National adverse event profile after lumbar spine surgery for lumbar degenerative disorders and comparison of complication rates between hospitals: a CSORN registry study

Oliver G. S. Ayling Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia;

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Raphaele Charest-Morin Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia;

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Matthew E. Eagles Department of Surgery, University of Calgary, Alberta;

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Tamir Ailon Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia;

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John T. Street Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia;

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Nicolas Dea Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia;

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Greg McIntosh Canadian Spine Society, Markdale, Ontario;

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Sean D. Christie Department of Surgery, Dalhousie University, Halifax, Nova Scotia; and

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Edward Abraham Department of Surgery, Canada East Spine Centre, Saint John, New Brunswick;

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W. Bradley Jacobs Department of Surgery, University of Calgary, Alberta;

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Christopher S. Bailey Department of Surgery, University of Western Ontario, London, Ontario;

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Michael G. Johnson Departments of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Manitoba;

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Najmedden Attabib Department of Surgery, Dalhousie University, Halifax, Nova Scotia; and

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Peter Jarzem Department of Surgery, McGill University, Montreal, Quebec, Canada;

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Michael Weber Department of Surgery, McGill University, Montreal, Quebec, Canada;

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Jerome Paquet Department of Surgery, Laval University, Quebec City, Quebec;

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Joel Finkelstein Department of Surgery, University of Toronto, Ontario;

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Alexandra Stratton Department of Surgery, University of Ottawa, Ontario;

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Hamilton Hall Department of Surgery, University of Toronto, Ontario;

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Neil Manson Department of Surgery, Canada East Spine Centre, Saint John, New Brunswick;

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Y. Raja Rampersaud Department of Surgery, University of Toronto, Ontario;

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Kenneth Thomas Department of Surgery, University of Calgary, Alberta;

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Charles G. Fisher Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia;

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OBJECTIVE

Previous works investigating rates of adverse events (AEs) in spine surgery have been retrospective, with data collection from administrative databases, and often from single centers. To date, there have been no prospective reports capturing AEs in spine surgery on a national level, with comparison among centers.

METHODS

The Spine Adverse Events Severity system was used to define the incidence and severity of AEs after spine surgery by using data from the Canadian Spine Outcomes and Research Network (CSORN) prospective registry. Patient data were collected prospectively and during hospital admission for those undergoing elective spine surgery for degenerative conditions. The Spine Adverse Events Severity system defined minor and major AEs as grades 1–2 and 3–6, respectively.

RESULTS

There were 3533 patients enrolled in this cohort. There were 85 (2.4%) individual patients with at least one major AE and 680 (19.2%) individual patients with at least one minor AE. There were 25 individual patients with 28 major intraoperative AEs and 260 patients with 275 minor intraoperative AEs. Postoperatively there were 61 patients with a total of 80 major AEs. Of the 487 patients with minor AEs postoperatively there were 698 total AEs. The average enrollment was 321 patients (range 47–1237 patients) per site. The rate of major AEs was consistent among sites (mean 2.9% ± 2.4%, range 0%–9.1%). However, the rate of minor AEs varied widely among sites—from 7.9% to 42.5%, with a mean of 18.8% ± 9.7%. The rate of minor AEs varied depending on how they were reported, with surgeon reporting associated with the lowest rates (p < 0.01).

CONCLUSIONS

The rate of major AEs after lumbar spine surgery is consistent among different sites but the rate of minor AEs appears to vary substantially. The method by which AEs are reported impacts the rate of minor AEs. These data have implications for the detection and reporting of AEs and the design of strategies aimed at mitigating complications.

ABBREVIATIONS

AE = adverse event; CSORN = Canadian Spine Outcomes and Research Network; PRO = patient-reported outcome; SAVES = Spine Adverse Events Severity.

OBJECTIVE

Previous works investigating rates of adverse events (AEs) in spine surgery have been retrospective, with data collection from administrative databases, and often from single centers. To date, there have been no prospective reports capturing AEs in spine surgery on a national level, with comparison among centers.

METHODS

The Spine Adverse Events Severity system was used to define the incidence and severity of AEs after spine surgery by using data from the Canadian Spine Outcomes and Research Network (CSORN) prospective registry. Patient data were collected prospectively and during hospital admission for those undergoing elective spine surgery for degenerative conditions. The Spine Adverse Events Severity system defined minor and major AEs as grades 1–2 and 3–6, respectively.

RESULTS

There were 3533 patients enrolled in this cohort. There were 85 (2.4%) individual patients with at least one major AE and 680 (19.2%) individual patients with at least one minor AE. There were 25 individual patients with 28 major intraoperative AEs and 260 patients with 275 minor intraoperative AEs. Postoperatively there were 61 patients with a total of 80 major AEs. Of the 487 patients with minor AEs postoperatively there were 698 total AEs. The average enrollment was 321 patients (range 47–1237 patients) per site. The rate of major AEs was consistent among sites (mean 2.9% ± 2.4%, range 0%–9.1%). However, the rate of minor AEs varied widely among sites—from 7.9% to 42.5%, with a mean of 18.8% ± 9.7%. The rate of minor AEs varied depending on how they were reported, with surgeon reporting associated with the lowest rates (p < 0.01).

CONCLUSIONS

The rate of major AEs after lumbar spine surgery is consistent among different sites but the rate of minor AEs appears to vary substantially. The method by which AEs are reported impacts the rate of minor AEs. These data have implications for the detection and reporting of AEs and the design of strategies aimed at mitigating complications.

In Brief

The objective of the paper was to compile the adverse event profile after surgery for lumbar degenerative pathologies, on a national level, and to compare rates among centers. The key finding in this study is that the rate of major adverse events was consistent among centers, but the minor adverse event rate was variable and depended on the strategy by which adverse events were captured. This study provides a framework for the detection and reporting of adverse events.

As spine surgery is increasingly used,1 its value, defined as outcome divided by cost, continues to be scrutinized.2 Previous research has demonstrated that significant improvements in patient outcomes can be obtained with lumbar spine surgery for degenerative conditions.3–5 Adverse events (AEs) diminish the value of spine surgery through increased costs,6 as well as reducing the ability to achieve meaningful clinical outcomes.7 Accurately defining and reporting the incidence of AEs is fundamental to clinical outcomes reporting and has implications for physician reimbursement and departmental funding as health care remuneration transitions to a performance-based model.

Most of the previous studies examining AEs have been retrospective and have used administrative database codes, such as the International Classification of Diseases (ICD) codes.8 Although common AEs may be captured in these administrative databases, their ability to precisely capture real-world clinical diagnoses has been questioned.9–13 Furthermore, the AE rates vary among studies depending on how they are defined.6 Together, these factors limit direct comparison of AE studies. Although the National Surgical Quality Improvement Program14 has been used to establish benchmarks for complications after surgery, it samples random patients within a given hospital and was not specifically designed for use in spine surgery. As such, there have been no reports examining the AE rates on a national level or comparing centers within a given country that have used a system specifically designed to capture AEs after spine surgery.

The purpose of this study was to examine the incidence of AEs after spine surgery for elective lumbar degenerative conditions on a national level and to compare AE rates among centers. In order to accomplish this, prospective data from 14 centers in the Canadian Spine Outcomes and Research Network (CSORN) were analyzed using the Spine Adverse Events Severity (SAVES) system to standardize the definition of AEs in the spine surgery population.

Methods

Study Population and Design

The methods of the study are reported in detail in a previously published study.7 A retrospective analysis of prospectively collected data on consecutive adult patients enrolled in the CSORN prospective database who underwent elective lumbar spine surgery for lumbar disc disease, degenerative spondylolisthesis, spinal stenosis, and isolated lumbar degenerative deformity were analyzed. Those with a diagnosis of infection, thoracic deformity, trauma, or tumor were excluded.

CSORN is composed of 14 tertiary hospitals in Canada that prospectively enroll patients. Three sites were excluded in the present analysis due to having fewer than 10 patients with data collected and entered into the database at the time of data abstraction (these sites had 10, 9, and 4 patients because they had joined the research network late in the data capture window used in this study). As previously published, “data quality and performance is audited by a national database coordinator which sends quarterly reports to each hospital site. Written informed consent is obtained from all participating patients. Patient identification is anonymized and all participating sites obtained research ethics board approval. Decisions regarding data collection, storage, and analysis are independent of any commercial interest.”7

Defining AEs

SAVES version 2 was used to define minor and major AEs.7,12,15,16 AEs were collected and included if they occurred during the index operation or during the hospital stay before discharge. The reporting method of AEs that each site used was defined as direct surgeon reporting, chart abstraction via research coordinators, or a weekly interdisciplinary meeting. Each site’s principal investigator was contacted directly to determine the AE reporting method.

AEs were defined as previously reported:7 “Minor AEs were defined by SAVES grades 1 and 2, an AE that does not require treatment and has no effect, and an AE that requires treatment (minor, non-invasive) but has no long-term effect, respectively. Major AEs were defined by SAVES grades 3–6: 3 (AE requires invasive or complex treatment (surgery or ICU monitoring) and is most likely to have temporary (< 6 months) effect on outcome, 4 (AE requires invasive or complex treatment (surgery or ICU monitoring) and is most likely to have prolonged (> 6 months) adverse outcome, 5 (significant neural injury (one or more grade deterioration in ASIA grade) or serious life or limb threatening event (a sentinel event that necessitates review to determine the root cause), 6 (death).”

The SAVES system is described in Supplemental Fig. 1.

Statistical Analysis

Clinical baseline and demographic variables are presented as frequency distributions or mean and standard deviation. Differences in continuous univariate variables were analyzed via Student t-test or Mann-Whitney U-test and categorical variables with the Fisher exact test. The Pearson correlation coefficient was used to assess correlation. A p value < 0.05 was used to determine significance. Statistical analyses were conducted using R Studio (RStudio Inc.).

Results

A total of 3533 patients who met inclusion criteria were enrolled in this national cohort. As defined by SAVES, there were 85 (2.4%) patients with major AEs and 680 (19.2%) with minor AEs. There were no in-hospital deaths.

Demographic variables are presented in Table 1. Patients with AEs were more likely to be older (age 62.7 ± 13.9 years vs 56.5 ± 14.9 years, p < 0.0001), to have had their condition for more than 2 years (54.4% vs 46.4%, p < 0.01), and were less likely to be currently working (20.0% vs 30.8%, p = 0.032). Medical comorbidities were also more common among patients experiencing AEs (Table 1). Patients with major AEs were more likely to undergo surgery for lumbar spondylolisthesis (37.7% vs 25.1%, p = 0.011) or lumbar degenerative deformity (12.9% vs 3.6%, p < 0.001).

TABLE 1.

Clinical and demographic variables in 3533 patients with lumbar degenerative disorders

VariableNo AE, n = 2768Major AE, n = 85Major vs No AE, p ValueMinor AE, n = 680Minor vs No AE, p Value
Age in yrs (± SD)56.49 (14.95)62.69 (13.95)<0.000162.45 (13.77)<0.001
Male (%)1410 (50.9)38 (44.71)0.27324 (47.6)0.13
BMI (± SD)27.35 (7.64)26.65 (10.38)0.5427.45 (8.08)0.77
Smoker (%)733 (26.48)17 (20.0)0.21123 (18.1)<0.01
College education (%)991 (35.8)25 (29.41)0.25230 (33.8)0.35
Currently working (%)853 (30.82)17 (20.0)0.032154 (22.6)<0.01
No insurance claims (%)1440 (52.02)50 (58.82)0.23435 (64.0)<0.001
Married (%)1994 (72.04)60 (70.59)0.81475 (69.9)0.25
>2 yrs w/ condition (%)1283 (46.35)47 (55.29)0.12370 (54.4)<0.01
Diagnosis (%)
 Lumbar disc962 (34.75)15 (17.65)<0.001117 (17.21)<0.001
 Lumbar stenosis1012 (36.56)27 (31.76)0.42259 (38.09)0.48
 Lumbar spondylolisthesis695 (25.11)32 (37.65)0.011237 (34.85)<0.001
 Lumbar degenerative deformity99 (3.57)11 (12.94)<0.00167 (9.9)<0.001
Comorbidities (%)
 Depression482 (17.41)15 (17.65)0.99150 (22.06)0.005
 Diabetes316 (11.42)17 (20.0)0.024105 (15.44)0.014
 Hypertension720 (26.01)41 (48.24)<0.0001278 (40.88)<0.001
 Congestive heart failure56 (2.02)5 (5.88)0.03420 (2.94)0.14
 Hx of myocardial infarction68 (2.45)6 (7.05)0.02122 (3.24)0.28
 Systemic vascular disease165 (5.96)14 (16.47)<0.00162 (9.12)<0.01
 Osteoarthritis784 (28.32)30 (35.29)0.18248 (36.47)<0.01

Hx = history.

Total AEs

There were 25 patients with major intraoperative AEs and 260 with minor intraoperative AEs. Among the individual patients, those with major intraoperative AEs had 48 total events (28 major, 20 minor) and those with minor intraoperative AEs had 275 total events. The most common intraoperative AEs were as follows: dural tears (231 total—219 minor, 12 major); intraoperative implant complications or intraoperative revisions (43 total—39 minor, 4 major); and massive blood loss (16 total—14 minor, 2 major).

Postoperatively there were 61 patients with major AEs, with a total of 80 major AEs and 84 minor AEs. Of the 487 patients with minor AEs postoperatively there were 698 total AEs. The most common postoperative AEs were as follows: infection (56 total—39 urinary tract infections, 2 systemic infections, 10 superficial wound infections, 5 deep wound infections); postoperative hematoma (24 total—19 minor, 5 major); delirium (65, all minor), cardiac events (42 total—36 minor, 6 major); and new postoperative pain not related to the surgical incision (73 total—70 minor, 3 major). A summary of AEs is presented in Supplemental Table 1.

AE Rate by Hospital

The average enrollment at each site was 321 patients (range 47–1237 patients) (Fig. 1). The rate of patient enrollment at each site did not correlate with the rate of AEs (major: r = −0.21; minor: r = 0.047). The rate of major AEs was consistent among sites (mean 2.9% ± 2.4%, range 0%–9.1%). However, the rate of minor AEs varied widely among sites—from 7.9% to 42.5%, with a mean of 18.8% ± 9.7% (site A, 25.5%; B, 13.8%; C, 21.3%; D, 11.5%; E, 7.9%; F, 9.1%; G, 18.7%; H, 14.5%; I, 20%; J, 21.7%; and K, 42.5%) (Fig. 2).

FIG. 1.
FIG. 1.

Scatterplot representing major (red dots) and minor (blue dots) AEs (y-axis) relative to the number of patients enrolled at each site (x-axis). Note that the rate of AEs does not correlate with the rate of patient enrollment at each site. Figure is available in color online only.

FIG. 2.
FIG. 2.

Bar graphs representing the rate of major and minor AEs (y-axis) for each type of AE reporting modality (x-axis) (i.e., surgeon reporting, chart abstraction by research coordinators, and multidisciplinary team meetings). The rate of major AEs is stable across reporting methods but the rate varies widely for minor AEs. Figure is available in color online only.

AE Reporting Method

In order to understand the variability in rates of minor AEs among different sites we analyzed the method by which AEs were recorded at each site. Three methods of AE entry into the CSORN database were used. Seven sites had surgeons directly report AEs; 3 sites had research coordinators perform chart abstractions to record AEs; and 1 site used a weekly multidisciplinary conference attended by surgeons, nursing staff, and allied health professionals (Fig. 2). There was no difference in the rate of major AEs between direct surgeon reporting and chart abstraction (3.3% ± 2.8% vs 1.5% ± 0.4%, p = 0.15); however, the rate of AEs was significantly lower when surgeons reported minor AEs, compared to chart abstraction methods (14.4% ± 6.1% vs 21.0% ± 0.9%, p = 0.028) (Table 2). The rate of minor AEs was highest with a multidisciplinary conference (42.2%).

TABLE 2.

Comparison of surgeon reporting to chart abstraction in patients with AEs after spine surgery

AE CategorySurgeon ReportingChart Abstractionp Value
Major (%, ± SD)3.3 ± 2.8%1.5 ± 0.4%0.15
Minor (%, ± SD)14.4 ± 6.1%21.0 ± 0.9%0.028

Discussion

Using multicenter prospectively collected data with a standardized definition of AEs, we demonstrated the Canadian national rate of major and minor AEs after spine surgery to be 2.4% and 19.2%, respectively. The method of adverse reporting significantly impacted the minor but not the major AE rates among contributing centers. Although minor AEs are often dismissed or considered less important, they have been shown to account for 42% of all AE costs and can indeed have a significant impact on the cost-effectiveness of surgery.6

Previous studies have demonstrated that using administrative database codes to study AEs leads to dramatic underreporting of the true AE incidence in a spine surgery population.12 This underreporting is probably due to the lack of a universally accepted definition of AEs in spine surgery, as well a deficiency in rigorous systems by which to capture AEs. A systematic review by Dekutoski et al.17 demonstrated that complication rates among lumbar spine surgeries ranged from 3.7% to 12.8%; however, there was no agreed-upon definition of a complication or AE. Furthermore, none of the studies included in the systematic review had examined the reliability of their respective reporting methods. Without a standardized and highly reliable definition of AEs it is nearly impossible to compare the outcomes of surgeries among surgeons, varying surgical approaches, or different centers. In turn this leads to an inability to effectively target specific AEs that can be modified or eliminated.16,18

With the proliferation of clinical databases in healthcare19 it is vital to establish benchmarks in care, especially in AEs and patient-reported outcomes (PROs). The National Surgical Quality Improvement Program14 has been used to establish benchmarks for complications after surgery, but it samples random patients and was not defined specially for use in spine surgery, limiting the conclusions that can be drawn from it. PROs research in spine surgery has provided standardized definitions of clinical outcomes, allowing comparisons among studies and benchmarks in clinical outcomes to be established.20 However, the same cannot be said for studies examining AEs. In the current study we have expanded on previous single-center studies examining AEs by demonstrating that AEs can be captured on a national level among multiple centers in a prospective fashion by using a standardized definition of AEs with the SAVES system.18 The SAVES system has been shown to have high validity and is designed for the spine surgery population.13,15 This has allowed a benchmark for AEs to be set among participating spine surgery centers in Canada. The rate of major AEs was 2.4%, with a range of 0%–9.1%. The rate of minor AEs was 19.2% but was highly variable among centers, with a range of 7.9%–42.5%. The rate of AEs reported here is consistent with the previous literature.13,17,18 Previous studies demonstrated a highly variable rate of minor AEs among centers, which may be due to how they are reported, even when the definition of the AEs is standardized, as it is in the present study. The reported rate of minor AEs was highest with a multidisciplinary team composed of surgeons, nurses, and allied health professionals (42%). The minor AE rate was significantly lower when reporting of the events was dependent on the attending surgeon compared to chart abstraction by research coordinators (14% vs 21%). The variability seen with the current data may be due to the perception of complications and AEs on the part of surgeons compared to other members of the healthcare team. An AE can be defined as any undesirable event due to an intervention, but does not necessarily have a negative outcome. In contrast, a complication is a disease or injury that is directly due to treatment of a preexisting condition. As stated by Rampersaud et al., “complications may be a consequence of an adverse event, but an adverse event may occur without complication.”18

Not all AEs negatively impact PROs.7 However, AEs are associated with significantly increased costs to the healthcare system.6 Future studies examining AEs should include both a reliable definition of what constitutes an AE and the reporting method used. This will lead to the generation of data that will identify modifiable AEs on a large scale. Once this is accomplished, evidence-based strategies to mitigate the occurrence and impact of AEs and complications can be accurately developed. In an era of decreasing reimbursements,21,22 strategies to mitigate the impact of AEs will lead to decreased costs for the system as well as improved outcomes for patients, optimizing the value of spine surgery. This is dependent on the accurate reporting of AEs.

There are several limitations with the present study. There is inherent bias with individual surgeons reporting their patients’ AEs, which is likely to lead to underreporting of AEs. Although the data from this study are from academic centers in Canada, it is possible that the case complexity varies among centers and this could lead to variability in AE rates. Additionally, only centers enrolling through CSORN included patients for analysis and not every single patient in the country was included, which could underestimate the true rate of AEs. The highest rate of minor AEs reported occurred with a multidisciplinary meeting, and because there was only 1 center using this method it is not possible to statistically determine if this truly captures a higher rate of potential AEs. Finally, because the total number of sites using each method to report AEs is small, future studies should also examine how the method of AE reporting influences their rates of AEs.

Conclusions

In Canada the rate of major perioperative AEs after elective lumbar spine surgery is consistent among different sites, but the rate of minor AEs appears to vary substantially. The rate of minor AEs may be influenced by the method used to report them. This has implications for the detection and reporting of AEs as well as for the design of strategies aimed at mitigating these events.

Disclosures

Dr. Fisher is a consultant for Medtronic and NuVasive. He also receives royalties from Medtronic, and his institution receives fellowship support from Medtronic and AO Spine. Dr. Ailon has received honoraria from Stryker and is a consultant for Medtronic. Dr. Dea is a consultant for Medtronic and Stryker; has direct stock ownership in Medtronic; and is on the speaker’s bureau for Baxter. Dr. Jacobs is a consultant for Medtronic, Stryker, and DePuy-Synthes. Dr. Johnson received clinical or research support for the study described (includes equipment or material) from Stryker. Dr. Manson is a consultant for and also receives support of a non–study-related clinical or research effort that he oversees from Medtronic Canada. Dr. Rampersaud receives royalties from Medtronic.

Author Contributions

Conception and design: Ayling. Acquisition of data: Ayling, Fisher. Analysis and interpretation of data: Ayling. Drafting the article: Ayling, Fisher. Critically revising the article: all authors. Reviewed submitted version of manuscript: Ayling. Approved the final version of the manuscript on behalf of all authors: Ayling. Statistical analysis: Ayling. Administrative/technical/material support: McIntosh. Study supervision: Fisher.

Supplemental Information

Online-Only Content

Supplemental material is available with the online version of the article.

Previous Presentations

This work has previously been presented as podium presentations at the Spine Summit, AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves (March 16, 2019, in Miami, Florida) and at the Canadian Spine Society annual meeting (March 1, 2019, in Toronto, Canada).

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    Rampersaud YR, Moro ERP, Neary MA, et al. Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine (Phila Pa 1976).2006;31(13):15031510.

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    Karhade AV, Larsen AMG, Cote DJ, et al. National databases for neurosurgical outcomes research: options, strengths, and limitations. Neurosurgery. 2018;83(3):333344.

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    Finkelstein JA, Schwartz CE. Patient-reported outcomes in spine surgery: past, current, and future directions. J Neurosurg Spine. 2019;31(2):155164.

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    Chotai S, Parker SL, Sivaganesan A, et al. Effect of complications within 90 days on patient-reported outcomes 3 months and 12 months following elective surgery for lumbar degenerative disease. Neurosurg Focus. 2015;39(6):E8.

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    Chotai S, Sivaganesan A, Parker SL, et al. Effect of complications within 90 days on cost per quality-adjusted life year gained following elective surgery for degenerative lumbar spine disease. Neurosurgery. 2017;64(CN_suppl_1):157164.

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Images and illustration from Akinduro et al. (pp 834–843). Copyright Tito Vivas-Buitrago. Published with permission.
  • FIG. 1.

    Scatterplot representing major (red dots) and minor (blue dots) AEs (y-axis) relative to the number of patients enrolled at each site (x-axis). Note that the rate of AEs does not correlate with the rate of patient enrollment at each site. Figure is available in color online only.

  • FIG. 2.

    Bar graphs representing the rate of major and minor AEs (y-axis) for each type of AE reporting modality (x-axis) (i.e., surgeon reporting, chart abstraction by research coordinators, and multidisciplinary team meetings). The rate of major AEs is stable across reporting methods but the rate varies widely for minor AEs. Figure is available in color online only.

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    Dekutoski MB, Norvell DC, Dettori JR, et al. Surgeon perceptions and reported complications in spine surgery. Spine (Phila Pa 1976).2010;35(9)(suppl):S9S21.

  • 18

    Rampersaud YR, Moro ERP, Neary MA, et al. Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine (Phila Pa 1976).2006;31(13):15031510.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Karhade AV, Larsen AMG, Cote DJ, et al. National databases for neurosurgical outcomes research: options, strengths, and limitations. Neurosurgery. 2018;83(3):333344.

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    Finkelstein JA, Schwartz CE. Patient-reported outcomes in spine surgery: past, current, and future directions. J Neurosurg Spine. 2019;31(2):155164.

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    Chotai S, Parker SL, Sivaganesan A, et al. Effect of complications within 90 days on patient-reported outcomes 3 months and 12 months following elective surgery for lumbar degenerative disease. Neurosurg Focus. 2015;39(6):E8.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Chotai S, Sivaganesan A, Parker SL, et al. Effect of complications within 90 days on cost per quality-adjusted life year gained following elective surgery for degenerative lumbar spine disease. Neurosurgery. 2017;64(CN_suppl_1):157164.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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