Validating a therapy-oriented complication grading system in lumbar spine surgery: a prospective population-based study

Lumbar endoscopic spine surgery for persistent genital arousal disorder/genitopelvic dysesthesia resulting from lumbosacral annular tear-induced sacral radiculopathy

BACKGROUND

Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by distressing, abnormal genitopelvic sensations, especially unwanted arousal. In a subgroup of patients with PGAD/GPD, cauda equina Tarlov cyst-induced sacral radiculopathy has been reported to trigger the disorder. In our evaluation of lumbosacral magnetic resonance images in patients with PGAD/GPD and suspected sacral radiculopathy, some had no Tarlov cysts but showed lumbosacral disc annular tear pathology.

AIM

The aims were 2-fold: (1) to utilize a novel multidisciplinary step-care management algorithm designed to identify a subgroup of patients with PGAD/GPD and lumbosacral annular tear-induced sacral radiculopathy who could benefit from lumbar endoscopic spine surgery (LESS) and (2) to evaluate long-term safety and efficacy of LESS.

METHODS

Clinical data were collected on patients with PGAD/GPD who underwent LESS between 2016 and 2020 with at least 1-year follow-up. LESS was indicated because all had lumbosacral annular tear-induced sacral radiculopathy confirmed by our multidisciplinary management algorithm that included the following: step A, a detailed psychosocial and medical history; step B, noninvasive assessments for sacral radiculopathy; step C, targeted diagnostic transforaminal epidural spinal injections resulting in a temporary, clinically significant reduction of PGAD/GPD symptoms; and step D, surgical intervention with LESS and postoperative follow-up.

OUTCOMES

Treatment outcome was based on the validated Patient Global Impression of Improvement, measured at postoperative intervals.

RESULTS

Our cohort included 15 cisgendered women and 5 cisgendered men (mean ± SD age, 40.3 ± 16.8 years) with PGAD/GPD who fulfilled the criteria of lumbosacral annular tear-induced sacral radiculopathy based on our multidisciplinary management algorithm. Patients were followed for an average of 20 months (range, 12-37) post-LESS. Lumbosacral annular tear pathology was identified at multiple levels, the most common being L4-L5 and L5-S1. Twenty-two LESS procedures were performed in 20 patients. Overall, 80% (16/20) reported improvement on the Patient Global Impression of Improvement; 65% (13/20) reported improvement as much better or very much better. All patients were discharged the same day. There were no surgical complications.

CLINICAL IMPLICATIONS

Among the many recognized triggers for PGAD/GPD, this subgroup exhibited lumbosacral annular tear-induced sacral radiculopathy and experienced long-term alleviation of symptoms by LESS.

STRENGTHS AND LIMITATIONS

Strengths include long-term post-surgical follow-up and demonstration that LESS effectively treats patients with PGAD/GPD who have lumbosacral annular tear-induced sacral radiculopathy, as established by a multidisciplinary step-care management algorithm. Limitations include the small study cohort and the unavailability of a clinical measure specific for PGAD/GPD.

CONCLUSION

LESS is safe and effective in treating patients with PGAD/GPD who are diagnosed with lumbosacral annular tear-induced sacral radiculopathy.

Predictors of Complications and Unfavorable Outcomes of Minimally Invasive Surgery Treatment in Elderly Patients With Degenerative Lumbar Spine Pathologies (Case Series)

Introduction

The use of minimally invasive surgery (MIS) results in fewer adverse and more improved outcomes. However, the literature data describing the factors increasing the number of complications, reoperation frequency and unscheduled re-hospitalizations in older patients after MIS are contradictory. In this study, a large number of patients was investigated for the complications of minimally invasive surgical treatment of degenerative disease of the lumbar spine in older patients. The objective of the study was to determine the predictors of unfavorable outcomes in such patients.

Materials and Methods

1,013 patients underwent MIS (decompression alone, TLIF, LLIF, ALIF) in 2013-2017. All operations were performed with the participation of the authors (neurosurgeons). The patient's average age was 66. The following data were collected: BMI; CCI; presence of postoperative complications according to the Dindo-Clavien classification; unplanned readmission at 90 days; hospital length of stay (LOS); surgical complexity (low, intermediate, and high); surgical time; and risk factors. The cumulative reoperation rate was determined at 5-years follow-up.

Results

A total of 256 patients suffered a complication (25.2%), 226 classified as mild (grade I, II, IIIA), and 30 - as severe (IIIB, IVA). Such factors as the surgical complexity, BMI > 30, surgical time, number of operated levels were associated with a significant risk of developing a complication. For patients with and without complications, LOS was 9.3 and 6.3 days, respectively (p < 0.0001), the unplanned readmission rate was 1.3%. 104 patients underwent 133 revision operations. The 5-year cumulative reoperation rate was 15.2%, and the reoperation index was 12.1%. The CCI had no statistically significant effect on the complication incidence after MIS. A higher risk of complications was found in patients who underwent intermediate-complexity surgery (MIS TLIF) compared with uncompounded (decompression alone) and more complex (MIS LLIF, MIS ALIF) surgical procedures (p < 0.001 and p = 0.001, respectively).

Conclusion

A register of postoperative complications is an important tool for health quality assessment and choosing the best surgical option that helps to establish measures to reduce such complications. Using MIS for the treatment of elderly patients reduces the number of severe complications.

Neurosurgery outcomes and complications in a monocentric 7-year patient registry

Introduction

Capturing adverse events reliably is paramount for clinical practice and research alike. In the era of “big data”, prospective registries form the basis of clinical research and quality improvement.

Research question

To present results of long-term implementation of a prospective patient registry, and evaluate the validity of the Clavien-Dindo grade (CDG) to classify complications in neurosurgery.

Materials and methods

A prospective registry for cranial and spinal neurosurgical procedures was implemented in 2013. The CDG – a complication grading focused on need for unplanned therapeutic intervention – was used to grade complications. We assess construct validity of the CDG.

Results

Data acquisition integrated into our hospital workflow permitted to include all eligible patients into the registry. We have registered 8226 patients that were treated in 11994 surgeries and 32494 consultations up until December 2020. Similarly, we have captured 1245 complications on 6308 patient discharge forms (20%) since full operational status of the registry. The majority of complications (819/6308 ​= ​13%) were treated without invasive treatment (CDG 1 or CDG 2). At discharge, there was a clear correlation of CDG and the Karnofsky Performance Status (KPS, rho ​= ​-0.29, slope -7 KPS percentage points per increment of CDG) and the length of stay (rho ​= ​0.43, slope 3.2 days per increment of CDG).

Discussion and conclusion

Patient registries with high completeness and objective capturing of complications are central to the process of quality improvement. The CDG demonstrates construct validity as a measure of complication classification in a neurosurgical patient population.

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A prospective registry for cranial and spinal neurosurgical procedures was implemented in 2013.

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We have registered 8226 patients that were treated in 11994 surgeries and 32494 consultations up until December 2020.

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There was a clear correlation of CDG with the Karnofsky Performance Status and with length of hospital stay.

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The Clavien-Dindo grading (CDG) demonstrates construct validity as a measure of complication severity in a neurosurgical patient population.

Validation of the Clavien-Dindo grading system of complications for microsurgical treatment of unruptured intracranial aneurysms

OBJECTIVE

Microsurgery plays an essential role in managing unruptured intracranial aneurysms (UIAs). The Clavien-Dindo classification is a therapy-oriented grading system that rates any deviation from the normal postoperative course in five grades. In this study, the authors aimed to test the applicability of the Clavien-Dindo grade (CDG) in patients who underwent microsurgical treatment of UIAs.

METHODS

The records of patients who underwent microsurgery for UIAs (January 2013-November 2018) were retrieved from a prospective database. Complications at discharge and at short-term follow-up (3 months) were rated according to the Clavien-Dindo system. Patient outcomes were graded using the modified Rankin Scale (mRS) and the National Institutes of Health Stroke Scale (NIHSS). A descriptive statistic was used for data analysis.

RESULTS

Overall, 156 patients underwent 157 surgeries for 201 UIAs (size range 4-42 mm). Thirty-nine patients (25%) had complex UIAs. An adverse event (CDG ≥ I) occurred in 21 patients (13.5%) by the time of discharge. Among these, 10 patients (6.4%) presented with a new neurological deficit. Significant correlations existed between a CDG ≥ I and an increase in mRS and NIHSS scores (p < 0.001). Patients treated for complex aneurysms had a significantly higher risk of developing new neurological deficits (20.5% vs 1.7%, p = 0.007). At the 3-month follow-up, a CDG ≥ I was registered in 16 patients (10.3%); none presented with a new neurological deficit. A CDG ≥ I was associated with a longer hospital length of stay (LOS) (no complication vs CDG ≥ I, 6.2 ± 3.5 days vs 9.3 ± 7.7 days, p = 0.02).

CONCLUSIONS

The CDG was applicable to patients who received microsurgery of UIAs. A significant correlation existed between CDG and outcome scales, as well as LOS. The aneurysm complexity was significantly associated with a higher risk for new neurological deficit.

Adverse Events in Neurosurgery: The Novel Therapy-Disability-Neurology Grade

BACKGROUND

The most widely used classifications of adverse events (AEs) in neurosurgery define their severity according to the therapy used to treat them. This concept has substantial shortcomings because it does not reflect the severity of AEs that are not treated, such as new neurological deficits.

OBJECTIVE

To present a novel multidimensional and patient-centered classification of the severity of AE in neurosurgery and evaluate its applicability.

METHODS

The Therapy-Disability-Neurology (TDN) grading system classifies AEs depending on the associated therapy, disability, and neurological deficits. We conducted a 2-center retrospective observational study on 6071 interventions covering the whole neurosurgical spectrum with data prospectively recorded between 2013 and 2019 at 2 institutions from 2 countries.

RESULTS

Using the first patient cohort (4680 interventions), a positive correlation was found between severity of AE and LOS as well as treatment cost. Each grade was associated with a greater deterioration of the Karnofsky Performance Status Scale (KPS) at discharge and at follow-up. When using the same methods on the external validation cohort (1391 interventions), correlations between the grades of AE, LOS, and KPS at discharge were even more pronounced.

CONCLUSION

Our results suggest that the TDN grade is consistent with clinical and economic repercussions of AE and thus reflects AE severity. It is easily interpreted and enables comparison between different medical centers. The standardized report of the severity of AE in the scientific literature could constitute an important step forward toward a more critical, patient-centered, and evidence-based decision-making in neurosurgery.

Reporting morbidity associated with pediatric brain tumor surgery: are the available scoring systems sufficient?

OBJECTIVE

Complications in pediatric neurooncology surgery are seldom and inconsistently reported. This study quantifies surgical morbidity after pediatric brain tumor surgery from the last decade in a single center, using existing morbidity and outcome measures.

METHODS

The authors identified all pediatric patients undergoing surgery for an intracranial tumor in a single tertiary pediatric neurosurgery center between January 2008 and December 2018. Complications between postoperative days 0 and 30 that had been recorded prospectively were graded using appropriate existing morbidity scales, i.e., the Clavien-Dindo (CD), Landriel, and Drake scales. The result of surgery with respect to the predetermined surgical aim was also recorded.

RESULTS

There were 477 cases (364 craniotomies and 113 biopsies) performed on 335 patients (188 males, median age 9 years). The overall 30-day mortality rate was 1.26% (n = 6), and no deaths were a direct result of surgical complication. Morbidity on the CD scale was 0 in 55.14%, 1 in 10.69%, 2 in 18.66%, 3A in 1.47%, 3B in 11.74%, and 4 in 1.05% of cases. Morbidity using the Drake classification was observed in 139 cases (29.14%). Neurological deficit that remained at 30 days was noted in 8.39%; 78% of the returns to the operative theater were for CSF diversion.

CONCLUSIONS

To the authors' knowledge, this is the largest series presenting outcomes and morbidity from pediatric brain tumor surgery. The mortality rate and morbidity on the Drake classification were comparable to those of published series. An improved tool to quantify morbidity from pediatric neurooncology surgery is necessary.

Machine Learning Algorithm Identifies Patients at High Risk for Early Complications After Intracranial Tumor Surgery: Registry-Based Cohort Study

INTRODUCTION

Reliable preoperative identification of patients at high risk for early postoperative complications occurring within 24 h (EPC) of intracranial tumor surgery can improve patient safety and postoperative management. Statistical analysis using machine learning algorithms may generate models that predict EPC better than conventional statistical methods.

OBJECTIVE

To train such a model and to assess its predictive ability.

METHODS

This cohort study included patients from an ongoing prospective patient registry at a single tertiary care center with an intracranial tumor that underwent elective neurosurgery between June 2015 and May 2017. EPC were categorized based on the Clavien-Dindo classification score. Conventional statistical methods and different machine learning algorithms were used to predict EPC using preoperatively available patient, clinical, and surgery-related variables. The performance of each model was derived from examining classification performance metrics on an out-of-sample test dataset.

RESULTS

EPC occurred in 174 (26%) of 668 patients included in the analysis. Gradient boosting machine learning algorithms provided the model best predicting the probability of an EPC. The model scored an accuracy of 0.70 (confidence interval [CI] 0.59-0.79) with an area under the curve (AUC) of 0.73 and a sensitivity and specificity of 0.80 (CI 0.58-0.91) and 0.67 (CI 0.53-0.77) on the test set. The conventional statistical model showed inferior predictive power (test set: accuracy: 0.59 (CI 0.47-0.71); AUC: 0.64; sensitivity: 0.76 (CI 0.64-0.85); specificity: 0.53 (CI 0.41-0.64)).

CONCLUSION

Using gradient boosting machine learning algorithms, it was possible to create a prediction model superior to conventional statistical methods. While conventional statistical methods favor patients' characteristics, we found the pathology and surgery-related (histology, anatomical localization, surgical access) variables to be better predictors of EPC.

Analysis of Postoperative Complications in Spinal Surgery, Hospital Length of Stay, and Unplanned Readmission: Application of Dindo-Clavien Classification to Spine Surgery

STUDY DESIGN

Retrospective study. Level of evidence III.

OBJECTIVE

Postoperative complications in spine surgery are associated with increased morbidity, hospital length of stay, and health care costs. Registry of complications in orthopedics and the spine surgery is heterogeneous.

METHODS

Between July 2016 and June 2017, 274 spinal surgeries were performed, the presence of postoperative complications was analyzed at 90 days (according to the classification of Dindo-Clavien, grades I-V), hospital length of stay, surgical complexity (low, medium, and high), unplanned readmission, and risk factors were evaluated.

RESULTS

A total of 79 patients suffered a complication (28.8%), of them 21 (26.7%) were grade I, 24 (30.3%) were grade II, 4 (5.7%) were grade IIIA, and 29 (37.3%) were grade IIIB. There were no IV and V grade cases. The most frequent complication was excessive pain followed by deep wound infection and anemia. Surgical complexity and surgical time were significantly associated with the risk of developing a complication. The average number of hospital length of stay in patients without and with complications were 2.7 and 10.6, respectively, and the unplanned readmission rate was 11%.

CONCLUSIONS

Registry of postoperative complications allows the correct standardization and risk factors required to establish measures to decrease them, the application of Dindo-Clavien classification was useful for the purpose of our study.

Incidence, depth, and severity of surgical site infections after neurosurgical interventions

BACKGROUND

Today, there are only few reports on the incidence of surgical site infections (SSIs) in neurosurgery. The objective of this work was to determine the rate of SSI at a tertiary neurosurgical department for benchmarking purpose.

METHODS

Data of consecutive patients undergoing neurosurgical treatment between January 2013 and December 2016 were prospectively entered into a registry. SSIs were diagnosed according to the 2017 Centers for Disease Control and Prevention criteria, with severity graded according to the Clavien-Dindo grade (CDG). We analyzed type and length of surgery (LOS), time to SSI, responsible microorganisms, and its association with the functional status (Karnofsky Performance Status = KPS).

RESULTS

Of n = 5463 procedures, a SSI occurred in n = 106 (1.94%). The highest rates of SSI occurred after vascular (3.4%) and cerebrospinal fluid (CSF) diversion procedures (3%), as well as after procedures performed to treat a previous complication (2.9%). There was no difference in LOS across procedures with and without SSI. The median time between the index procedure and SSI was 15.5 days. SSIs were most frequently diagnosed after hospital discharge (55%). The most common microorganisms were coagulase-negative staphylococci, Staphylococcus aureus, and Escherichia coli. In 62.3% of cases, SSI required invasive treatment (surgical revision). Patients with SSI in the in- and out-patient setting (SSI occurring after hospital discharge) presented both with a median KPS of 80.

CONCLUSIONS

The current report provides an overview on SSI in a contemporary, unselected, large series of patients undergoing modern neurosurgical care for benchmarking purposes. The overall rate of SSI was about 2%, but subpopulations with higher risks were identified where additional measures could be taken to prevent SSI and monitor patients at risk more closely for SSI.