Thirty-day readmissions following adult spinal deformity surgery: an analysis of the National Surgical Quality Improvement Program (NSQIP) database.

BACKGROUND: Adult spine deformity surgery (ASDS) is a significantly invasive procedure with a relatively high complication rate. The thirty-day hospital readmission rate following surgery is an important quality measure monitored by multiple quality reporting agencies. PURPOSE: This study seeks to determine the risk factors for 30- day readmission rate in patients undergoing ASDS and identify the risk factors associated with readmission. STUDY DESIGN: This is a retrospective multicenter study. METHODS: The National Surgical Quality Improvement Program database, which is a large multi-institutional database, was searched for patients that underwent ASDS from 2011 to 2013. The patients were identified by searching seven Current Procedural Terminology codes most commonly used for spinal deformity surgery. Twenty-seven preoperative variables, including patient demographics and comorbidities, intraoperative parameters, and postoperative complications were analyzed to identify risk factors for readmission. RESULTS: A total of 747 adult patients who underwent ASDS were identified. Of the 747 patients, 7.5% (56/747) were readmitted within 30 days. The most common causes of readmission were infection (n=11), hematoma or seroma formation (n=5), and postoperative pain (n=3). Univariate analysis revealed male gender (p=.038, odds ratio [OR]=1.83) and pulmonary embolism before discharge (p=.048, OR=8.44) to be associated with readmission. In multivariate analysis, obesity (p=.047, OR=1.80), peripheral vascular disease (p=.045, OR=17.52), pulmonary embolism before discharge (p=.012, OR=10.35), and total or partial dependent preoperative functional health status (p=.041, OR=2.45), were found to be independent risk factors for readmission. Age, smoking, and resident involvement during surgical procedure were among the many factors not associated with increased risk of readmission. CONCLUSIONS: The 30-day readmission rate for ASDS is increasingly becoming a significant health-care quality indicator. Patients with the aforementioned significant risk factors should be closely followed up, which can potentially avoid subsequent readmission.

Metastatic spinal cord compression as a result of the unknown primary tumour.

PURPOSE: Patients presenting with metastatic spinal cord compression (MSCC) due to an unknown primary tumour (UPT) present an interesting problem with limited literature available to provide guidance on management. Our aim was twofold-first, to analyse all our patients with MSCC due to a UPT pre-operatively, to review their treatment and outcome; second, make comparisons with those patients who presented with MSCC due to a known primary tumour (KPT) during the same period. METHODS: All data was collected retrospectively from October 2004 to October 2009, then prospectively from October 2009 to October 2012 (8 years). We reviewed all patient records held on the database, including patient demographics, primary tumour, neurological outcome (Frankel grade), complications and survival. RESULTS: During the 8-year study period, out of the 382 patients who underwent emergency surgery for MSCC, 285 patients were included in whom complete information was available. Of these, 17 patients presented with MSCC due to a UPT (6 %; mean age 61 years, 5 M, 12 F). When compared to those with a known primary, the UPT group trended to a longer duration of symptoms prior to surgery (200 vs. 156 days, p = 0.86). They had a similar neurological outcome (88 % remained the same or improved post-operatively vs. 90 % in KPT group; p = 0.42), similar complication rate (23.5 vs. 33.6 %; p = 0.32) and survival (222 vs. 251 days, p = 0.42). The primary site in the UPT group was confirmed in 10/17 (58.8 %)-all 10 were adenocarcinoma [lung (6) and GI (4)]. DISCUSSION: In our series, the incidence of MSCC due to an unknown primary was 6 %. They had similar overall outcome (neurology post-operatively, complications and survival) to those patients with MSCC from a known primary. Our experience would suggest that we need to treat these patients expeditiously with thorough evaluation and urgent treatment.

A large tuberculosis abscess causing spinal cord compression of the cervico-thoracic region in a young child.

INTRODUCTION: Despite numerous descriptive publications, the guidelines for treatment of cervical spinal tuberculosis (TB) are not very clear. The authors report a case of a young girl with cervico-thoracic spinal TB extending from C5 to T3 vertebrae presenting with weakness of the right hand and unsteady gait. CASE REPORT: An 11-year-old female who is an immigrant to the UK from Afghanistan, presented to our clinic with a 10-day history of difficulty in walking with an unsteady gait and 3-month history of progressive weakness in both her arms, the right side more affected than the left. Her immunisation history was unclear. Examination of the arms showed bilateral thenar and hypothenar wasting, more so on the right than the left. An MRI scan revealed a large para-spinal abscess extending from C3/4 to T4/5 with a significant anterior epidural cord compression from C5/6 to T2/3. Therapeutic/diagnostic aspiration was performed under ultrasound guidance and the aspirate was sent for microbiology. She was started empirically on multidrug anti-tubercular treatment and steroids. Although Ziehl-Neelsen stain was negative for acid-fast bacilli, microbiological confirmation of TB was obtained by positive TB culture sensitive to all first-line anti-TB drugs. She made a dramatic improvement within 3 weeks of anti-tubercular treatment. A follow-up MRI scan at 8 months showed complete resolution of the abscess. At 2 years of follow-up, she was a healthy looking child, back to her school with no residual clinical signs/symptoms of the disease. CONCLUSION: Our case of cervico-thoracic tuberculous abscess in a young child suggests that even with incomplete neurological deficit caused by epidural cord compression, ultrasound (or CT)-guided aspiration and anti-tubercular medication provide acceptable results at 2 years of follow-up.

Outcome of embolised vascular metastatic renal cell tumours causing spinal cord compression.

PURPOSE: To present the results of the surgical management of metastatic renal cell tumours of the spine with cord compression who underwent pre-operative embolisation. METHODS: We conducted a retrospective cohort study of all embolised vascular metastatic renal cell tumours of the spine that underwent urgent surgical intervention over a 7-year period (2005-2011). All medical notes, images and angiography/embolisation details were studied. We recorded the timing (immediate vs. delayed) and grade of embolisation and compared this to the estimated blood loss (EBL); extent of metastatic spinal cord compression (using the Tomita score and Bilsky scores) was also compared to EBL. Finally, neurological (Frankel grade), surgical outcome and complications were reviewed in all patients. RESULTS: During the study period, we operated on 25 emergency patients with metastatic renal cell carcinoma causing spinal cord compression who had received pre-operative embolisation (mean age 59.6 (24-78) years; 8 females, 17 males). All but one of our patients had hypervascularisation/arterio-venous fistulae on angiography. We were able to achieve greater than 90 % embolisation in the majority (17/25, 68 %) The estimated blood loss was 1,696 (400-5,000) ml; mean operating time was 276 (90-690) min and an average of 2.3 (0-7) units of whole blood was transfused. Nine patients had a posterior only decompression/stabilisation, nine patients had a posterior decompression ± cement augmentation, six had combined anterior/posterior procedures and one had anterior corpectomy/reconstruction alone. There was no statistical difference in the EBL between immediate versus delayed surgery after embolisation or the grade of embolisation. Immediate surgery after embolisation and interestingly less complete embolisation showed a trend towards less EBL. The extent of the tumour as graded by the Bilsky score correlated with increased EBL (p = 0.042). No complications occurred during the embolisation procedure. The surgical complication rate was 32 % (8/25) including two major complications (septicaemia (1) and metal work failure (2)) and five minor complications. Postoperatively, 52 % (13/25) had no change in neurological status, 36 % (9/25) improved by at least one Frankel grade and 12 % (3/25) had neurological deterioration by one Frankel grade. The average survival following surgery was 14.1 (0.5-72) months. CONCLUSION: Blood loss (mean 1,696 ml) and complications (32 %) remain a concern in the operative treatment of vascular metastatic spinal cord compression. Most patients remained the same neurologically or improved by at least 1 grade (22/25, 88 %). Paradoxically, greater embolisation showed a trend to more blood loss which could be due to more extensive surgery in this group, a rebound 'reperfusion' phenomena or even the presence of arterio-venous fistulae. Interestingly, we also found that the extent of the tumour, as graded by the Bilsky score, correlated with increased blood loss suggesting that more extensive cord compression by metastases could lead to more blood loss intra-operatively.

Accuracy of the revised Tokuhashi score in predicting survival in patients with metastatic spinal cord compression (MSCC).

PURPOSE: The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our aim was to analyse the actual survival time of patients treated for metastatic spinal cord compression (MSCC) in comparison with the predicted survival based on the revised Tokuhashi score. This would thereby allow us to determine the overall predictive value of this scoring system. METHODS: This study was a semi-prospective clinical study of all patients with MSCC presenting to our unit over 8 years-data from October 2003 to December 2009 were collected retrospectively and from December 2009, all data collected prospectively to October 2011. Patients were divided into three groups--Group 1 (Tokuhashi score 0-8, n = 84), Group 2 (Tokuhashi score 9-11, n = 83) and Group 3 (Tokuhashi score 12-15, n = 34). Data collected included demographic data, primary tumour histology, surgery type and complications, neurological outcome (Frankel grade) and survival. RESULTS: A total of 233 patients with MSCC were managed surgically in our unit during this time. Out of these complete data were available on 201 patients for analysis. Mean age of patients was 61 years (range 18-86; 127 M, 74 F). The primary tumour type was Breast (n = 29, 15 %), Haematological (n = 28, 14 %), Renal (n = 26, 13 %), Prostate (n = 26, 13 %), Lung (n = 23, 11 %), Gastro-intestinal (n = 11, 5 %), Sarcoma (n = 9, 4 %) and others (n = 49, 24 %). All patients included in the study had surgical intervention in the form of decompression and stabilisation. Posterior decompression and stabilisation was performed in 171 patients (with vertebrectomy in 31), combined anterior and posterior approaches were used in 18 patients and 12 had an anterior approach only. The overall complication rate was 19 % (39/201)--the most common being wound infection (n = 15, 8 %). There was no difference in the neurological outcome (Frankel grade) between Groups 1 and 2 (p = 0.34) or Groups 2 and 3 (p = 0.70). However, there was a significant difference between Groups 1 and 3 (p = 0.001), with Group 3 having a significantly better neurological outcome. Median survival was 93 days in Group 1, 229 days in Group 2 and 875 days in Group 3 (p = 0.001). The predictive value between the actual and predicted survival was 64 % (Group 1), 64 % (Group 2) and 69 % (Group 3). The overall predictive value of the revised Tokuhashi score using Cox regression for all groups was 66 %. CONCLUSION: We would conclude that although the predictive value of the Tokuhashi score in terms of survival time is at best modest (66 %), the fact that there were statistically significant differences in survival between the groups looked at in this paper indicates that the scoring system, and the components which it consists of, are important in the evaluation of these patients when considering surgery.

Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression.

PURPOSE: Metastatic spinal cord compression (MSCC) requires expeditious treatment. While there is no ambiguity in the literature about the urgency of care for patients with MSCC, the effect of timing of surgical intervention has not been investigated in detail. The objective of our study was to investigate whether or not the 'timing of surgery' is an important factor in survival and neurological outcome in patients with MSCC. METHODS: All patients with MSCC presenting to our unit from October 2005 to March 2010 were included in this study. Patients were divided into three groups-those who underwent surgery within 24 h (Group 1, n = 45), between 24 and 48 h (Group 2, n = 23) and after 48 h (Group 3, n = 53) from acute presentation of neurological symptoms. The outcome measures studied were neurological outcome (change in Frankel grade post-operatively), survival (survival rate and median survival in days), incidence of infection, length of stay and complications. RESULTS: Patients' age, gender, revised Tokuhashi score, level of spinal metastasis and primary tumour type were not significantly different between the three groups. Greatest improvement in neurology was observed in Group 1, although not significantly when compared against Group 2 (24-48 h; (p = 0.09). When comparisons of neurological outcome were performed for all patients having surgery within 48 h (Groups 1 and 2) versus after 48 h (Group 3), the Frankel grade improvement was significant (p = 0.048) favouring surgery within 48 h of presentation. There was a negative correlation (-0.17) between the delay in surgery and the immediate neurological improvement, suggesting less improvement in those who had delayed surgery. There was no difference in length of hospital stay, incidence of infection, post-operative complications or survival between the groups. CONCLUSIONS: Our results show that surgery should be performed sooner rather than later. Furthermore, earlier surgical treatment within 48 h in patients with MSCC resulted in significantly better neurological outcome. However, the timing of surgery did not influence length of hospital stay, complication rate or patient survival.

Surgical treatment of cauda equina compression as a result of metastatic tumours of the lumbo-sacral junction and sacrum.

PURPOSE: We performed a retrospective analysis of all cases of lumbo-sacral or sacral metastases presenting with compression of the cauda equina who underwent urgent surgery at our institution. Our objective was to report our experience on the clinical presentation, management and finally the surgical outcome of this cohort of patients. METHODS: We reviewed medical notes and images of all patients with compression of the cauda equina as a result of lumbo-sacral or sacral metastases during the study period (2004-2011). The collected clinical data consisted of time of onset of symptoms, neurology (Frankel grade), ambulatory status and continence. Operative data analysed were details of surgical procedure and complications. Post-operatively, we reviewed neurological outcome, ambulation, continence, destination of discharge and survival. RESULTS: During the 8-year study period, 20 patients [11 males, 9 females; mean age 61.8 years (29-87)] had received urgent surgery for metastatic spinal cauda compression caused by lumbo-sacral or sacral metastases. The majority of patients presented with symptoms of pain and neurological deterioration (n = 14) with onset of pain considerably longer than neurology symptoms [197 days (3-1,825) vs. 46 days (1-540)]; all patients were Frankel C (n = 2, both non-ambulatory), D (n = 13) or E (n = 5) at presentation and three patients were incontinent of urine. Operative procedures performed were posterior decompression with (out) fusion (n = 12), posterior decompression with sacroplasty (n = 1), decompression with lumbo-pelvic stabilisation with (out) kyphoplasty/sacroplasty (n = 7) and posterior decompression/reconstruction with anterior corpectomy/stabilisation (n = 2). Post-operatively, 5/20 (20 %) patients improved one Frankel grade, 1/20 (5 %) improved two grades, 13/20 (65 %) remained stable (8 D, 5 E) and 1/20 (5 %) deteriorated. All patients were ambulatory and 19/20 were continent on discharge. The mean length of stay was 7 days (4-22). There were 6/20 (30 %) complications: three major (PE, deep wound infection, implant failure) and three minor (superficial wound infection, incidental durotomy, chest infection). All patients returned back to their own home (n = 14/20, 70 %) or a nursing home (n = 6/20, 35 %). Thirteen patients are deceased (mean survival 367 days (120-603) and seven are still alive [mean survival 719 days (160-1,719)]. CONCLUSION: Surgical intervention for MSCC involving the lumbo-sacral junction or sacral spine has a high but acceptable complication rate (6/20, 30 %), and can be important in restoring/preserving neurological function, assisting with ambulatory function and allowing patients to return to their previous residence.

Modified step-cut osteotomy for post-traumatic cubitus varus: our experience with 14 children.

BACKGROUND: Lateral closing wedge osteotomy is a commonly described procedure for correcting cosmetically unacceptable post-traumatic cubitus varus deformity in children. However, complications like residual deformity, lateral prominence, loss of fixation and ulnar nerve palsies commonly contribute to poor outcomes with such an osteotomy. PATIENTS AND METHODS: Fourteen children (11 boys and three girls) presenting a mal-united extension type supracondylar fracture of the humerus with an average age of 9.07 years (6-14 years) were operated around 3.6 years (1.5-7 years) after the injury using a modified step-cut osteotomy. The average follow-up period was 2.1 years (1-4 years). Objective assessment included measurement of preoperative and postoperative lateral prominence index, carrying angle and range of elbow motion. Results were graded excellent, good or poor as per the Oppenheim criteria. RESULTS: There were eight excellent, five good and one poor result. A residual varus of more than 10° was seen in the single patient with poor result. None of the patients showed a prominent lateral humeral condyle or formation of hypertrophic scar. Our results were comparable to the published results of the classical lateral closing wedge osteotomy in terms of elbow motion and correction of deformity. CONCLUSION: A modified step-cut osteotomy is a safe and simple procedure which prevents lateral prominence and leads to good or excellent outcomes in most of the patients. The step-cut osteotomy procedure, mentioned here, might be beneficial over the conventional lateral closing wedge osteotomy in certain aspects like the lateral humeral condyle prominence, scar acceptibility and cosmesis. However, the apparent aforementioned advantages of this osteotomy over the conventional lateral closing wedge osteotomy needs to be further evaluated and confirmed on the basis of large, prospective randomised controlled trials.