Extension of previous fusions to the Sacro-Pelvis vs. Primary spino-pelvic fusions in the setting of adult deformity: A Comparison of health related quality of life measures and complications [abstract]

Comparative Medicine - OneHealth and Comparative Medicine Poster SessionSummary: Clinical and radiographic evaluation of revision extension of previous long thoracolumbar fusion to the sacro-pelvis compared to primary lumbosacral fusion indicates that although the two patient populations are heterogeneous, clinical outcomes and complication rates of salvage procedures where a prior spinal fusion procedure is extended to the sacropelvis compare favorably to primary sacro-pelvic fusion for adult spinal deformity. Introduction: Patients previously treated with thoracolumbar fusion for spinal deformity may develop degenerative changes below the fusion requiring revision fusion to the sacro-pelvis. Little data exists on the characteristics of patients treated with revision extension to sacro-pelvis compared to primary lumbosacral fusion. We evaluated the differences between patients undergoing revision extension of fusion vs. primary fusion to the sacro-pelvis, minimum 2-year follow-up. Methods: The revision group (REVISION) included multicenter retrospective evaluation of 44 of 54 consecutive patients (1995-2006) that had a previous long fusion ending from L3-5, revised by extension fusion to the sacro-pelvis for symptomatic degeneration. The primary group (PRIMARY) included 20 of 20 consecutive patients prospectively enrolled (2000-2006) at a single center database that received primary long arthrodesis to the sacro-pelvis for adult deformity. Clinical and radiographic evaluation included demographics, coronal and sagittal measures, postoperative SRS-22 scores, and perioperative complications. Results: Mean patient age was 52 years (range 21-81 years). Mean follow up was 43 months (range 23-135 months). PRIMARY had greater median age (59 vs. 49 years; p<0.01) and longer follow up (44 vs. 31 months, p<0.05) than REVISION. PRIMARY had larger preoperative thoracolumbar curve (median TL; 48° vs. 36°; p<0.01) and less sagittal imbalance (median SVA; 0.0. vs. 5.0 cm; p<0.05) than REVISION. Postoperative SVA was similar for PRIMARY and REVISION (median 0.9 vs. 2.6 cm, respectively; p=0.25). REVISION had better postoperative SRS-22 scores (median 3.80 vs. 3.12, p<0.01) and fewer patients with minimum one complication [11 (25%) vs. 11 (55%), p<0.05] than PRIMARY (Table 1) Conclusion: Significant differences were demonstrated between patients undergoing primary vs. revision extension to the sacro-pelvis. PRIMARY were older, and had larger TL curves, whereas REVISION had greater sagittal imbalance. While PRIMARY had more complications, multiple factors could account for this other than surgery type, including differences in age or number of levels fused. The retrospective nature of the study may have also underrepresented minor complications. Although the groups were heterogeneous, radiographic, SRS-22 and complications analysis indicate clinical outcomes of salvage procedures where a prior spinal fusion procedure is extended to the sacropelvis compare favorably to primary sacro-pelvic fusion for adult spinal deformity

Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery

BACKGROUND: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. OBJECTIVE: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers. STUDY DESIGN/SETTING: Retrospective cohort study of a prospectively collected multicenter database. METHODS: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility. RESULTS: A total of 930 patients were considered. Following PSM, 253 optimal (O) and 253 not optimal (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, CONCLUSIONS: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success

The cost of complications following major resection of malignant neoplasia

Background: Rising healthcare costs have led to increased focus on the need to achieve a higher value of care. As value-maximization efforts expand to include more complex surgical patients, evidence to support meaningful implementation of complication-based initiatives is lacking. The objective of this study was to compare incremental costs of complications following major gastrointestinal (GI) resections for organ-specific malignant neoplasia using nationally representative data. Methods: National (Nationwide) Inpatient Sample data, 2001-2014, were queried for adult (≥ 18 years) patients undergoing major resections for malignant neoplasia. Based on system-based complications considered relevant to the long-term treatment of GI disease, stratified differences in risk-adjusted incremental hospital costs and complication probabilities were compared. Differences in surgical outcomes and costs over time were also assessed. Results: A total of 293,967 patients were included, weighted to represent 1,408,117 patients nationwide. One fourth (26.1%; 95% CI, 25.7-26.4%) experienced ≥ 1 pre-discharge complication (range, 45.3% esophagectomy to 24.0% rectal resection). Resultant annual risk-adjusted incremental hospital costs totaled $540 million nationwide (19.5$20,900 per patient). Costs varied substantially with both cancer/resection type and complication group, ranging from $76.7 million for colectomies with infectious complications to$0.2 million for rectal resections with urinary complications. For each resection type, infectious ($154.7 million), GI ($85.5 million), and pulmonary ($77.9 million) complications were among the most significant drivers of increased hospital cost. Conclusions: Quantifying and comparing the impact of complications on an indication-specific level in more complex patients offers an important step toward allowing providers/payers to meaningfully prioritize the design of novel and adaptation of existing value-maximization approache

The effect of post-operative complications in complex adult spinal deformity surgery on surgical outcomes: an international, large-scale, prospective multi-center study

Rapid Fire Session: Degenerative spine: no. OP-27

Risk factors for non-neurological complications in adult spinal deformity surgery: an international, prospective, multi-center study

INTRODUCTION: High risk of complications has been noted in patients with complex adult spine deformity surgery. Although the overall complication rates had been reported, they are variable and can range from 14 to 46%. However, these studies were retrospective cohorts without a clear definition of inclusion criteria and systematic collection of clinical data. As such, a complete risk profile and an accurate complication rate remain unclear. The objectives of this study were to establish the prevalence and risk factors for non-neurological complications within first 6 months of surgery. METHODS: This is the first prospective, multicenter study involving 15 sites from North America, Europe, and Asia. Adult patients with severe spinal deformity were followed for 6 months postoperatively. Demographic characteristics, comorbidities, functional scores, and radiographic measurements were used to determine the risk factors using multivariate modeling. RESULTS: A total of 269 patients (68% women and 32% men) were recruited (mean age: 57.8 years). Overall, 163 patients (60.6%) reported at least one incidence of complication. The prevalence of intraoperative event and postoperative complications were 29.4 (n = 79) and 49.8% (n = 134), respectively. Fifty-eight patients (21.6%) had major complications and 112 (42%) experienced minor complications. Moreover, 37% of the patients reported multiple complications. A total of 91 intraoperative events were reported. Dural tear was the most common intraoperative complication, accounting for 53% of all reported events. Previous spine surgery (adjusted OR: 3.6; 95% CI: 1.8–7.2) was found to be associated with intraoperative events in multivariate risk analysis. For major postoperative complications, a total of 79 cases were reported. Of these, 32% of the cases were respiratory complications, followed by loss of correction and implant failure, which accounted for 25% of the cases. Diabetes (OR: 3.8; 95% CI: 1.3–10.8) and lung disease (OR: 3.1; 95% CI: 1.0–9.4) were significant risk factors for major complications. There were a total of 206 incidences of minor postoperative complications. Fifteen percent of the cases were urinary tract infections. Twenty-five patients (9.2%) also reported new onset or worsening back or lower extremity pain after surgery, accounting for 12% of all minor complications. Previous spine surgery was the most significant risk factor for minor complications (OR: 3.0; 95% CI: 1.5–6.3). Other significant contributors included age (OR: 1.03), female gender (OR: 2.7), and duration of surgery (OR: 0.99) (p < 0.05). CONCLUSION: To the best of our knowledge, this is the first and largest prospective study in the world to systematically address non-neurological complications of spine deformity surgery in adults. Our findings contribute to a complete “risk profile” of such patients.link_to_OA_fulltex