Age as a Predictor for Complications and Patient-reported Outcomes in Multilevel Transforaminal Lumbar Interbody Fusions: Analyses From the Michigan Spine Surgery Improvement Collaborative (MSSIC)

STUDY DESIGN: Retrospective review of a multi-institutional data registry. OBJECTIVE: The authors sought to determine the association between age and complications & patient-reported outcomes (PRO) in patients undergoing multilevel transforaminal interbody lumbar fusion (MTLIF). SUMMARY OF BACKGROUND DATA: Elderly patients undergoing MTLIF are considered high risk. However, data on complications and PRO are lacking. Additionally, safety of multilevel lumbar fusion in the elderly remains uncertain. METHODS: Patients ≥50-year-old who underwent MTLIF for degenerative lumbar spine conditions were analyzed. Ninety-day complications and PROs (baseline, 90-d, 1-y, 2-y) were queried using the MSSIC database. PROs were measured by back & leg visual analog scale (VAS), Patient-reported Outcomes Measurement Information System (PROMIS), EuroQol-5D (EQ-5D), and North American Spine Society (NASS) Patient Satisfaction Index. Univariate analyses were used to compare among elderly and complication cohorts. Generalized estimating equation (GEE) was used to identify predictors of complications and PROs. RESULTS: A total of 3120 patients analyzed with 961 (31%) ≥ 70-y-o and 2159 (69%) between 50-69. A higher proportion of elderly experienced postoperative complications (P = .003) including urinary retention (P = \u3c.001) and urinary tract infection (P = .002). Multivariate analysis demonstrated that age was not independently associated with complications. Number of operative levels was associated with any (P = .001) and minor (P = .002) complication. Incurring a complication was independently associated with worse leg VAS and PROMIS scores (P = \u3c.001). Preoperative independent ambulation was independently associated with improved PROMIS, and EQ5D (P = \u3c.001). Within the elderly, preoperative independent ambulation and lower BMI were associated with improved PROMIS (P = \u3c.001). Complications had no significant effect on PROs in the elderly. CONCLUSIONS: Age was not associated with complications nor predictive of functional outcomes in patients who underwent MTLIF. Age alone, therefore, may not be an appropriate surrogate for risk. Furthermore, baseline preoperative independent ambulation was associated with better clinical outcomes and should be considered during preoperative surgical counseling. Level of Evidence: 3

A Matched Cohort Analysis of Drain Usage in Elective Anterior Cervical Discectomy and Fusion: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study

STUDY DESIGN: This is a retrospective, cohort analysis of multi-institutional database. OBJECTIVE: This study was designed to analyze the impact of drain use following elective anterior cervical discectomy and fusion (ACDF) surgeries. SUMMARY OF BACKGROUND DATA: After ACDF, a drain is often placed to prevent postoperative hematoma. However, there has been no high quality evidence to support its use with ACDF despite the theoretical benefits and risks of drain placement. METHODS: The Michigan Spine Surgery Improvement Collaborative database was queried to identify all patients undergoing elective ACDF between February 2014 and October 2019. Cases were divided into two cohorts based on drain use. Propensity-score matching was utilized to adjust for inherent differences between the two cohorts. Measured outcomes included surgical site hematoma, length of stay, surgical site infection, dysphagia, home discharge, readmission within 30 days, and unplanned reoperation. RESULTS: We identified 7943 patients during the study period. Propensity-score matching yielded 3206 pairs. On univariate analysis of matched cohorts, there were no differences in rate of postoperative hematoma requiring either return to OR or readmission. We noted patients with drains had a higher rate of dysphagia (4.6% vs. 6.3%; P = 0.003) and had longer hospital stay (P \u3c 0.001). On multivariate analysis, drain use was associated with significantly increased length of stay (relative risk 1.23, 95% confidence interval [CI] 1.13-1.34; P \u3c 0.001). There were no significant differences in other outcomes measured. CONCLUSION: Our analysis demonstrated that drain use is associated with significant longer hospital stay.Level of Evidence: 3

Giant Cell Tumor of Bone Presenting as Left Posteromedial Chest Wall Tumor.

Giant cell tumor is a relatively uncommon bone tumor rarely originating from the chest wall. Given its proximity to vital structures in the thoracic cavity, treatment options may be challenging. We report the case of a patient with a giant cell tumor of the posterolateral chest wall with invasion of the thoracic spine treated with neoadjuvant denosumab, followed by surgical resection

Surgical site infection after transoral versus posterior approach for atlantoaxial fusion: a matched-cohort study

OBJECTIVE In the past, spine surgeons have avoided the transoral approach to the atlantoaxial segment because of concerns for unacceptable patient morbidity. The objective of this study was to measure 30-day postoperative complications, especially surgical site infection (SSI), after transoral versus posterior approach to atlantoaxial fusion. METHODS The source population was provided by the American College of Surgeons National Surgical Quality Improvement Program database, which was queried for all patients who underwent atlantoaxial fusion for degenerative/spondylotic disease and/or trauma between 2005 and 2014. To eliminate bias from unequal sample sizes, patients who underwent the transoral approach were matched with patients who underwent the posterior approach (generally 1:5 ratio) based on age ± 5 years and modified frailty index score (a measure of preoperative comorbidity burden). Because of rare SSI incidence, adjusted odds ratios (ORadj) of SSI were calculated using penalized maximum likelihood estimation. RESULTS A total of 318 patients were included in the study. There were no statistically significant differences between the transoral cohort (n = 56) and the posterior cohort (n = 262) in terms of 30-day postoperative individual complications, including SSI (1.79% vs 1.91%; p = 0.951) and composite complications (10.71% vs 6.87%; p = 0.323). Controlling for sex and smoking, the odds of SSI in the transoral approach were almost equal to the odds in the posterior approach (ORadj 1.17; p = 0.866). While the unplanned reoperation rate of 5.36% after transoral surgery was higher than the 1.53% rate after posterior surgery, the difference approached, but did not reach, statistical significance (p = 0.076). CONCLUSIONS Transoral versus posterior surgery for atlantoaxial fusion did not differ in 30-day unexpected outcomes. Therefore, spinal pathology, rather than concern for postoperative complications, should adjudicate the technical approach to the atlantoaxial segment

Surgical site infection after transoral versus posterior approach for atlantoaxial fusion: a matched-cohort study

OBJECTIVE In the past, spine surgeons have avoided the transoral approach to the atlantoaxial segment because of concerns for unacceptable patient morbidity. The objective of this study was to measure 30-day postoperative complications, especially surgical site infection (SSI), after transoral versus posterior approach to atlantoaxial fusion. METHODS The source population was provided by the American College of Surgeons National Surgical Quality Improvement Program database, which was queried for all patients who underwent atlantoaxial fusion for degenerative/spondylotic disease and/or trauma between 2005 and 2014. To eliminate bias from unequal sample sizes, patients who underwent the transoral approach were matched with patients who underwent the posterior approach (generally 1:5 ratio) based on age ± 5 years and modified frailty index score (a measure of preoperative comorbidity burden). Because of rare SSI incidence, adjusted odds ratios (ORadj) of SSI were calculated using penalized maximum likelihood estimation. RESULTS A total of 318 patients were included in the study. There were no statistically significant differences between the transoral cohort (n = 56) and the posterior cohort (n = 262) in terms of 30-day postoperative individual complications, including SSI (1.79% vs 1.91%; p = 0.951) and composite complications (10.71% vs 6.87%; p = 0.323). Controlling for sex and smoking, the odds of SSI in the transoral approach were almost equal to the odds in the posterior approach (ORadj 1.17; p = 0.866). While the unplanned reoperation rate of 5.36% after transoral surgery was higher than the 1.53% rate after posterior surgery, the difference approached, but did not reach, statistical significance (p = 0.076). CONCLUSIONS Transoral versus posterior surgery for atlantoaxial fusion did not differ in 30-day unexpected outcomes. Therefore, spinal pathology, rather than concern for postoperative complications, should adjudicate the technical approach to the atlantoaxial segment

Preventive effect of tamsulosin on postoperative urinary retention in neurosurgical patients

BACKGROUND: Postoperative urinary retention (POUR) is common in neurosurgical patients. The use of alpha-blockade therapy, such as tamsulosin, has benefited many patients with a history of obstructive uropathy by decreasing lower urinary tract symptoms such as distension, infections, and stricture formation, as well as the incidence of POUR. For this study, we targeted patients who had undergone spinal surgery to examine the prophylactic effects of tamsulosin. Increased understanding of this therapy will assist in minimizing the morbidity of spinal surgery. METHODS: We enrolled 95 male patients undergoing spine surgery in a double-blind, randomized, placebo-controlled trial. Patients were randomly assigned to receive either preoperative tamsulosin (N = 49) or a placebo (N = 46) and then followed-up prospectively for the development of POUR after removal of an indwelling urinary catheter (IUC). They were also followed-up for the incidence of IUC reinsertions. RESULTS: The rate of developing POUR was similar in both the groups. Of the 49 patients given tamsulosin, 16 (36%) developed POUR compared to 13 (28%) from the control group (P = 0.455). In the control group, 5 (11%) patients had IUC re-inserted postoperatively, whereas 7 (14%) patients in the tamsulosin group had IUC re-inserted postoperatively (P = 0.616). In patients suffering from axial-type symptoms (i.e., mechanical back pain), 63% who received tamsulosin and 18% from the control group (P = 0.048) developed POUR. CONCLUSION: Overall, there was no statistically significant difference in the rates of developing POUR among patients in either group. POUR is caused by a variety of factors, and further studies are needed to shed light on its etiology

A cohort study of the morbidity of combined anterior-posterior cervical spinal fusions: incidence and predictors of postoperative dysphagia

PURPOSE: To identify risk factors that may lead to the development of dysphagia after combined anterior and posterior (360°) cervical fusion surgery. METHODS: A single center, retrospective analysis of patients who had same-day, 360° fusion at Henry Ford Hospital between 2008 and 2012 was performed. Variables analyzed included demographics, medical co-morbidities, levels fused, and degree of dysphagia. RESULTS: The overall dysphagia rate was 37.7 %. Patients with dysphagia had a longer mean length of stay (p \u3c 0.001), longer mean operative time (p \u3c 0.001), greater intraoperative blood loss (p = 0.002), and fusion above the fourth cervical vertebra, C4, (p = 0.007). There were no differences in the rates of dysphagia when comparing patients undergoing primary or revision surgery (p = 0.554). CONCLUSION: Prolonged surgery and fusion above C4 lead to higher rates of dysphagia after 360° fusions. Prior anterior cervical fusion does not increase the risk of dysphagia development

Mechanomyography for Intraoperative Assessment of Cortical Breach During Instrumented Spine Surgery

OBJECTIVE: We sought to determine the utility of mechanomyography (MMG) in detecting and preventing pedicle breach in instrumented lumbar spine surgery. METHODS: In a prospective nonrandomized trial without controls, we selected consecutive patients to undergo intraoperative MMG during instrumented lumbar spine surgery. MMG testing was performed at the original pilot hole, after tapping, and after screw placement, with the minimum current to elicit a recorded MMG response. All patients underwent a postoperative computed tomography scan, and a single radiologist interpreted each pedicle to identify breach. Chi-square test was used to compare patients with and without breaches. Two sample Student\u27s t-tests were used to compare changes in functional outcomes. Sensitivity and specificity of MMG were computed using receiver operating characteristic curve analysis. RESULTS: There were 122 consecutive instrumented lumbar surgery patients enrolled, with a total of 890 lumbar pedicle screws tested with MMG. The medial or inferior breach rate was 2.25%, with no statistically significant difference in Oswestry Disability Index or visual analog scale between patients who breached and who did not. For the MMG measurement from the original pilot hole, the area under the receiver operating characteristic was 0.835; the maximum combination of sensitivity (80.42%) and specificity (80.6%) was found using MMG current ≤12 mA. We found that an MMG cutoff of \u3e12 mA resulted in a 99.5% likelihood of no medial or inferior breach. CONCLUSIONS: MMG can be safely used during instrumented lumbar spine surgery. A cutoff value of \u3e12 mA for MMG can accurately predict and prevent medial and inferior pedicle screw breach

Early Ambulation After Lumbar Spine Surgery

Introduction: The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a multicenter quality improvement collaborative. Using the MSSIC database, we sought to identify the relationship between ambulation on the day of surgery (POD#0) and 90-day adverse events after lumbar surgery, specifically length of stay (LOS), urinary retention (UR), urinary tract infection (UTI), ileus, readmission, surgical site infection (SSI), PE/DVT, and disposition to a rehab facility. Material and Methods: A total of 23295 lumbar surgery patients were analyzed. Multivariate logistic regression models were constructed, including variables on patient demographics, medical history, and surgical intensity. Matching was performed to account for unknown confounding variables. Results: POD#0 ambulation was associated with decreased LOS (OR0.83, p\u3c0.001), UR (OR0.73, p=0.008), UTI (OR0.52, p=0.001), ileus (OR0.52, p\u3c0.001), 30-day (OR0.84, p=0.035) and 90-day (OR0.86, p=0.009) readmission, and rehab discharge (OR0.52, p\u3c0.001) for all patients. POD#0 ambulation after single-level decompression (6244 patients) decreased LOS (OR0.72, p\u3c0.001), UR (OR0.73, p=0.004), UTI (OR0.43, p=0.003), and rehab discharge (OR0.18, p\u3c0.001). Ambulation after multi-level decompression (5526 patients) was associated with decreased LOS (OR0.73, p\u3c0.001), UR (OR0.75, p=0.04), ileus (OR0.60, p=0.027), and rehab discharge (OR0.44, p\u3c0.001). Ambulation after single-level fusion (5790 patients) decreased LOS (OR0.85 p\u3c0.001), 30-day readmission (OR0.77, p=0.032) and rehab discharge (OR0.65, p=0.004). Ambulation after multi-level fusion (5735 patients) decreased LOS (OR0.88, p\u3c0.001), UTI (OR0.60, p=0.003), ileus (OR0.51, p=0.02), 30-day readmission (OR0.77, p=0.032), and rehab discharge (OR0.59, p\u3c0.001). No change in rate of or DVT/PE was observed for patients who ambulated POD#0. Conclusion: POD#0 ambulation is associated with a significantly decreased risk for several key adverse events after lumbar spine surgery. Decreasing the incidence of these outcomes would be associated with significant cost savings. As ambulation POD#0 is a modifiable factor in any patient’s postoperative care following most spine surgery, it should be encouraged and incorporated into spine related enhanced recovery after surgery (ERAS) programs. My research will improve patient care by showing how early ambulation on POD#0 can decrease adverse events & costs and improve patient outcomes associated with lumbar spine surgery. Learning Objectives: By the conclusion of this session, participants will be able to: 1) Identify common adverse events and their costs after lumbar spine surgery 2) How ambulation on the day of surgery is associated with decreased incidence of adverse events 3) The importance of early ambulation on improving outcomes and decreasing costs of lumbar spine surgery.https://scholarlycommons.henryford.com/merf2019qi/1013/thumbnail.jp

Ambulation on Postoperative Day #0 Is Associated With Decreased Morbidity and Adverse Events After Elective Lumbar Spine Surgery: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC)

BACKGROUND: While consistently recommended, the significance of early ambulation after surgery has not been definitively studied. OBJECTIVE: To identify the relationship between ambulation on the day of surgery (postoperative day (POD)#0) and 90-d adverse events after lumbar surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective multicenter registry of spine surgery patients. As part of routine postoperative care, patients either ambulated on POD#0 or did not. The 90-d adverse events of length of stay (LOS), urinary retention (UR), urinary tract infection (UTI), ileus, readmission, surgical site infection (SSI), pulmonary embolism/deep vein thrombosis (PE/DVT), and disposition to a rehab facility were measured. RESULTS: A total of 23 295 lumbar surgery patients were analyzed. POD#0 ambulation was associated with decreased LOS (relative LOS 0.83, P \u3c .001), rehab discharge (odds ratio [OR] 0.52, P \u3c .001), 30-d (OR 0.85, P = .044) and 90-d (OR 0.86, P = .014) readmission, UR (OR 0.73, P = 10), UTI (OR 73, P = .001), and ileus (OR 0.52, P \u3c .001) for all patients. Significant improvements in LOS, rehab discharge, readmission, UR, UTI, and ileus were observed in subset analysis of single-level decompressions (4698 pts), multilevel decompressions (4079 pts), single-level fusions (4846 pts), and multilevel fusions (4413 pts). No change in rate of SSI or DVT/PE was observed for patients who ambulated POD#0. CONCLUSION: POD#0 ambulation is associated with a significantly decreased risk for several key adverse events after lumbar spine surgery. Decreasing the incidence of these outcomes would be associated with significant cost savings. As ambulation POD#0 is a modifiable factor in any patient\u27s postoperative care following most spine surgery, it should be encouraged and incorporated into spine-related, enhanced-recovery-after-surgery programs