Azeem Tariq Malik

The impact of surgeon volume on patient outcome in spine surgery: a systematic review

PurposeRecently, strategies aimed at optimizing provider factors have been proposed, including regionalization of surgeries to higher volume centers and adoption of volume standards. With limited literature promoting the regionalization of spine surgeries, we undertook a systematic review to investigate the impact of surgeon volume on outcomes in patients undergoing spine surgery.MethodsWe performed a systematic review examining the association between surgeon volume and spine surgery outcomes. To be included in the review, the study population had to include patients undergoing a primary or revision spinal procedure. These included anterior cervical discectomy and fusion (ACDF), anterior/posterior cervical fusion, laminectomy/decompression, anterior/posterior lumbar decompression with fusion, discectomy, and spinal deformity surgery (spine arthrodesis).ResultsStudies were variable in defining surgeon volume thresholds. Higher surgeon volume was associated with a significantly lower risk of postoperative complications, a lower length of stay (LOS), lower cost of hospital stay and a lower risk of readmissions and reoperations/revisions.ConclusionsFindings suggest a trend towards better outcomes for higher volume surgeons; however, further study needs to be carried out toxa0define objective volume thresholds for individual spine surgeries for surgeons to use as a marker of proficiency.

Fixation to Pelvis in Pediatric Spine Deformity—An Analysis of 30-Day Outcomes

OBJECTIVEnTo assess the impact of fixation to pelvis on 30-day outcomes after posterior spinal fusions in pediatric spine deformities.nnnMETHODSnThe 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program 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 codexa022848.nnnRESULTSnOf a total of 13,398 patients, 1092 (8.2%) patients underwent a fixation to the pelvis. After adjustment for differences in baseline characteristics, patients undergoing fixation to pelvis had a longer length of stay (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.04-1.48]), greater odds of any 30-day complication (OR 1.26; CI 1.03-1.55), pneumonia (OR 1.85; CI 1.26-2.70), renal insufficiency (OR 6.87; CI 2.02-23.40), acute renal failure (OR 14.23; CI 2.36-84.51), urinary tract infection (OR 1.99; CI 1.23-3.23), cardiac arrest (OR 2.98; CI 1.10-8.06), sepsis (OR 2.25; CI 1.35-3.74), bleeding (OR 1.51; CI 1.25-1.82), 30-day readmissions (OR 1.39; CI 1.07-1.81), and 30-day reoperations (OR 1.37; CI 1.06-1.76).nnnCONCLUSIONSnIn contrast to adult spinal deformity literature, pediatric patients undergoing a fixation to pelvis are at a greater risk of experiencing adverse outcomes within 30 days of surgery. Providers should use these data for preoperative counseling and/or risk-stratification to improve quality-of-care in the acute postoperative period in these patients.

Discharge to Inpatient Care Facility After Vertebroplasty/Kyphoplasty: Incidence, Risk Factors, and Postdischarge Outcomes

INTRODUCTIONnVertebral compression fractures are a common clinical occurrence in elderly individuals with osteoporosis. No current evidence exists on risk factors and clinical impact of discharge to inpatient (IP) care facility after vertebral augmentation procedures.nnnMATERIALS AND METHODSnThe 2012-2014 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database files were queried using Current Procedural Terminology codes for vertebroplasty (22520, 22521, and 22522) and kyphoplasty (22523, 22524, and 22525). Discharge to IP care facility included skilled-care facilities and IP rehabilitation units. A total of 2361 patients were included in the final cohort.nnnRESULTSnOf 2361 patients, 1962 (83.1%) were discharged home and 399 (16.9%) were discharged to an IP care facility. Multivariate analysis identified age ≥65 years (P < 0.001), dependent preoperative functional health status (P < 0.001), hypertension (Pxa0= 0.001), preoperative transfusion (Pxa0= 0.043), IP admission status (P < 0.001), thoracolumbar procedure versus thoracic-only procedure (Pxa0=xa00.012), and length of stay >1 day (P < 0.001) to be significant predictors for a discharge to an IP care facility. In addition, discharge to an IP care facility was associated with a significant greater risk of 30-day mortality (Pxa0=xa00.001). No significant associations were found with between IP-care discharge destination and any 30-day complication, 30-day readmission, and 30-day reoperation.nnnCONCLUSIONSnDischarge to IP care facilities after vertebroplasty/kyphoplasty is associated with a 3.6 times greater odds of mortality as compared with home discharge. Providers can use the risk profile data to better allow preoperative stratification of patients to ensure that discharge location is appropriate to a patients need to minimize the risk of adverse outcomes.

Is There a “Sex Effect” in 30-Day Outcomes After Elective Posterior Lumbar Fusions?

BACKGROUNDnSex has been known to significantly affect postoperative complications and length of stay after elective anterior cervical fusions. Current evidence on lumbar spine surgery is limited.nnnMETHODSnThe 2012-2016 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology codes 22612, 22630, and 22633 to identify patients undergoing posterior lumbar fusions. A total of 23,615 patients were included in the final cohort.nnnRESULTSnOut of 23,615 patients, 10,810 (45.8%) were men and 12,805 (54.2%) were women. After controlling for demographic, comorbidities-specific, preoperative, and operative differences between the 2 groups, female sex was found to be an independent risk factor significantly associated with a length of stay longer than 3 days (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.35-1.51; P < 0.001), occurrence of any complication within 30 days (OR, 1.31; 95% CI, 1.16-1.47; P < 0.001), wound complications (OR, 1.43; 95% CI, 1.18-1.74; P < 0.001), urinary tract infections (OR, 2.25; 95% CI, 1.79-2.83; P < 0.001), 30-day reoperations (OR, 1.19; 95% CI, 1.02-1.39; Pxa0= 0.025), 30-day readmissions (OR, 1.16; 95% CI, 1.03-1.31; Pxa0= 0.015), and nonhome discharge (OR, 1.83; 95% CI, 1.69-1.98; P < 0.001). Interestingly, the only adverse outcome associated with male sex was renal complication (OR, 2.28; 95% CI, 1.43-3.65; Pxa0= 0.001).nnnCONCLUSIONSnContrary to literature on cervical fusions, we found that female sex was independently tied to an increased risk of adverse outcomes after elective posterior lumbar fusion. The results from the study suggest that women may benefit from close surveillance during the postoperative period to minimize risk of complications and subsequent resource utilization in this group.

The Top 50 Most-Cited Articles on Cervical Spondylotic Myelopathy

BACKGROUNDnCervical spondylotic myelopathy (CSM) occurs due to chronic degenerative changes in the cervical spine causing compression of the spinal cord. CSM has been studied for decades, and numerous articles have been published on the topic. We sought to identify the top 50 most-cited articles on CSM.nnnMETHODSnThe top 50 most-cited articles were retrieved from the Scopus database using the search criteria cervical spondylosis with myelopathy OR cervical spondylotic myelopathy. Levels of evidence were also calculated and descriptive and statistical analyses were carried out.nnnRESULTSnThe total number of citations of the top 50 most-cited papers was 7072. The paper with the highest number of citations had 287. All articles were published between 1966 and 2010, with most published between 1990 and 1999 (nxa0= 22). The most prolific country in terms of the total number of publications was United States, with 25 publications, followed by Japan. The majority of the articles were level IV.nnnCONCLUSIONSnThere is a deficiency of high-level articles in the top 50 most-cited list. This study provides an important overview of historical development of treatment methods, as well as publication trends related to this pathology. Regardless, this comprehensive list of the top 50 most-cited articles can serve as a resource for future trainees and surgeons to draw on to build their knowledge base.

Discharge to skilled-care or rehabilitation following elective anterior cervical discectomy and fusion increases the risk of 30-day re-admissions and post-discharge complications

BackgroundnWith a shift toward value-based and bundled-payment models, identification of areas of cost and quality improvement will be required. Though abundant literature is present on the predictors of discharge destinations, few studies have studied the impact of discharge to a skilled-care or rehabilitation facility on post-discharge outcomes following elective spine surgery.nnnMethodsnThe 2015-2016 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes 22551 and 22552 to retrieve records of patients undergoing ACDF (≤3 levels). Patients who had concurrent posterior cervical spine procedures and surgery for malignancy and spinal deformity were excluded.nnnResultsnA total of 15,624 patients were finally included for analysis, 459 (2.9%) patients were discharged to a skilled care or rehabilitation facility. Age of ≥65 years, Black or African-American race, partially dependent or totally dependent functional health status, a LOS ≥3 days, a total operative time >150 min, ASA grade > II and inpatient surgery were significant predictors for a discharge to skilled care/rehabilitation facility. Following adjustment for pre-discharge clinical characteristics, discharge to skilled care or rehabilitation was an independent significant risk factor for renal complications (OR =8.22; 95% CI, 1.84-36.7; P=0.006) and 30-day readmissions (OR =1.63; 95% CI, 1.09-2.42; P=0.016).nnnConclusionsnDischarge to skilled-care or rehabilitation facilities following elective ACDF is associated with higher odds of renal complications and 30-day readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimize the risk of complications.

Chronic obstructive pulmonary disease is an independent predictor for 30-day readmissions following 1- to 2-level posterior lumbar fusions

BackgroundnChronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality worldwide. Past literature has demonstrated that patients with COPD are at an increased risk of post-operative complications. We assessed the impact of COPD on 30-day outcomes following a 1- to 2-level posterior lumbar fusion (PLF).nnnMethodsnThe 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using current procedural terminology (CPT) codes 22612, 22630 and 22633 to identify patients undergoing PLFs. Only patients undergoing a 1- to 2-level PLF for degenerative spine pathologies were included.nnnResultsnIn total, 1,123 (4.8%) of 23,481 patients undergoing an elective PLF had a diagnosis of COPD at the time of the surgery. Following adjusted logistic regression analysis, COPD was significantly associated with a longer length of stay of >3 days [odds ratio (OR), 1.40; 95% confidence interval (CI): 1.32-1.48; P=0.008], shorter total operative time (OR, 0.83; 95% CI: 0.73-0.94; P=0.003), discharge to skilled nursing care or rehabilitation facility (OR, 1.28; 95% CI: 1.09-1.51; P=0.002), pneumonia (OR, 2.53; 95% CI: 1.62-3.97; P<0.001) and 30-day readmissions (OR, 1.31; 95% CI: 1.03-1.65; P=0.025).nnnConclusionsnPatients with COPD are more likely to have a longer length of stay, discharge to nursing care/rehabilitation facility, and higher risk of pneumonia and readmissions within 30-days following 1- and 2-level PLF. Our analysis of a large national cohort of patients highlights the importance of pre-operative and post-operative medical optimization in these high-risk patients.

The Top 50 most-cited articles on Total Ankle Arthroplasty: A bibliometric analysis

Total Ankle Arthroplasty (TAA) is a relatively new and evolving field in Foot and Ankle surgery. We conducted a citation analysis to identify the characteristics of the top 50 most cited articles on total ankle arthroplasty. Using the Web of Science database and the search strategy total ankle arthroplasty OR total ankle replacement, we identified 2445 articles. After filtering for relevant articles, the top 50 cited articles on total ankle arthroplasty were retrieved for descriptive and statistical analysis. The publication years ranged from 1979 to 2013. USA was the most productive country in terms of research output, followed by the UK. Though citation analysis has its flaws, this is a comprehensive list of the top 50 articles significantly impacting literature on total ankle arthroplasty. Based on our study, we conclude that there is marked deficiency of high level articles with respect to the number of citations and future researches need to cater to this question to produce high quality studies.

Seasonal Influence on Postoperative Complications after Total Knee Arthroplasty

Purpose This study is aimed at investigating whether inpatient complications and surgical site infections (SSIs) occurred more commonly in patients undergoing total knee arthroplasty (TKA) during the summer season. Materials and Methods A total of 725 patients who underwent unilateral or bilateral TKA were included in this study. A total of 241 patients (33.2%) underwent TKA between May and August. Our outcomes of interest were the incidence of postoperative complications and length of stay. Results May–August surgeries were associated with a higher risk of postoperative inpatient complications (p=0.003). May–August surgeries (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.18 to 3.85), postoperative transfusion (OR, 2.46; 95% CI, 1.43 to 4.26), postoperative special care unit stay (OR, 4.68; 95% CI, 1.99 to 11.0) and chronic kidney disease (OR, 3.27; 95% CI, 1.15 to 9.28) were associated with a higher odds of developing inpatient complications. No association was present between summer surgeries and SSIs (p=0.486). Conclusions The results of this study show that overall complication rates following TKA exhibit a seasonal trend, with a peak during the summer months. These results may have some implication in clinical practice and stricter approaches to hospital guidelines during the summer months.

Does Surgeon Volume Affect Outcomes Following Primary Total Hip Arthroplasty? A Systematic Review

BACKGROUNDnSurgeon volume has been identified as an important factor impacting postoperative outcome in patients undergoing orthopedic surgeries. With an absence of a detailed systematic review, we sought to collate evidence on the impact of surgeon volume on postoperative outcomes in patients undergoing primary total hip arthroplasty.nnnMETHODSnPubMed (MEDLINE) and Google Scholar databases were queried for articles using the following search criteria: (Surgeon Volume OR Provider Volume OR Volume Outcome) AND (THA OR Total hip replacement OR THR OR Total hip arthroplasty). Studies investigating total hip arthroplasty being performed for malignancy or hip fractures were excluded from the review. Twenty-eight studies were included in the final review. All studies underwent a quality appraisal using the GRADE tool. The systematic review was performed in accordance with the PRISMA guidelines.nnnRESULTSnIncreasing surgeon volume was associated with a shorter length of stay, lower costs, and lower dislocation rates. Studies showed a significant association between an increasing surgeon volume and higher odds of early-term and midterm survivorship, but not long-term survivorships. Although complications were reported and recorded differently in studies, there was a general trend toward a lower postoperative morbidity with regard to complications following surgeries by a high-volume surgeon.nnnCONCLUSIONnThis systematic review shows evidence of a trend toward better postoperative outcomes with high-volume surgeons. Future prospective studies are needed to better determine long-term postoperative outcomes such as survivorship before healthcare policies such as regionalization and/or equal-access healthcare systems can be considered.