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Study Design
Retrospective study of prospectively collected data.
Objective
To determine if patients undergoing spinal deformity surgery with pelvic fixation are at an increased risk of morbidity.
Methods
The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively coll...
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Retrospective study.
Objectives
To determine rates of medical and surgical postoperative complications in adults with hypoalbuminemia undergoing anterior lumbar interbody fusion (ALIF).
Methods
This was a retrospective analysis of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement...
Study design:
Retrospective cohort study.
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To determine the effect of obesity (body mass index >30 kg/m2) on perioperative morbidity and mortality after surgical decompression of spinal metastases.
Methods:
The American College of Surgeons National Surgical Quality Improvement Program database is a large multicenter clinical registr...
Study design:
Retrospective study.
Objective:
To determine the rates of early postoperative mortality and morbidity in adults with hypoalbuminemia undergoing elective posterior lumbar fusion (PLF).
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The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedu...
Study Design
Case-control study.
Objective
To determine the incidence, impact, and risk factors for wound complications within 30 days following elective adult spinal deformity surgery.
Methods
Current Procedural Terminology and International Classification of Diseases, Ninth Edition, diagnosis codes were used to query the database for adults who...
Citations
... [1,2] Given the growing elderly population and increasing utilization of PF in long constructs and deformity surgery, there is a need to evaluate the 30-day outcome profile of supplementary PF in degenerative lumbar fusion. [3,4] Thus, the purpose of this Adjunct pelvic fixation in short-to-medium segment degenerative fusion constructs independently predicts readmission and morbidity study was to compare multilevel adult degenerative lumbar fusion with and without PF based on 30-day readmission, reoperation, and morbidity and to explore predictors of primary outcomes. ...
... Moreover, the rate of readmission in deformity surgery is 6% and, with PF, is 7%. [4,7] For patients undergoing multilevel fusion for degenerative purposes without PF in the present study, the readmission rate was 7%. In light of the 12% readmission rate, we found with PF, these findings suggest that degenerative patients, who are inherently older on average, are less able to tolerate more invasive and morbid procedures, such as fixation to the pelvis, resulting in greater readmission and ultimately greater health-care costs. ...
... The increased risk of blood loss with PF has been documented in deformity surgery. [4,7,8,13,14] Kothari et al. demonstrated a 74% transfusion rate for patients undergoing PF. [4] We observed a transfusion rate of 49%, likely lower than the 74% figure as that included larger constructs extending into the thoracic spine. However, this is notably higher than the 16% transfusion rate for patients without PF in the present study. ...
Context:
Despite increasing utilization of fusion to treat degenerative pathology, few studies have evaluated outcomes with pelvic fixation (PF). This is the first large-scale database study to compare multilevel fusion with and without PF for degenerative lumbar disease.
Aim:
The aim of this study was to compare the 30-day outcomes of multilevel lumbar fusion with and without PF.
Settings and design:
This was a retrospective cohort study.
Subjects and methods:
Lumbar fusion patients were identified using the National Surgical Quality Improvement Program database. Regression was utilized to analyze readmission, reoperation, morbidity, and specific complications and to evaluate for predictors thereof.
Statistical analysis used:
Student's t-test was used for continuous variables and Chi-squared or Fisher's exact test was used for categorical variables. Variables significant in the univariate analyses (P < 0.05) and PF were then evaluated for significance as independent predictors and control variables in a series of multivariate logistic regression analyses of primary outcomes.
Results:
We identified 38,413 patients. PF predicted 30-day readmission and morbidity. PF was associated with greater reoperation in univariate analysis, but not in multivariate analyses. PF predicted deep wound infections, organ-space infections, pulmonary complications, urinary tract infection, transfusion, deep venous thrombosis, and sepsis. PF was also associated with a longer hospital stay. Age, obesity, steroids, and American Society of Anesthesiologists (ASA) class ≥ 3 predicted readmission. Obesity, steroids, bleeding disorder, preoperative transfusion, ASA class ≥3, and levels fused predicted reoperation. Age, African American race, decreased hematocrit, obesity, hypertension, dyspnea, steroids, bleeding disorder, ASA class ≥3, levels fused, and interbody levels fused predicted morbidity. Male gender and inclusion of anterior lumbar interbody fusion (ALIF) were protective of reoperation. Hispanic ethnicity, ALIF, and computer-assisted surgery (CAS) were protective of morbidity.
Conclusions:
Adjunctive PF was associated with a 1.5-times and 2.7-times increased odds of readmission and morbidity, respectively. ASA class and specific comorbidities predicted poorer outcomes, while ALIF and CAS were protective. These findings can guide surgical solutions given specific patient factors.
... Pelvic fusion did not increase the operative time or blood loss compared to higher levels of fusion. Published studies have differed, with some demonstrating longer surgeries and more blood loss with pelvic fixation, while other studies did not find a difference [13,[19][20][21]. The long duration of surgery and magnitude of blood loss along with case to case variation may make it difficult to detect differences with statistical significance. ...
Background:
Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity.
Aim:
To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion.
Methods:
This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity.
Results:
The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 (P = 0.22). The pelvic obliquity was corrected by 43% and 36% in each group, respectively (P = 0.12). Regarding complications, patients fused to the pelvis had more total complications as compared to the other group (63.0% vs 30%, respectively, P = 0.025). After adjusting for differences in radiographic parameters (lumbar curve, L5 tilt, and pelvic obliquity), these patients had a 79% increased chance of developing complications (Relative risk = 1.79; 95%CI: 1.011-3.41).
Conclusion:
Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.
... However, the effect size is clinically compelling given that patients enrolled in UTSW POSH may have had a higher baseline risk for postoperative delirium due to their increased age, greater number of comorbidities, and procedural morbidity (pelvic fixation) compared to historical controls (Table 3). 3,31,[46][47][48][49][50] The lack of statistical difference may have stemmed from lack of power and possibility for type 2 error in our study. The limits of the confidence interval in the delirium rates of the aggregate patient population (0.35-1.03) suggest that inclusion of additional patients may have increased power to detect a difference (Table 4). ...
... While the UTSW POSH group were more likely to receive pelvic fixation, this is a change in surgical practice to reduce hardware failure and may add slightly more morbidity and blood loss to procedures. [48][49][50] Nonetheless, we feel that the 24-month time period preceding UTSW POSH program implementation represents a modern and comparable window. Lastly, the UTSW POSH program was implemented in a stepwise fashion and the initial patients were not followed by the geriatric consult service postoperatively. ...
Background:
Delirium is a common postoperative complication in geriatric patients, especially in those with underlying risk factors. Multicomponent nonpharmacologic interventions are effective in preventing delirium, however, implementation of these measures is variable in perioperative care. The aim of our study was to assess the impact of our Perioperative Optimization of Senior Health Program (UTSW POSH) on postoperative delirium in patients undergoing elective spine surgery.
Study design:
The UTSW POSH program is an interdisciplinary perioperative initiative involving geriatrics, surgery, and anesthesiology to improve care for high-risk geriatric patients undergoing elective spine surgery. Preoperatively, enrolled patients (n = 147) were referred for a geriatric assessment and optimization for surgery. Postoperatively, patients were co-managed by the primary surgical team and the geriatrics consult service. UTSW POSH patients were retrospectively compared to a matched historical control group (n = 177) treated with usual care. Main outcomes included postoperative delirium and provider recognition of delirium.
Results:
UTSW POSH patients were significantly older (75.5 vs 71.5 years; P < .001), had more comorbidities (8.02 vs 6.58; P < .001), and were more likely to undergo pelvic fixation (36.1% vs 17.5%; P < .001). The incidence of postoperative delirium was lower in the UTSW POSH group compared to historical controls, although not statistically significant (11.6% vs 19.2%; P = .065). Delirium was significantly lower in patients who underwent complex spine surgery (≥4 levels of vertebral fusion; N = 106) in the UTSW POSH group (11.7% vs 28.9%, P = .03). There was a threefold increase in the recognition of postoperative delirium by providers after program implementation, (76.5% vs 23.5%; P = .001).
Conclusions:
This study suggests that interdisciplinary care for high-risk geriatric patients undergoing elective spine surgery may reduce the incidence of postoperative delirium and increase provider recognition of delirium. The benefit may be greater for those undergoing larger procedures.
... However, once the number of levels fused and the patient's comorbidity profile was controlled for, the general complication profile of SPF procedures did not differ significantly from that of LF procedures. This result is similar to that of Kothari et al. who did not demonstrate an increase in morbidity in their SPF cohort, with the exception of increased rates of intra-or postoperative blood transfusion, and increased LOS 8) . ...
... The authors did not report on their patients' discharge disposition 8) . ...
Introduction: The effect of pelvic fixation on postoperative medical complications, blood transfusion, length of hospital stay, and discharge disposition is poorly understood. Determining factors that predispose patients to increased complications after spinopelvic fusion will help surgeons to plan these complex procedures and optimize patients preoperatively.
Methods: We conducted a retrospective cohort study using data from the ACS-NSQIP database between 2006 and 2016 of patients who underwent lumbar fusion with and without spinopelvic fixation. Data regarding demographics, complications, hospital stay, and discharge disposition were collected.
Results: A total of 57,417 (98.5%) cases of lumbar fusion without spinopelvic fixation (LF) and 887 (1.5%) cases of lumbar fusion with spinopelvic fixation (SPF) were analyzed. The transfusion rate in the SPF group was 59.3% vs 13% in the LF group (p < 0.001). The mean length of stay (LOS) and discharge to skilled nursing facility (SNF) were significantly different (LOS: SPF 6.5 days vs LF 3.5 days p < 0.001; SNF: SPF 21.3% vs LF 10.4% p < 0.001). After controlling for demographic differences, the overall complication rates were not significantly different between the groups (p = 0.531). The odds ratio for transfusion in the SPF group was 2.9 (p < 0.001). The odds ratio for increased LOS and increased care discharge disposition were elevated in the SPF group (LOS OR: 1.3, p < 0.012, Discharge disposition OR: 1.8, p < 0.001).
Conclusion: Patients who underwent SPF had increased complications, transfusion rate, LOS, and discharge to SNF or subacute rehab facilities as compared with patients who underwent LF. SPF remains an effective technique for achieving lumbosacral arthrodesis. Surgeons should consider the implications of the associated complication profile for SPF and the value of preoperative optimization in a select cohort of patients.
... Pelvic fixation has been shown to be independently associated with increased intraoperative and postoperative RBC transfusion in other studies in patients with ASD. 36 Importantly, in the patient population studied, pelvic fixation denoted only iliac or S2-alar-iliac fixation, with the majority being the former. However, even for iliac fixation multiple techniques may be utilized including placing dual iliac screws, and a kickstand or flying buttress construct. ...
Background:
Multilevel fusions and complex osteotomies to restore global alignment in adult spinal deformity (ASD) surgery can lead to increased operative time and blood loss. In this regard, we assessed factors predictive of perioperative blood product transfusion in patients undergoing long posterior spinal fusion for ASD.
Methods:
A single-institution retrospective review was conducted on 909 patients with ASD, age > 18 years, who underwent surgery for ASD with greater than 4 levels fused. Using conditional inference tree analysis, a machine learning methodology, we sought to predict the combination of variables that best predicted increased risk for intraoperative percent blood volume lost and perioperative blood product transfusion.
Results:
Among the 909 patients included in the study, 377 (41.5%) received red blood cell (RBC) transfusion. The conditional inference tree analysis identified greater than 13 levels fused, American Society of Anesthesiologists (ASA) score > 1, a history of hypertension, 3-column osteotomy, pelvic fixation, and operative time > 8 hours, as significant risk factors for perioperative RBC transfusion. The best predictors for the subgroup with the highest risk for intraoperative percent blood volume lost (subgroup mean: 53.1% ± 42.9%) were greater than 13 levels fused, ASA score > 1, preoperative hemoglobin < 13.6 g/dL, 3-column osteotomy, posterior column osteotomy, and pelvic fixation. Patients who underwent major blood transfusion intraoperatively had significantly longer length of stay (8.5 days) versus those who did not (6.1 days) (P < .0001). The overall 90-day complication rate in patients who underwent major blood transfusion intraoperatively was 49%, compared with 19% in those who did not (P < .0001). By multivariate regression analysis, patients with a preoperative hemoglobin > 13.0 were less likely to require major blood transfusion (odds ratio: 0.52, P = .046).
Conclusions:
Using a supervised learning technique, this study demonstrates that greater than 13 levels fused, ASA score > 1, 3-column osteotomy, and pelvic fixation are consistent risk factors for increased intraoperative percent blood volume lost and perioperative RBC transfusion. The addition of having a preoperative hemoglobin < 13.6 g/dL or undergoing a posterior column osteotomy conferred the highest risk for intraoperative blood loss. This information can assist spinal deformity surgeons in identifying at-risk individuals and allocating healthcare resources.
Level of evidence:
3.
... Previous studies on the inclusion of pelvic fixation in a spinal arthrodesis complex found that it independently increases blood loss, the need for perioperative transfusions, and postoperative morbidity. 16,20,25,27 Considering these data, we should expect patients in the TXA group to lose more blood and require a greater amount of perioperative blood products than the control group since they have received more complex surgery. 16,20,25,27 However, we observed no significant difference in any measure of intraoperative blood loss or utilization of blood products ( Table 3). ...
... 16,20,25,27 Considering these data, we should expect patients in the TXA group to lose more blood and require a greater amount of perioperative blood products than the control group since they have received more complex surgery. 16,20,25,27 However, we observed no significant difference in any measure of intraoperative blood loss or utilization of blood products ( Table 3). The similar amount of intraoperative blood loss in the TXA group despite larger procedures could be the result of a protective effect of TXA administration, since the two patient groups were otherwise similar at preoperative baseline. ...
OBJECTIVE
The aim of this study was to determine if the use of tranexamic acid (TXA) in long-segment spinal fusion surgery can help reduce perioperative blood loss, transfusion requirements, and morbidity.
METHODS
In this retrospective single-center study, the authors included 119 consecutive patients who underwent thoracolumbar fusion spanning at least 4 spinal levels from October 2016 to February 2019. Blood loss, transfusion requirements, perioperative morbidity, and adverse thrombotic events were compared between a cohort receiving intravenous TXA and a control group that did not.
RESULTS
There was no significant difference in any measure of intraoperative blood loss (1514.3 vs 1209.1 mL, p = 0.29) or transfusion requirement volume between the TXA and control groups despite a higher number of pelvic fusion procedures in the TXA group (85.9% vs 62.5%, p = 0.003). Postoperative transfusion volume was significantly lower in TXA patients (954 vs 572 mL, p = 0.01). There was no difference in the incidence of thrombotic complications between the groups.
CONCLUSIONS
TXA appears to provide a protective effect against blood loss in long-segment spine fusion surgery specifically when pelvic dissection and fixation is performed. TXA also seems to decrease postoperative transfusion requirements without increasing the risk of adverse thrombotic events.
... Selected postoperative complications relevant to the outcome of death were classified as major or minor in accordance with prior neurosurgical NSQIP studies (15)(16)(17). Minor complications included superficial or deep surgical site infection (SSI), pneumonia, urinary tract infection (UTI), and pneumonia. Major complications included deep venous thrombosis (DVT), acute kidney injury (AKI), ventilator for >48 h, unplanned intubation, sepsis/ septic shock, pulmonary embolism (PE), acute CVA, or myocardial infarction (MI). ...
Background:
Surgery for adult spinal deformity (ASD) can significantly improve quality of life but is associated with significant risk of morbidity. Among the most devastating potential complications after these operations is death. The current study aims to report the incidence, preoperative factors, and postoperative complications associated with all-cause mortality within 1 year following ASD surgery.
Methods:
Adults who underwent thoracolumbar spinal deformity correction between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Demographic characteristics were extracted. The primary outcome was death within 1 year of ASD surgery. Propensity score matching was used to control for confounding factors, followed by univariate/multivariable logistic regression to predict the odds of death within 1 year of ASD surgery.
Results:
A total of 6,158 patients underwent ASD surgery and 61 (0.99%) died within one year of surgery. Preoperative factors: controlling for age, gender, American Society of Anesthesiologists (ASA) score and postoperative complications, four independent risk factors were associated with all-cause mortality within 1 year of ASD surgery: increased age (OR =1.03; 95% CI, 1.01-1.06; P=0.012), ASA score (OR =4.32; 95% CI, 2.68-6.94; P<0.001), cancer history (OR =7.91; 95% CI, 4.23-14.78; P<0.001) and unintentional weight loss (OR =4.65; 95% CI, 1.68-12.89; P=0.003). Postoperative complications: using propensity score matching and multivariable logistic regression, three independent risk factors were associated with all-cause mortality within 1 year of ASD surgery: pneumonia (OR =4.00; 95% CI, 1.68-9.53), deep venous thrombosis (DVT) (OR =3.12; 95% CI, 1.20-8.10) and unplanned intubation (OR =3.13; 95% CI, 1.15-8.50).
Discussion:
Death after elective ASD surgery is a devastating yet uncommon event with an incidence of 1%. Preoperative factors of age, ASA score, cancer history, and unexpected weight loss, along with postoperative complications of pneumonia, DVT, and unplanned intubation were independently associated with all-cause mortality within 1 year of ASD surgery. Interestingly, the potentially more severe complications of sepsis, PE, and MI did not independently predict death.
Background
Adult spinal deformity (ASD) operations are complex and often require a multisurgeon team. Simultaneously, it is the responsibility of academic spine surgeons to train future complex spine surgeons. Our objective was to assess the effect of resident and fellow involvement (RFI) on ASD surgery in 4 areas: 1) perioperative outcomes, 2) length of stay (LOS), 3) discharge status, and 4) complications.
Methods
Adults undergoing thoracolumbar spinal deformity correction from 2008 to 2014 were identified in the National Surgical Quality Improvement Program database. Cases were divided into those with RFI and those with attendings only. Outcomes were operative time, transfusions, LOS, discharge status, and complications. Univariate and multivariable regression modeling was used. Covariates included preoperative comorbidities, specialty, and levels undergoing instrumentation.
Results
A total of 1471 patients underwent ASD surgery with RFI in 784 operations (53%). After multivariable regression modeling, RFI was independently associated with longer operations (β = 66.01 minutes; 95% confidence interval [CI], 35.82–96.19; P < 0.001), increased odds of transfusion (odds ratio, 2.80; 95% CI, 1.81–4.32; P < 0.001), longer hospital stay (β = 1.76 days; 95% CI, 0.18–3.34; P = 0.030), and discharge to an inpatient rehabilitation or a skilled nursing facility (odds ratio, 2.02; 95% CI, 1.34–3.05; P < 0.001). However, RFI was not associated with any increase in major or minor complications.
Conclusion
RFI in ASD surgery was associated with increased operative time, the need for additional transfusions, longer LOS, and nonhome discharge. However, no increase in major, minor, or severe complications occurred. These data support the continued training of future deformity and complex spine surgeons without fear of worsening complications; however, areas of improvement exist.
Objective:
To assess the impact of fixation to pelvis on 30-day outcomes following posterior spinal fusions in pediatric spine deformities.
Methods:
The 2012-2016 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database was queried using Current Procedural Terminology codes for patients undergoing posterior spinal fusions (22800, 22802 and 22804). Patients undergoing concurrent anterior fusion/combined fusion and anterior-only fusions were removed from the study. Patients undergoing additional fixation to pelvis were identified by CPT code 22848.
Results:
Out of a total of 13,398 patients, 1092 (8.2%) patients underwent a fixation to the pelvis. Following adjustment for differences in baseline characteristics, patient undergoing fixation to pelvis had a longer length of stay (OR 1.24 [1.04-1.48]), higher odds of any 30-day complication (OR 1.26 [1.03-1.55]), pneumonia (OR 1.85 [1.26-2.70), renal insufficiency (OR 6.87 [2.02-23.40), acute renal failure (OR 14.23 [2.36-84.51]), urinary tract infection (OR 1.99 [1.23-3.23]), cardiac arrest (OR 2.98 [1.10-8.06]), sepsis (OR 2.25 [1.35-3.74]), bleeding (OR 1.51 [1.25-1.82]), 30-day readmissions (OR 1.39 [1.07-1.81]) and 30-day re-operations (OR 1.37 [1.06-1.76]).
Conclusions:
In contrast to adult spinal deformity literature, pediatric patients undergoing a fixation to pelvis are at a higher risk of experiencing adverse outcomes within 30 days of surgery. Providers should utilize these data for pre-operative counselling and/or risk-stratification to improve quality-of-care in the acute post-operative period in these patients.
