Anesthetic Management of a Patient with Multidrug Allergy and Limited Anesthetic Options Undergoing Multilevel Lumbar Fusion Surgery

BackgroundThere are few studies about risk factors for poor outcomes from multi-level lumbar posterolateral fusion limited to three or four level lumbar posterolateral fusions. The purpose of this study was to analyze the outcomes of multi-level lumbar posterolateral fusion and to search for possible risk factors for poor surgical outcomes.MethodsWe retrospectively analyzed 37 consecutive patients who underwent multi-level lumbar or lumbosacral posterolateral fusion with posterior instrumentation. The outcomes were deemed either 'good' or 'bad' based on clinical and radiological results. Many demographic and radiological factors were analyzed to examine potential risk factors for poor outcomes. Student t-test, Fisher exact test, and the chi-square test were used based on the nature of the variables. Multiple logistic regression analysis was used to exclude confounding factors.ResultsTwenty cases showed a good outcome (group A, 54.1%) and 17 cases showed a bad outcome (group B, 45.9%). The overall fusion rate was 70.3%. The revision procedures (group A: 1/20, 5.0%; group B: 4/17, 23.5%), proximal fusion to L2 (group A: 5/20, 25.0%; group B: 10/17, 58.8%), and severity of stenosis (group A: 12/19, 63.3%; group B: 3/11, 27.3%) were adopted as possible related factors to the outcome in univariate analysis. Multiple logistic regression analysis revealed that only the proximal fusion level (superior instrumented vertebra, SIV) was a significant risk factor. The cases in which SIV was L2 showed inferior outcomes than those in which SIV was L3. The odds ratio was 6.562 (95% confidence interval, 1.259 to 34.203).ConclusionsThe overall outcome of multi-level lumbar or lumbosacral posterolateral fusion was not as high as we had hoped it would be. Whether the SIV was L2 or L3 was the only significant risk factor identified for poor outcomes in multi-level lumbar or lumbosacral posterolateral fusion in the current study. Thus, the authors recommend that proximal fusion levels be carefully determined when multi-level lumbar fusions are considered.

Introduction Hemorrhage and transfusion requirements in spine surgery are common. This is especially true for thoracic and lumbar fusion surgeries. There is limited data in the literature concerning predictive factors for transfusion and their effect on short-term post-operative outcomes. Material and Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent lumbar or thoracic fusion surgery from 2010 to 2013. Univariate and multivariate regression analysis was used to determine predictive factors and post-operative complications associated with transfusion. Results A total of 14,249 patients were included in this study; 13,586 had lumbar fusion and 663 had thoracic fusion surgery. The prevalence of transfusion was 35% for thoracic fusion and 17.5% for lumbar fusion. The multivariate analysis showed that age between 50–60 (OR 1.38, CI: 1.23–1.54), age between 61–70 (OR 1.65, CI: 1.40–1.95), dyspnea (OR 1.11, CI: 1.02–1.23), hypertension (OR 1.14, CI: 1.02–1.27), ASA class (OR 1.73, 1.18–1.45), pre-operative blood transfusion (OR 1.91, CI: 1.04–3.49), and extended surgical time (OR 4.51, CI: 4.09–4.98) were predictors of blood transfusion requirements for lumbar fusion. While only pre-operative BUN (OR 1.04, CI: 1.01–1.06) and extended surgical time (OR 4.70, CI: 3.12–6.96) were predictors of transfusion for thoracic fusion. In contrast, higher pre-operative hematocrit was protective against transfusion. Patients transfused who underwent lumbar fusion had an increased risk to develop superficial wound infection, deep wound infection, venous thromboembolism, myocardial infarction and had longer length of hospital stay. Patients transfused who underwent thoracic fusion were more likely to have venous thromboembolism and extended length of hospital stay. However, mortality was not associated with blood transfusion. Conclusion This study used a large database to characterize the incidence, predictors and post-operative complications associated with blood transfusion in thoracic and lumbar fusion surgeries. Pre- and post-operative planning for patients deemed to be at high-risk of requiring blood transfusion should be considered to reduce post-operative complication in this population.

Study Design: Descriptive, retrospective cohort study. Objective: To descriptively evaluate the 2-year health care burden post cervical and lumbar fusion surgeries using real-world data. Summary of Background Data: Reoperation, infection, and pseudarthrosis are common adverse events after cervical and lumbar fusion procedures. Methods: This was a descriptive, retrospective cohort study using Merative™ MarketScan® Commercial Claims Database (October 1, 2015 to October 31, 2022). International Classification of Diseases—Tenth Revision (ICD-10) codes were used to identify and study outcomes of adults who underwent cervical-only (N=28,674) or lumbar-only (N=14,527) fusion surgery. The outcomes included incidence and cost of reoperations, pseudarthrosis, and infection post cervical and lumbar spinal fusion surgery. Results: At 2-year follow-up, cervical and lumbar reoperations were performed in 11.6% and 11.0% of cases. A third of cervical and 57% of lumbar reoperation cases had spinal complications identified within the 90 days before and including the reoperation admission. Following cervical and lumbar fusion index surgeries, 2-year pseudarthrosis was reported in 3.9% and 5.6%, and infection in 2.2% and 4.3% of cases, respectively. ​Two-year postoperative health care costs associated with pseudarthrosis or infection following cervical fusion averaged $33,055 and $108,173, and those following lumbar fusion averaged $32,303 and $80,539, respectively. ​For patients with reoperations, the 2-year postoperative health care costs associated with cervical and lumbar fusion were $49,354 and $73,604, respectively.​ Conclusions: Using modern real-world data, our descriptive study suggested significant increased health care costs associated with adverse outcomes after cervical and lumbar fusion surgery. Innovative technologies that mitigate the risk of adverse outcomes after spine fusion have the potential to reduce costs postsurgeries.

P63. Current incidence of adjacent segment pathology following lumbar fusion versus motion preserving procedures: a systematic review and meta-analysis of recent projections

Retrospective analysis. To investigate sex differences in opioid use after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. Recent studies have demonstrated higher prevalence of chronic pain states and greater pain sensitivity among women compared with men. Furthermore, differences in responsivity to pharmacological and non-pharmacological treatments have been observed. Whether sex differences in perioperative opioid use exists in patients undergoing lumbar fusion for symptomatic stenosis or spondylolisthesis remains unknown. An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1,2, or 3-level index lumbar decompression and fusion procedures between 2007 and 2016. Records were searchable by International Classification of diseases diagnosis and procedure codes, and generic drug codes specific to Humana. Opioid use 6-months prior to through 2-years after index surgery was assessed. The primary outcome was sex differences in opioid use after index lumbar surgery. The secondary outcome was independent predictors of prolonged opioid use after lumbar fusion. Of the 13,257 participants (females: 7871, 59.8%), 58.4% of women used opioids compared with 56.9% of men prior to index surgery. At 1-year after surgery, continuous opioid use was observed in 67.1% of women compared with 64.2% of men (P < 0.001). Within 2-years postoperatively, opioid use was observed in 83.1% of women versus 82.5% men. In a multivariate logistic regression analysis, female sex (odds ration [OR] 1.14, 95% confidence interval [CI]: 1.058-1.237), obesity (OR 1.10, 95% CI: 1.004-1.212), and preoperative narcotic use (OR 3.43, 95% CI: 3.179-3.708) was independently associated with prolonged (>1 yr) opioid use after index surgery. We observed a higher prevalence of chronic opioid use among women following lumbar fusion surgery. Female sex was independently associated with prolonged opioid use after index surgery. 3.

The objective of this study is to illustrate the advantages of robot-assisted unilateral biportal endoscopy in lumbar decompression fusion and internal fixation surgery. According to the different surgical methods, we divided the 26 patients into 2 groups, robot-assisted unilateral biportal endoscopy for lumbar interbody fusion (R-ULIF) group and percutaneous endoscopic lumbar decompression and interbody fusion (Endo-LIF) group, with a 1:1 ratio. Gender, disease course, lesion site, fluoroscopy times, operative time, blood loss, postoperative hospital stay, screw placement success rate, fusion rate, complications rate, postoperative pain visual analog scale (VAS) (The VAS score is used only to evaluate pain in the lower back and legs.) Oswestry Disability Index (ODI) (The ODI score can serve as a reference indicator for evaluating the effectiveness of treatment for patients with low back pain, and has good responsiveness in assessing patients with chronic low back pain), and MacNab (The MacNab standard is divided into 4 levels: excellent, good, fair, and poor, which can be used to evaluate the therapeutic efficacy of certain spinal surgeries) standard efficacy evaluation were analyzed and compared between the 2 groups. All patients successfully completed the surgery. Compared with the Endo-LIF group, the R-ULIF group had fewer fluoroscopy procedures, less intraoperative blood loss, and shorter postoperative hospital stay (P < .05). The VAS scores and ODI scores of both groups significantly decreased at all-time points (P < .05). The ODI scores of the R-ULIF group were better than the Endo-LIF group at 1 month and 3 months after surgery (P = .017/P = .047), but there was no statistically significant difference between the groups before surgery and 1 week after surgery (P > .05). The efficacy was evaluated using the MacNab criteria at 6 months after surgery. The R-ULIF group has an excellent and good rate of 84.6%, while the Endo-LIF group has an excellent and good rate of 76.9% (P = 1.000). Robot-assisted unilateral biportal endoscopy for lumbar interbody and fusion surgery has shown short-term clinical efficacy in the treatment of lumbar disc herniation combined with lumbar instability, surpassing endoscopic lumbar interbody fusion surgery. Robot-assisted unilateral biportal endoscopy for lumbar interbody and fusion surgery has demonstrated high success rate in screw placement, minimal radiation exposure, less intraoperative blood loss, shorter hospital stay, and thus deserves further clinical promotion.

129. Presence of a surgical trainee does not affect patient outcomes in lumbar fusion surgery

Rationale:Lumbar Decompression and Fusion Surgery is an effective and safe surgical technique widely used for treating spondylolisthesis. Arachnoid ossification (AO) is a rare condition associated with neurological dysfunction after lumbar spine surgery, with limited reports in the literature. In this report, we present a rare case of AO detected 1 year after lumbar fusion, with serial imaging first revealing its emergence and guiding early detection and intervention.Patient concerns:A 61-year-old female who experienced progressive pain and numbness in both lower extremities 2 years after undergoing lumbar decompression and fusion surgery.Diagnoses:Based on the medical history, symptoms and imaging studies, the patient was diagnosed with Delayed AO.Interventions:After discussing the condition and evaluating surgical options, a conservative treatment regimen was implemented, including nonsteroidal anti-inflammatory drugs (NSAIDs) for analgesia and anti-inflammatory effects, methylcobalamin for neurotrophic support, mannitol combined with corticosteroids to reduce neuroinflammatory edema, and adjunctive acupuncture therapy.Outcomes:There was a partial relief of symptoms including pain and numbness in both lower limbs on the 7th day after systemic treatment. These symptoms had improved by the 12th day; however, mild pain and discomfort persisted in the right foot. Following symptom alleviation, the patient was discharged from the hospital.Lessons:Patients may experience pain and numbness in both lower limbs after lumbar decompression and fusion surgery. This condition is likely attributed to the compression of spinal nerves caused by AO within the spinal canal. Given the significant surgical risks associated with this procedure, a systematic conservative treatment approach is recommended, which can yield satisfactory therapeutic outcomes.

Study DesignA cross-sectional study.PurposeThis study aimed to investigate temporal patterns, seasonal variations, and geographic differences in the US public interest in lumbar decompression and fusion surgery.Overview of LiteratureThe number of lumbar decompression and fusion surgery procedures for various surgical indications has significantly increased in the United States over the past few decades. As the prevalence of these procedures increases, patients are increasingly seeking online information on these procedures.MethodsThis study analyzed US public interest in lumbar decompression and fusion surgery using Google Trends data from January 1, 2015 to December 31, 2024. The relative search volume (RSV) was used to measure public interest. Temporal trends were assessed using linear regression analysis, whereas seasonal and geographic variations were evaluated using analysis of variance and Tukey’s post hoc tests. Statistical significance was set at p<0.05.ResultsPublic interest in lumbar decompression and fusion surgery showed a statistically significant upward trend from 2015 to 2024 (p<0.05), with R2 ranging from 0.0141 to 0.6748 across search terms. Monthly analysis revealed that the average search volume was highest in October (78.8%) and lowest in December (68.7%). No significant differences were observed among seasons (p=0.102). Geographically, the highest mean RSV was in the Northeast (43.3%), followed by the West (19.5%), Midwest (12.6%), South (11.1%), and Southwest (10.2%), with significant differences among these regions (p<0.001).ConclusionsPublic interest in lumbar decompression and fusion surgery has shown a consistent and statistically significant upward trend over the past decade. Although seasonal variation was not significant, notable geographic differences in search volume were observed, with the northeast showing the highest level of interest. These findings highlighted regional disparities in public engagement and may serve as a basis for future healthcare resource planning and patient education strategies.

Outcomes after navigated lumbar fusion: Readmission, reoperation, and complications in 18,561 procedures.

Spinopelvic parameter consists of sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) which are measured by whole-spine-lateral-view radiograph in standing position. Measurement of the separameters is pivotalas the land mark analysis toachieve correct sagittal balance. The objective of the study is to analyze the correlation between PI, PT, SVA and SSwith theclinical outcomes which was measured usingOswestry Disability Index (ODI) scoring system.This is a cross-sectional study involving 19 patients who underwent thoracal and lumbar fusion surgery in our centerduring 2012-2014. Radiographi cevaluation of SVA, PI, PT, and SS and ODI score were performed 1 year after surgery. Pearson test was conducted to determine the correlation between SVA, PI, PT, and SS with ODI score.There wasa strong correlation between ODI withSVA and PI (p<0.001,r=0.866; p=0.006; r=0.603, respectively). There was no correlation between other parameters with ODI.Based on this study, spinopelvic parameters that can represent the clinical outcome after thoracal and lumbar fusion and stabilization surgeries are SVA and PI. Normal 0 false false false IN X-NONE X-NONE

BACKGROUND The efficacy of lumbar fusion surgery in patients age 80 years and older with lumbar spinal stenosis (LSS) is still controversial. This retrospective study aimed to evaluate the surgical outcomes of LSS patients ³80 vs 65-79 years. MATERIAL AND METHODS The study included 66 patients diagnosed with LSS from 2014 to 2020; 33 patients were ³80 years and 33 patients were 65-79 years. The 2 groups were matched for sex and surgical segment. All patients underwent posterior lumbar decompression, fixation, and fusion surgery. The Numerical Rating Scale (NRS) of leg and back pain, Oswestry Disability Index (ODI), Short-Form Health Survey (SF-36), and radiographic data were collected before surgery and at 3, 6, and 12 months postoperatively. RESULTS NRS (back) in the ≥80 years group was significantly higher than in the 65-79 years group at 3 months [2 (0-3) vs 1 (0-3), P=0.001]. Improvement of SF-36 (3 months: 15.7±4.9 vs 27.6±5.4, P<0.001; 6 months: 27.3±6.8 vs 31.5±5.6, P=0.011) and Physical Component Score (PCS) (3 months: 6.5±2.5 vs 17.0±3.6, P<0.001; 6 months: 15.9±3.4 vs 20.1±3.1, P<0.001) at 3 and 6 months in the ≥80 years group were significantly smaller than in 65-79 years group. There was a difference of Pfirrmann index of adjacent segment disc between the 2 groups at 12 months [≥80 vs 65-79 years group: 5.5 (4-8) vs 5 (3-8), P=0.003]. CONCLUSIONS Lumbar fusion surgery in patients ≥80 years with LSS can provide comparable improvements in clinical and radiographic outcomes compared with younger patients. Postoperative physiological function recovery was slower in patients ≥80 years.

Saturday, September 29, 2018 9:00 am–10:00 am A Fresh Look at Opioids: 272. Spinal anesthesia is a cost-effective alternative to general anesthesia in lumbar fusion surgery

The objective of this study is to identify the demographic and payer factors that are associated with lumbar fusion surgery. A case-control study was conducted utilizing a population of 38,092 patients from the 2010 Florida Agency for Health Care Administration (AHCA), USA hospital discharge data. The case population included 16,236 records with any of five ICD-9-CM principal procedure codes for initial lumbar fusion. The control group was comprised of 21,856 patients who were admitted for the same principal diagnoses as the cases, but who did not have initial fusion surgery. Logistic regression was used to analyze the association of age, gender, race and principal payer type with initial lumbar fusions. The interaction between age and payer was also examined, as payer type may moderate the association between age and lumbar fusion surgery. Gender, race, principal payer and age were all found to be significantly associated with lumbar fusion surgery. The interaction of payer and age was also found to be significant. Being female was significantly associated with having a fusion (OR=1.11, 95% CI 1.07-1.16). The association between age and receiving surgery was greatest for the less than 20 age group (OR=10.43, 95% CI 8.74-12.45). Employees and dependents of Federal government agencies (Tricare, etc.) and patients with commercial insurance were significantly associated with surgery (OR=1.48, 95% CI 1.29-1.70 and OR=1.12, 95% CI 1.04-1.20, respectively). Patients insured through Medicaid (a social health care program for those with low incomes and limited resources), and the uninsured were negatively associated with surgery (OR=0.53, 95% CI 0.47-0.60 and OR=0.52, 95% CI 0.46-0.58, respectively). Lumbar fusion surgery is not recommended in clinical practice guidelines for the top four principal diagnoses in this study. Yet, patients covered by certain types of insurance were found to be significantly associated with fusion surgery.

ObjectiveTo compare the patient-reported outcomes (PROs) between patients undergoing multilevel lumbar fusion with robot-assisted vs. freehand techniques. MethodsThis was a single-institution cohort study of adult patients (≥18 years old) undergoing robot-assisted spine surgery from 2016 to 2018 with minimum 2-year follow-up. A propensity-score matching (PSM) algorithm accounted for several perioperative factors. PROs were measured using the Oswestry Disability Index (ODI). The minimum clinically important difference (MCID) between groups were assessed at each follow-up period (6-weeks/6-months/1-year/2-years). Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively. ResultsAfter PSM, a total of 70 patients remained. The mean (standard deviation) charlson comorbidity index was 1.4 (1.0) and 57% of patients were female. The most common diagnoses included degenerative disc disease (37.1%), degenerative scoliosis (27.1%), and high grade spondylolisthesis (grade > 2) (19%), and the mean number of instrumented levels was 4.6 (4.4). Rates for intraoperative/postoperative complications, and any reoperation within 2 years after surgery were low and similar between groups. The baseline ODI scores were similar between freehand (39.1) and robot-assisted surgery (40.5, P-value = 0.736). By two years, substantial improvements in both groups (mean ODI-freehand: 4.6, robot-assisted: 1.5; MCID%-freehand: 77.1%, robot-assisted: 82.9%) were achieved, but not significantly different (P-value > 0.05). No differences were observed for the other follow-up periods. When comparing individual component scores, the robot-assisted group scored higher in “Lifting,” “Sitting,” and “Standing;” however, the magnitudes of these differences were less than 1 point. ConclusionRobot-assisted multi-level lumbar fusion can achieve excellent and similar patient-reported outcomes to conventional freehand techniques. Future studies should include large, prospective randomized controlled trials as well as the inclusion of other patient reported outcome measures.