Elective Spinal Fusion Research Articles

Economic and clinical outcomes of spinal fusion surgeries with skin closure through skin staples plus waterproof wound dressings versus 2-octyl cyanoacrylate plus polymer mesh tape

Background ContextSpinal fusion surgeries are one of the most common types of operations performed during inpatient stays in the United States. Successful wound closure, including watertight closure at the skin layer, plays in important role in patient outcomes. PurposeTo compare the economic and clinical outcomes of spinal fusion surgeries using one of two sutureless skin closure techniques: skin staples plus waterproof wound dressings (SSWWD) or 2-octyl cyanoacrylate plus polymer mesh tape (2OPMT). Study Design/SettingRetrospective study using a multi-hospital database. Patient SamplePatients undergoing inpatient spinal fusion surgery for a spine disorder between October 1, 2015 and March 31, 2019. Outcome MeasuresTotal costs from the hospital perspective, operating room time (ORT), hospital length of stay (LOS), non-home discharge, infection/wound complications during the 90-day global period (index surgery through 90 days post-discharge), and 30/60/90-day all-cause readmissions. MethodsOutcomes were compared between study groups using nearest neighbor propensity score matching with exact matching on 45 primary procedure/diagnosis code groupings and generalized estimating equations to account for hospital-level clustering. This study was sponsored by Ethicon, Inc., a Johnson & Johnson company; the authors are employees or consultants of Johnson & Johnson. ResultsA total of 11,991 patients met the study criteria (2OPMT=5,961; SSWWD=6,030), of which 3,602 were included in each post-match study comparison group (total=7,204). As compared with the SSWWD group, the 2OPMT group had statistically significant lower median ORT (240 vs. 270 minutes; p=0.002), mean LOS (3.35 [SD=2.6] vs. 3.86 [SD=2.8] days, p=0.031), risks of non-home discharge status (17.63% vs. 23.10%, p=0.035), overall infections/wound complications (1.37% vs. 2.48%, p=0.015), and surgical site infection (1.11% vs. 2.07%, p=0.023). Differences between the study groups in total hospital costs, all-cause readmissions, and other sub-components of the infection/wound complication composite outcome were statistically insignificant (p>0.05). ConclusionsIn this retrospective observational study of patients undergoing elective inpatient spinal fusion surgery, the use of 2OPMT for skin closure was associated with significantly lower ORT, LOS, non-home discharge, and 90-day rates of infections/wound complications as compared with SSWWD.

5. Are octogenarians at higher risk for complications after elective lumbar spinal fusion surgery compared with younger patients? A study from the Kaiser Permanente National Spine Registry

BACKGROUND CONTEXT Octogenarians, defined as patients aged ≥80 years, are undergoing elective lumbar spinal fusion surgery in increasing numbers. While it is commonly accepted that patients between 50-79 years of age with degenerative or deformity-related spinal disease can safely undergo spinal fusion, most clinicians approach octogenarians more cautiously given concerns for higher adverse outcome risks. PURPOSE To evaluate whether there is a difference in risk of adverse postoperative outcomes following elective lumbar spinal fusion for octogenarians compared to patients aged 50-79. STUDY DESIGN/SETTING Retrospective cohort study using integrated health care data from the Kaiser Permanente Spine Registry. PATIENT SAMPLE The cohort comprised 8,340 patients aged ≥50 who underwent primary elective lumbar spinal fusion (L1-S1) for degenerative or deformity-related spinal disorders (2009-2018). OUTCOME MEASURES Incidence of intraoperative durotomy; 90-day postoperative emergency department (ED) visit and readmission, infection, deep vein thrombosis (DVT), pulmonary embolism (PE); and 90-day and 2-year reoperation and mortality. METHODS Octogenarians were compared to patients aged 50-79 (reference group) using time-dependent multivariable Cox-Proportional Hazards regression with a competing risk of death and adjustment for confounders. Multivariable logistic regression was used to assess differences in operative durotomy. RESULTS A total of 576 patients aged ≥80 and 7,763 patients aged 50-79 were included. After adjustment for confounders, octogenarians had a higher likelihood of durotomy (odds ratio=1.6, 95% confidence interval [CI]=1.2-2.2), as well as higher risks of 90-day readmission (hazard ratio [HR]=1.4, 95% CI=1.1-1.8) and PE (HR=2.2, 95% CI=1.1-5.0), compared to their younger counterparts. No differences were observed for 90-day incidence of infection or DVT. As well, no differences were observed in reoperation risks at 90 days (HR=1.2, 95% CI=0.8-2-0) or 2 years (HR=0.8, 95% CI=0.6-1.1). Mortality risk was higher for octogenarians compared to their younger counterparts but did not vary at 90-day or 2-year timepoints (90-day: HR=2.6, 95% CI=1.3-5.1; 2-year: HR=2.6, 95% CI=1.8-3.9). In stratified analysis, octogenarians with ≥3 comorbidities had a higher risk of 90-day readmission (HR=1.8, 95% CI=1.0-3.3) and 2-year mortality (HR=4.7, 95% CI=1.6-13.3) than those with 0-2. CONCLUSIONS In a cohort of >8,000 elective lumbar fusion patients, no difference was observed in the risk of reoperation, infection or DVT when comparing octogenarians to their younger counterparts. However, the higher risk of intraoperative durotomy, 90-day PE, and 90-day readmission suggests closer intra- and postoperative surveillance may be warranted for these older patients. We did observe a higher mortality risk for octogenarians when compared to patients aged 50-79; this risk did not change between 90 days and 2 years, suggesting the elevated risk is unrelated to undergoing a lumbar fusion and more likely the age groups compared in this study. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

289. Risk of spinal surgery among individuals who have been revascularized for coronary artery disease

BACKGROUND CONTEXT For patients with coronary artery disease, the two most common options for intervention are a cardiac stent or a coronary artery bypass graft. Although less invasive, stents may pose a long-term risk for patients undergoing further invasive procedures such as elective spine surgery. This study aimed to provide surgeons with insight on possible major complications for elective spine surgery patients with a history of coronary artery disease. PURPOSE Investigate outcomes of elective spine fusion patients with prior history of cardiac intervention STUDY DESIGN/SETTING Retrospective review of the PearlDiver database between the years 2006-2013 PATIENT SAMPLE A total of 731,173 elective spine fusion patients OUTCOME MEASURES Comorbidity burden, 30-day and 90-day complications, readmission METHODS Elective spine fusion patients were isolated with ICD-9 and CPT procedures codes in the PearlDiver database. Patients were stratified by having previous history of a coronary stent (Stent), coronary artery bypass graft (CABG), and no previous heart procedure (No-HP). Means comparison tests (chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, and comorbidities. Logistic regression assessed the odds of 30-day and 90-day postoperative (postop) complications associated with each heart procedure (Odds Ratio [95% confidence interval]). Statistical significance was set p RESULTS A total of 731,173 elective spine fusion patients were included. Overall, 8,401 pts underwent a CABG, 24,037 patients Stent, and 698,735 had No-HP prior to spine fusion surgery. Compared to Stent and No-HP patients, CABG patients had higher rates of morbid obesity, chronic kidney disease and diabetes (p CONCLUSIONS With regards to spine surgery, coronary artery bypass graft remains the gold standard for risk reduction. Stenting does not appear to minimize risk as significantly as CABG. When assessing patients with a history of coronary artery disease for elective spine fusion surgery, surgeons should be cautious of the significant risk of major complications associated with stents compared to coronary artery bypass grafting. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

35. Failure to normalize risk profile of spine fusion patients with coronary artery disease

BACKGROUND CONTEXT Vascular stenting is a common intervention for patients afflicted with coronary artery disease. For elective spine fusion patients with a history of coronary artery disease, a stent provides a less invasive surgical intervention allowing patients to move forward with spinal surgery. However, the impact of an initially less invasive cardiac intervention on outcomes of future surgical spine procedures has been understudied. PURPOSE Investigate effect of coronary stents on postoperative outcomes in an elective spine fusion cohort. STUDY DESIGN/SETTING Retrospective review of the PearlDiver database between the years 2006-2013. PATIENT SAMPLE A total of 726,061 elective spine fusion patients. OUTCOME MEASURES Comorbidity burden, 30-day and 90-day complications (myocardial infarction, pneumonia, sepsis, death, would complications, transfusions), length of stay. METHODS Elective spine fusion patients were isolated with ICD-9 and CPT procedures codes in the PearlDiver database. Patients were stratified by number of coronary stents: (1) 1-2 stents (ST12); (2) 3-4 stents (ST34); (3) no stents. Means comparison tests compared differences in demographics, diagnoses, comorbidities, 30-day and 90-day complication outcomes. Logistic regression assessed the odds of complication associated with coronary stents, controlling for levels fused, age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was set p RESULTS A total of 726,061 elective spine fusion patients were isolated; 707,396 patients had no stent, 17,087 ST12 and 1,578 ST34. At BL, ST12 patients had higher rates of morbid obesity, chronic kidney disease, CHF, COPD, and diabetes mellitus compared to no stent and ST34 (all p CONCLUSIONS Cardiac stents failed to normalize risk profile of patients with coronary artery disease. Postoperatively at 90 days, elective spine fusion patients with 3 or more stents were significantly at risk of mortality compared to patients with fewer or no stents. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

6. PLF or ALIF+PS: which has a lower operative nonunion rate? Analysis of a cohort of 2,061 patients from a national spine registry

BACKGROUND CONTEXT Although fusion rates between posterolateral fusions with pedicle screws (PLFs) and anterior lumbar interbody fusions with pedicle screws (ALIFs+PS) have been well studied, there has been no consensus on the better technique with respect to clinical outcome and nonunion rates. Most studies determine nonunion rates based on radiographic studies; however, many of these nonunions are asymptomatic. A more clinically useful measure is the operative nonunion rate. To date, data comparing operative nonunion rates in PLF and ALIF+PS are limited. PURPOSE To determine whether there is a difference between nonunion reoperation rates in PLFs vs anterior lumbar interbody fusions with pedicle screws (ALIFs+PS). STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE The cohort comprised 8,340 patients aged ≥50 who underwent primary elective lumbar spinal fusion (L1-S1) for degenerative or deformity related spinal disorders (2009-2018). OUTCOME MEASURES Operative nonunions. METHODS Adult patients (≥18 years old) with degenerative disc disease who underwent primary elective PLFs and ALIFs+PS for 1-level and 2-level fusions (L4-S1) between 2009-2018 were identified using data from the Kaiser Permanente Spine Registry and followed until validated operative nonunion, membership termination, death, or 03/31/2019. Descriptive statistics and two-year incidence rates for validated operative nonunions were calculated by fusion level, fusion type, and levels fused. Time-dependent multivariable Cox-Proportional Hazards regression was used to evaluate operative nonunion rates with adjustment for covariates or risk change estimates more than 10%. RESULTS We identified 2,061 patients (PLF:1491, ALIF+PS:570) with average follow-up time of 4.8(±3.1) years, and average time to operative nonunion 1.3(±1.2) yrs. Comparatively, single and multilevel incidence rates for nonunion were higher in PLF vs ALIF+PS: 1-Level: 0.9% (95% CI=0.4-1.6) vs 0.6% (95% CI=0.1-2.1); 2-Level: 2.0% (95% CI=0.8-4.0) vs 0.9% (95% CI=0.1-3.3). There were no observed differences in risk of operative nonunions in multivariable models comparing ALIF+PS vs PLF (HR=0.3, 95% CI=0.1-1.1), 1-level vs 2-level fusions (HR=1.8, 95% CI=0.8-4.3), or by fusion level (L4-L5: HR=1.0, 95% CI=0.4-2.7; L5-S1: HR=2.0, 95% CI=0.7-5.4). CONCLUSIONS A large cohort of patients with >4 years follow-up found no difference in operative nonunions between PLF and ALIF+PS. Further research is warranted. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

141. The influence of glycemic control as measured by hemoglobin A1c levels on complications following elective lumbar spinal fusion

141. The influence of glycemic control as measured by hemoglobin A1c levels on complications following elective lumbar spinal fusion

P21. Inpatient outcomes after elective lumbar spinal fusion for patients with human immunodeficiency virus in the absence of acquired immunodeficiency syndrome

BACKGROUND CONTEXT To our knowledge, no prior study has evaluated outcomes after elective lumbar spinal surgery in human immunodeficiency virus (HIV) patients without acquired immunodeficiency syndrome (AIDS). PURPOSE This review investigated the impact of HIV-positive status (without AIDS) on outcomes after elective lumbar fusion for degenerative disc disease (DDD). STUDY DESIGN/SETTING Adult patients registered in the Nationwide Inpatient Sample (2002-2011) undergoing elective lumbar fusion for DDD were extracted. PATIENT SAMPLE The patient sample included 612,000 individual patient hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. OUTCOME MEASURES The following outcome measures were recorded: wound complications, infection rate, cardiac, respiratory, neurologic, gastrointestinal complications, thromboembolic events and death. METHODS This cohort included 612,000 hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. HIV-positive patients were compared with HIV-negative patients undergoing lumbar fusion surgery and complications/adverse outcomes were recorded. RESULTS This cohort included 612,000 hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. Compared with HIV-negative patients undergoing lumbar fusion, HIV-positive patients were younger (47 vs 55 years), male (61% vs 42%), largely insured by Medicare (30% vs 5%), and had higher rates of chronic obstructive pulmonary disease (23.7% vs 14.6%) (all P CONCLUSIONS Even in this selected cohort of well-controlled HIV patients, there were high complications, with concerning rates of death and respiratory complications. These data shed new light on elective spine surgery in HIV patients and may influence the treatment algorithm of surgeons who are familiar with older studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

22. Risk of surgical intervention is nearly normalized following coronary artery bypass grafting in spinal surgery with key exceptions

BACKGROUND CONTEXT The risk assessment of elective spine fusion patients with a previous history of cardiac intervention, particularly a coronary artery bypass graft (CABG), has been understudied. This study aimed to assess postoperative outcomes of elective spine fusion patients with a prior history of single- to multilevel coronary artery bypass grafting. PURPOSE Investigate effect of revascularization on 30-day and 90-day outcomes in elective spine fusion patients. STUDY DESIGN/SETTING Retrospective review of the PearlDiver database between the years 2006-2013. PATIENT SAMPLE A total of 733,007 elective spine fusion patients. OUTCOME MEASURES Comorbidity burden, 30-day and 90-day complications (myocardial infarction, pneumonia, sepsis, death, would complications, transfusions), readmission. METHODS Elective spine fusion patients were isolated with ICD-9 and CPT procedures codes in the PearlDiver database. Patients were stratified by number of coronary arteries grafted during a coronary artery bypass grafting procedure prior to spine fusion: (1) 1-2 grafts (G12); (2) 3-4 grafts (G34); (3) no grafts. Means comparison tests compared differences in demographics, diagnoses, comorbidities, and 30-day complication outcomes. Logistic regression assessed the odds of complication associated with number of arteries grafted, controlling for levels fused, age, sex, and comorbidities (odds ratio [95% confidence interval]). RESULTS A total of 733,007 elective spine fusion patients were isolated;723,606 pts had no grafts, 5,356 were G12, and 4,045 were G34. G12 patients at baseline had higher rates of morbid obesity, PVD, chronic kidney disease, CHF, and COPD (p 0.05). Overall, G34 patients had higher rates of 30-day and 90-day readmissions (p CONCLUSIONS Compared to patients who had no history of cardiac intervention, patients who had single or multivessel coronary artery bypass graft had an increase in 30-day complications. However, comparing between groups that had 1-2 or 3-4 level grafts, there were no significant differences in major and minor complications 30 days postoperatively. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

What Is the Impact of Prophylactic Nasal Decolonization in Prevention of SSI?

<h3>Background</h3> Surgical site infections (SSI) are common preventable healthcare associated infections (HAI) that create substantial burdens on care systems, payers, and patients. Developing, implementing, sustaining SSI prevention best practices is an organizational priority. Nationally, SSIs occur in 2%-4% of all patients undergoing inpatient surgery Fiscal years 2018-2019, SSIs increased 65%; Total Hip Arthroplasty (THA), Total Knee Arthroplasty (TKA), and Spinal Fusion(SF) surgeries accounted for over half (53%) of the infections <h3>Methods</h3> In 2019, the Model Operating room (OR) project began to pilot SSI reduction strategies in the total joint surgical population. Studies have shown that Staphylococcus aureus nasal decolonization protocols reduce SSIs in elective orthopedic surgeries. Using principles of total quality management (TQM) to implement a new broad spectrum antiseptic nasal swab product, an interdisciplinary team initiated nasal decolonization in elective total hip, total knee, and spinal fusion surgical patients. <h3>Results</h3> Since September 2019, there have been zero SSIs for the 47 THAs and 79 TKA surgeries performed, and only 1 SSI for the 320 SF surgeries completed. Their collective SSI rate (0.002) has decreased 60% from 3 months prior and is 3 times lower than the SSI rate of the 797 other surgeries (0.006) performed during the 3 month nasal decolonization period. NO adverse safety events pertaining to nasal decolonization have been reported. Due to the success of the nasal decolonization initiative, other surgeons outside of the pilot populations have requested the povidone iodine nasal swab administration for their patients preoperatively. <h3>Conclusions</h3> We found preoperative nasal povidone iodine decolonization to be a safe, efficient, and cost-effective strategy in reducing SSIs in elective orthopedic surgeries. Patients and organizations may benefit from incorporating this strategy into preoperative SSI prevention protocols.

Duration of Symptoms Does Not Affect Clinical Outcome After Lumbar Arthrodesis.

Retrospective cohort study at a single institution. To examine the effect of symptom duration on clinical outcomes after posterolateral lumbar fusion. Nonoperative measures are generally exhausted before patients are indicated for surgical intervention, leaving patients with their symptomatology for varying lengths of time. It is unclear at what point in time surgical intervention may become less efficacious at alleviating preoperative symptoms. Consecutive patients who underwent primary elective open posterior lumbar spinal fusion at a single academic institution were included. Patient and operative characteristics were compared between symptom duration groups (group 1: <12 mo of pain, group 2: ≥12 mo of pain). Preoperative and final postoperative visual analog scale back/leg pain, and Oswestry Disability Index, were collected. Preoperative, immediate postoperative, and final radiographs were assessed to measure lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), and the PI-LL difference was calculated. In total, 167 patients were included in group 1, whereas 359 patients were included in group 2. Baseline demographics and operative characteristics were similar between the 2 groups. Both groups had similar changes in sagittal parameters and had no significant difference in rates of complication, reoperation, discharge to rehabilitation facility, or early adjacent segment degeneration. Both groups demonstrated similar improvement in clinical outcome measures. Despite differences in symptom duration, patients who had pain for ≥12 months demonstrated similar improvement after posterolateral lumbar arthrodesis than those who had pain for <12 months. Extended effort of conservative treatments or delay of operative intervention does not appear to negatively impact the eventual outcome of surgery. Level III.

Does Local Administration of Liposomal Bupivacaine Reduce Pain and Narcotic Consumption in Adult Spinal Deformity Surgery?

Study Design:Retrospective cohort study.Objective:To determine if local administration of liposomal bupivacaine (LB) reduces postoperative pain scores and narcotic use in spinal deformity patients.Methods:Adult patients undergoing elective spinal fusion (7 or more levels) for scoliosis or kyphosis were selected for inclusion. Patients received either periincisional injections of combined liposomal and standard bupivacaine (n = 90, group L) or standard bupivacaine only (n = 69, group C). Perioperative pain scores (VAS [visual analogue scale]), opioid use, length of stay, functional outcome (ODI [Oswestry Disability Index]), and perioperative complications were recorded. No external funding was received for this study.Results:A total of 159 patients met inclusion criteria (mean age was 54.2 years of age). No significant baseline demographic differences were noted between the 2 groups. Group L experienced slight improvements in pain control on postoperative day (POD) 1 (P = .02). No difference in pain scores were otherwise noted. Group L transitioned off of intravenous (IV) narcotics faster with 52.6% less IV use by POD3 (P = .03). No differences in total narcotic consumption, perioperative complications, lengths of stay, and functional outcome scores were otherwise noted between the 2 cohorts.Conclusions:The use of LB in adult spinal deformity surgery does not appear to provide clinically important improvements in postoperative pain at the manufacturer’s recommended dosage. Furthermore, while patients receiving LB may transition more quickly off of IV narcotics, this does not appear to translate into an overall decrease in narcotic consumption, hasten return of bowel function, or decrease hospital lengths of stay. Future prospective randomized control trials are warranted. The use of varying dosages of LB may also help further clarify the true efficacy of LB in the setting of spinal deformity surgery.

Development and validation of a prediction tool for pain reduction in adult patients undergoing elective lumbar spinal fusion: a multicentre cohort study

PurposeOn average, 56% of patients report a clinically relevant reduction in pain after lumbar spinal fusion (LSF). Preoperatively identifying which patient will benefit from LSF is paramount to improve clinical decision making, expectation management and treatment selection. Therefore, this multicentre study aimed to develop and validate a clinical prediction tool for a clinically relevant reduction in pain 1 to 2 years after elective LSF.MethodsThe outcomes were defined as a clinically relevant reduction in predominant (worst reported pain in back or legs) pain 1 to 2 years after LSF. Patient-reported outcome measures and patient characteristics from 202 patients were used to develop a prediction model by logistic regression. Data from 251 patients were used to validate the model.ResultsNonsmokers (odds ratio = 0.41 [95% confidence interval = 0.19–0.87]), with lower Body Mass Index (0.93 [0.85–1.01]), shorter pain duration (0.49 [0.20–1.19]), lower American Society of Anaesthesiologists score (4.82 [1.35–17.25]), higher Visual Analogue Scale score for predominant pain (1.05 [1.02–1.08]), lower Oswestry Disability Index (0.96 [0.93–1.00]) and higher RAND-36 mental component score (1.03 [0.10–1.06]) preoperatively had a higher chance of a clinically relevant reduction in predominant pain. The area under the curve of the externally validated model yielded 0.68. A nomogram was developed to aid clinical decision making.ConclusionsUsing the developed nomogram surgeons can estimate the probability of achieving a clinically relevant pain reduction 1 to 2 years after LSF and consequently inform patients on expected outcomes when considering treatment.

PMD52 ECONOMIC AND CLINICAL OUTCOMES OF SPINAL FUSION SURGERIES WITH SKIN CLOSURE THROUGH SKIN STAPLES PLUS WATERPROOF WOUND DRESSINGS VERSUS 2-OCTYL CYANOACRYLATE PLUS POLYMER MESH TAPE

To compare economic and clinical outcomes of spinal fusion surgery with skin closure through skin staples plus waterproof wound dressings (SSWWD) versus 2-octyl cyanoacrylate plus polymer mesh tape (2OPMT). Retrospective observational study using data from the Premier Healthcare Database. Studied patients were aged ≥18 years who underwent elective inpatient spinal fusion surgery for a spine disorder (scoliosis, spondylolysis, , spinal stenosis, or intervertebral disc disease) between 1-October-2015—31-March-2019 (first=index surgery). Hospital administrative billing records were used to classify patients into two mutually-exclusive groups based on use of SSWWD or 2OPMT during the index surgery. Outcomes included total costs from the hospital perspective, operating room time (ORT), hospital length of stay (LOS), nonhome discharge, infection/wound complications during the 90-day global period (index surgery through 90 days post-discharge), and 30/60/90-day all-cause readmissions. We compared outcomes between study groups using a combination of nearest neighbor propensity score matching with exact matching on 45 primary procedure/diagnosis code groupings and generalized estimating equations to account for hospital-level clustering. A total of 11,991 patients met the study criteria (2OPMT=5,961; SSWWD=6,030), of which 3,602 were included in each post-match study comparison group (total=7,204); all variables were balanced (standardized mean difference<0.10) after matching. As compared with the SSWWD group, the 2OPMT group had a lower median ORT (240 vs. 270 minutes; p=0.0207) and mean LOS (3.4 [SD=2.6] vs. 3.9 [SD=2.8] days; p=0.0223); and lower incidence proportions of nonhome discharge status (17.6% vs. 23.1%; p=0.0290), overall infections/wound complications (1.69% vs. 2.83%; p=0.0266), and surgical site infection (1.11% vs. 2.20%; p=0.0128). Differences between groups in other outcomes were statistically insignificant (p>0.05). In this retrospective observational study of patients undergoing spinal fusion surgery, the use of 2OPMT for skin closure was associated with significantly lower ORT, LOS, nonhome discharge, and 90-day rates of infections/wound complications as compared with SSWWD.

Influence of gender on discharge disposition after spinal fusion for adult spine deformity correction

ObjectivesGender has been shown to impact several aspects of spine surgical care. However, the influence of gender disparities on discharge disposition after adult spine deformity correction (ASD) is relatively understudied. The aim of this study was to investigate the influence of gender on discharge disposition after elective spinal fusion involving ≥4 levels for ASD correction. Patients and methodsThe Nationwide Inpatient Sample database (2011–2014) was queried for patients with ASD (≥26 years-old) and elective spine fusion surgery involving ≥4 levels using ICD-9 codes. Patients were stratified by gender: Male or Female. Multivariate linear and logistic regressions were used to assess the impact of gender on length of hospital stay and discharge disposition. ResultsA total of 4972 patients were identified of which 3282 (66.0%) were Female and 1690 (34.0%) were Male. The Male cohort had a higher prevalence of comorbidities than the Female cohort. There was a difference in the number of levels operated on between cohorts, with the Female cohort having fewer 4−8-level fusions (77.6% vs. 86.8%) and more 9+-level fusions (23.0% vs. 13.6%) compared to Males. The Female cohort had greater rates of postoperative UTI (5.5% vs. 2.5%) and surgical site hematomas (2.6% vs. 1.3%), while the Male cohort had more postoperative MI (5.4% vs. 1.5%). The Female cohort spent slightly more time in the hospital than Male cohort (6.2 days vs. 5.9 days, P = 0.035). Female patients had a significantly greater proportion of non-routine discharge disposition (F: 48.5% vs. M: 40.3%, P < 0.001) compared to Male patients. However, in a multivariate analysis including patient and hospital factors, gender was not an independent predictor of discharge disposition (OR: 0.976, CI: 0.865–1.101, P = 0.688), but was independently associated with increased LOS [female (RR: 0.331, CI: 0.106−0.556, P = 0.004)]. Conclusion: Our study suggests gender disparities may not have a significant impact on discharge disposition after spinal fusion for ASD involving four levels or greater. Further studies are necessary to understand risk factors for non-routine discharges in ASD patients to improve quality of patient care and reduced healthcare costs.

Early and late hospital readmissions after spine deformity surgery in children with cerebral palsy

Retrospective review of a prospectively collected multicenter registry of pediatric patients with cerebral palsy (CP) and neuromuscular scoliosis (NMS) undergoing spinal fusion. To define risk factors for unplanned readmission after elective spinal deformity surgery. Patients with CP and NMS have high rates of hospital readmission; however, risk factors for readmission are not well established. Univariate and multivariate analyses were used to compare the demographics, operative and postoperative course, radiographic characteristics, and preoperative Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaires of patients who did not require readmission to those who required either early readmission (within 90days of the index surgery) or late readmission (readmission after 90days). Of the 218 patients identified, 19 (8.7%) required early readmission, while 16 (7.3%) required late readmission. Baseline characteristics were similar between the three cohorts. On univariate analysis, early readmission was associated with longer duration of surgery (p < 0.001) and larger magnitude of residual deformity (p = 0.003 and p = 0.029 for postoperative major and minor angles, respectively). The health score of the CPCHILD Questionnaire was lower in patients who required early readmission than in those who did not require readmission (p = 0.032). On multivariate analysis, oral feeding status was inversely related to early readmission (less likely to require readmission), while decreasing lumbar lordosis and increasing length of surgery were related to an increased likelihood of early readmission. In patients with CP and NMS, longer surgical time, larger residual major and minor Cobb angles, lumbar lordosis, feeding status, and overall health may be related to a greater likelihood for early hospital readmission after elective spinal fusion. No factors were identified that correlated with an increased need for late hospital readmission after elective spinal fusion in patients with CP. IV.

Evaluation of Risk Factors for Postoperative Urinary Retention in Elective Thoracolumbar Spinal Fusion Patients.

Study Design:Retrospective case series.Objectives:Postoperative urinary retention (POUR) represents a common postoperative complication of all elective surgeries. The aim of this study was to identify demographic, comorbid, and surgical factors risk factors for POUR in patients who underwent elective thoracolumbar spine fusion.Methods:Following institutional review board approval, patients who underwent elective primary or revision thoracic and lumbar instrumented spinal fusion in a 2-year period in tertiary and academic institution were reviewed. Sex, age, BMI, preoperative diagnosis, comorbid conditions, benign prostatic hyperplasia, diabetes, primary or revision surgery status, narcotic use, and operative factors were collected and analyzed between patients with and without POUR.Results:Of the 217 patients reviewed, 54 (24.9%) developed POUR. The average age for a patient with POUR was 67 ± 9, as opposed to 59 ± 10 for those without (P < .0001). Single-level fusions were associated with a 0% incidence of POUR, compared with 54.5% in 6 or more levels. The average hospital stay was increased by 1 day for those who had POUR (5.8 ± 3.3 vs 4.9 ± 3.9 days). There was no significant association with other demographic variables, comorbid conditions, or surgical factors.Conclusions:POUR was a common complication in our patient cohort, with an incidence of 24.9%. Our findings demonstrate that patients who developed POUR are significantly older and have larger constructs. Patients who developed POUR also had longer in-hospital stays. Although our study supports other findings in the spine literature, more prospective data is needed to define diagnostic criteria of POUR as well as its management.

Prior bariatric surgery is associated with lower complications, in-hospital mortality, and healthcare utilization after elective spine fusion surgery.

Grade 3 obesity could potentially increase postoperative complications after spinal fusion surgery. However, the relationship between prior bariatric surgery (BS) and postoperative complications after spinal fusion surgery is not well-established. Inpatient hospital admissions from the Nationwide Inpatient Sample. Patients with a primary procedure of spinal fusion surgery discharged between 2006 and 2014 were identified. In-hospital outcomes included postoperative complications, mortality, cost, and length of stay were compared between patients with prior BS and grade 3 obesity. A total of 3,132,192 patients who underwent elective spinal fusion surgery were identified. There were 33,936 (1.1%) patients with a diagnosis of prior BS. The prevalence of prior BS increased significantly from .1% in 2006 to 1.5% in 2014. Compared with patients with grade 3 obesity, patients with prior BS were younger, more likely to be female, had less co-morbidities, and higher proportion of cervical surgery. Multivariable analysis indicated that patients with prior BS had lower risk of overall complications (odds ratio [OR]: .44; 95% confidence interval [CI]: .38-.49), neurologic (OR: .55; 95%CI: .35-.84), respiratory (OR: .30; 95%CI: .23-.37), cardiac (OR: .38; 95%CI: .24-.60), gastrointestinal (OR: .61; 95%CI: .44-.84), urinary and renal (OR: .34; 95%CI: .26-.44), venous thromboembolism (OR: .35; 95%CI: .19-.63), wound-related complications (OR: .67; 95%CI: .53-.85), and in-hospital mortality (OR: .12; 95%CI: .02-.88). Prior BS was also related to 13% shorter length of stay and 2% lower cost. Among patients undergoing spinal fusion surgery, prior BS is associated with lower complications, in-hospital mortality, and healthcare utilization. BS might mitigate risk of worse outcomesassociated with grade 3 obesity after spine fusion surgery.

Impact of Sickle Cell Anemia on Inpatient Morbidity After Spinal Fusion.

A retrospective study. To determine the impact of sickle cell anemia on perioperative outcomes and resource utilization in elective spinal fusion surgery. Sickle cell anemia has been identified as an important surgical risk factor in otolaryngology, cardiothoracic surgery, general surgery, and total joint arthroplasty. However, the impact of sickle cell anemia on elective spine surgery is unknown. Hospitalizations for elective spinal fusion surgery between the years of 2001-2014 from the US National Inpatient Sample were identified using ICD-9-CM codes and patients were grouped into those with and without sickle cell anemia. The main outcome measures were in-hospital neurological, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, and wound-related complications and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing elective spinal fusion with or without sickle cell anemia. From a total of 4,542,719 patients undergoing elective spinal fusions from 2001 to 2014, 456 sickle cell disease patients were identified. Sickle cell anemia is a significant independent predictor for pulmonary embolism [odds ratio (OR)=7.37; confidence interval (CI), 4.27-12.71; P<0.001], respiratory complications (OR=2.36; CI, 1.63-3.42; P<0.001), wound complications (OR=3.84; CI, 2.72-5.44; P<0.001), and overall inpatient complications (OR=2.58; CI, 2.05-3.25; P<0.001). Sickle cell anemia patients also have significantly longer length of stay (7.0 vs. 3.8 d; P<0.001) and higher inpatient costs ($20,794 vs. $17,608 P<0.05). Sickle cell anemia is associated with increased risk of perioperative complications and greater health care resource utilization. Sickle cell anemia patients undergoing spinal fusion surgeries should be counseled on these increased risks. Moreover, current strategies for perioperative management of sickle cell anemia patients undergoing spinal fusion surgery need to be improved.

External validation of a prediction model for pain and functional outcome after elective lumbar spinal fusion.

Patient-reported outcome measures following elective lumbar fusion surgery demonstrate major heterogeneity. Individualized prediction tools can provide valuable insights for shared decision-making. We externally validated the spine surgical care and outcomes assessment programme/comparative effectiveness translational network (SCOAP-CERTAIN) model for prediction of 12-month minimum clinically important difference in Oswestry Disability Index (ODI) and in numeric rating scales for back (NRS-BP) and leg pain (NRS-LP) after elective lumbar fusion. Data from a prospective registry were obtained. We calculated the area under the curve (AUC), calibration slope and intercept, and Hosmer-Lemeshow values to estimate discrimination and calibration of the models. We included 100 patients, with average age of 50.4 ± 11.4years. For 12-month ODI, AUC was 0.71 while the calibration intercept and slope were 1.08 and 0.95, respectively. For NRS-BP, AUC was 0.72, with a calibration intercept of 1.02, and slope of 0.74. For NRS-LP, AUC was 0.83, with a calibration intercept of 1.08, and slope of 0.95. Sensitivity ranged from 0.64 to 1.00, while specificity ranged from 0.38 to 0.65. A lack of fit was found for all three models based on Hosmer-Lemeshow testing. The SCOAP-CERTAIN tool can accurately predict which patients will achieve favourable outcomes. However, the predicted probabilities-which are the most valuable in clinical practice-reported by the tool do not correspond well to the true probability of a favourable outcome. We suggest that any prediction tool should first be externally validated before it is applied in routine clinical practice. These slides can be retrieved under Electronic Supplementary Material.

Impact of Cirrhosis on Morbidity and Mortality After Spinal Fusion.

Study Design:Retrospective large database study.Objective:To determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery.Methods:Elective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion.Results:A total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs $29 068; P < .001).Conclusions:Cirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement.