Impact of Cirrhosis on Morbidity and Mortality After Spinal Fusion.

STUDY DESIGN: Retrospective large database study. OBJECTIVE: To determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery. METHODS: Elective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion. RESULTS: A total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs $29 068; P < .001). CONCLUSIONS: Cirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement.

Outcomes and Complications After Spinal Fusion in Patients With Obstructive Sleep Apnea.

STUDY DESIGN: Retrospective database study. OBJECTIVE: To investigate the impact obstructive sleep apnea (OSA) has on perioperative complications, inpatient mortality, and costs in patients undergoing spinal fusions. METHODS: Hospitalizations for spinal fusion surgery between the years 2009 and 2011 were identified using the Nationwide Inpatient Sample and grouped into patients with and without OSA. Patient demographic data, comorbidities, hospital characteristics, hospitalization outcomes, and costs were extracted and compared. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing spinal fusion with and without OSA. RESULTS: A total of 107 451 (7.7%) OSA patients who underwent spinal fusions were identified from 2009 to 2011. Compared with patients without OSA, OSA patients were significantly older, more likely to be male, and have significantly greater comorbidity burden. Multivariable regression analysis demonstrated that OSA had a significant independent association with slightly increased respiratory (odds ratio [OR] = 1.13, confidence interval [CI] = 1.09-1.16; P < .001), urinary and renal (OR = 1.11, CI = 1.07-1.16; P < .001) or overall inpatient complications (OR = 1.05, CI = 1.02-1.05; P < .001). OSA was also independently associated with significantly lower inpatient mortality (OR = 0.39, CI = 0.33-0.45; P < .001). CONCLUSIONS: While OSA confers greater comorbidity burden and is associated with slightly higher inpatient complication rates following spinal fusions, diagnosed OSA was not an independent predictor of inpatient mortality. A cautious interpretation of this finding is that on a national level, the current methods of preoperative medical optimization and inpatient management of OSA are satisfactory.

Traumatic Atlantoaxial Lateral Subluxation With Chronic Type II Odontoid Fracture: A Case Report.

BACKGROUND: We report a case of an elderly patient who was diagnosed with lateral atlantoaxial subluxation with type II odontoid fracture, an extremely uncommon upper cervical spine injury that has not been previously reported in the literature to the knowledge of the authors. METHODS: An 87-year-old male reported to the emergency room following a syncopal episode after sustaining a fall. He complained of dizziness, fatigue, disruption of vision and audition, and worsening neck pain. Computed tomographic scans were positive of partial dislocation of the C1 relative to C2 and chronic fracture of dens classified as type II according to the Anderson and D'Alonzo classification system. Magnetic resonance imaging further revealed large fracture pannus tissue at the level of the dens, reducing the space in the spinal cord. There was no evidence of spinal cord injury. Atlas-axis fusion with instrumentation was performed to manage the injury. A review of the classification, occurrence, and management of upper cervical spine surgeries was performed. RESULTS: An acute injury to a previously unrecognized type II odontoid fracture with partial C1-C2 dislocation was identified as a rare upper cervical spine injury and classified based on the Anderson and D'Alonzo and Fielding and Hawkins classification systems. The decision was made to perform instrumented spinal fusion by inserting mass screws into C1, pars screws into C2, and locking rods to realign the vertebral bodies and address the atlantoaxial instability. Follow-up scans indicated good postsurgical reduction and fixation, including resolution of the pannus overgrowth without direct intervention. CONCLUSIONS: Lateral atlantoaxial subluxation with chronic type II fracture of the dens constitutes a rare injury of the upper cervical vertebrae. Posterior instrumented spinal fusion was used to effectively manage the injury, leading to reabsorption of retro-odontoid pannus tissue.

Does Addition of Tobramycin Powder Reduce Infection Rates After Spine Surgery?

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To evaluate the efficacy of tobramycin and vancomycin powder in reducing surgical site infections in posterior lumbar instrumented fusion. METHODS: A multicenter, electronic database search was conducted for all patients who underwent posterior instrumented lumbar fusions. RESULTS: The addition of vancomycin powder decreased postoperative infections from an incidence of 5.7% down to a rate of 2.0%. This difference was statistically significant (P = .018). The addition of tobramycin powder to the wound in addition to vancomycin further decreased the infection rate down to 1.8%. The postoperative infection rate was statistically significant (P = .041) when compared with the no-powder group. However, the difference was not statistically significant (P = 1.00) when compared with vancomycin alone. There was also a trend toward gram-negative organisms with the addition of more antibiotic powder. In the control group, for example, the organisms cultured were 66% methicillin-sensitive Staphylococcus aureus and 33% gram-negative organisms. In the vancomycin group, 30% of the organisms cultured were Staphylococcus aureus and 60% gram-negative organisms. In the vancomycin and tobramycin powder group, 100% of the organisms cultured were gram-negative. CONCLUSIONS: There is a reduction in surgical site infections with addition of antibiotic powder to the wound prior to closure. However, the reduction in the infection rate was not as great with the addition of tobramycin powder to vancomycin alone and there was a noticeable change in the spectrum of organism cultured with this addition. Clinicians should consider the risk-to-benefit ratio in each case when deciding to use antibiotic powder.

Pseudo-Pedicle Heterotopic Ossification From Use of Recombinant Human Bone Morphogenetic Protein 2 (rhBMP-2) in Transforaminal Lumbar Interbody Fusion Cages.

We conducted a study to determine the common characteristics of patients who developed radiculopathy symptoms and corresponding heterotopic ossification (HO) from transforaminal lumbar interbody fusions (TLIF) using recombinant human bone morphogenetic protein 2 (rhBMP-2). HO can arise from a disk space with rhBMP-2 use in TLIF. Formation of bone around nerve roots or the thecal sac can cause a radiculopathy with a consistent pattern of symptoms. We identified 38 patients (26 males, 12 females) with a mean (SD) age of 50.8 (7.5) years who developed radiculopathy symptoms and corresponding HO from TLIF with rhBMP-2 in the disk space between 2002 and 2015. To document this complication and improve its recognition, we recorded common patterns of symptom development and radiologic findings: specifically, time from implantation of rhBMP-2 to symptom development, consistency with side of TLIF placement, and radiologic findings. Radicular pain generally developed a mean (SD) of 3.8 (1.0) months after TLIF with rhBMP-2. Development of radiculopathy symptoms corresponded to consistent "pseudo-pedicle"-like HO. In all 38 patients, HO arising from the annulotomy site showed a distinct pseudo-pedicle pattern encompassing nerve roots and the thecal sac. In addition, development of radiculopathy symptoms and corresponding HO appear to be independent of amount of rhBMP-2. HO resulting from TLIF with rhBMP-2 in the disk space is a pain generator and a recognizable complication that can be diagnosed by assessment of symptoms and computed tomography characteristics.

Robotic Guidance for S2-Alar-Iliac Screws in Spinal Deformity Correction.

STUDY DESIGN: A retrospective cohort study of patients who underwent S2-alar-iliac (S2AI) screw insertion using robotic guidance in long constructs for spinal deformity correction extending to the sacrum performed at a single institution. OBJECTIVE: To assess and evaluate the feasibility and accuracy of robotic guidance for S2AI screw insertion. SUMMARY OF BACKGROUND DATA: Pelvic fixation has become a common adjunct to long fusions extending to the sacrum. The S2AI method possesses advantages over the traditional Galveston technique. S2AI involves finding a pathway from S2 across the sacral ala and the sacroiliac joint into the ilium. Robotic guidance is a new modality for implant insertion that has shown high accuracy. METHODS: We identified all patients who underwent robotic-guided S2AI screw insertion in long constructs extending to the sacrum. Cortical breaches and protrusions, assessed on postoperative imaging, and complications were recorded. RESULTS: Fourteen patients (31 screws) underwent S2AI screw insertion using robotic guidance and free-hand probing. Average screw length was 80 mm (range, 65-90 mm). All trajectories were confirmed as accurate (no proximal breaches). Screw insertion, performed manually, resulted in 10 protrusions <2 mm, 1 by 2-4 mm, and 6 by ≥4 mm. No screw was intrapelvic or risked any visceral or neurovascular structures and none required removal or revision. Longer screws (>80 mm) were associated with distal protrusion. CONCLUSIONS: Robotic-guided S2AI screws are accurate and a feasible option. Although no complications from protrusion were identified, larger studies and instrumentation modifications are required to assess the clinical acceptance of robotic guidance in sacropelvic fixation.

Surgical techniques for spinopelvic reconstruction following total sacrectomy: a systematic review.

PURPOSE: To identify all available reconstruction methods for a total sacrectomy. Secondarily, we aimed to evaluate outcomes based on different interventions. METHODS: We searched PubMed to identify sacral resections for tumors requiring internal fixation for stabilization. Demographic information, fixation techniques and postoperative outcomes were abstracted. RESULTS: Twenty-three publications (43 patients) met inclusion criteria from an initial search of 856 (κ 0.93). Mean age was 37 years and follow-up was 33 months. Fixation methods included a combination of spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and/or anterior spinal column fixation (ASCF). For the purposes of analysis, patients were segregated based on whether they received ASCF. Postoperative complications including wound/instrument infections, GI or vascular complications were reported at a higher rate in the non-ASCF group (1.63 complications/patient vs. 0.7 complications/patient). Instrument failure was seen in 5 (16.1 %) out of the 31 patients with reported outcomes. Specifically, 1 out of 8 patients (12.5 %) with ASCF compared with 4 out of 23 patients (17.4 %) without ASCF had hardware failure. At final follow-up, 35 of 39 patients were ambulating. CONCLUSION: While surgical treatment of primary sacral tumors remains a challenge, there have been advances in reconstruction techniques following total sacrectomy. SPF has shifted from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems for improved rigidity. PPRF and ASCF have adapted for deficiencies in the posterior ring and anterior column. A trend toward a lower rate of hardware failure emerged in the group utilizing anterior spinal column support. Despite a more involved reconstruction with ASCF, surgical complications such as infection rates and blood loss were lower compared to the group without ASCF. While we cannot definitively say one system is superior to the other, based on the data gleaned from this systematic review, it is our opinion that incorporation of ASCF in reconstructing the spinopelvic junction may lead to improved outcomes. However, most importantly, we recommend that the treating surgeon operate on patients requiring a total sacrectomy based on his or her level of comfort, as these cases can be extremely challenging even among experts.

Fixation techniques for complex traumatic transverse sacral fractures: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To identify and describe reconstruction methods for the treatment of transverse sacral fracture (TSF) and to evaluate outcomes based on treatment interventions. SUMMARY OF BACKGROUND DATA: A variety of surgical interventions for stabilization of TSFs exist, yet the optimal management remains unclear. Although there are many individual case reports and series describing techniques to stabilize TSF, prior reviews fail to provide a comprehensive summary of current and past surgical techniques and their individual outcomes. METHODS: Our systematic review searched the PubMed database using keywords identifying sacral fractures with a transverse component, requiring internal fixation for stabilization as well as a review of bibliographies and archives from meeting proceedings. RESULTS: Our search located 417 publications for abstract review, of which 27 (109 patients) with TSF were included. Average follow-up was 22 months (range, 0-82 mo). Thirty-eight patients (34%) underwent spinopelvic fixation (SPF), 53 (49%) underwent posterior pelvic ring fixation (PPRF), and 18 (17%) underwent both. PPRF included iliosacral screws (37 patients), transiliac screws (11 patients), transiliac screws with plating (3 patients), posterior plating (1 patient), and transiliac bar (1 patient). Additional injuries causing lumbosacral instability were seen in 8 patients (42%) who underwent SPF, 2 patients (18%) treated with PPRF, and 5 patients (45%) who were treated with both SPF and PPRF. Of those who presented with a neurological deficit, 5 patients (45%) with SPF, 9 (39%) with PPRF, and 3 (30%) with SPF and PPRF experienced full neurological recovery. Five patients (45%) with SPF, 7 (30%) with PPRF, and 5 (50%) with both regained partial neurological function. One patient (9%) with SPF, 7 (30%) with PPRF, and 2 (20%) with both experienced no neurological recovery. CONCLUSION: PPRF seems to be effective for stabilization of TSF. However, in the setting of further injuries causing additional lumbosacral instability, SPF should be used to ensure effective stabilization.

Drivers of surgery for the degenerative hip, knee, and spine: a systematic review.

BACKGROUND: Surgical treatment for degenerative conditions of the hip, knee, and spine has an impact on overall healthcare spending. Surgical rates have increased dramatically and considerable regional variation has been observed. The reasons behind these increasing rates and variation across regions have not been well elucidated. QUESTIONS/PURPOSES: We therefore identified demographic (D), social structure (SS), health belief (HB), personal (PR) and community resources (CR), and medical need (MN) factors that drive rates of hip, knee, and spine surgery. METHODS: We conducted a systematic review to include all observational, population-based studies that compared surgical rates with potential drivers (D, SS, HB, PR, CR, MN). We searched PubMed combining key words focusing on (1) disease and procedure; (2) study methodology; and (3) explanatory models. Independent investigators selected potentially eligible studies from abstract review and abstracted methodological and outcome data. From an initial search of 256 articles, we found 37 to be potentially eligible (kappa 0.86) but only 28 met all our inclusion criteria. RESULTS: Age, nonminority, insurance coverage, and surgeon enthusiasm all increased surgical rates. Rates of arthroplasty were higher for females with higher education, income, obesity, rurality, willingness to consider surgery, and prevalence of disease, whereas spinal rates increased with male gender, lower income, and the availability of advanced imaging. CONCLUSIONS: Regional variation in these procedures exists because they are examples of preference-sensitive care. With strategies that may affect change in factors that are potentially modifiable by behavior or resources, extreme variation in rates may be reduced.

Lumbar disk replacement failures: review of 29 patients and rationale for revision.

The Charité III (DePuy Spine, Inc, Raynham, Massachusetts) and ProDisc II (Synthes Spine, West Chester, Pennsylvania) artificial disk replacements were approved for use by the United States Food and Drug Administration in October 2004 and January 2006, respectively. The purpose of this study was to retrospectively review 29 patients receiving either disk replacement who presented with complications to the University of California Irvine Spine Center. Specifically, patient outcome data from the Oswestry Disability Index (ODI) and the SF-36 were analyzed. The probable sources of pain were determined based on diagnostic facet and nerve root injections, single photon emission computed tomography bone scans, computed tomography scans, magnetic resonance imaging scans, flexion extension radiographs, patient history, and physical examination and direct surgical observation when possible. Results suggested that the main source of pain is facet degeneration and fractures in this area due to flawed biomechanics of disk replacement design. Oswestry Disability Index and SF-36 scores exhibited marked disability with a large improvement in all scores after revision surgery. This difference was statistically significant for the ODI and the SF-36 MCS (mental), but not for the SF-36 PCS (physical). A successful outcome in the revised patients was achieved completely in the majority, and only partially in some, by a solid fusion after meticulous and complete facet excision and correction of the segmental deformity.