Are preoperative depression and anxiety associated with patient-reported outcomes,health care payments,and opioid use after anterior discectomy and fusion?

BACKGROUND CONTEXTDepression and anxiety are common psychiatric conditions among US adults, and anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. Mental health conditions can affect physical health, and thus have the potential to contribute to adverse outcomes after spine surgery; however, a comprehensive assessment of long-term outcomes and the additive economic burden of these conditions in patients undergoing ACDF has not been well described.PURPOSEOur goal was to assess the associations between depression/anxiety and adverse outcomes and health-resource utilization after anterior cervical discectomy and fusion (ACDF).STUDY DESIGNRetrospective database study.PATIENT SAMPLEWe retrospectively analyzed a private administrative health claims database to identify patients who underwent ACDF in the United States from 2010 to 2013. A total of 16,306 patients met our inclusion criteria. Mean (± standard deviation) patient age was 50±7.9 years. Approximately 4,800 patients (30%) had a depression diagnosis and 4,000 (25%) had a diagnosis of anxiety.OUTCOME MEASURESThe primary outcomes of interest were intensive care unit admission, multiday hospitalization, discharge disposition, 30- and 90-day hospital readmission, 1- and 2-year rates of revision surgery, and chronic postoperative opioid use. Secondary outcomes were 1- and 2-year total cumulative health care payments and cumulative postoperative opioid consumption.METHODSRegression models controlled for demographic and medical covariates, alpha=0.05.RESULTSA preoperative diagnosis of depression was associated with higher odds of multiday hospitalization (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01–1.19), 90-day readmission (OR 1.71, 95% CI 1.46–2.02), revision surgery within 2 years (OR 1.43 95% CI 1.16–1.76), and chronic postoperative opioid use (OR 1.58, 95% CI 1.45–1.72) and an increase of $5,915 in adjusted 2-year health care payments (p<.001). Patients with a preoperative diagnosis of anxiety had higher odds of multiday hospitalization (OR 1.15, 95% CI 1.06–1.25), revision surgery within 2 years (OR 1.33, 95% CI 1.07–1.65), and chronic postoperative opioid use (OR 1.62, 95% CI 1.48–1.77) and an increase of $4,471 in adjusted 2-year health care payments (p<.001). Neither anxiety nor depression was associated with intensive care unit admission, discharge disposition, 30-day readmission, revision surgery within 1 year, 1-year cumulative health care payments, or cumulative postoperative opioid consumption.CONCLUSIONSPatients with preoperative diagnoses of depression or anxiety have a greater likelihood of adverse outcomes, increased opioid consumption, and increased cumulative health care payments after ACDF compared with patients without depression or anxiety.     

Combined anterior and posterior approach in treatment of ankylosing spondylitis-associated cervical fractures: a systematic review and meta-analysis

Objective

Cervical fractures with ankylosing spondylitis (CAS) are a specific type of spinal fracture with poor stability, low healing rate, and high disability rate. Its treatment is mainly surgical, predominantly through the anterior approach, posterior approach, and the anterior–posterior approach. Although many clinical studies have been conducted on various surgical approaches, controversy still exists concerning the choice of these surgical approaches by surgeons. The authors present here a systematic evaluation and meta-analysis exploring the utility of the anterior–posterior approach versus the anterior approach and the posterior approach.

Methods

After a comprehensive literature search of PubMed, Cochrane, Web of Science, and Embase databases, 12 clinical studies were included in the final qualitative analysis and 8 in the final quantitative analysis. Of these studies, 11 conducted a comparison between the anterior–posterior approach and the anterior approach and posterior approaches, while one examined only the anterior–posterior approach. Where appropriate, statistical advantage ratios and 95% confidence intervals were calculated.

Results

The present meta-analysis of postoperative neurological improvement showed no statistical difference in the overall neurological improvement rate between the anterior–posterior approach and anterior approach (OR 1.70, 95% CI 0.61 to 4.75; p = 0.31). However, the mean change in postoperative neurological function was lower in patients who received the anterior approach than in those who received the anterior–posterior approach (MD 0.17, 95% CI -0.02 to 0.36; p = 0.08). There was an identical trend between the anterior–posterior approach and posterior approach, with no statistically significant difference in the overall rate of neurological improvement (OR 1.37, 95% CI 0.70 to 2.56; p = 0.38). Nevertheless, the mean change in neurological function was smaller in patients receiving the anterior–posterior approach compared with the posterior approach, but there was no statistically significant difference between the two (MD 0.17, 95% CI -0.02 to 0.36; p = 0.08).

Conclusions

The results of this review and meta-analysis suggest that the benefits of the anterior–posterior approach are different from those of the anterior and posterior approaches in the treatment of ankylosing spondylitis-related cervical fractures. In a word, there is no significant difference between the cervical surgical approach and the neurological functional improvement. Therefore, surgeons should pay more attention to the type of cervical fracture, the displacement degree of cervical fracture, the spinal cord injury, the balance of cervical spine and other aspects to comprehensively consider the selection of appropriate surgical methods.

     

Analysis of swallowing function after anterior/posterior surgery for cervical degenerative disorders and factors related to the occurrence of postoperative dysphagia

BACKGROUND CONTEXTDysphagia is one of the postoperative complications of cervical degenerative disorders. However, few studies have evaluated the pre- and postoperative swallowing function in detail.PURPOSETo analyze pre- and postoperative swallowing dynamics kinetically and investigate factors associated with postoperative dysphagia in patients with cervical degenerative disorders.STUDY DESIGNRetrospective review of prospectively collected data.PATIENT SAMPLEA total of 41 consecutive patients who underwent an anterior approach (anterior cervical discectomy/corpectomy and fusion (ACDF, ACCF), hybrid surgery (ACDF+ACCF) and total disc replacement) and 44 consecutive patients who underwent a posterior approach (laminoplasty and laminoplasty/laminectomy with fusion).OUTCOME MEASURESWe compared the pre- and postoperative functional oral intake scale (FOIS), dysphagia severity scale (DSS), esophageal dysphagia, anterior/superior hyoid movement, upper esophageal sphincter (UES) opening, pharyngeal transit time, bolus residue scale (BRS), and the number of swallows.METHODSVideofluoroscopy was performed on the day before surgery and within two weeks after surgery. Data related to age, gender, disease, surgical procedure, surgical site, operative time, and blood loss were collected from the medical records. Pre- and postoperative data were compared for each item in the anterior and posterior approaches. The odds ratio of dysphagia after an anterior approach was also calculated.RESULTSIn the anterior approach, DSS, FOIS, the anterior and superior hyoid movements, maximum UES opening, BRS, and number of swallows worsened postoperatively (p<.05, respectively). In the posterior approach, DSS, FOIS, the anterior hyoid movement, and BRS worsened postoperatively (p<.05, respectively). The factors associated with dysphagia were a proximal surgical site above C3 (OR: 14.40, CI: 2.84−73.02), blood loss >100 mL (OR: 9.60, CI: 2.06−44.74), an operative time >200 minutes (OR: 8.18, CI: 1.51−44.49), and an extensive surgical field of more than three intervertebral levels (OR: 6.72, CI: 1.50−30.07). The decline in swallowing function after the posterior approach was related to aging (p=.045).CONCLUSIONSEach approach may decrease swallowing function, especially because of the limitation on the anterior hyoid movement. Dysphagia after anterior approaches was associated with the operative site, operative time, and blood loss.     

Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries

Background context

Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies.

Purpose

To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions.

Study design

Retrospective cohort study.

Patient sample

Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to 2007.

Outcome measures

Readmissions within 30 days of discharge, excluding readmissions for rehabilitation.

Methods

Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software).

Results

Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%–33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions.

Conclusions

Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit.     

Rates and reasons for reoperation within 30 and 90 days following cervical spine surgery: a retrospective cohort analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry

BACKGROUND CONTEXTReoperation following cervical spinal surgery negatively impacts patient outcomes and increases health care system burden. To date, most studies have evaluated reoperations within 30 days after spine surgery and have been limited in scope and focus. Evaluation within the 90-day period, however, allows a more comprehensive assessment of factors associated with reoperation.PURPOSEThe purpose of this study is to assess the rates and reasons for reoperations after cervical spine surgery within 30 and 90 days.DESIGNWe performed a retrospective analysis of a state-wide prospective, multi-center, spine-specific database of patients surgically treated for degenerative disease.PATIENT SAMPLEPatients 18 years of age or older who underwent cervical spine surgery for degenerative pathologies from February 2014 to May 2019. Operative criteria included all degenerative cervical spine procedures, including those with cervical fusions with contiguous extension down to T3.OUTCOME MEASURESWe determined causes for reoperation and independent surgical and demographic risk factors impacting reoperation.METHODSPatient-specific and surgery-specific data was extracted from the registry using ICD-10-DM codes. Reoperations data was obtained through abstraction of medical records through 90 days. Univariate analysis was done using chi-square tests for categorical variables, t-tests for normally distributed variables, and Wilcoxon rank-sum tests for variables with skewed distributions. Odds ratios for return to the operating room (OR) were evaluated in multivariate analysis.RESULTSA total of 13,435 and 13,440 patients underwent cervical spine surgery and were included in the 30 and 90-day analysis, respectively. The overall reoperation rate was 1.24% and 3.30% within 30 and 90 days, respectively. Multivariate analysis showed within 30 days, procedures involving four or more levels, posterior only approach, and longer length of stay had increased odds of returning to the OR (p<.05), whereas private insurance had a decreased odds of return to OR (p<.05). Within 90 days, male sex, coronary artery disease (CAD), previous spine surgery, procedures with 4 or more levels, and longer length of stay had significantly increased odds of returning to the OR (p<.05). Non-white race, independent ambulatory status pre-operatively, and having private insurance had decreased odds of return to the OR (p<.05). The most common specified reasons for return to the OR within 30 days was hematoma (19%), infection (17%), and wound dehiscence (11%). Within 90 days, reoperation reasons were pain (10%), infection (9%), and hematoma (8%).CONCLUSIONReoperation rates after elective cervical spine surgery are 1.24% and 3.30% within 30 and 90 days, respectively. Within 30 days, four or more levels, posterior approach, and longer length of stay were risk factors for reoperation. Within 90 days, male sex, CAD, four or more levels, and longer length of hospital stay were risk factors for reoperation. Non-white demographic and independent preoperative ambulatory status were associated with decreased reoperation rates.     

Optimal hemoglobin A1C target in diabetics undergoing elective cervical spine surgery

BACKGROUND CONTEXTDiabetes mellitus (DM) is a well-established risk factor for suboptimal outcomes following cervical spine surgery. Hemoglobin A1C (HbA1c), a surrogate for long-term glycemic control, is a valuable assessment tool in diabetic patients.PURPOSEIn patients undergoing elective cervical spine surgery, we sought to identify optimal HbA1c levels to: (1) maximize 1-year postoperative patient-reported outcomes (PROs), and (2) predict the occurrence of medical and surgical complications.STUDY DESIGN/SETTINGA retrospective cohort study using prospectively collected data was performed in a single academic center.Patient SampleDiabetic patients undergoing elective anterior cervical fusion and posterior cervical laminectomy and fusion (PCLF) between October 2010-March 2021 were included.OUTCOME MEASURESPrimary outcomes included Numeric Rating Scale (NRS)-Neck pain, NRS-Arm pain, and Neck Disability Index (NDI). Secondary outcomes included surgical site infection (SSI), complications, readmissions, and reoperations within 90-days postoperatively.METHODSHbA1c, demographic, comorbidity, and perioperative variables were gathered in diabetic patients only. PROs were analyzed as continuous variables and minimum clinically difference (MCID) was set at 30% improvement from baseline.RESULTSOf 1992 registry patients undergoing cervical surgery, 408 diabetic patients underwent cervical fusion surgery. Anterior: A total of 259 diabetic patients underwent anterior cervical fusion, 141 of which had an available HbA1c level within one year prior to surgery. Mean age was 55.8±10.1, and mean HbA1c value was 7.2±1.4. HbA1c levels above 6.1 were associated with failure to achieve MCID for NDI (AUC=0.77, 95%CI 0.70–0.84, p<.001), and HbA1c levels above 6.8 may be associated with increased odds of reoperation (AUC=0.61, 95%CI 0.52–0.69, p=.078). Posterior: A total of 149 diabetic patients underwent PCLF, 65 of which had an available HbA1c level within 1 year. Mean age was 63.6±9.2, and mean HbA1c value was 7.2±1.5. Despite a low AUC for NRS-Arm pain and readmission, HbA1c levels above 6.8 may be associated with failure to achieve MCID for NRS-Arm pain (AUC=0.61, 95%CI 0.49–0.73, p=.094), and HbA1c levels above 7.6 may be associated with higher readmission rate (AUC=0.63, 95%CI 0.50–0.75, p=.185).CONCLUSIONSIn a cohort of diabetic patients undergoing elective cervical spine surgery, HbA1c levels above 6.1 were associated with decreased odds of achieving MCID for NDI in anterior cervical fusion surgery. Though only moderate associations were seen for the select outcomes of reoperation (6.8), readmission (7.6), and MCID for NRS-Arm pain (6.8), preoperative optimization of HbA1c using these levels as benchmarks should be considered to reduce the risk of complications and maximize PROs for patients undergoing elective cervical spine surgery.     

Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: A retrospective cohort study

BACKGROUND CONTEXTAnterior lumbar interbody fusion (ALIF) exposes the anterior aspect of the spine through a retroperitoneal approach. Access to the anterior spine requires mobilization of intra-abdominal viscera/vasculature, which can become complicated as scarring and/or adhesions develop from prior abdominal surgical interventions, increasing risk of intraoperative complications. The literature suggests that “significant prior abdominal surgery” is a relative contraindication of ALIF surgery; however, there is no consensus within the literature as to what defines “major/significant” abdominal surgeries. Additionally, the association between the number of prior abdominal surgeries and perioperative complications in ALIF surgery has not been explored within the literature.PURPOSEThis study seeks to explore the association between perioperative complications of ALIF surgery and the type (major and/or minor) and number of prior abdominal surgeries.DESIGNA retrospective cohort study was performed to examine perioperative complications in ALIF patients with or without prior history of abdominal surgery.PATIENT SAMPLEAll consecutive patients undergoing ALIF with or without a history of prior abdominal surgery from 2008 to 2018 at a single tertiary center were evaluated. Patients under the age of 18, patients with spinal malignancy, or patients who had ALIF above L3 were excluded.OUTCOME MEASURESPerioperative complications included intraoperative complications during ALIF surgery and postoperative complications within 90 days of ALIF surgery. Intraoperative complications include vascular injury, ureter injury, retroperitoneal hematoma, etc. Postoperative complications include urinary tract infection, revision of abdominal scar, ileus, deep vein thrombosis, pulmonary embolism, etc. Other outcome measures include readmission within 90 days, length of ALIF surgery, and length of hospital stay.METHODSElectronic medical records of 660 patients who underwent ALIF between 2008 and 2018 were retrospectively reviewed. Patient demographics, Charleston Comorbidity Index (CCI), level of fusion, past abdominal surgical history, use of access surgeon during exposure, intraoperative, and postoperative complications were collected. Predictors of intraoperative and postoperative complications were analyzed using simple and multivariable logistic regression. Statistical analysis was performed using JMP 14.0 (SAS, Cary, NC, USA) software.RESULTSAfter controlling for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon, there was no significant association between the type of prior abdominal surgery (major and/or minor) and intraoperative complications on multivariable logistic regression analysis (Minor: odds ratio [OR]=1.68; 95% confidence interval [CI]: 0.58–4.86 & Major: OR=1.99; 95% CI: 0.80–4.91). On multivariable logistic regression, the odds of developing an intraoperative complication increases by 52% for each additional prior abdominal surgery after adjusting for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon (OR=1.52, 95% CI: 1.10–2.11). Iliac vein laceration was the most common intraoperative complication (n=27, 4%). Neither the type (major and/or minor) nor the number of prior abdominal surgeries were significant predictors of postoperative complications (Minor: OR=1.29; 95% CI: .72–2.31, Major: OR=1.24; 95% CI: 0.77–2.00, & Number: OR=1.03; 95% CI: .84–1.26).CONCLUSIONWith each additional prior abdominal surgery, accumulation of scarring and adhesions can likely obscure anatomical landmarks and increase the risk of developing an intraoperative complication. Therefore, the number of prior abdominal surgeries should be taken into consideration during planning and operative exposure of the anterior spine via a retroperitoneal approach.     

Complications,revision fusions,readmissions, and utilization over a 1-year period after bone morphogenetic protein use during primary cervical spine fusions

Background contextNationwide estimates examining bone morphogenetic protein (BMP) use with cervical spine fusions have been limited to perioperative outcomes.PurposeTo determine the 1-year risk of complications, cervical revision fusions, hospital readmissions, and health care services utilization.Study designA retrospective cohort study from 2002 to 2009 using a nationwide claims database.Patient sampleThere were 61,937 primary cervical spine fusions of which 1,677 received BMP.Outcome measuresComplications, revision fusions, 30-day hospital readmission, and health care utilization.MethodsData for these analyses come from the Thomson Reuters MarketScan Commercial Claims and Encounters Database 2010. Patients were aged 18 to 64 years, receiving and not receiving BMP with a primary (C2–C7) cervical spine fusion. All outcomes were defined by International Classification of Diseases, 9th edition Clinical Modification and Current Procedural and Terminology, 4th edition codes. Complications were analyzed as any complication and stratified by nervous system, wound, and dysphagia or hoarseness. Cervical revision fusions were determined in the 1-year follow-up. Hospital readmission discharge records defined 30-day hospital readmission and reason for the readmission. The utilization of at least one health care service of cervical spine imaging, epidural usage or rehabilitation service was examined. Poisson regression models were used to estimate the relative risk and 95% confidence interval (CI). Linear regression was used to determine the time to hospital readmission. Results were stratified by anterior or posterior and circumferential approaches.ResultsPatients receiving BMP were 29% more likely to have a complication (adjusted relative risk [aRR]=1.29 [95% CI, 1.14–1.46]) and a nervous system complication (aRR=1.42 [95% CI, 1.10–1.83]). Cervical revision fusions were more likely among patients receiving BMP (aRR=1.69 [95% CI, 1.35–2.13]). The risk of 30-day readmission was greater with BMP use (aRR=1.37 [95% CI, 1.07–1.73]) and readmission occurred 27.4% sooner on an average. Patients receiving BMP were more likely to receive computed tomography scans (aRR=1.34 [95% CI, 1.06–1.70]) and epidurals with anterior surgical approaches (aRR=1.29 [95% CI, 1.00–1.65]).ConclusionsThese findings question both the safety and effectiveness of off-label BMP use in primary cervical spine fusions.     

Trends,payments, and costs associated with BMP use in Medicare beneficiaries undergoing spinal fusion

BACKGROUND CONTEXTBone morphogenic protein (BMP) promotes bony fusion but increases costs. Recent trends in BMP use among Medicare patients have not been well-characterized.PURPOSETo assess utilization trends, complication, payments, and costs associated with BMP use in spinal fusion in a Medicare-insured population.STUDY DESIGN/SETTINGRetrospective cohort study.PATIENT SAMPLETotal of 316,070 patients who underwent spinal fusion in a 20% sample of Medicare-insured patients, 2006 to 2015.OUTCOME MEASURESUtilization trends across time and geography, complications, payments, and costs.METHODSPatients were stratified by fusion type and diagnosis. Multivariable logistic and linear regression were used to adjust for the effect of baseline characteristics on complications and total payments or cost, respectively.RESULTSBMP was used in 60,249 cases (19.1%). BMP utilization rates decreased from 23.1% in 2006 to 12.0% in 2015, most significantly in anterior cervical (7.5%–3.1%), posterior cervical (17.0%–8.3%), and posterior lumbar fusions (31.5%–15.8%). There are significant state- and region-level geographic differences in BMP utilization. Across all years, states with the highest BMP use were Indiana (28.5%), Colorado (26.6%), and Nevada (25.7%). States with the lowest BMP use were Maine (2.3%), Vermont (8.2%), and Mississippi (10.4%). After multivariate risk adjustment, BMP use was associated with decreased overall complications in thoracic (odds ratios [OR] [95% confidence intervals [CI]): 0.89 [0.81–0.99]) and anterior lumbar fusions (OR [95% CI]: 0.89 [0.84–0.95]), as well as increased reoperation rates in anterior cervical (OR [95% CI]: 1.11 [1.04–1.19]), posterior cervical (OR (95% CI): 1.14 (1.04–1.25)), thoracic (OR (95% CI): 1.32 (1.23–1.41)), and posterior lumbar fusions (OR (95% CI): 1.11 (1.06–1.16)). BMP use was also associated with greater total costs, independent of fusion type, after multivariate risk adjustment (p<.0001). Payments, however, were comparable between groups in anterior and posterior cervical fusion with or without BMP. BMP use was associated with greater total payments in thoracic, anterior lumbar, and posterior lumbar fusions. Notably, the difference in payments was smaller than the associated cost increase in all fusion types.CONCLUSIONSBMP use has declined across all fusion types over the last decade, after a peak in 2007. While BMP is associated with greater costs, reimbursement does not increase proportionally with BMP cost.     

Surgical treatment of metastatic spine disease: an update on national trends and clinical outcomes from 2010 to 2014

BACKGROUND CONTEXTMetastatic spine disease (MSD) is becoming more prevalent as medical treatment for cancers advance and extend survival. More MSD patients are treated surgically to maintain neurological function, ambulation, and quality of life.PURPOSEThe purpose of this study was to use a large, nationally representative database to examine the trends, patient outcomes, and health-care resource utilization associated with surgical treatment of MSD.DESIGNThis was an epidemiologic study using national administrative data from the Nationwide Readmissions Database (NRD).PATIENT SAMPLEAll patients in the NRD from 2010 to 2014 who underwent spinal surgery were included in the study.OUTCOME MEASURESMortality, blood transfusion, complications, length of stay, cost, and discharge location during index hospitalization as well as hospital readmission and revision surgery within 90-days of surgery were analyzed.METHODSInternational Classification of Diseases, Ninth Revision, (ICD-9) codes was used to identify patients of interest within the NRD from 2010 to 2014. Patients were separated into two cohorts – those with MSD and those without. Trends for surgical treatment of MSD were assessed and outcomes measures for both cohorts were analyzed and compared.RESULTSThe number of surgical treatments for MSD increased from 6,007 in 2010 to 7,032 in 2014 (p-trend<.0001) which represented a 17.1% increase. During index hospitalization, MSD patients had an increased risk of mortality (odds ratio [OR]=3.22, 95% confidence interval [CI]: 2.85–3.63, p<.0001), blood transfusion (OR=2.93, 95% CI: 2.66–3.23, p<.0001), any complication (OR=1.24, 95% CI: 1.18–1.31, p<.0001), and discharge to skilled nursing facility (OR=1.51, 95% CI:1.41–1.61, p<.0001). MSD patients had longer average length of stay (13.05 vs. 4.56 days, p<.0001) and cost ($49,421.75 vs. $26,190.37, p<.0001) during index hospitalization. Furthermore, MSD patients had an increased risk of hospital readmission (OR=2.82, 95% CI: 2.68–2.96, p<.0001), readmission for surgical site infection (OR=2.38, 95% CI: 2.20–2.58, p<.0001), and readmission with neurologic deficits (OR=1.62, 95% CI: 1.27–2.06, p<.0001) despite a decreased risk of revision fusion (OR=0.71, 95% CI: 0.53–0.96, p=.026).CONCLUSIONSThe number of MSD patients who undergo surgical treatments is increasing. Not only do these patients have worse outcomes during index hospitalization, but they are also at an increased risk of hospital readmission for surgical site infection and neurologic complications. These findings stress the need for multidisciplinary perioperative treatment plans that mitigate risks and facilitate quick, effective recovery in these unique, at-risk patients.     

Highlighting the Roles of Anemia and Aspirin in Predicting Ninety-Day Readmission Following Aseptic Revision Total Joint Arthroplasty

BackgroundRevision total joint arthroplasties (TJAs) are associated with an increased rate of complications. To date, it is unclear what drives readmission after aseptic revision arthroplasty and what measures can be taken to possibly avoid them. The purpose of this study is to (1) determine the reasons for readmission after aseptic revision TJA and (2) identify patient-specific or postoperative risk factors through a multivariate analysis.MethodsA retrospective study examined 1503 cases of aseptic revision TJA between 2009 and 2016 at an urban tertiary care hospital. Eighty-seven cases (5.8%) of readmission within 90 days of index surgery were identified. Bivariate and multivariate analyses were performed to assess independent risk factors for readmission.ResultsThe reasons for readmission were infection (38%), wound complications (22%), and dislocation/instability of the prosthetic joint (13%). Only preoperative anemia was associated with an increased odds ratio (OR) of readmission (OR 1.82, 95% confidence interval [CI] 1.126-2.970, P = .015), whereas postoperative venous thromboembolism prophylaxis with aspirin (OR 0.58, 90% CI 0.340-0.974, P = .039) and discharge to an inpatient rehab facility (OR 0.22, 95% CI 0.051-0.950, P = .042) were associated with significantly lower odds of readmission.ConclusionBased on this single institutional study, addressing preoperative anemia and considering the implementation of aspirin for venous thromboembolism prophylaxis may be 2 targets to potentially reduce readmission after aseptic revision TJA.     

Radical prostatectomy readmissions: Causes,risk factors,national rates, & costs

IntroductionReadmissions have substantial clinical and financial impacts on the healthcare system. Radical prostatectomy (RP) is considered a standard treatment in the management of clinically localized prostate cancer. Yet, there is a paucity of research evaluating readmissions for RP in a national dataset.Patients and methodsPatients with histologically confirmed prostate cancer managed with RP were identified within the 2016 to 2018 Nationwide Readmissions Database. Patient factors, facility factors, and surgical characteristics were evaluated for associations with readmission using univariable and multivariable analyses.ResultsA total of 133,727 patients receiving RP were identified. Early (30-day) and late (31–90-day) readmission rates were 4.2% and 1.8% respectively. The most common cause of early readmission was postoperative digestive system complication (10%) and the most common cause of late readmission was septicemia (13%). On multivariable logistic regression, factors associated with both early and late readmission include nonroutine discharge at index (early: OR 1.877, 95% CI 1.667–2.113; late: OR 1.801, 95% CI 1.490–2.183), and circulatory system comorbidity (early: OR 1.29, 95% CI 1.082–1.538); late: OR 1.515, 95% CI 1.157–1.984).ConclusionsOur findings regarding factors associated with readmission provide insight for RP counseling and may inform postoperative care pathways. Elucidation of readmission trends may allow the identification and proactive management of patients at higher risk for readmission.     

Nerve injury and recovery after lateral lumbar interbody fusion with and without bone morphogenetic protein-2 augmentation: a cohort-controlled study

Background contextDespite common use of intraoperative electrophysiologic neuromonitoring, injuries to the lumbar plexus during lateral lumbar interbody fusion (LLIF) have been reported. Emerging data suggest that recombinant human bone morphogenetic protein-2 (rhBMP-2) use during an anterior or transforaminal lumbar interbody fusion may be associated with an increased risk of neurological deficit. Clinical data on the sequelae of rhBMP-2 implantation in close proximity to the lumbosacral plexus during LLIF remains to be understood.PurposeThe purpose of this study was to compare the incidence of neurologic deficits and pain in patients undergoing LLIF with and without rhBMP-2.Study design/settingRetrospective outcome analysis in controlled cohorts undergoing the lateral exposure technique for LLIF with and without rhBMP-2.MethodsThe electronic medical records of patients undergoing LLIF with and without supplemental posterior fusion for degenerative spinal conditions were retrospectively reviewed over a 6-year period. Patients with previous lumbar spine surgery or follow-up of less than 6 months were excluded. Patients were divided into 2 groups, Group 1 (rhBMP-2 use; n=72) and Group 2 (autograft/allograft use; n=72), and were matched according to the age at the time of surgery, gender, weight, body mass index, side of approach, total number of treated spinal segments, use of supplemental posterior fusion, and length of follow-up.ResultsImmediately after surgery, a sensory deficit was recorded in 33 patients in Group 1 and 35 patients in Group 2 (odds ratio [OR] 0.895; 90% confidence interval [CI] 0.516–1.550; p=.739). At last follow-up, a persistent sensory deficit was identified in 29 patients whose LLIF procedure was supplemented by rhBMP-2 and 20 patients in whom autograft/allograft was used (OR 1.754; 90% CI 0.976–3.151; p=.115). A motor deficit was recorded in 37 patients immediately after the rhBMP-2 procedure and 28 patients treated with autograft/allograft (OR 1.661; 90% CI 0.953–2.895; p=.133). A persistent motor deficit was recorded in 35 and 17 patients in Groups 1 and 2, respectively, at last follow-up (OR 3.060; 90% CI 1.681–5.571; p=.002). During the first postoperative examination, 37 patients in Group 1 and 25 patients in Group 2 complained of anterior thigh or groin pain (OR 1.987; 90% CI 1.133–3.488; p=.045). At last follow-up, there was a significantly higher number of patients in Group 1 who complained of persistent anterior thigh or groin pain than Group 2 (8 vs. 0 patients) (OR 16.470; 90% CI 1.477–183.700; p=.006).ConclusionsOur results provide evidence of an increased rate of postoperative neurologic deficit and anterior thigh/groin pain after LLIF using rhBMP-2, when compared with matched controls without rhBMP-2 exposure. This study suggests a potential direct deleterious effect of rhBMP-2 on the lumbosacral plexus.     

Readmission following complex spine surgery in a prospective cohort of 679 patients – 2-years follow-up using the Spine AdVerse Event Severity (SAVES) system

BACKGROUND CONTEXTRecent studies suggest that prospective registration more accurately reflects the true incidence of adverse events (AEs). To our knowledge, no previous study has investigated prospectively registered AEs' influence on hospital readmission following spine surgery.PURPOSETo determine the frequency and type of unplanned readmissions after complex spine surgery, and to investigate if prospectively registered AEs can predict readmissions.DESIGNThis is a prospective, consecutive cohort study.PATIENT SAMPLEWe conducted a single-center study of 679 consecutive patients who underwent complex spine surgery defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment.OUTCOME MEASURESThe outcomes in this study were (1) readmission to any hospital department within 30 days of discharge and (2) readmission to a surgical spine center at any time in follow-up.METHODSAll patients undergoing complex spine surgery, at our tertiary referral center, were consecutively, and prospectively, included from January 1 to December 31, 2013. Demographics and perioperative AEs were registered using the Spine AdVerse Events Severity (SAVES) system. Patients were followed for a minimum of two years. A competing risk survival model was used to estimate rates of readmissions with death as a competing risk. Patient characteristics, surgical parameters and perioperative AEs were analyzed to identify factors associated with readmission. Analyses of 30-day readmission were performed using logistic regression models. A proportional odds model, with death as competing risk, was used for readmissions to a spine center at any time in follow-up. Results were reported as odds ratios with 95% confidence intervals (95% CI).RESULTSWithin 2 years of index discharge, 443 (65%) were readmitted. Only 20% of readmissions were to a spine center. Cumulative incidence (95% CI) of readmission was estimated to 13% (10%–16%) at 30 days, 26% (23%–30%) at 90 days, 50% (46%–54%) at 1 year, and 59% (55%–63%) at 2 years following discharge. Rates were markedly lower for readmissions to a spine center. Increased odds of 30-day readmission were correlated to intraoperative hypotension (p=.02) and major intraoperative blood loss (p<.01). Readmission to a spine center was associated with the number of instrumented vertebrae (p=.047), major intraoperative AE (p=.01), and intraoperative hypotension (p<.01).CONCLUSIONSTo the best of our knowledge, this is the first study to analyze prospectively registered AEs' association to readmission up to 2 years after complex spine surgery. We found that readmissions were more frequent than previously reported when including readmissions to any department or hospital. Factors related to major intraoperative blood loss were associated to increased odds of readmission. This should be considered during planning of postoperative observation and care.     

Social vulnerability index (SVI) and poor postoperative outcomes in children undergoing surgery in California

IntroductionArea-based social determinants of health (SDoH) associated with disparities in children's surgical outcomes are not well understood, though some may be risk factors modifiable by public health interventions.MethodsThis retrospective cohort study investigated the effect of high social vulnerability index (SVI), defined as ≥90th percentile, on postoperative outcomes in children classified as ASA 1–2 who underwent surgery at a large institution participating in the National Surgical Quality Improvement Program (2015–2021). Primary outcome was serious postoperative complications, defined as postoperative death, unplanned re-operation, or readmission at 30 days after surgery.ResultsAmong 3278 pediatric surgical procedures, 12.1% had SVI in the ≥90th percentile. Controlling for age, sex, racialization, insurance status, and language preference, serious postoperative complications were associated with high overall SVI (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.02–2.44) and high socioeconomic vulnerability (SVI theme 1, OR 1.75, 95% CI 1.03–2.98).ConclusionNeighborhood-level socioeconomic vulnerability is associated with worse surgical outcomes in apparently healthy children, which could serve as a target for community-based intervention.     

Cefuroxime concentrations in the anterior and posterior column of the lumbar spine – an experimental porcine study

BACKGROUND CONTEXTSurgical site infection following spine surgery is associated with increased morbidity and mortality. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and many surgeries involve the lumbar spine.PURPOSEThe objective of this study was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column during lumbar spine surgery with a posterior surgical approach.STUDY DESIGNIn vivo experimental pharmacokinetic study of cefuroxime concentrations in an acute preclinical porcine model.METHODSThe lumbar vertebral column was exposed from L1 to L5 in 8 female pigs. Microdialysis catheters were placed for sampling in the anterior column (vertebral body) and posterior column (posterior arch) within the same vertebra (L5). Cefuroxime (1.5 g) was administered intravenously. Microdialysates and plasma samples were continuously obtained over 8 hours. Cefuroxime concentrations were quantified by Ultra High Performance Liquid Chromatography Tandem Mass Spectrometry. The primary endpoint was the time above the cefuroxime clinical breakpoint minimal inhibitory concentration (T>MIC) for Staphylococcus aureus of 4 µg/mL. The secondary endpoint was tissue penetration (AUC_tissue/AUC_plasma).RESULTSMean T>MIC 4 µg/mL (95% confidence interval) was 123 min (105–141) in plasma, 97 min (79–115) in the anterior column and 93 min (75–111) in the posterior column. Tissue penetration (95% confidence interval) was incomplete for both the anterior column 0.48 (0.40–0.56) and posterior column 0.40 (0.33–0.48).CONCLUSIONST>MIC was comparable between the anterior and posterior column. Mean cefuroxime concentrations decreased below the clinical breakpoint minimal inhibitory concentration for S. aureus of 4 µg/mL after 123 minutes (plasma), 97 minutes (anterior column) and 93 minutes (posterior column). This is shorter than the duration of most lumbar spine surgeries, and therefore alternative dosing regimens should be considered in posterior open lumbar spine surgeries lasting more than 1.5 hours.CLINICAL SIGNIFICANCEOpen lumbar spine surgery often involves extensive soft tissue dissection, stripping and retraction of the paraspinal muscles which may impair the local blood flow exposing the lumbar vertebra to postoperative infections. A single intravenous administration of 1.5 g cefuroxime only provided sufficient prophylactic target tissue concentrations in the vertebra of the lumbar spine for up to 1.5 hours.     

Postoperative care fragmentation in bariatric surgery and risk of mortality: a nationwide study

BackgroundReadmission after bariatric surgery may to lead to fragmentation of care if readmission occurs at a facility other than the index hospital. The effect of readmission to a nonindex hospital on postoperative mortality remains unclear for bariatric surgery.ObjectivesTo determine postoperative mortality rates according to readmission destinations.SettingNationwide analysis of all surgical facilities in France.MethodsMulticenter, nationwide study of adult patients undergoing bariatric surgery from January 1, 2013, through December 31, 2018. Data from all surgical facilities in France were extracted from a national hospital discharge database.ResultsIn a cohort of 278,600 patients who received bariatric surgery, 12,760 (4.6%) were readmitted within 30 days. In cases of readmission, 23% of patients were admitted to a nonindex hospital. Patients readmitted to a nonindex facility had different characteristics regarding sex (men, 23.6% versus 18.2%, respectively; P < .001), co-morbidities (Charlson Co-morbidity Index, .74 versus .53, respectively; P < .001), and travel distance (38.3 km versus 26.9 km, respectively; P < .001) than patients readmitted to the index facility. The main reasons for readmission were leak/peritonitis and abdominal pain. The overall mortality rate after readmission was .56%. The adjusted odds ratio (OR) of mortality for the nonindex group was 4.96 (95% confidence interval [CI], 3.1–8.1; P < .001). In the subgroups of patients with a gastric leak, the mortality rate was 1.5% and the OR was 8.26 (95% CI, 3.7–19.6; P < .001).ConclusionReadmissions to a nonindex hospital are associated with a 5-fold greater mortality rate. The management of readmission for complications after bariatric surgery should be considered as a major issue to reduce potentially preventable deaths.     

Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study

Background contextThe natural history of cervical degenerative disease with operative management has not been well described. Even with symptomatic and radiographic evidence of multilevel cervical disease, it is unclear whether single- or multilevel anterior cervical discectomy and fusion (ACDF) procedures produce superior long-term outcomes.PurposeTo describe national trends in revision rates, complications, and readmission for patients undergoing single and multilevel ACDF.Study designAdministrative database study.Patient sampleBetween 2006 and 2010, 92,867 patients were recorded for ACDF procedures in the Thomson Reuters MarketScan database. Restricting to patients with >24 months follow-up, 28,777 patients fulfilled our inclusion criteria, of which 12,744 (44%) underwent single-level and 16,033 (56%) underwent multilevel ACDFs.Outcome measuresRevision rates and postoperative complications.MethodsWe used the MarketScan database from 2006 to 2010 to select ACDF procedures based on Current Procedural Terminology coding at inpatient visit. Outcome measures were ascertained using either International Classification of Disease version 9 or Current Procedural Terminology coding.ResultsPerioperative complications were more common in multilevel procedures (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2–1.6; p<.0001). Single-level ACDF patients had higher rates of postoperative cervical epidural steroid injections (OR, 0.88; 95% CI, 0.8–1.0; p=.01). Within 30 days after index procedure, the multilevel ACDF cohort was 1.6 times more likely to have undergone revision (OR, 1.6; 95% CI, 1.1–2.4; p=.02). At 2 years follow-up, revision rates were 9.13% in the single-level ACDF cohort and 10.7% for multilevel ACDFs (OR, 1.2; 95% CI, 1.1–1.3; p<.0001). In a multivariate analysis at 2 years follow-up, patients from the multilevel cohort were more likely to have received a surgical revision (OR, 1.1; 95% CI, 1.0–1.2; p=.001), to be readmitted into the hospital for any cause (OR, 1.2; 95% CI, 1.1–1.4; p=.007), and to have suffered complications (OR, 1.3; 95% CI, 1.1–1.5; p=.0003).ConclusionsIn this study, we report rates of adverse events and the need for revision surgery in patients undergoing single versus multilevel ACDFs. Increasing number of levels fused at the time of index surgery correlated with increased rate of reoperations. Multilevel ACDF patients requiring additional surgery more often underwent more extensive revision surgeries.     

Incidence of and risk factors associated with care fragmentation following bariatric surgery

BackgroundCurrent readmission rates do not account for readmissions to nonindex hospitals and may underestimate the actual burden of readmissions.ObjectiveUsing a nationally representative database, we sought to characterize nonindex readmissions following bariatric surgery and identify risk factors associated with readmission to a nonindex hospital.SettingPatients in the United States undergoing elective bariatric surgery.MethodsThe Nationwide Readmissions Database was used to identify a weighted sample of 545,377 patients undergoing elective bariatric surgery between 2010 and 2014. Multivariable logistic regression analysis was used to identify factors associated with readmission to a nonindex hospital.ResultsAmong all patients, 5.6% were readmitted at least once within 30 days. Within the subgroup of patients who were readmitted, 17.6% were readmitted to a different hospital than the index admission hospital. Factors independently associated with higher odds of readmission to a nonindex hospital were primary payor (Medicare: odds ratio [OR] = 1.48, 95% confidence interval [CI]: 1.24–1.75; Medicaid: OR = 1.56, 95% CI: 1.26–1.95), All Patients Refined Diagnosis Related Group severity of illness score (extreme versus minor: OR = 1.48; 95% CI: 1.04–2.09), primary procedure (laparoscopic sleeve gastrectomy versus laparoscopic gastric bypass: OR = 1.23; 95% CI: 1.05–1.44), hospital bed size (reference: small hospital, medium: OR = .52, 95% CI: .39–.70; large: OR = .47, 95% CI: .35–.63), hospital ownership (reference: private, nonprofit hospital, government: OR = 1.77, 95% CI: 1.32–2.37; private, investor-owned: OR = 1.33, 95% CI: 1.07–1.64), and hospital location (reference: metropolitan area >1 million population, metropolitan <1 million population: OR = .44, 95% CI: .34–.56; micropolitan/rural: OR = .44, 95% CI: .27–.73).ConclusionFailure to account for readmissions to different hospitals may underestimate readmission rates by approximately 18%.