Nikita Lakomkin

Impact of Gender on 30-Day Complications After Adult Spinal Deformity Surgery.

Study Design. Retrospective study of prospectively collected data. Objective. To determine if postoperative morbidity for patients undergoing spinal deformity surgery varies by sex. Summary of Background Data. Influence of sex has been investigated in other surgical procedures but has not yet been studied in adult spinal deformity surgery. Methods. The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent fusion for spinal deformity. Patients were separated into groups of male and female sex. Univariate analysis and multivariate logistic regression were used to analyze the effect of sex on the incidence of postoperative morbidity and mortality. Results. Female sex was found to be a predictor of any complication[odds ratio (OR): 1.4, 95% confidence interval (CI) 1.2–1.7, P < 0.0001], intra- or postoperative RBC transfusion (OR: 1.6, 95% CI 1.4–1.9, P < .0001), urinary tract infection (OR: 2.0, 95% CI 1.2–3.3, P = 0.0046), and length of stay >5 days (OR: 1.3, 95% CI 1.1–1.5, P = 0.0015). Male sex was associated with higher rate of pulmonary (2.9% vs. 2.0%, P = 0.0344) and cardiac complications (0.9% vs. 0.5%, P = 0.0497). However, male sex as an independent risk factor for pulmonary (OR: 1.4, 95% CI 1.0–2.1, P = 0.0715) and cardiac complications (OR: 1.9, 95% CI 0.9–4.0, P = 0.1076) did not reach significance. Conclusion. Female sex was found to increase overall morbidity, particularly for urinary tract infection, transfusion, and length of stay >5 days. Male sex was associated with greater incidence of pulmonary and cardiac complications. Thus, sex and other patient characteristics highlighted must be considered as part of surgical risk planning and patient counseling. Level of Evidence: 3

The Incidence and Risk Factors for 30-Day Unplanned Readmissions After Elective Posterior Lumbar Fusion.

Study Design. Retrospective study of prospectively collected data. Objective. To perform a multiinstitutional assessment on the incidence and risk factors for unplanned readmissions following elective posterior lumbar fusion (PLF) surgery. Summary of Background Data. Understanding what may drive rehospitalizations is a necessary step toward higher quality care. Identifying risk factors for unplanned readmission is especially important for elective PLF, which is a common procedure that is known to be associated with significant adverse events. Methods. Adult patients undergoing PLF were identified using current procedure terminology (CPT) from the American College of Surgeons National Surgical Quality Improvement Program. Both descriptive and comparative statistics were performed for patient characteristics, clinical factors, and postoperative complications. Subsequently, a step-wise multivariate logistic regression was employed. Results. Of the 2301 patients who met inclusion criteria for this study, 117 were unplanned readmissions (5.1%). These occurred at a mean of 15.9 days (range: 3–30 days) after surgery. The risk-adjusted analysis revealed that bleeding disorder (odds ratio, OR = 2.8, confidence intervals, CI = 1.0–7.6, P = 0.043), insulin dependent diabetes (OR = 2.5, CI = 1.4–4.4, P = 0.004), and total length of stay > 5 days (OR = 1.8, CI = 1.2–2.8, P = 0.009) were independent predictors for unplanned readmission. Significant postoperative complications included wound complications (OR = 27.6, CI = 13.9–54.8, P < 0.0001), pulmonary embolism and/or deep vein thrombosis/thrombophlebitis (OR = 11.9, CI = 5.0–28.5, P < 0.0001), sepsis (OR = 8.5, CI = 2.3–32.1, P = 0.002), and urinary tract infections (OR = 2.4, CI = 0.9–6.9, P = 0.094). Conclusion. The unplanned readmission rate for patients undergoing PLF was low, but this studys findings of potentially modifiable risk factors suggest that substantial improvement with this quality metric is possible. Level of Evidence:N/A

Impact of Resident Involvement on Morbidity in Adult Patients Undergoing Fusion for Spinal Deformity

Study Design. A retrospective study of prospectively collected data. Objective. The aim of this study was to determine whether patients undergoing spinal deformity surgery with resident involvement are at an increased risk of morbidity. Summary of Background Data. Resident involvement has been investigated in other orthopedic procedures but has not been studied in adult spinal deformity surgery. Methods. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current procedural terminology (CPT) codes were used to query the database for adults who underwent fusion for spinal deformity between 2005 and 2012. Patients were separated into propensity score matched groups of those with and without resident involvement. Univariate analysis and multivariate logistic regression were used to analyze the effect of resident involvement on the incidence of postoperative morbidity and other surgical outcomes. Results. Resident involvement was an independent predictor of overall morbidity [odds ratio (OR) 2.2, P < 0.0001], wound complication (OR 2.5, P = 0.0252), intra-/postoperative transfusion (OR 2.3, P < 0.0001), and length of stay > 5 days (OR 2.0, P < 0.0001). However, resident involvement was not an independent predictor for other complications, such as mortality. Conclusion. Resident participation was associated with significantly longer operative times. As a result, higher rate of certain morbidity, but not mortality, was found, specifically for complications that have been previously associated with long operative duration. Level of Evidence: 3

Another Time, Another Space: The Evolution of the Virtual Journal Club.

Virtual journal clubs (VJCs) provide a standardized, easily accessible forum for evidence-based discussion. The new virtual reality setting in which journal clubs and other online education events now take place offers great advantages and new opportunities for radiologists in academic medicine and private practice. VJCs continue to evolve, largely due to many emerging technologies and platforms. VJCs will continue to play an increasingly important role in medical education, interdisciplinary interaction, and multi-institutional collaboration. In this article, we discuss how to conduct and lead a critical review of medical literature in the setting of a virtual or traditional journal club. We discuss the current applications of VJCs in medical and graduate medical education and continued lifelong learning. We also explain the advantages and disadvantages of VJCs over traditional venues. Finally, the reader will be given the tools to successfully implement and run a VJC.

In Reply: Incidence and Predictive Factors of Sepsis Following Adult Spinal Deformity Surgery

To the Editor: We appreciate the thought-provoking letter1 in response to our original article, Incidence and Predictive Factors of Sepsis Following Adult Spinal Deformity Surgery.2 Themention of “sparse data bias” is important, especially when aiming to predict rare complications using large databases. In our statistical analysis, preoperative factors demonstrating univariate associations of P< .10 were incorporated into the multivariable model, a statistical method used in many clinical studies of adult spinal deformity (ASD) and large databases.3-9 We certainly agree that the confidence interval for the preoperative risk factor “ascites” was wide, and significance should be interpreted with caution. This was likely due to the low number of patients with ascites, which was 4 out of 6158. An alternative option would have been to remove this variable altogether given the low number of patients. We wholeheartedly agree with the author’s concluding statement that “sparse data bias” should be more widely addressed in the literature to avoid spurious statistical associations. While the request for reanalysis of the data through penalization mentioned is worthy, we will instead look forward and use this constructive suggestion for future studies. Perhaps more important is to qualify the a priori objective of the present study, which is similar to other NSQIP analyses.3-5,10-14 Our a priori objective was to better understand risk factors for the rare and devastating complication of sepsis and draw conclusions that are difficult to ascertain from single institution studies. These data were not intended to provide definitive or finite risk factors for sepsis. The concluding point is for surgeons and anesthesiologists to understand the possible—not absolute—risk for patients with ascites, decompensated cirrhosis, or end stage liver disease, in potentially developing sepsis after a large ASD surgery. Preoperative liver function has not typically been studied in predictive studies examining morbidity and mortality following ASD surgery,3,8,9,15 and despite the wide confidence interval, we felt it most beneficial to the spine surgery community to report this information. It is our hope these data can be used to improve clinical care and inform future research. We thank the authors for their interest in our article and constructive commentary.

Evaluation of previously embolized intracranial aneurysms: inter- and intra-rater reliability among neurosurgeons and interventional neuroradiologists

Background The angiographic evaluation of previously coiled aneurysms can be difficult yet remains critical for determining re-treatment. Objective The main objective of this study was to determine the inter-rater reliability for both the Raymond Scale and per cent embolization among a group of neurointerventionalists evaluating previously embolized aneurysms. Methods A panel of 15 neurointerventionalists examined 92 distinct cases of immediate post-coil embolization and 1 year post-embolization angiographs. Each case was presented four times throughout the study, along with alterations in demographics in order to evaluate intra-rater reliability. All respondents were asked to provide the per cent embolization (0–100%) and Raymond Scale grade (1-3) for each aneurysm. Inter-rater reliability was evaluated by computing weighted kappa values (for the Raymond Scale) and intraclass correlation coefficients (ICC) for per cent embolization. Results 10 neurosurgeons and 5 interventional neuroradiologists evaluated 368 simulated cases. The agreement among all readers employing the Raymond Scale was fair (κ=0.35) while concordance in per cent embolization was good (ICC=0.64). Clinicians with fewer than 10 years of experience demonstrated a significantly greater level of agreement than the group with greater than 10 years (κ=0.39 and ICC=0.70 vs κ=0.28 and ICC=0.58). When the same aneurysm was presented multiple times, clinicians demonstrated excellent consistency when assessing per cent embolization (ICC=0.82), but moderate agreement when employing the Raymond classification (κ=0.58). Conclusions Identifying the per cent embolization in previously coiled aneurysms resulted in good inter- and intra-rater agreement, regardless of years of experience. The strong agreement among providers employing per cent embolization may make it a valuable tool for embolization assessment in this patient population.

Incidence and predictors of all-cause mortality within one year after adult spinal deformity surgery

Background Surgery for adult spinal deformity (ASD) can significantly improve quality of life but is associated with significant risk of morbidity. Among the most devastating potential complications after these operations is death. The current study aims to report the incidence, preoperative factors, and postoperative complications associated with all-cause mortality within 1 year following ASD surgery. Methods Adults who underwent thoracolumbar spinal deformity correction between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Demographic characteristics were extracted. The primary outcome was death within 1 year of ASD surgery. Propensity score matching was used to control for confounding factors, followed by univariate/multivariable logistic regression to predict the odds of death within 1 year of ASD surgery. Results A total of 6,158 patients underwent ASD surgery and 61 (0.99%) died within one year of surgery. Preoperative factors: controlling for age, gender, American Society of Anesthesiologists (ASA) score and postoperative complications, four independent risk factors were associated with all-cause mortality within 1 year of ASD surgery: increased age (OR =1.03; 95% CI, 1.01-1.06; P=0.012), ASA score (OR =4.32; 95% CI, 2.68-6.94; P<0.001), cancer history (OR =7.91; 95% CI, 4.23-14.78; P<0.001) and unintentional weight loss (OR =4.65; 95% CI, 1.68-12.89; P=0.003). Postoperative complications: using propensity score matching and multivariable logistic regression, three independent risk factors were associated with all-cause mortality within 1 year of ASD surgery: pneumonia (OR =4.00; 95% CI, 1.68-9.53), deep venous thrombosis (DVT) (OR =3.12; 95% CI, 1.20-8.10) and unplanned intubation (OR =3.13; 95% CI, 1.15-8.50). Discussion Death after elective ASD surgery is a devastating yet uncommon event with an incidence of 1%. Preoperative factors of age, ASA score, cancer history, and unexpected weight loss, along with postoperative complications of pneumonia, DVT, and unplanned intubation were independently associated with all-cause mortality within 1 year of ASD surgery. Interestingly, the potentially more severe complications of sepsis, PE, and MI did not independently predict death.

Fluorescence-guided surgery for high-grade gliomas: LAKOMKIN and HADJIPANAYIS

5‐aminolevulinic acid (5‐ALA) is a prodrug that results in the fluorescence of high‐grade gliomas relative to the surrounding brain parenchyma. 5‐ALA has been increasingly utilized in fluorescence‐guided surgery for these tumors, and its intraoperative use has been associated with a significantly improved extent of resection and progression‐free survival. This review outlines the growing body of evidence that has culminated in the recent Food and Drug Administration approval of 5‐ALA, as well as emerging applications for this agent.

Coagulation Laboratory Testing Is Predictive of Wound Complications Following Microdiscectomy

Study Design: Retrospective review. Objective: To determine whether abnormal preoperative testing is associated with postoperative complications in patients undergoing a microdiscectomy. Methods: Patients undergoing a microdiscectomy between 2006 and 2013 were identified in the National Surgical Quality Improvement Program database based on appropriate current procedural terminology coding. Thirty-day postoperative complications were analyzed in addition to patient demographics, comorbidities, and abnormal preoperative laboratory values. A series of over 650 univariate analyses to determine which independent variables to include for each complication were completed. Based on those analyses, 12 logistic regression models were built, one for each specific complication. Each model adjusted for age, gender, comorbidities, American Society of Anesthesiologists classification, as well as operative time. Results: A total of 5947 patients undergoing a microdiscectomy were included in the study. Abnormal preoperative international normalized ratio (odds ratio [OR] = 5.85, P < .05) was associated with any wound infection, superficial or deep, and abnormal partial thromboplastin time was significantly associated with wound dehiscence (OR = 6.80, P < .05). Postoperative urinary tract infections were associated with abnormal preoperative hematocrit (OR = 8.00, P < .05). None of the identified preoperative labs were independently associated with pulmonary embolism, organ space surgical site infections, or intubation. Conclusions: Abnormal preoperative coagulation labs were significantly associated with postoperative wound complications. However, the majority of tests were not associated with adverse events following microdiscectomy. Further study is necessary to conclude whether these tests provide information that can modify perioperative management and whether widespread testing is cost-effective.

The utility of preoperative labs in predicting postoperative complications following posterolateral lumbar fusion

BACKGROUND CONTEXT Several studies have suggested that laboratory results have minimal impact on clinical decision making in surgery. Despite the widespread use of preoperative testing in spine surgery and the large volume of posterolateral lumbar fusions (PLFs) being performed each year, no study has assessed the ability of preoperative laboratories to predict adverse events following PLF. PURPOSE The purpose of this study was to explore the relationship between commonly obtained preoperative laboratory results and postoperative complications following one- to two-level PLF. STUDY DESIGN This is a retrospective study of prospectively collected data. PATIENT SAMPLE The 2006-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was employed to identify all patients who underwent one- to two-level PLF. OUTCOME MEASURES The outcome variables of interest were 30-day postoperative complications, which were assessed as major complications, minor adverse events, and total complications. MATERIALS AND METHODS Demographics, comorbidities, and perioperative characteristics were collected for each patient. Preoperative laboratories included sodium, blood urea nitrogen, creatinine, albumin, bilirubin, serum glutamic oxaloacetic transaminase, alkaline phosphatase, white blood cell count, hematocrit, platelet count, prothrombin time, international normalized ratio, and partial thromboplastin time. Bivariate analysis and multivariate logistic regression modeling were used to explore the relationship between abnormal preoperative laboratories and the incidence of postoperative complications. RESULTS After controlling for age, ASA score, length of surgery, and all significant comorbidities, abnormal sodium (odds ratio [OR]=2.47, 95% confidence interval [CI]: 1.45-4.19, p=.001) and abnormal INR (OR=2.33, 95% CI: 1.09-4.98, p=.029) were significantly associated with the development of any complication. Sodium (OR=1.61, 95% CI: 1.01-2.54, p=.04) and platelets (OR=1.58, 95% CI: 1.02-2.44, p=.04) were associated with minor complications. Meanwhile, creatinine (OR=1.74, 95% CI: 1.02-2.99, p=.04) and platelets (OR=1.71, 95% CI: 1.02-2.89, p=.04) were significant predictors of major adverse events. CONCLUSIONS This study represents the first attempt to assess the utility of preoperative laboratories in predicting postoperative complications in PLF. Although the majority of laboratories were not significantly associated with adverse events, abnormal sodium values, INR, creatinine, and platelets were shown to be predictive of various complications.