1
|
Chanbour H, Bendfeldt GA, Gangavarapu LS, Wright AH, Chotai S, Gardocki RJ, Schwarz JP, Abtahi AM, Stephens BF, Zuckerman SL, Berkman RA. Safety of early discharge after elective lumbar spine surgery with subfascial drains and association with significant reduction in length of stay. J Neurosurg Spine 2024:1-8. [PMID: 38759238 DOI: 10.3171/2024.3.spine231338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/11/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVE After lumbar spine surgery, postoperative drain removal often delays discharge. Whether inpatient drain removal reduces the risk of surgical site infection (SSI) or hematoma remains controversial. Therefore, in patients undergoing elective lumbar spine surgery, the authors sought to determine the impact of inpatient versus outpatient drain removal on the following variables: 1) length of hospital stay (LOS), and 2) postoperative complications. METHODS A single-center retrospective cohort study in which the authors used prospectively collected data of patients undergoing primary, elective, 1- or 2-level lumbar spine decompression and/or fusion was undertaken between 2016 and 2022. Patients with intraoperative or postoperative CSF leaks were excluded. The primary exposure variable was inpatient versus outpatient drain removal. The primary outcome was LOS, and secondary outcomes were postoperative complications, including 90-day postoperative SSI or hematoma. Multivariable logistic and linear regression were performed, controlling for age, body mass index, instrumentation, number of levels, antibiotics at discharge, and surgeons involved. RESULTS Of 483 patients included, 325 (67.3%) had inpatient drain removal and 158 (32.7%) had outpatient drain removal. Patients with outpatient drain removal were significantly younger (58.6 ± 12.4 vs 61.2 ± 13.2 years, p = 0.040); more likely to have 1-level surgery (75.9% vs 56.6%, p < 0.001); and less likely to receive instrumentation (50.6% vs 69.5%, p < 0.001). Postoperatively, patients with outpatient drain removal had a shorter LOS (0.7 ± 0.6 vs 2.3 ± 1.6 days, p < 0.001); were more likely to be discharged home (98.1% vs 92.3%, p = 0.015); were more likely to be discharged on antibiotics (76.6% vs 3.1%, p < 0.001); were less likely to be on opioids (32.3% vs 88.3%, p < 0.001); and were more likely to have Jackson-Pratt compared to Hemovac drains (96.2% vs 34.5%, p < 0.001). No difference was found in SSI (3.7% vs 3.8%, p > 0.999) or hematoma (0.9% vs 0.6%, p > 0.999), as well as reoperation or readmission due to SSI or hematoma. On multivariable regression, outpatient drain removal was significantly associated with shorter LOS (β = -1.15, 95% CI -1.56 to -0.73, p < 0.001). No association was found with SSI/hematoma (p > 0.05). CONCLUSIONS Outpatient drain removal after elective lumbar spine surgery was associated with a significantly decreased LOS without a significant increase in postoperative SSI or hematoma. Although the choice of drain removal and the LOS may be subject to surgeons' preference, these results may support the feasibility and safety of outpatient drain removal, and the potential cost savings resulting from shortened hospital stays. Drawbacks may exist regarding added burden to the patient and the surgeon's team to accommodate 1-week follow-up appointments for drain removal.
Collapse
Affiliation(s)
| | | | | | | | | | - Raymond J Gardocki
- 3Orthopedic Surgery, Vanderbilt University Medical Center, Nashville; and
| | | | - Amir M Abtahi
- Departments of1Neurological Surgery and
- 3Orthopedic Surgery, Vanderbilt University Medical Center, Nashville; and
| | - Byron F Stephens
- Departments of1Neurological Surgery and
- 3Orthopedic Surgery, Vanderbilt University Medical Center, Nashville; and
| | - Scott L Zuckerman
- Departments of1Neurological Surgery and
- 3Orthopedic Surgery, Vanderbilt University Medical Center, Nashville; and
| | | |
Collapse
|
2
|
Hou BQ, Croft AJ, Vaughan WE, Davidson C, Pennings JS, Bowers MF, Vickery JW, Abtahi AM, Gardocki RJ, Lugo-Pico JG, Zuckerman SL, Stephens BF. Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis. Spine (Phila Pa 1976) 2024; 49:694-700. [PMID: 38655789 DOI: 10.1097/brs.0000000000004793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/26/2023] [Indexed: 04/26/2024]
Abstract
STUDY DESIGN A retrospective cohort study using prospectively collected data. OBJECTIVE The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes. MATERIALS AND METHODS The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF. RESULTS Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF. CONCLUSIONS In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.
Collapse
Affiliation(s)
- Brian Q Hou
- Vanderbilt University School of Medicine, Nashville, TN
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew J Croft
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
| | - Wilson E Vaughan
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
| | - Claudia Davidson
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
| | - Jacquelyn S Pennings
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Mitchell F Bowers
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Justin W Vickery
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Amir M Abtahi
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Raymond J Gardocki
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Julian G Lugo-Pico
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Scott L Zuckerman
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Byron F Stephens
- Vanderbilt Spine Outcomes Lab, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
3
|
Chanbour H, Gardocki RJ, Zuckerman SL. Commentary: Keyhole Fenestration for Cerebrospinal Fluid Leaks in the Thoracic Spine: Quantification of Bone Removal and Microsurgical Anatomy. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01129. [PMID: 38648850 DOI: 10.1227/ons.0000000000001169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 04/25/2024] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
4
|
Croft AJ, Pennings JS, Hymel AM, Chanbour H, Khan I, Asher AL, Bydon M, Gardocki RJ, Archer KR, Stephens BF, Zuckerman SL, Abtahi AM. Impact of unplanned readmissions on lumbar surgery outcomes: a national study of 33,447 patients. Spine J 2024; 24:650-661. [PMID: 37984542 DOI: 10.1016/j.spinee.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/22/2023] [Accepted: 11/12/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND CONTEXT Unplanned readmissions following lumbar spine surgery have immense clinical and financial implications. However, little is known regarding the impact of unplanned readmissions on patient-reported outcomes (PROs) following lumbar spine surgery. PURPOSE To evaluate the impact of unplanned readmissions, including specific readmission reasons, on patient reported outcomes 12 months after lumbar spine surgery. STUDY DESIGN/SETTING A retrospective cohort study of prospectively collected data was conducted using patients included in the lumbar module of the Quality and Outcomes Database (QOD), a national, multicenter spine registry. PATIENT SAMPLE A total of 33,447 patients who underwent elective lumbar spine surgery for degenerative diseases were included. Mean age was 59.8 (SD=14.04), 53.6% were male, 89.5% were white, 45.9% were employed, and 47.5% had private insurance. OUTCOME MEASURES Unplanned 90-day readmissions and 12-month patient-reported outcomes (PROs) including numeric rating scale (NRS) scores for back and leg pain, Oswestry Disability Index (ODI) scores, EuroQol-5 Dimension (EQ-5D) scores, and North American Spine Society (NASS) patient-satisfaction scores. METHODS The lumbar module of the QOD was queried for adults undergoing elective lumbar spine surgery for degenerative disease. Unplanned 90-day readmissions were classified into 4 groups: medical, surgical, pain-only, and no readmissions. Medical and surgical readmissions were further categorized into primary reason for readmission. 12-month PROs assessing patient back and leg pain (NRS), disability (ODI), quality of life (EQ-5D), and patient satisfaction were collected. Multivariable models predicting 12-month PROs were built controlling for covariates. RESULTS A total of 31,430 patients (94%) had no unplanned readmission while 2,017 patients (6%) had an unplanned readmission within 90 days following lumbar surgery. Patients with readmissions had significantly worse 12-month PROs compared with those with no unplanned readmissions in covariate-adjusted models. Using Wald-df as a measure of predictor importance, surgical readmissions were associated with the worst 12-month outcomes, followed by pain-only, then medical readmissions. In separate covariate adjusted models, we found that readmissions for pain, SSI/wound dehiscence, and revisions were among the most important predictors of worse outcomes at 12-months. CONCLUSIONS Unplanned 90-day readmissions were associated with worse pain, disability, quality of life, and greater dissatisfaction at 12-months, with surgical readmissions having the greatest impact, followed by pain-only readmissions, then medical readmissions. Readmissions for pain, SSI/wound dehiscence, and revisions were the most important predictors of worse outcomes. These results may help providers better understand the factors that impact outcomes following lumbar spine surgery and promote improved patient counseling and perioperative management.
Collapse
Affiliation(s)
- Andrew J Croft
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, Nashville, TN 37232, USA
| | - Jacquelyn S Pennings
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville TN 37232, USA
| | - Alicia M Hymel
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville TN 37232, USA
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA
| | - Inamullah Khan
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville TN 37232, USA
| | - Anthony L Asher
- Neuroscience Institute, Atrium Health and Department of Neurosurgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC 28203, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Floor 8, Rochester, MN 55905, USA
| | - Raymond J Gardocki
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, Nashville, TN 37232, USA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville TN 37232, USA; Department of Physical Medicine & Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, 3401 West End Ave Suite 380, Nashville, TN 37203, USA
| | - Byron F Stephens
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA
| | - Scott L Zuckerman
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA
| | - Amir M Abtahi
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA.
| |
Collapse
|
5
|
Pennings JS, Chanbour H, Croft AJ, Vaughan WE, Khan I, Davidson C, Bydon M, Asher AL, Archer KR, Gardocki RJ, Berkman RA, Abtahi AM, Stephens BF, Zuckerman SL. Impact of Unplanned Readmission on Patient-Reported Outcomes After Cervical Spine Surgery: A National Study of 13 355 Patients. Neurosurgery 2024:00006123-990000000-01065. [PMID: 38380924 DOI: 10.1227/neu.0000000000002872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/19/2023] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Although risk factors for unplanned readmission after cervical spine surgery have been widely reported, less is known about how readmission itself affects patient-reported outcome measures (PROMs). Using the Quality Outcomes Database registry of patients undergoing elective cervical spine surgery, we sought to (1) determine the impact of unplanned readmission on PROMs and (2) compare the effect of specific readmission reasons on PROMs. METHODS An observational study was performed using a multi-institution, retrospective registry for patients undergoing cervical spine surgery. The occurrence of 90-day unplanned readmission classified into medical, surgical, pain only, and no readmissions was the exposure variable. Outcome variables included 12-month PROMs of Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck/arm pain, EuroQol-5D (EQ-5D), and patient dissatisfaction. Multivariable models predicting each PROM were built using readmission reasons controlling for demographics, clinical characteristics, and preoperative PROMs. RESULTS Data from 13 355 patients undergoing elective cervical spine surgery (82% anterior approach and 18% posterior approach) were analyzed. Unplanned readmission within 90 days of surgery occurred in 3.8% patients, including medical (1.6%), surgical (1.8%), and pain (0.3%). Besides medical reasons, wound infection/dehiscence was the most common reason for unplanned readmission for the total cohort (0.5%), dysphagia in the anterior approach (0.6%), and wound infection/dehiscence in the posterior approach (1.5%). Based on multivariable regression, surgical readmission was significantly associated with worse 12-month NDI, NRS-neck pain, NRS-arm pain, EQ-5D, and higher odds of dissatisfaction. Pain readmissions were associated with worse 12-month NDI and NRS-neck pain scores, and worse dissatisfaction. For specific readmission reasons, pain, surgical site infection/wound dehiscence, hematoma/seroma, revision surgery, deep vein thrombosis, and pulmonary embolism were significantly associated with worsened 12-month PROMs. CONCLUSION In patients undergoing elective cervical spine surgery, 90-day unplanned surgical and pain readmissions were associated with worse 12-month PROMs compared with patients with medical readmissions and no readmissions.
Collapse
Affiliation(s)
- Jacquelyn S Pennings
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew J Croft
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wilson E Vaughan
- Tulane University, School of Medicine, New Orleans, Louisiana, USA
| | - Inamullah Khan
- Department of Neurosurgery, University of Missouri Health Care, Columbia, Missouri, USA
| | - Claudia Davidson
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mohammad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony L Asher
- Department of Neurosurgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Kristin R Archer
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Physical Medicine & Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Richard A Berkman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
6
|
Chanbour H, Tang AR, Steinle AM, Jonzzon S, Roth SG, Gardocki RJ, Stephens BF, Abtahi AM, Zuckerman SL. In Reply: Transforaminal Lumbar Interbody Fusion Versus Posterolateral Fusion Alone in the Treatment of Grade 1 Degenerative Spondylolisthesis. Neurosurgery 2024; 94:e15-e16. [PMID: 37916821 DOI: 10.1227/neu.0000000000002747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 11/03/2023] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Alan R Tang
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Anthony M Steinle
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee , Wisconsin , USA
| | - Soren Jonzzon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Steven G Roth
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York , New York , USA
| | - Raymond J Gardocki
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville , Tennessee , USA
| |
Collapse
|
7
|
Chanbour H, Chen JW, Vaughan WE, Abtahi AM, Gardocki RJ, Stephens BF, Zuckerman SL. Which Bone Mineral Density Measure Offers a More Reliable Prediction of Mechanical Complications in Adult Spinal Deformity Surgery: Hounsfield Units or DEXA Scan? World Neurosurg 2023; 178:e657-e665. [PMID: 37543204 DOI: 10.1016/j.wneu.2023.07.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE In patients undergoing adult spinal deformity (ASD) surgery, we sought to: (1) determine the relationship between dual-energy x-ray absorptiometry (DEXA)-measured bone mineral density (BMD), T-scores, and Hounsfield units (HU), and (2) compare the ability of DEXA-measured BMD, T-scores, and HU to predict mechanical complications and reoperations. METHODS A single-institution retrospective cohort study was undertaken for cases from 2013 to 2017. INCLUSION CRITERIA ≥5-level-fusion, sagittal/coronal deformity, and 2-year follow-up. Multivariable regression controlled for age, body mass index, receiving anabolic medications, and postoperative sagittal vertical axis and pelvic-incidence lumbar-lordosis mismatch. A subanalysis was performed for osteopenic patients (-1 < T-score < -2). RESULTS Of 145 patients undergoing ASD surgery, 72 (49.6%) had both preoperative DEXA and computed tomography scans. Mean DEXA-measured BMD was 0.91 ± 0.52 g/cm2, mean T-score was -1.61 ± 1.03, and mean HU was 153.5 ± 52.8. While no correlation was found between DEXA-measured BMD and HU (r = 0.17, P = 0.144), T-score and HU had a weakly positive correlation (r = 0.31, P = 0.007). Mechanical complications occurred in 48 (66.7%) patients, including 27 (37.5%) proximal junctional kyphosis (PJK), 1 (1.4%) distal junctional kyphosis, 5 (6.9%) implant failure, 30 (41.7%) rod fracture/pseudarthrosis, 42 (58.3%) reoperations, and 16 (22.2%) reoperations due to PJK. No association was found between DEXA-measured BMD or T-scores with mechanical complications or reoperations. While univariate regression showed a significant association between lower HU and PJK (OR 0.98, 95%CI 0.97-0.99, P = 0.011), the significance was lost after multivariable analysis. When considering osteopenic patients (n = 37), only DEXA-measured BMD was an independent risk factor for PJK (OR 0.01, 95%CI 0.00-0.09, P = 0.017), with a threshold of 0.82 g/cm2 (AUC 0.70, 95%CI 0.53-0.84, P = 0.019). CONCLUSIONS Poor correlation was found between the 3 BMD modalities. DEXA-measured BMD may be superior to T-scores and HU in predicting PJK among patients with osteopenia with a threshold of BMD <0.82 g/cm2.
Collapse
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey W Chen
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Wilson E Vaughan
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| |
Collapse
|
8
|
Gardocki RJ, Chandler PJ, Vaughan WE, Zuckerman SL, Abtahi AM, Stephens BF. Endoscopic transforaminal treatment of a thoracic perineural cyst: a case report. Eur Spine J 2023; 32:2679-2684. [PMID: 36813905 DOI: 10.1007/s00586-023-07582-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/25/2023] [Accepted: 02/04/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND IMPORTANCE To describe the first case of a thoracic perineural cyst successfully treated using a direct thoracic transforaminal endoscopic approach. METHODS Case report. CLINICAL PRESENTATION A 66-year-old male presented with right-sided radicular pain in a T4 distribution. MRI of the thoracic spine revealed a right T4 perineural cyst caudally displacing the root in the T4-5 foramen. He had failed attempts at nonoperative management. The patient underwent an all endoscopic transforaminal perineural cyst decompression and resection as a same-day surgical procedure. Postoperatively, the patient noted near complete resolution of the preoperative radicular pain. A thoracic MRI with and without contrast was performed 3 months after surgery and showed no evidence of the preoperative perineural cyst and no symptom recurrence was noted by the patient. CONCLUSION This case report presents the first safe and successful report of an all endoscopic transforaminal decompression and resection of a perineural cyst in the thoracic spine.
Collapse
Affiliation(s)
- Raymond J Gardocki
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - Philip J Chandler
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.
| | - Wilson E Vaughan
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - Scott L Zuckerman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amir M Abtahi
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Byron F Stephens
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
9
|
Tang AR, Chanbour H, Steinle AM, Jonzzon S, Roth SG, Gardocki RJ, Stephens BF, Abtahi AM, Zuckerman SL. Transforaminal Lumbar Interbody Fusion Versus Posterolateral Fusion Alone in the Treatment of Grade 1 Degenerative Spondylolisthesis. Neurosurgery 2023; 93:186-197. [PMID: 36848669 DOI: 10.1227/neu.0000000000002402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/11/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone are two operations performed to treat degenerative lumbar spondylolisthesis. To date, it is unclear which operation leads to better outcomes. OBJECTIVE To compare TLIF vs PLF alone regarding long-term reoperation rates, complications, and patient-reported outcome measures (PROMs) in patients with degenerative grade 1 spondylolisthesis. METHODS A retrospective cohort study using prospectively collected data between October 2010 and May 2021 was undertaken. Inclusion criteria were patients aged 18 years or older with grade 1 degenerative spondylolisthesis undergoing elective, single-level, open posterior lumbar decompression and instrumented fusion with ≥1-year follow-up. The primary exposure was presence of TLIF vs PLF without interbody fusion. The primary outcome was reoperation. Secondary outcomes included complications, readmission, discharge disposition, return to work, and PROMs at 3 and 12 months postoperatively, including Numeric Rating Scale-Back/Leg and Oswestry Disability Index. Minimum clinically important difference of PROMs was set at 30% improvement from baseline. RESULTS Of 546 patients, 373 (68.3%) underwent TLIF and 173 underwent (31.7%) PLF. Median follow-up was 6.1 years (IQR = 3.6-9.0), with 339 (62.1%) >5-year follow-up. Multivariable logistic regression showed that patients undergoing TLIF had a lower odds of reoperation compared with PLF alone (odds ratio = 0.23, 95% CI = 0.54-0.99, P = .048). Among patients with >5-year follow-up, the same trend was seen (odds ratio = 0.15, 95% CI = 0.03-0.95, P = .045). No differences were observed in 90-day complications ( P = .487) and readmission rates ( P = .230) or minimum clinically important difference PROMs. CONCLUSION In a retrospective cohort study from a prospectively maintained registry, patients with grade 1 degenerative spondylolisthesis undergoing TLIF had significantly lower long-term reoperation rates than those undergoing PLF.
Collapse
Affiliation(s)
- Alan R Tang
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony M Steinle
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Soren Jonzzon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Steven G Roth
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
10
|
Chanbour H, Steinle AM, Chen JW, Waddell WH, Vickery J, LaBarge ME, Longo M, Gardocki RJ, Abtahi AM, Stephens BF, Zuckerman SL. The importance of Hounsfield units in adult spinal deformity surgery: finding an optimal threshold to minimize the risk of mechanical complications. J Spine Surg 2023; 9:149-158. [PMID: 37435329 PMCID: PMC10331500 DOI: 10.21037/jss-22-102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 04/25/2023] [Indexed: 07/13/2023]
Abstract
Background Low bone mineral density (BMD) is a well-established risk factor for mechanical complications following adult spinal deformity (ASD) surgery. Hounsfield units (HU) measured on computed tomography (CT) scans are a proxy of BMD. In ASD surgery, we sought to: (I) evaluate the association of HU with mechanical complications and reoperation, and (II) identify optimal HU threshold to predict the occurrence of mechanical complications. Methods A single-institution retrospective cohort study was undertaken for patients undergoing ASD surgery from 2013-2017. Inclusion criteria were: ≥5-level fusion, sagittal/coronal deformity, and 2-year follow-up. HU were measured on 3 axial slices of one vertebra, either at the upper instrumented vertebra (UIV) itself or UIV ±4 from CT scans. Multivariable regression controlled for age, body mass index (BMI), postoperative sagittal vertical axis (SVA), and postoperative pelvic-incidence lumbar-lordosis mismatch. Results Of 145 patients undergoing ASD surgery, 121 (83.4%) had a preoperative CT from which HU were measured. Mean age was 64.4±10.7 years, mean total instrumented levels was 9.8±2.6, and mean HU was 153.5±52.8. Mean preoperative SVA and T1PA were 95.5±71.1 mm and 28.8°±12.8°, respectively. Postoperative SVA and T1PA significantly improved to 61.2±61.6 mm (P<0.001) and 23.0°±11.0° (P<0.001). Mechanical complications occurred in 74 (61.2%) patients, including 42 (34.7%) proximal junctional kyphosis (PJK), 3 (2.5%) distal junctional kyphosis (DJK), 9 (7.4%) implant failure, 48 (39.7%) rod fracture/pseudarthrosis, and 61 (52.2%) reoperations within 2 years. Univariate logistic regression showed a significant association between low HU and PJK [odds ratio (OR) =0.99; 95% confidence interval (CI): 0.98-0.99; P=0.023], but not on multivariable analysis. No association was found regarding other mechanical complications, overall reoperations, and reoperations due to PJK. HU below 163 were associated with increased PJK on receiver operating characteristic (ROC) curve analysis [area under the curve (AUC) =0.63; 95% CI: 0.53-0.73; P<0.001]. Conclusions Though several factors contribute to PJK, it appears that 163 HU may serve as a preliminary threshold when planning ASD surgery to mitigate the risk of PJK.
Collapse
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony M. Steinle
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey W. Chen
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - William Hunter Waddell
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Justin Vickery
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew E. LaBarge
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Longo
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Raymond J. Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amir M. Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Byron F. Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott L. Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
11
|
Chanbour H, Gardocki RJ, Zuckerman SL. Commentary: Minimally Invasive Preganglionic C2 Root Section for Occipital Neuralgia: 2 Case Reports and Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e153-e154. [PMID: 36701602 DOI: 10.1227/ons.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/21/2022] [Indexed: 01/27/2023] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
12
|
Chanbour H, Zuckerman SL, Gardocki RJ. Commentary: Multi-level Endoscopic Transforaminal Interbody Fusion for Severe Discitis, Osteomyelitis, and Kyphotic Deformity in the Lumbar Spine. Oper Neurosurg (Hagerstown) 2023; 24:e373-e374. [PMID: 36815830 DOI: 10.1227/ons.0000000000000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 02/24/2023] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
13
|
Chanbour H, Steinle AM, Tang AR, Gardocki RJ, Abtahi AM, Stephens BF, Zuckerman SL. In Single-Level, Open, Posterior Lumbar Fusion, Does Transforaminal Lumbar Interbody Fusion or Posterolateral Fusion Lead to Better Outcomes? Neurosurgery 2023; 92:110-117. [PMID: 36519862 DOI: 10.1227/neu.0000000000002187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/17/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Two common approaches for open, one-level, posterior lumbar fusions include transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone without an interbody. OBJECTIVE To compare TLIF vs PLF alone in (1) discharge disposition, (2) return to work (RTW), and (3) patient-reported outcomes (PROs). METHODS A single-center, retrospective cohort study was undertaken between October 2010 and May 2021, all with a 1-year follow-up and excluding patients with isthmic spondylolisthesis. Minimum clinically important difference for each PRO was used, which included Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Logistic/linear regression controlled for age, body mass index, disc height, flexion-extension movement, amount of movement on flexion-extension, and spondylolisthesis grade. RESULTS Of 850 patients undergoing open, 1-level, posterior lumbar fusion, 591 (69.5%) underwent a TLIF and 259 (30.5%) underwent a PLF alone. Patients undergoing TLIF were younger (59.0 ± 11.3 vs 63.3 ± 12.6, P < .001), had higher body mass index (31.3 ± 6.6 vs 30.2 ± 12.6, P = .019), and more often had private insurance (50.3% vs 39.0%, P < .001). Regarding discharge disposition, no significance was found in multivariate regression (odds ratio = 2.07, 95% CI = 0.39-10.82, P = .385) with similar RTW between TLIF and PLF alone (80.8% vs 80.4%, P = .645) (odds ratio = 1.15, 95% CI = 0.19-6.81, P = .873). Regarding PROs, patients undergoing a TLIF had higher preoperative (6.7 ± 2.3 vs 6.4 ± 2.5, P = .046) and 3-month NRS-back pain (3.4 ± 2.6 vs 2.9 ± 2.5, P = .036), with similar 12-month NRS-back pain. Regarding NRS-leg pain, no differences were observed preoperatively ( P = .532) and at 3 months ( P = .808). No other significant differences were observed in ODI. CONCLUSION TLIF patients had slightly higher NRS-back pain at baseline and 3 months, but similar NRS-leg pain, despite the added risk of placing an interbody. No differences were seen in discharge disposition, RTW, and 12-month pain scores and ODI.
Collapse
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony M Steinle
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alan R Tang
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
14
|
Chambers JS, Kropp RG, Gardocki RJ. Reoperation rates and patient-reported outcomes of single and two-level anterior cervical discectomy and fusion. Arch Orthop Trauma Surg 2023; 143:265-268. [PMID: 34244874 DOI: 10.1007/s00402-021-04056-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 07/02/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purposes of this study were to identify the 2 year rate of reoperation and determine patient-reported outcomes after elective one- and two-level anterior cervical discectomy and fusion (ACDF) with structural allograft and anterior plating using indications similar to cervical disc arthroplasty. MATERIALS AND METHODS A retrospective chart review was performed on 116 consecutive one- and two-level primary ACDF for adult degenerative disease with structural allograft and anterior plating in one surgeon's practice. Patient-reported visual analog score (VAS), Oswestry disability index (ODI) and radiographs, collected prospectively on all operative patients preoperatively and postoperatively at 6 weeks, 3 months, 6 months, 1 year, and 2 years were reviewed. Patient demographics and reoperation rates were obtained from the chart. RESULTS One hundred and four patients were identified with a final reoperation rate of 2.9% at a mean final follow-up 2 years (95% CI 17.2-29.0). No reoperations occurred within 90 days. After 1 year, three patients required reoperation. The mean patient-reported outcomes improved (VAS, 6.6 preoperatively to 3.0 at final follow-up and ODI, 24.3 preoperatively to 12.3 at final follow-up). These improvements were statistically significant (p < 0.01). No significant patient risk factors for reoperation were found. CONCLUSIONS The rate of reoperation for one- and two-level anterior cervical discectomy and fusion at follow-up was found to be lower than those previously published in the literature quoted for CDA. Arthrodesis continues to demonstrate improvements in patient-reported outcomes.
Collapse
Affiliation(s)
- James S Chambers
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee/Campbell Clinic, Memphis, TN, USA
| | - Robert G Kropp
- University of Tennessee Health Science Center, 1211 Union Avenue, Suite 500, Memphis, TN, 38104, USA
| | - Raymond J Gardocki
- University of Tennessee Health Science Center, 1211 Union Avenue, Suite 500, Memphis, TN, 38104, USA.
| |
Collapse
|
15
|
Steinle AM, Nian H, Pennings JS, Bydon M, Asher A, Archer KR, Gardocki RJ, Zuckerman SL, Stephens BF, Abtahi AM. Complications, readmissions, reoperations and patient-reported outcomes in patients with multiple sclerosis undergoing elective spine surgery - a propensity matched analysis. Spine J 2022; 22:1820-1829. [PMID: 35779839 DOI: 10.1016/j.spinee.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/05/2022] [Accepted: 06/16/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Multiple sclerosis (MS) is an autoimmune, neurodegenerative disease that can lead to significant functional disability. Improving treatment regimens have extended life expectancy and led to an increase in the number of elective spine surgeries for degenerative conditions in the MS population. Recent literature has reported mixed results regarding the efficacy of elective spine surgery for patients with MS. There is also a paucity of literature comparing postoperative patient reported outcomes (PROs) and reoperation rates between patients with and without MS. PURPOSE To determine if patients with MS have worse PROs and higher complication, readmission and reoperation rates after elective spine surgery compared with patients without neurodegenerative conditions when adjusting for baseline covariates through propensity matching. STUDY DESIGN/SETTING Retrospective review of prospectively collected data from the Quality Outcomes Database (QOD), a national, longitudinal, multicenter spine outcomes registry. PATIENT SAMPLE For the lumbar cohort, 312 patients with MS and 46,738 patients without MS were included. The cervical myelopathy cohort included 91 patients with MS and 6,426 patients without MS. The cervical radiculopathy cohort consisted of 103 patients with MS and 13,751 patients without MS. OUTCOME MEASURES 1) complication rates, 2) readmission rates, 3) reoperation rates, and 4) PROs at 3- and 12-months including ODI/NDI, NRS back/neck/arm/leg pain, mJOA scores and patient satisfaction ratings. METHODS Data from the QOD was queried for patients with surgeries occurring between 04/2013-01/2019. Three surgical groups were included: 1) Elective lumbar surgery, 2) Elective cervical surgery for myelopathy, 3) Elective cervical surgery for radiculopathy. Patients with any neurodegenerative condition other than MS were excluded. Patients without MS were propensity matched against patients with MS in a 5 to 1 ratio without replacement based on ASA grade, arthrodesis, surgical approach, number of operated levels, age, and baseline ODI/NDI, NRS leg/arm pain, NRS back/neck pain, and EQ-5D. Multivariable regressions with cluster-robust standard errors were used to estimate average effect of how the outcome would change if the MS patient didn't have the disease. The mean difference was used for continuous outcomes and the risk difference was used for binary outcomes. RESULTS For the lumbar cohort, no differences were found between the 2 groups at 3 or 12 months in any of the outcome measures. For the myelopathy cohort, patients with MS patients had a lower rate of reoperation at 12 months (risk difference=-0.036, p=.007) and worse 3-month mJOA scores (mean difference=-1.044, p=.004) compared with patients without MS. For the radiculopathy cohort, patients with MS had a lower rate of reoperation at 3 months (risk difference=-0.019, p=.018) and 12 months (risk difference=-0.029, p=.007) compared with those without MS. CONCLUSIONS Patients with MS had similar PROs compared with patients without MS when adjusting for baseline covariates through propensity matching, except for 3-month mJOA scores in the myelopathy cohort. Reoperation rates were found to be lower in patients with MS undergoing elective cervical surgery for both myelopathy and radiculopathy. These results suggest that when analyzed independently, a diagnosis of MS does not significantly impact complication, readmission and reoperation rates or PROs, and therefore should not represent a major contraindication to elective spine surgery. Surgical decisions in this patient population should be made based on careful consideration of patient factors including other comorbidities as well as baseline patient functional status.
Collapse
Affiliation(s)
- Anthony M Steinle
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA
| | - Hui Nian
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Ave Ste 1100, Nashville, TN 37203, USA
| | - Jacquelyn S Pennings
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, 200 First St SW Floor 8. Rochester, MN 55905, USA
| | - Anthony Asher
- Neuroscience Institute, Atrium Health and Department of Neurosurgery, Carolinas Medical Center, Charlotte, North Carolina; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, 1021 Morehead Medical Dr, Charlotte, NC 28204, USA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA; Department of Physical Medicine & Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, 3401 West End Ave Suite 380, Nashville, TN 37203, USA
| | - Raymond J Gardocki
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA
| | - Scott L Zuckerman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA
| | - Byron F Stephens
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA
| | - Amir M Abtahi
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S #3200, Nashville, TN 37232, USA; Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, The Village at Vanderbilt, 1500 21st Ave S Suite 1506, Nashville, TN 37212, USA.
| |
Collapse
|
16
|
Chanbour H, Zuckerman SL, Gardocki RJ. Commentary: Ten-Step 3D-Navigated Single-Stage Lateral Surgery With Microtubular Decompression: A Case Series. Oper Neurosurg (Hagerstown) 2022; 23:e397-e398. [PMID: 36251427 DOI: 10.1227/ons.0000000000000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/06/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
17
|
Steinle AM, Fogel JD, Gupta R, Davidson C, Hymel AM, Vaughan WE, Croft AJ, Pennings JS, Archer KR, Zuckerman SL, Gardocki RJ, Abtahi AM, Stephens BF. Assessing the Insurance Deductible Effect on Outcomes After Elective Spinal Surgery. World Neurosurg 2022; 168:e354-e368. [DOI: 10.1016/j.wneu.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/08/2022]
|
18
|
Chanbour H, Gardocki RJ, Zuckerman SL. Commentary: Endoscope-Assisted Retroperitoneal Prepsoas Approach to Lumbar Intervertebral Disk Decompression. Technical Note. Oper Neurosurg (Hagerstown) 2022; 23:e49-e50. [PMID: 35726934 DOI: 10.1227/ons.0000000000000255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
19
|
Olinger CR, Gardocki RJ. Deep Venous Thrombosis and Pulmonary Embolism After Minimally Invasive Transforaminal Lumbar Interbody Fusion: Report of 2 Cases in 315 Procedures. Orthop Clin North Am 2020; 51:423-425. [PMID: 32498960 DOI: 10.1016/j.ocl.2020.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
When the guidelines of the North American Spine Society concerning deep venous thrombosis (DVT) prophylaxis were followed, only 2 (0.63%) of 315 patients with minimally invasive transforaminal lumbar interbody fusions developed DVT complications over a 9-year period. Based on these findings, mechanical DVT prophylaxis appears to be adequate in patients undergoing elective spinal surgery, with no current support for pharmacologic prophylaxis.
Collapse
Affiliation(s)
- Catherine R Olinger
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
| | - Raymond J Gardocki
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| |
Collapse
|
20
|
Cho H, Holt DC, Smith R, Kim SJ, Gardocki RJ, Hasty KA. The Effects of Platelet-Rich Plasma on Halting the Progression in Porcine Intervertebral Disc Degeneration. Artif Organs 2015; 40:190-5. [DOI: 10.1111/aor.12530] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Hongsik Cho
- Department of Orthopaedic Surgery and Biomedical Engineering; University of Tennessee Health Science Center; Memphis TN USA
- Veterans Affairs Medical Center; Memphis TN USA
| | - David C. Holt
- Department of Orthopaedic Surgery and Biomedical Engineering; University of Tennessee Health Science Center; Memphis TN USA
| | - Richard Smith
- Department of Orthopaedic Surgery and Biomedical Engineering; University of Tennessee Health Science Center; Memphis TN USA
| | - Song-Ja Kim
- Department of Biological Sciences; Kongju National University; Gongju-si South Korea
| | | | - Karen A. Hasty
- Department of Orthopaedic Surgery and Biomedical Engineering; University of Tennessee Health Science Center; Memphis TN USA
- Veterans Affairs Medical Center; Memphis TN USA
| |
Collapse
|
21
|
Huang EY, Acosta JM, Gardocki RJ, Danielson PD, Skaggs DL, Reynolds RAK, Tolo VT, Stein JE. Thoracoscopic anterior spinal release and fusion: evolution of a faster, improved approach. J Pediatr Surg 2002; 37:1732-5. [PMID: 12483643 DOI: 10.1053/jpsu.2002.36708] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The aim of this study was to compare the perioperative parameters and outcomes of video-assisted thoracoscopic surgery (VATS) with open thoracotomy for anterior release and fusion in the treatment of pediatric spinal deformities. METHODS Twenty-six patients treated with VATS anterior spinal release and posterior spinal fusion by the authors were reviewed retrospectively. Fourteen age- and disease-matched patients who underwent open thoracotomy for anterior spinal release and posterior spinal fusion by the same group of surgeons during the same time period were evaluated for comparison. Patients whose anterior level of exposure extended below the diaphragm were excluded. RESULTS Blood loss, operative transfusion, and length of postoperative chest tube use all were decreased in the VATS patients compared with thoracotomy patients (P < or =.05). The average operating time for VATS was less than that for thoracotomy but did not reach statistical significance. However, operating time was significantly shorter in the second 13 VATS patients compared with the first 13 patients. No complications specifically related to the VATS approach were identified. CONCLUSIONS The VATS technique is a safe and comparable alternative to open thoracotomy. Although there is a learning curve for VATS, greater experience could show an advantage in this approach to the anterior spine for the treatment of pediatric spinal deformity.
Collapse
Affiliation(s)
- Eunice Y Huang
- Division of Pediatric Surgery and Orthopedic Surgery, Childrens Hospital Los Angeles and the University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Gardocki RJ, Watkins RG, Williams LA. Measurements of lumbopelvic lordosis using the pelvic radius technique as it correlates with sagittal spinal balance and sacral translation. Spine J 2002; 2:421-9. [PMID: 14589266 DOI: 10.1016/s1529-9430(02)00426-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Maintenance of normal lumbar lordosis is important in the treatment of spinal disorders. Many attempts have been made to quantify normal sagittal spinal alignment and lordosis using a C7 plumb line and segmental angulations of the spinal vertebrae. Little attention has been given to pelvic compensation as it correlates to lumbar lordosis and overall sagittal spinal alignment. Better methods of measuring lordosis, which correlate with sagittal spinal balance and pelvic compensation, are needed in treating patients with spinal disorders. PURPOSE To determine the correlation between lumbopelvic lordosis, pelvic rotation and sagittal spinal balance and standardize a method for measuring lumbopelvic lordosis, sacral translation, and sagittal spinal alignment. STUDY DESIGN Sagittal alignments using the C7 plumb line, Cobb angles, sacral plumb line and the pelvic radius (PR) technique were used to measure standing 36-inch lateral radiographs of patients with various spinal disorders. PATIENT SAMPLE A review of the records identified 62 patients with various spinal pathologies presenting to the (RGW) spine clinic that had standing lateral spine radiographs. Only radiographs that allowed positive identification of the C7 vertebral body, the entire thoracolumbar spine, the sacrum and both femoral heads were studied. These criteria allowed inclusion of 28 subjects in this study. The final population had 12 women and 16 men with an average age of 52 years (SD, 16.6 years; range, 20 to 84 years). OUTCOME MEASURES No outcomes measures were used in this study. METHODS Measurements for sagittal spinal balance and lumbopelvic lordosis were made on 36-inch standing lateral radiographs of adult patients. Measurements included the C7 plumb line, segmental angulations of spinal vertebrae (Cobb angles), sacral translation and the PR technique for lumbopelvic lordosis. Data were analyzed for significant correlation between lumbopelvic lordosis, sagittal spinal balance, sacral translation and total segmental lumbar lordosis using the Cobb method. RESULTS Our population averaged 50 degrees of total segmental lumbar lordosis from L1 to S1 (SD, 14.3; maximum, 89.5; minimum, 17.9). Nearly 75% of total segmental lumbar lordosis measured from L1 to S1 can be accounted for through the L4 to S1 superior end plates and 47% through L5 to S1 superior end plates in our population. Total segmental lumbar lordosis correlated with total thoracic kyphosis (r=0.45, p=.008). Total segmental lumbar lordosis measured by the Cobb method significantly correlated with sagittal spinal balance (r=-0.35, p=.022) and sacral translation (r=0.41, p=.016). Measurements for lumbopelvic lordosis significantly correlated with sagittal spinal balance (r=-0.33, p=.042), sacral translation (r=-0.70, p=.00002) and total segmental lumbar lordosis (r=0.82, p<.000001). Measurements for sacral translation and sagittal spinal balance also correlated significantly (r=0.35, p=.034). CONCLUSIONS Sacral translation, the C7 plumb line and lumbopelvic lordosis are useful measures for sagittal spinal balance. Lumbopelvic lordosis and sacral translation can be correlated to the sagittal spinal balance. Understanding these measurements and the range of lumbopelvic compensation can be extremely helpful in treating patients with spinal pathology and in avoidance of flatback deformity. Application of these measures would be especially helpful in the treatment of patients with spinal fusion, degenerative spondylosis, disc disease, fractures, and in the prevention of sagittal malalignment.
Collapse
Affiliation(s)
- Raymond J Gardocki
- Los Angeles Spine Surgery Institute, #120, 2200 West Third Street, Los Angeles, CA 90057, USA.
| | | | | |
Collapse
|
23
|
Shepherd LE, Costigan WM, Gardocki RJ, Ghiassi AD, Patzakis MJ, Stevanovic MV. Local or free muscle flaps and unreamed interlocked nails for open tibial fractures. Clin Orthop Relat Res 1998:90-6. [PMID: 9602806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The treatment of open tibial fractures associated with severe soft tissue injuries remains a difficult dilemma, even to the experienced fracture surgeon. To ascertain the efficacy of nailing tibial fractures with severe soft tissue injuries, a review of all open tibial fractures treated at the authors' institution was done. Those fractures initially stabilized with nonreamed nails which required muscle flaps for coverage were selected for study. Thirty-three patients (26 men, seven women) were treated with intramedullary nailing and muscle flap coverage for the soft tissue defects. The average length of followup was 12.1 months (range, 7-42 months). The average time to union was 27 weeks (range, 14-45 weeks). There were five (15%) infections: two (6%) superficial wound infections, one (3%) flap infection, and two (6%) cases of osteomyelitis. In no patient did the infection result in limb ablation. Thirteen of 33 (42%) patients required secondary procedures to enhance union. In this study, it was found that although delayed procedures frequently were required to promote fracture union, the time to union, and infection rates were not significantly different from those reported for external fixation of fractures that require local or free muscle transfers.
Collapse
Affiliation(s)
- L E Shepherd
- Department of Orthopaedic Surgery, Los Angeles County/University of Southern California Medical Center 90033, USA
| | | | | | | | | | | |
Collapse
|