Posterior Cervical Decompression And Fusion Research Articles

Comparison of the Inpatient Complications and Health Care Costs of Anterior versus Posterior Cervical Decompression and Fusion in Patients with Multilevel Degenerative Cervical Myelopathy: A Retrospective Propensity Score–Matched Analysis

The optimal surgical approach for multilevel degenerative cervical myelopathy (DCM) is unclear, and there is significant variation in practice patterns. We sought to compare inpatient complications and costs of anterior (ACDF) versus posterior cervical decompression and fusion (PCDF). Patients who underwent multilevel ACDF or PCDF for DCM were identified from the National Inpatient Sample for 2004-2014 using ICD-9-CM codes. Propensity score matching was performed with age, sex, comorbidities, hospital bed size, and use of intraoperative monitoring as covariates. Hospitalization charges/costs, length of stay (LOS), discharge disposition, and inpatient morbidity/mortality were compared between matched ACDF and PCDF groups. Propensity score matching generated a cohort of 13,884 patients (n= 6,942 ACDF; n= 6,942 PCDF). PCDF was associated with greater LOS (mean difference [MD]+1.7 days, P < 0.001) and less frequent routine discharge home (odds ratio [OR] 0.26, P < 0.01). With regard to complications, PCDF had a higher rate of myocardial infarction (OR 1.6, P= 0.007), pulmonary embolism (OR 2.6, P= 0.009), deep vein thrombosis (OR 3.7, P < 0.001), neurological complications (OR 1.7, P= 0.037), hardware-related complications (OR 2.7, P < 0.001), wound infection/breakdown (OR 6.8, P < 0.001), and cerebrospinal fluid leak (OR 1.7, P= 0.011). By contrast, rates of postoperative hematoma (OR 0.61, P= 0.007), hoarseness (OR 0.13, P < 0.001), and dysphagia (OR 0.20, P < 0.001) were higher after ACDF. Mortality was comparable. Hospital charges (MD+$26,259, P < 0.001) and costs (MD+$7,728, P < 0.001) were significantly higher for PCDF. At a national level, for multilevel DCM, we found PCDF to be associated with greater LOS, in-hospital costs, and general medical and surgical complications. ACDF carried higher risk of postoperative hematoma, hoarseness, and dysphagia.

Reoperation for Proximal Adjacent Segment Pathology in Posterior Cervical Fusion Constructs that Fuse to C2 vs C3.

Few studies have described rates of proximal clinical adjacent segment pathology (CASP) after posterior cervical decompression and fusion (PCDF). To investigate rates of proximal CASP at C2 vs C3 in PCDFs for degenerative spine disease. A retrospective review of 380 cases of PCDF for degenerative disease with proximal constructs ending at C2 vs C3 was performed. Minimum follow-up was 12 mo. The primary outcome was proximal CASP requiring reoperation. Variable analysis included demographic, operative, and complication data. There were 119 patients in the C2 group and 261 in the C3 group with no significant differences in age, gender, comorbidities, presenting symptoms, or complications. Vertebral artery injury rates were 0.8% in the C2 group and 0.0% in the C3 group (P=.12). No patients in the C2 group had reoperation for proximal CASP, while 5.0% of patients in the C3 group did (P=.01). Patients with arthrodesis up to C3 had an increased risk of proximal failure when the fusion construct crossed the cervicothoracic junction (P=.03). Multivariate logistic regression analysis showed no factors that were independently associated with re-instrumentation for proximal CASP. Instrumenting to the C2 level reduces the risk for proximal CASP compared to fusion only up to C3. The type of instrumentation used at these 2 levels, form of ASP disease at C1-C2, and natural motion of the relevant proximal adjacent joint may contribute to this difference. Furthermore, within the C3 cohort, fusion across the cervicothoracic junction increased the risk for proximal CASP.

18. Safety and efficacy of tranexamic acid use in posterior cervical decompression and fusion surgery

BACKGROUND CONTEXT Posterior cervical decompression and fusion (PCDF) involves substantial blood loss, resulting in blood transfusions and associated complications, such as infections, hypotension and organ damage. The antifibrinolytic tranexamic acid (TXA), an inhibitor of the activation of plasminogen, has been shown to be beneficial in multiple surgical procedures without any apparent increase in postoperative complications. However, only a few studies report on TXA utilization in cervical spine surgery and there is currently no literature detailing the short-term safety of its use in this setting. PURPOSE To evaluate the short-term safety and efficacy of tranexamic acid use in multilevel posterior cervical decompression and fusion surgery. STUDY DESIGN/SETTING Retrospective case-control study from a single academic institution. PATIENT SAMPLE Forty-seven patients were identified to have undergone PCDF at our institution by one surgeon, 19 with the utilization of a TXA protocol and 28 patients without. Inclusion criteria were adults (age ≥18 years) with cervical stenosis and/or spondylosis who underwent cervical posterior spinal fusion surgery of at least 2 levels. OUTCOME MEASURES Intraoperative and postoperative blood loss and incidence of adverse events, including myocardial infarction (MI), acute renal failure, stroke, seizure, deep vein thrombosis (DVT) and pulmonary embolism (PE) were evaluated in the perioperative period and at 1-month follow-up. METHODS From January 2015 to April 2018, 47 patients were identified to have undergone PCDF, 19 with the utilization of a TXA protocol at our institution. Inclusion criteria were adults (age ≥18 years) with cervical stenosis and/or spondylosis who underwent cervical posterior spinal fusion surgery of at least 2 levels. The incidence of adverse events, including myocardial infarction (MI), acute renal failure, stroke, seizure, deep vein thrombosis (DVT) and pulmonary embolism (PE) were evaluated in the perioperative period and at 1-month follow-up. RESULTS Based on the inclusion criteria, 39 patients were selected. Nineteen (49%) received TXA as per our instructional protocol and 20 (51%) did not. Postoperative blood was significantly reduced (453ml vs 701ml; p = 0.03) in the group that received TXA. There was also a significant reduction in duration of surgery associated with TXA use (269 min vs 328 min; p = 0.05). There were no cardiac or thromboembolic complications on the first 30 days after surgical intervention on the TXA group, but there was a transient atrial fibrillation on the standard group. There were no infections, seizure activity, epidural hematomas or renal complications reported in either group. CONCLUSIONS TXA use during PCDF is a safe, effective method to reduce postoperative blood loss. Considering the limited number of patients in this study, these results should be validated on a larger group of patients. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

Short-term safety of tranexamic acid use in posterior cervical decompression and fusion surgery

Posterior cervical decompression and fusion (PCDF) can result in substantial blood loss, leading to blood transfusions and associated complications, such as infections, hypotension and organ damage. The antifibrinolytic tranexamic acid (TXA), an inhibitor of the activation of plasminogen, has been shown to be beneficial in multiple surgical procedures without any apparent increase in postoperative complications. However, there are only few studies reporting TXA utilization in cervical spine surgery and there is currently no literature detailing the short-term safety of its use in this setting. The purpose of our study is to determine the safety profile of TXA in posterior cervical decompression and fusion. From January 2015 to April 2018, 47 patients were identified to have undergone PCDF, 19 with the utilization of a TXA protocol at our institution. The incidence of adverse events was evaluated in the perioperative period and at 1 month follow-up. Of 39 patients, Nineteen (49%) received TXA as per our instructional protocol and 20 (51%) did not. Post-operative blood was significantly reduced (453 ml vs 701 ml; p = 0.03) in the group that received TXA. There was also a significant reduction in duration of surgery associated with TXA use (269 min vs 328 min; p = 0.05). There were no complications on the first 30 days after surgical intervention on the TXA group. TXA use during PCDF is a safe, effective method to reduce postoperative blood loss. Considering the limited number of patients in this study, these results should be validated on a larger group of patients.

Posterior Cervical Decompression and Fusion: Assessing Risk Factors for Nonhome Discharge and the Impact of Disposition on Postdischarge Outcomes

The purpose of this study was to identify predictors for postacute care facility discharge for patients undergoing posterior cervical decompression and fusion (PCDF) and to determine if discharge placement impacts postdischarge outcomes. Patients undergoing PCDF from 2012 to 2015 were queried from the NSQIP database (n= 8743) and separated by discharge placement. Outcomes included nonhome discharge, unplanned 30-day readmission, and adverse events (AEs), both before and after discharge. Demographics and comorbidities were analyzed using bivariate analysis. Multivariate logistic regression was used to identify predictors for nonhome discharge, readmission, and severe AE after discharge. Patients with nonhome discharges were significantly older (67.4 vs. 58.6 years; P < 0.001), sicker (82% vs. 54% American Society of Anesthesiologists >2; P<0.001), and more functionally dependent (16% vs. 3.4%; P < 0.001), with a greater comorbidity burden. Patients with PCDF had an increased likelihood of nonhome discharge if they had a dependent functional status (odds ratio [OR], 2.99; 95% confidence interval [CI], 2.33-3.82; P < 0.001), diabetes (OR, 1.32; 95% CI, 1.13-1.55; P= 0.0007), and an American Society of Anesthesiologists >2 (OR, 1.75; 95% CI, 1.5-2.05; P < 0.001), as well as if they were older (OR, 1.06; 95% CI, 1.05-1.06; P < 0.001) and female (OR, 1.31; 95% CI, 1.14-1.5; P= 0.0002). Patients with PCDF with nonhome discharges had an increased likelihood of having a severe postdischarge AE (OR, 1.71; 95% CI, 1.26-2.33; P= 0.0006) and an unplanned readmission (OR, 1.45; 95% CI, 1.15-1.82; P= 0.002). Results of this cross-sectional study suggest that patients with PCDF discharged to a postacute care facility have a higher likelihood of having a severe AE after discharge as well as a higher likelihood of being readmitted.

Assessing Variability in In-Hospital Complication Rates Between Surgical Services for Patients Undergoing Posterior Cervical Decompression and Fusion.

A retrospective study was performed including all patients who underwent posterior cervical decompression and fusion (PCDF) by an orthopedic or neurological surgeon at a single institution between January 1, 2006 and November 30, 2016, and all patients who underwent PCDF by a spine surgeon in the National Surgical Quality Improvement Project database between 2007 and 2015. In-hospital complications were compared between surgical specialties. The goal of this study was to determine if in-hospital complication rates differ significantly between surgical services for PCDF patients. Orthopedic and neurological surgeons commonly perform PCDF, and differences in surgical opinion and management have been cited between these two specialties in recent literature. This represents a variable that should be evaluated. Cases were preliminarily identified by CPT code and confirmed using the ICD-9 code 81.03 or ICD-10 code M43.22. Cases were separated based on if the primary surgeon was an orthopedic surgeon or a neurological surgeon. The primary outcome variable was in-hospital complication rates; cohorts were compared using bivariate and multivariate analysis. A total of 1221 patients at a single institution and 11,116 patients within the National Surgical Quality Improvement Project database underwent PCDF. Patients in the orthopedic surgery service had a higher proportion of bleeding requiring transfusion in both the institutional sample (14.5% vs. 9.08%, P = 0.003) and national sample (11.16% vs. 6.18%, P < 0.0001). In the national sample, orthopedic surgeons were 1.66 times as likely to encounter an in-hospital complication than neurological surgeons (95% CI: 1.44-1.91, P < 0.0001). When examining a large institutional sample and an even larger national sample, this study found that orthopedic surgeons were more likely to encounter perioperative bleeding requiring transfusion than neurological surgeons. When in-hospital complications were considered as a whole, in the national sample, orthopedic surgeons are more likely to encounter in-hospital complications than neurological surgeons when performing PCDF. 3.

Friday, September 28, 2018 9:00 AM–10:00 AM best papers Friday: 151. Evaluating risk factors for nonhome discharge and the impact of disposition on postdischarge outcomes for patients undergoing posterior cervical decompression and fusion

BACKGROUND CONTEXT Spinal fusion is becoming a candidate for bundled payment; understanding the risk factors for nonhome discharge, postdischarge adverse events (AE), and unplanned readmissions is key in making this system viable. This analysis focuses on the risk factors for these outcomes for patients undergoing posterior cervical decompression and fusion (PCDF), a surgical population especially at risk for AEs and readmission relative to other fusion procedures. PURPOSE To understand the risk factors for nonhome discharge, severe postdischarge AE, and unplanned readmission for patients undergoing PCDF. STUDY DESIGN/SETTING All patients undergoing PCDF between 2012 and 2015 were queried from the National Surgical Quality Improvement Project (NSQIP) database. Patients were identified using the current procedural terminology (CPT) codes 63,045, 63,001, 63,015, 22,210, 22,110 and 22,600. Patients undergoing anterior cervical fusion in the same hospital stay were excluded. PATIENT SAMPLE Over a 4-year period, a total of 8,743 patients underwent PCDF in the NSQIP database. OUTCOME MEASURES Outcomes included nonhome discharge, unplanned 30-day readmission, and severe postdischarge AE (deep wound infection, organ or space infection, wound dehiscence, reintubation, DVT, PE, weaning failure, renal insufficiency, renal failure, CVA, cardiac arrest, MI, sepsis, septic shock, reoperation and death). METHODS Demographic variables and comorbidity status were analyzed using bivariate analysis. Step-wise multiple logistic regression using backward elimination (p=.2) was utilized to analyze the outcomes stated above. Models included the following variables: nonhome discharge, severe predischarge AE, age, operative time, sex, functional status, BMI>40, diabetic status, length of stay, ASA status >2, and history of pulmonary disease, heart disease, hypertension requiring medication, stroke, renal failure or bleeding disorder. RESULTS Patients with nonhome discharges were significantly older (67.4 vs. 58.6 years, p CONCLUSIONS PCDF patients who are discharged home have a higher likelihood of having a severe adverse event postdischarge and having an unplanned readmission. As LOS remains a common target for cost reduction, it is important to note that it may not be worth sacrificing home discharge for decreased LOS, as these patients will be predisposed to adverse events and return to the hospital.

Friday, September 28, 2018 4:05 PM–5:05 PM abstracts: new concepts: cervical spine: 246. C5 palsy after single- and multilevel anterior cervical discectomy and fusion

BACKGROUND CONTEXT Postoperative C5 nerve root palsy is a known complication after decompressive cervical surgery, most commonly reported after posterior cervical decompression and fusion (PCDF). However, while the rate of C5 palsy after anterior cervical decompression and fusion (ACDF) is lower, the effect of increasing number of levels fused on the prevalence of C5 palsy is unclear. PURPOSE To examine the rate of C5 palsy after one-, two-, three- and four-level ACDF including the C4-5 level, without corpectomy, and without posterior decompression. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE Retrospective review of all anterior cervical discectomy and fusion patients at one institution over a 1 year period. OUTCOME MEASURES Manual motor testing grade. METHODS We performed a retrospective review of ACDFs performed at one institution by multiple surgeons between September 2015 and June 2016. Patient demographic and surgical information was reviewed, including postoperative motor examination results in the immediate postoperative period. C5 palsy was defined as motor decline of the deltoid muscle function by at least one level on standard manual muscle testing. Patients were excluded if undergoing concurrent posterior surgery or corpectomy, or if no postoperative motor strength was documented. Fisher's exact test was used to compare categorical variables between groups, and analysis of variance used to compare continuous variables. RESULTS We identified 226 patients undergoing single- or multilevel ACDF over the study time period, with a total of 196 meeting our inclusion criteria. Average age of all patients was 59.0 years and 49% were male, with no significant differences noted between groups undergoing single- or multilevel ACDF. Average follow up was 7 months. Ten patients developed postoperative C5 palsy, with an overall rate of 5.1%. There were no statistically significant differences in age, patient sex or numbers of levels fused between the palsy and no-palsy groups. We identified two C5 palsies in the single-level group (8.7%), two in the two-level group (3.1%), five in the three-level group (5.6%) and one in the four-level group (5.6%). These rates were not statistically significant between groups (p>.05). Six of the 10 patients with C5 palsy had complete recovery of final deltoid and/or biceps strength, while two patients had at least some level of strength recovery. Two patients had no measured improvement in C5 motor function by final follow up. CONCLUSIONS To our knowledge, no prior study has specifically compared the risk of C5 palsy between single- and multilevel ACDF when excluding corpectomy and posterior cervical cases. We found an overall C5 palsy rate of 5.1% for all patients undergoing one-, two-, three-, and four-level ACDF that included the C4-5 level at our institution. The rate of postoperative deltoid and/or biceps motor strength decline was lowest in the patients undergoing two-level ACDF and highest in the single-level group, but this finding did not reach statistical significance. Our rate of C5 palsy appears comparable to published literature.

National trends in the management of central cord syndrome: an analysis of 16,134 patients

Background contextCentral cord syndrome (CCS) is a common cause of incomplete spinal cord injury. However, to date, national trends in the management and mortality after CCS are not fully understood. PurposeTo analyze how patient, surgical, and institutional factors influence surgical management and mortality after CCS. Study designA retrospective cohort analysis. Patient sampleThe Nationwide Inpatient Sample (NIS) was queried for records of patients with a diagnosis of CCS from 2003 to 2010. Outcome measuresThey included in hospital mortality and surgical management, including anterior cervical decompression and fusion (ACDF), posterior cervical decompression and fusion (PCDF), and posterior cervical decompression (PCD). MethodsUsing International Classification of Diseases, Ninth Revision, Clinical Modification codes, patient records with a diagnosis of CCS from 2003 to 2010 were selected from the NIS database and sorted by inpatient mortality and surgical management. Demographic information (age, gender, and race) and hospital characteristics were evaluated with χ2-tests for categorical variables and t tests for continuous variables. Multivariate logistic regression models controlled for confounding. ResultsIn this sample of 16,134 patients, a total of 39.7% of patients (6,351) underwent surgery. ACDF was most common (19.4%), followed by PCDF (7.4%) and PCD (6.8%). From 2003 to 2010, surgical management increased by an average of 40% each year. The overall inpatient mortality rate was 2.6%. Increasing age and comorbidities were associated with higher rates of patient mortality and a decreasing surgical rate (p<.01). Hospitals greater than 249 beds (p<.01) and the south (p<.01) were associated with a higher surgical rate. Rural hospitals (p<.01) and people in the second income quartile (p<.01) were associated with higher inpatient mortality. ConclusionsElderly patients with medical comorbidities are associated with a lower surgical rate and a higher mortality rate. Surgical management was more prevalent in the south and large hospitals. Mortality was higher in rural hospitals. It is important for surgeons to understand how patient, surgical, and institutional factors influence surgical management and mortality.

C5 palsy after posterior cervical decompression and fusion: cost and quality-of-life implications

Background contextC5 palsy is a debilitating postoperative complication of cervical decompression surgery. Although the prognosis is typically good, patients may be unable to perform basic activities of daily living, resulting in a decreased quality of life. No studies have investigated the quality-of-life and financial implications. PurposeThe aim of the study was to determine the impact on quality-of-life and costs of C5 palsy after posterior cervical decompression and fusion (PCDF). Study design/settingA 2:1 matched retrospective cohort study was conducted at a single tertiary-care institution between 2007 and 2012. Patient sampleIndividuals who had undergone PCDF were included. Outcome measuresSelf-reported: Euroqol-5 Dimensions quality-of-life survey. Physiologic: postoperative change in deltoid and biceps strength via manual muscle testing. Functional: cost of interventions and missed workdays postoperatively. MethodsIndividuals with postoperative C5 palsy were matched to controls based on age, gender, body mass index, and diagnosis. Demographic, operative, postoperative, quality-of-life, and cost data were collected for both the C5 palsy and control groups, with 1-year follow-up. ResultsWe reviewed 245 patients who underwent PCDF and 17 were identified (6.9%) with C5 palsy and matched to 34 controls. No significant differences in demographic or operative characteristics were observed between groups. The C5 palsy group had a significantly reduced capacity for self-care in the immediate postoperative (2.0±0.71 vs. 1.2±0.4, p<.001) and long-term (1.6±0.6 vs. 1.2±0.4, p=.004) periods and a significantly reduced capacity for completion of usual activities (2.4±0.7 vs. 1.9±0.6, p=.014) compared with controls. Furthermore, the C5 group had a significantly greater cost of physical/occupational therapy, an increase of $2,078 ($4,386±$2,801 vs. $2,307±$1,907, p=.013). There were no significant differences between groups in the cost of hospital stay, surgery, or other direct or indirect costs. Overall, there was a significantly greater cost ($1,918) for the C5 palsy group compared with the control group ($7,584±$3,992 vs. $5,666±$2,359, respectively, p=.038). ConclusionsThis study represents the first quantification of the impact of C5 palsy on patients' quality of life and the associated costs for care. We found that C5 palsy adds a significant burden on patients' quality of life and presents a financial burden to the health-care system.