A Comprehensive Review of Spinal Cord Stimulator Infections.

Spinal cord stimulator (SCS) is approved to treat various pain conditions and is commonly seen in the chronic pain patient population. Due to the nature of the device and its location, infections associated with SCS have a particularly high morbidity. According to post-market data and medical device reports, 87% of patients receiving SCS implants were given perioperative antibiotics as the implantable neurostimulator or receiver pocket serve as the most common sites of infection. The most common antibiotics for surgical prophylaxis given are first-generation cephalosporins (cefalexin, cefazolin) at the time of implantation. If deep infection is suspected, imaging in the form of CT scan should be obtained as physical exam is not always sufficient. For infections involving the epidural space, vertebra, or intervertebral discs, MRI is the preferred imaging modality. If meningitis is suspected, a lumbar puncture is recommended. Positive cultures can help guide antibiotic therapy.

A Review of Sublingual Sufentanil Tablet (SST) and its Utility as an Analgesic Agent for Pain Procedures.

PURPOSE OF REVIEW: Sedation for pain medicine procedures provides a unique challenge for proceduralists. Many patients dealing with pain are on chronic opioids and require higher doses of sedation for adequate procedural comfort. Chronic pain patients have various comorbidities including depression, neuropsychiatric disorders, peripheral vascular disease, and renal impairment, among others [1]. These confounding variables make the overall treatment of their pain condition much more challenging. RECENT FINDINGS: For patients requiring intravenous (IV) sedation for their pain procedures, the constant need for access may render them a "difficult stick" over time. Another factor to consider is the increasing requirements by the hospital system needing IV sedatives and analgesics in the intensive care unit and operating rooms during the coronavirus (COVID-19) pandemic. Sublingual sufentanil (SST) provides an excellent analgesic option for patients undergoing interventional pain procedures. The use of SST allows hospitals to preserve IV agents for more critical areas and mitigates the difficulty of obtaining IV access in patients.

Outcomes of Anterior Cruciate Ligament Reconstruction in Obese and Overweight Patients: A Systematic Review.

OBJECTIVE: To evaluate the mechanism of injury, outcomes, and complications of anterior cruciate ligament (ACL) reconstruction in overweight and obese patients. DATA SOURCES: MEDLINE, EMBASE, and OVID electronic libraries were systematically searched from inception to December, 2017 for any eligible articles using a combination of the phrases "anterior cruciate ligament," "ACL," "overweight," "obese," and "BMI." RESULTS: Studies that evaluated patients with primary ACL reconstruction, classified patients as overweight or obese, and reported a minimum of 1-year follow-up data were included. Eight cohorts from 9 studies fulfilled the inclusion criteria. There were no significant differences for mechanism of injury, Lysholm scores, Knee injury and Osteoarthritis Outcome Scores values, or return to sports with a body mass index (BMI) above or below 25 kg/m. A significant difference was described in International Knee Documentation Committee (IKDC) scores when comparing obese patients (BMI >30 kg/m) to patients with BMI <25 kg/m (P <0.01). In patients with BMI >25 kg/m, the risk for arthritis was significantly higher but the risk for revision surgery or contralateral ACL tear was lower (P <0.05). There was no significant difference in complication rates (P = 0.77). CONCLUSION: Patient-reported outcome measures were similar for patients with BMI above and below 25 kg/m, but there is evidence that obese patients have lower IKDC scores. There is a consistent association between overweight status and developing arthritis among patients having an ACL reconstruction. Overweight and obese patients have a lower risk of revision ACL reconstruction and contralateral ACL tear. There is insufficient data to make any conclusions regarding mechanism of injury or complications. More research is needed to better understand what is the appropriate counsel and treatment for overweight or obese patients with ACL tears. PROSPERO REGISTRATION NUMBER: CRD42017055594.

Comparing psychological burden of orthopaedic diseases against medical conditions: Investigation on hospital course of hip, knee, and spine surgery patients.

Retrospective review of National Inpatient Sample (2000-2012) revealed that 31.28% of musculoskeletal (MSK) patients were found to have in-hospital psychological burdens (PBs). Adult spinal deformity (ASD), degenerative disc disease (DDD) and lung cancer patients had highest PB-prevalence. MSK patients with PB were more often young, white females with increased Deyo index compared to no-PB patients. Patients who underwent spinal revision procedures had higher PB rates than with primary procedures; a converse trend was observed for total hip/knee arthroplasty. Psychological disorders were identified as significant predictors of increased total-hospital charges. Augmenting counseling with psychological screening/support is recommended to complement MSK management.

The Impact of Comorbid Mental Health Disorders on Complications Following Cervical Spine Surgery With Minimum 2-Year Surveillance.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To improve understanding of the impact of comorbid mental health disorders (MHDs) on long-term outcomes following cervical spinal fusion in cervical radiculopathy (CR) or cervical myelopathy (CM) patients. SUMMARY OF BACKGROUND DATA: Subsets of patients with CR and CM have MHDs, and their impact on surgical complications is poorly understood. METHODS: Patients admitted from 2009 to 2013 with CR or CM diagnoses who underwent cervical surgery with minimum 2-year surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. Patients with a comorbid MHD were compared against those without (no-MHD). Univariate analysis compared demographics, complications, readmissions, and revisions between MHD and no-MHD cohorts. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: age, sex, Charlson/Deyo score, and surgical approach). RESULTS: A total of 20,342 patients (MHD: n = 4819; no-MHD: n = 15,523) were included. MHDs identified: depressive (57.8%), anxiety (28.1%), sleep (25.2%), and stress (2.9%). CR patients had greater prevalence of comorbid MHD than CM patients (P = 0.015). Two years postoperatively, all patients with MHD had significantly higher rates of complications (specifically: device-related, infection), readmission for any indication, and revision surgery (all P < 0.05); regression modeling corroborated these findings and revealed combined surgical approach as the strongest predictor for any complication (CR, odds ratio [OR]: 3.945, P < 0.001; CM, OR: 2.828, P < 0.001) and MHD as the strongest predictor for future revision (CR, OR: 1.269, P = 0.001; CM, OR: 1.248, P = 0.008) in both CR and CM cohorts. CONCLUSION: Nearly 25% of patients admitted for CR and CM carried comorbid MHD and experienced greater rates of any complication, readmission, or revision, at minimum, 2 years after cervical spine surgery. Results must be confirmed with retrospective studies utilizing larger national databases and with prospective cohort studies. Patient counseling and psychological screening/support are recommended to complement surgical treatment. LEVEL OF EVIDENCE: 3.

Novel Index to Quantify the Risk of Surgery in the Setting of Adult Spinal Deformity: A Study on 10,912 Patients From the Nationwide Inpatient Sample.

STUDY DESIGN: Retrospective review of the Nationwide Inpatient Sample from 2001 to 2010, a prospectively collected national database. OBJECTIVE: Structure an index to quantify adult spinal deformity (ASD) surgical risk based on risk factors for medical complications, surgical complications, revisions (R), mortality (M) rates, and length of hospital stay. SUMMARY OF BACKGROUND DATA: Evidence supporting ASD surgery cost-effectiveness and anticipating surgical risk is critical to evaluate the risk/benefit balance of such treatment for patients. MATERIALS AND METHODS: Discharges ages 25+, 4+ levels fused, diagnoses specific for scoliosis, and refusions. Five multivariate models determined independent risk factors that increased the risk of ≥1 for medical complications, surgical complications, R, M, and length of hospital stay. Models controlled for age, sex, race, revision status, surgical approach, levels fused, and osteotomy utilization. Odds ratios (ORs) were weighted using Nationwide Inpatient Sample weight files and based on their predictive category: 2 times for revision predictors and 4 times for mortality predictors. Predictors with OR≥1.5 were considered clinically relevant. Fifty points were distributed among the predictors based on their accumulative OR to establish a risk index. RESULTS: A total of 10,912 ASD discharges were identified (mean age: 62 y; 73% females; 14% revision cases). The structured risk index incorporated the following factors based on accumulative ORs: pulmonary circulation disorder (42.05), drug abuse (21.86), congestive heart failure (15.25), neurological disorder (17.31), alcohol abuse (13.24), renal failure (11.64), age>65 (12.28), coagulopathy (11.65), level +9 (6.7), revision (3.35), and osteotomy (3). These risk factors were scored: 14, 7, 5, 5, 4, 4, 4, 4, 2, 1, 1, respectively. Three risk thresholds were proposed: mild (0-10), moderate (10-20), severe >20/50 points. CONCLUSIONS: This study proposes an index to quantify the possible risk of morbidity before ASD surgery that will help patients, health insurance companies, and socioeconomic studies in assessing surgical risk/benefits. LEVEL OF EVIDENCE: Level III.