Implications of Drug Use Disorders on Spine Surgery

A Perioperative Blood Management Algorithm Aimed at Conservation of Platelets in Clinical Practice: The Role of the Anesthesiologist in Decision-Making

Platelet dysfunction and thrombocytopenia are associated with postoperative morbidity not only from modifiable preoperative factors but also from a lack of local patient blood management algorithms. In this regard, platelet transfusions have risen after the COVID-19 pandemic. Simultaneously, there has been a shortage of donors. It is logical, therefore, that each hospital should develop a triage tool, posting their algorithm on walls. Anesthesiologists should assist in planning a strategy to minimize blood transfusions while improving tissue oxygenation. A flowchart posted in each operating theatre may be customized per patient and hospital. Clinicians need reminders to draw a prothrombin time, fibrinogen, complete blood count every hour, and the appropriate threshold to transfuse. In summary, anesthesiologists are often unable to have a discussion with a patient until the preoperative day; thus, the onus falls on our surgical colleagues to reduce risk factors for coagulopathy or to delay surgery until after proper consultants have optimized a patient. The most important problems that an individual patient has ideally should be listed in a column where an anesthesiologist can write a timeline of key steps across a row, corresponding to each problem. If a handoff in the middle of the case is required, this handoff tool is superior to simply checking a box on an electronic medical record. In summary, in the operating suite, an anesthesiologist should emphasize the importance of a multidisciplinary approach. Continuing education, regular stakeholder meetings, and posters can assist in reinforcing algorithms in clinical practice.

Substance Use Disorders Are Independently Associated with Hospital Readmission Among Patients with Brain Tumors

BACKGROUND

Research on the effects of substance use disorders (SUDs) on postoperative outcomes within neurosurgical oncology has been limited. Therefore, the present study sought to quantify the effect of having a SUD on hospital length of stay, postoperative complication incidence, discharge disposition, hospital charges, 90-day readmission rates, and 90-day mortality rates following brain tumor surgery.

METHODS

The present study used data from patients who received surgical resection for brain tumor at a single institution between January 1, 2017, and December 31, 2019. The Mann-Whitney U test was used for bivariate analysis of continuous variables and Fisher exact test was used for bivariate analysis of categorical variables. Multivariate analysis was conducted using logistic regression models.

RESULTS

Our study cohort included a total of 2519 patients, 124 (4.9%) of whom had at least 1 SUD. More specifically, 90 (3.6%) patients had an alcohol use disorder, 27 (1.1%) had a cannabis use disorder, and 12 (0.5%) had an opioid use disorder. On bivariate analysis, 90-day hospital readmission was the only postoperative outcome significantly associated with a SUD (odds ratio 2.21, P = 0.0011). When controlling for patient age, sex, race, marital status, insurance, brain tumor diagnosis, 5-factor modified frailty index score, American Society of Anesthesiologists score, and surgery number, SUDs remained significantly and independently associated with 90-day readmission (odds ratio 1.82, P = 0.013).

CONCLUSIONS

In patients with brain tumor, SUDs significantly and independently predict 90-day hospital readmission after surgery. Targeted management of patients with SUDs before and after surgery can optimize patient outcomes and improve the provision of high-value neurosurgical care.

Elective surgery for acute pain in patients with substance use disorder: lessons learned at a rural neurosurgical center. Patient series

BACKGROUND

The incidence of pain-generating degenerative spinal problems in patients who are currently using or have previously used drugs has increased as substance use disorder (SUD) becomes a chronic, lifelong condition. Health system–level data in recent years indicate a significant increase in patients with coexisting SUD and degenerative disc disease, representing an emerging population. A retrospective electronic medical record review identified seven patients with SUD who underwent elective spine surgery by orthopedic or neurosurgical staff from 2012 to 2021. The authors present two of these illustrative cases and a framework that can be used in the treatment of similar patients.

OBSERVATIONS

Substances used included opioids, benzodiazepines, barbiturates, cocaine, methamphetamines, hallucinogens, lysergic acid diethylamide, phencyclidine, and cannabis. All were abstaining from drug use preoperatively, with four patients in a formal treatment program. Five patients were discharged with an opioid prescription, and two patients deferred opioids. Three experienced a relapse of substance use within 1 year. All patients presented for follow-up, although two required additional contact for follow-up compliance.

LESSONS

Perioperative protocols focusing on patient-led care plans, pain control, communication with medication for opioid use disorder providers, family and social support, and specific indicators of possible poor results can contribute to better outcomes for care challenges associated with these diagnoses.

Risk Factors for Aseptic Revision of Operatively Treated Ankle Fractures

BACKGROUND

Early revision rates within 12 months after ankle fracture open reduction internal fixation (AF-ORIF) are fairly low; however, they remain relevant given the volume of ankle fractures occurring annually. Understanding these rates is complex because reoperation due to technical or mechanical complications is typically reported alongside soft tissue-related problems such as symptomatic hardware, wound dehiscence, or infection. There are limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft tissue complications. Understanding variables that predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care.

METHODS

A retrospective cohort study was performed at 2 large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002 to 2019 were used to identify patients who underwent aseptic revision of AF-ORIF within 12 months (n = 33). A control group (n = 100) was selected by identifying sequential patients who underwent AF-ORIF not requiring revision within 12 months. Multiple factors were recorded for all patients in both cohorts. Each fracture was also evaluated according to the Ankle Reduction Classification System (ARCS) of Chien et al,⁸ which categorizes biplanar talar displacement in relation to a central tibial plumb line into 1 of 3 grades: A (0-2 mm), B (3-10 mm), and C (>10 mm). Adapted from its original purpose of grading reduction quality, we applied ARCS to pre-reduction radiographs to assess initial fracture displacement. All variables collected were compared in univariate analysis. Variables that achieved significance in univariate comparisons were included as candidates for multivariable analysis.

RESULTS

Final multivariable logistic regression modeling demonstrated the following factors to independently predict the need for aseptic revision surgery: documented falls in the early postoperative period (aOR, 298; 95% CI, 15.4, 5759; P < .001), movement-altering disorders (aOR, 81.7; 95% CI, 4.12, 1620; P = .004), a nonanatomic mortise (medial clear space [MCS] > superior clear space [SCS]) on immediate postoperative imaging (aOR, 38.4; 95% CI, 5.53, 267; P < .001), initial coronal plane tibiotalar displacement >10 mm and sagittal plane tibiotalar dislocation (ARCS-C) (aOR vs ARCS-A, 25.8; 95% CI, 2.81, 237; P = .004), substance abuse (aOR, 15.7; 95% CI, 2.66, 92.8; P = .002), and polytrauma (aOR, 12.3; 95% CI, 2.02, 74.8; P = .006).

CONCLUSION

In this investigation we found a notable increase in risk for revision surgery after AF-ORIF for patients who had one of the following: (1) falls in the early postoperative period, (2) movement-altering disorders, (3) a nonanatomic mortise (MCS > SCS) on immediate postoperative imaging, (4) more severe initial fracture displacement, (5) substance abuse, or (6) polytrauma. Identifying these factors may allow surgeons to better understand risk and counsel patients, and may serve as future targets for intervention aimed at improving patient safety and outcomes after ankle fracture ORIF.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Review of Neurologic Comorbidities in Hospitalized Patients With Opioid Abuse

Purpose of Review

To determine the prevalence and burden of neurologic comorbidities in hospitalized patients with opioid abuse.

Recent Findings

From 1 year of hospital discharges, 2,182 patients with opioid abuse were identified (prevalence 6.3%), with abuse greater among younger patients (p < 0.0001), women (p < 0.0001), Whites (p < 0.0001), and urban population (p = 0.028). Matching for age, sex, race, and urban-rural residence, 347 patients were reviewed, and 179 (52%) had a neurologic comorbidity. The comorbidities frequently overlapped and included encephalopathy (130), neuromuscular disorders (42), seizures (23), spine disorders (23), strokes (20), CNS infections (3), and movement disorders (2). Abuse patients with neurologic comorbidities experienced substantially greater number of hospital and intensive care unit days and mortality, independent of overdose.

Summary

Neurologic comorbidities are a frequent and heretofore underappreciated contributor to the disease burden of hospitalized patients with opioid abuse. The importance of neurologic comorbidities should be included in the public health discussions surrounding the opioid epidemic.

Mind the Difference: Characterizing the Impact of Behavioral Health Disorders on Facial Trauma

BACKGROUND

Patients with psychiatric diagnoses are at greater risk for traumatic injury than the general population. Current literature fails to characterize how premorbid behavioral health disorders (BHDs) complicate craniofacial trauma. This study aimed to describe the characteristics and outcomes of patients with premorbid BHD sustaining facial fractures.

METHODS

All adults in the 2013-2016 Trauma Quality Improvement Program datasets with facial fractures were identified. Demographics, injury characteristics, fracture patterns, and in-hospital outcomes were compared in patients with and without premorbid BHDs. BHDs included major psychiatric illnesses, alcohol or drug use disorders, attention deficit hyperactivity disorder, or dementia.

RESULTS

Twenty-five percent of the 240,104 subjects with facial fractures had at least one premorbid BHD. Assault (29.9% versus 23.9%, P< 0.001), self-inflicted injury (2.9% versus 1.2%, P< 0.001), and multiple facial fractures (40.2% versus 38.7%, P< 0.001) were more common among the BHD group. The BHD group displayed significantly higher rates of nearly all in-hospital complications, including pneumonia (4.3% versus 3.3%, P< 0.001), substance withdrawal (3.9% versus 0.3%, P< 0.001), unplanned intubation (1.5% versus 0.9%, P< 0.001) and unplanned transfer to the intensive care unit (ICU, 1.3% versus 0.8%, P< 0.001). BHD was strongly predictive of pneumonia, unplanned intubation, and unplanned ICU admission in multivariate analyses.

CONCLUSIONS

Patients with BHD represent a subset of facial trauma characterized by different mechanisms and patterns of injury and premorbid health status. BHDs are associated with higher in-hospital complication rates and resource utilization. Understanding the relationship between craniofacial trauma and premorbid BHD creates opportunities to improve morbidity and resource utilization in this group.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

None.

Evaluating new paralysis, mortality, and readmission among subgroups of patients with spinal epidural abscess: A latent class analysis

Background

Spinal epidural abscess (SEA) is increasing in incidence; this not-to-miss diagnosis can cause significant morbidity and mortality, particularly if diagnoses are delayed. While some risk factors for SEA and subsequent mortality have been identified, the SEA patient population is clinically heterogeneous and sub-populations have not yet been characterized in the literature. The primary objective of this project was to identify characteristics of subgroups of patients with SEA. The secondary objective was to identify associations between subgroups and three clinical outcomes: new onset paralysis, in-hospital mortality, and 180-day readmission.

Methods

Demographics and comorbid diagnoses were collected for patients diagnosed with SEA at an academic health center between 2015 and 2019. Latent class analysis was used to identify clinical subgroups. Chi-squared tests were used to compare identified subgroups with clinical outcomes.

Results

We identified two subgroups of patients in our analysis. Group 1 had a high rate of medical comorbidities causing immunosuppression, requiring vascular access, or both. Group 2 was characterized by a high proportion of people with substance use disorders. Patients in Group 2 were more likely to be readmitted within 6 months than patients in Group 1 (p = 0.03). There was no difference between groups in new paralysis or mortality.

Discussion

While prior studies have examined the SEA patient population as a whole, our research indicates that there are at least two distinct subgroups of patients with SEA. Patients who are younger, with substance use disorder diagnoses, may have longer hospital courses and are at higher risk of readmission within six months. Future research should explore how to best support patients in both groups, and additional implications for subgroup classification on health outcomes, including engagement in care.

Stigmatizing Diagnoses in Neurosurgery: A Narrative Review

Stigma is defined as a social process resulting in labeling, stereotyping, and separation that cause status loss, disapproval, rejection, exclusion, and discrimination of the labeled individuals. Stigma can be experienced by individuals or groups, can be real or perceived, and can include a wide array of characteristics (e.g., race/ethnicity, gender, and health conditions). It is well documented that stigma for health conditions is a barrier to treatment and leads to worse outcomes for vulnerable people. The purpose of this study is to examine the increasingly mature field of stigma theory and research, and how this relates to the practice of neurosurgery. This review provides an overview of stigma and its application in a neurosurgical setting, including diagnoses treated by neurosurgeons as well as diagnoses with impact on neurosurgical outcomes. Examples of stigmatizing diagnoses of relevance to neurosurgical practice include epilepsy, pain, smoking, obesity, and substance use disorder. This information is useful for the practicing neurosurgeon to understand the origins and higher-order effects of societal perceptions surrounding certain diagnoses, and the subsequent effects on health that those perceptions can create on a systemic level.