Complications And Length Of Stay Following Spine Surgery: Analyzing Local And National Cohorts

Complications following spine surgery are widely reported but poorly characterized. The effect of preoperative comorbidities and postoperative complications on length of stay (LOS) has not been evaluated. It would be ideal to have a clearer understanding of the variables affecting LOS to facilitate setting expectations and control costs. Using complications and LOS as outcomes, we can also characterize the risks inherent with surgical practices, such as the use of iliac crest bone graph (ICBG) in spinal fusion. The study consisted of three aspects. First, the effect of pre and perioperative variables on LOS for 103 patients undergoing posterior lumbar fusion at Yale was examined. Next, the National Surgical Quality Improvement Program (NSQIP) database was used to determine the variables associated with extended LOS and complications following 2,164 anterior cervical discectomy and fusion (ACDF) procedures. Finally, 13,927 spinal fusion cases from the NSQIP database were analyzed to determine the effect of harvesting ICBG on operative time, complications, LOS, and readmission. Multivariate analysis was used throughout the study to control for confounding while evaluating statistical significance. For lumbar fusion, average LOS was 3.6 ± 1.8 days. 79% had a stay of four days or less. Preoperative variables associated with increased LOS were age and ASA score. Heart disease was significantly associated with decreased LOS. Postoperative complications occurred in 32% of patients and led to a LOS of 5.1 ± 2.3 days vs. 2.9 ± 0.9 days for patients with no complication. For ACDF, average LOS was 2.0 ± 4.0. Age ≥ 65, functional status, transfer from facility, preoperative anemia, and diabetes were the preoperative factors predictive of extended LOS. Major complications, minor complications, and extended surgery time were the perioperative factors associated with increased LOS. 71 (3.3%) had a total of 92 major complications. ASA score ≥ 3, preoperative anemia, age ≥ 65, extended surgery time and male gender were predictive of major complications. Meanwhile, postoperative blood transfusion (OR 1.5), extended operative time (+ 22.0 min) and LOS (+0.2 days) were significantly associated with ICBG use. After lumbar fusion, patients that are older and have widespread systemic disease tend have longer LOS, but no single comorbidity was predictive of LOS. After ACDF, 1 in 33 patients develops a major post-operative complication, which are associated with an increased LOS of 5 days. Current ICBG usage in spinal fusion is low, with rates between 3.4% and 12.4% depending on approach. Use of ICBG is associated with extended operative time, extended LOS, and postoperative blood transfusion

The effect of iliac crest autograft on the outcome of fusion in the setting of degenerative spondylolisthesis: a subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT).

BACKGROUND: There is considerable controversy about the long-term morbidity associated with the use of posterior autologous iliac crest bone graft for lumbar spine fusion procedures compared with the use of bone-graft substitutes. The hypothesis of this study was that there is no long-term difference in outcome for patients who had posterior lumbar fusion with or without iliac crest autograft. METHODS: The study population includes patients enrolled in the degenerative spondylolisthesis cohort of the Spine Patient Outcomes Research Trial who underwent lumbar spinal fusion. Patients were divided according to whether they had or had not received posterior autologous iliac crest bone graft. RESULTS: There were 108 patients who had fusion with iliac crest autograft and 246 who had fusion without iliac crest autograft. There were no baseline differences between groups in demographic characteristics, comorbidities, or baseline clinical scores. At baseline, the group that received iliac crest bone graft had an increased percentage of patients who had multilevel fusions (32% versus 21%; p=0.033) and L5-S1 surgery (37% versus 26%; p=0.031) compared with the group without iliac crest autograft. Operative time was higher in the iliac crest bone-graft group (233.4 versus 200.9 minutes; p CONCLUSIONS: The outcome scores associated with the use of posterior iliac crest bone graft for lumbar spinal fusion were not significantly lower than those after fusion without iliac crest autograft. Conversely, iliac crest bone-grafting was not associated with an increase in the complication rates or rates of reoperation. On the basis of these results, surgeons may choose to use iliac crest bone graft on a case-by-case basis for lumbar spinal fusion

Cartilage restoration of patellofemoral lesions: a systematic review

Purpose This study aimed to systematically analyze the postoperative clinical, functional, and imaging outcomes, complications, reoperations, and failures following patellofemoral cartilage restoration surgery. Methods This review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, EMBASE, and Cochrane Library databases were searched up to August 31, 2018, to identify clinical studies that assessed surgical outcomes of patellofemoral cartilage restoration surgery. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess study quality. Results Forty-two studies were included comprising 1,311 knees (mean age of 33.7 years and 56% males) and 1,309 patellofemoral defects (891 patella, 254 trochlear, 95 bipolar, and 69 multiple defects, including the patella or trochlea) at a mean follow-up of 59.2 months. Restoration techniques included autologous chondrocyte implantation (56%), particulated juvenile allograft cartilage (12%), autologous matrix-induced chondrogenesis (9%), osteochondral autologous transplantation (9%), and osteochondral allograft transplantation (7%). Significant improvement in at least one score was present in almost all studies and these surpassed the minimal clinically important difference threshold. There was a weighted 19%, 35%, and 6% rate of reported complications, reoperations, and failures, respectively. Concomitant patellofemoral surgery (51% of patients) mostly did not lead to statistically different postoperative outcomes. Conclusion Numerous patellofemoral restoration techniques result in significant functional improvement with a low rate of failure. No definitive conclusions could be made to determine the best surgical technique since comparative studies on this topic are rare, and treatment choice should be made according to specific patient and defect characteristics

Establishing validity of the fundamentals of spinal surgery (FOSS) simulator as a teaching tool for orthopedic and neurosurgical trainees

Pedicle screw placement is a demanding surgical skill as a spine surgeon can face challenges including variations in pedicle morphology and spinal deformities. Available CT simulators for spine pedicle placement can be very costly and hands-on cadaver courses are limited by specimen availability and are not readily accessible. To conduct validation of a simulated training device for essential spine surgery skills. Cross-sectional, empirical study of physician performance on a surgical simulator model. Spine attending physicians and residents from four different academic institutions across the United States. Performance metrics on two surgical simulator tasks. After IRB approval, an inexpensive ($30) simulator was developed to test two main psychomotor tasks (1) creation of the pedicle screw path with a standard gearshift probe without cortical breaks and (2) the ability to palpate for the presence or absence of cortical breaches as well as determine the location of wall defects. Orthopedic and neurosurgery residents (N=72) as well as spine attending surgeons (N=26) participated from four different institutions. To test construct validity, performance metrics were compared between participants of different training status through one-way analysis of variance and linear regression analysis, with significance set at p<.05. Spine attending surgeons consistently scored higher than the residents, in the screw trajectory task with triangular base (p=.0027) and defect probing task (p=.0035). In defect probing, performance improved with linear trend by number of residency training years with approaching significance (p=.0721). In that task, independent of institutional affiliation, PGY-2 residents correctly identified an average of 1.25±0.43 fewer locations compared with attending physicians (p=.0049). More than 80% of the spine attendings reported they would use the simulator for training purposes. This low-cost fundamentals of spine surgery simulator detected differences in performances between spine attending surgeons and surgical residents. Programs should consider implementing a simulator such as fundamentals of spine surgery to assess and develop pedicle screw placement ability outside of the operating room

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Integrating Technology into Practice: 58. Validity of the Fundamental of Spinal Surgery (FOSS) simulator as a teaching tool for orthopedic and neurosurgical trainees

While all surgical disciplines require years of study to acquire knowledge and experience, surgical trainees must also develop the necessary psychomotor skills to perform surgical procedures. To date, there are limited validated tools to objectively assess trainees as they progress through their education. Pedicle screw placement is a demanding surgical skill set to learn and teach as challenges such as variations in pedicle morphology and spinal deformities can be encountered.  Available CT simulators for pedicle placement can be costly and hands on cadaver courses are limited by specimen availability. We sought to develop a cost-effective training tool that could be used by all orthopedic and neurosurgical residencies. Multicenter study (four academic institutions). Orthopedic and neurosurgery residents and spine attending surgeons are recruited. Outcomes measures include the scores for all three tasks and the time taken to complete the tasks. After IRB approval, a low cost spine simulator ($30.00) was created to test three main skill sets all pertaining to the task of placing a pedicle screw: ability to find appropriate trajectory, ability to navigate down the isthmus of a pedicle, and ability to recognize wall penetrations. Residents as well as spine attending surgeons were recruited to participate from four different institutions. Each participant was given three tasks to complete. Task 1 entails creation of the pedicle screw path with a standard gearshift probe, with the number of “cortical breaks” being recorded.  Task 2 entails testing the ability to palpate for the presence or absence of wall defects. Task 3 is the ability to determine the location of wall defects. The number of correct answers for task 2 and 3 are recorded. The ability to differentiate between surgical residents and master spine surgeons was obtained. In all tasks, spine attending surgeons scored higher than residents. Attending surgeons reported that FOSS simulator is a good tool which can be beneficial for training surgical residents in terms of tactile feedback and directionality of probe and pedicle placement. Moreover, the FOSS stimulator also allowed participants the ability to feel the difference between young cortical bone versus osteoporotic bone. Eighty-one percent of the spine attending surgeons reported that they would use this educational technology in the future for training purposes. Eighty-four percent of all residents, and 100% of PGY1 residents reported that they would use FOSS simulator for training. Recent published work has demonstrated the role of low cost tools for teaching and testing psychomotor skills in orthopedic surgery. Here, we developed the next tool to be used for spine surgery. FOSS is an invaluable asset as it will allow surgical trainees to engage and enhance their visual, auditory and proprioceptive feedback safely during pedicle screw placement outside of the operating room. This abstract does not discuss or include any applicable devices or drugs

Correction to: At the US Epicenter of the COVID-19 Pandemic, an Orthopedic Residency Program Reorganizes.

[This corrects the article DOI: 10.1007/s11420-020-09765-5.]