Diabetes as an Independent Predictor for Extended Length of Hospital Stay and Increased Adverse Post-Operative Events in Patients Treated Surgically for Cervical Spondylotic Myelopathy

Clinicosocial determinants of hospital stay following cervical decompression: A public healthcare perspective and machine learning model

OBJECTIVE

Post-operative length of hospital stay (LOS) is a valuable measure for monitoring quality of care provision, patient recovery, and guiding hospital resource management. But the impact of patient ethnicity, socio-economic deprivation as measured by the indices of multiple deprivation (IMD), and pre-existing health conditions on LOS post-anterior cervical decompression and fusion (ACDF) is under-researched in public healthcare settings.

METHODS

From 2013 to 2023, a retrospective study at a single center reviewed all ACDF procedures. We analyzed 14 non-clinical predictors-including demographics, comorbidities, and socio-economic status-to forecast a categorized LOS: short (≤2 days), medium (2-3 days), or long (>3 days). Three machine learning (ML) models were developed and assessed for their prediction reliability.

RESULTS

2033 ACDF patients were analyzed; 79.44 % had a LOS ≤ 2 days. Significant predictors of LOS included patient sex (HR:0.81[0.74-0.88], p < 0.005), IMD decile (HR:1.38[1.24-1.53], p < 0.005), smoking (HR:1.24[1.12-1.38], p < 0.005), DM (HR:0.70[0.59-0.84], p < 0.005), and COPD (HR:0.66, p = 0.01). Asian patients had the highest mean LOS (p = 0.003). Testing on 407 patients, the XGBoost model achieved 80.95 % accuracy, 71.52 % sensitivity, 85.76 % specificity, 71.52 % positive predictive value, and a micro F1 score of 0.715. This model is available at: https://acdflos.streamlit.app.

CONCLUSIONS

Utilizing non-clinical pre-operative parameters such as patient ethnicity, socio-economic deprivation index, and baseline comorbidities, our ML model effectively predicts postoperative LOS for patient undergoing ACDF surgeries. Yet, as the healthcare landscape evolves, such tools will require further refinement to integrate peri and post-operative variables, ensuring a holistic decision support tool.

Postoperative Length of Stay in Patients With Stress Hyperglycemia Compared to Patients With Diabetic Hyperglycemia: A Retrospective Cohort Study

BACKGROUND

Postoperative hospital length of stay (LOS) is longer in patients with diabetes than in patients without diabetes. Stress hyperglycemia (SH) in patients without a history of diabetes has been associated with adverse postoperative outcomes. The effect of SH on postoperative LOS is uncertain. The aim of this study is to compare postoperative LOS in patients with SH to patients with diabetic hyperglycemia (DH) following noncardiac surgery.

METHODS

We carried out a retrospective cohort study of inpatients with at least two glucose measurements ≥180 mg/dL. Two groups were compared. Patients with SH had no preoperative history of diabetes. Patients were considered to have DH if they had an established preoperative diagnosis of diabetes mellitus or a preoperative hemoglobin A1c (HbA1c) ≥6.5%. The primary outcome measure was hospital LOS.

RESULTS

We included 270 patients with postoperative hyperglycemia-82 in the SH group and 188 in the DH group. In a linear regression analysis, hospital LOS was longer in the SH group than in the DH group (10.4 vs 7.3 days; P = .03). Within the SH group, we found no association between LOS and prompt treatment of hyperglycemia within 12 hours (P = .43), insulin dose per day (P = .89), or overall mean glucose (P = .13).

CONCLUSIONS

Postoperative LOS was even longer in patients with SH than in patients with DH, representing a potential target for quality improvement efforts. We did not, however, find evidence that improved treatment of SH was associated with reduction in LOS.

The significance of metabolic disease in degenerative cervical myelopathy: a systematic review

Introduction

Degenerative cervical myelopathy (DCM) is a form of chronic spinal cord injury, with a natural history of potential for progression over time. Whilst driven by mechanical stress on the spinal cord from degenerative and congenital pathology, the neurological phenotype of DCM is likely to be modified by multiple systemic factors. The role of metabolic factors is therefore of interest, particularly given that ischaemia is considered a key pathological mechanism of spinal cord injury. The objective was therefore to synthesise current evidence on the effect of metabolism on DCM susceptibility, severity, and surgical outcomes.

Methods

A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English, with a focus on DCM and metabolism, including diabetes, cardiovascular disease, anaemia, and lipid profile, were eligible for inclusion. Risk of methodological bias was assessed using the Joanna Briggs Institute (JBI) critical assessment tools. Quality assessments were performed using the GRADE assessment tool. Patient demographics, metabolic factors and the relationships between metabolism and spinal cord disease, spinal column disease and post-operative outcomes were assessed.

Results

In total, 8,523 papers were identified, of which 57 met criteria for inclusion in the final analysis. A total of 91% (52/57) of included papers assessed the effects of diabetes in relation to DCM, of which 85% (44/52) reported an association with poor surgical outcomes; 42% of papers (24/57) discussed the association between cardiovascular health and DCM, of which 88% (21/24) reported a significant association. Overall, DCM patients with diabetes or cardiovascular disease experienced greater perioperative morbidity and poorer neurological recovery. They were also more likely to have comorbidities such as obesity and hyperlipidaemia.

Conclusion

Metabolic factors appear to be associated with surgical outcomes in DCM. However, evidence for a more specific role in DCM susceptibility and severity is uncertain. The pathophysiology and natural history of DCM are critical research priorities; the role of metabolism is therefore a key area for future research focus.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021268814.

Impact of Frailty and Cervical Radiographic Parameters on Postoperative Dysphagia Following Anterior Cervical Spine Surgery

STUDY DESIGN

Retrospective review of a prospectively collected registry.

OBJECTIVE

The purpose of the present study was to investigate the impact of frailty and radiographical parameters on postoperative dysphagia after anterior cervical spine surgery (ACSS).

SUMMARY OF BACKGROUND DATA

There is a growing body of literature indicating an association between frailty and increased postoperative complications following various surgeries. However, few studies have investigated the relationship between frailty and postoperative dysphagia after anterior cervical spine surgery.

MATERIALS AND METHODS

Patients who underwent anterior cervical spine surgery for the treatment of degenerative cervical pathology were included. Frailty and dysphagia were assessed by the modified Frailty Index-11 (mFI-11) and Eat Assessment Tool 10 (EAT-10), respectively. We also collected clinical demographics and cervical alignment parameters previously reported as risk factors for postoperative dysphagia. Multivariable logistic regression was performed to identify the odds ratio (OR) of postoperative dysphagia at early (2-6 weeks) and late postoperative time points (1-2 years).

RESULTS

Ninety-five patients who underwent ACSS were included in the study. Postoperative dysphagia occurred in 31 patients (32.6%) at the early postoperative time point. Multivariable logistic regression identified higher mFI-11 score (OR, 4.03; 95% CI: 1.24-13.16; P =0.021), overcorrection of TS-CL after surgery (TS-CL, T1 slope minus C2-C7 lordosis; OR, 0.86; 95% CI: 0.79-0.95; P =0.003), and surgery at C3/C4 (OR, 12.38; 95% CI: 1.41-108.92; P =0.023) as factors associated with postoperative dysphagia.

CONCLUSIONS

Frailty, as assessed by the mFI-11, was significantly associated with postoperative dysphagia after ACSS. Additional factors associated with postoperative dysphagia were overcorrection of TS-CL and surgery at C3/C4. These findings emphasize the importance of assessing frailty and cervical alignment in the decision-making process preceding ACSS.

Shenqisherong pill ameliorates neuronal apoptosis by inhibiting the JNK/caspase-3 signaling pathway in a rat model of cervical cord compression

ETHNOPHARMACOLOGICAL RELEVANCE

The Shenqisherong (SQSR) pill is an empirical prescription of traditional Chinese medicine (TCM), which originated from the National Chinese Medical Science Master, Shi Qi. It has been widely used in the treatment of cervical spondylotic myelopathy (CSM) and promote the recovery of spinal cord function, but underlying molecular mechanism remains unclear.

AIM OF THE STUDY

The objective of this study was to confirm the neuroprotective effects of the SQSR pill.

MATERIALS AND METHODS

A rat model of chronic compression at double-level cervical cord was used in vivo. The protective role of SQSR pill on CSM rats was measured by Basso, Beattie, and Bresnahan (BBB) locomotor scale, inclined plane test, forelimb grip strength assessment, hindlimb pain threshold assessment, and gait analysis. The levels of reactive oxygen species (ROS) were examined by Dihydroethidium (DHE) staining and 2',7'-Dichlorofluorescein (DCF) assay, and apoptosis was detected by TdT-mediated dUTP nick-end labeling (TUNEL) assay. The expression of apoptosis proteins was evaluated by immunofluorescence staining and Western blot.

RESULTS

SQSR pill could facilitate locomotor function recovery in rats with chronic cervical cord compression, reduce local ROS in the spinal cord and downregulate the c-Jun-N-terminal kinase (JNK)/caspase-3 signaling pathway. In addition, the SQSR pill could protect primary rat cortical neurons from glutamate-treated toxicity in vitro by reducing the ROS and downregulating the phosphorylation of JNK and its downstream factors related to neuronal apoptosis meditated by the caspase cascade. Then, the neuroprotective effect was counteracted by a JNK activator.

CONCLUSIONS

Together, SQSR pill could ameliorate neuronal apoptosis by restraining ROS accumulation and inhibiting the JNK/caspase-3 signaling pathway, indicating that SQSR pill could be a candidate drug for CSM.

The Effects of Blood Glucose Control in the Operative Spine Patient: A Systematic Review

OBJECTIVE

To our knowledge, this is the first systematic review to evaluate the available literature on the effects of perioperative serum glucose (SG) on outcomes for patients undergoing spine surgery. This review will add insight into how the perioperative management of SG affects the outcomes of patients undergoing spine surgery.

METHODS

Three databases were used in this review including Embase, PubMed, and Cochrane Library. The searches were from 2012 to 2022 and included the terms "spine surgery" and "glucose level" to identify studies that demonstrated a correlation between glucose level and postoperative outcomes. Pediatric studies, those that did not specify spine surgical outcomes related to glucose levels, and non-English studies were excluded. The methodological items for nonrandomized studies score was used to assess risk of bias in the included studies.

RESULTS

This review included a total of 9 cohort studies, both prospective and retrospective, encompassing a total of 431,156 subjects. Seven of the 9 studies reported an increased overall complication rate among patients with diabetes or with higher SG levels, and 4 studies demonstrated an increased infection rate among this population. Two studies reported an association between decreased SG levels and improved neurological recovery when a deficit was present preoperatively, and 1 of the studies found that this association was statistically significant.

LIMITATIONS

Limitations of this review include lack of standardization regarding type of surgery, location of the spine, and level of evidence.

CONCLUSION

Most of the current literature suggests that elevated SG levels in patients undergoing spine surgery likely leads to higher complication rates and may lead to increased infection rates, and this review reinforced the current evidence. Additionally, perioperative SG levels may be associated with the extent of neurological recovery after surgery, but further investigation may be warranted.

CLINICAL RELEVANCE

This review adds to the current body of evidence regarding perioperative SG levels and its association with complications.

LEVEL OF EVIDENCE: 2

Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery

STUDY DESIGN/SETTING

Retrospective cohort study.

OBJECTIVE

Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery.

METHODS

ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility.

RESULTS

By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001).

CONCLUSIONS

The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III.

Preoperative considerations for patients with diabetes

INTRODUCTION

Patients undergoing surgery require a thorough assessment preoperatively. Hyperglycemia is associated with poor outcomes, and stability of glucose levels is an important factor in preoperative management. Diabetes presents a particular challenge since patients are often on multiple medications encompassing glycemic management and cardiovascular therapies.

AREAS COVERED

A PubMed search of published data and reviews on preoperative approaches in diabetes was conducted. Consensus opinion drives most of the guidelines and recommendations for management of diabetes in surgical patients. Pathophysiology is often complex with varying levels of glucose and surgical stress. Establishing well-controlled diabetes prior to surgical intervention should be standard practice in non-emergent procedures. We review the best practices for implementing preoperative assessment, with diabetes with a focus on diabetes medications.

EXPERT OPINION

The management of a patient preoperatively varies by region and country. Institutions differ in approaches to preoperative evaluation and the establishment of consistent approaches would provide a platform for monitoring patient outcomes. Multidisciplinary teams and pre-assessment clinics for preoperative evaluation can enhance patient care for those undergoing surgery.

Risk factors for surgical site infection in advanced neuromodulation pain procedures: a retrospective study

Aim: To assess the effects of diabetes mellitus (DM) and related variables on surgical site infection (SSI) risk in neuromodulation. Methods: This retrospective study followed patients who underwent neuromodulation procedures for at least 9 months to identify postoperative infections. Demographics, clinical characteristics and surgical outcomes were compared. Results: Of 195 cases included, 5 (2.6%) resulted in SSIs. Median HbA1c was significantly higher for the cases with SSIs (8.2 vs 5.6%; p = 0.0044). The rate of SSI was significantly higher among patients with DM (17.9 vs 0%; p = 0.0005), HbA1c≥7% (37.5 vs 0%; p = 0.0009), and perioperative glucose ≥200 mg/dl (40 vs 2.3%; p = 0.0101). Conclusion: DM, elevated HbA1c and perioperative hyperglycemia may all contribute to increased risk of SSIs with neuromodulation procedures.

Postoperative short-term mortality between insulin-treated and non-insulin-treated patients with diabetes after non-cardiac surgery: a systematic review and meta-analysis

Background

Diabetes mellitus is an independent risk factor for postoperative complications. It has been reported that insulin-treated diabetes is associated with increased postoperative mortality compared to non-insulin-treated diabetes after cardiac surgery; however, it is unclear whether this finding is applicable to non-cardiac surgery.

Objective

We aimed to assess the effects of insulin-treated and non-insulin-treated diabetes on short-term mortality after non-cardiac surgery.

Methods

Our study was a systematic review and meta-analysis of observational studies. PubMed, CENTRAL, EMBASE, and ISI Web of Science databases were searched from inception to February 22, 2021. Cohort or case-control studies that provided information on postoperative short-term mortality in insulin-treated diabetic and non-insulin-treated diabetic patients were included. We pooled the data with a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to rate the quality of evidence.

Results

Twenty-two cohort studies involving 208,214 participants were included. Our study suggested that insulin-treated diabetic patients was associated with a higher risk of 30-day mortality than non-insulin-treated diabetic patients [19 studies with 197,704 patients, risk ratio (RR) 1.305; 95% confidence interval (CI), 1.127 to 1.511; p < 0.001]. The studies were rated as very low quality. The new pooled result only slightly changed after seven simulated missing studies were added using the trim-and-fill method (RR, 1.260; 95% CI, 1.076-1.476; p = 0.004). Our results also showed no significant difference between insulin-treated diabetes and non-insulin-treated diabetes regarding in-hospital mortality (two studies with 9,032 patients, RR, 0.970; 95% CI, 0.584-1.611; p = 0.905).

Conclusion

Very-low-quality evidence suggests that insulin-treated diabetes was associated with increased 30-day mortality after non-cardiac surgery. However, this finding is non-definitive because of the influence of confounding factors.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021246752, identifier: CRD42021246752.

Safety of body contouring surgery in an aging patient population

The fastest-growing age group undergoing cosmetic procedures are those over age 60, i.e. the aging patient group. While advanced age is a known predictor for increased surgical complications, the effects of age on complications in specific plastic procedures have yet to be thoroughly investigated. To determine the relationship between increased age and risk of surgical complications following body contouring procedures, specifically: abdominoplasty, brachioplasty, mastopexy, bilateral reduction, and thigh lift. A retrospective analysis of all patients undergoing body contouring procedures of the categories mentioned above between 2000-2018 at a tertiary university medical center. Patients were divided into two age groups: those below and those above, age 60. Data analysis included: demographics, underlying medical conditions, procedure type, and occurrence of postoperative complications (according to the Clavien-Dindo classification system). 803 body contouring procedures were identified, with 12% performed on the aging population. Aging patients had more underlying medical conditions than the younger ones. While the distribution of procedure type was similar in both groups, mastopexy was more common in aging patients. Of the 107 procedures identified as having complications, 37 were classified as grade I, 38 as grade II, and 32 as grade III. As a categorical variable, no relationship was found between the age of the patients and an increased risk of postoperative complications (age cut-off as 60). However, as a continuous variable, increased age did increase the overall risk of postoperative complications, although no optimal age as a cut-off point was identified. In multivariant analysis, diabetes mellitus with abdominoplasty was identified as a risk factor for postoperative complications. Conclusions: When undergoing body contouring procedures, we found that patients over the age of 60 are not at increased risk for postoperative complications than those under that age. Although age as a continuous variable was found to increase the overall postoperative complications, no optimal age could be defined as a cut-off point.

Stationäre Patienten mit der Nebendiagnose Diabetes mellitus: klinische Relevanz

In deutschen Krankenhäusern werden jährlich etwa 3 Mio. Patienten mit Diabetes stationär behandelt, davon 93 % nicht wegen, sondern mit dieser Erkrankung. In einzelnen Fachabteilungen liegt bei bis zu 40 % der Patienten die Nebendiagnose Diabetes vor. Sie haben oft eine relevante Komorbidität und im Vergleich zu Krankenhauspatienten ohne Diabetes eine längere stationäre Verweildauer, entwickeln deutlich häufiger Komplikationen und müssen öfter kurzfristig wieder aufgenommen werden. In dieser Übersicht wird die klinische Relevanz der Nebendiagnose Diabetes mellitus für Krankenhauspatienten besprochen.

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

Intensive glucose control during the perioperative period for diabetic patients undergoing surgery: An updated systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate the impact of intensive glucose control on diabetic patients undergoing surgery.

DESIGN

A systematic review and meta-analysis of randomized controlled trials. PubMed, CENTRAL, EMBASE, ISI Web of Science, and CINAHL databases were searched from inception to 13 December 2020.

SETTING

Operating room, postoperative recovery area and ward, up to 30 days after surgery.

PATIENTS

Diabetic patients undergoing surgery.

INTERVENTIONS

We used Review Manager 5.4 to pool the data with a random-effects model. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation system.

MEASUREMENTS

The primary outcomes were infectious complications, postoperative mortality, and hypoglycaemia. The secondary outcomes included atrial fibrillation, myocardial infarction, stroke, delirium, renal failure, postoperative mechanical ventilation time, length of intensive care unit (ICU) stay, and hospital stay.

MAIN RESULTS

Thirteen studies involving 1582 participants were included. Compared with conventional glucose control, intensive glucose control was associated with a lower risk of infectious complications (risk ratio [RR], 0.35; 95% confidence interval [CI], 0.19-0.63; low-quality evidence), atrial fibrillation (RR, 0.55; 95% CI, 0.42-0.71; high-quality evidence), and renal failure (RR, 0.38; 95% CI, 0.15-0.95; moderate-quality evidence), as well as a shorter length of stay in the ICU (mean difference (MD), -0.55 day; 95% CI, -1.05 to -0.05 days; very-low-quality evidence) and hospital (MD, -1.61 days; 95% CI, -2.78 to -0.44 days; very-low-quality evidence). However, intensive glucose control was associated with a higher risk of hypoglycaemia (RR, 3.00; 95% CI, 1.97-4.55; high-quality evidence). There were no significant differences in postoperative mortality, myocardial infarction, stroke, delirium, or postoperative mechanical ventilation time.

CONCLUSIONS

Intensive glucose control in diabetic patients is associated with a reduction in some adverse postoperative outcomes including infectious complications, but also appears to increase the risk of hypoglycaemia. Further well-designed studies may be needed to determine appropriate regimens to reduce hypoglycaemia incidence.

PROSPERO REGISTRATION NUMBER

CRD42021226138.

Length of Stay Beyond Medical Readiness in a Neurosurgical Patient Population and Associated Healthcare Costs

BACKGROUND

Length of stay beyond medical readiness (LOS-BMR) leads to increased expenses and higher morbidity related to hospital-acquired conditions.

OBJECTIVE

To determine the proportion of admitted neurosurgical patients who have LOS-BMR and associated risk factors and costs.

METHODS

We performed a prospective, cohort analysis of all neurosurgical patients admitted to our institution over 5 mo. LOS-BMR was assessed daily by the attending neurosurgeon and neuro-intensivist with a standardized criterion. Univariate and multivariate logistic regressions were performed.

RESULTS

Of the 884 patients admitted, 229 (25.9%) had a LOS-BMR. The average LOS-BMR was 2.7 ± 3.1 d at an average daily cost of $9 148.28 ± $12 983.10, which resulted in a total cost of $2 076 659.32 over the 5-mo period. Patients with LOS-BMR were significantly more likely to be older and to have hemiplegia, dementia, liver disease, renal disease, and diabetes mellitus. Patients with a LOS-BMR were significantly more likely to be discharged to a subacute rehabilitation/skilled nursing facility (40.2% vs 4.1%) or an acute/inpatient rehabilitation facility (22.7% vs 1.7%, P < .0001). Patients with Medicare insurance were more likely to have a LOS-BMR, whereas patients with private insurance were less likely (P = .048).

CONCLUSION

The most common reason for LOS-BMR was inefficient discharge of patients to rehabilitation and nursing facilities secondary to unavailability of beds at discharge locations, insurance clearance delays, and family-related issues.

Two-Year Clinical and Radiological Outcomes in Patients With Diabetes Undergoing Single-Level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Secondary analysis of data from the multicenter, randomized, parallel-controlled Food and Drug Administration (FDA) investigational device exemption study.

OBJECTIVE

Studies on outcomes following anterior cervical discectomy and fusion (ACDF) in individuals with diabetes are scarce. We compared 24-month radiological and clinical outcomes in individuals with and without diabetes undergoing single-level ACDF with either i-FACTOR or local autologous bone.

METHODS

Between 2006 and 2013, 319 individuals with single-level degenerative disc disease (DDD) and no previous fusion at the index level underwent ACDF. The presence of diabetes determined the 2 cohorts. Data collected included radiological fusion evaluation, neurological outcomes, Neck Disability Index (NDI), Visual Analog Scale (VAS) scores, and the 36-Item Short Form Survey Version 2 (SF-36v2) Physical and Mental component summary scores.

RESULTS

There were 35 individuals with diabetes (11.1%; average body mass index [BMI] = 32.99 kg/m²; SD = 5.72) and 284 without (average BMI = 28.32 kg/m²; SD = 5.67). The number of nondiabetic smokers was significantly higher than diabetic smokers: 73 (25.70%) and 3 (8.57%), respectively. Preoperative scores of NDI, VAS arm pain, and SF-36v2 were similar between the diabetic and nondiabetic participants at baseline; however, VAS neck pain differed significantly between the cohorts at baseline (P = .0089). Maximum improvement for NDI, VAS neck and arm pain, and SF-36v2 PCS and MCS scores was seen at 6 months in both cohorts and remained stable until 24 months.

CONCLUSIONS

ACDF is effective for cervical radiculopathy in patients with diabetes. Diabetes is not a contraindication for patients requiring single-level surgery for cervical DDD.

Effect of Titanium Miniplate Fixation on Hinge Fracture and Hinge Fracture Displacement Following Cervical Open-Door Laminoplasty

BACKGROUND

Cervical spondylotic myelopathy is a neuromotor disorder responsible for functional limitations and decreased daily activities. Expansive open-door laminoplasty is the widely accepted procedure for the treatment of multilevel cervical spondylotic myelopathy. Among the various fixation procedures to secure the open lamina, miniplate fixation provides better clinical and radiological outcomes. However, the immediate effects on hinge fracture and hinge fracture displacement following miniplate fixation have not been proven until now. The purpose of our study was to elucidate the impact of cervical open-door angle on the status of spinal cord expansion and hinge fracture, hinge fracture displacement, and the role of implants used during surgery.

METHODS

For this retrospective study, 122 patients who had undergone surgery from September 2016 to November 2017 with preoperative and postoperative radiographs were enrolled. Clinical and radiological outcomes were assessed before and after surgery.

RESULTS

There were no significant differences in demographics, surgery time, blood loss, medical comorbidities, or perioperative and postoperative complications between 2 groups. The recovery rate and Nurick score before and at the follow-up show no statistical significance between the 2 groups, P value > .05 (P = .672) and P > .05 (P = .553), respectively. The statistical analysis shows that the mean hinge fracture in the miniplate group with a cervical open angle >30° was 2.42 ± 1.68 and with a <30° open angle, 0.05 ± 0.23; whereas, in the anchor group the mean hinge fracture in >30° cervical open angle was 2.227 ± 2.50 and in <30° was 0.409 ± 0.503. The results revealed statistical significance between 2 implant groups, P = .024 in the aspect of hinge fracture displacement and implant used.

CONCLUSION

Laminoplasty by titanium miniplate fixation holds the laminae securely, prevents hinge fracture displacement, and promotes spinal cord expansion better than suture anchor fixation.

Diabetes Does Not Increase Complications, Length of Stay, or Hospital Costs After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To determine if the presence of diabetes mellitus as comorbidity is associated with complications, inpatient length of stay, or direct hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

Very few studies have investigated the effect of diabetes on complications, length of stay, or costs in minimally invasive lumbar surgeries.

METHODS

Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed. Diabetic and nondiabetic patients were propensity matched in a 1:1 manner for age, sex, and comorbidity burden. An association between diabetic status and preoperative demographic or perioperative variables, including inpatient length of stay, was tested for using Student t test or χ analysis. Multivariate linear regression was used to test for an association between diabetic status and direct hospital costs.

RESULTS

After 1:1 propensity matching, 100 patients were included in this analysis. There were no significant differences in age, sex, body mass index, smoking status, or Charlson Comorbidity Index between propensity-matched patients with and without diabetes. In regards to the length of stay, no significant differences existed between diabetic and nondiabetic groups (68.7 vs. 58.3 h, P=0.218). No other significant differences existed in other perioperative variables including operative time, intraoperative blood loss, or complication rate (P≥0.05 for each). Multivariate analysis indicated that diabetic status was not associated with differences in total direct hospital costs (US$20,428 vs. US$20,429, P=0.792) or cost subcategories after MIS TLIF (P≥0.05 for each).

CONCLUSIONS

In this investigation, diabetes was not associated with postoperative complication rates, inpatient length of stay, or direct hospital costs after primary, single-level MIS TLIF. The reduced extent of operative exposure and tissue trauma in MIS TLIF may mitigate the risk of complications in diabetic patients, possibly preventing extensions in hospital stay length and associated hospital costs.

Diabetes in day case general and vascular surgery: A multicentre regional audit

BACKGROUND

People with Diabetes Mellitus (DM) are at increased risk of postoperative complications if their HbA1C readings are not well controlled. In the UK, there are clear national guidelines requiring all people with DM to have HbA1C blood testing within 6months before undergoing surgery and that these readings should be below 69 mmol/mol if this is safe to achieve. The aim of this study was to determine whether hospitals in the region were compliant with the guidelines.

METHODS

Data were prospectively collected from seven hospitals across the East of England region from 1st October 2017 to 31st March 2018 (6 months) in all people with DM undergoing elective day case procedures in General and Vascular surgery for benign disease.

RESULTS

A total of 181 people with DM were included in the study, of whom 77.9% were male patients and the median age was 63 years. The three most commonly performed operations were laparoscopic cholecystectomy (20.9%, n = 38/181), inguinal hernia repair (20.4%, n = 37/181) and umbilical/para-umbilical hernia repair (11.0%, n = 20/181). In keeping with the national guidelines, only 86.7% (n = 157/181) of patients had an HbA1C tested within 6 months prior to their surgery date. Of the patients who had a preoperative HbA1C, 14 (n = 14/157, 8.9%) had an HbA1C ≥ 69 mmol/mol, and 12 (n = 12/14, 85.7%) of these proceeded to surgery without optimisation of their HbA1C.

CONCLUSION

A significant proportion of people with diabetes undergoing elective day case procedures in our region do not have HbA1C testing within 6 months of their procedure as recommended by the national guidelines. In patients who do have a high HbA1C, the majority still undergo surgery without adequate control of their DM. Greater awareness amongst healthcare workers and robust pathways are required for this vulnerable group of patients if we are to reduce the risk of developing postoperative complication rates.

Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies

Posterior cervical decompression and fusion (PCF) is a common surgical technique used to treat various cervical spine pathologies. However, there are various complications associated with PCF that can negatively impact patient outcome. We performed a comprehensive literature review to identify the most common complications following PCF using PubMed, Cochrane Database of Systematic Reviews, and Google Scholar. The overall complication rates of PCF are estimated to range from about 15% to 25% in the current literature. The most common immediate complications include acute blood loss anemia, surgical site infection (SSI), C5 palsy, and incidental durotomy; the most common long-term complications include adjacent segment degeneration, junctional kyphosis, and pseudoarthrosis. Three principal mechanisms are thought to contribute to complications. First, higher number of fusion levels, obesity, and more complex pathologies can increase the invasiveness of the planned procedure, thus increase complications. Second, wound healing and arthrodesis may be impaired due to poor blood flow due to various patient factors such as smoking, diabetes, increased frailty, steroid use, and other medical comorbidities. Finally, increased biomechanical stress on the upper instrumented vertebra (UIV) and lowest instrumented vertebra (LIV) may predispose patient to chronic degeneration and result in adjacent level degeneration and/or junctional problems. Reducing the modifiable risk factors pre-operatively can decrease the overall complication rate. Neurologic deficits may be reduced with adequate intraoperative decompression of neural elements. SSI may be reduced with meticulous wound closure that minimizes dead space, drain placement, and the use of intra-wound antibiotics. Careful design of the fusion construct with consideration in spinal alignment and biomechanics can help to reduce the rate of junctional problems. Spine surgeons should be aware of these complications associated with PCF and the corresponding prevention strategies optimize patient outcomes.

Infection prevention in cervical spine surgery

Surgical site infections (SSI) following cervical spine surgery can lead to significant patient morbidity and costs. Prevention of SSIs is multifactorial and can be divided in to preoperative patient optimization and intraoperative surgical factors. We performed a literature review to identify methods that can be used to prevent SSI development specifically in the cervical spine. We also present specific surgical pearls and techniques that have the potential to significantly decrease rates of cervical SSIs.

Preoperative Narcotic Use, Impaired Ambulation Status, and Increased Intraoperative Blood Loss Are Independent Risk Factors for Complications Following Posterior Cervical Laminectomy and Fusion Surgery

OBJECTIVE

This retrospective cohort study seeks to identify risk factors associated with complications following posterior cervical laminectomy and fusion (PCLF) surgery.

METHODS

Adults undergoing PCLF from 2012 through 2018 at a single center were identified. Demographic and radiographic data, surgical characteristics, and complication rates were compared. Multivariate logistic regression models identified independent predictors of complications following surgery.

RESULTS

A total of 196 patients met the inclusion criteria and were included in the study. The medical, surgical, and overall complication rates were 10.2%, 23.0%, and 29.1% respectively. Risk factors associated with medical complications in multivariate analysis included impaired ambulation status (odds ratio [OR], 2.27; p=0.02) and estimated blood loss over 500 mL (OR, 3.67; p=0.02). Multivariate analysis revealed preoperative narcotic use (OR, 2.43; p=0.02) and operative time (OR, 1.005; p=0.03) as risk factors for surgical complication, whereas antidepressant use was a protective factor (OR, 0.21; p=0.01). Overall complication was associated with preoperative narcotic use (OR, 1.97; p=0.04) and higher intraoperative blood loss (OR, 1.0007; p=0.03).

CONCLUSION

Preoperative narcotic use and estimated blood loss predicted the incidence of complications following PCLF for CSM. Ambulation status was a significant predictor of the development of a medical complication specifically. These results may help surgeons in counseling patients who may be at increased risk of complication following surgery.

[Increase of reparative potential of fabrics in sugar diabetes]

AIM

The purpose of the study was to study the effectiveness of the domestic drug Remaxol in reparative processes of laparotomic wound tissues in acute surgical abdominal pathology in patients with diabetes mellitus.

MATERIAL AND METHODS

Clinical and laboratory studies were performed in 86 patients with acute surgical pathology of the abdominal cavity, 56 patients with type 1 diabetes mellitus, including 26 patients who received Remaxol in the early postoperative period (daily intravenous infusions of 400.0 ml for 5 days).

RESULTS

It was established that diabetes mellitus is an important aggravating factor in the reparative process of tissue structures of a laparotomic wound. Undoubtedly, a significant factor in reducing the reparative potential of tissues is a significant activation of factors leading to membrane-destabilizing phenomena - oxidative stress, activation of phospholipases, hypoxia. The inclusion of Remaxol, which has antioxidant and antihypoxic effects, allows to significantly correct these pathogenetic components, which is the basis for optimization of the reparative process against the background of diabetes mellitus. There was a significant decrease in wound complications in the early postoperative period, a significant reduction in the stay of patients in the hospital.