How is the microbial diagnosis of bacterial vertebral osteomyelitis performed? An 11-year retrospective study.

Vertebral osteomyelitis (VOM) is often diagnosed with delays, resulting in poorer outcomes. Microbial documentation is particularly challenging and obtained using blood cultures (BCs) and vertebral biopsies (VBs; CT-guided or surgical). We retrospectively analysed VOM cases in a tertiary reference centre between 2004 and 2015, focusing on how and how quickly microbiological diagnosis was performed. Among 220 VOM, 88.2% had documentation, including Gram-positive cocci (GPC) (70.6%), Gram-negative rods (GNR) (9.3%), anaerobes (3.6%), polybacterial infections (6.7%) and tuberculosis (9.8%). BCs were performed in 98.2% and positive in 59.3%, identifying most GPC (80.3%) and half of GNR (54.6%). VBs were performed in fewer cases (37.7%), but were more frequently positive (68.8% for CT-guided and 81.0% for surgical biopsies). They documented all anaerobes (100.0%), most M. tuberculosis (84.2%) and polybacterial infections (76.9%), and GNR (45.4%). Extra-vertebral samples highly contributed to tuberculosis diagnosis (52.6%, and 15.8% as the only positive sample). Documentations most often followed radiological diagnosis (53.4%). They were obtained earlier by BCs than by VB after first clinical symptoms (median of 14 versus 51 days). Antibiotic treatments were mostly initiated after samplings (88.0%). BCs allow the documentation of most VOM and should be performed without delay in case of clinical or radiological suspicion; however, they may miss 1 out of 5 GPC and 1 out of 2 GNR. VBs have a higher positivity rate and should be rapidly performed if negative BCs. It is likely that delayed and missed diagnoses result from the insufficient use of VB.

Inaccuracy of standard geriatric scores in nonagenarians following hospitalization for various spinal pathologies.

Demographic trends make it incumbent on spine surgeons to recognize the special challenges involved in caring for older patients. The aim of this study was to identify variables that may predict early mortality in geriatric patients over the age of 90 following elective hospitalization for various spinal pathologies. Retrospective analyses of all patients over the age of 90 years, which were electively treated between 2006 and 2016 at out department for various spinal conditions, were performed. Patient characteristics, type of treatment, and comorbidities were analyzed with regard to the 30-day mortality rate. Twenty-six patients were identified. Mean age was 93 years (range 91-97), 19 (73%) were female. Eighteen (69%) patients were treated operatively. Mean hospital stay was 13 days (range 2-51). Seventeen (65%) patients were on anticoagulation therapy. Mean Charlson Comorbidity Index (CCI) was 5.3 (range 1-11); mean diagnosis count (DC) was 8.3 (range 2-17); mean Geriatric Index of Comorbidity (GIC) was 2.8 (range 1-4); and mean comorbidity-polypharmacy score (GPS) was 13.3 (range 5-23). The 30-day mortality rate was 16.7% in the surgically treated group compared with 12.5% in the conservatively treated group (p = 0.9), anticoagulation therapy (p = 0.91), gender (p = 0.49), length of hospital stay (p = 0.33), GIC (p = 0.54), CCI (p = 0.74), GPS (p = 0.82), and DC (p = 0.65) did not correlate with the 30-day mortality rate. Cause of death was pulmonary embolism in two cases and unknown in one case. Thirty-day mortality rate in patients over 90 years old with degenerative spinal diseases is relatively high regardless of the treatment modality. Standard geriatric prognostic scores seem less reliable for these patients.

Time-to-completed-imaging, survival and function in patients with spinal epidural abscess: Description of a series of 34 patients, 2015-2018.

INTRODUCTION: Spinal epidural abscess (SEA) is a rare and life-threatening infection with increasing incidence over the past two decades. Delays in diagnosis can cause significant morbidity and mortality among patients. OBJECTIVE: The objective of this study was to describe trends in time-to-imaging and intervention, risk factors, and outcomes among patients presenting to the emergency department with SEA at a single academic medical center in Portland, Oregon. METHODS: This retrospective cohort study analyzed data from patients with new SEA diagnosis at a single hospital from October 1, 2015 to April 1, 2018. We describe averages to time-to-imaging and interventions, and frequencies of risk factors and outcomes among patients presenting to the emergency department with SEA. RESULTS: Of the 34 patients included, 7 (20%) died or were discharged with plegia during the study period. Those who died or were discharged with plegia (n = 7) had shorter mean time-to-imaging order (20.8 h versus 29.2 h). Patients with a history of intravenous drug use had a longer mean time-to-imaging order (30.2 h versus 23.7 h) as compared to those without intravenous drug use. Patients who died or acquired plegia had longer times from imaging completed to final imaging read (20.9 h versus 7.1 h), but shorter times from final imaging read to surgical intervention among patients who received surgery (4.9 h versus 46.2 h). Further, only three (42.9%) of the seven patients who died or acquired plegia presented with the three-symptom classic triad of fever, neurologic symptoms, and neck or back pain. CONCLUSIONS: SEA is a potentially deadly infection that requires prompt identification and treatment. This research provides baseline data for potential quality improvement work at the study site. Future research should evaluate multi-center approaches for identifying and intervening to treat SEA, particularly among patients with intravenous drug use.

Symptomatic aneurysmal bone cysts of the spine: clinical features, surgical outcomes, and prognostic factors.

PURPOSE: The aim of the study was to report the long-term outcomes and analyze the potential prognostic factors that may contribute to symptomatic patients with aneurysmal bone cyst (ABC) of the spine undergoing surgical treatments. METHODS: A retrospective analysis of consecutive patients with ABCs of the spine was performed. The clinical features were reviewed, and the disease-free survival (DFS) and overall survival (OS) rates were estimated using the Kaplan-Meier method. Factors with p values ≤ 0.05 were subjected to multivariate analysis by Cox proportional hazards model to identify the independent prognostic contributors. p values < 0.05 were considered statistically significant. RESULTS: A total of 42 patients with ABCs of the spine were included in the study. All patients received surgical treatments. The mean follow-up period was 41.3 months (median 39.5, range 24-64). Local recurrence was detected in eight patients after surgery in our center, whereas death occurred in three patients. The estimated 5-year DFS and OS rate was 54.1% and 76.8%, respectively. The statistical analyses indicated that both en bloc resection and primary/secondary tumor status were independent prognostic factors for DFS. CONCLUSIONS: Secondary ABC status may be associated with worse prognosis, and en bloc resection remains the treatment of choice for ABCs with neurologic deficits or spinal instability of the spine, which is correlated with better prognosis for local tumor control. These slides can be retrieved under Electronic Supplementary Material.

Diagnosis and management of spinal infections.

The number of spinal infections has been increasing due to aging populations and larger numbers of immunocompromised hosts and intravenous drug users. Magnetic resonance imaging is a useful tool for the early diagnosis of spinal infections, and can yield positive findings just 3-5 days after disease onset. Before antibiotic administration, cultures must be initiated from blood and from specimens collected from the locus of infection. Based on the pathogens identified by culture, appropriate antibiotics should be selected with careful consideration of antimicrobial susceptibility and spinal tissue penetration. Antibiotic treatment of spinal infections should be continued for longer than for most other types of infections, although the optimal duration remains unknown. The indications for surgical treatment include progressive neurologic deficits, progressive deformity, spinal instability, persistent or recurrent infection, and unbearable pain. In most patients with spinal infection, the gold standard surgical treatment is anterior radical debridement followed by autologous strut bone grafting. The addition of posterior instrumentation has recently become popular. This procedure may be performed alone as an alternative surgical option in patients in poor condition, and if it dramatically reduces pain, subsequent observation may be reasonable. If progressive deformity is observed or pain relief is inadequate after posterior instrumentation, additional anterior debridement and bone grafting should be scheduled.

Risk factors associated with short-term complications and mortality after pediatric spinal arthrodesis.

OBJECTIVE Spinal arthrodesis is routinely performed in the pediatric population. However, there is limited information on the short-term outcomes of pediatric patients who have undergone spine fusion. Thus, the authors conducted a retrospective review of the Pediatric National Surgical Quality Improvement Program (NSQIP) database to determine the short-term mortality, complication, reoperation, and readmission rates of pediatric patients who underwent spinal arthrodesis for all indications. METHODS The Pediatric NSQIP database was queried for all patients who underwent spinal arthrodesis between 2012 and 2014. Patient demographics, comorbidities, body mass index, American Society of Anesthesiologists classification, and operative time were abstracted. Short-term mortality, reoperation, and readmission rates and complications were also noted. Univariate and multivariate analyses were performed to delineate patient risk factors that influence short-term mortality, complications, reoperation, and readmission rates. RESULTS A total of 4420 pediatric patients who underwent spinal fusion were identified. Common indications for surgical intervention included acquired/idiopathic scoliosis or kyphoscoliosis (71.2%) and genetic/syndromic scoliosis (10.7%). The mean patient age was 13.7 ± 2.9 years, and 70% of patients were female. The overall 30-day mortality was 0.14%. Multivariate analysis showed that female sex and pulmonary comorbidities significantly increased the odds of reoperation, with odds ratios of 1.43 and 1.78, respectively. CONCLUSIONS In the NSQIP database for pediatric patients undergoing spinal arthrodesis for all causes, there was a 3.6% unplanned reoperation rate, a 3.96% unplanned readmission rate, and a 9.0% complication rate. This analysis provides data for risk stratification of pediatric patients undergoing spinal arthrodesis, allowing for optimized care.

Long-term prognosis of hematogenous vertebral osteomyelitis: Mortality, quality of life, and pain.

BACKGROUND: Hematogenous vertebral osteomyelitis (HVO) has a generally favorable prognosis if appropriate treatment is initiated in its early phase; however, some intractable cases with HVO can develop neurological impairment as well as spinal deformity during the course of treatment and these sequelae may lead to impaired quality of life (QOL). In this study, we aimed to evaluate the long-term relapse rate, mortality, and QOL of patients with HVO. METHODS: In this retrospective case series study, medical records of 60 patients with HVO with a mean follow-up period of 8 years (5-23 years) were reviewed to assess demographic data, details of infection, and clinical course. Mortality rate was assessed using a Kaplan-Meier plot. QOL was measured using the EuroQol 5 Dimension (EQ-5D) questionnaire and residual pain using a numeric rating scale (NRS). RESULTS: HVO relapsed in 4 of 60 patients (7%). Overall 5-year survival rate in 60 patients with HVO was 85%. The factors associated with increased mortality were malignant tumor, diabetes mellitus, chronic use of glucocorticoids, and drug-resistant strains of staphylococcus. Female-to-male ratio, NRS, prevalence of neurological impairment were significantly higher in patients with low EQ-5D score (poor health) compared to those with high EQ-5D score (good health). CONCLUSIONS: Patients with HVO have shorter life expectancy if they have malignancy, diabetes mellitus, chronic use of glucocorticoids, and a history of drug-resistant strains of staphylococcus infection. Female gender, residual neurological defects and persistent back pain are associated with impaired QOL in patients with HVO.

Does the microendoscopic technique reduce mortality and major complications in patients undergoing lumbar discectomy? A propensity score-matched analysis using a nationwide administrative database.

OBJECTIVE Although minimally invasive spinal surgery has recently gained popularity, few nationwide studies have compared the adverse events that occur during endoscopic versus open spinal surgery. The purpose of this study was to compare perioperative complications associated with microendoscopic discectomy (MED) and open discectomy for patients with lumbar disc herniation. METHODS The authors retrospectively extracted from the Diagnosis Procedure Combination database, a national inpatient database in Japan, data for patients admitted between July 2010 and March 2013. Patients who underwent lumbar discectomy without fusion surgery were included in the analysis, and those with an urgent admission were excluded. The authors examined patient age, sex, Charlson Comorbidity Index, body mass index, smoking status, blood transfusion, duration of anesthesia, type of hospital, and hospital volume (number of patients undergoing discectomy at each hospital). One-to-one propensity score matching between the MED and open discectomy groups was performed to compare the proportions of in-hospital deaths, surgical site infections (SSIs), and major complications, including stroke, acute coronary events, pulmonary embolism, respiratory complications, urinary tract infection, and sepsis. The authors also compared the hospital length of stay between the 2 groups. RESULTS A total of 26,612 patients were identified in the database. The mean age was 49.6 years (SD 17.7 years). Among all patients, 17,406 (65.4%) were male and 6422 (24.1%) underwent MED. A propensity score-matched analysis with 6040 pairs of patients showed significant decreases in the occurrence of major complications (0.8% vs 1.3%, p = 0.01) and SSI (0.1% vs 0.2%, p = 0.02) in patients treated with MED compared with those who underwent open discectomy. Overall, MED was associated with significantly lower risks of major complications (OR 0.62, 95% CI 0.43-0.89, p = 0.01) and SSI (OR 0.29, 95% CI 0.09-0.87, p = 0.03) than open discectomy. There was a significant difference in length of hospital stay (11 vs 15 days, p < 0.001) between the groups. There was no significant difference in in-hospital mortality between MED and open discectomy. CONCLUSIONS The microendoscopic technique was associated with lower risks for SSI and major complications following discectomy in patients with lumbar disc herniation.

Does Pathogen Identification Influence the Clinical Outcomes in Patients With Pyogenic Spinal Infections?

STUDY DESIGN: Retrospective study. OBJECTIVE: To study the clinical outcomes of patients suffering from pyogenic spinal infections (PSI), by comparing the outcomes of patients with an identified microbiological agent with those of patients without an identified pathogen. SUMMARY OF BACKGROUND DATA: PSI is associated with significant risks for morbidity and mortality. Specific antibiotic treatment has been considered a key to successful medical treatment; however, clinicians frequently treat patients with PSI without an identified agent. A paucity of data is available comparing the clinical outcomes of patients with or without an identified pathogen. MATERIALS AND METHODS: The records of 97 consecutive patients discharged from a University Hospital with the diagnosis of PSI during a 14-year period were retrospectively reviewed. Patients' demographics, etiological agent, comorbidities, site of infection, white blood cell count, erythrocyte sedimentation rate, C-reactive protein at the time of presentation, neurological impairment, length of hospital stay, and mortality were registered to compare the clinical outcomes of patients with an identified pathogen with those of patients without an identified agent. RESULTS: The causative organism was identified in 74 patients (76.3%). Patients with microbiological diagnosis were younger, and a larger percentage of them exhibited elevated C-reactive protein value; however, they were not different from those without an identified agent in terms of sex, site of infection, comorbidities, and the presence of a concomitant infection. Our study could not demonstrate different neurological outcomes, length of stay, or mortality rates among the 2 groups. CONCLUSIONS: In a large series of patients with PSI, we did not demonstrate differences in clinical outcomes using empirical antibiotics in patients without an identified pathogen compared with patients with an identified microbiological agent receiving specific antibiotics. Future prospective multicenter studies should be conducted to obtain an answer to this important clinical question.

Stability of spinal bone metastases in breast cancer after radiotherapy: a retrospective analysis of 157 cases.

PURPOSE: This retrospective analysis was performed to evaluate osteolytic bone lesions of breast cancer in the thoracic and lumbar spine after radiotherapy (RT) in terms of stability using a validated scoring system. METHODS: The stability of 157 osteolytic metastases, treated from January 2000 to January 2012, in 115 patients with breast cancer was evaluated retrospectively using the Taneichi score. Predictive factors for stability were analyzed and survival rates were calculated. RESULTS: Eighty-five (54%) lesions were classified as unstable prior to RT. After 3 and 6 months, 109 (70%) and 124 (79%) lesions, respectively, were classified as stable. Thirty fractures were detected prior to RT, and after RT seven cases (4.5%) with pathologic fractures were found within 6 months. None of the examined predictive factors showed significant correlation with stability 6 months after RT. After a median follow-up of 16.7 months, Kaplan-Meier estimates revealed an overall survival of 83% after 5 years. CONCLUSION: The majority of patients showed an improved or unchanged stability of the involved vertebral bodies after 6 months. The patients showed only minor cancer-related morbidity during follow-up and reached comparably high survival rates.

Reduced mortality rates in a cohort of long-term underground iron-ore miners.

BACKGROUND: Historically, working in iron-ore mines has been associated with an increased risk of lung cancer and silicosis. However, studies on other causes of mortality are inconsistent and in the case of cancer incidence, sparse. The aim of this study was to examine the association between iron-ore mining, mortality and cancer incidence. METHODS: A 54-year cohort study on iron-ore miners from mines in northern Sweden was carried out comprising 13,000 workers. Standardized rate ratios were calculated comparing the disease frequency, mortality, and cancer incidence with that of the general population of northern Sweden. Poisson regression was used to evaluate the association between the durations of employment and underground work, and outcome. RESULTS: Underground mining was associated with a significant decrease in adjusted mortality rate ratios for cerebrovascular and digestive system diseases, and stroke. For several outcomes, elevated standardized rate ratios were observed among blue-collar workers relative to the reference population. However, only the incidence of lung cancer increased with employment time underground (P < 0.001). CONCLUSIONS: Long-term iron-ore mining underground was associated with lower rates regarding several health outcomes. This is possibly explained by factors related to actual job activities, environmental exposure, or the selection of healthier workers for long-term underground employment.

Lateral extracavitary, costotransversectomy, and transthoracic thoracotomy approaches to the thoracic spine: review of techniques and complications.

STUDY DESIGN: Systematic review. OBJECTIVE: The authors review complications, as reported in the literature, associated with ventral and posterolateral approaches to the thoracic spine. SUMMARY OF BACKGROUND: The lateral extracavitary, costotransversectomy, and transthoracic thoracotomy techniques allow surgeons to access the ventral thoracic spine for a wide range of spinal disorders including tumor, degeneration, trauma, and infection. Although the transthoracic thoracotomy has been used traditionally to reach the ventral thoracic spine when access to the vertebral body is required, modifications to the various dorsal approaches have enabled surgeons to achieve goals of decompression, reconstruction, and stabilization through a single approach. METHODS: A systematic Medline search from 1991 to 2011 was performed to identify series reporting clinical data related to these surgical approaches. The morbidity associated with each approach is reviewed and strategies for complications avoidance are discussed. RESULTS: Four thousand six hundred seventy-seven articles that assessed outcomes of the approaches to the thoracic spine were identified; of these 31 studies that consisted of 774 patients were selected for inclusion. A mean complication rate of 39%, 17%, and 15% for thoracotomy, lateral extracavitary, and costotransversectomy, respectively, was determined. The thoracotomy approach had the highest reoperation (3.5%) and mortality rates (1.5%). The specific complications and neurological outcomes were categorized. CONCLUSIONS: Outcomes of the surgical approaches to the thoracic spine have been reported with great detail in the literature. There are limited studies comparing the respective advantages and disadvantages and the differences in technique and outcome between these approaches. The present review suggests that in contrast to the historical experience of the laminectomy for thoracic spine disorders, these alternative approaches are safe and rarely associated with neurological deterioration. The differences between these approaches are based on their complication profiles. A thorough understanding of the regional anatomy will help avoid approach-related complications.

Circumferential cervical surgery: to stage or not to stage?

STUDY DESIGN: Retrospective review. OBJECTIVE: The objective of the study was to determine the morbidity and mortality rate associated with same day versus staged cervical circumferential approach. SUMMARY OF BACKGROUND DATA: A combined approach to the cervical spine is often indicated for complex cervical pathologies. Previous studies suggested superior results associated with same day combined surgery for thoracolumbar patients. This study examines the usefulness of p-Physiological and Operative Severity Score for enumeration of Morbidity and Mortality (POSSUM), an estimated mortality risk assessment for cervical spine patients and will compare same day surgery to staged procedures. METHODS: This is a retrospective chart review including patients who underwent ventral and dorsal approach within 2 weeks. Estimated mortality was calculated using p-POSSUM. The cohort was divided into same day surgery group and staged group. Risk factors were compared between groups. Mean p-POSSUM was calculated and compared with the actual mortality rate. Univariate analysis was used to compare the risk factors between groups and the groups' outcomes. Multivariable analysis was used to adjust for risk factor differences when comparing group outcomes. RESULTS: One hundred thirty-five patients were included, 106 patients were in the same day surgery group whereas 29 patients were in the staged group. Mean p-POSSUM was 2.8% predicted mortality with a 95% confidence interval of 1.6% to 4.1%. The actual mortality rate was 3.7%. The groups did not vary in most risk factors assessed. Univariate analysis demonstrated a statistically significantly higher rate of major complications (0.62 vs. 0.34, P=0.0369), infection (41.4% vs. 9.4%, P<0.0001), and length of hospital stay (9.3 vs. 6.8 d, P=0.0120) in the staged group. Multivariable analysis demonstrated significantly higher infection rate in the staged group. CONCLUSIONS: P-POSSUM mortality estimate may serve as a useful and valid tool for spine surgery studies. Staged combined cervical surgery harbors a higher complication rate and may be associated with lengthier hospitalization.

Neurological improvement and prognosis after occipito-thoracic fusion in patients with mutilating-type rheumatoid arthritis.

INTRODUCTION: Mutilating-type rheumatoid arthritis, the most aggressive type of rheumatoid arthritis, is frequently associated with destructive cervical involvement, both at the high-cervical and subaxial levels, causing significant neurological deficit, and their natural course of the disease and the survival are discouraging. For such cases, we have been actively performing occipito-thoracic fusion since 1991. Although medical treatment for rheumatoid patients has represented a marked improvement, it could not treat all of these patients because of several reasons. Therefore, it is still important to evaluate the past treatment results. METHODS: We investigated the neurological improvement and prognosis in 51 mutilating-type rheumatoid arthritis patients who underwent occipito-thoracic fusion between 1991 and 2010. The neurological status was evaluated using modified Ranawat classification; class IIIB was subdivided into IIIBa (able to sit upright) and IIIBb (bedridden). RESULTS: The preoperative neurologic status was IIIBa in 19 patients and IIIBb in 17 patients. 15 of the 19 patients with class IIIBa improved to being able to walk (79 %), whereas only 3 of the 17 patients with class IIIBb improved to being able to walk (18 %) after surgery. Of the 51 patients, 28 died during follow-up; the mean age at death was 67.2 years. The postoperative 5- and 10-year survival rates were 60.3 and 26.4 %, respectively. CONCLUSION: The neurological improvement and prognosis after surgery was poorer in class IIIBb patients than in the other patient groups. Occipito-thoracic fusion can improve the neurological symptoms and prognosis. However, early surgical intervention is recommended, before a patient becomes bedridden (class IIIBb).

Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease. METHODS: We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups. RESULTS: We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I2 = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I2 = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I2 = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I2 = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates. CONCLUSIONS: Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

Short term outcomes associated with patients requiring blood transfusion following elective laminectomy and fusion for lumbar stenosis: A propensity-matched analysis.

Perioperative blood transfusion has been associated with poor outcomes but the impacts of transfusion after fusion for lumbar stenosis have not been well-described. We assessed this effect in a large cohort of patients from 2012 to 2018 in the National Surgical Quality Improvement Program (NSQIP). We evaluated baseline characteristics including demographics, comorbidities, hematocrit, and operative characteristics. We generated propensity scores using baseline characteristics and patients were matched to approximate randomization. We assessed odds of 30-day outcomes including prolonged length-of-stay (LOS), complications, discharge to facility, readmission, reoperation, and death using logistic regression. We identified 16,329 eligible patients who underwent lumbar fusion for stenosis; 1,926 (11.8%) received a transfusion. Before matching, there were multiple differences in baseline covariates including age, gender, BMI, ASA class, medical comorbidities, hematocrit, coagulation indices, platelets, operative time, fusion technique, number of levels fused, and osteotomy. However, after matching, no significant differences remained. In the matched cohorts, transfusion was associated with increased prolonged LOS (OR 1.66, 95% CI 1.45-1.91, p < 0.001), minor complication (OR 1.60, 95% CI 1.20-2.12, p = 0.001), major complication (OR 1.51, 95% CI 1.16-1.98, p = 0.003), any complication (OR 1.54, 95% CI 1.24-1.92, p < 0.001), discharge to facility (OR 1.70, 95% CI 1.48-1.95, p < 0.001), 30-day readmission (OR 1.56, 95% CI 1.23-1.99, p < 0.001), and 30-day reoperation (OR 1.85, 95% CI 1.35-2.53, p < 0.001). Although transfusion is performed based on perceived clinical need, this study contributes to growing evidence that it is important to balance the risks of perioperative blood transfusion with its benefits.

Impact of Frailty on Outcomes Following Spine Surgery: A Prospective Cohort Analysis of 668 Patients.

BACKGROUND: With an aging population, elderly patients with multiple comorbidities are more frequently undergoing spine surgery and may be at increased risk for complications. Objective measurement of frailty may predict the incidence of postoperative adverse events. OBJECTIVE: To investigate the associations between preoperative frailty and postoperative spine surgery outcomes including mortality, length of stay, readmission, surgical site infection, and venous thromboembolic disease. METHODS: As part of a system-wide quality improvement initiative, frailty assessment was added to the routine assessment of patients considering spine surgery beginning in July 2016. Frailty was assessed with the Risk Analysis Index (RAI), and patients were categorized as nonfrail (RAI 0-29) or prefrail/frail (RAI ≥ 30). Comparisons between nonfrail and prefrail/frail patients were analyzed using Fisher's exact test for categorical data or by Wilcoxon rank sum tests for continuous data. RESULTS: From August 2016 through September 2018, 668 patients (age of 59.5 ± 13.3 yr) had a preoperative RAI score recorded and underwent scheduled spine surgery. Prefrail and frail patients suffered comparatively higher rates of mortality at 90 d (1.9% vs 0.2%, P < .05) and 1 yr (5.1% vs 1.2%, P < .01) from the procedure date. They also had longer in-hospital length of stay (LOS) (3.9 d ± 3.6 vs 3.1 d ± 2.8, P < .001) and higher rates of 60 d (14.6% vs 8.2%, P < .05) and 90 d (15.8% vs 9.8%, P < .05) readmissions. CONCLUSION: Preoperative frailty, as measured by the RAI, was associated with an increased risk of readmission and 90-d and 1-yr mortality following spine surgery. The RAI can be used to stratify spine patients and inform preoperative surgical decision making.

Statistics for orthopedic surgery 2006-2007: data from the Japanese Diagnosis Procedure Combination database.

BACKGROUND: The epidemiology of orthopedic surgery cases in Japan has not been determined adequately. This study analyzed statistics in orthopedic surgery for 2006 and 2007 using the Japanese Diagnosis Procedure Combination database. METHODS: Data were collected between July 1 and December 31 in both 2006 and 2007. We selected 78 diagnostic groups of musculoskeletal diseases and trauma, and recategorized them into eight specialties: trauma, spine, knee joint, hip joint, hand, oncology, rheumatoid arthritis, others. We then focused on the following five major diseases or procedures: spinal canal stenosis, disc degeneration or herniation, hip fracture, total hip arthroplasty, and total knee arthroplasty. We extracted the following information: type of admission, use of ambulance, age, sex, preoperative co-morbidities, surgical procedures, postoperative complications such as surgical-site infection or pulmonary embolism, in-hospital mortality, length of stay, and costs. RESULTS: A total of 226 644 patients were included. Approximately 33% were emergency cases. More than half of the patients were >or=60 years old. The surgery rate increased with age, with 13.1% of cases in their fifties to 22% in their seventies. The highest rate of surgery of the spine (5.8%), knee joint (4.5%), or hip joint (1.8%) occurred in patients in their seventies, and the highest rate of surgery for trauma (9.1%) occurred in patients in their eighties. The overall in-hospital mortality was 0.41%. Approximately 0.63% patients had a surgical-site infection, 0.22% had pulmonary embolism, 0.54% had cardiac events, and 0.41% had respiratory disorders. Hip fracture surgeries resulted in relatively high in-hospital mortality (1.38%) and postoperative complication rate (3.6%). CONCLUSIONS: This study presents an overview of the clinical features of orthopedic surgery in Japan, which may be of value for determining therapeutic strategies in the management of orthopedic surgery patients.

Revision surgery and mortality following complex spine surgery: 2-year follow-up in a prospective cohort of 679 patients using the Spine AdVerse Event Severity (SAVES) system.

STUDY DESIGN: Prospective study. OBJECTIVE: To determine the 2-year risk of revision surgery and all-cause mortality after complex spine surgery, and to assess if prospectively registered adverse events (AE) could predict either outcome. Revision surgery and mortality are serious complications to spine surgery. Previous studies of frequency have mainly been retrospective and few studies have employed competing risk survival analyses. In addition, assessment of predictors has focused on preoperative patient characteristics. The effect of perioperative AEs on revision and all-cause mortality risks are not fully understood. METHODS: Between January 1 and December 31, 2013, we prospectively included all patients undergoing complex spine surgery at a single, tertiary institution. Complex spine surgery was defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment. AEs were registered using the Spine Adverse Event Severity system and patients were followed for minimum 2 years regarding revision surgery and all-cause mortality. Incidences were estimated using competing risk survival analyses and correlation between AEs and either outcome was assessed using proportional odds models. RESULTS: We included a complete and consecutive cohort of 679 adult and pediatric patients. Demographics, surgical data, AEs, and events of revision or all-cause mortality were registered. The cumulative incidence of 2-year all-cause revision was 19% (16-22%) and all-cause mortality was 15% (12-18%). Deformity surgery was the surgical category with highest incidence of revision and the highest incidence of all-cause mortality was seen in the tumor group. Across surgical categories, cumulative incidences of 2-year revision ranged between 11% (tumor) and 33% (deformity), whilst 2-year all-cause mortality ranged between 3% (deformity) and 33% (tumor). We found that major intraoperative AEs were associated to increased odds of revision. Deep wound infection was associated to increased odds of all-cause mortality. CONCLUSIONS: We report the cumulative incidences of revision surgery and all-cause mortality following complex spine surgery. We found higher incidences of revision compared to previous retrospective studies. Prospectively registered AEs were correlated to increased odds of revision surgery and all-cause mortality. These results may serve as reference for future interventional studies and aid in identifying at-risk patients. LEVEL OF EVIDENCE: I.

Treatment outcomes in patients with pyogenic vertebral osteomyelitis who have cirrhosis.

Early diagnosis and proper treatment of pyogenic vertebral osteomyelitis (PVO) in patients with cirrhosis is challenging to clinicians, and the mortality rate is expected to be high. A retrospective study was conducted to investigate the treatment outcome in PVO patients with cirrhosis and to identify the predictors of their mortality. Mortality was divided into two categories, 30-day and 90-day mortality. A stepwise multivariate logistic regression model was used to identify predictors of mortality. Eighty-five patients were identified after initial exclusion. The patients' mean age was 60.5 years, and 50 patients were male. The early mortality rates within 30 and 90 days were 17.6% and 36.5%, respectively. Multivariate analysis revealed that increased age, CTP class C, and bacteremia at the time of PVO diagnosis were predictors of 30-day mortality, while higher MELD score, presence of combined infection, and multiple spinal lesions were predictors of 90-day mortality. Attention should be paid to the high mortality between 30 and 90 days after PVO diagnosis (18.8%), which was higher than the 30-day mortality. Liver function was consistently a strong predictor of mortality in PVO patients with cirrhosis. The high-risk patients should be targeted for an aggressive diagnostic approach, using spinal MRI and intensive monitoring and treatment strategies.