Short term outcomes associated with patients requiring blood transfusion following elective laminectomy and fusion for lumbar stenosis: A propensity-matched analysis.

Perioperative blood transfusion has been associated with poor outcomes but the impacts of transfusion after fusion for lumbar stenosis have not been well-described. We assessed this effect in a large cohort of patients from 2012 to 2018 in the National Surgical Quality Improvement Program (NSQIP). We evaluated baseline characteristics including demographics, comorbidities, hematocrit, and operative characteristics. We generated propensity scores using baseline characteristics and patients were matched to approximate randomization. We assessed odds of 30-day outcomes including prolonged length-of-stay (LOS), complications, discharge to facility, readmission, reoperation, and death using logistic regression. We identified 16,329 eligible patients who underwent lumbar fusion for stenosis; 1,926 (11.8%) received a transfusion. Before matching, there were multiple differences in baseline covariates including age, gender, BMI, ASA class, medical comorbidities, hematocrit, coagulation indices, platelets, operative time, fusion technique, number of levels fused, and osteotomy. However, after matching, no significant differences remained. In the matched cohorts, transfusion was associated with increased prolonged LOS (OR 1.66, 95% CI 1.45-1.91, p < 0.001), minor complication (OR 1.60, 95% CI 1.20-2.12, p = 0.001), major complication (OR 1.51, 95% CI 1.16-1.98, p = 0.003), any complication (OR 1.54, 95% CI 1.24-1.92, p < 0.001), discharge to facility (OR 1.70, 95% CI 1.48-1.95, p < 0.001), 30-day readmission (OR 1.56, 95% CI 1.23-1.99, p < 0.001), and 30-day reoperation (OR 1.85, 95% CI 1.35-2.53, p < 0.001). Although transfusion is performed based on perceived clinical need, this study contributes to growing evidence that it is important to balance the risks of perioperative blood transfusion with its benefits.

Risk Factors for Thirty-Day Morbidity and Mortality in Extradural Lumbar Spine Tumor Resection.

BACKGROUND: Epidural tumors in the lumbar spine represent a unique cohort of lesions with individual risks and challenges to resection. Knowledge of modifiable risk factors are important in minimizing postoperative complications. OBJECTIVE: To determine the risk factors for 30-day morbidity and mortality in patients undergoing extradural lumbar tumor resection. METHODS: A retrospective study of prospectively collected data using the American College of Surgeons National Quality Improvement Program database was performed. Adults who underwent laminectomy for excision of lumbar spine tumors between 2011 and 2014 were included in the study. Demographics and medical comorbidities were collected, along with morbidities and mortalities within 30 postoperative days. A multivariate binary logistic analysis of these clinical variables was performed to determine covariates of morbidity and mortality. RESULTS: The database search yielded 300 patients, of whom 118 (39.3%) were female. Overall, complications within 30 days of surgery occurred in 102 (34%) patients. Significant risk factors for morbidity included preoperative anemia (P < 0.0001), the need for preoperative blood transfusion (P = 0.034), preoperative hypoalbuminemia (P = 0.002), American Society of Anesthesiologists score 3 or 4 (P = 0.0002), and operative time >4 hours (P < 0.0001). Thirty-day mortality occurred in 15 (5%) patients and was independently associated with preoperative anemia (odds ratio 3.4, 95% confidence interval 1.8-6.5) and operative time >4 hours (odds ratio 2.6, 95% confidence interval 1.1-6.0). CONCLUSIONS: Excision of epidural lumbar spinal tumors carries a relatively high complication rate. This series reveals distinct risk factors that contribute to 30-day morbidity and mortality, which may be optimized preoperatively to improve surgical safety.

Pre-operative functional status as a predictor of morbidity and mortality after elective cervical spine surgery.

AIMS: Patients seeking cervical spine surgery are thought to be increasing in age, comorbidities and functional debilitation. The changing demographics of this population may significantly impact the outcomes of their care, specifically with regards to complications. In this study, our goals were to determine the rates of functionally dependent patients undergoing elective cervical spine procedures and to assess the effect of functional dependence on 30-day morbidity and mortality using a large, validated national cohort. PATIENTS AND METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program data files from 2006 to 2013 was conducted to identify patients undergoing common cervical spine procedures. Multivariate logistic regression models were generated to analyse the independent association of functional dependence with 30-day outcomes of interest. RESULTS: Patients with lower functional status had significantly higher rates of medical comorbidities. Even after accounting for these comorbidities, type of procedure and pre-operative diagnosis, analyses demonstrated that functional dependence was independently associated with significantly increased odds of sepsis (odds ratio (OR) 5.04), pulmonary (OR 4.61), renal (OR 3.33) and cardiac complications (OR 4.35) as well as mortality (OR 11.08). CONCLUSIONS: Spine surgeons should be aware of the inherent risks of these procedures with the functionally dependent patient population when deciding on whether to perform cervical spine surgery, delivering pre-operative patient counselling, and providing peri-operative management and surveillance. Cite this article: Bone Joint J 2017;99-B:824-8.

Palliative transpedicular partial corpectomy without anterior vertebral reconstruction in lower thoracic and thoracolumbar junction spinal metastases.

BACKGROUND: The thoracolumbar junction is the transition from a stiff (thoracic spine) to a mobile zone (lumbar spine) and is relatively unstable compared with the thoracic and lumbar portions of the spine. The need for anterior reconstruction after a corpectomy has been emphasized by several authors. However, for patients with a relatively short life expectancy, anterior reconstruction may be unnecessary. Posterior instrumentation alone may be sufficient to provide pain relief and stability for such patients. The goal of this study was to assess the postoperative outcomes and survival rates of patients with tumor metastases of the lower thoracic spine and thoracolumbar junction (T10-L1) who underwent transpedicular partial corpectomy without anterior vertebral reconstruction. METHODS: From November 2001 to February 2015, 29 patients diagnosed with symptomatic spinal cord compression caused by tumor metastasis involving T10 to L1 underwent palliative surgery that involved a posterolateral transpedicular partial corpectomy without anterior reconstruction. The surgical indication was neurologic progression. A follow-up was conducted for all of the patients, including reviewing medical records and performing an examination in the outpatient department. RESULTS: The patients ranged in age from 33 to 83 years (mean, 61.6 years). Neurologic improvement by at least one Frankel grade was noted in 75.9 % of the patients (N = 22). Neither intraoperative mortality nor implant failure was reported. The median survival rate was 7.43 months (range, 0.47-28 months). CONCLUSION: The results of this study suggest that the stability of implants can be maintained up to 28 months with satisfying functional outcome after a palliative posterolateral transpedicular partial corpectomy without anterior reconstruction.

Circumferential cervical surgery: to stage or not to stage?

STUDY DESIGN: Retrospective review. OBJECTIVE: The objective of the study was to determine the morbidity and mortality rate associated with same day versus staged cervical circumferential approach. SUMMARY OF BACKGROUND DATA: A combined approach to the cervical spine is often indicated for complex cervical pathologies. Previous studies suggested superior results associated with same day combined surgery for thoracolumbar patients. This study examines the usefulness of p-Physiological and Operative Severity Score for enumeration of Morbidity and Mortality (POSSUM), an estimated mortality risk assessment for cervical spine patients and will compare same day surgery to staged procedures. METHODS: This is a retrospective chart review including patients who underwent ventral and dorsal approach within 2 weeks. Estimated mortality was calculated using p-POSSUM. The cohort was divided into same day surgery group and staged group. Risk factors were compared between groups. Mean p-POSSUM was calculated and compared with the actual mortality rate. Univariate analysis was used to compare the risk factors between groups and the groups' outcomes. Multivariable analysis was used to adjust for risk factor differences when comparing group outcomes. RESULTS: One hundred thirty-five patients were included, 106 patients were in the same day surgery group whereas 29 patients were in the staged group. Mean p-POSSUM was 2.8% predicted mortality with a 95% confidence interval of 1.6% to 4.1%. The actual mortality rate was 3.7%. The groups did not vary in most risk factors assessed. Univariate analysis demonstrated a statistically significantly higher rate of major complications (0.62 vs. 0.34, P=0.0369), infection (41.4% vs. 9.4%, P<0.0001), and length of hospital stay (9.3 vs. 6.8 d, P=0.0120) in the staged group. Multivariable analysis demonstrated significantly higher infection rate in the staged group. CONCLUSIONS: P-POSSUM mortality estimate may serve as a useful and valid tool for spine surgery studies. Staged combined cervical surgery harbors a higher complication rate and may be associated with lengthier hospitalization.

Lateral extracavitary, costotransversectomy, and transthoracic thoracotomy approaches to the thoracic spine: review of techniques and complications.

STUDY DESIGN: Systematic review. OBJECTIVE: The authors review complications, as reported in the literature, associated with ventral and posterolateral approaches to the thoracic spine. SUMMARY OF BACKGROUND: The lateral extracavitary, costotransversectomy, and transthoracic thoracotomy techniques allow surgeons to access the ventral thoracic spine for a wide range of spinal disorders including tumor, degeneration, trauma, and infection. Although the transthoracic thoracotomy has been used traditionally to reach the ventral thoracic spine when access to the vertebral body is required, modifications to the various dorsal approaches have enabled surgeons to achieve goals of decompression, reconstruction, and stabilization through a single approach. METHODS: A systematic Medline search from 1991 to 2011 was performed to identify series reporting clinical data related to these surgical approaches. The morbidity associated with each approach is reviewed and strategies for complications avoidance are discussed. RESULTS: Four thousand six hundred seventy-seven articles that assessed outcomes of the approaches to the thoracic spine were identified; of these 31 studies that consisted of 774 patients were selected for inclusion. A mean complication rate of 39%, 17%, and 15% for thoracotomy, lateral extracavitary, and costotransversectomy, respectively, was determined. The thoracotomy approach had the highest reoperation (3.5%) and mortality rates (1.5%). The specific complications and neurological outcomes were categorized. CONCLUSIONS: Outcomes of the surgical approaches to the thoracic spine have been reported with great detail in the literature. There are limited studies comparing the respective advantages and disadvantages and the differences in technique and outcome between these approaches. The present review suggests that in contrast to the historical experience of the laminectomy for thoracic spine disorders, these alternative approaches are safe and rarely associated with neurological deterioration. The differences between these approaches are based on their complication profiles. A thorough understanding of the regional anatomy will help avoid approach-related complications.

Posterior-only approach for en bloc sacrectomy: clinical outcomes in 36 consecutive patients.

BACKGROUND: En bloc resection of primary sacral tumors has a demonstrated survival benefit. Total and high sacral amputations are traditionally performed by using a staged anterior and subsequent posterior approach. However, we have found that en bloc resection and biomechanical reconstruction of the spinal column is possible from a posterior-only approach in many cases. OBJECTIVE: To assess our series of posterior-only sacrectomies, emphasizing postoperative complications and overall surgical and oncologic outcome. METHODS: Sixty-nine consecutive patients underwent sacral resections for tumor at our institution between 2004 and 2009. Medical records of all patients were reviewed, and patients were excluded if they had an intentional intralesional resection, hemipelvectomy, or a previous operation. The records of the resulting 36 consecutive patients who underwent primary posterior-only en bloc sacral resections were retrospectively reviewed. RESULTS: Of the posterior-only patients, all underwent midline posterior approaches for en bloc sacral resection. Sacral amputation was defined by the by sacral root preservation: total (2 cases), high (8 cases), middle (9 cases), low (12 cases), and distal (5 cases). Chordoma was the most common tumor type (30 cases), and surgical margins were marginal in 34 cases and contaminated in 2. Overall, there were 13 complications, including 9 wound infections/revisions. The extent of sacrectomy, and thus the extent of roots sacrificed, correlated with functional outcome. CONCLUSION: It may be possible to perform a posterior-only approach to en bloc sacral resections/reconstructions in patients with tumors that do not extend beyond the lumbosacral junction or invade the bowel requiring bowel resection and diversion.

Surgical mortality and complications leading to reoperation in 318 consecutive posterior decompressions for cervical spondylotic myelopathy.

OBJECTIVE: To determine surgical mortality, incidence of surgery-related neurological deterioration and incidence of postoperative infection or hematoma requiring reoperation in a consecutive series of 318 patients surgically treated with laminectomy or laminoplasty for cervical spondylotic myelopathy (CSM). MATERIALS AND METHODS: This is a retrospective study of 318 consecutive patients treated with laminectomy or laminoplasty for CSM at Oslo University Hospital in the time period 2003-2008. The defined neurosurgical catchment area for OUS is the southeast region of Norway with 2.7 mill inhabitants. The patient charts were systematically reviewed, focusing primarily on operative notes, postoperative (po) complications, such as po deterioration of neurological function, po hematoma and po infection and neurological function at most recent follow-up. RESULTS: The mean age was 64 years (range 29-90 years). Laminectomy was performed in 310/318 (97.5%) and laminoplasty in 8/318 (2.5%) of the patients. The incidence of laminectomy/laminoplasty for CSM was 2.0/100,000 inhabitants per year. The surgical mortality was 0%, and 37 (11.6%) patients had a deterioration of neurological function in the immediate postoperative period. Four (1.3%) patients were reoperated because of po hematoma. We found a statistically significant association between po hematoma and previous posterior neck surgery and American Association of Anaesthetists (ASA) score. Five (1.6%) patients were reoperated because of postoperative infection. Univariate logistic regression analysis showed a statistically significant association between po infection and the number of levels decompressed. CONCLUSIONS: The incidence of laminectomy/laminoplasty for CSM is 2.0/100,000 inhabitants per year. Surgical mortality, postoperative hematoma and postoperative infection are rare complications of laminectomy/laminoplasty for CSM. Neurological deterioration is not an uncommon complication after posterior decompression for CSM.

Survivorship analysis of 150 consecutive patients with DIAM™ implantation for surgery of lumbar spinal stenosis and disc herniation.

Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1-48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4-5; 31, L5-6) and 4 two-level (L4-5 and L5-6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5-6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan-Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2-29 months). Kaplan-Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5-6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4-5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5-6 [hazard ratio (HR), 10.3; 95% CI, 1.7-63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2-90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5-6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4-5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5-6 and two-level in patients with LSTV are significant risk factors for reoperation.

Laminectomy and fusion after spinal cord injury: national inpatient complications and outcomes.

There is little information about national in-hospital complication rates, adverse outcomes, and mortality after spinal fusion for spinal cord injury (SCI). The National Inpatient Sample (NIS) was utilized to identify 31,381 admissions of acute spinal cord injured patients who underwent spinal decompression with laminectomy and/or fusion (lam/fusion) in the United States from 1993 to 2002. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on outcomes such as mortality, complications, and discharge disposition, which were then stratified by age, level, and type of injury. The overall mortality was 3.0%, with a complication rate of 26.3% and mean length of stay (LOS) of 17 days. Pulmonary complications (14.4%) and postoperative hemorrhages or hematomas (3.8%) were the most common complications reported. One postoperative complication doubled the length of stay, increased the mortality rate by fivefold and added over $50,000 to hospital charges. Age and comorbidities were the main significant predictors of mortality on multivariate analysis. Patients aged >85 or 65-84 had a 44- and 14-fold greater risk of dying compared with patients in the 18-44 age group respectively. Patients with >3 comorbidities also had an increased risk of mortality (odds ratio [OR] = 1.8). Alcohol abuse was the most common medical comorbidity (present in 12% of patients treated). This study represents the first major national estimate of in-hospital mortality and complication rates after nonoperative and operative treatment for SCI.

Surgical outcome for thoracic disc surgery in the postlaminectomy era.

In this article the author reviews outcomes of thoracic disc surgery reported in the literature. Care was taken to include only series in which none or a few patients underwent laminectomy for the treatment of thoracic disc lesions. The author found that thoracic discectomy may be performed in an efficacious and safe manner via the transthoracic, lateral extracavitary, transpedicular, or endoscopic approach. In the vast majority of patients, preoperative symptoms of pain (radiculopathy or axial loading pain) and myelopathy were improved after surgery. Measurements of operative time, blood loss, length of hospital stay, and patient satisfaction were often inadequately reported. Complications (systemic and neurological) were well documented and were not common. A plea is made for uniformity in documenting outcome in future series so that today's procedures for thoracic discectomy may be more accurately compared with future cases regardless of the inevitable advances in surgical techniques for removal of thoracic discs.

Vascular and visceral injuries associated with lumbar disc surgery: medicolegal implications.

Symptomatic perforation of the anterior annulus fibrosus/anterior longitudinal ligament during surgery for herniated lumbar disc disease is one of the more solemn and sobering complications experienced by neurosurgeons or orthopedic surgeons. This complication frequently results in the death of the patient. Its occurrence is probably more common than the medical community would expect. The authors report 21 cases since 1985 in which an injury to an intra-abdominal vessel or viscera occurred. In all cases litigation resulted and a settlement or verdict was rendered. A review of the literature is presented and the medicolegal implications of symptomatic ventral perforations of the annulus fibrosus/anterior longitudinal ligament are discussed.

Lumbar spine surgery and mortality among Medicare beneficiaries, 1986.

OBJECTIVES: The purpose of this study was to compare lumbar spine surgical procedures by age, gender, and number of comorbidities with respect to mortality in patients 65 years of age and older in the United States. METHODS: A 100% sample of the 1986 Medicare inpatient Health Care Financing Administration claims files databases involving lumbar spine surgical procedures was analyzed. RESULTS: Lumbar spine surgery in 34,418 patients (median age = 71 years) was associated with a significant increase in in-hospital and 1-year cumulative mortality only beyond 80 years of age. When adjusted for age, in-hospital and 1-year cumulative mortality with both decompression and excision procedures were significantly higher in men than in women. When adjusted for both age and gender, mortality increased significantly as the number of comorbidities increased. CONCLUSIONS: With lumbar spine surgery in elderly patients, mortality did not significantly increase until 80 years of age and was consistently associated with decompression and excision, with male gender, and with an increase in number of comorbidities.