Elective Lumbar Spine Research Articles

The spine intra-abdominal pressure (SIAP) trial. A prospective, observational, single arm, monocenter study looking at the evolutions of the IAP prior, during and after spine surgery

Background and aimsBoth anaesthesiologists and spine surgeons consider the intra-abdominal pressure (IAP) as an important peri-operative factor affected by patient positioning.We assessed the change in IAP caused by using a thoraco pelvic support (inflatable prone support, IPS) with the subject under general anesthesia. The IAP was measured before, during and immediately after surgery. MethodsThe Spine Intra-Abdominal Pressure study (SIAP trial) is a prospective, single-arm, monocenter, observational study looking at changes in IAP prior, during and after spine surgery. The objective is to assess the change in IAP, measured via an indwelling urinary catheter, using the inflatable prone support (IPS) device during prone positioning of patients in spinal surgery. ResultsForty (40) subjects requiring elective lumbar spine surgery in prone position were enrolled after providing informed consent. The inflation of the IPS results in a significant decrease of IAP (from a median of 9.2 mmHg to 6.46 mmHg (p < 0.001)) in patients undergoing spine surgery in prone position. This decrease in IAP was maintained throughout the procedure despite the discontinuation of muscle relaxants. No serious adverse events or unexpected adverse events occurred. ConclusionThe use of the thoraco-pelvic support IPS device was able to significantly lower the IAP during spine surgery.

Clinical Improvement After Lumbar Fusion: Using PROMIS to Assess Recovery Kinetics.

Retrospective review of a single institution cohort. The goal of this study is to identify features that predict delayed achievement of minimum clinically important difference (MCID) following elective lumbar spine fusion using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. Preoperative prediction of delayed recovery following lumbar spine fusion surgery is challenging. While many studies have examined factors impacting the achievement of MCID for patient-reported outcomes in similar cohorts, few studies have assessed predictors of early functional improvement. We retrospectively reviewed patients undergoing elective one-level posterior lumbar fusion for degenerative pathology. Patients were subdivided into two groups based on achievement of MCID for each respective PROMIS domain either before six months ("early responders") or after six months ("late responders") following surgical intervention. Multivariable logistic regression analysis was used to determine features associated with odds of achieving distribution-based MCID before or after six months follow up. 147 patients were included. The average age was 64.3±13.0 years. At final follow-up, 57.1% of patients attained MCID for PI and 72.8% for PF. However, 42 patients (49.4%) reached MCID for PI by six months, compared to 44 patients (41.1%) for PF. Patients with severe symptoms had the highest probability of attaining MCID for PI (OR 10.3; P =0.001) and PF (OR 10.4; P =0.001) Preoperative PROMIS symptomology did not predict early achievement of MCID for PI or PF. Patients who received concomitant iliac crest autograft during their lumbar fusion had increased odds of achieving MCID for PI (OR 8.56; P =0.001) before six months. Our study demonstrated that the majority of patients achieved MCID following elective one-level lumbar spine fusion at long-term follow-up, although less than half achieved this clinical benchmark for each PROMIS metric by six months. We also found that preoperative impairment was not associated with when patients would achieve MCID. Further prospective investigations are warranted to characterize the trajectory of clinical improvement and identify the risk factors associated with poor outcomes more accurately.

The Utilization of Intraoperative Neurophysiological Monitoring for Lumbar Decompression and Fusion Surgery in New York State.

Retrospective database analysis. To elucidate trends in the utilization of intraoperative neurophysiological monitoring (IONM) during elective lumbar surgery procedures and to investigate the association between the use of IONM and surgical outcomes. The routine use of IONM in elective lumbar spine procedures has recently been called into question due to longer operative time, higher cost, and other substitute advanced technologies. The Statewide Planning and Research Cooperative System database was accessed to perform this retrospective study. The trends of IONM use for lumbar decompression and fusion procedures were investigated from 2007 to 2018. The association between IONM use and surgical outcomes was investigated from 2017 to 2018. Multivariable logistic regression analyses, as well as propensity score matching (PS-matching), were conducted to assess IONM association in neurological deficits reduction. The utilization of IONM showed an increase in a linear fashion from 79 cases in 2007 to 6201 cases in 2018. A total of 34,592 (12,419 monitored and 22,173 unmonitored) patients were extracted, and 210 patients (0.6%) were reported for postoperative neurological deficits. Unadjusted comparisons demonstrated that the IONM group was associated with significantly fewer neurological complications. However, the multivariable analysis indicated that IONM was not a significant predictor of neurological injuries. After the PS-matching of 23,642 patients, the incidence of neurological deficits was not significantly different between IONM and non-IONM patients. The utilization of IONM for elective lumbar surgeries continues to gain popularity. Our results indicated that IONM use was not associated with a reduction in neurological deficits and will not support the routine use of IONM for all elective lumbar surgery.

426 Utility of the Fried Phenotype as a Frailty Assessment Tool in Predicting Post-Operative Outcomes in Lumbar Degenerative Spine Surgery Patients

INTRODUCTION: Frailty is a syndrome of physiological decline that can predispose surgical patients to increased peri-operative morbidity. The Fried phenotype is a clinical measure of frailty and categorizes patients’ frailty based on grip strength, walking speed, unintentional weight loss, low physical activity, and exhaustion. It has been validated in non-spine surgical populations and has been shown to be correlated with poor postoperative outcomes and longer hospital lengths of stay (LOS); it has not yet been validated in patients undergoing spine surgery. Other assessment tools, including the Modified Frailty Index-11 (mFI-11) and Charlson Comorbidity Index (CCI), are calculated based on comorbidities. The mFI-11 has previously been studied in spine patients - a higher mFI-11 score has been associated with a higher risk of post-operative morbidity and mortality. METHODS: Patients &gt;65 years of age who underwent elective lumbar spine surgery for degenerative disease since 2015 were included. Data for the Fried phenotype, mFI-11, CCI, and outcomes were gathered for each patient. ROC curves were generated, and multivariate analyses were performed. RESULTS: 248 patients (128 females; 120 males) with an average age of 71.8 years were included. The median Fried score was 1, median CCI was 1, and median mFI-11 was 0.18. The median LOS was 4 days, with 11 30-day re-admissions. Fried phenotype was found to be the best predictor of an extended LOS and of a non-home discharge. CONCLUSIONS: The Fried phenotype is now shown to be a validated measure of frailty in the spine population. Because it relies on categories that are impacted by the patient's functional condition (instead of the comorbidity burden), it has profound implications for optimizing patients through pre-habilitation prior to elective surgery.

Preventing Postoperative Urinary Retention (POUR) in Patients Undergoing Elective Lumbar Surgery: A Quality Improvement Project.

Postoperative urinary retention (POUR) is associated with significant morbidity. Our institution's POUR rate was elevated among patients undergoing elective lumbar spinal surgery. We sought to demonstrate that our quality improvement (QI) intervention would significantly lower our POUR rate and length of stay (LOS). A resident-led QI intervention was implemented from October 2017 to 2018 on 422 patients in an academically affiliated community teaching hospital. This consisted of standardized intraoperative indwelling catheter utilization, postoperative catheterization protocol, prophylactic tamsulosin, and early ambulation after surgery. Baseline data on 277 patients were collected retrospectively from October 2015 to September 2016. Primary outcomes were POUR and LOS. The focus, analyze, develop, execute, and evaluate (FADE) model was used. Multivariable analyses were used. P value <.05 was considered significant. We analyzed 699 patients (277 pre-intervention vs 422 post-intervention). The POUR rate (6.9% vs 2.6%, Δ confidence interval [CI] 1.15-8.08, P = .007) and mean LOS (2.94 ± 1.87 days vs 2.56 ± 2.2 days, Δ CI 0.066-0.68, P = .017) were significantly improved following our intervention. Logistic regression demonstrated that the intervention was independently associated with significantly decreased odds for developing POUR (odds ratio [OR] = 0.38, CI 0.17-0.83, P = .015). Diabetes (OR = 2.25, CI 1.03-4.92, P = .04) and longer surgery duration (OR = 1.006, CI 1.002-1.01, P = .002) were independently associated with increased odds of developing POUR. After implementing our POUR QI project for patients undergoing elective lumbar spine surgery, the institutional POUR rate significantly decreased by 4.3% (62% reduction) and LOS, by 0.37 days. We demonstrated that a standardized POUR care bundle was independently associated with a significant decrease in the odds of developing POUR.

Neighborhood-level socioeconomic status, extended length of stay, and discharge disposition following elective lumbar spine surgery

BackgroundIn the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery. MethodsWe employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively. Results779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge. ConclusionsPatient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.

A retrospective analysis of surgical, patient, and clinical characteristics associated with length of stay following elective lumbar spine surgery

BackgroundElective spine surgeries consume significant hospital resources, contributing greatly to the costs of care. Length of stay (LOS) is the major cost driver for most hospitals. This study aimed to describe the demographic, clinical, operative, and postoperative characteristics of patients undergoing elective lumbar spine with wide-ranging rural discharge destinations, and how these characteristics are independently associated with LOS. MethodsThis was a retrospective cohort study of patients at a quaternary institution undergoing surgery for single or two level lumbar degenerative conditions over a two year period. LOS was calculated as the number of days from the date of surgery to the date of discharge. A multiple quasi-Poisson regression was used to describe the characteristics independently associated with LOS. Surgery group was stratified when feasible to explore heterogeneity within the study population. ResultsA total of 473 patients met inclusion criteria. The median LOS was 3.0 days (Interquartile range (IQR) = 1–4) for the entire population, 4.0 days (IQR = 3–6) for 1-level transforaminal lumbar interbody fusion (TLIF) patients, 0 days (IQR = 0–1) for discectomy patients, and 2.0 days (IQR = 1–4) for laminectomy patients. Factors that were statistically significantly associated with LOS in adjusted analyses were age, BMI, preoperative antidepressant use, surgery group, long-acting intraoperative analgesics, operating surgeon, and postoperative blood transfusion. Stratified multivariable analysis showed effect modification by surgery group. ConclusionLOS following elective lumbar spine surgery for degenerative conditions is associated with several patient, clinical, and surgical factors and is highly dependent on the type of surgical procedure performed. Building predictive models for anticipated LOS can help hospitals plan for ideal resource use and scheduling.

Opioid Use Patterns in a Statewide Adult Medicaid Population Undergoing Elective Lumbar Spine Surgery.

Retrospective administrative database review. Analyze patterns of opioid use in patients undergoing lumbar surgery and determine associated risk factors in a Medicaid population. Opioid use in patients undergoing surgery for degenerative lumbar spine conditions is prevalent and impacts outcomes. There is limited information defining the scope of this problem in Medicaid patients. Longitudinal cohort study of adult South Carolina (SC) Medicaid patients undergoing lumbar surgery from 2014 to 2017. All patients had continuous SC Medicaid coverage for 15 consecutive months, including six months before and nine months following surgery. The primary outcome was a longitudinal assessment of postoperative opioid use to determine trajectories and group-based membership using latent modeling. Univariate and multivariable modeling was conducted to assess risk factors for group-based trajectory modeling and chronic opioid use (COU). A total of 1455 surgeries met inclusion criteria. Group-based trajectory model demonstrated patients fit into five groups; very low use (23.4%), rapid wean following surgery (18.8%), increasing use following surgery (12.9%), slow wean following surgery (12.6%) and sustained high use (32.2%). Variables predicting membership in high opioid use included preoperative opioid use, younger age, longer length of stay, concomitant medications, and readmissions. More than three quarter of patients were deemed COUs (76.4%). On bivariate analysis, patients with degenerative disk disease were more likely to be COUs (24.8% vs. 18.6%; P =0.0168), more likely to take opioids before surgery (88.5% vs. 61.9%; P <0.001) and received higher amounts of opioids during the 30 days following surgery (mean morphine milligram equivalents 59.6 vs. 25.1; P <0.001). Most SC Medicaid patients undergoing lumbar elective lumbar spine surgery were using opioids preoperatively and continued long-term use postoperatively at a higher rate than previously reported databases. Preoperative and perioperative intake, degenerative disk disease, multiple prescribers, depression, and concomitant medications were significant risk factors.

23. Understanding the influence of prior positive COVID-19 infection on 90-day outcomes following elective lumbar spine surgery

BACKGROUND CONTEXTThe COVID-19 pandemic has radically impacted and transformed surgical practice over the past couple of years. While a significant proportion of research has rightfully focused on prevention and/or treatment of acutely infected COVID-19 patients, little is known about how a prior history of a positive COVID-19 infection (ie, recovered patients) influences outcomes following major elective surgeries.PURPOSEThe purpose of the current study was to study whether previous positive COVID-19 infection has an impact on 90-day medical and surgical complication rates following elective lumbar spine surgeries.STUDY DESIGN/SETTINGRetrospective cohort utilizing large all-payer database.PATIENT SAMPLEThis study included 49,639 patients undergoing elective lumbar spine surgery between 2019 and 2021.OUTCOME MEASURESNinety-day medical and surgical complication rates.METHODSThe 2019 to 2021 PearlDiver Mariner Database, an all-payer claims database, was used to identify patients undergoing elective 1- to 2-level primary posterior/anterior/combined fusions or 1- to 2-level laminectomies for degenerative lumbar spine pathologies and 1- to 2-level primary microdiscectomies for herniated discs. Patients undergoing fusion for fracture, malignancy, infection and/or those undergoing revision procedures were excluded from the study. The study group was divided into two cohorts — those who had a prior history of a COVID-19 infection within the 6 months before surgery and those who were not infected by the virus. Patients who had a positive coded COVID-19 status on the day of surgery were excluded from the analysis. Multivariate logistic regression analyses were used to assess the impact of prior COVID-19 infection on 90-day medical and surgical complication rates, while controlling for baseline demographics (age, gender, payor type/insurance) and clinical characteristics (Charlson comorbidity index, type of surgery, and prior ventilator dependence).RESULTSA total of 49,639 patients undergoing elective lumbar spine surgery between 2019 and 2021 were included in the study, out of which 150 patients (0.3%) had had a positive COVID-19 status and/or infection in the 6 months prior to the surgery. After adjusting for baseline demographics and clinical characteristics, patients with a prior history of COVID-19 infection were more likely to experience cardiac complications (3.3% vs 1.1%, OR 2.75; p=0.021), thromboembolic complications (6.0% vs 2.3%, OR 2.35; p=0.014) and sepsis (5.3% vs 2.0%, OR 2.31; p=0.024) within 90 days of the index surgery.CONCLUSIONSBased on a national retrospective review of patients undergoing elective lumbar spine surgery, it appears that having harbored a positive COVID-19 infection in the 6 months prior to surgery is associated with higher risks of experiencing thromboembolic events, sepsis and acute myocardial infarctions or acute congestive heart failure. The findings of the study support the need of careful postoperative care monitoring and/or risk-stratification of prior COVID-19 patients.FDA DEVICE/DRUG STATUSThis abstract does not discuss or include any applicable devices or drugs.

44. Does recall bias exist in lumbar spine surgery patients as reported through PROMIS questionnaires?

<h3>BACKGROUND CONTEXT</h3> Surgical outcomes are increasingly judged on patients' perceptions of the results. Despite the improved quantitative data provided by patient-reported outcomes (PROs), they remain susceptible to confounding factors on patients' interpretations such as recall bias: the inability to accurately recall prior impairment. No studies to date have reported the accuracy of patient recall using PROMIS outcomes after lumbar spine surgeries. <h3>PURPOSE</h3> The purpose of this study is to determine the presence and extent of recall bias in adult patients after elective lumbar spine surgery. <h3>STUDY DESIGN/SETTING</h3> Subgroup analysis of ongoing prospective study. <h3>PATIENT SAMPLE</h3> This study included 98 patients who had undergone either lumbar decompression or lumbar decompression and fusion procedures. <h3>OUTCOME MEASURES</h3> Baseline preoperative PROMIS Physical Function (PF), PROMIS Pain Interference (PI) and recalled preoperative PROMIS PF and PI. <h3>METHODS</h3> Patients, at least 2 years after their index surgery, completed a recall questionnaire comprised of the PF CAT and PI CAT as though it was a time immediately before their surgery. All patients had prospectively completed PROMIS PF CAT and PI CAT prior to surgery and at 3 months, 6 months, 1 year and 2 years. T tests were used to compare recalled PROs with actual baseline PROs. Correlation coefficients were calculated to evaluate the agreement between recalled PROs and baseline PROs. Regression analysis was performed to determine the impact of patient characteristics or clinical factors. <h3>RESULTS</h3> Patient recollection of preoperative status at a minimum of 2 years postoperatively was significantly more severe than baseline preoperative status with mean difference in PF of -1.5 (p < 0.05) and PI of 2.1 (p < 0.01). There was only moderate correlation between recalled and baseline scores with regards to PF (r=0.52) and PI (r=0.38). No significant differences on recalled PROs were found based on age, gender, time between surgery and recalled outcomes, and duration of symptoms before surgery. <h3>CONCLUSIONS</h3> Our data indicate that patient recall of preoperative status after lumbar surgery is significantly different than actual baseline preoperative status as measured by PROMIS PF and PI scores with only moderate correlation existing between the two. Patients' interpretations of improvement after surgery may be impacted by significant recall bias. This may have an impact on patient satisfaction and perceived value of lumbar spine surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P88. Influence of time of discharge and length of stay on 30-day outcomes after elective lumbar spine surgery

<h3>BACKGROUND CONTEXT</h3> As health system reimbursements are restructured through bundled care and value-based payments, hospitals face increasing pressures to increase patient throughput while enhancing patient safety. Among many efforts, appropriate time of discharge (TOD) after medical and surgical admissions has received increasing scrutiny. Prior research suggests that earlier discharges after medical admissions result in higher likelihood of readmission and health care expenditures following discharge. Data specific to elective spine surgical admissions, however, are lacking. We hypothesize that likelihood of readmission or representation within 30 days is not affected by earlier time of discharge after surgical admissions for these procedures. <h3>METHODS</h3> We performed a retrospective cohort analysis on data collected between April 1, 2015, and December 1, 2021 from a single, large academic center following elective posterior, non-endoscopic lumbar laminectomy, discectomy, microdiscectomy, foraminotomy and/or facetectomy without fusion. The primary outcome measure of interest was readmission or emergency department (ED) re-presentation within 30 days following discharge. Analyses accounted for multiple patient and procedure-level covariates including, but not limited to, race, insurance status, socioeconomic status, procedure day of week, procedure length, use of tubular retractor system, evaluation by physical (PT) and occupational therapy (OT) and discharge disposition to location other than home. Discrete variables were normalized. Multivariable logistic regression analysis was performed to assess if covariates were independently predictive of 30-day readmission or ED representation. Poisson regression was used to assess the relationship between length of stay (LOS) in midnights and discharge disposition. <h3>RESULTS</h3> A total of 779 patients who had elective lumbar spine surgery were included, with a mean age of 66 (±15), median procedure duration of 94 minutes (IQR: 72, 131), and median LOS in midnights of 1 (IQR: 1,2). Results from multivariable logistic regression analysis demonstrated that time of discharge (OR 1.18 95% CI 0.92-1.52, p=0.192) and LOS (OR 1.13, 95% CI 0.86-1.50, p=0.374) were not associated with an increased risk of readmission or re-presentation to the ED. Patients discharged on a weekend were more likely to represent to the hospital (OR 2.14, 95% CI 1.11-4.12, p=0.023). Risk of readmission or ED re-presentation was not significantly associated with other sociodemographic or procedural characteristics. Patients operated on by a surgeon with less than one year of experience (OR 0.40, 95% CI 0.17-0.94, p=0.035) or two to five years of experience (OR 0.48, 95% CI 0.23-0.98, p=0.045), evaluated by physical therapy (OR 0.20, 95% CI 0.12-0.32, p < 0.001), or discharged on a weekend (OR 0.51, 95% CI 0.28-0.93, p=0.028) were less likely to be discharged before noon. Patients discharged not to home were associated with a significantly longer LOS (IRR 2.05, 95% CI 1.79-2.35, p < 0.001). <h3>CONCLUSIONS</h3> Patients undergoing elective lumbar spine surgery were not at higher risk of readmission or return to the ED with earlier TOD or length of stay following elective lumbar spine surgery but were at higher risk if discharged on a weekend. Patients operated on by less experienced surgeons, discharged on weekends, or evaluated by physical therapy while inpatient were all at decreased odds of discharge before noon. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

154. Social Vulnerability Index (SVI) can be used to predict health care resource utilization and persistent opioid use after elective lumbar spine surgery

<h3>BACKGROUND CONTEXT</h3> The national capacity for health care expenditures is nearing its limit, having experienced recent exponential growth nearing a total of 17% of US GDP. As with all other finite resources, the question of efficient utilization becomes essential. This is especially apparent in subsets of medicine, such as spine surgery, that are significantly more costly. Exploration of patient-specific traits and how they relate to health care resource utilization has become as essential to the practice of medicine as patient outcomes. <h3>PURPOSE</h3> The purpose of this study is to investigate the association between social determinants of health and healthcare resource utilization following elective lumbar spine surgery. <h3>METHODS</h3> Patients who underwent elective spine surgery for lumbar degenerative pathology between November 1, 2013 and September 30, 2018, at a single academic center were retrospectively identified. The Cook County Social Vulnerability Index (SVI) metrics for each patient were determined based on the ZIP code of their home neighborhood. The SVI is comprised of separate scores pertaining to socioeconomic status, household compensation, minority status & language, and housing & transportation. Possible scores range from 0 (lowest vulnerability) to 1 (highest vulnerability). Health resource utilization was quantified within one year postoperatively (imaging studies, emergency and urgent care visits, opioid prescriptions and others). These metrics were compared between patients with social vulnerability – defined as a SVI score in the upper quartile (SVI=0.75) and control patients (SVI score < 0.75). <h3>RESULTS</h3> A total of 92 patients were included in the final cohort. Of these, 33 (35.9%) were considered socially vulnerable based on their SVI metrics. Socially vulnerable patients were more likely to utilize the emergency department within 180 (0.5 ± 1.1 vs 0.1 ± 0.4; p=0.028) and 365 (0.7 ± 1.7 vs 0.2 ± 0.7; p=0.045) days postoperatively. Socially vulnerable patients were more than 3 times more likely to have persistent opioid use at 180 days postoperatively to controls (36.3% vs 11.9%; p=0.005). An overall SVI in the upper quartile was associated with persistent opioid use (OR 4.245; 95% CI: 1.469 – 12.265) and at least one emergency department visit within 180 days postoperatively (OR 4.050; 95% CI: 1.227 – 13.370). <h3>CONCLUSIONS</h3> The SVI was associated with postoperative opioid use and emergency department utilization after surgery. Socially vulnerable patients were more likely to utilize emergency department services and to have persistent opioid use at 6 months postoperatively from elective lumbar spine surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P70. Predictors of extended length of stay and discharge disposition following elective lumbar spine surgery

<h3>BACKGROUND CONTEXT</h3> In the context of increased attention afforded to hospital efficiency and safe patient throughput, safely decreasing hospital length of stay (LOS) is imperative. About 10% of patients contribute to 63% of all US health care expenditures. Given that lumbar spine procedures can be among a hospital's most profitable services, identifying patients at risk of extended LOS (eLOS) prior to surgery is a valuable opportunity to develop targeted pre- and perioperative intervention and quality improvement initiatives. We sought to elucidate patient factors that predict prolonged LOS as well as discharge disposition following elective lumbar spine surgery. <h3>METHODS</h3> We performed a retrospective cohort analysis on data collected between 2015 and 2021 from a single, large academic center following elective posterior, nonendoscopic, lumbar laminectomy, discectomy, microdiscectomy, foraminotomy and/or facetectomy without fusion. The primary outcome measure was eLOS following surgery, defined as the 90^th percentile or greater in the number of midnights admitted postprocedurally (three or more). Patient sociodemographic, procedural and discharge characteristics were collected. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment and housing quality based on patient zip code. Multivariable logistic and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of eLOS and discharge disposition, respectively. Discharge to home served as a reference category with the other two dispositions being to home with services and to a SNF or acute rehab. <h3>RESULTS</h3> There were 779 patients in the study, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Results demonstrated that patients in the most disadvantaged ADI quintile (OR 2.48 95% CI 1.14-5.40), who underwent minimally invasive surgery (OR 3.03 95% CI 1.06-8.74), who had an intraoperative drain placed (OR 4.46 95% CI 2.50-7.17), who had a CSF leak (OR 3.46 95% CI 1.57-7.62), who were discharged anywhere but home (OR 17.11 95% CI 9.07-32.26), and who were evaluated by PT (OR7.2395% CI 1.69-30.87) or OT (OR 2.20 95% CI 1.14-4.23) had a significantly increased chance of an eLOS. Preoperative opioid use was not associated with an increased LOS following surgery (OR 1.12 95% CI 0.69-1.80). Extended LOS was not associated with ED representation and readmission risk within 90 days following discharge (p=0.148). Patients who were older (OR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rdquintile; OR 1.90 95% CI 1.12-3.23, 4^thquintile; OR 1.79, 95% CI 1.05-3.05, 5thquintile; OR 2.16 95% CI 1.26-3.75), who had a CSF leak (OR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (OR 1.38 95% CI 1.17-1.62) were more likely to be discharged with some kind of support service. <h3>CONCLUSIONS</h3> Patient sociodemographics, along with procedural factors, and discharge characteristics were all associated with an increased chance of eLOS and disproportionate health care utilization with elective lumbar spine surgery. Notably, some of these identified factors could be reliably identified in a preoperative visit and therefore may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the perioperative period may allow for reduced inpatient length of stays. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Analgesic efficacy of erector spinae plane blocks for lumbar spine surgery: a randomized double-blind controlled clinical trial

IntroductionErector spinae plane block has been proposed to reduce opioid use and improve pain relief with controversial results. This randomized clinical study aimed to assess the efficacy of erector spinae...

Frailty and Sarcopenia: Impact on Outcomes Following Elective Degenerative Lumbar Spine Surgery

This is a retrospective review of prospectively collected data. The aim was to evaluate the impact of frailty and sarcopenia on outcomes after lumbar spine surgery. Elderly patients are commonly diagnosed with degenerative spine disease requiring surgical intervention. Frailty and sarcopenia result from age-related decline in physiological reserve and can be associated with complications after elective spine surgery. Little is known about the impact of these factors on patient-reported outcomes (PROs). Patients older than 70 years of age undergoing elective lumbar spine surgery were included. The modified 5-item frailty index (mFI-5) was calculated. Sarcopenia was defined using total psoas index, which is obtained by dividing the mid L3 total psoas area by VB area (L3-TPA/VB). PROs included Oswestry disability index (ODI), EuroQual-5D (EQ-5D), numeric rating scale (NRS)-back pain, NRS leg pain (LP), and North American Spine Society (NASS) at postoperative 12 months. Clinical outcomes included length of stay (LOS), 90-day readmission and complications. Univariate and multivariable regression analyses were performed. Total 448 patients were included. The mean mFI-5 index was 1.6±1.0 and mean total psoas index was 1.7±0.5. There was a significant improvement in all PROs from baseline to 12 months ( P <0.0001). After adjusting for age, body mass index, smoking status, levels fused, and baseline PROs, higher mFI-5 index was associated with higher 12-month ODI ( P <0.001), lower 12-month EQ-5D ( P =0.001), higher NRS-L P ( P =0.039), and longer LOS ( P =0.007). Sarcopenia was not associated with 12-month PROs or LOS. Neither sarcopenia or mFI-5 were associated with 90-day complication and readmission. Elderly patients demonstrate significant improvement in PROs after elective lumbar spine surgery. Frailty was associated with worse 12 months postoperative ODI, EQ-5D, NRS-LP scores, and longer hospital stay. While patients with sarcopenia can expect similar outcomes compared with those without, the mFI-5 should be considered preoperatively in counseling patients regarding expectations for disability, health-related quality of life, and leg pain outcomes after elective lumbar spine surgery. 3.

Incidence of medical and surgical complications after elective lumbar spine surgery

IntroductionThe demographic change results in an ever increasing number of older patients with pre-existing medical conditions who require spinal surgery, and recovery is often severely impaired by procedure-related complications. The purpose of this retrospective study was to determine patients at risk of medical and surgical complications. MethodUsing our database, we reviewed 1244 patients with lumbar degenerative disk disease, spinal stenosis, and instability, who had undergone surgery at our department between 2009 and 2014. We screened for medical complications (thromboembolic and cardiac events, pneumonia, and sepsis) and surgical complications (hemorrhage, wound infection, and CSF fistula). Furthermore, a matched 1:1 control group consisted of 103 patients without any surgical and medical complications in the randomly selected period of May 2009 to October 2014. Results93 patients (46 women, 47 men), mean age 70 years (range 33–86 years, median 67.4 years), with complications were identified (overall morbidity 7.6 %): 22.6 % (n = 26) had medical complications and 77.4 % (n = 89) surgical complications. In 93 patients (46 females, 47 males), mean age 70 years (range 33–86 years, median 67.4 years), a total of 115 complications were noted (overall morbidity of the 93 patients 7.6 %): 22.6 % (n = 26) medical complications and 77.4 % (n = 89) surgical complications. Age and pre-existing conditions were independently associated with medical complications (p < 0.001). Infections (pneumonia and sepsis) were correlated with multi-segmental interventions (p = 0.009), duration of surgery (p = 0.009), and pre-existing conditions (p = 0.014). Surgical complications were significantly correlated with age (p = 0.016) and duration of surgery (p = 0.014) and occurred significantly more often in patients with instability (p < 0.001). Wound healing disorders were associated with coagulopathy (p = 0.013) and transfusion (p < 0.001). ConclusionsWe identified predictors that help identify patients at risk of medical and surgical complications. These correlations should be taken into account when advising older patients with pre-existing conditions on lumbar spine surgery.

Effects of Workload on Return to Work After Elective Lumbar Spine Surgery.

Retrospective analysis was performed of a multi-center Canadian Spine Outcomes and Research Network (CSORN) surgical database. To determine the rate and time to return to work (RTW) based on workload intensity after elective degenerative lumbar spine surgery. Patients working pre-operatively, aged greater than 18, who underwent a primary one- or two-level elective lumbar spine surgery for degenerative conditions between January 2015 and October 2020 were evaluated. The percentage of patients who returned to work at 1year and the time to RTW post-operatively were analyzed based on workload intensity. Of the 1290 patients included in the analysis, the overall rate of RTW was 82% at 1 year. Based on workload there was no significant difference in time to RTW after a fusion procedure, with median time to RTW being 10 weeks. For non-fusion procedure, the sedentary group had a statistically significantly quicker time to RTW than the light-moderate (P < .005) and heavy-very heavy (<.027) groups. The rate of RTW ranged between 84% for patients with sedentary work to 77% for patient with a heavy-very heavy workload. Median time to resumption of work was about 10weeks following a fusion regardless of work intensity. There was more variability following non-fusion surgeries such as laminectomy and discectomy reflecting the patient's job demands.

History of Prior Lumbar Surgery Does Not Impact Mental Health Outcomes Following Anterior Cervical Discectomy and Fusion.

This was a retrospective cohort study. The objective of this study was to evaluate the impact of undergoing a prior lumbar procedure on mental health outcomes following anterior cervical discectomy and fusion. Revision and reoperations are perceived as risk factors for worse mental health outcomes. A retrospective review of a surgical database was performed for cervical and lumbar procedures. The mental health measures used were: Short Form 12-Item Mental Composite Score (SF-12 MCS) and Patient Health Questionnaire 9 (PHQ-9). Secondary outcomes of interest were Visual Analogue Scale for neck and arm pain, Neck Disability Index, and Short Form 12-Item Physical Composite Score (SF-12 PCS). All outcomes were collected preoperatively and at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Minimum clinically important difference (MCID) was calculated using established values. Patients were grouped based on the surgical history of an elective lumbar spine procedure and propensity-matched. Differences in postoperative outcome scores and MCID achievement were evaluated using linear and logistic regression respectively. A total of 74 patients were included in this study. Mental health outcomes did not demonstrate significant differences between groups for SF-12 MCS and PHQ-9 for all time points except at 6 weeks for PHQ-9 ( P =0.038). MCID achievement was not significantly impacted by surgical history for all outcome measures at all postoperative time points (all P >0.050). The majority of patients achieved an MCID by the 1-year time point for all outcomes for patients without a prior lumbar surgery except for Visual Analogue Scale arm and SF-12 PCS, while those with a surgical history achieved an MCID for all outcomes except SF-12 PCS and PHQ-9. Anterior cervical discectomy and fusion patients with a past history of lumbar surgery demonstrated significant improvements in depression, neck and arm pain, disability, and physical function as those without a past lumbar surgical history. Prior surgery also did not impact MCID achievement for all outcomes.

Effects of general anesthesia with and without thoracic epidural block on length of stay after open spine surgery: a single-blinded randomized controlled trial

BACKGROUND CONTEXTLength of hospital stay (LOS) is an important concern in all types of surgery, and the enhanced recovery after surgery (ERAS) protocol has been developed to improve perioperative management and outcomes, which require multidisciplinary management. In terms of pain control, intraoperative regional anesthesia and postoperative opioid-sparing analgesia are recommended. For open spine surgery, we aimed to combine thoracic epidural analgesia to reduce pain and opioid-related side effects, thereby hastening recovery. PURPOSEThis study aimed to compare the length of hospital stay after open complete laminectomy with fusion between general anesthesia and combined general anesthesia involving a single thoracic epidural injection. DESIGNA randomized single-blinded controlled study. PATIENT SAMPLEThirty-eight patients scheduled for elective open laminectomy with fusion between I and III levels were selected. OUTCOME MEASURESLOS, postoperative pain, patient-controlled morphine consumption at 24 hours, patient satisfaction score, and other opioid-related side effects were recorded. METHODSPatients were randomly selected to receive standard general anesthesia (GA) or GA combined with a single-shot thoracic epidural at T11–T12 or T12–L1, a block with 10 mL of 0.25% bupivacaine, and 4 mg of morphine. RESULTSThere were no significant differences in the demographic variables between groups. LOS was significantly lower in the combined epidural and/or GA than in the control group (3.78±0.81 [mean±standard deviation] and 4.79±1.51 days, respectively; p=.017). Numeric rating score (at rest) at the post-anesthesia care unit, 24 hours postoperative morphine consumption (mg), operating time, and blood loss were significantly lower in the epidural group. Patients who received combined epidural and/or GA were more likely to report higher patient satisfaction (p=.008). However, the incidence of intraoperative hypotension was significantly higher in the epidural group (72.2% vs. 21.1%, p=.003). The incidences of adverse events and surgical field rating scores did not differ between the 2 patient groups. CONCLUSIONSCombined lower thoracic epidural and/or GA in patients undergoing elective lumbar spine surgery was associated with decreased LOS.

Attenuation of metabolic stress response during spinal surgery under general anaesthesia - A comparison between preoperative carbohydrate drink or no carbohydrate load

Background: Surgery is a stress which stimulates the increase of counter regulatory hormones. Pre-operative prolonged fasting increases stress further. Although a pre-operative carbohydrate (CHO) drink has been variably reported to yield benefit in reducing the perioperative stress and is being used frequently for elective surgeries, some recent reports also reports that preoperative CHO loading did not result in increase or decrease in the post-operative complication rates when compared with placebo or fasting group. Aims and Objectives: The present study was designed to determine the stress response in the postoperative period at 24 h in terms of changes in the levels of cortisol and other biomarkers. Materials and Methods: This randomized, parallel group, and double-blind study was conducted in 75 patients aged 18–65 years, of American Society of Anesthesiologists Physical Status Classes I and II, scheduled for elective lumbar spine surgery under general anesthesia. The patients were randomly allocated to receive 300 ml plain water at 9 pm on the day before surgery and 2 h before operation (Group C, control, n=25), or 300 ml plain water at 9 pm on the day before surgery and solution containing 75 grams of glucose dissolved in 300 ml water in the morning 2 h before surgery (Group CHO-1, n=25), or to receive 75 grams of glucose dissolved in 300 ml water at 9 pm in the night before the surgery and again in the morning at 2 h before surgery (Group CHO-2, n=25). In all the three groups, the levels of insulin (C-peptide), lactate, glucose, and cortisol were determined preoperatively (before the induction of anesthesia) and 24 h postoperatively. Results: There was considerable difference between post-operative blood cortisol level among the three groups (583.9 vs. 462.3 vs. 389.6 nMol/L, Control vs., CHO load once or twice, respectively, P&lt;0.0001). A significant difference in post-operative values was also seen with other parameters such as serum lactate, glucose, and C-peptide. Considerable differences were seen in both preoperative and postoperative period in case of cortisol and lactate whereas it was limited to postoperative values in case of glucose and C-peptide. Conclusion: Pre-operative glucose loading showed better efficacy in suppressing perioperative stress response in terms of less rise of serum cortisol and lactate as compared to no CHO load.