How old is too old?: Matched analysis of geriatric patients undergoing anterior lumbar interbody fusion.

STUDY DESIGN: Retrospective Review INTRODUCTION/OBJECTIVE: The aim of this study is to utilize a national database to identify how age affects patient outcomes following anterior lumbar interbody fusion (ALIF). There are no established age guidelines for the geriatric population within the spine specialty, which makes patient selection challenging. Furthermore, there are conflicting studies for the risks of performing spine surgeries in the elderly. METHODS: A retrospective review of the Mariner Claims Database was conducted on patients who underwent a single level ALIF (CPT 22558) between 2010 and 2018. Patients were separated into three groups by age: 50-64, 65-74, and 75-84 and matched with respect to gender, smoking, and comorbidity burden. Multivariable logistic regression was used to determine the independent effect of outpatient surgery on the postoperative outcomes after adjusting for demographic factors and pertinent comorbidities. Statistical significance was set at p < 0.05. RESULTS: The study identified 8459 matched patients (3350 50-64; 3350 65-74; and 1759 75-84). Compared with patients aged 50-64, patients aged 65-74 and 75-84 had significantly increased risks of pneumonia (65-74: OR 1.53, 95% CI 1.06-2.24, p = 0.025; 75-84: OR 1.62, 95% CI 1.07-2.42, p = 0.022), sepsis (65-74: OR 2.20, 95% CI 1.36-3.76, p = 0.002; 75-84: OR 2.42, 95% CI 1.43-4.13, p = 0.001), and major complications (65-74: OR 1.35, 95% CI 1.05-1.74, p = 0.021; 75-84: OR 1.48, 95% CI 1.11-1.95, p = 0.006) (Table 2). There were no significant differences between patients aged 65-74 and 75-84 for risks of postoperative pneumonia, sepsis, and major complications (p > 0.05). There were no differences between any groups in terms of long-term outcomes such as pseudoarthrosis, implant related complications, or reoperation (p > 0.05) (Table 3). DISCUSSION/CONCLUSION: The study showed that those older than 65 had a significant increase in risk of pneumonia, sepsis, and major complications following ALIF. In the two cohorts above the age of 65 (65-74 and 75-84) there was no significant differences in postoperative outcomes. LEVEL OF EVIDENCE: 3.

Osteoporosis is associated with increased minor complications following single level ALIF and PSIF: an analysis of 7,004 patients.

BACKGROUND: Osteoporosis is a prevalent disease that predisposes patients to fracture and additional post-operative complications, potentially contributing to decreased quality of life. The objective of the current study is to (I) characterize the demographic trends of individuals with osteoporosis undergoing single level posterior spine instrumentation and fusion (PSIF) and anterior lumbar interbody fusion (ALIF); (II) determine the association between osteoporosis and postoperative complications; (III) identify whether the use of bone strengthening medications is associated with improved outcomes. METHODS: A retrospective review of the Mariner Claims Database was conducted on patients undergoing single level ALIF (CPT 22558) and PSIF (CPT 22840) between 2011 and 2017. Diagnosis of osteoporosis (CPT 77080, CPT 77801, CPT 77082) included a bone density scan within two years of surgery. Patients with osteoporosis were 1:1 matched to controls. Patients taking bone enhancing medications prior to surgery were compared to those that did not take medications. Multivariable logistic regression analyses were performed to evaluate post-operative complication risk factors. RESULTS: 3,502 patients with diagnosed osteoporosis underwent ALIF and PSIF, of which 788 (22.5%) were treated with supplemental medication. Diagnosis of osteoporosis was associated with an increased risk of pulmonary embolism [1.1% vs. 0.4%, odds ratio (OR) 2.48, 95% confidence interval (CI): 1.36-4.53, P=0.003] and minor complications (16.7% vs. 12.9%, OR 1.15, 95% CI: 1.01-1.30, P=0.039). Revision rates two-years post-operatively were not significantly different between patients with osteoporosis and matched controls (P>0.05). There were no differences in outcomes between osteoporotic patients who received medications and those who did not receive medication (P>0.05). CONCLUSIONS: Osteoporosis is common in a nationally-representative Medicare database cohort. Pre-operative diagnosis of osteoporosis is associated with increased minor complications following ALIF and PSIF. Pre-operative osteoporosis treatment is not associated with a significant difference in post-operative outcomes. The current study can guide pre-operative counseling in this cohort.

The Demographics and Epidemiology of Infantile, Juvenile, and Adolescent Idiopathic Scoliosis in a Southern California Integrated Health Care System.

STUDY DESIGN: Prognostic study, Level III. OBJECTIVES: The aim of this study was to determine the incidence and demographics of idiopathic scoliosis (IS) in a large cohort of children in a Southern California integrated healthcare system, and to identify the demographic or clinical factors associated with the greatest risk of IS. SUMMARY OF BACKGROUND DATA: Although many authors have reported on the incidence and prevalence of IS in children, there have been few incidence studies in the United States on large, self-contained populations. METHODS: A retrospective chart analysis was done on diagnosed cases of IS within our integrated health care system in patients under age 18 years during the entire 2013 calendar year. Patient demographics were recorded and the incidence of IS was determined. Odds ratios (ORs) for having IS and for having more severe initial curve magnitudes based on demographics were determined using logistic regression models. RESULTS: IS Incidence was 3.9, 28.6, and 393 per 100,000, respectively, for the infantile, juvenile, and adolescent group. The female incidence was more than twice that of males in all age groups. Multivariate logistic regression analysis showed Asians and non-Hispanic Whites had the highest OR of IS (OR 1.54 and 1.32 with 95% confidence interval [CI] 1.33-1.79 and 1.19-1.47). Whites, Blacks, and mixed-race patients had a significantly higher initial curve magnitude than Hispanics; females also had a significantly greater initial curve magnitude than boys (18.1° vs. 16.7°). Underweight patients had a 50% increased OR of IS versus normal weight (95% CI 1.16-1.94) with a progressively decreased OR of IS as weight increased. CONCLUSION: Our study of a large integrated healthcare system sheds light on the incidence of IS and the ORs based on weight, sex, and ethnicity/race. The overall incidence was lower overall than previously thought.Level of Evidence: 3.

Clostridium difficile Infection Following Spine Surgery: Incidence, Risk Factors, and Association With Preoperative Antibiotic Use.

STUDY DESIGN: Retrospective database review. OBJECTIVE: The aim of this study was to determine the incidence of Clostridium difficile infection (CDI) within 90 days following elective spine surgery; examine risk factors associated with its development; and evaluate the impact of CDI on postoperative outcomes. SUMMARY OF BACKGROUND DATA: Although previous studies provided valuable insight into the rate of CDI following spine surgery and associated risk factors, to date no study has evaluated the role preoperative antibiotics use plays in the development of CDI, as well as its impact on 90-day outcomes. METHODS: A retrospective database review of Humana patients ages 20 to 84 years who underwent elective spine surgery between 2008 and 2016 was conducted. Following exclusion criteria, the population was divided into patients who developed CDI within 90 days of surgery and those who did not. All risk factors and outcomes were analyzed using multivariate regression. RESULTS: A total of 63,667 patients met study criteria. Ninety-day incidence of CDI was 0.68%. Notable medical risk factors (P < 0.05) included preoperative fluoroquinolone use (odds ratio [OR] 1.40), advanced age (OR 1.86), chronic kidney disease stage I/II (OR 1.76) and III-V (OR 1.98), decompensated chronic liver disease (OR 3.68), and hypoalbuminemia (OR 3.15). Combined anterior-posterior cervical (OR 2.74) and combined anterior-posterior lumbar (OR 2.43) approaches and procedures spanning more than eight levels (OR 3.99) were associated with the highest surgical risk (P < 0.05) of CDI. CDI was associated with a 12.77-day increase in length of stay (P < 0.05) and increased risk of readmission (OR 6.08, P < 0.05) and mortality (OR 8.94, P < 0.05). CONCLUSION: Following elective spine surgery, CDI increases risk of readmission and mortality. In addition to preoperative fluoroquinolone use, novel risk factors associated with the highest risk of CDI included decompensated chronic liver disease, posterior approaches, and multilevel involvement. Perioperative optimization of modifiable risk factors may help to prevent occurrence of CDI. LEVEL OF EVIDENCE: 3.

Outcomes Following Posterior Lumbar Fusion in Patients with Polycythemia Vera.

BACKGROUND: Polycythemia vera (PV) is a chronic myeloproliferative neoplasm that is associated with increased risk for venous and arterial thromboembolism. The aim of this study was to evaluate outcomes following elective posterior lumbar fusion (PLF) and/or posterior interbody fusion (PLIF) among patients with PV. METHODS: Using PearlDiver retrospective national database, Medicare patients <85 years old who underwent elective primary PLF (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 81.07) and/or PLIF (ICD-9-CM code 81.08) for degenerative lumbar spine pathologies during 2006-2013 were identified. Patients included in the PLF and/or PLIF cohort were separated into patients with a prior diagnosis of PV (ICD-9-CM code 238.4) and a control cohort of patients without PV. Comparisons of postoperative outcomes were made between the PV patient group and matched control group. Significance was set at 0.05. RESULTS: Selected study participants included 1491 patients with PV and 29,056 patients in the matched control group. Patients with PV had a significantly increased rate of 90-day acute pulmonary embolism (1.9% vs. 1.2%, odds ratio [OR] 1.65, 95% confidence interval [CI] 1.10-2.38, P = 0.010), 90-day lower extremity deep vein thrombosis (3.4% vs. 1.9%, OR 1.81, 95% CI 1.33-2.40, P < 0.001), and 1-year diagnosis of surgical site infection (5.4% vs. 4.2%, OR 1.30, 95% CI 1.02-1.63, P = 0.027) compared with patients without PV. Nonetheless, PV was not associated with other major medical complications, including stroke, myocardial infarction, and mortality, following PLF and/or PLIF. CONCLUSIONS: Patients with PV undergoing elective PLF and/or PLIF have a significantly increased risk for pulmonary embolism, lower extremity deep vein thrombosis, and surgical site infection.