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BACKGROUND: There is considerable heterogeneity in findings and a lack of consensus regarding the interplay between osteoporosis and outcomes in patients with lumbar degenerative spine disease. Therefore, the purpose of this systematic review and meta-analysis was to gather and analyze existing data on the effect of osteoporosis on radiographic, surgical, and clinical outcomes following surgery for lumbar degenerative spinal disease. METHODS: A systematic review was performed to determine the effect of osteoporosis on the incidence of adverse outcomes after surgical intervention for lumbar degenerative spinal diseases. The approach focused on the radiographic outcomes, reoperation rates, and other medical and surgical complications. Subsequently, a meta-analysis was performed on the eligible studies. RESULTS: The results of the meta-analysis suggested that osteoporotic patients experienced increased rates of adjacent segment disease (ASD; p=0.015) and cage subsidence (p=0.001) while demonstrating lower reoperation rates than non-osteoporotic patients (7.4% vs. 13.1%; p=0.038). The systematic review also indicated that the length of stay, overall costs, rates of screw loosening, and rates of wound and other medical complications may increase in patients with a lower bone mineral density. Fusion rates, as well as patient-reported and clinical outcomes, did not differ significantly between osteoporotic and non-osteoporotic patients. CONCLUSIONS: Osteoporosis was associated with an increased risk of ASD, cage migration, and possibly postoperative screw loosening, as well as longer hospital stays, incurring higher costs and an increased likelihood of postoperative complications. However, a link was not established between osteoporosis and poor clinical outcomes.
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BACKGROUND: Lumbar spinal pathology is known to affect outcomes following total hip arthroplasty (THA). However, the effect of hip osteoarthritis (OA) on outcomes following lumbar fusion has not been well studied. The purpose of this study was to determine the association between hip OA and spinal reoperation following lumbar spinal fusion. METHODS: The 5% Medicare Part B claims database was queried for all patients who underwent primary elective lumbar fusion from 2005 to 2019. Patients were divided into 2 groups: those who underwent elective THA within 1 year after primary lumbar fusion, indicating that they had severe hip OA at the time of lumbar fusion, and those who underwent lumbar fusion with no diagnosed hip OA and no THA during the study period. Exclusion criteria included THA as a result of trauma, revision THA or primary THA in the 5-year period before primary lumbar fusion, <65 years of age, and no enrollment in the database for 5 years before and 1 year after primary lumbar fusion. The primary outcome was spinal reoperation within 1, 3, and 5 years. Multivariable Cox regression was performed with age, sex, diabetes, heart disease, obesity, smoking status, osteoporosis, number of levels fused, use of posterior instrumentation, use of an interbody device, use of bone graft, and surgical approach as covariates. RESULTS: Overall, 1,123 patients (63.4% female; 91.3% White; mean age, 76.8 ± 4.1 years) were included in the hip OA group and 8,893 patients (56.2% female; 91.3% White; mean age, 74.8 ± 4.9 years) were included in the control group. After multivariable analysis, patients with severe hip OA had significantly greater rates of revision surgery at 3 years (odds ratio [OR], 1.61; p < 0.001) and 5 years (OR, 1.87; p < 0.001) after the index lumbar fusion. CONCLUSIONS: Patients with severe hip OA at the time of primary lumbar fusion had a significantly increased risk of spinal reoperation at 3 and 5 years postoperatively. These data provide further evidence to support performing THA prior to lumbar fusion in the unsettled debate regarding which surgery should be prioritized for patients with simultaneous degenerative diseases of the hip and lumbar spine. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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STUDY DESIGN: Systematic Review. OBJECTIVES: While substantial research has explored the impact of osteoporosis on patients undergoing adult spinal deformity (ASD) correction, the literature remains inconclusive. As such, the purpose of this study is to synthesize and analyze existing studies pertaining to osteoporosis as a predictor of postoperative outcomes in ASD surgery. METHODS: We performed a systematic review and meta-analysis to determine the effect that a diagnosis of osteoporosis, based on ICD-10 coding, dual-energy X-ray absorptiometry (DEXA) or computed tomography, has on the incidence of adverse outcomes following surgical correction of ASD. Statistical analysis was performed using Comprehensive Meta-Analysis (Version 2) using a random effects model to account for heterogeneity between studies. RESULTS: After application of inclusion and exclusion criteria, 36 and 28 articles were included in the systematic review and meta-analysis, respectively. The meta-analysis identified greater rates of screw loosening amongst osteoporotic patients (70.5% vs 31.9%, P = .009), and decreased bone mineral density in patients who developed proximal junctional kyphosis (PJK) (.69 vs .79 g/cm2, P = .001). The systematic review demonstrated significantly increased risk of any complication, reoperation, and proximal junctional failure (PJF) associated with reduced bone density. No statistical difference was observed between groups regarding fusion rates, readmission rates, and patient-reported and/or functional outcome scores. CONCLUSION: This study demonstrates a higher incidence of screw loosening, PJK, and revision surgery amongst osteoporotic ASD patients. Future investigations should explore outcomes at various follow-up intervals in order to better characterize how risk changes with time and to tailor preoperative planning based on patient-specific characteristics.
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BACKGROUND: This review outlines clinical data and characteristics of current Food and Drug Administration (FDA)-approved implants in cervical disc replacement/cervical disc arthroplasty (CDR/CDA) to provide a centralized resource for spine surgeons. METHODS: Randomized controlled trials (RCTs) on CDR/CDA were identified using a search of the PubMed, Web of Science, and Google Scholar databases. The initial search identified 69 studies. Duplicates were removed, and the following inclusion criteria were applied when determining eligibility of RCTs for the current review: (1) discussing CDR/CDA prosthesis and (2) published within between 2010 and 2020. Studies without clinical data or that were not RCTs were excluded. All articles were reviewed independently by 2 authors, with the involvement of an arbitrator to facilitate consensus on any discrepancies. RESULTS: A total of 34 studies were included in the final review. Findings were synthesized into a comprehensive table describing key features and clinical results for each FDA-approved CDR/CDA implant and are overall suggestive of expanding indications and increasing utilization. CONCLUSIONS: RCTs have provided substantial evidence to support CDR/CDA for treating single- and 2-level cervical degenerative disc disease in place of conventional anterior cervical discectomy and fusion. CLINICAL RELEVANCE: This review provides a resource that consolidates relevant clinical data for current FDA-approved implants to help spine surgeons make an informed decision during preoperative planning.
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BACKGROUND: As the elderly population grows, the increasing prevalence of osteoporosis presents a unique challenge for surgeons. Decreased bone strength and quality are associated with hardware failure and impaired bone healing, which may increase the rate of revision surgery and the development of complications. The purpose of this review is to determine the impact of osteoporosis on postoperative outcomes for patients with cervical degenerative disease or deformity. METHODS: A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Medical Subject Headings terms involving spine surgery for cervical degenerative disease and osteoporosis were performed. This review focused on radiographic outcomes, as well as surgical and medical complications. RESULTS: There were 16 studies included in the degenerative group and 9 in the deformity group. Across degenerative studies, lower bone mineral density was associated with increased rates of cage subsidence in osteoporotic patients undergoing operative treatment for cervical degenerative disease. Most studies reported varied results on the relationship between osteoporosis and other outcomes such as revision and readmission rates, costs, and perioperative complications. Our meta-analysis suggests that osteoporotic patients carry a greater risk of reduced fusion rates at 6 months and 1 year postoperatively. With respect to cervical deformity correction, although individual complication rates were unchanged with osteoporosis, the collective risk of incurring any complication may be increased in patients with poor bone stock. CONCLUSIONS: Overall, the literature suggests that outcomes for osteoporotic patients after cervical spine surgery are multifactorial. Osteoporosis seems to be a significant risk factor for developing cage subsidence and pseudarthrosis postoperatively, whereas reports on medical and hospital-related metrics were inconclusive. Our findings highlight the challenges of caring for osteoporotic patients and underline the need for adequately powered studies to understand how osteoporosis changes the risk index of patients undergoing cervical spine surgery. CLINICAL RELEVANCE: In patients undergoing cervical spine surgery for degenerative disease, osteoporosis is a significant risk factor for long-term postoperative complications-notably cage subsidence and pseudarthrosis. Given the elective nature of these procedures, interdisciplinary collaboration between providers should be routinely implemented to enable medical optimization of patients prior to cervical spine surgery.
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BACKGROUND: Previously reported estimates of vertebral artery injuries (VAIs) during cervical spine surgery relied on self-reported survey studies and retrospective cohorts, which may not be reflective of national averages. The largest study to date reports an incidence of 0.07%; however, significant variation exists between different cervical spine procedures. This study aimed to identify the incidence of VAIs in patients undergoing cervical spine procedures for degenerative pathologies. METHODS: In this retrospective cohort study, a national insurance database was used to access data from the period 2010-2020 of patients who underwent anterior cervical discectomy and fusion, anterior corpectomy, posterior cervical fusion (C3-C7), or C1-C2 posterior fusion for degenerative pathologies. Patients who experienced a VAI were identified, and frequencies for the different procedures were compared. RESULTS: This study included 224,326 patients, and overall incidence of VAIs across all procedures was 0.03%. The highest incidence of VAIs was estimated in C1-C2 posterior fusion (0.12%-1.10%). The number of patients with VAIs after anterior corpectomy, anterior cervical discectomy and fusion, and posterior fusion was 14 (0.06%), 43 (0.02%), and 26 (0.01%), respectively. CONCLUSIONS: This is the largest study to date to our knowledge that provides frequencies of VAIs in patients undergoing cervical spine surgery in the United States. The overall incidence of 0.03% is lower than previously reported estimates, but significant variability exists between procedures, which is an important consideration when counseling patients about risks of surgery.
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Fusão Vertebral , Artéria Vertebral , Humanos , Estudos Retrospectivos , Artéria Vertebral/cirurgia , Incidência , Vértebras Cervicais/cirurgia , Vértebras Cervicais/lesões , Discotomia/métodos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodosRESUMO
STUDY DESIGN/SETTING: Retrospective cohort analysis. OBJECTIVES: This study evaluates utilization and demographic trends for sacroiliac joint (SIJ) fusions across the United States (US). METHODS: Patients who underwent SIJ fusion from 2010-2021 were identified within the PearlDiver national database using International Classification of Disease (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes. Indications for trauma, malignancy, or infection were excluded. Demographic, clinical, and procedure characteristics were recorded along with annual utilization rates. Annual percent change (APC) was calculated to identify increasing or decreasing utilization from prior years. Negative binomial regression was performed to project subsequent utilization for 2022-2028. Chi-squared analysis followed by post-hoc comparisons were used to compare differences in diagnostic indications and clinical features associated with SIJ fusion across regions. Bonferroni adjustments were applied to P-values for pairwise analyses. RESULTS: Overall, 18 032 patients (69.8% female, mean age = 51.0 + 13.4 years) underwent SIJ fusion between 2010 and 2021. Annual utilization increased by 33.5% on average. The South comprised the largest proportion of cases (48.9%). Projections for 2022-2028 predict continued growth in procedures, with an overall increase of 1100% from 1350 cases in 2021 to 16 195 by end of 2028. Spondyloarthropathy-induced sacroilitis was the most prevalent diagnostic indication nationwide (51%). Of patients undergoing SIJ fusion, 18% had a prior lumbar fusion, and only 45% received a preoperative diagnostic SIJ injection. CONCLUSION: As SIJ fusion is increasingly utilized to treat refractory SIJ-based pain, establishing evidence-based guidelines, improving diagnostic strategies, and defining indications are imperative to support growing applications within clinical practice.
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OBJECTIVE: The objective of this study is to assess differences in complication profiles between 3-level posterior column osteotomy (PCO) and single-level pedicle subtraction osteotomy (PSO) as both are reported to provide similar degrees of sagittal correction. METHODS: The PearlDiver database was queried retrospectively using International Classification of Disease, 9th and 10th edition and Current Procedural Terminology codes to identify patients who underwent PCO or PSO for degenerative spine disease. Patients under age 18 or with history of spinal malignancy, infection, or trauma were excluded. Patients were separated into 2 cohorts, 3-level PCO or single-level PSO, matched at a 1:1 ratio based on age, sex, Elixhauser comorbidity index, and number of fused posterior segments. Thirtyday systemic and procedure-related complications were compared. RESULTS: Matching resulted in 631 patients for each cohort. PCO patients had decreased odds of respiratory (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.43-0.82; p = 0.001) and renal complications (OR, 0.59; 95% CI, 0.40-0.88; p = 0.009) compared to PSO patients. There was no significant difference in cardiac complications, sepsis, pressure ulcer, dural tear, delirium, neurologic injuries, postoperative hematoma, postoperative anemia, or overall complications. CONCLUSION: Patients who undergo 3-level PCO have decreased respiratory and renal complications compared to single-level PSO. No differences were found in the other complications studied. Considering both procedures achieve similar sagittal correction, surgeons should be aware that 3-level PCO offers an improved safety profile compared to single-level PSO.
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STUDY DESIGN/SETTING: Retrospective cohort analysis. OBJECTIVES: To characterize the impact of COVID-19 on utilization of the ten most common spine procedures and percentages of outpatient procedures. METHODS: The PearlDiver national database was queried from January 2010 to April 2021 for short (<6 segments) and long segment posterior instrumented fusion (≥6 segments), posterior cervical fusion, anterior cervical decompression and fusion (ACDF), cervical laminectomy, laminoplasty, and disc arthroplasty, lumbar laminectomy, microdiscectomy, and interbody fusion. Annual procedure utilization between January 2010 through April 2021 was recorded and compared. Monthly trends were compared to January 2020. Outpatient trends were compared between 2010-2019 and 2019-2021 using segmented linear regression. RESULTS: Overall, all ten procedures decreased 4.3% in 2020 compared to 2019 and increased 6.3% in 2021 compared to 2019. March and April of 2020 had the largest decreases, with March 2020 decreasing 18.2% and April 2020 decreasing 51.6% compared to January 2020. Despite increasing COVID cases in January 2021, overall procedure utilization decreased only 1.8% compared to January 2020, and increased later in 2021 with April 2021 case volumes increasing by 138% compared to January 2020. Outpatient utilization of short segment posterior lumbar fusion and lumbar interbody fusion significantly increased during this time (P < .001). CONCLUSION: The greatest impact on spine surgery volume from the COVID-19 pandemic occurred in March and April 2020. Spine procedure utilization was otherwise similar or increased compared to January 2020. Additionally, the volume of outpatient short segment posterior fusion and lumbar interbody fusions increased during this time period.
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BACKGROUND: Cervical disc arthroplasty (CDA) was originally approved by the US Food and Drug Administration (FDA) in 2007 as a motion-sparing procedure to treat cervical degenerative disc disease. Since then, promising results from randomized control trials have led to increasing popularity. However, data discussing monetary trends are limited. The aim of this study was to determine how utilization, hospital charges, and Medicare physician reimbursement for CDA have changed over time. METHODS: In this retrospective cohort study, International Classification of Diseases procedure codes were used to identify all patients who underwent CDA from 2007 to 2017 in the National Inpatient Sample database. The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was queried for primary CDA using current procedural terminology codes to determine Medicare physician reimbursement from 2009 to 2021. Nominal monetary values were adjusted for inflation using the Consumer Price Index and inflation-adjusted data reported in 2021 US dollars. RESULTS: A total of 33,079 weighted patients who underwent CDA were included for analysis. CDA utilization increased by 183% from 2007 to 2017, with Medicare beneficiary utilization increasing 149%. Inflation-adjusted total hospital charges for CDA increased by 22.4%. However, inflation-adjusted Medicare physician reimbursement fell by 1.20% per year, demonstrating a total decrease of 12.9%, starting at $1928 in 2009 and declining to $1679 in 2021. CONCLUSIONS: While utilization and total hospital charges for CDA continue to rise, Medicare physician reimbursement has not shown the same trend. In fact, inflation-adjusted reimbursement has seen a steady decline since FDA approval in 2007. If this trend persists, it may become unsustainable for physicians to continue offering CDA to Medicare patients. As disproportionate increases in hospital charges incentivize a transition to outpatient CDA, stricter patient selection criteria associated with outpatient procedures may create health care disparities for Medicare patients and those with higher comorbidity burden. CLINICAL RELEVANCE: This study shows the decreasing reimbursement trends for CDA, which may disproportionately affect Medicare patients and those with increased comorbidities.
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BACKGROUND: The purpose of this review is to provide a brief history of previous attempts at developing patient screening tools and to further examine the definitions of these psychological concepts, relevance to clinical outcomes, and implications for spine surgeons during preoperative patient assessments. METHODS: A literature review was performed by 2 independent researchers to identify original manuscripts related to spine surgery and novel psychological concepts. The history of presurgical psychology screening was also studied, and definitions of frequently utilized metrics were detailed. RESULTS: Seven manuscripts were identified that utilized psychological metrics for preoperative risk assessments and correlated outcomes with these scores. The metrics most frequently used in the literature included resilience, patient activation, grit, and self-efficacy. DISCUSSION: Current literature favors resilience and patient activation as important metrics for preoperative patient screening. Available studies demonstrate significant associations between these character traits and patient outcomes. Further research is warranted to investigate the roles of preoperative psychological screening to optimize patient selection in spine surgery. CLINICAL RELEVANCE: The purpose of this review is to provide clinicians with a reference for available psychosocial screening tools and their relevance to patient selection. This review also serves to guide future research directions given the importance of this topic.
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STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study was to characterize the infection risk of preoperative epidural steroid injection (ESI) in patients undergoing posterior cervical surgery. SUMMARY OF BACKGROUND DATA: ESI is a helpful tool for alleviating pain and is often used as a diagnostic tool before cervical surgery. However, a recent small-scale study found that ESI before cervical fusion was associated with an increased risk of postoperative infection. MATERIALS AND METHODS: Patients from 2010 to 2020 with cervical myelopathy, spondylosis, and radiculopathy who underwent posterior cervical procedure including laminectomy, laminoforaminotomy, fusion, or laminoplasty were queried from the PearlDiver database. Patients who underwent revision or fusion above C2 or who had a diagnosis of neoplasm, trauma, or preexisting infection were excluded. Patients were divided on whether they received an ESI within 30 days before the procedure and subsequently matched by age, sex, and preoperative comorbidities. The χ 2 analysis was used to calculate the risk of postoperative infection within 90 days. Logistic regression controlling for age, sex, Elixhauser Comorbidity Index, and operated levels was conducted within the unmatched population to assess infection risk for injected patients across procedure subgroups. RESULTS: Overall, 299,417 patients were identified with 3897 having received a preoperative ESI and 295,520 who did not. Matching resulted in 975 in the injected group and 1929 in the control group. There was no significant difference in postoperative infection rate in those who received an ESI within 30 days preoperatively and those who did not (3.28% vs. 3.78%, odds ratio=0.86, 95% CI: 0.57-1.32, P =0.494). Logistic regression accounting for age, sex, Elixhauser Comorbidity Index, and levels operated demonstrated that injection did not significantly increase infection risk in any of the procedure subgroups. CONCLUSIONS: The present study found no association between preoperative ESI within 30 days before surgery and postoperative infection in patients undergoing posterior cervical surgery.
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Vértebras Cervicais , Fusão Vertebral , Humanos , Estudos Retrospectivos , Vértebras Cervicais/cirurgia , Laminectomia/métodos , Fusão Vertebral/métodos , Complicações Pós-Operatórias/epidemiologia , Esteroides , Resultado do TratamentoRESUMO
STUDY DESIGN: Narrative review. OBJECTIVES: The purpose of this review is to outline the role of sex hormones, particularly estrogen, in the pathogenesis of degenerative disc disease (DDD). METHODS: A narrative review of studies discussing sex hormones and intervertebral disc (IVD) degeneration was conducted through a search of bibliographic databases to identify various mechanisms involved in effectuating DDD. RESULTS: Estrogen-deficient states negatively impact various aspects of IVD function. These internal hormone environments reflect routine changes that commonly arise with physiologic aging and can compromise IVD structural integrity through a host of processes. Additionally, allosteric molecules such as micro-RNAs (mi-RNAs) and G protein-coupled estrogen receptors (GPER) antagonists can bind to estrogen receptors and inhibit protective downstream effects with estrogen receptor signaling. Furthermore, cursory studies have observed chondrogenic effects with testosterone supplementation, although the specific mechanism remains unclear. CONCLUSIONS: Regulation of sex hormones, namely estrogen and testosterone, significantly impacts the structural integrity and function of IVDs. Uncovering underlying interactions driving these regulatory processes can facilitate development of novel, clinical therapies to treat DDD.
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BACKGROUND: Painful vertebral osteoporotic compression fractures (OCFs) are often treated with cement augmentation, although controversies exist as to whether or not this increases the secondary fracture risk. Prevention of secondary fracture includes treatment of underlying osteoporosis. The purposes of this study were to determine (1) whether cement augmentation increases the rate of secondary fracture compared with nonoperative management, (2) whether anti-osteoporotic medications reduce the rate of secondary fracture, and (3) the rate of osteoporosis treatment with medications following vertebral OCF. METHODS: The PearlDiver database was queried for all patients with a diagnosis of OCF from 2015 to 2019. Patients were excluded if they were <50 years old, had a diagnosis of spinal neoplasm or infection, or underwent lumbar fusion in the perioperative period. Secondary fracture risk was assessed using univariate and multivariate logistic regression analysis, with kyphoplasty, vertebroplasty, anti-osteoporotic medications, age, gender, and Elixhauser Comorbidity Index as variables. RESULTS: A total of 36,145 patients were diagnosed with an OCF during the study period. Of those, 25,904 (71.7%) underwent nonoperative management and 10,241 (28.3%) underwent cement augmentation, including 1,556 who underwent vertebroplasty and 8,833 who underwent kyphoplasty. Patients who underwent nonoperative management had a secondary fracture rate of 21.8% following the initial OCF, compared with 14.5% in the vertebroplasty cohort and 18.5% in the kyphoplasty cohort, which was not a significant difference on multivariate analysis. In the entire cohort, 2,833 (7.8%) received anti-osteoporotic medications and 33,312 (92.2%) did not. The rate of secondary fracture was 10.1% in patients who received medications and 21.9% in those who did not, which was a significant difference on multivariate analysis (odds ratio = 1.23, p < 0.001). CONCLUSIONS: Cement augmentation did not alter the rate of secondary fracture, whereas anti-osteoporotic medications significantly decreased the risk of subsequent OCF by 19%. Only 7.8% of patients received a prescription for an anti-osteoporotic medication following the initial OCF. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Fraturas por Compressão , Cifoplastia , Osteoporose , Fraturas por Osteoporose , Fraturas da Coluna Vertebral , Vertebroplastia , Humanos , Pessoa de Meia-Idade , Fraturas por Compressão/etiologia , Fraturas por Compressão/cirurgia , Fraturas da Coluna Vertebral/etiologia , Fraturas por Osteoporose/etiologia , Fraturas por Osteoporose/prevenção & controle , Osteoporose/complicações , Osteoporose/tratamento farmacológico , Cimentos Ósseos/uso terapêutico , Resultado do Tratamento , Estudos RetrospectivosRESUMO
STUDY DESIGN: Retrospective national database study design. PURPOSE: This study was designed to determine whether acute percutaneous vertebral augmentation (PVA) alters morbidity compared with nonoperative management. OVERVIEW OF LITERATURE: Osteoporotic vertebral compression fractures (OCFs) are common and represent a large economic and patient burden. Several recent studies have focused on whether PVA offers benefits compared with nonoperative treatment. METHODS: A retrospective cohort analysis was conducted using the Nationwide Inpatient Sample from 2015 to 2018. Patients with nonelective admissions for OCFs were identified using International Classification of Diseases (10th edition) codes. The exclusion criteria included age of less than 50 years, fusion and decompression procedures, and the presence of neoplasms and infections. Propensity score matching was implemented to construct 2:1 matched cohorts with similar comorbidities at admission. The patients were divided into the operative and nonoperative treatment groups. Univariate and multivariate regression analyses were performed to compare differences in in-hospital complication rates between the groups. All p-values of less than 0.05 were considered significant. RESULTS: We identified 14,850 patients in the operative group and 29,700 patients in the nonoperative group. In the multivariate analysis, operative treatment was associated with significantly lower rates of pneumonia (odds ratio [OR], 0.75; p<0.001), acute respiratory failure (OR, 0.84; p=0.009), myocardial infarction (OR, 0.20; p<0.001), acute heart failure (OR, 0.80; p=0.001), cardiogenic shock (OR, 0.23; p=0.001), sepsis (OR, 0.39; p<0.001), septic shock (OR 0.50; p<0.001), and pressure ulcerations (OR, 0.71; p<0.001). However, operative treatment was associated with a significantly greater risk of acute renal failure (OR, 1.19; p<0.001) than nonoperative treatment. CONCLUSIONS: Patients who undergo acute PVA for OCFs have lower rates of respiratory complications, cardiac complications, sepsis, and pressure ulcerations while having a higher risk of acute renal failure.
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STUDY DESIGN: This is a retrospective cohort study of consecutive patients undergoing lumbar spinal fusion (LSF) within the PearlDiver Humana research database from 2010 to 2018. OBJECTIVE: The aim of this study was to determine if timing of total hip arthroplasty (THA) affects LSF outcomes. SUMMARY OF BACKGROUND DATA: In patients with both spine and hip pathology, outcomes of THA have been shown to be affected by the timing of THA relative to LSF. However, few studies have assessed postoperative outcomes following LSF in this clinical scenario. MATERIALS AND METHODS: A national database was queried for patients undergoing lumbar fusion and divided into 4 groups: (1) those who underwent LSF without THA (No THA); (2) those who underwent THA at least 2 years before LSF (>2 Prior THA); (3) those who underwent THA in the 2 years before LSF (0-2 Prior THA); and (4) those who underwent THA after LSF (THA After). We assessed lumbar-specific outcomes, including pseudarthrosis, revision, mechanical failure, and adjacent segment disease (ASD); as well as systemic complications. Controlling for age, sex, and Charlson comorbidity index, complication rates between all groups were assessed using univariate and multivariate logistic regression analysis. Post hoc comparisons were performed using the Fisher exact test with Bonferroni correction to account for multiple pairwise comparisons, resulting in an adjusted threshold for statistical significance of P<0.007. RESULTS: When compared with the no THA group, those in the THA After group had a higher rate of ASD on multivariate analysis [adjusted odds ratio: 1.53, 95% confidence interval: 1.20-1.94, P<0.001]. When compared with all patients who underwent THA before LSF, patients who underwent THA after LSF had an increased risk of ASD (adjusted odds ratio: 3.80, 95% confidence interval: 2.21-6.98, P<0.001). CONCLUSIONS: Patients who undergo THA after LSF have an increased rate of lumbar-related complications both when compared with patients who do not undergo THA and when compared with patients who undergo THA before LSF.
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Artroplastia de Quadril , Fusão Vertebral , Artroplastia de Quadril/efeitos adversos , Humanos , Vértebras Lombares/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Período Pós-Operatório , Reoperação/métodos , Estudos Retrospectivos , Fatores de Risco , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodosRESUMO
BACKGROUND CONTEXT: Recently, a single position lumbar fusion has been described in which both the anterior or lateral interbody fusion as well as posterior percutaneous pedicle screw fixation are performed in a single position. PURPOSE: The purpose of this study was to present and analyze the current evidence for single position lumbar fusion. STUDY DESIGN/SETTING: This is a systematic review and meta-analysis. PATIENT SAMPLE: Prospective or retrospective studies published in English that assessed outcomes of single position lumbar fusion surgery for patients with lumbar degenerative disease, spondylolisthesis, or radiculopathy were included. OUTCOME MEASURES: Outcome measures included operative time, estimated blood loss, hospital length of stay, X-Ray exposure time, and postoperative outcomes including leg numbness or pain, leg weakness, lumbar lordosis, and segmental lordosis. METHODS: This systematic review was performed in accordance with PRISMA guidelines. Two separate meta-analyses were performed. The first compared single position (SP) surgery, both lateral and prone, to dual position or flipped (F) surgery. The second meta-analysis compared lateral single position (LSP) surgery to prone single position (PSP) surgery. Variables were included if (1) they were a mean with a reported standard deviation or (2) if they were a categorical variable. For calculating standard error of the mean, we used sample size, mean, and standard deviation. A random effects model was used. The heterogeneity among studies was assessed with a significance level of <0.05. RESULTS: Twenty-one articles were included for analysis. Three studies were prospective nonrandomized studies, while 18 were retrospective. Seven articles studied lateral single position only, 10 articles compared lateral single position to traditional repositioning surgery, three articles studied prone single position surgery, and one article compared prone single position surgery to traditional repositioning surgery. A detailed review is provided for all 21 articles. Seventeen studies were included for meta-analysis comparing the SP versus F groups, for a total of 942 patients in the SP group and 254 in the F group. Mean operative time was significantly less for the SP group compared with the F group (SP: 127.5±7.9, F: 188.7±15.5, p<.001). Average hospital length of stay was 2.87±0.3 days in the SP group and 6.63±0.6 days in the F group (p<.001). Complication rates did not significantly differ between groups. Pedicle screws placed in the lateral position had a higher rate of complication as compared with those placed in a prone position (L: 10.2±2%, P: 1.6±1%, p=.015). Seventeen studies were included in the LSP versus PSP analysis, including 13 in the LSP group and four in the PSP group, with a total of 785 patients in the LSP group and 85 patients in the PSP group. Operative time and X-Ray exposure was significantly less in the LSP compared with the PSP group (117.1±5.5 minutes vs. 166.9±21.9 minutes, p<.001; 43.7±15.5 minutes vs. 171.0±25.8 minutes, p<.001). Postoperative segmental lordosis was greater in the prone single position group (p<.001). CONCLUSIONS: Single position surgery decreases operative times and hospital length of stay, while maintaining similar complication rates and radiographic outcomes. PSP surgery was found to be longer in duration and have increased radiation exposure time compared with LSP, while increasing postoperative segmental lordosis.
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Fusão Vertebral , Espondilolistese , Humanos , Vértebras Lombares/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Fusão Vertebral/efeitos adversos , Espondilolistese/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Facial transplantation is a complex surgical procedure that requires education of medical professionals, patients, and the general public. The objective of this randomized controlled trial was to compare the educational efficacy of facial transplantation digital animation versus text resources for teaching medical students a complex surgical procedure and its applicable anatomical and surgical principles. METHODS: Medical student volunteers were recruited and prospectively randomized to an animation or a text group. Students completed preintervention and postintervention assessments of confidence and knowledge of head and neck anatomy and facial transplantation. Student Evaluations of Educational Quality survey assessed student satisfaction with both tools following study crossover. Knowledge assessment was developed using National Board of Medical Examiners guidelines and content validated by four experts. The Cohen d statistic was used to measure the effect size of each intervention. RESULTS: Thirty-six students were assigned randomly to the animation group (n = 19) or the text (n = 17) group. Postintervention analysis demonstrated significantly higher performance scores in the animation group compared to the text group (p = 0.029). The animation group had a larger effect size (Cohen d = 1.96 versus 1.27). Only students in the animation group reported significantly improved confidence in head and neck anatomy after the intervention (p = 0.002). Both groups demonstrated significantly increased postintervention confidence in knowledge of facial transplantation (p < 0.001). Satisfaction scores revealed that students significantly favored the animation resource (p < 0.001). CONCLUSIONS: Animation can be an effective tool for facial transplantation education and results in improved student knowledge, confidence, and satisfaction compared to text resources. Facial transplantation can also be used as an educational framework for teaching medical students anatomical and surgical principles.
Assuntos
Educação de Graduação em Medicina/métodos , Avaliação Educacional/estatística & dados numéricos , Transplante de Face/educação , Filmes Cinematográficos , Adulto , Estudos Cross-Over , Feminino , Humanos , Masculino , Satisfação Pessoal , Avaliação de Programas e Projetos de Saúde , Estudantes de Medicina/psicologia , Estudantes de Medicina/estatística & dados numéricos , Inquéritos e Questionários/estatística & dados numéricos , Adulto JovemRESUMO
Analysis of new anticancer drugs licensed in the UK found that 44 new therapies were approved from 2015 to 2019. No other 5-year period has produced as many new therapies. Most new drugs are kinase inhibitors (KIs, N=18) and monoclonal antibodies (mAbs, N=16) with only one classical cytotoxic chemotherapy (CC) licensed. The average median treatment duration has risen by 55 days to 318 days (263 days in 2010-2014). Drug costs have escalated; an average treatment course now costs £62 343, compared to £35 383 in 2010-2014. New drugs are delivering significant clinical benefits with longer treatment durations. However, the financial burden is greater, heralding economic challenges for healthcare providers.