Clinical Outcomes between Stand-Alone Zero-Profile Spacers and Cervical Plate with Cage Fixation for Anterior Cervical Discectomy and Fusion: A Retrospective Analysis of 166 Patients

Stand-alone (SA) zero-profile implants are an alternative to cervical plating (CP) in anterior cervical discectomy and fusion (ACDF). In this study, we investigate differences in surgical outcomes between SA and CP in ACDF. We conducted a retrospective analysis of 166 patients with myelopathy and/or radiculopathy who had ACDF with SA or CP from Jan 2013-Dec 2016. We measured surgical outcomes including Bazaz dysphagia score at 3 months, Nurick grade at last follow-up, and length of hospital stay. 166 patients (92F/74M) were reviewed. 92 presented with radiculopathy (55%), 37 with myelopathy (22%), and 37 with myeloradiculopathy (22%). The average operative time with CP was longer than SA (194 ± 69 vs. 126 ± 46 min) (p < 0.001), as was the average length of hospital stay (2.1 ± 2 vs. 1.5 ± 1 days) (p = 0.006). At 3 months, 82 patients (49.4%) had a follow-up for dysphagia, with 3 patients reporting mild dysphagia and none reporting moderate or severe dysphagia. Nurick grade at last follow-up for the myelopathy and myeloradiculopathy cohorts improved in 63 patients (85%). Prolonged length of stay was associated with reduced odds of having an optimal outcome by 0.50 (CI = 0.35-0.85, p = 0.003). Overall, we demonstrate that there is no significant difference in neurological outcome or rates of dysphagia between SA and CP, and that both lead to overall improvement of symptoms based on Nurick grading. However, we also show that the SA group has shorter length of hospital stay and operative time compared to CP.

Reduced influence of affective disorders on perioperative complication rates, length of hospital stay, and healthcare costs following spinal fusion for adolescent idiopathic scoliosis

OBJECTIVE

In the past decade, a gradual transition of health policy to value-based healthcare has brought increased attention to measuring the quality of care delivered. In spine surgery, adolescents with scoliosis are a population particularly at risk for depression, anxious feelings, and impaired quality of life related to back pain and cosmetic appearance of the deformity. With the rising prevalence of mental health ailments, it is necessary to evaluate the impact of concurrent affective disorders on patient care after spinal surgery in adolescents. The aim of this study was to investigate the impact that affective disorders have on perioperative complication rates, length of stay (LOS), and total costs in adolescents undergoing elective posterior spinal fusion (PSF) (≥ 4 levels) for idiopathic scoliosis.

METHODS

A retrospective study of the Kids' Inpatient Database for the year 2012 was performed. Adolescent patients (age range 10-17 years old) with AIS undergoing elective PSF (≥ 4 levels) were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Patients were categorized into 2 groups at discharge: affective disorder or no affective disorder. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were assessed. The primary outcomes were perioperative complication rates, LOS, total cost, and discharge dispositions.

RESULTS

There were 3759 adolescents included in this study, of whom 164 (4.4%) were identified with an affective disorder (no affective disorder: n = 3595). Adolescents with affective disorders were significantly older than adolescents with no affective disorders (affective disorder: 14.4 ± 1.9 years vs no affective disorder: 13.9 ± 1.8 years, p = 0.001), and had significantly different proportions of race (p = 0.005). Aside from hospital region (p = 0.016), no other patient- or hospital-level factors differed between the cohorts. Patient comorbidities did not differ significantly between cohorts. The number of vertebral levels involved was similar between the cohorts, with the majority of patients having 9 or more levels involved (affective disorder: 76.8% vs no affective disorder: 79.5%, p = 0.403). Postoperative complications were similar between the cohorts, with no significant difference in the proportion of patients experiencing a postoperative complication (p = 0.079) or number of complications (p = 0.124). The mean length of stay and mean total cost were similar between the cohorts. Moreover, the routine and nonroutine discharge dispositions were also similar between the cohorts, with the majority of patients having routine discharges (affective disorder: 93.9% vs no affective disorder: 94.9%, p = 0.591).

CONCLUSIONS

This study suggests that affective disorders may not have a significant impact on surgical outcomes in adolescent patients undergoing surgery for scoliosis in comparison with adults. Further studies are necessary to elucidate how affective disorders affect adolescent patients with idiopathic scoliosis, which may improve provider approach in managing these patients perioperatively and at follow-up in hopes to better the overall patient satisfaction and quality of care delivered.

Erratum to intraoperative ketamine may increase risk of post-operative delirium after complex spinal fusion for adult deformity correction

[This corrects the article DOI: 10.21037/jss.2018.12.10.].

Impact of patient and hospital-level risk factors on extended length of stay following spinal fusion for adolescent idiopathic scoliosis

OBJECTIVE

Health policy changes have led to increased emphasis on value-based care to improve resource utilization and reduce inpatient hospital length of stay (LOS). Recently, LOS has become a major determinant of quality of care and resource utilization. For adolescent idiopathic scoliosis (AIS), the determinants of extended LOS after elective posterior spinal fusion (PSF) remain relatively unknown. In the present study, the authors investigated the impact of patient and hospital-level risk factors on extended LOS following elective PSF surgery (≥ 4 levels) for AIS.

METHODS

The Kids' Inpatient Database (KID) was queried for the year 2012. Adolescent patients (age range 10-17 years) with AIS undergoing elective PSF (≥ 4 levels) were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended hospital LOS was defined as greater than the 75th percentile for the entire cohort (> 6 days), and patients were dichotomized as having normal LOS or extended LOS. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were recorded. A multivariate logistic regression model was used to determine the odds ratio for risk-adjusted LOS. The primary outcome was the degree to which patient comorbidities or postoperative complications correlated with extended LOS.

RESULTS

Comorbidities were overall significantly higher in the extended-LOS cohort than the normal-LOS cohort. Patients with extended LOS had a significantly greater proportion of blood transfusion (p < 0.001) and ≥ 9 vertebral levels fused (p < 0.001). The overall complication rates were greater in the extended-LOS cohort (20.3% [normal-LOS group] vs 43.5% [extended-LOS group]; p < 0.001). On average, the extended-LOS cohort incurred $18,916 more in total cost than the normal-LOS group ($54,697 ± $24,217 vs $73,613 ± $38,689, respectively; p < 0.001) and had more patients discharged to locations other than home (p < 0.001) than did patients in the normal-LOS cohort. On multivariate logistic regression, several risk factors were associated with extended LOS, including female sex, obesity, hypertension, fluid electrolyte disorder, paralysis, blood transfusion, ≥ 9 vertebrae fused, dural injury, and nerve cord injury. The odds ratio for extended LOS was 1.95 (95% CI 1.50-2.52) for patients with 1 complication and 5.43 (95% CI 3.35-8.71) for patients with > 1 complication.

CONCLUSIONS

The authors' study using the KID demonstrates that patient comorbidities and intra- and postoperative complications all contribute to extended LOS after spinal fusion for AIS. Identifying multimodality interventions focused on reducing LOS, bettering patient outcomes, and lowering healthcare costs are necessary to improve the overall value of care for patients undergoing spinal fusion for AIS.

Reduced Influence of Affective Disorders on 6-Week and 3-Month Narcotic Refills After Primary Complex Spinal Fusions for Adult Deformity Correction: A Single-Institutional Study

OBJECTIVE

Previous studies have identified the impact of affective disorders on preoperative and postoperative perception of pain. However, there is a scarcity of data identifying the impact of affective disorders on postdischarge narcotic refills. The aim of this study was to determine whether patients with affective disorders have more narcotic refills after complex spinal fusion for deformity correction.

METHODS

The medical records of 121 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, baseline and postoperative patient-reported pain scores, ambulatory status, and narcotic refills were collected for each patient. The primary outcome was the rate of 6-week and 3-month narcotic refills.

RESULTS

Of the 121 patients, 43 (35.5%) had a clinical diagnosis of anxiety or depression (affective disorder) (AD n = 43; No-AD n = 78). Preoperative narcotic use was significantly higher in the AD cohort (AD 65.9% vs. No-AD 37.7%, P = 0.0035). The AD cohort had significantly higher pain scores at baseline (AD 6.5 ± 2.9 vs. No-AD 4.7 ± 3.1, P = 0.004) and at the first postoperative pain score reported (AD 6.7 ± 2.6 vs. No-AD 5.6 ± 2.9, P = 0.049). However, there were no significant differences in narcotic refills at 6 weeks (AD 34.9% vs. No-AD 25.6%, P = 0.283) and 3 months (AD 23.8% vs. No-AD 17.4%, P = 0.411) after discharge between the cohorts.

CONCLUSIONS

Our study suggests that whereas spinal deformity patients with affective disorders may have a higher baseline perception of pain and narcotic use, the impact of affective disorders on narcotic refills at 6 weeks and 3 months may be minimal after complex spinal fusion.

Association Between Preoperative Narcotic Use with Perioperative Complication Rates, Patient Reported Pain Scores, and Ambulatory Status After Complex Spinal Fusion (≥5 Levels) for Adult Deformity Correction

OBJECTIVE

The widespread over-use of narcotics has been increasing. However, whether narcotic use impacts surgical outcomes after complex spinal fusion remains understudied. The aim of this study was to evaluate whether there is an association between preoperative narcotic use with perioperative complication rates, patient-reported pain scores, and ambulatory status after complex spinal fusions.

METHODS

The medical records of 134 adult (age ≥18 years) patients with spinal deformity undergoing elective, primary complex spinal fusion (≥5 levels) for deformity correction in a major academic institution from 2005-2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, pain scores, and ambulatory status were collected for each patient.

RESULTS

Patient demographics and comorbidities were similar between both cohorts, except that the Narcotic-User cohort had a greater mean age (57.5 years vs. 50.7 years; P = 0.045) and prevalence of depression (39.4% vs. 16.2%; P = 0.003). Complication rates were similar between both cohorts. The Narcotic-User cohort had significantly higher pain scores at baseline (6.7 ± 2.4 vs. 4.0 ± 3.4; P < 0.001) and at the first postoperative pain score reported (6.7 ± 2.8 vs. 5.3 ± 2.9; P = 0.013), but had a significantly greater improvement from baseline to last pain score (Narcotic-User: -2.5 ± 3.9 vs. Non-User: -0.5 ± 4.7; P = 0.031). The Narcotic-User cohort had significantly greater ambulation on the first postoperative ambulatory day compared with the Non-User cohort (103.8 ± 144.4 vs. 56.4 ± 84.0; P = 0.031).

CONCLUSIONS

Our study suggests that the preoperative use of narcotics may impact patient perception of pain and improvement after complex spinal fusions (≥5 levels). Consideration of patients' narcotic status preoperatively may facilitate tailored pain management and physical therapy regimens.

Intraoperative ketamine may increase risk of post-operative delirium after complex spinal fusion for adult deformity correction

BACKGROUND

For complex surgery, intraoperative ketamine administration is readily used to reduce post-operative pain. However, there have been a few studies suggesting that intraoperative ketamine may have deleterious effects and impact post-operative delirium. Therefore, we sought to identify the impact that intraoperative ketamine has on post-operative outcomes after complex spinal surgery involving ≥5 level fusions.

METHODS

The medical records of 138 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. We identified 98 (71.0%) who had intraoperative ketamine administration and 40 (29%) who did not (Ketamine-Use: n=98; No-Ketamine: n=40). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative delirium. A multivariate nominal-logistic regression analysis was used to determine the independent association between intraoperative ketamine and post-operative delirium.

RESULTS

Patient demographics and comorbidities were similar between both cohorts, including age, gender, and BMI. The median number of fusion levels operated, length of surgery, estimated blood loss, and proportion of patients requiring blood transfusions were similar between both cohorts. Postoperative complication profile was similar between the cohorts, except for the Ketamine-Use cohort having significantly higher proportion of patients experiencing delirium (Ketamine-Use: 14.3% vs. No-Ketamine: 2.6%, P=0.047). In a multivariate nominal-logistic regression analysis, intraoperative Ketamine-Use was independently associated with post-operative delirium (OR: 9.475, 95% CI: 1.026-87.508, P=0.047).

CONCLUSIONS

Our study suggests that the intraoperative use of ketamine may increase the risk of post-operative delirium. Further studies are necessary to understand the physiological effect intraoperative ketamine has on patients undergoing complex spinal fusions in order to better overall patient care and reduce healthcare resources.

Rate of instrumentation changes on postoperative and follow-up radiographs after primary complex spinal fusion (five or more levels) for adult deformity correction

OBJECTIVEIn the United States, healthcare expenditures have been soaring at a concerning rate. There has been an excessive use of postoperative radiographs after spine surgery and this has been a target for hospitals to reduce unnecessary costs. However, there are only limited data identifying the rate of instrumentation changes on radiographs after complex spine surgery involving ≥ 5-level fusions.METHODSThe medical records of 136 adult (≥ 18 years old) patients with spine deformity undergoing elective, primary complex spinal fusion (≥ 5 levels) for deformity correction at a major academic institution between 2010 and 2015 were reviewed. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient. The authors reviewed the first 5 subsequent postoperative and follow-up radiographs, and determined whether revision of surgery was performed within 5 years postoperatively. The primary outcome investigated in this study was the rate of hardware changes on follow-up radiographs.RESULTSThe majority of patients were female, with a mean age of 53.8 ± 20.0 years and a body mass index of 27.3 ± 6.2 kg/m2 (parametric data are expressed as the mean ± SD). The median number of fusion levels was 9 (interquartile range 7-13), with a mean length of surgery of 327.8 ± 124.7 minutes and an estimated blood loss of 1312.1 ± 1269.2 ml. The mean length of hospital stay was 6.6 ± 3.9 days, with a 30-day readmission rate of 14.0%. Postoperative and follow-up change in stability on radiographs (days from operation) included: image 1 (4.6 ± 9.3 days) 0.0%; image 2 (51.7 ± 49.9 days) 3.0%; image 3 (142.1 ± 179.8 days) 5.6%; image 4 (277.3 ± 272.5 days) 11.3%; and image 5 (463.1 ± 525.9 days) 15.7%. The 3rd year after surgery had the highest rate of hardware revision (5.55%), followed by the 2nd year (4.68%), and the 1st year (4.54%).CONCLUSIONSThis study suggests that the rate of instrumentation changes on radiographs increases over time, with no changes occurring at the first postoperative image. In an era of cost-conscious healthcare, fewer orders for early radiographs after complex spinal fusions (≥ 5 levels) may not impact patient care and can reduce the overall use of healthcare resources.

Carbon dioxide laser for corpus callosotomy in the pediatric population

OBJECT

The authors describe the application of a flexible CO2 laser for corpus callosotomy in children with epilepsy.

METHODS

This retrospective case series reviews all cases in which pediatric patients underwent a corpus callosotomy performed using the CO2 OmniGuide laser between May 2005 and October 2012. Data were collected from 8 corpus callosotomy procedures in 6 pediatric patients presenting with medically refractory epilepsy marked by drop attacks.

RESULTS

Complete corpus callosotomies were performed in 6 patients (3 boys, 3 girls; ages 5-14 years). In 4 patients the complete callosotomy occurred as a single procedure, and in 2 patients an anterior two-thirds callosotomy was performed first. These 2 patients subsequently required a complete callosotomy due to inadequate control of their drop attacks. In all cases there was clean lesioning of the tract with preservation of the ependymal plane and less inadvertent thermal tissue damage due to low penetration of the laser through cerebrospinal fluid. All patients had resolution or improvement of drop attacks after surgery. No complications were encountered, and imaging demonstrated a clean sectioning of callosal fibers with preservation of normal ventricular anatomy.

CONCLUSIONS

These cases illustrate the use of this device in completing corpus callosotomy in pediatric patients. The low-profile laser fiber tip was well suited for working in the depths of the interhemispheric fissure with minimal brain retraction. The flexible CO2 laser allows a precise callosal lesioning through an interhemispheric approach and is a useful adjunct to be employed in these cases.

Multi-institutional validation of a preoperative scoring system which predicts survival for patients with glioblastoma

Glioblastoma is the most common and aggressive type of primary brain tumor in adults. Average survival is approximately 1 year, but individual survival is heterogeneous. Using a single institutional experience, we have previously identified preoperative factors associated with survival and devised a prognostic scoring system based on these factors. The aims of the present study are to validate these preoperative factors and verify the efficacy of this scoring system using a multi-institutional cohort. Of the 334 patients in this study from three different institutions, the preoperative factors found to be negatively associated with survival in a Cox analysis were age >60 years (p<0.0001), Karnofsky Performance Scale score ≤80 (p=0.03), motor deficit (p=0.02), language deficit (p=0.04), and periventricular tumor location (p=0.04). Patients possessing 0-1, 2, 3, and 4-5 of these variables were assigned a preoperative grade of 1, 2, 3, and 4, respectively. Patients with a preoperative grade of 1, 2, 3, and 4 had a median survival of 17.9, 12.3, 10, and 7.5 months, respectively. Survival of each of these grades was statistically significant (p<0.05) in log-rank analysis. This grading system, based only on preoperative variables, may provide patients and physicians with prognostic information that may guide medical and surgical therapy before any intervention is pursued.

Neurosphere assays: growth factors and hormone differences in tumor and nontumor studies

The "no new neuron" dogma that the brain is quiescent throughout adult life has been challenged by the discovery of cells with stem cell-like qualities of self-renewal and multipotency in the subventricular zone of the lateral ventricles and the dentate gyrus of the hippocampus in adults. This self-renewing capacity also makes these neural stem cells a possible source of brain tumors, which was supported by the discovery of self-sustaining brain tumor stem-like cells in cancers such as glioblastoma multiforme. Neurosphere assays are the standard for studying these stem-like cells in both normal and cancer tissues. Despite the importance of these assays, there is no standardized protocol to allow for a comparison of results because several studies use different growth factors and hormones at different concentrations. The primary objective of this study is to review the literature for both nontumor and tumor studies to assess their respective neurosphere assay components. We found significant variation in assay components, namely hormones and growth factors, as well as their respective concentrations. This illustrates the need for a standardized protocol to allow proper comparison among studies and a better assessment of the effects of different factors.