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Postoperative changes in neurological function after 3-column osteotomy: risk factor analysis of 199 patients

Morsi Khashan, Micheal Raad, Mostafa H. El Dafrawy, Varun Puvanesarajah, and Khaled M. Kebaish

OBJECTIVE

The authors evaluated the neurological outcomes of adult spinal deformity patients after 3-column osteotomy (3CO), including severity and long-term improvement of neurological complications, as well as risk factors for neurological deficit at 1 year postoperatively. Although 3CO is effective for correcting rigid spinal deformity, it is associated with a high complication rate. Neurological deficits, in particular, cause disability and dissatisfaction.

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作者回顾性查询一个准database of adult spinal deformity patients who underwent vertebral column resection or pedicle subtraction osteotomy between 2004 and 2014 by one surgeon at a tertiary care center. The authors included 199 adults with at least 1-year follow-up. The primary outcome measure was change in lower-extremity motor scores (LEMSs), which were obtained preoperatively, within 2 weeks postoperatively, and at 6 and 12 months postoperatively. To identify risk factors for persistent neurological deficit, the authors compared patient and surgical characteristics with a declined LEMS at 12-month follow-up (n = 10) versus those with an improved/maintained LEMS at 12-month follow-up (n = 189).

RESULTS

At the first postoperative assessment, the LEMS had improved in 15% and declined in 10% of patients compared with preoperative scores. At the 6-month follow-up, 6% of patients continued to have a decline in LEMS, and 16% had improvement. At 12 months, LEMS had improved in 17% and declined in 5% of patients compared with preoperative scores. The only factor significantly associated with a decline in 12-month LEMS was high-grade spondylolisthesis as an indication for surgery (OR 13, 95% CI 3.2–56).

CONCLUSIONS

Although the LEMS declined in 10% of patients immediately after 3CO, at 12 months postoperatively, only 5% of patients had neurological motor deficits. A surgical indication of high-grade spondylolisthesis was the only factor associated with neurological deficit at 12 months postoperatively.

InJournal of Neurosurgery: Spine Volume 30: Issue 5 (May 2019)

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Determinants of perioperative transfusion risk in patients with adult spinal deformity

Varun Puvanesarajah, Sandesh S. Rao, Hamid Hassanzadeh, and Khaled M. Kebaish

OBJECTIVE

To determine predictors of perioperative allogeneic packed red blood cell (pRBC) transfusion requirement (total units transfused) in patients with adult spinal deformity (ASD).

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The authors retrospectively analyzed records of patients aged 18 years or older who underwent surgical correction of ASD that involved 4 or more spinal levels by the same spine surgeon between 2010 and 2016. Data regarding patient characteristics, comorbidities, surgical factors, and perioperative transfusions (up to 10 days after surgery) were analyzed using a linear regression model. Significance was set at p < 0.05.

RESULTS

作者分析了165名患者(118’n) with a mean (± SD) age of 61 ± 12 years. Three-column osteotomies were associated with a mean intraoperative transfusion volume of 1.74 additional units of pRBCs. Each unit of intraoperatively salvaged blood used was associated with a mean 0.39-U increase in postoperative transfusion volume (p = 0.031). Every unit of allogeneic blood transfused intraoperatively was associated with a mean 0.23-U decrease in postoperative transfusion volume (p = 0.001). A preoperative hemoglobin concentration of 11.5 g/dl or more was associated with significantly fewer units transfused intraoperatively; a preoperative hemoglobin concentration of 14.0 g/dl or more was associated with fewer units transfused postoperatively. A history of smoking and intraoperative antifibrinolytic use were associated with increased and decreased numbers of units transfused postoperatively, respectively.

CONCLUSIONS

Effective blood management is key to perioperative care of patients with ASD. Three-column osteotomies were associated with a greater number of units of blood transfused. When considering postoperative transfusion requirements, surgeons should note that intraoperative blood salvage might be inferior to intraoperative allogeneic blood transfusion. Using antifibrinolytics and increasing the preoperative hemoglobin concentration to 11.5 g/dl or more are strategies for decreasing the need for perioperative transfusion. A history of smoking is a risk factor for postoperative transfusion requirement (total units transfused).

InJournal of Neurosurgery: Spine Volume 28 (2018): Issue 4 (Apr 2018)

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The engaged patient: patient activation can predict satisfaction with surgical treatment of lumbar and cervical spine disorders

Andrew B. Harris, Floreana Kebaish, Lee H. Riley III, Khaled M. Kebaish, and Richard L. Skolasky

OBJECTIVE

Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment.

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Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status).

RESULTS

虽然大多数病人支持最高level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8–5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5–5.3).

CONCLUSIONS

Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

InJournal of Neurosurgery: Spine Volume 32: Issue 6 (Jun 2020)

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Preoperative patient expectations and pain improvement after adult spinal deformity surgery

Micheal Raad, Andrew B. Harris, Varun Puvanesarajah, Mostafa H. El Dafrawy, Floreana N. Kebaish, Brian J. Neuman, Richard L. Skolasky, David B. Cohen, and Khaled M. Kebaish

OBJECTIVE

Patients’ expectations for pain relief are associated with patient-reported outcomes after treatment, although this has not been examined in patients with adult spinal deformity (ASD). The aim of this study was to identify associations between patients’ preoperative expectations for pain relief after ASD surgery and patient-reported pain at the 2-year follow-up.

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The authors analyzed surgically treated ASD patients at a single institution who completed a survey question about expectations for back pain relief. Five ordinal answer choices to “I expect my back pain to improve” were used to categorize patients as having low or high expectations. Back pain was measured using the 10-point numeric rating scale (NRS) and Scoliosis Research Society–22r (SRS-22r) patient survey. Preoperative and postoperative pain were compared using analysis of covariance.

RESULTS

Of 140 ASD patients eligible for 2-year follow-up, 105 patients (77 women) had pre- and postoperative data on patient expectations, 85 of whom had high expectations. The mean patient age was 59 ± 12 years, and 46 patients (44%) had undergone previous spine surgery. The high-expectations and low-expectations groups had similar baseline demographic and clinical characteristics (p > 0.05), except for lower SRS-22r mental health scores in those with low expectations. After controlling for baseline characteristics and mental health, the mean postoperative NRS score was significantly better (lower) in the high-expectations group (3.5 ± 3.5) than in the low-expectations group (5.4 ± 3.7) (p = 0.049). The mean postoperative SRS-22r pain score was significantly better (higher) in the high-expectations group (3.3 ± 1.1) than in the low-expectations group (2.6 ± 0.94) (p = 0.019).

CONCLUSIONS

Despite similar baseline characteristics, patients with high preoperative expectations for back pain relief reported less pain 2 years after ASD surgery than patients with low preoperative expectations.

InJournal of Neurosurgery: Spine Volume 33: Issue 4 (Oct 2020)

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Surgical outcomes of long spinal fusions for scoliosis in adult patients with rheumatoid arthritis

Addisu Mesfin, Mostafa H. El Dafrawy, Amit Jain, Hamid Hassanzadeh, John P. Kostuik, Mesfin A. Lemma, and Khaled M. Kebaish

OBJECT

In this study, the authors compared outcomes and complications in patients with and without rheumatoid arthritis (RA) who underwent surgery for spinal deformity.

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The authors searched the Johns Hopkins University database for patients with RA (Group RA) and without RA (Group NoRA) who underwent long spinal fusion for scoliosis by 3 surgeons at 1 institution from 2000 through 2012. Groups RA and NoRA each had 14 patients who were well matched with regard to sex (13 women/1 man and 12 women/2 men, respectively), age (mean 66.3 years [range 40.5–81.9 years] and 67.6 years [range 51–81 years]), follow-up duration (mean 35.4 months [range 1–87 months] and 44 months [range 24–51 months]), and number of primary (8 and 8) and revision (6 and 6) surgeries. Surgical outcomes, invasiveness scores, and complications were compared between the groups using the nonpaired Student t-test (p < 0.05).

RESULTS

For Groups RA and NoRA, there were no significant differences in the average number of levels fused (10.6 [range 9–17] vs 10.3 [range 7–17], respectively; p = 0.4), the average estimated blood loss (2892 ml [range 1300–5000 ml] vs 3100 ml [range 1700–5200 ml]; p = 0.73), or the average invasiveness score (35.5 [range 21–51] vs 34.5 [range 23–58]; p = 0.8). However, in Group RA, the number of major complications was significantly higher (23 vs 11; p < 0.001), the number of secondary procedures was significantly higher (14 vs 6; p < 0.001), and the number of minor complications was significantly lower (4 vs 12; p < 0.001) than those in Group NoRA.

CONCLUSIONS

Long spinal fusion in patients with RA is associated with higher rates of major complications and secondary procedures than in patients without RA.

InJournal of Neurosurgery: Spine Volume 22 (2015): Issue 4 (Apr 2015)

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Inpatient morbidity and mortality after adult spinal deformity surgery in teaching versus nonteaching hospitals

Rafael De la Garza-Ramos, Amit Jain, Khaled M. Kebaish, Ali Bydon, Peter G. Passias, and Daniel M. Sciubba

OBJECTIVE

The goal of this study was to compare inpatient morbidity and mortality after adult spinal deformity (ASD) surgery in teaching versus nonteaching hospitals in the US.

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The Nationwide Inpatient Sample was used to identify surgical patients with ASD between 2002 and 2011. Only patients > 21 years old and elective cases were included. Patient characteristics, inpatient morbidity, and inpatient mortality were compared between teaching and nonteaching hospitals. A multivariable logistic regression analysis was performed to examine the effect of hospital teaching status on surgical outcomes.

RESULTS

A total of 7603 patients were identified, with 61.2% (n = 4650) in the teaching hospital group and 38.8% (n = 2953) in the nonteaching hospital group. The proportion of patients undergoing revision procedures was significantly different between groups (5.2% in teaching hospitals vs 3.9% in nonteaching hospitals, p = 0.008). Likewise, complex procedures (defined as fusion of 8 or more segments and/or osteotomy) were more common in teaching hospitals (27.3% vs 21.7%, p < 0.001). Crude overall complication rates were similar in teaching hospitals (47.9%) compared with nonteaching hospitals (49.8%, p = 0.114). After controlling for patient characteristics, case complexity, and revision status, patients treated at teaching hospitals were significantly less likely to develop a complication when compared with patients treated at a nonteaching hospital (OR 0.89; 95% CI 0.82–0.98). The mortality rate was 0.4% in teaching hospitals and < 0.4% in nonteaching hospitals (p = 0.210).

CONCLUSIONS

Patients who undergo surgery for ASD at a teaching hospital may have significantly lower odds of complication development compared with patients treated at a nonteaching hospital.

InJournal of Neurosurgery: Spine Volume 25 (2016): Issue 1 (Jul 2016)

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Determining validity, discriminant ability, responsiveness, and minimal clinically important differences for PROMIS in adult spinal deformity

Alvaro Ibaseta, Rafa Rahman, Nicholas S. Andrade, Richard L. Skolasky, Khaled M. Kebaish, Daniel M. Sciubba, and Brian J. Neuman

OBJECTIVE

The aim of this study was to determine the concurrent validity, discriminant ability, and responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) in adult spinal deformity (ASD) and to calculate minimal clinically important differences (MCIDs) for PROMIS scores.

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The authors used data obtained in 186 surgical patients with ASD. Concurrent validity was determined through correlations between preoperative PROMIS scores and legacy measure scores. PROMIS discriminant ability between disease severity groups was determined using the preoperative Oswestry Disability Index (ODI) value as the anchor. Responsiveness was determined through distribution- and anchor-based methods, using preoperative to postoperative changes in PROMIS scores. MCIDs were estimated on the basis of the responsiveness analysis.

RESULTS

作者发现强烈的舞会之间的相关性IS Pain Interference and ODI and the Scoliosis Research Society 22-item questionnaire Pain component; PROMIS Physical Function and ODI; PROMIS Anxiety and Depression domains and the 12-Item Short Form Health Survey version 2, Physical and Mental Components, Scoliosis Research Society 22-item questionnaire Mental Health component (anxiety only), 9-Item Patient Health Questionnaire (anxiety only), and 7-Item Generalized Anxiety Disorder questionnaire; PROMIS Fatigue and 9-Item Patient Health Questionnaire; and PROMIS Satisfaction with Participation in Social Roles (i.e., Social Satisfaction) and ODI. PROMIS discriminated between disease severity groups in all domains except between none/mild and moderate Anxiety, with mean differences ranging from 3.7 to 8.4 points. PROMIS showed strong responsiveness in Pain Interference; moderate responsiveness in Physical Function and Social Satisfaction; and low responsiveness in Anxiety, Depression, Fatigue, and Sleep Disturbance. Final PROMIS MCIDs were as follows: –6.3 for Anxiety, –4.4 for Depression, –4.6 for Fatigue, –5.0 for Pain Interference, 4.2 for Physical Function, 5.7 for Social Satisfaction, and –3.5 for Sleep Disturbance.

CONCLUSIONS

PROMIS is a valid assessment of patient health, can discriminate between disease severity levels, and shows responsiveness to changes after ASD surgery. The MCIDs provided herein may help clinicians interpret postoperative changes in PROMIS scores, taking into account the fact that they are pending external validation.

InJournal of Neurosurgery: Spine Volume 34: Issue 5 (May 2021)

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Opioid use after adult spinal deformity surgery: patterns of cessation and associations with preoperative use

Mark Ren, Barry R. Bryant, Andrew B. Harris, Khaled M. Kebaish, Lee H. Riley III, David B. Cohen, Richard L. Skolasky, and Brian J. Neuman

OBJECTIVE

The objectives of the study were to determine, among patients with adult spinal deformity (ASD), the following: 1) how preoperative opioid use, dose, and duration of use are associated with long-term opioid use and dose; 2) how preoperative opioid use is associated with rates of postoperative use from 6 weeks to 2 years; and 3) how postoperative opioid use at 6 months and 1 year is associated with use at 2 years.

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Using a single-center, longitudinally maintained registry, the authors identified 87 patients who underwent ASD surgery from 2013 to 2017. Fifty-nine patients reported preoperative opioid use (37 high-dose [≥ 90 morphine milligram equivalents daily] and 22 low-dose use). The duration of preoperative use was long-term (≥ 6 months) for 44 patients and short-term for 15. The authors evaluated postoperative opioid use at 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. Multivariate logistic regression was used to determine associations of preoperative opioid use, dose, and duration with use at each time point (alpha = 0.05).

RESULTS

The following preoperative factors were associated with opioid use 2 years postoperatively: any opioid use (adjusted odds ratio [aOR] 14, 95% CI 2.5–82), high-dose use (aOR 7.3, 95% CI 1.1–48), and long-term use (aOR 17, 95% CI 2.2–123). All patients who reported high-dose opioid use at the 2-year follow-up examination had also reported preoperative opioid use. Preoperative high-dose use (aOR 247, 95% CI 5.8–10,546) but not long-term use (aOR 4.0, 95% CI 0.18–91) was associated with high-dose use at the 2-year follow-up visit. Compared with patients who reported no preoperative use, those who reported preoperative opioid use had higher rates of use at each postoperative time point (from 94% vs 62% at 6 weeks to 54% vs 7.1% at 2 years) (all p < 0.001). Opioid use at 2 years was independently associated with use at 1 year (aOR 33, 95% CI 6.8–261) but not at 6 months (aOR 4.3, 95% CI 0.95–24).

CONCLUSIONS

Patients’ preoperative opioid use, dose, and duration of use are associated with long-term use after ASD surgery, and a high preoperative dose is also associated with high-dose opioid use at the 2-year follow-up visit. Patients using opioids 1 year after ASD surgery may be at risk for long-term use.

InJournal of Neurosurgery: Spine Volume 33: Issue 4 (Oct 2020)

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Trends in isolated lumbar spinal stenosis surgery among working US adults aged 40–64 years, 2010–2014

Micheal Raad, Callum J. Donaldson, Mostafa H. El Dafrawy, Daniel M. Sciubba, Lee H. Riley III, Brian J. Neuman, Khaled M. Kebaish, and Richard L. Skolasky

OBJECTIVE

Recommendations for the surgical treatment of isolated lumbar spinal stenosis (LSS) (i.e., in the absence of concomitant scoliosis or spondylolisthesis) are unclear. The aims of this study were to investigate trends in the surgical treatment of isolated LSS in US adults and determine implications for outcomes.

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The authors analyzed inpatient and outpatient claims from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database for 20,279 patients aged 40–64 years who underwent surgery for LSS between 2010 and 2014. Only patients with continuous 12-month insurance coverage after surgery were included. The rates of decompression with arthrodesis versus decompression only and of simple (1- or 2-level, single-approach) versus complex (> 2-level or combined-approach) arthrodesis were analyzed by year and geographic region. These trends were further analyzed with respect to complications, length of hospital stay, payments made to the hospital, and patient discharge status. Statistical significance was set at p < 0.05.

RESULTS

病人的比例decompression with arthrodesis compared with decompression only increased significantly and linearly from 2010 to 2014 (OR 1.08; 95% CI 1.06–1.10). Arthrodesis was more likely to be complex rather than simple with each subsequent year (OR 1.4; 95% CI 1.33–1.49). This trend was accompanied by an increased likelihood of postoperative complications (OR 1.11; 95% CI 1.02–1.21), higher costs (payments increased by a mean of US$1633 per year; 95% CI 1327–1939), and greater likelihood of being discharged to a skilled nursing facility as opposed to home (OR 1.11; 95% CI 1.03–1.20). The South and Midwest regions of the US had the highest proportions of patients undergoing arthrodesis (48% and 42%, respectively). The mean length of hospital stay did not change significantly (p = 0.324).

CONCLUSIONS

From 2010 to 2014, the proportion of adults undergoing decompression with arthrodesis versus decompression only for the treatment of LSS increased, especially in the South and Midwest regions of the US. A greater proportion of these fusions were complex and were associated with more complications, higher costs, and a greater likelihood of being discharged to a skilled nursing facility.

InJournal of Neurosurgery: Spine Volume 29: Issue 2 (Aug 2018)

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An S-2 alar iliac pelvic fixation

Technical note

Lauren E. Matteini, Khaled M. Kebaish, W. Robert Volk, Patrick F. Bergin, Warren D. Yu, and Joseph R. O'Brien

Multiple techniques of pelvic fixation exist. Distal fixation to the pelvis is crucial for spinal deformity surgery. Fixation techniques such as transiliac bars, iliac bolts, and iliosacral screws are commonly used, but these techniques may require separate incisions for placement, leading to potential wound complications and increased dissection. Additionally, the use of transverse connector bars is almost always necessary with these techniques, as their placement is not in line with the S-1 pedicle screw and cephalad instrumentation. The S-2 alar iliac pelvic fixation is a newer technique that has been developed to address some of these issues. It is an in-line technique that can be placed during an open procedure or percutaneously.

InNeurosurgical Focus Volume 28 (2010): Issue 3 (Mar 2010)

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