Evaluation of complications and neurological deficits with three-column spine reconstructions for complex spinal deformity: a retrospective Scoli-RISK-1 study.

OBJECT: The goal in this study was to evaluate the risk factors for complications, including new neurological deficits, in the largest cohort of patients with adult spinal deformity to date. METHODS: The Scoli-RISK-1 inclusion criteria were used to identify eligible patients from 5 centers who were treated between June 1, 2009, and June 1, 2011. Records were reviewed for patient demographic information, surgical data, and reports of perioperative complications. Neurological deficits were recorded as preexisting or as new deficits. Patients who underwent 3-column osteotomies (3COs) were compared with those who did not (posterior spinal fusion [PSF]). Between-group comparisons were performed using independent samples t-tests and chi-square analyses. RESULTS: Two hundred seven patients were identified-75 who underwent PSF and 132 treated with 3CO. In the latter group, patients were older (58.9 vs 49.4 years, p < 0.001), had a higher body mass index (29.0 vs 25.8, p = 0.029), smaller preoperative coronal Cobb measurements (33.8° vs 56.4°, p < 0.001), more preoperative sagittal malalignment (11.7 cm vs 5.4 cm, p < 0.001), and similar sagittal Cobb measurements (45.8° vs 57.7°, p = 0.113). Operating times were similar (393 vs 423 minutes, p = 0.130), although patients in the 3CO group sustained higher estimated blood loss (2120 vs 1700 ml, p = 0.066). Rates of new neurological deficits were similar (PSF: 6.7% vs 3CO: 9.9%, p = 0.389), and rates of any perioperative medical complication were similar (PSF: 46.7% vs 3CO: 50.8%, p = 0.571). Patients who underwent vertebral column resection (VCR) were more likely to sustain medical complications than those treated with pedicle subtraction osteotomy (73.7% vs 46.9%, p = 0.031), although new neurological deficits were similar (15.8% vs 8.8%, p = 0.348). Regression analysis did not reveal significant predictors of neurological injury or complication from collected data. CONCLUSIONS: Despite higher estimated blood loss, rates of all complications (49.3%) and new neurological deficits (8.7%) did not vary for patients who underwent complex reconstruction, whether or not a 3CO was performed. Patients who underwent VCR sustained more medical complications without an increase in new neurological deficits. Prospective studies of patient factors, provider factors, and refined surgical data are needed to define and optimize risk factors for complication and neurological deficits.

Pelvic fixation for adult scoliosis.

INTRODUCTION: Obtaining a fusion, especially to the sacrum for adult deformity correction remains a challenge. Prior to modern fixation techniques, the reported fusion rates for adult scoliotic deformities were low. However sacropelvic fixation techniques for adult deformity continue to evolve. As a result, modern day pelvic fixation techniques have improved fusion rates at the base of long constructs. The purpose of this article is to discuss the history, indications, and modern fixation techniques for pelvic fixation in the surgical management of adult scoliosis patients. METHODS: We searched PUBMED using the search terms pelvic fixation, deformity, lumbopelvic, sacropelvic, and iliac fixation. Linkage or association studies published in English and available full-text were analyzed specifically regarding techniques and innovations in pelvic fixation. RESULTS: Sacropelvic fixation should be considered in any patient with a long construct ending in the sacrum, those patients with associated risk factors for loss of distal fixation or high risk for pseudarthrosis at L5-S1, and those undergoing three column osteotomies or vertebral body resections in the low lumbar spine. Current pelvic fixation techniques with iliac screws, multiple screw/rod constructs, and S2-alar-iliac screws are all viable techniques for achieving pelvic fixation. CONCLUSIONS: There is growing evidence that pelvic fixation may become the standard for obtaining long fusions in adult scoliosis. Although technically challenging, in selected cases the use of four pelvic screws and/or four rods across the lumbosacral pelvis can help address pseudarthroses, implant breakage, and screw pullout secondary to osteoporosis. Ultimately, indications and techniques should be individualized to the patient and based on surgeon preference and experience.

Patient-reported outcome measures in spine surgery.

The ultimate goals of intervention for spinal pathology are to improve the patient's quality of life, restore function, and relieve pain. Traditional clinician-based assessments typically fall short of adequately addressing these important outcomes because these assessments are inherently biased and may not describe patients' perception of their state of health. Patient-reported outcome measures have been developed to obtain quantitative data regarding general health quality, function, and pain. These data can aid the clinician in stratifying the severity of the disorder to formulate an appropriate treatment plan. This information also can be followed over time to assess treatment efficacy. Patient-reported outcome measures have become increasingly important with increased scrutiny of quality of care. Given the increasing importance and use of patient-reported outcome measures, knowledge regarding proper implementation of these tools is essential for accurate assessment of general health quality, function, and pain.

The Feasibility of Translaminar Screws in the Subaxial Cervical Spine: Computed Tomography and Cadaveric Validation.

BACKGROUND: The use of translaminar screws may serve as a viable salvage method for complicated cases. To our understanding, the study of the feasibility of translaminar screw insertion in the actual entire subaxial cervical spine has not been carried out yet. The purpose of this study was to report the feasibility of translaminar screw insertion in the entire subaxial cervical spine. METHODS: Eighteen cadaveric spines were harvested from C3 to C7 and 1-mm computed tomography (CT) scans and three-dimensional reconstructions were created to exclude any bony anomaly. Thirty anatomically intact segments were collected (C3, 2; C4, 3; C5, 3; C6, 8; and C7, 14), and randomly arranged. Twenty-one segments were physically separated at each vertebral level (group S), while 9 segments were not separated from the vertebral column and left in situ (group N-S). CT measurement of lamina thickness was done for both group S and group N-S, and manual measurement of various length and angle was done for group S only. Using the trajectory proposed by the previous studies, translaminar screws were placed at each level. Screw diameter was the same or 0.5 mm larger than the proposed diameter based on CT measurement. Post-insertion CT was performed. Cortical breakage was checked either visually or by CT. RESULTS: When 1° and 2° screws of the same size were used, medial cortex breakage was found 13% and 33% of the time, respectively. C7 was relatively safer than the other levels. With larger-sized screws, medial cortex breakage was found in 47% and 46% of 1° and 2° screws, respectively. There were no facet injuries due to the screws in group N-S. CONCLUSIONS: Translaminar screw insertion in the subaxial cervical spine is feasible only when the lamina is thick enough to avoid any breakage that could lead to further complications. The authors do not recommend inserting translaminar screws in the subaxial cervical spine except in some salvage cases in the presence of a thick lamina.

Lumbosacral Spondylolysis and Spondylolisthesis.

Repetitive stress on the lumbosacral spine during sporting activity places the athletic patient at risk of developing symptomatic pars defect. Clinical history, physical examination, and diagnostic imaging are important to distinguish spondylolysis from other causes of lower back pain. Early pars stress reaction can be identified with advanced imaging, before the development of cortical fracture or vertebral slip progression to spondylolisthesis. Conservative management is first-line for low-grade injury with surgical intervention indicated for refractory symptoms, severe spondylolisthesis, or considerable neurologic deficit. Prompt diagnosis and management of spondylolysis leads to good outcomes and return to competition for most athletes.

Fluoroscopically Guided Facet Cyst Rupture: Rate of Conversion to Surgery and Risk Factor Analysis.

STUDY DESIGN: Retrospective case series at a single academic medical center. OBJECTIVE: The aim was to determine if specific clinical, radiologic, and procedural factors are associated with conversion to surgery after fluoroscopically guided cyst rupture. SUMMARY OF BACKGROUND DATA: Percutaneous fluoroscopic rupture of facet cysts can often be the definitive treatment; however, it is unknown before the procedure who will ultimately proceed to formal surgical decompression. Differences in clinical, radiographic, and procedural factors of facet cysts may relate to the difference in efficacy of fluoroscopically guided cyst rupture. METHODS: A continuous cohort of 45 patients who underwent fluoroscopically guided cyst rupture was evaluated. The primary outcome measured rate of conversion to surgery and of those that underwent surgery, the rate of decompression and fusion compared with fusion alone was noted. Secondary outcomes included analysis of clinical, radiologic, and procedural variables to determine if there were risk factors associated with conversion to surgery. RESULTS: Twenty-nine percent of patients eventually underwent a surgical procedure with an average interval to surgery of 95 days after attempted rupture. Thirty-eight percent of patients that underwent surgery had a decompression and fusion. Failure of percutaneous cyst rupture trended toward significance for a future surgical decompression (P=0.08). CONCLUSIONS: Percutaneous facet cyst rupture is potentially a definitive treatment for this condition; however, it is unknown ahead of time who will proceed to definitive surgical decompression. On the basis of the data in this study, less than one-third of patients who had a fluoroscopically guided facet cyst rupture went on to surgery. There were no clinical, radiographic, or procedural details which could be used to robustly predict failure of percutaneous treatment. At this time, it is recommended to continue to attempt this nonoperative treatment intervention when there is a clinical indication after discussion of the risks and benefits with the patient.

Unplanned Immediate Return to Operating Room After Spine Surgery: Significance of Immediate Postoperative Radiographs.

STUDY DESIGN: Retrospective analysis; single center data. OBJECTIVE: The purpose of this study is to look at the utility and relevance of immediate postoperative radiographs in providing vital information leading to immediate revision after spine surgery. SUMMARY OF BACKGROUND DATA: Immediate postoperative radiographs are routinely obtained in the recovery room after spine surgery to verify the level, alignment of the spine, implant position, and the adequacy of the procedure. However, with the ability to utilize intraoperative fluoroscopy imaging for the same purpose, the requirement for immediate postoperative radiographs needs to be validated. The purpose of this study is to look at the utility and relevance of these postoperative radiographs in providing critical information that may warrant immediate intervention. METHODS: Retrospective analysis of all spine surgeries (elective and emergent), performed at a single center from 2011 to 2016, was done and cases returning to operating room within 48 hours were identified. Indication of immediate revision was reviewed and utility of immediate postoperative radiographs in guiding immediate revision was analyzed. RESULTS: A total of 1804 elective and urgent spinal surgeries were performed by seven surgeons. Twenty-two patients returned to operating room within 48 hours of their index procedures. Of these 22 cases, only two patients were noted to have positive findings on recovery room radiographs. The findings of suboptimal spinal alignment or failed instrumentation led to the immediate revision in both cases. Both cases involved instrumentation at cervicothoracic region and intraoperative imaging provided only limited visualization. CONCLUSION: Routine recovery room radiographs played a role in the decision to emergently return to the operating room in 0.10% (2/1804) cases at our institution. The potential benefit of immediate recovery room radiographs after spine surgery should be weighed against the added healthcare cost and patient discomfort associated with obtaining these radiographs routinely. Imaging may be delayed to a more elective time without any significant risk in majority of spine cases. LEVEL OF EVIDENCE: 3.

Risk of Surgical Site Infection and Mortality Following Lumbar Fusion Surgery in Patients With Chronic Steroid Usage and Chronic Methicillin-Resistant Staphylococcus aureus Infection.

STUDY DESIGN: A retrospective database analysis among Medicare beneficiaries OBJECTIVE.: The aim of this study was to determine the effect of chronic steroid use and chronic methicillin-resistant Staphylococcus aureus (MRSA) infection on rates of surgical site infection (SSI) and mortality in patients 65 years of age and older who were treated with lumbar spine fusion. SUMMARY OF BACKGROUND DATA: Systemic immunosuppression and infection focus elsewhere in the body are considered risk factors for SSI. Chronic steroid use and previous MRSA infection have been associated with an increased risk of SSI in some surgical procedures, but their impact on the risk of infection and mortality after lumbar fusion surgery has not been studied in detail. METHODS: The PearlDiver insurance-based database (2005-2012) was queried to identify 360,005 patients over 65 years of age who had undergone lumbar spine fusion. Of these patients, those who had been taking oral glucocorticoids chronically and those with a history of chronic MRSA infection were identified. The rates of SSI and mortality in these two cohorts were compared with an age- and risk-factor matched control cohort and odds ratio (OR) was calculated. RESULTS: Chronic oral steroid use was associated with a significantly increased risk of 1-year mortality [OR = 2.06, 95% confidence interval (95% CI) 1.13-3.78, P = 0.018] and significantly increased risk of SSI at 90 days (OR = 1.74, 95% CI 1.33-1.92, P < 0.001) and 1 year (OR = 1.88, 95% CI 1.41-2.01, P < 0.001). Chronic MRSA infection was associated with a significantly increased risk of SSI at 90 days (OR = 6.99, 95% CI 5.61-9.91, P < 0.001) and 1 year (OR = 24.0, 95%CI 22.20-28.46, P < 0.001) but did not significantly impact mortality. CONCLUSION: Patients over 65 years of age who are on chronic oral steroids or have a history of chronic MRSA infection are at a significantly increased risk of SSI following lumbar spine fusion. LEVEL OF EVIDENCE: 3.

Surgeon Reimbursement Relative to Hospital Payments for Spinal Fusion: Trends From 10-year Medicare Analysis.

STUDY DESIGN: Retrospective, economic analysis. OBJECTIVE: The aim of this study was to analyze the trend in hospital charge and payment adjusted to corresponding surgeon charge and payment for cervical and lumbar fusions in a Medicare sample population from 2005 to 2014. SUMMARY OF BACKGROUND DATA: Previous studies have reported trends and variation in hospital charges and payments for spinal fusion, but none have incorporated surgeon data in analysis. Knowledge of the fiscal relationship between hospitals and surgeons over time will be important for stakeholders as we move toward bundled payments. METHODS: A 5% Medicare sample was used to capture hospital and surgeon charges and payments related to cervical and lumbar fusion for degenerative disease between 2005 and 2014. We defined hospital charge multiplier (CM) as the ratio of hospital/surgeon charge. Similarly, the hospital/surgeon payment ratio was defined as hospital payment multiplier (PM). The year-wise and regional trend in patient profile, length of stay, discharge disposition, CM, and PM were studied for all fusion approaches separately. RESULTS: A total of 40,965 patients, stratified as 15,854 cervical and 25,111 lumbar fusions, were included. The hospital had successively higher charges and payments relative to the surgeon from 2005 to 2014 for all fusions with an inverse relation to hospital length of stay. Increasing complexity of fusion such as for anterior-posterior cervical fusion had higher hospital reimbursements per dollar earned by the surgeon. There was regional variation in how much the hospital charged and received per surgeon dollar. CONCLUSION: Hospital charge and payment relative to surgeon had an increasing trend despite a decreasing length of stay for all fusions. Although the hospital can receive higher payments for higher-risk patients, this risk is not reflected proportionally in surgeon payments. The shift toward value-based care with shared responsibility for outcomes and cost will likely rely on better aligning incentives between hospital and providers. LEVEL OF EVIDENCE: 3.

Rheumatoid Arthritis Is Associated With an Increased Risk of Postoperative Infection and Revision Surgery in Elderly Patients Undergoing Anterior Cervical Fusion.

STUDY DESIGN: Retrospective review. OBJECTIVE: To identify the incidence and analyze the risk of postoperative complications amongst elderly patients with rheumatoid arthritis undergoing anterior cervical fusion. SUMMARY OF BACKGROUND DATA: Previous studies have reported elevated risks of postoperative complications for patients with rheumatoid arthritis undergoing orthopedic procedures. However, little is known about the risk of postoperative complications in rheumatoid arthritis patients after spine surgery. METHODS: A commercially available database was queried for all Medicare patients 65 years of age and older undergoing one- or two-level primary anterior cervical fusion surgeries from 2005 to 2013. Complications, hospitalization costs, and length of stay were queried. Multivariate logistic regression analyses were performed to estimate the odds ratio for each complication adjusted for age, sex, and Charlson Comorbidity Index. RESULTS: A total of 6067 patients with a history of rheumatoid arthritis and 113,187 controls were identified. Significantly higher incidences of major medical complications (7.5% vs. 5.9%, P < 0.001), postoperative infections (2.6% vs. 1.5%, P < 0.001), and revision surgery (1.1% vs. 0.6%, P < 0.001) were observed amongst the rheumatoid arthritis cohort. Significantly greater average cost of hospitalization ($17,622 vs. $12,489, P < 0.001) and average length of stay (3.13 vs. 2.08 days, P < 0.001) were also observed. CONCLUSION: Patients with rheumatoid arthritis undergoing anterior cervical fusion face increased risks of postoperative infection and revision surgery compared to normal controls. This information is valuable for preoperative counseling and risk stratification. LEVEL OF EVIDENCE: 3.

Perioperative Complications Associated With Posterolateral Spine Fusions: A Study of Elderly Medicare Beneficiaries.

STUDY DESIGN: A retrospective database review. OBJECTIVE: The aim of this study was to compare the occurrence of complications in patients treated with one to two-level, three to seven-level, and more than eight level fusions. SUMMARY OF BACKGROUND DATA: Elderly patients constitute a rapidly growing demographic with an increasing need for spinal procedures. Complication rates for spinal surgery in elderly patients range from 37% to 80% with major complications occurring in 12% to 21% of patients. METHODS: The PearlDiver database (2005-2012) was utilized to compare perioperative complication rates in patients aged 65 years and older undergoing posterolateral fusion of one to two (n = 90,527); three to seven (n = 23,827), and more than eight (n = 2758) thoracolumbar levels. Cohorts were matched by demographics and comorbidities. Ninety-day medical and surgical complication and mortality rates were determined. RESULTS: In the full, unmatched cohort, the major complication rate was 15.9%, with matched cohorts of one to two, three to seven, and eight-level fusions associated with major complication rates of 12.5%, 20.5%, and 35.4%, respectively. Patients treated with 8+ level fusions had 3.8 and 2.1 times greater odds of developing a major complication than patients treated with 1 to 2 and 3 to 7-level fusions, respectively (P < 0.0001). Patients treated with more than eight-level fusions had 3.9 and 10.8 times increased odds of experiencing mortality than those treated with three to seven-level and one to two-level fusions, respectively. CONCLUSION: Elderly patients treated with spine fusions spanning more than eight levels experience significantly increased complication rates when compared with patients treated with fusions of shorter length. LEVEL OF EVIDENCE: 3.

Quantitative Assessment of the Anatomical Footprint of the C1 Pedicle Relative to the Lateral Mass: A Guide for C1 Lateral Mass Fixation.

STUDY DESIGN: Anatomic study. OBJECTIVES: To determine the relationship of the anatomical footprint of the C1 pedicle relative to the lateral mass (LM). METHODS: Anatomic measurements were made on fresh frozen human cadaveric C1 specimens: pedicle width/height, LM width/height (minimum/maximum), LM depth, distance between LM's medial aspect and pedicle's medial border, distance between LM's lateral aspect to pedicle's lateral border, distance between pedicle's inferior aspect and LM's inferior border, distance between arch's midline and pedicle's medial border. The percentage of LM medial to the pedicle and the distance from the center of the LM to the pedicle's medial wall were calculated. RESULTS: A total of 42 LM were analyzed. The C1 pedicle's lateral aspect was nearly confluent with the LM's lateral border. Average pedicle width was 9.0 ± 1.1 mm, and average pedicle height was 5.0 ± 1.1 mm. Average LM width and depth were 17.0 ± 1.6 and 17.2 ± 1.6 mm, respectively. There was 6.9 ± 1.5 mm of bone medial to the medial C1 pedicle, which constituted 41% ± 9% of the LM's width. The distance from C1 arch's midline to the medial pedicle was 13.5 ± 2.0 mm. The LM's center was 1.6 ± 1 mm lateral to the medial pedicle wall. There was on average 3.5 ± 0.6 mm of the LM inferior to the pedicle inferior border. CONCLUSIONS: The center of the lateral mass is 1.6 ± 1 mm lateral to the medial wall of the C1 pedicle and approximately 15 mm from the midline. There is 6.9 ± 1.5 mm of bone medial to the medial C1 pedicle. Thus, the medial aspect of C1 pedicle may be used as an anatomic reference for locating the center of the C1 LM for screw fixation.

Spinal subdural abscess following repeat lumbar microdiscectomy: A case report of imaging findings for a rare infection.

Spinal subdural abscess is a rare central nervous system infection with just over a hundred cases reported. It is much less common than spinal epidural abscess. While most case reports have focused on route of infection and treatment options, there have not been any reports that focused on the unique MRI findings of spinal subdural abscess. We describe a case of spinal subdural abscess diagnosed by MRI in a 33-year-old male who presented with headaches after undergoing a microdiscectomy procedure, and review the underlying anatomic features of the spinal meninges which produce the appearance of a spinal subdural abscess.

Readmission Rates, Reasons, and Risk Factors Following Anterior Cervical Fusion for Cervical Spondylosis in Patients Above 65 Years of Age.

STUDY DESIGN: A retrospective database review. OBJECTIVE: The aim of this study was to determine readmission reasons and rates following primary, elective anterior cervical spinal fusion surgery for cervical spondylosis and determine risk factors predicting increased risk of 30-day readmission in an exclusively elderly population. SUMMARY OF BACKGROUND DATA: In the United States, there were almost 190,000 cervical spine procedures in 2009. Many cervical spine surgery patients are elderly, a demographic increasingly requiring surgery for degenerative cervical spine pathology. Unfortunately, this patient population is poorly studied, particularly concerning readmission rates. METHODS: Medicare data from 2005 to 2012 were queried for elderly patients (65-84 years) who underwent primary one to two and ≥three-level anterior cervical spine fusion surgeries for cervical spondylosis. Forty-five thousand two hundred eighty-four patients treated with one to two-level and 12,103 patients with ≥three-level anterior cervical fusion (ACF) were identified and included in two study cohorts. Reasons for and rates of readmission were determined within 30 days, 90 days, and one-year postoperatively. Risk factors for medical, surgical, and all 30-day readmissions were also determined, selecting from various comorbidities, demographics, and surgical variables. RESULTS: Readmission rates of 1.0% to 1.4%, 2.7% to 3.6%, and 13.2% to 14.1% were observed within 30 days, 90 days, and one year. Within 30 days, over 30% of patients from both study cohorts were readmitted for surgical reasons. Of surgical reasons for 30-day readmission, hematoma/seroma diagnoses were the most frequent (11.4%-15.4% of all readmissions). Male gender, diabetes mellitus, chronic pulmonary disease, obesity, and smoking history were all found to be predictive of all-cause readmissions. CONCLUSION: Unplanned 30-day readmission rates following primary, elective ACF in elderly patients is low and often due to medical reasons. Frequent surgical reasons for 30-day readmission include hematoma/seroma formation. Male gender and various comorbid diagnoses are significant predictors of all-cause readmissions within 30 days. LEVEL OF EVIDENCE: 3.

Complication and Reoperation Rates Following Surgical Management of Cervical Spondylotic Myelopathy in Medicare Beneficiaries.

STUDY DESIGN: Retrospective database review. OBJECTIVE: To compare complication and reoperation rates after anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCFs), and anterior cervical corpectomy and fusion (ACCF) for cervical spondylotic myelopathy (CSM) using a large national database of Medicare beneficiaries. SUMMARY OF BACKGROUND DATA: CSM is the most common cause of myelopathy in patients over 55 years and is considered the most common cause of spinal cord dysfunction in the world. Surgical treatment includes ACDF, PCF, or ACCF procedures. METHODS: The PearlDiver database (2005-2012) was utilized to determine revision rates after surgical treatment of CSM by one of the aforementioned surgical treatments. Specifically, 1 to 2 level ACDF, ACCF, and PCF and 3+ level PCF cohorts were included. Each cohort was stratified by the age of 65 years. Survivorship curves were graphed and compared. RESULTS: Of the patients younger than 65 years of age, there were 10,557 patients treated with 1 to 2 level ACDF procedures, 1319 patients with 1 to 2 level PCF procedures, 1203 patients with 1 to 2 level ACCF procedures, and 2312 patients treated with 3+ level PCF procedures. Of the elderly patients, 24,310 patients were treated with 1 to 2 level ACDFs, 4776 with 1 to 2 level PCF procedures, 3109 with 1 to 2 level ACCFs, and 7760 with 3+ level PCFs. Patients younger than 65 years of age were significantly more likely to have a reoperation procedure, than those 65 years or older when analyzing ACCF, ACDF, and 3+ level PCF procedures. ACCFs were significantly more likely than ACDFs to require reoperation. Patients treated with PCF were consistently more likely to have nondysphagia-related complications than those treated with ACDF. Rates of transfusion, dysphagia, and hematoma/seroma formation were significantly increased with ACCF compared with ACDF within the elderly population. CONCLUSION: The elderly are significantly less likely to have a revision surgery after surgical treatment for CSM. Patients treated with ACCF are more likely to need a revision than those treated with ACDF. LEVEL OF EVIDENCE: 3.

Complications and Mortality Following 1 to 2 Level Lumbar Fusion Surgery in Patients Above 80 Years of Age.

STUDY DESIGN: Retrospective database review. OBJECTIVE: To determine the 90-day complication rate and 90-day and 1-year mortality in patients 80 years of age and older who were treated with posterolateral lumbar spinal fusion surgery and to compare these rates against those of elderly patients ages 65 to 79. SUMMARY OF BACKGROUND DATA: Patients over 80 years of age specifically represent a substantial proportion of the US population, with over 11 million such individuals in 2010. Few studies have comprehensively assessed the morbidity associated with spinal fusion surgery in patients older than 80 years. METHODS: The PearlDiver database (2005-2012) was utilized to determine morbidity and mortality rates after posterolateral lumbar or lumbosacral spinal fusion surgery of 2-3 vertebrae. Patients 65 to 79 (72,547) and ≥80-year old (12,187) were selected. Charlson comorbidity index scores were analyzed and compared, as were various comorbid conditions 90-day complication rates and mortality at 90-days and 1 year compared between cohorts. RESULTS: The ≥80 year cohort had a higher average Charlson Comorbidity Index score than the 65 to 79 year cohort (7.99 vs. 6.54, P <0.0001). The proportion of patients experiencing at least one major complication was relatively increased by 45.6% in patients ≥80 year (13.87 vs. 9.52%; OR 1.53 95% CI 1.44 - 1.62 P <0.0001). Ninety-day (0.30 vs. 0.09%; OR: 3.50, 95% confidence interval: 2.33-5.26, P <0.0001) and 1-year (0.48 vs. 0.18%; OR: 2.58, 95% confidence interval: 1.90-3.52, P <0.0001) mortality were significantly higher in the ≥80 year cohort compared with the 65 to 79-year-old control group. CONCLUSION: Patients 80 years of age or older have significantly greater rates of major medical complication and mortality following 1 to 2 level lumbar spinal posterolateral fusion surgery compared with patients 65 to 79 years of age. LEVEL OF EVIDENCE: 3.

Does the Timing of Preoperative Epidural Steroid Injection Affect Infection Risk After ACDF or Posterior Cervical Fusion?

STUDY DESIGN: A retrospective database analysis. OBJECTIVE: The aim of this study was to determine whether any association exists between preoperative cervical epidural steroid injections (CESIs) at various time intervals before anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF) and the incidence of postoperative infection. SUMMARY OF BACKGROUND DATA: Although infectious complications following CESI are uncommon, the association between preoperative CESI and postoperative infection following ACDF or PCF has yet to be evaluated in the current literature. METHODS: A national insurance database was utilized to compare postoperative infection rates within 90 days in patients who received a CESI before ACDF or PCF. Three cohorts were created for each procedure: PCF (n = 402) or ACDF (n = 4354) within 3 months, PCF (n = 586) or ACDF (n = 5183) between 3 and 6 months, and PCF (n = 629) or ACDF (3648) between 6 and 12 months following a CESI. These cohorts were compared with control cohorts who underwent PCF (n = 61,253) or ACDF (n = 241,678) without prior CESI. Postoperative infection rates within 90 days were assessed using International Classification of Disease, 9th Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Odds ratios (ORs), 95% confidence intervals (95% CIs), and P values were then calculated using SPSS. A multivariate binomial logistic regression analysis was performed to determine the independent effect of preoperative injection on postoperative infection following ACDF or PCF controlling for known risk factors for infection, including age, gender, obesity, diabetes, and smoking. RESULTS: Patients who underwent CESI within 3 months (OR 2.21, P < 0.0001) and within 3 to 6 months (OR 1.95, P = 0.0002) before PCF had significantly increased odds of developing a postoperative infection. Patients who underwent CESI within 3 months (OR 1.83, P < 0.0001) before ACDF had significantly increased odds of developing a postoperative infection. CONCLUSION: The present study demonstrates that cervical ESI within 6 months of PCF, and within 3 months of ACDF, is independently associated with significantly increased rates of postoperative infection. LEVEL OF EVIDENCE: 3.

Perioperative hemoglobin A1c as a predictor of deep infection following single-level lumbar decompression in patients with diabetes.

BACKGROUND CONTEXT: Although multiple studies have cited that diabetes mellitus as a risk factor decreased functional outcomes, increased infectious complications, and overall increased reoperation rate following degenerative lumbar spinal surgery, few have investigated how perioperative glycemic control influences such complications. PURPOSE: The primary goal of the present study was to use a national database to evaluate the association of perioperative glycemic control as demonstrated by hemoglobin A1c (HbA1c) levels in patients with diabetes undergoing primary, single-level decompression without concomitant fusion with the incidence of deep postoperative infection requiring operative irrigation and debridement. Our secondary objective was to calculate a threshold level of HbA1c above which the risk of postoperative infection after lumbar decompression increases significantly in patients with diabetes. STUDY DESIGN/SETTING: This is a retrospective case control database study, with Level III evidence. PATIENT SAMPLE: This study comprised private-payer patients with diabetes mellitus undergoing single-level lumbar decompression with an HbA1c laboratory value recorded in the database within 3 months of surgery. OUTCOME MEASURES: The outcome examined in this study was deep infection following primary, single-level lumbar decompression requiring surgical intervention. Postoperative infection within 1 year of the index primary, single-level lumbar decompression was assessed using Current Procedural Terminology (CPT) procedure codes and the International Classification of Diseases, 9th Revision (ICD-9) diagnostic codes. METHODS: The Humana private-payer dataset from the PearlDiver database was used for this study. The database was queried for patients with diabetes mellitus undergoing primary, single-level lumbar decompression surgery using CPT codes. Patients with a diagnosis of diabetes mellitus who had an HbA1c level drawn within 3 months before or after their surgical date were then selected to form the study group using the ICD-9 diagnostic codes. Patients were then divided into groups based on their HbA1c level by increments of 0.5 mg/dL. The incidence of deep infection requiring operative intervention within 1 year for each HbA1c group was then identified using CPT and ICD-9 codes. A receiver operating characteristic (ROC) and area under the curve (AUC) analysis was performed to determine an optimal threshold value of the HbA1c above which the risk of postoperativeinfection was significantly increased. The threshold value was tested using a multivariable binomial logistic regression analysis. RESULTS: A total of 5,194 patients who underwent primary, single-level lumbar decompression with diabetes and a perioperative HbA1c recorded within 3 months of surgery were included in the study. The rate of infection ranged from a low of 0.5% up to 3.5% for patients with an HbA1c level >11.0 mg/dL (p=.012). The inflection point of the ROC curve corresponded to an HbA1c level above 7.5 mg/dL (p=.01, AUC=0.71, specificity=70%, sensitivity=53%). After controlling for patient demographics and medical comorbidities, patients with an HbA1c level of 7.5 mg/dL or above had a significantly higher risk for deep infection compared with patients below this threshold (odds ratio: 2.9, 95% confidence interval: 1.8-4.9, p<.0001). CONCLUSIONS: The risk of deep postoperative infection requiring surgical intervention following single-level lumbar decompression in patients with diabetes mellitus increases as the perioperative HbA1c increases. The ROC and multivariable regression analyses determined that a perioperative HbA1c above 7.5 mg/dL could serve as a threshold for a significantly increased risk of deep postoperative infection following lumbar decompression.

The Association of Perioperative Glycemic Control with Deep Postoperative Infection After Anterior Cervical Discectomy and Fusion in Patients with Diabetes.

OBJECTIVE: To evaluate the association of perioperative hemoglobin A1c (HbA1c) level in patients with diabetes with the incidence of infection after anterior cervical discectomy and fusion requiring operative intervention, in addition to determining if a threshold level of HbA1c above which the risk of infection increases significantly exists. METHODS: A national administrative database was queried for patients who underwent primary anterior cervical discectomy and fusion with diabetes who had a perioperative HbA1c level recorded within 3 months of surgery. These patients were stratified based on their HbA1c level in 0.5-mg/dL increments from <5.49 mg/dL to >11.5 mg/dL. The incidence of infection requiring operative intervention within 1 year was then identified using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. A receiver operating characteristic (ROC) analysis was performed to determine a threshold value of the HbA1c level. RESULTS: A total of 3341 patients with a perioperative HbA1c level were included. The rate of deep infection requiring irrigation and debridement postoperatively stratified by HbA1c level ranged from a low of 1.5% to a high of 6.4% and was significantly correlated with increasing HbA1c levels (P = 0.005). The results of ROC analysis determined that the inflection point of the ROC curve corresponded to an HbA1c level higher than 7.5 mg/dL (P = 0.022; area under the curve, 0.67; specificity, 68%; sensitivity, 46%). CONCLUSIONS: The risk of deep postoperative infection in patients with diabetes mellitus increases as the perioperative HbA1c level increases. ROC analysis determined that a perioperative HbA1c level higher than 7.5 mg/dL could serve as a threshold for a significantly increased risk of infection.