Nikhil Jain

Chronic preoperative opioid use is a risk factor for increased complications, resource use, and costs after cervical fusion

BACKGROUND CONTEXT As health-care transitions to value-based models, there has been an increased focus on patient factors that can influence peri- and postoperative adverse events, resource use, and costs. Many studies have reported risk factors for systemic complications after cervical fusion, but none have studied chronic opioid therapy (COT) as a risk factor. PURPOSE The objective of this study was to answer the following questions from a large cohort of patients who underwent primary cervical fusion for degenerative pathology: (1) What is the patient profile associated with preoperative COT? (2) Is preoperative COT a risk factor for 90-day systemic complications, emergency department (ED) visits, readmission, and 1-year adverse events? (3) What are the risk factors and 1-year adverse events related to long-term postoperative opioid use? (4) How much did payers reimburse for management of complications and adverse events? STUDY DESIGN This is a retrospective review of Humana commercial insurance data (2007-Q3 2015). PATIENT SAMPLE The patient sample included 29,101 patients undergoing primary cervical fusion for degenerative pathology. METHODS Patients and procedures of interest were included using International Classification of Diseases (ICD) coding. Patients with opioid prescriptions for >6 months before surgery were considered as having preoperative COT. Patients with continued opioid use until 1-year after surgery were considered as long-term users. Descriptive analysis of patient cohorts has been done. Multiple-variable logistic regression analyses adjusting for approach, number of levels of surgery, discharge disposition, and comorbidities were done to answer first three study questions. Reimbursement data from insurers have been reported to answer our fourth study question. RESULTS Of the entire cohort, 6,643 (22.8%) had preoperative COT. Preoperative COT was associated with a higher risk of 90-day wound complications (odds ratio [OR] 1.39, 95% confidence interval [CI]: 1.16-1.66), all-cause 90-day ED visits (adjusted OR 1.22, 95% CI: 1.13-1.32), and pain-related ED visits (adjusted OR 1.39, 95% CI: 1.24-1.55). Patients who had preoperative COT were more likely to receive epidural or facet joint injections within 1 year after surgery (adjusted OR 1.68, 95% CI: 1.47-1.92). These patients were also more likely to undergo a repeat cervical fusion within a year than patients who did not have preoperative COT (adjusted OR 1.21, 95% CI: 1.01-1.43). Preoperative COT had a higher likelihood of long-term use after surgery (adjusted OR 4.72, 95% CI: 4.41-5.06). Long-term opioid use after surgery was associated with a higher risk of new-onsetconstipation (adjusted OR 1.34, 95% CI: 1.22-1.48). The risk of complications and adverse events was not found to be significant in patients with <3 months of preoperative opioid use or those who stopped opioids for at least 6 weeks before surgery. The cost of additional resource use for medications, ED visits, constipation, injections, and revision fusion ranged from

Prophylactic muscle flap reconstruction after complex spine surgery for degenerative disease: case series and institutional protocol

623 to

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

27,360 per patient. CONCLUSIONS Preoperative opioid use among patients who underwent cervical fusion increases complication rates, postoperative opioid usage, health-care resource use, and costs. These risks may be reduced by restricting the duration of preoperative opioid use or weaning off before surgery. Better understanding and management of pain in the preoperative period with judicious use of opioids is critical to enhance outcomes after cervical fusion surgery.

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

Background Wound complications can occur in up to 20% of patients following multilevel posterior spinal fusion. Currently, the use of local flaps has been reported in high-risk patients with a history of spinal neoplasm, radiation therapy, exposed hardware, multiple spine surgeries, or wound infections. However, there are no reports of prophylactic muscle flap wound closure in patients undergoing multi-level spinal fusion for degenerative pathology. Given the extensive soft tissue dissection for exposure compounded by patient comorbidities, there is potential to minimize the risk of wound complications with prophylactic trapezius and/or paraspinal flap coverage. We sought to describe the utility and outcomes of prophylactic muscle flaps for wound coverage after instrumented posterior spinal fusion for multi-level degenerative spine disease and spinal deformity. Methods An institutional review board (IRB)-approved retrospective review of 26 consecutive patients who underwent a multi-level posterior spinal fusion for degenerative pathology with concurrent muscle flap coverage at a single institution (August 2016 to February 2017) was done. Patient demographics, clinical profile, procedures, and outcomes at a minimum 6-month post-operatively have been described. Results Patients had a mean age of 59.7±13.0 years with a mean body mass index (BMI) of 31.0±8.6 kg/m2. Paraspinous muscle flap (61.5%), trapezius (3.8%), and combination flaps (34.6%) were used for coverage of an average wound defect of 325 cm2 extending over average 10.2 vertebral levels. All wounds healed completely with no complications at an average of 9.1 months follow-up. Only 1 patient (3.8%) developed a seroma for which interventional radiology (IR)-drainage was sufficient. Conclusions Prophylactic trapezius and/or paraspinous muscle flap coverage using a team approach can reduce the risk of wound complications after extensive spinal fusion for multi-level degenerative disease or adult spinal deformity (ASD). Preliminary results from our institution suggest that routine use of such a protocol has the potential to improve quality of care and reduce healthcare expenditure associated with this relatively morbid procedure.

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

Background With 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. Methods The 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. Results A 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). Conclusions Discharge 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.

Sexual activity after spine surgery: a systematic review

Background Chronic 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). Methods The 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. Results In 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). Conclusions Patients 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.

Factors associated with post-operative sepsis following surgery for spinal tumors: An analysis of the ACS-NSQIP database

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 22 551 (single-level) and 22 552 (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 14 835 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.

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

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.

Cervical fracture patterns associated with vertebral artery injuries

OBJECTIVES Sepsis is a rare but potentially devastating complication when it occurs after surgery for spinal tumors. Given the morbidity associated with sepsis, we sought to collate evidence using a large national surgical database to identify the incidence, pre-operative predictors and post-operative factors associated with sepsis following spinal tumor surgery. PATIENTS AND METHODS The 2005-2014 ACS-NSQIP database was queried for patients undergoing surgery for spinal tumors using ICD-9 codes for primary (170.2, 170.6, 213.2, 213.6) or secondary (198.3, 198.4 and 198.5) spinal tumor. Data were then filtered to include patients who underwent a laminectomy, corpectomy and/or spinal fusion for the tumor. A total of 1468 patients were included in the final cohort. Pre-operative risk factors were assessed using univariate regression models while adjusting for the occurrence of missing variables. Post-operative infectious sources such as urinary tract infection (UTI), pneumonia and surgical site infection were assessed for any association with the occurrence of sepsis. RESULTS A total of 44 patients (3.0%) had an episode of sepsis within 30 days after surgery. Independent pre-operative factors significantly associated with the occurrence of sepsis were history of prior systemic inflammatory response syndrome (SIRS) (OR 2.89 [95% CI 1.3-6.2]), presence of Insulin-dependent Diabetes Mellitus (IDDM) (OR 3.52 [95% CI 1.4-8.7] and a length of stay>8 days (OR 2.5 [95% CI 1.0-6.2]). Independent infectious sources associated with occurrence of sepsis were surgical site infection (SSI) (OR 23.3 [95% CI 8.6-63.7]), pneumonia (OR 5.8 [95% CI 2.2-15.2]) and urinary tract infection (UTI) (OR 14.7 [95% CI 5.96-36.1]). Up to 52% of the cases of sepsis were associated with at least one source of infection (UTI, pneumonia or SSI) with UTI being the most common (29.5%) followed by pneumonia (22.7%) and SSI (18%). CONCLUSION Three percent of patients following surgery for spinal tumor experience an episode of sepsis within 30 days. The most likely sources of sepsis include UTI, pneumonia and SSI. Pre- and post-operative targeted interventions in these high risk patients will be most beneficial in reducing the incidence, morbidity and mortality from sepsis after surgery for spinal tumors.

Pre-operative Chronic Opioid Therapy: A Risk Factor for Complications, Readmission, Continued Opioid Use and Increased Costs After One- and Two-Level Posterior Lumbar Fusion.

OBJECTIVES Despite 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. PATIENTS AND METHODS The 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. RESULTS Following 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; p = 0.010), pre-operative sepsis/SIRS (OR 2.52; p = 0.009), history of COPD (OR 1.62; p = 0.025), disseminated cancer (OR 1.94; p = 0.028), pre-operative wound infection (OR 3.47; p = 0.003) and inpatient admission status (OR 3.22; p < 0.001) 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; p = 0.002), pre-operative dialysis use (OR 11.74; p = 0.003), Disseminated cancer (OR 7.09; p < 0.001), chronic steroid use (OR 3.59; p < 0.001), and inpatient admission status (OR 4.95; p < 0.001). CONCLUSION Vertebroplasty/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.