Charles A. Sansur

Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age.

Study Design. Retrospective review of a prospective, multicenter database. Objective. The purpose of this study was to assess whether elderly patients undergoing scoliosis surgery had an incidence of complications and improvement in outcome measures comparable with younger patients. Summary of Background Data. Complications increase with age for adults undergoing scoliosis surgery, but whether this impacts the outcomes of older patients is largely unknown. Methods. This is a retrospective review of a prospective, multicenter spinal deformity database. Patients complete the Oswestry Disability Index (ODI), SF-12, Scoliosis Research Society-22 (SRS-22), and numerical rating scale (NRS; 0–10) for back and leg pain. Inclusion criteria included age 25 to 85 years, scoliosis (Cobb ≥ 30°), plan for scoliosis surgery, and 2-year follow-up. Results. Two hundred six of 453 patients (45%) completed 2-year follow-up, which is distributed among age groups as follows: 25 to 44 (n = 47), 45 to 64 (n = 121), and 65 to 85 (n = 38) years. The percentages of patients with 2-year follow-up by age group were as follows: 25 to 44 (45%), 45 to 64 (48%), and 65 to 85 (40%) years. These groups had perioperative complication rates of 17%, 42%, and 71%, respectively (P < 0.001). At baseline, elderly patients (65–85 years) had greater disability (ODI, P = 0.001), worse health status (SF-12 physical component score (PCS), P < 0.001), and more severe back and leg pain (NRS, P = 0.04 and P = 0.01, respectively) than younger patients. Mean SRS-22 did not differ significantly at baseline. Within each age group, at 2-year follow-up there were significant improvements in ODI (P ⩽ 0.004), SRS-22 (P ⩽ 0.001), back pain (P < 0.001), and leg pain (P ⩽ 0.04). SF-12 PCS did not improve significantly for patients aged 25 to 44 years but did among those aged 45 to 64 (P < 0.001) and 65 to 85 years (P = 0.001). Improvement in ODI and leg pain NRS were significantly greater among elderly patients (P = 0.003, P = 0.02, respectively), and there were trends for greater improvements in SF-12 PCS (P = 0.07), SRS-22 (P = 0.048), and back pain NRS (P = 0.06) among elderly patients, when compared with younger patients. Conclusion. Collectively, these data demonstrate the potential benefits of surgical treatment for adult scoliosis and suggest that the elderly, despite facing the greatest risk of complications, may stand to gain a disproportionately greater improvement in disability and pain with surgery.

Rates of infection after spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee.

Study Design. Retrospective review of a prospectively collected database. Objective. Our objective was to assess the rates of postoperative wound infection associated with spine surgery. Summary of Background Data. Although wound infection after spine surgery remains a common source of morbidity, estimates of its rates of occurrence remain relatively limited. The Scoliosis Research Society prospectively collects morbidity and mortality data from its members, including the occurrence of wound infection. Methods. The Scoliosis Research Society morbidity and mortality database was queried for all reported spine surgery cases from 2004 to 2007. Cases were stratified based on factors including diagnosis, adult (≥21 years) versus pediatric (<21 years), primary versus revision, use of implants, and whether a minimally invasive approach was used. Superficial, deep, and total infection rates were calculated. Results. In total, 108,419 cases were identified, with an overall total infection rate of 2.1% (superficial = 0.8%, deep = 1.3%). Based on primary diagnosis, total postoperative wound infection rate for adults ranged from 1.4% for degenerative disease to 4.2% for kyphosis. Postoperative wound infection rates for pediatric patients ranged from 0.9% for degenerative disease to 5.4% for kyphosis. Rate of infection was further stratified based on subtype of degenerative disease, type of scoliosis, and type of kyphosis for both adult and pediatric patients. Factors associated with increased rate of infection included revision surgery (P < 0.001), performance of spinal fusion (P < 0.001), and use of implants (P < 0.001). Compared with a traditional open approach, use of a minimally invasive approach was associated with a lower rate of infection for lumbar discectomy (0.4% vs. 1.1%; P < 0.001) and for transforaminal lumbar interbody fusion (1.3% vs. 2.9%; P = 0.005). Conclusion. Our data suggest that postsurgical infection, even among skilled spine surgeons, is an inherent potential complication. These data provide general benchmarks of infection rates as a basis for ongoing efforts to improve safety of care.

Incidence of symptomatic hemorrhage after stereotactic electrode placement

OBJECT Intracranial hemorrhage (ICH) is the most significant complication associated with the placement of stereotactic intracerebral electrodes. Previous reports have suggested that hypertension and the use of microelectrode recording (MER) are risk factors for cerebral hemorrhage. The authors evaluated the incidence of symptomatic ICH in a large cohort of patients with various diseases treated with stereotactic electrode placement. They examined the effect of comorbidities on the risk of ICH and independently assessed the risks associated with age, sex, use of MER, diagnosis, target location, hypertension, and previous use of anticoagulant medications. The authors also evaluated the effect of hemorrhage on length of hospital stay and discharge disposition. METHODS Between 1991 and 2005, 567 electrodes were placed by two neurosurgeons during 337 procedures in 259 patients. Deep brain stimulation (DBS) was performed in 167 procedures, radiofrequency lesioning (RFL) of subcortical structures in 74, and depth electrodes were used in 96 procedures in patients with epilepsy. Electrodes were grouped according to target, patient diagnosis, use of MER, patient history of hypertension, and patient prior use of anticoagulant medication (stopped 10 days before surgery). The Charlson Comorbidity Index (CCI) was used to evaluate the effect of comorbidities. The CCI score, patient age, length of hospital stay, and discharge status were continuous variables. Symptomatic hemorrhages were grouped as transient or leading to permanent neurological deficits. RESULTS The risk of hemorrhage leading to permanent neurological deficits in this study was 0.7%, and the risk of symptomatic hemorrhage was 1.2%. A patient history of hypertension was the most significant factor associated with hemorrhage (p = 0.007). Older age, male sex, and a diagnosis of Parkinson disease (PD) were also significantly associated with hemorrhage (p = 0.01, 0.04, 0.007, respectively). High CCI scores, specific target locations, and prior use of anticoagulant therapy were not associated with an increased risk of hemorrhage. The use of MER was not found to be correlated with an increased hemorrhage rate (p = 0.34); however, the number of hemorrhages in the patients who underwent DBS was insufficient to draw definitive conclusions. The mean length of stay for the DBS, RFL, and depth electrode patient groups was 2.9, 2.6, and 11.0 days, respectively. For patients who received DBS and RFL, the mean duration of hospitalization in cases of symptomatic hemorrhage was 8.2 days compared with 2.7 days in those without hemorrhaging (p < 0.0001). Three of the seven patients with symptomatic hemorrhages were discharged home. CONCLUSIONS The placement of stereotactic electrodes is generally safe, with a symptomatic hemorrhage rate of 1.2%, and a 0.7% rate of permanent neurological deficit. Consistent with prior reports, this study confirms that hypertension is a significant risk factor for hemorrhage. Age, male sex, and diagnosis of PD were also significant risk factors. Patients with symptomatic hemorrhage had longer hospital stays and were less likely to be discharged home.

Rates of new neurological deficit associated with spine surgery based on 108,419 procedures: A report of the scoliosis research society morbidity and mortality committee

Study Design. Retrospective review of a prospectively collected, multicenter database. Objective. To assess rates of new neurologic deficit (NND) associated with spine surgery. Summary of Background Data. NND is a potential complication of spine surgery, but previously reported rates are often limited by small sample size and single-surgeon experiences. Methods. The Scoliosis Research Society morbidity and mortality database was queried for spinal surgery cases complicated by NND from 2004 to 2007, including nerve root deficit (NRD), cauda equina deficit (CED), and spinal cord deficit (SCD). Use of neuromonitoring was assessed. Recovery was stratified as complete, partial, or none. Rates of NND were stratified based on diagnosis, age (pediatric < 21; adult ≥ 21), and surgical parameters. Results. Of the 108,419 cases reported, NND was documented for 1064 (1.0%), including 662 NRDs, 74 CEDs, and 293 SCDs (deficit not specified for 35 cases). Rates of NND were calculated on the basis of diagnosis. Revision cases had a 41% higher rate of NND (1.25%) compared with primary cases (0.89%; P < 0.001). Pediatric cases had a 59% higher rate of NND (1.32%) compared with adult cases (0.83%; P < 0.001). The rate of NND for cases with implants was more than twice that for cases without implants (1.15% vs. 0.52%, P < 0.001). Neuromonitoring was used for 65% of cases, and for cases with new NRD, CED, and SCD, changes in neuromonitoring were reported in 11%, 8%, and 40%, respectively. The respective percentages of no recovery, partial, and complete recovery for NRD were 4.7%, 46.8%, and 47.1%, respectively; for CED were 9.6%, 45.2%, and 45.2%, respectively; and for SCD were 10.6%, 43%, and 45.7%, respectively. Conclusion. Our data demonstrate that, even among skilled spinal deformity surgeons, new neurologic deficits are inherent potential complications of spine surgery. These data provide general benchmark rates for NND with spine surgery as a basis for patient counseling and for ongoing efforts to improve safety of care.

Scoliosis research society morbidity and mortality of adult scoliosis surgery

Study Design. A retrospective review. Objective. To obtain an assessment of complication incidence using the largest known database of adult scoliosis and to determine whether the rate of complication depends on various clinical parameters. Summary of Background Data. The Scoliosis Research Society (SRS) morbidity and mortality database has previously been used to assess complication rates in adolescents undergoing scoliosis correction. To better understand complications in adults, degenerative and idiopathic adult scoliosis (AS) cases were studied. Methods. The SRS morbidity and mortality database was queried to identify cases of AS from 2004 to 2007. Complications were identified and analyzed on the basis of patient type of scoliosis (degenerative vs. adult idiopathic), age, use of osteotomy, revision surgery status, and surgical approach. Age was stratified into less than or equal to 60 and greater than 60. Surgical approach was stratified into anterior only, posterior only, and combined anterior/posterior. Results. A total of 4980 cases of AS were submitted from 2004 to 2007. There were 521 patients with complications (10.5%), and a total of 669 complications (13.4%). The most common complications were dural tear 142 (2.9%), superficial wound infection 46 (0.9%), deep wound infection 73 (1.5%), implant complication 80 (1.6%), acute neurological deficits 49 (1.0%), delayed neurological deficits 41 (0.5%), epidural hematoma 12 (0.2%), wound hematoma 22 (0.4%), pulmonary embolus 12 (0.2%), and deep venous thrombosis 9 (0.2%). There were 17 deaths (0.3%). There were 2555 patients with degenerative and 2425 patients with adult idiopathic scoliosis. Complication rates in these two groups were not significantly different (11.0% and 9.9%, respectively, P = 0.20). Age was not associated with complication rate (P = 0.32). Significantly higher complication rates were identified in osteotomies, revision surgery, and/or combined anterior-posterior surgery (P = 0.0006, 0.006, and 0.03, respectively). Conclusions. The overall complication rate for AS treatment is 13.4%. Complication rate is significantly higher when osteotomies, revision procedures, and combined anterior/posterior approaches are used. Complication rate is not influenced by scoliosis type or age.

Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee.

Study Design. Retrospective review. Objective. Our objective was to assess the short-term complication rate in patients undergoing treatment of thoracolumbar fixed sagittal plane deformity (FSPD). Summary of Background Data. The reported morbidity and mortality for the surgical treatment of thoracolumbar FSPD is varied and based on studies with small sample sizes. Further studies are needed to better assess FSPD complication rate, and the factors that influence it. Methods. The Scoliosis Research Society (SRS) Morbidity and Mortality Database was queried to identify cases of thoracolumbar FSPD from 2004 to 2007. Complications were analyzed based on correction technique, surgical approach, surgeon experience (SRS membership status used as a surrogate), patient age, and history of prior surgery. Results. Five hundred and seventy-eight cases of FSPD were identified. Osteotomies were performed in 402 cases (70%), including 215 pedicle subtraction osteotomies (PSO), 135 Smith–Petersen osteotomies (SPO), 19 anterior discectomy with corpectomy procedures (ADC), 18 vertebral column resections (VCR), and 15 unspecified osteotomies. There were 170 complications (29.4%) in 132 patients. There were three deaths (0.5%). The most common complications were durotomy (5.9%), wound infection (3.8%), new neurologic deficit (3.8%), implant failure (1.7%), wound hematoma (1.6%), epidural hematoma (1.4%), and pulmonary embolism (1.0%). Procedures including an osteotomy had a higher complication rate (34.8%) than cases not including an osteotomy (17.0%, P < 0.001), and this remained significant after adjusting for the effects of patient age, surgeon experience, and history of prior surgery (P = 0.003, odds ratio = 2.070, 95% CI = 1.291–3.321). Not significantly associated with complication rate were patient age (P = 0.68), surgeon experience (P = 0.18), and history of prior surgery (P = 0.10). Complication rates were progressively higher from no osteotomy (17.0%), to SPO (28.1%), to PSO (39.1%), to VCR (61.1%). Conclusion. The short-term complication rate for treatment of FSPD is 29.4%. The complication rate was significantly higher in patients undergoing osteotomies, and more aggressive osteotomies were associated with progressively higher complication rates.

Complication rates of three common spine procedures and rates of thromboembolism following spine surgery based on 108,419 procedures: A report from the scoliosis research society morbidity and mortality committee

Study Design. Retrospective review of a prospectively collected database. Objective. The Scoliosis Research Society (SRS) collects morbidity and mortality (M and M) data from its members. Our objectives were to assess complication rates for 3 common spine procedures, compare these results with prior literature as a means of validating the database, and to assess rates of pulmonary embolism (PE) and deep venous thrombosis (DVT) in all cases reported to the SRS over 4 years. Summary of Background Data. Few modern series document complication rates of spinal surgery as routinely practiced across academic and community settings. Those available are typically based on relatively low numbers of procedures or confined to single-surgeon experiences. Methods. The SRS M and M database was queried for lumbar microdiscectomy (LD), anterior cervical discectomy and fusion (ACDF), and lumbar stenosis decompression (LSD) cases from 2004 to 2007. Revisions were excluded. The database was also queried for occurrence of clinically evident PE and DVT in all cases from 2004 to 2007. Results. A total of 9692 LDs, 6735 ACDFs, and 10,329 LSDs were identified, with overall complication rates of 3.6%, 2.4%, and 7.0%, respectively. These rates are comparable to previously published smaller series. For assessment of PE and DVT, 108,419 cases were identified and rates were calculated per 1000 cases based on diagnosis, age group, and implant use. Overall rates of PE, death due to PE, and DVT were 1.38, 0.34, and 1.18, respectively. Among 82,082 adults, the rate of PE ranged from 0.47 for LD to 12.4 for metastatic tumor. Similar variations were noted for DVT and deaths due to PE. Conclusion. Overall major complication rates for LD, ACDF, and LSD based on the SRS M and M database are comparable to those in previously reported smaller series, supporting the validity of this database for study of other less common spinal disorders. In addition, our data provide general benchmarks of clinically evident PE and DVT rates as a basis for ongoing efforts to improve care.

Radiographic restoration of lumbar alignment after transforaminal lumbar interbody fusion.

OBJECTIVERestoration of lumbar lordosis is a critical factor in long-term success after lumbar fusions. Transforaminal lumbar interbody fusion (TLIF) is a popular surgical technique in the lumbar spine, but few data exist on change in spinal alignment after the procedure. METHODSEighty patients who underwent TLIF surgery were retrospectively reviewed (minimum follow-up period, 2 years). Standing x-rays were assessed for changes in focal and segmental kyphosis, and restoration of lumbar lordosis. Improvement in spondylolisthesis, sagittal balance, and scoliosis were also assessed. Fusion was assessed as well. RESULTSEighty operations were performed at 107 levels. Mean presenting lumbar Cobb angle measurement (L1–S1) was 36.3 ± 4.5 degrees (range, 12–77 degrees). Forty patients (50%) had sagittal imbalance. Mean postoperative Cobb angle (L1–S1) was 55.1 ± 6.6. Thirty-three of 36 patients with segmental kyphosis (92%) had restoration of lordosis. Improvement in alignment was most prominent at the surgical level (mean increase in lordosis, 20.2 ± 4.2 degrees). The improvement in lumbar lordosis among patients undergoing multilevel TLIFs (27.3 ± 3.4 degrees) was significantly higher compared with patients undergoing single-level operations (17.4 ± 4.4) (Students t test, P = 0.0004). Thirty of the 40 patients with sagittal imbalance (75%) achieved immediate restoration of normal sagittal balance. The ability to restore normal sagittal balance was correlated with a sagittal imbalance of less than 10 cm (P = 0.0001). Spondylolisthesis was completely corrected at the TLIF site in 90 of 99 levels (91%). Three patients (4%) required reoperation, 2 for implant disengagement and 1 for worsening kyphoscoliosis above the original surgical levels. Two of the 80 patients had pseudoarthrosis; hence, the rate of pseudoarthrosis was 2.5%. CONCLUSIONThe TLIF operation is highly effective in improving spinal alignment in patients with degenerative spinal disorders when the appropriate surgical technique is implemented.

Morbidity and mortality in the surgical treatment of 10,329 adults with degenerative lumbar stenosis

OBJECT The purpose of this study was to evaluate the prospectively collected Scoliosis Research Society (SRS) database to assess the incidences of morbidity and mortality (M&M) in the operative treatment of degenerative lumbar stenosis, one of the most common procedures performed by spine surgeons. METHODS All patients who underwent surgical treatment for degenerative lumbar stenosis between 2004 and 2007 were identified from the SRS M&M database. Inclusion criteria for analysis included an age >or= 21 years and no history of lumbar surgery. Patients were treated with either decompression alone or decompression with concomitant fusion. Statistical comparisons were performed using a 2-sided Fisher exact test. RESULTS Of the 10,329 patients who met the inclusion criteria, 6609 (64%) were treated with decompression alone, and 3720 (36%) were treated with decompression and fusion. Among those who underwent fusion, instrumentation was placed in 3377 (91%). The overall mean patient age was 63 +/- 13 years (range 21-96 years). Seven hundred nineteen complications (7.0%), including 13 deaths (0.1%), were identified. New neurological deficits were reported in 0.6% of patients. Deaths were related to cardiac (4 cases), respiratory (5 cases), pulmonary embolus (2 cases), and sepsis (1 case) etiologies, and a perforated gastric ulcer (1 case). Complication rates did not differ based on patient age or whether fusion was performed. Minimally invasive procedures were associated with fewer complications and fewer new neurological deficits (p = 0.01 and 0.03, respectively). CONCLUSIONS The results from this analysis of the SRS M&M database provide surgeons with useful information for preoperative counseling of patients contemplating surgical intervention for symptomatic degenerative lumbar stenosis.

Incidence of Unintended Durotomy in Spine Surgery Based on 108 478 Cases

BACKGROUND:Unintended durotomy is a common complication of spinal surgery. However, the incidences reported in the literature vary widely and are based primarily on relatively small case numbers from a single surgeon or institution. OBJECTIVE:To provide spine surgeons with a reliable incidence of unintended durotomy in spinal surgery and to assess various factors that may influence the risk of durotomy. METHODS:We assessed 108 478 surgical cases prospectively submitted by members of the Scoliosis Research Society to a deidentified database from 2004 to 2007. RESULTS:Unintended durotomy occurred in 1.6% (1745 of 108 478) of all cases. The incidence of unintended durotomy ranged from 1.1% to 1.9% on the basis of preoperative diagnosis, with the highest incidence among patients treated for kyphosis (1.9%) or spondylolisthesis (1.9%) and the lowest incidence among patients treated for scoliosis (1.1%). The most common indication for spine surgery was degenerative spinal disorder, and among these patients, there was a lower incidence of durotomy for cervical (1.0%) vs thoracic (2.2%; P = .01) or lumbar (2.1%, P < .001) cases. Scoliosis procedures were further characterized by etiology, with the highest incidence of durotomy in the degenerative subgroup (2.2% vs 1.1%; P < .001). Durotomy was more common in revision compared with primary surgery (2.2% vs 1.5%; P < .001) and was significantly more common among elderly (> 80 years of age) patients (2.2% vs 1.6%; P = .006). There was a significant association between unintended durotomy and development of a new neurological deficit (P < .001). CONCLUSION:Unintended durotomy occurred in at least 1.6% of spinal surgeries, even among experienced surgeons. Our data provide general benchmarks of durotomy rates and serve as a basis for ongoing efforts to improve safety of care.