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Shahrestani S, Chung LK, Brown NJ, Reese S, Liu RC, Prasad RAA, Alluri RK, Hah R, Liu JC, Safaee MM. Integration of chronological age does not improve the performance of a mixed-effect model using comorbidity burden and frailty to predict 90-day readmission after surgery for degenerative scoliosis. World Neurosurg 2024:S1878-8750(24)00702-2. [PMID: 38679382 DOI: 10.1016/j.wneu.2024.04.129] [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: 04/02/2024] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE We evaluated the contributions of chronological age, comorbidity burden, and/or frailty in predicting 90-day readmission in patients undergoing degenerative scoliosis surgery. METHODS Patients were identified through the Healthcare Cost and Utilization Project Nationwide Readmissions Database. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty-defining indicator. Comorbidity was assessed using the Elixhauser Comorbidity Index (ECI). Generalized linear mixed-effects models were created to predict readmission using age, frailty, and/or ECI. Area under the curve (AUC) were compared using DeLong's test. RESULTS 8,104 patients were identified. Readmission rate was 9.8%, with infection representing the most common cause (3.5%). Our first model utilized chronological age, ECI, and/or frailty as primary predictors. The combination of ECI+frailty+age performed best, but the inclusion of chronological age did not significantly improve performance compared to ECI+frailty alone (AUC 0.603 vs. 0.599, p=0.290). A second model using only chronological age and frailty as primary predictors performed better, however the inclusion of chronological age worsened performance when compared to frailty alone (AUC 0.747 vs. 0.743, p=0.043). CONCLUSIONS These data support frailty as a predictor of 90-day readmission within a nationally representative sample. Frailty alone performed better than combinations of ECI and age. Interestingly, the integration of chronological age did not dramatically improve the model's performance. Limitations include the use of a national registry and a single frailty index. This provides impetus to explore biological age, rather than chronological age, as a potential tool for surgical risk assessment.
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Affiliation(s)
- Shane Shahrestani
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA; Department of Neurological Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lawrance K Chung
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - Nolan J Brown
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Sofia Reese
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ryan C Liu
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - R Apurva A Prasad
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - R Kiran Alluri
- Department of Orthopedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Raymond Hah
- Department of Orthopedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - John C Liu
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael M Safaee
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA.
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Ton A, Wishart D, Ball JR, Shah I, Murakami K, Ordon MP, Alluri RK, Hah R, Safaee MM. The Evolution of Risk Assessment in Spine Surgery: A Narrative Review. World Neurosurg 2024:S1878-8750(24)00690-9. [PMID: 38677646 DOI: 10.1016/j.wneu.2024.04.117] [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: 03/17/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Risk assessment is critically important in elective and high-risk interventions, particularly spine surgery. This narrative review describes the evolution of risk assessment from the earliest instruments focused on general surgical risk stratification, to more accurate and spine-specific risk calculators that quantified risk, to the current era of big data. METHODS The PubMed and SCOPUS databases were queried on October 11, 2023 using search terms to identify risk assessment tools in spine surgery. A total of 108 manuscripts were included after screening with full-text review using the following inclusion criteria: 1) study population of adult spine surgical patients, 2) studies describing validation and subsequent performance of preoperative risk assessment tools, and 3) studies published in English. RESULTS Early risk assessment tools provided stratified patients into broad categories and allowed for improved communication between physicians. Subsequent risk calculators attempted to quantify risk by estimating general outcomes such as mortality, but then evolved to estimate spine-specific surgical complications. The integration of novel concepts such as invasiveness, frailty, genetic biomarkers, and sarcopenia led to the development of more sophisticated predictive models that estimate the risk of spine-specific complications and long-term outcomes. CONCLUSIONS Risk assessment tools have undergone a transformative shift from generalized risk stratification to quantitative predictive models. The next generation of tools will likely involve integration of radiographic and genetic biomarkers, machine learning, and artificial intelligence to improve the accuracy of these models and better inform patients, surgeons, and payers.
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Affiliation(s)
- Andy Ton
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Danielle Wishart
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jacob R Ball
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ishan Shah
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Kiley Murakami
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Matthew P Ordon
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - R Kiran Alluri
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Raymond Hah
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Michael M Safaee
- Department of Neurological Surgery, Keck School of MedicineUniversity of Southern California, Los Angeles, CA.
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Campbell DH, Dowling TJ, Hah R, Alluri RK, Wang JC. Surgical strategies for spinal infections: A narrative review. N Am Spine Soc J 2023; 16:100293. [PMID: 38162170 PMCID: PMC10757275 DOI: 10.1016/j.xnsj.2023.100293] [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] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 01/03/2024]
Abstract
The successful operative management of spinal infections necessitates a thoughtful approach. Ideal treatment combines the universal goals of any spine operation, which are decompression of the neural elements and stabilization of instability, with source control and eradication of infection. Techniques to treat infection have evolved independently and alongside advances in implant technology and surgical techniques. This review will seek to outline current thinking on approaches to both primary and secondary spinal infections.
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Affiliation(s)
- David H. Campbell
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Thomas J. Dowling
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Raymond Hah
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - R. Kiran Alluri
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Jeffrey C. Wang
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
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4
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Bakhsheshian J, Shahrestani S, Buser Z, Hah R, Hsieh PC, Liu JC, Wang JC. The performance of frailty in predictive modeling of short-term outcomes in the surgical management of metastatic tumors to the spine. Spine J 2022; 22:605-615. [PMID: 34848345 DOI: 10.1016/j.spinee.2021.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/28/2021] [Revised: 11/10/2021] [Accepted: 11/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden. PURPOSE The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease. STUDY DESIGN/SETTING Retrospective analysis of a nationwide database to include patients undergoing spinal fusion for metastatic spine disease. PATIENT SAMPLE A total of 1,974 frail patients who received spinal fusion with spinal metastasis, and 1,975 propensity score matched non-frail patients. OUTCOME MEASURES Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs. METHODS A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub-group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI). RESULTS 7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n=1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC=0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups. CONCLUSIONS A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty.
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Affiliation(s)
- Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shane Shahrestani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Zorica Buser
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Raymond Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Patrick C Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey C Wang
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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5
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Alluri R, Mok JK, Vaishnav A, Shelby T, Sivaganesan A, Hah R, Qureshi SA. Intraoperative Neuromonitoring During Lateral Lumbar Interbody Fusion. Neurospine 2021; 18:430-436. [PMID: 34610671 PMCID: PMC8497239 DOI: 10.14245/ns.2142440.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To review the evidence for the use of electromyography (EMG), motor-evoked potentials (MEPs), and somatosensory-evoked potentials (SSEPs) intraoperative neuromonitoring (IONM) strategies during lateral lumbar interbody fusion (LLIF), as well as discuss the limitations associated with each technique.
Methods A comprehensive review of the literature and compilation of findings relating to clinical studies investigating the efficacy of EMG, MEP, SSEP, or combined IONM strategies during LLIF.
Results The evidence for the use of EMG is mixed with some studies demonstrating the efficacy of EMG in preventing postoperative neurologic injuries and other studies demonstrating a high rate of postoperative neurologic deficits with EMG monitoring. Multimodal IONM strategies utilizing MEPs or saphenous SSEPs to monitor the lumbar plexus may be promising strategies based on results from a limited number of studies.
Conclusion The use of traditional EMG during LLIF remains without consensus. There is a growing body of evidence utilizing multimodal IONM with MEPs or saphenous SSEPs demonstrating a possible decrease in postoperative neurologic injuries after LLIF. Future prospective studies, with clear definitions of neurologic injury, that evaluate different multimodal IONM strategies are needed to better assess the efficacy of IONM during LLIF.
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Affiliation(s)
- Ram Alluri
- Hospital for Special Surgery, New York, NY, USA
| | | | | | - Tara Shelby
- Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | | | - Raymond Hah
- Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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Shahrestani S, Bakhsheshian J, Chen XT, Ton A, Ballatori AM, Strickland BA, Robertson DM, Buser Z, Hah R, Hsieh PC, Liu JC, Wang JC. The influence of modifiable risk factors on short-term postoperative outcomes following cervical spine surgery: A retrospective propensity score matched analysis. EClinicalMedicine 2021; 36:100889. [PMID: 34308307 PMCID: PMC8257994 DOI: 10.1016/j.eclinm.2021.100889] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Modifiable risk factors (MRFs) represent patient variables associated with increased complication rates that may be prevented. There exists a paucity of studies that comprehensively analyze MRF subgroups and their independent association with postoperative complications in patients undergoing cervical spine surgery. Therefore, the purpose of this study is to compare outcomes between patients receiving cervical spine surgery with reported MRFs. METHODS Retrospective analysis of the Nationwide Readmissions Database (NRD) from the years 2016 and 2017, a publicly available and purchasable data source, to include adult patients undergoing cervical fusion. MRF cohorts were separated into three categories: substance abuse (alcohol, tobacco/nicotine, opioid abuse); vascular disease (hypertension, dyslipidemia); and dietary factors (malnutrition, obesity). Three-way nearest-neighbor propensity score matching for demographics, hospital, and surgical characteristics was implemented. FINDINGS We identified 9601 with dietary MRFs (D-MRF), 9654 with substance abuse MRFs (SA-MRF), and 9503 with vascular MRFs (V-MRF). Those with d-MRFs had significantly higher rates of medical complications (9.3%), surgical complications (8.1%), and higher adjusted hospital costs compared to patients with SA-MRFs and V-MRFs. Patients with d-MRFs (16.3%) and V-MRFs (14.0%) were independently non-routinely discharged at a significantly higher rate compared to patients with SA-MRFs (12.6%) (p<0.0001 and p = 0.0037). However, those with substance abuse had the highest readmission rate and were more commonly readmitted for delayed procedure-related infections. INTERPRETATION A large proportion of patients who receive cervical spine surgery have potential MRFs that uniquely influence their postoperative outcomes. A thorough understanding of patient-specific MRF subgroups allows for improved preoperative risk stratification, tailored patient counseling, and postoperative management planning. FUNDING None.
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Affiliation(s)
- Shane Shahrestani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States
- Corresponding author at: Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Xiao T. Chen
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Andy Ton
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Alexander M. Ballatori
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Ben A. Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Djani M. Robertson
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Zorica Buser
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Raymond Hah
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Patrick C. Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - John C. Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jeffrey C. Wang
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Abstract
STUDY DESIGN Retrospective database. OBJECTIVES Although posterior decompression is the most common approach for surgical treatment of degenerative thoracic spine disease, anterior approach is gaining interest due to its advantage in disc visualization. The objective of this study was to compare the intra- and postoperative medical complication rates between anterior and posterior decompression for degenerative thoracic spine pathologies. METHODS A national US insurance database was queried for patients with degenerative diagnoses who had undergone anterior or posterior thoracic decompression. Incidence of intra- and postoperative complications were evaluated on the day of surgery and within 1 and 3 months. Two subgroups were matched based on age, gender, and comorbidity. The association of decompression approach and complications was assessed using logistic regression. RESULTS A total of 1459 patients were included, consisting of 1004 patients in posterior and 455 patients in anterior group. Respiratory complications were the most common complications on the day of surgery (8.57%) and within 30 days (17.75%). Matched analysis showed that anterior approach was associated with organ failure, gastrointestinal, and device-/implant-/graft-related complications in all follow-up periods; and with cardiovascular, deep venous thrombosis/pulmonary embolism, and respiratory complications in at least 1 follow-up period. Among respiratory complications, anterior decompression was significantly associated with noninfectious etiologies on the day of surgery (odds ratio [OR] = 1.72), within 30 days (OR = 2.05), and within 90 days (OR = 1.92). CONCLUSIONS Anterior approach was associated with increased rates of several complications. High rates of respiratory complications necessitate comprehensive preoperative risk stratification to identify those who may benefit more from posterior approach.
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Affiliation(s)
- Aidin Abedi
- University of Southern
California, Los Angeles, CA, USA
| | | | - Raymond Hah
- University of Southern
California, Los Angeles, CA, USA
| | - Zorica Buser
- University of Southern
California, Los Angeles, CA, USA
- Zorica Buser, Department of Orthopaedic
Surgery, Keck School of Medicine, University of Southern California, 1450 San
Pablo Street, HC4 #5400A, Los Angeles, CA 90033, USA.
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Abstract
STUDY DESIGN Review. OBJECTIVE A comparative overview of cost-effectiveness between minimally invasive versus and equivalent open spinal surgeries. METHODS A literature search using PubMed was performed to identify articles of interest. To maximize the capture of studies in our initial search, we combined variants of the terms "cost," "minimally invasive," "spine," "spinal fusion," "decompression" as either keywords or MeSH terms. PearlDiver database was queried for open and minimally invasive surgery (MIS; endoscopic or percutaneous) reimbursements between Q3 2015 and Q2 2018. RESULTS In general, MIS techniques appeared to decrease blood loss, shorten hospital lengths of stay, mitigate complications, decrease perioperative pain, and enable quicker return to daily activities when compared to equivalent open surgical techniques. With regard to cost, primarily as a result of these latter benefits, MIS was associated with lower costs of care when compared to equivalent open techniques. However, cost reporting was sparse, and relevant methodology was inconsistent throughout the spine literature. Within the PearlDiver data sets, MIS approaches had lower reimbursements than open approaches for both lumbar posterior fusion and discectomy. CONCLUSIONS Current data suggests that overall cost-savings may be incurred with use of MIS techniques. However, data reporting on costs lacks in uniformity, making it difficult to formulate any firm conclusions regarding any incremental improvements in cost-effectiveness that may be incurred when utilizing MIS techniques when compared to equivalent open techniques.
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Affiliation(s)
| | | | | | - Elliot Min
- University of Southern California, Los Angeles, CA, USA
| | | | - John Liu
- University of Southern California, Los Angeles, CA, USA
| | - Patrick Hsieh
- University of Southern California, Los Angeles, CA, USA
| | - Raymond Hah
- University of Southern California, Los Angeles, CA, USA
| | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA,Zorica Buser, Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, 1520 San Pablo St, Suite 2000, Los Angeles, CA 90033, USA.
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Abstract
Coronavirus-19 (COVID-19) has disrupted the normal delivery of healthcare for spine surgeons across the world. In this review, we will provide an overview of COVID-19's clinical features, and discuss the optimization and treatment of spine pathology during the ongoing global pandemic.
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Affiliation(s)
- Nickul S. Jain
- Southern California Orthopedic Institute, Van Nuys, CA, USA
| | - Ram K. Alluri
- University of Southern California Spine Center, Los Angeles, CA, USA
| | | | - Raymond Hah
- University of Southern California Spine Center, Los Angeles, CA, USA
| | - Jeffrey C. Wang
- University of Southern California Spine Center, Los Angeles, CA, USA
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Barkoh K, Ohiorhenuan IE, Lee L, Lucas J, Arakelyan A, Ornelas C, Buser Z, Hsieh P, Acosta F, Liu J, Wang JC, Hah R. The DOWN Questionnaire: A Novel Screening Tool for Cervical Spondylotic Myelopathy. Global Spine J 2019; 9:607-612. [PMID: 31448193 PMCID: PMC6693067 DOI: 10.1177/2192568218815863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Case-control study. OBJECTIVES Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord injury in adults aged over 55 years. However, since the onset is typically insidious, accurately diagnosing CSM can be challenging, often requiring referral to a subspecialist and advanced imaging. To help identify patients at risk for CSM, this case-control study compared responses to a series of 4 questions (DOWN questionnaire) in myelopathic and non-myelopathic patients. METHODS Ninety-two patients, 46 with and 46 without myelopathy, were recruited for the study. Each patient answered 4 questions encompassing common symptoms associated with CSM. Responses between patient groups were compared, and Cohen's κ was used to assess for agreement between responses and the diagnosis of myelopathy. RESULTS We found a sensitivity of 91% and a κ of 0.54 to 3 positive responses and a sensitivity of 72% and a κ of 0.61 to 4 positive responses. CONCLUSIONS Positive responses to 3 or more DOWN questions has high sensitivity and moderate agreement with the diagnosis of myelopathy based on history, physical exam, and review of advanced imaging by an orthopedic or neurological surgeon. The DOWN questionnaire is a potentially useful screening tool to identify patients at risk for CSM.
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Affiliation(s)
- Kaku Barkoh
- University of Southern California, Los Angeles, CA, USA
| | - Ifije E. Ohiorhenuan
- University of Southern California, Los Angeles, CA, USA,Ifije E. Ohiorhenuan, University of Southern
California, 1200 N State Street, Suite 3300, Los Angeles, CA 90042, USA.
| | - Larry Lee
- University of Southern California, Los Angeles, CA, USA
| | - Joshua Lucas
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA
| | - Patrick Hsieh
- University of Southern California, Los Angeles, CA, USA
| | - Frank Acosta
- University of Southern California, Los Angeles, CA, USA
| | - John Liu
- University of Southern California, Los Angeles, CA, USA
| | | | - Raymond Hah
- University of Southern California, Los Angeles, CA, USA
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Abstract
PURPOSE To review the relevant recent literature regarding minimally invasive, lateral, and oblique approaches to the anterior lumbar spine, with a particular focus on the operative and postoperative complications. METHODS A literature search was performed on Pubmed and Web of Science using combinations of the following keywords and their acronyms: lateral lumbar interbody fusion (LLIF), oblique lateral interbody fusion (OLIF), anterior-to-psoas approach (ATP), direct lateral interbody fusion (DLIF), extreme lateral interbody fusion (XLIF), and minimally invasive surgery (MIS). All results from January 2016 through January 2019 were evaluated and all studies evaluating complications and/or outcomes were included in the review. RECENT FINDINGS Transient neurological deficit, particularly sensorimotor symptoms of the ipsilateral thigh, remains the most common complication seen in LLIF. Best available current literature demonstrates that approximately 30-40% of patients have postoperative deficits, primarily of the proximal leg. Permanent symptoms are less common, affecting 4-5% of cases. Newer techniques to reduce this rate include different retractors, direct visualization of the nerves, and intraoperative neuromonitoring. OLIF may have lower deficit rates, but the available literature is limited. Subsidence rates in both LLIF and OLIF are comparable to ALIF (anterior lumbar interbody fusion), but further study is required. Supplemental posterior fixation is an active area of investigation that shows favorable biomechanical results, but additional clinical studies are needed. Minimally invasive lumbar interbody fusion techniques continue to advance rapidly. As these techniques continue to mature, evidence-based risk-stratification systems are required to better guide both the patient and clinician in the joint decision-making process for the optimal surgical approach.
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Affiliation(s)
- Raymond Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Suite 5400, Los Angeles, CA 90033 USA
| | - H. Paco Kang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Suite 5400, Los Angeles, CA 90033 USA
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12
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Simcox T, Antoku D, Jain N, Acosta F, Hah R. Frailty Syndrome and the Use of Frailty Indices as a Preoperative Risk Stratification Tool in Spine Surgery: A Review. Asian Spine J 2019; 13:861-873. [PMID: 31154707 PMCID: PMC6773997 DOI: 10.31616/asj.2018.0239] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 02/12/2019] [Indexed: 12/21/2022] Open
Abstract
This comprehensive narrative literature review aims to extract studies related to frailty indices and their use in elective spine procedures, as limited studies regarding frailty exist in the spine literature. Most studies are retrospective analyses of prospectively collected databases. Evidence suggests a positive correlation between frailty level and mortality rate, postoperative complication rate, length of stay, and the possibility of discharge to a skilled nursing facility; these correlations have been illustrated across various spine procedures. The leading index is the modified frailty index, which measures 11 deficits. The development of more comprehensive frailty indices, such as the Adult Spinal Deformity Frailty Index, are promising and have high predictive value regarding postoperative complication rate in patients with spinal deformity. However, a frailty index that combines clinical, radiographic, and laboratory measures awaits development. Perhaps, the use of a frailty index in preoperative risk stratification for elective spine procedures could serve multiple purposes, including screening for high-risk patients, enhancement of operative decision making, approximation of complication rate for informed decision making, and refinement of perioperative care. Further prospective studies are warranted to determine clinically meaningful interventions in frail individuals.
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Affiliation(s)
- Trevor Simcox
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Derek Antoku
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Nickul Jain
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Frank Acosta
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA.,USC Spine Center at Keck Medicine of USC, Los Angeles, CA, USA
| | - Raymond Hah
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA.,USC Spine Center at Keck Medicine of USC, Los Angeles, CA, USA
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Nazareth A, D’Oro A, Liu JC, Schoell K, Heindel P, Jakoi A, Hah R, Wang JC, Buser Z. Risk Factors for Postoperative Venous Thromboembolic Events in Patients Undergoing Lumbar Spine Surgery. Global Spine J 2019; 9:409-416. [PMID: 31218200 PMCID: PMC6562217 DOI: 10.1177/2192568218797094] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
STUDY DESIGN Retrospective, database study. OBJECTIVES The aim of this study was to investigate incidence and risk factors associated with venous thromboembolic events (VTEs) after lumbar spine surgery. METHODS Patients who underwent lumbar surgery between 2007 and 2014 were identified using the Humana within PearlDiver database. ICD-9 (International Classification of Diseases Ninth Revision) diagnosis codes were used to search for the incidence of VTEs among surgery types, patient demographics and comorbidities. Complications including DVT and PE were queried each day from the day of surgery to postoperative day 7 and for periods 0 to 1 week, 0 to 1 month, 0 to 2 months, and 0 to 3 months postoperatively. RESULTS A total of 64 892 patients within the Humana insurance database received lumbar surgery between 2007 and 2014. Overall VTE rate was 0.9% at 1 week, 1.8% at 1 month, and 2.6% at 3 months postoperatively. Among patients that developed a VTE within 1 week postoperatively, 45.3% had a VTE on the day of surgery. Patients with 1 or more identified risk factors had a VTE incidence of 2.73%, compared with 0.95% for patients without risk factors (P < .001). Risk factors associated with the highest VTE incidence and odds ratios (ORs) were primary coagulation disorder (10.01%, OR 4.33), extremity paralysis (7.49%, OR 2.96), central venous line (6.70%, OR 2.87), and varicose veins (6.51%, OR 2.58). CONCLUSIONS This study identified several patient comorbidities that were independent predictors of postoperative VTE occurrence after lumbar surgery. Clinical VTE risk assessment may improve with increased focus toward patient comorbidities rather than surgery type or patient demographics.
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Affiliation(s)
| | - Anthony D’Oro
- University of Southern California, Los Angeles, CA, USA
| | - John C. Liu
- University of Southern California, Los Angeles, CA, USA
| | - Kyle Schoell
- University of Southern California, Los Angeles, CA, USA
| | | | - Andre Jakoi
- University of Southern California, Los Angeles, CA, USA
| | - Raymond Hah
- University of Southern California, Los Angeles, CA, USA
| | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA,Zorica Buser, Department of Orthopaedics,
Keck School of Medicine, University of Southern California, 1540 Alcazar Street,
CHP207, Los Angeles, CA 90033, USA.
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