Adult Spinal Deformity Introduction Surgical Complications ...Adult Spinal Deformity Surgical...
Transcript of Adult Spinal Deformity Introduction Surgical Complications ...Adult Spinal Deformity Surgical...
SPINE CENTER
UCDAVIS
Adult Spinal DeformitySurgical Complications and
Classification
Eric Klineberg, MDProfessor and Vice Chair
Department of OrthopaedicsUniversity of California, Davis
9th Annual UCSF Practical Course in Advanced Spinal Techniques
SPINE CENTER
UCDAVIS
I have no financial interest with any company
regarding this subject
Eric Klineberg, MD
Consulting: Depuy/Synthes, Stryker, Medicrea
Speaking: AO Spine
Fellowship Funding: AO Spine
SPINE CENTERUCDAVIS
Introduction
Surgical intervention can have a significant impact
Complications can be significant
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Introduction
Deformity Surgery
– Considered to have higher risks
– Perioperative complications are frequent (up to 40%)
Glassman et al. Spine 2007
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What is a complication?
com·pli·ca·tion noun \ˌkäm-plə-ˈkā-shən\ : something that makes something
harder to understand, explain, or deal with medical : a disease or condition that happens in addition to
another disease or condition : a problem that makes a disease or condition more dangerous or harder to treat
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What is a complication?
Does it matter?
Complication List Infection Majoro Deep, Pneumonia, Sepsis Minoro Superficial, UTI, C Diff infection Implant Majoro Hook dislodgement, Interbody fracture/migration, Rod fracture/dislodgement, Screw fracture Minoro Painful/promininent, Screw malposition/loosening, Interbody subsidence/dislodgement
Radiographic Majoro DJK, PJK, Pseudoarthrosis Minoro Coronal/Sagittal imbalance, Curve decompensation, HO, Adjacent segment degeneration Neurologic Majoro Visual deficit/blindness, Brachial plexus injury, CVA/Stroke, Spinal cord injury, Nerve root injury with weakness, Retrograde ejaculation, Bowel/Bladder deficit Minoro Neuropathy or sensory deficit, Pain (radiculopathy), Peripheral nerve palsy, Delirium Mortality All majorCardiopulmonary Majoro Cardiac arrest, PE, Respiratory arrest, DVT, MI, Reintubation, ARDS Minor o Coagulopathy, Arrhythmia, Pleural effusion, Hypotension, CHF
Gastrointestinal Majoro Obstruction, Perforation, Bleed requiring surgery, Pancreatitis/Cholecystitis requiring surgery, Liver Failure, SMA Syndrome Minoro Ileus, Bleed not requiring surgical intervention, Pancreatitis/Cholecystitis no surgery
Renal Majoro Acute Renal failure requiring dialysis Minoro Acute Renal failure requiring medical intervention Operative Majoro Retained sponge/instrument, Wrong surgical level, Unintended extension of fusion, Vascular injury, Visceral injury, EBL >4L Minoro Dural tear, Fixation failure (hook/screw), Pedicle fracture, Posterior element fracture, Vertebral body fracture Wound Problems Majoro Dehiscence requiring surgery, Hematoma/seroma requiring surgery +/- neurological deficit, Incisional hernia Minoro Hematoma/seroma not requiring surgery, Hernia
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INTRODUCTION
Glassman et al– major and minor complications did not adversely
effect the improvement found in the HRQOL measures
– except for deterioration in the SF-12 for major complications.
Theorized that outcome instruments were not sensitive enough to detect a difference
Perioperative complications may not have a continued impact at one year.
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What is a complication?
Physician and patient dependent
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Prevention
Medical Optimization– Cardiac
– Pulmonary
– Nutritional
– Metabolic
– Bone Quality
– What about consent?
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Informed Consent
Despite ranking the consent process as important, patient recall was only 41% immediately after discussion and video re-enforcement.
Recall subsequently declined to 20% at 6 months post-operatively.
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Prevention
Medical Optimization– Cardiac
– Pulmonary
– Nutritional
– Metabolic
– Bone Quality
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Surgical Strategy
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Surgical Strategy
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Surgical Strategy
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Complication CategoryPeri-op (<6wks)
minor/major(%)
Delayed (>6wks)minor/major
(%)
Totalminor/major
(%)
Implant 3/8 (3.8) 11/59 (24.1) 14/67 (27.8)Radiographic 4/10 (4.8) 25/42 (23.0) 29/52 (27.8)Neurologic 21/24 (15.5) 16/20 (12.4) 37/44 (27.8)Operative 41/32 (25.1) 0/1 (0.3) 41/33 (25.4)Cardiopulmonary 31/20 (17.5) 1/3 (1.4) 32/23 (18.9)Infection 11/20 (10.7) 5/7 (4.1) 16/27 (14.8)Gastrointestinal 24/1 (8.6) 0/0 (0) 24/1 (8.6)Wound (excluding infection) 3/7 (3.4) 0/5 (1.7) 3/12 (5.2)Vascular 4/0 (1.4) 1/0 (0.3) 5/0 (1.7)Musculoskeletal 0/0 (0) 3/0 (1.0) 3/0 (1.0)Renal 1/2 (1.0) 0/0 (0) 1/2 (1.0)Other 2/1 (1.0) 0/0 (0) 2/1 (1.0)Total (minor/major) 270 (145/125) 199 (62/137) 469 (207/262)Mean # complications/patient (minor/major)
0.93 (0.50/0.43) 0.68 (0.21/0.47) 1.61 (0.71/0/90)
Number of patients affected (%)150 (51.5) 124 (42.6) 203 (69.8)
Results: 246 patients with 2 year f/u
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Complication CategoryPeri-op (<6wks)
minor/major(%)
Delayed (>6wks)minor/major
(%)
Totalminor/major
(%)
Implant 3/8 (3.8) 11/59 (24.1) 14/67 (27.8)
Radiographic 4/10 (4.8) 25/42 (23.0) 29/52 (27.8)
Neurologic 21/24 (15.5) 16/20 (12.4) 37/44 (27.8)
Operative 41/32 (25.1) 0/1 (0.3) 41/33 (25.4)
Cardiopulmonary 31/20 (17.5) 1/3 (1.4) 32/23 (18.9)
Infection 11/20 (10.7) 5/7 (4.1) 16/27 (14.8)
Gastrointestinal 24/1 (8.6) 0/0 (0) 24/1 (8.6)
Wound (excluding infection) 3/7 (3.4) 0/5 (1.7) 3/12 (5.2)
Vascular 4/0 (1.4) 1/0 (0.3) 5/0 (1.7)
Musculoskeletal 0/0 (0) 3/0 (1.0) 3/0 (1.0)
Renal 1/2 (1.0) 0/0 (0) 1/2 (1.0)
Other 2/1 (1.0) 0/0 (0) 2/1 (1.0)
Total (minor/major) 270 (145/125) 199 (62/137) 469 (207/262)
Mean # complications/patient (minor/major)0.93 (0.50/0.43) 0.68 (0.21/0.47) 1.61 (0.71/0/90)
Number of patients affected (%) 150 (51.5) 124 (42.6) 203 (69.8)
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Can We Develop A Better Complication Score?
We rely on AE/Minor/Major determination– No consensus
– Severity of complication may be biased
Can a less biased score better predict HRQoL outcomes?
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CMS
Increased interest in complications and when they occur
All complications that occur within 30 days from the operation
All readmission/reoperations that occur within 90 days
May have significant impact with bundling of payments
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Canadian (SAVES)
Have led the way with the development of a intervention severity score– Use a scale from I-IV to determine severity (or grades 1-6)
– Also assign a Length Of Stay modifier
– Do not have specific score for neurology, readmission or reoperation
– How we obtain the information is critical
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AO Spine/Scoli-Risk-1
Gathers info for non-neurologic complications
Granular information regarding neurologic injury
Defines the neurologic injury – (cord, motor, sensory, incontinence etc…)
– Level of injury
Describes timing, intervention, and outcome
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Factor that predicted 2-year SF-36PCS – Age (p < .001), ASA grade (p < .001)– Maximum preoperative Cobb angle (p = .007)– Number of three-column osteotomies (p = .049)– Type of neurologic complication (p = .068)
Factors predictive of 2-year SRS-22R Total scores Maximum preoperative Cobb angle (p = .001) Number of serious adverse events (p = .071)
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Do Complications Effect HRQoL?
355 pts prospectively enrolled in the ISSG multicenter study
202 met the inclusion criteria
Mean age 57.4, levels fused 12
Four groups identified:– No Complications N=84
– Minor Complications N=87
– Major Complications N=65
– Both Major and Minor N=35
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Baseline Pre-OP Demographics
Similar distribution for Age, BMI, and ASA, as well as Pre-OP spinopelvic parameters.
Sig lower Charlson Comorbidity Index for the no complication group.
No Complications Minor Major Both p‐value Age 55.2 57.7 61.1 58.8 0.072 BMI 26.9 27.3 28.1 28.4 0.487 ASA 2.2 2.4 2.4 2.4 0.06 Charlson 1.2 1.9 2.0 1.9 0.015* Smoker (%) 6 11 8 11 0.693 SVA (mm) 45.6 53.9 68.6 68.5 0.217 Max Cobb (Degrees) 41.5 45.0 41.9 44.2 0.689 Prior Spine Fusion Surgery (%)
75.0 73.0 80.6 70.6 0.853
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Operative Summary
Trend towards > PSO for Major and Both complication groups
No complication group also had the lowest percent of BMP, anterior approach, EBL and Time in the OR.
– May be a surrogate for surgical complexity.
No Complications Minor Major Both p‐value Levels Fused 12.0 11.9 12.3 12.4 0.825 Osteotomy (%) 71.1 55.6 71.4 73.0 0.997 PSO/PVCR (%) 22.9 21.1 31.7 29.7 0.413 BMP (%) 51.8% 86.7% 86.5% 69.8% 0.0001 Anterior (%) 14.5 30.0 30.2 40.5 0.013 EBL (cc) 1783 2061 2698 2704 0.005* OR Time (min) 412 494 517 533 0.0001** Length of Stay (Days) 8.0 8.9 10.5 9.9 0.073
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Baseline/1 Year HRQoL
All
ComplicationNo
ComplicationMajor Minor Both Pvalues
BaselineODI(Std)
42.5(19.6)
41.3(19.5)
46.4(17)
39.5(19.5)
42.5(16.9)
NS
1yearODI(Std)
28.3(20.2)
26.6(18.6)
29.9(20)
26.9(20.0)
28.1(19.5)
NS
BaselinePCS(Std)
32.9(10.3)
32.9(9.75)
31.1(8.8)
33.9(10.3)
31.8(9.9)
NS
1yearPCS(Std)
39.5(11.1)
41.3(10.9)
38.0(12)
40.7(10.8)
39.8(11.3)
NS
Significant improvement in All groups from Baseline to 1 year
No differences between groups for any of the outcome measures, regardless of complication
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1 Year HRQoL
Significant impact on ODI and PCS for readmission, reoperation and no complication resolution.
NoReadmission Readmission PValue1yearODI 24.5 39.5 P<0.011yearPCS 41.3 31.9 P<0.01 NoReoperation Reoperation 1yearODI 24.8 37.1 P<0.011yearPCS 41.1 33.9 P<0.01 ResolutionOf
Complication NoResolution
1yearODI 24.5 39.5 P<0.011yearPCS 41.3 31.9 P<0.01
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ISSG/AO/ESSG
Working to develop a comprehensive score
Using: – 1. Complication Category
– 2. Intervention severity
– 3. Complication Severity
– 4. Neurologic severity
– 5. Reoperation/readmission
– 6. Resolution of complication
– 7. Timing/Effect on LOS
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Complication Grading System
Complication Score
0 1 2 3
Severity Adverse Event
Minor Major Death
Intervention None Non-Invasive Invasive Surgical
Neurologic Sensory Motor Bowel/BladderSpinal Cord
InjuryImpact on Length
of StayNone <2 days 3-7 days >7 days
Readmission No Yes
Revision Surgery No Yes
Resolution Resolved Unresolved
Timing Intra-op In HospitalEarly Post-Op
(<90 days)Late Post OP (>3 mo - 1 yr)
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Application of the system
Different components of the score could be used for different outcome metrics
Ie: LOS vs HRQoL
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Complication Impact on LOS
Univariate analysis identified factors that correlated with increase over predicted LOS: – cumulative complication severity (OR 1.23, p=.0001)
– cumulative intervention severity (OR 1.15, p=0.0001)
– number of complications (OR 1.26, p=.02)
Development of a model to predict hospital LOS based on complications– Actual LOS was sigificantly higher than predicted LOS (10.7 days vs
8.3 days, p=0.0001)
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Impact on HRQoL at 2 years
Minimum one complication had lower 2-yr improvements in HRQL– (SF-36 PCS 6.91 vs 9.48, p=.012, and SRS-22r 0.79 vs 0.95,
p=.03).
Number of complications – (PCS -0.1159, p=.016, SRS -0.0929, p=.048)
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Impact on HRQoL at 2 years
Severity Score: – maximum severity score (PCS -0.1157, p=0.016)
– cumulative severity score (PCS -0.1223, p=.011, SRS -0.1487, p=.03)
Intervention Score:– Maximum intervention score (PCS -0.16, p=.001, SRS -0.125, p=.008)
– Cumulative Intervention Score (PCS 0.1245, p=.0096)
Complication resolution:– resolved complication PCS -2.22, p=.048,
– unresolved complication PCS -3.12 p=.012
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Spine Complication Classification
A simple classification system with discrete data points
A more comprehensive one with additional data points and subgroups that captures more granular data.
Determining what data points need to be acquired is our first challenge
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Complication Category
Each complication receives a categorical letter and sub-letter to define its primary complication category
Then each complication is stratified into the four complication modifiers: – neurologic
– timing
– intervention severity
– resolution
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Universal Spine Complication Classification
Neurological
Timing
Intervention
Resolution
Classification
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Neurological
LEMS Score
Severity
No Deficit
Sensory only +/- Pain
Motor+/- Impact on ambulatory
status
Spinal Cord Injury
+/- Impact on ambulatory
status
+/- Impact on bowel/bladder
function
Neurologic Sub Score
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Timing (of complication diagnosis)
Intraoperative
In-Hospital
+/- Reoperation
+/- <30 days
Post-discharge
<30 days
+/-Readmission
+/- Reoperation
30-90 days
+/-Readmission
+/- Reoperation
>90 days
+/-Readmission
+/- Reoperation
Timing Sub Score
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Intervention
(choose highest)
Mild
consultation, lab values, diagnostic imaging, small
needle intervention (contrast, epidural, transfusion)
Moderate
large needle intervention (PICC line, chest tube,
angiocath, dialysis), cardioversion
Severe
Surgical treatment (knife intervention)
Intervention Sub Score
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Resolution status
Completeresolution
Partial resolution
Unresolved (unchanged)
Death
Resolution Sub Score
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Universal Spine Complications Classification
Medical
Neurological
Timing
Intervention
Resolution
Surgical
Neurological
Timing
Intervention
Resolution
ISSG/AO/ESSG
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Validation
Identification and classification of complications can be difficult, and simple categories will improve our ability to classify and quantify the impact of complications.
Intrinsic surgeon bias may increase accuracy of reporting for some complications more then others– Ie better reporting of surgical vs medical complications
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Methods
10 randomized cases were sent to participants, and they were asked to identify the complications and complete a standardized data collection form.
There were 34 events that occurred: – 25 events with only one complication
– 5 with 2 complications
– 4 with 2 or more complications
Cat N % Cases with Mean StD
Gastro 2 20% 0.2 0.421637
Musculoskeletal 3 30% 0.3 0.483046
CNS 3 30% 0.3 0.483046
Cardiac 5 20% 0.5 1.080123
Pulmonary 1 10% 0.1 0.316228
Renal 1 10% 0.1 0.316228
Radiographic 4 30% 0.4 0.699206
Neurologic 7 50% 0.7 0.948683
Operative 8 70% 0.8 0.632456
Wound/Approach 2 10% 0.2 0.632456
Implant 1 10% 0.1 0.316228
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Results
17 people filled out all questionnaires: – 10 attending surgeons, 5 trainees, and 2 research
coordinators.
Overall accuracy– 87.4% high level (i.e. neurologic vs gastrointestinal vs cardiac
etc.)
– 75.7% with more granular data (i.e. motor deficit vs ileus vs MI etc).
Accuracy for medical and surgical complications is similar– (87.6% vs 87.1% for high level, 77.4% vs 74.3% for detail).
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Results
Highest overall accurate rate– CVA, gastrointestinal and
radiographic (above 94%)
Lowest overall accurate rate – renal (44.8%), pulmonary
(54.5%) cardiac (55%).
Overall event accuracy (combination of complications occurring simultaneously) is 57.1%.
HighLevel 2 Detail Level 3
Gastro 94.1% 94.1%
Musculoskeletal 80.6% 80.6%
CNS 100.0% 98.1%
Cardiac 88.2% 55.0%
Pulmonary 54.5% 54.5%
Renal 81.3% 44.8%
Radiographic 96.2% 96.2%
Neurologic 77.9% 66.9%
Operative 89.7% 79.6%
Wound/Approach 100.0% 65.6%
Implant 81.3% 81.3%
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Results
Neurologic impairment per event was accurate for 79.1%.
Intervention severity is 79.6% accurate, with the highest rate for severe intervention (98.6%).
Resolution was accurately reported for 70.3% of the events– 80.1% for Resolved
– 42.9% for Unresolved
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Conclusions
Accurate reporting and gathering of complications is difficult to standardize.
In this cased based survey, complex complications were categorized accurately 87%, neuro deficits accurately 79%, intervention accuracy of 80% and resolution accuracy of 70%.
Surgeons need to be actively involved in complication reporting to enhance accuracy.
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Does this system help us?
What is the effect / incidence of timing?
What is the effect on HRQL?
Can it predict LOS?
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Background: Timing of complication
The timing and impact of complications over time is important to understand for patients, payors and providers. While most medical and operative complications occur proximate to the index surgical intervention, complications may occur at any time point during the care of our adult spinal deformity patients.
Understanding the timing of specific complications may be helpful to guide patients and surgeons. The impact of those complications on health outcomes at 2 years is also critically important.
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CompsIntra Operative Before discharge After discharge
Sum % Event Sum % Event Sum % Event
Adverse Event 43 28.9% 73 47.1% 71 23.3%
Cardiopulmonary 14 9.4% 41 26.5% 20 6.6%
Gastrointestinal 3 2.0% 37 23.9% 4 1.3%
Implant 6 4.0% 1 0.6% 111 36.4%
Infection 1 0.7% 21 13.5% 31 10.2%
Neurologic 19 12.8% 19 12.3% 61 20.0%
Operative 97 65.1% 7 4.5% 6 2.0%
Other 0 0.0% 1 0.6% 2 0.7%
Radiographic 0 0.0% 1 0.6% 130 42.6%
Renal 0 0.0% 3 1.9% 0 0.0%
Wound 1 0.7% 2 1.3% 7 2.3%
Before 30D Between 30 and 90D After 90D
Sum % Event Sum % Event Sum % Event
Adverse Event 82 55.0% 12 7.7% 55 18.0%
Cardiopulmonary 51 34.2% 7 4.5% 3 1.0%
Gastrointestinal 39 26.2% 1 0.6% 1 0.3%
Implant 6 4.0% 6 3.9% 100 32.8%
Infection 39 26.2% 11 7.1% 3 1.0%
Neurologic 27 18.1% 18 11.6% 36 11.8%
Operative 10 6.7% 1 0.6% 2 0.7%
Other 2 1.3% 0 0.0% 1 0.3%
Radiographic 11 7.4% 21 13.5% 99 32.5%
584/732 patients met inclusion criteria (mean age 58.6yrs, 78% female, mean BMI 27.5, mean CCI 1.64, mean ODI 43.5).70.9% had least one complication event over the 2-year period, with an average of 1.45 events per patient.
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Complications over time….
Early
Continue
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All Complications: Relationship to Timing
All Complications
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Propensity Matching
grp Mean p
BE
FO
RE
MA
TC
HIN
G
BL_ODI 0 40.340.001
1 45.85
BL_PCS 0 33.920.000
1 30.62
demo_AgeBase0 55.86
0.0011 60.31
BL_Frailty_Index0 2.909
0.0001 3.504
LATpre_PI_LL0 12.54
0.0031 18.08
AF
TE
R M
AT
CH
ING
BL_ODI 0 42.150.791
1 41.66
BL_PCS 0 32.840.878
1 33.00
demo_AgeBase0 57.69
0.9381 57.81
BL_Frailty_Index0 3.054
0.7901 3.013
LATpre_PI_LL0 14.44
0.5871 15.62
grp Mean p
Y2_ODI 0 23.430.104
1 26.72
Y2_PCS 0 42.600.043
1 40.24
Y2_MCS 0 51.170.925
1 51.29
Y2_SRS_ACTIVITY 0 3.750.168
1 3.61
Y2_SRS_PAIN 0 3.650.055
1 3.44
Y2_SRS_APPEARANCE 0 3.780.143
1 3.64
Y2_SRS_MENTAL 0 3.900.933
1 3.91
Y2_SRS_SATIS 0 4.300.093
1 4.13
Y2_SRS_TOTAL 0 3.820.133
1 3.70
Y2_SF36_PF 0 41.090.015
1 38.20
Y2_SF36_RP 0 42.530.522
1 41.72
Y2_SF36_BP 0 45.830.053
1 43.56
Y2_SF36_GH 0 49.300.347
1 48.19
Y2_SF36_VT 0 49.730.372
1 48.66
Y2_SF36_SF 0 45.880.680
1 45.37
Y2 SF36 RE 0 46 62
• With only one complication: regardless of type had worse final outcomes then no comps
• No complication:• ODI (40 to 22, p=0.01)• PCS (33.9 to 43, p=0.05)
• One complication • ODI (45.8 to 30.5, p=0.05)• PCS (30.6 to 38, p=0.05)
When we sub-analyze for type of complication, those that occur early have
minimal effect, while those that occur later have a much more significant effect.
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Conclusion: Timing
Complications occur over-time and can be predicted by type.
Implant, radiographic and neurologic complications continue to occur over time, and need to be followed closely.
Complication type is critical, and those complications that occur later, and increase over-time are more impactful for our patients at 2 years.
Determining the relationship of the timing of complications and its impact to our patients is critical to understand.
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LOS: Hypothesis
Investigate the role of complications that occur during the initial hospitalization to predict LOS based on a novel classification that includes treatment severity.
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LOS: distribution
This parameter is not normally distributed
– Kolmogorov-Smirnov p = 1.1737E-27
Comparison with poison distribution
– Kolmogorov-Smirnov p = 0.103964
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LOS Parameters
List of surgical parameters simplified for abstract analysis– Posterior length of fusion:
“short” versus “medium” versus “long” fusion
– Threshold for short < 5
– Threshold for long > 13
– Major osteo versus no
– IBF versus no IBF
– Primary versus revision
– Stage yes/no
– Posterior only vs combined
N Mean StD Min Max 25th 50th 75th
Length of fusion
Short 102 4.24 2.09 1 11 3 4 5
Medium 407 6.43 2.01 2 12 5 6 7
Long 138 6.88 1.93 2 12 6 7 8
3 column ostotomy
No Major 574 6.07 2.24 1 12 5 6 7
Major 86 6.57 1.84 3 12 5 6 8
Interbody fusion
No 242 5.95 1.71 1 12 5 6 7
Yes 414 6.22 2.41 1 12 4.75 6 8
revision
Primary 476 6.17 2.24 1 12 5 6 7
Revision 184 6.05 2.10 1 12 5 6 7
Approach
Posterior Only 426 5.95 1.79 1 12 5 6 7Anterior-Posterior (APSF) 223 6.58 2.72 1 12 4 7 9
Stage
Same Day 492 5.79 1.97 1 12 5 6 7
Staged 109 8.11 2.13 2 12 7 8 9.5
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LOS Demographics
494 patients included in the analysis– Mean age: 61 year
– 73.8% female
– 28.07 kb/m2
Mean ASA grade was 2.44– 45.3% Grade 2
– 45.7% Grade 3
Mean number of levels fused posterior:– 11.6 +/- 3.9
Mean number of levels fused using IBF– 2.5 +/- 1.6
77.3% underwent some type of osteotomy– 26.1% underwent a major osteotomy (PSO / VCR)
78.7% same day surgery
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LOS by Intervention
During the hospital stay– 65.1% of the maximum intervention where minor
– 10.1% had at least one moderate intervention
– 10.5% had at least one severe intervention
Reop rate: 9.5%
Number of events per patient between surgery and discharge– Mean Number events: 1.7 +/- 1.1
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Multivariate Analysis
4 independent predictors identified – Group posterior fusion (short being reference)
Medium (p = 5.0798E-10)
Long (p = 8.7728E-12)
– Major Osteo (No Major being reference) Use of Major (p = 0.000986)
– Stage (Same day being reference) Stage (p = 0.0E0)
– Intervention (No complication being reference) No intervention (p = 0.000219)
Minor intervention (p = 0.000004)
Moderate intervention (p = 0.000006)
Severe intervention (p = 0.006724)
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Predicators of LOS
3 parameters are significant independent predictor of LOS– Posterior fusion length group
– Stage yes/no
– Intervention
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Conclusion: LOS
LOS is correlated to in-hospital complications and to complication intervention severity.
Surgical factors that affect LOS included length of fusion, major osteotomy or need for staged surgery.
Increased invasiveness of complication treatment was identified by a novel complication severity assessment scale as the only non-surgical factor that independently predicted increased hospital LOS following ASD surgery.
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Much left to understand
Relationship of complication to HRQoL measure (ie timing)– Likely a correlation, and effect of complication weaken with time
– Complication that has no effect now, but does later
Cost of complication– May use scoring system
Consensus for component score– AO Spine, ISSG, ESSG, Canadians, others….
Development of a complication score
SPINE CENTERUCDAVIS
• Although surgical treatment for ASD can improve pain and disability, it is associated with high rates of complications.
• Many complications likely have minimal or no impact on ultimate patient outcome at 2 years• But may have impact on LOS, cost, recovery time
• No classification is currently able to predict LOS or HRQoL
• Can a comprehensive scores better classify complications for us and our patients?
Conclusion