Predictors of hospital-acquired pressure injuries in patients with complete spinal cord injury: a retrospective case-control study.

BACKGROUND: Despite current best practices, pressure injuries (PI) remain a devastating and prevalent hospital-acquired complication for patients with acute traumatic spinal cord injuries (SCIs). This study examined associations between risk factors for PI development in patients with complete SCI, such as norepinephrine dose and duration, and other demographic factors or lesion characteristics. METHODS: This case-control study included adults with acute complete SCIs ASIA-A, who were admitted to a level-one trauma center between 2014-18. A retrospective review was implement using data on patient and injury characteristics, including age, gender, level of SCI (cervical vs. thoracic), Injury Severity Score (ISS), length of stay (LOS) and mortality; presence/absence of PI during their acute hospital stay; and treatment factors such as spinal surgery, mean arterial pressure (MAP) targets, and vasopressor treatment. Multivariable logistic regression evaluated associations with PI. RESULTS: Eighty-two out of 103 eligible patients had complete data, and 30 (37%) developed PIs. Patient and injury characteristics, including age (Mean: 50.6; SD:21.3), location of SCI (48 cervical, 59%) and ISS (Mean 33.1; SD:11.8), did not differ between PI and non-PI groups. Logistic regression analysis revealed that male gender (OR:34.1; CI95:2.3-506.5, p = 0.010) and increased LOS (log-transformed; OR:20.5, CI95:2.8-149.9, p = 0.003) were associated with increased risk of PI. Having an order for a MAP > 80mmg (OR:0.05; CI95:0.01-0.30, p = 0.001) was associated with a reduced risk of PI. There were no significant associations between PI and duration of norepinephrine treatment. CONCLUSIONS: Norepinephrine treatment parameters were not associated with development of PI, suggesting that MAP targets should be a focus for future investigations for SCI management. Increasing LOS should highlight the need for high-risk PI prevention and vigilance.

Moving toward better health: exercise practice is associated with improved outcomes after spine surgery in people with degenerative lumbar conditions.

Background: Recovery and rehabilitation following surgery can take many months. Understanding what patients can do to facilitate recovery would be beneficial for spinal surgeons. This study sought to evaluate the impact of exercise practice, before and after surgery, on long-term outcomes of spine surgery in a robust clinical sample. Methods: This prospective longitudinal cohort study included adult patients undergoing spinal surgery for degenerative spinal conditions. Patients were administered a survey that included preoperative and postoperative exercise practices and the following patient-reported outcome measures: the physical component score (PCS) and mental component score (MCS) of the Medical Outcomes Study 36-Item Short Form Survey (Rand-36), the Oswestry Disability Index (ODI) score, the Numeric Rating Scale (NRS) score for pain and the Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference Short Form score. Random effects models investigated the relationship of exercise, follow-up time and their interaction in predicting each patient-reported outcome measure over time, with and without sociodemographic covariates. Results: There were 168 patients in the study sample with up to 12 months of follow-up data. Analysis revealed modest significant main effects of exercise on PCS, MCS, ODI and PROMIS scores and main effects of time on all outcomes. The exercise-by-time interaction was significant in predicting the trajectories of the ODI and MCS scores. When full models were adjusted for education and employment status, interaction effects were no longer significant, but exercise main effects remained significant for ODI score. Conclusion: Patients who engage in exercise before and after spine surgery have better mental health and spine-specific recovery trajectories than those who do not. All health care providers should encourage patients to exercise while they are waiting for surgery within preoperative limitations and as soon as they are able after surgery and to continue this over the long term.

Contexte: Le rétablissement et la réadaptation postopératoires s'échelonnent parfois sur plusieurs mois. Comprendre ce que les patients peuvent faire pour faciliter leur rétablissement serait utile aux spécialistes de la chirurgie de la colonne vertébrale. Cette étude a voulu évaluer l'impact de la pratique d'exercices avant et après une chirurgie de la colonne vertébrale sur son issue à long terme dans un solide échantillon clinique. Méthodes: Cette étude de cohorte longitudinale prospective a regroupé des patients adultes qui devaient subir une chirurgie de la colonne vertébrale pour des maladies dégénératives. Les patients ont été invités à répondre à un questionnaire qui portait entre autre sur la pratique d'exercices pré- et postopératoires et sur les paramètres autorapportés suivants : scores aux composantes physique (PCS) et mentale (MCS) du questionnaire SF-36 (Medical Outcomes Study 36-Item Short Form Survey [Rand-36]), à l'échelle d'incapacité d'Oswestry (ODI), à une échelle d'évaluation numérique (ÉÉN) de la douleur et au questionnaire court PROMIS (Patient-Reported Outcome Measurement Information System) sur l'interférence de la douleur. Des modèles à effets aléatoires ont permis d'analyser les liens entre l'exercice, la durée du suivi et leur interaction pour ce qui est de prédire chacun des paramètres autorapportés au fil du temps, avec et sans les covariables sociodémographiques. Résultats: L'étude a regroupé 168 patients et les données pour un suivi allant jusqu'à 12 mois. L'analyse a fait état d'effets majeurs significatifs modestes de l'exercice sur les paramètres PCS, MCS, ODI et PROMIS et d'effets majeurs du temps sur tous les paramètres. L'interaction entre exercices et durée du suivi a été significative pour prédire la trajectoire des scores ODI et MCS. Lorsque les modèles intégraux ont été ajustés pour tenir compte du niveau de scolarité et du statut professionnel, les effets de l'interaction n'étaient plus significatifs, mais les effets majeurs de l'exercice sont demeurés significatifs pour le score ODI. Conclusion: Les patients qui ont fait des exercices avant et après une chirurgie de la colonne vertébrale ont présenté des trajectoires plus favorables au plan de la santé mentale et du rétablissement de leur colonne vertébrale comparativement à ceux qui n'avaient pas fait d'exercices. Tous les professionnels de la santé devraient encourager les patients à faire des exercices pendant qu'ils attendent leur chirurgie en tenant compte de leurs limites préopératoires, à les reprendre le plus rapidement possible après la chirurgie et à les maintenir à long terme.

Responsiveness of standard spine outcome tools: do they measure up?

OBJECTIVE: Over the past 2 decades, spine outcome research has become more standardized in response to recommendations from Deyo and others. By using the same generic and condition-specific patient-reported outcome (PRO) measures across studies, results are more easily compared. Given the challenges of maintaining high-quality data in clinical research studies, it would be important to evaluate the contribution of each PRO to confirm that it merits the respondent burden. This study aimed to examine the spine PROs' association with clinically important change and relative responsiveness in explaining variance in patients' global assessment of change (GAC). METHODS: This prospective longitudinal cohort study included adults recruited from 4 active spine surgery practices at a Toronto-based hospital. Patients were diagnosed with a degenerative lumbar spinal condition and underwent spinal decompression and/or fusion surgery. Participants completed the RAND-36 (to generate the physical component score [PCS] and mental component score [MCS]), Oswestry Disability Index (ODI), the numeric rating scale (NRS) for pain, Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference, and a GAC item. Random-effects models were used to investigate the sensitivity of PROs to the GAC and their responsiveness over time (i.e., PRO main effects and PRO-by-time interactions, respectively). RESULTS: The study sample included 168 patients (mean age 61 years, 50% female) with preoperative and up to 12 months of postoperative data. Random-effects models revealed significant main effects for all PROs. Significant time-by-PRO interactions were detected for the PCS, PROMIS, ODI, and NRS (p < 0.0005 in all cases), but not for the MCS. Further examination revealed different sensitivity of the PROs to the GAC at different times. The NRS, PROMIS, and PCS showed higher sensitivity early after surgery, and the PCS evinced a marked drop in sensitivity to the GAC at about 8 months postsurgery. CONCLUSIONS: All PROs currently included in the spine outcome core measures are associated with patients' subjective assessment of a clinically important change, and all but the MCS scores are responsive to such change. Based on these findings, the core spine PROs could be reduced to include fewer estimates of pain. The authors suggest replacing the less responsive measures with tools that help to characterize factors that are driving the patients' subjective assessment of change and that meaningfully address some of the higher levels in the hierarchy of quality-of-life outcomes.