PMC8758777 DOI: 10.1038/s41394-021-00472-9] [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: 05/11/2021] [Revised: 12/19/2021] [Accepted: 12/24/2021] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Surgical site infections (SSI) following spinal surgery can result in serious complications. Although early detection and intensive care are essential to minimize possible sequelae, more than one surgical intervention is required to alleviate the infection in some cases. CASE PRESENTATION A 66-year-old man with long-standing Parkinson's disease (PD) developed SSIs after cervical laminoplasty. Despite surgical debridement and irrigation, his neurological status worsened severely and anterior infectious involvement at the C4-5 level was identified by magnetic resonance imaging. He underwent another urgent surgery for anterior debridement and iliac bone grafting. His laboratory results gradually normalized with antibiotic therapy, and his neurological status improved. One year after surgery, he was ambulatory with walker assistance. However, his right hand remained difficult to control with significant sensory loss and numbness. DISCUSSION To our knowledge, this is the first case of SSI that extended rapidly to the anterior side despite immediate and intensive treatment in a patient with PD after laminoplasty. During SSI treatment, meticulous observation should be performed to check for exacerbations.
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Affiliation(s)
- Munehisa Koizumi
- Department of Spine and Spinal cord Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Yoshinobu Kato
- Department of Spine and Spinal cord Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Azusa Yoneda
- grid.410814.80000 0004 0372 782XDepartment of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Kensuke Okamura
- grid.410814.80000 0004 0372 782XDepartment of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Naoki Tsukada
- Department of Orthopaedic Surgery, Hanna Central Hospital, Nara, Japan
| | - Takahiro Mui
- grid.417344.10000 0004 0377 5581Department of Orthopaedic Surgery, Otemae Hospital, Osaka-shi, Japan
| | - Yoshinobu Hyakuda
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Haruka Shoji
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Syunsuke Nakayama
- Department of Orthopaedic Surgery, Nara Prefecture General Medical Center, Nara, Japan
| | - Yasuhito Tanaka
- grid.410814.80000 0004 0372 782XDepartment of Orthopaedic Surgery, Nara Medical University, Nara, Japan
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Wang H, Fan T, Yang B, Lin Q, Li W, Yang M. Development and Internal Validation of Supervised Machine Learning Algorithms for Predicting the Risk of Surgical Site Infection Following Minimally Invasive Transforaminal Lumbar Interbody Fusion. Front Med (Lausanne) 2022; 8:771608. [PMID: 34988091 PMCID: PMC8720930 DOI: 10.3389/fmed.2021.771608] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/30/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose: Machine Learning (ML) is rapidly growing in capability and is increasingly applied to model outcomes and complications in medicine. Surgical site infections (SSI) are a common post-operative complication in spinal surgery. This study aimed to develop and validate supervised ML algorithms for predicting the risk of SSI following minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Methods: This single-central retrospective study included a total of 705 cases between May 2012 and October 2019. Data of patients who underwent MIS-TLIF was extracted by the electronic medical record system. The patient's clinical characteristics, surgery-related parameters, and routine laboratory tests were collected. Stepwise logistic regression analyses were used to screen and identify potential predictors for SSI. Then, these factors were imported into six ML algorithms, including k-Nearest Neighbor (KNN), Decision Tree (DT), Support Vector Machine (SVM), Random Forest (RF), Multi-Layer Perceptron (MLP), and Naïve Bayes (NB), to develop a prediction model for predicting the risk of SSI following MIS-TLIF under Quadrant channel. During the training process, 10-fold cross-validation was used for validation. Indices like the area under the receiver operating characteristic (AUC), sensitivity, specificity, and accuracy (ACC) were reported to test the performance of ML models. Results: Among the 705 patients, SSI occurred in 33 patients (4.68%). The stepwise logistic regression analyses showed that pre-operative glycated hemoglobin A1c (HbA1c), estimated blood loss (EBL), pre-operative albumin, body mass index (BMI), and age were potential predictors of SSI. In predicting SSI, six ML models posted an average AUC of 0.60–0.80 and an ACC of 0.80–0.95, with the NB model standing out, registering an average AUC and an ACC of 0.78 and 0.90. Then, the feature importance of the NB model was reported. Conclusions: ML algorithms are impressive tools in clinical decision-making, which can achieve satisfactory prediction of SSI with the NB model performing the best. The NB model may help access the risk of SSI following MIS-TLIF and facilitate clinical decision-making. However, future external validation is needed.
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Affiliation(s)
- Haosheng Wang
- Department of Orthopedics, Taizhou Central Hospital (Affiliated Hospital to Taizhou College), Taizhou, China.,Department of Orthopedics, Baoji City Hospital of Traditional Chinese Medicine, Baoji, China
| | - Tingting Fan
- Department of Endocrinology, Baoji City Hospital of Traditional Chinese Medicine, Baoji, China
| | - Bo Yang
- Department of Orthopedics, Baoji City Hospital of Traditional Chinese Medicine, Baoji, China
| | - Qiang Lin
- Department of Orthopedics, Baoji City Hospital of Traditional Chinese Medicine, Baoji, China
| | - Wenle Li
- Department of Orthopedics, Xianyang Central Hospital, Xianyang, China.,Clinical Medical Research Center, Xianyang Central Hospital, Xianyang, China
| | - Mingyu Yang
- Department of Orthopedics, Taizhou Central Hospital (Affiliated Hospital to Taizhou College), Taizhou, China
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Harrop JS, Mohamed B, Bisson EF, Dhall S, Dimar J, Mummaneni PV, Wang MC, Hoh DJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Surgical Risk Assessment. Neurosurgery 2021; 89:S9-S18. [PMID: 34490886 DOI: 10.1093/neuros/nyab316] [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: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patient factors (increased body mass index [BMI], smoking, and diabetes) may impact outcomes after spine surgery. There is a lack of consensus regarding which factors should be screened for and potentially modified preoperatively to optimize outcome. OBJECTIVE The purpose of this evidence-based clinical practice guideline is to determine if preoperative patient factors of diabetes, smoking, and increased BMI impact surgical outcomes. METHODS A systematic review of the literature for studies relevant to spine surgery was performed using the National Library of Medicine PubMed database and the Cochrane Library. Clinical studies evaluating the impact of diabetes or increased BMI with reoperation and/or surgical site infection (SSI) were selected for review. In addition, the impact of preoperative smoking on patients undergoing spinal fusion was reviewed. RESULTS A total of 699 articles met inclusion criteria and 64 were included in the systematic review. In patients with diabetes, a preoperative hemoglobin A1c (HbA1c) >7.5 mg/dL is associated with an increased risk of reoperation or infection after spine surgery. The review noted conflicting studies regarding the relationship between increased BMI and SSI or reoperation. Preoperative smoking is associated with increased risk of reoperation (Grade B). There is insufficient evidence that cessation of smoking before spine surgery decreases the risk of reoperation. CONCLUSION This evidence-based guideline provides a Grade B recommendation that diabetic individuals undergoing spine surgery should have a preoperative HbA1c test before surgery and should be counseled regarding the increased risk of reoperation or infection if the level is >7.5 mg/dL. There is conflicting evidence that BMI correlates with greater SSI rate or reoperation rate (Grade I). Smoking is associated with increased risk of reoperation (Grade B) in patients undergoing spinal fusion.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/2-preoperative-surgical-risk-assessement.
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Affiliation(s)
- James S Harrop
- Department of Neurological Surgery and Department of Orthopedic Surgery, Thomas Jefferson University, Division of Spine and Peripheral Nerve Surgery, Delaware Valley SCI Center, Philadelphia, Pennsylvania, USA
| | - Basma Mohamed
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Erica F Bisson
- Clinical Neurosciences Center, University of Utah Health, Salt Lake City, Utah, USA
| | - Sanjay Dhall
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - John Dimar
- Department of Orthopedics, University of Louisville, Pediatric Orthopedics, Norton Children's Hospital; Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Marjorie C Wang
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | - Daniel J Hoh
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
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Bajpai RR, Razdan S, Sanchez-Gonzalez MA, Razdan S. Minimizing transrectal prostate biopsy-related infections; A prospective randomized trial of povidone-iodine intrarectal cleaning versus formalin needle disinfection. Indian J Urol 2021; 37:254-260. [PMID: 34465955 PMCID: PMC8388331 DOI: 10.4103/iju.iju_34_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/31/2021] [Accepted: 06/21/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction: Transrectal prostate biopsies are associated with post biopsy infection and sepsis. We compared the efficacy of povidone-iodine rectal disinfection versus formalin needle disinfection in preventing post biopsy infection among patients undergoing transrectal ultrasound-guided prostate biopsy. Methods: Patients scheduled to undergo ultrasound-guided transrectal prostate biopsy (n = 621) over 20 months were randomized into 2 groups to receive either povidone-iodine intrarectal disinfection or formalin disinfection of needle after each core. These were compared to assess which methodology better prevented postprocedure infection. Statistical analysis were used to identify independent factors promoting infections. Results: Two hundred and ninety-eight patients from povidone-iodine intrarectal disinfection were compared with 300 from formalin needle disinfection group. Formalin needle disinfection was associated with significantly more infections (P = 0.02). Escherichia coli was the dominant pathogen, with >50% of cases being quinolone resistant. Type of disinfection (P = 0.002), BMI (P = 0.001), chronic prostatitis (P = 0.002), and diabetes mellitus (P = 0.01) were independent predictors of infections. BMI at 28.95 kg/m2 provided the best predictive cut-off point for infections, irrespective of method of disinfection. Area under the curve for all these parameters together was 0.91. Conclusions: We conclude that along with oral cephalosporin prophylaxis, povidone-iodine intrarectal disinfection is a superior to formalin needle disinfection alone in preventing post biopsy infection. Patients with BMI >28.95 kg/m2 should be considered at a higher risk for infections.
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Affiliation(s)
- Rajesh Raj Bajpai
- Department of Urology, Larkin Community Hospital, South Miami, Florida, USA
| | - Shirin Razdan
- Department of Urology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, USA
| | - Marcos A Sanchez-Gonzalez
- Division of Clinical and Translational Research, Larkin Community Hospital, South Miami, Florida, USA
| | - Sanjay Razdan
- Department of Urology, International Robotic Prostatectomy Institute, Doral, Florida, USA
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Keidan L, Barash A, Lenzner Z, Pick CG, Been E. Sexual dimorphism of the posterior cervical spine muscle attachments. J Anat 2021; 239:589-601. [PMID: 33876427 PMCID: PMC8349410 DOI: 10.1111/joa.13448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/24/2021] [Accepted: 04/01/2021] [Indexed: 01/14/2023] Open
Abstract
Cervical spinal injury and neck pain are common disorders with wide physical implications. Neck pain and disability are reported to occur in females more often than in males, and chronic or persistent neck pain after whiplash is twice as common in females. Female athletes also sustain a higher percentage of concussions compared to male athletes. Still, while sexual differences in clinical presentation and outcome are well-established, the underlying etiology for the disparity remains less clear. It is well-established that the origin and insertion landmarks of posterior neck muscles are highly variable, but we do not know if these interindividual differences are associated with sex. Expanding our knowledge on sexual dimorphism in the anatomy of the cervical muscles is essential to our understanding of the possible biomechanical differences between the sexes and hence improves our understanding as to why females suffer from cervical pain more than males. It is also of paramount importance for accurate planning of posterior cervical spine surgery, which cuts through the posterior cervical musculature. Therefore, our main objective is to characterize the anatomy of posterior neck musculature and to explore possible sexual differences in the location of their attachment points. Meticulous posterior neck dissection was performed on 35 cadavers, 19 females, and 16 males. In each specimen, 8 muscle groups were examined bilaterally at 45 osseous anatomical landmarks. Muscles and their attachment sites were evaluated manually then photographed and recorded using Microscribe Digitizer technology built into 3D models. A comparison of attachment landmarks between males and females for each muscle was conducted. Out of the eight muscles that were measured, only two muscles demonstrated significant sex-related anatomical differences-Spinotranversales (splenius capitis and cervicis) and Multifidus. Male Spinotransversales muscle has more attachment points than female. It showed more cranial insertion points in the upper cervical attachments (superior nuchal line, C1 posterior tubercle, and mastoid process) and more caudal insertion points in the spinous processes and transverse processes of the lower cervical and upper thoracic vertebrae. Thus, the male subjects in this study exhibited a greater coverage of the posterior neck both cranially and caudally. Female Multifidus has more attachment points on the spinous processes and articular processes at middle and lower cervical vertebrae and at the transverse processes of the upper thoracic vertebrae. All remaining muscles exhibited no sexual differences. Our findings highlight, for the first time, a sexual dimorphism in attachment points of posterior cervical musculature. It reinforces the notion that the female neck is not a scaled version of the male neck. These differences in muscle attachment could partially explain differences in muscle torque production and range of motion and thus biomechanical differences in cervical spine stabilization between sexes. It sheds a much-needed light on the reason for higher whiplash rates, concussion, and chronic cervical pain among females. Surgeons should take these sexual morphological differences into consideration when deliberating the best surgical approach for posterior cervical surgery.
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Affiliation(s)
- Lee Keidan
- Department of Anatomy and AnthropologySackler Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Alon Barash
- Azrieli Faculty of MedicineBar Ilan UniversitySafedIsrael
| | - Ziv Lenzner
- Screen Based Art DepartmentBezalel Academy of Arts and DesignJerusalemIsrael
| | - Chaim G. Pick
- Department of Anatomy and AnthropologySackler Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
- Sagol School of NeuroscienceTel Aviv UniversityTel AvivIsrael
- The Dr. Miriam and Sheldon G. Adelson Chair and Center for the Biology of Addictive DiseasesTel‐Aviv UniversityTel‐AvivIsrael
- Sylvan Adams Sports InstituteTel Aviv UniversityTel AvivIsrael
| | - Ella Been
- Department of Anatomy and AnthropologySackler Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
- Department of Sports TherapyFaculty of Health ProfessionsOno Academic CollegeKiryat OnoIsrael
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Hersh AM, Feghali J, Hung B, Pennington Z, Schilling A, Antar A, Patel J, Ehresman J, Cottrill E, Lubelski D, Elsamadicy AA, Goodwin CR, Lo SFL, Sciubba DM. A Web-Based Calculator for Predicting the Occurrence of Wound Complications, Wound Infection, and Unplanned Reoperation for Wound Complications in Patients Undergoing Surgery for Spinal Metastases. World Neurosurg 2021; 155:e218-e228. [PMID: 34403800 DOI: 10.1016/j.wneu.2021.08.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/08/2021] [Accepted: 08/09/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND In the present study, we identified the risk factors for wound complications, wound infection, and reoperation for wound complications after spine metastasis surgery and deployed the resultant model as a web-based calculator. METHODS Patients treated at a single comprehensive cancer center during a 7-year period were included. The demographics, pathology, comorbidities, laboratory values, and operative details were collected. Factors with P < 0.15 on univariable regression were entered into multivariable logistic regression to generate predictive models internally validated using 1000 bootstrapped samples. RESULTS Of the 330 patients included, 29 (7.6%) had experienced a surgical site infection. The independent predictive factors for wound-related complications were a higher Charlson comorbidity index (CCI; odds ratio [OR], 1.41 per point; P < 0.01), Karnofsky performance scale score ≤70 (OR, 2.14; P = 0.04), lower platelet count (OR, 0.49 per 105/μL; P < 0.01), revision versus index surgery (OR, 3.10; P = 0.02), and increased incision length (OR, 1.21 per level; P = 0.02). Wound infection was associated with a higher CCI (OR, 1.60 per point; P < 0.01), a lower platelet count (OR, 0.35 per 105/μL; P < 0.01), revision surgery (OR, 4.63; P = 0.01), and a longer incision length (OR, 1.25 per level; P = 0.03). Unplanned reoperation for wound complications was predicted by a higher CCI (OR, 1.39 per point; P = 0.003), prior irradiation (OR, 2.52; P = 0.04), a lower platelet count (OR, 0.57 per 105/μL; P = 0.02), and revision surgery (OR, 3.34; P = 0.03), The optimism-corrected areas under the curve were 0.75, 0.81, and 0.72 for the wound complication, infection, and reoperation models, respectively. CONCLUSIONS Low platelet counts, poorer health status, more invasive surgery, and revision surgery all independently predicted the risk of wound complications, including infection and unplanned reoperation for infection. Validation of the calculators in a prospective study is merited.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bethany Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andy Schilling
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert Antar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jaimin Patel
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA.
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Dockery DM, Allu S, Vishwanath N, Li T, Berns E, Glasser J, Spake CSL, Antoci V, Born CT, Garcia DR. Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery. Surg Infect (Larchmt) 2021; 22:1004-1013. [PMID: 34388024 DOI: 10.1089/sur.2021.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.
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Affiliation(s)
- Dominique M Dockery
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Sai Allu
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Neel Vishwanath
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Troy Li
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Ellis Berns
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jillian Glasser
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Carole S L Spake
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher T Born
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Dioscaris R Garcia
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Morishita S, Yoshii T, Inose H, Hirai T, Yuasa M, Matsukura Y, Ogawa T, Fushimi K, Okawa A, Fujiwara T. Comparison of Perioperative Complications in Anterior Decompression With Fusion and Posterior Decompression With Fusion for Cervical Spondylotic Myelopathy: Propensity Score Matching Analysis Using a Nationwide Inpatient Database. Clin Spine Surg 2021; 34:E425-E431. [PMID: 34039894 DOI: 10.1097/bsd.0000000000001209] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A retrospective cohort study with a national inpatient database. OBJECTIVE This study aimed to research the perioperative complication rates of cervical spondylotic myelopathy (CSM) patients who underwent anterior decompression with fusion (ADF) and posterior decompression with fusion (PDF) using a large national inpatient database and propensity score matching (PSM) analysis. SUMMARY OF BACKGROUND DATA There are several ways to successfully achieve surgical spinal decompression in CSM patients; however, evidence of the systemic complications and reoperation rates in ADF and PDF is lacking. MATERIALS AND METHODS We identified patients who were hospitalized for CSM and underwent either ADF or PDF from 2010 to 2016 using the Japanese Diagnosis Procedure Combination database. In the ADF and PDF groups, we compared postoperative complications (systemic and local), medical costs during hospitalization, and mortality before and after PSM. In addition, multivariate regression analysis was performed to identify risk factors for perioperative systemic complications. RESULTS A total of 1013 matched pairs were made after PSM. More perioperative systemic complications were detected in the ADF group than in the PDF group (at least 1 complication: ADF vs. PDF: 15.2% vs. 12.0%, P=0.038), especially for respiratory failure (1.4% vs. 0.4%, P=0.018), pneumonia (1.9% vs. 0.5%, P=0.004), and dysphagia (3.0% vs. 1.1%, P=0.003). The costs were ~$8000 higher (P<0.001) and the length of hospital stay was almost 5 days longer (P<0.001) in the PDF group. The risk factors for perioperative systemic complications in ADF were high age, low body mass index, and preoperative respiratory disease, and the factors in PDF were high body mass index and preoperative renal disease. CONCLUSION More systemic complications, especially respiratory events, were more frequently observed in the ADF group, while the medical costs were higher and the hospital stay was longer in the PDF group. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Takeo Fujiwara
- Global Health Promotion, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
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Lasry O, Ailon T, Charest-Morin R, Dea N, Dvorak M, Fisher C, Gara A, Kwon B, Smith EL, Paquette S, Wong T, Street J. Accuracy of hospital-based surveillance systems for surgical site infection after adult spine surgery: A Bayesian latent class analysis. J Hosp Infect 2021; 117:117-123. [PMID: 34273471 DOI: 10.1016/j.jhin.2021.07.005] [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: 06/04/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) of the spine are morbid and costly complications. An accurate surveillance system is required to properly describe the disease burden and the impact of interventions that mitigate SSI risk. Unfortunately, uniform approaches to conducting SSI surveillance are lacking because of varying SSI case definitions, the lack of a perfect reference case definition and heterogeneous data sources. AIM We assessed the accuracy of 4 independent data sources that capture SSIs after spine surgery, with estimation of a measurement error-adjusted SSI incidence. METHODS A Bayesian latent class model assessed the sensitivity/specificity of each data source to identify SSI and to estimate a measurement-error adjusted incidence. The four data sources used were: the discharge abstract database (DAD), the National Surgical Quality Improvement Program (NSQIP) database, the Infection Prevention and Control Canada (IPAC) database, and the Spine Adverse Events Severity database. FINDINGS A total of 904 patients underwent spine surgery in 2017. The most sensitive data source was DAD (0.799, 95% CrI 0.597, 0.943), while the least sensitive was NSQIP (0.497, 95% CrI 0.308, 0.694). The most specific data source was IPAC (0.997, 95% CrI 0.993, 1.000) and the least specific was DAD (0.969, 95% CrI 0.956, 0.981). The measurement error-adjusted SSI incidence was 0.030 (95% CrI 0.019, 0.045). The crude incidence using the DAD over-estimated the incidence, and the 3 other data sources under-estimated it. CONCLUSION SSI surveillance in the spine surgery population is feasible using several data sources, provided that measurement error is considered.
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Affiliation(s)
- Oliver Lasry
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
| | - Tamir Ailon
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raphaëlle Charest-Morin
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicolas Dea
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcel Dvorak
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles Fisher
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Aleksandra Gara
- Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, Brisitsh Columbia, Canada
| | - Brian Kwon
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elisa Lloyd Smith
- Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, Brisitsh Columbia, Canada
| | - Scott Paquette
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Titus Wong
- Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, Brisitsh Columbia, Canada
| | - John Street
- Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Amelot A, Riche M, Latreille S, Degos V, Carpentier A, Mathon B, Korinek AM. Antimicrobial prophylaxis in noninstrumented spine surgery: a prospective study to determine efficacy and drawbacks. J Neurosurg Spine 2021:1-10. [PMID: 34243156 DOI: 10.3171/2020.11.spine201891] [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: 10/22/2020] [Accepted: 11/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to evaluate the roles of perioperative antibiotic prophylaxis in noninstrumented spine surgery (NISS), both in postoperative infections and the impact on the selection of resistant bacteria. To the authors' knowledge, only one prospective study recommending preoperative intravenous (IV) antibiotics for prophylaxis has been published previously. METHODS Two successive prospective IV antibiotic prophylaxis protocols were used: from 2011 to 2013 (group A: no prophylactic antibiotic) and from 2014 to 2016 (group B: prophylactic cefazolin). Patient infection rates, infection risk factors, and bacteriological status were determined. RESULTS In total, 2250 patients (1031 in group A and 1219 in group B) were followed for at least 1 year. The authors identified 72 surgical site infections, 51 in group A (4.9%) and 21 in group B (1.7%) (p < 0.0001). A multiple logistic regression hazard model identified male sex (HR 2.028, 95% CI 1.173-3.509; p = 0.011), cervical laminectomy (HR 2.078, 95% CI 1.147-3.762; p = 0.016), and postoperative CSF leak (HR 43.782, 95% CI 10.9-189.9; p < 0.0001) as independent predictive risk factors of infection. In addition, preoperative antibiotic prophylaxis was the only independent favorable factor (HR 0.283, 95% CI 0.164-0.488; p < 0.0001) that significantly reduced infections for NISS. Of 97 bacterial infections, cefazolin-resistant bacteria were identified in 26 (26.8%), with significantly more in group B (40%) than in group A (20.9%) (p = 0.02). CONCLUSIONS A single dose of preoperative cefazolin is effective and mandatory in preventing surgical site infections in NISS. Single-dose antibiotic prophylaxis has an immediate impact on cutaneous flora by increasing cefazolin-resistant bacteria.
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Affiliation(s)
- Aymeric Amelot
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris.,2Department of Neurosurgery, Bretonneau Hospital, Hopitaux de Tours
| | - Maximilien Riche
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris
| | - Samuel Latreille
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
| | - Vincent Degos
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and.,4Sorbonne University, Paris, France
| | - Alexandre Carpentier
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris.,4Sorbonne University, Paris, France
| | - Bertrand Mathon
- 1Department of Neurosurgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris.,4Sorbonne University, Paris, France
| | - Anne-Marie Korinek
- 3Department of Neuro-anesthesiology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris; and
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Patel PD, Canseco JA, Wilt Z, Okroj KT, Chang M, Reyes AA, Bowles DR, Kurd MF, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Postoperative Glycemic Variability and Adverse Outcomes After Posterior Cervical Fusion. J Am Acad Orthop Surg 2021; 29:580-588. [PMID: 34135295 DOI: 10.5435/jaaos-d-20-00126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 09/03/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Posterior cervical decompression and fusion (PCDF) is a procedure commonly performed to help alleviate symptoms and improve quality of life in patients experiencing cervical spondylotic myelopathy, multilevel stenosis, and cervical deformity. Although various risk factors have been linked to adverse outcomes in patients after PCDF, this is the first study that specifically explores postoperative glycemic variability and its association with adverse outcomes. METHODS A retrospective cohort study was conducted with a total of 264 patients after PCDF procedures that had available postoperative blood glucose measurements. Patients were divided into tertiles based on their coefficient of variation as an indicator of glycemic variability. Outcomes measured included inpatient complications, length of stay (LOS), 90-day readmission, revision, and surgical site infection rates. RESULTS Results showed a significant difference in glycemic variability among tertiles with respect to LOS (P = 0.01). The average LOS for the first, second, and third tertiles was 3.90 (3.20, 4.59), 5.73 (4.45, 7.00), and 6.06 (4.89, 7.22), respectively. Logistic regression analysis showed significantly higher odds of readmission (odds ratio: 4.77; P = 0.03) and surgical site infections (odds ratio: 4.35; P = 0.04) in the high glycemic variability group compared with the low glycemic variability group within 90 days of surgery. No significant difference was noted among tertiles with respect to inpatient complications. DISCUSSION This study establishes a relationship between postoperative glycemic variability and LOS, as well as 90-day readmission and surgical site infection rates after PCDF. Our results suggest that limiting fluctuations in blood glucose levels may curtail inpatient healthcare costs related to in-hospital stay. Although immediate postoperative glycemic variability is ultimately acceptable, before discharge, proper glucose management plans should be in place to help prevent adverse patient outcomes.
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Affiliation(s)
- Parthik D Patel
- From the Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
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Shahrestani S, Bakhsheshian J, Chen XT, Ton A, Ballatori AM, Strickland BA, Robertson DM, Buser Z, Hah R, Hsieh PC, Liu JC, Wang JC. The influence of modifiable risk factors on short-term postoperative outcomes following cervical spine surgery: A retrospective propensity score matched analysis. EClinicalMedicine 2021; 36:100889. [PMID: 34308307 PMCID: PMC8257994 DOI: 10.1016/j.eclinm.2021.100889] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Shane Shahrestani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States
- Corresponding author at: Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Xiao T. Chen
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Andy Ton
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Alexander M. Ballatori
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Ben A. Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Djani M. Robertson
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Zorica Buser
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Raymond Hah
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Patrick C. Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - John C. Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jeffrey C. Wang
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Ogihara S, Yamazaki T, Shiibashi M, Chikuda H, Maruyama T, Miyoshi K, Inanami H, Oshima Y, Azuma S, Kawamura N, Yamakawa K, Hara N, Morii J, Okazaki R, Takeshita Y, Nishimoto J, Tanaka S, Saita K. Risk factors for deep surgical site infection after posterior cervical spine surgery in adults: a multicentre observational cohort study. Sci Rep 2021; 11:7519. [PMID: 33824381 PMCID: PMC8024328 DOI: 10.1038/s41598-021-87110-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Surgical site infection (SSI) is a serious complication following spine surgery and is correlated with significant morbidities, poor clinical outcomes, and increased healthcare costs. Accurately identifying risk factors can help develop strategies to reduce this devastating consequence; however, few multicentre studies have investigated risk factors for SSI following posterior cervical spine surgeries. Between July 2010 and June 2015, we performed an observational cohort study on deep SSI in adult patients who underwent posterior cervical spine surgery at 10 research hospitals. Detailed patient- and procedure-specific potential risk variables were prospectively recorded using a standardised data collection chart and were reviewed retrospectively. Among the 2184 consecutive adult patients enrolled, 28 (1.3%) developed postoperative deep SSI. Multivariable regression analysis revealed 2 statistically significant independent risk factors: occipitocervical surgery (P < 0.001) and male sex (P = 0.024). Subgroup analysis demonstrated that occipitocervical surgery (P = 0.001) was the sole independent risk factor for deep SSI in patients with instrumented fusion. Occipitocervical surgery is a relatively rare procedure; therefore, our findings were based on a large cohort acquired using a multicentre study. To the best of our knowledge, this is the first study to identify occipitocervical procedure as an independent risk variable for deep SSI after spinal surgery.
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Affiliation(s)
- Satoshi Ogihara
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.
| | - Takashi Yamazaki
- Department of Orthopaedic Surgery, Musashino Red Cross Hospital, 1-26-1 Kyonancho, Musashino, Tokyo, 180-8610, Japan
| | - Michio Shiibashi
- Information Technology Center, Saitama Medical University, 38 Morohongo Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Toru Maruyama
- Department of Orthopaedic Surgery, Saitama Rehabilitation Center, 148-1 Nishikaizuka, Ageo, Saitama, 362-0057, Japan
| | - Kota Miyoshi
- Department of Orthopaedic Surgery, Yokohama Rosai Hospital, 3211 Kozukuecho, Kouhoku-ku, Yokohama, Kanagawa, 222-0036, Japan
| | - Hirohiko Inanami
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa-ku, Tokyo, 140-0002, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Seiichi Azuma
- Department of Orthopaedic Surgery, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Naohiro Kawamura
- Department of Spine and Orthopaedic Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Kiyofumi Yamakawa
- Department of Orthopaedic Surgery and Musculoskeletal Oncology, Tokyo Metropolitan Komagome Hospital, 3-18 Honkomagome, Bunkyo-ku, Tokyo, 113-0021, Japan
| | - Nobuhiro Hara
- Department of Orthopaedic Surgery, Musashino Red Cross Hospital, 1-26-1 Kyonancho, Musashino, Tokyo, 180-8610, Japan
| | - Jiro Morii
- Department of Orthopaedic Surgery, Sanraku Hospital, 2-5 Surugadai, Kanda, Chiyoda-ku, Tokyo, 101-8326, Japan
| | - Rentaro Okazaki
- Department of Orthopaedic Surgery, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Yujiro Takeshita
- Department of Orthopaedic Surgery, Yokohama Rosai Hospital, 3211 Kozukuecho, Kouhoku-ku, Yokohama, Kanagawa, 222-0036, Japan
| | - Junji Nishimoto
- Department of Rehabilitation, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuo Saita
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan
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