Measuring the Delay in the Referral of Unstable Vertebral Metastasis to the Spine Surgeon: A Retrospective Study in a Latin American Institution.

Background: The delay in the referral of patients with potential surgical vertebral metastasis (VM) to the spine surgeon is strongly associated with a worse outcome. The spinal instability neoplastic score (SINS) allows for determining the risk of instability of a spine segment with VM; however, it is almost exclusively used by specialists or residents in neurosurgery or orthopedics. The objective of this work is to report the delay in surgical consultation of patients with potentially unstable and unstable VM (SINS >6) at our center. Material: We performed a 5-year single-center retrospective analysis of patients with spine metastasis on computed tomography (CT). Patients were divided into Group 1 (G1), potentially unstable VM (SINS 7-12), and Group 2 (G2), unstable VM (SINS 13-18). Time to surgical referral was calculated as the number of days between the report of the VM in the CT and the first clinical assessment of a spinal surgeon on the medical records. Results: We analyzed 220 CT scans, and 98 met the selection criteria. Group 1 had 85 patients (86.7%) and Group 2 had 13 (13.3%). We observed a mean time to referral of 83.5 days in the entire cohort (std = 127.6); 87.6 days (std = 135.1) for G1, and 57.2 days (std = 53.8) for G2. The delay in referral showed no significant correlation with the SINS score. Conclusion: We report a mean delay of 83.5 days in the surgical referral of VM (SINS >6, n = 98). Both groups showed cases of serious referral delay, with 25% of patients having the first surgical consultation more than three months after the CT study.

Delay in hip fracture surgery and its outcomes. A reflection / Retraso en cirugía de fractura de cadera y sus desenlaces. Una reflexión

Abstract Hip fracture is one of the major public healthcare problems in elderly patients around the world, mainly because of the risk of falls and osteoporosis which are typical during this stage of life, and may be the cause for up to 36% of deaths among those affected. Its management in principle is surgical and the best results are achieved with patients undergoing surgery during the first 24 to 72 hours after the fracture. Any delays in surgery are mostly associated with decompensated personal pathological factors, delays in perioperative assessment, or in presurgical complementary tests; sometimes, the delays are the result of administrative formalities of the healthcare providers. These determining factors may affect both morbidity and mortality, and contribute to functional decline, disability, and reduced quality of life of these patients. A third party intervention is then necessary to improve the preventable factors that delay the osteosynthesis in these types of fractures, in addition to ensuring education, infrastructure, inputs, skilled human resources, and prompt referral of patients from the first level of care. Investigating this scenario and assessing the quality of life impact on these patients should be a priority.

Resumen La fractura de cadera representa uno de los problemas de salud pública más grandes en los pacientes ancianos en todo el mundo, principalmente, por el riesgo de caídas y la osteoporosis típicos en esta etapa de la vida, que puede causar la muerte de hasta el 36 % de los afectados; su manejo es en principio quirúrgico y los mejores resultados se presentan cuando se interviene en las primeras 24 a 72 horas después de la fractura. El retraso en la corrección quirúrgica está asociado principalmente a factores patológicos personales no compensados, demora en la valoración perioperatoria o en los estudios complementarios prequirúrgicos, o por trámites administrativos de las empresas prestadoras de servicios de salud. Estos determinantes pueden afectar la morbimortalidad y contribuir a un deterioro funcional, incapacidad y pérdida de la calidad de vida de estos pacientes. Se hace necesaria una intervención por parte de terceros para mejorar los factores prevenibles que retrasan la osteosíntesis de este tipo de fracturas; además, asegurar educación, infraestructura, insumos, talento humano capacitado y remisión rápida de pacientes desde el primer nivel de atención. Investigar en este escenario y evaluar los efectos en la calidad de vida de estos pacientes debería ser una prioridad.

Pre-operative factors associated with increased mortality in elderly patients with a hip fracture: A cohort study in a developing country.

BACKGROUND: Hip fractures are a public health problem worldwide, and several factors are involved with post-operative mortality. The aim of this study was to identify the pre-operative factors associated with increased mortality in elderly patients with hip fractures in a developing country during the first post-operative year. METHODS: An ambidirectional cohort study was conducted with patients ≥ 65 years of age who underwent hip surgery due to a hip fracture caused by a fall from a standing position. Socio-demographic data, time to surgery, and comorbidities measured by the Charlson Comorbidity Index (CCI) were recorded. One-year mortality from all causes was the primary outcome, and 30-day and 6-month mortality were the secondary outcomes. Log-rank test was used to evaluate survival, and Cox's proportional hazard regression was used to detect the factors associated with increased mortality. RESULTS: 478 patients who underwent hip surgery were included in this study. The mean age was 80.2 ±â€¯9.9, and 297 (62%) were females. There were 150 (31.4%) deaths at the end of the first follow-up year, and the mean of surgical delay was 8.8 days ±â€¯6.4. Patients who underwent surgery during the first 4 days (Log-rank test < 0.001) after hip fracture occurred and patients with a CCI ≤ 2 (Log-rank test < 0.001) showed better survival (90%), comparing to mortality (52%) of patients with a CCI ≥ 3 and surgical delay > 4 days. The age ≥ 80 years (Hazard ratio 2.55 (HR), 95% confidence interval (CI) 1.70 to 3.84, p < 0.001), CCI ≥ 3 (HR 1.61, 95% CI 1.14-2.26, p 0.006), surgical delay > 4 days (HR 2.41, 95% CI 1.38-4.21, p 0.006), and haemoglobin < 10 g/dl (HR 1.51, 95% CI 1.06-2.15, p 0.02) were associated with increased 1-year mortality. In addition, 30-day mortality was associated with age ≥ 80 years (HR 4.15, 95% CI 1.98-8.70, p < 0.001), CCI ≥ 3 (HR 1.80, 95% CI 1.08-2.99, p 0.023), pre-surgical time >48 h (HR 3.0, 95% CI 1.58-5.92, p 0.001), and surgical delay > 4 days (HR 3.0, 95% CI 1.33-6.81, p 0.008); and 6-month mortality was associated with surgical delay > 4 days (HR 2.72, 95% CI 1.42-5.23, p 0.003), and haemoglobin < 10 g/dl (HR 1.56, 95% CI 1.04-2.33, p < 0.028). CONCLUSIONS: Surgical delay greater than 4 days and Charlson Comorbidity Index ≥ 3 were found as factors associated with increased mortality, along with anaemia < 10 g/dl and age ≥ 80 years. A similar mortality rate was found in this study compared to the rates reported by the literature, despite a surgical delay of 8.8 days.

Morbimortalidad posterior a fracturas intertrocantéricas de cadera. Efecto del retraso en el tratamiento quirúrgico / Morbidity and mortality after delayed surgical treatment of intertrochanteric hip fractures

Introducción La tendencia mundial es realizar cirugía temprana en el manejo de las fracturas intertrocantéricas de cadera con el objetivo de disminuir mortalidad y complicaciones postoperatorias, pero los resultados no son concluyentes y el consenso mundial está basado en evidencia de moderada y baja calidad. El objetivo del estudio es evaluar si existen diferencias en mortalidad y tiempo de estancia hospitalaria postoperatoria en pacientes intervenidos quirúrgicamente antes y después de las 48 horas del ingreso hospitalario. Materiales y métodos Estudio retrospectivo de los pacientes operados por fracturas intertrocantéricas entre 2007 y 2013 con datos extraídos de historias clínicas y encuestas telefónicas. Se realizó un análisis de supervivencia a los 6 y 12 meses con el método estadístico Kaplan Meier y Log-Rank-test. Para comparar las proporciones de mortalidad y las medias entre grupos se utilizó X2 y t student respectivamente. Resultados La mortalidad a los 6 meses en el grupo de cirugía temprana alcanzó el 2,9% y en cirugía tardía, el 15,1% (p=0,02). La estancia hospitalaria disminuyó 5 días en los pacientes operados antes de 48 horas (p=0,008). No se puso de manifiesto diferencia estadísticamente significativa en la mortalidad al año en los grupos comparados. Discusión En el estudio se evidenció menor porcentaje de mortalidad a los 6 meses de la intervención quirúrgica y disminución en la estancia hospitalaria postoperatoria en el grupo de cirugía temprana. Respecto a la bibliografía mundial, la cirugía temprana tiene mayor repercusión en mortalidad en el primer semestre. Nivel de evidencia clínica. Nivel III.

Background The global trend is to perform early surgery in the treatment of hip fractures, with the objective of reducing mortality and post-surgery complications. As the global consensus is based on evidence of moderate and low quality, the results are not conclusive. The aim of this study is to evaluate whether there are differences in mortality and postoperative hospital stay in operated patients before and after 48 hours of hospital admission. Materials and methods Retrospective study was conducted on patients admitted to a trauma centre with a diagnosis of intertrochanteric fracture between 2007 and 2013. Data was extracted from clinical records and using telephone surveys. A survival analysis at 6 and 12 months was performed using the Kaplan Meier test and Log-Rank-test. The chi-squared test was used to compare the mortality percentages and the Student t test used to compare means between groups. Results Mortality at 6 months in the early surgery group was 2.9%, and 15.1% (p=.02) in the late surgery group. Hospital stay decreased by 5 days in patients operated before 48 hours (p=.008). There was no statistically significant difference in mortality at one year between the compared groups. Discussion The study showed a lower percentage of post-surgical mortality at 6 months, and a decrease in the post-surgical hospital stay in the early surgery group. According to literature, early surgery has the greatest impact on mortality during the first 6 months after the intervention. Evidence level. III.