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OBJECTIVE: Hounsfield unit (HU) values measured using CT have been increasingly recognized to stand as a reliable corollary to dual-energy x-ray absorptiometry (DEXA) scores in evaluating bone mineral density. The authors examined the correlation between cervical HU values and DEXA T- and Z-scores and determined novel cervical HU thresholds for determining bone quality classification. METHODS: One hundred patients who underwent both cervical spine CT and DEXA, 85 patients who underwent both lumbar CT and DEXA, and 128 patients who underwent cervical and lumbar CT within 24 months at a single institution were included in this retrospective review. Two independent reviewers collected HU values from 3 cervical vertebral levels (C4-6) and 4 lumbar vertebral levels (L1-4), and the averaged values were used. Pearson's correlation coefficient analysis was performed to compare the association of cervical HU values with lumbar HU values and T- and Z-scores. The mean cervical HU values for each DEXA classification were calculated and compared. Receiver operating characteristic (ROC) curves were created to determine the threshold and its sensitivity and specificity for diagnosis. RESULTS: Cervical (C4-6) HU values and average, lumbar, and femoral T- and Z-scores had significant correlations (0.436 > r > 0.274, all p < 0.01). A strong positive correlation between cervical and lumbar HU values was found (r = 0.79, p < 0.01). The average cervical HU value of healthy patients was 361.2 (95% CI 337.1-385.3); of osteopenic patients, 312.1 (95% CI 290.3-333.8); and of osteoporotic patients, 288.4 (95% CI 262.6-314.3). There was a significant difference between the cervical HU values of healthy and osteopenic patients (p = 0.0134) and between those of healthy and osteoporotic patients (p = 0.0304). The cervical HU value of 340.98 was 73.5% specific and 57.9% sensitive for diagnosing osteopenia with an area under the ROC (AUROC) curve of 0.655. The cervical HU value of 326.5 was 88.9% specific and 63.2% sensitive for diagnosing osteoporosis with an AUROC curve of 0.749. CONCLUSIONS: This is the second large-scale study and first with a patient population from the United States to show that HU values obtained using cervical CT were significantly correlated with bone quality based on DEXA T- and Z-scores and to establish a cervical HU threshold for determining bone quality classification. These results show that cervical HU values can and should be used to predict poor bone quality in surgical cervical spine patients.
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The rate of major complications and 30-day mortality after surgery for metastatic spinal tumors is relatively high. While most studies have focused on baseline comorbid conditions and operative parameters as risk factors, there is limited data on the influence of other parameters such as sociodemographic or socioeconomic data on outcomes. We retrospectively analyzed data from 165 patients who underwent surgery for spinal metastases between 2012-2023. The primary outcome was development of major complications (i.e., Clavien-Dindo Grade III-IV complications), and the secondary outcome was 30-day mortality (i.e., Clavien-Dindo Grade V complications). An exploratory data analysis that included sociodemographic, socioeconomic, clinical, oncologic, and operative parameters was performed. Following multivariable analysis, independent predictors of Clavien-Dindo Grade III-IV complications were Frankel Grade A-C, lower modified Bauer score, and lower Prognostic Nutritional Index. Independent predictors of Clavien-Dindo Grade V complications) were lung primary cancer, lower modified Bauer score, lower Prognostic Nutritional Index, and use of internal fixation. No sociodemographic or socioeconomic factor was associated with either outcome. Sociodemographic and socioeconomic factors did not impact short-term surgical outcomes for metastatic spinal tumor patients in this study. Optimization of modifiable factors like nutritional status may be more important in improving outcomes in this complex patient population.
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BACKGROUND: This study sought to identify associations between the Yost Index, a geocoded area neighborhood socioeconomic status (nSES) score, and race/ethnicity with patient refusal of recommended surgery for metastatic bone disease. METHODS: Patients with metastatic bone disease were extracted from the Surveillance, Epidemiology, and End Results database. The Yost Index was geocoded using factor analysis and categorized into quintiles using census tract-level American Community Service (ACS) 5-year estimates and seven nSES measures. Multivariable logistic regression models calculated odds ratios (ORs) of refusal of recommended surgery and 95% confidence intervals (CIs), adjusting for clinical covariates. RESULTS: A total of 138,257 patients were included, of which 14,943 (10.8%) were recommended for surgical resection. Patients in the lowest nSES quintile had 57% higher odds of refusing surgical treatment than those in the highest quintile (aOR = 1.57, 95% CI 1.30-1.91, p < 0.001). Patients in the lowest nSES quintile also had a 31.2% higher age-adjusted incidence rate of not being recommended for surgery compared with those in the highest quintile (186.4 vs. 142.1 per 1 million, p < 0.001). Black patients had 34% higher odds of refusing treatment compared with White patients (aOR = 1.34, 95% CI 1.14-1.58, p = 0.003). Advanced age, unmarried status, and patients with aggressive cancer subtypes were associated with higher odds of refusing surgery (p < 0.001). CONCLUSIONS: nSES and race/ethnicity are independent predictors of a patient refusing surgery for metastatic cancer to bone, even after adjusting for various clinical covariates. Effective strategies for addressing these inequalities and improving the access and quality of care of patients with a lower nSES and minority backgrounds are needed.
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Neoplasias Óseas , Programa de VERF , Clase Social , Negativa del Paciente al Tratamiento , Humanos , Femenino , Masculino , Neoplasias Óseas/secundario , Neoplasias Óseas/cirugía , Anciano , Persona de Mediana Edad , Negativa del Paciente al Tratamiento/estadística & datos numéricos , Estudios de Seguimiento , Pronóstico , Adulto , Características del Vecindario , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: Contemporary management of sacral chordomas requires maximizing the potential for recurrence-free and overall survival while minimizing treatment morbidity. En bloc resection can be performed at various levels of the sacrum, with tumor location and volume ultimately dictating the necessary extent of resection and subsequent tissue reconstruction. Because tumor resection involving the upper sacrum may be quite destabilizing, other pertinent considerations relate to instrumentation and subsequent tissue reconstruction. The primary aim of this study was to survey the surgical approaches used for managing primary sacral chordoma according to location of lumbosacral spine involvement, including a narrative review of the literature and examination of the authors' institutional case series. METHODS: The authors performed a narrative review of pertinent literature regarding reconstruction and complication avoidance techniques following en bloc resection of primary sacral tumors, supplemented by a contemporary series of 11 cases from their cohort. Relevant surgical anatomy, advances in instrumentation and reconstruction techniques, intraoperative imaging and navigation, soft-tissue reconstruction, and wound complication avoidance are also discussed. RESULTS: The review of the literature identified several surgical approaches used for management of primary sacral chordoma localized to low sacral levels (mid-S2 and below), high sacral levels (involving upper S2 and above), and high sacral levels with lumbar involvement. In the contemporary case series, the majority of cases (8/11) presented as low sacral tumors that did not require instrumentation. A minority required more extensive instrumentation and reconstruction, with 2 tumors involving upper S2 and/or S1 levels and 1 tumor extending into the lower lumbar spine. En bloc resection was successfully achieved in 10 of 11 cases, with a colostomy required in 2 cases due to rectal involvement. All 11 cases underwent musculocutaneous flap wound closure by plastic surgery, with none experiencing wound complications requiring revision. CONCLUSIONS: The modern management of sacral chordoma involves a multidisciplinary team of surgeons and intraoperative technologies to minimize surgical morbidity while optimizing oncological outcomes through en bloc resection. Most cases present with lower sacral tumors not requiring instrumentation, but stabilizing instrumentation and lumbosacral reconstruction are often required in upper sacral and lumbosacral cases. Among efforts to minimize wound-related complications, musculocutaneous flap closure stands out as an evidence-based measure that may mitigate risk.
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Cordoma , Sacro , Neoplasias de la Columna Vertebral , Humanos , Cordoma/cirugía , Cordoma/diagnóstico por imagen , Cordoma/patología , Sacro/cirugía , Sacro/diagnóstico por imagen , Neoplasias de la Columna Vertebral/cirugía , Neoplasias de la Columna Vertebral/diagnóstico por imagen , Neoplasias de la Columna Vertebral/patología , Masculino , Persona de Mediana Edad , Femenino , Anciano , Adulto , Procedimientos de Cirugía Plástica/métodosRESUMEN
Background: Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types. Methods: A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses. Results: Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007). Conclusions: Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.
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STUDY DESIGN: This was a single-institutional retrospective cohort study. OBJECTIVE: Wound infections are common following spine metastasis surgery and can result in unplanned reoperations. A recent study published an online wound complication risk calculator but has not yet undergone external validation. Our aim was to evaluate the accuracy of this risk calculator in predicting 30-day wound infections and 30-day wound reoperations using our operative spine metastasis population. METHODS: An internal operative database was used to identify patients between 2012 and 2022. The primary outcomes were 1) any surgical site infection and 2) wound-related revision surgery within 30 days following surgery. Patient details were manually collected from electronic medical records and entered into the calculator to determine predicted complication risk percentages. Predicted risks were compared to observed outcomes using receiver operator characteristic (ROC) curves with areas under the curve (AUC). RESULTS: A total of 153 patients were included. The observed 30-day postoperative wound infection incidence was 5% while the predicted wound infection incidence was 6%. In ROC analysis, good discrimination was found for the wound infection model (AUC = 0.737; P = 0.024). The observed wound reoperation rate was 5% and the predicted wound reoperation rate was 6%. ROC analysis demonstrated poor discrimination for wound reoperations (AUC = 0.559; P = 0.597). CONCLUSIONS: The online wound-related risk calculator was found to accurately predict wound infections but not wound reoperations within our metastatic spine surgery cohort. We suggest that the model may be clinically useful despite underlying population differences, but further work must be done to generate and validate accurate prediction tools.
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Reoperación , Neoplasias de la Columna Vertebral , Infección de la Herida Quirúrgica , Humanos , Neoplasias de la Columna Vertebral/cirugía , Neoplasias de la Columna Vertebral/secundario , Masculino , Infección de la Herida Quirúrgica/epidemiología , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Anciano , Medición de Riesgo , Adulto , Estudios de Cohortes , Factores de Riesgo , Curva ROCRESUMEN
BACKGROUND: The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases. METHODS: This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals. RESULTS: A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients. DISCUSSION: Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.
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Neoplasias , Clase Social , Humanos , Estados Unidos/epidemiología , Pobreza , Modelos de Riesgos Proporcionales , EscolaridadRESUMEN
STUDY DESIGN: Systematic Review and Meta-analysis. OBJECTIVES: To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States. METHODS: PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients. RESULTS: 53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included. CONCLUSIONS: AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.
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STUDY DESIGN/SETTING: Retrospective single-center study. BACKGROUND: The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD). PURPOSE: Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD. METHODS: Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years. RESULTS: One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF. CONCLUSION: The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement.
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Cifosis , Lordosis , Adulto , Humanos , Lordosis/diagnóstico por imagen , Lordosis/cirugía , Estudios Retrospectivos , Cifosis/cirugía , Cuello , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugíaRESUMEN
OBJECTIVE: The distributions and proportions of lean and fat tissues may help better assess the prognosis and outcomes of patients with spinal metastases. Specifically, in obese patients, sarcopenia may be easily overlooked as a poor prognostic indicator. The role of this body phenotype, sarcopenic obesity (SO), has not been adequately studied among patients undergoing surgical treatment for spinal metastases. To this end, here the authors investigated the role of SO as a potential prognostic factor in patients undergoing surgical treatment for spinal metastases. METHODS: The authors identified patients who underwent surgical treatment for spinal metastases between 2010 and 2020. A validated deep learning approach evaluated sarcopenia and adiposity on routine preoperative CT images. Based on composition analyses, patients were classified with SO or nonsarcopenic obesity. After nearest-neighbor propensity matching that accounted for confounders, the authors compared the rates and odds of postoperative complications, length of stay, 30-day readmission, and all-cause mortality at 90 days and 1 year between the SO and nonsarcopenic obesity groups. RESULTS: A total of 62 patients with obesity underwent surgical treatment for spinal metastases during the study period. Of these, 37 patients had nonsarcopenic obesity and 25 had SO. After propensity matching, 50 records were evaluated that were equally composed of patients with nonsarcopenic obesity and SO (25 patients each). Patients with SO were noted to have increased odds of nonhome discharge (OR 6.0, 95% CI 1.69-21.26), 30-day readmission (OR 3.27, 95% CI 1.01-10.62), and 90-day (OR 4.85, 95% CI 1.29-18.26) and 1-year (OR 3.78, 95% CI 1.17-12.19) mortality, as well as increased time to mortality after surgery (12.60 ± 19.84 months vs 37.16 ± 35.19 months, p = 0.002; standardized mean difference 0.86). No significant differences were noted in terms of length of stay or postoperative complications when comparing the two groups (p > 0.05). CONCLUSIONS: The SO phenotype was associated with increased odds of nonhome discharge, readmission, and postoperative mortality. This study suggests that SO may be an important prognostic factor to consider when developing care plans for patients with spinal metastases.
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Sarcopenia , Neoplasias de la Columna Vertebral , Humanos , Sarcopenia/complicaciones , Neoplasias de la Columna Vertebral/complicaciones , Neoplasias de la Columna Vertebral/cirugía , Obesidad/complicaciones , Pronóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
OBJECTIVE: Inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) have shown promise in predicting mortality in various types of cancer. The purpose of this study was to assess NLR, PLR, and SII in predicting 30-day mortality and overall survival (OS) among surgically treated patients with spinal metastasis. METHODS: This was a retrospective study including 153 patients who underwent surgery for spinal metastasis between 2012 and 2022. Electronic medical records were manually reviewed, and NLR, PLR, and SII were calculated from preoperative neutrophil, platelet, and lymphocyte counts. Receiver operating characteristic curves with areas under the curve were generated to determine cutoff values. Logistic regression was used to determine the odds ratios (ORs) for 30-day mortality. The Kaplan-Meier method and Cox regression were used to determine the hazard ratio (HR) for OS limited to 5 years postoperatively. RESULTS: Preoperative cutoff values were as follows: NLR > 10.2, PLR > 260, and SII > 2900. Overall, 35.9% (55/153) of patients had elevated NLR, 45.7% (70/153) had elevated PLR, and 30.7% (47/153) had elevated SII. The overall 30-day mortality was 8.5% (13/153). After controlling for confounders such as performance status and primary tumor type, high NLR (OR 5.20, 95% CI 1.21-22.28; p = 0.026) and SII (OR 4.92, 95% CI 1.17-20.63; p = 0.029) were associated with increased odds of 30-day postoperative mortality. The median OS time in the study population was 26 months (95% CI 12-40 months). After controlling for confounders such as Eastern Cooperative Oncology Group status, primary tumor, and hypoalbuminemia, high NLR was associated with shorter OS (HR 2.23, 95% CI 1.48-3.97; p = 0.003). CONCLUSIONS: High preoperative NLR and SII were independently associated with 30-day postoperative mortality in this study. Elevated NLR was also found to be associated with shorter OS. The prognostic role of these metrics warrants further investigation.
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Neoplasias de la Columna Vertebral , Humanos , Pronóstico , Neoplasias de la Columna Vertebral/cirugía , Neoplasias de la Columna Vertebral/patología , Neutrófilos/patología , Estudios Retrospectivos , Linfocitos/patología , InflamaciónRESUMEN
INTRODUCTION: Estimated postoperative survival is an important consideration during the decision-making process for patients with spinal metastases. Nutritional status has been associated with poor outcomes and limited survival in the general cancer population. The objective of this study was to evaluate the predictive utility of the prognostic nutritional index (PNI) for postoperative mortality after spinal metastasis surgery. METHODS: A total of 139 patients who underwent oncologic surgery for spinal metastases between April 2012 and August 2022 and had a minimum 90-day follow-up were included. PNI was calculated using preoperative serum albumin and total lymphocyte count, with PNI < 40 defined as low. The mean PNI of our cohort was 43 (standard deviation: 7.7). The primary endpoint was 90-day mortality, and the secondary endpoint was 12-month mortality. Multivariate logistic regression analyses were performed. RESULTS: The 90-day mortality was 27% (37/139), and the 12-month mortality was 56% (51/91). After controlling for age, ECOG performance status, total psoas muscle cross-sectional area (TPA), and primary cancer site, the PNI was associated with 90-day mortality [odds ratio 0.86 (95% confidence interval 0.79-0.94); p = 0.001]. After controlling for ECOG performance status and primary cancer site, the PNI was associated with 12-month mortality [OR 0.89 (95% CI 0.82-0.97); p = 0.008]. Patients with a low PNI had a 50% mortality rate at 90 days and an 84% mortality rate at 12 months. CONCLUSION: The PNI was independently associated with 90-day and 12-month mortality after metastatic spinal tumor surgery, independent of performance status, TPA, and primary cancer site.
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Neoplasias de la Médula Espinal , Neoplasias de la Columna Vertebral , Humanos , Evaluación Nutricional , Neoplasias de la Columna Vertebral/cirugía , Pronóstico , Estado Nutricional , Recuento de Linfocitos , Estudios RetrospectivosRESUMEN
OBJECTIVE: Assessment of nutritional status is fundamental in cancer patients. The objective of this study was to assess the predictive ability of 6 nutritional biomarkers for postoperative mortality and wound infection after metastatic spinal tumor surgery. METHODS: A total of 139 patients who underwent oncological surgery for metastatic spine disease between April 2012 and August 2022 and had a minimum follow-up of 90 days were included. Six unique nutritional biomarkers were assessed: Prognostic Nutritional Index (PNI), Nutritional Risk Index (NRI), Controlling Nutritional Status Score (CONUT), total psoas cross-sectional area (TPA), body mass index (BMI), and body weight. Study endpoints were 90-day mortality rate, 12-month mortality rate, and wound infection. The discriminative ability of each of these markers was assessed with the c-statistic. A multivariate analysis was done for each of the biomarkers after a univariate analysis was first performed. RESULTS: The 90-day mortality rate was 27% (37 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.74), NRI (0.75), CONUT (0.71), TPA (0.64), BMI (0.59), and body weight (0.60). The 12-month mortality rate was 56% (51 of 91). The biomarkers and respective c-statistics were as follows: PNI (0.72), NRI (0.73), CONUT (0.70), TPA (0.63), BMI (0.59), and body weight (0.60). The wound infection rate was 8% (11 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.57), NRI (0.53), CONUT (0.55), TPA (0.57), BMI (0.48), and body weight (0.52). The PNI, NRI, and CONUT all predicted 90-day and 12-month mortality after multivariate regression analysis. No association between nutrition and wound infection was found. CONCLUSIONS: In this study, nutritional status was associated with postoperative mortality following oncological spine surgery. Three biomarkers predicted outcome independent of variables such as performance status or primary cancer. Future validation of these metrics is needed.
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Neoplasias , Infección de Heridas , Humanos , Estado Nutricional , Pronóstico , Biomarcadores , Peso Corporal , Estudios RetrospectivosRESUMEN
OBJECTIVE: Surgery for metastatic spinal tumors can have a substantial impact on patients' quality of life by alleviating pain, improving function, and correcting spinal instability when indicated. The decision to operate is difficult because many patients with cancer are frail. Studies have highlighted the importance of preoperative nutritional status assessments; however, little is known about which aspects of nutrition accurately inform clinical outcomes. This study investigates the interaction and prognostic importance of various nutritional and frailty measures in patients with spinal metastases. METHODS: A retrospective analysis of consecutive patients who underwent surgery for spinal metastases between 2014 and 2020 at the Massachusetts General Hospital was performed. Patients were stratified according to the New England Spinal Metastasis Score (NESMS). Frailty was assessed using the metastatic spinal tumor frailty index. Nutrition was assessed using the prognostic nutritional index (PNI), preoperative body mass index, albumin, albumin-to-globulin ratio, and platelet-to-lymphocyte ratio. Outcomes included postoperative survival and complication rates, with focus on wound-related complications. RESULTS: This study included 154 individuals (39% female; mean [SD] age 63.23 [13.14] years). NESMS 0 and NESMS 3 demonstrated the highest proportions of severely frail patients (56.2%) and nonfrail patients (16.1%), respectively. Patients with normal nutritional status (albumin-to-globulin ratio and PNI) had a better prognosis than those with poor nutritional status when stratified by NESMS. Multivariable regression adjusted for NESMS and frailty showed that a PNI > 40.4 was significantly associated with decreased odds of 90-day complications (OR 0.93, 95% CI 0.85-0.98). After accounting for age, sex, primary tumor pathology, physical function, nutritional status, and frailty, a preoperative nutrition consultation was associated with a decrease in postoperative wound-related complications (average marginal effect -5.00%; 95% CI -1.50% to -8.9%). CONCLUSIONS: The PNI was most predictive of complications and may be a key biomarker for risk stratification in the 90 days following surgery. Nutrition consultation was associated with a reduced risk of wound-related complications, attesting to the importance of this preoperative intervention. These findings suggest that nutrition plays an important role in the postsurgical course and should be considered when developing a treatment plan for spinal metastases.
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BACKGROUND AND PURPOSE: In spine neurosurgery practice, patient-reported outcome measures (PROMs) are tools used to convey information about a patient's health experience and are an integral component of a clinician's decision-making process as they help guide treatment strategies to improve outcomes and minimize pain. Currently, there is limited research showing effective integration strategies of PROMs into electronic medical records. This study aims to provide a framework for other healthcare systems by outlining the process from start to finish in seven Hartford Healthcare Neurosurgery outpatient spine clinics throughout the state of Connecticut. METHODS: On March 1, 2021, a pilot implementation program began in one clinic and on July 1, 2021, all outpatient clinics were implementing the revised clinical workflow that included the electronic collection of PROMs within the electronic health record (EHR). A retrospective chart analysis studied all adult (18+) new patient visits in seven outpatient clinics by comparing the rates of PROMs collection in Half 1 (March 1, 2021-August 31, 2022) and in Half 2 (September 1, 2022-February 28, 2022) across all sites. Additionally, patient characteristics were studied to identify any variables that may lead to higher rates of collection. RESULTS: During the study period, 3528 new patient visits were analyzed. There was a significant change in rates of PROMs collection across all departments between H1 and H2 (p < 0.05). Additional significant predictors for PROMs collection were the sex and ethnicity of the patient as well as the provider type for the visit (p < 0.05). CONCLUSIONS: This study proved that implementing the electronic collection of PROMs into an already existing clinical workflow reduces previously identified collection barriers and enables PROMs collection rates that meet or exceed current benchmarks. Our results provide a successful step-by-step framework for other spine neurosurgery clinics to implement a similar approach.
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Registros Electrónicos de Salud , Dolor , Adulto , Humanos , Estudios Retrospectivos , Columna Vertebral , Medición de Resultados Informados por el PacienteRESUMEN
OBJECTIVE: Headache disorders are a prevalent yet frequently underestimated issue in patients with unruptured intracranial aneurysms (UIAs). The primary aim of this study is to systematically examine the incidence, specific characteristics, and associated risk factors of headache disorders in the context of individuals diagnosed with UIAs. Through this investigation, we hope to contribute valuable insights to the current understanding of this complex relationship and potentially inform future diagnostic and treatment approaches. METHODS: Data from 146 consecutive patients harboring UIAs were evaluated. The location and morphological characteristics of the aneurysm were analyzed. Factors associated with headache incidence and methods of treatment were investigated. The headache pattern in 48 patients was assessed using self-reported questionnaires. RESULTS: A total of 146 patients were identified. Out of 146 patients, 95 (65%) were in the Headache Group (HG) and 51 (35%) were asymptomatic and in the No Headache Group (NHG). Factors associated with a higher likelihood of headache were past or current tobacco, alcohol, and illicit drug use (p=0.029). On average, patients had 1.49 (SD=1) aneurysms in the HG and 1.43 (SD=.92) in the NHG group, respectively. In our series, the size of aneurysms, the status of the aneurysm (treated vs untreated), and the method of treatment did not significantly differ between the groups. There was a high incidence of headaches in patients with aneurysms of the ophthalmic segment (C6) of the internal carotid artery (ICA) and sphenoidal segment (M1) of the middle cerebral artery (MCA). Of 48 patients that completed headache questionnaires, 25 had headaches on more than 15 days a month. The majority of participants (85.4%) reported the severity of their pain as being greater than 5 on a scale of 10, while one-third (33.3%) experienced the maximum pain level of 10 out of 10. CONCLUSION: Headache more often occurs in patients with aneurysms of the ophthalmic segment (C6) of the ICA and sphenoidal segment (M1) of the MCA. Its distinctive features are deep pain for more than 15 days a month. Although the treatment of aneurysms reduces the risk of aneurysmal rupture, its efficacy in relieving the headache is still uncertain.
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BACKGROUND: Patients undergoing surgery for adult spinal deformity (ASD) are often elderly, frail, and at elevated risk of adverse events perioperatively, with proximal junctional failure (PJF) occurring relatively frequently. Currently, the specific role of frailty in potentiating this outcome is poorly defined. PURPOSE: To determine if the benefits of optimal realignment in ASD, with respect to the development of PJF, can be offset by increasing frailty. STUDY DESIGN: Retrospective cohort. MATERIALS AND METHODS: Operative ASD patients (scoliosis >20°, SVA>5 cm, pelvic tilt>25°, or TK>60°) fused to the pelvis or below with available baseline and 2-year (2Y) radiographic and HRQL data were included. The Miller Frailty Index (FI) was used to stratify patients into 2 categories: Not Frail (FI <3) and Frail (>3). Proximal Junctional Failure (PJF) was defined using the Lafage criteria. "Matched" and "unmatched" refers to ideal age-adjusted alignment postoperatively. Multivariable regression determined the impact of frailty on the development of PJF. RESULTS: Two hundred eighty-four ASD patients met inclusion criteria [62.2yrs±9.9, 81%F, BMI: 27.5 kg/m 2 ±5.3, ASD-FI: 3.4±1.5, Charlson Comorbidity Index (CCI): 1.7±1.6]. Forty-three percent of patients were characterized as Not Frail (NF) and 57% were characterized as Frail (F). PJF development was lower in the NF group compared with the F group (7% vs . 18%; P =0.002). F patients had 3.2 × higher risk of PJF development compared to NF patients (OR: 3.2, 95% CI: 1.3-7.3, P =0.009). Controlling for baseline factors, F unmatched patients had a higher degree of PJF (OR: 1.4, 95% CI:1.02-1.8, P =0.03); however, with prophylaxis, there was no increased risk. Adjusted analysis shows F patients, when matched postoperatively in PI-LL, had no significantly higher risk of PJF. CONCLUSIONS: An increasingly frail state is significantly associated with the development of PJF after corrective surgery for ASD. Optimal realignment may mitigate the impact of frailty on eventual PJF. Prophylaxis should be considered in frail patients who do not reach ideal alignment goals.
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Fragilidad , Cifosis , Fusión Vertebral , Adulto , Humanos , Anciano , Cifosis/cirugía , Estudios Retrospectivos , Fragilidad/epidemiología , Complicaciones Posoperatorias/etiología , Fusión Vertebral/métodos , Factores de RiesgoRESUMEN
STUDY DESIGN: Retrospective. OBJECTIVE: The objective of this study is to describe the rate of postoperative morbidity before and after two-year (2Y) follow-up for patients undergoing surgical correction of adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Advances in modern surgical techniques for deformity surgery have shown promising short-term clinical results. However, the permanence of radiographic correction, mechanical complications, and revision surgery in ASD surgery remains a clinical challenge. Little information exists on the incidence of long-term morbidity beyond the acute postoperative window. METHODS: ASD patients with complete baseline and five-year (5Y) health-related quality of life and radiographic data were included. The rates of adverse events, including proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and reoperations up to 5Y were documented. Primary and revision surgeries were compared. We used logistic regression analysis to adjust for demographic and surgical confounders. RESULTS: Of 118 patients eligible for 5Y follow-up, 99(83.9%) had complete follow-up data. The majority were female (83%), mean age 54.1 years and 10.4 levels fused and 14 undergoing three-column osteotomy. Thirty-three patients had a prior fusion and 66 were primary cases. By 5Y postop, the cohort had an adverse event rate of 70.7% with 25 (25.3%) sustaining a major complication and 26 (26.3%) receiving reoperation. Thirty-eight (38.4%) developed PJK by 5Y and 3 (4.0%) developed PJF. The cohort had a significantly higher rate of complications (63.6% vs. 19.2%), PJK (34.3% vs. 4.0%), and reoperations (21.2% vs. 5.1%) before 2Y, all P <0.01. The most common complications beyond 2Y were mechanical complications. CONCLUSIONS: Although the incidence of adverse events was high before 2Y, there was a substantial reduction in longer follow-up indicating complications after 2Y are less common. Complications beyond 2Y consisted mostly of mechanical issues.
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Cifosis , Fusión Vertebral , Humanos , Adulto , Masculino , Femenino , Persona de Mediana Edad , Estudios de Seguimiento , Estudios Retrospectivos , Calidad de Vida , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Cifosis/cirugía , Cifosis/etiología , Incidencia , Fusión Vertebral/efectos adversos , Fusión Vertebral/métodosRESUMEN
STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to assess the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator performance in patients undergoing surgery for metastatic spine disease. SUMMARY OF BACKGROUND DATA: Patients with spinal metastases may require surgical intervention for cord compression or mechanical instability. The ACS-NSQIP calculator was developed to assist surgeons with estimating 30-day postoperative complications based on patient-specific risk factors and has been validated within several surgical patient populations. MATERIALS AND METHODS: We included 148 consecutive patients at our institution who underwent surgery for metastatic spine disease between 2012 and 2022. Our outcomes were 30-day mortality, 30-day major complications, and length of hospital stay (LOS). Predicted risk, determined by the calculator, was compared with observed outcomes using receiver operating characteristic curves with area under the curve (AUC) and Wilcoxon signed-rank tests. Analyses were repeated using individual corpectomy and laminectomy Current Procedural Terminology (CPT) codes to determine procedure-specific accuracy. RESULTS: Based on the ACS-NSQIP calculator, there was good discrimination between observed and predicted 30-day mortality incidence overall (AUC=0.749), as well as in corpectomy cases (AUC=0.745) and laminectomy cases (AUC=0.788). Poor 30-day major complication discrimination was seen in all procedural cohorts, including overall (AUC=0.570), corpectomy (AUC=0.555), and laminectomy (AUC=0.623). The overall median observed LOS was similar to predicted LOS (9 vs. 8.5 d, P =0.125). Observed and predicted LOS were also similar in corpectomy cases (8 vs. 9 d; P =0.937) but not in laminectomy cases (10 vs. 7 d, P =0.012). CONCLUSIONS: The ACS-NSQIP risk calculator was found to accurately predict 30-day postoperative mortality but not 30-day major complications. The calculator was also accurate in predicting LOS following corpectomy but not laminectomy. While this tool may be utilized to predict risk short-term mortality in this population, its clinical value for other outcomes is limited.