Coagulation Profile as a Significant Risk Factor for Short-Term Complications and Mortality after Anterior Cervical Discectomy and Fusion.

BACKGROUND: Cervical degenerative disc disease is the most common indication for anterior cervical discectomy and fusion. Given the possible complications, patients are stratified before anterior cervical discectomy and fusion by preoperative risk factors to optimize treatment. One preoperative factor is a patient's coagulation profile. METHODS: The American College of Surgeons-National Surgical Quality Improvement Database was used to identify patient preoperative coagulation profile and postoperative complications. By generating binary logistic regression models, each of the 4 abnormal coagulation categories (bleeding disorder, low platelet count, high partial thromboplastin time, and high international normalized ratio [INR]) were analyzed for their independent impact on increased risk for complications compared with the control cohort. RESULTS: A total of 61,977 patients were assessed. The most common abnormal coagulation was abnormal platelet count (n = 2149). The most common postoperative outcome was an extended length of hospital stay among patients with an abnormal coagulation profile relative to the control cohort. After multivariate analysis, patients with an abnormal INR (odds ratio, 2.2 [1.3-3.8]; P = 0.003) or abnormal platelet count (odds ratio, 1.5 [1.2-2.1]; P = 0.003) had a higher chance of having an extended length of hospital stay relative to patients having a normal coagulation profile. Having an abnormal INR was found to be associated with an increased risk for having "Any complication." CONCLUSIONS: Our results show significant differences in the incidence rates of a multitude of complications among the 5 groups based on univariate analysis. Patients with any abnormal coagulation disorder had increased rates of developing any complication or having an extended length of hospital stay.

Pre-operative functional status as a predictor of morbidity and mortality after elective cervical spine surgery.

AIMS: Patients seeking cervical spine surgery are thought to be increasing in age, comorbidities and functional debilitation. The changing demographics of this population may significantly impact the outcomes of their care, specifically with regards to complications. In this study, our goals were to determine the rates of functionally dependent patients undergoing elective cervical spine procedures and to assess the effect of functional dependence on 30-day morbidity and mortality using a large, validated national cohort. PATIENTS AND METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program data files from 2006 to 2013 was conducted to identify patients undergoing common cervical spine procedures. Multivariate logistic regression models were generated to analyse the independent association of functional dependence with 30-day outcomes of interest. RESULTS: Patients with lower functional status had significantly higher rates of medical comorbidities. Even after accounting for these comorbidities, type of procedure and pre-operative diagnosis, analyses demonstrated that functional dependence was independently associated with significantly increased odds of sepsis (odds ratio (OR) 5.04), pulmonary (OR 4.61), renal (OR 3.33) and cardiac complications (OR 4.35) as well as mortality (OR 11.08). CONCLUSIONS: Spine surgeons should be aware of the inherent risks of these procedures with the functionally dependent patient population when deciding on whether to perform cervical spine surgery, delivering pre-operative patient counselling, and providing peri-operative management and surveillance. Cite this article: Bone Joint J 2017;99-B:824-8.

Mortality Caused by Surgery for Degenerative Lumbar Spine.

STUDY DESIGN: Register study. OBJECTIVE: The purpose of this study was to assess the safety of lumbar spine surgery for degenerative disorders and to assess the predictive factors for mortality and causes of death. SUMMARY OF BACKGROUND DATA: Growing numbers and relative indications of spine surgery emphasize the importance of patient safety. We assessed the incidence of mortality related to surgery, overall case fatality and factors predicting mortality in elective spinal surgery. METHODS: A national database was utilized to assess patient characteristics, surgical procedures, and outcomes of degenerative spinal surgery in Finland. Patients were classified into four diagnostic categories: disc herniation, spinal stenosis, degenerative disc disease, and spondylolysis and spondylolisthesis. The mortality related to surgery and overall mortality in each diagnostic group was analyzed at 7 days, 30 days, 90 days, and 1 year after surgery. We categorized the deaths into medical errors, sequelae of surgery, surgery probably a contributing factor, and deaths not associated with surgery. Age, sex, comorbid conditions, and hospital characteristics were considered as potential risk factors for mortality. RESULTS: Out of 408 deaths (0.67% of total of 61,166 patients) deaths that occurred during the 1-year follow up, 49 deaths (12% of deaths, 0.08% of patients) were classified as having an association with surgery: two deaths by medical errors, 28 deaths by complications after surgery and 19 deaths related to the surgery. The surgery-related 1-year mortality was 0.08%. Age >75 years, male sex, diabetes, and hypertension showed an association with increased risk of death related to surgery. CONCLUSION: Mortality caused by elective spinal surgery is rare. Cardiovascular incidents are the most common reasons for deaths occurring soon after surgery. Consideration of expected gains and risks of surgery, prevention of unintended errors during surgery and recognition and treatment of complications once they occur are recommended. LEVEL OF EVIDENCE: 3.

Comparison of in-hospital morbidity and mortality rates between anterior and nonanterior approach procedures for thoracic disc herniation.

STUDY DESIGN: Analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample. OBJECTIVE: To compare in-hospital morbidity and mortality rates between anterior and nonanterior approach procedures for thoracic disc herniation at national level. SUMMARY OF BACKGROUND DATA: Surgical treatment for thoracic disc herniation can be largely divided into anterior and nonanterior approach procedures. An anterior approach necessitates invasion of the thoracic cavity, which may subject the patient to increased risk of certain complications. Large sample studies comparing anterior and nonanterior procedures in terms of morbidity and mortality are lacking. METHODS: The Nationwide Inpatient Sample was used to identify patients who underwent surgical treatment for thoracic disc herniation from 2000 to 2009 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes. Patients were then divided into those who underwent anterior approach procedures and those who received nonanterior approach procedures using the appropriate ICD-9 codes. Patient- and health care system-related demographic data were retrieved and analyzed. RESULTS: There were 25,413 patients included in this study. Anterior approach procedures were associated with a significantly higher overall in-hospital complication rate (26.8% vs. 9.6%) and mortality rate (0.7% vs. 0.2%), as well as a longer hospital stay (7.6 vs. 4.8 d) and increased hospital charges ($84,199 vs. $46,837) compared with nonanterior approach procedures. Risk factors for mortality in surgical treatment for thoracic disc herniation included age 85 years or more, female sex, and the presence of complications (respiratory, cardiac, and urinary and renal). CONCLUSION: Anterior approach procedures for thoracic disc herniation were associated with increased in-hospital morbidity and mortality rates, as well as increased health care burden, compared with nonanterior approach procedures. If thoracic disc herniation can be adequately excised by either approach, a nonanterior approach procedure may be a better option.

Comparative analysis of patients with cauda equina syndrome versus an unaffected population undergoing spinal surgery.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To determine patient demographics, incidence of comorbidities, and procedure-related complications and identify risk factors associated with morbidity and mortality after spinal surgery for cauda equina syndrome (CES). SUMMARY OF BACKGROUND DATA: To our knowledge, no study has provided nationwide estimates of patient characteristics and procedure-related complication rates after spinal surgery for CES relative to an unaffected population. METHODS: Nationwide Inpatient Sample data collected between 2001 and 2010 were analyzed. Discharges with procedural codes for lumbar spinal fusion, decompression, or discectomy were included. The CES cohort included diagnoses of CES, and the unaffected cohort included lumbar spinal pathology diagnoses. Patient demographics, incidence of comorbidities and procedure-related complications, and risk factors associated with morbidity and mortality were compared. RESULTS: Discharges for 11,207 CES and 689,799 unaffected patients were identified. Differences between cohorts were found for demographic and hospital data. Average comorbidity indices for the CES cohort were found to be increased (0.23 vs. 0.13, P < 0.0001), as well as the incidence of total procedure-related complications (18.63% vs. 13.12%, P < 0.0001). In-hospital mortality rate was significantly increased for the CES cohort (0.30% vs. 0.08%, P < 0.0001). A number of comorbidities associated with additional risk for morbidity and mortality among the CES cohort were identified. CONCLUSION: Relative to an unaffected population undergoing similar treatment, patients with CES were more likely to have increased associated comorbidities on presentation, as well as increased complication rates with a prolonged hospital course postoperatively. CES was found to carry an increased incidence of procedure-related complications as well as in-hospital mortality. A number of comorbidities associated with additional risk for morbidity and mortality among the CES cohort were identified. This study provides clinically useful data for surgeons to educate patients at risk for morbidity and mortality as well as direct future research to improve patient outcomes. LEVEL OF EVIDENCE: 3.

Surgical complications of anterior cervical diskectomy and fusion for cervical degenerative disk disease: a single surgeon's experience of 1,576 patients.

BACKGROUND: Although anterior cervical diskectomy and fusion (ACDF) is a safe and effective procedure, the complications associated with it cannot be underestimated. The aim of this study was to highlight the potential complications associated with ACDF and the strategies to avoid them. METHODS: A total of 1576 patients was included in this retrospective study from 1995 to 2012. All patients were operated by a single surgeon, who used the standard technique. Data pertaining to the postoperative complications and mortality were collected from the database. RESULTS: The overall ACDF-related complication rate in our series was 8.4% (n = 133). Dysphagia was the most common complication encountered in 3.3 % (n = 52) of our patients. The inadvertent dural tear was encountered in 1.3% (n = 20) of our patients. Hoarseness was seen in 1.2% (n = 19) of our patients. A total of 0.88% (n = 14) of the patients had worsening of myelopathy/radiculopathy in the immediate postoperative period. Superficial wound infection occurred in 0.2% (n = 3) of our patients. Postoperative neck hematoma was seen in 0.1% (n = 2), recurrent laryngeal nerve palsy in 0.1% (n = 2), esophageal tear in 0.1% (n = 1), and graft extrusion in 0.88% (n = 14) of our cases. There was 0.1% (n = 1) mortality in our series. Of all these complications, only dysphagia was significantly correlated with 3-level ACDF as compared to 1- or 2-level ACDF (H = 12.89, df= 3, P = 0.05). CONCLUSION: ACDF is a relatively safe procedure with very low morbidity and almost no mortality. In this study, the common complications encountered were postoperative dysphagia, dural injury, and hoarseness.

A comparison of perioperative charges and outcome between open and mini-open approaches for anterior lumbar discectomy and fusion.

The objectives of this study were to examine charge data and long-term outcomes of two approaches for anterior lumbar interbody fusion: a mini-open lateral approach (extreme lateral interbody fusion, XLIF) and an open anterior approach (anterior lumbar interbody fusion, ALIF) through retrospective chart review. A total of 202 patients underwent surgery: 87 with ALIF (Open) and 115 with XLIF (Mini-open) procedures, all with transpedicular fixation. Complications occurred in 16.7% of Open, and 8.2% of Mini-open, procedures (p = 0.041). The mean charges ($US) for one-level Mini-open and Open procedures were $91,995 and $102,146, and for two-level procedures were $124,540 and $144,183, respectively. All differences were statistically significant (p < 0.05). This represents a 10% cost-savings, based on charges, for one-level and 13.6% for two-level Mini-open compared to Open procedures. Functional outcomes improved significantly at two years for both cohorts, although the difference between groups was not statistically significant. In conclusion, the Mini-open approach, compared to the Open, resulted in clinical as well as cost benefits with similar long-term outcomes.

Survivorship analysis of 150 consecutive patients with DIAM™ implantation for surgery of lumbar spinal stenosis and disc herniation.

Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1-48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4-5; 31, L5-6) and 4 two-level (L4-5 and L5-6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5-6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan-Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2-29 months). Kaplan-Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5-6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4-5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5-6 [hazard ratio (HR), 10.3; 95% CI, 1.7-63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2-90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5-6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4-5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5-6 and two-level in patients with LSTV are significant risk factors for reoperation.

Complication rates of three common spine procedures and rates of thromboembolism following spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee.

STUDY DESIGN: Retrospective review of a prospectively collected database. OBJECTIVE: The Scoliosis Research Society (SRS) collects morbidity and mortality (M and M) data from its members. Our objectives were to assess complication rates for 3 common spine procedures, compare these results with prior literature as a means of validating the database, and to assess rates of pulmonary embolism (PE) and deep venous thrombosis (DVT) in all cases reported to the SRS over 4 years. SUMMARY OF BACKGROUND DATA: Few modern series document complication rates of spinal surgery as routinely practiced across academic and community settings. Those available are typically based on relatively low numbers of procedures or confined to single-surgeon experiences. METHODS: The SRS M and M database was queried for lumbar microdiscectomy (LD), anterior cervical discectomy and fusion (ACDF), and lumbar stenosis decompression (LSD) cases from 2004 to 2007. Revisions were excluded. The database was also queried for occurrence of clinically evident PE and DVT in all cases from 2004 to 2007. RESULTS: A total of 9692 LDs, 6735 ACDFs, and 10,329 LSDs were identified, with overall complication rates of 3.6%, 2.4%, and 7.0%, respectively. These rates are comparable to previously published smaller series. For assessment of PE and DVT, 108,419 cases were identified and rates were calculated per 1000 cases based on diagnosis, age group, and implant use. Overall rates of PE, death due to PE, and DVT were 1.38, 0.34, and 1.18, respectively. Among 82,082 adults, the rate of PE ranged from 0.47 for LD to 12.4 for metastatic tumor. Similar variations were noted for DVT and deaths due to PE. CONCLUSION: Overall major complication rates for LD, ACDF, and LSD based on the SRS M and M database are comparable to those in previously reported smaller series, supporting the validity of this database for study of other less common spinal disorders. In addition, our data provide general benchmarks of clinically evident PE and DVT rates as a basis for ongoing efforts to improve care.

Anterior exposure of the lumbar spine with and without an "access surgeon": morbidity analysis of 265 consecutive cases.

STUDY DESIGN: Retrospective review OBJECTIVE: To compare the incidence and type of exposure-related complications for anterior lumbar surgery performed with and without an "access" surgeon. SUMMARY OF BACKGROUND DATA: No data exist comparing the incidence and type of exposure-related complications for anterior lumbar surgery performed with and without a vascular surgeon's assistance. METHODS: A retrospective review was performed for 265 consecutive patients who underwent anterior lumbar spine surgery at our institution from 2003 to 2005. Each patient's records were reviewed for diagnosis, procedure, whether the surgical exposure was conducted by the spine surgeon (Spine) or with a vascular surgeon's assistance (Team), levels exposed, complications, and any lasting sequelae. RESULTS: The percentage of patients with at least 1 intraoperative complication was 8% and 12% for the Spine and Team cases, respectively. Two percent of the Spine patients experienced an intraoperative vascular complication compared with 7% of the Team cases. No intraoperative vascular complication occurred in the single-level Spine exposures. Four percent of the patients with single-level exposures with Team approaches sustained an intraoperative vascular complication. Eight percent of the multilevel Spine cases sustained an intraoperative vascular complication compared with 9% of the multilevel Team exposures. There were 14 vascular injuries appreciated intraoperatively in a total of 13 patients. These injuries were directly repaired in 10 patients without any residual sequelae. The rate of vascular complications was statistically higher for multiple-level exposures (9%) versus single-level exposure (3%; P = 0.0357). The rate of retrograde ejaculation was 6% in the Spine cases whereas it was 7% in the Team approach. CONCLUSIONS: Our results do not support the notion that the presence of an "access" surgeon will change the type and rate of complications. With adequate training and judgment, spine surgeons may safely perform such exposures, provided vascular surgical assistance is readily available.

Two-level total lumbar disc replacement.

Total lumbar disc replacement (TDR) has been widely used as a treatment option for 2-level symptomatic degenerative disc disease. However, recent studies have presented conflicting results and some authors concluded that outcome deteriorated when disc replacement was performed bisegmentally, with an increase of complications for bisegmental replacements in comparison with monosegmental disc arthroplasty. The goal of the present retrospective study is to investigate results in a group of patients who have received bisegmental TDR with SB Charitè III artificial disc for degenerative disc disease with a minimum follow-up of 3 years, and to compare the results of 2-level disc replacement versus 1-level patients treated with the same prosthesis. A total of 32 patients had at least 3-years follow-up and were reviewed. The average age of the patients was 38.5 years. There were 11 males and 21 females. About 16 patients received 2-level TDR (SB Charitè III) and 16 received 1-level TDR (SB Charitè III). Both radiographic and functional outcome analysis, including patient's satisfaction, was performed. There were no signs of degenerative changes of the adjacent segments in any case of the 2- or 1-level TDR. There was no statistically significant difference between 2- and 1-level TDR both at 12 months and at 3-years follow-up on functional outcome scores. There was a statistically insignificant difference concerning the patients satisfaction between 1- and 2-level surgeries at the last follow-up (P = 0.46). In the 2-level TDR patients, there were 5 minor complications (31.25%), whereas major complications occurred in 4 more patients (25%) and required a new surgery in 2 cases (12.5%). In the 1-level cases there were 2 minor complications (12.5%) and 2 major complications (12.5%) and a new revision surgery was required in 1 patient (6.25%). In conclusion, the use of 2-level disc replacement at last follow-up presented a higher incidence of complications than in cases with 1-level replacement. At the same time it was impossible to delineate a clear difference in evaluating the questionnaires between the follow-up results of patients receiving 2- and 1-level TDR: the 2-level group presented slightly lower scores at follow-up, but none was statistically significant.

Peridural scar and its relation to clinical outcome: a randomised study on surgically treated lumbar disc herniation patients.

A prospective randomised 2-year follow-up study on patients undergoing lumbar disc herniation surgery. The objective was to investigate the relationship between peridural scarring and clinical outcome, the scar development 6 and 24 months postoperatively by using MRI, and if ADCON-L (a bioresorbable carbohydrate polymer gel) has an effect on scar size and/or improve patients' outcome after lumbar disc herniation surgery. The association between peridural scarring and recurrent pain after lumbar disc herniation surgery is debated. Numerous materials have been used in attempts to prevent or reduce postoperative peridural scarring; however, there are conflicting data regarding the clinical effects. The study included 119 patients whose mean age was 39 years (18-66); 51 (47%) were women. Sixty patients (56%) were perioperatively randomised to receive ADCON-L, and 48 (44%) served as controls. All patients underwent MRI at 6 and 24 months postoperatively, and an independent radiologist graded the size, location and development of the scar, by using a previously described scoring system. Pre- and 2-year postoperatively patients graded their leg pain on a visual analogue scale (VAS). At the 2-year follow-up patients rated their satisfaction with treatment (subjective outcome) and were evaluated by an independent neurologist (objective outcome), using MacNab score. There was no relationship between size or localisation of the scar and any of the clinical outcomes (VAS, subjective and objective outcome). The scar size decreased between 6 and 24 months in 49%, was unchanged in 42% and increased in 9% of the patients. Patients treated with ADCON-L did not demonstrate any adverse effects, nor did they demonstrate less scarring or better clinical outcome than control patients. No significant association between the presence of extensive peridural scar or localisation of scar formation and clinical outcome could be detected in the present study. Further, no positive or negative effects of ADCON-L used in disc herniation surgery could be seen.

Anterior cervical discectomy and fusion associated complications.

STUDY DESIGN: Retrospective review study with literature review. OBJECTIVE: The goal of our current study is to raise awareness on complications associated with anterior cervical discectomy and fusion (ACDF) and their early detection and proper management. SUMMARY OF BACKGROUND DATA: It is known that ACDF constitutes one of the most commonly performed spinal procedures. Its outcome is quite satisfactory in the majority of cases. However, occasional complications can become troublesome, and in rare circumstances, catastrophic. Although there are several case reports describing such complications, their rate of occurrence is generally underreported, and data regarding their exact incidence in large clinical series are lacking. Meticulous knowledge of potential intraoperative and postoperative ACDF-related complications is of paramount importance so as to avoid them whenever possible, as well as to successfully and safely manage them when they are inevitable. METHODS: In a retrospective study, 1015 patients undergoing first-time ACDF for cervical radiculopathy and/or myelopathy due to degenerative disc disease and/or cervical spondylosis were evaluated. A standard Smith-Robinson approach was used in all our patients, while an autologous or allograft was used, with or without a plate. Operative reports, hospital and outpatient clinic charts, and radiographic studies were reviewed for procedure-related complications. Mean follow-up time was 26.4 months. RESULTS: The mortality rate in our current series was 0.1% (1 of 1015 patients, death occurred secondary to an esophageal perforation). Our overall morbidity rate was 19.3% (196 of 1015 patients). The most common complication was the development of isolated postoperative dysphagia, which observed in 9.5% of our patients. Postoperative hematoma occurred in 5.6%, but required surgical intervention in only 2.4% of our cases. Symptomatic recurrent laryngeal nerve palsy occurred in 3.1% of our cases. Dural penetration occurred in 0.5%, esophageal perforation in 0.3%, worsening of preexisting myelopathy in 0.2%, Horner's syndrome in 0.1%, instrumentation backout in 0.1%, and superficial wound infection in 0.1% of our cases. CONCLUSION: Meticulous knowledge of the ACDF-associated complications allows for their proper management. Postoperative dysphagia, hematoma, and recurrent laryngeal nerve palsy were the most common complications in our series. Management of complications was successful in the vast majority of our cases.

Risk of multiple reoperations after lumbar discectomy: a population-based study.

STUDY DESIGN: Retrospective follow-up study of patients undergoing multiple (two or more) reoperations after initial lumbar discectomy using an administrative database. OBJECTIVES: To identify the population-based risk of multiple reoperations after lumbar discectomy and to analyze factors associated with the risk. SUMMARY OF BACKGROUND DATA: Although multiple reoperations after initial lumbar discectomy are likely uncommon, research to better understand reasons for and outcomes of reoperations is needed because of the large number of discectomies performed. METHODS: Data on all lumbar spine operations during 1987-1998 were obtained from the Finnish Hospital Discharge Register. The patient's initial disc operation during the study period was linked to subsequent operations, and patients with two or more reoperations were analyzed further. The risk of multiple reoperations was determined using the methods of event history analysis. RESULTS: Among 35,309 patients undergoing an initial discectomy, 4943 (14.0%) had at least one reoperation and 803 (2.3%) had two or more reoperations. A total of 63% of the second reoperations were discectomies, 14% were fusions, and the remaining 23% were decompressions. Patients with one reoperation after lumbar discectomy had a 25.1% cumulative risk of further spinal surgery in a 10-year follow-up. Reduced risk was seen when the first reoperation took place more than 1 year after the initial discectomy (relative risk 0.83, 95% confidence interval 0.72-0.96), in patients for whom the first reoperation had been a fusion (relative risk 0.27, 95% confidence interval 0.12-0.61), and in patients 50-64 years of age (relative risk 0.62, 95% confidence interval 0.48-0.79). CONCLUSION: Patients with one reoperation after lumbar discectomy are at considerable risk of further spinal surgery.

Surgical outcome for thoracic disc surgery in the postlaminectomy era.

In this article the author reviews outcomes of thoracic disc surgery reported in the literature. Care was taken to include only series in which none or a few patients underwent laminectomy for the treatment of thoracic disc lesions. The author found that thoracic discectomy may be performed in an efficacious and safe manner via the transthoracic, lateral extracavitary, transpedicular, or endoscopic approach. In the vast majority of patients, preoperative symptoms of pain (radiculopathy or axial loading pain) and myelopathy were improved after surgery. Measurements of operative time, blood loss, length of hospital stay, and patient satisfaction were often inadequately reported. Complications (systemic and neurological) were well documented and were not common. A plea is made for uniformity in documenting outcome in future series so that today's procedures for thoracic discectomy may be more accurately compared with future cases regardless of the inevitable advances in surgical techniques for removal of thoracic discs.

Review: complications of surgery for thoracic disc disease.

BACKGROUND: Thoracic discectomy has evolved over the last 60 years from resection through standard laminectomy, to posterolateral procedures to open thoracotomy and finally thoracoscopy. Comparison of relative morbidity and mortality between these approaches is now possible. METHODS: Peer-reviewed publications reporting clinical data relating to thoracic discectomy, and which provided sufficient information to enable adequate assessment of mortality and morbidity were reviewed. These articles were determined via review of the results of MedLine searches and articles gathered through compilation of references from those articles. RESULTS: Articles reviewed spanned a period of over 60 years. Surgical procedures used for thoracic discectomy included laminectomy, pediculectomy, costotransversectomy, lateral extracavitary, transverse arthropediculectomy, anterolateral thoracotomy, and thoracoscopy. Complications included death, paralysis, paresis, loss of bowel and/or bladder control, pulmonary embolism, pneumonia, atelectasis, compression fracture, infection, pleural tear, bowel obstruction, and anesthesia dolorosa. Mortality dropped to nearly zero after development of anterior and posterolateral approaches. Morbidity seems relatively similar between most procedures other than laminectomy. Not enough procedures have been reported using thoracoscopy to adequately assess its morbidity. CONCLUSION: Comparison of relative rates of morbidity and mortality between surgical approaches to thoracic discectomy suggest that laminectomy does not provide adequate access for the safe removal of these lesions. Choice of approach among the alternatives should be based on the evacuation of the herniated fragment and experience of the surgeon. Thoracoscopy, although promising, has not had sufficient time for evaluation of morbidity to make definite statements regarding its safety.

Vascular and visceral injuries associated with lumbar disc surgery: medicolegal implications.

Symptomatic perforation of the anterior annulus fibrosus/anterior longitudinal ligament during surgery for herniated lumbar disc disease is one of the more solemn and sobering complications experienced by neurosurgeons or orthopedic surgeons. This complication frequently results in the death of the patient. Its occurrence is probably more common than the medical community would expect. The authors report 21 cases since 1985 in which an injury to an intra-abdominal vessel or viscera occurred. In all cases litigation resulted and a settlement or verdict was rendered. A review of the literature is presented and the medicolegal implications of symptomatic ventral perforations of the annulus fibrosus/anterior longitudinal ligament are discussed.