Robert T. Arrigo

Morbid Obesity Increases Cost and Complication Rates in Spinal Arthrodesis

Study Design. A retrospective cross-sectional study of all spinal fusions in California from 2003 to 2007. Objective. This study analyzes whether morbid obesity alters rates of complications and charges in patients undergoing spinal fusion. Summary of Background Data. Prior studies of obesity have focused on lumbar fusion; some identified increases in wound complications. However, these studies typically do not account for comorbidities, do not examine nonlumbar fusions, and usually are small single institution series. Methods. Our study used the Healthcare Cost and Utilization Projects California State Inpatient Databases (CA-SID) to identify normal weight and morbidly obese patients admitted in California between 2003 and 2007 for 4 types of spinal fusion: anterior cervical fusion (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] procedure code 810.2), posterior cervical fusion (810.3), anterior lumbar fusion (810.6), and posterior lumbar fusion (810.8). Demographic, comorbidity, and complications data were collected. Primary outcome was in-hospital complication; secondary outcomes were total cost, length of stay, and in-hospital mortality. Multivariate logistic regression was performed. Results. In total 84,607 admissions were identified, of which 1455 were morbidly obese. Morbid obesity was associated with 97% higher in-hospital complication rates (13.6% vs. 6.9%), sustained across nearly all complication types (cardiac, renal, pulmonary, wound complications, among others). Mortality among the morbidly obese was slightly higher (0.41 vs. 0.13, P < 0.01) as were average hospital costs (

Modulation of soleus H reflex by spinal DC stimulation in humans.

108,604 vs.

Predictors of survival after surgical treatment of spinal metastasis.

84,861, P < 0.0001). Length of stay was longer as well (4.8 d vs. 3.5 d, P < 0.0001). All effects were less pronounced in posterior cervical fusions. On multivariate analysis, morbid obesity was the most significant predictor of complications in the anterior cervical and posterior lumbar fusion groups (more than age, demography, and other comorbidity). Conclusion. Morbid obesity seems to increase the risk of multiple complication types in spinal fusion surgery, most particularly in anterior cervical and posterior lumbar approaches.

Venous thromboembolism after thoracic/thoracolumbar spinal fusion.

Transcranial direct current stimulation (tDCS) of the human motor cortex induces changes in excitability within cortical and spinal circuits that occur during and after the stimulation. Recently, transcutaneous spinal direct current stimulation (tsDCS) has been shown to modulate spinal conduction properties, as assessed by somatosensory-evoked potentials, and transynaptic properties of the spinal neurons, as tested by postactivation depression of the H reflex or by the RIII nociceptive component of the flexion reflex in the lower limb. To further explore tsDCS-induced plastic changes in spinal excitability, we examined, in a double-blind crossover randomized study, the stimulus-response curves of the soleus H reflex before, during, at current offset and 15 min after anodal, cathodal, and sham tsDCS delivered at the Th11 level (2.5 mA, 15 min, 0.071 mA/cm(2), 0.064 C/cm(2)) in 17 healthy subjects. Anodal tsDCS induced a progressive leftward shift of the recruitment curve of the soleus H reflex during the stimulation; the effects persisted for at least 15 min after current offset. In contrast, both cathodal and sham tsDCS had no significant effects. This exploratory study provides further evidence for the use of tsDCS as an expedient, noninvasive tool to induce long-lasting plastic changes in spinal circuitry. Increased spinal excitability after anodal tsDCS may have potential for spinal neuromodulation in patients with central nervous system lesions.

Charlson score is a robust predictor of 30-day complications following spinal metastasis surgery.

BACKGROUND:Surgery for spinal metastasis is a palliative treatment aimed at improving patient quality of life by alleviating pain and reversing or delaying neurologic dysfunction, but with a mean survival time of less than 1 year and significant complication rates, appropriate patient selection is crucial. OBJECTIVE:To identify the most significant prognostic variables of survival after surgery for spinal metastasis. METHODS:Chart review was performed on 200 surgically treated spinal metastasis patients at Stanford Hospital between 1999 and 2009. Survival analysis was performed and variables entered into a Cox proportional hazards model to determine their significance. RESULTS:Median overall survival was 8.0 months, with a 30-day mortality rate of 3.0% and a 30-day complication rate of 34.0%. A Cox proportional hazards model showed radiosensitivity of the tumor (hazard ratio: 2.557, P < .001), preoperative ambulatory status (hazard ratio: 2.355, P = .0001), and Charlson Comorbidity Index (hazard ratio: 2.955, P < .01) to be significant predictors of survival. Breast cancer had the best prognosis (median survival, 27.1 months), whereas gastrointestinal tumors had the worst (median survival, 2.66 months). CONCLUSION:We identified the Charlson Comorbidity Index score as one of the strongest predictors of survival after surgery for spinal metastasis. We confirmed previous findings that radiosensitivity of the tumor and ambulatory status are significant predictors of survival.

Is Cauda Equina Syndrome Being Treated Within the Recommended Time Frame

OBJECTIVE Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a serious and potentially fatal surgical complication. The goal of our study was to examine preoperative characteristics, incidence, and outcomes of patients with VTE after elective thoracic/thoracolumbar level spine fusion. METHODS We identified 430,081 patients from the Nationwide Inpatient Sample database who underwent spinal fusion between 2002 and 2008. Patients undergoing thoracic/thoracolumbar level fusion (n = 8617) were found to have the greatest concurrent rate of VTE. We then performed multivariate analyses on this cohort to identify predictors of and outcomes after VTE in patients undergoing thoracic/thoracolumbar level fusion. RESULTS The overall VTE rate in spinal fusion surgery was 0.40% (cervical = 0.22%, thoracic/thoracolumbar = 1.90%, lumbar/lumbosacral = 0.49%, re-fusions = 0.64%, and fusions not otherwise specified = 0.84%). On multivariate logistic regression analysis of patients undergoing spinal fusion at the thoracic/thoracolumbar level, increasing age, Medicare insurance coverage (vs. private insurance), urban teaching hospital (vs. urban nonteaching hospital), combined anterior/posterior surgical approach (vs. posterior-only approach), and the presence of congestive heart failure or weight loss (Elixhauser comorbidity groups) were each independently associated with an increased odds ratio of VTE complication. VTE after thoracic/thoracolumbar surgery was significantly associated with longer hospital stays (16.6 vs. 6.74 days), increased total hospital costs (

Impact of age, injury severity score, and medical comorbidities on early complications after fusion and halo-vest immobilization for C2 fractures in older adults: a propensity score matched retrospective cohort study.

260,208 vs.

Retrospective, Propensity Score-Matched Cohort Study Examining Timing of Fracture Fixation for Traumatic Thoracolumbar Fractures

115,474), and increased mortality (4.33% vs. 0.33%). CONCLUSIONS Multivariate logistic regression analysis reveals age, insurance status, hospital type, combined anterior/posterior surgical approach, and the presence of congestive heart failure or weight loss to be independently associated with an increased odds ratio of VTE complication. This complication is associated with increased hospital costs, length of stay, and overall mortality.

A Population-Based Study of Inpatient Outcomes After Operative Management of Nontraumatic Intracerebral Hemorrhage in the United States

Study Design. Retrospective chart review. Objective. To identify predictors of 30-day complications after the surgical treatment of spinal metastasis. Summary of Background Data. Surgical treatment of spinal metastasis is considered palliative with the aim of reducing or delaying neurologic deficit. Postoperative complication rates as high as 39% have been reported in the literature. Complications may impact patient quality of life and increase costs; therefore, an understanding of which preoperative variables best predict 30-day complications will help risk-stratify patients and guide therapeutic decision making and informed consent. Methods. We retrospectively reviewed 200 cases of spinal metastasis surgically treated at Stanford Hospital between 1999 and 2009. Multiple logistic regression was performed to determine which preoperative variables were independent predictors of 30-day complications. Results. Sixty-eight patients (34%) experienced one or more complications within 30 days of surgery. The most common complications were respiratory failure, venous thromboembolism, and pneumonia. On multivariate analysis, Charlson Comorbidity Index score was the most significant predictor of 30-day complications. Patients with a Charlson score of two or greater had over five times the odds of a 30-day complication as patients with a score of zero or one. Conclusion. After adjusting for demographic, oncologic, neurologic, operative, and health factors, Charlson score was the most robust predictor of 30-day complications. A Charlson score of two or greater should be considered a surgical risk factor for 30-day complications, and should be used to risk-stratify surgical candidates. If complications are anticipated, medical staff can prepare in advance, for instance, scheduling aggressive ICU care to monitor for and treat complications. Finally, Charlson score should be controlled for in future spinal metastasis outcomes studies and compared to other comorbidity assessment tools.

Morbidity and mortality of C2 fractures in the elderly: surgery and conservative treatment.

BACKGROUND:Cauda equina syndrome (CES) is a rare but devastating medical condition requiring urgent surgery to halt or reverse neurological compromise. Controversy exists as to how soon surgery must be performed after diagnosis, and clinical and medicolegal factors make this question highly relevant to the spine surgeon. It is unclear from the literature how often CES patients are treated within the recommended time frame. OBJECTIVE:To determine whether CES patients are being treated in compliance with the current guideline of surgery within 48 hours and to assess incidence, demography, comorbidities, and outcome measures of CES patients. METHODS:We searched the 2003 to 2006 California State Inpatient Databases to identify degenerative lumbar disk disorder patients surgically treated for CES. An International Classification of Disease, ninth revision, clinical modification, diagnosis code was used to identify CES patients with advanced disease. RESULTS:The majority (88.74%) of Californias CES patients received surgery within the recommended 48-hour window after diagnosis. The incidence of CES in surgically treated degenerative lumbar disk patients was 1.51% with an average of 397 cases per year in California. CES patients had worse outcomes and used more healthcare resources than other surgically treated degenerative lumbar disk patients; this disparity was more pronounced for patients with advanced CES. CES patients treated after 48 hours had 3 times the odds of a nonroutine discharge as patients treated within 48 hours (odds ratio = 3.082; P < .001). CONCLUSION:In California, patients are being treated within the recommended 48-hour time frame.