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.

Does Coronavirus Disease 2019 (COVID-19) Affect Perioperative Morbidity and Mortality for Patients Requiring Emergency Instrumented Spinal Surgery? A Single-Center Cohort Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic sent shockwaves through health services worldwide. Resources were reallocated. Patients with COVID-19 still required instrumented spinal surgery for emergencies. Clinical outcomes for these patients are not known. The objective of this study was to evaluate the effects of COVID-19 on perioperative morbidity and mortality for patients undergoing emergency instrumented spinal surgery and to determine risk factors for increased morbidity/mortality. METHODS: This retrospective cohort study included 11 patients who were negative for COVID-19 and 8 patients who were positive for COVID-19 who underwent emergency instrumented spinal surgery in 1 hospital in the United Kingdom during the pandemic peak. Data collection was performed through case note review. Patients in both treatment groups were comparable for age, sex, body mass index (BMI), comorbidities, surgical indication, and preoperative neurologic status. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariable analysis was used to identify risk factors for increased morbidity. RESULTS: There were no mortalities in either treatment group. Four patients positive for COVID-19 (50%) developed a complication compared with 6 (55%) in the COVID-19-negative group (P > 0.05). The commonest complication in both groups was respiratory infection. Three patients positive for COVID-19 (37.5%) required intensive care unit admission, compared with 4 (36%) in the COVID-19-negative group (P > 0.05). The average time between surgery and discharge was 19 and 10 days in COVID-19-positive and -negative groups, respectively (P = 0.02). In the COVID-19 positive group, smoking, abnormal BMI, preoperative oxygen requirement, presence of fever, and oxygen saturations <95% correlated with increased risk of complications. CONCLUSIONS: Emergency instrumented spinal surgery in patients positive for COVID-19 was associated with increased length of hospital stay. There was no difference in occurrence of complications or intensive care unit admission. Risk factors for increased morbidity in patients with COVID-19 included smoking, abnormal BMI, preoperative oxygen requirement, fever and saturations <95%.

Predicting Readmission After Anterior, Posterior, and Posterior Interbody Lumbar Spinal Fusion: A Neural Network Machine Learning Approach.

BACKGROUND: Readmission after spine surgery is costly and a relatively common occurrence. Previous research identified several risk factors for readmission; however, the conclusions remain equivocal. Machine learning algorithms offer a unique perspective in analysis of risk factors for readmission and can help predict the likelihood of this occurrence. This study evaluated a neural network (NN), a supervised machine learning technique, to determine whether it could predict readmission after 3 lumbar fusion procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried between 2009 and 2018. Patients who had undergone anterior, lateral, and/or posterior lumbar fusion were included in the study. The Python scikit Learn package was used to run the NN algorithm. A multivariate regression was performed to determine risk factors for readmission. RESULTS: There were 63,533 patients analyzed (12,915 anterior lumbar interbody fusion, 27,212 posterior lumbar interbody fusion, and 23,406 posterior spinal fusion cases). The NN algorithm was able to successfully predict 30-day readmission for 94.6% of anterior lumbar interbody fusion, 94.0% of posterior lumbar interbody fusion, and 92.6% of posterior spinal fusion cases with area under the curve values of 0.64-0.65. Multivariate regression indicated that age >65 years and American Society of Anesthesiologists class >II were linked to increased risk for readmission for all 3 procedures. CONCLUSIONS: The accurate metrics presented indicate the capability for NN algorithms to predict readmission after lumbar arthrodesis. Moreover, the results of this study serve as a catalyst for further research into the utility of machine learning in spine surgery.

Survival, fusion, and hardware failure after surgery for spinal metastatic disease.

OBJECTIVE: Decompression with instrumented fusion is commonly employed for spinal metastatic disease. Arthrodesis is typically sought despite limited knowledge of fusion outcomes, high procedural morbidity, and poor prognosis. This study aimed to describe survival, fusion, and hardware failure after decompression and fusion for spinal metastatic disease. METHODS: The authors retrospectively examined a prospectively collected, single-institution database of adult patients undergoing decompression and instrumented fusion for spinal metastases. Patients were followed clinically until death or loss to follow-up. Fusion was assessed using CT when performed for oncological surveillance at 6-month intervals through 24 months postoperatively. Estimated cumulative incidences for fusion and hardware failure accounted for the competing risk of death. Potential risk factors were analyzed with univariate Fine and Gray proportional subdistribution hazard models. RESULTS: One hundred sixty-four patients were identified. The mean age ± SD was 62.2 ± 10.8 years, 61.6% of patients were male, 98.8% received allograft and/or autograft, and 89.6% received postoperative radiotherapy. The Kaplan-Meier estimate of median survival was 11.0 months (IQR 3.5-37.8 months). The estimated cumulative incidences of any fusion and of complete fusion were 28.8% (95% CI 21.3%-36.7%) and 8.2% (95% CI 4.1%-13.9%). Of patients surviving 6 and 12 months, complete fusion was observed in 12.5% and 16.1%, respectively. The estimated cumulative incidence of hardware failure was 4.2% (95% CI 1.5-9.3%). Increasing age predicted hardware failure (HR 1.2, p = 0.003). CONCLUSIONS: Low rates of complete fusion and hardware failure were observed due to the high competing risk of death. Further prospective, case-control studies incorporating nonfusion instrumentation techniques may be warranted.

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.

Technical approach, outcomes, and exposure-related complications in patients undergoing anterior lumbar interbody fusion.

OBJECTIVE: To describe our technique, evaluate access related complications and factors contributing to adverse outcomes in patients undergoing retroperitoneal anterior lumbar interbody fusion (ALIF). METHODS: We conducted a retrospective analysis of prospectively collected data on patients undergoing ALIF at our institution from January 2008 to December 2017. Access was performed by a vascular surgeon who remained present for the duration of the case. Data collected included patients' demographics, comorbidities, exposure related complications and ileus. Study end points included major adverse events and minor complications. Major adverse events included any vascular injuries requiring repair, bowel and ureter injuries, postoperative bleeding requiring reoperation, myocardial infarction, stroke, venous thromboembolism (pulmonary embolism/deep venous thrombosis), wound dehiscence, and death. Minor complications included postoperative paralytic ileus, urinary tract infections, and surgical site infections. The incidence of incisional hernia was also evaluated. RESULTS: During this period, 1178 patients (514 males and 664 females; mean age, 54.1 ± 13.8 years) underwent a total of 2352 levels ALIF at our institution (single level, 422 patients; 2 levels, 450; 3 levels, 205; 4 levels, 98; 5 levels, 6; 6 levels, 1; and 7 levels, 1). The median estimated blood loss was 25 mL (interquartile range, 25-50). There were 57 exposure-related complications (4.8%), including vascular injuries (venous, 13; arterial, 4) in 17 patients (1.4%), bowel injuries in three patients (serosa tear in two and arterial embolization with subsequent bowel ischemia in one). Eleven of the 13 venous injuries (84.6%) occurred while exposing the L4 to L5 lumbar level. Two of the four patients with arterial injuries developed acute limb ischemia requiring embolectomy. One embolized to the superior mesenteric artery and underwent bowel resection. Twenty patients (1.7%) developed venous thromboembolism, two of whom had sustained left iliac vein injury during exposure. Sixteen patients (1.4%) developed a retroperitoneal hematoma/seroma with nine requiring evacuation in the operating room. Thirty-six patients (3.1%) developed postoperative ileus, defined as an inability to tolerate diet on postoperative day 3. Four patients (0.4%) had a postoperative myocardial infarction, and two had a stroke and two (0.17%) died within the first 30 postoperative days. Thirty-one patients developed incisional complications, including surgical site infection in 24 and incisional hernia in 7. CONCLUSIONS: Our findings suggest that ALIF exposure can be performed safely with a relatively low overall complication rate. The majority of vascular injuries associated with this procedure are venous in nature, occurring predominantly while exposing the L4 to L5 level and can be safely addressed by an experienced vascular team.

How Safe Is Minimally Invasive Transforaminal Lumbar Interbody Fusion for Octogenarians?: A Perioperative Complication Analysis.

BACKGROUND: Technical advances in minimally invasive spine surgery have reduced blood loss, access trauma, and postoperative length of stay. However, operating on the susceptible group of octogenarians still poses a dilemma because of a plethora of age-related comorbidities. The aim of this study was to investigate the safety of minimally invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF) in octogenarians. METHODS: We conducted a retrospective single-center study of all patients over 80 years of age who, between March 2009 and February 2014, had undergone MIS TLIF. The primary outcome was recorded major and minor complications within 30 days of surgery. RESULTS: Twenty-one patients with an average age of 84.1 ± 2.7 years underwent MIS TLIF in 31 levels for degenerative lumbar disk disease with intolerable pain after failure of conservative treatment. Of the patients, 33.3% showed no perioperative complications. In the remaining 66.7%, 6 major complications and 24 minor complications occurred within 30 days of surgery. Two of these patients died within 30 days of surgery because of sepsis and pulmonary embolism (mortality rate 9.5%). CONCLUSIONS: Our study spotlighted the susceptible group of octogenarians and evaluated the safety of MIS TLIF. The perioperative morbidity for octogenarians undergoing MIS TLIF is substantial and even higher than for patients over 65 years of age. Two thirds of patients in this subgroup suffer at least 1 complication. The 30-day mortality rate was 9.5%. Therefore, it is advisable for these patients to exploit all available conservative options prior to surgery.

Failure to extubate and delayed reintubation in elective lumbar fusion: An analysis of 57,677 cases.

OBJECTIVES: There is a scarcity of literature exploring the consequences of Failure To Extubate (FTE) and Delayed Reintubation (DRI) in spine surgery. While it is reasonable to believe that patients who FTE or undergo DRI after Posterior Lumbar Fusion (PLF) and Transforaminal Lumbar Interbody Fusion (TLIF) are at risk for graver outcomes, there is minimal data to explicitly support that. The goal of this study was to investigate the morbidity and mortality associated with FTE and DRI after lumbar spine surgery in a large pool of patients. PATIENTS AND METHODS: We conducted a retrospective multicenter study of patients that underwent elective posterior lumbar fusion (PLF) and transforaminal lumbar interbody fusion (TLIF) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2016. We excluded patients with disseminated cancer, metastatic disease to the neural axis, patient with spinal epidural abscess, and patients with ventilator dependency prior to the operation. RESULTS: 57,677 patients from 2006 to 2016 were identified; 55 patients (0.1 %) had FTE and 262 patients (0.46 %) had DRI. The incidence of pneumonia was 27.2-fold greater in the FTE group and septic shock was 63.5-fold greater. All complications listed below are significance to p < 0.001. Deep vein thrombosis, pulmonary embolism, myocardial infarction and cardiac arrest were respectively, 10.4-, 12.2-, 22.8-, and 45.5- fold greater in the FTE group. Overall complication rate differed significantly between the two groups and were 9.8-fold greater in the FTE group. FTE was associated with increased, length of stay and all complications except DVT and pulmonary embolism. FTE was profoundly associated with severe complications (OR 13.0, 95 % CI 7.2-23.5) and mortality (OR = 21.5, CI = 7.5-61.0). The DRI group had a significantly higher morbidity (OR = 71.0, CI = 44.1-114.4), including overall complication (OR = 21.2, CI = 16.0-28.0) and severe complications (OR = 34.4, CI = 26.1-45.3). The DRI group had significantly higher rates of pneumonia (OR = 37.0), DVT (OR = 9.6) and pulmonary embolism (OR = 7.0), septic shock (OR = 60.5), myocardial infarction (OR = 32.1,) and cardiac arrest (OR = 236.4). CONCLUSION: FTE and DRI were highly predictive of morbidity and mortality. Overall, investigations of the effects of FTE and DRI following spine procedures are lacking. This large multi-center national database review is one of the first to provide insight into the consequences of FTE and DRI in lumbar fusion cases. Future investigation into the consequences and predictors of FTE and DRI in spine surgery are required.

The Effect of Older Age on the Perioperative Outcomes of Spinal Fusion Surgery in Patients With Lumbar Degenerative Disc Disease With Spondylolisthesis: A Propensity Score-Matched Analysis.

BACKGROUND: Degenerative spondylolisthesis (DS) is often treated with lumbar spinal fusion (LSF). However, there is concern that the morbidity of LSF may be prohibitively high in older adults. OBJECTIVE: To evaluate the impact of advanced age on the safety of LSF for DS. METHODS: Patients who underwent LSF for DS were retrospectively identified from National Surgical Quality Improvement Program datasets for 2011 to 2015 using Current Procedural Terminology codes. Data on demographic characteristics, comorbidities, surgical factors, and 30-d morbidity and mortality were collected. Propensity score matching (nearest neighbor) was performed with age (<70 vs ≥70 yr) as the dependent variable and sex, type of fusion procedure, number of levels fused, diabetes, smoking, hypertension, and chronic steroid use as covariates. Outcomes were compared between age <70 and ≥70 groups. RESULTS: The study cohort consisted of 2238 patients (n = 1119, age <70; n = 1119, age ≥70). The 2 age groups were balanced for key covariates including sex, race, diabetes, hypertension, CHF, smoking, chronic steroid use, type of fusion, and number of levels. Rates of all complications were similar between younger and older age groups, except urinary tract infection, which was more frequent among the ≥70 age group (OR 2.32, P = .009). Further, patients in the older age group were more likely to be discharged to a rehabilitation (OR 2.94, P < .001) or skilled care (OR 3.66, P < .001) facility, rather than directly home (OR 0.25, P < .001). CONCLUSION: LSF may be performed safely in older adults with DS. Our results suggest older age alone should not exclude a patient from undergoing lumbar fusion for DS.

Complications and Mortality in Octogenarians Undergoing Lumbopelvic Fixation.

BACKGROUND: Advancements in modern medicine have led to longer life expectancy. Literature on spinopelvic fixation in elderly patients is limited. We investigated morbidity and mortality in octogenarians who underwent spinopelvic fixation. METHODS: A retrospective chart review was conducted of patients who underwent spinopelvic fixation from January 2014 through December 2018 at a single institution. Patients were grouped into the octogenarian group (OG), 80-89 years old, and comparison group (CG), 40-50 years old. Demographics; pathology; Charlson Comorbidity Index; Hounsfield units; surgery details; and clinical data including complications, intensive care unit and length of hospital stay, and mortality were collected and compared. RESULTS: Inclusion criteria were met by 26 patients (OG: n = 14; CG: n = 12). Diagnoses in the OG were deformity (42.9%), pseudarthrosis (35.7%), fracture (7.1%), infection (7.1%), and tumor (7.1%). The only significant differences in baseline patient characteristics were that Charlson Comorbidity Index was significantly higher in the OG (6.0 ± 1.4) compared with the CG (1.1 ± 1.0) (P < 0.001) and the OG had lower Hounsfield units (P < 0.001), indicating poorer bone quality. More patients in the CG underwent staged and anterior approaches compared with the OG (P = 0.031). Major and minor complication rates were 57.1% and 42.9%, respectively, in the OG (P = 0.98) and 25% and 25% in the CG (P = 0.34). Mortality rate was 14.3%. CONCLUSIONS: With an aging population, the number of patients requiring spinopelvic fixation will continue to grow. Spine surgeons must carefully weigh benefits and risks in patients with multiple comorbidities.

Solid Organ Transplant Is Associated With Increased Morbidity and Mortality in Patients Undergoing One or Two-level Anterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective database review OBJECTIVE.: The aim of this study was to analyze the implications of solid organ transplant (SOT) on postoperative outcomes following elective one or two-level anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Although SOTs have been associated with increased morbidity, postoperative outcomes in SOT recipients undergoing cervical spinal surgery are not well studied. METHODS: A retrospective database review of Medicare patients younger than 85 years who underwent an elective one to two-level ACDF from 2006-2013 was conducted. Following our exclusion criteria, patients were then divided into the following groups: those with a prior history of kidney, liver, heart or lung transplant (SOT group) and non-SOT patients. Both groups were compared for hospital length of stay, 90-day major medical complications, 90-day hospital readmission, 1-year surgical site infection (SSI), 1-year revision ACDF, and 1-year mortality. RESULTS: A total of 992 (0.5%) SOT recipients (1,144 organs) were identified out of 199,288 ACDF patients. SOT recipients had a significantly longer length of stay (2.32 vs. 5.22 days, p<0.001), higher rate of major medical complications (8.2% vs. 4.5%; OR 1.85, 95% CI 1.45-2.33, p<0.001) and hospital readmission (19.5% vs. 7.5%, OR 2.05, 95% CI 1.74-2.41, p<0.001). In addition, SOT patients had increased mortality within one year of surgery (5.8% vs. 1.3%; OR 3.01, 95% CI 2.26-3.94, p<0.001) compared to non-SOT patients. SOT was not independently associated with SSI (OR 1.25, 95% CI 0.85-1.75, p=0.230), and there was no significant difference in revision rate (0.9% vs. 0.5%; OR 1.54, 95% CI 0.73-2.82, p=0.202) between both groups. CONCLUSION: SOT is independently associated with longer hospital stay, increased rate of major medical complications, hospital readmission and mortality. Spine surgeons should be aware of the higher rates of morbidity and mortality in these patients and take it into consideration when developing patient-specific treatment plans. LEVEL OF EVIDENCE: 3.

Unintended Consequences After Postoperative Ileus in Spinal Fusion Patients.

BACKGROUND: Postoperative ileus is not uncommon after spinal surgery. Although previous research has focused on the frequency of ileus formation, little has been done to investigate the clinical sequelae after development. We investigated the effect of postoperative ileus on patients' length of stay and rates of deep vein thrombosis (DVT) formation, myocardial infarction (MI), aspiration pneumonia, sepsis, and death. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample was queried to identify adult patients who underwent any spinal fusion procedure. Patient characteristics and outcomes for discharges involving spinal fusion surgery were compared between patients with and without postoperative ileus. The Rao-Scott χ2 test of association was used for categorical variables, and a t test for equality of means was used for continuous variables. Among discharges with postoperative ileus, a multivariate linear regression model was used to assess how fusion approach and fusion length were associated with length of hospital stay, controlling for sex, age, and race. RESULTS: A total of 250,221 patients were included. The mean length of stay was 3.75 days for patients without postoperative ileus and 9.40 days for patients with postoperative ileus. Patients with postoperative ileus are more likely to have DVT (4.1% vs. 20.8%, P < 0.001), MI (2.5% vs. 7.1%, P < 0.001), aspiration pneumonia (6.6% vs. 34.3%, P < 0.001), sepsis (5.7% vs. 35.7%, P < 0.001), and death (2.6% vs. 11.4%, P < 0.001). CONCLUSIONS: This study demonstrates that patients with postoperative ileus are significantly more likely to have DVT, experience MI, acquire aspiration pneumonia, develop sepsis, and die.

Trends of the neurosurgical economy in the United States.

BACKGROUND: The objective of this study was to identify the neurosurgical MS-DRGs highest national bills and to analyze economic, demographic, and patient outcome trends. METHODS: This retrospective cohort study used the Nationwide Inpatient Sample (NIS) database to achieve the results. All MS-DRG codes for the years 2014 were ranked based on total aggregate charges. The highest ranked relevant to neurosurgery were identified and retrospectively reviewed to 2008. The data was analyzed by Z-test. RESULTS: In 2014, NIS reported the MS-DRG with the highest national bill of $22,894,340,928 was "Spinal Fusion Except Cervical without MCC," which also had the largest rise over the cohort period, increasing from $15,853,679,222 in 2008 (p < .001). It was also the MS-DRG with the highest incidence, totaling 1,443,112 discharges and increasing from 190,692 in 2008 to 214,100 in 2014 (p < .10). "Craniotomy with major Device Implant/Acute Complex CNS Procedure w/MCC or Chemo Implant" had the longest length of stay (LOS) with a mean patient stay of 12.9 days. This MS-DRG also had the oldest patient population mean age of 57.5 years old. "Craniotomy & Endovascular Intracranial Procedures with MCC" had the most in-hospital deaths totaling 28,707 increasing significantly from 3602 in 2008 to 4410 in 2014 (p < .05). CONCLUSIONS: "Spinal fusion except cervical without MCC," had the highest national bill in the USA over the period of the cohort. Healthcare organizations can benefit from awareness of this information by using it to establish the most efficient healthcare investments and preparing a health-care roadmap for the following decades.

Mortality Rates After Posterior C1-2 Fusion for Displaced Type II Odontoid Fractures in Octogenarians.

STUDY DESIGN: Retrospective cohort study OBJECTIVE.: To assess 30-day and 1-year mortality rates as well as the most common complications associated with posterior C1-2 fusion in an octogenarian cohort. SUMMARY OF BACKGROUND DATA: Treatment of unstable type II odontoid fractures in elderly patients can present challenges. Recent evidence indicates in patients older than 80 years, posterior C1-2 fusion results in improved survival as compared to other modes of treatment. METHODS: Retrospective analysis of 43 consecutive patients (25 female and 18 male; mean age 84.3 yr, range 80-89 yr; mean Charlson Comorbidity Index 1.4, (range 1-6); mean body mass index 24.8 ±â€Š4.2 kg/m, who underwent posterior C1-C2 fusion for management of unstable type II odontoid fracture by four fellowship trained spine surgeons at a single institution between January 2006 to June 2016. RESULTS: Mean fracture displacement was 5.1 ±â€Š3.6 mm and mean absolute value of angulation was 19.93°â€Š±â€Š12.93°. The most common complications were altered mental status (41.9%, n = 18), dysphagia (27.9%, n = 12) with 50% of those patients (6/12) requiring a feeding tube, and emergency reintubation (9.3%, n = 4). To the date of review completion, 25 of 43 patients expired (58.1%), median survival of 1.76 years from the date of surgery. Thirty-day and 1-year mortality rates were 2.3% and 18.6%, respectively. Patients who developed dysphagia were 14.5 times more likely to have expired at 1 year; dysphagia was also found to be significantly associated with degree of displacement. Fracture displacement was found to be associated with increased odds for 1-year mortality when accounting for age and requirement of a feeding tube. CONCLUSION: Posterior C1-2 fusion results in acceptably low mortality rates in octogenarians with unstable type II odontoid fractures when compared to nonoperative management mortality rates in current literature. Initial fracture displacement is associated with higher mortality rate in this patient population. LEVEL OF EVIDENCE: 4.

External fixation and surgical fusion for pediatric cervical spine injuries: Short-term outcomes.

OBJECTIVE: To compare in-hospital complication rates in pediatric patients with atlantoaxial and subaxial injuries undergoing either external fixation or surgical fusion. PATIENTS AND METHODS: Baseline and outcome data were obtained from the 2002-2011 Nationwide Inpatient Sample (NIS) for patients under the age of 18 with a diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation. Patients who underwent external immobilization or internal fixation were included for analysis. Variables analyzed included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of at least one in-hospital complication. RESULTS: A total of 2878 pediatric patients with cervical spine injury were identified; 1462 patients (50.8%) with atlantoaxial (C1-2) injury and 1416 (49.2%) with subaxial (C3-7) injury. Among atlantoaxial injury patients, external fixation was associated with lower total charges ($73,786 vs. $98,158, p = .040) and a lower likelihood of developing at least one complication (1.9% vs. 6.8%, p = .029) compared to surgical fusion, and was a more common treatment for subluxation alone (16.4% vs. 2.6%, p < .001). Among subaxial injury patients, there were no significant differences in age (p = .262), length of stay (p = .196), occurrence of at least one complication (p = .334), or total charges (p = .142). Subaxial subluxation injuries alone were treated more often with surgical fusion (2.2% vs. 1.2%, p < .001). CONCLUSION: Optimal treatment of patients with cervical injury may vary by location of injury. Our findings warrant further investigation into the difference in clinical outcomes between surgical and non-surgical management of atlantoaxial and subaxial injury.

Lumbar Spine Fusion Surgery in Solid Organ Transplant Recipients Is Associated With Increased Medical Complications and Mortality.

STUDY DESIGN: Retrospective database review. OBJECTIVE: To characterize the outcomes of solid organ transplant (SOT) patients after one- or two-level lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: Over the past decade advances in SOT patients have improved graft survival. As such, this patient population is increasingly eligible for elective surgery such as lumbar fusion procedures to improve mobility and quality of life. However, the outcomes of spine surgery in this population are not well defined. METHODS: Data from the full 100% Medicare sample between 2005 and 2014 were used for the study. Patients were included if they had an elective one- or two-level lumbar spine fusion and previous history of renal, heart, liver, or lung SOT patients during this period. SOT patients were compared to non-SOT patients with respect to baseline characteristics, 90-day medical complications, 1-year rate of revision surgery, and 1-year mortality. RESULTS: There were 961 patients in the transplant cohort and 258,342 in the non-SOT cohort. Seventy-seven percent of the SOT patients had prior renal transplant. SOT patients had a longer length of stay (P < 0.001), and a higher 30-day readmission rate compared to non-SOT patients (P =  < 0.001). In addition, SOT patients experienced a 23.8% rate of 90-day postoperative major medical complications and 3.0%, 1-year mortality, significantly larger than respective rates in the control population (P < 0.001). One-year infection, revision surgery rates, and wound dehiscence were not significantly different between the two cohorts. CONCLUSION: Spine surgery is associated with significant medical complications and 1-year mortality in the SOT population. Although there may be a substantial benefit from lumbar fusion in the SOT population, judicious patient selection is of paramount importance. LEVEL OF EVIDENCE: 3.

Risk Factors for and Complications After Surgical Delay in Elective Single-Level Lumbar Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To assess the incidence of and risk factors for delay of elective lumbar fusion surgery, as well as medical and surgical complications associated with surgical delay. SUMMARY OF BACKGROUND DATA: Lumbar fusion is a well-established treatment for patients with degenerative spondylolisthesis with stenosis who have failed conservative management. Rarely, patients admitted for elective lumbar fusion may experience a delay in surgery past the day of admission. The incidence of, and risk factors for, delay of elective lumbar fusion surgery and the complications associated therewith have never been previously evaluated. METHODS: We retrospectively reviewed the ACS-NSQIP registry utilizing Current Procedural Terminology (CPT) codes 22612, 22558, 22630, and 22633 to identify all patients undergoing a single level spinal fusion. The data were then subdivided into cohorts consisting of patients with and without surgical delay. Demographic information, preoperative risk factors for delay, as well as intraoperative and postoperative complications were compared between the groups. RESULTS: We identified 2758 (5.46%) patients as experiencing a delay before lumbar fusion. Multivariate analysis was then performed and identified male sex, American Society of Anesthesiologists classes 3 and 4, and chronic steroid use as risk factors increasing the rate of surgical delay. Multiple complication rates were also significantly higher in the delayed group, including an almost 10-fold increase in mortality rate (0.2% vs. 1.9%, respectively, P < 0.001). CONCLUSION: Delays in elective surgery can affect medical system resource utilization, increasing costs and leading to worse patient outcomes. Patients with chronic steroid use and higher American Society of Anesthesiologists class may be at risk for surgical delay in lumbar fusion beyond the day of admission, and are at increased risk for significant complications postoperatively. Thorough medical evaluation and preoperative optimization may be indicated for these patients. LEVEL OF EVIDENCE: 4.

Complications and operative spine fusion construct length in Parkinson's disease: A nationwide population-based analysis.

There remains a dearth of information regarding the surgical complications following multilevel spine surgery in Parkinson's disease (PD) patients. This retrospective cohort study was performed to address this issue on a nationwide level using the Nationwide Inpatient Sample from 2001 to 2012. More than 25 postoperative variables were analyzed to assess the impact of fusion construct length on each variable. Subsequently, the same analysis was performed on admissions without PD. 4301 PD patients with spine fusion were identified, of whom 934 (21.7%) underwent fusion of at least three levels; the remaining 3367 underwent fusion of 1-2 levels. Patients with 3+ level fusions were more likely to suffer paraplegia (P=.001; OR=3.0; 95%CI=1.5-6.1), hematoma/seroma (P=.009; OR=1.9; 95%CI=1.2-3.2), IVC filter placement (P=.018; OR=2.1; 95%CI=1.1-3.9), RBC transfusion (P<.001; OR=3.2; 95%CI=2.7-3.8), PE (P=.027; OR=4.5; 95%CI=1.2-16.9), postoperative shock (P=.023; OR=7.3; 95%CI=1.3-39.6), ARDS (P<.001; OR=4.1; 95%CI=2.7-6.3), VTE (P=.006; OR=2.6; 95%CI=1.3-5.4), acute posthemorrhagic anemia (P<.001; OR=2.0; 95%CI=1.7-2.4), device-related complications (P<.001; OR=3.1; 95%CI=2.3-4.2), and in-hospital mortality (P=.005; OR=3.4; 95%CI=1.5-7.4). 3+ level fusions were also more likely to have LOS>1week (P<.001; OR=2.1; 95%CI=1.8-2.5), and a nonroutine discharge (P=.005; OR=1.9; 95%CI=1.4-2.4). 692,173 non-PD patients with spine fusion were identified; 123,964 (17.9%) underwent 3+ level fusion. Differences between 3+ versus 1-2 level fusions were similar to those in PD patient, but unlike PD patients, postoperative infection was significant while in-hospital mortality, PE and VTE were not. Fusion of at least three levels increased morbidity, mortality, and adverse discharge disposition compared with 1-2 level fusions. Nearly 80% of all spine fusions performed in the United States are fewer than three levels. These findings are worth considering during operative decision-making in both PD and non-PD patients.

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.

Does chronic kidney disease affect the mortality rate in patients undergoing spine surgery?

The number of patients with chronic kidney disease (CKD) and their life expectancy has been increasing. With time number of patients undergoing spine surgery has also been on a rise. This study we did a retrospective review of registry data to investigate the mortality rate of chronic kidney disease patients following spine surgery using a large, multi-center spine registry. 12,276 consecutive spine-fusion patients from January 2009 to December 2012 were included and mortality rates in patients with CKD compared to those with normal kidney function following spine surgery. Logistic regression was usedto evaluate risk of mortality following spine surgery. The average age of the cohort was 59 (SD=13.4). 53% were female. Patients who had stage 3, 4 or 5 CKD were older than non-CKD patients (mean=71,SD=9.2 vs. 59, SD=13.3). After adjusting for confounding variables, patients with stage 3 or 4 CKD had higher mortality rates than patients with normal kidney function (OR 1.78, 95% CI 1.3-2.45) Hemodialysis-dependent patients (stage 5 CKD) had even higher rates of mortality compared to patients with normal function (OR 4.18, 95% CI1.87-9.34). our findings suggest that spine surgery is associated with significantly higher mortality rates in patients with CKD compared to patients with normal kidney function. Understanding the additional morbidity and mortality of spine surgery in this medically complicated group of patients is imperative for accurate preoperative risk assessment.