Elective Posterior Cervical Fusion Research Articles

Stopping at C2 Versus C3/4 in Elective Posterior Cervical Decompression and Fusion: A 5-Year Follow-up Study.

This is a retrospective cohort study. In patients undergoing elective posterior cervical laminectomy and fusion (PCLF) with a minimum of 5-year follow-up, we sought to compare reoperation rates between patients with an upper instrumented vertebra (UIV) of C2 versus C3/4. The long-term outcomes of choosing between C2 versus C3/4 as the UIV in PCLF remain unclear. A single-institution, retrospective cohort study from a prospective registry was conducted of patients undergoing elective, degenerative PCLF from December 2010 to June 2018. The primary exposure was UIV of C2 versus C3/4. The primary outcome was reoperation. Multivariable logistic regression controlled for age, smoking, diabetes, and fusion to the thoracic spine. Of the 68 patients who underwent PCLF with 5-year follow-up, 27(39.7%) had a UIV of C2, and 41(60.3%) had a UIV of either C3/4. Groups had similar duration of symptoms (P=0.743), comorbidities (P>0.999), and rates of instrumentation to the thoracic spine (70.4% vs. 53.7%, P=0.210). The C2 group had significantly longer operative time (231.8±65.9 vs. 181.6±44.1mins, P<0.001) and more fused segments (5.9±1.8 vs. 4.2±0.9, P<0.001). Reoperation rate was lower in the C2 group compared with C3/4 (7.4% vs. 19.5%), though this did not reach statistical significance (P=0.294). Multivariable logistic regression showed increased odds of reoperation for the C3/4 group compared with the C2 group (OR=3.29, 95%CI=0.59-18.11, P=0.170), though statistical significance was not reached. Similarly, the C2 group had a lower rate of instrumentation failure (7.4% vs. 12.2%, P=0.694) and adjacent segment disease/disk herniation (0% vs. 7.3%, P=0.271), though neither trend attained statistical significance. Patients with a UIV of C2 had less than half the number of reoperations and less adjacent segment disease, though neither trend was statistically significant. Despite a lack of statistical significance, whether a clinically meaningful difference exists between UIV of C2 versus C3/4 should be validated in larger samples with long-term follow-up. Level-3.

Barbed Suture versus Interrupted Suture in Posterior Cervical Spine Surgery: Are They Equivalent?

Posterior cervical spine approaches have been associated with increased rates of wound complications compared to anterior approaches. While barbed suture wound closure for lumbar spine surgery has been shown to be safe and efficacious, there is no literature regarding its use in posterior cervical spine surgery. In a cohort of patients undergoing elective posterior cervical spine surgery, we sought to compare postoperative complication rates between barbed and traditional interrupted suture closure. A retrospective review of demographics, past medical history, and operative and postoperative variables collected from a prospective registry between July 1, 2016, and June 30, 2020 was undertaken. All patients 18 years old and above undergoing elective posterior cervical fusion were included. The primary outcome of interest was wound complications, including surgical site infection (SSI), dehiscence, or hematoma. In addition, numerical rating scale (NRS) neck pain (NP), NRS arm pain (AP), Neck Disability Index (NDI), and operative time were collected. A variety of statistical tests were used to compare the two suture groups. Of 117 patients undergoing posterior cervical fusion, 89 (76%) were closed with interrupted suture and 28 (24%) with barbed suture. The interrupted cohort were more likely to have >1 comorbidity (p<0.001), diabetes mellitus (p=0.013), and coronary artery disease (p=0.002). No difference in postoperative wound complications between interrupted/barbed sutures was observed after univariate (OR 1.07, 95% CI: 0.27-4.25, p=0.927) and multivariable logistic regression analysis (OR 0.77, 95% CI: 0.15-4.00, p=0.756). Univariate logistic regression revealed no differences in achieving minimal clinically important difference (MCID) NRS-NP (OR 0.73, 95% CI: 0.28-1.88, p=0.508) or NRS-AP (OR 0.68, 95% CI: 0.25-1.90, p=0.464) at 3 months between suture groups. The interrupted suture group was less likely to achieve MCID NDI at 3 months (OR 0.29, 95% CI: 0.11-0.80, p=0.016). Barbed suture closure in posterior cervical spine surgery does not lead to higher rates of postoperative wound complications/SSI compared to traditional interrupted fascial closure.

Utility of the Modified 5-Items Frailty Index to Predict Complications and Mortality After Elective Cervical, Thoracic and Lumbar Posterior Spine Fusion Surgery: Multicentric Analysis From ACS-NSQIP Database.

Retrospective review of multicentric data. The modified 5-item frailty index is a relatively new tool to assess the post-operative complication risks. It has been recently shown a good predictive value after posterior lumbar fusion. We aimed to compare the predictive value of the modified 5-item frailty index in cervical, thoracic and lumbar surgery. The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database 2015-2020 was used to identify patients who underwent elective posterior cervical, thoracic, or lumbar fusion surgeries for degenerative conditions. The mFI-5 score was calculated based on the presence of 5 co-morbidities: congestive heart failure within 30days prior to surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on the postoperative morbidity while controlling for baseline clinical characteristics. 53252 patients were included with the mean age of 64.2 ± 7.2. 7946 suffered medical complications (14.9%), 1565 had surgical complications (2.9%), and 3385 were readmitted (6.3%), 363 died (.68%) within 30days postoperative (6.3%). The mFI-5 items score was significantly associated with higher rates of complications, readmission, and mortality in cervical, thoracic, and lumbar posterior fusion surgery. The modified 5-item frailty score is a reliable tool to predict complications, readmission, and mortality in patients planned for elective posterior spinal fusion surgery.

P84. Day of admission is associated with hospital length of stay following elective posterior cervical decompression and fusion for cervical myelopathy

BACKGROUND CONTEXTThe COVID-19 pandemic has caused significant strain on the US health care system, with many hospitals struggling to provide resources for perioperative care and even necessitating the cessation of elective surgery for periods of time. Therefore, it is imperative to understand the hospital resource demands of elective surgery and identify ways to optimize them. With the traditional hospital staffing structure, there is minimal coverage on weekends, which can lead to delays in discharge for surgeries performed later in the week.PURPOSETo identify 1) length of hospital stay 2) cost of hospital episode and 3) discharge destination following treatment of cervical spondylotic myelopathy (CSM) with posterior cervical decompression and fusion (PCDF) based on day of hospital admission.STUDY DESIGN/SETTINGRetrospective case-control analysis.PATIENT SAMPLEThe 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File were utilized. Patients undergoing elective PCDF for CSM were included. Nonelective surgery, combined anterior and posterior cervical fusions, revision cases, thoracic extension, disc replacements, fractures, traumatic spinal cord injury and epidural abscesses were excluded.OUTCOME MEASURESLength of stay, cost, and discharge destination.METHODSPotential demographic, comorbidity, surgical, perioperative and hospital confounders were evaluated. Multivariate models for hospital length of stay, cost of care and discharge destination were performed including surgical approach and potential confounders.RESULTSThere were 7,212 cases that met inclusion criteria. There were 4,026 males (55.8%) and 3,186 females (44.2%). The majority of patients were aged 65-74 (n=3,609, 50.0%) and 75-84 (n=2,009, 27.9%). The mean length of stay was 3.89±3.171 days and cost of hospital episode was $28,854.066±15,649.294 for elective surgical treatment of CSM with PCDF. The majority of patients were discharged home (n=4,605, 63.9%). There were 1,507 cases admitted on Tuesday (20.9%), 1,601 cases admitted on Wednesday (22.2%),623 cases admitted on Thursday (22.5%), 373 cases admitted on Friday (19.0%) and 1,108 cases admitted on Saturday (15.4%). On univariate analysis, there were significant differences in length of stay based on day of admission (Tuesday: 3.59±2.58 days, Wednesday: 3.74±2.919 days, Thursday: 3.89±2.92 days, Friday: 4.13±3.76 days and Saturday: 4.23±3.71 days, p=0.006). However, there were no differences in cost (p=0.340) or incidence of discharge home (p=0.389). On multivariate analysis, day of admission was associated with length of stay, with each later day in the week associated with a 0.155 days increased length of hospital stay (95% confidence interval: 0.101-0.208, p<0.001). Day of admission was not associated with cost of hospital episode (p=0.591) or discharge destination (p=0.813).CONCLUSIONSElective PCDF for CSM involves significant hospital resource utilization with almost 4 day mean length of stay and 40% of patients discharged to non-home destinations. Cost of care reached almost $30,000 for the acute hospital episode. Surgery performed later in the week was independently associated with increased length of stay. Interestingly, cost of care and discharge destination were not associated with day of surgery. These findings may aid surgeons and hospitals organize weekly surgery schedules to optimize hospital resources.FDA DEVICE/DRUG STATUSThis abstract does not discuss or include any applicable devices or drugs.

What Is the Impact of Smoking on Patient-Reported Outcomes Following Posterior Cervical Decompression and Fusion?

The purpose of this retrospective cohort study was to investigate the impact of smoking on patient-reported outcome measures (PROMs) following elective posterior cervical decompression and fusion (PCF). Electronic medical records at a single institution were reviewed for patients undergoing elective PCF. Patients were grouped based on smoking history: current smokers, former smokers, and never smokers. A delta score (Δ) was calculated for all PROMs (postoperative minus preoperative scores). Continuous and categorical data were compared using analysis of variance or χ2 tests. Regression analysis controlled for demographics. Patients were then regrouped into current smokers and nonsmokers for reanalysis. A total of 195 patients were included, of whom 35 (22.1%) were current smokers, 51 (26.2%) were former smokers, and 101 (51.8%) were never smokers. Preoperative and postoperative Short-Form 12 Mental Component Score (MCS-12) were significantly lower in the current smoker group (preoperative: current 42.7, former 49.9, and never 46.6; P= 0.024; postoperative: current 44.6, former 53.7, and never 52.2; P= 0.003). Only never smokers improved in MCS-12 and Neck Disability Index following surgery. On regrouping, current smokers had significantly lower preoperative MCS-12 (42.7 vs. 47.7, P= 0.031), lower preoperative modified Japanese Orthopaedic Association (12.2 vs. 14.0, P= 0.039), greater preoperative visual analog scale Arm (6.39 vs. 4.94, P= 0.025), and lower postoperative MCS-12 (44.6 vs. 52.7, P= 0.001). Only the nonsmokers improved in MCS-12 and Neck Disability Index following surgery. On regression analysis, smoking was not an independent predictor of ΔPROMs. Univariate analysis found that smokers have worse symptoms at baseline. However, smoking status was not an independent predictor of improvement in ΔPROMs following elective PCF.

Is it Better to Stop at C2 or C3/4 in Elective Posterior Cervical Decompression and Fusion?

Retrospective cohort study. (a) Compare operative variables, complications, and patient-reported outcomes (PROs) in patients with an upper instrumented vertebrae (UIV) of C2 versus C3/4, and (b) assess outcomes based on C2 screw type. When performing elective posterior cervical laminectomy and fusion (PCLF), spine surgeons must choose the upper instrumented vertebrae (UIV) at the subaxial cervical spine (C3/4) versus C2. Differences in long-term complications and PROs remain unknown. A single-institution, retrospective cohort study from a prospective registry was conducted. All patients undergoing elective, degenerative PCLF from December 2010 to June 2018 were included. Patients were divided into a UIV of C2 versus C3/4. Groups were 2:1 propensity matched for fusion extending to the thoracic spine. Demographics, operative, perioperative, complications, and 1-year PRO data were collected. One hundred seventeen patients underwent elective PCLF and were successfully propensity matched (39 C2 vs. 78 C3/4). Groups were similar in fusion extending to the thoracic spine (P = 0.588). Expectedly, the C2 group had more levels fused (5.63 ± 1.89) compared with the C3/4 group (4.50 ± 0.91) (P = 0.001). The C2 group had significantly longer operative time (P < 0.001), yet no differences were seen in estimated blood loss (EBL) (P = 0.494) or length of stay (LOS) (P = 0.424). Both groups significantly improved all PROs at 1-year (EQ-5D; NRS-NP/AP; NDI). Both groups had the same percentage of surgical adverse events at 6.8% (P = 1.00). Between C2 screw type, no differences were seen in operative time, EBL, LOS, complications, or PROs. In patients undergoing elective PCLF, those instrumented to C2 had only longer operative times compared with those stopping at C3/4. No differences were seen in EBL, LOS, 1-year PROs, and complications. Type of C2 screw had no impact on outcomes. Besides increased operative time, instrumenting to C2 had no detectable difference on surgical outcomes or adverse event rates.Level of Evidence: 3.

Perioperative Risk of the Sitting Position for Elective Posterior Cervical Spine Surgery: A Retrospective Case Series

ABSTRACT BACKGROUND The sitting cervical position for elective posterior cervical decompression and fusion affords advantages over prone positioning, but remains unpopular due to concerns about venous air embolism (VAE). OBJECTIVE To demonstrate the safety and efficacy of sitting cervical surgery in our series and in the literature. METHODS To evaluate the incidence of complications, we retrospectively identified all adult patients who underwent elective sitting posterior cervical surgeries at our institution from 2009 to 2014. Using International Classification of Diseases-9 coding, we searched for incidences of air embolism, myocardial infarction, pulmonary embolism, and deep vein thrombosis. Operative time, estimated blood loss, and case type distribution were also recorded. We then calculated the incidence of clinically significant VAE in sitting cervical surgeries. RESULTS Between 2009 and 2014, 558 surgeries were performed in the sitting cervical position. No VAE was identified. The average operative time was 1 h 25 min. A total of 30-d perioperative complications among sitting position patients included 3 myocardial infarctions, 1 pulmonary embolism attributed to venous thrombosis, and 2 patients with deep venous thrombosis for a total cardiovascular complication rate of 1.1%. The incidence of clinically significant VAE in the literature is 1.5%. CONCLUSION We present the second largest case series to date on the sitting position for cervical surgeries, highlighting its safety and efficacy. This position provides a surgical field with superior visualization, allowing decreased operative time and blood loss. The risk of clinically significant VAE is low. Intraoperative monitoring for these events with less invasive means is safe and effective.

Does Obesity Correlate with Postoperative Complications After Elective Posterior Cervical Spine Fusion?

With the increasing prevalence of obesity, there is a need to understand the impact of body mass index (BMI) on spine surgery outcomes. Previous literature has reported the influence of obesity in thoracolumbar surgery; however, the impact of obesity on postoperative complications after posterior cervical fusion (PCF) is unknown. Consecutive patients who underwent cervical laminectomy and multi-level instrumented fusion for degenerative spinal conditions at an academic tertiary care hospital between 2012 and 2019 were evaluated. Patients were categorized into groups with a BMI ≥30.0 kg/m2. The modified Japanese Orthopedic Association (mJOA) score, Nurick grading, complications, and postoperative radiographic factors were analyzed. Correlations between postoperative outcomes and obesity were calculated at baseline and 1 year. A total of 275 patients were included, with 80 obese (29.1%) and 195 nonobese (70.9%) patients. At baseline, obesity was associated with worse myelopathy (mJOA score: 10.2 vs. 13.1, P = 0.04 and Nurick grading: 3.2 vs. 1.1, P = 0.05) and abnormal cervical radiographic alignment (C2-7 sagittal vertical axis: 43.9 vs. 38.1 mm, P = 0.04). The intraoperative estimated blood loss was higher among obese patients (561.1 vs. 391.2 mL, P < 0.001). There was no significant difference in absolute scores for neurologic outcomes and radiographic alignment at 12 months after surgery. However, obese patients had significantly more complications than nonobese patients in terms of mechanical failure (6.3% vs. 0.5%, P = 0.05) and wound infection (8.7% vs. 0.0%, P = 0.04). Our results corroborate that PCF surgery provides significant improvement in neurologic and radiographic outcomes at 12 months after surgery for degenerative cervical spinal disorders. Obesity is a factor to consider in the pre-operative risk assessment.

Elixhauser Comorbidity Measure is Superior to Charlson Comorbidity Index In-Predicting Hospital Complications Following Elective Posterior Cervical Decompression and Fusion

The predictive ability of Elixhauser Comorbidity Index (ECI) and Charlson Comorbidity Index (CCI) have been compared in orthopedic and gastrointestinal surgery; however, their predictive ability for complications secondary to spine surgery and posterior cervical decompression and fusion (PCDF) specifically is understudied. This study examines the predictive ability of the ECI and CCI for complications and morbidity following PCDF. ECI and CCI were retrospectively computed for all PCDF cases in the National Inpatient Sample database from 2013 to 2014 and complications or morbidity were identified. C-statistics were used to analyze ECI and CCI predictive ability in a range of complications and compared with a base comorbidity model that included age, sex, race, and primary payer. PCDF was performed in 46,700 hospitalizations between 2013 and 2014. The complications for which ECI was found to be a significantly better predictor included airway complications (69.16% superior to CCI), hemorrhagic anemia (79.04% superior), cardiac arrest (72.39% superior), pulmonary embolism (83.01% superior), sepsis (62.44% superior), septic shock (78.90% superior), urinary tract infection (63.53% superior), death (74.28% superior), any minor complication (75% superior), any major complication (133% superior), and any complication at all (63.72% superior). The complications for which neither the ECI Index nor the CCI proved superior were acute kidney injury, myocardial infarction, cerebrovascular accident, deep vein thrombosis, pneumonia, wound dehiscence, and superficial surgical-site infection following PCDF. ECI showed superior predictive ability to the CCI in predicting 8 of the 18 complications that were analyzed and inferior in none.

40. Posterior cervical fusion for fracture vs degenerative cervical spine disease: implications for a bundled payment model

BACKGROUND CONTEXT Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement (BCPI) revolve around the use of Diagnosis-Related-Groups (DRGs) to categorize patients for reimbursement purposes. Though a posterior cervical fusion (PCF) performed for a fracture may have a different postoperative course of care as compared to a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate patients based on the indication/cause of surgery. PURPOSE Understand differences in 30-day outcomes between patients undergoing PCF for fracture vs degenerative cervical spine disease. STUDY DESIGN/SETTING Retrospective review of prospectively collected registry. PATIENT SAMPLE The 2012-2017 American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) was queried using Current Procedural Terminology code 22600 to identify patients receiving elective posterior cervical fusions. Patients undergoing anterior fusions, combined anterior-posterior surgery, surgery for deformity and tumors were excluded to capture an isolated cohort of patients receiving fusion for fractures or degenerative cervical pathology. OUTCOME MEASURES Rates of 30-day adverse events, readmissions, length of stay and non-home discharge. METHODS Multivariate analyses were used to compare rates of 30-day severe adverse events (SAE), minor adverse events (MAE), readmissions, length of stay and non-home discharges between the two groups while controlling for differences in baseline clinical characteristics. RESULTS A total of 2,786 PCFs were included, out of which 2,546 (91.4%) were performed for degenerative cervical spine pathology and 240 (8.6%) for fracture. Following adjustment for differences in baseline clinical characteristics, patients undergoing a PCF for a fracture vs degenerative pathology had higher odds of severe adverse events (18.8% vs 10.6%, OR 1.65 [95% CI 1.10-2.46]; p=0.015), prolonged length of stay >3 days (54.2% vs 40.5%, OR 1.93 [95% CI 1.44-2.59]; p CONCLUSIONS Patients undergoing PCFs for fracture have significantly higher rates of postoperative adverse events and greater resource utilization as compared to individuals undergoing elective PCF for degenerative spine pathology. The study calls into question the need of risk-adjustment of bundled-prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Crossing the Cervicothoracic Junction in Posterior Cervical Decompression and Fusion: A Cohort Analysis

The cervicothoracic junction (CTJ) has often been identified as an area of biomechanical vulnerability; however, few studies have examined the relative merits of extending fusions across this area. In this study, we sought to investigate the tradeoffs involved in fusing across the CTJ in cases of elective posterior cervical laminectomy and fusion. We conducted a single-institution retrospective cohort study of patients undergoing elective, multilevel, posterior cervical decompression and fusion for degenerative cervical stenosis. Data were collected on baseline clinical and radiographic variables as well any subsequent complications or reoperations. Outcomes measures were compared between those who received fusion stopping at C7 with those who received fusion crossing the CTJ, with multivariate logistic regression used to adjust for any known confounders. Patients whose fusion crossed the CTJ were found to have more levels fused (mean: 5.8 vs. 3.5 levels, P < 0.0001), longer surgical times (mean: 216 vs. 149 minutes, P < 0.0001), and higher estimated blood losses (mean: 475 vs. 116 mL, P < 0.0001) despite no significant differences in number of levels decompressed (mean: 4.2 vs. 4.3 levels, P= 0.63). The groups did not differ in overall reoperation rate (10.8% vs. 9.4%, P= 1.00), but crossing the CTJ was associated with a higher rate of wound dehiscence (7.8% vs. 0%, P= 0.03). This difference persisted in multivariate analysis (P < 0.001). Crossing the CTJ was associated with increased surgical time, estimated blood loss, and the rates of wound dehiscence. These tradeoffs should be considered in planning posterior cervical decompression and fusion procedures.

Predictive Risk Factors of Nonhome Discharge Following Elective Posterior Cervical Fusion

To identify risk factors that are predictive of nonhome discharge after elective posterior cervical fusion. We performed a retrospective cohort study of adult patients who underwent elective posterior cervical fusion using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014. Patients were divided into 2 groups: home discharge and nonhome discharge. Univariate analysis was performed to compare incidence of 30-day postoperative complications between groups. Multivariate analysis was performed to identify complications that were predictive of nonhome discharge. The cohort included 2875 patients; 24.1% were discharged to a nonhome facility, including skilled and nonskilled care facilities, nursing homes, assisted living facilities, and rehabilitation facilities. Nonhome discharge was associated with higher rates of 30-day pulmonary complication, cardiac complication, venous thromboembolism, urinary tract infection, blood transfusion, sepsis, and reoperation. Significant predictors of nonhome discharge were wound complication (odds ratio [OR]= 1.73; 95% confidence interval [CI], 1.07-2.80; P= 0.024), pulmonary complication (OR= 3.61; 95% CI, 1.96-6.63; P<0.001), cardiac complication (OR= 6.13; 95% CI, 1.61-23.4; P= 0.008), venous thromboembolism (OR= 2.97; 95% CI, 1.43-6.19; P=0.004), urinary tract infection (OR= 2.69; 95% CI, 1.50-4.82; P < 0.001), blood transfusion (OR= 1.70; 95% CI, 1.20-2.39; P= 0.003), sepsis (OR= 2.75; 95% CI, 1.25-6.02; P= 0.012), and prolonged length of stay (OR= 4.07; 95% CI, 3.34-4.95; P < 0.001). Early identification of patients who are at high risk for nonhome discharge is important to implement early comprehensive discharge planning protocols and minimize hospital-acquired conditions related to prolonged length of stay and associated health care costs.

The Impact of Resident Involvement in Elective Posterior Cervical Fusion.

Retrospective study of prospectively collected data OBJECTIVE.: The aim of this study was to assess the impact of resident surgeon involvement on patient outcomes following posterior cervical fusion (PCF) surgery. Recently, there has been a significant uptrend in the number of PCF performed in the United States. Prior studies have investigated patient outcomes after cervical arthrodesis. Despite the heightened concern for patient safety and quality improvement, the data on the safety of resident participation in PCF is sparse. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology codes were used to query the database for adults (≥18 years) who underwent PCF. Multivariate logistic regression models were employed on data adjusted by propensity scores to determine whether resident involvement was an independent predictor for the outcomes of interest. A total of 448 cases were assessed in NSQIP. Less than half of these cases involved residents (224, 43.1%). Resident involvement was found to be a significant predictor for blood transfusions [odds ratio (OR) = 1.7, confidence interval (CI) = 1.1-2.6, P = 0.010], length of stay of more than 5 days (OR = 1.6, CI = 1.0-2.6, P = 0.040), and operative time more than 4 hours (OR = 3.6, CI = 1.7-7.4, P = 0.0007). Other independent risk factors for prolonged length of stay included age 81 years or older versus 50 years or younger (OR = 4.7, CI = 1.7-12.6, P = 0.016) and diabetes (OR = 2.3, CI = 1.3-4.1, P = 0.006). In addition, multifusion was identified as a significant risk factor for extended operative time (OR = 1.8, CI = 1.1-2.9, P = 0.023). The present study used a large, nationwide sample to assess the impact of resident involvement in PCF. Resident participation was not associated with mortality, but had a minimal association with morbidity. 3.

Patient Factors Contributing to Prolonged Postoperative Length of Stay and Increased Rate of Readmission After Elective Posterior Cervical Fusion.

This is retrospective study of prospectively collected data. To identify patient factors that are independently associated with prolonged length of stay (LOS) and readmission after posterior cervical fusion (PCF) utilizing a large national database. A number of studies have investigated the morbidity and mortality after PCF; however, little is known about the factors that are associated with prolonged LOS and readmission, both of which incur increased costs for patients and hospitals. The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2014. Current Procedural Terminology code 22600 was used to identify patients who underwent PCF. All patient factors were assessed for association with LOS and readmission rate using bivariate and multivariate logistic regressions. A total of 2667 patients who underwent PCF met the inclusion criteria for LOS analysis. Average (±SD) LOS was 3.92 (±3.24) days, and median LOS was 3 days (interquartile range, 2-5 d). On multivariate analysis, increased LOS was found to be significantly associated with dependent functional status (P<0.001), diabetes mellitus (P=0.021), preoperative anemia (P=0.001), American Society of Anesthesiologists class 3 or 4 (P<0.001), and number of fused levels (P<0.001). A total of 2591 patients met criteria (LOS≤11 d) for analysis of readmission. Readmission rate among these patients was 7.1%. Average (±SD) LOS of the patients not readmitted within 30 days of operation was 3.89 (±3.25), whereas the average (±SD) LOS of the patients readmitted was 4.24 (±3.08). On multivariate analysis, readmission was found to be significantly associated with only dependent functional status (P=0.019) and increased number of fused levels (P=0.032). The current study provides valuable information on patient factors that are associated with prolonged LOS and readmission, which would be useful in enhanced informed consent before surgery, surgical planning, discharge planning, and optimizing postoperative care. Level III.

Impact of Preoperative Anemia on Outcomes in Adults Undergoing Elective Posterior Cervical Fusion.

Study Design:Retrospective analysis of prospectively collected data.Objectives:Few studies have investigated the role of preoperative anemia on postoperative outcomes of posterior cervical fusion. This study looked to investigate the potential relationship between preoperative anemia and postoperative outcomes following posterior cervical spine fusion.Methods:Data from patients undergoing elective posterior cervical fusions between 2005 and 2012 was collected from the American College of Surgeons National Surgical Quality Improvement Program database using inclusion/exclusion criteria. Multivariate analyses were used to identify the predictive power of anemia for postoperative outcomes.Results:A total of 473 adult patients undergoing elective posterior cervical fusions were identified with 106 (22.4%) diagnosed with anemia preoperatively. Anemic patients had higher rates of diabetes (P = .0001), American Society of Anesthesiologists scores ≥3 (P < .0001), and higher dependent functional status prior to surgery (P < .0001). Intraoperatively, anemic patients also had higher rates of neuromuscular injuries (P = .0303), stroke (P = .013), bleeding disorders (P = .0056), lower albumin (P < .0001), lower hematocrit (P < .0001), and higher international normalized ratio (P = .002). Postoperatively, anemic patients had higher rates of complications (P < .0001), death (P = .008), blood transfusion (P = .001), reoperation (P = .012), unplanned readmission (P = .022), and extended length of stay (>5 days; P < .0001).Conclusions:Preoperative anemia is linked to a number of postoperative complications, which can increase length of hospital stay and increase the likelihood of reoperation. Identifying preoperative anemia may play a role in optimizing and minimizing the complication rates and severity of comorbidities following posterior cervical fusion.

Impact of Obesity on Outcomes in Adults Undergoing Elective Posterior Cervical Fusion.

Retrospective study of prospectively collected data. To determine the effect of obesity (body mass Index > 30) on postoperative morbidity and mortality after elective posterior cervical fusion in adults. In those with spine disease, obesity has been shown to portend poorer general and disease-specific functional health status. The effect of obesity on outcomes after spine surgery, especially posterior cervical fusion, however, remains unclear. Previous studies have been contradictory to one another and largely limited by small sample sizes. The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent posterior cervical fusion between 2005 and 2012. Patients were separated into cohorts based on obesity status. Univariate analysis and multivariate logistic regression were used to analyze the effect of obesity on postoperative morbidity and mortality. There was a significantly higher rate of only venous thromboembolism (VTE) in the obese group compared with nonobese cohort (3.5% vs. 0.6%, P = 0.015). On multivariate analysis, obesity was found to be an independent predictor (odds ratio 6.15; 95% confidence interval [CI], 1.26-30.20; P = 0.02) for VTE. The present study demonstrated that patients with obesity can safely undergo posterior cervical fusion surgery. Although obesity predisposed to an elevated risk of VTE, postoperative mortality and morbidity were otherwise not significantly increased in this population. 3.

Nutritional Status as an Adjunct Risk Factor for Increased Complications and Prolonged Length of Hospital Stay in Adults Undergoing Elective Posterior Cervical Fusion Surgery

Previous studies have described preoperative nutritional status to be an important predictor of postoperative recovery as well as outcomes. Serum albumin concentration is an established clinical marker of overall nutritional status and systemic disease; however, its correlation to outcomes following posterior cervical fusion (PCF) has not been previously studied.

The Impact of Resident Involvement in Outcomes for Adults Undergoing Elective Posterior Cervical Fusion

Patients admitted to teaching hospitals are exposed to resident surgeons with varying degree of surgical and clinical experience. Previous studies have evaluated the “July effect,” the start of the new academic year at teaching hospitals and its impact on perioperative outcomes. Perception biases exist regarding the perioperative outcomes of posterior cervical fusion (PCF) based on resident surgeon involvement.

Impact of Preoperative Anemia on Perioperative Outcomes in Adults Undergoing Elective Posterior Cervical Fusion

Anemia has been shown to be an independent risk factor of postoperative mortality and morbidity in several surgical procedures. Preoperative anemia is of particular concern in posterior cervical fusion (PCF) due to the frequent diagnosis of spinal stenosis associated with this procedure and the substantial metabolic demand of the spinal cord. No previous studies have evaluated the effect of preoperative anemia on outcomes in PCF.

Influencing Factors on Length of Stay in Adults Undergoing Elective Posterior Cervical Fusion: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database

Many studies have investigated complications after posterior cervical spine surgery but little is known about the factors predicting postoperative length of hospital stay. Awareness of these variables can identify patients at risk for increased length of stay preoperatively and help adjust expectations and appropriately plan for the hospital admission postoperatively.