Taylor E. Purvis

Concurrent Validity and Responsiveness of PROMIS Health Domains Among Patients Presenting for Anterior Cervical Spine Surgery

Study Design. Prospective cohort study. Objective. The aim of this study was to determine the validity and responsiveness of Patient-Reported Outcomes Measurement Information System (PROMIS) health domains. Summary of Background Data. PROMIS health domains (anxiety, depression, fatigue, pain, physical function, satisfaction with participation in social roles, sleep disturbance) may measure quality of care and determine minimal important differences (MIDs) after spine surgery. We examined concurrent validity of PROMIS domains before and PROMIS domain MIDs after anterior cervical spine surgery. Methods. We included 148 adults undergoing cervical spine surgery from February 2015 through June 2016. We determined concurrent validity by correlations of preoperative PROMIS domains with legacy measures and responsiveness of PROMIS domains using distribution-based and anchor-based criteria (preoperative to postoperative change, within 6 months) anchored to treatment expectations (assessed using North American Spine Society Patient Satisfaction Index criteria). Statistical significance was accepted as P < 0.05. Results. All PROMIS domains showed moderate to strong correlations with Neck Disability Index, Short-Form Health Survey, version 2 (SF-12v2), and Brief Pain Inventory pain interference and weak correlations with intensity of arm/neck pain (except between PROMIS pain and neck pain [r = 0.45, P < 0.001] and PROMIS physical function and SF-12v2 physical [r = –0.14, P = 0.138] and mental [r = 0.39, P < 0.001] components). PROMIS domains were well correlated with Generalized Anxiety Disorder-7 and Patient Health Questionnaire-8 except PROMIS physical function (r = –0.29, P = 0.002). Distribution-based PROMIS MID estimates ranged from 2.3 to 3.9 points. Incorporating cross-sectional and longitudinal anchor-based criteria, final PROMIS MID estimates were as follows: anxiety, –5.7; depression, –4.6, fatigue, –5.8; pain, –5.2; physical function, 4.5; satisfaction with participation in social roles, 4.4; and sleep disturbance, –7.4. Conclusion. PROMIS domains are a valid assessment of health in this population and were responsive to postoperative improvements in symptoms and quality of life. Level of Evidence: 2

Impact of smoking on postoperative complications after anterior cervical discectomy and fusion

The relationship between smoking and the risk of postoperative complications among anterior cervical discectomy and fusion (ACDF) patients remains uncertain. We compared the postoperative complication rates following ACDF surgery among non-smokers, current smokers, and ever-smokers. Baseline and outcome data were obtained from the 2005- to 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for patients over the age of 18 who underwent non-emergent ACDF surgery. Information on current smoking and ever-smoking status was extracted. Outcomes included development of at least one complication, development of a major complication, in-hospital mortality, and length of stay. ACDF patients were either current smokers (7847, 30.3%) or not current smokers (18,022, 69.7%); 33.0% of all patients (n=8542) had ever smoked. Current smoking status was not associated with increased odds of any one complication (P=0.584) or any major complication (P=0.138). In addition, using the number of pack-years as the primary independent variable, multivariate logistic regression analysis revealed that the number of pack-years was not significantly associated with greater odds of developing any one complication (P=0.276) or any major complication (P=0.334). However, ever-smoker status did present significantly higher odds of any major complication (OR, 1.333; 95% CI 1.007-1.764; P=0.044) than for non-smokers. These results suggest that any patient with a prior smoking history should be considered a higher risk surgical candidate when attempting ACDF.

Effect of Liberal Blood Transfusion on Clinical Outcomes and Cost in Spine Surgery Patients

BACKGROUND CONTEXT Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin (Hb) trigger-defined as an intraoperative Hb level of ≥10 g/dL, a postoperative level of ≥8 g/dL, or a whole hospital nadir between 8 and 10 g/dL-and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study. PURPOSE This study aimed to describe the perioperative outcomes and economic cost associated with liberal Hb trigger transfusion among spine surgery patients. STUDY DESIGN/SETTING This is a retrospective study. PATIENT SAMPLE The surgical billing database at our institution was queried for inpatients discharged between 2008 and 2015 after the following procedures: atlantoaxial fusion, anterior cervical fusion, posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, other procedures, and tumor-related surgeries. In total, 6,931 patients were included for analysis. OUTCOME MEASURES The primary outcome was composite morbidity, which was composed of (1) infection (sepsis, surgical-site infection, Clostridium difficile infection, or drug-resistant infection); (2) thrombotic event (pulmonary embolus, deep venous thrombosis, or disseminated intravascular coagulation); (3) kidney injury; (4) respiratory event; and (5) ischemic event (transient ischemic attack, myocardial infarction, or cerebrovascular accident). MATERIALS AND METHODS Data on intraoperative transfusion were obtained from an automated, prospectively collected anesthesia data management system. Data on postoperative hospital transfusion were obtained through a Web-based intelligence portal. Based on previous research, we analyzed the data using three definitions of a liberal transfusion trigger in patients who underwent red blood cell transfusion: a liberal intraoperative Hb trigger as a nadir Hb level of 10 g/dL or greater, a liberal postoperative Hb trigger as a nadir Hb level of 8 g/dL or greater, or a whole hospital nadir Hb level of 8-10 g/dL. Variables analyzed included in-hospital morbidity, mortality, length of stay, and total costs associated with a liberal transfusion strategy. RESULTS Among patients with a whole hospital stay nadir Hb between 8 and 10 g/dL, transfused patients demonstrated a longer in-hospital stay (median [interquartile range], 6 [5-9] vs. 4 [3-6] days; p<.0001) and a higher perioperative morbidity (n=145 [11.5%] vs. n=74 [6.1%], p<.0001) than those not transfused. Even after adjusting for age, gender, race, American Society of Anesthesiologists class, Charlson Comorbidity Index score, estimated blood loss, baseline Hb value, and surgery type, logistic regression analysis revealed that patients with a nadir Hb of 8-10 g/dL who were transfused had an independently higher risk of perioperative morbidity (odds ratio=2.11, 95% confidence interval, 1.44-3.09; p<.0001). Estimated additional costs associated with liberal trigger use, defined as a transfusion occurring in patients with a whole hospital stay nadir Hb of 8-10 g/dL, ranged from

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

202,675 to

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

700,151 annually. CONCLUSIONS Transfusion using a liberal trigger is associated with increased morbidity, even after controlling for possible confounders. Our results suggest that modification of transfusion practice may be a potential area for improving patient outcomes and reducing costs.

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

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.

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

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

The effect of renal dysfunction on short-term outcomes after lumbar fusion

135,644 and

Review of stereotactic radiosurgery for intradural spine tumors

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

Is Decompressive Surgery for Cervical Spondylotic Myelopathy Effective in Patients Suffering from Concomitant Multiple Sclerosis or Parkinson’s Disease?

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.