Jeffery Kim

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.

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.

Chronic Obstructive Pulmonary Disease Is an Independent Predictor for 30-Day Complications and Readmissions Following 1- to 2-Level Anterior Cervical Discectomy and Fusion

Study Design: Retrospective cohort. Objectives: To study evidence to assess the impact of chronic obstructive pulmonary disease (COPD) on 30-day outcomes following 1- to 2-level anterior cervical discectomy and fusion (ACDF). Methods: The 2015-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using Current Procedural Terminology (CPT) codes 22u2009551 (single-level) and 22u2009552 (additional level). Patients undergoing disc arthroplasty, multilevel (>2) fusion, posterior cervical spine surgery, and patients with fracture, tumor, and/or infection were excluded. Results: Out of 14u2009835 patients undergoing an elective 1- to 2-level ACDF, 649 (4.4%) had a diagnosis of COPD at the time of the surgery. Following adjusted logistic regression analysis, prior history of COPD was significantly associated with a longer length of stay (odds ratio [OR] 1.25 [95% confidence interval (CI0 1.04-1.52]; P = .019), superficial surgical site infection (OR 2.68 [95% CI 1.06-6.80]; P = .038), discharge destination other than home (OR 1.49 [95% CI 1.05-2.12]; P = .026), pneumonia (OR 4.37 [95% CI 2.42-7.88]; P < .001), ventilator use >48 hours (OR 5.34 [95% CI 1.88-15.15]; P = .002), unplanned reintubation (OR 3.36 [1.48-7.62]; P = .004), and 30-day readmissions (OR 1.69 [95% CI 1.20-2.38]; P = .003). Conclusions: The findings of this study show that COPD patients are more likely to have postoperative complications and 30-day readmissions, despite elective ACDF itself being a low-risk surgery in general. Results show that majority of the complications were pulmonary in nature, further stressing the need for accurate medical optimization following surgery in these patients.

Sexual activity after spine surgery: a systematic review

IntroductionSexual function is an important determinant of quality of life, and factors such as surgical approach, performance of fusion, neurological function and residual pain can affect it after spine surgery. Our aim was to perform a systematic review to collate evidence regarding the impact of spine surgery on sexual function.MethodsA systematic review of studies reporting measures of sexual function, and incidence of adverse sexual outcomes (retrograde ejaculation) after major spine surgery was done, regardless of spinal location. Pubmed (MEDLINE) and Google Scholar databases were queried using the following search words “Sex”, “Sex life”, “Sexual function”, “Sexual activity”, “retrograde ejaculation”, “Spine”, “Spine surgery”, “Lumbar surgery”, “Lumbar fusion”, “cervical spine”, “cervical fusion”, “Spinal deformity”, “scoliosis” and “Decompression”. All articles published between 1997 and 2017 were retrieved from the database. A total of 81 studies were included in the final review.ResultsMajority of the studies were retrospective case series and were low quality (Level IV) in evidence. Anterior lumbar approaches were associated with a higher incidence of retrograde ejaculation, especially with the utilization of transperitoneal laparoscopic approach. There is inconclusive evidence on the preferred sexual position following fusion, and also on the impact of BMP-2 usage on retrograde ejaculation/sexual dysfunction.ConclusionDespite limited evidence from high-quality articles, there is a general trend towards improvement of sexual activity and function after spine surgery. Future studies incorporating specific assessments of sexual activity will be required to address this important determinant of quality of life so that appropriate pre-operative counselling can be done by providers.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

30-day adverse outcomes, re-admissions and mortality following vertebroplasty/kyphoplasty

OBJECTIVESnDespite vertebral fractures being a common occurrence in elderly osteoporotic individuals, literature remains scant with regards to 30-day outcomes following vertebral augmentation for these injuries. We studied a national database of elderly osteoporotic patients who underwent vertebroplasty and kyphoplasty.nnnPATIENTS AND METHODSnThe 2012-2014 ACS-NSQIP database was queried using CPT codes for vertebroplasty (22520, 22521 and 22522) and kyphoplasty (22523, 22524 and 22525). Patients undergoing concurrent spinal fusion and/or laminectomies/laminotomies/laminoplasties were removed from the study. Patients with missing data were also excluded from the study.nnnRESULTSnFollowing inclusion/exclusion criteria, a total of 2433 patients were included in the study out of which 242(9.9%) underwent vertebroplasty and 2191(90.1%) underwent kyphoplasty. Following adjusted analysis, having a dependent functional health status pre-operatively (OR 1.78; pu2009=u20090.010), pre-operative sepsis/SIRS (OR 2.52; pu2009=u20090.009), history of COPD (OR 1.62; pu2009=u20090.025), disseminated cancer (OR 1.94; pu2009=u20090.028), pre-operative wound infection (OR 3.47; pu2009=u20090.003) and inpatient admission status (OR 3.22; pu2009<u20090.001) were independent predictors of having any complication within 30-days of the procedure. Significant independent risk factors for 30-day mortality were functional health status prior to surgery (OR 2.92; pu2009=u20090.002), pre-operative dialysis use (OR 11.74; pu2009=u20090.003), Disseminated cancer (OR 7.09; pu2009<u20090.001), chronic steroid use (OR 3.59; pu2009<u20090.001), and inpatient admission status (OR 4.95; pu2009<u20090.001).nnnCONCLUSIONnVertebroplasty/Kyphoplasty is associated with significant adverse outcomes. Providers can utilize these data to better pre-operatively filter high-risk patients and tailor an appropriate peri-operative medical optimization program to enhance care to lower the risk of complications, readmissions and mortality from this procedure.