William W. Long

Malnutrition Predicts Infectious and Wound Complications Following Posterior Lumbar Spinal Fusion

Study Design. A retrospective review of data collected prospectively by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Objective. The aim of this study was to investigate the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days following posterior lumbar fusion surgery. Summary of Background Data. Malnutrition is a potentially modifiable risk factor that may contribute to complications following spinal surgery. Although prior studies have identified associations between malnutrition, delayed wound healing, and surgical site infection (SSI), the evidence for such a relationship within spine surgery is mixed. Methods. Patients who underwent posterior lumbar spinal fusion of one to three levels as part of the ACS-NSQIP were identified. Patients without preoperative serum albumin concentration were excluded. Outcomes were compared between patients with and without hypoalbuminemia (defined as serum albumin concentration <3.5 g/dL). All comparisons were adjusted for baseline differences between populations. Results. Four thousand three hundred ten patients were included. The prevalence of hypoalbuminemia was 4.8%. In comparison to patients with normal albumin concentration, patients with hypoalbuminemia had a higher risk for occurrence of wound dehiscence [1.5% vs. 0.2%, adjusted relative risk (RR) = 5.8, P = 0.006], SSI (5.4% vs. 1.7%, adjusted RR = 2.3, P = 0.010), and urinary tract infection (5.4% vs. 1.5%, adjusted RR = 2.5, P = 0.005). Similarly, patients with hypoalbuminemia had a higher risk for unplanned hospital readmission within 30 days of surgery (11.7% vs. 5.4%, RR = 1.8, P < 0.001). Finally, patients with hypoalbuminemia had a longer mean inpatient stay (5.2 vs. 3.7 days, RR = 1.2, P < 0.001). Conclusion. The present study suggests that malnutrition is an independent risk factor for infectious and wound complications following posterior lumbar fusion. Malnutrition was also associated with an increased length of stay and readmission. Future studies should evaluate methods of correcting malnutrition before lumbar spinal surgery. Such efforts have the potential to meaningfully decrease the rates of adverse events following this procedure. Level of Evidence: 3

Anterior Cervical Discectomy and Fusion: The Surgical Learning Curve

Study Design. Case-series Objective. The aim of the study was to investigate changes in intraoperative and postoperative parameters associated with the surgical learning curve for anterior cervical discectomy and fusion (ACDF). Summary of Background Data. ACDF is a common surgical spine procedure. The surgical learning curve for this procedure has not been previously characterized. Methods. A prospectively maintained surgical database of consecutive patients who underwent primary 1–2 level ACDF for degenerative spine disease from 2006 to 2014 was reviewed. Patients with concurrent or revision procedures were excluded. The series began after the surgeons fellowship and includes his first case as an attending. A total of 374 patients were divided sequentially into cohorts of 125 (early), 125 (middle), and 124 (late). Statistical analyses utilized independent sample t tests, chi squared tests, and multivariate regression adjusted for preoperative characteristics. The learning curve of operative time was characterized using three-parameter asymptotic regression and two separate linear regressions. Results. The earliest cohort had a greater comorbidity burden, percentage of smokers, and Medicare patients, with fewer workers’ compensation patients when compared to later cohorts. Later cohorts demonstrated decreased mean operative time and estimated blood loss (EBL) and increased arthrodesis rate. Asymptotic and linear regression analyses demonstrated that 50% of the learning curve occurred at case 17 and 31, respectively, whereas 90% of potential improvement occurred by case 56 and 57, respectively. Conclusion. A significant learning curve exists for surgeons performing ACDFs. Patients undergoing ACDF will experience shorter operations, less EBL, and greater arthrodesis rates as the surgeon gains experience. Operative proficiency can be expected to occur by case 60, with arthrodesis rate increasing over a longer period. These results suggest that despite longer operative times and increased EBL with earlier cases, ACDF can safely and effectively be performed at the onset of a surgeons career. This conclusion may be useful to new surgeons debating between operative and nonoperative management of cervical degenerative disc disease. Level of Evidence: 4

Multimodal Versus Patient-Controlled Analgesia After an Anterior Cervical Decompression and Fusion.

Study Design. Retrospective analysis of a prospectively maintained surgical registry. Objective. To compare postoperative narcotic consumption between multimodal analgesia (MMA) and patient-controlled analgesia (PCA) after an anterior cervical discectomy and fusion (ACDF). Summary of Background Data. Studies suggest that a multimodal approach to pain management leads to decreased pain and morphine consumption after total joint arthroplasty and lumbar spinal procedures. Patients and surgeons would benefit from knowing whether a multimodal approach to pain management is superior to PCA for ACDF. Methods. A retrospective cohort study of ACDF patients receiving either MMA or PCA was conducted. Inpatient narcotic consumption, pain scores, nausea/vomiting, hospital length of stay, and narcotic dependence during the months after surgery were compared between MMA and PCA. Results. A total of 239 patients met inclusion criteria. Of these, 55 (23.0%) received MMA and 184 (77.0%) received PCA. Patients who received MMA had a lower rate of inpatient narcotic consumption (2.5 OME/h vs. 5.8 OME/h, P < 0.001) were less likely to experience nausea/vomiting during the hospitalization (5.5% vs. 37.5%, P < 0.001), and had a shorter hospital length of stay (27.3 vs. 40.1 h, P < 0.001). However, there was no difference between groups in mean visual analogue pain scale during postoperative day zero (4.7 for MMA vs. 5.2 for PCA, P = 0.126) or during postoperative day one (4.1 for MMA vs. 4.1 for PCA, P = 0.937). In addition, there was no difference in the rate of narcotic dependence at the first (P = 0.626) or second (P = 0.480) postoperative visits. Conclusion. These data suggest that MMA results in lower narcotic consumption than PCA after an ACDF. This difference is associated with a shorter inpatient stay and a decrease in postoperative nausea/vomiting. Critically, MMA and PCA appear to provide similar postoperative analgesia. Level of Evidence: 3

Multimodal Analgesia versus Intravenous Patient-controlled Analgesia For Minimally Invasive Transforaminal Lumbar Interbody Fusion Procedures.

Study Design. Retrospective analysis. Objective. To compare postoperative narcotic consumption and pain scores between multimodal analgesia (MMA) and patient-controlled analgesia (PCA) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Summary of Background Data. A multimodal analgesic approach to pain management may lead to decreased pain and narcotic consumption after orthopedic procedures. Additional evidence is, however, required to determine how MMA compares to intravenous PCA after MIS TLIF. Methods. Patients undergoing 1-level MIS TLIF followed by either MMA or PCA at our institution were compared in terms of inpatient pain scores, narcotic consumption, hospital length of stay, rates of surgical complications, rates of inpatient nausea/vomiting, rates of postoperative urinary retention, and rates of narcotic consumption during the months after discharge. Results. A total of 139 patients met inclusion criteria. Of these, 39 (28.1%) received MMA and 100 (71.9%) received PCA. Demographic and comorbidity characteristics did not differ between cohorts. Compared with patients receiving PCA, patients receiving MMA had a lower rate of inpatient narcotic consumption (2.8 ± 1.9 vs. 5.3 ± 4.4 oral morphine equivalents/hour, P < 0.001), a lower rate of inpatient nausea/vomiting (20.5% vs. 48.0%; P = 0.003), and a shorter hospital length of stay (53.0 ± 25.3 vs. 62.6 ± 24.4 h, P = 0.041). There were no differences in Numeric Rating Scale pain score between cohorts for day 0, postoperative day 1, or postoperative day 2 (P > 0.05 for each). There was no difference in the rate of postoperative urinary retention (P > 0.05). Similarly, there were no differences in narcotic consumption at 6 or 12 weeks postoperatively (P > 0.05 for each). Conclusion. These findings suggest that MMA results in reduced inpatient hospital narcotic consumption compared with PCA after MIS TLIF. The decrease in narcotic consumption may contribute to the observed decrease in the rate of inpatient nausea/vomiting and shorter hospital length of stay. Importantly, MMA and PCA resulted in similar analgesia for patients during the inpatient stay. Level of Evidence: 4

Preoperative mental health status may not be predictive of improvements in patient-reported outcomes following an anterior cervical discectomy and fusion

OBJECTIVE Prior studies have correlated preoperative depression and poor mental health status with inferior patient-reported outcomes following lumbar spinal procedures. However, literature regarding the effect of mental health on outcomes following cervical spinal surgery is limited. As such, the purpose of this study is to test for the association of preoperative SF-12 Mental Component Summary (MCS) scores with improvements in Neck Disability Index (NDI), SF-12 Physical Component Summary (PCS), and neck and arm pain following anterior cervical discectomy and fusion (ACDF). METHODS A prospectively maintained surgical database of patients who underwent a primary 1- or 2-level ACDF during 2014-2015 was reviewed. Patients were excluded if they did not have complete patient-reported outcome data for the preoperative or 6-week, 12-week, or 6-month postoperative visits. At baseline, preoperative SF-12 MCS score was assessed for association with preoperative NDI, neck visual analog scale (VAS) score, arm VAS score, and SF-12 PCS score. The preoperative MCS score was then tested for association with changes in NDI, neck VAS, arm VAS, and SF-12 PCS scores from the preoperative visit to postoperative visits. These tests were conducted using multivariate regression controlling for baseline characteristics as well as for the preoperative score for the patient-reported outcome being assessed. RESULTS A total of 52 patients were included in the analysis. At baseline, a higher preoperative MCS score was negatively associated with a lower preoperative NDI (coefficient: -0.74, p < 0.001) and preoperative arm VAS score (-0.06, p = 0.026), but not preoperative neck VAS score (-0.03, p = 0.325) or SF-12 PCS score (0.04, p = 0.664). Additionally, there was no association between preoperative MCS score and improvement in NDI, neck VAS, arm VAS, or SF-12 PCS score at any of the postoperative time points (6 weeks, 12 weeks, and 6 months, p > 0.05 for each). The percentage of patients achieving a minimum clinically important difference at 6 months did not differ between the bottom and top MCS score halves (p > 0.05 for each). CONCLUSIONS The results of this study suggest that better preoperative mental health status is associated with lower perceived preoperative disability but is not associated with severity of preoperative neck or arm pain. In contrast to other studies, the present study was unable to demonstrate that preoperative mental health is predictive of improvement in patient-reported outcomes at any postoperative time point following an ACDF.

Effects of Intraoperative Anesthetic Medications on Postoperative Urinary Retention After Single-Level Lumbar Fusion.

Study Design. Retrospective cohort analysis. Objective. The aim of the study was to identify medications that may potentially contribute to developing postoperative urinary retention (POUR) after lumbar spinal fusion procedures. Summary of Background Data. POUR is a concerning event that may occur after routine orthopedic surgery. The relation between intraoperative medications and POUR after lumbar spine surgery has not been well characterized. Methods. A prospectively maintained database of patients who underwent a primary single-level, minimally invasive transforaminal lumbar interbody fusion between 2009 and 2013 was reviewed. POUR was defined as a bladder scan of 300 mL or higher, the postoperative necessity of a straight catheterization, or a urology consult for urinary retention. The use and dose-response of intraoperative medications between patients with and without POUR were compared. Potential risk factors for developing POUR were analyzed using multivariate analysis. Results. A total of 205 patients were included in the study, 17% of whom experienced POUR (n = 34). Administration of phenylephrine and neostigmine was associated with POUR (phenylephrine: 32.3% vs. 13.8%, P = 0.017; neostigmine: 19.5% vs. 6.5%, P = 0.042). Parametric analysis demonstrated an association of increasing dose of neostigmine with POUR (4.66 vs. 4.22 mg, P = 0.023). Similarly, a nonparametric analysis demonstrated an association of increasing doses of both neostigmine and phenylephrine with POUR (neostigmine: 4.25 vs. 3.16 mg, P = 0.02; phenylephrine: 105.88 vs. 40.64 mg, P = 0.008). Conclusion. Approximately 20% of patients may develop POUR after routine lumbar spine surgery. The use of certain intraoperative anesthetics such as phenylephrine and neostigmine is strongly associated with the development of POUR postoperatively. This finding suggests that there may be modifiable anesthetic risk factors to prevent the development of POUR in patients undergoing lumbar spine surgery. Future prospective, controlled studies specifically addressing these findings could lead to improved patient care and decreased healthcare costs. Level of Evidence: 4

Lateral lumbar interbody fusion: a systematic review of complication rates

BACKGROUND CONTEXT Lateral lumbar interbody fusion (LLIF) is a frequently used technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach. PURPOSE To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF. STUDY DESIGN Systematic review. PATIENT SAMPLE 6,819 patients who underwent LLIF reported in clinical studies through June 2016. OUTCOME MEASURES Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and spine (MSK) categories. METHODS This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and MSK categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work. RESULTS A total of 2,232 articles were identified. Following screening of title, abstract, and full-text availability, 63 articles were included in the review. A total of 6,819 patients had 11,325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval [CI]=1.00%-1.85%), cardiac (1.86%; CI=1.33%-2.52%), vascular (0.81%; CI=0.44%-1.36%), pulmonary (1.47; CI=0.95%-2.16%), gastrointestinal (1.38%; CI=1.00%-1.87%), urologic (0.93%; CI=0.55%-1.47%), transient neurologic (36.07%; CI=34.74%-37.41%), persistent neurologic (3.98%; CI=3.42%-4.60%), and MSK or spine (9.22%; CI=8.28%-10.23%). CONCLUSIONS The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks to and expectations for patients following LLIF procedures.

Spinal Surgeon Variation in Single-Level Cervical Fusion Procedures: A Cost and Hospital Resource Utilization Analysis.

Study Design. Retrospective analysis. Objective. To compare perioperative costs and outcomes of patients undergoing single-level anterior cervical discectomy and fusions (ACDF) at both a service (orthopedic vs. neurosurgical) and individual surgeon level. Summary of Background Data. Hospital systems are experiencing significant pressure to increase value of care by reducing costs while maintaining or improving patient-centered outcomes. Few studies have examined the cost-effectiveness cervical arthrodesis at a service level. Methods. A retrospective review of patients who underwent a primary 1-level ACDF by eight surgeons (four orthopedic and four neurosurgical) at a single academic institution between 2013 and 2015 was performed. Patients were identified by Diagnosis-Related Group and procedural codes. Patients with the ninth revision of the International Classification of Diseases coding for degenerative cervical pathology were included. Patients were excluded if they exhibited preoperative diagnoses or postoperative social work issues affecting their length of stay. Comparisons of preoperative demographics were performed using Student t tests and chi-squared analysis. Perioperative outcomes and costs for hospital services were compared using multivariate regression adjusted for preoperative characteristics. Results. A total of 137 patients diagnosed with cervical degeneration underwent single-level ACDF; 44 and 93 were performed by orthopedic surgeons and neurosurgeons, respectively. There was no difference in patient demographics. ACDF procedures performed by orthopedic surgeons demonstrated shorter operative times (89.1 ± 25.5 vs. 96.0 ± 25.5 min; P = 0.002) and higher laboratory costs (&Dgr;+

Improvements in Neck and Arm Pain Following an Anterior Cervical Discectomy and Fusion.

6.53 ± 

Effects of Intraoperative Anesthetic Medications on Postoperative Urinary Retention after Single Level Lumbar Fusion

5.52 USD; P = 0.041). There were significant differences in operative time (P = 0.014) and labor costs (P = 0.034) between individual surgeons. There was no difference in total costs between specialties or individual surgeons. Conclusion. Surgical subspecialty training does not significantly affect total costs of ACDF procedures. Costs can, however, vary between individual surgeons based on operative times. Variation between individual surgeons highlights potential areas for improvement of the cost effectiveness of spinal procedures. Level of Evidence: 4