Spine surgery in geriatric patients: Sometimes unnecessary, too much, or too little

Frailty is a Risk Factor for Postoperative Complications in Older Adults with Lumbar Degenerative Disease: A Prospective Cohort Study

Objective

Frailty, representing the physiological reserve and tolerance of the body, serves as a crucial evaluation index of the overall status of the older adults. This study aimed to investigate the prevalence of preoperative frailty and its impact on postoperative outcomes among older adults with lumbar degenerative disease in China.

Patients and Methods

In this prospective study, a total of 280 patients aged 60 and above, diagnosed with lumbar degenerative disease and scheduled for surgical intervention were enrolled. The prevalence of frailty pre-surgery was evaluated using the Tilburg Frailty Indicator (TFI) and the modified Frailty Index 11 (mFI-11). The primary outcome was postoperative complication within 30 days post-surgery. The secondary outcomes were the length of hospital stay, hospital costs, reoperation within 30 days post-surgery and unplanned readmission within 30 days post-discharge. Both univariable and multivariable logistic regression were employed to screen and identify the risk factors predisposing patients to postoperative complications.

Results

A total of 272 older adults were included in the study ultimately. The frailty detection rates of TFI and mFI-11 were 15.8% (43/272) and 10.7% (29/272) respectively. Thirty-four patients (12.5%) encountered complications. Significantly elevated rates of complications, prolonged hospital stays, increased hospital costs, and heightened readmission rates were observed in the frail group compared to the non-frail group (P<0.05). Univariable analysis showed that the potential factors related to complications are TFI, mFI-11 and albumin. Multivariable logistic regression revealed that TFI was an independent risk factor for postoperative complications (OR=5.371, 95% CI: 2.338-12.341, P < 0.001).

Conclusion

Frailty was an independent predictor of postoperative complications in older adults undergoing lumbar fusion surgery. Frailty assessment should be performed in such patients to improve preoperative risk stratification and optimize perioperative management strategies.

Clinical Outcomes and Complication Profile of Spine Surgery in Septuagenarians and Octogenarians: Case Series

OBJECTIVE

The aging global population presents an increasing challenge for spine surgeons. Advancements in spine surgery, including minimally invasive techniques, have broadened treatment options, potentially benefiting older patients. This study aims to explore the clinical outcomes of spine surgery in septuagenarians and octogenarians.

METHODS

This retrospective analysis, conducted at a US tertiary center, included patients aged 70 and older who underwent elective spine surgery for degenerative conditions. Data included the Charlson Comorbidity Index (CCI), ASA classification, surgical procedures, intraoperative and postoperative complications, and reoperation rates. The objective of this study was to describe the outcomes of our cohort of older patients and discern whether differences existed between septuagenarians and octogenarians.

RESULTS

Among the 120 patients meeting the inclusion criteria, there were no significant differences in preoperative factors between the age groups (P > 0.05). Notably, the septuagenarian group had a higher average number of fused levels (2.36 vs. 0.38, P = 0.001), while the octogenarian group underwent a higher proportion of minimally invasive procedures (P = 0.012), resulting in lower overall bleeding in the oldest group(P < 0.001). Mobility outcomes were more favorable in septuagenarians, whereas octogenarians tended to maintain or experience a decline in mobility(P = 0.012). A total of 6 (5%) intraoperative complications and 12 (10%) postoperative complications were documented, with no statistically significant differences observed between the groups.

CONCLUSIONS

This case series demonstrates that septuagenarians and octogenarians can achieve favorable clinical outcomes with elective spine surgery. Spine surgeons should be well-versed in the clinical and surgical care of older adults, providing optimal management that considers their increased comorbidity burden and heightened fragility.

A Comprehensive Prospective Analysis of Surgical Outcomes and Adverse Events in Spinal Procedures Among Octogenarians: A Detailed Analysis From a German Tertiary Center

STUDY DESIGN

Prospective case series.

OBJECTIVES

Drawing from prospective data, this study delves into the frequency and nature of adverse events (AEs) following spinal surgery specifically in octogenarians, shedding light on the challenges and implications of treating this specific cohort as well as on risk factors for their occurrence.

METHODS

Octogenarians who received spinal surgery and were discharged between January 2019 and December 2022 were proactively included in our study. An AE was characterized as any incident transpiring within the initial 30 days after surgery that led to an unfavorable outcome.

RESULTS

From January 2020 to December 2022, 184 octogenarian patients (average age: 83.1 ± 2.8 years) underwent spinal surgeries. Of these, 81.5% were elective and 18.5% were emergencies, with 69.0% addressing degenerative pathologies. Using the Charlson Comorbidity Index, the mean score was 8.1 ± 2.2, highlighting cardiac diseases as predominant. Surgical details show 71.2% had decompression, with 28.8% receiving instrumentation. AEs included wound infections 3.1% for degenerative, 13.3% for tumor and dural leaks. The overall incidence of dural leaks was found to be 2.7% (5/184 cases), and each case underwent surgical revision. Pulmonary embolism resulted in two fatalities post-trauma. Wound infections (26.7%) were prevalent in infected spine cases. Significant AE risk factors were comorbidities, extended surgery durations, and instrumentation procedures.

CONCLUSIONS

In octogenarian spinal surgeries, AEs occurred in 15.8% of cases, influenced by comorbidities and surgical complexities. The 2.2% mortality rate wasn't linked to surgeries. Accurate documentation remains crucial for assessing outcomes in this age group.

Incidence of subsequent surgical decompression following minimally invasive approaches to treat lumbar spinal stenosis: A retrospective review

BACKGROUND CONTEXT

Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression.

PURPOSE

To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image-guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years.

OUTCOME MEASURES

The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery.

METHODS

Patient data were collected using the PearlDiver-Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors.

RESULTS

A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively.

CONCLUSIONS

Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.

Mapping knowledge structure and themes trends in geriatric spine surgery: A bibliometric analysis

To analyze the status, hotspots, and frontiers of spine surgery in the geriatric using bibliometric method, the Web of Science Core Collection was searched for all papers concerning the use of spine surgery in the elderly from January 1, 1982 to August 3, 2022. VOSviewer and R software were used to perform the bibliometric analysis, which included retrieving the country, institution, author, journal, and keyword. A total of 663 articles were identified. The investigation revealed a growing number of publications over the past 20 years. The country with the highest number of publications was the United States (195 papers). The institution with the highest number of publications was the University of California (31 papers). H. Hassanzadeh and A. Jain were the most productive authors (14 publications), while R. A. Deyo was the most co-cited author. The journal with the most published papers was Spine (67 papers). According to Bradford Low, Spine, World Neurosurgery, and European Spine Journal were core journals in the field of geriatric spine surgery. The most recent trend topic was "readmission," "vertebroplasty," "kyphoplasty," "risk," "osteoporosis," "outcomes," "surgery," "complications," "scoliosis," and "management." In particular, osteoporosis has been a topic of attention in the field of geriatric spine surgery since 2005. Over time, research on spinal surgery in the elderly and allied topics has grown in importance and scope, indicating a tendency toward globalization. Researchers should pay more attention to the outcomes, complications, and management associated with spine surgery in the elderly.

Percutaneous Computed Tomography-Guided Oxygen-Ozone (O2O3) Injection Therapy in Patients with Lower Back Pain-An Interventional Two-Year Follow-Up Study of 321 Patients

OBJECTIVES

To assess the effect of oxygen-ozone therapy guided by percutaneous Computed Tomography (CT) compared to corticosteroids in individuals experiencing lower back pain (LBP) not attributed to underlying bone-related issues.

METHODS

A total of 321 patients (192 males and 129 females, mean age: 51.5 ± 15.1 years) with LBP were assigned to three treatment groups: group A) oxygen-ozone only, group B) corticosteroids only, group C) oxygen-ozone and corticosteroids. Treatment was administered via CT-guided injections to the intervertebral disc (i.e., intradiscal location). Clinical improvement of pain and functionality was assessed via self-reported pain scales and magnetic resonance (MR) and CT imaging.

RESULTS

At all follow-up times, the mean score of the numeric rating scale and the total global pain scale (GPS) of study groups receiving oxygen-ozone (groups A and C) were statistically significantly lower than the study group receiving corticosteroids only (group B), with p < 0.001. There was a statistically significant difference between groups A and C at 30 days for the numeric rating scale.

CONCLUSIONS

The percutaneous application of oxygen-ozone in patients with LBP due to degeneration of the lumbosacral spine showed long-lasting significant pain reduction of up to two years post-treatment when compared to corticosteroids alone. Combination therapy of oxygen-ozone and corticosteroids can be useful as corticosteroids showed statistically significant improvement in LBP earlier than the oxygen-ozone-only treatment.

Patient-specific Risk Factors Increase Episode of Care Costs After Lumbar Decompression

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression.

SUMMARY OF BACKGROUND DATA

Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression.

METHODS

Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05.

RESULTS

A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (β = $324.70, P < 0.001), comorbid depression (β = $4368.30, P = 0.037), revision procedures (β = $6538.43, P =0.012), increased hospital length of stay (per day) (β = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (β = $14,417.42, P = 0.001), incidence of a complication (β = $8178.07, P < 0.001), and readmission (β = $18,734.24, P < 0.001) within 90 days.

CONCLUSIONS

Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.

Comorbidity data collection across different spine registries: an evidence map

INTRODUCTION

Comorbidities are significant patient factors that contribute to outcomes after surgery. There is highly variable collection of this information across the literature. To help guide the systematic collection of best practice data, the Australian Spine Registry conducted an evidence map to investigate (i) what comorbidities are collected by spine registries, (ii) how they are collected and (iii) the compliance and completeness in collecting comorbidity data.

METHOD

A literature search was performed to identify published studies of adult spine registry data reporting comorbidities. In addition, targeted questionnaires were sent to existing global spine registries to identify the maximum number of relevant results to build the evidence map.

RESULTS

Thirty-six full-text studies met the inclusion criteria. There was substantial variation in the reporting of comorbidity data; 55% of studies reported comorbidity collection, but only 25% reported the data collection method and 20% reported use of a comorbidity index. The variation in the literature was confirmed with responses from 50% of the invited registries (7/14). Of seven, three use a recognised comorbidity index and the extent and methods of comorbidity collection varied by registry.

CONCLUSION

This evidence map identified variations in the methodology, data points and reporting of comorbidity collection in studies using spine registry data, with no consistent approach. A standardised set of comorbidities and data collection methods would encourage collaboration and data comparisons between patient cohorts and could facilitate improved patient outcomes following spine surgery by allowing data comparisons and predictive modelling of risk factors.

Geriatric relationship with inpatient opioid consumption and hospital outcomes after open posterior spinal fusion for adult spine deformity

OBJECTIVE

As the population ages, increasing attention has been placed on identifying risk factors for poor surgical outcomes in the elderly. The aim of this study was to assess the impact of geriatric status on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity.

METHODS

A retrospective study was performed using the Premier Healthcare Database (2016-2017). All adult patients who underwent thoracic/thoracolumbar fusion for spine deformity were identified using ICD-10-CM codes. Patients were categorized by age: 18-49 years-old (Young), 50-64 years-old (Older), and 65 + years-old (Geriatric). Patient demographics, comorbidities, hospital characteristics, intraoperative variables, adverse events (AEs), and healthcare resource utilization were assessed. Increased inpatient opioid use was categorized by MME (morphine milligram equivalents) admission consumption greater than the 75th percentile of the cohort. Multivariate logistic regression analysis was used to identify independent predictors of increased opioid usage, increased cost, and non-routine discharge (NRD).

RESULTS

Of the 1831 patients identified, 199 (10.9 %) were in the Young cohort, 599 (32.7 %) were in the Older cohort, and 1033 (56.4 %) were in the Geriatric cohort. The Geriatric cohort had a greater proportion of patients who were Non-Hispanic White (p < 0.001) and government-insured (p < 0.001). Comorbidities [CCI (p < 0.001)] and frailty [mFI-5 (p < 0.001)] increased with age. AEs occurred at similar rates between cohorts. A greater proportion of Older patients consumed an increased amount of MMEs during their hospital stay (Young: 24.9 % vs. Older: 33.1 % vs. Geriatric: 20.2 %, p < 0.001). A greater proportion of Geriatric patients experienced high costs (p = 0.018), longer LOS (p = 0.011), and 30-day readmission (p = 0.004) compared to other cohorts. A significantly greater proportion of the Geriatric cohort experienced NRD (Young: 25.3 % vs. Older: 58.8 % vs. Geriatric: 83.0 %, p < 0.001) On multivariate analysis, Geriatric age was independently associated with NRD (OR: 11.59, p < 0.001), and inversely associated with increased MME use (OR: 0.66, p = 0.038). However, Older age was independently associated with increased MME use (OR: 1.58, p = 0.026) and NRD (OR: 4.27, p < 0.001), though not increased cost (OR: 1.49, p = 0.077).

CONCLUSION

Our study demonstrates that geriatric patients may require fewer opioids than younger patients but require greater resource utilization on discharge. Additional studies investigating the impact of aging are necessary to improve patient risk stratification, healthcare delivery, and patient outcomes.

Octogenarians Are Independently Associated With Extended LOS and Non-Routine Discharge After Elective ACDF for CSM

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the impact age has on LOS and discharge disposition following elective ACDF for cervical spondylotic myelopathy (CSM).

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) database from 2016 and 2017. All adult patients >50 years old undergoing ACDF for CSM were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then stratified by age: 50 to 64 years-old, 65 to 79 years-old, and greater than or equal to 80 years-old. Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total cost of admission were assessed.

RESULTS

A total of 14 865 patients were identified. Compared to the 50-64 and 65-79 year-old cohorts, the 80+ years cohort had a significantly higher rate of postoperative complication (50-64 yo:10.2% vs. 65-79 yo:12.6% vs. 80+ yo:18.9%, P = 0.048). The 80+ years cohort experienced significantly longer hospital stays (50-64 yo: 2.0 ± 2.4 days vs. 65-79 yo: 2.2 ± 2.8 days vs. 80+ yo: 2.3 ± 2.1 days, P = 0.028), higher proportion of patients with extended LOS (50-64 yo:18.3% vs. 65-79 yo:21.9% vs. 80+ yo:28.4%, P = 0.009), and increased rates of non-routine discharges (50-64 yo:15.1% vs. 65-79 yo:23.0% vs. 80+ yo:35.8%, P < 0.001). On multivariate analysis, age 80+ years was found to be a significant independent predictor of extended LOS [OR:1.97, 95% CI:(1.10,3.55), P = 0.023] and non-routine discharge [OR:2.46, 95% CI:(1.44,4.21), P = 0.001].

CONCLUSIONS

Our study demonstrates that octogenarian age status is a significant independent risk factor for extended LOS and non-routine discharge after elective ACDF for CSM.

Hospital Frailty Risk Score and healthcare resource utilization after surgery for metastatic spinal column tumors

OBJECTIVE

The Hospital Frailty Risk Score (HFRS) was developed utilizing ICD-10 diagnostic codes to identify frailty and predict adverse outcomes in large national databases. While other studies have examined frailty in spine oncology, the HFRS has not been assessed in this patient population. The aim of this study was to examine the association of HFRS-defined frailty with complication rates, length of stay (LOS), total cost of hospital admission, and discharge disposition in patients undergoing spine surgery for metastatic spinal column tumors.

METHODS

A retrospective cohort study was performed using the years 2016 to 2019 of the National Inpatient Sample (NIS) database. All adult patients (≥ 18 years old) undergoing surgical intervention for metastatic spinal column tumors were identified using the ICD-10-CM diagnostic codes and Procedural Coding System. Patients were categorized into the following three cohorts based on their HFRS: low frailty (HFRS < 5), intermediate frailty (HFRS 5-15), and high frailty (HFRS > 15). Patient demographics, comorbidities, treatment modality, perioperative complications, LOS, discharge disposition, and total cost of hospital admission were assessed. A multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, nonroutine discharge, and increased cost.

RESULTS

Of the 11,480 patients identified, 7085 (61.7%) were found to have low frailty, 4160 (36.2%) had intermediate frailty, and 235 (2.0%) had high frailty according to HFRS criteria. On average, age increased along with progressively worsening frailty scores (p ≤ 0.001). The proportion of patients in each cohort who experienced ≥ 1 postoperative complication significantly increased along with increasing frailty (low frailty: 29.2%; intermediate frailty: 53.8%; high frailty: 76.6%; p < 0.001). In addition, the mean LOS (low frailty: 7.9 ± 5.0 days; intermediate frailty: 14.4 ± 13.4 days; high frailty: 24.1 ± 18.6 days; p < 0.001), rate of nonroutine discharge (low frailty: 40.4%; intermediate frailty: 60.6%; high frailty: 70.2%; p < 0.001), and mean total cost of hospital admission (low frailty: $48,603 ± $29,979; intermediate frailty: $65,271 ± $43,110; high frailty: $96,116 ± $60,815; p < 0.001) each increased along with progressing frailty. On multivariate regression analysis, intermediate and high frailty were each found to be significant predictors of both prolonged LOS (intermediate: OR 3.75 [95% CI 2.96-4.75], p < 0.001; high: OR 7.33 [95% CI 3.47-15.51]; p < 0.001) and nonroutine discharge (intermediate: OR 2.05 [95% CI 1.68-2.51], p < 0.001; high: OR 5.06 [95% CI 1.93-13.30], p = 0.001).

CONCLUSIONS

This study is the first to use the HFRS to assess the impact of frailty on perioperative outcomes in patients with metastatic bony spinal tumors. Among patients with metastatic bony spinal tumors, frailty assessed using the HFRS was associated with longer hospitalizations, more nonroutine discharges, and higher total hospital costs.

Safety Evaluation of Cervical Dorsal Instrumentation in Geriatric Patients: Experience at a Level 1 Center for Spinal Surgery-A Single Center Cohort Study

Objective

Dorsal instrumentation of the cervical spine is an established treatment in spine surgery. However, careful planning is required, particularly in elderly patients. This study evaluates early clinical outcomes in geriatric patients undergoing complex spine surgery.

Methods

In this retrospective, single center cohort study, we included all geriatric patients (aged ≥65 years) who underwent dorsal instrumentation between January 2013 and December 2020. We analyzed postoperative complications and the 30-day in-hospital mortality rate. Furthermore, the Charlson comorbidity index (CCI) and Clavien-Dindo grading system (CDG) were used to assess the patients' comorbidity burden.

Results

In total, 153 patients were identified and included. The mean age of patients was 78 years (SD ± 7). Traumatic injury (53.6%) was the most common reason for surgery. 60.8% of the patients underwent dorsal instrumentation with 3 or more levels. The most common comorbidities were arterial hypertension (64%), diabetes mellitus (22.2%), coronary heart disease and atrial fibrillation (19.6%). The most common adverse event (AE) was pneumonia (4%) and the most common surgery-related complication was wound infection (5.2%). Among patients categorized as high risk for AE (CCI > 5), 14.6% suffered a postoperative AE. In our univariate analysis, we found no risk factors for high rates of complications or mortality.

Conclusion

Our data demonstrates that older patients were at no significant risk of postoperative complications. The CCI/CDG scores may identify patients at higher risk for adverse events after dorsal instrumentation, and these assessments should become an essential component of stratification in this older patient population.

The impact of frailty on postoperative complications in geriatric patients undergoing multi-level lumbar fusion surgery

STUDY DESIGN

Retrospective Cohort Study.

PURPOSE

This study evaluates the impact of patient frailty status on postoperative complications in those undergoing multi-level lumbar fusion surgery.

METHODS

The Nationwide Readmission Database (NRD) was retrospectively queried between 2016 and 2017 for patients receiving multi-level lumbar fusion surgery. Demographics, frailty status, and relevant complications were queried at index admission and readmission intervals. Primary outcome measures included perioperative complications and 30-, 90-, and 180-day complication and readmission rates. Perioperative complications of interest were infection, urinary tract infection (UTI), and posthemorrhagic anemia. Secondary outcome measures included inpatient length of stay (LOS), adjusted all-payer costs, and discharge disposition. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail patients with similar diagnoses and procedures. Subgroup analysis of minimally invasive surgery (MIS) versus open surgery within frail and non-frail cohorts was conducted to evaluate differences in surgical and medical complication rates. The analysis used nonparametric Mann-Whitney U testing and odds ratios.

RESULTS

Frail patients encountered higher rates perioperative complications including posthemorrhagic anemia (OR: 1.73, 95%CI 1.50-2.00, p < 0.0001), infection (OR: 2.94, 95%CI 2.04-4.36, p < 0.0001), UTI (OR: 2.57, 95%CI 2.04-3.26, p < 0.0001), and higher rates of non-routine discharge (OR: 2.07, 95%CI 1.80-2.38, p < 0.0001). Frail patients had significantly greater LOS and total all-payer inpatient costs compared to non-frail patients (p < 0.0001). Frailty was associated with significantly higher rates of 90- (OR: 1.43, 95%CI 1.18-1.74, p = 0.0003) and 180-day (OR: 1.28, 95%CI 1.03-1.60, p = 0.02) readmissions along with higher rates of wound dehiscence (OR: 2.21, 95%CI 1.17-4.44, p = 0.02) at 90 days. Subgroup analysis revealed that frail patients were at significantly higher risk for surgical complications with open surgery (16%) compared to MIS (0%, p < 0.0001). No significant differences were found between surgical approaches with respect to medical complications in both cohorts, nor surgical complications in non-frail patients.

CONCLUSIONS

Frailty was associated with higher odds of all perioperative complications, LOS, and all-payer costs following multi-level lumbar fusion. Frail patients had significantly higher rates of 90 and 180-day readmission and higher rates of wound disruption at 90-days. On subgroup analysis, MIS was associated with significantly reduced rates of surgical complications specifically in frail patients. Our results suggest frailty status to be an important predictor of perioperative complications and long-term readmissions in geriatric patients receiving multi-level lumbar fusions. Frail patients should undergo surgery utilizing minimally invasive techniques to minimize risk of surgical complications. Future studies should explore the utility of implementing frailty in risk stratification assessments for patients undergoing spine surgery.

Comparison of Lumbar Fusion With and Without Interbody Fusion for Lumbar Stenosis Using Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Testing (CAT)

Study design

This was a retrospective analysis of patient-reported outcomes across a two-year period.

Summary of background data

Patients suffering from lumbar stenosis may experience low back pain, neurogenic claudication, and weakness. Patients can benefit from surgical intervention, including decompression with or without fusion. However, the superiority of any single fusion construct remains controversial.

Objective

The goal of this study was to compare Patient-Reported Outcomes Measurement Information System (PROMIS®) Computer Adaptive Testing (CAT) measures in patients with lumbar spinal stenosis treated surgically with lumbar decompression and fusion with or without interbody fusion.

Methods

A retrospective review of patients with lumbar stenosis undergoing lumbar decompression and one-level fusion was performed. PROMIS® CAT Physical Function (PF) and Pain Interference (PI) assessments were administered using a web-based platform pre and postoperatively.

Results

Sixty patients with lumbar stenosis undergoing one-level lumbar fusion were identified. Twenty-seven patients underwent posterior lumbar fusion (PSF) alone and 33 underwent one-level lumbar interbody fusion (IF). Patients undergoing IF had better absolute PF scores compared to patients undergoing PSF at one-year postoperatively (48.9 v 41.6, p=0.002) and greater relative improvement in PF scores from baseline at one-year postoperatively (D13.6 v D8.6, p=0.02). A subgroup analysis of patients undergoing TLIF v PSF showed better absolute PF scores at the one-year follow-up in the TLIF group (47.1 v 42.3, p=0.04). No differences were found in PI scores at any time point between the PSF and IF groups. Patients undergoing IF had significantly shorter hospital stays (2.5 v 3.3 days, p=0.02) compared to patients undergoing PSF.

Conclusions

Patients with lumbar spinal stenosis treated with one-level IF reported higher absolute PF scores and experienced greater relative improvement in PF scores from baseline at one-year follow-up compared to patients treated with PSF alone. Additionally, IF is associated with a decreased length of hospital stay as compared to PSF.

How old is too old?: Matched analysis of geriatric patients undergoing anterior lumbar interbody fusion

STUDY DESIGN

Retrospective Review INTRODUCTION/OBJECTIVE: The aim of this study is to utilize a national database to identify how age affects patient outcomes following anterior lumbar interbody fusion (ALIF). There are no established age guidelines for the geriatric population within the spine specialty, which makes patient selection challenging. Furthermore, there are conflicting studies for the risks of performing spine surgeries in the elderly.

METHODS

A retrospective review of the Mariner Claims Database was conducted on patients who underwent a single level ALIF (CPT 22558) between 2010 and 2018. Patients were separated into three groups by age: 50-64, 65-74, and 75-84 and matched with respect to gender, smoking, and comorbidity burden. Multivariable logistic regression was used to determine the independent effect of outpatient surgery on the postoperative outcomes after adjusting for demographic factors and pertinent comorbidities. Statistical significance was set at p < 0.05.

RESULTS

The study identified 8459 matched patients (3350 50-64; 3350 65-74; and 1759 75-84). Compared with patients aged 50-64, patients aged 65-74 and 75-84 had significantly increased risks of pneumonia (65-74: OR 1.53, 95% CI 1.06-2.24, p = 0.025; 75-84: OR 1.62, 95% CI 1.07-2.42, p = 0.022), sepsis (65-74: OR 2.20, 95% CI 1.36-3.76, p = 0.002; 75-84: OR 2.42, 95% CI 1.43-4.13, p = 0.001), and major complications (65-74: OR 1.35, 95% CI 1.05-1.74, p = 0.021; 75-84: OR 1.48, 95% CI 1.11-1.95, p = 0.006) (Table 2). There were no significant differences between patients aged 65-74 and 75-84 for risks of postoperative pneumonia, sepsis, and major complications (p > 0.05). There were no differences between any groups in terms of long-term outcomes such as pseudoarthrosis, implant related complications, or reoperation (p > 0.05) (Table 3).

DISCUSSION/CONCLUSION

The study showed that those older than 65 had a significant increase in risk of pneumonia, sepsis, and major complications following ALIF. In the two cohorts above the age of 65 (65-74 and 75-84) there was no significant differences in postoperative outcomes.

LEVEL OF EVIDENCE

3.

Construct Validity and Item Response Theory Analysis of the PROMIS-29 v2.0 in Recipients of Lumbar Spine Surgery

STUDY DESIGN

Observational cohort design involving measurement property assessment.

OBJECTIVES

The aim of this study was to assess construct validity through hypothesis testing and to examine reliability and discrimination of the PROMIS-29 v2.0 using item response theory (IRT) analyses.

SUMMARY OF BACKGROUND DATA

Patient-Reported Outcomes Measurement Information System (PROMIS) 29.0 version 2.0 includes 28 questions for the seven domains of Physical function, Anxiety, Depression, Fatigue, Sleep disturbance, Social role, and Pain interference, and one item related to pain intensity. To date, the tool has not been tested for construct validity for selected concepts, nor has it been evaluated using IRT in a population of spine surgery recipients.

METHODS

Using the Quality Outcomes Dataset lumbar registry, we evaluated the construct validity of the PROMIS-29 v2.0 against pain intensity measures for back and leg, the Oswestry Disability Index, the EQ5D 3L-visual analog scale (quality of life) and proxy measures of activities, mobility and self-care. IRT was used to test PROMIS-29 v2.0 assumptions and fit.

RESULTS

The sample included 652 surgery recipients (mean age = 60.1, SD = 14.0) who had a high level of baseline disability. Hypothesis testing confirmed direction and magnitude of correlation between the PROMIS and legacy measures in 10 of the 12 hypotheses. IRT identified three misfit items, but otherwise adequate scale reliability and unidimensionality.

CONCLUSION

The PROMIS-29 v2.0 measures several different constructs pertinent to a patient's health and recovery during spine surgery. We feel that the PROMIS-29 v2.0 tool is a useful and effective outcome measure for populations who receive spine surgery.Level of Evidence: 4.

Perspective on robotic spine surgery: Who's doing the thinking?

Background

Robotic assisted (RA) spine surgery was developed to reduce the morbidity for misplaced thoracolumbar (TL) pedicle screws (PS) resulting in neurovascular injuries, dural fistulas, and/or visceral/other injuries. RA is gaining the attention of spine surgeons to optimize the placement of TL PSs, and to do this more safely/effectively versus utilizing stereotactic navigation alone, or predominantly free hand (FH) techniques. However, little attention is being focused on whether a significant number of these TL RA instrumented fusions are necessary.

Methods

RA spine surgery has been developed to improve the safety, efficacy, and accuracy of minimally invasive TL versus open FH PS placement.

Results

Theoretical benefits of RA spine surgery include; enhanced accuracy of screw placement, fewer complications, less radiation exposure, smaller incisions, to minimize blood loss, reduce infection rates, shorten operative times, reduce postoperative recovery periods, and shorten lengths of stay. Cons of RA include; increased cost, increased morbidity with steep learning curves, robotic failures of registration, more soft tissue injuries, lateral skiving of drill guides, displacement of robotic arms impacting accurate PS placement, higher reoperation rates, and potential loss of accuracy with motion versus FH techniques. Notably, insufficient attention has been focused on the necessity for performing many of these TL PS instrumented fusions in the first place.

Conclusion

RA spinal surgery is still in its infancy, and comparison of RA versus FH techniques for TL PS placement demonstrates several potential pros, but also multiple cons. Further, more attention must be focused on whether many of these TL PS instrumented procedures are even warranted.

Second opinion in spine surgery: A scoping review

Background:

As a growing number of patients seek consultations for increasingly complex and costly spinal surgery, it is of both clinical and economic value to investigate the role for second opinions (SOs). Here, we summarized and focused on the shortcomings of 14 studies regarding the role and value of SOs before proceeding with spine surgery.

Methods:

Utilizing PubMed, Google Scholar, and Scopus, we identified 14 studies that met the inclusion criteria that included: English, primary articles, and studies published in the past 20 years.

Results:

We identified the following findings regarding SO for spine surgery: (1) about 40.6% of spine consultations are SO cases; (2) 61.3% of those received a discordant SO; (3) 75% of discordant SOs recommended conservative management; and (4) SO discordance applied to a variety of procedures.

Conclusion:

The 14 studies reviewed regarding SOs in spine surgery showed that half of the SOs differed from those given in the initial consultation and that SOs in spine surgery can have a substantial impact on patient care. Absent are prospective studies investigating the impact of following a first versus second opinion. These studies are needed to inform the potential benefit of universal implementation of SOs before major spine operations to potentially reduce the frequency and type/extent of surgery.

The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery

PURPOSE

This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery.

METHODS

The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios.

RESULTS

Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals.

CONCLUSIONS

Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.

Inclusion of Frailty Improves Predictive Modeling for Postoperative Outcomes in Surgical Management of Primary and Secondary Lumbar Spine Tumors

BACKGROUND

Malignant spinal tumors are common, continually increasing in incidence as a function of improved survival times for patients with cancer. Using predictive analytics and propensity score matching, we evaluated the influence of frailty on postoperative complications compared with age in patients with malignant neoplasms of the lumbar spine.

METHODS

We used the Nationwide Readmissions Database from 2016 and 2017 to identify patients with malignant neoplasms of the lumbar spine who received a fusion procedure. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups. Propensity score matching for age, sex, Charlson Comorbidity Index, surgical approach, and number of levels fused was implemented between frail and nonfrail patients, identifying 533 frail patients and 538 nonfrail patients. The area under the curve (AUC) of each ROC served as a proxy for model performance.

RESULTS

Frail patients reported significantly higher inpatient lengths of stay, costs, infection, posthemorrhagic anemia, and urinary tract infections (P < 0.05). In addition, frail patients were more often discharged to skilled nursing facilities and short-term hospitals compared with nonfrail patients (P < 0.0001). Regression models for mortality (AUC = 0.644), nonroutine discharge (AUC = 0.600), and acute infection (AUC = 0.666) were improved when using frailty as the primary predictor. These models were also improved using frailty when predicting 30-day readmission and 90-day hardware failure.

CONCLUSIONS

Frailty demonstrated a significant relationship with increased postoperative patient complications, length of stay, costs, and acute complications in patients receiving fusion following resection of a malignant neoplasm of the lumbar spine region. Frailty demonstrated better predictive validity of outcomes compared with patient age.

Spine Surgery in the Octogenarian Population: A Comparison of Demographics, Surgical Approach, and Healthcare Utilization With the PearlDiver Database

Background

With the recent advances in technology and healthcare, increasing numbers of individuals over the age of 80 will require surgical intervention for spinal pathology. Given the risk of increased complications in the elderly, a limited number of spinal surgeries are performed on octogenarians every year. This makes it difficult to generalize the trends and outcomes of these surgeries to a greater population. This study attempts to understand the trends in the safety profile and healthcare utilization across the United States for octogenarians undergoing spinal fusion and/or decompression surgery for spinal stenosis and/or degenerative disease using the PearlDiver database.

Methodology

Patients who underwent fusion and/or decompression for stenosis and/or degenerative diseases were extracted using International Classification of Disease ninth and tenth revisions (ICD-9 prior to October 2015, ICD-10 after) from 2007 to 2016 in the PearlDiver database. Three comparative groups were considered: (1) primary fusion without concurrent decompression, (2) primary decompression with concurrent fusion, and (3) fusion with concurrent decompression. Outcomes of interest were patient characteristics, demographics, length of stay, surgery hospitalization payments, and discharge disposition. These outcomes were compared to patients over the age of 20 who also underwent spinal surgery.

Results

A total of 9,715 patients who underwent spinal surgery were identified in the search. Of the 9,139 patients, 503 were octogenarians and 73 were nonagenarians. Octogenarians and nonagenarians diagnosed with spinal stenosis were more likely to undergo decompression alone rather than fusion or both fusion and decompression (21 for both fusion and decompression; p < 0.0001). Patients diagnosed with both spinal stenosis and degeneration were more likely to undergo both fusion and decompression than fusion or decompression alone (239 for both, 208 for decompression alone, and 23 for fusion alone; p < 0.0001). No statistically significant difference was found in the percentage of patients discharged home following either fusion or decompression or both surgeries (p = 0.0737). The mean length of stay for patients in the 20-79-year age group was 2.79 days, whereas for the octogenarian and nonagenarian cohort it was 3.85 days. The index hospitalization pay for patients in the 20-79-year age group was $19,220, whereas for the octogenarians and nonagenarians cohort it was $15,091.

Conclusions

Patients over the age of 80 were more likely to undergo either a fusion procedure or a decompression procedure alone rather than both unless they were diagnosed with spinal degeneration. The PearlDiver database analysis indicates that the length of stay for octogenarians and nonagenarians is longer than that for patients in the 20-79-year age group, and that younger patients are more likely to be discharged earlier than patients over the age of 80. Moreover, we observed that the index hospitalization pay was higher for patients over the age of 20 than for octogenarians and nonagenarians in all cases except for a fusion procedure.

Are the Outcomes of Minimally Invasive Transforaminal/Posterior Lumbar Fusion Influenced by the Patient's Age or BMI?

STUDY DESIGN

A retrospective subgroup analysis of a prospective observational study was carried out.

SUMMARY OF BACKGROUND DATA

Patients' baseline characteristics may influence the clinical outcomes after minimally invasive lumbar interbody fusion (MILIF).

OBJECTIVE

This study aimed to investigate the influence of patient's age and body mass index (BMI) on the clinical outcomes of MILIF for degenerative lumbar disorder.

MATERIALS AND METHODS

A total of 252 patients underwent MILIF. The clinical outcomes, including time to first ambulation, time to postsurgical recovery, back/leg pain in visual analog scale, Oswestry Disability Index, and EuroQol-5 Dimension, were collected at baseline, 4 weeks, 6, and 12 months. Patients were subgrouped by age (50 y and below: N=102; 51-64 y: N=102; 65 y and above: N=48) and BMI (≤25.0: N=79; 25.1-29.9: N=104; ≥30.0: N=69). Data from baseline to 12 months were compared for all clinical outcomes within age/BMI subgroups. Adverse events (AEs) and serious adverse events (SAEs) were summarized by age and BMI subgroups.

RESULTS

All age and BMI subgroups showed significant improvements in clinical outcomes at 12 months compared with the baseline. The median time to first ambulation was similar for all subgroups (age groups: P=0.8707; BMI: P=0.1013); older people show a trend of having longer time to postsurgical recovery (age groups: P=0.0662; BMI: P=0.1591). Oswestry Disability Index, back, and leg pain visual analog scale, and EuroQol-5 Dimension were similar in all subgroups at every timepoint. A total of 50 AEs (N=39) were reported, 9 of which were SAEs; 3 AEs and 1 SAE were considered to be related to surgical procedure. No differences were observed in safety by age groups and BMI groups.

CONCLUSION

MILIF appears to be safe and effective, independent of age or weight in the treatment of degenerative lumbar disorder.

LEVEL OF EVIDENCE

Level II.

Cortical bone trajectory instrumentation provides favorable perioperative outcomes compared to pedicle screws for single-level lumbar spinal stenosis and degenerative spondylolisthesis

Objective

To compare perioperative outcomes between cortical bone trajectory (CBT) instrumentation with pedicle screws (PS) in patients undergoing laminectomy and posterolateral fusion for single-level lumbar spinal stenosis, and degenerative grade I spondylolisthesis.

Methods

A consecutive series of 91 patients from a single institution between January 2017 and July 2019 were retrospectively reviewed.

Results

Patients in CBT group had significantly shorter operative time, lower blood loss and shorter length of stay.

Conclusion

CBT instrumentation demonstrated favorable perioperative outcomes that may enhance the overall value in patients undergoing laminectomy and posterolateral fusion for single-level lumbar spinal stenosis, and degenerative grade I spondylolisthesis.

The Role of Minimally Invasive Spinal Surgical Procedures in the Elderly Patient: An Analysis of 49 Patients Between 75 and 95 Years of Age

As the population gets older, yet remains active, the number of patients presenting with symptomatic spinal disease over the age of 75 increases. These include pain from osteoporotic spinal fractures, lumbar degenerative disease, as well as radiculopathy or neurogenic claudication from stenosis over the age of 75 and older increases. While some of these patients are very healthy, taking minimal medication, many are not good candidates for more invasive surgical procedures under general anesthesia because of medical co-morbidities such as insulin-dependent diabetes and medication use such as anti-coagulants. Past reviews of lumbar surgery in elderly patients have examined the risk factors with spinal fusion and multilevel surgery and many were written before the recent advent of more minimally invasive spinal procedures that reduce both operative time and the need for general anesthesia. This review examines effectiveness in return to activity and reduction in pain in these elderly patients stratified by underlying disease category, i.e. fractures, stenosis with neurogenic claudication and chronic pain, rather than just by the procedure, since there are often several minimally invasive procedures that are available. This review demonstrates very similar pain relief outcomes as measured by the visual analog scale (VAS) scores which dropped in the range of 70% or more with the different procedures. Since the majority of these procedures involve short surgical times and minimal blood loss with small incisions that lower the risk of wound infection as well as cardio-respiratory stress and can be performed under local anesthesia as an outpatient, they are particularly advantageous for the properly selected elderly patient.

Evaluating Mechanisms of Postoperative Delirium and Cognitive Dysfunction Following Elective Spine Surgery in Elderly Patients (CONFESS): Protocol for a Prospective Observational Trial

Background

Elderly people are at particular high risk for postoperative delirium (POD) following spine surgery, which is associated with longer hospital stays, higher costs, risk for delayed complications, long-term care dependency, and cognitive dysfunction (POCD). It is insufficiently understood which mechanisms and risk factors contribute to the development of POD and POCD following these major but plannable surgeries.

Objective

This study aims to identify modifiable risk factors in spine surgery. A better understanding thereof would help adapt medical management and surgical strategies to individual risk profiles.

Methods

This is a single-center observational study jointly conducted by the departments of neurosurgery, neurology, and anesthesiology at a tertiary care hospital in Germany. All patients aged 60 years and older presenting to the neurosurgery outpatient clinic or ward for elective spine surgery are screened for eligibility. Exclusion criteria include presence of neurodegenerative or history of psychiatric disease and medication with significant central nervous system activity (eg, antidepressants, antipsychotics, sedatives). Surgical and anesthetic procedures including duration of surgery as primary end point of this study are thoroughly documented. All patients are furthermore evaluated for their preoperative cognitive abilities by a number of tests, including the Consortium to Establish a Registry for Alzheimer's Disease Plus test battery. Physical, mental, and social health and well-being are assessed using the Patient-Reported Outcome Measurement Information System Profile 29 and Hospital Anxiety and Depression Scale. Patients additionally receive preoperative cerebrovascular ultrasound and structural and functional brain imaging. The immediate postoperative period includes screening for POD using the Nursing Delirium Screening Scale and validation through Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria. We furthermore investigate markers of (neuro)inflammation (eg, interleukins, C-reactive protein, tumor necrosis factor alpha). Preoperative examinations are repeated 3 months postoperatively to investigate the presence of POCD and its mechanisms. Statistical analyses will compare delirious and nondelirious patients for predictors of immediate (POD) and delayed (POCD) cognitive dysfunction.

Results

This is the first study to prospectively evaluate risk factors for POD and POCD in spine surgery. Recruitment is ongoing, and data collection is estimated to be finished with the inclusion of 200 patients by mid-2020.

Conclusions

The identification of mechanisms, possibly common, underlying POD and POCD would be a major step toward defining effective interventional strategies early in or even before the postoperative period, including the adaptation of surgical strategies to individual risk profiles.

Trial Registration

ClinicalTrials.gov NCT03486288; https://clinicaltrials.gov/ct2/show/NCT03486288

The immense heterogeneity of frailty in neurosurgery: a systematic literature review

The aim of this study was to review and analyze the neurosurgery body of literature to document the current knowledge of frailty within neurosurgery, standardizing terminology and how frailty is defined, including the different levels of frailty, while determining what conclusions can be drawn about frailty's impact on neurosurgical outcomes. While multiple studies on frailty in neurosurgery exist, no literature reviews have been conducted. Therefore, we performed a literature review in order to organize, tabulate, and present findings from the data to broaden the understanding about what we know from frailty and neurosurgery. We performed a PubMed search to identify studies that evaluated frailty and neurosurgery. The terms "frail," "frailty," "neurosurgery," "spine surgery," "craniotomy," and "neurological surgery" were all used in the query. We then organized, analyzed, and summarized the comprehensive frailty and neurosurgical literature. The literature contained 25 published studies analyzing frailty in neurosurgery between December 2015 and December 2018. Five of these studies were cranial neurosurgical studies, the remaining studies focused on spinal neurosurgery. Over 100,000 surgical cases were analyzed among the 25 studies. Of these, 18 studies demonstrated that increasing frailty was associated with increased rate of complications, 10 studies showed that frailty was associated with higher mortality rates, 11 studies demonstrated an association between frailty and increased hospital length of stay, and 5 studies noted that higher frailty was associated with discharge to a higher level of care. The current body of literature repeatedly demonstrates that frailty is associated with worse outcomes across the neurosurgical subspecialties.

[An age-stratified follow-up of complications and clinical benefit of posterior lumbar intervertebral fusion procedure in middle-aged and older patients]

Objective

To compare the complications and clinical scores of posterior lumbar intervertebral fusion (PLIF) in middle-aged and older patients of different ages, and to assess the risk of complications of PLIF in different ages, providing a reference for clinical treatment.

Methods

The clinical data of 1 136 patients, who were more than 55 years old and underwent PLIF between June 2013 and June 2016, were retrospectively analyzed. According to the age of patients undergoing surgery, they were divided into 3 groups as 55-64 years old, 65-74 years old, and ≥75 years old. The general characteristics, comorbidities, and surgical data of the three groups were compared, with comparison the morbidity of complications. According to the minimal clinical important difference (MCID), the improvement of patient's pain visual analogue scale (VAS) score and the Oswestry disability index (ODI) score were compared. Univariate logistic regression analysis was used to analyze the difference of complications and the improvement of VAS and ODI scores. Multivariate logistic regression analysis was performed for the risk factors of complications.

Results

There were significant differences in the number of surgical fusion segments and osteoporosis between groups ( P<0.05); there was no significant difference in gender, body mass index, operation time, preoperative American Society of Anesthesiologists (ASA) classification, and comorbidities between groups ( P>0.05). All patients were followed up 6-62 months with an average of 27.4 months. Among the results of postoperative complications, there were significant differences in the total incidence of intraoperative complications, systemic complications, minor complications, and the percentage of improvement of ODI score to MCID between groups ( P<0.05); but there was no significant difference in the total incidence of complications at the end of long-term follow-up and the percentage of improvement of VAS score to MCID between groups ( P>0.05). Univariate logistic regression analysis showed that after adjusting the confounding factors, there were significant differences in intraoperative complications and the percentage of improvement of ODI score to MCID between 55-64 and 65-74 years old groups ( P<0.05); systemic complications, minor complications, complications at the end of long-term follow-up, and the percentage of improvement of ODI score to MCID in ≥75 years old group were significantly different from those in the other two groups ( P<0.05). Multivariate logistic regression analysis showed that age was a risk factor for systemic complications, minor complications, and complications at the end of long-term follow-up. Except for age, long operation time was a risk factor for intraoperative complications, increased number of fusion segments was a risk factor for systemic complications, the number of comorbidities was a risk factor for minor complications, and osteoporosis was a risk factor for complications at the end of long-term follow-up.

Conclusion

The risk of surgical complications is higher in the elderly patients (≥75 years) with lumbar degenerative diseases than in the middle-aged and older patients (<75 years), while the improvements of postoperative VAS and ODI scores were similar. Under the premise of fully assessing surgical indications, PLIF has a positive effect on improving the elderly patients' quality of life.

Surgical Treatment of Lumbar Spondylolisthesis in the Elderly

By 2060, population projections estimate the number of individuals older than 65 will double. Prevalence of degenerative spondylolisthesis is reported as 4.1%-11.1% within the general population. Given the growing older population, the need for evidence-based guidance is essential. Regarding benefit derived from decompression alone versus decompression plus fusion for degenerative spondylolisthesis, the consensus is that all patients do not require a fusion; however, clarity around clearly identifying this cohort is lacking. Nevertheless, instrumented fusion is an effective strategy in the elderly. Numerous options exist, and individual patient characteristics as well as surgeon experience should be evaluated when planning surgery.

Frailty status as a predictor of 3-month cognitive and functional recovery following spinal surgery: a prospective pilot study

BACKGROUND CONTEXT

As increasing numbers of elderly Americans undergo spinal surgery, it is important to identify which patients are at highest risk for poor cognitive and functional recovery. Frailty is a geriatric syndrome that has been closely linked to poor outcomes, and short-form screening may be a helpful tool for preoperative identification of at-risk patients.

PURPOSE

This study aimed to conduct a pilot study on the usefulness of a short-form screening tool to identify elderly patients at increased risk for prolonged cognitive and functional recovery following elective spine surgery.

STUDY DESIGN/SETTING

This is a prospective, comparative cohort study.

PATIENT SAMPLE

The sample comprised 100 patients over age 65 who underwent elective spinal surgery (cervical or lumbar) at a single, large academic medical center from 2013 to 2014.

OUTCOME MEASURES

Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight (FRAIL) scale, Postoperative Quality of Recovery Scale (PQRS), and instrumental activities of daily living (IADL) scores were the outcome measures.

METHODS

Included patients were assessed with the FRAIL scale and stratified as robust, pre-frail, or frail. The PQRS and IADL scores were also obtained. Patients were re-examined at 1 day, 3 days, 1 month, and 3 months after surgery for cognitive recovery at 3 months, and secondarily, functional recovery at 3 months.

RESULTS

At 3 months, only 50% of frail patients had recovered to their cognitive baseline compared with 60.7% of pre-frail and 69.2% of robust patients (trend). At 3 months, 66.7% of frail patients had recovered to their functional baseline compared with 57% of pre-frail and 76.9% of robust patients (trend). Using multivariate regression modeling, at 3 months, frail patients were less likely to have recovered to their cognitive baseline compared with pre-frail and robust patients (odds ratio 0.39, confidence interval 0.131-1.161).

CONCLUSIONS

This pilot study demonstrates a trend toward poorer cognitive recovery 3 months following elective spinal surgery for frail patients. Frailty screening can help preoperatively identify patients who may experience protracted cognitive and functional recovery.

Surgical and Clinical Results of Minimally Invasive Spinal Fusion Surgery in an Unselected Patient Cohort of a Spinal Care Unit

OBJECTIVES

To review the surgical results and to identify possible parameters influencing the clinical outcomes in an unselected patient collective undergoing minimally invasive lumbar interbody fusion in a spinal care unit.

METHODS

A total of 229 adult patients who underwent minimally invasive lumbar spinal fusion between 2008 and 2016 were included in this retrospective analysis. Lumbar fusion was performed using transforaminal interbody fusion (TLIF) devices and posterolateral fusion. To eliminate confounding parameters, in all patients interbody fusion was indicated by lumbar degenerative pathologies, and surgery was performed using the same fusion device. Treatment efficacy was evaluated using scores describing pain (visual analogue scale [VAS]) and health impairment (EQ-5D, Oswestry Disability Index [ODI]). The influence of patient age, obesity, active smoking status, and co-morbidities on clinical outcome and perioperative complications was analyzed.

RESULTS

The patient population reviewed had improved VAS (P_{(leg pain)} ≤ 0.0001, P_{(back pain)} ≤ 0.0001), ODI (P ≤ 0.0001), EQ-VAS (P ≤ 0.0001), and EQ-5D subscales "mobility", "self-care", "pain", and "anxiety" (P_(mobility) ≤ 0.0001, P_(self-care)  = 0.41, P_(pain) ≤ 0.0001, P_(anxiety)  = 0.011) postoperatively. Neither advanced patient age, nor increased body mass index (BMI), hypertension, or active smoking status had a significantly limiting influence on the success of minimally invasive spinal surgeries (MIS). Duration of surgery strongly correlated with the number of spinal levels treated and with intraoperative blood loss (r = 0.774, P ≤ 0.0001, n = 208). Weak positive correlations were found between patient age and duration of surgery (r = 0.184, P = 0.005, n = 229), intraoperative blood loss (r = 0.165, P = 0.012, n = 229), and duration of hospitalization (r = 0.270, P ≤ 0.0001, n = 228), respectively. When compared to non-smokers, smokers were younger (P ≤ 0.0001), and had a significantly lower BMI (P = 0.001), shorter durations of surgery (P ≤ 0.0001), decreased intraoperative blood loss (P = 0.022), and shorter hospital stays (P = 0.006), respectively. Complications occurred in 17 patients (7%) and were not affected by patient age, BMI, hypertension, or active smoking status.

CONCLUSION

Minimally invasive spinal surgery is a safe and effective treatment option and may be superior to open surgery in subpopulations with significant co-morbidities and risk factors, such as elderly and obese patients as well as patients with an active smoking status.

Short-term outcomes following posterior cervical fusion among octogenarians with cervical spondylotic myelopathy: a NSQIP database analysis

BACKGROUND CONTEXT

Degenerative changes in the cervical spine occur in an age-dependent manner. As the US population continues to age, the incidence of age-dependent, multilevel, degenerative cervical pathologies is expected to increase. Similarly, the average age of patients with cervical spondylotic myelopathy (CSM) will likely trend upward. Posterior cervical fusion (PCF) is often the treatment modality of choice in the management of multilevel cervical spine disease. Although outcomes following anterior cervical fusion for degenerative disease have been studied among older patients (aged 80 years and older), it is unknown if these results extend to octogenarian patients undergoing PCF for the surgical management of CSM.

PURPOSE

The present study aimed to quantify surgical outcomes following PCF for the treatment of CSM among the octogenarian patient population compared with patients younger than 80 years old.

STUDY DESIGN/SETTING

This was a retrospective study that used the National Surgical Quality Improvement Program (NSQIP).

PATIENT SAMPLE

The sample included patients aged 60-89 who had CSM and who underwent PCF from 2012 to 2014.

OUTCOME MEASURES

The outcome measures were multimorbidity, prolonged length of stay (LOS), discharge disposition (to home or skilled nursing/rehabilitation facility), 30-day all-cause readmission, and 30-day reoperation.

METHODS

The NSQIP database was queried for patients with CSM (International Classification of Disease, Ninth Revision, Clinical Modification code 721.1) aged 60-89 who underwent PCF (Current Procedural Terminology code 22600) from 2012 to 2014. Cohorts were defined by age group (60-69, 70-79, 80-89). Data were collected on gender, race, elective or emergent status, inpatientor outpatient status, where patients were admitted from (home vs. skilled nursing facility), American Society of Anesthesiologists class, comorbidities, and single- or multilevel fusion. After controllingfor these variables, logistic regression analysis was used to compare outcome measures in the different age groups.

RESULTS

A total of 819 patients with CSM who underwent PCF (416 aged 60-69, 320 aged 70-79, and 83 aged 80-89) were identified from 2012 to 2014. Of the PCF procedures, 79.7% were multilevel. There were no significant differences in the odds of multimorbidity, prolonged LOS, readmission, or reoperation when comparing octogenarian patients with CSM with patients aged 60-69 or 70-79. Patients aged 60-69 and 70-79 were significantly more likely to be discharged to home than patients over 80 (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.8-10.4, p<.0001, and OR 2.7, 95% CI 1.1-6.4, p=.0005, respectively).

CONCLUSIONS

Compared with patients aged 60-69 and 70-79, octogenarian patients with CSM were significantly more likely to be discharged to a location other than home following PCF. After controlling for patient comorbidities and demographics, 80- to 89-year-old patients with CSM who underwent PCF did not differ in other outcomes when compared with the other age cohorts. These results can improve preoperative risk counseling and surgical decision-making.

Factors affecting lumbar surgery outcome: A nation-wide, population-based retrospective study

BACKGROUND

Lower back pain is a very common symptom and treatment strategies vary according the severity and duration of illness. Surgical approaches are becoming increasingly popular with the advent of new and less invasive technologies; however, treatment outcomes are not yet well established on a population-based level. Taiwan's National Health Insurance Research Database (NHIRD) is longitudinal and includes 98% of the population since its inception in 1995. The database includes the ICD 9.0 codes (International Classification of Diseases) of all patients with lower back pain and lumbar surgery; furthermore, all the prescriptions.

METHODS

As part of a population-based cohort study of one million participants randomly selected from the NHIRD, we analyzed changes in prescription of analgesics 1 year before and 1 year after lumbar surgery; comorbidities, such as diabetes, asthma, osteoporosis, arthritis, depression and anxiety were also analyzed as covariates. A total of 3916 cases were enrolled in final analysis.

RESULTS

Post-operatively, the defined daily dosage (DDD) of analgesics decreased from a median DDD of 50.0 to a median of 14.2. In a multivariate model analysis, female, older age, anxiety and asthma were the significant factors for unfavorable outcome (defined by dosage of analgesics decreased less than 50% after surgery).

CONCLUSIONS

The analgesics significantly decreased for patients received lumbar surgeries, implying the decreased of pain. In addition, co-morbidity factors were identified by the failure for analgesics reduction, such as female, older age, anxiety and asthma. For patients with lower back pain, these factors should be considered before receiving lumbar surgeries.

Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients

BACKGROUND CONTEXT

There is a paucity of literature describing risk factors for adverse outcomes after geriatric lumbar spinal surgery. As the geriatric population increases, so does the number of lumbar spinal surgeries in this cohort.

PURPOSE

The purpose of the study was to determine how safe lumbar surgery is in elderly patients. Does patient selection, type of surgery, length of surgery, and other comorbidities in the elderly patient affect complication and readmission rates after surgery?

STUDY DESIGN/SETTING

This is a retrospective cohort study.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Database was used in the study.

OUTCOME MEASURES

The outcome data that were analyzed were minor and major complications, mortality, and readmissions in geriatric patients who underwent lumbar spinal surgery from 2005 to 2015.

MATERIALS AND METHODS

A retrospective cohort study was performed using data from the ACS NSQIP database. Patients over the age of 80 years who underwent lumbar spinal surgery from 2005 to 2013 were identified using International Statistical Classification of Diseases and Related Health Problems diagnosis codes and Current Procedural Terminology codes. Outcome data were classified as either a major complication, minor complication, readmission, or mortality. Multivariate logistic regression models were used to determine risks for developing adverse outcomes in the initial 30 postoperative days.

RESULTS

A total of 2,320 patients over the age of 80 years who underwent lumbar spine surgery were identified. Overall, 379 (16.34%) patients experienced at least one complication or death. Seventy-five patients (3.23%) experienced a major complication. Three hundred thirty-eight patients (14.57%) experienced a minor complication. Eighty-six patients (6.39%) were readmitted to the hospital within 30 days. Ten deaths (0.43%) were recorded in the initial 30 postoperative days. Increased operative times were strongly associated with perioperative complications (operative time >180 minutes, odds ratio [OR]: 3.07 [95% confidence interval {CI} 2.23-4.22]; operative time 120-180 minutes, OR: 1.77 [95% CI 1.27-2.47]). Instrumentation and fusion procedures were also associated with an increased risk of developing a complication (OR: 2.56 [95% CI 1.66-3.94]). Readmission was strongly associated with patients who were considered underweight (body mass index [BMI] <18.5) and who were functionally debilitated at the time of admission (OR: 4.10 [1.08-15.48] and OR: 2.79 [1.40-5.56], respectively).

CONCLUSIONS

Elderly patients undergoing lumbar spinal surgery have high complications and readmission rates. Risk factors for complications include longer operative time and more extensive procedures involving instrumentation and fusion. Higher readmission rates are associated with low baseline patient functional status and low patient BMI.

Learning curves for minimally invasive spine surgeries: Are they worth it?

Background:

Minimally invasive surgery (MIS) spine procedures were developed to limit operative time, the extent of dissection, and reduce perioperative morbidity. Here, we asked what are the “learning curves” for these MIS spine procedures?

Methods:

We reviewed studies in the literature that discussed the “learning curves” attributed to performing different MIS spine surgical procedures. Of interest, the majority were single-surgeon series.

Results:

Very few articles assessed the learning curves for different MIS spine procedures. One study reported no learning curve for open vs. MIS discectomy/laminotomy. Another study indicated that 20–30 cases were required for a surgeon to become proficient in performing a variety of MIS spine fusions [e.g., cervical MIS fusions, MIS anterior lumbar interbody fusions (ALIF), MIS transforaminal lumbar interbody fusions (TLIF), and MIS pedicle/screw placement in the thoracic/lumbar spine]. Several other studies specifically cited that, to become proficient in the performance of TLIF, surgeons had to have performed between 10, to 32, to 40, to 44 such cases.

Conclusions:

There is a very limited literature available that focuses on the “learning curves” associated with the performance of different types of MIS spine procedures. The number of cases required to satisfy the “learning curves” for different operations varied from 0 for MIS vs. open discectomy/laminotomy, to 20-30 for a variety of cervical-thoracic-lumbar procedures, and up to 44 cases for TLIF. Shouldn’t we ask whether better oversight measures and/or mentoring programs could limit the morbidity/AE occurring during these “learning curves” in the future?

Complication rate during multilevel lumbar fusion in patients above 60 years

BACKGROUND

Spine surgery in elderly with comorbidities is reported to have higher complication rates and increased cost. However, the surgical outcome is good irrespective of the complications. Hence, it is essential to identify the factors affecting the complication rates in such patients and the measures to reduce them. This retrospective observational study determines the perioperative complications, their incidence and the measures to reduce complications in the elderly with comorbidities, operated by instrumented multilevel lumbar fusion.

MATERIALS AND METHODS

Patients aged 60 years and above with one or more comorbidities operated by multilevel instrumented lumbar fusion in our center between January 2012 and December 2013 were included in the study. Perioperative complications and their incidence were calculated. Age, number of levels fused, operative time, blood loss, and complication rates were correlated with the duration of stay and the incidence of perioperative complications using SPSS software. Measures to reduce complications are determined by these results and by review of literature.

RESULTS

Fifty two patients were included in the study (28 females and 24 males) with an average age of 69 years (range 60-84 years). Hypertension was the most common comorbidity followed by diabetes. Spondylolisthesis was the most common indication. Eleven complications were noted with an incidence of 21%. Three were systemic complications which required transfer to Intensive Care Unit. Local complications were incidental durotomy (three), transient root deficits (two), wound infections (one), and persistent radicular pain (two). Operative time and blood loss were significantly higher in patients with complications.

CONCLUSION

Complication rates strongly correlate with the blood loss and operative time. Reducing the operative time and blood loss by intraoperative tranexamic acid, laminectomy using osteotome, simultaneous bilateral exposure and instrumentation and reducing the number of interbody fusions can help in reducing the complications.

Impact of old age on patient-report outcomes and cost utility for anterior cervical discectomy and fusion surgery for degenerative spine disease

PURPOSE

With growing older population and increasing rates of cervical spinal surgery, it is vital to understand the value of cervical surgery in this population. We set forth to determine the cost utility following anterior cervical decompression and fusion (ACDF) for degenerative disease in older patients.

METHODS

Patients undergoing ACDF for degenerative diseases were enrolled into prospective longitudinal registry. Patient-reported outcomes (PROs) were recorded at baseline, 1-year, and 2-year postoperatively. Two-year medical resource utilization, missed work, and health-state values [quality-adjusted life years (QALYs)] were assessed to compute cost per QALY gained. Patients were dichotomized based on age: <65 years (younger) and ≥65 years (older) to compare the cost utility in these age groups.

RESULTS

Total 218 (87%) younger patients and 33 (13%) older patients who underwent ACDF were analyzed. Both the groups demonstrated a significant improvement in PROs 2-year following surgery. The older patients had a lower mean cumulative gain in QALYs compared to younger patients at 1 year (0.141 vs. 0.28, P = 0.05) and 2 years (0.211 vs. 0.424, P = 0.04). There was no significant difference in the mean total 2-year cost between older [$21,041 (95% CI $18,466-$23,616)] and younger [$22,669 (95% CI $$21,259-$24,079)] patients (P = 0.27). Two-year cost per QALY gained in older vs. younger patients was ($99,720/QALYs gained vs. ($53,464/QALYs gained, P = 0.68).

CONCLUSION

ACDF surgery provided a significant gain in health-state utility in older patients with degenerative cervical pathology, with a mean cumulative 2-year cost per QALY gained of $99,720/QALY. While older patients have a slightly higher cost utility compared to their younger counterparts, surgery in the older cohort does provide a significant improvement in pain, disability, and quality-of-life outcomes.

Obesity Is an Independent Risk Factor of Early Complications After Revision Spine Surgery

STUDY DESIGN

Retrospective cohort analysis of risk factors in revision spine surgery using a prospectively collected database.

OBJECTIVE

To examine the risk of developing early (30-day) complications across obesity level after adjusting for comorbidities in patients undergoing revision spine surgery.

SUMMARY OF BACKGROUND DATA

Prior studies suggest obesity influences early complications after primary surgery. The association between obesity and early complications after revision surgery remains to be characterized.

METHODS

Data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012. Adult Caucasian patients undergoing removal/revision of instrumentation or exploration of fusion were included. Patients were categorized by WHO body mass index (BMI, kg/m): Non-Obese (18.5-29.9), Obese Class I (30-34.9), and Obese Class II/III (≥35). Univariate regression was performed to assess the predictive value of obesity level and baseline risk factors in the presence of at least one early complication, and significant predictors were entered into the multivariable model.

RESULTS

Of 2538 patients, 57.6% were nonobese, 23% Obese Class I, and 19.4% Obese Class II/III. Obesity was associated with diabetes, hypertension, respiratory disease, and American Society of Anesthesiologists (ASA) score of 3-4 (all P < 0.001). BMI group (P = 0.01), older age (P = 0.008), functional dependence (P < 0.001), ASA 3-4 (P = 0.008), bleeding disorder (P = 0.04), and diabetes (P = 0.016) were identified as univariate predictors for early complications. In the multivariable model, higher BMI (P = 0.04), older age (P = 0.014), and functional dependence (P < 0.001) remained significant predictors for early complications. Notably, patients who were Obese Class II/III (OR 1.66, 95% CI [1.12-2.45]), age ≥75 (OR 1.83, [1.20-2.81]), and functionally dependent (OR 3.02 [1.85-4.94]) had significantly higher risk compared with their reference groups.

CONCLUSION

Obesity is an independent risk factor for early complications after revision spine surgery. Although obesity may not contraindicate revision surgery, its status as a modifiable risk factor warrants disclosure and preoperative counseling to optimize outcomes.

LEVEL OF EVIDENCE

3.

Risk Assessment and Characterization of 30-Day Perioperative Myocardial Infarction Following Spine Surgery: A Retrospective Analysis of 1346 Consecutive Adult Patients

STUDY DESIGN

A retrospective review.

OBJECTIVE

The aim of the study was to perform a risk assessment of 30-day perioperative myocardial infarction (MI) for spine surgery patients.

SUMMARY OF BACKGROUND DATA

There is an increased emphasis to reduce complications and improve outcomes after spinal surgery. One of the more devastating perioperative complications of spinal surgery is MI.

METHODS

We evaluated all medical records of 1346 consecutive patients who underwent spinal surgery at a single institution from 2008 to 2010 for incidence of MI within 30 days of surgery and documented all demographic, preoperative, and operative variables. Associations between postoperative MI and individual risk factors were determined using logistic regression analysis. Patients were stratified into emergent and elective groups and a similar analysis was performed.

RESULTS

Overall, 22 patients (1.6%) had 30-day perioperative MI, 14 patients (1.2%) undergoing elective surgery, and 8 patients (4.2%) after emergent surgery (P = 0.047). Three (13.6%) patients experienced 30-day mortality and an additional 3 (13.6%) patients experienced mortality within 1 year. Multivariate logistic regression determined that age more than 65 years, atrial fibrillation, hypertension, prior MI, anticoagulant use, low albumin, length of stay more than 7 days, intraoperative transfusion, trauma etiology, baseline creatinine more than 1  mg/dL, and at least 2 levels of spinal fusion were predictive of postoperative MI. For patients undergoing emergent surgery, age more than 65 years was associated with an increased risk of postoperative MI. When stratified by elective surgery, we found that age more than 65, postoperative stay more than 7 days, intraoperative blood transfusion, baseline creatinine more than 1  mg/dL, and fusion of more than 1 level were associated with an increased risk of MI.

CONCLUSION

The present study demonstrates a low incidence of MI after elective surgery with a higher incidence after emergent spine surgery and identifies patient factors predictive of postoperative MI.

LEVEL OF EVIDENCE

3.

Minimally invasive posterior transforaminal lumbar interbody fusion: One-year postoperative morbidity, clinical and radiological results of a prospective multicenter study of 182 cases

INTRODUCTION

Interbody fusion is the gold standard treatment for the management of numerous diseases of the spine. Minimally invasive techniques may be more beneficial than conventional techniques. The main goal of this study was to report the one-year postoperative results of a series of posterior lumbar interbody fusions by a minimally invasive technique in relation to improvement in functional outcome, interbody fusion and morbidity.

MATERIALS AND METHODS

Between January 2012 and May 2013, 182 patients treated by minimally invasive posterior transforaminal lumbar interbody fusion (TLIF) were included in this prospective multicenter study. Clinical assessment was based on a comparison of the preoperative and one-year postoperative Oswestry (ODI), SF-12 and Quebec Scores and the Visual Analog Scale (VAS). Surgical and postoperative follow-up data were evaluated. Radiological assessment was based preoperative and one-year postoperative full spine teleradiographs. Interbody fusion at one-year was systematically evaluated by CT scan.

RESULTS

One hundred and eighty-two patients were included, mean age 58.9 years old. Surgery lasted a mean 101 minutes, mean preoperative bleeding was 143 mL, and mean radiation exposure was 247.4 cGy/cm(2). The rate of postoperative complications was 7.7%. The ODI, the Quebec Score, the SF-12 and the VAS were all significantly improved at one-year (P<0.0001). The rate of fusion was 72.6% at the final follow-up. There was no significant difference in functional outcome between patients with and without fusion.

DISCUSSION

The one-year postoperative radiological results and functional outcome of minimally invasive posterior lumbar fusion are satisfactory. The benefits of this minimally invasive approach are mainly found in the first 6 postoperative months. Successful radiological interbody fusion was not correlated to functional outcome at the final follow-up.

Complications due to the use of BMP/INFUSE in spine surgery: The evidence continues to mount

Increasingly, adverse events (AE) attributed to utilizing BMP/INFUSE (Bone Morphogenetic Protein, Medtronic, Memphis, TN, USA) “off-label” in spine surgery are being reported. In 2008, the Food and Drug Administration (FDA) issued a warning that in anterior cervical spine surgery, the “off-label” use of BMP/INFUSE contributed to marked dysphagia, hematoma, seroma, swelling, and/or the need for intubation/tracheostomy. Subsequent studies have cited the following AE; heterotopic ossification (HO), osteolysis, infection, arachnoiditis, increased neurological deficits, retrograde ejaculation, and cancer. Furthermore, in 2011, Carragee et al. noted that 13 of the original industry-sponsored BMP/INFUSE spinal surgery studies failed to acknowledge multiple AE. Additionally, in 2012, Comer et al. observed that the frequency of retrograde ejaculation reported for BMP/INFUSE used “on-label” to perform Anterior Lumbar Interbody Fusion/Lumbar Tapered Fusion-Cage Device (ALIF/LT-Cage) was also largely “under-reported.” To summarize, there is mounting evidence in the spinal literature that utilizing BMP/INFUSE in spinal fusions contributes to major perioperative and postoperative morbidity.

How much medicine do spine surgeons need to know to better select and care for patients?

Background:

Although we routinely utilize medical consultants for preoperative clearance and postoperative patient follow-up, we as spine surgeons need to know more medicine to better select and care for our patients.

Methods:

This study provides additional medical knowledge to facilitate surgeons’ “cross-talk” with medical colleagues who are concerned about how multiple comorbid risk factors affect their preoperative clearance, and impact patients’ postoperative outcomes.

Results:

Within 6 months of an acute myocardial infarction (MI), patients undergoing urological surgery encountered a 40% mortality rate: similar rates may likely apply to patients undergoing spinal surgery. Within 6 weeks to 2 months of placing uncoated cardiac, carotid, or other stents, endothelialization is typically complete; as anti-platelet therapy may often be discontinued, spinal surgery can then be more safely performed. Coated stents, however, usually require 6 months to 1 year for endothelialization to occur; thus spinal surgery is often delayed as anti-platelet therapy must typically be continued to avoid thrombotic complications (e.g., stroke/MI). Diabetes and morbid obesity both increase the risk of postoperative infection, and poor wound healing, while the latter increases the risk of phlebitis/pulmonary embolism. Both hypercoagluation and hypocoagulation syndromes may require special preoperative testing/medications and/or transfusions of specific hematological factors. Pulmonary disease, neurological disorders, and major psychiatric pathology may also require further evaluations/therapy, and may even preclude successful surgical intervention.

Conclusions:

Although we as spinal surgeons utilize medical consultants for preoperative clearance and postoperative care, we need to know more medicine to better select and care for our patients.