Revisiting Anticoagulation in Spine Surgery: Balancing Venous Thromboembolic Events and Epidural Hematoma.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Venous thromboembolic events (VTE) and post-operative epidural hematoma (EDH) are significant complications after spine surgery. Guidelines for chemoprophylaxis are controversial and variability amongst surgeons remains. The objective of this study was to establish the incidence of clinical VTE and EDH at our institution and evaluate the association of chemoprophylaxis with clinical VTE and EDH. METHODS: We conducted a retrospective cohort study of patients undergoing spine surgery at a high-volume tertiary care center in Seattle, WA between January 2016 and December 2019. The Premier Health Care Database and Agency for Healthcare Research and Quality (AHRQ) patient indicators PSI-9 (Perioperative hemorrhage and hematoma) and PSI-12(Perioperative PE or DVT) were used to identify patients experiencing VTE and/or post-operative EDH. The primary outcome was the incidence of clinical VTE and EDH in post-operative spine patients. Secondary outcomes included the association of chemoprophylaxis with clinical VTE and EDH. RESULTS: From 2016 to 2019, 4587 patients underwent spine surgery, totaling 4764 hospital stays. The incidence of clinical VTE was .21% (10/4764) and the incidence of EDH was .10% (5/4764). Most hemorrhages occurred prior to the initiation of chemoprophylaxis. One patient with EDH received chemoprophylaxis prior to hemorrhage. CONCLUSIONS: The rate of post-operative clinical VTE and EDH in spine surgery is low. Despite early initiation of chemoprophylaxis after major spine surgery we did not appreciate a high rate of EDH. We attribute our low rate of clinical VTE to multimodal prophylaxis with SCDs, early mobilization and chemoprophylaxis on post-operative day 1.

Rates of early complications and mortality in patients older than 80 years of age after surgical treatment of acute traumatic spinal fractures: ankylosing spondylitis versus osteoporosis.

OBJECTIVE: The purpose of this retrospective cohort study was to analyze the early complications and mortality associated with multilevel spine surgery for unstable fractures in patients older than 80 years of age with ankylosing spondylitis and to compare the results with an age- and sex-matched cohort of patients with unstable osteoporotic fractures. METHODS: A retrospective review of the electronic medical records at a single institution was conducted between January 2014 and December 2019. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were stratified using the age-adjusted Charlson Comorbidity Index (CCI). RESULTS: Among 11,361 surgically treated patients, 22 patients with ankylosing spondylitis (AS group) and 24 patients with osteoporosis (OS group) were identified. The mean ages were 83.1 ± 3.1 years and 83.2 ± 2.6 years, respectively. A significant difference in the mean CCI score was found (7.6 vs 5.6; p < 0.001). Multilevel posterior fusion procedures were conducted in all patients, with 6.7 ± 1.4 fused levels in the AS group and 7.1 ± 1.1 levels fused in the OS group (p > 0.05). Major complications developed in 10 patients (45%) in the AS group compared with 4 patients (17%) in the OS group (p < 0.05). The 90-day mortality was 36% in the AS group compared with 0% in the OS group (p < 0.001). CONCLUSIONS: Patients older than 80 years of age with AS bear a high risk of adverse events after multilevel spinal fusion procedures. The high morbidity and 90-day mortality should be clearly discussed and carefully weighed against surgical treatment.

Surgical Management of Charcot Spinal Arthropathy in the Face of Possible Infection.

BACKGROUND: The design is a retrospective cohort study. Charcot spinal arthropathy (CSA) is a rare and poorly understood progressive destructive spine condition that usually affects patients with preexisting spinal cord injury. The complexity of this condition, especially when additionally burdened by superimposed infection in the CSA zone, can potentially lead to suboptimal management such as protracted antibiotic therapy, predisposition to hardware failure, and pseudarthrosis. While in noninfected CSA primary stabilization is the major goal, staged surgical management has not been stratified based upon presence of a superinfected CSA. We compare clinical and radiological outcomes of surgical treatment in CSA patients with and without concurrent spinal infections. METHODS: Our single-institution database was reviewed for all patients diagnosed with CSA and surgically treated, who were subsequently divided into 2 cohorts: spinal arthropathy with superimposed infection and those without. Those were comparatively studied for complications and reoperation rate. RESULTS: Fifteen patients with CSA underwent surgical intervention; mean follow up of 15.3 months (range, 0-43). Eleven patients received stabilization with a quadruple-rod thoracolumbopelvic construct, while 4 patients with superinfected CSA underwent a staged procedure. Patients treated with a staged approach experienced fewer intraoperative complications (0% versus 18%) and fewer revision surgeries (25% versus 36%). Both cohorts had the same eventual healing. CONCLUSIONS: Surgical management in CSA patients with primary emphasis on stability and modified surgical treatment based on presence of an active infection in the zone of neuropathic destruction will lead to similar eventual successful results with relatively few and manageable complications in this challenging patient population. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: The proposed treatment algorithm including the use of a quadruple-rod construct with lumbopelivic fixation and a staged approach in patients with superinfected CSA represents a reasonable option in the surgical treatment of CSA.