Comparison of surgical invasiveness and morbidity of adult spinal deformity surgery to other major operations

Causes of Intraoperative Neuromonitoring Events in Adult Spine Deformity Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Intraoperative neuromonitoring (IOMN) has become a standard practice in the detection and prevention of nerve damage and postoperative deficit. While multicenter studies have addressed this inquiry, there have been no systematic reviews to date. This systematic review identifies the leading causes of IONM alerts during adult spinal deformity (ASD) surgeries.

METHODS

Following PRISMA guidelines, a literature search was performed in PubMed and Embase. IONM alert causes were grouped by equivalent terms used across different studies and binned into larger categories, including surgical maneuver, Changes in blood pressure/temperature, Oxygenation, Anesthesia, Patient position, and Unknown.

RESULTS

Inclusion criteria were studies on adult patients receiving ASD correction surgery using IONM with documented alert causes. 1544 references were included in abstract review, 128 in full text review, and 16 studies qualified for data extraction. From those studies, there was a total of 3945 adult patients with 299 IONM alerts. Surgical maneuver led the alert causes (258 alerts/86.3%), with signal loss most commonly occurring at correction or osteotomy (101/33.8% and 95/31.8% respectively). Pedicle screw placement caused 35 alerts (11.7%). Changes in temperature and blood pressure were the third largest category (34/11.4%).

CONCLUSIONS

The most frequent causes of IONM alerts in ASD surgery were surgical maneuvers such as correction, osteotomy, and pedicle screw placement. This information provides spine surgeons with a quantitative perspective on the causes of IONM changes and show that most occur at predictable times during ASD surgery.

AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus.

SUMMARY OF BACKGROUND DATA

Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition.

METHODS

Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables.

RESULTS

Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P< 0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P< 0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus ( P= 0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus.

CONCLUSIONS

In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management.

LEVEL OF EVIDENCE

Level-III.

Impact of Controlled Versus Uncontrolled mFI-5 Frailty on Perioperative Complications After Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

We substratified the mFI-5 frailty index to reflect controlled and uncontrolled conditions and assess their relationship to perioperative complications.

SUMMARY OF BACKGROUND DATA

Risk assessment before adult spinal deformity (ASD) surgery is critical because the surgery is highly invasive with a high complication rate. Although frailty is associated with risk of surgical complications, current frailty measures do not differentiate between controlled and uncontrolled conditions.

METHODS

Frailty was calculated using the mFI-5 index for 170 ASD patients with fusion of ≥5 levels. Uncontrolled frailty was defined as blood pressure >140/90 mm Hg, HbA1C >7% or postprandial glucose >180 mg/dL, or recent chronic obstructive pulmonary disease (COPD) exacerbation, while on medication. Patients were divided into nonfrailty, controlled frailty, and uncontrolled frailty cohorts. The primary outcome measure was perioperative major and wound complications. Bivariate analysis was performed. Multivariable analysis assessed the relationship between frailty and perioperative complications.

RESULTS

The cohorts included 97 nonfrail, 54 controlled frail, and 19 uncontrolled frail patients. Compared with nonfrail patients, patients with uncontrolled frailty were more likely to have age older than 60 years (84% vs. 24%), hyperlipidemia (42% vs. 20%), and Oswestry Disability Index (ODI) score >42 (84% vs. 52%) ( P <0.05 for all). Controlled frailty was associated with those older than 60 years (41% vs. 24%) and hyperlipidemia (52% vs. 20%) ( P <0.05 for all). On multivariable regression analysis controlling for hyperlipidemia, functional independence, motor weakness, ODI>42, and age older than 60 years, patients with uncontrolled frailty had greater odds of major complications (OR 4.24, P =0.03) and wound complications (OR 9.47, P =0.046) compared with nonfrail patients. Controlled frailty was not associated with increased risk of perioperative complications ( P >0.05 for all).

CONCLUSIONS

Although patients with uncontrolled frailty had higher risk of perioperative complications compared with nonfrail patients, patients with controlled frailty did not, suggesting the importance of controlling modifiable risk factors before surgery.

LEVEL OF EVIDENCE

3.

Palliative Care Consultation Utilization Among Patient Undergoing Surgery for Metastatic Spinal Tumors

OBJECTIVE

In patients undergoing surgery for spinal metastasis, we sought to: (1) describe patterns of palliative care consultation, (2) evaluate the factors that trigger palliative care consultation, and (3) determine the association of palliative care consultation on longer-term outcomes.

METHODS

A single-center, retrospective, case-control study was conducted for patients undergoing spinal metastasis surgery from February 2010 to January 2021. The primary outcome was receiving a palliative care consultation, and the timing of consultation was divided into same hospital stay consultation, preoperative versus postoperative consultation, and early (

RESULTS

Of 363 patients undergoing surgery for spinal metastasis, 62 (17.0%) patients received palliative care consultation during the same hospitalization, 11 (17.7%) were preoperative, and 51 (82.2%) were postoperative. Among same-stay consultations, 32 (51.6%) were early and 30 (48.4%) were late. Palliative care consultation recipients had worse preoperative Karnofsky Performance Scale (KPS) score (P < 0.001), were more likely to have other organ metastases (P = 0.005) or cord compression (P = 0.026), had longer hospitalization (P < 0.001), and were less likely to be discharged home (P < 0.001). Patients presenting with mechanical pain were more likely to receive preoperative consults compared with postoperative (P = 0.029), and earlier compared with later consultations (P = 0.046). Regarding long-term outcomes, patients with same-stay palliative care consultation had significantly shorter overall survival (log-rank; P < 0.001), worse KPS postoperatively (P = 0.017), and worse KPS and Modified McCormick Scale at the last follow-up (P < 0.001).

CONCLUSIONS

Only 1 in 6 patients received palliative care consultation. Patients receiving same-stay palliative care consultation had more advanced local and systemic disease burden. Increased utilization of palliative care consultation in patients with spine metastasis is needed.

Collapse

Key Words

• Overall survival
• Palliative care
• Spinal metastasis
• Spinal tumors

Collapse

MESH Headings

• Humans
• Palliative Care
• Spinal Neoplasms/secondary
• Retrospective Studies
• Case-Control Studies
• Spinal Cord Neoplasms
• Central Nervous System Neoplasms
• Referral and Consultation

Collapse

Grants Collapse

Affiliation(s)

Jeffrey W Chen Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Hani Chanbour Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Gabriel A Bendfeldt Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Lakshmi Suryateja Gangavarapu Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Mohana B Karlekar Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Amir M Abtahi Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Byron F Stephens Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Scott L Zuckerman Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Silky Chotai Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Collapse

Mid- and Long-Term Comparison Analysis of Two Approaches for the Treatment of Level III or Higher Lenke-Silva Adult Degenerative Scoliosis: Radical or Limited Surgery?

Objective

As the population in general is living longer, less invasive adult degenerative scoliosis (ADS) surgery that balances risks and benefits requires long‐term clinical outcomes to determine its strengths and weaknesses. We design a retrospective study to compare the postoperative mid‐ and long‐term outcomes in terms of efficacy, surgical complications, and reoperation rate of patients with ADS treated with two different surgical approaches (long‐segment complete reconstruction or short‐segment limited intervention).

Methods

In this retrospective study, 78 patients with ADS (Lenke–Silva levels III or higher), who accepted surgical treatment at our hospital between June 2012 and June 2019 were included. These patients were assigned to the long‐segment radical group (complete decompression with deformity correction involves ≥3 segments) and the short‐segment limited group (symptomatic segment decompression involves <3 segments). In addition, general information such as age, gender, fixed segment number, efficacy, radiographic parameters, and reoperation rate of patients in the two groups were compared and analyzed.

Results

There were no significant differences between the two groups with regard to gender, follow‐up time, long‐term surgical complications and reoperation rate (P > 0.05). The mean age of patients in the long‐segment strategy group was 57.1 ± 7.9 years, with a mean number of fixed segments of 7.9 ± 2.4. The mean age of patients in the short‐segment strategy group was 60.8 ± 8.4 years, with a mean number of fixed segments of 1.4 ± 0.5. At the final follow‐up visit, the long‐segment radical group showed better results than the short‐segment limited group with regard to coronal Cobb angle, lumbar lordosis angle and sagittal balance (P < 0.05). The long‐segment strategy group had a higher implant‐related complication rate (P = 0.010); the adjacent segment‐related complication in the two groups showed no significant difference (P = 0.068).

Conclusion

Considering the risk, rehabilitation pathway and costs of long‐segment radical surgery, short‐segment limited intervention is a better strategy for patients who cannot tolerate the long‐segment surgery, improving symptoms and maintaining efficacy in the mid‐ and long‐term, and not increasing the reoperation rate.

The Clinical Impact of Failing to Achieve Ideal Proportional Realignment in Adult Spinal Deformity Patients

SUMMARY OF BACKGROUND DATA

The impact of not achieving ideal realignment in the global alignment and proportion (GAP) score in adult spinal deformity (ASD) correction on clinical outcomes is understudied at present.

OBJECTIVE

To identify the clinical impact of failing to achieve GAP proportionality in ASD surgery.

STUDY DESIGN

Retrospective cohort.

METHODS

Operative ASD patients with fusion to S1/pelvis and with pre-(BL) and 2-year (2Y) data were included. Patients were assessed for matching their 6-week (6W) age-adjusted alignment goals. 1 Patients were stratified by age-adjusted match at 6W postoperatively (Matched) and 6W GAP proportionality (proportioned: GAP-P; moderately disproportioned: GAP-MD; severely disproportioned: GAP-SD). Groups were assessed for differences in demographics, surgical factors, radiographic parameters, and complications occurring by 2Y. Multivariable logistic regression was used to assess independent effects of not achieving GAP proportionality on postoperative outcomes for Matched and Unmatched patients.

RESULTS

Included: One hundred twenty three ASD patients. At baseline, 39.8% were GAP-SD, and 12.2% GAP-SD at 6W. Of 123 patients, 51.2% (n =63) had more than or equal to one match at 6W. GAP-SD rates did not differ by being Matched or Unmatched ( P = 0.945). GAP-SD/Unmatched patients had higher rates of reoperation, implant failure, and PJF by 2Y postop (all P <0.05). Regressions controlling for age at BL, levels fused, and CCI, revealed 6W GAP-SD/Unmatched patients had higher odds of reoperation (OR: 54 [3.2-899.9]; P =0.005), implant failure (OR: 6.9 [1.1-46.1]; P =0.045), and PJF (OR: 30.1 [1.4-662.6]; P =0.031). Compared to GAP-P or GAP-MD patients, GAP-SD/ Matched patients did not have higher rates of reoperation, implant failure, or junctional failure (all P >0.05). The regression results for both Matched and Unmatched cohorts were consistent when proportionality was substituted by the continuous GAP score.

CONCLUSION

In ASD patients who meet age-adjusted realignment goals, GAP proportionality does not significantly alter complication rates. However, GAP proportionality remains an important consideration in patients with sub-optimal age- adjusted alignment. In these cases, severe global disproportion is associated with higher rates of reoperation, implant failure, rod fracture, and junctional failure.