In vitro comparison of manual and robotic endovascular thrombectomy for acute ischemic stroke.

BACKGROUND: Robotic endovascular systems have the potential to reduce radiation exposure to physicians and expand timely neurointerventional access to patients in remote areas. The goal of the study was to determine the feasibility of robotic endovascular thrombectomy (EVT) in an in vitro model. METHODS: In vitro procedures were conducted manually and robotically using the Corpath GRX robotic system in a human vascular simulator with an elastic ovine clot in the M1 segment of the left middle cerebral artery. Due to the limited device compatibility of the CorPath GRX, a simple technique with a stent retriever and guiding catheter without a balloon was used in the study. Seven robotic EVT and manual EVT were carried out in each group. Metrics including procedural time, success rate, and radiation dose were compared between the two groups. RESULTS: In robotic EVT, the mean total preparation and procedural time was 892 s, which was significantly longer than manual operation at 357 (p = 0.0001). There was no significant difference in the success rate between the two approaches (robotic: 28.6% vs. manual 42.9%, p = 0.577). The mean radiation exposure to operating physicians was significantly lower during robotic operation compared to manual operation (0.02 µSv vs. 0.22 µSv, p < 0.0001). CONCLUSIONS: Robotic EVT was feasible in our human vascular simulator with significantly reduced radiation exposure to the operating physicians, despite an increased length of procedure when compared to manual procedures. Future technological advancement is warranted for reducing procedural length using endovascular robotic techniques.

Intermittent Orbital Pain due to Hemodynamic Collapse of an Orbital Varix: A Case Report.

Orbital varices typically present with symptoms related to dilation or thrombosis. We describe a rare presentation of an orbital varix with pain caused by hemodynamic collapse of the varix. A woman in the third decade presented with position-dependent orbital pain and enophthalmos. She was found to have an intraorbital varix and a separate pterygoid varix. The patient underwent endovascular treatment of the pterygoid varix using coils and sclerosing agents which altered the venous outflow from the orbital varix. The patient had immediate resolution of symptoms after the procedure. Our findings suggest that extraorbital venous outflow abnormalities may be the cause of symptoms in selected cases of orbital varices. By understanding the venous structures on cerebral angiography and treating the extraorbital component, orbital intervention may be avoided, reducing the risk of complications.

First-in-human trial of Center Wire for neuroendovascular therapy to avoid guidewire-related complications.

BACKGROUND: An exchange maneuver is useful for the delivery of devices to target vessels. However, hemorrhagic complications can occur due to vessel perforation during an exchange maneuver. In addition, the exchange is often challenging due to unfavorable anatomy. Center Wire is an exchange-length wire with a nondetachable stent that was developed to improve navigation and stability during exchange maneuvers. The aim of this study is to investigate the safety and efficacy of Center Wire of the anchor wire technique during neuroendovascular treatment. METHODS: Ten patients with intracranial aneurysms were treated after signing a Certified Review Board-approved consent. Anchor wire technique was used in all patients to navigate catheters to the target vessel for aneurysm treatment. RESULTS: Anchor wire technique was successfully applied in all 10 cases using Center Wire. One device-related incident of vasospasm occurred which was asymptomatic. No device-related dissection, perforation, or thromboembolic events occurred. One patient had intraoperative aneurysm rupture during coil placement which was treated immediately without clinical consequences. Two patients had postoperative ischemic strokes due to thrombotic occlusion of branches originating from the aneurysm which were unrelated to the device. CONCLUSIONS: This first-in-human trial of Center Wire demonstrated the safety and efficacy of the anchor wire technique for neuroendovascular treatment in a strictly regulated prospective registry trial.

First-in-human trial of Stabilizer device in neuroendovascular therapy.

Objectives: Flow diverter or stent implantation to intracranial target lesion requires large inner diameter microcatheter navigation. The exchange method using stiff long wire is often necessary if it is difficult to navigate over the regular guidewire. However, this method has an intrinsic risk of vessel damage and may cause severe complications. We investigated the safety and efficacy of a new device, the Stabilizer device for navigation in a first-in-human clinical trial under the Certified Review Board agreement. Materials and methods: The Stabilizer is a 320 cm length exchange wire with a stent for anchoring and is compatible with a 0.0165" microcatheter. The trial design is a prospective single-arm open-label registry. Inclusion criteria are elective flow diverter treatment or stent-assisted coiling, expected to be difficult to navigate a microcatheter with a regular micro guidewire, and obtained documented consent. The primary endpoint of the study was a hemorrhagic complication. Results: Five patients were enrolled in this trial. The median age is 52 years, ranges from 41 to 70, and all patients were female. Three aneurysms were located on the internal carotid artery, one on the vertebral artery, and one on the basilar artery. Basilar artery aneurysm was treated by stent-assisted coiling and others were treated by flow diverter deployment. All cases successfully navigate microcatheter for the treatment by the trial method using Stabilizer device without any adverse event. Conclusions: The results from this first-in-human consecutive five cases show the safety of the Stabilizer device in neuro-endovascular therapy for navigation of devices to the intracranial target lesion.

A novel intracranial exchange guidewire improves the navigation of various endovascular devices: An in vitro study of challenging situations.

OBJECTIVE: Neuroendovascular procedures rely on successful navigation and stable access to the target vessel. The Stabilizer is a 300 cm long exchange wire with a 0.014 diameter and a soft, flexible stent at the distal end designed to assist with navigation and device delivery. This study aims to assess the efficacy of the Stabilizer for navigation in a variety of challenging environments. METHODS: The efficacy of the Stabilizer was evaluated using three challenging vascular models: a giant aneurysm model, a severe tortuosity model, and an M1 stenosis model. The Stabilizer was compared with a conventional wire during navigation in each model. RESULTS: In the giant aneurysm model, there was no significant difference of success during straightening of a looped wire and significantly higher success rates when advancing an intermediate catheter with the Stabilizer beyond the aneurysm neck compared to a conventional guidewire. The Stabilizer also significantly increased success rates when advancing an intermediate catheter through a model with severe tortuosity compared to a conventional guidewire, as well as exchange maneuver for intracranial stenting in a stenosis model compared to an exchange wire. CONCLUSIONS: In our experimental model, the Stabilizer significantly improved navigation and device delivery in a variety of challenging settings compared to conventional wires.

A novel technique for stenting of intracranial stenosis using the Neuroform Atlas stent and Gateway balloon catheter.

Management of intracranial stenosis remains controversial. Stenting for intracranial stenosis has been associated with high complication and restenosis rates. Morbidity may be related to the intracranial microcatheter exchange that is required in stent placement after the angioplasty. We present a technique in which we deploy an Neuroform Atlas stent through the lumen of a Gateway balloon microcatheter in order to avoid intracranial microcatheter exchange and the associated morbidity. We discuss advantages and pitfalls of this novel technique.

Radiolucent Carbon Fiber-Reinforced Implants for Treatment of Spinal Tumors-Clinical, Radiographic, and Dosimetric Considerations.

The management of spine tumors is multimodal and personalized to each individual patient. Patients often require radiation therapy after surgical fixation. Although titanium implants are used most commonly, they produce significant artifact, leading to decreased confidence in target-volume coverage and normal tissue sparing. Carbon-based materials have been found to have minimal effects on dose perturbation in postoperative radiation therapy and have shown biostability and biocompatibility that are comparable to titanium implants. Using the PubMed and Web of Sciences databases, we conducted a systematic review of carbon-based screw and rod fixation systems in the treatment of spinal tumors. We reviewed clinical studies regarding safety of spine fixation with carbon fiber-reinforced (CFR) implants and biomechanical studies, as well as radiation and dosimetric studies. The radiolucency of CFR-polyether ether ketone implants has the potential to benefit patients with spine tumor. Clinical studies have shown no increase in complications with implementation of CFR-polyether ether ketone implants, and these devices seem to have sufficient stiffness and pullout strength. However, further trials are necessary to determine if there is a clinically significant impact on local tumor control.

Utilization of epilepsy surgery in the United States: A study of the National Inpatient Sample investigating the roles of race, socioeconomic status, and insurance.

BACKGROUND: Epilepsy is estimated to affect 70 million people worldwide and is medically refractory in 30% of cases. METHODS: This is a retrospective cross-sectional study using a US database from 2012 to 2014 to identify patients aged ≥18 years admitted to the hospital with epilepsy as the primary diagnosis. The sampled population was weighted using Healthcare Cost and Utilization Project guidelines. Procedural ICD-9 codes were utilized to stratify the sampled population into two cohorts: resective surgery and implantation or stimulation procedure. RESULTS: Query of the database yielded 152,925 inpatients, of which 8535 patients underwent surgical intervention. The nonprocedural group consisted of 76,000 White patients (52.6%) and 28,390 Black patients (19.7%) while the procedural group comprised 5550 White patients (64%) and 730 Black patients (8.6%) (P < 0.001). Patients with Medicare were half as likely to receive a surgical procedure (14.8% vs. 28.4%) while patients with private insurance were twice as likely to receive a procedure (53.4% vs. 29.3%), both were statistically significant (P < 0.01). Those in the lowest median household income quartile by zip code (<$40,000) were 68% less likely to receive a procedure (21.5% vs. 31.4%) while the highest income quartile was 133% more likely to receive a procedure (26.1% vs. 19.5%). Patients from rural and urban nonteaching hospitals were, by a wide margin, less likely to receive a surgical procedure. CONCLUSION: We demonstrate an area of need and significant improvement at institutions that have the resources and capability to perform epilepsy surgery. The data show that institutions may not be performing enough epilepsy surgery as a result of racial and socioeconomic bias. Admissions for epilepsy continue to increase without a similar trend for epilepsy surgery despite its documented effectiveness. Race, socioeconomic status, and insurance all represent significant barriers in access to epilepsy surgery. The barriers can be remedied by improving referral patterns and implementing cost-effective measures to improve inpatient epilepsy services in rural and nonteaching hospitals.

Retraction: Effects of the COVID-19 Pandemic on Stroke Patients.

[This retracts the article DOI: 10.7759/cureus.9995.].

Risk Factors Associated with 90-Day Readmissions Following Occipitocervical Fusion-A Nationwide Readmissions Database Study.

BACKGROUND: Occipitocervical fusion (OCF) procedures are increasing due to an aging population and the prevalence of trauma, rheumatoid arthritis, and tumors. Reoperation rates and readmission risk factors for cervical fusions have been established, but in relation to OCF they have not been explored. This study investigates the patterns of readmissions and complications following OCF using a national database. METHODS: The 2016 U.S. Nationwide Readmissions Database was used for sample collection. Adults (>18 years) who underwent OCF were identified using the 2016 ICD-10 coding system, and we examined the readmission rates (30-day and 90-day) and reoperation rates. RESULTS: Between January and September 2016, a total of 477 patients underwent OCF; the 30-day and 90-day readmission rates were 10.4% and 22.4%, respectively. The 90-day reoperation rate related to the index surgery was 5.7%. Mean age (68.58 years) was significantly greater in the readmitted group versus nonreadmitted group (61.76 years) (P < 0.001). The readmitted group had a significantly higher Charlson Comorbidity Index and Elixhauser Comorbidity Index (5.00 and 2.41, respectively) than the nonreadmitted group (3.25 and 1.15, respectively; P < 0.001). Nonelective OCF showed a higher readmission rate (29.18%) versus elective OCF (12.23%) (P < 0.001). Medicare and Medicaid patients showed the highest rates of readmission (27.27% and 20.41%, respectively). Readmitted patients had higher total health care costs. CONCLUSIONS: Nonelective OCF was found to have a readmission rate of almost 2½× that of elective OCF. Understanding risk factors associated with OCF will help with operative planning and patient optimization.

Risk Factors Associated with 90-day Readmissions Following Odontoid Fractures: A Nationwide Readmissions Database Study.

STUDY DESIGN: Nationwide Readmissions Database Study. OBJECTIVE: The aim of this study was to investigate readmission rates and factors related to readmission after surgical and nonsurgical management of odontoid fractures. SUMMARY OF BACKGROUND DATA: Management of odontoid fractures, which are the most common isolated spine fracture in the elderly, continues to be debated. The choice between surgical or nonsurgical treatment has been reported to impact mortality and might influence readmission rates. Hospital readmissions represent a large financial burden upon our healthcare system. Factors surrounding hospital readmissions would benefit from a better understanding of their associated causes to lower health care costs. METHODS: A retrospective study was performed using the 2016 Healthcare Utilization Project (HCUP) Nationwide Readmission Database (NRD). Demographic information and factors associated with readmission were collected. Readmission rates, complications, length of hospital stay were collected. Patients treated operatively, nonoperatively, and patients who were readmitted or not readmitted were compared. Statistical analysis was performed using open source software SciPy (Python v1.3.0) for all analyses. RESULTS: We identified 2921 patients who presented with Type II dens fractures from January 1, 2016 to September 30, 2016, 555 of which underwent surgical intervention. The readmission rate in patients who underwent surgery was 16.4% (91/555) and 29.4% (696/2366) in the nonoperative group. Hospital costs for readmitted and nonreadmitted patients were $353,704 and $174,922, and $197,099 and $80,715 for nonoperatively managed patients, respectively. Medicaid and Medicare patients had the highest readmission rate in both groups. Charlson and Elixhauser comorbidity indices were significantly higher in patients who were readmitted (P < 0.0001). CONCLUSION: We report an overall 90-day readmission rate of 16.4% and 29.4%, in operative and nonoperative management of type II odontoid fractures, respectively. In the face of a rising incidence of this fracture in the elderly population, an understanding of the comorbidities and age-related demographics associated with 90-day readmissions following both surgical and nonsurgical treatment are critical.Level of Evidence: 3.

Diagnosis, Management, and Treatment Options: A Cervical Spine Osteochondroma Meta-Analysis.

Osteochondroma is described as a capped benign bony neoplasm that forms on the outer surface of bone. These tumors affect nearly 6 million people per year. Although osteochondromas most often involve the appendicular skeleton, many involve the spine, with many cases located in the cervical spine. When osteochondromas involve the spine, they can present with a variety of symptoms, including pain, radiculopathy, and myelopathy, which may necessitate surgical treatment. Spinal osteochondromas can be classified into 2 types: multiple osteochondromas in the context of patients with multiple hereditary exostosis (MHE) and solitary osteochondroma or solitary exostosis (SE). Previous reviews have captured only some of the available literature on cervical osteochondromas and have generally focused on either SE or those associated with MHE. The purpose of our review was to provide an extensive review of all previously reported cervical osteochondromas and to compare osteochondroma characteristics, clinical presentation, and outcomes in the context of MHE and SE.

Surgical Treatment of Ossifications of the Cervical Anterior Longitudinal Ligament: A Retrospective Cohort Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The study aims to evaluate anterior cervical discectomy and fusion (ACDF) in the treatment of patients with ossification of the anterior longitudinal ligament (OALL). METHODS: We retrospectively reviewed cases performed at our institution between January 2015 and December 2018; adult (age ≥18 years) patients who underwent anterior cervical decompression and fusion in the presence of dysphagia and OALL. Ten patients (9 male, 1 female, mean age 64.4 years) with OALL who underwent ACDF were included. Charts were reviewed for demographics and comorbidities. Primary outcomes assessed were intra- and postoperative complications. Secondary outcomes were fusion rates, instrumentation failure, postsurgical instability/deformity, and readmission rates. RESULTS: The average duration of symptoms prior to surgery was 12.3 months. All patients presented with dysphagia (mean Bazaz score 2.0). The average number of levels with OALL was 4.7 (±1.67). All patients underwent ACDF and 3 patients underwent additional posterior cervical fusion for kyphotic deformity correction or when extensive laminectomy was required. We did not encounter any intraoperative complications. Eight patients (72%) had solid fusion demonstrated on the lateral x-rays and no evidence of progressive kyphotic deformity. We did not encounter any instrumentation failure or loosening. Two patients developed recurrence of dysphagia (Bazaz scores 2 and 3 respectively). CONCLUSION: ACDF for OALL with dysphagia and concomitant myelopathy in our small series of 10 patients demonstrate good fusion and clinical outcomes. Larger studies will be necessary to determine the optimal treatment for patients with dysphagia due to OALL.

Extreme Lateral Interbody Fusion for Thoracic and Thoracolumbar Disease: The Diaphragm Dilemma.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Complication profiles for lateral approaches to the spine are well established. However, the influence of level of surgery on complication rates and subtypes are less well established. To determine risk factors for complications as determined by level and surgery type in patients undergoing a lateral (retroperitoneal or retropleural approach) to the thoracolumbar spine. METHODS: All adult patients undergoing a lateral thoracolumbar fusion with or without posterior instrumentation performed at a single institution were identified. Primary outcomes assessed were presence of complication, complication subtype, and need for reoperation. The primary independent variables were spinal level (thoracic, thoracolumbar, or lumbar) and type of surgery (discectomy or corpectomy). Categorical outcomes were compared using chi-square test. Unadjusted and adjusted odds ratios for corpectomy status were calculated to determine risk of complication by level. P < .05 was considered statistically significant. RESULTS: A total of 165 patients aged 18 to 75 years were identified as having undergone a lateral fusion. Complication rates were 28.6%, 36.4%, and 11% for thoracic, thoracolumbar, and lumbar lateral approach fusions, respectively. Under univariate analysis, patients undergoing lateral approach in the thoracic spine group had significantly higher rates of postoperative complications than those in the lumbar group (P = .005). After adjusting for corpectomy status, there was no difference in complication rates. CONCLUSIONS: Lateral (retroperitoneal or retropleural) approaches to the thoracic and thoracolumbar spine may be used with complication rates comparable to well-established lumbar approaches. Extent of surgery (corpectomy vs discectomy) rather than level of surgery may represent the primary driver of complications.

Spontaneous Spinal Subdural Hematoma Mimicking Myocardial Infarction.

Spontaneous spinal subdural hematomas (SSDHs) are rarely encountered in clinical practice. In this paper, we report a case of a 70-year-old female who presented to the Emergency Department with symptoms of mid-epigastric pain radiating to her mid-scapular region. Her workup demonstrated mildly elevated cardiac troponin I levels and electrocardiogram (ECG) leads V3-V5 ST-depressions. She was subsequently treated through the non-ST elevation myocardial infarction (NSTEMI) protocol and given an antiplatelet agent. The next morning, she developed bilateral lower extremity paresthesias, progressive left lower extremity weakness, and urinary retention. Magnetic resonance imaging (MRI) of the spine demonstrated a hematoma in the thoracic region resulting in spinal cord compression. The patient underwent surgical decompression. After the decompression of the thoracic spinal cord, the patient's neurological symptoms gradually improved and she regained lower extremity function. This report brings to light a very unusual presentation of an uncommon clinical entity. To the best knowledge of the authors, spontaneous SSDH presenting as myocardial injury and subsequently exacerbated by anticoagulation therapy has not been reported in the literature to date.

Effects of the COVID-19 Pandemic on Stroke Patients.

Introduction The severe acute respiratory syndrome coronavirus 2 (SARS2-CoV-2) induced pandemic (COVID-19 pandemic) has affected healthcare in all aspects, including stroke care. We sought to investigate this effect with analysis of our hospital's stroke treatment protocols as well as stroke volume on state, regional, and national levels. Methods This was a retrospective review of prospectively collected data from our stroke registry to assess the impact of the SARS2-CoV-2 induced pandemic on the volume of stroke patients presenting to our facility. Demographics collected included age, sex, race, National Institute of Health Stroke Scale (NIHSS) on admission, discharge modified Rankin Score (mRS), type of stroke (ischemic, hemorrhagic, or transient ischemic attack), time of symptom onset, and time to initial imaging. Data were also stratified by date and comparison was made between the intra-COVID-period (March and April 2020), pre-COVID period (March and April 2019), and peri-COVID period (January and February 2020). To determine stroke trends on a national level, we utilized the Get with the Guidelines (GWTG) stroke database to compare stroke volumes in the pre-COVID, peri-COVID, and intra-COVID periods between our hospital, all California hospitals, and the West and Pacific regions. Results There was a significant increase in last known well time (LKWT) to arrival to the emergency department (ED) (LKWT to door) as well as time from arrival to the ED to obtaining a computed tomography (CT) of the head (door to CT) in March 2020 compared to 2019 (p=0.0220 and p=0.0475, respectively). There were significantly fewer transient ischemic attacks (TIAs) in California hospitals as well as in March and April 2020 in comparison to January and February 2020 (p=0.0417). Similarly, there were significantly fewer TIAs in March and April 2019 compared to March and April 2020 (p=0.0360). The decrease in TIAs was also seen at our hospital in both time frame comparisons as well as in West Regional Hospitals in March and April 2020 compared to March and April 2019 (p=0.0111, p=0.0215, and p=0.0414, respectively). Conclusion Stroke care has been disrupted by the COVID-19 pandemic worldwide. We identified a delay in LKWT to door as well as time from door to CT in March 2020 compared to March 2019 at our institution. There was a statistically significant decrease in final diagnosis of TIA at our hospital, all California hospitals, and all West Regional hospitals during the March-April 2020 window, suggesting that some patients with minor stroke symptoms may not be presenting to the hospital in the midst of the pandemic. Strategies to minimize delays in care and maximize functional recovery must continue to evolve as new challenges are met during the COVID-19 pandemic.

A Novel Method for Practicing Fascial Closure with Suture.

Closure of the fascial layer can be challenging to learn for junior level residents. Wound dehiscence involving the fascial layer can lead to complicated clinical courses for patients, including readmission to the hospital, wound vacuum placement, antibiotic regimens, and re-operation. Typical suturing techniques taught in medical school focus more on basic techniques of suture placement such as interrupted or running techniques. The aim of this study is to introduce a method of practicing fascial closure using easily obtainable items. Though there is no substitute for placement of suture and closure of fascia in vivo, this method allows one to practice the motor repetition of fascial suture placement and provides one with the ability to check their work.

Cervical osteochondroma: surgical planning.

INTRODUCTION: Osteochondromas are benign bone tumors which occur as solitary lesions or as part of the syndrome multiple hereditary exostoses. While most osteochondromas occur in the appendicular skeleton, they can also occur in the spine. Most lesions are asymptomatic however some may encroach on the spinal cord or the nerve roots causing neurological symptoms. While most patients with osteochondromas undergo laminectomy without fusion, laminectomy with fusion is indicated in appropriately selected cases of spinal decompression. CASE PRESENTATION: We present a case of a 32-year-old male with history of multiple hereditary exostoses who presented with symptoms of bilateral upper extremity numbness and complaints of gait imbalance and multiple falls. He reported rapid progression of his symptoms during the 10 days before presentation. Computed tomography of the cervical spine revealed a lobulated bony tumor along the inner margin of the cervical 4 lamina. He underwent cervical 3 and 4 laminectomies, partial cervical 2 and 5 laminectomies and cervical 3-5 mass screw placement. Pathology was consistent with osteochondroma. The patient's symptoms had markedly improved at follow-up. CONCLUSION: According to our literature review, osteochondromas most commonly occur at cervical 2 and cervical 5. We present a case of an osteochondroma at a less common level, cervical 4. While most osteochondromas are addressed with laminectomy without arthrodesis, the decision of whether arthrodesis is necessary should be considered in all patients with osteochondroma as with any cervical decompression.

Impact of Chronic DMARD Therapy in Patients With Rheumatoid Arthritis Undergoing Surgery of the Craniovertebral Junction: A Multi-center Retrospective Study.

STUDY DESIGN: A multi-centered retrospective review from five institutions. OBJECTIVE: The aim of this study was to determine whether continuing or withholding disease-modifying antirheumatoid drugs (DMARDs) in the perioperative period affect outcomes in rheumatoid arthritis (RA) patients undergoing arthrodesis at the craniovertebral junction SUMMARY OF BACKGROUND DATA.: RA is a chronic systemic inflammatory disease that affects the cervical spine and is treated with DMARDs. Some advocate withholding DMARDs in the perioperative period due to concern for the cytotoxic effects of these medications. However, the impact of DMARDs in the perioperative period is not well understood. METHODS: A multicenter retrospective study from five affiliated institutions was performed. Adult patients with RA on chronic DMARDs undergoing posterior arthrodesis of the craniovertebral junction (occipital-cervical or atlanto-axial arthrodesis) were identified. Patients were stratified based on whether DMARD therapy was continued (C group) or discontinued (DC group) in the perioperative period. The primary outcome was the need for reoperation and reason for reoperation. RESULTS: Thirty-nine patients met inclusion criteria, 19 in C group and 20 in DC group. Average follow-up time was 42 months. Four patients (three in DC group and one in C group) required reoperation. Two patients from the DC group required readmission secondary to RA flare-up. CONCLUSION: Our cohort of RA patients who underwent occipital-cervical and C1/C2 posterior arthrodesis showed no significant differences in surgical complications when DMARD therapy was continued or discontinued in the perioperative period. The decision to continue or discontinue DMARD therapy in the perioperative period is at the discretion of the treating physician, but we encourage physicians to counsel patients regarding this theoretical risk and their tolerance of the medications as well as the risk of RA flare-up. Factors such as overall health, disease burden, nutrition, bone quality, smoking status, and other comorbid conditions are likely to have a larger influence on perioperative complications. LEVEL OF EVIDENCE: 3.

Complications and Mortality in Octogenarians Undergoing Lumbopelvic Fixation.

BACKGROUND: Advancements in modern medicine have led to longer life expectancy. Literature on spinopelvic fixation in elderly patients is limited. We investigated morbidity and mortality in octogenarians who underwent spinopelvic fixation. METHODS: A retrospective chart review was conducted of patients who underwent spinopelvic fixation from January 2014 through December 2018 at a single institution. Patients were grouped into the octogenarian group (OG), 80-89 years old, and comparison group (CG), 40-50 years old. Demographics; pathology; Charlson Comorbidity Index; Hounsfield units; surgery details; and clinical data including complications, intensive care unit and length of hospital stay, and mortality were collected and compared. RESULTS: Inclusion criteria were met by 26 patients (OG: n = 14; CG: n = 12). Diagnoses in the OG were deformity (42.9%), pseudarthrosis (35.7%), fracture (7.1%), infection (7.1%), and tumor (7.1%). The only significant differences in baseline patient characteristics were that Charlson Comorbidity Index was significantly higher in the OG (6.0 ± 1.4) compared with the CG (1.1 ± 1.0) (P < 0.001) and the OG had lower Hounsfield units (P < 0.001), indicating poorer bone quality. More patients in the CG underwent staged and anterior approaches compared with the OG (P = 0.031). Major and minor complication rates were 57.1% and 42.9%, respectively, in the OG (P = 0.98) and 25% and 25% in the CG (P = 0.34). Mortality rate was 14.3%. CONCLUSIONS: With an aging population, the number of patients requiring spinopelvic fixation will continue to grow. Spine surgeons must carefully weigh benefits and risks in patients with multiple comorbidities.