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Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative

Hesham Mostafa Zakaria, Michael Bazydlo, Lonni Schultz, Markian A. Pahuta, Jason M. Schwalb, Paul Park, Ilyas Aleem, David R. Nerenz, Victor Chang, and for the MSSIC Investigators

OBJECTIVE

密歇根Collaborati脊柱手术的改进ve (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.

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A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.

RESULTS

Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.

CONCLUSIONS

A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

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

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Postoperative opioid prescription and patient-reported outcomes after elective spine surgery: a Michigan Spine Surgery Improvement Collaborative study

Seokchun Lim, Hsueh-han Yeh, Mohamed Macki, Sameah Haider, Travis Hamilton, Tarek R. Mansour, Edvin Telemi, Lonni Schultz, David R. Nerenz, Jason M. Schwalb, Muwaffak Abdulhak, Paul Park, Ilyas Aleem, Richard Easton, Jad G. Khalil, Miguelangelo Perez-Cruet, and Victor Chang

OBJECTIVE

This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery.

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Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis.

RESULTS

Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56).

CONCLUSIONS

The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors’ analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.

InJournal of Neurosurgery: Spine Volume 38: Issue 2 (Feb 2023)

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The association of patient education level with outcomes after elective lumbar surgery: a Michigan Spine Surgery Improvement Collaborative study

Travis Hamilton, Mohamed Macki, Seok Yoon Oh, Michael Bazydlo, Lonni Schultz, Hesham Mostafa Zakaria, Jad G. Khalil, Miguelangelo Perez-Cruet, Ilyas Aleem, Paul Park, Richard Easton, David R. Nerenz, Jason Schwalb, Muwaffak Abdulhak, and Victor Chang

OBJECTIVE

Socioeconomic factors have been shown to impact a host of healthcare-related outcomes. Level of education is a marker of socioeconomic status. This study aimed to investigate the relationship between patient education level and outcomes after elective lumbar surgery and to characterize any education-related disparities.

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密歇根Collaborati脊柱手术的改进ve registry was queried for all lumbar spine operations. Primary outcomes included patient satisfaction determined by the North American Spine Society patient satisfaction index, and reaching the minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score and return to work up to 2 years after surgery. Multivariate Poisson generalized estimating equation models reported adjusted risk ratios.

RESULTS

共有26229个腰椎患者数据vailable for inclusion in this study. On multivariate generalized estimating equation analysis all comparisons were done versus the high school (HS)/general equivalency development (GED)–level cohort. For North American Spine Society satisfaction scores after surgery the authors observed the following: at 90 days the likelihood of satisfaction significantly decreased by 11% (p < 0.001) among < HS, but increased by 1% (p = 0.52) among college-educated and 3% (p = 0.011) among postcollege-educated cohorts compared to the HS/GED cohort; at 1 year there was a decrease of 9% (p = 0.02) among < HS and increases of 3% (p = 0.02) among college-educated and 9% (p < 0.001) among postcollege-educated patients; and at 2 years, there was an increase of 5% (p = 0.001) among postcollege-educated patients compared to the < HS group. The likelihood of reaching a minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score at 90 days increased by 5% (p = 0.005) among college-educated and 9% (p < 0.001) among postcollege-educated cohorts; at 1 year, all comparison cohorts demonstrated significance, with a decrease of 12% (p = 0.007) among < HS, but an increase by 6% (p < 0.001) among college-educated patients and 14% (p < 0.001) among postcollege-educated compared to the HS/GED cohort; at 2 years, there was a significant decrease by 19% (p = 0.003) among the < HS cohort, an increase by 8% (p = 0.001) among the college-educated group, and an increase by 16% (p < 0.001) among the postcollege-educated group. For return to work, a significant increase was demonstrated at 90 days and 1 year when comparing the HS or less group with college or postcollege cohorts.

CONCLUSIONS

This study demonstrated negative associations on all primary outcomes with lower levels of education. This finding suggests a potential disparity linked to education in elective spine surgery.

InJournal of Neurosurgery: Spine Volume 36: Issue 6 (Jun 2022)

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Impact of Michigan’s new opioid prescribing laws on spine surgery patients: analysis of the Michigan Spine Surgery Improvement Collaborative

Paul Park, Victor Chang, Hsueh-Han Yeh, Jason M. Schwalb, David R. Nerenz, Lonni R. Schultz, Muwaffak M. Abdulhak, Richard Easton, Miguelangelo Perez-Cruet, Osama N. Kashlan, Mark E. Oppenlander, Nicholas J. Szerlip, Kevin N. Swong, and Ilyas S. Aleem

OBJECTIVE

2017年,密歇根通过新的立法设计to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.

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Patient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.

RESULTS

Patients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).

CONCLUSIONS

有一个有意义的preopera下降tive narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

InJournal of Neurosurgery: Spine Volume 34: Issue 3 (Mar 2021)

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Association of prolonged symptom duration with poor outcomes in lumbar spine surgery: a Michigan Spine Surgery Improvement Collaborative study

Travis Hamilton, Seamus Bartlett, Nachiket Deshpande, Moustafa Hadi, Jared C. Reese, Tarek R. Mansour, Edvin Telemi, Kylie Springer, Lonni Schultz, David R. Nerenz, Muwaffak Abdulhak, Teck Soo, Jason Schwalb, Jad G. Khalil, Ilyas Aleem, Richard Easton, Miguelangelo Perez-Cruet, Paul Park, and Victor Chang

OBJECTIVE

There is a scarcity of large multicenter data on how preoperative lumbar symptom duration relates to postoperative patient-reported outcomes (PROs). The objective of this study was to determine the effect of preoperative and baseline symptom duration on PROs at 90 days, 1 year, and 2 years after lumbar spine surgery.

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密歇根Collaborati脊柱手术的改进ve registry was queried for all lumbar spine operations between January 1, 2017, to December 31, 2021, with a follow-up of 2 years. Patients were stratified into three subgroups based on symptom duration: < 3 months, 3 months to < 1 year, and ≥ 1 year. The primary outcomes were reaching the minimal clinically important difference (MCID) for the PROs (i.e., leg pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), EQ-5D, North American Spine Society satisfaction, and return to work). The EQ-5D score was also analyzed as a continuous variable to calculate quality-adjusted life years. Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios, with the < 3-month cohort used as the reference.

RESULTS

There were 37,223 patients (4670 with < 3-month duration, 9356 with 3-month to < 1-year duration, and 23,197 with ≥ 1-year duration) available for analysis. Compared with patients with a symptom duration of < 1 year, patients with a symptom duration of ≥ 1 year were significantly less likely to achieve an MCID in PROMIS PF, EQ-5D, back pain relief, and leg pain relief at 90 days, 1 year, and 2 years postoperatively. Similar trends were observed for patient satisfaction and return to work. With the EQ-5D score as a continuous variable, a symptom duration of ≥ 1 year was associated with 0.04, 0.05, and 0.03 (p < 0.001) decreases in EQ-5D score at 90 days, 1 year, and 2 years after surgery, respectively.

CONCLUSIONS

A symptom duration of ≥ 1 year was associated with poorer outcomes on several outcome metrics. This suggests that timely referral and surgery for degenerative lumbar pathology may optimize patient outcome.

InJournal of Neurosurgery: Spine Publish Before Print

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Disparities in outcomes after spine surgery: a Michigan Spine Surgery Improvement Collaborative study

Mohamed Macki, Travis Hamilton, Seokchun Lim, Edvin Telemi, Michael Bazydlo, David R. Nerenz, Hesham Mostafa Zakaria, Lonni Schultz, Jad G. Khalil, Miguelangelo J. Perez-Cruet, Ilyas S. Aleem, Paul Park, Jason M. Schwalb, Muwaffak M. Abdulhak, and Victor Chang

OBJECTIVE

Most studies on racial disparities in spine surgery lack data granularity to control for both comorbidities and self-assessment metrics. Analyses from large, multicenter surgical registries can provide an enhanced platform for understanding different factors that influence outcome. In this study, the authors aimed to determine the effects of race on outcomes after lumbar surgery, using patient-reported outcomes (PROs) in 3 areas: the North American Spine Society patient satisfaction index, the minimal clinically important difference (MCID) on the Oswestry Disability Index (ODI) for low-back pain, and return to work.

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密歇根Collaborati脊柱手术的改进ve was queried for all elective lumbar operations. Patient race/ethnicity was categorized as Caucasian, African American, and “other.” Measures of association between race and PROs were calculated with generalized estimating equations (GEEs) to report adjusted risk ratios.

RESULTS

The African American cohort consisted of a greater proportion of women with the highest comorbidity burden. Among the 7980 and 4222 patients followed up at 1 and 2 years postoperatively, respectively, African American patients experienced the lowest rates of satisfaction, MCID on ODI, and return to work. Following a GEE, African American race decreased the probability of satisfaction at both 1 and 2 years postoperatively. Race did not affect return to work or achieving MCID on the ODI. The variable of greatest association with all 3 PROs at both follow-up times was postoperative depression.

CONCLUSIONS

While a complex myriad of socioeconomic factors interplay between race and surgical success, the authors identified modifiable risk factors, specifically depression, that may improve PROs among African American patients after elective lumbar spine surgery.

InJournal of Neurosurgery: Spine Volume 35: Issue 1 (Jul 2021)

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