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Richard Menger, Paul J. Park, Elise C. Bixby, Gerard Marciano, Meghan Cerpa, David Roye, Benjamin D. Roye, Michael Vitale, and Lawrence Lenke

–based proportional parameter. The key emphasis within those with fusion to the pelvis would be the inability to compensate. Lordosis specifically is locked into place, as would be the lordosis distribution index (L4–S1 lordosis divided by the L1–S1 lordosis multiplied by 100) and corresponding pelvic parameters. Depending on extension of the proximal construct, so too would thoracic kyphosis and even distal cervical lordosis. Unplanned Return to the Operating Room Unplanned return to the operating room in patients with AIS hovers around 3.5%. 25 In neurosurgical data

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Kristina Bianco, Robert Norton, Frank Schwab, Justin S. Smith, Eric Klineberg, Ibrahim Obeid, Gregory Mundis Jr., Christopher I. Shaffrey, Khaled Kebaish, Richard Hostin, Robert Hart, Munish C. Gupta, Douglas Burton, Christopher Ames, Oheneba Boachie-Adjei, Themistocles S. Protopsaltis, and Virginie Lafage

456.9 ± 131.1 Incidence of Complications and Site Variability After 3CO surgery, 7% of patients experienced a major IOC, 39% experienced a major POC, and 42% experienced an overall complication. The incidence of each type of major IOC ( Table 2 ) and POC ( Table 3 ) was determined. The most common IOC was spinal cord deficit (2.6%), and the most common POC was unplanned return to the operating room (19.4%). Another significant POC was bowel or bladder dysfunction (6.9%), defined as significant complications of the gastrointestinal or urinary system following

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Elise C. Bixby, Kira Skaggs, Gerard F. Marciano, Matthew E. Simhon, Richard P. Menger, Richard C. E. Anderson, and Michael G. Vitale

studies. The presence of two attending surgeons has been shown to decrease total operative time (OT) and estimated blood loss (EBL) during pedicle subtraction osteotomy and posterior spinal fusion. Postoperatively, patients treated by two attending surgeons have shown greater improvement in Cobb angle, shorter length of hospital stay, lower complication rates, and lower rates of unplanned return to the operating room (OR). 13–17 Other surgical specialties have taken this concept a step further and demonstrated the utility of two-specialty approaches, which utilize

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Erik J. van Lindert, Hans Delye, and Jody Leonardo


The authors conducted a study to compare the complication rate (CR) of pediatric neurosurgical procedures in a general neurosurgery department to the CRs that are reported in the literature and to establish a baseline of CR for further targeted improvement of quality neurosurgical care.


The authors analyzed the prospectively collected data from a complication registration of 1000 consecutive pediatric neurosurgical procedures in 581 patients from the beginning of the registration in January 2004 through August 2008. A pediatric neurosurgeon was involved in 50.5% of the procedures. All adverse events (AEs) from induction of anesthesia until 30 days postoperatively were recorded.


Overall, 229 complications were counted in 202 procedures. The overall CR was 20.2%, with a 2.7% intraoperative CR and a 17.5% postoperative CR. Tumor surgery was associated with the highest CR (32.7%), followed by CSF disorders (21.8%). The mortality rate was 0.3%. An unplanned return to the operating room in relation to an AE happened in 10.5% of all procedures and in 52% of procedures associated with AEs, the majority of which were related to CSF disorders.


The CR in pediatric neurosurgical procedures was significant, and more than half of the patients with an AE required a repeat surgical procedure. Analysis of CRs should be a prerequisite for the prevention of complications and for the development of targeted interventions to reduce the CR (for example, infection rates).

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Hesham Mostafa Zakaria, Lonni Schultz, Feras Mossa-Basha, Brent Griffith, and Victor Chang


Improved objective assessments of perioperative risk after spine surgery are necessary to decrease postoperative morbidity and mortality rates. Morphometric analysis has proven utility in predicting postoperative morbidity and mortality in surgical disciplines. The aim of the present study was to evaluate whether morphometrics can be applied to the cases of patients undergoing lumbar spine surgery.


The authors performed a retrospective review of the perioperative course of 395 patients who underwent lumbar surgery at their institution from 2013 to 2014. Preoperative risk factors such as age, diabetes, smoking, coronary artery disease, and body mass index (BMI) were recorded. Preoperative MRI was used to measure the psoas muscle area at the L-4 vertebra and paraspinal muscle area at the T-12 vertebra. Primary outcomes included unplanned return to the operating room, 30- and 90-day readmissions, surgical site infection, wound dehiscence, new neurological deficit, deep vein thrombosis, pulmonary embolism, myocardial infarction, urinary tract infection, urinary retention, hospital-acquired pneumonia, stroke, and prolonged stay in the intensive care unit.


The overall rate of adverse events was 30%, the most common event being urinary retention (12%). Greater age (p = 0.015) and tobacco usage (p = 0.026) were both significantly associated with complications for all patients, while diabetes, coronary artery disease, and high BMI were not. No surgery-related characteristics were associated with postoperative morbidity, including whether surgery required instrumentation, whether it was a revision, or the number of vertebral levels treated. Using multivariate regression analysis, male and female patients with the lowest psoas tertile had an OR of 1.70 (95% CI 1.04–2.79, p = 0.035) for having postoperative complications. Male patients in the lowest psoas tertile had an OR of 2.42 (95% CI 1.17–5.01, p = 0.016) for having a postoperative complication. The paraspinal muscle groups did not provide any significant data for postoperative morbidity, even after multivariate analysis.


The morphometric measurement of psoas muscle size may be a sensitive predictive tool compared with other risk factors for perioperative morbidity in male patients undergoing lumbar surgery.

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Oren Sagher

The classic teaching of neurosurgery residents has always emphasized the importance of the neurological examination in medical decision making. This is particularly true when deciding whether the postoperative patient requires an unplanned return to the operating room. The threshold for a return to the operating room to evacuate a hematoma or correct an unforeseen surgical issue is necessarily high, because such a return significantly increases the risk of untoward outcomes. It is therefore not terribly surprising that the analysis of the institutional

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Nitin Mukerji, Alistair Jenkins, Claire Nicholson, and Patrick Mitchell

reoperation is a potentially useful marker of quality for the following reasons: 5 it is more common than other indices such as mortality; it can occur (for different reasons) after almost any procedure and thus is broadly applicable; compared with other potential broad-based quality measures (for example, wound infection), it is relatively nondiscretionary (patients generally undergo a reoperation only if they really need to); and it is easily tracked with administrative data. Therefore, an unplanned return to the operating room has been suggested as a screening tool for

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Nancy McLaughlin, Peng Jin, and Neil A. Martin

, Vincent C , : Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection . Br J Surg 98 : 1775 – 1783 , 2011 2 Ansari MZ , Collopy BT : The risk of an unplanned return to the operating room in Australian hospitals . Aust N Z J Surg 66 : 10 – 13 , 1996 3 Baker GR , Norton PG , Flintoft V , Blais R , Brown A , Cox J , : The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada . CMAJ 170 : 1678 – 1686 , 2004 4

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Anil K. Roy, Jason Chu, Caroline Bozeman, Samir Sarda, Michael Sawvel, and Joshua J. Chern

: Chern, Roy, Chu, Bozeman, Sawvel. Critically revising the article: Chern, Roy, Chu, Sawvel. Reviewed submitted version of manuscript: all authors. Statistical analysis: Bozeman, Sarda. References 1 Birkmeyer JD , Hamby LS , Birkmeyer CM , Decker MV , Karon NM , Dow RW : Is unplanned return to the operating room a useful quality indicator in general surgery? . Arch Surg 136 : 405 – 411 , 2001 10.1001/archsurg.136.4.405 11296110 2 Buchanan CC , Hernandez EA , Anderson JM , Dye JA , Leung M , Buxey F , : Analysis of 30-day

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Justin K. Scheer, Jessica A. Tang, Justin S. Smith, Eric Klineberg, Robert A. Hart, Gregory M. Mundis Jr., Douglas C. Burton, Richard Hostin, Michael F. O'Brien, Shay Bess, Khaled M. Kebaish, Vedat Deviren, Virginie Lafage, Frank Schwab, Christopher I. Shaffrey, Christopher P. Ames, and the International Spine Study Group

return to the operating room as a result of the original surgery. The reoperation indications were divided into the following categories: instrumentation malposition/rod fracture, radiographic (proximal junction failure, distal junction failure, pseudarthrosis, coronal malalignment) neurological compromise, infection, medical (cardiopulmonary, vascular gastrointestinal, renal), operative, and wound. The instrumentation malposition/fracture category described situations in which there was implant failure or migration, malpositioning, painful implants, or bony fracture