Readmission-Free Survival Analysis in Metastatic Spine Tumour Surgical Patients: A Novel Concept.

BACKGROUND: Outcomes commonly used to ascertain success of metastatic spine tumour surgery (MSTS) are 30-day complications/mortality and overall/disease-free survival. We believe a new, effective outcome indicator after MSTS would be the absence of unplanned hospital readmission (UHR) after index discharge. We introduce the concept of readmission-free survival (ReAFS), defined as 'the time duration between hospital discharge after index operation and first UHR or death'. The aim of this study is to identify factors influencing ReAFS in MSTS patients. PATIENTS AND METHODS: We retrospectively analysed 266 consecutive patients who underwent MSTS between 2005 and 2016. Demographics, oncological characteristics, procedural, preoperative and postoperative details were collected. ReAFS of patients within 2 years or until death was reviewed. Perioperative factors predictive of reduced ReAFS were evaluated using multivariate regression analysis. RESULTS: Of 266 patients, 230 met criteria for analysis. A total of 201 had UHR, whilst 1 in 8 (29/230) had no UHR. Multivariate analysis revealed that haemoglobin ≥ 12 g/dL, ECOG score of ≤ 2, primary prostate, breast and haematological cancers, comorbidities ≤ 3, absence of preoperative radiotherapy and shorter postoperative length of stay significantly prolonged the time to first UHR. CONCLUSIONS: Readmission-free survival is a novel concept in MSTS, which relies on patients' general condition, appropriateness of interventional procedures and underlying disease burden. Additionally, it may indicate the successful combination of a multi-disciplinary treatment approach. This information will allow oncologists and surgeons to identify patients who may benefit from increased surveillance following discharge to increase ReAFS. We envisage that ReAFS is a concept that can be extended to other surgical oncological fields.

Analysis of unplanned hospital readmissions up to 2-years after metastatic spine tumour surgery.

PURPOSE: The aim of this study was to investigate rates, causes, and risk factors of unplanned hospital readmissions (UHR) within 30 days, 90 days, 1 year and 2 years after metastatic spine tumour surgery (MSTS) to augment multi-disciplinary treatment planning and improve patient education. METHODS: We retrospectively reviewed 272-patients who underwent MSTS between 2005 and 2016. Hospital records were utilised to obtain demographics, oncological, procedural details, and postoperative outcomes. All UHR within 2 years were reviewed. Primary outcomes were rates, causes, and risk factors of UHR. Risk factors for UHR were evaluated utilising multivariate logistic regression analysis. RESULTS: Thirty-day, 90 day, 1 year, and 2 year UHR-rates after MSTS were 17.2%, 31.1%, 46.2%, and 52.7%, respectively. Lung cancer primaries had the highest UHR-events (24.7%) whilst renal/thyroid displayed the least (6.6%). Disease-related causes (16.2%) were the most common reason for readmissions across all timeframes, followed by respiratory (13.7%) and progression of metastatic spine disease (12.7%). Urological conditions accounted for majority of readmissions within 30-days; disease-related causes, symptomatic spinal metastases, and respiratory conditions represented the most common causes at 30-90 days, 90 days-1 year, and 1-2 years, respectively. An ECOG >1 (p = 0.057), CCI >7 (p = 0.01), and primary lung tumour (p = 0.02) significantly increased UHR-risk on multivariate analysis. CONCLUSION: Seventy-four percent of patients had at least one UHR within 2 years of MSTS and majority were secondary to disease-related causes. Majority of first UHR occurred between 30 and 90 days post-surgery. Local disease progression and overall disease progression account for the highest UHR-events at 90 days-1 year and 1-2 year timeframes, respectively. We define UHR in specific timeframes, thus enabling better surveillance and reducing unnecessary morbidity.

The lateral entry point S2 alar-iliac (L-S2AI) screw: a preoperative computed tomography analysis of adult spinal deformity patients.

PURPOSE: To radiographically compare lateral entry point S2-alar-iliac (L-S2AI) screw with conventional S2AI (C-S2AI) and conventional iliac screw (CIS) lengths and trajectories. METHODS: Twenty-five preoperative CT scans of consecutive patients undergoing adult spinal deformity realignment surgery over a random 2-year period were analysed. Maximum in-bone length, caudal and lateral trajectories of CIS, C-S2AI, and L-S2AI screws were measured and compared using One-way ANOVA with Tukey's post hoc tests. Multivariate logistic regression was performed to identify predictors of high screw length discrepancy between C-S2AI and L-S2AI. RESULTS: Potential screw length was longest for CIS, followed by L-S2AI, then C-S2AI (114.5 ± 8.3 mm vs 101.4 ± 9.6 mm vs 80.6 ± 5.9 mm, respectively) in all patients (p < 0.001). Actual screw lengths found both CIS and L-S2AI to be longer than C-S2AI (95.3 ± 8.5 mm and 93.4 ± 7.5 mm vs 82.1 ± 7.3 mm; p = 0.008 and 0.003). Potential lateral angulation was smallest for CIS, followed by L-S2AI, then C-S2AI (21.9 ± 7.0° vs 31.9 ± 7.1° vs 40.9 ± 6.7°, respectively) in all patients (p < 0.001). L-S2AI and C-S2AI had the same caudal angulation (24.9 ± 6.8°), which was smaller than CIS (30.8 ± 5.8°) in all patients (p < 0.001). Univariate, but not multivariate analysis, revealed that lumbar lordosis > 40° (OR 7.2, p = 0.041), diagnosis of degenerative spondylolisthesis (OR 10.5, p = 0.017), and > 7 instrumented levels (OR 2.6, p = 0.049) were significantly associated with high screw discrepancies. CONCLUSION: The L-S2AI screw combines advantages of CIS and C-S2AI screws, which includes increased screw length, reduced lateral angulation, a low-profile screw head, ease of connection to proximal hardware, and the biomechanical advantage of a quadcortical purchase.

Multilevel, Percutaneous Posterior Cervical Interfacet Distraction and Fusion for Cervical Spondylotic Radiculopathy: Clinical and Radiographic Outcomes.

STUDY DESIGN: Retrospective review of patients who underwent multilevel posterior cervical interfacet distraction and fusion (PCIDF) using cages for cervical spondylotic radiculopathy (CSR). OBJECTIVE: To determine clinical and radiographic outcomes following multilevel PCIDF. SUMMARY OF BACKGROUND DATA: Anterior cervical discectomy and fusion has long been the standard of treatment for CSR. Advancements in surgery have employed minimally invasive techniques such as endoscopic discectomy, foraminotomy, and PCIDF. Studies on single-level PCIDF have reported good clinical outcomes, short hospital stays, and rare complications, but its application in multilevel disease is still evolving. METHODS: Patients with CSR and confirmed radiologic evidence of multilevel foraminal stenosis without central canal stenosis were reviewed. Two-year outcomes of multilevel PCIDF included Neck Disability Index, neck and arm Visual Analogue Scale (VAS), radiographic cervical alignment parameters, evidence of fusion, and incidence of adjacent segment degeneration were compared at different time points. RESULTS: Thirty patients (mean age 54.6 ±â€Š8.3) were included in the study with an average of 3.4 ±â€Š0.8 levels treated. Mean surgical duration and intraoperative blood loss was 143.2 ±â€Š69.7 minutes and 27.7 ±â€Š28.7 mL, respectively, with an average length of stay at 1.8 ±â€Š1.5 days. Neck Disability Index, VAS-neck, and VAS-arm all significantly improved at 2 weeks (P < 0.001) and was maintained until 2 years postoperatively. A significant decrease in segmental and C2-C7 lordosis, with a corresponding increase in sagittal vertical axis, was observed at 3 months postoperatively (P < 0.001) but did not deteriorate further on subsequent visits. Successful fusion was achieved in 90% of patients after 2 years. There was a 13.3% incidence of adjacent segment degeneration in the study cohort and one perioperative complication (3.3%). CONCLUSION: Our study suggests that multilevel PCIDF is safe and effective for CSR caused by foraminal stenosis. However, its potential to cause kyphosis and clinical impact on global sagittal alignment requires further scrutiny and long-term evaluation.Level of Evidence: 4.

Risk factors for surgical complications in the management of ossification of the posterior longitudinal ligament.

BACKGROUND CONTEXT: Ossification of the posterior longitudinal ligament (OPLL) is a progressive, debilitating disease most commonly affecting the cervical spine. When compared to other degenerative pathologies, OPLL procedures carry a significantly higher risk of complications owing to increased case complexity and technical difficulties. Most previous studies have focused on functional outcomes and few have reported on risk factors for postoperative complications in OPLL patients. PURPOSE: To identify clinical and radiological risk factors of surgical complications following treatment for cervical OPLL STUDY DESIGN: Retrospective review PATIENT SAMPLE: One hundred thirty-one patients with cervical myelopathy secondary to OPLL who underwent surgical decompression with complete 2-year follow-up. OUTCOME MEASURES: Surgical and medical postoperative complications were analyzed. Revision surgery rates and mortality rates were recorded. METHODS: Clinical, surgical, and radiological characteristics were collected for each patient. Complications within 30 days were identified. Univariate and multivariate analysis were performed to identify risk factors for surgical complications. RESULTS: There were 39 (29.8%) surgical complications in the cohort, which included C5 palsy (7.6%), dural tear (3.1%), surgical site infection (3.1%), and epidural hematoma (1.5%). 2-year revision and mortality rates were 4.6% and 2.3%, respectively. Univariate analysis revealed that blood loss ≥750mL (OR 3.42, p=0.028), operative duration ≥5.5 hours (OR 3.16, p=0.008), hill-type OPLL (OR 3.08, p=0.011), K-line (-) OPLL (OR 5.39, p<0.001), and presence of a double-layer sign (OR 3.79, p=0.002) were significant risk factors. In multivariate analysis, only hill-type OPLL (OR 2.61, p=0.048) and K-line (-) OPLL (OR 2.98, p=0.031) were found to be significant. Patients with both hill-type and K-line (-) OPLL had a 3.5 times risk of developing surgical complications (p=0.009). CONCLUSIONS: Patients with OPLL have a higher risk of perioperative surgical complications if they had a hill-shaped OPLL and K-line (-) OPLL on preoperative imaging studies. To the best of the authors' knowledge, this study is the first to link hill-type and K-line (-) OPLL morphology as risk factors for perioperative surgical complications.

The "Spinal Metastasis Invasiveness Index": A Novel Scoring System to Assess Surgical Invasiveness.

STUDY DESIGN: Retrospective review. OBJECTIVE: The aim of this study was to develop a surgical invasiveness index for metastatic spine tumor surgery (MSTS) that can serve as a standardized tool in predicting intraoperative blood loss and surgical duration; for the purpose of ascertaining resource requirements and aiding in patient education. SUMMARY OF BACKGROUND DATA: Magnitude of surgery is important in the metastatic spine disease (MSD) population since these patients have a continuing postoperative oncological process; a consideration that must be taken into account to maintain or improve quality of life. Surgical invasiveness indices have been established for general spine surgery, adult deformity, and cervical deformity, but not yet for spinal metastasis. METHODS: Demographic, oncological, and procedural data were collected from consecutive patients that underwent MSTS. Binary logistic regression, using median values for surgical duration and intraoperative estimated blood loss (EBL), was used to determine statistical significance of variables to be included in the "spinal metastasis invasiveness index" (SMII). The corresponding weightage of each of these variables was agreed upon by experienced spine surgeons. Multivariable regression analysis was used to predict operative time and EBL while controlling for demographical, procedural, and oncological characteristics. RESULTS: Two hundred and sixty-one MSD patients were included with a mean age of 59.7-years and near equal sex distribution. The SMII strongly predicted extended surgical duration (R2 = 0.28, P < 0.001) and high intraoperative blood loss (R2 = 0.18, P < 0.001). When compared to a previously established surgical invasiveness index, the SMII accounted for more variability in the outcomes. For every unit increase in score, there was a 42-mL increase in mean blood loss (P < 0.001) and 5-minute increase in mean operative time (P < 0.001). CONCLUSION: Long surgical duration and high blood loss were strongly predicted by the newly developed SMII. The use of the SMII may aid in preoperative risk assessment with the goal of improving patient outcomes and quality of life.Level of Evidence: 4.

Risk Factors Predicting C- Versus S-shaped Sagittal Spine Profiles in Natural, Relaxed Sitting: An Important Aspect in Spinal Realignment Surgery.

STUDY DESIGN: A cross-sectional study on a randomly selected prospective cohort of patients presenting to a single tertiary spine center. OBJECTIVE: The aim of this study was to describe the clinical and radiographic parameters of patients with S- and C-shaped thoracolumbar sagittal spinal profiles, and to identify predictors of these profiles in a natural, relaxed sitting posture. SUMMARY OF BACKGROUND DATA: Sagittal realignment in adult spinal deformity surgery has to consider the sitting profile to minimize the risks of junctional failure. Persistence of an S-shaped sagittal profile in the natural, relaxed sitting posture may reflect a lesser need to accommodate for this posture during surgical realignment. METHODS: Consecutive patients with low back pain underwent whole body anteroposterior and lateral radiographs in both standing and sitting. Baseline clinical data of patients and radiographic parameters of both standing and sitting sagittal profiles were compared using χ, unpaired t tests, and Wilcoxon rank-sum test. Subsequently, using stepwise multivariate logistic regression analysis, predictors of S-shaped curves were identified while adjusting for confounders. RESULTS: Of the 120 patients included, 54.2% had S-shaped curves when sitting. The most common diagnoses were lumbar spondylosis (26.7%) and degenerative spondylolisthesis (26.7%). When comparing between patients with S- and C-shaped spines in the sitting posture, only diagnoses of degenerative spondylolisthesis (odds ratio [OR], 5.44; P = 0.01) and degenerative scoliosis (OR, 2.00; P = 0.039), and pelvic incidence (PI) >52.5° (OR, 5.48; P = 0.008), were predictive of an S-shaped sitting sagittal spinal alignment on multivariate analysis. CONCLUSION: Stiffer lumbar curves (eg, patients with degenerative spondylolisthesis and degenerative scoliosis) or those who have a predilection for an S-shaped standing sagittal profile when sitting (eg, high PI) may be more amenable to fusion in accordance with previously studied sagittal realignment targets. In contrast, more flexible curves may benefit from less aggressive lordotic realignment to prevent potential junctional failures. LEVEL OF EVIDENCE: 3.

Vacuum-Assisted Closure: An Effective Technique to Manage Wound Complications After Metastatic Spine Tumour Surgery (MSTS)-A Case Report.

The management of wound complications following metastatic spine tumor surgery (MSTS) remains a formidable task. Plastic coverage procedures after MSTS are challenging due to unhealthy donor sites following previous radiotherapy and prolonged nonambulation. Negative pressure wound therapy (NPWT) is usually not recommended after MSTS due to fear of tumor seeding and excessive blood loss. However, in certain patients post-MSTS, who may be considered as receiving palliative treatment, NPWT can be effective in managing wound complications. We describe our initial experience with the use of NPWT in a 57-year-old lady diagnosed with multiple lumbar and cervicothoracic vertebral metastases secondary to non-small cell lung carcinoma. She underwent 2 cycles of preoperative radiotherapy followed by decompression and posterior instrumentation of lumbosacral and cervicothoracic regions succeeded by another cycle of radiotherapy. The patient developed wound dehiscence and poly-microbial surgical site infection that was not responsive to regular debridements and antibiotics. Hence, we applied NPWT as an alternative treatment to plastic surgical procedures. The patient clinically improved with a reduced quantity of wound discharge, increased granulation tissue, and a downward trend in the inflammatory markers. Subsequently, wound was secondarily closed after 14 days. The patient was discharged after a total hospital stay of 41 days. The intravenous antibiotics (piperacillin/tazobactam) were changed to oral (ciprofloxacin) after 6 weeks and continued for 4 months. The patient survived for 3 years without any wound complications. Our case report suggests that NPWT can be a potential treatment option for managing wound complications following MSTS.