Complex Spine Research Articles

Canadian Spine Society

# Abstract 57. Radiographic reporting in adolescent idiopathic scoliosis: Is there a discrepancy comparing radiologists’ reports and surgeons’ assessments? {#article-title-2} Cobb angle measurement is the standard method for quantification of scoliosis in adolescent idiopathic scoliosis (AIS),

Variation in Prevertebral Soft Tissue Swelling after Staged Combined Multilevel Anterior-Posterior Complex Cervical Spine Surgery: Anterior Then Posterior (AP) versus Posterior Then Anterior-Posterior (PAP) Surgery.

The influence of the sequence of surgery in the development of prevertebral soft tissue swelling (PSTS) in staged combined multilevel anterior-posterior complex spine surgery was examined. This study was conducted as a retrospective study of patients who underwent staged combined multilevel anterior-posterior complex cervical spine surgery from March 2014 to February 2021. Eighty-two patients were identified, of which fifty-seven were included in the final analysis after screening. PSTS was measured from routine serial monitoring lateral cervical radiographs prior to and after surgery for five consecutive days at each cervical level from C2 to C7 in patients who underwent anterior then posterior (AP) and posterior then anterior-posterior (PAP) surgery. The mean PSTS measurements significantly differed from the preoperative to postoperative monitoring days at all cervical levels (p = 0.0000) using repeated measures analysis of variance in both groups. PSTS was significantly greater in PAP than in AP at level C2 on postoperative day (POD) 1 (p = 0.0001). PSTS was more prominent at levels C2-4 during PODs 2-4 for both groups. In staged combined multilevel anterior-posterior complex spine surgery, PSTS is an inevitable complication. Therefore, surgeons should monitor PSTS after surgery when performing anterior-posterior complex cervical spine surgery, especially in the immediate postoperative period after PAP surgery.

A Spine Assistive Robot With a Routed Twisted String Actuator and a Flat-Back Alleviation Mechanism for Lumbar-Degenerative Flat Back

A lumbar-degenerative flat back is a condition caused by a decline in back muscle strength with aging. The symptoms of this condition include severe lower back pain and spinal disorders, which restrict people from performing activities of daily living (ADL). Recently, various wearable robots have been developed to assist the weakened muscles. However, despite their effectiveness, the wearables require either bulky and rigid structures (active wearables) or tend to constrain users’ motion (passive wearables). In addition, the complex biomechanics of the human spine have not been sufficiently investigated during the design process. To address these issues, we propose a human-inspired spine assistive robot with a routed twisted string actuator (RTSA, active element) and a flat-back alleviation mechanism (FAM, passive element). This innovative RTSA conforms to the complex human spine curvature while minimizing friction and assists the ADL with its unique prioritizing characteristics. The human spine-inspired FAM, on the other hand, was designed to prevent spinal disorder injury while performing ADL. The experimental results showed that the proposed system successfully reduced the electromyography signals while performing ADL. Furthermore, the spinal disorder injury during trunk motion could be prevented by reducing the lumbopelvic ratio of the users.

Diagnosis-Related Group–Based Payments for Adult Spine Deformity Surgery Significantly Vary across Centers: Results from a Multicenter Prospective Cohort Study

To investigate the variation in total episode-of-care (EOC) payment and quality-adjusted life-year (QALY) gain for complex adult spine deformity surgeries in the United States, adjusting for case type and surgeon preferences. Patients aged >18 years with adult spine deformity with Medicare Severity-Diagnosis-Related Groups (DRGs) 453-460 and a minimum of 2 years of follow-up from index surgery were included. Index and total payments were calculated using Medicare's Inpatient Prospective Payment System. All costs were adjusted for inflation to 2020 U.S. dollar values. QALYs gained were calculated using baseline, 1-year, and 2-year Short-Form 6D scores. Mixed-effect models were used to estimate the proportion of variation in total EOC payment and QALY gain. A total of 330/543 patients from 6 sites were included. Mean age was 62.4 ± 11.9 years, 79% were women, and 92% were white. The mean index and total EOC payment were $77,302 and $93,182, respectively. Patients gained on average 0.15 QALY (P < 0.0001) 2 years after surgery. In unadjusted analysis, 39% of the variation in total EOC payment across the 6 centers was attributable to relative weight of DRG and base rate. Adjusting for patient and procedural factors increased the proportion of variation in total EOC payments across the centers to 56%. Less than 2% of the variation in QALY gain was observed across the 6 centers. Medicare-based payments for complex spine deformity fusions are primarily driven by relative weight of the DRG and the hospital's base rate. Patient and procedural factors are unaccounted for in the DRG-based payments made to the providers.

Gabapentin plus celecoxib as preemptive analgesia in complex spine surgery for improving perioperative patient anxiety and satisfaction, Is it effective? randomized double- blind controlled clinical trial

Gabapentin plus celecoxib as preemptive analgesia in complex spine surgery for improving perioperative patient anxiety and satisfaction, Is it effective? randomized double- blind controlled clinical trial

Comparative Analysis of Early Outcomes and Complications of PSO Among Neurosurgeons and Orthopedic Surgeons.

Retrospective comparative cohort study using the National Surgical Quality Improvement Program. The aim of this study was to evaluate trends in the annual number of PSOs performed, describe the patient populations associated with each cohort, and compare outcomes between specialties.Summary of Background Data:Pedicle subtraction osteotomies (PSO) are complex and advanced spine deformity surgical procedures performed by neurosurgeons and orthopedic surgeons. Though both sets of surgeons can be equally qualified and credentialed to perform a PSO, it is possible that differences in training and exposure could translate into differences in patient management and outcomes. Patients that underwent lumbar PSO from 2005 to 2014 in the American College of Surgeons-National Surgical Quality Improvement Program registry were identified. Relevant demographic, preoperative comorbidity, and postoperative 30-day complications were queried and analyzed. The data was divided into 2 cohorts consisting of those patients who were treated by neurosurgeons versus orthopedic surgeons. Additional data from the Scoliosis Research Society Morbidity and Mortality database was queried and analyzed for comparison. Demographic and comorbidity factors were similar between the neurosurgery and orthopedic surgery cohorts, except there were higher rates of hypertension among orthopedic surgeon-performed PSOs (65.66% vs. 48.67%, P =0.004). Except for 2012, in every year queried, orthopedic surgeons reported more PSOs than neurosurgeons. In patients who underwent lumbar fusion surgery, there was a higher rate of PSOs if the surgery was performed by an orthopedic surgeon (OR 1.7824, 95% CI: 1.4017-2.2665). The incidence of deep vein thrombosis after PSOs was higher for neurosurgery compared with orthopedic surgery (8.85% vs. 1.20%, P =0.004). However, besides deep vein thrombosis, there were no salient differences in surgical complication rates between neurosurgeon-performed PSOs and orthopedic surgeon-performed PSOs. The number of PSO procedures performed by neurosurgeons and orthopedic surgeons has increased annually. Differences in outcomes between neurosurgeons and orthopedic surgeons suggest an opportunity for wider assessment and alignment of adult spinal deformity surgery exposure and training across specialties.

Infrastructural Limitations in Establishing Neurosurgical Specialty Services in Liberia.

IntroductionLiberia recently employed the first neurosurgeon in the country’s history. In a country with a population of 4.7 million people and staggering rates of cranial and spine trauma, as well as hydrocephalus and neural tube defects, neurosurgery is considered a luxury. Our study documents the experience of a team of neurosurgeons, critical care nurses, scrub technicians, nurses, and biomedical engineers who carried out a series of neurosurgical clinics and complex brain and spine surgeries in Liberia. Specifically, we aim to highlight some of the larger obstacles, beyond staff and equipment, facing the development of a neurosurgical or any other specialty practice in Liberia. MethodsOur institutions, in collaboration with the Korle-Bu Neuroscience Foundation, spent 10 days in Liberia, based in Tappita, and performed 18 surgeries in addition to seeing several hundred clinic patients. This is a retrospective review of the cases performed along with outcomes to investigate obstacles in providing neurosurgical services in the country.ResultsBefore arriving in Liberia, we evaluated, planned, and supplied staff and materials for treating complex neurosurgical patients. Sixteen patients underwent 18 surgeries at a hospital in Tappita, Liberia, in November 2018. Their ages ranged from 1 month to 72 years (average 20 years). Five patients (28%) were female. Ten patients (56%) were under the age of 18. Surgeries included ventriculoperitoneal shunting (VP-shunt), lumbar myelomeningocele repair, encephalocele repair, laminectomy, and a craniotomy for tumor resection. Ten patients (55%) underwent VP-shunting. Two patients (11%) had a craniotomy for tumor resection. Three patients (17%) had laminectomy for lumbar stenosis. Two patients (11%) had repair of lumbar myelomeningocele.ConclusionAfter an aggressive and in-depth approach to planning, conducting, and supplying complex neurosurgical procedures in Liberia, the greatest limiting factor to successful outcomes lie in real-time is access to health care, which is largely limited by overall infrastructure. Our study documents the experience of a team of neurosurgeons, critical care nurses, scrub technicians, nurses, and biomedical engineers who carried out a series of neurosurgical clinics and complex brain and spine surgeries in Liberia. Specifically, we aim to highlight some of the larger obstacles, beyond staff and equipment, facing the development of a neurosurgical or any other specialty procedural practice in the country of Liberia. Most notably, we focus on infrastructure factors, including power, roads, water, education, and overall health care.

Blood Conservation Techniques and Strategies in Orthopedic Anesthesia Practice.

Orthopedic surgery procedures involving joint arthroplasty, complex spine, long bone and pelvis procedure, and trauma and oncological cases can be associated with a high risk of bleeding and need for blood transfusion, making efforts to optimize patient care and reduce blood loss very important. Patient blood management programs incorporate efforts to optimize preoperative anemia, develop transfusion protocols and restrictive hemoglobin triggers, advance surgical and anesthesia practice, and use antifibrinolytic therapies. Perioperative management of anticoagulant therapies, a multidisciplinary decision-making task, weighs in risks and benefits of thromboembolic risk and surgical bleeding and is patient- and surgery-specific.

Intraoperative Methadone and Short Stay Spine Surgery: Possible Barriers to Implementation and Future Opportunities.

The frequency of shorter stay spine surgery is increasing. Acute pain is a common barrier to discharge following spine surgery. Long-acting opioid medications like methadone have the potential to provide sustained analgesia when given intraoperatively. Methadone has been effectively used in complex spine surgery, cardiac surgery, and more recently applied to ambulatory procedures. In this article, we summarize the pertinent available literature on the use of intraoperative methadone for spine surgery as well as the recent data on intraoperative methadone for ambulatory surgery. The aim of this perspectives article is to describe the potential opportunities for applying intraoperative methadone to shorter stay spine surgery as well as barriers to more widespread use. While there are currently no trials that have specifically studied methadone for shorter stay spine surgery specifically to date, it is a promising area for future research.

Incorporation of Blood and Fluid Management Within an Enhanced Recovery after Surgery Protocol in Complex Spine Surgery.

retrospective review. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary set of evidence-based interventions to reduce morbidity and accelerate postoperative recovery. Complex spine surgery carries high risks of perioperative blood loss, blood transfusion, and suboptimal fluid states. This study evaluates the efficacy of a perioperative fluid and blood management component comprised of a restrictive transfusion policy, goal directed fluid management, number of tranexamic acid (TXA) utilization, and autologous blood transfusion within our ERAS protocol for complex spine surgery. A retrospective review compared patients undergoing elective complex spine surgery prior to and following implementation of an ERAS protocol with intraoperative blood and fluid management. Outcomes included incidence of blood transfusion, estimated blood loss, intraoperative crystalloids administered, frequency of intraoperative TXA utilized, incidence of patients extubated within the operating room (OR), intensive care unit (ICU) admission, and hospital length of stay. Following implementation, the rate of blood transfusion decreased by 11.7%(P = .017) and average crystalloid infusion was reduced 680 mL per case(P < .001). Intraoperative blood loss decreased on average 342 mL per case(P = .001) and TXA use increased significantly by 25%(P < .001). Postoperative ICU admissions declined by 8.5%(P = .071); extubation within the OR increased by 13.3%(P = .005). This protocol presents a unique perspective with the inclusion of an interdisciplinary and comprehensive blood and fluid management protocol as an integral part of our ERAS pathway for complex spine surgery. These results indicate that a standardized approach is associated with reduced rates of blood transfusion and optimized fluid states which was correlated with decreased postoperative ICU admissions.

158. Plasma cytokine biomarkers are predictive of chronic postsurgical pain following complex spine surgery

<h3>BACKGROUND CONTEXT</h3> Spine surgery in older adults is beneficial and often results in decreased pain. However, in a subset of older adults, surgical outcomes are less desirable, with up to 20% experiencing persistent postsurgical pain (>3 months). The physiological mechanisms underlying persistent postsurgical pain remain unclear. An emerging hypothesis focuses on the immune system's interplay with the nervous system wherein immune responses modulate the excitability of pain pathways, eventually driving chronic pain hypersensitivity. <h3>PURPOSE</h3> The aim of this study was to correlate immune activity with postoperative pain states by analyzing cytokine levels following complex spine surgery. <h3>STUDY DESIGN/SETTING</h3> Prospective, single-center cohort. <h3>PATIENT SAMPLE</h3> Fifteen patients undergoing complex spine surgery for adult spinal deformity were enrolled in this study. <h3>OUTCOME MEASURES</h3> Pearson correlation and linear regression models were used to assess the association between cytokine profile and patient reported pain outcomes at 3 months (VAS Back and PROMIS pain scores). <h3>METHODS</h3> Whole blood samples were collected at three timepoints: preoperatively, postoperative day 0 (POD0), then at postoperative day 3 (POD3). Plasma was isolated using Ficoll density centrifugation. Plasma IL-4, IL-6, IL-8, IL-10, IL-22, TNF-α; were measured using a Quanterix Multi-Plex cytokine assay. <h3>RESULTS</h3> Compared to baseline there was a 2.7-fold and 5-fold increase in IL-6 at POD0 and POD3, respectively (p<0.01). There were no statistically significant differences in other cytokines expression levels following surgery. On linear regression analysis, increase in IL-6 levels from baseline to POD3 were correlated with increased opioid utilization on POD3. At 3-months, cytokine expression levels in IL-6, IL-10 and TNF-α at POD0 were inversely correlated with 3-month VAS Back Pain scores and PROMIS scores. <h3>CONCLUSIONS</h3> Following spine surgery, patients exhibited a robust increase in IL-6, a pro-inflammatory cytokine. Patients with higher pain scores at 3-months postoperatively had a more blunted immune response immediately after surgery (POD0). Further biochemical and ex-vivo studies are needed to fully characterize immune response to surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The "kickstand rod" technique for correction of coronal malalignment: two-year clinical and radiographic outcomes.

Restoring coronal alignment in spine deformity patients has been shown to play an important role in improving patient reported outcomes (PRO). Recently, the "kickstand rod" (KSR) technique was developed as a novel coronal correction method in complex spine deformity cases. The goal of the present study was to assess outcomes of this technique at two years of follow-up. Consecutive, unique adult patients who underwent KSR constructs for coronal spinal malalignment between 2015 and 2019 with a minimum 2year clinical and radiographic follow-up were identified. A KSR construct includes a more laterally placed iliac screw and additional rod that effectively depresses the ipsilateral ilium/pelvis for coronal correction, while serving as a buttress to prevent future loss of correction. Outcomes included revision for instrumentation-related complications, radiographic alignment, and PROs. Twenty patients were included with a mean age of 54years [range: 20-73years]. Mean follow-up time was 2.5years [range: 2.0-5.0]. Mean number of levels fused was 17.3 [range: 10-24]. There were significant improvements in coronal alignment (CVA: 5.8cm ± 2.6cm vs. 1.7cm ± 1.5cm), sagittal alignment (SVA: 5.6cm ± 5.9cm vs. 1.6cm ± 2.5cm) and major Cobb angle (55º ± 32 vs. 26º ± 21) maintained at 2 years (p < 0.05). One patient experienced an asymptomatic fracture at the shank of the KSR iliac screw. There were significant improvements in Oswestry Disability Index and SRS-22 domains (p < 0.05). The KSR technique is a safe and effective method for correcting coronal malalignment in complex spinal deformity patients with no revisions specific for the KSR or iliac screw and significantly improved PROs at a minimum two-year follow-up.

Pain Scores and Analgesic Therapy for Complex Spine Surgery in Tertiary Care Center

Background: Complex spine surgery is an extensive operation with severe pain. At Siriraj Hospital, multimodal analgesia has been used, but it is not clear whether this technique provides adequate analgesia for major spine surgery. Objective: To assess the incidence and related factors of severe pain in patients undergoing complex spine surgery. Materials and Methods: A prospective, descriptive, observational study was conducted on adult patients undergoing complex thoracolumbar spine surgery at Siriraj Hospital between September 2016 and November 2018. The authors collected the patient demographic data, surgical data, perioperative pain management, and postoperative pain scores at rest and in movement. The data were analyzed using descriptive statistics, and the related factors to postoperative pain severity were analyzed using logistic regression analyses. Results: The present study enrolled 195 adults with a mean age of 61 years. Most were female (67.7%). The main diagnosis was spinal stenosis (38.5%). The procedures were laminectomies with posterior instrumentation (54.4%) and posterior instrumentation with interbody fusion (40.4%). The incidences of postoperative severe pain, a numeric pain rating scale score of more than 7 at rest/movement, at the PACU and at 4, 8, 12, 16, 20, 24, and 48 hours were 37.4%/47.2%, 33.3%/48.7%, 25.6%/39.0%, 17.4%/34.4%, 13.8%/31.3%, 11.8%/24.6%, 10.3%/24.6%, and 8.7%/15.9%, respectively. The overall incidence of postoperative severe pain was 35.4%. No relationships were established between the patient and the surgical factors. The related factors were intraoperative ketamine administration and severe pain in the recovery room. Conclusion: The incidence of severe pain remained high despite multimodal analgesia. There is room for improvement. Keywords: Complex spine surgery; Postoperative pain; Multimodal analgesia; Pain management

P.166 Subcutaneous intrathecal catheter and port implants for administration of Nusinersen in patients with Spinal Muscular Atrophy

Background: Until recently, no effective treatment was available for spinal muscular atrophy (SMA). In 2017, Health Canada approved intrathecal Nusinersen a medication that prevents degeneration of the motor neurons in the spinal cord. The administration is intrathecally most commonly via lumbar puncture (LP) to have a direct effect on the motor neurons of the spinal cord.Many older patients with SMA and concomitant spinal deformities present technical challenges to access the thecal sac. Different routes have been described for delivery of the medication. These techniques may require sedation, are associated with radiation exposure, and demand experience personnel. Methods: A new surgical technique has been proposed to overcome these obstacles by combining two Health Canada approved devices: 1) an intrathecal catheter designed for intrathecal baclofen pumps and 2) an implantable subcutaneous port designed for intravascular medication administration Results: We describe the technical nuances and outline the clinical outcomes of six patients with complex spine deformities who have undergone such an implant for administration of Nusinersen. Conclusions: We discuss the benefits of the procedure which includes: 1) administration in the outpatient setting without sedation, 2) avoidance of costly imaging and experienced personnel, and 3) placement of the catheter in the cervicothoracic junction.

Safety and feasibility of spinal anesthesia during simple and complex lumbar spine surgery in the extreme elderly (≥80 years of age)

ObjectiveThe extreme elderly population (≥80 years of age) is expected to triple globally by 2050 and surgeries in this age group are likely to increase. Spinal anesthesia has emerged as a safe and effective alternative to general anesthesia in lumbar surgery and may particularly benefit extreme elderly patients concerned with post-operative cognitive dysfunction, poor physiological reserves, and polypharmacy. However, literature supporting its use in this population is lacking and there are potential challenges such as degenerative anatomy and medical comorbidities. Here, we assess the safety and feasibility of using spinal anesthesia in the extreme elderly. MethodsBetween 2017 and 2021, 424 consecutive lower thoracic and lumbar spine surgeries were performed under spinal anesthesia by a single surgeon at a large academic hospital and procedural details were collected in a prospective database. Forty-six patients were ≥ 80 years in age. Demographic, surgical, perioperative, and anesthetic data were retrospectively analyzed. ResultsThe extreme elderly cohort had increased ASA scores, levels of surgery, and length of stay. Similar rates occurred for spinal headache, deep vein thrombosis, pneumonia, urinary tract infection, urinary retention, readmission within 30 days, acute pain service consult, return to the operating room, and durotomy. Intraoperative visualization of the spinal anesthesia dural puncture was increased in the extreme elderly (3 vs. 1 patient). ConclusionWe report one of the largest series of extreme elderly patients undergoing spinal anesthesia for simple and complex lumbar spine surgeries and demonstrate that spinal anesthesia can be safe and feasible in this population.

Vasoplegia Following Complex Spine Surgery: Incidence and Risk.

Retrospective cohort study. Vasoplegia is a life-threatening form of distributive or vasodilatory shock that is characterized by reduced systemic vascular resistance with resultant hypotension and normal to elevated cardiac output affecting morbidity and mortality. Vasoplegia in the context of Spine Surgery has not been described previously. The purpose of this case series is to determine incidence, risk factors, complications and postoperative outcome in patients with vasoplegia after complex multi-level thoraco-lumbar spine surgery. A retrospective review of the electronic medical records at our institution was conducted between January 2014 and June 2018. All patients undergoing multi-level spine surgery (>6 levels) were screened for intraoperative hypotension. Patient demographics, surgical characteristics, neurological status, blood loss, risk factors, medical treatment, complications, hospital course and mortality were collected. All patients included in this study had a minimum follow-up period of 3 months. Out of 8521 surgically treated patients, 994 patients with multi-level thoraco-lumbar spine surgery were identified. A total of 41 patients had intraoperative hypotensive events. Of those, 5 patients with vasoplegia could be identified after elimination of all other potential contributing factors. Vasoplegia did not influence the neurological outcome. One major and three minor complications occurred. All patients showed full recovery. The risk factors identified for vasoplegia include prolonged surgery with osteotomies. Vasoplegia is a rare condition with an incidence of .6%. Patients experiencing vasoplegia did not appear to experience worse surgical outcomes. The use of special intraoperative hemodynamic monitoring should be considered in selected cases.

Anterior spine surgery for the treatment of complex spine pathology: a state-of-the-art review.

The use of anterior spinal surgery for the treatment of spinal pathology has experienced a dramatic increase over the past decade. Long relegated to treat complicated anterior pathologies it has returned to mainstream spine surgery techniques for all types of conditions, providing a significant boost to the spine surgeons' armamentarium to address a wide variety of types of spinal diseases more effectively. Anterior surgery is useful whenever there is significant spinal pathology that requires direct visualization of the anterior vertebral column to best restore spinal alignment, structural integrity and neurologic function. These pathologies include spinal deformities, tumors, burst fractures, infections, vertebral avascular necrosis, pseudoarthrosis and other miscellaneous indications. Currently available approaches to the spine include transabdominal, paramedian retroperitoneal, lateral oblique retroperitoneal, thoracotomy, and thoracolumbar extensile. Most of the lumbar approaches are now done through a muscle splitting, minimalistic approach that has decreased their morbidity or more recently via tubular approaches, such as lateral lumbar interbody fusions or other ante-psoas approaches. New retractors, instrumentation, hyperlordotic implants, approved biologics and even image guidance for disc preparation and precise implant placement are all recent advances that will hopefully improve surgical outcomes in patients following anterior spinal surgery. Most importantly, these approaches require added expertise and training with a dedicated team consisting of an anteriorly trained spine surgeon working simultaneously with a dedicated vascular surgeon to ensure maximum safety and superior patient outcomes. This state of the review is dedicated to familiarizing practicing spine surgeons with the most commonly used anterior spinal approaches along with cutting-edge instrumentation and fusion techniques to improve their options for the treatment of difficult spinal pathologies.

Safety Evaluation of Cervical Dorsal Instrumentation in Geriatric Patients: Experience at a Level 1 Center for Spinal Surgery—A Single Center Cohort Study

ObjectiveDorsal instrumentation of the cervical spine is an established treatment in spine surgery. However, careful planning is required, particularly in elderly patients. This study evaluates early clinical outcomes in geriatric patients undergoing complex spine surgery.MethodsIn this retrospective, single center cohort study, we included all geriatric patients (aged ≥65 years) who underwent dorsal instrumentation between January 2013 and December 2020. We analyzed postoperative complications and the 30-day in-hospital mortality rate. Furthermore, the Charlson comorbidity index (CCI) and Clavien-Dindo grading system (CDG) were used to assess the patients' comorbidity burden.ResultsIn total, 153 patients were identified and included. The mean age of patients was 78 years (SD ± 7). Traumatic injury (53.6%) was the most common reason for surgery. 60.8% of the patients underwent dorsal instrumentation with 3 or more levels. The most common comorbidities were arterial hypertension (64%), diabetes mellitus (22.2%), coronary heart disease and atrial fibrillation (19.6%). The most common adverse event (AE) was pneumonia (4%) and the most common surgery-related complication was wound infection (5.2%). Among patients categorized as high risk for AE (CCI > 5), 14.6% suffered a postoperative AE. In our univariate analysis, we found no risk factors for high rates of complications or mortality.ConclusionOur data demonstrates that older patients were at no significant risk of postoperative complications. The CCI/CDG scores may identify patients at higher risk for adverse events after dorsal instrumentation, and these assessments should become an essential component of stratification in this older patient population.

Spinal anesthesia in contemporary and complex lumbar spine surgery: experience with 343 cases.

Spinal anesthesia (SA) is an alternative to general anesthesia (GA) for lumbar spine surgery, including complex instrumented fusion, although there are relatively few outcome data available. The authors discuss their experience using SA in a modern complex lumbar spine surgery practice to describe its utility and implementation. Data from patients receiving SA for lumbar spine surgery by one surgeon from March 2017 to December 2020 were collected via a retrospective chart review. Cases were divided into nonfusion and fusion procedure categories and analyzed for demographics and baseline medical status; pre-, intra-, and postoperative events; hospital course, including Acute Pain Service (APS) consults; and follow-up visit outcome data. A total of 345 consecutive lumbar spine procedures were found, with 343 records complete for analysis, including 181 fusion and 162 nonfusion procedures and spinal levels from T11 through S1. The fusion group was significantly older (mean age 65.9 ± 12.4 vs 59.5 ± 15.4 years, p < 0.001) and had a significantly higher proportion of patients with American Society of Anesthesiologists (ASA) Physical Status Classification class III (p = 0.009) than the nonfusion group. There were no intraoperative conversions to GA, with infrequent need for a second dose of SA preoperatively (2.9%, 10/343) and rare preoperative conversion to GA (0.6%, 2/343) across fusion and nonfusion groups. Rates of complications during hospitalization were comparable to those seen in the literature. The APS was consulted for 2.9% (10/343) of procedures. An algorithm for the integration of SA into a lumbar spine surgery practice, from surgical and anesthetic perspectives, is also offered. SA is a viable, safe, and effective option for lumbar spine surgery across a wide range of age and health statuses, particularly in older patients and those who want to avoid GA. The authors' protocol, based in part on the largest set of data currently available describing complex instrumented fusion surgeries of the lumbar spine completed under SA, presents guidance and best practices to integrate SA into contemporary lumbar spine practices.

Pre-Operative Planning in Complex Deformities and Use of Patient-Specific UNiD™ Instrumentation.

Study DesignReview of current literature and authors experience.ObjectivePre-operative planning is an integral part of complex spine surgery. With the advent of computer-assisted planning, multiple surgical plans can be evaluated utilizing alignment parameters, and the best plan for individual patients selected. However, the ability to evaluate and measure surgical correction goals intraoperatively are still limited. The use of patient-specific UNiD rods, created based on pre-operative plans, provided an initial tool for implementation of pre-operative plans in the operative setting.MethodsA literature review for the use of patient-specific UNiD rods in thoracolumbar spine complex surgery was performed. The articles were selected and reviewed for the initial experience/outcomes of these techniques. Further, the initial experience of the authors at The University of Colorado is described.ResultsThe use of UNiD patient-specific rods, in combination with pre-operative planning has been shown to provide a higher rate of patients with spinopelvic alignment parameters within currently accepted ranges. This includes improvement of sagittal vertical axis (SVA) < 50 mm and pelvic incidence (PI)–lumbar lordosis (LL) = ± 10°. Multiple authors have shown improvement in pelvic tilt to age adjusted values but note continued difficulties in obtaining correction goals.ConclusionsThe use of pre-operative planning software and UNiD patient-specific rods has been shown to improve surgeon’s ability to achieve spinopelvic alignment parameters, specifically SVA and PI-LL, along with other possible benefits. Further research is needed regarding long-term value of the technology.