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Andrew B. Harris, Floreana Kebaish, Lee H. Riley III, Khaled M. Kebaish and Richard L. Skolasky

OBJECTIVE

Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment.

METHODS

Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status).

RESULTS

While a majority of patients endorsed the highest level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8–5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5–5.3).

CONCLUSIONS

Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

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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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Morsi Khashan, Micheal Raad, Mostafa H. El Dafrawy, Varun Puvanesarajah and Khaled M. Kebaish

OBJECTIVE

The authors evaluated the neurological outcomes of adult spinal deformity patients after 3-column osteotomy (3CO), including severity and long-term improvement of neurological complications, as well as risk factors for neurological deficit at 1 year postoperatively. Although 3CO is effective for correcting rigid spinal deformity, it is associated with a high complication rate. Neurological deficits, in particular, cause disability and dissatisfaction.

METHODS

The authors retrospectively queried a prospective database of adult spinal deformity patients who underwent vertebral column resection or pedicle subtraction osteotomy between 2004 and 2014 by one surgeon at a tertiary care center. The authors included 199 adults with at least 1-year follow-up. The primary outcome measure was change in lower-extremity motor scores (LEMSs), which were obtained preoperatively, within 2 weeks postoperatively, and at 6 and 12 months postoperatively. To identify risk factors for persistent neurological deficit, the authors compared patient and surgical characteristics with a declined LEMS at 12-month follow-up (n = 10) versus those with an improved/maintained LEMS at 12-month follow-up (n = 189).

RESULTS

At the first postoperative assessment, the LEMS had improved in 15% and declined in 10% of patients compared with preoperative scores. At the 6-month follow-up, 6% of patients continued to have a decline in LEMS, and 16% had improvement. At 12 months, LEMS had improved in 17% and declined in 5% of patients compared with preoperative scores. The only factor significantly associated with a decline in 12-month LEMS was high-grade spondylolisthesis as an indication for surgery (OR 13, 95% CI 3.2–56).

CONCLUSIONS

Although the LEMS declined in 10% of patients immediately after 3CO, at 12 months postoperatively, only 5% of patients had neurological motor deficits. A surgical indication of high-grade spondylolisthesis was the only factor associated with neurological deficit at 12 months postoperatively.

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Micheal Raad, Andrew B. Harris, Varun Puvanesarajah, Mostafa H. El Dafrawy, Floreana N. Kebaish, Brian J. Neuman, Richard L. Skolasky, David B. Cohen and Khaled M. Kebaish

OBJECTIVE

Patients’ expectations for pain relief are associated with patient-reported outcomes after treatment, although this has not been examined in patients with adult spinal deformity (ASD). The aim of this study was to identify associations between patients’ preoperative expectations for pain relief after ASD surgery and patient-reported pain at the 2-year follow-up.

METHODS

The authors analyzed surgically treated ASD patients at a single institution who completed a survey question about expectations for back pain relief. Five ordinal answer choices to “I expect my back pain to improve” were used to categorize patients as having low or high expectations. Back pain was measured using the 10-point numeric rating scale (NRS) and Scoliosis Research Society–22r (SRS-22r) patient survey. Preoperative and postoperative pain were compared using analysis of covariance.

RESULTS

Of 140 ASD patients eligible for 2-year follow-up, 105 patients (77 women) had pre- and postoperative data on patient expectations, 85 of whom had high expectations. The mean patient age was 59 ± 12 years, and 46 patients (44%) had undergone previous spine surgery. The high-expectations and low-expectations groups had similar baseline demographic and clinical characteristics (p > 0.05), except for lower SRS-22r mental health scores in those with low expectations. After controlling for baseline characteristics and mental health, the mean postoperative NRS score was significantly better (lower) in the high-expectations group (3.5 ± 3.5) than in the low-expectations group (5.4 ± 3.7) (p = 0.049). The mean postoperative SRS-22r pain score was significantly better (higher) in the high-expectations group (3.3 ± 1.1) than in the low-expectations group (2.6 ± 0.94) (p = 0.019).

CONCLUSIONS

Despite similar baseline characteristics, patients with high preoperative expectations for back pain relief reported less pain 2 years after ASD surgery than patients with low preoperative expectations.

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Lauren E. Matteini, Khaled M. Kebaish, W. Robert Volk, Patrick F. Bergin, Warren D. Yu and Joseph R. O'Brien

Multiple techniques of pelvic fixation exist. Distal fixation to the pelvis is crucial for spinal deformity surgery. Fixation techniques such as transiliac bars, iliac bolts, and iliosacral screws are commonly used, but these techniques may require separate incisions for placement, leading to potential wound complications and increased dissection. Additionally, the use of transverse connector bars is almost always necessary with these techniques, as their placement is not in line with the S-1 pedicle screw and cephalad instrumentation. The S-2 alar iliac pelvic fixation is a newer technique that has been developed to address some of these issues. It is an in-line technique that can be placed during an open procedure or percutaneously.

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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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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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Mark Ren, Barry R. Bryant, Andrew B. Harris, Khaled M. Kebaish, Lee H. Riley III, David B. Cohen, Richard L. Skolasky and Brian J. Neuman

OBJECTIVE

The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years.

METHODS

Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05).

RESULTS

The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5–82), high-dose use (aOR 7.3, 95% CI 1.1–48), and long-term use (aOR 17, 95% CI 2.2–123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8–10,546) but not long-term use (aOR 4.0, 95% CI 0.18–91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8–261) but not at 6 months (aOR 4.3, 95% CI 0.95–24).

CONCLUSIONS

Patients’ preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.

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Paraspinal muscle size as an independent risk factor for proximal junctional kyphosis in patients undergoing thoracolumbar fusion

Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Zach Pennington, Ethan Cottrill, A. Karim Ahmed, Peter Passias, Themistocles Protopsaltis, Brian Neuman, Khaled M. Kebaish, Jeff Ehresman, Erick M. Westbroek, Matthew L. Goodwin and Daniel M. Sciubba

OBJECTIVE

Proximal junctional kyphosis (PJK) is a structural complication of spinal fusion in 5%–61% of patients treated for adult spinal deformity. In nearly one-third of these cases, PJK is progressive and requires costly surgical revision. Previous studies have suggested that patient body habitus may predict risk for PJK. Here, the authors sought to investigate abdominal girth and paraspinal muscle size as risk factors for PJK.

METHODS

All patients undergoing thoracolumbosacral fusion greater than 2 levels at a single institution over a 5-year period with ≥ 6 months of radiographic follow-up were considered for inclusion. PJK was defined as kyphosis ≥ 20° between the upper instrumented vertebra (UIV) and two supra-adjacent vertebrae. Operative and radiographic parameters were recorded, including pre- and postoperative sagittal vertical axis (SVA), sacral slope (SS), lumbar lordosis (LL), pelvic tilt, pelvic incidence (PI), and absolute value of the pelvic incidence–lumbar lordosis mismatch (|PI-LL|), as well as changes in LL, |PI-LL|, and SVA. The authors also considered relative abdominal girth and the size of the paraspinal muscles at the UIV.

RESULTS

One hundred sixty-nine patients met inclusion criteria. On univariate analysis, PJK was associated with a larger preoperative SVA (p < 0.001) and |PI-LL| (p = 0.01), and smaller SS (p = 0.004) and LL (p = 0.001). PJK was also associated with more positive postoperative SVA (p = 0.01), ΔSVA (p = 0.01), Δ|PI-LL| (p < 0.001), and ΔLL (p < 0.001); longer construct length (p = 0.005); larger abdominal girth–to-muscle ratio (p = 0.007); and smaller paraspinal muscles at the UIV (p < 0.001). Higher postoperative SVA (OR 1.1 per cm), smaller paraspinal muscles at the UIV (OR 2.11), and more aggressive reduction in |PI-LL| (OR 1.03) were independent predictors of radiographic PJK on multivariate logistic regression.

CONCLUSIONS

A more positive postoperative global sagittal alignment and smaller paraspinal musculature at the UIV most strongly predicted PJK following thoracolumbosacral fusion.

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Micheal Raad, Jay S. Reidler, Mostafa H. El Dafrawy, Raj M. Amin, Amit Jain, Brian J. Neuman, Lee H. Riley III, Daniel M. Sciubba, Khaled M. Kebaish and Richard L. Skolasky

OBJECTIVE

It is important to identify differences in the treatment of common diseases over time and across geographic regions. Several studies have reported increased use of arthrodesis to treat lumbar spinal stenosis (LSS). The purpose of this study was to investigate geographic variations in the treatment of LSS by US region.

METHODS

The authors reviewed inpatient and outpatient medical claims from 2010 to 2014 using the MarketScan Commercial Claims and Encounters database (Truven Health Analytics), which includes data on commercially insured members younger than 65 years. ICD-9 code 724.02 was used to identify patients aged ≥ 40 and < 65 years who underwent surgery for “spinal stenosis of the lumbar region” and for whom LSS was the only principal diagnosis. The primary outcome was the performance of spinal arthrodesis as part of the procedure. Geographic regions were based on patient residence and defined according to the US Census Bureau as the Northeast, Midwest, South, and West.

RESULTS

Rates of arthrodesis, as opposed to decompression alone, varied significantly by region, from 48% in the South, to 42% in the Midwest, 36% in the Northeast, and 31% in the West. After controlling for patient age, sex, and Charlson Comorbidity Index values, the differences remained significant. Compared with patients in the Northeast, those in the South (OR 1.6, 95% CI 1.50–1.75) and Midwest (OR 1.3, 95% CI 1.18–1.41) were significantly more likely to undergo spinal arthrodesis. On multivariate analysis, patients in the West were significantly less likely to have a prolonged hospital stay (> 3 days) than those in the Northeast (OR 0.84, 95% CI 0.75–0.94). Compared with the rate in the Northeast, the rates of discharge to a skilled nursing facility were lower in the South (OR 0.41, 95% CI 0.31–0.55) and West (OR 0.72, 95% CI 0.53–0.98). The 30-day readmission rate was significantly lower in the West (OR 0.81, 95% CI 0.65–0.98) than in the Northeast and similar between the other regions. Mean payments were significantly higher in the Midwest (mean difference $5503, 95% CI $4279–$6762), South (mean difference $6187, 95% CI $5041–$7332), and West (mean difference $7732, 95% CI $6384–$9080) than in the Northeast.

CONCLUSIONS

The use of spinal arthrodesis, as well as surgical outcomes and payments for the treatment of LSS, varies significantly by US region. This highlights the importance of developing national recommendations for the treatment of LSS.