Adding Vertebral Bone Quality to the Fusion Risk Score: Does It Improve Predictions of Postoperative Complications?

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: The current study evaluates whether the addition of the Vertebral Bone Quality (VBQ) score to the Fusion Risk Score (FRS) improves its ability to predict perioperative outcomes. SUMMARY OF BACKGROUND DATA: The FRS was developed to assess preoperative risk in patients undergoing thoracic and lumbar fusions. It includes patient-derived and surgical variables, but it does not include one that directly accounts for bone health. The VBQ score allows assessment of bone quality and has been shown to correlate to DEXA-measured bone mineral density (BMD) scores. METHODS: The VBQ score was weighted based on a regression model and then added to the FRS (FRS/VBQ). The ability of the two scores to predict the outcomes was then assessed using the area under the curve (AUC). PATIENT SAMPLE: Patients undergoing elective thoracic and lumbar spinal fusion from January 2019 to June 2020 were included. OUTCOME MEASURES: The study evaluated various perioperative adverse outcomes, including major and minor adverse events, discharge other than home, extended length of stay, 90-day emergency department visits, 90-day readmission, and 90-day and 2-year reoperation rates. RESULTS: A total of 353 met the inclusion and exclusion criteria. The FRS/VBQ demonstrated improved predictive ability compared with the FRS alone when evaluating 90-day reoperation. Both scores showed fair predictive ability for any adverse event, major adverse events, minor adverse events, and 2-year reoperation rates, with AUCs ranging from 0.700 to 0.737. Both had poor predictive ability for the other outcomes. CONCLUSIONS: Adding VBQ to the FRS significantly enhances its predictive accuracy for reoperation rate. This updated risk score provides a more comprehensive understanding of a patient's preoperative risk profile, aiding both patients and physicians in assessing surgical risks and optimizing outcomes through preoperative risk stratification. LEVEL OF EVIDENCE: 3.

Pedicle Screw Placement Accuracy in Robot-Assisted Spinal Fusion in a Multicenter Study.

Pedicle screw fixation is a spinal fusion technique that involves the implantation of screws into vertebral pedicles to restrict movement between those vertebrae. The objective of this research is to measure pedicle screw placement accuracy using a novel automated measurement system that directly compares the implanted screw location to the planned target in all three anatomical views. Preoperative CT scans were used to plan the screw trajectories in 122 patients across four surgical centers. Postoperative scans were fused to the preoperative plan to quantify placement accuracy using an automated measurement algorithm. The mean medial-lateral and superior-inferior deviations in the pedicle region for 500 screws were 1.75 ± 1.36 mm and 1.52 ± 1.26 mm, respectively. These deviations were measured using an automated system and were statistically different from manually determined values. The uncertainty associated with the fusion of preoperative to postoperative images was also quantified to better understand the screw-to-plan accuracy results. This study uses a novel automated measurement system to quantify screw placement accuracy as it relates directly to the planned target location, instead of analyzing for breaches of the pedicle, to quantify the validity of using of a robotic-guidance system for accurate pedicle screw placement.

Choose Wisely: Surgical Selection of Candidates for Outpatient Anterior Cervical Surgery Based on Early Complications Among Inpatients.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are attractive targets for transition to the outpatient setting. We assessed the prevalence of rapid responses and major complications in the inpatient setting following 1 or 2-level ACDFs and CDAs. We evaluated factors that may place patients at greater risk for a rapid response or a postoperative complication. METHODS: This was an institutional review board-approved, retrospective cohort study of adults undergoing 1 or 2-level ACDF or CDA at 1 hospital over a 2-year period (2018 and 2019). Data on patient demographic characteristics, surgical procedures, and comorbidities were collected. Rapid response events were identified by hospital floor staff and involved acute changes in a patient's clinical condition. Complications were events that were life-threatening, required an intervention, or led to delayed hospital discharge. RESULTS: In this study, 1,040 patients were included: 888 underwent ACDF and 152 underwent CDA. Thirty-six patients (3.5%) experienced a rapid response event; 22% occurred >24 hours after extubation. Patients having a rapid response event had a significantly higher risk of developing a complication (risk ratio, 10; p < 0.01) and had a significantly longer hospital stay. Twenty-four patients (2.3%) experienced acute complications; 71% occurred >6 hours after extubation. Patients with a complication were older and more likely to be current or former smokers, have chronic obstructive pulmonary disease, have asthma, and have an American Society of Anesthesiologists (ASA) score of >2. The length of the surgical procedure was significantly longer in patients who developed a complication. All patients who developed dysphagia had a surgical procedure involving C4-C5 or more cephalad. Patients with a rapid response event or complication were more commonly undergoing revision surgical procedures. CONCLUSIONS: Rapid response and complications are uncommon following 1 or 2-level ACDFs or CDAs but portend a longer hospital stay and increased morbidity. Revision surgical procedures place patients at higher risk for rapid responses and complications. Additionally, older patients, patients with chronic obstructive pulmonary disease or asthma, patients who are current or former smokers, and patients who have an ASA score of ≥3 are at increased risk for postoperative complications. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Vacuum-Assisted Wound Closure Management for Posterior Lumbar Spine Infections.

A postoperative infection involving the tissues deep to the fascia is defined as a deep wound infection (DWI). Management of such infections after lumbar spinal surgery remains a challenge. One strategy is the use of vacuum-assisted wound closure (VAC) which applies negative pressure to the wound to improve microcirculation and to promote the formation of granulation tissue. When combined with antibiotics, VAC has been shown to successfully treat DWIs and is now a common strategy for treating deep postoperative wound infections after spinal surgery. In this article, we review the technique of VAC, its mechanism of action, indications and contraindications, and clinical outcomes in the treatment of DWIs after lumbar spinal surgery.

Ninety-day complication, revision, and readmission rates for current-generation robot-assisted thoracolumbar spinal fusion surgery: results of a multicenter case series.

OBJECTIVE: Robotics is a major area for research and development in spine surgery. The high accuracy of robot-assisted placement of thoracolumbar pedicle screws is documented in the literature. The authors present the largest case series to date evaluating 90-day complication, revision, and readmission rates for robot-assisted spine surgery using the current generation of robotic guidance systems. METHODS: An analysis of a retrospective, multicenter database of open and minimally invasive thoracolumbar instrumented fusion surgeries using the Mazor X or Mazor X Stealth Edition robotic guidance systems was performed. Patients 18 years of age or older and undergoing primary or revision surgery for degenerative spinal conditions were included. Descriptive statistics were used to calculate rates of malpositioned screws requiring revision, as well as overall complication, revision, and readmission rates within 90 days. RESULTS: In total, 799 surgical cases (Mazor X: 48.81%; Mazor X Stealth Edition: 51.19%) were evaluated, involving robot-assisted placement of 4838 pedicle screws. The overall intraoperative complication rate was 3.13%. No intraoperative implant-related complications were encountered. Postoperatively, 129 patients suffered a total of 146 complications by 90 days, representing an incidence of 16.1%. The rate of an unrecognized malpositioned screw resulting in a new postoperative radiculopathy requiring revision surgery was 0.63% (5 cases). Medical and pain-related complications unrelated to hardware placement accounted for the bulk of postoperative complications within 90 days. The overall surgical revision rate at 90 days was 6.63% with 7 implant-related revisions, representing an implant-related revision rate of 0.88%. The 90-day readmission rate was 7.13% with 2 implant-related readmissions, representing an implant-related readmission rate of 0.25% of cases. CONCLUSIONS: The results of this multicenter case series and literature review suggest current-generation robotic guidance systems are associated with low rates of intraoperative and postoperative implant-related complications, revisions, and readmissions at 90 days. Future outcomes-based studies are necessary to evaluate complication, revision, and readmission rates compared to conventional surgery.

Minimally Invasive Percutaneous Fasciotomy in Lumbar Paraspinal Compartment Syndrome: A Case Report and Review of Literature.

CASE: Lumbar paraspinal compartment syndrome (LPCS) is a rare but potentially catastrophic pathology caused by increased intracompartmental pressures leading to potential ischemic necrosis of muscle, local denervation, and complications of rhabdomyolysis. A combination of unique clinical history and examination findings, laboratory findings, and radiologic imaging help in diagnosis. CONCLUSION: Early detection and intervention with minimally invasive percutaneous fasciotomy can minimize local soft tissue trauma while providing extensive fascial release with good clinical outcomes. Radiographic follow-up in this case suggests that the muscle at risk in LPCS can be spared with early surgical intervention.

Complications with Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis in the Obese Population.

STUDY DESIGN: A level-3 retrospective cohort analysis. OBJECTIVE: The aim of this study was to describe obesity's effect on complications and outcomes in degenerative spondylolisthesis patients treated by minimally invasive transforaminal lumbar interbody fusion (MI TLIF). SUMMARY OF BACKGROUND DATA: Obesity is associated with a greater complication rate among lumbar spine surgery patients. Poor clinical outcomes might likewise be supposed, but the association is not well established. Minimally invasive techniques have been developed to reduce complications and improve clinical outcomes in comparison to traditional open techniques. METHODS: We reviewed 134 consecutive patients with degenerative spondylolisthesis undergoing MI TLIF. Subjects were grouped into nonobese (N = 65) and obese (N = 69) cohorts. The obese group was further subdivided by BMI. Patient demographics, perioperative complications, and outcome scores were collected over a minimum of 24 months. Four periods (intraoperative, postoperative hospitalization, 6-month, and 24-month postoperative) were assessed. RESULTS: Cohort demographics were not significantly different, but it was noted that obese patients had more major comorbidities than nonobese patients. There was no difference in intraoperative complications between the two groups. The in-hospital complication rate was significantly greater in the obese group. The 6-month postoperative complication rate was not different between cohorts. Wound drainage was most common and noted only in the obese cohort. Complications at 24 months were not different but did trend toward significance in the obese for recurrence of symptoms and total complications. Functional outcome was better among nonobese subjects compared with obese subjects at every interval (significant at 6 and 12 months). Back pain scores were significantly better among nonobese subjects than obese subjects at 24 months, but Leg Pain scores were not different. CONCLUSIONS: MI TLIF can be safely performed in the obese population despite a higher in-hospital complication rate. Knowledge of common complications will help the treatment team appropriately manage obese patients with degenerative spondylolisthesis. LEVEL OF EVIDENCE: 3.

Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Outpatient Setting.

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has been shown to have long-term clinical outcomes similar to those with open TLIF and decreased perioperative morbidity. This study assessed whether this procedure can be safely performed in outpatient settings. Ninety-six consecutive patients undergoing 1- or 2-level MIS-TLIFs were retrospectively reviewed. They were divided into inpatient and outpatient cohorts (36%). All had a minimum of 2 years of follow-up. Patient demographics, comorbidities, complications, and readmissions were examined. Early postoperative complications were stratified into wound related, infection, neurologic, implant related, and vascular injuries. Patients in the outpatient cohort were significantly younger, had lower American Society of Anesthesiologists physical status scores, and had lower Charlson Comorbidity Index scores than patients in the inpatient cohort. There were no statistically significant differences in overall postoperative complication rates, readmission rates, or final Oswestry Disability Index or visual analog scale scores between the 2 cohorts. The clinical outcomes of the outpatient TLIF procedure were similar to those of the inpatient procedure and it had an acceptable complication rate. [Orthopedics. 2016; 39(6):e1218-e1222.].

Comparison of Instrumented and Noninstrumented Surgical Treatment of Severe Vertebral Osteomyelitis.

The purpose of this study was to compare the outcomes of instrumented versus noninstrumented (decompression) surgical treatment of vertebral osteomyelitis. The study population included 104 patients with spinal osteomyelitis who were treated at the authors' institution between 2004 and 2012. This included 62 men and 42 women who underwent either instrumented (n=57) or noninstrumented (n=47) surgery. Mean patient age was 59 years, and mean follow-up was 38 months (range, 12-78 months). Specifically, the following criteria were assessed: mortality rates, infection clearance rates, clinical outcomes measured by Oswestry Disability Index (ODI), mean length of stay, and baseline differences between the 2 cohorts. Although patients in the instrumented cohort had more instability, more neurologic symptoms, and larger volume infection, they had similar clearance of infection (54% vs 42.5%; odds ratio [OR], 1.55; 95% confidence interval [CI], 0.61-3.9; P=.35), mortality rate (9% vs 17%; OR, 0.47; 95% CI, 0.14-1.54; P=.21), and ODI scores (40 vs 45 points; P=.32) compared with patients in the noninstrumented group. However, mean length of stay (19 vs 13 days; P=.02) was significantly higher for patients in the instrumented group. Even in more severe cases of vertebral osteomyelitis, instrumentation resulted in comparable outcomes to decompression. [Orthopedics. 2016; 39(3):e504-e508.].

The role of magnetic resonance imaging in acute cervical spine fractures.

BACKGROUND CONTEXT: The role of magnetic resonance imaging (MRI) in neurologically intact cervical spine fractures is not well defined. To our knowledge, there are no studies that clearly identify the indications for MRI in this particular scenario. Controversy remains regarding the use of MRI in at-risk patients, primarily the obtunded and elderly patients. PURPOSE: The purpose of the present study was to examine the predisposing conditions where an MRI would provide additional findings that would affect management in acute cervical spine fractures. STUDY DESIGN: Retrospective cohort involving radiographic and clinical review. PATIENT SAMPLE: Consecutive patients with acute cervical injuries at a single institution. OUTCOME MEASURES: Neurologic recovery. METHODS: A review of 830 patients with cervical spinal injuries between 2006 and 2010 was performed. Clinical information was obtained for all the patients: Glasgow Coma Scale, mechanism of injury, major medical comorbidities, associated injuries, neurologic examination, neurologic symptoms, sex, age, and alertness. Two experienced fellowship-trained spine surgeons determined if the MRI study changed the management in the individual cases based on the Sub-axial Cervical Spine Injury classification system. RESULTS: Ninety-nine patients with a cervical fracture were included in the final analysis: median age 54 years (interquartile range, 42 years), mean Glasgow Coma Scale 13 (standard deviation ± 3.0), 68% males, 32% females, 42% older patients (age>60 years), 30% spondylosis, 27% polytrauma, 67% alert, 28% neurologic deficit. Major medical comorbidities, prior to injury level of activity, atlantoaxial versus subaxial, and gender were not associated with changes in diagnosis and management (p>.05). Age >60 years, neurologic deficit, polytrauma status, alertness, and spondylosis were associated with having additional clinically relevant findings seen on MRI and changes in management (p<.05). The majority of the changes in management were related to MRI's illustration of the spinal cord injury and not due to an occult instability. Eighty-one percent of the changes in management were related to the depiction of the spinal cord compression seen on MRI, whereas 19% of the changes in management were related to occult instability seen on MRI. CONCLUSIONS: Older age (>60 years), obtunded or temporary non-assessable status, cervical spondylosis, polytrauma, and neurologic deficit are predisposing factors for further injury found on MRI but missed on computed tomographic scan alone. These additional findings can affect the management in acute cervical spine fractures. The rational of the on-call spine surgeon to order an MRI for a cervical spine fracture is well founded and often that MRI will affect the fracture management. Magnetic resonance imaging particularly helps with better defining the type of spinal cord compression. Picking up occult instability missed on computed tomographic scan was possible with MRI but not as common.

Inheritable risk factors for venous thromboembolism in patients undergoing lower extremity total joint arthroplasty.

Venous thromboembolism is a common and undesirable complication of both total hip and knee arthroplasty. The basic biology and major modifiable risk factors predisposing to thromboembolism are well established, but a complete understanding of the role and management of inherited coagulopathies is lacking. In this manuscript, we have attempted to review the fundamental pathophysiology of the coagulation cascade, analyze recent literature on heritable coagulopathies leading to venous thromboembolism in patients undergoing lower extremity joint arthroplasty, and discuss how an understanding of such factors may affect clinical practice. We advocate that a sound understanding of inherited coagulopathies, as they relate to hip and knee arthroplasty, may help to aid decision making regarding prophylaxis which may eventually lead to an established algorithm system for screening and managing patients at high risk for adverse thromboembolic events.