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OBJECTIVE: Anterior approaches to the lumbar spine have been used extensively for various indications but they are also associated with unique complications and have been linked with higher incisional morbidity.This study aimsto evaluate incisional morbidity related to anterior lumbar surgeries and to assess how incisional outcomes correlate with patient and surgery-related factors. METHODS: Patients ≥18 years old and with planned anterior lumbar fusions from L1 to S1 were prospectively enrolled. Follow-up ended at two years, and patients who did not complete the follow-up were excluded. Incision was assessed for general appearance, width, color, cross-hatching, hypertrophy, and pain by using a validated scoring system and a visual analog scale (VAS). Patient and surgery-related factors were analyzed for possible correlations with complications or wound-related parameters. RESULTS: A total of 205 patients with a mean age of 54.4 ± 11.5 were included. Significant improvements were seen in color, hypertrophy, pain, and appearance of the incision. At two years, the mean patient-based VAS for appearance was 8.6 while surgeon-based VAS was 8.8. The total rate of complications was 9%, with no incisional hernia or bulging. No significant relation was found between incision-related parameters and the demographic and surgical variables. CONCLUSION: This study reports acceptable cosmetic results and no chronic pain after anterior lumbar surgery, which is contrary to previous reports. Together with a low total rate of complications, anterior approaches are safe when carefully executed, and have low morbidity.
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STUDY DESIGN: Retrospective chart review. OBJECTIVE: To provide reference values for Hounsfield unit (HU) measured on computed tomography (CT) scans of children and adolescents. SUMMARY OF BACKGROUND DATA: Spine surgeons increasingly use HU on spine CT as a measure of bone mineral density (BMD). This has not been described in children and adolescents. PATIENTS AND METHODS: Pediatric patients who had a spine CT between 2012 and 2022 were identified. Patients who had more than 1 comorbidity or were syndromic were excluded. Using the bone window, 3 axial images (cephalad, middle, and caudal) of each vertebra were selected. In each axial view, the HU was measured using a "region of interest" (ROI) that included the total cancellous bone area and an ROI excluding the radiolucency present in the posterior vertebral body ("total" vs . "limited"). HU values were compared between total and limited areas and between the axial images at the cephalad, middle, and caudal levels. Each age category data were estimated and stratified. RESULTS: A total of 144 patients (79 females and 65 males) from 2 to 17 years old were included. Mean limited HU was consistently lower than total HU across all images and lumbar levels except for L1. Limited HU taken mid-vertebral body was also consistently lower than those taken cephalad or caudad. Mean limited HU across all ages including all levels was 227 ± 50 (range: 109-357). Stratifying by age showed a gradual decrease in BMD from age 2 to 10 followed by an increase. CONCLUSIONS: This is the first study to measure HU on lumbar CTs in children and adolescents. The technique of measuring BMD in adults should be modified in children by using an ROI that excludes the rarefaction present in the posterior vertebral body. Further studies are needed to evaluate the age-dependent changes in BMD seen in this study.
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Densidade Óssea , Osteoporose , Adulto , Masculino , Feminino , Humanos , Adolescente , Criança , Pré-Escolar , Estudos Retrospectivos , Vértebras Lombares , Tomografia Computadorizada por Raios X/métodos , Absorciometria de Fóton/métodosRESUMO
BACKGROUND CONTEXT: Circumferential lumbar fusions (cLFs) are becoming more common with increasing and more minimally invasive anterior access techniques. Staging allows reassessment of indirect decompression and alignment prior to the posterior approach, and optimization of OR time management. Safety of staging has been well documented in deformity surgery but has yet to be delineated in less extensive, degenerative cLFs. PURPOSE: The purpose of this study is to compare perioperative complications and outcomes between staged versus single-anesthetic circumferential fusions in the lumbar spine. STUDY DESIGN: Propensity-matched comparative observational cohort. PATIENT SAMPLE: Patients who underwent cLFs for lumbar degenerative disease. OUTCOME MEASURES: In-hospital, 30-day, 90-day, and 1-year complications. METHODS: From 123 patients undergoing single-anesthetic and 154 patients undergoing staged cLF, 95 patients in each group were propensity-matched based on age, sex, BMI, ASA score, smoking, revision, and number of levels. We compared perioperative, 30-day, 90-day, and 1-year complications between the two cohorts. RESULTS: Mean days between stages was 1.58. Single-anesthetic cLF had longer total surgery time (304 vs 240 minutes, p<.001) but shorter total PACU total time (133 vs 196 minutes, p<.001). However, there was no difference in total anesthesia time (368 vs 374 minutes, p=.661) and total EBL (357 vs 320cc, p=.313). Intraoperative complications were nine incidental durotomies in the single-anesthetic and one iliac vein injury in the staged group (9% vs 1%, p=.018). There was no difference of in-hospital (38 vs 31, p=.291), 30-day (16 vs 23, p=.281), 90-day (10 vs 15, p=.391), 1-year complications (9 vs 12, p=.644), and overall cumulative 1-year complications (54 vs 56, p=.883) between the two cohorts. CONCLUSIONS: There is a decrease in total surgical time and intraoperative complications during staged compared with single-anesthetic cLF with no difference in in-hospital, 30-day, 90-day, and 1-year complications between approaches.
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Anestésicos , Fusão Vertebral , Humanos , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Vértebras Lombares/cirurgia , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Estudos de Coortes , Estudos Retrospectivos , Resultado do TratamentoRESUMO
STUDY DESIGN: Propensity-matched cohort. OBJECTIVE: The aim of this study was to determine if opioid-sparing anesthesia (OSA) reduces in-hospital and 1-year postoperative opioid consumption. SUMMARY OF BACKGROUND DATA: The recent opioid crisis highlights the need to reduce opioid exposure. We developed an OSA protocol for lumbar spinal fusion surgery to mitigate opioid exposure. MATERIALS AND METHODS: Patients undergoing lumbar fusion for degenerative conditions over one to four levels were identified. Patients taking opioids preoperatively were excluded. OSA patients were propensity-matched to non-OSA patients based on age, sex, smoking status, body mass index, American Society of Anesthesiologists grade, and revision versus primary procedure. Standard demographic and surgical data, daily in-hospital opioid consumption, and opioid prescriptions 1 year after surgery were compared. RESULTS: Of 296 OSA patients meeting inclusion criteria, 172 were propensity-matched to non-OSA patients. Demographics were similar between cohorts (OSA: 77 males, mean age=57.69 yr; non-OSA: 67 males, mean age=58.94 yr). OSA patients had lower blood loss (326 mL vs. 399 mL, P =0.014), surgical time (201 vs. 233 min, P <0.001) emergence to extubation time (9.1 vs. 14.2 min, P< 0.001), and recovery room time (119 vs. 140 min, P =0.0.012) compared with non-OSA patients. Fewer OSA patients required nonhome discharge (18 vs. 41, P =0.001) compared with the non-OSA cohort, but no difference in length of stay (90.3 vs. 98.5 h, P =0.204). Daily opioid consumption was lower in the OSA versus the non-OSA cohort from postoperative day 2 (223 vs. 185 morphine milligram equivalents, P =0.017) and maintained each day with lower total consumption (293 vs. 225 morphine milligram equivalents, P =0.003) throughout postoperative day 4. The number of patients with active opioid prescriptions at 1, 3, 6, and 12 months postoperative was statistically fewer in the OSA compared with the non-OSA patients. CONCLUSIONS: OSA for lumbar spinal fusion surgery decreases in-hospital and 1-year postoperative opioid consumption. The minimal use of opioids may also lead to shorter emergence to extubation times, shorter recovery room stays, and fewer discharges to nonhome facilities.
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Analgésicos Opioides , Anestesia , Masculino , Humanos , Pessoa de Meia-Idade , Analgésicos Opioides/uso terapêutico , Estudos de Coortes , Dor Pós-Operatória/tratamento farmacológico , Estudos Retrospectivos , Hospitais , Derivados da MorfinaRESUMO
STUDY DESIGN: Retrospective single-center study using prospectively collected data. OBJECTIVE: To describe the incidence of and identify risk factors for intraoperative screw malposition secondary to skive or shift during robot-assisted cortical bone trajectory (RA-CBT) insertion. SUMMARY OF BACKGROUND DATA: RA-CBT screw malposition occurs through two distinct modes, skive or shift. Skive occurs when a downward force applied to the cannula, drill, tap, or screw, causes the instrument to deflect relative to its bony landmark. Shift is a change in position of the robot-assisted system relative to the patient after registration. METHODS: A consecutive series of patients older than 18 years who underwent RA-CBT screw placement between January 2019 and July 2022 were enrolled. Baseline demographic and surgical data, Hounsfield Units (HU) at L1, and vertebral shape related to screw planning were collected. Skive or shift was recorded in the operating room on a data collection form. RESULTS: Of 1344 CBT screws in 256 patients, malposition was recognized intraoperatively in 33 screws (2.4%) in 27 patients (10.5%); 19 via skive in 17 and 14 via shift in 10 patients. These patients had higher BMI than patients without malposition (33.0 kg/m2 vs 30.5 kg/m2, P=0.037). Patients with skive had higher HU (178.2 vs 145.2, P=0.035), compared to patients with shift (139.2 vs 145.2, P=0.935) and patients without screw malposition. More than half of screw malposition was observed at the UIV. At the UIV, if the screw's overlap to the bone surface at the insertion point was decreased, skive was more likely (57% vs 87%, P<0.001). No patients were returned to the operating room for screw revision. CONCLUSIONS: Intraoperative screw malposition occurred in 2.4% of RA-CBT. High BMI was associated with screw malposition, regardless of etiology. Skive was associated with high HU and decreased screw overlap to bone surface at the insertion point.
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BACKGROUND: Cost, efficiency, patient preference, and safety have driven utilization of wide awake, local anesthesia, no tourniquet (WALANT) in hand surgery. This is not well documented in adolescents. We hypothesize that the use of WALANT with adolescents reduced time spent in the operating room (OR) and in the hospital when compared with patients who underwent surgery with traditional anesthesia (TA). METHODS: After institutional review board approval, we performed a retrospective review of patients aged 10 to 17 who underwent surgery at a regional hospital system including the level 1 pediatric trauma hospital. Operative notes were assessed for use of WALANT. We excluded those operations not traditionally amenable to WALANT. Using a propensity matched cohort, hospital time, OR time, and perioperative complications were recorded and compared to evaluate efficiency and perioperative safety. RESULTS: There were 28 cases in the WALANT group and 28 cases in the TA group after excluding cases not amenable to WALANT, and cases were propensity matched. Although the operative time (incision to closure) was similar, for WALANT patients, the in-room to procedure time (15 vs 22 minutes), procedure end to out-room time (5 vs 10 minutes), total room time (52.81 vs 63.68), and length of hospital stay (222 vs 342 minutes) were shorter than patients in the TA group. CONCLUSION: Our case series demonstrates time-savings both in the OR and in the hospital overall. Avoiding TA when WALANT is feasible may result in significant savings to hospital systems, patients, and payers while also freeing up anesthesia staff and perioperative nurses.
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STUDY DESIGN: Retrospective single center propensity-matched observational cohort study that included patients who underwent 1- to 3-level lumbar fusion surgery for degenerative conditions. OBJECTIVE: To compare 90-day complication rates between robotic-assisted and non-robotic-assisted lumbar spinal fusions in propensity-matched cohorts. SUMMARY OF BACKGROUND DATA: A recent administrative database (PearlDiver) study reported increased 30-day complications with the utilization of robotic-assisted enabling technology. METHODS: Of 146 robotic-assisted cases that met inclusion criteria, 114 were successfully propensity matched to 114 patients from 214 cases who had 1 to 3 level lumbar fusion without robotic assistance based on age, sex, body mass index, smoking status, American Society of Anesthesiologist grade, number of surgical levels, primary versus revision, and surgical approach (posterior-only or anterior-posterior). We excluded tumor, trauma, infection, or deformity cases. Outcomes included surgical and medical (major/minor) complications at intraoperative, immediately postoperative, 30- and 90-day postoperative intervals, including reoperations, and readmissions within 90âdays. RESULTS: All cause intraoperative complication rates were similar between non-robotic-assisted (5.3%) and robotic-assisted groups (10.5%, Pâ=â0.366). Immediate postoperative medical complication rate was also similar between non-robotic-assisted (6.1%) and robotic-assisted groups (1.8%, Pâ=â0.089). Thirty-day complication rates, 90-day complication rates, reoperation rates, and readmission rates showed no difference between non-robotic-assisted and robotic-assisted groups. There was no difference between return to OR for infection between the cohorts (non-robotic-assisted: 6 [5%] vs. robotic-assisted: 1 [0.8%], Pâ=â0.119). There was however improved length of stay (LOS) in the robotic-assisted group compared with non-robotic-assisted group (2.5 vs. 3.17âdays, Pâ=â0.018). CONCLUSION: In propensity-matched cohorts, patients undergoing 1- to 3-level robotic-assisted posterior lumbar fusion for degenerative conditions did not have increased 90-day complication rate, and had a shorter length of stay compared with non-robotic-assisted patients. There findings differ from a prior administrative database study as the robotic-assisted group in the current study had 0% return to OR for malpositioned screws and 0.8% return to OR for infection.Level of Evidence: 2.
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Procedimentos Cirúrgicos Robóticos , Robótica , Fusão Vertebral , Humanos , Vértebras Lombares/cirurgia , Região Lombossacral , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Fusão Vertebral/efeitos adversosRESUMO
BACKGROUND CONTEXT: Excessive use of postoperative imaging after lumbar surgery has been documented, becoming a target for cutting costs. This must be balanced with the patient's need for information and allay their postoperative concerns. PURPOSE: To determine the incidence and associated costs of patient interactions with the healthcare system, outside the standard follow up routine, in the first postoperative year. STUDY DESIGN: Retrospective longitudinal cohort. PATIENT SAMPLE: Consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 from a multi-surgeon single tertiary spine center. OUTCOME MEASURES: All healthcare encounters: phone calls, office and emergency department visits, and additional testing METHODS: A consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 were identified. All non-routine healthcare encounters: phone calls, office and emergency department visits, and additional testing were collected. Direct costs for all healthcare services were determined using the Medicare Allowable rates. Indirect costs were determined using local, median income, length of office visits, and distance from the clinic to the patient's home. RESULTS: Of 200 patients, 14 with thoracic fusion were excluded. The mean age of the 186 included patients was 58.26 years and 85 (46%) were male. Forty-seven percent (87/186) had only routine postoperative visits and 24 had revision surgery. Seventy-five patients made a total of 102 phone calls, 55 office visits, leading to 38 diagnostic studies none of which led to an additional intervention. Using Medicare Allowable rates, the mean direct cost was $776 per patient and the using a median income of $16/h the mean indirect cost was $124 per patient. There were no differences in the baseline characteristics among the patients who only had routine post-op encounters, had non-routine encounters or had a repeat surgery. CONCLUSIONS: Forty percent of the patients undergoing lumbar surgery had a healthcare encounter outside their routine follow up that did not result in additional intervention after their index operation. These potentially unnecessary encounters create additional cost and inconvenience to both the patient and healthcare system. Providing patient reassurance is important and providers should identify ways to reduce associated costs through patient education, virtual visits, or new technologies to monitor patient's postoperative progress.
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Fusão Vertebral , Idoso , Humanos , Vértebras Lombares/cirurgia , Masculino , Uso Excessivo dos Serviços de Saúde , Medicare , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND CONTEXT: Surgical decision making for cervical spondylotic myelopathy (CSM) relies on evaluation of symptoms and physical examination. The Romberg test is a clinical exam used to identify balance issues with CSM. However, the Romberg test has a subjective interpretation and has a binary (positive or negative) result. PURPOSE: This study aims to compare force plate pressure readings during a standard Romberg test in patients with CSM to age-matched normal healthy volunteers. STUDY DESIGN/SETTING: Prospective cross sectional observational comparative cohort from a single multi-surgeon spine center. PATIENT SAMPLE: Patients who were clinically diagnosed with CSM were compared to age-matched healthy volunteers without a clinical history of spine pathology. OUTCOME MEASURES: Quantitative Romberg Force Plate Measurements METHODS: Patients with CSM requiring surgery and healthy normal volunteers were asked to perform the Romberg test while on a force plate measuring the center of pressure (COP): standing up straight with arms extended for 30 seconds with eyes open, followed by 30 seconds with eyes closed. The change for total sway area, sway frequency and sway speed with eyes closed and eyes open were calculated and compared between patients with CSM and healthy volunteers. RESULTS: Thirty-four CSM patients were age-matched to 34 healthy volunteers. There was a larger change in quantitative Romberg measurements with eyes open versus eyes closed in CSM patients compared to normal volunteers for maximum lateral movement (10.79 cm vs. 0.94 cm, p=.003), maximum anterior-posterior movement (15.06 cm vs. 10.00 cm p=.201), total lateral CoP movement (89.82cm vs. 18.71cm, p=.007), total AP CoP movement (154.68 cm vs. 87.47 cm, p=.601), total CoP trace movement (199.79 cm vs. 88.44 cm, p=.014), sway area (284.74 cm2 vs. 57.76 cm2, p=.006), and average speed (7.00 cm/s vs. 2.91 cm/s, p=.006). DISCUSSION: Poor standing balance can be quantified in patients with CSM. Quantifying standing balance in patients with CSM shows significantly worse objective measures than age-matched healthy volunteers. The Romberg test on a force plate may help diagnose and evaluate patients with CSM, guide patient management and potentially grade the severity of spinal pathology. Further studies are needed to determine its utility in monitoring disease progression and measure treatment effectiveness.
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Doenças da Medula Espinal , Espondilose , Vértebras Cervicais , Estudos Transversais , Humanos , Equilíbrio Postural , Estudos Prospectivos , Doenças da Medula Espinal/diagnóstico , Doenças da Medula Espinal/cirurgia , Espondilose/diagnóstico , Espondilose/cirurgiaRESUMO
STUDY DESIGN: Longitudinal cohort. OBJECTIVE: It is unclear if patients with a recurrent disc herniation benefit from a concurrent fusion compared with a repeat decompression alone. We compared outcomes of decompression alone (D0) versus decompression and fusion (DF) for recurrent disc herniation. METHODS: Patients enrolled in the Quality and Outcomes Database from 3 sites with a first episode of recurrent disc herniation were identified. Demographic, surgical, and radiographic data including the presence of listhesis and extent of facet resection on computed tomography or magnetic resonance imaging prior to the index surgery were collected. Patient-reported outcomes were collected preoperatively and at 3 and 12 months postoperatively. RESULTS: Of 94 cases identified, 55 had D0 and 39 had DF. Patients were similar in age, sex distribution, smoking status, body mass index, American Society of Anesthesiologists grade and surgical levels. Presence of listhesis (D0 = 7, DF = 5, P = .800) and extent of facet resection (D0 = 19%, DF = 16%, P = .309) prior to index surgery were similar between the 2 groups. Estimated blood loss (D0 = 26 cm3, DF = 329 cm3, P < .001), operating room time (D0 = 79 minutes, DF = 241 minutes, P < .001) and length of stay (D0 <1 day, DF = 4 days, P < .001) were significantly less in the D0 group. Preoperative and 1-year postoperative patient-reported outcomes were similar in both groups. Three patients in the D0 group and 2 patients in the DF group required revision. Regression analysis showed that presence of listhesis, extent of facet resection and fusion were not associated with the 12-month Oswestry Disability Index (ODI) score. CONCLUSION: For a first episode recurrent disc herniation, surgeons can expect similar outcomes whether patients are treated with decompression alone or decompression and fusion.
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BACKGROUND CONTEXT: Health literacy, defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions," has been demonstrated to affect access to care and appropriate healthcare utilization. PURPOSE: To determine the impact of health literacy in the evaluation and management of patients with chronic low back pain. STUDY DESIGN: Cross sectional. PATIENT SAMPLE: Patients seen at a multisurgeon spine specialty clinic. OUTCOME MEASURES: Oswestry Disability Index, EQ-5D, and Numeric Rating Scales (0-10) for back and leg pain. METHODS: The Newest Vital Sign (NVS) and Health Literacy Survey, Oswestry Disability Index, EQ-5D and pain scales were administered to patients undergoing evaluation and treatment for lumbar degenerative disease in the outpatient setting. Patients were surveyed regarding their use of medication, therapy, and pain management modalities. RESULTS: Of 201 patients approached for participation, 186 completed the health literacy surveys. Thirty (17%) were assessed as having limited literacy, 52 (28%) as possibly having limited literacy and 104 (56%) having adequate literacy based on their NVS scores. The cohort with low NVS scores also had low Health Literacy Survey Scores. Patients with limited literacy had worse back and leg pain scores compared with patients with possibly limited literacy and adequate literacy. Patients with adequate health literacy were more likely to use medications (80% vs. 53%, pâ¯=â¯.017) and were more likely to see a specialist (34% vs. 17%) compared with those with limited literacy. Patients with limited health literacy were not more likely to see a chiropractor (7% vs. 7%), but reported more visits (19 vs. 8). CONCLUSIONS: Patients with lower health literacy reported worse back and leg pain scores, indicating either more severe disease or a fundamental difference in their responses to standard health-related quality of life measures. This study also suggests that patients with limited health literacy may underutilize some resources and overutilize other resources. Further study is needed to clarify these patterns, and to examine their impact on health status and clinical outcomes.