Does MIS Surgery Allow for Shorter Constructs in the Surgical Treatment of Adult Spinal Deformity?

Abstract BACKGROUND: The length of construct can potentially influence perioperative risks in adult spinal deformity (ASD) surgery. A head-to-head comparison between open and minimally invasive surgery (MIS) techniques for treatment of ASD has yet to be performed. OBJECTIVE: To examine the impact of MIS approaches on construct length and clinical outcomes in comparison to traditional open approaches when treating similar ASD profiles. METHODS: Two multicenter databases for ASD, 1 involving MIS procedures and the other open procedures, were propensity matched for clinical and radiographic parameters in this observational study. Inclusion criteria were ASD and minimum 2-year follow-up. Independent t-test and chi-square test were used to evaluate and compare outcomes. RESULTS: A total of 1215 patients were identified, with 84 patients matched in each group. Statistical significance was found for mean levels fused (4.8 for circumferential MIS [cMIS] and 10.1 for open), mean interbody fusion levels (3.6 cMIS and 2.4 open), blood loss (estimated blood loss 488 mL cMIS and 1762 mL open), and hospital length of stay (6.7 days cMIS and 9.7 days open). There was no significant difference in preoperative radiographic parameters or postoperative clinical outcomes (Owestry Disability Index and visual analog scale) between groups. There was a significant difference in postoperative lumbar lordosis (43.3° cMIS and 49.8° open) and pelvic incidence-lumbar lordosis correction (10.6° cMIS and 5.2° open) in the open group. There was no significant difference in reoperation rate between the 2 groups. CONCLUSION: MIS techniques for ASD may reduce construct length, reoperation rates, blood loss, and length of stay without affecting clinical and radiographic outcomes when compared to a similar group of patients treated with open techniques.

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Blood, Sweat, Toil, and Tears of Surgical Training. Part I: Blood

Asian Cardiovascular and Thoracic Annals ◽

10.1177/021849230701500408 ◽

2007 ◽

Vol 15 (4) ◽

pp. 307-309 ◽

Cited By ~ 2

Author(s):

Andrew J Drain ◽

Jonathon I Ferguson ◽

Sharon Wilkinson ◽

Samer AM Nashef

Keyword(s):

Adverse Effect ◽

Blood Loss ◽

Operating Room ◽

Clinical Outcomes ◽

Surgical Training ◽

Clinical Service ◽

Significant Difference ◽

Potential Impact ◽

The Impact ◽

Cardiac Operations

There may be conflict between the requirements of surgical training and those of the clinical service if training has an impact on clinical outcomes. One area of potential impact is perioperative blood loss. We compared total and 12-hour blood loss after 2,079 consecutive cardiac operations performed over 2 years by trainees and consultants. One- and two-way analyses of variance with EuroSCORE and surgeon status as factors were carried out to evaluate the impact of surgeon status on blood loss. There was no difference in blood loss between consultants and trainees. We also compared the rates between consultants and trainees of patients returning to the operating room due to bleeding. This showed a significant difference, with trainees having a higher rate of investigation for bleeding. Cardiac surgical training can be achieved without an adverse effect on blood loss, but it may be associated with a higher rate of re-intervention for bleeding.

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Comparison of Radiographic And Clinical Outcomes Observed After Adult Spinal Deformity Correction Using Iliac Screw Versus S2-Alar-Iliac Screw

10.21203/rs.3.rs-492643/v1 ◽

2021 ◽

Author(s):

Qiang Luo ◽

Yong-Chan Kim ◽

Ki-Tack Kim ◽

Kee-Yong Ha ◽

Joonghyun Ahn ◽

...

Keyword(s):

Clinical Outcomes ◽

Spinal Deformity ◽

Lumbar Lordosis ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Postoperative Change ◽

Iliac Screw ◽

Vas Scores ◽

Correction Surgery

Abstract Background: To date, there is a paucity of reports clarifying the change of spinopelvic parameters in patients with adult spinal deformity (ASD) who underwent long segment spinal fusion using iliac screw (IS) and S2-alar-iliac screw (S2AI) fixation.Methods: A retrospective review of consecutive patients underwent deformity correction surgery for ASD between 2013 and 2017 was performed. Patients were divided into two groups based on whether IS or S2AI fixation was performed. All radiographic parameters were measured preoperatively, immediately postoperatively, and the last follow-up. Demographics, intraoperative and clinical data were analyzed between the two groups. Additionally, the cohort was subdivided according to the postoperative change in pelvic incidence (PI): subgroup (C) was defined as change in PI ≥5° and subgroup (NC) with change <5°. In subgroup analyses, the 2 different types of postoperative change of PI were directly compared.Results: A total of 142 patients met inclusion criteria: 111 who received IS and 31 received S2AI fixation. The IS group (65.6 ± 26, 39.8 ± 13.8) showed a significantly higher change in lumbar lordosis (LL) and upper lumbar lordosis (ULL) than the S2AI group (54.4 ± 17.9, 30.3 ± 9.9) (p<0.05). In subgroup (C), PI significantly increased from 53° preoperatively to 59° postoperatively at least 50% of IS cohort, with a mean change of 5.8° (p<0.05). The clinical outcomes at the last follow-up were significantly better in IS group than in S2AI group in terms of VAS scores for back and leg. The occurrence of sacroiliac joint pain and pelvic screw fracture were significantly greater in S2AI group than in IS group (25.8% vs 9%, p<0.05) and (16.1% vs 3.6%, p<0.05).Conclusions: IS fixation showed a greater change in LL and ULL than S2AI fixation in ASD surgery. PI may be changed under certain circumstances.

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Body Mass Index Greater Than 35 Is Associated With Increased Major and Radiographic Complications After Minimally Invasive Adult Spinal Deformity Surgery

Neurosurgery ◽

10.1093/neuros/nyz310_819 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Khoi D Than ◽

Stacie Tran ◽

Dean Chou ◽

Kai-Ming G Fu ◽

Paul Park ◽

...

Keyword(s):

Body Mass Index ◽

Minimally Invasive ◽

Clinical Outcomes ◽

Body Mass ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Surgical Site Infections ◽

Neurological Complications ◽

Obese Patients ◽

The Impact

Abstract INTRODUCTION As the obesity epidemic continues and the recognition of adult spinal deformity (ASD) increases, a growing number of obese patients are undergoing surgery to correct ASD. Minimally invasive techniques may be advantageous for obese patients to minimize blood loss. To date, the literature examining the impact of obesity on complications after minimally invasive ASD surgery has been scarce. METHODS A multicenter database of ASD patients was reviewed. Patients who had at least 2 yr of follow-up were analyzed. Demographic, radiographic, clinical outcomes, and postoperative complications were assessed. A body mass index (BMI) threshold of 35 was selected to more accurately reflect real-world practices. RESULTS A total of 220 patients were included: 196 had a BMI <35 and 24 had a BMI >35 (26.3 vs 38.4, P < .001). When comparing patients with a BMI threshold of 35, there was no difference in baseline age, levels instrumented, and most pre- and postoperative radiographic parameters and clinical outcomes. Patients with BMI >35 did have higher preopearative back pain than BMI <35 (visual analog scale 7.9 vs 6.8, P = .013) and postoperative Cobb angle (17.8 vs 12.6, P = .031). There was no difference between groups in overall complications, reoperations, infections, implant failures, surgical site infections, or minor, cardiopulmonary, gastrointestinal, and operative complications. Patients with BMI >35 had more major (45.8% vs 23.0%, P = .015) and radiographic (37.5% vs 19.9%, P = .049) complications than patients with BMI <35. Patients with BMI <35 had more neurological complications (17.3% vs 0%, P = .026). CONCLUSION In this retrospective review of a large database of patients undergoing minimally invasive surgery for ASD, patients with BMI > 35 suffered from more major and radiographic complications but fewer neurological complications than patients with BMI <35.

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Robotic-assisted Ivor-Lewis esophagectomy in the elderly patient.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.3_suppl.93 ◽

2014 ◽

Vol 32 (3_suppl) ◽

pp. 93-93

Author(s):

Andrea M. Abbott ◽

Tobin Joel Crill Strom ◽

Nadia Saeed ◽

Ravi Shridhar ◽

Sarah E. Hoffe ◽

...

Keyword(s):

Blood Loss ◽

The Elderly ◽

Separate Analysis ◽

Ivor Lewis ◽

Robotic Assisted ◽

Ivor Lewis Esophagectomy ◽

Estimated Blood Loss ◽

Increased Risk ◽

Significant Difference ◽

The Impact

93 Background: Esophageal cancer continues to increase in incidence worldwide with the age of diagnosis continuing to move towards an older onset. Robotic assisted approaches to esophagectomy have demonstrated decreased complications and length of hospitalization (LOH). We sought to examine the impact of age on outcomes in patients undergoing robotic assisted esophagectomy (RAIL). Methods: From 2009-2013, we identified patients undergoing robotic assisted Ivor Lewis esophagectomy. Patients were then stratified according to 3 age groups. Cohort 1, age less then 50, cohort 2, age 50-70, and cohort 3 >70. Statistical comparisons between LOH, operative time (OT), estimated blood loss (EBL), adverse events (AE) and mortality were made with Kruskal-Wallis and Chi-square tests. Results: We identified 134 patients who underwent RAIL and found no statistically significant difference between the three cohorts for OT, LOH, days spent in intensive care, AE or mortality. There was a difference in EBL with higher median blood loss (150 cc) seen in cohort 1 (50-600cc) and 3 (50-400cc) compared to cohort 2 (100 cc, (25-400cc)), p < 0.01. The most common AE were arrhythmia and pneumonia but this was not significantly different between the cohorts. The overall AE rate was 10% (cohort 1), 21% (cohort 2), 34% (cohort 3), p=0.14. There were 4 leaks (p =0.38) and 2 deaths (p=0.90) in the entire cohort. A separate analysis was done to compare elderly (>70) to the non-elderly (<70). Median EBL was higher in the elderly cohort (100cc (25-600) vs 150cc (50-400), p <0.01). There was a trend towards longer LOH in the elderly (9 (4-35) vs 11 (6-38) days, p =0.06). AE and mortality were not significantly different, although there was a trend toward increased AE (19.8% vs 34%, p=0.07) in the elderly, with arrhythmia being the most common AE. Conclusions: RAIL is a safe surgical technique for use in an aging patient population. We demonstrated there was no increased risk of LOH, AE or death in the elderly patients compared to their younger cohort.

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The impact of preoperative supine radiographs on surgical strategy in adult spinal deformity

Journal of Neurosurgery Spine ◽

10.3171/2021.3.spine201739 ◽

2021 ◽

pp. 1-7

Author(s):

Francis Lovecchio ◽

Jonathan Charles Elysee ◽

Renaud Lafage ◽

Jeff Varghese ◽

Mathieu Bannwarth ◽

...

Keyword(s):

Spinal Deformity ◽

Lumbar Lordosis ◽

Adult Spinal Deformity ◽

Surgical Decision ◽

Spinal Flexibility ◽

Grade 3 ◽

Upper Instrumented Vertebra ◽

Invasive Techniques ◽

The Impact ◽

Surgical Decision Making

OBJECTIVE Preoperative planning for adult spinal deformity (ASD) surgery is essential to prepare the surgical team and consistently obtain postoperative alignment goals. Positional imaging may allow the surgeon to evaluate spinal flexibility and anticipate the need for more invasive techniques. The purpose of this study was to determine whether spine flexibility, defined by the change in alignment between supine and standing imaging, is associated with the need for an osteotomy in ASD surgery. METHODS A single-center, dual-surgeon retrospective analysis was performed of adult patients with ASD who underwent correction of a thoracolumbar deformity between 2014 and 2018 (pelvis to upper instrumented vertebra between L1 and T9). Patients were stratified into osteotomy (Ost) and no-osteotomy (NOst) cohorts according to whether an osteotomy was performed (Schwab grade 2 or higher). Demographic, surgical, and radiographic parameters were compared. The sagittal correction from intraoperative prone positioning alone (sagittal flexibility percentage [Sflex%]) was assessed by comparing the change in lumbar lordosis (LL) between preoperative supine to standing radiographs and preoperative to postoperative alignment. RESULTS Demographics and preoperative and postoperative sagittal alignment were similar between the Ost (n = 60, 65.9%) and NOst (n = 31, 34.1%) cohorts (p > 0.05). Of all Ost patients, 71.7% had a grade 2 osteotomy (mean 3 per patient), 21.7% had a grade 3 osteotomy, and 12.5% underwent both grade 3 and grade 2 osteotomies. Postoperatively, the NOst and Ost cohorts had similar pelvic incidence minus lumbar lordosis (PI-LL) mismatch (mean PI-LL 5.2° vs 1.2°; p = 0.205). Correction obtained through positioning (Sflex%) was significantly lower for in the osteotomy cohort (38.0% vs 76.3%, p = 0.004). A threshold of Sflex% < 70% predicted the need for osteotomy at a sensitivity of 78%, specificity of 56%, and positive predictive value of 77%. CONCLUSIONS The flexibility of the spine is quantitatively related to the use of an osteotomy. Prospective studies are needed to determine thresholds that may be used to standardize surgical decision-making in ASD surgery.

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Abstract 17173: Association of Acute Gout Flares and Colchicine Use With Clinical Outcomes During Admission for Acute Decompensated Heart Failure

Circulation ◽

10.1161/circ.142.suppl_3.17173 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Melissa E Chinn ◽

Mary E Roth ◽

Steven P Dunn ◽

Kenneth C Bilchick ◽

Sula Mazimba

Keyword(s):

Heart Failure ◽

Length Of Stay ◽

Hospital Mortality ◽

Clinical Outcomes ◽

Hospital Discharge ◽

Readmission Rate ◽

Acute Gout ◽

Significant Difference ◽

The Impact ◽

Gout Flare

Introduction: Gout is a common comorbidity in heart failure (HF) patients, and is often exacerbated by diuretic use. The impact of gout or the treatment of gout on HF outcomes is unknown. The purpose of this study was to assess clinical outcomes in patients being treated for an acute HF exacerbation and receiving colchicine for an acute gout flare. Methods: This was a single center, retrospective cohort study of patients treated for an acute HF exacerbation from March 2011 to February 2020. The gout group included patients receiving colchicine for an acute gout flare during admission. The control group included those who did not receive colchicine for an acute gout flare. The primary outcome was 30-day readmission rate. Secondary outcomes included in-hospital mortality and length of stay. Results: In the cohort of 1,047 patients (68.8 +/- 13.7 years, 38% female), 237 patients received colchicine for acute gout during admission. Length of stay was significantly greater (9.93 days vs. 7.96 days, p < 0.0001) and in-hospital mortality was significantly lower (2.2% vs. 6.6%, p = 0.009) in patients with versus without gout. In a multivariate logistic regression model, in-hospital colchicine given for a gout flare was significantly associated with reduced in-hospital mortality (OR 0.322, 95% CI 0.105-0.779, p = 0.02) after adjustment for home beta blocker use, inotrope use, age, and diabetes mellitus (p < 0.05 for all in the model). The association between colchicine and survival to hospital discharge was only observed in patients who received colchicine during the hospitalization, as opposed to home use only. There was no significant difference in 30-day readmission rate based on gout status for patients surviving to hospital discharge (21.5% vs. 19.5%, p = 0.495). Conclusions: Among patients with an acute HF exacerbation, patients treated for an acute gout flare with colchicine had a greater length of stay and lower in-hospital mortality compared with those not having gout. Future analyses are warranted to identify the relationship between colchicine use and HF outcomes.

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Two-level corpectomy versus three-level discectomy for cervical spondylotic myelopathy: a comparison of perioperative, radiographic, and clinical outcomes

Journal of Neurosurgery Spine ◽

10.3171/2014.12.spine14545 ◽

2015 ◽

Vol 23 (3) ◽

pp. 280-289 ◽

Cited By ~ 35

Author(s):

Darryl Lau ◽

Dean Chou ◽

Praveen V. Mummaneni

Keyword(s):

Length Of Stay ◽

Neck Pain ◽

Cobb Angle ◽

Clinical Outcomes ◽

Subgroup Analysis ◽

Cervical Spondylotic Myelopathy ◽

Complication Rates ◽

Second Stage ◽

Estimated Blood Loss ◽

Significant Difference

OBJECT In the treatment of cervical spondylotic myelopathy (CSM), anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF) are effective decompressive techniques. It remains to be determined whether ACCF and ACDF offer equivalent outcomes for multilevel CSM. In this study, the authors compared perioperative, radiographic, and clinical outcomes between 2-level ACCF and 3-level ACDF. METHODS Between 2006 and 2012, all patients at the authors' hospital who underwent 2-level ACCF or 3-level ACDF performed by 1 of 2 surgeons were identified. Primary outcomes of interest were sagittal Cobb angle, adjacent-segment disease (ASD) requiring surgery, neck pain measured by visual analog scale (VAS), and Nurick score. Secondary outcomes of interest included estimated blood loss (EBL), length of stay, perioperative complications, and radiographic pseudarthrosis rate. Chi-square tests and 2-tailed Student t-tests were used to compare the 2 groups. A subgroup analysis of patients without posterior spinal fusion (PSF) was also performed. RESULTS Twenty patients underwent 2-level ACCF, and 35 patients underwent 3-level ACDF during a 6-year period. Preoperative Nurick scores were higher in the ACCF group (2.1 vs 1.1, p = 0.014), and more patients underwent PSF in the 2-level ACCF group compared with patients in the 3-level ACDF group (60.0% vs 17.1%, p = 0.001). Otherwise there were no significant differences in demographics, comorbidities, and baseline clinical parameters between the 2 groups. Two-level ACCF was associated with significantly higher EBL compared with 3-level ACDF for the anterior stage of surgery (382.2 ml vs 117.9 ml, p < 0.001). Two-level ACCF was also associated with a longer hospital stay compared with 3-level ACDF (7.2 days vs 4.9 days, p = 0.048), but a subgroup comparison of patients without PSF showed no significant difference in length of stay (3.1 days vs 4.4 days for 2-level ACCF vs 3-level ACDF, respectively; p = 0.267). Similarly, there was a trend toward more complications in the 2-level ACCF group (20.0%) than the 3-level ACDF group (5.7%; p = 0.102), but a subgroup analysis that excluded those who had second-stage PSF no longer showed the same trend (2-level ACCF, 0.0% vs 3-level ACDF, 3.4%; p = 0.594). There were no significant differences between the ACCF group and the ACDF group in terms of postoperative sagittal Cobb angle (7.2° vs 12.1°, p = 0.173), operative ASD (6.3% vs 3.6%, p = 0.682), and radiographic pseudarthrosis rate (6.3% vs 7.1%, p = 0.909). Both groups had similar improvement in mean VAS neck pain scores (3.4 vs 3.2 for ACCF vs ACDF, respectively; p = 0.860) and Nurick scores (0.8 vs 0.7, p = 0.925). CONCLUSIONS Two-level ACCF was associated with greater EBL and longer hospital stays when patients underwent a second-stage PSF. However, the length of stay was similar when patients underwent anterior-only decompression with either 2-level ACCF or 3-level ACDF. Furthermore, perioperative complication rates were similar in the 2 groups when patients underwent anterior decompression without PSF. Both groups obtained similar postoperative cervical lordosis, operative ASD rates, radiographic pseudarthrosis rates, neurological improvement, and pain relief.

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Classifying Complications: Assessing Adult Spinal Deformity 2-Year Surgical Outcomes

Global Spine Journal ◽

10.1177/2192568220937473 ◽

2020 ◽

Vol 10 (7) ◽

pp. 896-907

Author(s):

Eric O. Klineberg ◽

Peter G. Passias ◽

Gregory W. Poorman ◽

Cyrus M. Jalai ◽

Abiola Atanda ◽

...

Keyword(s):

Postoperative Complications ◽

Postoperative Complication ◽

Spinal Deformity ◽

Surgical Outcomes ◽

Perioperative Complications ◽

Adult Spinal Deformity ◽

Complication Rates ◽

Estimated Blood Loss ◽

Patient Reported ◽

The Impact

Study Design: Retrospective review of prospective database. Objective: Complication rates for adult spinal deformity (ASD) surgery vary widely because there is no accepted system for categorization. Our objective was to identify the impact of complication occurrence, minor-major complication, and Clavien-Dindo complication classification (Cc) on clinical variables and patient-reported outcomes. Methods: Complications in surgical ASD patients with complete baseline and 2-year data were considered intraoperatively, perioperatively (<6 weeks), and postoperatively (>6 weeks). Primary outcome measures were complication timing and severity according to 3 scales: complication presence (yes/no), minor-major, and Cc score. Secondary outcomes were surgical outcomes (estimated blood loss [EBL], length of stay [LOS], reoperation) and health-related quality of life (HRQL) scores. Univariate analyses determined complication presence, type, and Cc grade impact on operative variables and on HRQL scores. Results: Of 167 patients, 30.5% (n = 51) had intraoperative, 48.5% (n = 81) had perioperative, and 58.7% (n = 98) had postoperative complications. Major intraoperative complications were associated with increased EBL ( P < .001) and LOS ( P = .0092). Postoperative complication presence and major postoperative complication were associated with reoperation ( P < .001). At 2 years, major perioperative complications were associated with worse ODI, SF-36, and SRS activity and appearance scores ( P < .02). Increasing perioperative Cc score and postoperative complication presence were the best predictors of worse HRQL outcomes ( P < .05). Conclusion: The Cc Scale was most useful in predicting changes in patient outcomes; at 2 years, patients with raised perioperative Cc scores and postoperative complications saw reduced HRQL improvement. Intraoperative and perioperative complications were associated with worse short-term surgical and inpatient outcomes.

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Factors Associated With Short Length of Stay After Long Fusions for Adult Spinal Deformity: Initial Steps Toward Developing an Enhanced Recovery Pathway

Global Spine Journal ◽

10.1177/2192568220941448 ◽

2020 ◽

pp. 219256822094144

Author(s):

Francis Lovecchio ◽

Michael Steinhaus ◽

Jonathan Charles Elysee ◽

Alex Huang ◽

Bryan Ang ◽

...

Keyword(s):

Cohort Study ◽

Length Of Stay ◽

Spinal Deformity ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Adult Spinal Deformity ◽

Clinical Care ◽

Medical Complication ◽

Factors Associated ◽

Estimated Blood Loss

Study Design: Retrospective cohort study. Objectives: The identification of case types and institutional factors associated with reduced length of stay (LOS) is a key initial step to inform the creation of clinical care pathways that can assist hospitals to maximize the benefit of value-based payment models. The objective of this study was to identify preoperative, intraoperative, and postoperative factors associated with shorter than expected LOS after adult spinal deformity (ASD) surgery. Methods: A retrospective cohort study was performed of 82 patients with ASD who underwent ≥5 levels of fusion to the pelvis between 2013 and 2018. A LOS <6 days was determined as a basis for comparison, as 5.7 days was the “expected LOS” generated through Poisson regression modeling of the sample. Clinical, radiographic, surgical, and postoperative factors were compared between those staying ≥6 days (L group) and <6 days (S group). Logistic regression was used to identify factors associated with LOS <6 days. Results: A total of 35 patients were in group S (42.7%). Gender, age, body mass index, ASA (American Society of Anesthesiologists) class, and use of preoperative narcotics, revision surgery, day of admission, and surgical complications did not vary between the cohorts ( P > .05). Mild-moderate preoperative sagittal deformity (sagittal Schwab modifiers 0 or +), lower estimated blood loss (<1200 mL), fewer levels fused (7 vs 10 levels), shorter operating room time, procedure end time before 15:00, and no intensive care unit stay, were associated with short LOS ( P < .05). Only 1 major medical complication occurred in the short LOS group ( P < .05). Conclusions: This study identifies the ASD “case phenotype,” intra-, and postoperative benchmarks associated with shorter LOS, providing targets for pathways designed to reduce LOS.

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