Mohamad Bydon, Nicholas B. Abt, Rafael De la Garza-Ramos, Mohamed Macki, Timothy F. Witham, Ziya L. Gokaslan, Ali Bydon and Judy Huang
The authors sought to determine the impact of resident participation on overall 30-day morbidity and mortality following neurosurgical procedures.
The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who had undergone neurosurgical procedures between 2006 and 2012. The operating surgeon(s), whether an attending only or attending plus resident, was assessed for his or her influence on morbidity and mortality. Multivariate logistic regression, was used to estimate odds ratios for 30-day postoperative morbidity and mortality outcomes for the attending-only compared with the attending plus resident cohorts (attending group and attending+resident group, respectively).
The study population consisted of 16,098 patients who had undergone elective or emergent neurosurgical procedures. The mean patient age was 56.8 ± 15.0 years, and 49.8% of patients were women. Overall, 15.8% of all patients had at least one postoperative complication. The attending+resident group demonstrated a complication rate of 20.12%, while patients with an attending-only surgeon had a statistically significantly lower complication rate at 11.70% (p < 0.001). In the total population, 263 patients (1.63%) died within 30 days of surgery. Stratified by operating surgeon status, 162 patients (2.07%) in the attending+resident group died versus 101 (1.22%) in the attending group, which was statistically significant (p < 0.001). Regression analyses compared patients who had resident participation to those with only attending surgeons, the referent group. Following adjustment for preoperative patient characteristics and comorbidities, multivariate regression analysis demonstrated that patients with resident participation in their surgery had the same odds of 30-day morbidity (OR = 1.05, 95% CI 0.94–1.17) and mortality (OR = 0.92, 95% CI 0.66–1.28) as their attendingonly counterparts.
Cases with resident participation had higher rates of mortality and morbidity; however, these cases also involved patients with more comorbidities initially. On multivariate analysis, resident participation was not an independent risk factor for postoperative 30-day morbidity or mortality following elective or emergent neurosurgical procedures.
Mohamad Bydon, Mohamed Macki, Rafael De la Garza-Ramos, Daniel M. Sciubba, Jean-Paul Wolinsky, Ziya L. Gokaslan, Timothy F. Witham and Ali Bydon
This study aimed to identify the factors predicting an increased risk for reoperation in patients who had undergone a lumbar laminectomy.
The authors retrospectively reviewed the electronic medical records of all patients who had undergone firsttime, bilateral laminectomy at 1, 2, or 3 levels for lumbar spondylosis at the authors' institution. Patients who underwent fusion, laminotomy, discectomy, or complete facetectomy were excluded. The patients' preoperative symptoms and comorbidities were also obtained from their medical records.
Over an average follow-up period of 46.8 months, of 500 patients who had undergone laminectomy at 1, 2, or 3 levels, 81 patients (16.2%) developed subsequent spinal disorders that required a reoperation. A multiple logistic regression analysis identified smoking as an independent predictor of reoperation (OR 2.15, p = 0.01). Smoking was also an independent predictor of reoperation after a single-level laminectomy (OR 11.3, p = 0.02) and after a multilevel (that is, involving 2 or 3 levels) laminectomy (OR 1.98, p = 0.05). For 72 patients undergoing reoperation only for spinal degeneration, smoking remained an independent, statistically significant predictor of reoperation (OR 2.06, p = 0.04). Nine patients underwent reoperation for nondegenerative conditions (hematoma, wound infection, or wound dehiscence), and in these patients, chronic obstructive pulmonary disease was the only statistically significant predictor of reoperation (OR 8.92, p = 0.03).
Smoking was the strongest predictor of reoperation in patients who had undergone single-level laminectomy, multilevel laminectomy, or reoperation for progression of spinal degeneration. These findings suggest that smokers have worse outcomes of lumbar decompression than nonsmokers.
Mohamad Bydon, Dimitrios Mathios, Mohamed Macki, Rafael de la Garza-Ramos, Daniel M. Sciubba, Timothy F. Witham, Jean-Paul Wolinsky, Ziya L. Gokaslan and Ali Bydon
The authors conducted a study to investigate the rate and timing of reoperation due to symptom recurrence after unilateral posterior cervical foraminotomy (PCF).
The authors retrospectively reviewed demographic, surgical, and clinical data from 151 patients who underwent unilateral PCF at their institution with an average follow-up of 4.15 years. The main outcome variables were reoperation rate, time to reoperation, and short- and long-term radiculopathy improvement rates. Kaplan-Meier analyses were conducted to assess risk of reoperation and recurrence of radiculopathy over time.
After index PCF in 151 patients, the overall reoperation rate was 9.9% (15 patients). The average time until reoperation was 2.4 years, and the average last follow-up examination was 4.15 years after the first surgery. Patients who presented with preoperative neck pain in addition to radiculopathy had a higher risk for reoperation and a shorter time to reoperation. The majority of patients who underwent a reoperation had an anterior cervical discectomy and fusion (80%). A smaller number of patients had reoperation that included a repeat PCF (6.7%) or laminectomy with posterior cervical fusion (13.3%). The rate of same-level reoperation (6.6%, 10 patients) was significantly higher (p = 0.05) when compared with adjacent-segment (1.3%, 2 patients) or distant-segment (1.9%, 3 patients) reoperation. At last follow-up, the overall rate of improvement in radiculopathy was 85%, with the majority of patients (91.4%) experiencing resolution as early as 1 month after index surgery. Following the subgroup that experienced initial symptom improvement, 16.1% of these patients experienced radiculopathy recurrence an average of 7.3 years after the initial operation. While the reoperation rate for the overall cohort in this series was 9.9%, patients with follow-up periods longer than 2 years had a reoperation rate of 18.3%. Moreover, patients with more than 10 years of follow-up had a reoperation rate of 24.3%.
PCF is a procedure performed to address nerve root compression in the cervical spine. The authors evaluated 151 patients who underwent unilateral PCF and found a reoperation rate of 9.9% at an average of 2.4 years after the initial surgery (6.6% at same level, 3.3% elsewhere). The reoperation rates reached 18.3% and 24.3% in patients with follow-up periods longer than 2 and 10 years, respectively. The authors' analysis revealed that patients with no preoperative neck pain had the lowest rates of revision surgery after PCF.
Mohamad Bydon, Risheng Xu, Anubhav G. Amin, Mohamed Macki, Paul Kaloostian, Daniel M. Sciubba, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan and Timothy F. Witham
A number of imaging techniques have been introduced to minimize the risk of pedicle screw placement. Intraoperative CT has been recently introduced to assist in spinal instrumentation. The aim of this study was to study the effectiveness of intraoperative CT in enhancing the safety and accuracy of pedicle screw placement.
The authors included all cases from December 2009 through July 2012 in which intraoperative CT scanning was used to confirm pedicle screw placement.
A total of 203 patients met the inclusion criteria. Of 1148 screws, 103 screws (8.97%) were revised intraoperatively in 72 patients (35.5%): 14 (18.42%) were revised in the cervical spine (C-2 or C-7), 25 (7.25%) in the thoracic spine, and 64 (8.80%) in the lumbar spine. Compared with screws in the thoracic and lumbar regions, pedicle screws placed in the cervical region were statistically more likely to be revised (p = 0.0061). Two patients (0.99%) required reoperations due to undetected misplacement of pedicle screws.
The authors describe one of the first North American experiences using intraoperative CT scanning to confirm the placement of pedicle screws. Compared with a similar cohort of patients from their institution who had pedicle screws inserted via the free-hand technique with postoperative CT, the authors found that the intraoperative CT lowers the threshold for pedicle screw revision, resulting in a statistically higher rate of screw revision in the thoracic and lumbar spine (p < 0.0001). During their 2.5-year experience with the intraoperative CT, the authors did not find a reduction in rates of reoperation for misplaced pedicle screws.
Mohamad Bydon, Risheng Xu, David Santiago-Dieppa, Mohamed Macki, Daniel M. Sciubba, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan and Timothy F. Witham
The aim of this study was to study the long-term outcomes of patients undergoing instrumented posterior fusion of the lumbar spine.
The authors present 511 patients who underwent instrumented arthrodesis for lumbar degenerative disease over a 23-year period at a single institution. Patients underwent follow-up for an average of 39.73 ± 46.52 months (± SD) after the index lumbar arthrodesis procedure.
The average patient age was 59.45 ± 13.48 years. Of the 511 patients, 502 (98.24%) presented with back pain, 379 (74.17%) with radiculopathy, 76 (14.87%) with motor weakness, and 32 (6.26%) with preoperative bowel/bladder dysfunction. An average of 2.04 ± 1.03 spinal levels were fused. Postoperatively, patients experienced a significant improvement in back pain (p < 0.0001) and radiculopathy (p < 0.0001). Patients with fusions excluding the sacrum (floating fusions) were statistically more likely to develop adjacent-segment disease (ASD) than those with fusion constructs ending at S-1 distally (p = 0.030) but were less likely to develop postoperative radiculopathy (p = 0.030). In the floating fusion cohort, 31 (12.11%) of 256 patients had cephalad ASD, whereas 39 (15.29%) of 255 patients in the lumbosacral cohort had cephalad ASD development; this was not statistically different (p = 0.295). This suggests that caudad ASD development in the floating fusion cohort is due to the added risk of an unfused L5–S1 vertebral level. Because of the elevated risk of symptomatic radiculopathy but lower risk of ASD, patients in the lumbosacral fusion cohort had a reoperation rate similar to those undergoing floating fusions (p = 0.769).
In this paper, the authors present one of the largest cohorts in the Western literature of patients undergoing instrumented fusion for degenerative lumbar spine disease. Patients who had floating lumbar fusions were statistically more likely to develop ASD over time than those who had lumbosacral fusions incorporating the S-1 spinal segment, but were less likely to experience postoperative radicular symptoms. Additional prospective studies may more clearly delineate the long-term risks of instrumented posterolateral fusions of the lumbar spine.