¿Por que os índices de fragilidade não são usados sistematicamente durante as consultas de coluna no pré-operatório?

Introduction: Frailty indices are highly predictive of major medical and mechanical complications, lengths of hospital stay, and mortality rates after spine procedures. However, several barriers limit the extent to which spine surgeons employ these indices. The main purposes of the current study were to assess the use of frailty indices by Latin-American spine surgeons and identify the main barriers perceived to restrict their clinical application. Methods: For this cross-sectional survey, a questionnaire evaluating the demographic characteristics of participating surgeons and their utilization of frailty indices were created in Google form and sent by e-mail to every registered member of AO Spine Latin America between October and November 2020. Results: Of the 1047 surgeons sent the survey, 293 responded (response rate=28%). Half of the surgeons (51.7%) said they were unfamiliar with the terms ¨frailty´ and ¨frailty index”, while 70.3% claimed not to use any frailty scale during their pre-operative assessments. The most frequently utilized index was the modified Frailty Index (mFI) (18%). The most important perceived barrier was the excessive amount of time required to calculate each patient’s frailty score. Ninety-two percent of the spine surgeons felt sure that these scores could influence their therapeutic decisions, while 91% desired an easier-to-use risk-prevention scale. Conclusion: The main perceived barriers restricting the use of frailty indices were the time required to complete them, lack of index validation, and need for specific instruments to calculate the index score.Introducción: Los índices de fragilidad aplicados a procedimientos quirúrgicos de columna vertebral, son altamente predictivos de complicaciones mecánicas y médicas mayores, de duración de estadías hospitalarias y de tasas de mortalidad. Sin embargo, existen barreras que limitan el uso extensivo de estos indices. El objetivo principal de este estudio es de evaluar el uso de Índices de fragilidad por cirujanos Latino-Americanos de Columna vertebral y de identificar las principales barreras percibidas que restringen su aplicación clínica. Métodos: Encuesta transversal en la cual se utilizó un cuestionario (Google Forms) enviado por correo electrónico a cada miembro registrado de AO Spine Latin-America entre octubre y noviembre de 2020. El mismo indaga las características demográficas de los cirujanos participantes y la utilización de los índices de fragilidad en su práctica clínica. Resultados: De los 1047 cirujanos a quienes se envió la encuesta, 293 respondieron (tasa de respuesta = 28%). La mitad de los cirujanos (51,7%) dijo no estar familiarizado con los términos “fragilidad” e “índice de fragilidad”, mientras que el 70,3% afirmó no utilizar ninguna escala de fragilidad durante sus evaluaciones preoperatorias. El índice más utilizado fue el índice de fragilidad modificado (mFI) (18%). La barrera percibida más importante fue la excesiva cantidad de tiempo necesario para calcular la puntuación de fragilidad de cada paciente. El 92% de los cirujanos de columna estaban seguros de que estas puntuaciones podrían influir en sus decisiones terapéuticas, mientras que el 91% deseaba una escala de prevención de riesgos más fácil de usar. Conclusión: Las principales barreras percibidas que restringen el uso de índices de fragilidad fueron el tiempo requerido para completarlos, la falta de validación de los índices y la necesidad de instrumentos específicos para calcularlos.Introdução: Os índices de fragilidade são altamente preditivos de complicações médicas e mecânicas importantes, tempo de internação hospitalar e taxas de mortalidade após procedimentos na coluna vertebral. No entanto, várias barreiras limitam a extensão em que os cirurgiões de coluna empregam esses índices. Os principais objetivos do presente estudo foram avaliar a utilização de índices de fragilidade por cirurgiões de coluna latino-americanos e identificar as principais barreiras percebidas para restringir sua aplicação clínica. Métodos: Para esta pesquisa transversal, um questionário avaliando as características demográficas dos cirurgiões participantes e sua utilização dos índices de fragilidade foi criado no formulário do Google e enviado por e-mail a todos os membros registrados da AO Spine Latin America entre outubro e novembro de 2020. Resultados: Dos 1.047 cirurgiões que enviaram a pesquisa, 293 responderam (taxa de resposta = 28%). Metade dos cirurgiões (51,7%) afirmou não conhecer os termos ¨fragilidade´ e ¨índice de fragilidade”, enquanto 70,3% afirmaram não utilizar nenhuma escala de fragilidade durante as avaliações pré-operatórias. O índice mais utilizado foi o Índice de Fragilidade modificado (mFI) (18%). A barreira percebida mais importante foi a quantidade excessiva de tempo necessária para calcular a pontuação de fragilidade de cada paciente. Noventa e dois por cento dos cirurgiões de coluna tinham certeza de que essas pontuações poderiam influenciar suas decisões terapêuticas, enquanto 91% desejavam uma escala de prevenção de risco mais fácil de usar. Conclusão: As principais barreiras percebidas que restringem o uso dos índices de fragilidade foram o tempo necessário para completá-los, a falta de validação do índice e a necessidade de instrumentos específicos para o cálculo do escore do índice

Comparison of complication rates between anterior versus posterior approaches for treating unstable Hangman's fracture. A systematic review and meta-analysis

Study design: Systematic Review and Meta-analysis. Objective: To compare the complication rates associated with anterior and posterior approaches for the surgical treatment of unstable hangman's fractures. Methods: A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in PubMed, Web of Science, and Scopus databases to identify comparative studies reporting complications of anterior versus posterior approaches for the treatment of unstable hangman's fractures. Results: The search yielded 1163 papers from which 5 studies were fully included. One hundred fifteen (115) patients were operated on using an anterior approach versus 65 through a posterior approach. The average complication rates for the anterior and posterior approaches were 26.1 % and 13.8 %, respectively. No complications following the anterior approach required pharmacological or surgical intervention (Clavien-Dindo, Grade 1), while 88.9 % of complications following the posterior approach did (Clavien-Dindo, Grade 2). Conclusion: No significant differences in the complication rates were found when comparing anterior versus posterior surgery for treating a C2 traumatic spondylolisthesis. However, most of the complications presented in the posterior surgery group were more severe

Utility of the Modified 5-Items Frailty Index to Predict Complications and Mortality After Elective Cervical, Thoracic and Lumbar Posterior Spine Fusion Surgery: Multicentric Analysis From ACS-NSQIP Database.

STUDY DESIGN: Retrospective review of multicentric data. OBJECTIVES: The modified 5-item frailty index is a relatively new tool to assess the post-operative complication risks. It has been recently shown a good predictive value after posterior lumbar fusion. We aimed to compare the predictive value of the modified 5-item frailty index in cervical, thoracic and lumbar surgery. METHODS: The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database 2015-2020 was used to identify patients who underwent elective posterior cervical, thoracic, or lumbar fusion surgeries for degenerative conditions. The mFI-5 score was calculated based on the presence of 5 co-morbidities: congestive heart failure within 30 days prior to surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on the postoperative morbidity while controlling for baseline clinical characteristics. RESULTS: 53 252 patients were included with the mean age of 64.2 ± 7.2. 7946 suffered medical complications (14.9%), 1565 had surgical complications (2.9%), and 3385 were readmitted (6.3%), 363 died (.68%) within 30 days postoperative (6.3%). The mFI-5 items score was significantly associated with higher rates of complications, readmission, and mortality in cervical, thoracic, and lumbar posterior fusion surgery. CONCLUSION: The modified 5-item frailty score is a reliable tool to predict complications, readmission, and mortality in patients planned for elective posterior spinal fusion surgery

Educational Status of Minimally Invasive Spine Surgery

Introduction The objective of this study was to understand how spine surgeons learn minimally invasive spine surgery (MISS) and how the COVID-19 pandemic impacted the educational experience of MISS. Potential solutions for increasing the spine surgeon's access to MISS educational resources were also discussed

The impact of stratified hypoalbuminemia and dialysis on morbidity/mortality after posterior spinal fusion surgery: An ACS-NSQIP study.

BackgroundPreoperative optimization in patients undergoing posterior spinal fusion is essential to limit the number and severity of postoperative complications. Here, we, additionally, evaluated the impact of hypoalbuminemia on morbidity and mortality after posterior spinal fusion surgery.MethodsThis retrospective analysis was performed using data from a prospective multicentric database (ACSNSQIP:2015-2020) regarding patients undergoing posterior spinal fusions. Factors studied included; baseline demographics and 30-day postoperative complications (i.e., reoperations, readmissions, and mortality rates).ResultsThere were 6805 patients who met the inclusion criteria. They averaged 62 years of age and had an average BMI of 30.2. Within the 30-day postoperative period, 634 (9.3%) sustained complications; 467 (6.9%) were readmitted, 263 (3.9%) required reoperations, and 37 (0.5%) expired. Although multiple preoperative risk factors were analyzed, hypoalbuminemia, severe hypoalbuminemia, and dialysis were the strongest independent risk factors associated with complications (i.e., reoperations, readmissions, and mortality).ConclusionHypoalbuminemia, severe hypoalbuminemia, and dialysis were significant predictors for morbidity and mortality after posterior spinal fusion surgery

An inter- and intra-rater agreement assessment of a novel classification of pyogenic spinal infections

Purpose Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification. Methods Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (w kappa) to establish the inter- and intra-observer agreement. Results The inter-observer agreement was substantial considering the main categories (w kappa = 0.77; 0.71-0.82), but moderate considering the subtypes (w kappa = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (w kappa = 0.65; 0.59-0.71), and moderate considering the subtypes (w kappa = 0.58; 0.54-0.63). Conclusion The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate

Time to surgery for adolescent idiopathic scoliosis: How long does it take? A multicenter study

Study design: Retrospective review of multicentric data. Objectives: To estimate the time from initial visit to surgery in adolescent idiopathic scoliosis (AIS) patients and the main reasons for the time to surgery in a multicenter study. Methods: This retrospective study evaluated 509 patients with AIS from 16 hospitals across six Latin American countries. From each hospital's deformity registry, the following patient data were extracted: demographics, main curve Cobb angle, Lenke Classification at the initial visit and time of surgery, time from indication-for-surgery to surgery, curve progression, Risser skeletal-maturity score and causes for surgical cancelation or delay. Surgeons were asked if they needed to change the original surgical plan due to curve progression. Data also were collected on each hospital's waiting list numbers and mean delay to AIS surgery. Results: 66.8% of the patients waited over six months and 33.9% over a year. Waiting time was not impacted by the patient's age when surgery first became indicated (p = 0.22) but waiting time did differ between countries (p < 0.001) and hospitals (p < 0.001). Longer time to surgery was significantly associated with increasing magnitude of the Cobb angle through the second year of waiting (p < 0.001). Reported causes for delay were hospital-related (48.4%), economic (47.3%), and logistic (4.2%). Oddly, waiting time for surgery did not correlate with the hospital's reported waiting-list lengths (p = 0.57) Conclusion: Prolonged waits for AIS surgery are common in Latin America, with rare exceptions. At most centers, patients wait over six months, most commonly for economic and hospital-related reasons. Whether this directly impacts surgical outcomes in Latin America still must be studied

Prevention of Surgical Site Infections in Spine Surgery: An International Survey of Clinical Practices Among Expert Spine Surgeons.

STUDY DESIGN: Questionnaire-based survey. OBJECTIVES: Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research. METHODS: An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy. RESULTS: Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus (SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbA1c level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions. CONCLUSIONS: With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trials

Prevention of Surgical Site Infections in Spine Surgery: An International Survey of Clinical Practices Among Expert Spine Surgeons

Study Design: Questionnaire-based survey. Objectives: Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research. Methods: An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy. Results: Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus (SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbAIc level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions. Conclusions: With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trails