Rafael De la Garza Ramos

The epidemiology of spinal tuberculosis in the United States: an analysis of 2002–2011 data

OBJECTIVE The aim of this study was to investigate the incidence of spinal tuberculosis (TB) in the US between 2002 and 2011. METHODS The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify patients with a discharge diagnosis of TB and spinal TB. Demographic and hospital data were obtained for all admissions, and included age, sex, race, comorbid conditions, insurance status, hospital location, hospital teaching status, and hospital region. The incidence rate of spinal TB adjusted for population growth was calculated after application of discharge weights. RESULTS A total of 75,858 patients with a diagnosis of TB were identified, of whom 2789 had a diagnosis of spinal TB (3.7%); this represents an average of 278.9 cases per year between 2002 and 2011. The incidence of spinal TB decreased significantly-from 0.07 cases per 100,000 persons in 2002 to 0.05 cases per 100,000 in 2011 (p < 0.001), corresponding to 1 case per 2 million persons in the latter year. The median age for patients with spinal TB was 51 years, and 61% were male; 11.6% were patients with diabetes, 11.4% reported recent weight loss, and 8.1% presented with paralysis. There were 619 patients who underwent spinal surgery for TB, with the most common location being the thoracolumbar spine (61.9% of cases); 50% of patients had instrumentation of 3 or more spinal segments. CONCLUSIONS During the examined 10-year period, the incidence of spinal TB was found to significantly decrease over time in the US, reaching a rate of 1 case per 2 million persons in 2011. However, the absolute reduction was relatively small, suggesting that although it is uncommon, spinal TB remains a public health concern and most commonly affects male patients approximately 50 years of age. Approximately 20% of patients with spinal TB underwent surgery, most commonly in the thoracolumbar spine.

The Impact of Smoking on 30-day Morbidity and Mortality in Adult Spinal Deformity Surgery.

Study Design. A retrospective cohort study of a prospectively collected surgical database. Objective. The aim of this study was to investigate the effect of smoking on 30-day morbidity and mortality in patients undergoing surgery for adult spinal deformity (ASD). Summary of Background Data. There is conflicting evidence regarding the impact of smoking on short-term outcomes after spinal fusion. Methods. A retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement database was performed for the years 2007 to 2013. Patients who underwent spinal fusion for ASD were identified. Thirty-day morbidity and mortality were compared between current smokers and nonsmokers. The independent effect of smoking was investigated via multivariate logistic regression analysis. Results. A total of 1368 patients met inclusion criteria and were included in this study. Of the 1368 patients, 15.9% were smokers and 84.1% nonsmokers. The proportion of smokers who developed at least one complication was 9.7% versus 13.6% for nonsmokers (P = 0.119). Major complication rates (including 30-day mortality) were 6.5% for smokers and 8.4% for nonsmokers (P = 0.328). Current smoking status was not associated with increased odds of developing any complication [odds ratio (OR) 0.90; 95% confidence interval (95% CI), 0.47–1.71; P = 0.752] or major complications (OR 1.32; 95% CI 0.64–2.70; P = 0.447) after multivariate analysis. Conclusion. Smoking was not associated with higher 30-day complications or mortality after corrective surgery for ASD in this study. However, given the negative effects of smoking on overall health and spine surgery outcomes in the long term, smoking cessation before spinal fusion is still recommended. Level of Evidence: 3

Timing of Complications Occurring Within 30 Days After Adult Spinal Deformity Surgery

STUDY DESIGN Cross-sectional study of a national surgical database. OBJECTIVE To investigate the timing of complications after adult spinal deformity (ASD) surgery. There is limited data on the range of days when complications after ASD surgery occur. METHODS The American College of Surgeons National Surgical Quality Improvement database was reviewed for the years 2007-2013. Inclusion criteria were adult patients (over 21 years of age) who underwent spinal fusion for ASD. Ten unique complications occurring within 30 postoperative days were examined and the median day to diagnosis was recorded. RESULTS A total of 1,250 patients met inclusion criteria with an overall complication rate of 13.5%. The median day of diagnosis (and interquartile range) for each complication was as follows: myocardial infarction (3.5, 1-5), pulmonary embolism (4, 2-16), reintubation (4.5, 1-11), pneumonia (6, 3-9), urinary tract infection (11, 5-15), sepsis (12, 6-18.5), deep vein thrombosis (12, 6-19), deep surgical site infection (SSI; 18.5, 13-23), superficial SSI (19, 13-24), and organ space SSI (21, 17-25). The three complications that were most commonly diagnosed before hospital discharge included pneumonia, reintubation, and myocardial infarction (diagnosed before discharge on more than 70% of cases). On the other hand, superficial, deep, and organ space infection were diagnosed in less than 40% of cases before patients left the hospital. On univariate analysis, predictors of complication occurrence included older age (p = .014), instrumentation of 7-12 levels (p = .034), and instrumentation of 13 or more levels (p = .035). CONCLUSION Understanding the timing of specific complications after adult spinal deformity surgery is important for both patients and clinicians. Efforts in prevention of such conditions should continue, as well as heightened awareness during the periods of highest risk.

Incidence, Risk Factors, and Mortality of Reintubation in Adult Spinal Deformity Surgery.

Study Design: Retrospective study of an administrative database. Objective: The objective was to investigate the incidence, risk factors, and mortality rate of reintubation after adult spinal deformity (ASD) surgery. Background Data: There are limited data regarding the occurrence of reintubation after ASD surgery. Materials and Methods: The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify adult patients who underwent elective surgery for scoliosis. Patients who required reintubation were identified and compared with controls (no reintubation). A multivariable logistic regression analysis was performed to identify independent factors associated with reintubation. Results: A total of 9734 patients who underwent surgery for ASD were identified, and 182 required reintubation [1.8%; 95% confidence interval (CI), 1.6%–2.1%] on average 2 days after surgery (range, 0–28 d). After multivariable analysis, the strongest independent risk factors associated with reintubation included postoperative acute respiratory failure [odds ratio (OR), 12.0; 95% CI, 8.6–16.6], sepsis (OR, 6.9; 95% CI, 3.5–13.6), and deep vein thrombosis (OR, 5.7; 95% CI, 3.0–10.9); history of chronic lung disease (OR, 1.6; 95% CI, 1.1–2.3) and fusion of 8 or more segments (OR, 1.5; 95% CI, 1.1–2.2) were also independent risk factors. Mortality rates were significantly higher in reintubated patients (7.3%) compared with that in nonreintubated patients (0.2%, P<0.001). More importantly, reintubation was an independent risk factor for inpatient mortality (OR, 9.8; 95% CI, 4.1–23.5; P<0.001). Conclusions: The reintubation rate after ASD surgery is approximately 1.8%. Patients with a history of chronic lung disease and patients undergoing fusion of 8 or more segments may be at an increased risk for reintubation; other associated factors included acute respiratory failure, sepsis, and deep vein thrombosis. Patients who required postoperative airway management after ASD surgery were 9.8 times more likely to die during their hospital stay compared with controls.

Thirty-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion versus those after cervical disc replacement

OBJECTIVE The goal of this study was to compare 30-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion (ACDF) versus those after cervical disc replacement (CDR). METHODS The authors used the 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database. Included were adult patients who underwent first-time single-level ACDF or CDR for cervical spondylosis or disc herniation. Primary outcome measures were readmission and/or reoperation within 30 days of the original surgery. Logistic regression analysis was used to assess the independent effect of the procedure (ACDF or CDR) on outcome, and results are presented as odds ratios with 95% confidence intervals. RESULTS A total of 6077 patients met the inclusion criteria; 5590 (92.0%) patients underwent single-level ACDF, and 487 (8.0%) patients underwent CDR. The readmission rates were 2.6% for ACDF and 0.4% for CDR (p = 0.003). When stratified according to age groups, only patients between the ages of 41 and 60 years who underwent ACDF had a significantly higher readmission rate than those who underwent CDR (2.5% vs 0.7%, respectively; p = 0.028). After controlling for patient age, sex, body mass index, smoking status, history of chronic obstructive pulmonary disease (COPD), diabetes, hypertension, steroid use, and American Society of Anesthesiologists (ASA) class, patients who underwent CDR were significantly less likely to undergo readmission within 30 days than patients who underwent ACDF (OR 0.23 [95% CI 0.06-0.95]; p = 0.041). Patients with a history of COPD (OR 1.97 [95% CI 1.08-3.57]; p = 0.026) or hypertension (OR 1.62 [95% CI 1.10-2.38]; p = 0.013) and those at ASA Class IV (OR 14.6 [95% CI 1.69-125.75]; p = 0.015) were significantly more likely to require readmission within 30 days. The reoperation rates were 1.2% for ACDF and 0.4% for CDR (p = 0.086), and multivariate analysis revealed that CDR was not associated with lower odds of reoperation (OR 0.60 [95% CI 0.14-2.55]; p = 0.492). However, increasing age was associated with a higher risk (OR 1.02 [95% CI 1.00-1.05]; p = 0.031) of reoperation; a 2% increase in risk per year of age was found. CONCLUSIONS Patients who underwent single-level ACDF had a higher readmission rate than those who underwent single-level CDR in this study. When stratified according to age, this effect was seen only in the 41- to 60-year age group. No significant difference in the 30-day single-level ACDF and single-level CDR reoperation rates was found. Although patients in the ACDF group were older and sicker, other unmeasured covariates might have accounted for the increased rate of readmission in this group, and further investigation is encouraged.

Posterior approaches for symptomatic metastatic spinal cord compression.

Surgical interventions for spinal metastasis are commonly performed for mechanical stabilization, pain relief, preservation of neurological function, and local tumor reduction. Although multiple surgical approaches can be used for the treatment of metastatic spinal lesions, posterior approaches are commonly performed. In this study, the role of posterior surgical procedures in the treatment of spinal metastases was reviewed, including posterior laminectomy with and without instrumentation for stabilization, transpedicular corpectomy, and costotransversectomy. A review of the literature from 1980 to 2015 was performed using Medline, as was a review of the bibliographies of articles meeting preset inclusion criteria, to identify studies on the role of these posterior approaches among adults with spinal metastasis. Thirty-four articles were ultimately analyzed, including 1 randomized controlled trial, 6 prospective cohort studies, and 27 retrospective case reports and/or series. Some of the reviewed articles had Level II evidence indicating that laminectomy with stabilization can be recommended for improvement in neurological outcome and reduction of pain in selected patients. However, the use of laminectomy alone should be carefully considered. Additionally, transpedicular corpectomy and costotransversectomy can be recommended with the expectation of improving neurological outcomes and reducing pain in properly selected patients with spinal metastases. With improvements in the treatment paradigms for patients with spinal metastasis, as well as survival, surgical therapy will continue to play an important role in the management of spinal metastasis. While this review presents a window into determining the utility of posterior approaches, future prospective studies will provide essential data to better define the roles of the various options now available to surgeons in treating spinal metastases.

Primary Versus Revision Spinal Fusion in Children: An Analysis of 74,525 Cases From the Nationwide Inpatient Sample

Study Design. Retrospective cohort study of a nationwide database. Objective. To compare in-hospital outcomes for pediatric patients who underwent primary versus revision spinal fusion. Summary of Background Data. There is limited data on outcomes after primary versus revision spinal fusion in children. Methods. Data from the Nationwide Inpatient Sample from 2002 to 2011 were analyzed. Pediatric patients (age <18 yr) who underwent ≥3 level spinal fusion were identified. Demographics, in-hospital complications, length of stay, and hospital charges were compared between primary and revision (refusion) procedures. All analyses were performed after application of discharge weights. Results. Data from 72,483 primary fusion and 2042 revision fusion procedures (2.7%) were analyzed. Average length of stay was 7.9 days for the revision group and 6.6 for the primary group (P = 0.022). Average total charges were

Effect of body mass index on surgical outcomes after posterior spinal fusion for adolescent idiopathic scoliosis

135,644 and

The nationwide burden of neurological conditions requiring emergency neurosurgery

142,029 for the revision and primary fusion groups, respectively (P = 0.252). The percentage of patients who developed at least one in-hospital complication was 16.7% in the revision group and 8.6% in the primary fusion group (P < 0.001). Specific complications that were more common in the revision group were reintubation (4.3% vs. 2.3%, P = 0.008), hemorrhage/hematoma (5.0% vs. 2.5%, P = 0.001), wound complications (4.0% vs. 1.1%, P < 0.001), accidental vessel/nerve puncture (2.6% vs. 0.8%, P < 0.001), implant-related complications (5.3% vs. 0.4%, P < 0.001), and incidental durotomy (2.1% vs. 0.3%, P < 0.001). On multivariate analysis, revision procedures (odds ratio [OR] 2.64; 95% confidence interval [CI] 1.93–3.59; P < 0.001), male sex (OR 1.73; 95% CI 1.52–1.98; P < 0.001), and fusion of eight or more spinal levels (OR 1.27; 95% CI 1.09–1.47; P = 0.001) were risk factors for complication development. Conclusion. In the present study, pediatric patients who underwent spinal refusion had significantly higher complication rates compared to patients who underwent primary fusion, consistent with previous investigations. Male patients and patients who underwent fusion of eight or more spinal levels also had higher complication rates. Level of Evidence: 3

Factors associated with prolonged ventilation and reintubation in adult spinal deformity surgery

OBJECTIVE Obesity is an increasing public health concern in the pediatric population. The purpose of this investigation was to examine the impact of body mass index (BMI) on 30-day outcomes after posterior spinal fusion for adolescent idiopathic scoliosis (AIS). METHODS The American College of Surgeons National Surgical Quality Improvement Program Pediatric database (2013 and 2014) was reviewed. Patients 10-18 years of age who had undergone fusion of 7 or more spinal levels for AIS were included. Thirty-day outcomes (complications, readmissions, and reoperations) were compared based on patient BMI per age- and sex-adjusted growth charts as follows: normal weight (NW; BMI < 85th percentile), overweight (OW; BMI 85th-95th percentile), and obese (OB; BMI > 95th percentile). RESULTS Patients eligible for study numbered 2712 (80.1% female and 19.9% male) and had a mean age of 14.4 ± 1.8 years. Average BMI for the entire cohort was 21.9 ± 5.0 kg/m2; 2010 patients (74.1%) were classified as NW, 345 (12.7%) as OW, and 357 (13.2%) as OB. The overall complication rate was 1.3% (36/2712). For NW and OW patients, the complication rate was 0.9% in each group; for OB patients, the rate was 4.2% (p < 0.001). The 30-day readmission rate was 2.0% (55/2712) for all patients, 1.6% for NW patients, 1.2% for OW patients, and 5.0% for OB patients (p < 0.001). The 30-day reoperation rate was 1.4% (39/2712). Based on BMI, this reoperation rate corresponded to 0.9%, 1.2%, and 4.8% for NW, OW, and OB patients, respectively (p < 0.001). After controlling for patient age, number of spinal levels fused, and operative/anesthesia time on multiple logistic regression analysis, obesity remained a significant risk factor for complications (OR 4.61), readmissions (OR 3.16), and reoperations (OR 5.33; all p < 0.001). CONCLUSIONS Body mass index may be significantly associated with short-term outcomes after long-segment fusion procedures for AIS. Although NW and OW patients may have similar 30-day outcomes, OB patients had significantly higher wound complication, readmission, and reoperation rates and longer hospital stays than the NW patients. The findings of this study may help spine surgeons and patients in terms of preoperative risk stratification and perioperative expectations.