Joseph F. Baker

In-Hospital Complications and Resource Utilization Following Lumbar Spine Surgery in Patients with Parkinson Disease: Evaluation of the National Inpatient Sample Database

BACKGROUND Previous reports suggest that patients with Parkinson disease (PD) have elevated rates of complications following spine surgery; however, these reports are limited by small patient series. In this study, we used the National Inpatient Sample (NIS) database to compare in-hospital complications following elective lumbar spine surgery in patients with a diagnosis of PD and patients without PD. METHODS The NIS database was accessed to identify patients with PD and those without PD who underwent lumbar spine surgery. All patients identified had a diagnosis code consistent with degenerative lumbar spine pathology. The patients were evaluated for the presence or absence of PD and divided into 4 lumbar spine procedure groups: decompression alone, lateral fusion, posterior fusion, and anterior fusion technique. Propensity score matching (PSM) was performed for the PD versus non-PD patients in each procedure group to control for confounding demographic variables, and in-hospital complications were compared between the 2 groups. RESULTS Between 2001 and 2012, a total of 613,522 lumbar spine surgery patient episodes were identified, of which 4492 (0.7%) involved a diagnosis of PD. Following PSM for patient age, sex, and race, the patients with PD were at increased risk for acute postoperative hemorrhagic anemia, increased blood transfusion requirements, and increased genitourinary, neurologic, and cardiac complications compared with the patients without PD. CONCLUSIONS PSM analysis of the NIS database demonstrated that patients with PD are at increased risk for acute in-hospital complications and greater blood transfusion requirements than those without PD. Surgeons should be aware of the increased risks and differing requirements when treating spinal pathology in patients with PD.

Impact of Parkinson’s disease on perioperative complications and hospital cost in multilevel spine fusion: A population-based analysis

Parkinsons disease (PD) is a neurodegenerative disorder manifesting over time to result in reduced mobility. The impact of PD on spinal fusion has yet to be addressed on a nationwide level. The Nationwide Inpatient Sample (NIS) from 2001 to 2012 was used for analysis. Admissions with spinal fusion of two or more vertebrae (ICD-9 codes=81.62, 81.63 and 81.64) were included and then stratified based on the presence or absence of PD (ICD-9 code=332.0); patients with cancer (ICD-9 codes=140-239) or trauma (ICD-9 codes=805.0-806.9) were excluded. Propensity score matching adjusted for potential confounding effects introduced by patient age, race, sex, and primary payer for care. 570,858 patients receiving spinal fusion of two or three vertebrae (1-2 levels) were identified, 2648 (0.5%) of whom had PD. Analysis revealed that PD was independently predictive for increased in-hospital mortality, durotomy, paraplegia, postoperative infection, venous thrombotic events, inferior vena cava filter placement, red blood cell transfusion, pulmonary embolism, total hospital charge >

Complications and operative spine fusion construct length in Parkinson’s disease: A nationwide population-based analysis

200,000, length of stay >1week, non-routine discharge disposition, acute respiratory distress syndrome, acute posthemorrhagic anemia, multisystem complications (nervous system, cardiac, respiratory, urinary), and device-related complications (all P<0.001). In conclusion, these findings from a nationwide analysis comprising a 12-year period indicate that PD is significantly associated with increased in-hospital morbidity, mortality, and cost following spine fusion of 1-2 levels when compared with the general population. These findings point to the need for risk stratification and adjustment of quality metrics for this growing patient population, and should be integrated into operative decision-making and patient counseling.

Degenerative spondylolisthesis: contemporary review of the role of interbody fusion

There remains a dearth of information regarding the surgical complications following multilevel spine surgery in Parkinsons disease (PD) patients. This retrospective cohort study was performed to address this issue on a nationwide level using the Nationwide Inpatient Sample from 2001 to 2012. More than 25 postoperative variables were analyzed to assess the impact of fusion construct length on each variable. Subsequently, the same analysis was performed on admissions without PD. 4301 PD patients with spine fusion were identified, of whom 934 (21.7%) underwent fusion of at least three levels; the remaining 3367 underwent fusion of 1-2 levels. Patients with 3+ level fusions were more likely to suffer paraplegia (P=.001; OR=3.0; 95%CI=1.5-6.1), hematoma/seroma (P=.009; OR=1.9; 95%CI=1.2-3.2), IVC filter placement (P=.018; OR=2.1; 95%CI=1.1-3.9), RBC transfusion (P<.001; OR=3.2; 95%CI=2.7-3.8), PE (P=.027; OR=4.5; 95%CI=1.2-16.9), postoperative shock (P=.023; OR=7.3; 95%CI=1.3-39.6), ARDS (P<.001; OR=4.1; 95%CI=2.7-6.3), VTE (P=.006; OR=2.6; 95%CI=1.3-5.4), acute posthemorrhagic anemia (P<.001; OR=2.0; 95%CI=1.7-2.4), device-related complications (P<.001; OR=3.1; 95%CI=2.3-4.2), and in-hospital mortality (P=.005; OR=3.4; 95%CI=1.5-7.4). 3+ level fusions were also more likely to have LOS>1week (P<.001; OR=2.1; 95%CI=1.8-2.5), and a nonroutine discharge (P=.005; OR=1.9; 95%CI=1.4-2.4). 692,173 non-PD patients with spine fusion were identified; 123,964 (17.9%) underwent 3+ level fusion. Differences between 3+ versus 1-2 level fusions were similar to those in PD patient, but unlike PD patients, postoperative infection was significant while in-hospital mortality, PE and VTE were not. Fusion of at least three levels increased morbidity, mortality, and adverse discharge disposition compared with 1-2 level fusions. Nearly 80% of all spine fusions performed in the United States are fewer than three levels. These findings are worth considering during operative decision-making in both PD and non-PD patients.

Cervical disc replacement - emerging equivalency to anterior cervical discectomy and fusion.

Degenerative spondylolisthesis is a common presentation, yet the best surgical treatment continues to be a matter of debate. Interbody fusion is one of a number of options, but its exact role remains ill defined. The aim of this study was to provide a contemporary review of the literature to help determine the role, if any, of interbody fusion in the surgical treatment of degenerative spondylolisthesis. A systematic review of the literature since 2005 was performed. Details on study size, patient age, surgical treatments, levels of slip, patient reported outcome measures, radiographic outcomes, complications and selected utility measures were recorded. Studies that compared a cohort treated with interbody fusion and at least one other surgical intervention for comparison were included for review. Only studies examining the effect in degenerative spondylolisthesis were included. Two authors independently reviewed the manuscripts and extracted key data. Thirteen studies were included in the final analysis. A total of 565 underwent interbody fusion and 761 underwent other procedures including decompression alone, interspinous stabilisation and posterolateral fusion with or without instrumentation. Most studies were graded Level III evidence. Heterogeneous reporting of outcomes prevented formal statistical analysis. However, in general, studies reviewed concluded no significant clinical or radiographic difference in outcome between interbody fusion and other treatments. Two small studies suggested interbody fusion is a better option in cases of definite instability. Interbody fusion only provided outcomes as good as instrumented posterolateral fusion. However, most studies were Level III, and hence, we remain limited in defining the exact role of interbody fusion—cases with clear instability appear to be most appropriate. Future work should use agreed-upon common outcome measures and definitions.

Management of spinal conditions in patients with Parkinson disease

PurposeCervical disc replacement has become an acceptable alternative to anterior cervical fusion for the surgical treatment of cervical spine spondylosis resulting in radiculopathy or myelopathy following anterior discectomy and decompression. This concise overview considers the current state of knowledge regarding the continued debate of the role of cervical disc replacement with an update in light of the latest clinical trial results.MethodsA literature review was performed identifying clinical trials pertaining to the use of cervical disc replacement compared to cervical discectomy and fusion. Single level disease and two level disease were considered. Outcome data from the major clinical trials was reviewed and salient points identified.ResultsWith lengthier follow-up data becoming available, the equivalence of CDR in appropriately selected cases is becoming clear. This is chiefly manifested by reduced re-operation rates and reduced incidence of adjacent level disease in those treated with arthroplasty.ConclusionCervical disc replacement shows emerging equivalence in outcomes compared to the gold standard anterior cervical discectomy and fusion. Further longer term results are anticipated to confirm this trend.

Analysis of Two Different Arthroscopic Broström Repair Constructs for Treatment of Chronic Lateral Ankle Instability in 110 Patients: A Retrospective Cohort Study

Parkinson disease (PD) is increasingly prevalent in the aging population. Spine disorders in patients with PD may be degenerative in nature or may arise secondary to motor effects related to the parkinsonian disease process. Physicians providing care for patients with PD and spine pathologies must be aware of several factors that affect treatment, including the patterns of spinal deformity, complex drug interactions, and PD-associated osteoporosis. Following spine surgery, complication rates are higher in patients with PD than in those without the disease. Literature on spine surgery in this patient population is limited by small cohort size, the heterogeneous patient population, and variable treatment protocols. However, most studies emphasize the need for preoperative optimization of motor control with appropriate medications and deep brain stimulation, as well as consultation with a movement disorder specialist. Future studies must control for confounding variables, such as the type of surgery and PD severity, to improve understanding of spinal pathology and treatment options in this patient population.

The Role of Prognostic Scoring Systems in Assessing Surgical Candidacy for Patients With Vertebral Metastasis: A Narrative Review

ABSTRACT Chronic lateral ankle instability is a common condition treated by most foot and ankle surgeons. Once conservative treatment has failed, patients often undergo surgical reconstruction, either anatomic or nonanatomic. The present retrospective cohort study compared the clinical outcomes of 2 different arthroscopic Broström procedures. A total of 110 patients (83 females [75.5%] and 27 males [24.5%]) were treated with 1 of the 2 lateral ankle stabilization techniques from October 1, 2014 to December 31, 2015. Of the 110 patients, 75 were included in the arthroscopic lateral ankle stabilization group with an additional suture anchor used proximally and 35 were included in the arthroscopic lateral ankle stabilization group using the knotless design. The age of the cohort was 46.05 ± 17.89 (range 12 to 83) years. The body mass index was 30.03 ± 7.42 (range 18.3 to 52.5) kg/m2. Of the 110 patients, 25 (22.7%) had undergone concomitant procedures during lateral ankle stabilization. Overall, postoperative complications occurred in 14 patients (12.7%). No statistically significant differences were found between the 2 groups regarding the complication rates, use of concomitant procedures, and the presence of diabetes and workers compensation claims. No statistically significant differences were found in the mean age, body mass index, or gender distribution between the 2 groups. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle‐Hindfoot scores were 50.85 ± 13.56 (range 18 to 76) and 51.26 ± 13.32 (range 18 to 69) in groups 1 and 2, respectively. The postoperative AOFAS Ankle‐Hindfoot scores were 88.19 ± 10.72 (range 54 to 100) and 84 ± 15.41 (range 16 to 100) in groups 1 and 2, respectively. No statistically significant difference was found between these 2 groups. The preoperative visual analog scale score was 7.45 ± 1.39 (range 3 to 10) and 6.97 ± 1.25 (range 5 to 10), which had improved to 1.12 ± 1.38 (range 0 to 5) and 1.8 ± 1.98 (range 1 to 9) postoperatively for groups 1 and 2, respectively. The difference in the postoperative visual analog scale score between the 2 groups was statistically significant. The preoperative and postoperative AOFAS scale, Foot Function Index, and Karlsson‐Peterson scores showed no statistically significant differences between the 2 groups. From our experience, either procedure is an acceptable treatment option for chronic lateral ankle instability, with the knotless technique showing a trend toward more complications. Level of Clinical Evidence: 4

Open Ankle Dislocation Without Fractures With Tibialis Posterior Tendon Interposition Through the Interosseous Space

Study Design: Narrative review. Objectives: To review the relevant literature regarding scoring systems for vertebral metastases and quantify their role in contemporary orthopedic practice. Methods: A literature search of PubMed, Google Scholar, and Embase was performed on February 7, 2017. Eight scoring systems were selected for detailed review—7 of which were scores focused solely on patient prognosis (Tokuhashi, Tomita, Bauer, Oswestry Spinal Risk Index, Van der Linden, Rades, and Katagiri). The eighth system reviewed was the Spinal Instability Neoplastic Score, which examines for impending spinal instability in patients with vertebral metastases and represents a novel approach compared with hitherto scoring systems. Results: The Bauer and Oswestry Spinal Risk Index have the most accurate prognostic predictive ability, with the newer Oswestry Spinal Risk Index being favored by the contemporary literature as it demands less investigation and is therefore more readily accessible. There was a growing trend in studies designed to customize scoring systems for individual cancer pathological subtypes. The Spinal Instability Neoplastic Score shows good reliability for predicting instability among surgeons and oncologists. Conclusions: The increased understanding of cancer pathology and subsequent development of customized treatments has led to prolonged survival. For patients with vertebral metastases, this affects surgical candidacy not only on the basis of prognosis but also provides prolonged opportunity for the development of spinal instability. Scoring systems have a useful guidance role in these deciding for/against surgical intervention, but in order to remain contemporary ongoing review, development, and revalidation is mandatory.

Incidence of Congenital Spinal Abnormalities Among Pediatric Patients and Their Association With Scoliosis and Systemic Anomalies

Open ankle dislocations without fracture are rare injuries. Dislocation or interposition of adjacent tendons are a rare associated feature of ankle fracture-dislocation. We report an extremely unusual case of open ankle dislocation without fracture with concurrent tibialis posterior tendon interposition through the interosseous space that was detected incidentally on computed tomography. We highlight the clinical, radiologic, and intraoperative features to avoid missing similar diagnoses.