Risk Factors for Nonroutine Discharge in Patients Undergoing Spinal Fusion for Intervertebral Disc Disorders.

BACKGROUND: Although outcomes following spinal fusion for intervertebral disc disorders have been studied, factors influencing discharge disposition and health care resource utilization have not been determined. This study sought to clarify perioperative risk factors for non-routine discharge and prolonged hospital stay in patients undergoing fusion for intervertebral disc disorders. METHODS: The National Hospital Discharge Survey was queried to identify all patients discharged from U.S. hospitals following spinal fusion for intervertebral disc disorders between 1990 and 2007. A cohort representative of 1,943,707 patients was identified and separated into those who were discharged home and those who were discharged to rehabilitation facilities. Multivariable logistic regression analysis was used to identify independent predictors of non-routine discharge to another inpatient facility and prolonged hospital stay. RESULTS: The strongest risk factors for non-routine discharge were age>65 years, congestive heart failure, atrial fibrillation, any general in-hospital complication, diabetes mellitus, osteoporosis, hypertension and any surgery-related complication. Patients younger than 50 years and males had the lowest rate of non-routine discharge. The strongest risk factors for prolonged hospital stay were any surgery-related complication, congestive heart failure, any general in-hospital complication, atrial fibrillation, age > 65 years, osteoporosis and diabetes mellitus. Patients 36-50 years of age had the lowest risk of increased length of hospital stay. CONCLUSIONS: Knowledge of these risk factors may aid in better resource allocation and improved strategies for managing patients with spondylosis in order to decrease healthcare costs. LEVEL OF EVIDENCE: 3.

Reduction of Mean Arterial Pressure at Incision Reduces Operative Blood Loss in Adolescent Idiopathic Scoliosis.

BACKGROUND: Spinal fusion surgery for adolescent idiopathic scoliosis (AIS) has been associated with significant blood loss and transfusion requirements. Reduction of mean arterial pressure (MAP) has benefits, but has been debated. This study aimed to analyze hypotensive anesthesia (MAP less than 65 mm Hg) at incision for its effect on blood loss. METHODS: Retrospective analysis of 327 AIS patients treated by a single surgeon from 2000 to 2008. We recorded demographic, laboratory, and radiographic measurements and perioperative data, including complications. We estimated MAP from the anesthesia flow sheet at incision (I-MAP) and during the entire surgery (Avg MAP). Patients were stratified into 3 groups: low (MAP less than 65), medium (MAP 65-75), or high (MAP greater than 75). We also evaluated the effect of elevated blood pressure at incision. The groups were as follows: reduced (I-MAP less than Avg MAP), stable (I-MAP = Avg MAP), or elevated (I-MAP greater than Avg MAP). We performed comparisons using analysis of variance with Tukey's Multiple Comparison Test. Blood loss was recorded as absolute volume and percent total blood volume (%EBV). RESULTS: Of the 327 patients (mean age, 15 years; range, 10-21 years; 248 females), 129 received blood transfusions (29% allogenic). There was a reduction in blood loss comparing low (584 mL; 14% EBV) versus high I-MAP (871 mL; 20.3% EBV) (p = .03). Likewise, an elevated blood pressure at incision led to increased blood loss: reduced, 510 mL, 11.5% EBV; stable, 735 mL, 17.6% EBV; and elevated, 1,033 mL, 24.9% EBV (p = .000-.02). Operative time was decreased in the low group by up to 48 minutes (p = .002), as was blood loss per minute (2.6 mL/min vs. 3.8 mL/min). There were no complications related to the use of hypotension. CONCLUSIONS: Induction of hypotensive anesthesia (MAP less than 65 mm Hg) at incision reduces operative blood loss by 33%. In addition, elevations in blood pressure at incision increase blood loss by 29%, and operative time by 29 minutes.

Predictors of postoperative infection in spinal deformity surgery - which curves are at greatest risk?

BACKGROUND: Numerous studies have reported on post- operative infection following spinal arthrodesis for spinal deformity. The incidence of infection associated with spinal surgery overall ranges from less than 1% to 15%. Certain factors may increase the risk of surgical site infection (SSI) in patients who undergo surgical treatment for spinal deformities. These include a diagnosis of neuromuscular disease, use of surgical drain or lack thereof, patient comorbidities, increased blood transfusions, and an allergic inflammatory response to the use of instrumentation. Many of these studies, however, have been limited by small numbers and confounded by multiple surgeons and hospitals. PURPOSE: The purpose of this study was to determine the rate of spinal wound infection following spinal deformity surgery in a single surgeon's practice and to identify risk factors for infection, particularly those related to type of deformity and surgical procedures performed. STUDY DESIGN: This is a retrospective review of prospectively collected data from a single surgeon. Only spinal deformity patients' records were reviewed. METHODS: We reviewed 941 spinal deformity operative procedures (806 patients, 584 females, 222 males) done by a single surgeon from 1999 to 2009. Outcome measures were superficial wound infection, deep wound infection, possible infection, and no infection. The following variables were assessed: gender, age, height, weight, body mass index (BMI), primary diagnosis, associated comorbidities, prior spinal surgeries, surgical approach, type and number of procedures performed, radiographic measurements, operative data (including operative time), and complications. A one-way ANOVA and Turkey post-hoc analysis was used. RESULTS: The average age was 22.3 years (range 1.8 to 82 years). There were 13 deep wound infections (1.4%) and 17 incidences of superficial wound infection (1.8%), for an overall infection rate of 3.2%. The following variables were found to be independent predictors of deep infection: neuromuscular scoliosis (odd ratio (O.R. 9.2) and Lenke 3 or 4 curve types in adolescent idiopathic scoliosis patients (O.R. 7.4). Kyphosis (O.R. 4.38), combined approach (O.R. 0.81), total number of levels fused (O.R. 1.16), and Lenke 3 or 4 curve types in AIS (O.R. 4.54) were independent predictors of superficial infection. Lastly, logistic regression identified the following as predictors of any infection: BMI (O.R. 1.11), total number of comorbidities (O.R. 1.24), osteotomy procedure (O.R. 3.14), number of levels fused (O.R. 1.13), and Lenke 3 or 4 curve types (O.R. 1.67). CONCLUSION: Age, BMI, number of levels, Lenke 3-4 curves, osteotomy, and number of comorbidities were found to be predictors of any infection. Of these, only Lenke 3-4 and neuromuscular comorbidity was correlated with deep infection.

Prefemoral fat pad impingement syndrome: identification and diagnosis.

Fat pad impingement syndrome refers to anterior knee pain caused by hemorrhage, inflammation, fibrosis and/or degeneration of the anterior knee fat pads. Symptomatic impingement of the prefemoral fat pad can be clinically significant but easily overlooked on magnetic resonance imaging, unless looked for. It should be evaluated in patients with persistent anterior knee pain, particulary if accompanied with mechanical symptoms and lack of intra-articular pathology.