Complications and mortality in cervical spine surgery: racial differences

Predictors of Nonhome Discharge After Cervical Disc Replacement

STUDY DESIGN

Retrospective review of a national database.

OBJECTIVE

The aim of this study was to identify the factors that increase the risk of nonhome discharge after CDR.

SUMMARY OF BACKGROUND DATA

As spine surgeons continue to balance increasing surgical volume, identifying variables associated with patient discharge destination can help expedite postoperative placement and reduce unnecessary length of stay. However, no prior study has identified the variables predictive of nonhome patient discharge after cervical disc replacement (CDR).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent primary 1-level or 2-level CDR between 2011 and 2020. Multivariable Poisson regression with robust error variance was employed to identify the predictors for nonhome discharge destination following surgery.

RESULTS

A total of 7276 patients were included in this study, of which 94 (1.3%) patients were discharged to a nonhome destination. Multivariable regression revealed older age (OR: 1.076, P <0.001), Hispanic ethnicity (OR: 4.222, P =0.001), BMI (OR: 1.062, P =0.001), ASA class ≥3 (OR: 2.562, P =0.002), length of hospital stay (OR: 1.289, P <0.001), and prolonged operation time (OR: 1.007, P <0.001) as predictors of nonhome discharge after CDR. Outpatient surgery setting was found to be protective against nonhome discharge after CDR (OR: 0.243, P <0.001).

CONCLUSIONS

Age, Hispanic ethnicity, BMI, ASA class, prolonged hospital stay, and prolonged operation time are independent predictors of nonhome discharge after CDR. Outpatient surgery setting is protective against nonhome discharge. These findings can be utilized to preoperatively risk stratify expected discharge destination, anticipate patient discharge needs postoperatively, and expedite discharge in these patients to reduce health care costs associated with prolonged length of hospital stay.

LEVEL OF EVIDENCE

IV.

Impact of Racial/Ethnic Disparities on Patient-Reported Outcomes Following Cervical Spine Surgery: QOD Analysis

STUDY DESIGN

Retrospective analysis of data from the cervical module of a National Spine Registry, the Quality Outcomes Database.

OBJECTIVE

To examine the association of race and ethnicity with patient-reported outcome measures (PROMs) at one year after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Evidence suggests that Black individuals are 39% to 44% more likely to have postoperative complications and a prolonged length of stay after cervical spine surgery compared with Whites. The long-term recovery assessed with PROMs after cervical spine surgery among Black, Hispanic, and other non-Hispanic groups ( i.e . Asian) remains unclear.

MATERIALS AND METHODS

PROMs were used to assess disability (neck disability index) and neck/arm pain preoperatively and one-year postoperative. Primary outcomes were disability and pain, and not being satisfied from preoperative to 12 months after surgery. Multivariable logistic and proportional odds regression analyses were used to determine the association of racial/ethnic groups [Hispanic, non-Hispanic White (NHW), non-Hispanic Black (NHB), and non-Hispanic Asian (NHA)] with outcomes after covariate adjustment and to compute the odds of each racial/ethnic group achieving a minimal clinically important difference one-year postoperatively.

RESULTS

On average, the sample of 14,429 participants had significant reductions in pain and disability, and 87% were satisfied at one-year follow-up. Hispanic and NHB patients had higher odds of not being satisfied (40% and 80%) and having worse pain outcomes (30%-70%) compared with NHW. NHB had 50% higher odds of worse disability scores compared with NHW. NHA reported similar disability and neck pain outcomes compared with NHW.

CONCLUSIONS

Hispanic and NHB patients had worse patient-reported outcomes one year after cervical spine surgery compared with NHW individuals, even after adjusting for potential confounders, yet there was no difference in disability and neck pain outcomes reported for NHA patients. This study highlights the need to address inherent racial/ethnic disparities in recovery trajectories following cervical spine surgery.

Outcomes and survival analysis of adult cervical deformity patients with 10-year follow-up

BACKGROUND

Previous studies have demonstrated that adult cervical deformity patients may be at increased risk of death in conjunction with increased frailty or a weakened physiologic state. However, such studies have often been limited by follow-up duration, and longer-term studies are needed to better assess temporal changes in ACD patients and associated mortality risk.

PURPOSE

To assess if patients with decreased comorbidities and physiologic burden will be at lessened risk of death for a greater length of time after undergoing adult cervical deformity surgery.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

Two hundred ninety ACD patients.

OUTCOME MEASURES

Morbidity and mortality data.

METHODS

Operative ACD patients ≥18 years with pre-(BL) and 10-year (10Y) data were included. Patients were stratified as expired versus living, as well as temporally grouped by Expiration prior to 5Y or between 5Y and 10Y. Group differences were assessed via means comparison analysis. Backstep logistic regression identified mortality predictors. Kaplan-Meier analysis assessed survivorship of expired patients. Log rank analysis determined differences in survival distribution groups.

RESULTS

Sixty-six total patients were included (60.97±10.19 years, 48% female, 28.03±7.28 kg/m2). Within 10Y, 12 (18.2% of ACD cohort) expired. At baseline, patients were comparable in age, gender, BMI, and CCI total on average (all p>.05). Furthermore, patients were comparable in BL HRQLs (all p>.05). However, patients who expired between 5Y and 10Y demonstrated higher BL EQ5D and mJOA scores than their earlier expired counterparts at 2Y (p<.021). Furthermore, patients who presented with no CCI markers at BL were significantly more likely to survive until the 5Y-10Y follow-up window. Surgically, the only differences observed between patients who survived until 5Y was in undergoing osteotomy, with longer survival seen in those who did not require it (p=.003). Logistic regression revealed independent predictors of death prior to 5Y to be increased BMI, increased frailty, and increased levels fused (model p<.001). KM analysis found that by Passias et al frailty, not frail patients had mean survival time of 170.56 weeks, versus 158.00 in frail patients (p=.949).

CONCLUSIONS

Our study demonstrates that long-term survival after cervical deformity surgery may be predicted by baseline surgical factors. By optimizing BMI, frailty status, and minimizing fusion length when appropriate, surgeons may be able to further assist ACD patients in increasing their survivability postoperatively.

Racial Disparities in Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

To synthesize previous studies evaluating racial disparities in spine surgery.

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay.

RESULTS

A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications.

CONCLUSIONS

This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

Utilization Trends of Intraoperative Neuromonitoring for Anterior Cervical Discectomy and Fusion in New York State

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To elucidate trends in the utilization of intraoperative neuromonitoring (IONM) during anterior cervical discectomy and fusion (ACDF) procedures in NY state using the Statewide Planning and Research Cooperative System and to determine if utilization of IONM resulted in a reduction in postoperative neurological deficits.

SUMMARY OF BACKGROUND DATA

IONM has been available to spinal surgeons for several decades. It has become increasingly prevalent in all facets of spinal surgery including elective ACDF procedures. The utility of IONM for preventing a neurological deficit in elective spine procedures has recently been called into question.

MATERIALS AND METHODS

The Statewide Planning and Research Cooperative System database were accessed to perform a retrospective cohort study comparing monitored versus unmonitored ACDF procedures between 2007 and 2018 as defined by the International Classification of Disease-9 and 10 Procedural Coding System (ICD-9 PCS, ICD-10 PCS) codes. Patient demographics, medical history, surgical intervention, pertinent in-hospital events, and urban versus rural medical centers (as defined by the United States Office of Management and Budget) were recorded. Propensity-score-matched comparisons were used to identify factors related to the utilization of IONM and risk factors for neurological deficits after elective ACDF.

RESULTS

A total of 70,838 [15,092 monitored (21.3%) and 55,746 (78.7%) unmonitored] patients' data were extracted. The utilization of IONM since 2007 has increased in a linear manner from 0.9% of cases in 2007 to 36.7% by 2018. Overall, baseline characteristics of patients who were monitored during cases differed significantly from unmonitored patients in age, race/ethnicity, insurance type, presence of myelopathy or radiculopathy, and Charlson Comorbidity Index; however, only race/ethnicity was statistically significant when analyzed using propensity-score-matched. When comparing urban and rural medical centers, there is a significant lag in the adoption of the technology with no monitored cases in rural centers until 2012 with significant fluctuations in utilization compared with steadily increasing utilization among urban centers. From 2017 to 2018, reporting of neurological deficits after surgery resembled literature-established norms. Pooled analysis of these years revealed that the incidence of neurological complications occurred more frequently in monitored cases than in unmonitored (3.0% vs. 1.4%, P < 0.001).

CONCLUSIONS

The utility of IONM for elective ACDF remains uncertain; however, it continues to gain popularity for routine cases. For medical centers that lack similar resources to centers in more densely populated regions of NY state, reliable access to this technology is not a certainty. In our analysis of intraoperative neurological complications, it seems that IONM is not protective against neurological injury.

Incidence of spinal cord injuries in Constanta County (Romania) between 2017-2021

Background: The purpose of this study was to investigated cases of spinal cord injury (SCI) during the years 2017-2021, in Constanta County (Romania) to update the data on SCI and thus identify the SCI trends in this region of Romania. Methods: The study retrospectively analysed patients with SCI in Constanța County, whose data (medical records) were provided to us by the Romania Motivation Foundation. This analysis was made for the period January 1, 2017 - August 31, 2021. Results: Ninety-six new traumatic cases of SCI were reported between 2017 and 2021 in Constanța County. It was found that the annual incidence is 2.48 per hundred thousand inhabitants. The male / female ratio was 5:1 and the mean age at injury was 33.52 ± 15.1 (33.41 ± 14.80 for men and 33.92 ± 16.01 for women). The most common cause of injury was unintentional fall (48.95%), followed by road accidents (39.58%), stab wounds (4.16%), gunshot wounds (3.12%) and injuries caused by diving 2.08%). Fifteen patients (15.62%) were quadriplegic, and 81 patients (84.37%) were paraplegic. The most common level of lesions was C4 (33.33%) in tetraplegics and T12 (25.92%) in paraplegics. The most common associated injury was head trauma (15.8%), followed by limb fractures (9.5%). The incidence rate of SCI in Constanta County increased (p <0.05) and the highest increase in the incidence of spinal cord injuries was observed among patients in the age groups 29 - 49 years. Conclusions: Due to the existence of limitations, it is difficult to obtain accurate epidemiological data for SCI. Therefore, more studies are needed to provide a large amount of data and evidence. Our data indicate the need to take measures both for prevention and to provide specialized care for this type of traumatic pathology.

Impact of Race/Ethnicity on Hospital Resource Utilization After Elective Anterior Cervical Decompression and Fusion for Degenerative Myelopathy

INTRODUCTION

With the advent of bundled care payments for spine surgery, there is increasing scrutiny on the costs and resource utilization associated with surgical care. The purpose of this study was to compare (1) the total cost of the hospital episode of care and (2) discharge destination between White, Black, and Hispanic patients receiving elective anterior cervical decompression and fusion for degenerative cervical myelopathy (DCM) in Medicare patients.

METHODS

The 2019 Medicare Provider Analysis and Review Limited Data Set and the 2019 Impact File were used for this project. Multivariate models were created for total cost and discharge destination, controlling for confounders found on univariate analysis. We then performed a subanalysis for differences in specific cost-center charges.

RESULTS

There were 11,506 White (85.4%), 1,707 Black (12.7%), and 261 Hispanic (1.9%) patients identified. There were 6,447 males (47.8%) and 7,027 females (52.2%). Most patients were between 65 to 74 years of age (n = 7,101, 52.7%). The mean cost of the hospital episode was $20,919 ± 11,848. Most patients were discharged home (n = 11,584, 86.0%). Race/ethnicity was independently associated with an increased cost of care (Black: $783, Hispanic: $1,566, P = 0.001) and an increased likelihood of nonhome discharge (Black: adjusted odds ratio: 1.990, P < 0.001, Hispanic: adjusted odds ratio: 1.822, P < 0.001) compared with White patients. Compared with White patients, Black patients were charged more for accommodations ($1808), less for supplies (-$1780), and less for operating room (-$1072), whereas Hispanic patients were charged more ($3556, $7923, and $5162, respectively, P < 0.05).

CONCLUSION

Black and Hispanic race/ethnicity were found to be independently associated with an increased cost of care and risk for nonhome discharge after elective anterior cervical decompression and fusion for DCM compared with White patients. The largest drivers of this disparity appear to be accommodation, medical/surgical supply, and operating room-related charges. Further analysis of these racial disparities should be performed to improve value and equity of spine care for DCM.

Impact of Social Determinants of Health in Spine Surgery

PURPOSE OF REVIEW

Social determinants of health (SDH) are factors that affect patient health outcomes outside the hospital. SDH are "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Current literature has shown SDH affecting patient reported outcomes in various specialties; however, there is a dearth in research relating spine surgery with SDH. The aim of this review article is to identify connections between SDH and post-operative outcomes in spine surgery. These are important, yet understudied predictors that can impact health outcomes and affect health equity.

RECENT FINDINGS

Few studies have shown associations between SDH pillars (environment, race, healthcare, economic, and education) and spine surgery outcomes. The most notable relationships demonstrate increased disability, return to work time, and pain with lower income, education, environmental locations, healthcare status and/or provider. Despite these findings, there remains a significant lack of understanding between SDH and spine surgery. Our manuscript reviews the available literature comparing SDH with various spine conditions and surgeries. We organized our findings into the following narrative themes: 1) education, 2) geography, 3) race, 4) healthcare access, and 5) economics.

Do racial disparities exist in a spine surgery practice that serves a predominately minority population? Outcomes of transforaminal lumbar interbody fusion: A retrospective review

Background

Racial minority status is associated with inferior peri-operative outcomes following spinal fusion. Findings have largely been reported within institutions serving few minority patients. This study aimed to identify if racial disparities exist for transforaminal lumbar interbody fusion (TLIF) procedures within an urban academic medical center which serves a majority non-White population.

Methods

This is a retrospective review of patients who underwent a TLIF procedure at our institution between 06/2016-10/2019. Primary outcome measures included length of stay (LOS), discharge disposition, 30-day return to the emergency department (ED), 30-day readmission rate, and 30-day complication rates. One-hundred-fifty-six patients (female: male, 99: 57) met inclusion criteria. Demographic and clinical data (body mass index (BMI), comorbidities, preoperative lab values) were compared.

Results

The mean LOS was 6.2, 5.9, and 6 days in the White, Hispanic, and Black cohorts, respectively (p = 0.92). There were no differences in discharge disposition between groups (p = 0.52). Thirty-day post-operative complication rates did not differ between groups (p > 0.07). Readmission rates did not differ between groups (p > 0.05). ED visits were more prevalent in the Hispanic group with 16 visits as compared to 8 and 4 in the White and Black groups respectively (p = 0.01).

Conclusions

We found no racial disparities in terms of LOS, discharge disposition, or 30-day readmission rates. Hispanic patients demonstrated an increased utilization of the ED in the early post-operative period. Efforts to overcome language barriers, communicate instructions clearly, and outline post-operative expectations and plans may prevent the need for post-operative ED visits.

Social Determinants of Health Influence Access to Care and Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To investigate the impact social determinants of health (SDOH) have on accessing orthopaedic treatment after an anterior cruciate ligament injury, as well as patient-reported and surgical outcomes after anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic search of the PubMed, MEDLINE, Epub Ahead of Print, Embase, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that reported at least 1 SDOH and its effect on patient-reported outcomes or surgical outcomes after anterior cruciate ligament reconstruction. Our search identified 937 studies. After eliminating 273 duplicates, 2 authors screened 664 articles on the basis of title and abstract. After this initial screening, 76 studies were evaluated for data extraction. Studies were categorized based on the social determinant(s) of health reported.

RESULTS

Twenty-two articles published between 2002 and 2020 were included in this study, encompassing 15 retrospective cohort studies, 3 prospective cohort studies, 3 cross-sectional studies, and 1 case-control study from 9 journals across 3 countries. Of these articles, 9 investigated race/ethnicity, 8 investigated insurance status, 4 investigated income, 5 investigated education level, 2 investigated employment status, and 5 investigated socioeconomic status. Reported outcomes included time to treatment, concomitant knee injury, patient-reported outcome measurement scores, postoperative complications, need for additional surgery, and postoperative healthcare utilization.

CONCLUSIONS

Certain SDOH, including black race, Hispanic ethnicity, public health insurance, and lower socioeconomic status contribute to a delay in access to care, which may result in increased severity of concomitant knee injuries encountered at the time of anterior cruciate ligament reconstruction and inferior outcomes.

STUDY DESIGN

Level III, systematic review of level I-III evidence.

Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review

BACKGROUND

Our goal was to systematically review the literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement.

METHODS

We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES).

RESULTS

Of 2679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 studies were analyzed. Forty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. After discharge, white patients reported better outcomes than did black patients. Thirty-three studies (55%) reported no disparities within at least 1 examined metric.

CONCLUSIONS

This comprehensive systematic review underscores ongoing potential for health care disparities among adult patients in spinal surgery. We show a need for continued efforts to promote equity and cultural competency within neurologic surgery.

Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease.

METHODS

We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups.

RESULTS

We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I² = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I² = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I² = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I² = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates.

CONCLUSIONS

Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

Racial disparities in complications and mortality after bariatric surgery: A systematic review

BACKGROUND

Studies have shown racial discrepancies in the rates of postoperative adverse events following bariatric surgery (BS). We aim to systematically review the literature examining racial disparities in postoperative adverse events.

METHODS

PubMed, Embase, and SCOPUS databases were searched for studies that reported race, postoperative adverse events and/or length of stay.

RESULTS

Thirty-five studies were included. Most compared Black and White patients using standardized databases. Racial/ethnic terminology varied. The majority found increased 30-day mortality and morbidity and length of stay in Black relative to White patients. Differences between White and Hipanic patients were mostly non-significant in these outcomes.

CONCLUSIONS

Black patients may experience higher rates of adverse events than White patients within 30 days following bariatric surgery. Given the limitations in the large multicenter databases, explanations for this disparity were limited. Future research would benefit from longer-term studies that include more races and ethnicities and consider socioeconomic factors.

National utilization and inpatient safety measures of lumbar spinal fusion methods by race/ethnicity

BACKGROUND CONTEXT

Degenerative lumbar conditions are prevalent, disabling, and frequently managed with decompression and fusion. Black patients have lower spinal fusion rates than White patients.

PURPOSE

Determine whether specific lumbar fusion procedure utilization differs by race/ethnicity and whether length of stay (LOS) or inpatient complications differ by race/ethnicity after accounting for procedure performed.

STUDY DESIGN

Large database retrospective cohort study PATIENT SAMPLE: Lumbar fusion recipients at least age 50 in the 2016 National Inpatient Sample with diagnoses of degenerative lumbar conditions.

OUTCOME MEASURES

Type of fusion procedure used and inpatient safety measures including LOS, prolonged LOS, inpatient medical and surgical complications, mortality, and cost.

METHODS

We examined the association between race/ethnicity and the safety measures above. Covariates included several patient and hospital factors. We used multiple linear or logistic regression to determine the association between race and fusion type (PLF, P/TLIF, ALIF, PLF + P/TLIF, and PLF + ALIF [anterior-posterior fusion]) and to determine whether race was associated independently with inpatient safety measures, after adjustment for patient and hospital factors.

RESULTS

Fusion method use did not differ among racial/ethnic groups, except for somewhat lower anterior-posterior fusion utilization in Black patients compared to White patients (crude odds ratio [OR]: 0.81 [0.67-0.97]). Inpatient safety measures differed by race/ethnicity for rates of prolonged LOS (Blacks 18.1%, Hispanics 14.5%, and Whites 11.7%), medical complications (Blacks 9.9%, Hispanics 8.7%, and Whites 7.7%), and surgical complications (Blacks 5.2%, Hispanics 6.9%, and Whites 5.4%). Differences persisted after adjustment for procedure type as well as patient and hospital factors. Blacks and Hispanics had higher risk for prolonged LOS compared to Whites (adjusted OR Blacks 1.39 [95% confidence interval {CI} 1.22-1.59]; Hispanics 1.24 [95% CI 1.02-1.52]). Blacks had higher risk for inpatient medical complications compared to Whites (adjusted OR 1.24 [95% CI 1.05-1.48]), and Hispanics had higher risk for inpatient surgical complications compared to Whites (adjusted OR 1.34 [95% CI 1.06-1.68]).

CONCLUSIONS

Fusion method use was generally similar between racial/ethnic groups. Inpatient safety measures, adjusted for procedure type, patient and hospital factors, were worse for Blacks and Hispanics.

Traumatic spinal cord injury caused by low falls and high falls: a comparative study

BACKGROUND

Quite a few traumatic spinal cord injuries (TSCI) were caused by falls. However, the comparison of different causes of TSCI or the epidemiological characteristics of TSCI caused by falls of different heights are rare. This study investigated the epidemiological characteristics of TSCI caused by falls and conducted a comparison between low falls and high falls.

METHOD

Data from cases with TSCI admitted to China Rehabilitation Research Center from 2010 to 2019 were collected, including age, gender, occupation, cause, neurological level, and severity of the injury in admission, combined injuries, complications, and rehabilitation length of stay. Mann-Whitney U and chi-square (χ2) tests were used to assess the differences between two groups at a statistical significance level of 0.05.

RESULT

A total of 1858 TSCI cases were included and 41.7% were caused by falls, 11.4% by low falls and 30.3% by high falls, respectively. Patients with fall-induced TSCI were older and had a shorter rehabilitation length of stay than those with non-fall-induced TSCI. Patients with high fall-induced TSCI were younger and more likely to suffer from paraplegia, severer injuries, and combined injuries, and had longer time from injury to rehabilitation and rehabilitation length of stay, compared with patients with low fall-induced TSCI.

CONCLUSION

Falls is the leading causes of TSCI and high fall is becoming more common. Attention not only should be paid to high falls for the severe injury and longer hospitalization, but also low falls due to the higher neurological level of the injury and the aging of population in China.

Association of Race with Early Outcomes of Elective Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Propensity-Matched and Subgroup Analysis

OBJECTIVE

To investigate the impact of race on 30-day postoperative complication rates of elective posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

Patients who underwent PSF between 2012 and 2018 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program pediatric database. Propensity score matching was utilized to evaluate whether patient race (i.e., black vs. white) was correlated with postoperative complications.

RESULTS

A total of 4051 PSF for AIS cases met criteria for inclusion. Of these, 3221 (79.5%) patients were white and 830 (20.5%) were black. Several baseline characteristics significantly differed between cohorts. Patients in the black cohort had a significantly higher body mass index, a greater proportion of female patients, higher ASA scores, preoperative diagnosis of asthma or cardiac risk factors, and prior use of steroids. The total number of vertebral segments fused was also greater in the black cohort. After controlling for differences in baseline characteristics with propensity score matching analysis, the only significant difference in morbidity and mortality identified was a higher incidence of venous thromboembolism among the black cohort (2.8% vs. 0.1%; P < 0.001).

CONCLUSIONS

In contrast to prior literature, our analysis did not identify black race as an independent risk factor for higher perioperative morbidity or mortality in patients of young age group undergoing elective PSF for AIS, except the higher incidence of venous thromboembolism. The findings of the present study suggest that previously reported perioperative morbidity and mortality outcomes in black patients may be secondary to baseline health characteristics, and not due to race itself.

A sandwich structured drug delivery composite membrane for improved recovery after spinal cord injury under longtime controlled release

A sandwich structured composite membrane for longtime controlled release of nerve growth factor (NGF) to repair spinal cord injury (SCI) is prepared through electrospray. In this system, PLA film is used as the sealing layer to prevent drug diffusion and provide mechanical support, PLGA microspheres as the sandwich layer to load and controlled release NGF, and chitosan (CS) film as the planting layer to seed bone marrow mesenchymal stem cells (BMSCs). The composite membrane has good biocompatibility and can effectively promote PC-12 cells to differentiate into neurons. In addition, the composite membrane can be directly applied to the injured areas without further damage. The longtime sustained release of NGF guaranteed enough requirement time for SCI repair, which will decrease the administration frequency and improve patient compliance. The administration of BMSCs coupled with the sandwich composite membrane effectively relieves SCI, decreases cavity formation, enhances neuronal regeneration and tissue repair, as well as improves the recovery of locomotor functions. Overall, this present work provides a future perspective for the treatment of SCI by the NGF-loaded sandwich composite membrane with prolonged drug release function.

Portending Influence of Racial Disparities on Extended Length of Stay after Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

The aim of this study was to investigate whether race is an independent predictor of extended length of stay (LOS) after elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult patients undergoing ACDF for CSM were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification coding system.

RESULTS

A total of 15,400 patients were identified, of whom 13,250 (86.0%) were Caucasian (C) and 2150 (14.0%) were African American (AA). The C cohort tended to be older, whereas the AA cohort had 2 times as many patients in the 0-25th income quartile. The prevalence of comorbidities was greater in the AA cohort. Intraoperative fusion levels were similar between the cohorts, whereas the AA cohort had a higher rate of cerebrospinal fluid leak/dural tear. In relation to the number of complications, the C cohort had a lower rate compared with the AA cohort (P = 0.006), including no complication (89.4% vs. 85.3%), 1 complication (9.9% vs. 12.8%), and >1 complication (0.7% vs. 1.9%). The AA cohort experienced significantly longer hospital stays (C, 1.9 ± 2.3 days vs. AA, 2.7 ± 3.5; P < 0.001), greater proportion of extended LOS (C, 17.5% vs. AA, 29.1%; P < 0.001) and nonroutine discharges (C, 16.1% vs. AA, 28.6%; P < 0.001). AA race was a significant independent risk factor for extended LOS (odds ratio, 1.98; 95% confidence interval, 1.50-2.61; P < 0.001).

CONCLUSIONS

Our study suggests that AA patients have a significantly higher risk of prolonged LOS after elective ACDF for CSM compared with C patients.

Racial Disparities in Outcomes of Reconstructive Breast Surgery: An Analysis of 51,362 Patients from the ACS-NSQIP

BACKGROUND

 In various surgical specialties, racial disparities in postoperative complications are widely reported. It is assumed that the effect of race can also be found in plastic surgical outcomes, although this remains largely undefined in literature. This study aims to provide data on the impact of race on outcomes of reconstructive breast surgery.

METHODS

 Data were collected using the NSQIP (National Surgical Quality Improvement Program) database (2008-2016). Outcomes of the reconstructive breast surgery of White patients were compared with those of African American, Asian, or other races. Logistic regression was performed to control for variations between all groups. Analysis of racial disparities was further sub-stratified according to four different types of breast reconstruction: delayed or immediate autologous, and delayed or immediate prosthesis-based reconstruction.

RESULTS

 In total, this study included 51,362 patients of which 43,864 were Caucasian, 5,135 African American, 2,057 Asian, and 332 of other races. When compared with White patients, patients of African American race had larger body mass indices (31.3 ± 7.0 vs. 27.6 ± 6.3, p-value < 0.001) in addition to higher rates of diabetes (12.3 vs 4.6%, p-value < 0.001) and hypertension (44.7 vs. 23.4%, p-value < 0.001). Both multivariate analysis and the sub-stratified analysis of different types of reconstruction showed no differences in overall complication rate.

CONCLUSION

 Among the four types of reconstructive procedures, differences in surgical outcomes do not appear to be based on race and therefore seem to be less evident in reconstructive breast surgery compared with the current literature within other surgical specialties.

Epidemiological characteristics of spinal cord injury in Northwest China: a single hospital-based study

Background

While the cities in China in which spinal cord injury (SCI) studies have been conducted previously are at the forefront of medical care, northwest China is relatively underdeveloped economically, and the epidemiological characteristics of SCI have rarely been reported in this region.

Methods

The SCI epidemiological survey software developed was used to analyze the data of patients treated with SCI from 2014 to 2018. The sociodemographic characteristics of patients, including name, age, sex, and occupation, were recorded. The following medical record data, obtained from physical and radiographic examinations, were included in the study: data on the cause of injury, fracture location, associated injuries, and level of injury. Neurological function was evaluated using the American Spinal Injury Association (ASIA) impairment scale. In addition, the treatment and complications during hospitalization were documented.

Results

A total of 3487 patients with SCI with a mean age of 39.5 ± 11.2 years were identified in this study, and the male to female ratio was 2.57:1. The primary cause of SCI was falls (low falls 47.75%, high falls 37.31%), followed by traffic accidents (8.98%), and impact with falling objects (4.39%). Of all patients, 1786 patients (51.22%) had complications and other injuries. According to the ASIA impairment scale, the numbers of grade A, B, C, and D injuries were 747 (21.42%), 688 (19.73%), 618 (17.72%), and 1434 (41.12%), respectively. During the hospitalization period, a total of 1341 patients experienced complications, with a percentage of 38.46%. Among all complications, pulmonary infection was the most common (437, 32.59%), followed by hyponatremia (326, 24.31%), bedsores (219, 16.33%), urinary tract infection (168, 12.53%), deep venous thrombosis (157, 11.71%), and others (34, 2.53%). Notably, among 3487 patients with SCI, only 528 patients (15.14%) received long-term rehabilitation treatment.

Conclusion

The incidence of SCI in northwest China was on the rise with higher proportion in males; fall and the MCVs were the primary causes of SCI. The occupations most threatened by SCI are farmers and workers. The investigation and analysis of the epidemiological characteristics of SCI in respiratory complications are important factors leading to death after SCI, especially when the SCI occurs in the cervical spinal cord. Finally, the significance of SCI rehabilitation should be addressed.

Do Medicare Accountable Care Organizations Reduce Disparities After Spinal Fracture?

BACKGROUND

National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures.

MATERIALS AND METHODS

We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent.

RESULTS

We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09).

CONCLUSIONS

Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.

Racial Disparities in Surgical Outcomes After Spine Surgery: An ACS-NSQIP Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Racial disparities in postoperative outcomes are unfortunately common. We present data assessing race as an independent risk factor for postoperative complications after spine surgery for Native American (NA) and African American (AA) patients compared with Caucasians (CA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for spine procedures performed in 2015. Data was subdivided by surgery, demography, comorbidity, and 30-day postoperative outcomes, which were then compared by race. Regression was performed holding race as an independent risk factor.

RESULTS

A total of 4803 patients (4106 CA, 522 AA, 175 NA) were included in this analysis. AA patients experienced longer length of stay (LOS) and operative times (P < .001) excluding lumbar fusion, which was significantly shorter (P = .035). AA patients demonstrated higher comorbidity burden, specifically for diabetes and hypertension (P < .005), while NA individuals were higher tobacco consumers (P < .001). AA race was an independent risk factor associated with longer LOS across all cervical surgeries (β = 1.54, P <.001), lumbar fusion (β = 0.77, P = .009), and decompression laminectomy (β = 1.23, P < .001), longer operative time in cervical fusion (β = 12.21, P = .032), lumbar fusion (β = -24.00, P = .016), and decompression laminectomy (OR = 20.95, P < .001), greater risk for deep vein thrombosis in lumbar fusion (OR = 3.72, P = .017), and increased superficial surgical site infections (OR = 5.22, P = .001) and pulmonary embolism (OR = 5.76, P = .048) in decompression laminectomy. NA race was an independent risk factor for superficial surgical site infections following cervical fusion (OR = 14.58, P = .044) and decompression laminectomy (OR = 4.80, P = .021).

CONCLUSION

AA and NA spine surgery patients exhibit disproportionate comorbidity burden and greater 30-day complications compared with CA patients. AA and NA race were found to independently affect rates of complications, LOS, and operation time.

Acute post-operative airway complications following anterior cervical spine surgery and the role for cricothyrotomy

Anterior cervical spine surgery (ACSS) is a common procedure, but not without its own risks and complications. Complications that can cause airway compromise occur infrequently, but can rapidly lead to respiratory arrest, leading to severe morbidity or death. Knowing emergent post-operative airway management including surgical airway placement is critical. We aim to review the different etiologies of post-operative airway compromise following ACSS, the predictable timeline in which they occur, and the most appropriate treatment and management for each. We place special emphasis on the timing and proper surgical technique for an emergent cricothyrotomy. Angioedema is seen the earliest as a cause of post-operative airway compromise, typically within 6-12 hours. Retropharyngeal hematomas can be seen between 6-24 hours, most commonly within 12 hours. Pharyngolaryngeal edema is seen within 24-72 hours. After 72 hours, retropharyngeal abscess is the most likely etiology. Several studies have utilized delayed extubation protocols following ACSS based on patient risk factors and found reduced postoperative airway complications and reintubation rates. The administration of perioperative corticosteroids continues to be controversial with high-level studies recommending both for and against their use. Animal studies showed that after cardiac arrest, the brain can recover if oxygenation is restored within 5 minutes, but this time is likely shorter with asphyxia prior to cardiac arrest. Experience and training are essential to reduce the time for successful cricothyrotomy placement. Physicians must be prepared to diagnose and treat acute postoperative airway complications following ACSS to prevent anoxic brain injury or death. If emergent intubation cannot be accomplished on the first attempt, physicians should not delay placement of a surgical airway such as cricothyrotomy.

The Effect of Race on Early Perioperative Outcomes After Shoulder Arthroplasty: A Propensity Score Matched Analysis

There is a paucity of data on how racial disparities may affect early outcomes following shoulder arthroplasty. The purpose of this study was to evaluate differences in 30-day complications and readmission rates after shoulder arthroplasty based on race. White and black patients who underwent hemiarthroplasty, anatomic or reverse total shoulder arthroplasty (Current Procedural Terminology codes 23470 and 23472) between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Black patients were propensity score matched 1:4 based on preoperative demographics and comorbidities to white patients. Multivariable analysis was performed to assess postoperative complications based on race. Of the 12,663 patients with shoulder arthroplasty identified, 10,717 (84.6%) were white and 559 (4.4%) were black. Overall, 557 black patients were matched to 2228 white patients, for a total cohort of 2785 patients (mean age, 63.9±11.7 years; female, 61.0%). Surgical indications were similar between black and white patients. The 2 races had similar rates of overall complications, major complications, minor complications, readmissions, and discharge to facility. Mortality was significantly higher among black patients compared with white patients (0.6% vs 0.05%; P=.033). Black patients also experienced longer operative time (mean, 126.4 vs 112.5 minutes; P<.001) and length of stay (mean, 2.4 vs 2.1 days; P<.001). There was a significant disparity with underutilization of shoulder arthroplasty for black patients in the American College of Surgeons National Surgical Quality Improvement Program database. Black and white patients undergoing shoulder arthroplasty experienced similar rates of 30-day complications, readmissions, and discharge to facility. However, black patients experienced greater operative time, total length of stay, and mortality compared with white patients. [Orthopedics. 2019; 42(2):95-102.].

Rates of Mortality in Lumbar Spine Surgery and Factors Associated With Its Occurrence Over a 10-Year Period: A Study of 803,949 Patients in the Nationwide Inpatient Sample

Background

The rate of mortality in surgical procedures involving the lumbar spine has historically been low, and as a result, there has been difficulty providing accurate quantitative mortality rates to patients in the preoperative planning phase. Awareness of these mortality rates is essential in reducing postoperative complications and improving outcomes. Additionally, mortality rates can be influenced by procedure type and patient profile, including demographics and comorbidities. The purpose of this study is to assess rates and risk factors associated with mortality in surgical procedures involving the lumbar spine using a large national database.

Methods

The Nationwide Inpatient Sample database was reviewed from 2003 to 2012. A total of 803,949 patients age 18 years or older were identified by ICD-9CM procedure codes for spinal fusion or decompression of the lumbar spine. Mortality was stratified based on type of procedure (simple or complex fusion, decompression), patient demographics and comorbidities, and in-hospital complications. Binary logistic regression was used to identify the risk of death while controlling for comorbidities, race, sex, and procedure performed. Significance was defined as P < .05 differences relative to the overall cohort.

Results

Mortality for all patients requiring surgery of the lumbar spine was 0.13%. Mortality based on procedure type was 0.105% for simple fusions, 0.321% for complex fusions, and 0.081% for decompression only. Increased mortality was observed demographically in patients who were male (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.51-2.03), black (OR: 1.40; CI: 1.10-1.79), ages 65-74 (OR: 1.46; CI: 1.25-1.70), and age 75+ (OR: 2.70; CI: 2.30-3.17). Comorbidities associated with the greatest increase in mortality were mild (OR: 10.04; CI: 7.76-13.01) and severe (OR: 26.47; CI: 16.03-43.70) liver disease and congestive heart failure (OR: 4.57; CI: 3.77-5.53). The complications with the highest mortality rates were shock (OR: 20.67; CI: 13.89-30.56) and pulmonary embolism (OR: 20.15; CI: 14.01-29.00).

Conclusions

From 2003 to 2012, the overall mortality rate in 803,949 lumbar spine surgery patients was 0.13%. Risk factors that were significantly associated with increased mortality rates were male gender, black race, and ages 65-74 and 75+. Comorbidities associated with an increased mortality rate were mild and severe liver disease and congestive heart failure. Inpatient complications with the highest mortality rates were shock and pulmonary embolism. These findings can be helpful to surgeons providing preoperative counseling for patients considering elective lumbar procedures and for allocating resources to treat and prevent perioperative complications leading to mortality.

Level of Evidence

3.

Rates of Mortality in Cervical Spine Surgical Procedures and Factors Associated With Its Occurrence Over a 10-Year Period: A Study of 342 477 Patients on the Nationwide Inpatient Sample

Background

Risk of death is important in counseling patients and improving quality of care. Incidence of death in cervical surgery is not firmly established due to its rarity and limited sample sizes, particularly in the context of different surgeries, demographics, and risk factors. Particularly, different patient risk profiles may have varying degrees of risk in terms of surgeries, comorbidities, and demographics. This study aims to use a large patient cohort available on a national database to study the prevalence of death associated with cervical spine surgery.

Methods

This study was a retrospective review of the Nationwide Inpatient Sample (NIS) years 2003-2012. A total of 342 477 patients were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes undergoing spinal fusion or decompression for disc degeneration, stenosis, spondylosis, myelopathy, postlaminectomy syndrome, scoliosis, or neck pain associated with the cervical region. Patients with malignancy were excluded from analysis. Incidence of mortality was assessed by χ² tests across different patient demographics and comorbidities, procedures performed, and concurrent in-hospital complications. Binary logistic regression identified significant increases or decreases in risk of death while controlling for comorbidities, race, sex, and Mirza invasiveness. Significance was defined as P < .05 differences relative to overall cohort.

Results

The study analyzed 342 477 patients with an overall mortality rate of 0.32%. A total of 231 977 simple fusions (single approach and <3 levels) experienced a mortality rate of 0.256%; 49 594 complex fusions (combined approach or ≥3 levels) had a mortality rate of 0.534%; and 61 285 decompression-only procedures reported a 0.424% mortality rate, all P < .001 from overall rate. In reporting rates across different demographics, male patients experienced a significantly higher risk for mortality (odds ratio [OR], 2.16; 95% CI, 1.87-4.49), as did black patients (OR, 1.58; CI, 1.32-1.90) and patients over age 75 (OR, 7.55; 95% CI, 6.58-8.65), all P < .001. Patients with liver disease reported 6.40% mortality. Similarly, patients with congestive heart failure (3.91%), cerebrovascular disease (3.41%), and paraplegia (3.79%) experienced high mortality rates, all in cohorts of over 2000 patients, all P < .001. Concurrent in-hospital complications with the highest risk of mortality were shock (OR, 51.41; 95% CI, 24.08-109.76), pulmonary embolism (OR, 25.01; 95% CI, 14.70-42.56), and adult respiratory distress disorder (OR, 14.94; 95% CI, 12.75-17.52), all P < .001.

Conclusion

In 342 477 cervical spine surgery patients an overall mortality rate of 0.32% was reported. The rate was 3.91% in a cohort of 5933 patients with congestive heart failure and 3.79% in a cohort of 6947 patients with paraplegia. These findings are consistent with previous estimates and may help counsel patients and improve in-hospital safety.

Level of Evidence

3.

Patient and surgeon factors explain variation in the frequency of frontal sinus surgery

OBJECTIVES/HYPOTHESIS

Ethmoidectomy may be sufficient to address frontal sinus disease, but some surgeons may perform frontal recess dissection initially. Our objectives were to describe patient-associated factors with frequency of frontal sinus surgery and analyze the association with provider volume.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

The 2013 State Ambulatory Surgery Databases of New Jersey, Florida, and Kentucky were queried to identify adults who underwent anterior ethmoidectomy or total ethmoidectomy using standard Current Procedural Terminology codes. Univariate and multivariate logistic regression was performed to determine the odds of undergoing concurrent frontal sinus exploration along with ethmoidectomy, adjusting for age, gender, race, insurance type, median income, and the metropolitan designation by zip code. We also examined provider and center volume, use of image guidance, and total charges.

RESULTS

There were 10,564 ethmoidectomies, of which 4,726 had concurrent frontal sinus surgery. Women were less likely to have frontal sinus surgery (P = .0011), as were patients with Medicare (P = .007). Hispanics were more likely to have frontal sinus surgery (P = .0003). Surgeons with higher surgical volumes were more likely to perform frontal sinus surgery; it was also more likely to be performed in centers where more sinus procedures occurred (P < .0001, both).

CONCLUSIONS

Variation in the utilization of frontal sinus surgery is associated with patient sex, ethnicity, insurance status, geography, as well as provider and hospital volumes. These data support the idea that nonclinical factors may influence the treatment of frontal sinus disease.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2008-2014, 2018.

Patient and social characteristics contributing to disparities in outcomes after burn injury: application of database research to minority health in the burn population

BACKGROUND

Although racial disparities have been well described in trauma and medical literature, less is known about disparities in the burn population, especially the Native American, Hispanic, Black, and Asian minority groups. This study seeks to identify at-risk populations for differences in patient and social characteristics that may link certain race groups to disparate burn outcomes.

METHODS

Data was reviewed from the National Burn Repository. Information regarding patient demographics, co-morbidities, complications, and clinical outcomes was recorded. Student's T-test, ANOVA, and binary logistic regression were used to assess relationships between patient factors and outcomes.

RESULTS

The Native American cohort had higher rates of alcoholism, drug abuse, and homelessness compared to all patients. Native Americans also had significantly longer hospital lengths of stay, and higher rates of respiratory failure, pneumonia, sepsis, and wound complications. The Black population demonstrated the highest percentage of injury at home, child abuse, and non-insurance. Mortality was highest in the Black population compared to all patients.

CONCLUSIONS

These findings suggest that outcome disparities exist in burn-injured patients in multiple minority groups.

ANTERIOR PERCUTANEOUS CERVICAL DISCECTOMY. TWO-YEAR FOLLOW-UP OF A BLUNT TECHNIQUE PROCEDURE

ABSTRACT Objective: To report the outcomes of non-endoscopic percutaneous cervical discectomy by anterior blunt approach for the treatment of degenerative disc disease. Methods: A review of the medical records of patients with axial cervical pain resulting from degenerative disc disease and treated with discectomy and percutaneous nucleoplasty by anterior blunt approach with radiofrequency source was carried out. The data were evaluated according to modified MacNab and pre- and postoperative VAS criteria at 3, 12 and 24 months. Results: Sixty-two procedures were performed in 48 patients between 2008 and 2014. The mean age of the population was 52.4 years. MacNab results were 84.6%, 92.3%, and 89.2% improvement (excellent and good results) at 3, 12 and 24 months, respectively. The VAS changed from 7.4 to 2.3 two years after the procedure, showing a statistically significant difference (p=0.000). There were no major complications or re-interventions related to the technique. Conclusions: Anterior non-endoscopic discectomy and nucleoplasty for the treatment of discogenic axial cervical pain may be an effective alternative to open surgery. In the two-year follow-up, our blunt technique proved to be a safe procedure with no approach-related complications, and provided outcomes comparable to those reported using the original needle technique.

High-Risk Subgroup Membership Is a Predictor of 30-Day Morbidity Following Anterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine if membership in a high-risk subgroup is predictive of morbidity and mortality following anterior lumbar fusion (ALF).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify patients undergoing ALF between 2010 and 2014. Multivariate analysis was utilized to identify high-risk subgroup membership as an independent predictor of postoperative complications.

RESULTS

Members of the elderly (≥65 years) (OR = 1.3, P = .02) and non-Caucasian (black, Hispanic, other) (OR = 1.7, P < .0001) subgroups were at greater risk for a LOS ≥5 days. Obese patients (≥30 kg/m² ) were at greater risk for an operative time ≥4 hours (OR = 1.3, P = .005), and wound complications (OR = 1.8, P = .024) compared with nonobese patients. Emergent procedures had a significantly increased risk for LOS ≥5 days (OR = 4.9, P = .021), sepsis (OR = 14.8, P = .018), and reoperation (OR = 13.4, P < .0001) compared with nonemergent procedures. Disseminated cancer was an independent risk factor for operative time ≥4 hours (OR = 8.4, P < .0001), LOS ≥5 days (OR = 15.2, P < .0001), pulmonary complications (OR = 7.4, P = .019), and postoperative blood transfusion (OR = 3.1, P = .040).

CONCLUSIONS

High-risk subgroup membership is an independent risk factor for morbidity following ALF. These groups should be targets for aggressive preoperative optimization, and quality improvement initiatives.

A novel index for quantifying the risk of early complications for patients undergoing cervical spine surgeries

OBJECTIVE It is becoming increasingly necessary for surgeons to provide evidence supporting cost-effectiveness of surgical treatment for cervical spine pathology. Anticipating surgical risk is critical in accurately evaluating the risk/benefit balance of such treatment. Determining the risk and cost-effectiveness of surgery, complications, revision procedures, and mortality rates are the most significant limitations. The purpose of this study was to determine independent risk factors for medical complications (MCs), surgical complications (SCs), revisions, and mortality rates following surgery for patients with cervical spine pathology. The most relevant risk factors were used to structure an index that will help quantify risk and anticipate failure for such procedures. METHODS The authors of this study performed a retrospective review of the National Inpatient Sample (NIS) database for patients treated surgically for cervical spine pathology between 2001 and 2010. Multivariate models were performed to calculate the odds ratio (OR) of the independent risk factors that led to MCs and repeated for SCs, revisions, and mortality. The models controlled for age (< and > 65 years old), sex, race, revision status (except for revision analysis), surgical approach, number of levels fused/re-fused (2-3, 4-8, ≥ 9), and osteotomy utilization. ORs were weighted based on their predictive category: 2 times for revision surgery predictors and 4 times for mortality predictors. Fifty points were distributed among the predictors based on their cumulative OR to establish a risk index. RESULTS Discharges for 362,989 patients with cervical spine pathology were identified. The mean age was 52.65 years, and 49.47% of patients were women. Independent risk factors included medical comorbidities, surgical parameters, and demographic factors. Medical comorbidities included the following: pulmonary circulation disorder, coagulopathy, metastatic cancer, renal failure, congestive heart failure, alcohol abuse, neurological disorder, nonmetastatic cancer, liver disease, rheumatoid arthritis/collagen vascular diseases, and chronic blood loss/anemia. Surgical parameters included posterior approach to fusion/re-fusion, ≥ 9 levels fused/re-fused, corpectomy, 4-8 levels fused/re-fused, and osteotomy; demographic variables included age ≥ 65 years. These factors increased the risk of at least 1 of MC, SC, revision, or mortality (risk of death). A total of 50 points were distributed among the factors based on the cumulative risk ratio of every factor in proportion to the total risk ratios. CONCLUSIONS This study proposed an index to quantify the potential risk of morbidity and mortality prior to surgical intervention for patients with cervical spine pathology. This index may be useful for surgeons in patient counseling efforts as well as for health insurance companies and future socioeconomics studies in assessing surgical risks and benefits for patients undergoing surgical treatment of the cervical spine.

Intraoperative Death During Cervical Spinal Surgery: A Retrospective Multicenter Study

STUDY DESIGN

A retrospective multicenter study.

OBJECTIVE

Routine cervical spine surgeries are typically associated with low complication rates, but serious complications can occur. Intraoperative death is a very rare complication and there is no literature on its incidence. The purpose of this study was to determine the intraoperative mortality rates and associated risk factors in patients undergoing cervical spine surgery.

METHODS

Twenty-one surgical centers from the AOSpine North America Clinical Research Network participated in the study. Medical records of patients who received cervical spine surgery from January 1, 2005, to December 31, 2011, were reviewed to identify occurrence of intraoperative death.

RESULTS

A total of 258 patients across 21 centers met the inclusion criteria. Most of the surgeries were done using the anterior approach (53.9%), followed by posterior (39.1%) and circumferential (7%). Average patient age was 57.1 ± 13.2 years, and there were more male patients (54.7% male and 45.3% female). There was no case of intraoperative death.

CONCLUSIONS

Death during cervical spine surgery is a very rare complication. In our multicenter study, there was a 0% mortality rate. Using an adequate surgical approach for patient diagnosis and comorbidities may be the reason how the occurrence of this catastrophic adverse event was prevented in our patient population.

Atlantoaxial Fusion: Sixteen Years of Epidemiology, Indications, and Complications in New York State

STUDY DESIGN

A retrospective state database analysis.

OBJECTIVE

The aim of this study was to describe the epidemiology and complications of as well as indications for primary isolated atlantoaxial fusion.

SUMMARY OF BACKGROUND DATA

Atlantoaxial fusion involves unique indications, techniques, and complications. There is limited epidemiologic literature focused specifically on this procedure.

METHODS

New York's Statewide Planning and Research Cooperative System database, an all-payer hospitalization reporting system, was queried to identify all patients undergoing primary isolated atlantoaxial fusion in the state from 1997 to 2012. Demographic and clinical data were extracted and analyzed. United States Census Bureau figures were used to calculate population-adjusted surgical rates.

RESULTS

One thousand five hundred fifty-nine patients underwent isolated primary atlantoaxial fusion during the study period. The overall population-adjusted annual surgical rate did not change significantly over time. By 2012, individuals aged ≥70 years had the highest incidence of surgery [2.37 per 100,000 population; 95% confidence interval (95% CI) 1.68-3.07]. Medicare was the most common payer (44.0% of claims). Approximately 85% of patients had a Charlson/Deyo Comorbidity Index of zero or one. Over time, a significantly lower proportion of atlantoaxial fusions were attributable to rheumatic disease, and a significantly higher proportion were due to fracture. By 2012, management of fractures was the most common indication for C1-C2 fusion (44.1% of cases). Dysphagia or dysphonia occurred after 0.8% of cases, dural tear after 0.3%, infection after 0.5%, and seroma, hematoma, or hemorrhage after 0.5%. In-hospital mortality was 2.7%, of which 76% had fracture as the surgical indication.

CONCLUSION

Isolated atlantoaxial fusions have been performed at a stable, low level over the past 16 years in New York. Although most of these patients are relatively healthy pre-operatively, approximately one in 10 experience an in-hospital complication and nearly 3% die in-hospital. Knowledge of these risks will hopefully spur further efforts to minimize them and allow for more accurate counseling of patients and their families.

LEVEL OF EVIDENCE

4.

Do Caucasians and East Asians have Different Outcomes Following Surgery for the Treatment of Degenerative Cervical Myelopathy?: Results From the Prospective Multicenter AOSpine International Study

STUDY DESIGN

A prospective multicenter cohort study.

OBJECTIVE

The aim of this study was to compare outcomes of surgery for the treatment for degenerative cervical myelopathy (DCM) between Caucasians and East Asians.

SUMMARY OF BACKGROUND DATA

Numerous studies have indicated that race can influence both disease prevalence and clinical prognosis in a variety of medical conditions; however, none have evaluated the impact of race on surgical outcomes in patients with DCM.

METHODS

Four hundred and seventy-nine patients with symptomatic DCM were enrolled in the prospective AOSpine CSM-International study at 16 global sites. Preoperatively, and at each follow-up, patients were evaluated using the modified Japanese Orthopedic Association scale (mJOA), the Nurick score, the Neck Disability Index (NDI), and the Short- Form 36 (SF-36) Health Survey. A mixed-model analytic approach was used to evaluate differences in outcomes between races at 24 months postoperatively, while controlling for relevant baseline characteristics and surgical factors.

RESULTS

Three hundred and twenty-four (67.64%) patients were Caucasian and 106 (22.13%) were East Asian. There was no difference in the incidence of ossification of the posterior longitudinal ligament (OPLL) between the two races; however a greater percentage of Caucasians in India (46.15%) and Turkey (41.38%) displayed evidence of OPLL than Caucasians in other regions (P < 0.001). The frequency of spondylosis was significantly higher in Caucasians (P < 0.001). Caucasians had a longer duration of symptoms (27.33 ± 34.47 months) than East Asians (23.11 ± 35.68 months) (P < 0.001), and a lower preoperative score on the SF-36 Physical Component Score (33.85 ± 9.04) than East Asians (37.47 ± 8.67) (P < 0.001). At 24 months after surgery, there were no differences in functional status or QOL between East Asians and Caucasians, after adjusting for baseline characteristics, surgical preferences, and disease causation. Rates of perioperative complications were not significantly different between the races (P = 0.261).

CONCLUSION

Decompressive surgery for DCM results in comparable functional gains and is equally safe in Caucasians and East Asians.

LEVEL OF EVIDENCE

2.

The influence of race and hospital environment on the care of patients with cervical spine fractures

BACKGROUND

The influence of non-white race on outcomes following orthopedic injury has been described in the past. The impact of such factors on hospital processes and quality of care after spinal trauma is less well understood.

STUDY DESIGN

A cohort control study using the Massachusetts Statewide Inpatient Dataset (2003-2010) was used as the study design.

PURPOSE

This study aimed to determine whether (1) hospital processes and quality of care associated with the treatment of cervical spine fractures was significantly altered by non-white race and (2) whether findings were different among those treated at academic medical centers (AMCs).

SAMPLE

The study comprised 10,841 patients.

OUTCOMES

Surgical rate, postoperative morbidity, mortality, and length of stay (LOS) were the outcome measures.

METHODS

Baseline differences between cohorts were evaluated using chi-square or Wilcoxon rank sum tests. Logistic and negative binomial regression techniques were used to adjust for confounders, including whether a surgical intervention was performed. Subset analyses were performed to evaluate whether findings were different for individuals treated at AMCs.

RESULTS

The rate of surgical intervention was not significantly different between non-whites and whites (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.82-1.04). LOS (regression coefficient [RC] 0.18, 95% CI 0.13-0.23), mortality (OR 1.49, 95% CI 1.20-1.85), and complications (OR 1.17, 95% CI 1.02-1.33) were significantly increased among non-white patients. These findings were largely preserved among those treated at AMCs.

CONCLUSIONS

Our results reinforce the fact that efforts at universal access to care may be insufficient to reduce differences in care among minority patients following cervical trauma. Future mixed-methods research is necessary to more effectively evaluate the etiologies behind health-care disparities associated with race in different health-care environments.

LEVEL OF EVIDENCE

The level of evidence is Level III, prognostic study.

Awareness of racial/ethnic disparities in surgical outcomes and care: factors affecting acknowledgment and action

BACKGROUND

Studies have demonstrated racial/ethnic disparities in surgical outcomes and care. Surgeon awareness and its association with institutional action remain unclear. The study sought to assess surgeons' awareness of racial/ethnic disparities, ascertain whether demographic and practice factors influence acknowledgement of disparities, and determine whether surgeons are seeking to mitigate disparities.

METHODS

Anonymous online survey was administered to a random sample of American College of Surgeons (ACS) general surgeons (July 2013 to March 2014). Responses were weighted for nonresponse and risk-adjusted using logistic regression.

RESULTS

172 surgeons completed the survey. Levels of acknowledged disparities were low. Less than one half reported institutional efforts to address disparities, and less than one fourth had taken efforts to investigate disparities in their personal practice. Several respondent factors including Academic Medical Center affiliation, awareness of the ACS statement on optimal access, and year of medical school graduation significantly associated with expressed acknowledgment of disparities.

CONCLUSIONS

Such associations speak to the need for continued efforts to promote enhanced provider awareness and participation. As the field of surgical disparities moves from understanding to action, we must acknowledge the contributing role that providers play.