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Hendrix CG, Goheer HE, Newcomb AH, Carmouche JJ. Advanced chronic kidney disease increases complications in anterior cervical discectomies with fusions: An analysis of 75,508 patients. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 19:100331. [PMID: 39006534 PMCID: PMC11239708 DOI: 10.1016/j.xnsj.2024.100331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 07/16/2024]
Abstract
Background Although anterior cervical discectomy and fusion (ACDF) procedures for cervical spine disease have been increasing amid a growing population of patients with kidney dysfunction, there is a scarcity of literature focusing on kidney dysfunction as a risk-factor for post-operative ACDF complications. The purpose is to evaluate the differential impact of kidney dysfunction on perioperative outcomes including surgical and medical complications, extended length of hospital stay (LOS), and death within 30 days following ACDF. Patient Sample This was a retrospective cohort study of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who had undergone an elective ACDF procedure between 2011-2021 using Current Procedural Terminology code 22551. Patients were categorized into five cohorts based on eGFR according to the "Kidney Disease: Improving Global Outcomes" Classification: values of: ≥ 90(reference cohort), 60-89 (G2), 30-59 (G3), 15-29 (G4), and <15 (G5). One-way ANOVA for continuous variables and chi-square tests for categorical variables were used to identify differences in perioperative variables between the five groups. Multivariable logistic regression analysis assessed the effect of kidney dysfunction on post-operative surgical outcomes. Significance was defined as p<.05. Results About 75,508 ACDF patients were included, of who 57,480 were G1, 15,186 were G2, 2,192 were G3, 312 were G4, and 338 were G5. G4 and G5 independently increased the risk of medical complications (OR: 1.893, 95% CI [1.296-2.705]; OR: 2.241, 95% CI [1.222-3.964]) and blood transfusion. Only G5 independently increased the risk for extended LOS (OR: 2.410, 95% CI [1.281-4.371], p=.005). Conclusion High grade CKD is an independent risk factor for medical complications, extended hospital LOS, and blood transfusions following ACDF, underscoring the importance of risk stratification to optimize perioperative management and reduce the burden of complications and healthcare costs. Conversely, low grade CKD does not increase the risk of complications in ACDF.
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Affiliation(s)
- Christopher G. Hendrix
- Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, 2331 Franklin Road Southwest, Roanoke, VA 24014, United States
| | - Haseeb E. Goheer
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, United States
| | - Alden H. Newcomb
- Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, 2331 Franklin Road Southwest, Roanoke, VA 24014, United States
| | - Jonathan J. Carmouche
- Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, 2331 Franklin Road Southwest, Roanoke, VA 24014, United States
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA 24016, United States
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Arnautovic A, Mijares J, Begagić E, Ahmetspahić A, Pojskić M. Four-level ACDF surgical series 2000-2022: a systematic review of clinical and radiological outcomes and complications. Br J Neurosurg 2024:1-12. [PMID: 38606493 DOI: 10.1080/02688697.2024.2337020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE The primary objective of this investigation is to systematically scrutinize extant surgical studies delineating Four-Level Anterior Cervical Discectomy and Fusion (4L ACDF), with a specific emphasis on elucidating reported surgical indications, clinical and radiological outcomes, fusion rates, lordosis correction, and the spectrum of complication rates. METHODS The literature review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, employing the MEDLINE (PubMed), Embase, and Scopus databases. This analysis encompasses studies implementing the 4L ACDF procedure, with detailed extraction of pertinent data pertaining to surgical methodologies, types of employed interbody cages, clinical and radiological endpoints, rates of fusion, and the incidence of complications. RESULTS Among the 15 studies satisfying inclusion criteria, a marginal increment in the year 2022 (21.4%) was discerned, with a preponderance of study representation emanating from China (35.7%) and the United States (28.6%). 50% of the studies were single-surgeon studies. Concerning follow-up, studies exhibited variability, with 42.9% concentrating on periods of five years or less, and an equivalent proportion extending beyond this timeframe. Across the amalgamated cohort of 2457 patients, males constituted 51.6%, manifesting a mean age range of 52.2-61.3 years. Indications for surgery included radiculopathy (26.9%) and myelopathy (46.9%), with a predilection for involvement at C3-7 (24.9%). Meta-analysis yielded an overall complication rate of 16.258% (CI 95%: 14.823%-17.772%). Dysphagia (4.563%), haematoma (1.525%), hoarseness (0.205%), C5 palsy (0.176%) were the most prevalent complications of 4L ACDF. Fusion rates ranging from 41.3% to 94% were documented. CONCLUSION The 4L ACDF is commonly performed to address mylopathy and radiculopathy. While the surgery carries a complication rate of around 16%, its effectiveness in achieving bone fusion can vary considerably.
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Affiliation(s)
- Alisa Arnautovic
- George Washington University School of Medicine, Washington, DC, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph Mijares
- George Washington University School of Medicine, Washington, DC, USA
| | - Emir Begagić
- Department of General Medicine, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Adi Ahmetspahić
- Department of Neurosurgery, Clinical Center of Sarajevo University, Sarajevo, Bosnia and Herzegovina
| | - Mirza Pojskić
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- School of Medicine, Josip Juraj Strossmayr University, Osijek, Croatia
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Ye J, Zielinski E, Richardson S, Petrone B, McCarthy MM, Boody B. Is It Safe to Perform True Outpatient Multilevel ACDFs in a Surgery Center? Clin Spine Surg 2023; 36:151-153. [PMID: 36727974 DOI: 10.1097/bsd.0000000000001415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Jason Ye
- Indiana Spine Group, Carmel Carmel
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Koller H, Hostettler IC, Stengel FC, Koller J, Ferraris L, Hitzl W, Hempfing A. Surgical Realignment After Anterior Multilevel Decompression Using Cages and Plate for 3-level to 5-level Degenerative Fusions: Lessons Learned From the Analysis of Geometric Changes, Reciprocal Coupling, and Prediction of Sagittal Cervical Balance. Clin Spine Surg 2022; 35:E649-E659. [PMID: 35700093 DOI: 10.1097/bsd.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 03/01/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective, single-center case study. OBJECTIVE Postoperative cervical imbalance with cervical sagittal vertical axis (cSVA) >4 cm can be predicted in 3-level to 5-level anterior-only cervical multilevel fusion surgery (ACMS). SUMMARY OF BACKGROUND DATA Previous studies established correlations between cervical kyphosis (CK) correction and postoperative balance (cSVA ≤4 cm) with improved clinical outcomes. Understanding of what influences restoration of cervical lordosis (CL) in patients with degenerative disease with mild to moderate CK subjected to ACMS is important. To achieve a better understanding of geometric changes after ACMS, this study examines factors predicting perioperative alignment changes and regional interdependencies. MATERIALS AND METHODS Analysis of patients with ACMS. Analysis included patient baseline characteristics, demographics and complications, and focused on radiographic measures including CL C2-7, fusion angle (FA), C7-Slope (C7S), T1-slope (T1S), T1-CL mismatch, and cSVA (cSVA ≤4 cm/>4 cm). We aimed to predict postoperative imbalance (cSVA >4 cm) and conducted a multivariable logistic regression analysis. RESULTS Inclusion of 126 patients with 3-level to 5-level ACMS, mean age was 56 years and 4 fusion levels on average. Preoperative CK was present in 9%, mean FA-correction was 8 degrees, maximum 46 degrees. Postoperatively, 14 patients had cSVA >4 cm. A neural network model for prediction of cSVA >4 cm was established including preoperative cSVA, preoperative CL and correction of FA. The model achieved high performance (positive predictive value=100%, negative predictive value=94%, specificity=100%, sensitivity=20%). Also, variables such as nonunion, chronic lumbar pain or thoracolumbar multilevel fusion influenced the postoperative cSVA >4 cm rate. Alignment analysis highlighted strong correlations between C7S/T1S and cSVA/C2-tilt ( r =0.06/ r =0.7, P <0.0001). A formula was established to transfer cSVA data into C2-tilt data. CONCLUSION This study identified independent variables predicting postoperative cSVA >4 cm including FA, which can be influenced by the surgeon. Our model supports the decision-making process targeting a postoperative cSVA ≤4 cm.
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Affiliation(s)
- Heiko Koller
- Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Isabel C Hostettler
- Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Felix C Stengel
- Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Juliane Koller
- Department for Orthopedic Surgery, Schoen Clinic Vogtareuth, Vogtareuth
| | - Luis Ferraris
- Spine Center, Werner-Wicker-Clinic, Bad Wildungen, Germany
| | - Wolfgang Hitzl
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
| | - Axel Hempfing
- Spine Center, Werner-Wicker-Clinic, Bad Wildungen, Germany
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Bakare AA, Smitherman AD, Fontes RBV, O'Toole JE, Deutsch H, Traynelis VC. Clinical outcomes after 4- and 5-level Anterior Cervical Discectomy and Fusion for treatment of symptomatic multilevel cervical spondylosis. World Neurosurg 2022; 163:e363-e376. [PMID: 35367642 DOI: 10.1016/j.wneu.2022.03.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE There are limited patient-reported outcome measure (PROM) data on 4- and 5-level ACDF. The largest series to date solely focused on complications. This retrospective series evaluates PROMs after 4- and 5-level ACDF. METHODS Pertinent data from adult patients treated with a 4- or 5-level ACDF in 2011-2019 were analyzed. PROMs and minimal clinically important differences (MCID) were assessed. Factors associated with favorable and unfavorable outcomes were identified. RESULTS There were thirty-four patients (thirty underwent 4-level and four underwent 5-level ACDFs) with mean age of 59.6; 55.9% were women. At 3 months, there were significant improvements in PROMs except SF-12 MCS with modest improvement. At 12 months, there were significant improvements in PROMs except SF-12 PCS with moderate improvement. The proportions of patients that met the MCID cut-offs ranged from 35.3% (NRS-neck) to 75% (VR-12 PCS) at 3 months and 38.2% (NRS-arm) to 65.5% (VR-12 MCS) at 12 months. Shorter symptom duration was associated with significantly reduced postoperative pain and NDI scores. Shorter length of stay was associated with significantly improved postoperative functional outcomes. 4-level compared 5-level ACDF patients achieved better postoperative PROMs. Shorter procedure duration was associated with improved PROMs at 3 months. No patients returned to the operating room within 30 days. Patients that required reoperation achieved significantly inferior NDI, NRS-neck, and SF-12 PCS at 3 months. CONCLUSIONS This study demonstrated satisfactory PROMs up to 12 months after 4- and 5-level ACDF despite the complication rate. With thorough preoperative planning and meticulous technique, performing this procedure in carefully selected patients may be associated with acceptable PROM.
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Affiliation(s)
- Adewale A Bakare
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
| | | | | | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
| | - Harel Deutsch
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
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Are outpatient three- and four-level anterior cervical discectomies and fusion safe? Spine J 2021; 21:231-238. [PMID: 33049410 DOI: 10.1016/j.spinee.2020.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The safety of outpatient one- and two-level anterior cervical discectomy and fusion (ACDF) has been validated in a number of recent studies. However, recent advancements in anesthetic and surgical technique have rendered procedures previously only performed in an inpatient setting, such as three- and four-level ACDF, potentially amenable to outpatient management. PURPOSE The present study aimed to investigate the safety of outpatient three- and four-level ACDF. STUDY DESIGN Retrospective cohort study PATIENT SAMPLE: The National Surgical Quality Improvement Program - a large, prospectively-collected registry - was queried to identify patients undergoing three- and four-level ACDF in an inpatient and outpatient setting. OUTCOME MEASURES The rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status. METHODS Baseline patient characteristics and 30-day outcomes were tabulated and compared by inpatient or outpatient status using bivariate analysis. A multivariate analysis was also employed to adjust for differences in baseline patient characteristics when comparing outcomes, and was also used to identify independent predictors of complications and readmissions in patients undergoing three- and four-level ACDF. RESULTS In total 3,441 patients underwent three- or four-level ACDF, with 2,718 (79.0%) procedures occurring inpatient and 723 (21.0%) outpatient. Of patients undergoing outpatient ACDF, 596 patients (82.4%) underwent a three-level and 127 patients (17.6%) underwent four-level procedures. There was an increase in the utilization of outpatient procedures, increasing from 7.0% to 32.9% between 2011 and 2018. Patients undergoing outpatient surgery were younger, white, more likely to have three-level fusions (vs four-level), had a lower American Society of Anesthesiologists (ASA) classification, and were less likely to have a history of diabetes mellitus or dependent functional status. Among the inpatient and outpatient cohorts, there was no significant difference in the rates of total complications (4.49% vs 2.49%) or unplanned readmissions (4.96% vs 3.72%). Increasing age, operative duration, and ASA classification were independent predictors of complications and readmissions, however, inpatient or outpatient surgery status and number of levels fused was not. CONCLUSIONS This present study represents one of the largest cohorts of patients undergoing outpatient three- and four-level ACDF. Outpatient multilevel ACDF is performed in younger and healthier patients, with three-level procedures more commonly the four-level. There was no observed increased rates of total complications or readmissions in patients undergoing outpatient relative to inpatient surgery, however, we did identify increased age, operative duration, and ASA classification as independent predictors of these complications. Patient selection for outpatient procedures is of the highest importance, and future studies developing reproducible selection criteria are warranted.
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Samuel AM, Langhans MT, Iyer S. Spine surgeon ownership of ambulatory surgery centers. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S161. [PMID: 31624727 DOI: 10.21037/atm.2019.05.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Andre M Samuel
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Mark T Langhans
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sravisht Iyer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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