Elective Spine Surgery Patients Research Articles

Optimizing Preoperative Chronic Pain Management in Elective Spine Surgery Patients

» Chronic preoperative opioid use negatively affects outcomes after spine surgery, with increased complications and reoperations, longer hospital stays, decreased return-to-work rates, worse patient-reported outcomes, and a higher risk of continued opioid use postoperatively.» The definition of chronic opioid use is not consistent across studies, and a more specific and consistent definition will aid in stratifying patients and understanding their risk of inferior outcomes.» Preoperative weaning periods and maximum dose thresholds are being established, which may increase the likelihood of achieving a meaningful improvement after surgery, although higher level evidence studies are needed.» Spinal cord stimulators and intrathecal drug delivery devices are increasingly used to manage chronic back pain and are equivalent or perhaps even superior to opioid treatment, although few studies exist examining how patients with these devices do after subsequent spine surgery.» Further investigation is needed to determine whether a true mechanistic explanation exists for spine-related analgesia related to spinal cord stimulators and intrathecal drug delivery devices.

Trends in usage of navigation and robotic assistance in elective spine surgeries: a study of 105,212 cases from 2007 to 2015.

Identify trends of navigation and robotic-assisted elective spine surgeries. Elective spine surgery patients between 2007 and 2015 in the Nationwide Inpatient Sample (NIS) were isolated by ICD-9 codes for Navigation [Nav] or Robotic [Rob]-Assisted surgery. Basic demographics and surgical variables were identified via chi-squared and t tests. Each system was analyzed from 2007 to 2015 for trends in usage. Included 3,759,751 patients: 100,488 Nav; 4724 Rob. Nav were younger (56.7 vs 62.7years), had lower comorbidity index (1.8 vs 6.2, all p < 0.05), more decompressions (79.5 vs 42.6%) and more fusions (60.3 vs 52.6%) than Rob. From 2007 to 2015, incidence of complication increased for Nav (from 5.8 to 21.7%) and Rob (from 3.3 to 18.4%) as well as 2-3 level fusions (from 50.4 to 52.5%) and (from 1.3 to 3.2%); respectively. Invasiveness increased for both (Rob: from 1.7 to 2.2; Nav: from 3.7 to 4.6). Posterior approaches (from 27.4 to 41.3%), osteotomies (from 4 to 7%), and fusions (from 40.9 to 54.2%) increased in Rob. Anterior approach for Rob decreased from 14.9 to 14.4%. Nav increased posterior (from 51.5% to 63.9%) and anterior approaches (from 16.4 to 19.2%) with an increase in osteotomies (from 2.1 to 2.7%) and decreased decompressions (from 73.6 to 63.2%). From 2007 to 2015, robotic and navigation systems have been performed on increasingly invasive spine procedures. Robotic systems have shifted from anterior to posterior approaches, whereas navigation computer-assisted procedures have decreased in rates of usage for decompression procedures.

The Impact of Unexpected Billing in Spine Surgery and How the Price Calculator Can Improve Patient Care.

Survey study. The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery. The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery. Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected. Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs. Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden.

Trends and Prediction of Surgical Site Infection After Elective Spine Surgery: An Analysis of the American College of Surgeons National Surgical Quality Improvement Project Database.

Background: Surgical site infection (SSI) is an infrequent but costly complication after elective spine surgery. Identification of important temporal changes and predictive factors may inform targeted prevention efforts. Patients and Methods: A retrospective study of elective spine surgery patients was performed using the National Surgical Quality Improvement Programs (NSQIP) database from 2011 and 2019. Temporal changes in SSI and related factors were examined descriptively. Recursive partitioning and bootstrap forest techniques were used to inform the development of predictive models for SSI. Results: A total of 6,038 (1.66%) of 363,754 patients had an SSI recorded. Peri-operative transfusion and preoperative anemia decreased over the nine-year period, however, obesity and diabetes mellitus increased, whereas the SSI rate remained essentially unchanged. A full model including 15 variables had an area under the curve (AUC) of 0.693 (95% confidence interval [CI], 0.686-0.700) whereas a reduced model with just nine variables had an AUC of 0.690 (95% CI, 0.683-0.697). Adjusted odd ratios (aOR) greater than two were noted for only three variables; a posterior approach (aOR, 2.32; 95% CI, 2.14-2.50), body mass index (BMI) >40 kg/m2 (aOR, 2.63; 95% CI, 2.39-2.90), and surgical duration longer than 350 minutes (aOR, 2.39; 95% CI, 2.14-2.67). Remaining retained variables included albumin <3.5 g/dL, inpatient procedure, peri-operative transfusion, diabetes mellitus (both insulin/non-insulin), anemia, and smoking. Conclusions: Surgical site infection rate remained unchanged over a nine-year period despite the lower rates of allogeneic blood transfusion. Class 3 obesity, long operative times, and a posterior approach mainly for thoracic/lumbar spine procedures seemed more pragmatic, but their predictive performance was only modest in our prediction models for SSI.

Pain Self-Efficacy (PSEQ) score of

BACKGROUND CONTEXTPain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse. PURPOSEThe primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores. PATIENT SAMPLEFive hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study. STUDY DESIGN/SETTINGRetrospective review of prospectively collected data. OUTCOME MEASURESPROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience. METHODSElective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores. RESULTSOf 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all). CONCLUSIONSIn patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.

Opioid use after elective spine surgery: Do spine surgery patients consume less than prescribed today?

BackgroundThe opioid epidemic in the US has led prescribers to reevaluate postoperative pain control particularly in the field of spine surgery, where postoperative analgesia requirements and consumption have historically been high. There is a need to mitigate the quantity of unused pills after surgery by adjusting prescribing practices. Achieving the balance of pain control after surgery without overprescribing opioids may be accomplished by developing a modified approach to prescribing practices; however, there is a need to first understand the opioid requirements of the modern spine surgery patient with respect to their elective spine surgery. Therefore, the primary aim of this study was to determine the percentage of opioids not utilized at 90-days after elective spine surgery. Secondary aims were to identify differences in the percentage of unused opioids between surgical subgroups and preoperative opioid status, to determine factors associated with opioid utilization, and to estimate the distribution of opioids consumed to control pain up to the 90th percentile in each surgical subgroup. MethodsIn this prospective, observational cohort study, adults undergoing elective spine surgery at a multi-surgeon, single center were prospectively enrolled and divided into subgroups: anterior cervical, lumbar decompression, and short-segment lumbar fusion. Prescribed MMEs were identified from prescriptions, consumed MMEs were obtained from pill counts, and the percent leftover was calculated. Distributions of MMEs consumed were analyzed to compare utilization between preoperative opioid users or non-users within each surgical subgroup. ResultsOf 117 patients, 41.9% were preoperative opioid users. The percentage of unused opioids by surgical subgroup was: 45.4% cervical, 57.3% lumbar decompression, and 37.4% lumbar fusion (p=0.066). The percentage of unused opioids by preoperative opioid exposure was greater in the opioid non-users (58.0%) than users (28.4%, p<0.001)). Regression analysis showed that surgical subgroup and preoperative opioid exposure were associated with leftover opioids. ConclusionsAt 90-days, the percentage of unused opioids was over 45% in this cohort of elective spine surgery patients and was nearly double in the group without preoperative opioid exposure. These results suggest the modern elective spine surgery patient is using less opioids than prescribed, supporting the conclusion that the number of MMEs prescribed can be reduced to minimize quantities of leftover pills available for diversion, without sacrificing the priority of appropriate postoperative pain control.

Pain Plan Implementation Effect: Analysis of Postoperative Opioid Use, Hospital Length of Stay, and Clinic Resource Utilization for Patients Undergoing Elective Spine Surgery.

The Pain Plan was developed collaboratively and implemented a unique systematic approach to reduce opioid usage in elective spine surgery. This was a retrospective cohort study comparing patients who underwent elective spine surgery before and after Pain Plan implementation. The Pain Plan was implemented on May 1, 2019. The experimental group comprised patients over the subsequent 1-year period with a Pain Plan (n = 319), and the control group comprised patients from the previous year without a Pain Plan (n = 385). Outcome variables include hospital length of stay (LOS), inpatient opioid use, outpatient opioid prescription quantities, number of clinic communication encounters, and communication encounter complexity. Patients were prospectively divided into three surgical invasiveness index subgroups representing small-magnitude, medium-magnitude, and large-magnitude spine surgeries. There was a statistically significant decrease in hospital LOS ( P = 0.028), inpatient opioid use ( P = 0.001), and the average number of steps per communication encounter ( P = 0.010) for Pain Plan patients and a trend toward decreased outpatient opioid prescription quantities ( P = 0.052). No difference was observed in patient-reported pain scores. Statistically significant decreases in inpatient opioid use were seen in large-magnitude (50% reduction, P < 0.001) and medium-magnitude surgeries (49% reduction, P < 0.001). For small-magnitude surgeries, there was no difference (1.7% reduction, P = 0.99). The median LOS for large-magnitude surgeries decreased by 38% (20.5-hour decrease, P < 0.001) and decreased by 34% for medium-magnitude surgeries (17-hour difference, P = 0.055). For small-magnitude surgeries, there was no significant difference ( P = 0.734). Outpatient opioid prescription quantities were markedly decreased in small-magnitude surgeries only. The total number of communication encounters was not statistically significant in any group. However, the number of steps within a communication encounter was significantly decreased ( P = 0.010), and staff survey respondents reported more efficient and effective postoperative pain management for Pain Plan patients. Pain Plan implementation markedly decreased hospital LOS, inpatient opioid use and outpatient opioid prescription quantities, and clinic resource utilization in elective spine surgery patients.

A predictive model of perioperative myocardial infarction following elective spine surgery

Myocardial infarction (MI), and its predictive factors, has been an understudied complication following spine operations. The objective was to assess the risk factors for perioperative MI in elective spine surgery patients as a retrospective case control study. Elective spine surgery patients with a perioperative MI were isolated in the NSQIP. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests. Univariate/multivariate analyses assessed predictive factors of MI. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. The study included 196,523 elective spine surgery patients (57.1 yrs, 48%F, 30.4 kg/m2), and 436 patients with acute MI (Spine-MI). Incidence of MI did not change from 2010 to 2016 (0.2%–0.3%, p = 0.298). Spine-MI patients underwent more fusions than patients without MI (73.6% vs 58.4%, p < 0.001), with an average of 1.03 levels fused. Spine-MI patients also had significantly more SPO (5.0% vs 1.8%, p < 0.001) and 3CO (0.9% vs 0.2%, p < 0.001), but less decompression-only procedures (26.4% vs 41.6%, p < 0.001). Spine-MI underwent more revisions (5.3% vs 2.9%, p = 0.003), had greater invasiveness scores (3.41 vs 2.73, p < 0.001) and longer operative times (211.6 vs 147.3 min, p < 0.001). Mortality rate for Spine-MI patients was 4.6% versus 0.05% (p < 0.001). Multivariate modeling for Spine-MI predictors yielded an AUC of 83.7%, and included history of diabetes, cardiac arrest and PVD, past blood transfusion, dialysis-dependence, low preoperative platelet count, superficial SSI and days from operation to discharge. A model with good predictive capacity for MI after spine surgery now exists and can aid in risk-stratification of patients, consequently improving preoperative patient counseling and optimization in the peri-operative period.

42. Do no harm: a retrospective analysis of the initial risk of complications in robotic spine surgery

<h3>BACKGROUND CONTEXT</h3> Incorporation of open and MIS robotic techniques in spine surgery has been growing over the past decade, resulting in altered surgical techniques and the need for newly developed skills. With the initial learning curve involved in using this new technology, the upfront risk of complications and poor outcomes during the learning process has been understudied in the literature. <h3>PURPOSE</h3> To evaluate the initial risk of complications with the incorporation of robotic assisted spine surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of a national patient database between 2007-2016. <h3>PATIENT SAMPLE</h3> A total of 3,759,824 elective spine surgery patients. <h3>OUTCOME MEASURES</h3> Comorbidity burden, perioperative complication rates, year-to-year complications, mechanical complications. <h3>METHODS</h3> Inclusion criteria: elective spine surgery procedures from 2007-2016 as defined by ICD-9-CM and ICD-10-CM codes. Exclusion criteria: emergency, trauma or nonelective surgery. Descriptive statistics assessed demographic information. Rates of open and MIS robot-assisted procedures were assessed, as well as trends in postoperative complications and length of stay. Logistic regressions were performed to see if robotic use was independently predictive of a postoperative complication. <h3>RESULTS</h3> The study included 3,759,824 elective spine surgery patients. Overall, 4,185 patients underwent robotic spine surgery (0.1%). There was a significant increase from in robotic surgery cases from 2010 to 2016 with 11 patients in 2010 to 1,535 patients in 2016 (p<0.001). During this time, 93% of robotic spine cases were open compared to 7% MIS (p<0.001). Relative to nonrobotic patients, robotic-spine patients presented with higher rates of anemia, rheumatoid arthritis, uncomplicated diabetes, hypertension, hypothyroidism, fluid and electrolyte disorders (all p<0.001). Overall, robotic-spine patients had higher overall perioperative complication rates, including cardiac, urinary and anemia (all p<0.001). Postoperatively, year-to-year overall complications in robotic surgery patients increased from 25% in 2011 to 29.6% in 2016 (p <0.001), with a high of 31.8% in 2015. Robotic-open cases compared to robotic-MIS cases were shown to have significantly higher overall complications (28.2 vs 13.6%, p<0.001), including complications associated with anemia and mechanical complications (both p<0.001). <h3>CONCLUSIONS</h3> The rise of robotic assisted spine surgery has yielded a concurrent rise in perioperative complications as surgeons adjust to this new technology. Until the learning curve lessens for incorporation of robotic techniques in spine surgery, providers should weigh MIS or open robotic procedures with an eye towards perioperative complications. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P36. Quantifying complications associated with robotic elective spine surgery

<h3>BACKGROUND CONTEXT</h3> Robot-assisted surgical techniques are being increasingly implemented to increase surgeon accuracy and stamina; however, further investigation of the introductory phase of robot technology on surgical outcomes remains warranted. <h3>PURPOSE</h3> To assess complication rates of robotic surgery in elective spine patients. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> A total of 10,501 elective spine patients. <h3>OUTCOME MEASURES</h3> intra- and postoperative complication rates; reoperation rate. <h3>METHODS</h3> Patients ≥18 years undergoing elective spine surgery with BL to 2-year follow-up were isolated in a single-center spine database. Patients were grouped by absence or presence of robotic assistance during operation. Univariate analyses identified differences in perioperative outcomes [op time, estimated blood loss, length of stay], rates of intraoperative [durotomy, massive blood loss, neurologic deficit] and postoperative complications [cardiopulmonary, neurologic, GI, GU, infection, mechanical], and reoperation rates by 2Y postop]. Regression analysis assessed the impact of robotic surgery on outcomes. <h3>RESULTS</h3> A total of 10,501 patients met inclusion criteria (57years, 49% F, 29.0kg/m2) and underwent elective spine surgery (mean levels fused: 3.0±3.3, EBL: 375mL, op time: 206 min, mean UIV: T9, mean LIV: T12). Of these patients, 424 (4.0%) underwent operation with robotic assistance. Compared to a general cohort of elective spine surgery patients, robotic-assisted surgeries had lower levels fused (1.99 vs 3.07), longer op time (301 vs 202min), and longer LOS (4.2 vs 3.2 days); all p<0.01. Robotic patients were more likely to undergo combined approach (p<0.001). Amongst common primary or concurrent diagnoses of patients undergoing robotic spine surgery, 152 patients (36%) had DDD, 161 patients (38%) HNP, 250 patients (59%) degenerative spondylolisthesis, 287 patients (68%) stenosis, and 228 patients (54%) had radiculopathy. Robotic and non-robotic patients did not differ in terms of functional HRQL outcomes [NDI, EQ5D, NRS Neck, NRS Arm] up to 2-year postop (all p>0.05). Robotic and non-robotic patients did not differ in rates of intraoperative complications, including durotomy, massive blood loss, and delayed extubation (all p>0.05). Robotic patients had higher rates of postop ileus (12% vs 7%, p=0.04), but did not differ in overall postop complications, surgical site infection, cardiopulmonary, mechanical, or neurologic complication. Robotic patients had higher rate of reoperation (6% vs 4%, p=0.004). Regression analysis controlling for revision status, decompression, and approach found that robotic surgery patients had lower odds of delayed extubation (OR: 0.155 p=0.025). Robotic surgery did affect the odds for other complications, including durotomy, neurologic, cardiopulmonary, mechanical, infection, and reoperation (all p>0.05). <h3>CONCLUSIONS</h3> Robotic and non-robotic procedures for elective spine patients were equally as safe in terms of intraoperative and postoperative complications with equivocal functional outcomes up to 2-years postoperatively. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The impact of pathoanatomical diagnosis on elective spine surgery patient expectations: a Canadian Spine Outcomes and Research Network study.

Patients undergoing spine surgery generally have high expectations for improvement postoperatively. Little is known about how these expectations are affected by the diagnosis. The purpose of this study was to examine whether preoperative expectations differ based on diagnostic pathoanatomical patterns in elective spine surgery patients. Patients with common degenerative cervical/lumbar pathology (lumbar/cervical stenosis, lumbar spondylolisthesis, and cervical/lumbar disc herniation) who had given their consent for surgery were analyzed using the Canadian Spine Outcomes and Research Network (CSORN). Patients reported the changes they expected to experience postoperatively in relation to 7 separate items using a modified version of the North American Spine Society spine questionnaire. Patients were also asked about the most important item that would make them consider the surgery a success. Sociodemographic, lifestyle, and clinical variables were also collected. There were 3868 eligible patients identified within the network for analysis. Patients with lumbar disc herniation had higher expectations for relief of leg pain compared with stenosis and lumbar degenerative spondylolisthesis cohorts within the univariate analysis. Cervical stenosis (myelopathy) patients were more likely to rank general physical capacity as their most important expectation from spine surgery. The multinomial regression analysis showed that cervical myelopathy patients have lower expectations for relief of arm or neck pain from surgery (OR 0.54, 0.34-0.88; p < 0.05). Patient factors, including age, symptoms (pain, disability, depression), work status, and lifestyle factors, were significantly associated with expectation, whereas the diagnoses were not. Patients with degenerative spinal conditions consenting for spine surgery have high expectations for improvement in all realms of their daily lives. With the exception of patients with cervical myelopathy, patient symptoms rather than diagnoses had a more substantial impact on the dimensions in which patients expected to improve or their most important expected change. Determination of patient expectation should be individualized and not biased by pathoanatomical diagnosis.

Cannabis Abuse and Perioperative Complications Following Inpatient Spine Surgery in the United States.

Due to its complicated legal status, the effects of cannabis on elective spine surgery patients have not been well studied. In this nationwide analysis, we find that cannabis abuse is associated with higher perioperative thromboembolism and neurologic complications, respiratory complications, sepsis, length of stay, hospital charges, and rates of unfavorable discharge disposition.

Patients with psychiatric diagnoses have increased odds of morbidity and mortality in elective orthopedic surgery

Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p < 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p < 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p < 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p < 0.001).

Healthy Elective Spine Surgery Patients With Elevated Pre-operative Anxiety Send More Patient Portal Messages and Have More Post-Surgical Complications

Christian, Zachary; Afuwape, Olusoji A MD, PhD; Aoun, Salah G MD; Hall, Kristen BS; Bagley, Carlos A MD Author Information

Urinary Tract Infection after Elective Spine Surgery: Timing, Predictive Factors, and Outcomes.

Retrospective review of prospectively collected data. The aim of this study was to investigate risk factors associated with the timing of urinary tract infection (UTI) after elective spine surgery, and to determine whether postoperative UTI timing affects short-term outcomes. Urinary tract infection (UTI) is a common post-surgical complication; however, the predominant timing, location, and potential differential effects have not been carefully studied. We analyzed elective spine surgery patients from 2012 to 2018 in the ACS National Surgical Quality Improvement Program (NSQIP). We grouped patients with postoperative UTI by day of onset relative to discharge, to create cohorts of patients who developed inpatient UTI and post-discharge UTI. We compared both UTI cohorts with a control (no UTI) population and with each other to identify differences in baseline characteristics including demographic, comorbidity and operative factors. We performed multivariate logistic regression to identify predictors of UTI in each cohort and to assess adjusted risks of poor outcomes associated with UTI timing. A total of 289,121 patients met inclusion criteria and 0.88% developed UTI (n = 2553). Only 31.6% of UTIs occurred before discharge (n = 806), with 68.4% occurring after discharge (n = 1747). The inpatient UTI cohort had significantly longer operative time, more fusion procedures, more posterior procedures, and more procedures involving the lumbar levels than the post-discharge cohort. Predictors of inpatient UTI included procedure type, spine region, and approach. Predictors of post-discharge UTI included length-of-stay and discharge destination. Both UTI cohorts were significantly associated with sepsis; however, post-discharge UTI carried a higher odds (adjusted odds ratio [aOR] = 24.90, 95% confidence interval [CI] = 21.05-29.45, P < 0.001 vs. aOR = 14.31, 95% CI = 11.09-18.45, P < 0.001). Inpatient UTI was not associated with 30-day readmission, although post-discharge UTI was (aOR = 8.23, 95% CI = 7.36-9.20, P < 0.001). Conversely, inpatient UTI was associated with increased odds of 30-day mortality (aOR = 3.23, 95% CI = 1.62-6.41, P = 0.001), but post-discharge UTI was not. Predictive factors and outcomes differ based on timing of UTI after elective spine surgery. Before discharge, procedure -specific details predict UTI, but after discharge they do not. These findings suggest that traditional thinking about UTI prevention may need modification.Level of Evidence: 3.

Venous Thromboembolism Prophylaxis in Elective Spine Surgery.

Study Design:Review.Objective:Venothromboembolic (VTE) complications, composed of deep vein thrombosis and pulmonary embolism are commonly observed in the perioperative setting. There are approximately 500 000 postoperative VTE cases annually in the United States and orthopedic procedures contribute significantly to this incidence. Data on the use of VTE prophylaxis in elective spinal surgery is sparse. This review aims to provide an updated consensus within the literature defining the risk factors, diagnosis, and the safety profile of routine use of pharmacological prophylaxis for VTE in elective spine surgery patients.Methods:A comprehensive review of the literature and compilation of findings relating to current identified risk factors for VTE, diagnostic methods, and prophylactic intervention and safety in elective spine surgery.Results:VTE prophylaxis use is still widely contested in elective spine surgery patients. The outlined benefits of mechanical prophylaxis compared with chemical prophylaxis varies among practitioners.Conclusion:The benefits of any form of VTE prophylaxis continues to remain a controversial topic in the elective spine surgery setting. A specific set of guidelines for implementing prophylaxis is yet to be determined. As more risk factors for thromboembolic events are identified, the complexity surrounding intervention selection increases. The benefits of prophylaxis must also continue to be balanced against the increased risk of bleeding events and neurologic injury.

Brief Preoperative Screening for Frailty and Cognitive Impairment Predicts Delirium after Spine Surgery.

Frailty and cognitive impairment are associated with postoperative delirium, but are rarely assessed preoperatively. The study was designed to test the hypothesis that preoperative screening for frailty or cognitive impairment identifies patients at risk for postoperative delirium (primary outcome). In this prospective cohort study, the authors administered frailty and cognitive screening instruments to 229 patients greater than or equal to 70 yr old presenting for elective spine surgery. Screening for frailty (five-item FRAIL scale [measuring fatigue, resistance, ambulation, illness, and weight loss]) and cognition (Mini-Cog, Animal Verbal Fluency) were performed at the time of the preoperative evaluation. Demographic data, perioperative variables, and postoperative outcomes were gathered. Delirium was the primary outcome detected by either the Confusion Assessment Method, assessed daily from postoperative day 1 to 3 or until discharge, if patient was discharged sooner, or comprehensive chart review. Secondary outcomes were all other-cause complications, discharge not to home, and hospital length of stay. The cohort was 75 [73 to 79 yr] years of age, 124 of 219 (57%) were male. Many scored positive for prefrailty (117 of 218; 54%), frailty (53 of 218; 24%), and cognitive impairment (50 to 82 of 219; 23 to 37%). Fifty-five patients (25%) developed delirium postoperatively. On multivariable analysis, frailty (scores 3 to 5 [odds ratio, 6.6; 95% CI, 1.96 to 21.9; P = 0.002]) versus robust (score 0) on the FRAIL scale, lower animal fluency scores (odds ratio, 1.08; 95% CI, 1.01 to 1.51; P = 0.036) for each point decrease in the number of animals named, and more invasive surgical procedures (odds ratio, 2.69; 95% CI, 1.31 to 5.50; P = 0.007) versus less invasive procedures were associated with postoperative delirium. Screening for frailty and cognitive impairment preoperatively using the FRAIL scale and the Animal Verbal Fluency test in older elective spine surgery patients identifies those at high risk for the development of postoperative delirium.

Risk Factors Associated with Symptomatic Deep Vein Thrombosis Following Elective Spine Surgery: A Case–Control Study

Few studies provide insight into risk factors (RFs) associated with postoperative deep vein thrombosis (DVT) following elective spinal surgery. DVTs are detrimental in this population because of the risk of pulmonary embolization or surgical site hemorrhage with treatment. Elective spine surgery patients have a low incidence of DVT, thus a case-control study was selected to investigate RFs associated with postoperative, symptomatic DVT. Cases were matched to controls in a 1:2 ratio based on surgery type. Risk of having a prior DVT and choice of subcutaneous heparin dosing following surgery was analyzed in a multivariate regression model with other potentially confounding variables. A total of 195 patients were included in this study. Independent of patient age, history of DVT was associated with postoperative symptomatic DVT (odds ratio [OR], 4.09; 95% confidence interval [CI], 1.22-13.78). Two versus 3 times daily postoperative heparin dosing (OR, 1.56; 95% CI, 0.32-7.56), surgery length (OR, 1.32; 95% CI, 0.98-1.79), and patient age (OR, 1.04; 95% CI, 1.0-1.08) were not statistically significant, independent RFs. Older age and longer length of surgery trended toward association with DVT without reaching significance. Length of stay was increased from 3-5 days (P < 0.001) in DVT patients compared with controls. These results suggest that patients with a history of DVT undergoing elective spinal surgery are at higher risk of developing symptomatic DVT postoperatively resulting in significantly increased length of stay. Further studies on additional preoperative screening and medical optimization in elective spine surgery patients may help reduce the rate of symptomatic, postoperative DVT.

284. Activity goals of patients considering spine surgery: a pilot study

BACKGROUND CONTEXT Quality of life (QoL) is impacted by the ability for patients to participate in physical activities which interest them. Surgeons may not systematically ask about related activity goals. PURPOSE To determine what specific physical activity goals elective spine surgery patients have and which of these goals surgeons suggest modifying. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE Elective spine surgery patients at Hospital for Special Surgery (NY, USA). OUTCOME MEASURES Patient reported outcome measures (PROMs). METHODS A standard-of-care survey previously developed for hip and knee arthroplasty patients was adapted for the elective spine surgery population with degenerative spinal conditions to solicit patient physical activity goals, current and future desired performance, current difficulty performing these activities, and time since the activities could last be performed at the desired level. This pilot survey was administered to new adult patients contemplating spine surgery for degenerative pathology between May 2019 and July 2019. Patient responses were individually reviewed by their respective spine surgeon (seven surgeons participated). Each surgeon recorded whether they agreed with the patient's goal or discussed how to modify the goal. These data were retrospectively assessed for significant associations (p RESULTS During this study, 173 patients were surveyed with 169 (97.7%) having one or more reported physical activity goals (215 total goals). After excluding workers compensation patients (n=5), average patient age was 59.9 years (σ=16.4, range: 19.0–93.0 years). Average patient BMI was 27.4 (σ=5.3, range: 16.0–47.9). This study population included patients with lumbar spine degeneration (72.0%), cervical spine degeneration (23.8%), as well as thoracic and combined regional degeneration (4.3%). Patient activity goals involved: exercise (31.1%), walking (28.2%), recreational activities not including golf (12.9%), golf (7.2%), activities of daily living or ADLs (11.5%), and hobbies (9.1%). Activity goals could be performed at a satisfactory level on average 3.2 years prior to being surveyed (range: 2.0 days–28.0 years) with a longer period associated with higher BMI (p=0.046). Older age was associated with having exercise goals (p CONCLUSIONS Patient activity goals were related to region of spinal degeneration, age and BMI. The low rate of suggested goal modification by surgeons in this study reflects the central role of communication, education, as well as shared decision-making during presurgical assessment and care planning when treating patients with spine conditions. Most patients undergoing elective spine surgery have very particular activity goals that are not currently captured by patient-reported outcome measure (PROM) questionnaires. However, these activity goals are generally not systematically communicated to surgeons. Awareness of patient physical activity goals is important and may ultimately impact patient satisfaction with spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

127. Preoperative optimization of modifiable frailty factors reduces risk of hospital acquired conditions in elective surgical spine patients

BACKGROUND CONTEXT Hospital acquired conditions (HACs) were established in the Affordable Care Act, and are defined as reasonably preventable complications that are nonreimbursable. In high risk patient populations for HACs, such as frail surgical spine patients, preoperative evaluation should consider modifiable factors. PURPOSE To identify if optimizing the modifiable factors in the frailty index reduce the risk of developing HACs in population of surgical spine patients. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE This study included 196,523 elective spine surgery patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). OUTCOME MEASURES Modifiable patient frailty factors: hypertension and diabetes mellitus; rates of HACs, superficial or deep surgical site infection (SSI), deep venous thromboembolism (VTE) and urinary tract infection (UTI), across frailty scores. METHODS Patients >18 years who underwent elective spine surgery were identified in ACS-NSQIP database from 2005-2016. HACs identified: SSI, VTE, and UTI. Patient frailty was assessed utilizing the modified NSQIP 5-factor frailty index. The modified frailty score (mFI-5) is assessed on a scale between 0 and 1 (no frailty [NF] 0.5). Descriptive analysis quantified rates of patient characteristics, operative details, and HAC prevalence. Stepwise linear regression models determined significant predictors of baseline frailty using controllable patient factors. HACs were compared between ‘optimized’ and ‘non-optimized’ frailty status in the cohort. Level of significance was set to P RESULTS A total of 196,523 patients (57±14.2 years, 30.4 kg/m2, 48%F) met inclusion criteria. Overall, 5,720 (2.9%) of patients developed an HAC, the most common was an SSI (1.3%), followed by UTI (1.1%). When stratified by the mFI-5 frailty severity groups at baseline, 83.6% of patients were categorized NF, 15.1% MF and 1.3% SF. Within the frailty severity groups, prevalence of overall HACs increased significantly (NF: 2.64%, MF: 4.17%, 5.93%, p CONCLUSIONS Stepwise linear regression models determined that hypertension and diabetes account for 89.7% of variance in baseline mFI-5 score. Patients with these optimal controllable factors had reduced incidence of all hospital acquired conditions. In order to optimize hospital resources and treatment outcomes, physicians and patients should be aware of the modifiable factors that contribute to a patient's frailty that can ultimately impact acquiring HACs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.