Can C7 Slope Be Used as a Substitute for T1 Slope? A Radiographic Analysis.

STUDY DESIGN: Retrospective radiographic study. OBJECTIVES: T1 slope is an important parameter of sagittal spinal balance. However, the T1 superior endplate can be difficult to visualize on radiographs due to overlying anatomical structures. C7 slope has been proposed as a potential substitute for T1 slope when the T1 superior endplate is not well visualized. The objective of this study was 2-fold: (1) to assess the correlation between C7 and T1 slopes on upright cervical spine radiographs and (2) to evaluate the interrater reliability of C7 slope. METHODS: Cervical spine radiographs taken between December 2017 and June 2018 at a single institution were reviewed. Two observers measured upper C7 slope, lower C7 slope, and T1 slope. The correlations between upper and lower C7 slope and T1 slope were evaluated, and linear regression analyses were performed. Interrater reliability of C7 slope was also assessed. RESULTS: In this cohort of 152 patients, there was a strong correlation between upper C7 slope and T1 slope (r = 0.91, P < .001), as well as between lower C7 slope and T1 slope (r = 0.90, P < .001). T1 slope could be estimated from the linear regression equation, T1 slope = 0.87 × C7 slope + 7, with an overall model fit of R 2 = 0.8. There was strong interrater reliability for upper (intraclass correlation coefficient [ICC] = 0.95, P < .001) and lower C7 slope (ICC = 0.96, P < .001). CONCLUSIONS: Both the upper and lower C7 slope are strongly correlated with T1 slope and can be used as a substitute to estimate T1 slope when the superior endplate of T1 is not well visualized.

Predictors of Discharge Disposition Following Laminectomy for Intradural Extramedullary Spinal Tumors.

OBJECTIVE: To identify independent risk factors for non-home discharge in patients undergoing laminectomy for intradural extramedullary spinal tumors. METHODS: We performed a retrospective cohort analysis of data from the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014. Adult patients who underwent laminectomy for the excision of intradural extramedullary spinal tumors were included and divided into 2 groups based on home or non-home discharge disposition. We compared baseline patient characteristics, comorbidities, and operative factors between the 2 groups, and then performed multivariate regression analyses to identify independent risk factors for non-home discharge. RESULTS: A total of 1232 patients were included, of whom 248 (20.1%) were discharged to a non-home facility. Univariate analysis demonstrated that patients discharged to a non-home facility were more frequently aged ≥65 years and American Society of Anesthesiologists classification ≥3 with obesity, diabetes, dyspnea, functional dependence, cardiac comorbidity, renal comorbidity, and anemia. Operative factors correlated with non-home discharge were operative time of ≥4 hours and tumor location in the cervical or thoracic spine. Multivariate regression analysis identified age ≥65 years (odds ratio [OR] 2.73; confidence interval [CI] 1.80-4.13; P < 0.001), American Society of Anesthesiologists classification ≥3 (OR 2.36; CI 1.53-3.65; P < 0.001), dependent functional status (OR 4.30; CI 1.95-9.48; P < 0.001), hospital-acquired conditions (OR 2.32; CI 1.15-4.68; P = 0.019), and prolonged length of stay (OR 4.05; CI 2.72-6.03; P < 0.001) as predictors of non-home discharge. CONCLUSIONS: Early identification of patients at risk for non-home discharge is important in order to implement comprehensive discharge planning protocols that reduce inpatient length of stay, as well as associated complications and costs.

Anterior Column Realignment in Adult Spinal Deformity: A Case Report and Review of the Literature.

OBJECTIVE: Anterior column realignment (ACR) is a new emerging minimally invasive surgical technique for adult spinal deformity (ASD) that has the potential to provide similar corrective ability to traditional posterior approaches. This article reviews the current literature on the clinical efficacy and safety of ACR and illustrates an additional use of this technique in a case of sagittal imbalance after posterior spinal fusion with segmental instrumentation. METHODS: We performed a literature search of all published ACR reports using PubMed, including only clinical studies describing the ACR technique and reporting radiographic and/or clinical outcomes. RESULTS: Thirteen studies were included. Improvement in lumbar lordosis after ACR ranged from 12.7° to 39°, and increases in focal segmental lordosis at each ACR level ranged from 1° to 34°. Good clinical and functional outcomes have consistently been reported after ACR. The complication rate has been comparable to or lower than traditional posterior-based techniques. We also illustrate the use of ACR in a patient with sagittal imbalance after a prior posterior instrumented spinal fusion. ACR in combination with a posterior osteotomy allowed for the induction of lordosis by cantilevering of rods and compression of pedicle screws. CONCLUSIONS: Radiographic and clinical outcomes after ACR have been promising so far. In addition to primary ASD surgery, ACR can also be effectively used in cases with prior posterior instrumented spinal fusion to correct sagittal imbalance.

The Effects of Preoperative Steroid Therapy on Perioperative Complications After Elective Anterior Lumbar Fusion.

OBJECTIVE: To examine the effects of chronic preoperative steroid therapy on 30-day perioperative complications after anterior lumbar fusion (ALF). METHODS: We retrospectively analyzed data from the American College of Surgeons National Surgical Quality Improvement Program between 2008 and 2015. Adult patients who underwent ALF were included and divided into 2 groups: steroids and no steroids. We compared baseline patient demographics, comorbidities, and operative variables between these 2 groups and then performed a multivariate regression analysis to determine complications that were independently associated with chronic steroid therapy. We also performed a subgroup analysis of the steroid group to identify additional risk factors that further predispose these patients to postoperative complications. RESULTS: A total of 9483 patients were included, of whom 289 (3.0%) were on chronic steroid therapy. Univariate analysis showed that chronic steroid use was independently associated with 4 perioperative complications, including deep surgical site infection (odds ratio [OR], 2.78; confidence interval [CI], 1.09-7.10; P = 0.033), pulmonary complications (OR, 1.98; CI, 1.02-3.86; P = 0.044), blood transfusion (OR, 1.60; CI, 1.15-2.23; P = 0.005), and extended length of stay (OR, 1.58; CI, 1.17-2.16; P = 0.003). In patients on chronic steroid therapy, pulmonary comorbidity and extended operative time were additional risk factors that further predisposed to perioperative complications, including deep surgical site infection, blood transfusion, and extended length of stay. CONCLUSIONS: Chronic preoperative steroid therapy is associated with perioperative complications after ALF. Decisions about the discontinuing or holding steroid therapy preoperatively should be determined through an interdisciplinary approach between the medical and surgical teams.

Age Is a Risk Factor for Postoperative Complications Following Excisional Laminectomy for Intradural Extramedullary Spinal Tumors.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: The incidence of intradural extramedullary (IDEM) spinal tumors is increasing. Excisional laminectomy for removal and decompression is the standard of care, but complications associated with patient age are unreported in the literature. Our objective is to identify if age is a risk factor for postoperative complications after excisional laminectomy of IDEM spinal tumors. METHODS: A retrospective analysis was performed on the 2011 to 2014 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database for patients undergoing excisional laminectomy of IDEM spinal tumors. Age groups were determined by interquartile analysis. Chi-squared tests, t tests, and multivariate logistic regression models were employed to identify independent risk factors. Institutional review board approval was not needed. RESULTS: A total of 1368 patients met the inclusion criteria for the study. Group 1 (age ≤ 44) contained 372 patients, group 2 (age 45-54) contained 314 patients, group 3 (age 55-66) contained 364 patients, and group 4 (age > 66) contained 318 patients. The univariate analysis showed that mortality and unplanned readmission were highest among patients in group 4 (1.26%, P = .011, and 10.00%, P = .039, respectively). Postoperative wound complications were highest among patients in group 1 (2.15%, P = .009), and postoperative venous thromboembolism and cardiac complications were highest among patients in group 3 (4.4%, P = .007, and 1.10%, P = .032, respectively). Multivariate logistic regression revealed that elderly age was an independent risk factor for postoperative venous thromboembolism (group 3 vs group 1; odds ratio = 6.739, confidence interval = 1.522-29.831, P = .012). CONCLUSIONS: This analysis revealed that increased age is an independent risk factor for postoperative venous thromboembolism in patients undergoing excisional laminectomy for IDEM spinal tumors.

The Effects of Preoperative Steroid Therapy on Perioperative Morbidity and Mortality After Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVES: To identify the effects of preoperative steroid therapy on 30-day perioperative complications after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Chronic steroid therapy has demonstrated therapeutic effects in the treatment of various medical conditions but is also known to be associated with surgical complications. There remains a gap in the literature regarding the impact of chronic steroid therapy in predisposing patients to perioperative complications after elective surgery for ASD. METHODS: We performed a retrospective analysis of data from the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were divided into two groups based on preoperative steroid therapy. Differences in baseline patient characteristics, comorbidities, and operative variables were assessed. Univariate analysis was performed to compare the incidence of perioperative complications. Multivariate stepwise logistic regression models were then used to adjust for baseline patient and operative variables in order to identify perioperative complications that were associated with preoperative steroid therapy. RESULTS: We identified 7,936 patients who underwent surgery for ASD, of which 418 (5.3%) were on preoperative steroid therapy. Preoperative steroid therapy was an independent risk factor for four perioperative complications, including mortality (odds ratio [OR] 2.42, 95% confidence interval [CI] 1.30, 4.51; p = .005), wound dehiscence (OR 3.12, 95% CI 1.45, 6.70; p = .004), deep vein thrombosis (DVT) (OR 2.10, 95% CI 1.24, 3.55; p = .006), and blood transfusion (OR 1.34, 95% CI 1.08, 1.66; p < .007). CONCLUSIONS: Patients on preoperative steroid therapy are at increased risk of 30-day mortality, wound dehiscence, DVT, and blood transfusion after surgery for ASD. An interdisciplinary approach to the perioperative management of steroid regimens is critical. LEVEL OF EVIDENCE: Level III.

Thirty-Day Perioperative Complications, Prolonged Length of Stay, and Readmission Following Elective Posterior Lumbar Fusion Associated With Poor Nutritional Status.

STUDY DESIGN: Retrospective study. OBJECTIVE: To determine the rates of early postoperative mortality and morbidity in adults with hypoalbuminemia undergoing elective posterior lumbar fusion (PLF). METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology (CPT) codes were used to query the database for adults (≥18 years) who underwent PLF and/or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Patients were divided into those with normal albumin concentration (≥3.5g/dL) and those with hypoalbuminemia (<3.5 g/dL). Both univariate and multivariate analyses were performed. RESULTS: A total of 2410 patients were included, of whom 2251 (93.4%) were normoalbuminemic and 159 (6.6%) were hypoalbuminemic. Patients with preoperative serum albumin levels <3.5 g/dL were older with a higher American Society of Anesthesiologists (ASA) score, and more comorbidities, including anemia, diabetes, dependent functional status, and preoperative history of chronic steroid therapy. Hypoalbuminemic patients had higher rates of any 30-day perioperative complication (P < .001), unplanned readmission (P = .019), and prolonged length of stay (LOS) >5 days (P < .001). However, hypoalbuminemia was not significantly associated with any specific perioperative complication. On multivariate analysis, preoperative hypoalbuminemia was found to be an independent predictor of prolonged LOS (OR 2.4, 95% CI 1.7-3.5; P < .001) and unplanned readmission (OR 2.7, 95% CI 1.1-6.3; P = .023). CONCLUSION: Hypoalbuminemia was found to be an important predictor of patient outcomes in this population. This study suggests that clinicians should consider nutritional screening and optimization as part of the preoperative risk assessment algorithm. LEVEL OF EVIDENCE: III.

Impact of Obesity on Surgical Outcomes Following Laminectomy for Spinal Metastases.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To determine the effect of obesity (body mass index >30 kg/m2) on perioperative morbidity and mortality after surgical decompression of spinal metastases. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database is a large multicenter clinical registry that collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent decompression with laminectomy for treatment of metastatic spinal lesions between 2010 and 2014. Patients were separated into 2 cohorts based on the presence of absence of obesity. Univariate analysis and multivariate logistic regression analysis were used to analyze the effect of obesity on perioperative morbidity and mortality. RESULTS: There was a significantly higher rate of venous thromboembolism (VTE; obese 6.6% vs nonobese 4.2%; P = .01) and pulmonary complications (obese 2.6% vs nonobese 2.2%; P = .046) in the obese group compared with the nonobese group. The nonobese group had prolonged hospitalization (obese 62.0% vs nonobese 69.0%; P = .001) and a higher incidence of blood transfusions (obese 26.8% vs nonobese 34.2%; P < .001). On multivariate analysis, obesity was found to be an independent risk factor for VTE (odds ratio = 1.75, confidence interval = 1.17-2.63, P = .007). CONCLUSIONS: Obese patients were predisposed to an elevated risk of VTE following laminectomy for spinal metastases. Early postoperative mobilization and a low threshold to evaluate for perioperative VTE are important in these patients in order to appropriately diagnose and treat these complications and minimize morbidity.

Anterior Lumbar Fusion: Differences in Patient Selection and Surgical Outcomes Between Neurosurgeons and Orthopaedic Surgeons.

OBJECTIVE: Anterior lumbar fusion (ALF) is performed by both neurosurgeons and orthopaedic surgeons. The aim of this study was to determine differences between the 2 surgical subspecialties in terms of patient selection and postoperative outcomes after ALF. METHODS: A retrospective cohort study of adult patients undergoing ALF in the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014 was performed. Univariate analyses were performed to identify differences in baseline patient demographics, comorbidities, operative characteristics, and 30-day postoperative outcomes between neurosurgery and orthopaedic surgery patients. Multivariate logistic regression analysis was used to determine whether surgical subspecialty was an independent risk factor for postoperative complications. RESULTS: The study included 3182 patients, with 1629 (51.2%) neurosurgery patients and 1553 (48.8%) orthopaedic surgery patients. A greater proportion of neurosurgery patients were >65 years old, were being treated with preoperative steroids, had cardiac or pulmonary comorbidities, and had an American Society of Anesthesiologists classification III or higher. ALF procedures performed by neurosurgeons more frequently involved use of intervertebral devices and bone graft. On multivariate logistic regression analysis, ALF procedures performed by neurosurgeons were independently associated with a higher risk of reoperation (odds ratio = 1.61; 95% confidence interval, 1.02-2.56; P = 0.042) and urinary tract infection (odds ratio = 1.94; 95% confidence interval, 1.02-3.68; P = 0.043). CONCLUSIONS: In addition to differences in baseline patient demographics and comorbidities and operative characteristics, ALF performed by neurosurgeons had a higher risk of 30-day reoperation and urinary tract infection compared with ALF performed by orthopaedic surgeons.

Risk Factors for Perioperative Complications in Morbidly Obese Patients Undergoing Elective Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The prevalence of obesity-related low back pain and degenerative disc disease is on the rise. Past studies have demonstrated that obesity is associated with higher perioperative complication rates, but there remains a gap in the literature regarding additional risk factors that further predispose this already high-risk patient population to poor surgical outcomes following elective posterior lumbar fusion (PLF). The aim of the study is to identify independent risk factors for poor 30-day perioperative outcomes in morbidly obese patients undergoing elective PLF. METHODS: We identified 22 909 patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent elective PLF. There were 1861 morbidly obese patients. Baseline patient demographics and medical comorbidities were collected. Univariate analysis was performed to compare perioperative complication rates between non-morbidly obese and morbidly obese patients. The 5 most common complications in the morbidly obese group were then selected for multivariate regression analysis to identify independent risk factors for poor 30-day outcomes. RESULTS: Morbidly obese patients had a higher perioperative complication rate. The 5 most common complications were prolonged hospitalization, blood transfusion, readmission, wound complications, and reoperation. Independent risk factors for these complications were age ≥65 years, super obesity (ie, BMI > 48.6), chronic steroid use, American Society of Anesthesiology classification ≥3, poor functional status, long length of fusion ≥4 levels, and extended operative time (ie, operative time ≥318 minutes). CONCLUSIONS: Morbidly obese patients are at higher risk of perioperative complications following elective PLF. Modifiable risk factors for the most common complications are obesity and preoperative steroid use.

Primary Versus Revision Discectomy for Adults With Herniated Nucleus Pulposus: A Propensity Score-Matched Multicenter Study.

STUDY DESIGN: Retrospective propensity score matched analysis. OBJECTIVE: To compare the incidence of any 30-day perioperative complication following primary and revision discectomy for lumbar disc herniation. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was used to identify patients undergoing primary or revision lumbar discectomy from 2005 to 2012. Propensity score matching was performed to create matched pairs of primary and revision discectomy cases for analysis. Univariate analysis was then performed to compare 30-day morbidity and mortality between propensity score-matched pairs. RESULTS: We identified 4730 cases of primary discectomy performed through a minimally invasive or open approach and 649 revision discectomy cases. Baseline patient characteristics and comorbidities were compared and then propensity score-matched adjustments were made to create 649 matched pairs of primary and revision cases. On univariate analysis, there were no significant differences in 30-day perioperative outcomes between the 2 groups. CONCLUSION: While there were no significant differences in 30-day perioperative complications between patients undergoing primary lumbar discectomy and those undergoing revision lumbar discectomy, this finding should be interpreted with caution since the ACS-NSQIP database lacks functional and pain outcomes, and also does not include dural tear or durotomy as a complication. Future large-scale and long-term prospective studies including these variables are needed to better understand the outcomes and complications following primary versus revision discectomy for lumbar disc herniation.

The Effects of Chronic Preoperative Steroid Therapy on Perioperative Complications Following Elective Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Chronic steroid therapy is used in the treatment of various inflammatory and autoimmune conditions, but it is known to be associated with adverse effects. There remains a gap in the literature regarding the role of chronic steroid therapy in predisposing patients to perioperative complications following elective posterior lumbar fusion (PLF). We aimed to identify the effects of chronic preoperative steroid therapy on 30-day perioperative complications in patients undergoing PLF. METHODS: A retrospective analysis was performed using the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. We identified 22 903 patients who underwent elective PLF. There were 849 patients (3.7%) who received chronic preoperative steroid therapy. Univariate and multivariate analyses were performed to examine steroid therapy as an independent risk factor for 30-day perioperative complications. A subgroup analysis of patients on chronic steroid therapy was then performed to identify additional patient characteristics that further increased the risk for perioperative complications. RESULTS: Chronic preoperative steroid therapy was an independent risk factor for 7 perioperative complications, including superficial surgical site infection (SSI), deep SSI, wound dehiscence, urinary tract infection, pulmonary embolism, nonhome discharge, and readmission. Subgroup analysis demonstrated that morbid obesity further predisposed patients on chronic steroid therapy to an increased risk of superficial SSI and wound dehiscence. CONCLUSIONS: Patients on chronic preoperative steroid therapy are at increased risk of multiple perioperative complications following elective PLF, particularly surgical site complications and venous thromboembolic events. This risk is further elevated in patients who are morbidly obese.

Predictive Risk Factors of Nonhome Discharge Following Elective Posterior Cervical Fusion.

OBJECTIVE: To identify risk factors that are predictive of nonhome discharge after elective posterior cervical fusion. METHODS: We performed a retrospective cohort study of adult patients who underwent elective posterior cervical fusion using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014. Patients were divided into 2 groups: home discharge and nonhome discharge. Univariate analysis was performed to compare incidence of 30-day postoperative complications between groups. Multivariate analysis was performed to identify complications that were predictive of nonhome discharge. RESULTS: The cohort included 2875 patients; 24.1% were discharged to a nonhome facility, including skilled and nonskilled care facilities, nursing homes, assisted living facilities, and rehabilitation facilities. Nonhome discharge was associated with higher rates of 30-day pulmonary complication, cardiac complication, venous thromboembolism, urinary tract infection, blood transfusion, sepsis, and reoperation. Significant predictors of nonhome discharge were wound complication (odds ratio [OR] = 1.73; 95% confidence interval [CI], 1.07-2.80; P = 0.024), pulmonary complication (OR = 3.61; 95% CI, 1.96-6.63; P < 0.001), cardiac complication (OR = 6.13; 95% CI, 1.61-23.4; P = 0.008), venous thromboembolism (OR = 2.97; 95% CI, 1.43-6.19; P = 0.004), urinary tract infection (OR = 2.69; 95% CI, 1.50-4.82; P < 0.001), blood transfusion (OR = 1.70; 95% CI, 1.20-2.39; P = 0.003), sepsis (OR = 2.75; 95% CI, 1.25-6.02; P = 0.012), and prolonged length of stay (OR = 4.07; 95% CI, 3.34-4.95; P < 0.001). CONCLUSIONS: Early identification of patients who are at high risk for nonhome discharge is important to implement early comprehensive discharge planning protocols and minimize hospital-acquired conditions related to prolonged length of stay and associated health care costs.

Risk Factors for Perioperative Blood Transfusions in Adult Spinal Deformity Surgery.

OBJECTIVE: Adult spinal deformity (ASD) surgery is associated with a high rate of perioperative blood transfusions, and it is important to understand the risk factors for perioperative blood transfusions to implement strategies to reduce transfusions. The aim of this study was to identify independent risk factors of perioperative blood transfusions in patients undergoing surgery for ASD. METHODS: A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014. Adult patients undergoing surgery for ASD were separated into 2 cohorts based on whether they received a perioperative blood transfusion. Univariate and multivariate regression models were used to identify risk factors for blood transfusion. RESULTS: In our cohort of 5805 patients, 27.1% received a blood transfusion. Multivariate regression analysis showed that patient-specific risk factors were age 65 years or older (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.49-2.03; P < 0.001), American Society of Anesthesiologists classification of 3 or greater (OR, 1.18; 95% CI, 1.01-1.37; P = 0.033), cardiac comorbidity (OR, 1.21; 95% CI, 1.03-1.41; P = 0.018) and bleeding disorder (OR, 2.01; 95% CI, 1.10-3.66; P = 0.023). Surgery-specific risk factors were a posterior approach (OR, 4.25; 95% CI, 3.46-5.22; P < 0.001), pelvic fixation (OR, 1.73; 95% CI, 1.36-2.20; P < 0.001), and osteotomy (OR, 2.08; 95% CI, 1.71-2.51; P < 0.001). Longer operative time was also a risk factor with a duration-dependent effect on the odds of blood transfusion. CONCLUSIONS: Recognition of patient- and surgery-specific risk factors for perioperative blood transfusion is important to identify patients who are at high risk and to implement strategies to minimize intraoperative blood loss and decrease healthcare costs.