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Varun Puvanesarajah, Sandesh S. Rao, Hamid Hassanzadeh and Khaled M. Kebaish

OBJECTIVE

To determine predictors of perioperative allogeneic packed red blood cell (pRBC) transfusion requirement (total units transfused) in patients with adult spinal deformity (ASD).

METHODS

The authors retrospectively analyzed records of patients aged 18 years or older who underwent surgical correction of ASD that involved 4 or more spinal levels by the same spine surgeon between 2010 and 2016. Data regarding patient characteristics, comorbidities, surgical factors, and perioperative transfusions (up to 10 days after surgery) were analyzed using a linear regression model. Significance was set at p < 0.05.

RESULTS

The authors analyzed 165 patients (118 women) with a mean (± SD) age of 61 ± 12 years. Three-column osteotomies were associated with a mean intraoperative transfusion volume of 1.74 additional units of pRBCs. Each unit of intraoperatively salvaged blood used was associated with a mean 0.39-U increase in postoperative transfusion volume (p = 0.031). Every unit of allogeneic blood transfused intraoperatively was associated with a mean 0.23-U decrease in postoperative transfusion volume (p = 0.001). A preoperative hemoglobin concentration of 11.5 g/dl or more was associated with significantly fewer units transfused intraoperatively; a preoperative hemoglobin concentration of 14.0 g/dl or more was associated with fewer units transfused postoperatively. A history of smoking and intraoperative antifibrinolytic use were associated with increased and decreased numbers of units transfused postoperatively, respectively.

CONCLUSIONS

Effective blood management is key to perioperative care of patients with ASD. Three-column osteotomies were associated with a greater number of units of blood transfused. When considering postoperative transfusion requirements, surgeons should note that intraoperative blood salvage might be inferior to intraoperative allogeneic blood transfusion. Using antifibrinolytics and increasing the preoperative hemoglobin concentration to 11.5 g/dl or more are strategies for decreasing the need for perioperative transfusion. A history of smoking is a risk factor for postoperative transfusion requirement (total units transfused).

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Anuj Singla, Scott Yang, Brian C. Werner, Jourdan M. Cancienne, Ali Nourbakhsh, Adam L. Shimer, Hamid Hassanzadeh and Francis H. Shen

OBJECTIVE

Lumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion.

METHODS

A nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI.

RESULTS

The overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1–3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI.

CONCLUSIONS

Lumbar spinal fusion performed within 3 months after LESI may be associated with an increased rate of postoperative infection. This association was not found when lumbar fusion was performed more than 3 months after LESI.

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Addisu Mesfin, Mostafa H. El Dafrawy, Amit Jain, Hamid Hassanzadeh, John P. Kostuik, Mesfin A. Lemma and Khaled M. Kebaish

OBJECT

In this study, the authors compared outcomes and complications in patients with and without rheumatoid arthritis (RA) who underwent surgery for spinal deformity.

METHODS

The authors searched the Johns Hopkins University database for patients with RA (Group RA) and without RA (Group NoRA) who underwent long spinal fusion for scoliosis by 3 surgeons at 1 institution from 2000 through 2012. Groups RA and NoRA each had 14 patients who were well matched with regard to sex (13 women/1 man and 12 women/2 men, respectively), age (mean 66.3 years [range 40.5–81.9 years] and 67.6 years [range 51–81 years]), follow-up duration (mean 35.4 months [range 1–87 months] and 44 months [range 24–51 months]), and number of primary (8 and 8) and revision (6 and 6) surgeries. Surgical outcomes, invasiveness scores, and complications were compared between the groups using the nonpaired Student t-test (p < 0.05).

RESULTS

For Groups RA and NoRA, there were no significant differences in the average number of levels fused (10.6 [range 9–17] vs 10.3 [range 7–17], respectively; p = 0.4), the average estimated blood loss (2892 ml [range 1300–5000 ml] vs 3100 ml [range 1700–5200 ml]; p = 0.73), or the average invasiveness score (35.5 [range 21–51] vs 34.5 [range 23–58]; p = 0.8). However, in Group RA, the number of major complications was significantly higher (23 vs 11; p < 0.001), the number of secondary procedures was significantly higher (14 vs 6; p < 0.001), and the number of minor complications was significantly lower (4 vs 12; p < 0.001) than those in Group NoRA.

CONCLUSIONS

Long spinal fusion in patients with RA is associated with higher rates of major complications and secondary procedures than in patients without RA.

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Varun Puvanesarajah, Francis H. Shen, Jourdan M. Cancienne, Wendy M. Novicoff, Amit Jain, Adam L. Shimer and Hamid Hassanzadeh

OBJECTIVE

Surgical correction of adult spinal deformity (ASD) is a complex undertaking with high revision rates. The elderly population is poorly studied with regard to revision surgery, yet senior citizens constitute a rapidly expanding surgical demographic. Previous studies aimed at elucidating appropriate risk factors for revision surgery have been limited by small cohort sizes. The purpose of this study was to assess factors that modify the risk of revision surgery in elderly patients with ASD.

METHODS

The PearlDiver database (2005–2012) was used to determine revision rates in elderly ASD patients treated with a primary thoracolumbar posterolateral fusion of 8 or more levels. Analyzed risk factors included demographics, comorbid conditions, and surgical factors. Significant univariate predictors were further analyzed with multivariate analysis. The causes of revision at each year of follow-up were determined.

RESULTS

A total of 2293 patients who had been treated with posterolateral fusion of 8 or more levels were identified. At the 1-year follow-up, 241 (10.5%) patients had been treated with revision surgery, while 424 (18.5%) had revision surgery within 5 years. On univariate analysis, obesity was found to be a significant predictor of revision surgery at 1 year, while bone morphogenetic protein (BMP) use was found to significantly decrease revision surgery at 4 and 5 years of followup. Diabetes mellitus, osteoporosis, and smoking history were all significant univariate predictors of increased revision risk at multiple years of follow-up. Multivariate analysis at 5 years of follow-up revealed that osteoporosis (OR 1.98, 95% CI 1.60–2.46, p < 0.0001) and BMP use (OR 0.70, 95% CI 0.56–0.88, p = 0.002) were significantly associated with an increased and decreased revision risk, respectively. Smoking history trended toward significance (OR 1.37, 95% CI 1.10–1.70, p = 0.005). Instrument failure was consistently the most commonly cited reason for revision. Five years following surgery, it was estimated that the cohort had 68.8% survivorship.

CONCLUSIONS

For elderly patients with ASD, osteoporosis increases the risk of revision surgery, while BMP use decreases the risk. Other comorbidities were not found to be significant predictors of long-term revision rates. It is expected that within 5 years following the index procedure, over 30% of patients will require revision surgery.

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Amit Jain, Hamid Hassanzadeh, Varun Puvanesarajah, Eric O. Klineberg, Daniel M. Sciubba, Michael P. Kelly, D. Kojo Hamilton, Virginie Lafage, Aaron J. Buckland, Peter G. Passias, Themistocles S. Protopsaltis, Renaud Lafage, Justin S. Smith, Christopher I. Shaffrey, Khaled M. Kebaish and the International Spine Study Group

OBJECTIVE

Using 2 complication-reporting methods, the authors investigated the incidence of major medical complications and mortality in elderly patients after surgery for adult spinal deformity (ASD) during a 2-year follow-up period.

METHODS

The authors queried a multicenter, prospective, surgeon-maintained database (SMD) to identify patients 65 years or older who underwent surgical correction of ASD from 2008 through 2014 and had a minimum 2 years of follow-up (n = 153). They also queried a Centers for Medicare & Medicaid Services claims database (MCD) for patients 65 years or older who underwent fusion of 8 or more vertebral levels from 2005 through 2012 (n = 3366). They calculated cumulative rates of the following complications during the first 6 weeks after surgery: cerebrovascular accident, congestive heart failure, deep venous thrombosis, myocardial infarction, pneumonia, and pulmonary embolism. Significance was set at p < 0.05.

RESULTS

During the perioperative period, rates of major medical complications were 5.9% for pneumonia, 4.1% for deep venous thrombosis, 3.2% for pulmonary embolism, 2.1% for cerebrovascular accident, 1.8% for myocardial infarction, and 1.0% for congestive heart failure. Mortality rates were 0.9% at 6 weeks and 1.8% at 2 years. When comparing the SMD with the MCD, there were no significant differences in the perioperative rates of major medical complications except pneumonia. Furthermore, there were no significant intergroup differences in the mortality rates at 6 weeks or 2 years. The SMD provided greater detail with respect to deformity characteristics and surgical variables than the MCD.

CONCLUSIONS

The incidence of most major medical complications in the elderly after surgery for ASD was similar between the SMD and the MCD and ranged from 1% for congestive heart failure to 5.9% for pneumonia. These complications data can be valuable for preoperative patient counseling and informed consent.

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Micheal Raad, Brian J. Neuman, Amit Jain, Hamid Hassanzadeh, Peter G. Passias, Eric Klineberg, Gregory M. Mundis Jr., Themistocles S. Protopsaltis, Emily K. Miller, Justin S. Smith, Virginie Lafage, D. Kojo Hamilton, Shay Bess, Khaled M. Kebaish, Daniel M. Sciubba and the International Spine Study Group

OBJECTIVE

Given the recent shift in health care toward quality reporting requirements and a greater emphasis on a cost-quality approach, patient stratification with respect to long-term outcomes and the use of health care resources is of increasing value. Stratification tools may be effective if they are simple and evidence based. The authors hypothesize that preoperative patient-reported activity levels might independently predict postoperative outcomes in patients with adult spinal deformity.

METHODS

This is a retrospective cohort. A total of 575 patients in a prospective adult spinal deformity surgical database were identified with complete data regarding the preoperative level of activity. Answers to question 5 of the Scoliosis Research Society-22r Patient Questionnaire (SRS-22r) were used to stratify patients into active and inactive groups. Outcomes were length of hospital stay (LOS), level of activity, and reaching the minimum clinically important difference (MCID) for SRS-22r domains and the Physical Component Summary (PCS) of the SF-36 at 2 years postoperatively. The 2 groups were compared with respect to several potential confounders. Covariates with p < 0.1 were controlled for. The impact of activity on LOS was assessed using multivariate negative binomial regression analysis. Multivariate logistic regression models additionally controlling for the respective baseline health-related quality of life (HRQOL) scores were used to assess the association between preoperative activity levels and reaching the MCID at 2 years postoperatively.

RESULTS

A total of 420 (73%) of the 575 patients who met the inclusion criteria had complete data at 2 years postoperatively. The inactive group was more likely to be significantly older, have a higher Charlson Comorbidity Index, worse baseline radiographic deformity, and greater correction of most radiographic parameters. After controlling for possible confounders, the active group had a significantly shorter LOS (incidence risk ratio 0.91, p = 0.043). After adding respective baseline HRQOL scores to the models, active patients were significantly more likely to reach the MCID for the SRS-22r pain domain (OR 1.72, p = 0.026) and PCS (OR 1.94, p = 0.013). Active patients were also significantly more likely to be active at 2 years postoperatively on multivariate analysis (OR 8.94, p < 0.001).

CONCLUSIONS

The authors’ results show that patients who belong to the inactive group are likely to have a longer LOS and lower odds of reaching the MCID in HRQOL or being active at 2 years postoperatively. Inquiring about patients’ preoperative activity levels might be a reliable and simple stratification tool in terms of long- and short-term outcomes in ASD patients.