Risk Factors for Nonroutine Discharge in Patients Undergoing Spinal Fusion for Intervertebral Disc Disorders.

BACKGROUND: Although outcomes following spinal fusion for intervertebral disc disorders have been studied, factors influencing discharge disposition and health care resource utilization have not been determined. This study sought to clarify perioperative risk factors for non-routine discharge and prolonged hospital stay in patients undergoing fusion for intervertebral disc disorders. METHODS: The National Hospital Discharge Survey was queried to identify all patients discharged from U.S. hospitals following spinal fusion for intervertebral disc disorders between 1990 and 2007. A cohort representative of 1,943,707 patients was identified and separated into those who were discharged home and those who were discharged to rehabilitation facilities. Multivariable logistic regression analysis was used to identify independent predictors of non-routine discharge to another inpatient facility and prolonged hospital stay. RESULTS: The strongest risk factors for non-routine discharge were age>65 years, congestive heart failure, atrial fibrillation, any general in-hospital complication, diabetes mellitus, osteoporosis, hypertension and any surgery-related complication. Patients younger than 50 years and males had the lowest rate of non-routine discharge. The strongest risk factors for prolonged hospital stay were any surgery-related complication, congestive heart failure, any general in-hospital complication, atrial fibrillation, age > 65 years, osteoporosis and diabetes mellitus. Patients 36-50 years of age had the lowest risk of increased length of hospital stay. CONCLUSIONS: Knowledge of these risk factors may aid in better resource allocation and improved strategies for managing patients with spondylosis in order to decrease healthcare costs. LEVEL OF EVIDENCE: 3.

Outpatient anterior cervical discectomy and fusion for cervical disk disease: a prospective consecutive series of 96 patients.

OBJECTIVES: To evaluate surgical complications and clinical outcome in a consecutive series of 96 patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical disk degeneration (CDD) in an outpatient setting. METHODS: Pre-, per-, and postoperative data on patients undergoing single- or two-level outpatient ACDF at the private Oslofjord Clinic were prospectively collected. RESULTS: This study includes 96 consecutive patients with a mean age of 49.1 years. 36/96 had a two-level ACDF. Mean postoperative observation time before discharge was 350 min, and 95/96 were successfully discharged either to their home or to a hotel on the day of surgery. The surgical mortality was 0%, while the surgical morbidity rate was 5.2%. Two (2.1%) patients developed postoperative hematoma, 2 (2.1%) patients experienced postoperative dysphagia, and 1 (1%) experienced deterioration of neurological function. Radicular pain, neck pain, and headache decreased significantly after surgery. 91% of patients were satisfied with the surgery, according to the NASSQ. CONCLUSION: ACDF in carefully selected patients with CDD appears to be safe in the outpatient setting, provided a sufficient postoperative observation period. The clinical outcome and patient satisfaction of outpatients are comparable to that of inpatients.

Uncovertebral hypertrophy is a significant risk factor for the occurrence of heterotopic ossification after cervical disc replacement: survivorship analysis of Bryan disc for single-level cervical arthroplasty.

OBJECTIVES: The purpose of this study is to investigate the incidence of heterotopic ossification (HO) in the Bryan cervical arthroplasty group and to identify associations between preoperative factors and the development of HO. METHODS: We performed a retrospective review of clinical and radiological data on patients who underwent single-level cervical arthroplasty with Bryan prosthesis between January 2005 and September 2007. Patients were postoperatively followed-up at 1, 3, 6, 12 months and every year thereafter. The clinical assessment was conducted using Odom's criteria. The presence of HO was evaluated on the basis of X-ray at each time-point according to the McAfee classification. In this study, we focused on survivorship of Bryan prosthesis for single-level arthroplasty. The occurrence of ROM-affecting HO was defined as a functional failure and was used as an endpoint for determining survivorship. RESULTS: Through the analysis of 19 cases of Bryan disc arthroplasty for cervical radiculopathy and/or myelopathy, we revealed that ROM-affecting HO occurs in as many as 36.8% of cases and found that 37% of patients had ROM-affecting HO within 24 months following surgery. The overall survival time to the occurrence of ROM-affecting HO was 36.4 ± 4.4 months. Survival time of the prosthesis in the patient group without preoperative uncovertebral hypertrophy was significantly longer than that in the patient group with preoperative uncovertebral hypertrophy (47.2 months vs 25.5 months, p = 0.02). Cox regression proportional hazard analysis illustrated that preoperative uncovertebral hypertrophy was determined as a significant risk factor for the occurrence of ROM-affecting HO (hazard ratio = 12.30; 95% confidential interval = 1.10-137.03; p = 0.04). CONCLUSION: These findings suggest that the condition of the uncovertebral joint must be evaluated in preoperative planning for Bryan cervical arthroplasty.

Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To assess the effectiveness of interventions for treating cervical disc herniation. SUMMARY OF BACKGROUND DATA: Cervical disc herniation is 1 of the 23 specific disorders included in the CANS (Complaints of the Arm, Neck, and/or Shoulder) model. Treatment options range from conservative to surgical, but evidence for the effectiveness of these interventions is not yet well documented. METHODS: The Cochrane Library, MEDLINE, EMBASE, PEDro, and CINAHL were searched for relevant systematic reviews and randomized clinical trials (RCTs) up to February 2009. Two reviewers independently selected relevant studies, assessed the methodological quality, and extracted data. RESULTS: Pooling of the data was not possible; thus, a best-evidence synthesis was used to summarize the results. Of the 11 RCTs included, 1 compared conservative with surgical intervention, and 10 compared various surgical interventions. No evidence was found for the effectiveness of conservative treatment (nonsteroidal anti-inflammatory drugs, cortisonics, and physical therapy) compared with percutaneous nucleoplasty. Moderate evidence was found for the effectiveness of anterior cervical discectomy with fusion (ACDF) using a titanium cage compared with ACDF using polymethyl methacrylate, and for BRYAN cervical disc (Medtronic Sofamor Danek, Memphis, TN) prostheses compared with ACDF using allograft bone and plating. No outcomes regarding adjacent-level disease were reported. There is conflicting evidence for the effectiveness of ACD compared with ACDF. Only limited or no evidence was found for the other surgical interventions. CONCLUSION: No evidence for effectiveness of conservative treatment compared with surgery was found. Although there is moderate evidence for the effectiveness of some surgical interventions, no unequivocal evidence for the superiority of 1 particular surgical treatment was found. Worldwide, most patients receive supplementary implants; however, cervical discectomy without graft may be preferred because of similar outcomes, lower costs, and possibly a lower risk of adjacent-level disease. More high-quality RCTs using validated outcome measures (including adjacent level disease) are needed.

Survivorship analysis of 150 consecutive patients with DIAM™ implantation for surgery of lumbar spinal stenosis and disc herniation.

Recently, the Device for Intervertebral Assisted Motion (DIAM™) has been introduced for surgery of degenerative lumbar disc diseases. The authors performed the current study to determine the survivorship of DIAM™ implantation for degenerative lumbar disc diseases and risk factors for reoperation. One hundred and fifty consecutive patients underwent laminectomy or discectomy with DIAM™ implantation for primary lumbar spinal stenosis or disc herniation. The characteristics of the 150 patients included the following: 84 males and 66 females; mean age at the time of surgery, 46.5 years; median value of follow-up, 23 months (range 1-48 months); 96 spinal stenosis and 54 disc herniations; and 146 one-level (115, L4-5; 31, L5-6) and 4 two-level (L4-5 and L5-6). In the current study, due to lumbosacral transitional vertebra (LSTV) L6 meant lumbarization of S1 and this had a prominent spinous process so that the DIAM™ was implanted at L5-6. Reoperations due to any reasons of the DIAM™ implantation level or adjacent levels were defined as a failure and used as the end point for determining survivorship. The cumulative reoperation rate and survival time were determined via Kaplan-Meier analysis. The log-rank test and Cox regression model were used to evaluate the effect of age, gender, diagnosis, location, and level of DIAM™ implantation on the reoperation rate. During a 4-year follow-up, seven patients (two males and five female) underwent reoperation at the DIAM™ implantation level, giving a reoperation rate of 4.7%. However, no patients underwent reoperation for adjacent level complications. The causes of reoperation were recurrent spinal stenosis (n = 3), recurrent disc herniation (n = 2), post-laminectomy spondylolisthesis (n = 1), and delayed deep wound infection (n = 1). The mean time between primary operation and reoperation was 13.4 months (range 2-29 months). Kaplan-Meier analysis predicted an 8% cumulative reoperation rate 4 years post-operatively. Survival time was predicted to be 45.6 ± 0.9 months (mean ± standard deviation). Based on the log-rank test, the reoperation rate was higher at L5-6 (p = 0.002) and two-level (p = 0.01) DIAM™ implantation compared with L4-5 and one-level DIAM™ implantation. However, gender (p = 0.16), age (p = 0.41), and diagnosis (p = 0.67) did not significantly affect the reoperation rate of DIAM™ implantation. Based on a Cox regression model, L5-6 [hazard ratio (HR), 10.3; 95% CI, 1.7-63.0; p = 0.01] and two-level (HR, 10.4; 95% CI, 1.2-90.2; p = 0.04) DIAM™ implantation were also significant variables associated with a higher reoperation rate. Survival time was significantly lower in L5-6 (47 vs. 22 months, p = 0.002) and two-level DIAM™ implantation (46 vs. 18 months, p = 0.01) compared with L4-5 and one-level DIAM™ implantation. The current results suggest that 8% of the patients who have a DIAM™ implantation for primary lumbar spinal stenosis or disc herniation are expected to undergo reoperation at the same level within 4 years after surgery. Based on the limited data set, DIAM™ implantation at L5-6 and two-level in patients with LSTV are significant risk factors for reoperation.

Comparison of recovery times and complication rates between a modified slanted slot and the standard ventral slot for the treatment of cervical disc disease in 20 dogs.

OBJECTIVES: To compare the recovery times and complication rates between the standard ventral slot and the modified slanted ventral slot for the treatment of cervical disc disease in dogs with the same neurological grade. METHODS: A retrospective analysis of an equal number of cervical disc cases for each procedure was carried out specifically to determine the recovery times and complication rates. To allow for meaningful comparison only dogs that had the same neurological grade were selected. Outcomes were determined by time to recover and the resolution of symptoms and complications were graded in terms of severity. RESULTS: The standard ventral slot cases had a higher complication rate than the modified slanted slot cases with one case dying in the postoperative period. However, the modified slanted slot cases on average had a marginally slower recovery time than standard ventral slot cases. CLINICAL SIGNIFICANCE: Ventral decompression using the modified slanted slot instead of the standard ventral slot will allow for spinal decompression with potentially less destabilisation, and incur a similar incidence of complications and rate of recovery.

Long-term actuarial survivorship analysis of an interspinous stabilization system.

In 1986, an interspinous dynamic stabilization system (the prototype of the current Wallis implant) was designed to stiffen unstable operated degenerate lumbar segments with a hard interspinous blocker to limit extension and a tension band around the spinous processes to secure the implant and limit flexion. Restoring physiological mechanical conditions to the treated level(s) while preserving some intervertebral mobility was intended to treat low-back pain related to degenerative instability without increasing stress forces in the adjacent segments. The procedure was easily reversible. If low back pain persisted or recurred, the device was removed and stability was achieved using fusion. The intermediate-term results were promising, but the long-term safety and efficacy of this dynamic interspinous stabilization device has not been previously documented. We retrospectively reviewed the hospital files of all the patients (n = 241) who had this dynamic stabilization system implanted between 1987 and 1995, contacting as many as possible to determine the actuarial survivorship of the system. In this manner, 142 of the 241 patients (58.9%) were contacted by telephone. The endpoints used for the survivorship analysis were 'any subsequent lumbar operation' and 'implant removal'. At 14 years follow-up, values of actuarial survivorship with 95% confidence interval were 75.9 +/- 8.3 and 81.3 +/- 6.8% for the endpoints 'any subsequent lumbar operation' and 'implant removal', respectively. There was no difference in survivorship of multiple-level implants with respect to single-level devices. Although the conclusions of the present study must be tempered by the 41% attrition rate, these findings support the long-term safety of this system, and possibly long-term protective action against adjacent-level degeneration by motion preservation. Outcomes at least equivalent to those of fusion were observed without the primary drawbacks of fusion.

Surgery for herniation of a lumbar disc in Sweden between 1987 and 1999. An analysis of 27,576 operations.

The National Inpatient Register and the Swedish Death Register were linked to determine the incidence of surgical intervention, the trends and characteristics of the patients, the death rate and the pre- and post-operative admissions for herniation of a lumbar disc based on comprehensive national data between 1987 and 1999. There were 27,576 operations which were followed cumulatively for 155,249 years, with a median of 6.0 years. The mean annual rate of operation was 24 per 100,000 inhabitants, the median age of the patients was 42 years. The 30-day death rate was 0.5 per 1000 operations. The rates of re-operation at one and ten years were 5% and 10%, respectively, decreasing significantly (40%) with time. The mean length of stay decreased from nine to five days. Patients who had been in hospital because of a previous spinal disorder had a significantly higher risk of readmission.

Outcomes in patients admitted for rehabilitation with spinal neurological lesions following intervertebral disc herniation.

BACKGROUND: Little information is available about the survival, neurological recovery, and length of stay in hospital for rehabilitation (LOS) of patients with spinal neurological deficit following disc herniation (DH). STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To report on outcomes and factors affecting these. SETTING: The Spinal Research Laboratory, Loewenstein Rehabilitation Hospital, Israel. SUBJECTS: A total of 158 patients with DH spinal neurological lesions (DHSNL). METHOD: Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method; relative mortality risk by the Cox proportional hazard model. Neurological recovery was evaluated by calculating the change in Frankel grades, and factors that affect it were assessed by logistic regression. LOS associations were analyzed with ANOVA. RESULTS: The median age at lesion onset was 48 years, and the median survival 29 years. Age and gender had a significant effect on survival, but not so lesion severity, level, or decade of onset. Of the 69 patients who had Frankel grades A, B, or C on admission, 72% achieved useful recovery to grades D or E. The severity and level of the spinal neurological lesion (SNL) had a significant effect on recovery. The mean LOS was 87 days; it was significantly affected by lesion severity and level and by the decade of admission to rehabilitation, and decreased with time. CONCLUSIONS: Patients with DHSNL who were admitted for rehabilitation have favorable survival and recovery rates compared with previously studied patients with other types of SNL. Their LOS is probably a function of medical requirements, but is decreasing with time.

Evaluation of 70/30 D,L-PLa for use as a resorbable interbody fusion cage.

Titanium lumbar interbody spinal fusion devices are reported to be 90% effective for single-level lumbar interbody fusion, although radiographic determination of fusion has been debated. Using blinded radiographic, biomechanic, histologic, and statistical measures, researchers in the present study evaluated a radiolucent 70/30 poly(L-lactide-co-D,L-lactide) (70/30 D,L-PLa) interbody fusion device packed with autograft or rhBMP-2 on a collagen sponge in 25 sheep at 3, 6, 12, 18, and 24 months. A trend of increased fusion stiffness, radiographic fusion, and histologic fusion was demonstrated from 3 months to 24 months. Device degradation was associated with a mild to moderate chronic inflammatory response at all postoperative sacrifice times.

[Quality assurance of back surgery. A follow-up of 350 patients treated for sciatica by means of survival analysis]. / Kvalitetssikring av ryggkirurgi. Oppfølging av 350 isjiasopererte ved bruk av overlevingsanalyse.

350 patients underwent a follow-up 2-16 years after back surgery. The aim was to find quality indicators, such as frequency of complications, recurrences and reoperation, in addition to establishing postoperative status and patient satisfaction. The complication rate was 9.7%. Most complications were not serious, and there was no mortality. We found a cumulative recurrency rate of 18% and a cumulative reoperation rate of 12%. Women had significantly better long-term results than men, psychosocial problems being a strong negative predictor. Questionnaires revealed that 76% of the patients were satisfied, whereas 22% were not. Postoperatively, 59% reported a persistent, but usually slight back problem.

Review: complications of surgery for thoracic disc disease.

BACKGROUND: Thoracic discectomy has evolved over the last 60 years from resection through standard laminectomy, to posterolateral procedures to open thoracotomy and finally thoracoscopy. Comparison of relative morbidity and mortality between these approaches is now possible. METHODS: Peer-reviewed publications reporting clinical data relating to thoracic discectomy, and which provided sufficient information to enable adequate assessment of mortality and morbidity were reviewed. These articles were determined via review of the results of MedLine searches and articles gathered through compilation of references from those articles. RESULTS: Articles reviewed spanned a period of over 60 years. Surgical procedures used for thoracic discectomy included laminectomy, pediculectomy, costotransversectomy, lateral extracavitary, transverse arthropediculectomy, anterolateral thoracotomy, and thoracoscopy. Complications included death, paralysis, paresis, loss of bowel and/or bladder control, pulmonary embolism, pneumonia, atelectasis, compression fracture, infection, pleural tear, bowel obstruction, and anesthesia dolorosa. Mortality dropped to nearly zero after development of anterior and posterolateral approaches. Morbidity seems relatively similar between most procedures other than laminectomy. Not enough procedures have been reported using thoracoscopy to adequately assess its morbidity. CONCLUSION: Comparison of relative rates of morbidity and mortality between surgical approaches to thoracic discectomy suggest that laminectomy does not provide adequate access for the safe removal of these lesions. Choice of approach among the alternatives should be based on the evacuation of the herniated fragment and experience of the surgeon. Thoracoscopy, although promising, has not had sufficient time for evaluation of morbidity to make definite statements regarding its safety.

5-year reoperation rates after different types of lumbar spine surgery.

STUDY DESIGN: Population-based cohort study of Washington State patients who underwent lumbar spine surgery for degenerative conditions in 1988. OBJECTIVES: To compare complications and reoperation rates during the 5-year period after surgery between patients who have undergone lumbar spine fusion surgery and those who have undergone laminectomy or discectomy alone. SUMMARY OF BACKGROUND DATA: Spinal fusion is associated with wider surgical exposure, more extensive dissection, and longer operative times than lumbar surgery without fusion, and previous studies have shown higher complication rates and hospital charges associated with these more complex procedures. In elderly patients, spinal fusion operations were associated with higher mortality rates than laminectomy or discectomy alone, and reoperation rates were not lower. In the current study, reoperations, mortality, and complications following lumbar spine surgery were examined for the general population. METHODS: A statewide hospital discharge database was used to identify all Washington patients who underwent spine surgery in 1988 and to determine the rate of reoperation during the subsequent 5 years. Administrative records also were used to identify complications, mortality, and hospital charges associated with the operations. Unadjusted complication and reoperation rates for the groups were compared using chi-square statistics. Adjusted rates were compared using logistic regression and proportional hazards (Cox) regression after controlling for age, gender, prior spine surgery, diagnosis, comorbidity, type of surgery, and coverage by Workers' Compensation. RESULTS: Of 6376 patients who underwent lumbar surgery for degenerative conditions in Washington in 1988, 1041 (16%) had operations involving spine fusion. Diagnoses of degenerative disc disease or possible instability were more frequent among patients undergoing fusion surgery, whereas herniated discs were more frequent among those undergoing discectomy or laminectomy alone. Complications were recorded in 18% of fusion patients and 7% of nonfusion patients (P < 0.01), but mortality rates did not differ. Unadjusted reoperation rates over the 5-year period were greater for patients who underwent fusion than for patients who underwent nonfusion surgery (18% vs. 15%, respectively), but after adjustment for baseline characteristics, fusion patients had only a slightly greater (and nonsignificant) risk of reoperation (relative risk 1.1, confidence interval .9-1.3). CONCLUSION: As in previous studies, complications in the current study occurred more frequently among patients who underwent lumbar spine fusion than among those who underwent laminectomy or discectomy alone. Reoperations were at least as frequent after fusion, but the authors could not assess treatment efficacy in terms of pain relief or improved function. Although the characteristics of patients undergoing fusion differed from those undergoing a laminectomy or discectomy alone, there appeared to be sufficient overlap in the clinical populations to warrant closer scrutiny of the safety, efficacy, and indications for spinal fusions, preferably in randomized trials.

Hernia discal traumatica da coluna cervical / Traumatic disk hernia in the cervical spine

Os autores apresentam 26 casos de hernia discal traumatica da coluna cervical que foram submetidas a tratamento cirurgico, com discectomia por via anterior. Todos os pacientes apresentavam deficit neurologico no atendimento inicial sendo 18 classificados como Frankel A, tres como Frankel B, dois como Frankel C e tres como D. Foram observados tres obitos nas duas primeiras semanas por problemas respiratorios em pacientes com Frankel A. Os 23 casos restantes tiveram seguimento de 14 meses, variando de seis a 84 meses e foi observada melhora do deficit neurologico em seis dos pacientes classificados inicialmente como Frankel B, C ou D e em apenas um dos classificados como Frankel A. Os autores salientam a importancia do diagnostico por imagem neste tipo de lesao que muitas vezes passava desapercebida.

[Traumatic disk hernia of the cervical spine]. / Hérnia discal traumática da coluna cervical.

The authors present 26 cases of traumatic disc herniation in the cervical spine submitted to anterior discectomy. All of the patient presented neurologic deficit, being 18 classified as Frankel A, three as Frankel B, 2 Frankel C and 3 Frankel D. There were observed three deaths in the immediate post-operative period due to respiratory insufficiency in patients classified as Frankel A. The other 23 cases have a follow-up of 14 months (6-84 months), presenting improvement of the neurologic deficit in six patients classified as Frankel B, C and D and only one as Frankel A. The authors emphasize the importance of the image methods in the diagnosis of this lesion.

[Intraoperative complications in lumbar intervertebral disk operations. Cooperative study of the spinal study group of the German Society of Neurosurgery]. / Intraoperative Komplikationen während lumbaler Bandscheibenoperationen. Kooperative Studie der Arbeitsgemeinschaft Wirbelsäule der Deutschen Gesellschaft für Neurochirurgie.

The workshop "Wirbelsüle" of the German Society of Neurological Surgery started a cooperative study about the incidence of intraoperative complications during lumbar disc surgery. The results relate a number of 68,329 operations, among them a percentage of 2.560% of total complications, including 0.0132% with fatal ending. The highest number of complications related to the lesions of spinal structures (3.202%). Abdominal bleeding by vascular lesions occurred in 0.045%., the incidence of abdominal organ injury was reported in single cases (0.003%).