Brian Lenehan

Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients

BACKGROUND CONTEXT To date, most reports on the incidence of adverse events (AEs) in spine surgery have been retrospective and dependent on data abstraction from hospital-based administrative databases. To our knowledge, there have been no previous rigorously performed prospective analysis of all AEs occurring in the entire population of patients presenting to an academic quaternary referral center. PURPOSE To determine the mortality and true incidence and severity of morbidity (major and minor, medical and surgical) in adults undergoing complex spinal surgery, both trauma and elective, in a quaternary referral center. To examine the influence of the introduction of a dedicated weekly multidisciplinary rounds, and a formal abstraction tool, on the recording of this prospective perioperative morbidity data. To examine the validity and inter- and intraobserver reliability of a dedicated Spine AdVerse Events Severity system, version 2 (SAVES V2) AE abstraction tool. STUDY DESIGN Ours is an academic quaternary referral center serving a population of 4.5 million people. Beginning in April 2008, a spine-specific AE-recording instrument, entitled SAVES V2, was introduced at our center for reporting, categorization, and classification of AEs. The use of this system remains an ongoing prospective study. PATIENT SAMPLE All adult patients admitted to the spine service of a quaternary referral center for a 12-month period. OUTCOME MEASURES A validity and an inter- and intraobserver reliability examination of the SAVES V2 system, as used at our institution. Morbidity and inhospital deaths, unplanned second surgeries during index admission, wound infections requiring reoperation, and readmissions during the same calendar year. We also examined in detail all intraoperative and nonsurgical postoperative AEs, as well as hospital length of stay (LOS). METHODS Data on all patients undergoing surgery over a 12-month period were prospectively collected using a perioperative morbidity abstraction tool at weekly dedicated mortality and morbidity rounds. This tool allows identification of each specific AE and grades the severity. Before the introduction of this system, and using the hospital inpatient database, our documented perioperative morbidity rate (major and minor, medical and surgical) was 23%. Diagnosis, operative data, hospital data, major and minor complications both medical and surgical, and deaths were recorded. RESULTS One hundred percent of all patients discharged from the unit had complete data available for analysis. Nine hundred forty-two patients with an age range of 16 to 90 years (mean, 54 years; mode, 38 years) were identified. There were 552 males and 390 females. Around 58.5% of patients had undergone elective surgery. Thirty percent of patients were American Spinal Injury Association class D or worse on admission. The average LOS was 13.5 days (range, 1-221 days). Eight hundred twenty-two (87%) patients had at least one documented complication. Thirty-nine percent of these adversely affected hospital LOS. There were 14 mortalities during the study period. The rate of intraoperative surgical complication was 10.5% (4.5% incidental durotomy and 1.9% hardware malposition requiring revision and 2.2% blood loss >2 L). The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%). CONCLUSIONS Major spinal surgery in the adult is associated with a high incidence of intra- and postoperative complications. We identified a very high rate of previously unrecognized postoperative complications, which adversely affect LOS. Without strict adherence to a prospective data collection system, the true complexity of this surgery may be greatly underestimated.

The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability.

Study Design. Systematic review, ambispective analysis of observational data. Objective. To make recommendations as to whether or not urgent surgical decompression is ever indicated as the optimal treatment for enhancing neurologic recovery in a patient with acute central cord injury without fracture or instability. Summary of Background Data. There are currently no standards regarding the role and timing of decompression in acute traumatic central cord syndrome. In the setting of TCCS without spinal column instability, much controversy exists. Methods. We have performed a thorough literature search based on the following question: “Is there a role for urgent (within 24 hours from injury to surgery) surgical decompression in acute central cord syndrome without fracture or instability specifically to enhance neurologic recovery?” Data including patient demographics, mechanism of injury, comorbidities, neurologic status, and surgical treatment was analyzed from a multicenter STSG observational database. Outcome measured included ASIA Motor Score, ASIA Grade, Functional Independence Measure (FIM) Score, SF-36, Sphincter Disturbance, and Ambulatory status. Measures were recorded on admission, discharge, 6 months and 1 year. Results. At 12-month follow-up, early surgery resulted in a 6.31 point greater improvement in total motor score than did the late surgery group, with a P = 0.0358. At 6-month follow-up, early surgery result in higher chance of improvement in ASIA Grade than late surgery, with an odds ratio = 3.39, while at 12-month follow-up early surgery resulted in a higher chance of improvement in ASIA Grade, with an odds ratio of 2.81. Patients who were operated on within 24 hours had 7.79 U more improvement in FIM Total Score than late surgery at 6 month follow-up, with P = 0.0474. Conclusion. The consensus of experts following review of relevant and examination of observational dataset concluded that it is reasonable and safe to consider early surgical decompression in patients with profound neurologic deficit (ASIA = C) and persistent spinal cord compression due to developmental cervical spinal canal stenosis without fracture or instability. Those with less severe deficit (ASIA = D) can be treated with initial observation with surgery potentially at a later date depending on the extent and temporal profile of the patients neurologic recovery.

Intraobserver and interobserver reliabilty of measures of kyphosis in thoracolumbar fractures.

BACKGROUND CONTEXT Consensus documents have recently been developed enumerating the radiographic parameters thought to be most valid in the clinical evaluation of patients with thoracolumbar fractures. PURPOSE The objective of this study was to assess the measurement reliability of plain X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) and their inter-modality agreement, as the three imaging modalities are often clinically interchangeable. This process is an essential reliability evaluation of the measurement parameters being proposed. STUDY DESIGN This study evaluated the interobserver and intraobserver reliability of plain radiographs, CT, and MRI measurements of sagittal kyphosis in thoracolumbar fractures. PATIENT SAMPLE Suitable plain X-ray, CT, and MRI radiographic imaging of ten cases of thoracolumbar fracture were examined. METHODS Suitable plain X-ray, CT, and MRI radiographic imaging of ten cases of thoracolumbar fracture were examined by ten independent spine surgery fellowship-trained observers. OUTCOME MEASURES Cobb angle measurement, Gardner segmental deformity angle, and anterior body compression percentage were measured. RESULTS Regardless of the imaging modality or the parameter being measured, the intraobserver reliability is always better than the interobserver. Plain radiography has better overall, interobserver and intraobserver reliability, followed by CT and then MRI. Reliability is very high in general, with the highest reliability for intraobserver reliability of the linear measures on plain radiographs. The inter-modality agreement is highest for plain X-ray and CT. CONCLUSIONS This study demonstrates that Cobb angle measurement, Gardner segmental deformity angle, and anterior body compression percentage are reliable measures of thoracolumbar fracture kyphosis with very high interobserver and intraobserver reliability and very high inter-modality agreement of plain X-ray with CT.

Primary Pyogenic Infection of the Spine in Intravenous Drug Users : A Prospective Observational Study

Study Design. A prospective comparative analysis of surgically-treated nontuberculous primary pyogenic infection of the spine (PPIS). Objective. To evaluate and compare the demographics, presentation, treatment and outcomes of surgically-treated PPIS between intravenous drug users (IVDU) and non-IVDU patients. Summary of Background Data. This is the first prospective cohort comparative analysis of the clinical outcomes of surgically-treated PPIS between IVDU and non-IVDU populations. This is also the largest cohort of consecutive surgically-treated PPIS in a population of IVDU. Methods. Data on all patients with PPIS presenting to a quaternary referral center during a 4-year period from 2004 were collected in a prospectively maintained customized database. Results. During the study period there were 102 patients treated for PPIS of which 51 were IVDU. Of this IVDU group, the mean age was 43 years (range: 25–57). Twenty-three had human immunodeficiency virus, 43 had hepatitis C, and 13 had hepatitis B. All were using cocaine, 26 were also using heroin and 44 were using at least 3 recreational drugs. Thirty patients presented with axial pain of a mean duration of 51 days (range: 3–120 days). Of the IVDU patients with neurological deficit on presentation, the mean American Spinal Injury Association (ASIA) motor score was 58.6. The most common ASIA motor levels involved were C4 and C5. Mean duration of neurological symptoms was 7 days (range: 1–60 days). Twenty-six were already receiving IV antibiotics for known spinal infection and 33 patients had an identifiable organism on blood cultures (19 methicillin-sensitive Staphylococcus aureus, 9 methicillin-resistant S. aureus). Forty-four of the 51 IVDU patients were treated surgically. Thirty-four of the 44 surgically treated cases involved the cervical spine. Twenty-two had a posterior approach alone, 13 had anterior only while 9 required combined anterior and posterior approaches at the index surgery. Seven required early revision for hardware failure (none of whom has combined approach) and 2 developed a postoperative surgical site infection (SSI). Thirty-seven of the 51 IVDU patients were apprehended at least once using illicit drugs while in hospital. Mean duration of antibiotic treatment after surgery was 62 days. At discharge, 28 of 44 patients had neurological improvement (mean = 20 ASIA points, range: 1–55), 11 had neurological deterioration during treatment (mean = 13, range = 1–50), and 5 were unchanged. Among the IVDUs there were no in-hospital deaths. At 2 years after index admission 13 IVDU patients were dead, and none were attending for follow-up despite all efforts to locate the patients. In the non-IVDU group, the mean age of the 51 patients was 56 years (range 25–83). Thirty-four patients presented with axial pain with a mean duration of 105 days (range 2–365). Mean ASIA motor score of patients with neurological deficit on admission was 74. Most common ASIA level was T12. Mean duration of neurological symptoms was 12 days (range 1–84). Thirteen patients were receiving IV antibiotics for known spinal infection and 20 patients had an identifiable organism on blood culture (30% methicillin-sensitive S. aureus, 50% methicillin-resistant S. aureus). Forty-four of these 51 non-IVDU patients were treated surgically. Thirty-five of the 44 surgically-treated cases involved the thoracic or lumbar spines. Twenty-nine had a posterior approach alone, 3 had anterior alone while 12 required combined approaches. No early hardware failures were seen in the non-IVDU group while 4 developed SSI. Mean duration of antibiotic treatment after surgery was 45 days. At discharge 21 patients had neurological improvement (mean 9 ASIA points, range: 1–17). Five had neurologic deterioration with a mean motor loss of 16 points (10–23). There were 4 in-hospital deaths among the non-IVDU group. At 2 years after index admission, 19 patients were dead and the remainder were all available for follow-up. Conclusion. There are significant differences in demographics, presentation, treatment and outcomes of primary spinal pyogenic infection between a population of IVDU and a comparable cohort of non-IVDU. The IVDU group presents with cervical quadriplegia while it is the thoracolumbar spine that is almost exclusively involved in the non-IVDU group. Among the IVDUs, surgical management is complex with a high incidence of early hardware failure. SSI is significantly more common among non-IVDU. Significant neurological improvement can be expected in the majority of IVDU patients with a high mortality rate among the non-IVDU. IVDU are unreliable patients and in-hospital, in-halo incarceration is recommended where possible.

Introducing a new health-related quality of life outcome tool for metastatic disease of the spine: content validation using the International Classification of Functioning, Disability, and Health; on behalf of the Spine Oncology Study Group.

Study Design. A systematic review of Health Related-Quality of Life Outcomes (HRQOL) in metastatic disease of the spine and content validation of a new Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ). Objective. To identify HRQOL questionnaires previously reported for spinal metastases and to validate the content of the new SOSGOQ based on the International Classification of Function and Disability (ICF). Summary of Background Data. Literature on metastatic tumors of the spine and clinical outcomes is limited and generally of poor quality. The SOSG has developed a “quality of life” outcome tool specific for patients with metastatic of the spine. The ICF is a universal framework allowing content exploration, comparison, and validation of all questionnaires relating to HRQOL. Methods. A systematic review identified 141 studies. Reported outcome tools were enumerated. The most commonly used (ESAS, Karnofsky Scale, and Oswestry Disability Index) and the SOSGOQ were linked to the ICF. Descriptive statistics examined the frequency and specificity of the ICF linkage. Linkage reliability was evaluated by interinvestigator percentage agreement. Results. The SOSGOQ contains 56 concepts, with all 4 domains of the ICF represented. Four concepts could not be linked. There was 100% interobserver agreement (IOA) for total number of concepts and for those “not covered.” Hundred percent of concepts had “First and Second” level linkage. Hundred percent IOA exists at both “Component” and “First Level” linkage. There was 96.1% IOA at “Second Level”. Thirty-three concepts linked to Third Level with 96.9% IOA. Ten concepts linked at the Fourth Level with 100% IOA. Conclusion. The SOSGOQ includes all domains relevant for measurement of function and disability and its content validity is confirmed by linkage with the ICF. This new questionnaire has superior content capacity to measure disease burden of patients with metastatic disease of the spine than any instruments previously identified in the literature.

Diversity and Commonalities in the Care of Spine Trauma Internationally

Study Design. Questionnaires administered to practicing orthopedic and neurosurgical spine surgeons from North America, Europe, Asia, Australia, and New Zealand. Objective. To determine diversity and commonalities in the treatment of spine trauma internationally. Summary of Background Data. Previous studies have had suggested that there is significant variability in the treatment of common spinal trauma conditions. Methods. Questionnaires based on 10 commonly encountered spine trauma cases were administered to 77 experienced spinal surgeons across 4 continents. The questions for each case scenario were similar, but were tailored to be appropriate for the case being presented. Questions focused on the discipline of the specialist who would treat the injury, the treatment itself, and how long it would take for the patient to return home or to work. Questions pertaining to investigations, funding, estimated in-hospital length of stay, prehospital care, and mortality were also included. Each question was followed by 4 to 8 options from which the surgeon could chose a response. Data were analyzed using, SAS v9.2, a software analytical package, to determine the level of agreement between respondents on different items. Results. Of the 77 surgeons completing the questionnaire, 66% were fellowship trained spine surgeons, 20% orthopedic surgeons, and 14% neurosurgeons. In all regions, the majority of spinal trauma care is provided in a regional trauma center with dedicated spine surgeons. In all but 1 case significant differences were found in treatment with European and Asian surgeons have a higher operative rate. A combined anterior/posterior surgical approach was more commonly used in Europe and Asia. North American patients are expected to have a shorter hospital stay and return to work earlier. Significant differences exist between Asia and the other regions with regard to prehospital care. Conclusion. These findings suggest that despite the subspecialty focus in the care of spinal trauma, there continues to exist a lack of consensus among treating surgeons as to the optimum management and appropriateness of multiple aspects of specific operative and nonoperative interventions and indeed the postinjury management.

Simultaneous bilateral septic arthritis of the knee after intraarticular steroid injection: A clinical report

Osteoarthritis of knee is one of the common problems in elderly population. Intraarticular corticosteroid injection is a conservative management modality in osteoarthritis of knee. Septic arthritis is an infective complication of intraarticular corticosteroid injection. Septic arthritis in rheumatoid arthritis patients have worse prognosis because of delay in diagnosis. A higher rate of infectious complications following intraarticular injection is expected in immunocompromised and rheumatoid patients. We would like to report an extremely rare case of simultaneous bilateral knee septic arthritis after bilateral knee intraarticular steroid injection in a rheumatoid arthritis patient. Patient was treated successfully with multiple bilateral knee arthroscopic washouts and long-term intravenous antibiotics. This case report emphasizes the increased risk of infection in rheumatoid arthritis patients and a risk benefit assessment on individual basis before carrying out intraarticular steroid injection. Patient should be aware of this increased risk of infection.