Ahmed Aoude

Predictors of Discharge Destination After Lumbar Spine Fusion Surgery

Study Design. Retrospective cohort study of the prospective collected American College of Surgeons National Surgical Quality Improvement Program database. Objective. The aim of the study was to identify predictive factors for the need of discharging patients to a facility other than home after lumbar spine fusion surgery. Summary of Background Data. Lumbar spine fusion surgery is a common surgical procedure used to treat a variety of lumbar spine conditions. A great number of patients fail to go home after surgery and require admission to a rehabilitation center. Predictive factors for discharging patients to a facility other than home after lumbar fusion surgery do not exist in the literature. Methods. A total of 15,092 patients undergoing lumbar spine fusion were dichotomized based on discharge destination to patients who were discharged home (N = 12,339) and others who were discharged to a facility other than home (N = 2753). Outcomes included patient demographics, comorbidities, and clinical characteristics. A multivariate logistic regression was used to identify whether outcomes studied were predictive factors for discharging patients to a facility other than home after lumbar fusion surgery. Results. Majority of patients were discharged home after lumbar fusion surgery (81.76%), with only some discharged to a facility other than home (18.24%). Multivariate analysis identified age, female sex, comorbidities (diabetes, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and obesity), minor and major complications, hospital length of stay, operative time at least 259 minutes, and multilevel surgery as significant predictive factors of discharging patients to a facility other than home after lumbar fusion surgery. Conclusion. The identified predictive factors can help the health system in developing an algorithm for early recognition of patients requiring postoperative admission to a facility other than home and possibly decreasing their hospital length of stay. This can significantly decrease the hospital costs for such patients. Level of Evidence: 3

Incidence, Predictors, and Postoperative Complications of Blood Transfusion in Thoracic and Lumbar Fusion Surgery: An Analysis of 13,695 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

Study Design Retrospective cohort study. Objective To identify predictive factors for blood transfusion and associated complications in lumbar and thoracic fusion surgeries. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent lumbar or thoracic fusion from 2010 to 2013. Multivariate analysis was used to determine predictive factors and postoperative complications associated with transfusion. Results Out of 13,695 patients, 13,170 had lumbar fusion and 525 had thoracic fusion. The prevalence of transfusion was 31.8% for thoracic and 17.0% for lumbar fusion. The multivariate analysis showed that age between 50 and 60, age between 61 and 70, age > 70, dyspnea, American Society of Anesthesiologists class 3, bleeding disease, multilevel surgery, extended surgical time, return to operation room, and higher preoperative blood urea nitrogen (BUN) were predictors of blood transfusion for lumbar fusion. Multilevel surgery, preoperative BUN, and extended surgical time were predictors of transfusion for thoracic fusion. Patients receiving transfusions who underwent lumbar fusion were more likely to develop wound infection, venous thromboembolism, pulmonary embolism, and myocardial infarction and had longer hospital stay. Patients receiving transfusions who underwent thoracic fusion were more likely to have extended hospital stay. Conclusion This study characterizes incidence, predictors, and postoperative complications associated with blood transfusion in thoracic and lumbar fusion. Pre- and postoperative planning for patients deemed to be at high risk of requiring blood transfusion might reduce postoperative complications in this population.

Spontaneous spinal epidural hematoma management: a case series and literature review

Objective:Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord and leading to acute neurological deficits. Standard therapy is decompressive laminectomy, although spontaneous recoveries have been reported. Sub-optimal therapeutic principles contribute to SSEH’s 5.7% mortality—which patient will benefit from surgery remains unclear. This study aims to investigate parameters that affect SSEH’s progression, outlining a best-practice therapeutic approach.Materials and methods:Literature review yielded 65 cases from 12 studies. Furthermore, 6 cases were presented from our institution. All data were analyzed under American Spinal Injury Association (ASIA) score guidelines.Results:Fifty percent of SSEH patients do not fully recover. In all, 30% of patients who presented with an ASIA score of A did not improve with surgery, although every SSEH patient who presented at C or D improved. Spontaneous recovery is rare—only 23% of patients were treated conservatively. Seventy-three percent of those made a full recovery, as opposed to the 48% improvement in patients managed surgically. Thirty-three percent of patients managed conservatively had an initial score of A or B, all improving to a score of D or E without surgery. Regardless, conservative management tends toward low-risk presentations. Patients managed conservatively were three times as likely to have an initial score of D than their surgically managed counterparts.Discussion:The degree of pre-operative neural deficit is a major prognostic factor. Conservative management has proven effective, although feasible only if spontaneous recovery is manifested. Decompressive laminectomy should continue to remain readily available, given the inverse correlation between operative interval and recovery.

Differences between Manufacturers of Computed Tomography-Based Computer-Assisted Surgery Systems Do Exist: A Systematic Literature Review

Study Design Literature review. Objective Several studies have shown that the accuracy of pedicle screw placement significantly improves with use of computed tomography (CT)-based navigation systems. Yet, there has been no systematic review directly comparing accuracy of pedicle screw placement between different CT-based navigation systems. The objective of this study is to review the results presented in the literature and compare CT-based navigation systems relative only to screw placement accuracy. Methods Data sources included CENTRAL, Medline, PubMed, and Embase databases. Studies included were randomized clinical trials, case series, and case–control trials reporting the accuracy of pedicle screws placement using CT-based navigation. Two independent reviewers extracted the data from the selected studies that met our inclusion criteria. Publications were grouped based on the CT-based navigation system used for pedicle screw placement. Results Of the 997 articles we screened, only 26 met all of our inclusion criteria and were included in the final analysis, which showed a significant statistical difference (p < 0.0001, 95% confidence interval 0.92 to 1.23) in accuracy of pedicle screw placement between three different CT-based navigation systems. The mean (weighted) accuracy of pedicle screws placement based on the CT-based navigation system was found to be 97.20 ± 2.1% in StealthStation (Medtronic, United States) and 96.1 ± 3.9% in VectorVision (BrainLab, Germany). Conclusion This review summarizes results presented in the literature and compares screw placement accuracy using different CT-based navigation systems. Although certain factors such as the extent of the procedure and the experience and skills of the surgeon were not accounted for, the differences in accuracy demonstrated should be considered by spine surgeons and should be validated for effects on patients’ outcome.

Canadian Consensus for the Prevention of Blood Loss in Spine Surgery

Study Design. Cross-sectional, modified Delphi approach. Objective. The primary objective of this study was to identify patients at risk of increased perioperative blood loss according to the opinion of expert spine surgeons across Canada. The secondary objective was to obtain information about the experts’ approach on how to minimize significant blood loss perioperatively. Summary of Background Data. Significant blood loss in major spinal surgeries has been associated with increased intra- and perioperative complications and costs. The current available evidence regarding risk factors and preventive measures for increased blood loss remains incomplete. Methods. A modified Delphi approach was employed to generate consensus opinion on the risk factors and preventive measures for significant blood loss in major spinal surgeries. Twenty-five spine surgeons in Canada participated in this study. Results. Among various factors, surgery for the treatment of spine tumors and prolonged operative time of greater than 5 hours were found to be the most important predictive factors for blood loss in spine surgery. On the other hand, appropriate surgical hemostasis was considered the most effective measure for the prevention of blood loss in these surgeries. Conclusion. We recommend the reduction of blood loss by means of meticulous hemostasis and shorter operative time when it is safe and possible. This might result in better treatment outcomes. It would also lead to a reduction in costs associated with major spine surgeries and would ultimately lead to greater value-based spine care. Level of Evidence: 4

Postoperative Assessment of Pedicle Screws and Management of Breaches: A Survey among Canadian Spine Surgeons and a New Scoring System

Study Design This study was designed as a survey amongst Canadian spine surgeon to determine a scoring system to standardize pedicle screw placement assessment. Purpose This study aimed to obtain and analyze the opinions of spine surgeons regarding the assessment of pedicle screw accuracy, with the goal of establishing clinical guidelines for interventions for malpositioned pedicle screws. Overview of Literature Accurate placement of pedicle screws is challenging, and misalignment can lead to various complications. To date, there is no recognized gold standard for assessing pedicle screw placement accuracy. The literature is lacking studies attempting to standardize pedicle screw placement accuracy assessment. Methods A survey of the clinical methods and imaging criteria that are used for assessing pedicle screw placement accuracy was designed and sent to orthopedic and neurosurgery spine surgeons from the Canadian Spine Society for their anonymous participation. Results Thirty-five surgeons completed the questionnaire. The most commonly used modalities for assessing pedicle screw position postoperatively were plain X-rays (97%) and computed tomography (CT, 97%). In both symptomatic and asymptomatic patients, the most and least worrisome breaches were medial and anterior breaches, respectively. The majority of surgeons tended not to re-operate on asymptomatic breaches. More than 60% of surgeons would re-operate on patients with new-onset pain and a ≤4-mm medial or inferior breach in both thoracic and lumbar regions. If a patient experienced sensory loss and a breach on CT, in either the thoracic or lumbar levels, 90% and 70% of the surgeons would re-operate for a medial breach and an inferior breach, respectively. Conclusions Postoperative clinical presentation and imaging findings are crucial for interpreting aberrant pedicle screw placement. This study presents a preliminary scoring system for standardizing the classification of pedicle screws.

Use of Computer Assistance in Lumbar Fusion Surgery: Analysis of 15 222 Patients in the ACS-NSQIP Database:

Study Design: Retrospective cohort study. Objective: Several studies have shown that the accuracy of pedicle screw placement significantly improves with use of computer-assisted surgery (CAS). Yet few studies have compared the incidence of postoperative complications between CAS and conventional techniques. The objective of this study is to determine the difference in postoperative complication rates between CAS and conventional techniques in spine surgery. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent posterior lumbar fusion from 2011 to 2013. Multivariate analysis was conducted to demonstrate the difference in postoperative complication rates between CAS and conventional techniques in spine surgery. Results: Out of 15 222 patients, 14 382 (95.1%) were operated with conventional techniques and 740 (4.90%) were operated with CAS. Multivariate analysis showed that patients in the CAS group had fewer odds to experience adverse events postoperatively (odds ratio [OR] = 0.57, P < .001). Minor adverse events occurred in 2905 (20.2%) patients in the conventional group and in 98 (13.2%) patients in the CAS group (OR = 0.57, P < .001). Blood transfusion was present in 2488 (17.3%) of the patients in the conventional group compared to 81 (11.0%) of the patients in the CAS group (OR = 0.56, P < .001). The mean operative time in the conventional group was 205.2 ± 106.1 minutes, and it was 227.0 ± 111.9 minutes in the CAS group. This difference was statistically significant (r = 20.14, P < .001). Conclusion: This article examined the complications in lumbar spinal surgery with or without the use of CAS. These results suggest that CAS may provide a safer technique for implant placement in lumbar fusion surgeries.

Prevalence and Complications of Postoperative Transfusion for Cervical Fusion Procedures in Spine Surgery: An Analysis of 11,588 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

Study Design Retrospective cohort study. Purpose The purpose of this study was to assess the rate of blood transfusion after cervical fusion surgery, and its effect on complication rates. Overview of Literature Cervical spine fusions have gained interest in the literature since these procedures are now ever more frequently being performed in an outpatient setting with few complications. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent cervical fusion from 2010 to 2013. Multivariate regression analysis was used to determine postoperative complications associated with transfusion and cervical fusion. Results We identified 11,588 patients who had cervical fusion between 2010 and 2013. The rate of blood transfusion following cervical fusion found to be 1.47%. All transfused patients were found to have increased risk of venous thromboembolism (TBE) (odds ratio [OR], 3.19; 95% confidence interval [95% CI], 1.16–8.77), myocardial infarction (MI) (OR, 9.12; 95% CI, 2.53–32.8), increased length of stay (LOS) (OR, 28.03; 95% CI, 14.28–55.01) and mortality (OR, 4.14; 95% CI, 1.44–11.93). Single level fusion had increased risk of TBE (OR, 3.37; 95% CI, 1.01–11.33), MI (OR, 10.5; 95% CI, 1.88–59.89), and LOS (OR, 14.79; 95% CI, 8.2–26.67). Multilevel fusion had increased risk of TBE (OR, 5.64; 95% CI, 1.15–27.6), surgical site infection (OR, 16.29; 95% CI, 3.34–79.49), MI (OR, 10.84; 95% CI, 2.01–58.55), LOS (OR, 26.56; 95% CI, 11.8–59.78), and mortality (OR, 10.24; 95% CI, 2.45–42.71). Patients who had anterior cervical discectomy and fusion surgery and received a transfusion had an increased risk of TBE (OR, 4.87; 95% CI, 1.04–22.82), surgical site infection (OR, 9.73; 95% CI, 2.14–44.1), MI (OR, 9.88; 95% CI, 1.87–52.2), increased LOS of more than 2 days (OR, 28.34; 95% CI, 13.79–58.21) and increase in mortality (OR, 6.3; 95% CI, 1.76–22.48). While, transfused patients who had posterior fusion surgery had increased risk of MI (OR, 10.45; 95% CI, 1.42–77.12) and increased LOS of more than 6 days (OR, 4.42; 95% CI, 2.68–7.29). Conclusions Our results demonstrate that although cervical fusions can be done as outpatient procedures special precautions and investigations should be done for patients who receive transfusion after cervical fusion. These patients are demonstrated to have higher rate of MI, TBE, wound infection and mortality when compared to those who do not receive transfusion.

Traumatic posterior shoulder dislocation with a large engaging Hill-Sachs lesion: splinting technique

Posterior shoulder dislocations are rare and are often associated with seizures, electrocution, and high-energy trauma. They can be missed and, therefore, left untreated. Early diagnosis and treatment can help avoid future complications and surgical intervention.

Multiple Soft Tissue Sarcomas in a Single Patient: An International Multicentre Review

Developing multiple soft tissue sarcomas (STSs) is a rare process, sparsely reported in the literature to date. Little is known about the pattern of disease development or outcomes in these patients. Patients were identified from three tertiary orthopaedic oncology centres in Canada and the UK. Patients who developed multiple extremity STSs were collated retrospectively from prospective oncology databases. A literature review using MEDLINE was also performed. Six patients were identified in the case series from these three institutions, and five studies were identified from the literature review. Overall, 17 patients were identified with a median age of 51 years (range: 19 to 77). The prevalence of this manifestation in STS patients is 1 in 1225. The median disease-free interval between diagnoses was 2.3 years (range: 0 to 19 years). Most patients developed the secondary STS in a metachronous pattern, the remaining, synchronously. The median survival after the first sarcoma was 6 years, and it was 1.6 years after the second sarcoma. The 5-year overall survival rate was 83.3% and 50% following the first and second STS diagnoses, respectively. A diagnosis of two STSs does not confer a worse prognosis than the diagnosis of a single STS. Developing a second STS is a rare event with no identifiable histological pattern of occurrence. Presentation in a metachronous pattern is more common. A high degree of vigilance is required in patients with a previous STS both to detect both local recurrence and to identify new masses remote from the previous STS site. Acquiring an early histological diagnosis should be attempted.