The Postoperative Airway Compromise Score-First Steps to Developing a Postoperative Tool for the Assessment of Upper Airway-Related Complications Following Anterior Cervical Spine Surgery.

BACKGROUND: Acute upper airway compromise is a rare but catastrophic complication after anterior cervical discectomy and fusion. This study aims to develop a score to identify patients at risk of acute postoperative airway compromise (PAC). METHODS: Potential risk factors for acute PAC were selected by a modified Delphi process. Ten patients with acute PAC were identified of 1466 patients who underwent elective anterior cervical discectomy and fusion between July 2014 and May 2019. A comparison group was created by a randomized selection process (non-PAC group). Factors associated with PAC and a P value of < 0.10 were entered into a logistic regression model and coefficients contributed to each risk factor's overall score. Calibration of the model was evaluated using the Hosmer-Lemeshow goodness-of-fit test. Quantitative discrimination was calculated, and the final model was internally validated with bootstrap sampling. RESULTS: We identified 18 potential risk factors from our Delphi process, of which 6 factors demonstrated a significant association with airway compromise: age >65 years, current smoking status, American Society of Anesthesiologists class >2, history of a bleeding disorder, surgery of upper subaxial cervical spine (above C4), and duration of surgery >179 minutes. The final prediction model included 5 predictors with very strong performance characteristics. These 5 factors formed the PAC score, with a range from 0 to 100. A score of 20 yielded the greatest balance of sensitivity (80%) and specificity (88%). CONCLUSIONS: The acute PAC score demonstrates strong performance characteristics. The PAC score might help identify patients at risk of upper airway compromise caused by surgical site abnormalities.

A novel scoring system concept for de novo spinal infection treatment, the Spinal Infection Treatment Evaluation Score (SITE Score): a proof-of-concept study.

OBJECTIVE: De novo infections of the spine are an increasing healthcare problem. The decision for nonsurgical or surgical treatment is often made case by case on the basis of physician experience, specialty, or practice affiliation rather than evidence-based medicine. To create a more systematic foundation for surgical assessments of de novo spinal infections, the authors applied a formal validation process toward developing a spinal infection scoring system using principles gained from other spine severity scoring systems like the Spine Instability Neoplastic Score, Thoracolumbar Injury Classification and Severity Score, and AO Spine classification of thoracolumbar injuries. They utilized an expert panel and literature reviews to develop a severity scale called the "Spinal Infection Treatment Evaluation Score" (SITE Score). METHODS: The authors conducted an evidence-based process of combining literature reviews, extracting key elements from previous scoring systems, and obtaining iterative expert panel input while following a formal Delphi process. The resulting basic SITE scoring system was tested on selected de novo spinal infection cases and serially refined by an international multidisciplinary expert panel. Intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC) and Fleiss' and Cohen's kappa, respectively. A receiver operating characteristic analysis was performed for cutoff value analysis. The predictive validity was assessed through cross-tabulation analysis. RESULTS: The conceptual SITE scoring system combines the key variables of neurological symptoms, infection location, radiological variables for instability and impingement of neural elements, pain, and patient comorbidities. Ten patients formed the first cohort of de novo spinal infections, which was used to validate the conceptual scoring system. A second cohort of 30 patients with de novo spinal infections, including the 10 patients from the first cohort, was utilized to validate the SITE Score. Mean scores of 6.73 ± 1.5 and 6.90 ± 3.61 were found in the first and second cohorts, respectively. The ICCs for the total score were 0.989 (95% CI 0.975-0.997, p < 0.01) in the first round of scoring system validation, 0.992 (95% CI 0.981-0.998, p < 0.01) in the second round, and 0.961 (95% CI 0.929-0.980, p < 0.01) in the third round. The mean intraobserver reliability was 0.851 ± 0.089 in the third validation round. The SITE Score yielded a sensitivity of 97.77% ± 3.87% and a specificity of 95.53% ± 3.87% in the last validation round for the panel treatment decision. CONCLUSIONS: The SITE scoring concept showed statistically meaningful reliability parameters. Hopefully, this effort will provide a foundation for a future evidence-based decision aid for treating de novo spinal infections. The SITE Score showed promising inter- and intraobserver reliability. It could serve as a helpful tool to guide physicians' therapeutic decisions in managing de novo spinal infections and help in comparison studies to better understand disease severity and outcomes.

Who Needs Surgical Stabilization for Pyogenic Spondylodiscitis? Retrospective Analysis of Non-Surgically Treated Patients.

STUDY DESIGN: Retrospective case series analysis. OBJECTIVE: To identify relevant clinical and radiographic markers for patients presenting with infectious spondylo-discitis associated with spinal instability directly related to the infectious process. METHODS: We evaluated patients presenting with de-novo intervertebral discitis or vertebral osteomyelitis /discitis (VOD) who initiated non-surgical treatment. Patients who failed conservative treatment and required stabilization surgery within 90 days were defined as "failed treatment group" (FTG). Patients who experienced an uneventful course served as controls and were labeled as "nonsurgical group" (NSG). A wide array of baseline clinical and radiographic parameters was retrieved and compared between 2 groups. RESULTS: Overall 35 patients had initiated non-surgical treatment for VOD. 25 patients had an uneventful course (NSG), while 10 patients failed conservative treatment ("FTG") within 90 days. Factors found to be associated with poorer outcome were intra-venous drug abuse (IVDA) as well as the presence of fever upon initial presentation. Radiographically, involvement of the same-level facets and the extent of caudal and rostral VB involvement in both MRI and CT were found to be significantly associated with poorer clinical and radiographic outcome. CONCLUSIONS: We show that clinical factors such as IVDA status and fever as well as the extent of osseous and posterior element involvement may prove to be helpful in favoring surgical treatment early on in the management of spinal infections.

Surgical Treatment of Ossifications of the Cervical Anterior Longitudinal Ligament: A Retrospective Cohort Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The study aims to evaluate anterior cervical discectomy and fusion (ACDF) in the treatment of patients with ossification of the anterior longitudinal ligament (OALL). METHODS: We retrospectively reviewed cases performed at our institution between January 2015 and December 2018; adult (age ≥18 years) patients who underwent anterior cervical decompression and fusion in the presence of dysphagia and OALL. Ten patients (9 male, 1 female, mean age 64.4 years) with OALL who underwent ACDF were included. Charts were reviewed for demographics and comorbidities. Primary outcomes assessed were intra- and postoperative complications. Secondary outcomes were fusion rates, instrumentation failure, postsurgical instability/deformity, and readmission rates. RESULTS: The average duration of symptoms prior to surgery was 12.3 months. All patients presented with dysphagia (mean Bazaz score 2.0). The average number of levels with OALL was 4.7 (±1.67). All patients underwent ACDF and 3 patients underwent additional posterior cervical fusion for kyphotic deformity correction or when extensive laminectomy was required. We did not encounter any intraoperative complications. Eight patients (72%) had solid fusion demonstrated on the lateral x-rays and no evidence of progressive kyphotic deformity. We did not encounter any instrumentation failure or loosening. Two patients developed recurrence of dysphagia (Bazaz scores 2 and 3 respectively). CONCLUSION: ACDF for OALL with dysphagia and concomitant myelopathy in our small series of 10 patients demonstrate good fusion and clinical outcomes. Larger studies will be necessary to determine the optimal treatment for patients with dysphagia due to OALL.

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.