Victoria D. Vuong

Association of Intraoperative Blood Transfusions on Postoperative Complications, 30-Day Readmission Rates, and 1-Year Patient-Reported Outcomes.

Study Design. Ambispective cohort review. Objective. The aim of this study was to determine the effect of allogeneic red blood cell (RBC) transfusion on postoperative patient complications profiles and 30-day readmission rates following elective spine surgery. Summary of Background Data. Thirty-day hospital readmission rates are being used as a proxy for quality of care. Intra- or perioperative allogeneic RBC transfusions are associated with deleterious effects. Whether allogeneic RBC transfusions are associated with higher perioperative complications and 30-day readmission rates after elective spine surgery remains unknown. Methods. The medical records of 160 patients undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and postoperative complication rates were collected. All patients completed patient-reported outcomes instruments (Oswestry Disability Index, SF-36, and VAS-NP/BP/LP) before surgery, then at 3, 6, and 12 months after surgery. The association between intra- or perioperative allogeneic RBC transfusions and 30-day readmission rate was assessed via multivariate logistic regression analysis. Results. Baseline characteristics were similar in both cohorts. The mean pre- and postoperative hemoglobin levels were lower for the transfusion than nontransfusion cohorts. Postoperative complication rates were 44.67% and 23.00% in the transfusion and nontransfusion cohorts, respectively. Overall, 9.38% of patients were re-admitted within 30 days of hospital discharge, with a three-fold higher increase in 30-day readmission rate in the transfusion cohort compared to the nontransfusion cohort (no transfusion: 5% vs. transfusion: 16.67%, P = 0.01). In a multivariate logistic regression model, intra- or perioperative allogeneic RBC transfusion was an independent predictor of 30-day readmission after elective spine surgery (P = 0.005). Conclusion. Our study suggests that allogeneic RBC transfusions may be associated with increased postoperative complications, length of hospital stay, and 30-day readmission rates. Level of Evidence: 3

Association between baseline cognitive impairment and postoperative delirium in elderly patients undergoing surgery for adult spinal deformity

OBJECTIVE Postoperative delirium is common in elderly patients undergoing spine surgery and is associated with a longer and more costly hospital course, functional decline, postoperative institutionalization, and higher likelihood of death within 6 months of discharge. Preoperative cognitive impairment may be a risk factor for the development of postoperative delirium. The aim of this study was to investigate the relationship between baseline cognitive impairment and postoperative delirium in geriatric patients undergoing surgery for degenerative scoliosis. METHODS Elderly patients 65 years and older undergoing a planned elective spinal surgery for correction of adult degenerative scoliosis were enrolled in this study. Preoperative cognition was assessed using the validated Saint Louis University Mental Status (SLUMS) examination. SLUMS comprises 11 questions, with a maximum score of 30 points. Mild cognitive impairment was defined as a SLUMS score between 21 and 26 points, while severe cognitive impairment was defined as a SLUMS score of ≤ 20 points. Normal cognition was defined as a SLUMS score of ≥ 27 points. Delirium was assessed daily using the Confusion Assessment Method (CAM) and rated as absent or present on the basis of CAM. The incidence of delirium was compared in patients with and without baseline cognitive impairment. RESULTS Twenty-two patients (18%) developed delirium postoperatively. Baseline demographics, including age, sex, comorbidities, and perioperative variables, were similar in patients with and without delirium. The length of in-hospital stay (mean 5.33 days vs 5.48 days) and 30-day hospital readmission rates (12.28% vs 12%) were similar between patients with and without delirium, respectively. Patients with preoperative cognitive impairment (i.e., a lower SLUMS score) had a higher incidence of postoperative delirium. One- and 2-year patient reported outcomes scores were similar in patients with and without delirium. CONCLUSIONS Cognitive impairment is a risk factor for the development of postoperative delirium. Postoperative delirium may be associated with decreased preoperative cognitive reserve. Cognitive impairment assessments should be considered in the preoperative evaluations of elderly patients prior to surgery.

Assessing the effectiveness of routine use of post-operative in-patient physical therapy services

BACKGROUND The association between functional decline occurring with prolonged bed rest after surgery is well-known. Immediate in-patient post-operative ambulation with the physical therapy (PT) service has been reported to improve pain and disability, while decreasing the incidence of perioperative complications. Whether formal PT evaluation prior to hospital discharge leads to improved ambulation (number of steps ambulated), shorter duration of hospital stay and lower peri-operative complications compared to nurse-assisted ambulation protocols remain unknown. METHODS The medical records of 274 patients (No PT: n=87, PT: n=187) undergoing elective spine surgery at a major academic medical center were reviewed. Patients were categorized based on whether PT services were delivered during the post-operative in-patient stay. Patient demographics, comorbidities, and post-operative complication rates were collected and compared. Ambulation status and the number of steps ambulated were recorded. RESULTS Baseline characteristics were similar in both cohorts. Operative variables were similar between both cohorts, with no significant difference in operative time, estimated blood loss (EBL), and number of fusion levels. Peri-operative complication rates were similar between the cohorts. Compared to patients in the nurse-assisted ambulation cohort (No PT), patients in the PT cohort had a longer duration of hospital stay (4.17 vs. 3.39 days, P=0.15). 30-day readmission rates, although higher in the PT cohort, was not statistically significantly different (PT 6.57% vs. No PT: 2.30%, P=0.13). CONCLUSIONS Our study suggests that the routine use of the PT services compared to nurse-assisted ambulation programs is associated with a modest increase in the duration of hospital stay without any significant reduction in peri-operative complications profile. In a health conscious healthcare climate, appropriate screening mechanisms and risk stratification should be performed to optimize utilization of post-operative in-patient PT services.

Geriatric comanagement reduces perioperative complications and shortens duration of hospital stay after lumbar spine surgery: A prospective single-institution experience

OBJECTIVE Geriatric patients undergoing lumbar spine surgery have unique needs due to the physiological changes of aging. They are at risk for adverse outcomes such as delirium, infection, and iatrogenic complications, and these complications, in turn, contribute to the risk of functional decline, nursing home admission, and death. Whether preoperative and perioperative comanagement by a geriatrician reduces the incidence of in-hospital complications and length of in-hospital stay after elective lumbar spine surgery remains unknown. METHODS A unique model of comanagement for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Perioperative Optimization of Senior Health (POSH) program was launched with the aim of improving outcomes in elderly patients (> 65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, in addition to performing routine preoperative anesthesia surgical screening, and comanages them daily throughout the course of their hospital stay to manage medical comorbid conditions and coordinate multidisciplinary rehabilitation along with the neurosurgical team. The first 100 cases were retrospectively reviewed after initiation of the POSH protocol and compared with the immediately preceding 25 cases to assess the incidence of perioperative complications and clinical outcomes. RESULTS One hundred twenty-five patients undergoing lumbar decompression and fusion were enrolled in this pilot program. Baseline characteristics were similar between both cohorts. The mean length of in-hospital stay was 30% shorter in the POSH cohort (6.13 vs 8.72 days; p = 0.06). The mean duration of time between surgery and patient mobilization was significantly shorter in the POSH cohort compared with the non-POSH cohort (1.57 days vs 2.77 days; p = 0.02), and the number of steps ambulated on day of discharge was 2-fold higher in the POSH cohort (p = 0.04). Compared with the non-POSH cohort, the majority of patients in the POSH cohort were discharged to home (24% vs 54%; p = 0.01). CONCLUSIONS Geriatric comanagement reduces the incidence of postoperative complications, shortens the duration of in-hospital stay, and contributes to improved perioperative functional status in elderly patients undergoing elective spinal surgery for the correction of adult degenerative scoliosis.

Regional Variation in Opioid Use After Lumbar Spine Surgery

OBJECTIVE The aim of this study was to investigate regional variations in use of opioids after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. METHODS An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients undergoing 1-level, 2-level, or 3-level index lumbar decompression and fusion procedures between 2007 and 2016. Research records were searchable by International Classification of Diseases diagnosis and procedure codes, and generic drug codes specific to Humana. Opioid use 6 months before index surgery to 2 years after surgery was assessed. RESULTS Of the 13,257 patients included in the study, 63.1% were from the South, 24.3% from the Midwest, 10.5% from the West, and 2.1% from the Northeast. Of patients, 57.8% had a history of opioid use before index surgery, of whom 64.4% were from the South and 23.0% from the Midwest. Over the 6-month preoperative period, 51.6 opioid pills were billed by opioid users monthly (Midwest, 52.7 pills/patient/month; Northeast, 64.9 pills/patient/month; South, 50.6 pills/patient/month; West, 52.2 pills/patient/month). During the 2-year period after surgery, an average of 33.6 opioid pills were billed by opioid users monthly (Midwest, 32.9 pills/patient/month; Northeast, 35.4 pills/patient/month; South, 33.9 pills/patient/month; West, 32.9 pills/patient/month). In a multivariate logistic regression analysis, receiving treatment in the South (odds ratio, 1.18; 95% confidence interval, 1.07-1.29) or West (odds ratio, 1.26; 95% confidence interval, 1.10-1.45) was independently associated with prolonged (>1 year) opioid use after index surgery. CONCLUSIONS Our study suggests that regional variations may exist in the use of opioids after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis.

Interdisciplinary Care Model Independently Decreases Use of Critical Care Services After Corrective Surgery for Adult Degenerative Scoliosis

OBJECTIVE Interdisciplinary management of elderly patients requiring spine surgery has been shown to improve short- and long-term outcomes. The aim of this study was to determine whether an interdisciplinary team approach mitigates use of intensive care unit (ICU) resources. METHODS A unique comanagement model for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Peri-operative Optimization of Senior Health Program (POSH) was launched with the aim of improving outcomes in elderly patients (>65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, comanages daily throughout hospital course, and coordinates multidisciplinary rehabilitation, along with the neurosurgical team. We retrospectively reviewed the first 100 cases after the initiation of the POSH protocol and compared them with the immediately preceding 25 cases to assess the rates of ICU transfer and independent predictors of ICU admission. RESULTS A total of 125 patients undergoing lumbar decompression and fusion surgery were enrolled in this pilot program. Baseline characteristics and intraoperative variables, as well as number of fusion levels and duration of surgery, were similar between both cohorts. There was a significant difference in the use of ICU services (ICU admission rates) between both cohorts, with the non-POSH cohort having a 3-fold increase compared with the POSH cohort (P < 0.0001). In a multivariate analysis, lack of an interdisciplinary comanagement team approach was an independent predictor for ICU transfers in elderly patients undergoing corrective surgery (odds ratio 8.51, 95% confidence interval 2.972-24.37, P < 0.0001). CONCLUSIONS Our study suggests that an interdisciplinary comanagement model between geriatrics and neurosurgery is independently associated with reduced use of critical care services.

Extended Length of Stay in Elderly Patients after Anterior Cervical Discectomy and Fusion Is Not Attributable to Baseline Illness Severity or Postoperative Complications

BACKGROUND Health care systems are increasing efforts to minimize postoperative hospital stays to improve resource use. Common explanations for extended postoperative stay are baseline patient sickness, postoperative complications, or physician practice differences. However, the degree to which extended length of stay (LOS) represents patient illness or postoperative complications remains unknown. The aim is to investigate the influence of postoperative complications and elderly patient comorbidities on extended LOS after anterior cervical discectomy and fusion. METHODS This retrospective study was performed from January 1, 2008, to December 31, 2014, on data from the American College of Surgeons National Surgical Quality Improvement Program. Patient demographics, comorbidities, LOS, and inpatient complications were recorded. Multivariable logistic regression analysis was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree extended LOS represented patient illness or postoperative complications. RESULTS Of 4730 participants, 1351 (28.56%) had extended LOS. A minority of patients with extended LOS had a history of relevant comorbidities-diabetes (29.53%), chronic obstructive pulmonary disease (9.4%), congestive heart failure (1.04%), myocardial infarction (0.33%), acute renal failure (0.3%), and stroke (5.92%). Among patients with normal LOS, 96.8% had no complications, 2.7% had 1 complication, and 0.5% had greater than 1 complication. In patients with extended LOS, 79.4% had no complications, 14.5% had 1 complication, and 6.1% had greater than 1 complication (P < 0.0001). CONCLUSIONS Our study suggests much of LOS variation after an anterior cervical discectomy and fusion is not attributable to baseline patient illness or complications and most likely represents differences in practice style or surgeon preference.

Post-operative drain use in patients undergoing decompression and fusion: incidence of complications and symptomatic hematoma

Background Surgical drains are commonly used after spine surgery to minimize infection and hematoma formation. The aim of this study was to determine the incidence of post-operative complications after spinal decompression and fusion with and without a subfascial drain. Methods The medical records of 139 adult (≥18 years old) spinal deformity patients undergoing elective spinal decompression and fusion at a major academic institution were reviewed. We identified 116 (83.5%) who had a post-operative drain and 23 (16.5%) who did not have a postoperative drain (No-Drain: n=23; Drain-Use: n=116). Patient demographics, comorbidities, intra- and post-operative complication rates were collected for each patient. The primary outcome investigated in this study was the rate of post-operative complications, specifically surgical site infections (SSI) and hematoma formation. Results Patient demographics and comorbidities were similar between both cohorts, with the body mass index (BMI) slightly higher in the Drain-Use cohort (No-Drain: 26.1 kg/m2vs. Drain-Use: 29.1 kg/m2, P=0.02). Operative time and the median number of levels fused were similar between the cohorts. The postoperative complications profile was similar between both cohorts, including deep and superficial SSIs (P=0.52 and P=0.66, respectively), and incidence of hematoma formation (P=0.66). Length of hospital stay (LOS) was significantly higher for the Drain-use cohort compared to the No-Drain cohort (5.0 vs. 2.8 days, P<0.0001). There were no significant differences in the 30-day hospital readmission rate or incidence of 30-day wound dehiscence, draining wound, incision & drainage (I & D), or bleeding between both patient groups. Conclusions Our study suggests that the use of postoperative subfascial drains in patients undergoing spinal decompression with fusion may not be associated with a reduction in SSIs or hematoma formation.

Immediate Postoperative Pain Scores Predict Neck Pain Profile up to 1 Year Following Anterior Cervical Discectomy and Fusion

Study Design: Retrospective cohort review. Objective: To assess whether immediate postoperative neck pain scores accurately predict 12-month visual analog scale–neck pain (VAS-NP) outcomes following Anterior Cervical Discectomy and Fusion surgery (ACDF). Methods: This was a retrospective study of 82 patients undergoing elective ACDF surgery at a major academic medical center. Patient reported outcomes measures VAS-NP scores were recorded on the first postoperative day, then at 6-weeks, 3, 6, and 12-months after surgery. Multivariate correlation and logistic regression methods were utilized to determine whether immediate postoperative VAS-NP score accurately predicted 1-year patient reported VAS-NP Scores. Results: Overall, 46.3% male, 25.6% were smokers, and the mean age and body mass index (BMI) were 53.7 years and 28.28 kg/m2, respectively. There were significant correlations between immediate postoperative pain scores and neck pain scores at 6 weeks VAS-NP (P = .0015), 6 months VAS-NP (P = .0333), and 12 months VAS-NP (P = .0247) after surgery. Furthermore, immediate postoperative pain score is an independent predictor of 6 weeks, 6 months, and 1 year VAS-NP scores. Conclusion: Our study suggests that immediate postoperative patient reported neck pain scores accurately predicts and correlates with 12-month VAS-NP scores after an ACDF procedure. Patients with high neck pain scores after surgery are more likely to report persistent neck pain 12 months after index surgery.

The prevalence of undiagnosed pre-surgical cognitive impairment and its post-surgical clinical impact in elderly patients undergoing surgery for adult spinal deformity

BACKGROUND Pre-existing cognitive impairment (CI) is emerging as a predictor of poor post-operative outcomes in elderly patients. Little is known about impaired preoperative cognition and outcomes after elective spine surgery in this patient population. The purpose of this study was to assess the prevalence of neuro CI in elderly patients undergoing deformity surgery and its impact on postoperative outcomes. METHODS Elderly subjects undergoing elective spinal surgery for correction of adult degenerative scoliosis were enrolled in this study. Pre-operative baseline cognition was assessed using the Saint Louis Mental Status (SLUMS) test. SLUMS consists of 11 questions, which can give a maximum of 30 points. Mild CI was defined as a SLUMS score between 21-26 points, while severe CI was defined as a SLUMS score of ≤20 points. Normal cognition was defined as a SLUMS score of ≥27 points. Complication rates, duration of hospital stay, and 30-day readmission rates were compared between patients with and without baseline CI. RESULTS Eighty-two subjects were included in this study, with mean age of 73.26±6.08 years. Fifty-seven patients (70%) had impaired cognition at baseline. The impaired cognition group had the following outcomes: increased incidence of one or more postoperative complications (39% vs. 20%), higher incidence of delirium (20% vs. 8%), and higher rate of discharge institutionalization at skilled nursing or acute rehab facilities (54% vs. 30%). The length of hospital stay and 30-day hospital readmission rates were similar between both cohorts (5.33 vs. 5.48 days and 12.28% vs. 12%, respectively). CONCLUSIONS CI is highly prevalent in elderly patients undergoing surgery for adult degenerative scoliosis. Impaired cognition before surgery was associated with higher rates of post-operative delirium, complications, and discharge institutionalization. CI assessments should be considered in the pre-operative evaluations of elderly patients prior to surgery.