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Rafael De la Garza-Ramos, Amit Jain, Khaled M. Kebaish, Ali Bydon, Peter G. Passias and Daniel M. Sciubba

OBJECTIVE

The goal of this study was to compare inpatient morbidity and mortality after adult spinal deformity (ASD) surgery in teaching versus nonteaching hospitals in the US.

METHODS

The Nationwide Inpatient Sample was used to identify surgical patients with ASD between 2002 and 2011. Only patients > 21 years old and elective cases were included. Patient characteristics, inpatient morbidity, and inpatient mortality were compared between teaching and nonteaching hospitals. A multivariable logistic regression analysis was performed to examine the effect of hospital teaching status on surgical outcomes.

RESULTS

A total of 7603 patients were identified, with 61.2% (n = 4650) in the teaching hospital group and 38.8% (n = 2953) in the nonteaching hospital group. The proportion of patients undergoing revision procedures was significantly different between groups (5.2% in teaching hospitals vs 3.9% in nonteaching hospitals, p = 0.008). Likewise, complex procedures (defined as fusion of 8 or more segments and/or osteotomy) were more common in teaching hospitals (27.3% vs 21.7%, p < 0.001). Crude overall complication rates were similar in teaching hospitals (47.9%) compared with nonteaching hospitals (49.8%, p = 0.114). After controlling for patient characteristics, case complexity, and revision status, patients treated at teaching hospitals were significantly less likely to develop a complication when compared with patients treated at a nonteaching hospital (OR 0.89; 95% CI 0.82–0.98). The mortality rate was 0.4% in teaching hospitals and < 0.4% in nonteaching hospitals (p = 0.210).

CONCLUSIONS

Patients who undergo surgery for ASD at a teaching hospital may have significantly lower odds of complication development compared with patients treated at a nonteaching hospital.

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Rafael De la Garza-Ramos, Risheng Xu, Seba Ramhmdani, Thomas Kosztowski, Mohamad Bydon, Daniel M. Sciubba, Jean-Paul Wolinsky, Timothy F. Witham, Ziya L. Gokaslan and Ali Bydon

OBJECTIVE

The purpose of this study was to report the long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion (ACDF).

METHODS

A retrospective review of all adult neurosurgical patients undergoing elective ACDF for degenerative disease at a single institution between 1996 and 2013 was performed. Patients who underwent first-time 3- or 4-level ACDF were included; patients with previous cervical spine surgery, those undergoing anterior/posterior approaches, and those with corpectomy were excluded. Outcome measures included perioperative complication rates, fusion rates, need for revision surgery, Nurick Scores, Odom's criteria, symptom resolution, neck visual analog scale (VAS) pain score, and persistent narcotics usage.

RESULTS

Seventy-one patients who underwent 3-level ACDF and 26 patients who underwent 4-level ACDF were identified and followed for an average of 7.6 ± 4.2 years. There was 1 case (3.9%) of deep wound infection in the 4-level group and 1 case in the 3-level group (1.4%; p = 0.454). Postoperatively, 31% of patients in the 4-level group complained of dysphagia, compared with 12.7% in the 3-level group (p = 0.038). The fusion rate was 84.6% after 4-level ACDF and 94.4% after 3-level ACDF (p = 0.122). At last follow-up, a significantly higher proportion of patients in the 4-level group continued to have axial neck pain (53.8%) than in the 3-level group (31%; p = 0.039); the daily oral morphine equivalent dose was significantly higher in the 4-level group (143 ± 97 mg/day) than in the 3-level group (25 ± 10 mg/day; p = 0.030). Outcomes based on Odom's criteria were also different between cohorts (p = 0.044), with a significantly lower proportion of patients in the 4-level ACDF group experiencing an excellent/good outcome.

CONCLUSIONS

In this study, patients who underwent 4-level ACDF had significantly higher rates of dysphagia, postoperative neck pain, and postoperative narcotic usage when compared with patients who underwent 3-level ACDF. Pseudarthrosis and deep wound infection rates were also higher in the 4-level group, although this did not reach statistical significance. Additionally, a smaller proportion of patients achieved a good/excellent outcome in the 4-level group than in the 3-level group. These findings suggest a significant increase of perioperative morbidity and worsened outcomes for patients who undergo 4- versus 3-level ACDF.

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Mohamad Bydon, Mohamed Macki, Rafael De la Garza-Ramos, Daniel M. Sciubba, Jean-Paul Wolinsky, Ziya L. Gokaslan, Timothy F. Witham and Ali Bydon

OBJECT

This study aimed to identify the factors predicting an increased risk for reoperation in patients who had undergone a lumbar laminectomy.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.