Mortality and morbidity after spinal surgery in patients with Parkinson's disease: a retrospective matched-pair cohort study

Understanding the role of surgical intervention for patients with concomitant degenerative spinal disease without deformity and Parkinson's disease: a meta-analysis

INTRODUCTION

Parkinson's disease is a common neurodegenerative disease. With an aging population, co-existent degenerative diseases of the spine in these patients will become more prevalent.

RESEARCH QUESTION

This systematic review and meta-analysis aims to establish the incidence and risk of adverse outcomes following spinal surgery in patients with Parkinson's disease. Material and Methods A literature review was carried out in order to identify studies assessing the outcomes of adult patients with Parkinson's disease undergoing spinal surgery for degenerative conditions. Studies with less than ten subjects or those assessing surgery for spinal deformity or trauma were excluded.

RESULTS

Of 74 studies identified, seven were included for meta-analysis. In the 689,578 participants, there was a significantly higher incidence, but not higher risk, of complications (0.54 95% CI [0.19-0.85] vs 0.07 95% CI [0.01-0.41]; p = 0.048) and revision surgery (0.6 95% CI [0.25-0.88] vs 0.1 95% CI [0.05-0.19]; p = 0.003) amongst patients with Parkinson's disease compared to controls. We also demonstrated a significantly lower incidence but not lower risk of clinical improvement (0.27 95% CI [0.16-0.41] vs 0.57 95% CI [0.36-0.76]; p = 0.02) after surgery in patients with Parkinson's disease. There was no difference in the incidence or risk of death following surgery.

DISCUSSION AND CONCLUSION

Spinal surgery for concomitant degenerative diseases in patients with Parkinson's disease is associated with a lower incidence of clinical improvement and a higher incidence of complications. Medical management should be optimised before an individually tailored and well-considered surgical intervention is implemented.

Postoperative Complications of Surgery for Cervical Spondylotic Myelopathy with and Without Athetoid Cerebral Palsy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

With the aging of the Japanese population, patients with athetoid cerebral palsy (ACP) are getting older, and the rate of surgery for CSM is increasing in ACP patients. However, postoperative complications of such surgery among adult patients with ACP have not been reported yet. We investigated postoperative complications of surgery for CSM with ACP and compared them with those of surgery for CSM without ACP using a national inpatient database of Japan.

METHODS

Using the Diagnosis Procedure Combination database, we identified 61382 patients who underwent surgery for CSM from July 2010 to March 2018. We examined patient backgrounds, surgical procedures, and type of hospital, and a 4:1 propensity score matching was performed to compare the outcomes between the non-ACP and ACP groups.

RESULTS

There were 60 847 patients without ACP and 535 patients with ACP. The mean age was 68.5 years in the non-ACP group and 55 years in the ACP group. The percentages of patients who underwent fusion surgery were 21.6% and 68.8% in the non-ACP and ACP groups, respectively. The 4:1 propensity score matching selected 1858 in the non-ACP group and 465 in the ACP group. The ACP group was more likely to have postoperative urinary tract infection (.4% vs 2.8%, P < .001), postoperative pneumonia (.4% vs 2.4%, P < .001), and 90-day readmission for reoperation (1.9% vs 4.3%, P = .003).

CONCLUSIONS

We found that ACP patients were more vulnerable to postoperative complications and reoperation after CSM than non-ACP patients.

Estimated number of spine surgeries and related deaths in Japan from 2014 to 2020

BACKGROUND

The total number of spine surgeries per year and their related deaths in Japan has not been adequately estimated in the literature.

METHODS

We retrospectively reviewed the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) between April 2014 to March 2021, which covers 99.9 % of health insurance claim receipts by general practitioners. The annual number of surgeries was counted using K codes, a procedure classification unique to Japan, and classified into the following six categories; percutaneous vertebroplasty, endoscopic surgery, open discectomy, laminoplasty/laminectomy, instrumentation surgery, and others. The data distribution was also summarized by sex and age. Additionally, by reviewing DPC database-related papers for evaluation of the mortality rate after spine surgery in Japan, the number of spine surgery-related deaths was calculated.

RESULTS

The NDB showed that the number of spine surgeries analyzed in this study increased from 170,081 in 2014 to 193,903 in 2019, with a slight decrease in 2020. The ratio of instrumentation surgery increased from 33.0 % in 2014 to 37.9 % in 2020. The rate of patients aged 75 or older increased 31.6 % to 39.6 %. Combining these findings with DPC data showing a mortality rate of 0.1 % to 0.4 % revealed that the estimated number of deaths related to spine surgery in Japan ranged from 200 to 800 per year.

CONCLUSIONS

Approximately 200,000 spine surgeries and 200 to 800 spine surgery-related inpatient deaths were estimated to have occurred in Japan around 2020.

Association of Postoperative Delirium and Parkinson Disease After Common United States Surgical Procedures

INTRODUCTION

To determine the association of Parkinson disease (PD) and postoperative delirium following common surgical procedures.

METHODS

We performed a retrospective database analysis of the National Inpatient Sample. We used a matched sample of patients with and without PD who underwent any of ten common surgical procedures in the US, 2005-2014. Primary outcome measure was postoperative delirium for patients with and without PD. Secondary measures included disposition, length of stay, and hospital costs.

RESULTS

There were 3,235,866 patients receiving any of the ten most common operative procedures, 2005-2014. There were 35,743 patients with and without PD matched based on age, sex, elective admission status, Charlson Comorbidity index, and presence of dementia. Median age was 77 y (interquartile range 72-82), median Charlson Comorbidity index was 1 (standard deviation 0-2), 46.6% were female, and 46.8% were admitted electively. The three most common operative procedures were hip arthroplasty (28.5%), knee arthroplasty (16.1%), and percutaneous coronary angioplasty (14.9%). Postoperative delirium was present in 1519 patients with PD compared to 828 matched patients without PD (4.2% versus 2.3%; P < 0.001). The adjusted odds ratio of postoperative delirium for PD compared to the matched cohort without PD was 1.88 (95% confidence interval 1.73-2.05). Those undergoing spinal fusion (adjusted odds ratio 2.99, 95% confidence interval 2.06-4.38) had the greatest odds of delirium. For patients with PD, adjusted length of stay, adjusted hospital costs, and adjusted odds of postacute care facility discharge were greater compared to the matched cohort without PD.

CONCLUSIONS

Patients with PD are more likely to develop postoperative delirium and have a more complicated postoperative course with longer length of stay and greater hospitalization costs.

Risk factors for postoperative complications in patients with Parkinson disease: A single center retrospective cohort study

Surgical treatment for patients with Parkinson disease (PD) under general anesthesia has become frequent. PD is a significant predictor of postoperative complications. However, the factors that predict complications in patients with PD remain unknown. We retrospectively recruited patients with PD who underwent surgery between April 2015 and March 2019. The prevalence of postoperative complications was analyzed. We compared the patient characteristics, medical data, and surgical data between patients with and without postoperative complications. We also estimated the odds ratios (OR) for postoperative complications in patients with PD who underwent surgery. Sixty-five patients were enrolled. Eighteen patients presented with 22 complications, including urinary tract infections (UTI) (n = 3; 5%), pneumonia (n = 1; 2%), surgical site infections (SSI) (n = 3; 5%), postoperative delirium (POD) (n = 7; 10%), and others (n = 8; 12%). Four patients presented with 2 complications each. The operation time, the red blood cell transfusion and the rate of rotigotine usage were higher in patients with complications than those without (314 ± 197 min vs 173 ± 145 min, P = .006; 0 [0-560] mL vs 0 [0-0] mL, P = .02; 39% vs 6%, P = .003, respectively) (mean ± standard deviation or median [interquartile range]). Preoperative rotigotine usage (OR: 9.33; 95% confidential interval [CI]: 2.07-42.07; P = .004) was an independent risk factors for postoperative complications. The findings indicate that clinicians should closely monitor postoperative complications when patients with PD who have received transdermal dopamine agonists undergone longer time surgery.

The level of adherence to best-practice guidelines by interprofessional teams with and without acute care nurse practitioners in cardiac surgery: A study protocol

BACKGROUND

Acute care nurse practitioners (ACNPs) in postoperative cardiac surgery settings provide significant benefits to patients and organizations. Recent studies have suggested that ACNPs increase the level of adherence to best-practice guidelines by interprofessional teams. It is however, unknown whether interprofessional teams with ACNP are associated with higher levels of adherence to best-practice guidelines compared to interprofessional teams without ACNPs. Furthermore, no extraction tool is available to measure the level of adherence to best-practice guidelines by interprofessional teams in postoperative cardiac surgery settings. This project aims to measure and examine the level of adherence to best-practice guidelines of interprofessional teams with and without ACNPs in a postoperative cardiac surgery setting in Québec, Canada.

METHODS

A retrospective observational study will be conducted of 300 patients hospitalized between January 1, 2019 and January 31, 2020 in a postoperative cardiac surgery unit in Québec, Canada. Data will be collected from patient health records and electronic databases. An extraction tool will be developed based on systematic review of the literature, and will include best-practice guidelines and confounding variables related to patient and interprofessional teams' characteristics. Content and criterion validation, and a pilot-test will be conducted for the development of the tool. A multivariate linear regression model will be developed and adjusted for confounding variables to examine the association between interprofessional teams with and without ACNPs, and level of adherence to best-practice guidelines by those teams.

DISCUSSION

This project represents the first study to measure and examine the level of adherence to best-practice guidelines by interprofessional teams with and without ACNPs in a postoperative cardiac surgery setting. The findings of this project will generate empirical data focusing on the contribution of ACNPs within interprofessional teams, and ultimately enhance the delivery of high quality and evidence-based care for patients and families.

Postsurgical morbidity and mortality favorably informs deep brain stimulation for new indications including schizophrenia and schizoaffective disorder

Background

Deep brain stimulation (DBS) shows promise for new indications like treatment-refractory schizophrenia in early clinical trials. In the first DBS clinical trial for treatment refractory schizophrenia, despite promising results in treating psychosis, one of the eight subjects experienced both a symptomatic hemorrhage and an infection requiring device removal. Now, ethical concerns about higher surgical risk in schizophrenia/schizoaffective disorder (SZ/SAD) are impacting clinical trial progress. However, insufficient cases preclude conclusions regarding DBS risk in SZ/SAD. Therefore, we directly compare adverse surgical outcomes for all surgical procedures between SZ/SAD and Parkinson's disease (PD) cases to infer relative surgical risk relevant to gauging DBS risks in subjects with SZ/SAD.

Design

In the primary analysis, we used browser-based statistical analysis software, TriNetX Live (trinetx.com TriNetX LLC, Cambridge, MA), for Measures of Association using the Z-test. Postsurgical morbidity and mortality after matching for ethnicity, over 39 risk factors, and 19 CPT 1003143 coded surgical procedures from over 35,000 electronic medical records, over 19 years, from 48 United States health care organizations (HCOs) through the TriNetX Research Network™. TriNetXis a global, federated, web-based health research network providing access and statistical analysis of aggregate counts of deidentified EMR data. Diagnoses were based on ICD-10 codes. In the final analysis, logistic regression was used to determine relative frequencies of outcomes among 21 diagnostic groups/cohorts being treated with or considered for DBS and 3 control cohorts.

Results

Postsurgical mortality was 1.01-4.11% lower in SZ/SAD compared to the matched PD cohort at 1 month and 1 year after any surgery, while morbidity was 1.91-2.73% higher and associated with postsurgical noncompliance with medical treatment. Hemorrhages and infections were not increased. Across the 21 cohorts compared, PD and SZ/SAD were among eight cohorts with fewer surgeries, nine cohorts with higher postsurgical morbidity, and fifteen cohorts within the control-group range for 1-month postsurgical mortality.

Conclusions

Given that the subjects with SZ or SAD, along with most other diagnostic groups examined, had lower postsurgical mortality than PD subjects, it is reasonable to apply existing ethical and clinical guidelines to identify appropriate surgical candidates for inclusion of these patient populations in DBS clinical trials.

A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease

Background

Following orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology.

Methods

The 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD.

Results

After weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality.

Conclusions

After matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.

Postoperative Complication Rates After One-Level Cervical Spine Surgery in Patients with Parkinson Disease: A Database Study

OBJECTIVE

Parkinson disease (PD) is a risk factor for worse surgical outcomes. The degree to which PD affects outcomes in cervical spine surgery is not well understood. Therefore, we characterize rates of postoperative complications among patients with PD who undergo cervical spine surgery.

METHODS

Using the PearlDiver database, we identified patients who underwent 1-level anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), or discectomy/decompression with concomitant PD between 2011 and 2019. Patients with PD who underwent surgery and had 1 year follow-up were included. Complications 30, 60, and 90 days after surgery were identified and aggregated into body systems (e.g., respiratory and gastrointestinal). Comparison controls without concomitant PD who received cervical spine (C-spine) surgery were matched for age, sex, and comorbidities.

RESULTS

A total of 259,443 ACDFs, 30,929 PCFs, and 29,563 decompressions were identified. Of these procedures, 1117 were performed on patients with PD (0.35%). The highest 90-day complications rates in patients with PD were pulmonary and gastrointestinal related (6.05%) in those who received ACDF, neuro related (8.51%) in those who received PCF, and genitourinary related (8.76%) in those who received a decompression. Compared with patients without PD, postoperative complications rates were similar and not significantly different.

CONCLUSIONS

Patients with PD who receive ACDF have higher rates of pulmonary (6.05%), neurologic (5.24%), and psychiatric (3.23%) complications at 90 days. The differences did not reach statistical significance. This finding suggests that patients with PD do not experience higher rates of acute postoperative complications when undergoing 1-level cervical spine surgery.

High rates of blood transfusion associated with Parkinson’s disease

Background

As evidence continues to accumulate regarding the multi-organ dysfunction associated with Parkinson’s disease (PD), it is still unclear as to whether PD increases the risk of hematological pathology. In this study, the authors investigate the association between PD and hematological pathology risk factors.

Methods

This retrospective cohort analysis was conducted using 8 years of the National Readmission Database. All individuals diagnosed with PD were queried at the time of primary admission. Readmissions, complications, and risk factors were analyzed at 30-, 90-, 180-, and 300-day intervals. Statistical analysis included multivariate Gaussian-fitted modeling using age, sex, comorbidities, and discharge weights as covariates. Coefficients of model variables were exponentiated and interpreted as odds ratios.

Results

The database query yielded 1,765,800 PD patients (mean age: 76.3 ± 10.4; 44.1% female). Rates of percutaneous blood transfusion in readmitted patients at 30, 90, 180, and 300 days were found to be 8.7%, 8.6%, 8.3%, and 8.3% respectively. Those with anti-parkinsonism medication side effects at the primary admission had increased rates of gastrointestinal (GI) hemorrhage (OR: 1.02; 95%CI: 1.01–1.03, p < 0.0001) and blood transfusion (OR: 1.06; 95%CI: 1.05–1.08, p < 0.0001) at all timepoints after readmission. PD patients who experienced GI hemorrhage of any etiology, including as a side effect of anti-parkinsonism medication, were found to have significantly higher rates of blood transfusion at all timepoints (OR: 1.14; 95%CI: 1.13–1.16, p < 0.0001).

Conclusions

Blood transfusions were found to be significantly associated with anti-parkinsonism drug side effects and GI hemorrhage of any etiology.

Association between Baseline Cognitive Score and Postoperative Delirium in Parkinson’s Disease Patients following Deep Brain Stimulation Surgery

Background

Deep brain stimulation of the subthalamic nuclei (STN-DBS) is a standard treatment option for advanced Parkinson's disease (PD) patients. Delirium following DBS electrode implantation is common, by several studies, and cognitive impairment is a risk factor for developing postoperative delirium (POD). This prospective observational study was conducted to identify whether preoperative baseline cognitive status has an association with POD in PD patients undergoing DBS surgery.

Methods

Preoperatively, neuropsychiatric and neuropsychological assessments of the patients were performed including clinical dementia rating (CDR) score, instrumental activities of daily living (IADL) score, mini-mental state exam (MMSE) score, Montreal cognitive assessment (MoCA) score, Hamilton anxiety (HAMA) and Hamilton depression (HAMD) scores, and numerical cancellation test. POD was identified by the confusion assessment method (CAM) twice per day on postoperative day 1 until discharge.

Results

Twenty-seven (21.6%) of 125 patients developed POD. Among the variables screened, age, CDR score, MMSE score, and HAMA score were indicated to be independent influence factors of POD. The cutoff score, AUC, sensitivity, and specificity of age, CDR score, MMSE score, and HAMA score associated with POD was 58.5, 0.751, 92.6%, 52.0%; 0.5, 0.848, 77.8%, 91.8%; 27.5, 0.827, 88.9%, 62.2%; and 12.5, 0.706, 85.2%, 54.1%, respectively.

Conclusions

We observed age, CDR score, MMSE score, and HAMA score were independent influence factors of POD in PD patients who received DBS. It is necessary to assess the cognitive status of PD patients before surgery to identify high-risk patients.

Parkinson Disease, Dysphagia, and Cervical Spine Surgery

STUDY DESIGN

An analysis of a National Database.

OBJECTIVE

The objective of this study was to evaluate the rate of dysphagia for Parkinson disease (PD) patients undergoing cervical spine surgery for cervical myelopathy.

SUMMARY OF BACKGROUND DATA

Cervical spondylotic myelopathy (CSM) is an increasingly common problem in the aging population. Several surgical options exist to treat this condition including anterior, posterior and combined surgical approaches. Each approach carries its own set of postoperative complications. Little is known of the of outcomes after cervical spine surgery in PD.

MATERIALS AND METHODS

The National Inpatient sample was queried 1998 to 2016, all elective admissions with CSM were identified. Surgical treatments were identified as either: anterior cervical discectomy and fusion (ACDF), posterior laminectomies, posterior cervical fusion or combined anterior/posterior surgery. Preexisting PD was identified. Endpoints included mortality, length of stay (LOS), swallowing dysfunction measured by placement of feeding tube (NGT), and postprocedure pneumonia.

RESULTS

A total of 73,088 patients underwent surgical procedures for CSM during the study period. Of those, 552 patients (7.5%) had concomitant PD. The most common procedure was ACDF. Patients with PD had a higher rate of dysphagia (NGT placement) after surgery compared with those without PD (P<0.001). Multiple regression analysis showed that PD patients had a higher risk of having NGT placement or developing pneumonia [odds ratio 2.98 (1.7-5.2), P<0.001] after surgery.Patients with PD who underwent ACDF, posterior laminectomies or posterior cervical fusion had a longer LOS compared with those who did not have PD (P<0.001). There was no difference in LOS for patients who underwent combined anterior/posterior surgery. Inpatient mortality was higher in patients with PD who underwent ACDF or combined surgery (P<0.001).

CONCLUSIONS

While ACDF is the most commonly performed procedure for CSM in patients with PD, it is associated with longer LOS, higher incidence of postoperative dysphagia, and postprocedural pneumonia, as well as higher inpatient mortality compared with posterior cervical procedures.

LEVEL OF EVIDENCE

Level III.

Impact of orthogeriatric care management by orthopedic surgeons and physicians on in-hospital clinical outcomes: A difference-in-difference analysis

AIM

The orthopedic surgery unit in our suburb serves a large elderly trauma population in addition to providing elective surgeries. As patients with hip fractures have become older and at higher risk of medical complications, our hospital has initiated integrated co-management of these patients by orthopedic surgeons and geriatricians from the point of hospital admission. The aim of this study was to evaluate the impact of the hospital policy change on hip fracture management and clinical outcome indicators.

METHODS

Using the difference-in-difference approach, in total, 288 consecutive patients with hip fractures treated during the 1 year before and 2 years after transition to orthogeriatric care from a geriatric consultation model to integrated orthogeriatric care model were compared with 576 patients from other local hospitals.

RESULTS

Despite a seasonal trend toward increased length of hospital stay in winter, the intervention significantly reduced the change in mean length of stay (mean difference [95% confidence interval], -12.9 days [-21.5 to -4.3]; P = 0.007) and discharge to home tended to change less frequently (-12.6%; P = 0.10). There was no significant reduction in mean time to surgery (-0.2 days; P = 0.83), mortality (-0.8%; P = 0.62), or complications (-1.0%; P = 0.85).

CONCLUSIONS

Changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly reduced length of hospital stay probably due to a lower chance of discharge to home. To our knowledge, this is the first study in Japan to compare two orthogeriatric care models considering the nationwide improvement in hip fracture management.

AUTHOR

Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

Musculoskeletal pain in Parkinson's disease: a narrative review

The prevalence of musculoskeletal (MSK) pain in people with Parkinson's disease (PD) is higher than that of age-matched controls. In this review, we outline what is known about MSK pain in PD, focusing on the neck, shoulder, knee, hip and low back. We also compare what is known about MSK pain in PD to what is known in older adults without PD. Finally, we outline areas of for future research related to MSK pain in people with PD.

Clinical and imaging features of surgically treated low lumbar osteoporotic vertebral collapse in patients with Parkinson's disease

Osteoporosis and Parkinson's disease (PD) are age-related diseases, and surgery for osteoporotic vertebral collapse (OVC) in PD patients become more common. OVC commonly affects the thoracolumbar spine, but low lumbar OVC is frequent in patients with lower bone mineral density (BMD). The aim of this study was to identify differences in clinical and imaging features of low lumbar OVC with or without PD and to discuss the appropriate treatment. The subjects were 43 patients with low lumbar OVC below L3 who were treated surgically, including 11 patients with PD. The main clinical symptoms were radicular pain in non-PD cases and a cauda equina sign in PD cases. Rapid progression and destructive changes of OVC were seen in patients with PD. The morphological features of OVC were flat-type in non-PD cases with old compression fracture, and destruction-type in PD cases without old compression fracture. Progression of PD was associated with decreased lumbar lordosis, lower lumbar BMD, and severe sarcopenia. High postoperative complication rates were associated with vertebral fragility and longer fusion surgery. Progression of postural instability as a natural course of PD may lead to mechanical stress and instrumentation failure. Invasive long-fusion surgery should be avoided for single low lumbar OVC.

Sagittal alignment changes and postoperative complications following surgery for adult spinal deformity in patients with Parkinson's disease: a multi-institutional retrospective cohort study

Background

Parkinson’s disease (PD) has been found to increase the risk of postoperative complications in patients with adult spinal deformity (ASD). However, few studies have investigated this by directly comparing patients with PD and those without PD.

Methods

In this multicenter retrospective cohort study, we reviewed all surgically treated ASD patients with at least 2 years of follow-up. Among them, 27 had PD (PD+ group). Clinical data were collected on early and late postoperative complications as well as any revision surgery. Radiographic parameters were evaluated before and immediately after surgery and at final follow-up, including sagittal vertical axis (SVA), thoracic kyphosis, lumbar lordosis, sacral slope, and pelvic tilt. We compared the surgical outcomes and radiographic parameters of PD patients with those of non-PD patients.

Results

For early complications, the PD+ group demonstrated a higher rate of delirium than the PD− group. In terms of late complications, the rate of non-union was significantly higher in the PD+ group. Rates of rod failure and revision surgery due to mechanical complications also tended to be higher, but not significantly, in the PD+ group (p = 0.17, p = 0.13, respectively). SVA at final follow-up and loss of correction in SVA were significantly higher in the PD+ group.

Conclusion

Extra attention should be paid to perioperative complications, especially delirium, in PD patients undergoing surgery for ASD. Furthermore, loss of correction and rate of non-union were greater in these patients.

Appendectomy Does Not Increase the Risk of Future Emergence of Parkinson's Disease: A Meta-analysis

OBJECTIVE

To explore the impact of appendectomy history on emergence of Parkinson's disease (PD).

BACKGROUND

Although there are several studies to investigate the relationship between appendectomy history and emergence of PD, the results are still controversial.

METHODS

We performed a comprehensive electronic search of the literature (the Cochrane Library, PubMed, and the Web of Science) up to April 2020 to identify studies that had employed databases allowing comparison of emergence of PD between patients with and those without appendectomy history. To integrate the impact of appendectomy history on emergence of PD, a meta-analysis was performed using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI) for the selected studies, and heterogeneity was analyzed using I² statistics.

RESULTS

Four studies involving a total of 6 080 710 patients were included in this meta-analysis. Among 1 470 613 patients with appendectomy history, 1845 (.13%) had emergences of PD during the observation period, whereas among 4 610 097 patients without appendectomy history, 6743 (.15%) had emergences of PD during the observation period. These results revealed that patients with appendectomy history and without appendectomy had almost the same emergence of PD (RR, 1.02; 95% CI, .87-1.20; P = .83; I² = 87%).

CONCLUSION

This meta-analysis has demonstrated that there was no significant difference in emergence of PD between patients with and those without appendectomy history.

Surgical outcome of upper extremity fractures in patients with Parkinson's disease

Patients with Idiopathic Parkinson’s Disease (PD) have an increased risk for fractures. Currently, many studies have reported inferior outcomes in PD patients after orthopedic procedures. However, there are very few studies assessing the outcome of upper extremity fractures (UEF) in PD patients. In this study, we reviewed 40 patients with PD that received surgical intervention for an UEF. We retrospectively reviewed patients with PD that received surgical fixation for an UEF at a tertiary trauma center. The primary objective was to determine the treatment failure rate after surgical fixation. The secondary outcomes include mode of failure, time to treatment failure, length of hospital stay, readmission rate, reoperation rate, and postoperative complications. A total of 40 patients with PD (42 fractures) underwent surgery. The most common fracture type was radius fracture (n = 19), followed by humerus fracture (n = 15), metacarpal/phalangeal fracture (n = 5), clavicle fracture (n = 2) and olecranon fracture (n = 1). The overall treatment failure rate was 40.5% (n = 17). The time to treatment failure was 1.24 ± 3.1 months and length of hospital stay was 6 ± 3.9 days, the readmission rate within 30 days was 14% (n = 6), and reoperation rate was 14% (n = 6). The complication rate was 16.6% (n = 7) and patients with humeral fractures appeared to have the longest hospital stays (6.6 days) and increased complication rates (13%, n = 2). Patients with PD have high treatment failure rates despite surgical fixation of an UEF. These patients often have a frail status with multiple comorbidities which may complicate their postoperative course.

Level of evidence level 4 case series.

Spinal Surgery for Parkinson Disease With Camptocormia: Propensity Score-Matched Cohort Study With Degenerative Sagittal Imbalance (DSI)

STUDY DESIGN

A propensity score-matched cohort study.

OBJECTIVE

The objective of this study was to compare the radiologic and clinical outcomes of camptocormia in Parkinson disease (PD) with degenerative sagittal imbalance (DSI) patients.

SUMMARY OF BACKGROUND DATA

Camptocormia in PD and DSI could be characterized by a dynamic deformity. However, no study has directly evaluated the outcomes of patients with camptocormia and DSI.

METHODS

Thirteen consecutive PD patients undergoing surgical correction for camptocormia were matched in a 1-to-2 format with 26 patients in the DSI group by propensity score-matching. Radiologic outcomes, including paravertebral muscle changes, and clinical outcomes were compared between the 2 groups. The rate of proximal junctional problems and reoperations were assessed.

RESULTS

PD patients with camptocormia had significantly greater preoperative coronal and sagittal malalignments (29.9 vs. 16.9 mm, P=0.019; 142.8 vs. 64.4 mm, P=0.0001, respectively) and weakness of paravertebral muscles compared with the DSI patients. Regarding the clinical outcomes, reoperations were significantly higher in the camptocormia group, compared with the DSI group (53.8% vs. 7.7%, P=0.001). Moreover, proximal junctional failure was developed in 8 patients in the camptocormia group, while 1 patient in the DSI group (61.5% vs. 3.8%, P=0.0001). In subgroup analysis, independent risk factors for the proximal junctional failure were the total fusion levels (hazard ratio=0.26, P=0.018) and the degree of fatty changes of the paravertebral muscles (hazard ratio=1.15, P=0.048).

CONCLUSIONS

PD patients undergoing spinal surgery for camptocormia had global malalignment and higher rates of complications compared with DSI patients. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

Management of Pain in Parkinson's Disease

Pain is a very frequent symptom with influence on the quality of life in Parkinson’s disease (PD), but is still underdiagnosed and commonly treated only unsystematically. Pain etiology and pain character are often complex and multi-causal, and data regarding treatment recommendations are limited. Pain can be primarily related to PD but frequently it is associated with secondary diseases, such as arthrosis of the spine or joints. However, even basically PD-unrelated pain often is amplified by motor- or non-motor PD symptoms, such as akinesia or depression. Beyond an optimization of anti-parkinsonian treatment, additional pain treatment strategies are usually needed to properly address pain in PD. A careful pain history and diagnostic work-up is essential to rate the underlying pain pathophysiology and to develop a targeted therapeutic concept. This review gives an overview on how pain is treated in PD patients and how patients assess the effectiveness of these therapies; here, the manuscript focuses on pathophysiology-driven suggestions for a multimodal pain management in clinical practice.

ADAPTATION OF THE FRAILTY INDEX FOR BRAZILIAN PORTUGUESE IN ADULT SPINE DEFORMITY SURGERY

ABSTRACT Objectives To adapt the adult spinal deformity frailty index (ASD-FI), which was presented as an instrument for stratification of risk of surgical complications, for application in the Brazilian population. Methods This is a consensus-building study, following the Delphi method, in which a team of six Brazilian spine surgery specialists worked alongside the International Spine Study Group (ISSG), the group responsible for preparing the original version of the ASD-FI, in order to adapt the index for the Brazilian population. The variables to be included in the new version, as well as the translation of the terminology into Portuguese, were evaluated and a consensus was considered to have been reached when all (100%) of the Brazilian experts were in agreement. Results A version of the ASD-FI was created, composed of 42 variables, with the inclusion of two new variables that were not included in the original version. The new version was then back translated into English and approved by the ISSG members, resulting in the adapted version of the ASD-FI for the Brazilian population. Conclusion This study presents an adapted version of the adult spinal deformity frailty index for the Brazilian population, for the purpose of risk stratification in the surgical treatment of these complex deformities. Level of evidence II; Study of adaptation of a valid score.

Comparison of Perioperative Complications Between Anterior Decompression With Fusion and Laminoplasty For Cervical Spondylotic Myelopathy: Propensity Score-matching Analysis Using Japanese Diagnosis Procedure Combination Database

STUDY DESIGN

A retrospective comparative study with a large national database.

OBJECTIVE

The objective of this study was to compare the perioperative complications and costs of anterior decompression with fusion (ADF) and laminoplasty (LAMP) for patients who had cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

CSM is the most common spinal cord disorder in the upper middle-aged people in Japan. ADF and LAMP represent 2 major treatments; however, few studies have reported large-scale investigations for perioperative complications with CSM. Thus, it is controversial which surgical approach will lead to the best clinical outcome in CSM.

MATERIALS AND METHODS

All data in this study were collected from the Japanese Diagnosis Procedure Combination database for patients diagnosed with CSM. We adjusted for known confounding biases with propensity score matching. One-to-one matched pairs between each surgical procedure were analyzed for the purposes of comparing systemic complication rates, local complication rates, medical costs, and mortality.

RESULTS

After propensity score matching, 1638 pairs of patients undergoing ADF and LAMP were made. More perioperative systemic complications were observed in the ADF group, such as atrial fibrillation (ADF/LAMP=0.7%/0.2%, P=0.032), respiratory failure (1.4%/0.1%, P<0.001), dysphagia (2.2%/0.2%, P<0.001), and sepsis (0.5%/0.1%, P=0.019). In contrast, a high rate of pulmonary embolism was observed with LAMP groups (ADF/LAMP=0%/0.2%, P=0.045). Local complications, such as infection (ADF/LAMP=0.8%/1.7%, P=0.026) and meningitis (0%/0.2%, P<0.045), were more common in the LAMP group. Conversely, spinal fluid leakage (ADF/LAMP=0.6%/0%, P=0.003) was more common in the ADF group. The costs (P<0.001) were higher in the ADF group.

CONCLUSIONS

More systemic complications, such as respiratory disease, cardiovascular events, and sepsis, were observed in the ADF group, although local infection was more frequently seen in the LAMP group. Medical costs were higher in the ADF group. The findings in this study will contribute to each CSM patient by allowing suitable adaptation of cervical surgeries.

LEVEL OF EVIDENCE

Level III.

Incidence and Risk Factors for Postoperative Delirium in Patients Undergoing Spine Surgery: A Systematic Review and Meta-Analysis

Background

The present study aims to investigate the incidence and risk factors associated with postoperative delirium in patients undergoing spine surgery.

Methods

PubMed, EMBASE, Cochrane Library, and Science Citation Index were searched up to August 2019 for studies examining postoperative delirium following spine surgery. Incidence and risk factors associated with delirium were extracted. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for outcomes. The Newcastle-Ottawa Scale (NOS) was used for the study quality evaluation.

Results

The final analysis includes a total of 40 studies. The pooled analysis reveals that incidence of delirium is 8%, and there are significant differences for developing delirium in age (OR 1.07; 95% CI 1.04-1.09), age more than 65 (OR 4.77; 95% CI 4.37-5.16), age more than 70 (OR 15.87; 95% CI 6.03-41.73), and age more than 80 (OR 1.91; 95% CI 1.78-2.03) years, male (OR 0.81; 95% CI 0.76-0.86), a history of alcohol abuse (OR 2.11; 95% CI 1.67-2.56), anxiety (OR 1.74; 95% CI 1.04-2.44), congestive heart failure (OR 1.4; 95% CI 1.21-1.6), depression (OR 2.5; 95% CI 1.52-3.49), hypertension (OR 1.12; 95% CI 1.04-1.2), kidney disease (OR 1.41; 95% CI 1.16-1.66), neurological disorder (OR 4.66; 95% CI 4.22-5.11), opioid use (OR 1.86; 95% CI 1.18-2.54), psychoses (OR 2.77; 95% CI 2.29-3.25), pulmonary disease (OR 1.81; 95% CI 1.27-2.35), higher mini-mental state examination (OR 0.7; 95% CI 0.5-0.89), preoperative pain (OR 1.88; 95% CI 1.11-2.64), and postoperative urinary tract infection (OR 5.68; 95% CI 2.41-13.39).

Conclusions

A comprehensive understanding of incidence and risk factors of delirium can improve prevention, diagnosis, and management. Risk of postoperative delirium can be reduced based upon identifiable risk factors.

Orthopedic Care of Patients with Parkinson Disease

This article summarizes existing literature examining orthopedic interventions for patients with Parkinson disease (PD). It reviews complications and functional outcomes of shoulder, spine, knee, and hip surgeries in PD. Causes of fall-related fractures in PD and the risk of postoperative cognitive decline after orthopedic interventions in PD are also briefly discussed.

Complications after spinal fixation surgery for osteoporotic vertebral collapse with neurological deficits: Japan Association of Spine Surgeons with ambition multicenter study

BACKGROUND

There have been few reports on the incidence and risk factors of the complications after spinal fixation surgery for osteoporotic vertebral collapse (OVC) with neurological deficits. This study aimed to identify the incidence and risk factors of the complications after OVC surgery.

METHODS

In this retrospective multicenter study, a total of 403 patients (314 women and 89 men; mean age 73.8 years) who underwent spinal fixation surgery for OVC with neurological deficits between 2005 and 2014 were enrolled. Data on patient demographics were collected, including age, sex, body mass index, smoking, steroid use, medical comorbidities, and surgical procedures. All postoperative complications that occurred within 6 weeks were recorded. Patients were classified into two groups, namely, complication group and no complication group, and risk factors for postoperative complications were investigated by univariate and multivariate analyses.

RESULTS

Postoperative complications occurred in 57 patients (14.1%), and the most common complication was delirium (5.7%). In the univariate analysis, the complication group was found to be older (p = 0.039) and predominantly male (p = 0.049), with higher occurrence rate of liver disease (p = 0.001) and Parkinson's disease (p = 0.039) compared with the no-complication group. In the multivariate analysis, the significant independent risk factors were age (p = 0.021; odds ratio [OR] 1.051, 95% confidence interval [CI] 1.007-1.097), liver disease (p < 0.001; OR 8.993, 95% CI 2.882-28.065), and Parkinson's disease (p = 0.009; OR 3.636, 95% CI 1.378-9.599).

CONCLUSIONS

Complications after spinal fixation surgery for OVC with neurological deficits occurred in 14.1%. Age, liver disease, and Parkinson's disease were demonstrated to be independent risk factors for postoperative complications.

Perioperative complications of anterior decompression with fusion versus laminoplasty for the treatment of cervical ossification of the posterior longitudinal ligament: propensity score matching analysis using a nation-wide inpatient database

BACKGROUND CONTEXT

Surgical treatment of cervical ossification of the posterior longitudinal ligament (OPLL) has a high risk of various complications. Anterior decompression with fusion (ADF) and laminoplasty (LAMP) are the most representative surgical procedures. However, few studies have compared the two procedures in terms of perioperative surgical complications.

PURPOSE

To compare the perioperative complications post-ADF and LAMP for cervical OPLL using a large national inpatient database.

STUDY DESIGN

A retrospective cohort study with propensity score matching analysis.

PATIENT SAMPLE

Overall, 8,718 (ADF/LAMP:1,333/7,485) patients who underwent surgery for cervical OPLL from April 1, 2010 to March 31, 2016 in hospitals using the diagnosis procedure combination were analyzed.

OUTCOME MEASURES

The occurrence of postoperative complications during hospitalization.

METHODS

We compared the perioperative systemic and local complications, reoperation rates, and costs between ADF and LAMP using propensity score matching analysis.

RESULTS

One-to-one matching resulted in 1,192 pairs of patients who underwent ADF and LAMP. The postoperative cardiovascular event rate was significantly higher (ADF/LAMP=1.9/0.8%, p=.013) in the ADF group. The incidence rates of dysphagia (similarly, 2.4/0.2%, p<.001), pneumonia (1.0/0.3%, p=.045), and spinal fluid leakage (2.4/0.4%, p<.001) were also higher in the ADF group, even after matching. The costs were also higher in the ADF group. However, surgical site infection (2.0/3.4%, p=.033) was significantly lower in the ADF group. No significant difference in the reoperation rates was found between the groups.

CONCLUSION

The present study, using a large nationwide database, demonstrated that perioperative complications were more common in the ADF group, but that surgical site infection (SSI) was more frequently observed in the LAMP group.

The risk factors associated with delirium after lumbar spine surgery in elderly patients

Background

To prospectively explore the incidence and risk factors for postoperative delirium in elderly patients following lumbar spine surgery.

Methods

This prospective study enrolled 148 consecutive patients over the age of 65 who were scheduled to undergo spine surgery. Patients were screened for delirium using the short Confusion Assessment Method (CAM) postoperatively. Patient demographics and relevant medical information were collected. Logistic regression analysis was used to identify the risk factors associated with postoperative delirium.

Results

Eighty-three patients (56.1%) who underwent lumbar spine surgery (not coexisting with cervical or thoracic spine surgery) were enrolled in our study. Post-operative delirium was noted in 14.5% of patients over 65 years old. The presence of preoperative Parkinsonism was significantly higher in the delirium group (41.7% vs. 8.5%, P=0.002), as was a higher preoperative C-reactive protein (CRP) (7.0±15.2 vs. 1.3±2.3 mg/L, P=0.017) when compared with the non-delirium group. Of the risk factors, male sex [odds ratio (OR) =0.10, 95% confidence interval (CI): 0.01-0.66, P=0.017], Parkinsonism (OR =5.83, 95% CI: 1.03-32.89, P=0.046), and lower baseline MMSE score (OR =0.71, 95% CI: 0.52-0.97, P=0.032) were independently associated with postoperative delirium in elderly patients undergoing lumbar spine surgery.

Conclusions

Post-operative delirium occurred in 14.5% of elderly patients who underwent lumbar spine surgery. Male sex, Parkinsonism, and lower baseline MMSE score were identified as independent risk factors for postoperative delirium in elderly patients following lumbar surgery.

Surgical outcomes of spinal fusion for osteoporotic thoracolumbar vertebral fractures in patients with Parkinson's disease: what is the impact of Parkinson's disease on surgical outcome?

BACKGROUND

To date, there have been little published data on surgical outcomes for patients with PD with thoracolumbar OVF. We conducted a retrospective multicenter study of registry data to investigate the outcomes of fusion surgery for patients with Parkinson's disease (PD) with osteoporotic vertebral fracture (OVF) in the thoracolumbar junction.

METHODS

Retrospectively registered data were collected from 27 universities and their affiliated hospitals in Japan. In total, 26 patients with PD (mean age, 76 years; 3 men and 23 women) with thoracolumbar OVF who underwent spinal fusion with a minimum of 2 years of follow-up were included (PD group). Surgical invasion, perioperative complications, radiographic sagittal alignment, mechanical failure (MF) related to instrumentation, and clinical outcomes were evaluated. A control group of 296 non-PD patients (non-PD group) matched for age, sex, distribution of surgical procedures, number of fused segments, and follow-up period were used for comparison.

RESULTS

The PD group showed higher rates of perioperative complications (p < 0.01) and frequency of delirium than the non-PD group (p < 0.01). There were no significant differences in the degree of kyphosis correction, frequency of MF, visual analog scale of the symptoms, and improvement according to the Japanese Orthopaedic Association scoring system between the two groups. However, the PD group showed a higher proportion of non-ambulators and dependent ambulators with walkers at the final follow-up (p < 0.01).

CONCLUSIONS

A similar surgical strategy can be applicable to patients with PD with OVF in the thoracolumbar junction. However, physicians should pay extra attention to intensive perioperative care to prevent various adverse events and implement a rehabilitation regimen to regain walking ability.

Can Elective Spine Surgery Be Performed Safely Among Nonagenarians?: Analysis of a National Inpatient Database in Japan

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare morbidity and mortality between nonagenarians and other older adult patients who underwent elective spine surgery.

SUMMARY OF BACKGROUND DATA

There is a lack of information of the perioperative risks of nonagenarians undergoing spine surgery.

METHODS

Data of patients aged ≥65 years who underwent elective spine surgery from July 2010 to March 2013 were extracted from the Diagnosis Procedure Combination database, a nationwide administrative inpatient database in Japan. Clinical outcomes included mortality, occurrence of major complications (cardiac events, respiratory complications, pulmonary embolism, stroke, and acute renal failure), urinary tract infection, and postoperative delirium. These clinical outcomes in nonagenarians were compared with those in patients aged 65 to 79 years and octogenarians. A multivariate logistic regression model fitted with a generalized estimation equation was used to evaluate the influence of advanced age on 90-day mortality and postoperative major complications.

RESULTS

Of 88,370 patients identified in the database, 418 were nonagenarians. Compared with patients aged 65 to 79 years and octogenarians, nonagenarians had the highest rates of 90-day mortality (0.2%, 0.3%, and 1.7%, respectively; P < 0.001) and at least one major complication (3.7%, 5.0%, and 7.4%, respectively; P < 0.001). Nonagenarians had the highest proportions of cardiac events, respiratory complications, urinary tract infections, and delirium. The multivariable logistic regression analyses revealed that nonagenarians had increased risks of both 90-day mortality (odds ratio, 8.65; 95% confidence interval, 3.62-20.6) and postoperative major complications (odds ratio, 2.32; 95% confidence interval, 1.61-3.36) compared with patients aged 65 to 79 years.

CONCLUSION

Nonagenarians had increased morbidity and mortality following elective spine surgery compared with other older adult patients. Among the complications, cardiac events, respiratory complications, urinary tract infection, and delirium were more likely to occur in nonagenarians.

LEVEL OF EVIDENCE

3.

Matched Cohort Analysis of Elective Lumbar Spinal Fusion in Patients With and Without Parkinson's Disease: In-hospital Complications, Length of Stay, and Hospital Charges

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

Parkinson's disease (PD) is a neurodegenerative condition associated with significant morbidity and mortality. PD patients often develop spinal conditions and are known to have high complication rates following surgery. This study evaluated the outcomes of lumbar fusion surgery in patients with PD using a large, public, national database.

METHODS

The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) was used to identify elective lumbar spinal fusion patients with and without PD for the years 2000 to 2012. PD patients were matched with non-PD controls for comorbidity and age using propensity score matching. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort.

RESULTS

A total of 231 351 elective lumbar fusion patients were examined, of which 1332 had PD. Before matching, elective lumbar fusion patients with PD were significantly older (P < .001) and more likely male (P < .001) compared with non-PD patients. In the matched cohort, PD was associated with increased length of stay (6.91 vs 5.78 days) (P < .001) and total hospital charges ($129 212.40 vs $110 324.40) (P < .001). There was no significant difference in overall in-hospital complication rate between PD patients and matched non-PD patients (22.3% vs 21.4%) (P = .524).

CONCLUSIONS

Analysis demonstrated significant increases in length and cost of hospitalization for elective lumbar spinal fusion in patients with PD. However, inpatient complication rates in PD patients were not significantly increased. As a growing number of PD patients undergo elective spine surgery, further studies are needed to optimize operative planning. Further study is needed to assess the long-term outcomes of lumbar spinal fusion in PD.

Surgical Site Infection in Spine Surgery: Who Is at Risk?

STUDY DESIGN

Retrospective literature review of spine surgical site infection (SSI).

OBJECTIVE

To perform a review of SSI risk factors and more specifically, categorize them into patient and surgical factors.

METHODS

A review of published literature on SSI risk factors in adult spine surgery was performed. We included studies that reported risk factors for SSI in adult spinal surgery. Excluded are pediatric patient populations, systematic reviews, and meta-analyses. Overall, we identified 72 cohort studies, 1 controlled-cohort study, 1 matched-cohort study, 1 matched-paired cohort study, 12 case-controlled studies (CCS), 6 case series, and 1 cross-sectional study.

RESULTS

Patient-associated risk factors-diabetes mellitus, obesity (body mass index >35 kg/m²), subcutaneous fat thickness, multiple medical comorbidities, current smoker, and malnutrition were associated with SSI. Surgical associated factors-preoperative radiation/postoperative blood transfusion, combined anterior/posterior approach, surgical invasiveness, or levels of instrumentation were associated with increased SSI. There is mixed evidence of age, duration of surgery, surgical team, intraoperative blood loss, dural tear, and urinary tract infection/urinary catheter in association with SSI.

CONCLUSION

SSIs are associated with many risk factors that can be patient or surgically related. Our review was able to identify important modifiable and nonmodifiable risk factors that can be essential in surgical planning and discussion with patients.

Hospital Volume and Mortality following Diagnostic Bronchoscopy in Lung Cancer Patients: Data from a National Inpatient Database in Japan

BACKGROUND

Recent advances in bronchoscopy utilizing endobronchial ultrasound (EBUS) as well as lung cancer therapy may have driven physicians to perform diagnostic bronchoscopy (DB) for high-risk patients.

OBJECTIVES

The aim of this study was to clarify the relationship between hospital volume (HV) and outcomes of DB.

METHODS

We collected data on inpatients with lung cancer who underwent DB from July 2010 to March 31, 2014. The annual HV of DB was classified as "very low" (≤50 cases/year), "low" (51-100 cases/year), "high" (101-300 cases/year), or "very high" (> 300 cases/year). The primary outcome was all-cause 7-day mortality after DB. Multivariable logistic regression fitted with a generalized estimation equation was performed to evaluate the association between HV and all-cause 7-day mortality after DB, adjusted for patient background factors.

RESULTS

We identified a total of 77,755 eligible patients in 954 hospitals. All-cause 7-day mortality was 0.5%. Compared with the low-volume group, 7-day mortality was significantly lower in the high-volume group (odds ratio [OR] = 0.69, 95% confidence interval [CI]: 0.52-0.92, p = 0.010), and a similar trend was shown in the very-high-volume group (OR = 0.67; 95% CI: 0.43-1.05, p = 0.080). Radial EBUS with the guide sheath method and EBUS-guided transbronchial needle aspiration showed a significantly lower 7-day mortality.

CONCLUSIONS

All-cause 7-day mortality was inversely associated with HV. The risk of DB in patients with lung cancer should be recognized, and the exploitation of EBUS may help reduce mortality after DB.

In-hospital complication rate following microendoscopic versus open lumbar laminectomy: a propensity score-matched analysis

BACKGROUND CONTEXT

The incidence of postoperative complications after microendoscopic laminectomy (MEL) has not been compared with that after open laminectomy in a large study, so it is not clear whether MEL is a safer procedure.

PURPOSE

The objective of this study was to compare postoperative morbidity and mortality following lumbar laminectomy between patients treated with MEL and with open laminectomy.

STUDY DESIGN

This is a retrospective cohort study with propensity score-matched analysis.

PATIENT SAMPLE

Data of patients who underwent elective spinal surgery between July 2010 and March 2013 were extracted from the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan.

OUTCOME MEASURES

Clinical outcomes included length of hospital stay, occurrence of major complications (cardiac events, respiratory complications, pulmonary embolism, stroke, and acute renal failure), surgical site infection (SSI), postoperative delirium, and in-hospital death.

MATERIALS AND METHODS

Propensity score matching was performed to adjust for measured confounding factors, including patient age, sex, Charlson Comorbidity Index, body mass index, smoking status, blood transfusion, duration of anesthesia, number of operated disc levels, and type of hospital and hospital volumes. The clinical outcomes of one-to-one propensity-matched pairs of the MEL and the open laminectomy groups were compared.

RESULTS

Of 23,317 patients identified in the database, 1,536 underwent MEL (6.6%). By one-to-one propensity score matching, 1,536 pairs were selected. The distributions of patient backgrounds were closely balanced between the MEL and the open laminectomy groups. An analysis of 1,536 pairs revealed that there was a significantly lower incidence of major postoperative complications in those who underwent MEL (1.0% vs. 2.8% for open laminectomy, risk difference 1.8%, 95% confidence interval [CI] 0.9%-2.9%), SSI (0.5% vs. 1.6% for open laminectomy, risk difference 1.1%, 95% CI 0.4%-1.9%), and postoperative delirium (1.1% vs. 2.3% for open laminectomy, risk difference1.2%, 95% CI 0.3%-2.1%). The length of hospital stay was significantly shorter in those treated with MEL (12 days vs. 16 days for open laminectomy, p<.001). There was no significant difference in in-hospital mortality between the groups.

CONCLUSIONS

Patients who underwent MEL were significantly less likely to experience major postoperative complications and were less likely to develop SSI and postoperative delirium than those who underwent open laminectomy.

Defining delirium in idiopathic Parkinson's disease: A systematic review

BACKGROUND

Parkinson's disease patients may be at increased risk of delirium and developing adverse outcomes, such as cognitive decline and increased mortality. Delirium is an acute state of confusion that has overlapping symptoms with Parkinson's dementia, making it difficult to identify. This study aimed to determine the diagnostic criteria, prevalence, management strategies and outcomes of delirium in Parkinson's through a systematic review of the literature.

METHODS

Seven databases were used to identify all articles published before February 2017 comprising two key terms: "Parkinson's Disease" and "delirium". Data were extracted from studies meeting predefined inclusion criteria.

RESULTS

Twenty articles were identified. Delirium prevalence in Parkinson's ranged from 0.3 to 60% depending on setting; a diagnosis of Parkinson's was associated with an increased risk of developing delirium. Delirium was identified/diagnosed using seven different criteria. Delirium may be associated with an increased length of hospital stay and worsening motor symptoms. We did not identify any studies examining the management of delirium in Parkinson's.

DISCUSSION

This review highlights the paucity of well-designed, appropriately powered studies investigating delirium in Parkinson's. The results suggest that delirium is a significant issue in people with Parkinson's and that having delirium may be a risk factor for adverse outcomes, particularly in inpatient settings. Further prospective research is needed to accurately determine the prevalence of delirium in Parkinson's, its management strategies and outcomes, and to evaluate diagnostic criteria to differentiate between the overlapping symptoms of Parkinson's and delirium.

Does Parkinson Disease Increase the Risk of Perioperative Complications After Total Hip Arthroplasty? A Nationwide Database Study

BACKGROUND

Parkinson disease (PD) is the second most common neurodegenerative disorder in the United States, affecting over 1 million people. As part of the disease process, PD can cause poor bone quality and other musculoskeletal problems that can affect a patient's quality of life. With advances in treatment, PD patients can be more active and may be candidates for total hip arthroplasty (THA). However, there is a paucity of literature on the outcomes of THA in PD patients. Therefore, the purpose of this study was to evaluate the perioperative outcomes of PD patients who underwent THA. Specifically, we assessed: (1) perioperative surgical and medical complications; (2) lengths of stay (LOSs); and (3) total hospital charges.

METHODS

Using the Nationwide Inpatient Sample, patients who had PD and underwent THA between 2002 and 2013 were identified. With the use of propensity scores, PD patients were matched in a 1:3 ratio to patients without PD by the year of surgery, age, gender, race, Charlson/Deyo score, and insurance type. This yielded a total of 10,519 PD and 31,679 non-PD THA patients. Regression analyses were used to compare the risk of perioperative complications (any, surgical, medical), the percent differences in mean LOS, and the percent differences in total hospital charges.

RESULTS

Compared with the matched cohort, PD patients had a 52% higher risk for any complication (odds ratio [OR] = 1.52; 95% confidence interval [CI], 1.37-1.69), a 30% higher risk for any surgical complication (OR = 1.30; 95% CI: 0.88-1.91), and a 54% higher risk for any medical complication (OR = 1.54; 95% CI, 1.38-1.71). Specifically, PD patients were more likely to have postoperative delirium (OR = 2.61; 95% CI: 1.77-3.85), altered mental status (OR = 3.01; 95% CI: 1.35-6.71), urinary tract infection (OR = 1.34; 95% CI: 1.09-1.76), and blood transfusion (OR = 1.62; 95% CI: 1.44-1.82). Also, PD patients had a mean LOS that was 8.57% longer (P < .0001), and mean total hospital charges that were 3.85% higher (P < .0001).

CONCLUSION

Orthopedic surgeons and neurologists should be involved in the preoperative counseling of PD patients regarding their potential increased risks associated with THA, which could help optimize their preoperative care. Furthermore, the risk of complications and higher costs could potentially lead to the development of different reimbursement methods in this population of patients.

Parkinson's disease and the risk of osteoporotic vertebral compression fracture: a nationwide population-based study

Patients with Parkinson's disease (PD) were at higher risk of osteoporotic vertebral compression fractures (OVCF) compared to controls and had elevated mortality rates. Compared to conservative treatment, surgical treatment for OVCF in PD patients seemed to be associated with better outcomes.

INTRODUCTION

The purpose of this study was to evaluate the risk of OVCF in patients with PD.

METHODS

Data from patients over the age of 60 years who were diagnosed with PD were collected between 2004 and 2013 from the Korean National Health Insurance Database (n = 3370). The comparison group (non-PD) consisted of randomly selected patients (five per patient with PD; n = 16,850) matched to the PD group, who were newly diagnosed annually according to age and sex. Cox proportional hazard regressions were used to examine the relationships between osteoporosis, OVCF, surgery for OVCF, and PD. Household income and residential area of patients were also assessed. Overall survival rates were calculated after adjusting for confounding factors, such as hypertension, diabetes mellitus, and chronic kidney disease.

RESULTS

OVCF was developed in 12.5% of patients in the PD group and in 7.4% of patients in the control group. PD was associated with increased risk of osteoporosis (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.21-1.43; p < 0.001), OVCF (HR 1.66; 95% CI, 1.47-1.87; p < 0.001), and surgery for OVCF (HR 2.69; 95% CI, 1.78-4.08; p < 0.001). Household income was not significantly related with development of osteoporosis, incidence of OVCF, or surgery for OVCF. Residential area was statistically associated with osteoporosis, OVCF, and surgery for OVCF. The mortality rate of the PD group was about 1.7 times higher than that of the non-PD group after adjusting for potential confounders, and the mortality rate of the PD with OVCF group was higher than that of the non-PD group, but not significantly (p = 0.09). The survival rate of the PD group with surgery for OVCF showed a trend toward a more positive prognosis compared with that of the PD group with conservative treatment.

CONCLUSIONS

Patients with PD had significantly increased risk of osteoporosis and OVCF. Surgical treatment for OVCF in PD patients was associated with a better prognosis than conservative treatment.

Total Joint Arthroplasty in Patients With Parkinson's Disease: Survivorship, Outcomes, and Reasons for Failure

BACKGROUND

Gait instability and muscle rigidity are known characteristics of Parkinson's disease (PD), putting PD patients at risk for complications following total joint arthroplasty (TJA). The outcomes of Parkinson's patients undergoing TJA are largely unknown. This study evaluated the outcomes of TJA in this population.

METHODS

A single institution retrospective cohort of 123 TJAs (52 hips, 71 knees) from 2000 to 2016 was reviewed. An electronic chart query was performed using International Classification of Diseases, Ninth revision codes to identify this population. A manual chart review was performed to confirm the diagnosis of PD, survivorship, and reason for failure. A control cohort was matched 2:1 based on age, body mass index, joint, and comorbidities. Outcomes were assessed using revision for any reason as the primary endpoint. Functional outcomes were assessed using Short-Form 12 scores.

RESULTS

At an average follow-up of 5.3 years, 23.6% of patients required revision surgery. The most common reasons for revision for total knee arthroplasty (TKA) were periprosthetic infection and for total hip arthroplasty (THA) were periprosthetic fracture and dislocation. Overall survivorship of TJA at years 2, 5, and 10 respectively were 94.9%, 87.9%, and 72.3%. The survivorship of TKA was 95.2%, 89.8%, and 66.2%. THA implant survivorship was 94.3%, 85.3%, and 78.7%. Functional score improvement was less in PD cohort than the control.

CONCLUSION

Patients with PD are at increased risk for complications, particularly periprosthetic infection following TKA and periprosthetic fracture and dislocation following THA. Despite this increased risk of complications, patients with PD can demonstrate improved functional outcomes but not as high as patients without PD. Patients with PD should be counseled appropriately prior to undergoing TJA.

Association between dementia and discharge status in patients hospitalized with pneumonia

Background

Pneumonia is the most common cause of death in patients with dementia, but the outcomes of patients with dementia hospitalized with pneumonia are poorly understood. We sought to illuminate the association between dementia and in-hospital mortality and discharge status in patients hospitalized with pneumonia.

Methods

We used the Diagnosis Procedure Combination database, a national inpatient database in Japan, to identify retrospectively patients aged ≥60 years admitted to hospital with pneumonia during the study period of May 1, 2010 to March 31, 2014. We recorded their sex, age, body mass index, severity of pneumonia and comorbidities (including dementia). The outcomes were in-hospital mortality and discharge home. Multivariable Cox regression analysis was performed to analyze factors influencing discharge home.

Results

We identified 470,829 patients hospitalized with pneumonia; 45,031 were recorded as having dementia (9.6%). In-hospital mortality was 13.1% and 13.4% in patients with and without dementia, respectively (P = 0.63). The proportions of patients discharged home were 52.9% and 71.3% in patients with and without dementia, respectively (P < 0.001). The adjusted hazard ratio for discharge home for patients with dementia was 0.68 (95% confidence interval, 0.67–0.69; P < 0.001).

Conclusions

In-hospital mortality from pneumonia did not differ significantly between patients with and without dementia; however, those with dementia were less likely to be discharged home.

The Influence of Parkinson Disease on Lumbar Decompression Surgery: A Retrospective Case Control Study

BACKGROUND

Parkinson disease (PD) is a major risk factor during spine surgery, and its frequency is increasing as the population ages. The study aim was to examine the influence of PD specifically on lumbar decompression surgery.

METHODS

A retrospective review was performed of all patients with PD who underwent elective lumbar decompression surgery at 2 university hospital departments between December 2003 and July 2016. For each patient, 2 controls without PD were selected randomly among those who were matched for sex and age and had a similar year of surgery (±3) and comorbidity profile. The main outcomes were complications and reoperation rate.

RESULTS

The mean follow up was 1.2 ± 1.6 years in the PD group (n = 36) and 1.4 ± 2.1 years in the control group (n = 72). The overall complication rate was 47.2% in the PD group and 19.4% in the control group (P < 0.01). The reoperation rate was 27.8% in the PD group and 9.7% in the control group (P = 0.02).

CONCLUSIONS

There is a significantly greater rate of perioperative complications in patients with PD undergoing elective decompression surgery. Although the difference in major complication rates was minimal, minor complications were more frequent in patients with PD.