Factors associated with increased length of stay in degenerative cervical spine surgery: a cohort analysis from the Canadian Spine Outcomes and Research Network.

OBJECTIVE: Postoperative length of stay (LOS) significantly contributes to healthcare costs and resource utilization. The primary goal of this study was to identify patient, clinical, surgical, and institutional variables that influence LOS after elective surgery for degenerative conditions of the cervical spine. The secondary objectives were to examine the variability in LOS and institutional practices used to decrease LOS. METHODS: This was a multicenter observational retrospective cohort study of patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and October 2020 who underwent elective anterior cervical discectomy and fusion (ACDF) (1-3 levels) or posterior cervical fusion (PCF) (between C2 and T2) with/without decompression for degenerative conditions of the cervical spine. Prolonged LOS was defined as LOS greater than the median for the ACDF and PCF populations. The principal investigators at each participating CSORN healthcare institution completed a survey to capture institutional practices implemented to reduce postoperative LOS. RESULTS: In total, 1228 patients were included (729 ACDF and 499 PCF patients). The median (IQR) LOS for ACDF and PCF were 1.0 (1.0) day and 5.0 (4.0) days, respectively. Predictors of prolonged LOS after ACDF were female sex, myelopathy diagnosis, lower baseline SF-12 mental component summary score, multilevel ACDF, and perioperative adverse events (AEs) (p < 0.05). Predictors of prolonged LOS after PCF were nonsmoking status, education less than high school, lower baseline numeric rating scale score for neck pain and EQ5D score, higher baseline Neck Disability Index score, and perioperative AEs (p < 0.05). Myelopathy did not significantly predict prolonged LOS within the PCF cohort after multivariate analysis. Of the 8 institutions (57.1%) with an enhanced recovery after surgery (ERAS) protocol or standardized protocol, only 3 reported using an ERAS protocol specific to patients undergoing ACDF or PCF. CONCLUSIONS: Patient and clinical factors predictive of prolonged LOS after ACDF and PCF are highly variable, warranting individual consideration for possible mitigation. Perioperative AEs remained a consistent independent predictor of prolonged LOS in both cohorts, highlighting the importance of preventing intra- and postoperative complications.

Effectiveness of prophylactic intranasal photodynamic disinfection therapy and chlorhexidine gluconate body wipes for surgical site infection prophylaxis in adult spine surgery.

BACKGROUND: Current measures to prevent spinal surgical site infection (SSI) lack compliance and lead to antimicrobial resistance. We aimed to examine the effectiveness of bundled preoperative intranasal photodynamic disinfection therapy (nPDT) and chlorhexidine gluconate (CHG) body wipes in the prophylaxis of spine SSIs in adults, as well as determine our institutional savings attributable to the use of this strategy and identify adverse events reported with nPDT-CHG. METHODS: We performed a 14-year prospective observational interrupted time-series study in adult (age > 18 yr) patients undergoing emergent or elective spine surgery with 3 time-specific cohorts: before rollout of our institution's nPDT-CHG program (2006-2010), during rollout (2011-2014) and after rollout (2015-2019). We used unadjusted bivariate analysis to test for temporal changes across patient and surgical variables, and segmented regression to estimate the effect of nPDT-CHG on the annual SSI incidence rates per period. We used 2 models to estimate the cost of nPDT-CHG to prevent 1 additional SSI per year and the annual cumulative cost savings through SSI prevention. RESULTS: Over the study period, 13 493 patients (mean 964 per year) underwent elective or emergent spine surgery. From 2006 to 2019, the mean age, mean Charlson Comorbidity Index (CCI) score and mean Spine Surgical Invasiveness Index (SSII) score increased from 48.4 to 58.1 years, from 1.7 to 2.6, and from 15.4 to 20.5, respectively (p < 0.001). Unadjusted analysis confirmed a significant decrease in the annual number (74.6 to 26.8) and incidence (7.98% to 2.67%) of SSIs with nPDT-CHG (p < 0.001). After adjustment for mean age, mean CCI score and mean SSII score, segmented regression showed an absolute reduction in the annual SSI incidence rate of 3.36% per year (p < 0.001). The estimated annual cost to prevent 1 additional SSI per year was about $1350-$1650, and the estimated annual cumulative cost savings were $2 484 856-$2 495 016. No adverse events were reported with nPDT-CHG. CONCLUSION: Preoperative nPDT-CHG administration is an effective prophylactic strategy for spinal SSIs, with significant cost savings. Given its rapid action, minimal risk of antimicrobial resistance, broad-spectrum activity and high compliance rate, preoperative nPDT-CHG decolonization should be the standard of care for all patients undergoing emergent or elective spine surgery.

The Role of Frailty and Sarcopenia in Predicting Major Adverse Events, Length of Stay and Reoperation Following En Bloc Resection of Primary Tumours of the Spine.

STUDY DESIGN: Retrospective observational cohort study. OBJECTIVE: En bloc resection for primary tumours of the spine is associated with a high rate of adverse events (AEs). The objective was to explore the relationship between frailty/sarcopenia and major perioperative AEs, length of stay (LOS), and unplanned reoperation following en bloc resection of primary spinal tumours. METHODS: This is a unicentre study consisting of adult patients undergoing en bloc resection for a primary spine tumor. Frailty was calculated with the modified frailty index (mFI) and spine tumour frailty index (STFI). Sarcopenia was quantified with the total psoas area/vertebral body area ratio (TPA/VB) at L3 and L4. Univariable regression analysis was used to quantify the association between frailty/sarcopenia and major perioperative AEs, LOS and unplanned reoperation. RESULTS: 95 patients met the inclusion criteria. The mFI and STFI identified a frailty prevalence of 3% and 18%. Mean CT TPA/VB ratios were 1.47 (SD ± .05) and 1.83 (SD ± .06) at L3 and L4. Inter-observer reliability was .93 and .99 for CT and MRI L3 and L4 TPA/VB ratios. Unadjusted analysis demonstrated sarcopenia and mFI did not predict perioperative AEs, LOS or unplanned reoperation. Frailty defined by an STFI score ≥2 predicted unplanned reoperation for surgical site infection (SSI) (P < .05). CONCLUSIONS: The STFI was only associated with unplanned reoperation for SSI on unadjusted analysis, while the mFI and sarcopenia were not predictive of any outcome. Further studies are needed to investigate the relationship between frailty, sarcopenia and perioperative outcomes following en bloc resection of primary spinal tumors.

Generic versus disease-specific adverse event reporting: a comparison of the NSQIP and SAVES databases for the identification of acute care adverse events in adult spine surgery.

OBJECTIVE: The accurate identification and reporting of adverse events (AEs) is crucial for quality improvement. A myriad of AE systems are utilized. There is a lack of understanding of the differences between prospective versus retrospective, disease-specific versus generic, and point-of-care versus chart-abstracted systems. The objective of this study was to compare the benefits and limitations between the prospective, disease-specific, point-of-care Spine Adverse Events Severity System (SAVES) and the retrospective, generic, and chart-abstracted National Surgical Quality Improvement Program (NSQIP) for the identification and reporting of AEs in adult patients undergoing spinal surgery. METHODS: The authors conducted an observational ambidirectional cohort study of adult patients undergoing spine surgery other than for trauma between 2011 and 2019 in a quaternary spine center. Patients were identified using Current Procedural Terminology codes in the NSQIP database and matched using unique medical record numbers to their corresponding record in SAVES. The incidence of AEs and per-patient AEs as recorded in NSQIP and SAVES was the primary outcome of interest. Comparable AEs were identified by matching NSQIP AEs to equivalent ones in SAVES. Chi-square tests were used to test for significant differences in the incidence of overall and comparable AEs between the databases. RESULTS: There were 2198 patients identified in NSQIP, of whom 2033 also had complete records in SAVES. SAVES identified 5342 individual AEs in 1484 patients (73%) compared with 1291 individual AEs in 807 patients (39.7%) with the NSQIP database (p < 0.001). SAVES identified 250 intraoperative and 422 postoperative spine-specific AEs that NSQIP did not record. NSQIP captured a greater number of AEs beyond 30 days, including prolonged length of stay > 30 days, unplanned readmission, unplanned reoperation, and death later than 30 days after surgery compared with SAVES. CONCLUSIONS: SAVES captures a greater incidence of peri- and intraoperative spine-specific AEs than NSQIP, while NSQIP identifies a greater number of AEs beyond 30 days. While a prospective, disease-specific, point-of-care AE system such as SAVES is specific for guiding quality improvement in spine surgery, it incurs greater time and financial costs. Conversely, a retrospective, generic, and chart-abstracted system such as NSQIP provides equivocal cross-institutional comparability with reduced time and financial costs. Specific contextual and aim-specific needs should guide the choice and implementation of an AE system.

The measurements of frailty and their possible application to spinal conditions: a systematic review.

BACKGROUND CONTEXT: Frailty is associated with an increased risk of postoperative adverse events (AEs) within the surgical spine population. Multiple frailty tools have been reported in the surgical spine literature. However, the applicability of these tools remains unclear. PURPOSE: Primary objective is to appraise the construct, feasibility, objectivity, and clinimetric properties of frailty tools reported in the surgical spine literature. Secondary objectives included determining the applicability and the most sensitive surgical spine population for each tool. STUDY DESIGN: Systematic Review. PATIENT SAMPLE: Studies reporting the use of a clinical frailty tool with a defined methodology in the adult surgical population (age ≥18 years). OUTCOME MEASURES: Postoperative adverse events (AEs) including mortality, major and minor morbidity, length of stay (LOS), unplanned readmission and reoperation, admission to the Intensive Care Unit (ICU), and adverse discharge disposition; postoperative patient-reported outcomes (health-related quality of life (HRQoL), functional, cognitive, and symptomatic); radiographic outcomes; and postoperative frailty trajectory. METHODS: This systematic review was registered with PROSPERO: CRD42019109045. Publications from January 1950 to December 2020 were identified by a comprehensive search of PubMed, Ovid, and Embase, supplemented by manual screening. Studies reporting and validating a frailty tool in the surgical spine population with a measurable outcome were included. Each tool and its clinimetric properties were evaluated using validated criteria and definitions. The applicability of each tool and its most sensitive surgical spine population was determined by panel consensus. Bias was assessed using the Newcastle-Ottawa Scale. RESULTS: 47 studies were included in the final qualitative analysis. A total of 14 separate frailty tools were identified, in which 9 tools assessed frailty according to the cumulative deficit definition, while 4 instruments utilized phenotypic or weighted frailty models. One instrument assessed frailty according to the comprehensive geriatric assessment (CGA) model. Twelve measures were validated as risk stratification tools for predicting postoperative AEs, while 1 tool investigated the effect of spine surgery on postoperative frailty trajectory. The modified frailty index (mFI), 5-item mFI, adult spinal deformity frailty index (ASD-FI), FRAIL Scale, and CGA had the most positive ratings for clinimetric properties assessed. CONCLUSIONS: The assessment of frailty is important in the surgical decision-making process. Cumulative deficit and weighted frailty instruments are appropriate risk stratification tools. Phenotypic tools are sensitive for capturing the relationship between spinal pathology, spine surgery, and prehabilitation on frailty trajectory. CGA instruments are appropriate screening tools for identifying health deficits susceptible to improvement and guiding optimization strategies. Studies are needed to determine whether spine surgery and prehabilitation are effective interventions to reverse frailty.

Effect of Frailty on Outcome after Traumatic Spinal Cord Injury.

Frailty negatively affects outcome in elective spine surgery populations. This study sought to determine the effect of frailty on patient outcome after traumatic spinal cord injury (tSCI). Patients with tSCI were identified from our prospectively collected database from 2004 to 2016. We examined effect of patient age, admission Total Motor Score (TMS), and Modified Frailty Index (mFI) on adverse events (AEs), acute length of stay (LOS), in-hospital mortality, and discharge destination (home vs. other). Subgroup analysis (for three age groups: <60, 61-75, and 76+ years), and multi-variable analysis was performed to investigate the impact of age, TMS, and mFI on outcome. For the 634 patients, the mean age was 50.3 years, 77% were male, and falls were the main cause of injury (46.5%). On bivariate analysis, mFI, age at injury, and TMS were predictors of AEs, acute LOS, and in-hospital mortality. After statistical adjustment, mFI was a predictor of LOS (p = 0.0375), but not of AEs (p = 0.1428) or in-hospital mortality (p = 0.1245). In patients <60 years of age, mFI predicted number of AEs, acute LOS, and in-hospital mortality. In those aged 61-75, TMS predicted AEs, LOS, and mortality. In those 76+ years of age, mFI no longer predicted outcome. Age, mFI, and TMS on admission are important determinants of outcome in patients with tSCI. mFI predicts outcomes in those <75 years of age only. The inter-relationship of advanced age and decreased physiological reserve is complex in acute tSCI, warranting further study. Identifying frailty in younger patients with tSCI may be useful for peri-operative optimization, risk stratification, and patient counseling.

Sarcopenia, but not frailty, predicts early mortality and adverse events after emergent surgery for metastatic disease of the spine.

BACKGROUND CONTEXT: Frailty and sarcopenia variably predict adverse events (AEs) in a number of surgical populations. PURPOSE: The aim of this study was to investigate the ability of frailty and sarcopenia to independently predict early mortality and AEs following urgent surgery for metastatic disease of the spine. STUDY DESIGN: A single institution, retrospective cohort study. PATIENT SAMPLE: One hundred eight patients undergoing urgent surgery for spinal metastases from 2009 to 2015. OUTCOME MEASURES: The incidence of AEs including 1- and 3-month mortality. METHODS: Sarcopenia was defined using the L3 Total Psoas Area/Vertebral body Area (L3-TPA/VB) technique on CT. The modified Frailty Index (mFI), Metastatic Frailty Index (MSTFI) and the Bollen prognostic scales were calculated for each patient. Additional data included demographics, tumor type and burden, neurological status, the extent of surgical treatment and the use of radiation-therapy. Spearman correlation test, logistic regression and Kaplan-Meier were used to study the relation between the outcomes measures and potential predictors (L3-TPA/VB, MSTFI, mFI, and the Bollen prognostic scales). RESULTS: Eighty-five percent of patients had at least one acute AE. Sarcopenia predicted the occurrence of at least one postop AE (L3-TPA/VB, 1.07±0.40 vs. 1.25±0.52; p=.031). Sarcopenia (L3-TPA/VB) and the degree of neurological impairment were predictive of postoperative AE but MFI or MSTFI were not. Sarcopenia predicted 3-month mortality, independent of primary tumor type (L3-TPA/VB: 0.86±0.27 vs. 1.12±0.41; p<.001). Kaplan-Meyer analysis showed L3-TPA/VB and the Bollen Scale to significantly discriminate patient survival. CONCLUSIONS: Sarcopenia, easily measured by the L3-TPA/VB on conventional CT, predicts both early postoperative mortality and adverse events in patients undergoing urgent surgery for spinal metastasis, thus providing a practical tool for timely therapeutic decision-making in this complex patient population.

The impact of frailty and sarcopenia on postoperative outcomes in adult spine surgery. A systematic review of the literature.

STUDY DESIGN: Systematic review. OBJECTIVES: To identify currently used measures of frailty and sarcopenia in the adult spine surgery literature. To assess their ability to predict postoperative outcomes including mortality, morbidity, in-hospital length of stay (LOS), and discharge disposition. To determine which is the best clinical measure of frailty and sarcopenia in predicting outcome after spine surgery. SUMMARY OF BACKGROUND DATA: Frailty and sarcopenia have been identified as predictors of mortality and adverse-events (AEs) in numerous nonsurgical and nonspine populations. This topic is an emerging area of interest and study in patients undergoing spinal surgery. METHODS: A systematic literature review using the PRISMA methodology of MEDLINE, PubMed, Ovid, EMBASE, and Cochrane databases was performed from January 1950 to August 2017. Included studies consisted of those that examined measures of frailty or sarcopenia in adult patients undergoing any spinal surgery. The literature was synthesized and recommendations are proposed based on the GRADE system. RESULTS: The initial search yielded 210 results, 11 of which met our complete inclusion criteria. Seven reported on measures of frailty and four reported on measures of sarcopenia. Frailty, assessed using a variety of measurement tools, was a consistent predictor of mortality, major and minor morbidity, prolonged in-hospital LOS, and discharge to a center of higher care for adult patients undergoing spinal surgery. The relationship between sarcopenia and postoperative outcomes was inconsistent due to the lack of consensus regarding the definition, measurement tools, and wide variability in sarcopenia measured in the spinal population. CONCLUSIONS: Frailty is predictive of AEs, mortality, in-hospital LOS, and discharge disposition in a number of distinct spinal surgery populations. The impact of sarcopenia on postoperative outcomes is equivocal given the current state of the literature. The relationship between spinal pathology, frailty, sarcopenia, and how they interact to yield outcome remains to be clarified. Frailty and sarcopenia are potentially useful tools for risk stratification of patients undergoing spinal surgery. This systematic review was registered with PROSPERO, registration number 85096.