Classifying Complications: Assessing Adult Spinal Deformity 2-Year Surgical Outcomes.

STUDY DESIGN: Retrospective review of prospective database. OBJECTIVE: Complication rates for adult spinal deformity (ASD) surgery vary widely because there is no accepted system for categorization. Our objective was to identify the impact of complication occurrence, minor-major complication, and Clavien-Dindo complication classification (Cc) on clinical variables and patient-reported outcomes. METHODS: Complications in surgical ASD patients with complete baseline and 2-year data were considered intraoperatively, perioperatively (<6 weeks), and postoperatively (>6 weeks). Primary outcome measures were complication timing and severity according to 3 scales: complication presence (yes/no), minor-major, and Cc score. Secondary outcomes were surgical outcomes (estimated blood loss [EBL], length of stay [LOS], reoperation) and health-related quality of life (HRQL) scores. Univariate analyses determined complication presence, type, and Cc grade impact on operative variables and on HRQL scores. RESULTS: Of 167 patients, 30.5% (n = 51) had intraoperative, 48.5% (n = 81) had perioperative, and 58.7% (n = 98) had postoperative complications. Major intraoperative complications were associated with increased EBL (P < .001) and LOS (P = .0092). Postoperative complication presence and major postoperative complication were associated with reoperation (P < .001). At 2 years, major perioperative complications were associated with worse ODI, SF-36, and SRS activity and appearance scores (P < .02). Increasing perioperative Cc score and postoperative complication presence were the best predictors of worse HRQL outcomes (P < .05). CONCLUSION: The Cc Scale was most useful in predicting changes in patient outcomes; at 2 years, patients with raised perioperative Cc scores and postoperative complications saw reduced HRQL improvement. Intraoperative and perioperative complications were associated with worse short-term surgical and inpatient outcomes.

Bariatric Surgery Population at Significantly Increased Risk of Spinal Disorders and Surgical Intervention Compared With Morbidly Obese Patients.

INTRODUCTION: Obesity is associated with acceleration of musculoskeletal degenerative diseases and functional impairment secondary to spinal disorders. Bariatric surgery (BS) is an increasingly common treatment for severe obesity but can affect bone and mineral metabolism. The effect of BS on degenerative spinal disorders is yet to be fully described. The aim of our study was to analyze changes in bariatric patients' risk for spinal degenerative diseases and spinal surgery. METHODS: Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years (2004-2013) using patient linkage codes. The incidence of degenerative spinal diagnoses and spinal surgery was queried using International Classification of Diseases, Ninth Revision (ICD)-9 codes for morbidly obese patients (ICD-9 278.01) with and without a history of BS. The incidence of degenerative spinal diagnoses and spinal surgery was determined using χ tests for independence. Logistic testing controlled for age, sex, and comorbidity burden. RESULTS: A total of 18,176 patients were identified in the NYSID database with a history of BS and 146,252 patients were identified as morbidly obese without a history of BS. BS patients have a significantly higher rate of spinal diagnoses than morbidly obese patients without BS (19.3% vs. 8.1%, P<0.001). Bariatric patients were more likely to have spinal diagnoses and procedures than nonbariatric obese patients (P<0.001). This was mostly observed in lumbar spinal stenosis (5.0%), cervical disk herniation (3.3%), lumbar disk degeneration (3.4%), lumbar spondylolisthesis (2.9%), lumbar spondylosis (1.9%), and cervical spondylosis with myelopathy (2.0%). Spine procedure rates are higher for bariatric patients than nonbariatric overall (25.6% vs. 2.3, P<0.001) and for fusions and decompressions (P<0.001). When controlling for age, sex, and comorbidities (and diagnosis rate with regards to procedure rates), these results persist, with BS patients having a higher likelihood of spinal diagnoses and procedures. In addition, bariatric patients had a lower comorbidity burden than morbidly obese patients without a history of BS. CONCLUSIONS: Morbidly obese BS patients have a dramatically higher incidence of spinal diagnoses and procedures, relative to morbidly obese patients without BS. Further study is necessary to determine if there is a pathophysiological mechanism underlying this higher risk of spinal disease and intervention in bariatric patients, and the effect of BS on these rates following treatment. LEVEL OF EVIDENCE: Level III.

Correction to: Prior bariatric surgery lowers complication rates following spine surgery in obese patients.

The AHRQ (Agency for Healthcare Research and Quality) has requested the correction of the result Tables 1-3 of this study: All stated numbers below 10 shall be modified to read "<10" instead.

Congenital Etiology Is an Independent Risk Factor for Complications in Adolescents Undergoing Corrective Scoliosis Surgery: Comparison of In-hospital Comorbidities Using Nationwide KID's Inpatient Database.

BACKGROUND: Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. METHODS: A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval). RESULTS: In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P<0.001), had fewer comorbidities (P<0.001), and sustained similar complication incidence. In the 10 and over age analysis, CS patients similarly had shorter fusions, but greater comorbidities, and significantly more complications (odds ratio, 1.6; confidence interval, 1.4-1.8). CONCLUSIONS: CS patients have higher in-hospital complication rates. With more comorbidities, these patients have increased risk of sustaining procedure-related complications such as shock, infection, and Adult Respiratory Distress Syndrome. These data help to counsel patients and their families before spinal fusion. LEVEL OF EVIDENCE: Level III-retrospective review of a prospectively collected database.

Incidence of Congenital Spinal Abnormalities Among Pediatric Patients and Their Association With Scoliosis and Systemic Anomalies.

BACKGROUND: Congenital abnormalities when present, according to VACTERL theory, occur nonrandomly with other congenital anomalies. This study estimates the prevalence of congenital spinal anomalies, and their concurrence with other systemic anomalies. METHODS: A retrospective cohort analysis on Health care Cost and Utilization Project's Kids Inpatient Database (KID), years 2000, 2003, 2006, 2009 was performed. ICD-9 coding identified congenital anomalies of the spine and other body systems. OUTCOME MEASURES: Overall incidence of congenital spinal abnormalities in pediatric patients, and the concurrence of spinal anomaly diagnoses with other organ system anomalies. Frequencies of congenital spine anomalies were estimated using KID hospital-and-year-adjusted weights. Poisson distribution in contingency tables tabulated concurrence of other congenital anomalies, grouped by body system. RESULTS: Of 12,039,432 patients, rates per 100,000 cases were: 9.1 hemivertebra, 4.3 Klippel-Fiel, 56.3 Chiari malformation, 52.6 tethered cord, 83.4 spina bifida, 1.2 absence of vertebra, and 6.2 diastematomyelia. Diastematomyelia had the highest concurrence of other anomalies: 70.1% of diastematomyelia patients had at least one other congenital anomaly. Next, 63.2% of hemivertebra, and 35.2% of Klippel-Fiel patients had concurrent anomalies. Of the other systems deformities cooccuring, cardiac system had the highest concurrent incidence (6.5% overall). In light of VACTERL's definition of a patient being diagnosed with at least 3 VACTERL anomalies, hemivertebra patients had the highest cooccurrence of ≥3 anomalies (31.3%). With detailed analysis of hemivertebra patients, secundum ASD (14.49%), atresia of large intestine (10.2%), renal agenesis (7.43%) frequently cooccured. CONCLUSIONS: Congenital abnormalities of the spine are associated with serious systemic anomalies that may have delayed presentations. These patients continue to be at a very high, and maybe higher than previously thought, risk for comorbidities that can cause devastating perioperative complications if not detected preoperatively, and full MRI workups should be considered in all patients with spinal abnormalities. LEVEL OF EVIDENCE: Level III.

Full-Body Radiographic Analysis of Postoperative Deviations From Age-Adjusted Alignment Goals in Adult Spinal Deformity Correction and Related Compensatory Recruitment.

BACKGROUND: Full-body stereographs for adult spinal deformity (ASD) have enhanced global deformity and lower-limb compensation associations. The advent of age-adjusted goals for classic ASD parameters (sagittal vertical axis, pelvic tilt, spino-pelvic mismatch [PI-LL]) has enabled individualized evaluation of successful versus failed realignment, though these remain to be radiographically assessed postoperatively. This study analyzes pre- and postoperative sagittal alignment to quantify patient-specific correction against age-adjusted goals, and presents differences in compensation in patients whose postoperative profile deviates from targets. METHODS: Single-center retrospective review of ASD patients ≥ 18 years with biplanar full-body stereographic x-rays. Inclusion: ≥ 4 levels fused, complete baseline and early (≤ 6-month) follow-up imaging. Correction groups generated at postoperative visit for actual alignment compared to age-adjusted ideal values for pelvic tilt, PI-LL, and sagittal vertical axis derived from clinically relevant formulas. Patients that matched exact ± 10-year threshold for age-adjusted targets were compared to unmatched cases (undercorrected or overcorrected). Comparison of spinal alignment and compensatory mechanisms (thoracic kyphosis, hip extension, knee flexion, ankle flexion, pelvic shift) across correction groups were performed with ANOVA and paired t tests. RESULTS: The sagittal vertical axis, pelvic tilt, and PI-LL of 122 patients improved at early postoperative visits (P < .001). Of lower-extremity parameters, knee flexion and pelvic shift improved (P < .001), but hip extension and ankle flexion were similar (P > .170); global sagittal angle decreased overall, reflecting global postoperative correction (8.3° versus 4.4°, P < .001). Rates of undercorrection to age-adjusted targets for each spino-pelvic parameter were 30.3% (sagittal vertical axis), 41.0% (pelvic tilt), and 43.6% (PI-LL). Compared to matched/overcorrections, undercorrections recruited increased posterior pelvic shift to compensate (P < .001); knee flexion was recruited in undercorrections for sagittal vertical axis and pelvic tilt; thoracic hypokyphosis was observed in PI-LL undercorrections. All undercorrected groups displayed consequentially larger global sagittal angle (P < .001). CONCLUSIONS: Global alignment cohort improvements were observed, and when comparing actual to age-adjusted alignment, undercorrections recruited pelvic and lower-limb flexion to compensate. LEVEL OF EVIDENCE: 3.

Effect of Obesity on Radiographic Alignment and Short-Term Complications After Surgical Treatment of Adult Cervical Deformity.

OBJECTIVE: We investigated the 30-day complication incidence and 1-year radiographic correction in obese patients undergoing surgical treatment of cervical deformity. METHODS: The patients were stratified according to World Health Organization's definition for obesity: obese, patients with a body mass index of ≥30 kg/m2; and nonobese, patients with a body mass index of <30 kg/m2. The patients had undergone surgery for the treatment of cervical deformity. The patient baseline demographic, comorbidity, and radiographic data were compared between the 2 groups at baseline and 1 year postoperatively. The 30-day complication incidence was stratified according to complication severity (any, major, or minor), and type (cardiopulmonary, dysphagia, infection, neurological, and operative). Binary logistic regression models were used to assess the effect of obesity on developing those complications, with adjustment for patient age and levels fused. RESULTS: A total of 124 patients were included, 53 obese and 71 nonobese patients. The 2 groups had a similar T1 slope minus cervical lordosis (obese, 37.2° vs. nonobese, 36.9°; P = 0.932) and a similar C2-C7 (-5.9° vs. -7.3°; P = 0.718) and C2-C7 (50.1 mm vs. 44.1 mm; P = 0.184) sagittal vertical axis. At the 1-year follow-up examination, the T1 pelvic angle (1.0° vs. -3.1°; P = 0.021) and C2-S1 sagittal vertical axis (-5.9 mm vs. -35.0 mm; P = 0.036) were different, and the T1 spinopelvic inclination (-1.0° vs. -2.9°; P = 0.123) was similar. The obese patients had a greater risk of overall short-term complications (odds ratio, 2.5; 95% confidence interval, 1.1-6.1) and infectious complications (odds ratio, 5.0; 95% confidence interval, 1.0-25.6). CONCLUSIONS: Obese patients had a 5 times greater odds of developing infections after surgery for adult cervical deformity. Obese patients also showed significantly greater pelvic anteversion after cervical correction.

Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database.

BACKGROUND: The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database. METHODS: The Kids' Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ2 for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P < .05. RESULTS: A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P < .001). CONCLUSIONS: Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Pre-operative planning and rod customization may optimize post-operative alignment and mitigate development of malalignment in multi-segment posterior cervical decompression and fusion patients.

Patient-specific rods designed based on a particular pre-operative plan are a recent advancement to help achieve desired operative alignment goals. This study investigated the role of pre-operative planning and patient-specific rods on post-operative alignment and outcomes. Patients were grouped according to use of pre-operative planning and patient-specific, pre-contoured rods (PLAN) or absence of planning/rods (NON). Pre-operative and post-operative alignment were measured: cervical sagittal vertical axis (cSVA), cervical lordosis (CL), T1 Slope minus CL (TS-CL). Alignment differences between the groups were assessed using independent and paired samples t-tests. 34 patients were identified (15 PLAN, 19 NON). Pre- and post-operative CL, cSVA and TS were similar between the two groups (p > 0.05), though pre-operative TS-CL was slightly higher in PLAN patients (28.13° versus 18.42°, p = 0.049). There were no improvement differences pre- to post-operative for CL, cSVA and TS between the groups (p > 0.05). However, PLAN patients exhibited a greater correction of TS-CL, with an average of 5.8° decrease versus a 3.5° increase in TS-CL for NON patients (p = 0.015). PLAN patients did not demonstrate a significant change from pre- to post-operative alignment for cSVA or TS-CL (cSVA: 27.5 mm to 31.1 mm, p = 0.255; TS-CL: 28.1° to 22.3°, p = 0.13), though their TS-CL did trend towards significant post-operative improvement. In contrast, NON patients worsened in cSVA and TS-CL post-operatively (cSVA: 21.8 mm to 30.3 mm, p < 0.001; TS-CL: 18.4° to 22.0°, p = 0.035). Multi-segment posterior decompression and fusion patients have the potential to worsen with regards to post-operative alignment without pre-operative planning. Patients with pre-contoured rods and pre-operative planning exhibited a greater correction of TS-CL after surgery than un-planned cases, though limited by the pre-operative difference in cervical-thoracic mismatch between planned and unplanned cases. LEVELS OF EVIDENCE: III.

Prior bariatric surgery lowers complication rates following spine surgery in obese patients.

BACKGROUND: Bariatric surgery (BS) is an increasingly common treatment for morbid obesity that has the potential to effect bone and mineral metabolism. The effect of prior BS on spine surgery outcomes has not been well established. The aim of this study was to assess differences in complication rates following spinal surgery for patients with and without a history of BS. METHODS: Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years 2004-2013. BS patients and morbidly obese patients (non-BS) were divided into cervical and thoracolumbar surgical groups and propensity score matched for age, gender, and invasiveness and complications compared. RESULTS: One thousand nine hundred thirty-nine spine surgery patients with a history of BS were compared to 1625 non-BS spine surgery patients. The average time from bariatric surgery to spine surgery is 2.95 years. After propensity score matching, 740 BS patients were compared to 740 non-BS patients undergoing thoracolumbar surgery, with similar comorbidity rates. The overall complication rate for BS thoracolumbar patients was lower than non-BS (45.8% vs 58.1%, P < 0.001), with lower rates of device-related (6.1% vs 23.2%, P < 0.001), DVT (1.2% vs 2.7%, P = 0.039), and hematomas (1.5% vs 4.5%, P < 0.001). Neurologic complications were similar between BS patients and non-BS patients (2.3% vs 2.7%, P = 0.62). For patients undergoing cervical spine surgery, BS patients experienced lower rates of bowel issues, device-related, and overall complication than non-BS patients (P < 0.05). CONCLUSIONS: Bariatric surgery patients undergoing spine surgery experience lower overall complication rates than morbidly obese patients. This study warrants further investigation into these populations to mitigate risks associated with spine surgery for bariatric patients.

Rates of Mortality in Lumbar Spine Surgery and Factors Associated With Its Occurrence Over a 10-Year Period: A Study of 803,949 Patients in the Nationwide Inpatient Sample.

BACKGROUND: The rate of mortality in surgical procedures involving the lumbar spine has historically been low, and as a result, there has been difficulty providing accurate quantitative mortality rates to patients in the preoperative planning phase. Awareness of these mortality rates is essential in reducing postoperative complications and improving outcomes. Additionally, mortality rates can be influenced by procedure type and patient profile, including demographics and comorbidities. The purpose of this study is to assess rates and risk factors associated with mortality in surgical procedures involving the lumbar spine using a large national database. METHODS: The Nationwide Inpatient Sample database was reviewed from 2003 to 2012. A total of 803,949 patients age 18 years or older were identified by ICD-9CM procedure codes for spinal fusion or decompression of the lumbar spine. Mortality was stratified based on type of procedure (simple or complex fusion, decompression), patient demographics and comorbidities, and in-hospital complications. Binary logistic regression was used to identify the risk of death while controlling for comorbidities, race, sex, and procedure performed. Significance was defined as P < .05 differences relative to the overall cohort. RESULTS: Mortality for all patients requiring surgery of the lumbar spine was 0.13%. Mortality based on procedure type was 0.105% for simple fusions, 0.321% for complex fusions, and 0.081% for decompression only. Increased mortality was observed demographically in patients who were male (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.51-2.03), black (OR: 1.40; CI: 1.10-1.79), ages 65-74 (OR: 1.46; CI: 1.25-1.70), and age 75+ (OR: 2.70; CI: 2.30-3.17). Comorbidities associated with the greatest increase in mortality were mild (OR: 10.04; CI: 7.76-13.01) and severe (OR: 26.47; CI: 16.03-43.70) liver disease and congestive heart failure (OR: 4.57; CI: 3.77-5.53). The complications with the highest mortality rates were shock (OR: 20.67; CI: 13.89-30.56) and pulmonary embolism (OR: 20.15; CI: 14.01-29.00). CONCLUSIONS: From 2003 to 2012, the overall mortality rate in 803,949 lumbar spine surgery patients was 0.13%. Risk factors that were significantly associated with increased mortality rates were male gender, black race, and ages 65-74 and 75+. Comorbidities associated with an increased mortality rate were mild and severe liver disease and congestive heart failure. Inpatient complications with the highest mortality rates were shock and pulmonary embolism. These findings can be helpful to surgeons providing preoperative counseling for patients considering elective lumbar procedures and for allocating resources to treat and prevent perioperative complications leading to mortality. LEVEL OF EVIDENCE: 3.

Arm Pain Versus Neck Pain: A Novel Ratio as a Predictor of Post-Operative Clinical Outcomes in Cervical Radiculopathy Patients.

BACKGROUND: Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain. METHODS: Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of "degenerative." Diagnoses included in the "degenerative" category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy. Baseline variables considered as predictors were: (1) age, (2) body mass index (BMI), (3) gender, (4) history of cervical spine surgery, (5) baseline Neck Disability Index (NDI) score, (6) baseline SF-36 Physical Component Summary (PCS) scores, (7) baseline SF-36 Mental Component Summary (MCS) scores, (8) Visual Analog Scale (VAS) Arm score, and (9) VAS Neck. Outcome Measures: Improvement in NDI (≥50%), VAS Arm/Neck (≥50%), SF-36 PCS/MCS (≥10%) scores at 2-years postoperative. An arm-to-neck ratio (ANR) was also generated from baseline VAS scores. Univariate and multivariate analyses evaluated predictors for 2-year postoperative outcome improvements, controlling for surgical complications and technique. RESULTS: Three hundred ninety-eight patients were included. Patients with ANR ≤ 1 (n = 214) were less likely to reach improvements in 2-year NDI (30.0% vs 39.2%, P = .050) and SF-36 PCS (42.4% vs 53.5%, P = .025). Multivariate analysis for neck disability revealed higher baseline SF-36 PCS (odds ratio [OR] 1.053) and MCS (OR 1.028) were associated with over 50% improvements. Higher baseline NDI were reduced odds of postoperative neck pain improvement (OR 0.958). Arm pain greater than neck pain at baseline was associated with both increased odds of postoperative arm pain improvement (OR 1.707) and SF36 PCS improvement (OR 1.495). CONCLUSIONS: This study identified specific symptom locations and health-related quality of life (HRQL) scores, which were associated with postoperative pain and disability improvement. In particular, baseline arm pain greater than neck pain was determined to have the greatest impact on whether patients met at least 50% improvement in their upper body pain score. These findings are important for clinicians to optimize patient outcomes through effective preoperative counseling.

Trends in Nonoperative Treatment Modalities Prior to Cervical Surgery and Impact on Patient-Derived Outcomes: Two-Year Analysis of 1522 Patients From the Prospective Spine Treatment Outcome Study.

BACKGROUND: Effects of nonoperative treatments on surgical outcomes for patients who failed conservative management for cervical spine pathologies remain unknown. The objective is to describe conservative modality use in patients indicated for surgery for degenerative cervical spine conditions and its impact on perioperative outcomes. METHODS: The current study comprises a retrospective review of a prospective multicenter database. A total of 1522 patients with 1- to 2-level degenerative cervical pathology who were undergoing surgical intervention were included. Outcome measures used were health-related quality-of-life scores, length of hospitalization, estimated blood loss, length of surgery, and return-to-work status at 2 weeks, 6 months, 1 year, and 2 years postoperatively. Patients were grouped by diagnosis (radiculopathy vs. myelopathy), then divided based on epidural injection(s), physical therapy (PT), or opioid use prior to enrollment. Univariate t-tests and χ2 tests were performed to determine differences between groups and impact on outcomes. RESULTS: Among 1319 radiculopathy patients, 25.7% received preoperative epidural injections, 35.3% received PT, and 35.5% received opioids. Radiculopathy patients who received epidurals and PT had higher 1-year postoperative return-to-work rates (P < .05). Radiculopathy patients without preoperative PT had longer hospitalization times, whereas those who received PT had higher 36-Item Short Form Health Survey (SF-36) physical functioning and physical component scores, lower 2-year visual analog scale (VAS) neck/arm pain scores, and higher 2-year return-to-work incidence (P < .05). Of myelopathy patients (n = 203), 14.8% received epidural injections, 25.1% received opioids, and 41.5% received PT. Myelopathy patients with preoperative PT had worse VAS arm pain scores 2 years postoperatively (P < .05). Patients receiving opioids were younger and had greater baseline-2-year Neck Disability Index improvement (P < .05). CONCLUSIONS: Radiculopathy patients receiving epidurals returned to work after 1 year more frequently. PT was associated with shorter hospitalizations, greater SF-36 bodily pain norm and physical component score improvements, and increased return-to-work rates after 1 and 2 years. No statistically significant nonoperative treatment was associated with return-to-work rate in myelopathy patients. CLINICAL RELEVANCE: These findings suggest certain preoperative conservative treatment modalities are associated with improved outcomes in radiculopathy patients.

The Influence of Body Mass Index on Achieving Age-Adjusted Alignment Goals in Adult Spinal Deformity Corrective Surgery with Full-Body Analysis at 1 Year.

BACKGROUND: The impact of obesity on global spinopelvic alignment is poorly understood. This study investigated the effect of body mass index on achieving alignment targets and compensation mechanisms after corrective surgery for adult spinal deformity (ASD). METHODS: Retrospective review of a single-center database. Inclusion: patients ≥18 years with full-body stereographic images (baseline and 1 year) and who met ASD criteria (sagittal vertical axis [SVA] >5 cm, pelvic incidence minus lumbar lordosis [PI-LL] >10°, coronal curvature >20° or pelvic tilt >20°). Patients were stratified by age (<40, 40-65, and ≥65 years) and body mass index (<25, 25-30, and >30). Postoperative alignment was compared with age-adjusted ideal values. Prevalence of patients who matched ideals and unmatched (undercorrected/overcorrected) was assessed. Health-related quality of life (HRQL) scores, alignment, and compensatory mechanisms were compared across cohorts using analysis of variance and temporally with paired t tests. RESULTS: A total of 116 patients were included (average age, 62 years; 66% female). After corrective surgery, obese and overweight patients had more residual malalignment (worse PI-LL, T1 pelvic angle, pelvic tilt, and SVA) compared with normal patients (P < 0.05). In addition, obese and overweight patients recruited more pelvic shift (obese, 62.36; overweight, 49.80; normal, 31.50) and had a higher global sagittal angle (obese, 6.51; overweight, 6.35; normal, 3.40) (P < 0.05). Obese and overweight patients showed lower overcorrection rates and higher undercorrection rates (P < 0.05). Obese patients showed worse postoperative HRQL scores (Scoliosis Research Society 22 Questionnaire, Oswestry Disability Index, visual analog scale-leg) than did overweight and normal patients (P < 0.05). Obese and overweight patients who matched age-adjusted alignment targets for SVA or PI-LL showed no HRQL improvements (P > 0.05). CONCLUSIONS: After surgery, obese patients were undercorrected, showed more residual malalignment, recruited more pelvic shift, and had a greater global sagittal angle and worse HRQL scores. The benefits from age-adjusted alignment targets seem to be less substantial for obese and overweight patients.

Adverse Outcomes and Prediction of Cardiopulmonary Complications in Elective Spine Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The purpose of this study was to report incidence of cardiopulmonary complications in elective spine surgery, demographic and surgical predictors, and outcomes. Understanding the risks and predictors of these sentinel events is important for risk evaluation, allocation of hospital resources, and counseling patients. METHODS: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) was performed on 60 964 patients undergoing elective spine surgery (any region; laminectomy, arthrodesis, discectomy, or laminoplasty) between 2011 and 2013. Incidence of myocardial infarction, cardiac arrest, unplanned reintubation, on ventilator >48 hours, perioperative pneumonia, and pulmonary embolism was measured. Demographic and surgical predictors of cardiopulmonary complications and associated outcomes (length of stay, discharge disposition, and mortality) were measured using binary logistic regression controlling for confounders. RESULTS: Incidence rates per 1000 elective spine patients were 2.1 myocardial infarctions, 1.3 cardiac arrests, 4.3 unplanned intubations, 3.5 on ventilator >48 hours, 6.1 perioperative pneumonia, and 3.7 pulmonary embolisms. In analysis of procedure, diagnosis, and approach risk factors, thoracic cavity (odds ratio = 2.47; confidence interval = 1.95-3.12), scoliosis diagnosis, and combined approach (odds ratio = 1.51; confidence interval = 1.15-1.96) independently added the most risk for cardiopulmonary complication. Cardiac arrest had the highest mortality rate (34.57%). Being on ventilator greater than 48 hours resulted in the greatest increase to length of stay (17.58 days). CONCLUSIONS: Expected risk factors seen in the Revised Cardiac Risk Index were applicable in the context of spine surgery. Surgical planning should take into account patients who are at higher risk for cardiopulmonary complications and the implications they have on patient outcome.

Predictors of adverse discharge disposition in adult spinal deformity and associated costs.

BACKGROUND CONTEXT: With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount. PURPOSE: Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges. STUDY DESIGN/SETTING: This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database. PATIENT SAMPLE: Patients undergoing thoracolumbar surgery for correction of ASD were included in the study. OUTCOME MEASURES: Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups. METHODS: Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion. RESULTS: A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio [OR]: 0.28, confidence interval [CI]: 0.22-0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35-0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40-0.64), interbody device placement (OR: 0.80, CI: 0.64-0.98), and fixation to the iliac (OR: 0.54, CI: 0.41-0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21-0.57) and blood transfusions (OR: 0.42, CI: 0.34-0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p<.001), but again not different from skilled nursing facility discharges (+$6,091, p=.212). CONCLUSIONS: Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility.

Full-Body Analysis of Adult Spinal Deformity Patients' Age-Adjusted Alignment at 1 Year.

BACKGROUND: Previous studies have built a foundation for understanding compensation in patients with adult spinal deformity (ASD) by using full-body stereographic assessments. These mechanisms, in relation to age-adjusted alignment targets, have yet to be studied fully. The aim of this study was to assess lower-limb compensatory mechanisms of patients failing to meet age-adjusted alignment goals. METHODS: Patients with ASD ≥40 years with full body baseline and follow-up radiographs were included. Patients were stratified by age (40-65 years, >65 years) and spinopelvic correction. Lower-limb compensation parameters (pelvic shift, hip extension, knee flexion [KA], ankle flexion [AA], and global sagittal angle [GSA]) for patients who matched and failed to match age-adjusted alignment targets were compared with analysis of variance and t-test analysis. RESULTS: In total, 108 patients were included. At 1 year, AA increased with age in the "match" pelvic tilt (PT) and spinopelvic mismatch (PI-LL) cohorts (PT: AA, 5.6-7.8, P = 0.041; PI-LL: 4.9-8.8, P = 0.026). KA, AA, and GSA increased with age in the "match" sagittal vertical axis (SVA) cohort (KA: 3.8-13.1, P = 0.002; AA: 5.8-10.2, P = 0.008; GSA: 3.9-7.8, P < 0.001), as did KA and GSA in the "match" T1 pelvic angle group (KA: 1.8-8.7, P = 0.020; GSA: 2.6-5.7, P = 0.004). CONCLUSIONS: Greater compensation captured by KA and GSA was associated with age progression in the "match" SVA and T1 pelvic angle cohorts. In addition, older SVA, PT, and PI-LL "match" cohorts used increased AA, suggesting that ideal postoperative alignment of aged individuals with ASD involves increased compensation.

Comparing psychological burden of orthopaedic diseases against medical conditions: Investigation on hospital course of hip, knee, and spine surgery patients.

Retrospective review of National Inpatient Sample (2000-2012) revealed that 31.28% of musculoskeletal (MSK) patients were found to have in-hospital psychological burdens (PBs). Adult spinal deformity (ASD), degenerative disc disease (DDD) and lung cancer patients had highest PB-prevalence. MSK patients with PB were more often young, white females with increased Deyo index compared to no-PB patients. Patients who underwent spinal revision procedures had higher PB rates than with primary procedures; a converse trend was observed for total hip/knee arthroplasty. Psychological disorders were identified as significant predictors of increased total-hospital charges. Augmenting counseling with psychological screening/support is recommended to complement MSK management.

Baseline mental status predicts happy patients after operative or non-operative treatment of adult spinal deformity.

BACKGROUND: The study is a retrospective review of a multi-institutional database, aiming to determine predictors of non-depressed, satisfied adult spinal deformity (ASD) patients with good self-image at 2-year follow-up (2Y). ASD significantly impacts a patients' psychological status. Following treatment, little is known about predictors of satisfied patients with high self-image and mental status. METHODS: Inclusion: primary ASD pts >18 y/o with complete 2Y follow-up. Non-depressed [Short Form 36-mental component score (SF36-MCS) >42], satisfied patients (SRS22-satisfaction >3) with good self-image (SR22-self-image >3) at 2Y were isolated (happy). Happy and control patients were propensity-matched by baseline and 2Y leg pain, Charlson, frailty, and radiographic measures for the operative (OP) and non-operative cohorts (NOP). Health related quality of life (HRQL), surgical and radiographic metrics were compared. Regression models identified predictors of happy patients. Thresholds were calculated using area under the curve (AUC) and 95%CI. RESULTS: Of 480 patients, 94 OP (happy: 47 vs. control: 47) and 92 NOP (46 each) reached inclusion. At baseline, groups had similar age, gender, Oswestry disability index (ODI) (OP: 39.13 vs. 37.49, NOP: 17.70 vs. 19.74) and SF36-physical component score (PCS) (OP: 33.51 vs. 35.04, NOP: 47.93 vs. 44.72). Despite similar (P>0.05) surgeries, length of stay (LOS), and radiographic outcomes between OP happy and control groups, happy had less peri-operative complications (31.9% vs. 57.4%, P=0.13), better 2Y ODI (17.77 vs. 29.98), SRS22 component, total, and SF36 scores (P<0.05). NOP happy patients also exhibited better 2Y ODI (13.24 vs. 22.09), SRS22 component, total, and SF36 scores (P<0.05). Baseline SRS-mental (OR: 2.199, AUC: 0.617, cutoff: 2.5) and ODI improvement (OR: 1.055, AUC: 0.717, cutoff: >12) predicted happy OP patients, while baseline SRS-self-image (OR: 5.195, AUC: 0.740, cutoff: 3.5) and ODI improvement (OR: 1.087, AUC: 0.683, cutoff: >9) predicted happy NOP patients. CONCLUSIONS: Baseline mental-status, self-image and ODI improvement significantly impact long-term happiness in ASD patients. Despite equivalent management and alignment outcomes, operative and non-operative happy patients had better 2Y disability scores. Management strategies aimed at improving baseline mental-status, perception-of-deformity, and maximizing ODI may optimize treatment outcomes.

Vertebral Osteomyelitis: A Comparison of Associated Outcomes in Early Versus Delayed Surgical Treatment.

BACKGROUND: The recommended timing of surgical intervention for vertebral osteomyelitis (VO) is controversial; however, most studies are not sufficiently powered. Our goal was to investigate the associated effects of delaying surgery in VO patients on in-hospital complications, neurologic deficits, and mortality. METHODS: Retrospective review of the National Inpatient Sample. Patients who underwent surgery for VO from 1998 to 2013 were identified using codes from the International Classification of Disease, Ninth Revision, Clinical Modification. Patients were stratified into groups based on incremental delay of surgery: 0-day delay (same-day surgery), 1-day delay, 2-day delay, 3- to 6-day delay, 7- to 14-day delay, and 14- to 30-day delay. Univariate analysis compared demographics and outcomes between groups. Multivariate logistic regression models calculated independent predictors of any complication, mortality, and neurologic deficits. A 0-day delay was the reference group. RESULTS: A total of 34 465 patients were identified. Delayed groups were older (same day: 53.5 vs. 7-14-day delay: 61.1) and had a higher Deyo-Charlson score (same day: 0.4901 vs. 14-30-day delay: 1.66), length of stay (same day: 4.2 vs. 14-30-day delay: 34.04 days), and total charges (same day: $63,390.78 vs. 14-30-day delay: $245,752.4), all P < .001. Delayed groups had higher surgical combined-approach rates (same day: 9.1% vs. 14-30-day delay: 31.5%) and lower anterior-approach rates (same day: 42.4% vs. 14-30-day delay: 24.2%). Delayed groups had increased mortality and complication rates. Regressions showed delayed groups as the strongest independent indicators of any complication (14-30-day delay: odds ratio [OR] 3.384), mortality (14-30-day delay: OR 10.658), and neurologic deficits (14-30-day delay: OR 3.464), all P < .001. CONCLUSION: VO patients who operate within 24 hours of admission are more likely to have desirable outcomes. Patients with delayed surgery had a significantly increased risk of developing any complication, mortality, and discharging with neurologic deficits. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Medically fit patients may benefit from earlier surgical management in order to reduce risk of postoperative complications, improve outcomes, and reduce overall hospital costs.