RESUMEN
OBJECT: Complications after spine surgery have an impact on overall outcome and health care expenditures. The increased cost of complications is due in part to associated prolonged hospital stays. The authors propose that certain complications have a greater impact on length of stay (LOS) than others and that those complications should be the focus of future targeted prevention efforts. They conducted a retrospective analysis of a prospectively maintained database to identify complications with the greatest impact on LOS as well as the predictive value of these complications with respect to 90-day readmission rates. METHODS: Data on 249 patients undergoing spine surgery at Thomas Jefferson University from May to December 2008 were collected by a study auditor. Any complications occurring within 30 days of surgery were recorded as was overall LOS for each patient. Stepwise regression analysis was performed to determine whether specific complications had a statistically significant effect on LOS. For correlation, all readmissions within 90 days were recorded and organized by complication for comparison with those complications affecting LOS. RESULTS: The mean LOS for patients without postoperative complications was 6.9 days. Patients who developed pulmonary complications had an associated increase in LOS of 11.1 days (p < 0.005). The development of a urinary tract infection (UTI) was associated with an increase in LOS of 3.4 days (p = 0.002). A new neurological deficit was associated with an increase in LOS of 8.2 days (p = 0.004). Complications requiring return to the operating room (OR) showed a trend toward an increase in LOS of 4.7 days (p = 0.09), as did deep wound infections (3.3 days, p = 0.08). The most common reason for readmission was for wound drainage (n = 21; surgical drainage was required in 10 [4.01%] of these 21 cases). The most common diagnoses for readmission, in decreasing order of incidence, were categorized as hardware malpositioning (n = 4), fever (n = 4), pulmonary (n = 2), UTI (n = 2), and neurological deficit (n = 1). Complications affecting LOS were not found to be predictive of readmission (p = 0.029). CONCLUSIONS: Postoperative complications in patients who have undergone spine surgery are not uncommon and are associated with prolonged hospital stays. In the current cohort, the occurrence of pulmonary complications, UTI, and new neurological deficit had the greatest effect on overall LOS. Further study is required to determine the causative factors affecting readmission. These specific complications may be high-yield targets for cost reduction and/or prevention efforts.
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Tiempo de Internación , Readmisión del Paciente , Complicaciones Posoperatorias , Enfermedades de la Columna Vertebral/cirugía , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Análisis de Regresión , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OF BACKGROUND DATA: A patient comorbidity score (RCS) was developed from a prospective study of complications occurring in spine surgery patients. OBJECTIVE: To validate the RCS, we present an International Classification of Disease Clinical Modification (ICD-CM)-9 model of the score and correlate the score with complication incidence in a group of patients from the Nationwide Inpatient Sample database. We compare the predictive value of the score with the Charlson index. STUDY DESIGN: We conducted a retrospective assessment of Nationwide Inpatient Sample patients undergoing cervical or thoracolumbar spine surgery for degenerative pathology from 2002 to 2009. METHODS: We generated an ICD-9-CM coding-based model of our prospectively derived RCS, categorizing diagnostic codes to represent relevant comorbidities. Multivariate models were constructed to eliminate the least significant variables. ICD-9-CM coding was also used to calculate a Charlson comorbidity score for each patient. The accuracy of the RCS was compared with the Charlson index through the use of a receiver-operating curve. RESULTS: A total of 352,535 patients undergoing 369,454 spine procedures for degenerative disease were gathered. Hypertension and hyperlipidemia were the most common comorbidities. Cervical procedures resulted in 8286 complications (4.50%), whereas thoracolumbar procedures produced 25,118 complications (13.55%). Increasing RCS correlated linearly with increasing complication incidence (odds ratio [OR] 1.11; 95% confidence interval [CI], 1.10-1.13; P<0.0001). Logistic regression revealed that neurological deficit, cardiac conditions, and drug or alcohol use had greatest association with complication occurrence. The Charlson index also correlated with complication occurrence in both cervical (OR 1.25; 95% CI, 1.23-1.27) and thoracolumbar (OR 1.11; 95% CI, 1.10-1.12) patient groups. Receiver-operating curve analysis allowed a comparison of accuracy of the indices by comparing predictive values. The RCS performed as well as the Charlson index in predicting complication occurrence in both cervical and thoracic spine patients. CONCLUSIONS: ICD-9-based modeling validated that RCS correlates with complication occurrence. The RCS performed as well as the Charlson index in predicting risk of complication in spine patients.
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Complicaciones Intraoperatorias/epidemiología , Procedimientos Ortopédicos/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Columna Vertebral/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Comorbilidad , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Clasificación Internacional de Enfermedades , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Periodo Perioperatorio , Estudios Prospectivos , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , Vértebras Torácicas/cirugía , Adulto JovenRESUMEN
STUDY DESIGN: Laboratory study. OBJECTIVE: To evaluate the differential gene expression of cytokines and growth factors in anterior versus posterior annulus fibrosus (AF) intervertebral disc (IVD) specimens. SUMMARY OF BACKGROUND DATA: Histological analysis has demonstrated regional differences in vascular and neural ingrowth in the IVD, and similar differences may exist for cytokine and growth factor expression in patients with degenerative disc disease (DDD). Regional expression of these cytokines may also be related to the pain experienced in DDD. METHODS: IVD tissue was obtained from patients undergoing anterior lumbar interbody fusion surgery for back pain with radiological evidence of disc degeneration. For a control group, the discs of patients undergoing anterior lumbar discectomy for degenerative scoliosis were obtained as well. The tissue was carefully removed and separated into anterior and posterior AF. After tissue processing, an antibody array was completed to determine expression levels of 42 cytokines and growth factors. RESULTS: Nine discs from 7 patients with DDD and 5 discs from 2 patients with scoliosis were analyzed. In the DDD group, there were 10 cytokines and growth factors with significantly increased expression in the posterior AF versus the anterior AF ([interleukin] IL-4, IL-5, IL-6, M-CSF, MDC, tumor necrosis factor ß, EGF, IGF-1, angiogenin, leptin). In the scoliosis group, only angiogenin and PDGF-BB demonstrated increased expression in the posterior AF. No cytokines or growth factors had increased expression in the anterior AF compared with posterior AF. CONCLUSION: The posterior AF expresses increased levels of cytokines and growth factors compared with the anterior AF in patients with DDD. This differential expression may be important for targeting treatment of painful IVDs. LEVEL OF EVIDENCE: N/A.
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Citocinas/biosíntesis , Regulación de la Expresión Génica , Péptidos y Proteínas de Señalización Intercelular/biosíntesis , Disco Intervertebral/metabolismo , Adulto , Anciano , Citocinas/genética , Femenino , Humanos , Péptidos y Proteínas de Señalización Intercelular/genética , Disco Intervertebral/patología , Degeneración del Disco Intervertebral/genética , Degeneración del Disco Intervertebral/metabolismo , Degeneración del Disco Intervertebral/patología , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND CONTEXT: The Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) Physical Status Classification System (ASA grade) are useful for predicting morbidity and mortality for a variety of disease processes. PURPOSE: To evaluate CCI and ASA grade as predictors of complications after spinal surgery and examine the correlation between these comorbidity indices and the cost of care. STUDY DESIGN/SETTING: Prospective observational study. PATIENT SAMPLE: All patients undergoing any spine surgery at a single academic tertiary center over a 6-month period. OUTCOME MEASURES: Direct health-care costs estimated from diagnosis related group and Current Procedural Terminology (CPT) codes. METHODS: Demographic data, including all patient comorbidities, procedural data, and all complications, occurring within 30 days of the index procedure were prospectively recorded. Charlson Comorbidity Index was calculated from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and ASA grades determined from the operative record. Diagnosis related group and CPT codes were captured for each patient. Direct costs were estimated from a societal perspective using Medicare rates of reimbursement. A multivariable analysis was performed to assess the association of the CCI and ASA grade to the rate of complication and direct health-care costs. RESULTS: Two hundred twenty-six cases were analyzed. The average CCI score for the patient cohort was 0.92, and the average ASA grade was 2.65. The CCI and ASA grade were significantly correlated, with Spearman ρ of 0.458 (p<.001). Both CCI and ASA grade were associated with increasing body mass index (p<.01) and increasing patient age (p<.0001). Increasing CCI was associated with an increasing likelihood of occurrence of any complication (p=.0093) and of minor complications (p=.0032). Increasing ASA grade was significantly associated with an increasing likelihood of occurrence of a major complication (p=.0035). Increasing ASA grade showed a significant association with increasing direct costs (p=.0062). CONCLUSIONS: American Society of Anesthesiologists and CCI scores are useful comorbidity indices for the spine patient population, although neither was completely predictive of complication occurrence. A spine-specific comorbidity index, based on ICD-9-CM coding that could be easily captured from patient records, and which is predictive of patient likelihood of complications and mortality, would be beneficial in patient counseling and choice of operative intervention.
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Costos de la Atención en Salud , Procedimientos Ortopédicos/efectos adversos , Complicaciones Posoperatorias/epidemiología , Enfermedades de la Columna Vertebral/cirugía , Columna Vertebral/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Comorbilidad , Costo de Enfermedad , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Procedimientos Ortopédicos/economía , Complicaciones Posoperatorias/economía , Estudios Prospectivos , Enfermedades de la Columna Vertebral/economía , Enfermedades de la Columna Vertebral/epidemiologíaRESUMEN
STUDY DESIGN: Laboratory study. OBJECTIVE: To evaluate expression of chemokine regulated and normal T cell expressed and secreted (RANTES)/C-C motif ligand 5 (CCL5) and interleukins in intervertebral discs (IVDs) specimens from patients with discogram-proven painful degeneration. SUMMARY OF BACKGROUND DATA: Discogenic back pain results in tremendous costs related to treatment and lost productivity. The relationship between inflammation, degeneration (IVD), and cytokine upregulation is well established, but other mediators of the inflammatory cascade are not well characterized. METHODS: Painful IVDs were taken from 18 patients undergoing surgery for discogenic pain with positive preoperative discogram. Painless control tissue was taken at autopsy from patients without back pain/spinal pathology or spinal levels with negative discograms resected for deformity.Quantitative real time polymerase chain reaction (qRT-PCR) was performed to evaluate RANTES, IL-1ß, IL-6, and IL-8 expression in painful and control discs. RANTES and interleukin expression were analyzed on the basis of Pfirrmann grade.Disc cells were cultured in alginate beads using 2 groups: an untreated group and a group treated with 10 ng/mL IL-1ß, 10 ng/mL TNF-α, and 1% fetal bovine serum to induce a degenerative phenotype. RESULTS: Nine painless IVD specimens and 7 painful IVD specimens were collected. RANTES expression demonstrated a 3.60-fold increase in painful discs versus painless discs, a significant difference (P = 0.049). IL-1ß expression demonstrated significantly higher expression in painful discs (P = 0.03). RANTES expression data demonstrated significant upregulation with increasing Pfirrmann grade (P = 0.045). RANTES expression correlated significantly with IL-1ß expression (ρ = 0.67, P < 0.0001). RANTES expression increased more than 200-fold in the alginate culture model in cells treated with IL-1ß/TNF-α, 1% fetal bovine serum (P < 0.001). CONCLUSION: RANTES and IL-1ß expression was significantly elevated in painful IVDs after careful selection of painless versus painful IVD tissue. RANTES expression was found to correlate significantly with expression of IL-1ß. RANTES was upregulated by IL-1ß/TNF-α/1% fetal bovine serum an in vitro treatment to induce a degenerative phenotype.
Asunto(s)
Quimiocina CCL5/genética , Expresión Génica , Interleucina-1beta/genética , Disco Intervertebral/metabolismo , Adulto , Anciano , Animales , Bovinos , Células Cultivadas , Estudios de Cohortes , Medios de Cultivo/química , Medios de Cultivo/farmacología , Sangre Fetal/química , Humanos , Mediadores de Inflamación/metabolismo , Interleucina-1beta/farmacología , Interleucina-6/genética , Interleucina-8/genética , Disco Intervertebral/patología , Disco Intervertebral/cirugía , Degeneración del Disco Intervertebral/genética , Degeneración del Disco Intervertebral/fisiopatología , Degeneración del Disco Intervertebral/cirugía , Persona de Mediana Edad , Dolor/genética , Dolor/fisiopatología , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Suero/química , Factor de Necrosis Tumoral alfa/farmacología , Regulación hacia Arriba/efectos de los fármacosRESUMEN
BACKGROUND AND OBJECT: Complex intracranial aneurysms present a treatment challenge for both open and endovascular modalities of treatment. This report seeks to illustrate a series of patients with aneurysms treated with telescoping stents as a method of flow diversion for small and fusiform intracranial aneurysms. MATERIAL AND METHODS: A retrospective evaluation of six patients treated with a telescoping stent technique utilizing available stents (at that time before the pipeline era) for complex cerebral aneurysms between January 2009 and January 2010 was performed. Five patients had dissecting aneurysms and one patient had a small superior hypophyseal artery aneurysm. One of the patients was treated in the setting of a Hunt and Hess grade IV subarachnoid hemorrhage. Follow-up cerebral angiography was performed postprocedure at 6 months. RESULTS: At a mean follow-up period of 9 months, all the patients experienced complete or near-complete occlusion (>95%). No periprocedural complications were noted in this series. No episodes of hemorrhage or thromboembolic complications occurred. CONCLUSIONS: Overlapping Neuroform and Enterprise stents may induce complete thrombosis of intracranial aneurysms and facilitate parent artery remodeling. The use of self-expanding stents is still an adequate treatment modality, especially if there is a need for vessel wall stabilization rather than flow diversion. The technique is also a sufficient alternative in small intracranial aneurysms not readily amenable to open surgical treatment or traditional endovascular coil embolization.
Asunto(s)
Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/métodos , Aneurisma Intracraneal/cirugía , Procedimientos Neuroquirúrgicos/instrumentación , Procedimientos Neuroquirúrgicos/métodos , Stents , Adulto , Anciano , Prótesis Vascular , Angiografía Cerebral , Procedimientos Endovasculares/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Aneurisma Intracraneal/diagnóstico por imagen , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/efectos adversos , Estudios Retrospectivos , Hemorragia Subaracnoidea/epidemiología , Tromboembolia/epidemiología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: The risk factors predictive of intracranial aneurysm rupture remain incompletely defined. OBJECTIVE: To examine the association between various nonmodifiable risk factors and aneurysm rupture in a large cohort of patients evaluated at a single institution. METHODS: A retrospective analysis of patients admitted to a cerebrovascular facility between January 2006 and 2010 with a primary diagnosis of cerebral aneurysm. Aneurysms were divided into 2 groups: unruptured or ruptured. The dome diameter, aspect ratio (AR), location, sidedness, neck morphology, and multiplicity were entered into a central database. A full model was constructed, and a systematic removal of the least significant variables was performed in a sequential fashion until only those variables reaching significance remained. RESULTS: We identified 2347 patients harboring 5134 individual aneurysms, of which 34.90% were ruptured and 65.09% were unruptured. On admission, 25.89% of aneurysms with a dome diameter <10 mm and 58.33% of aneurysms with a dome >10 mm were ruptured (P < .001). Of aneurysms with an AR >1.6, 52.44% presented following a rupture (P < .001). The highest incidence of rupture (69.21%) was observed in aneurysms with an AR >1.6, dome diameter <10 mm, and a deviated neck. Deviated neck-type aneurysms had a significantly greater incidence of rupture than classical neck-type aneurysms (P < .001). CONCLUSION: An AR >1.6, dome diameter >10 mm, a deviated neck, and right-sidedness are independently associated with aneurysm rupture.
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Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/epidemiología , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/epidemiología , Angiografía Cerebral , Circulación Cerebrovascular , Estudios de Cohortes , Bases de Datos Factuales/estadística & datos numéricos , Humanos , Incidencia , Estudios Retrospectivos , Medición de Riesgo/métodos , Factores de RiesgoRESUMEN
STUDY DESIGN: Prospective observational study. OBJECTIVE: To determine how patient comorbidities and perioperative complications after spinal surgery affect the health care costs to society. SUMMARY OF BACKGROUND DATA: Despite efforts to reduce adverse events related to spinal surgery, complications are common and significantly increased by patient comorbidities. METHODS: Patients who underwent spinal surgery at a tertiary academic center during a 6-month period (May 2008 to December 2008) were prospectively followed. All demographic data, comorbidities, procedural information, and complications to 30-day follow-up were recorded. Diagnosis-Related Group codes and Current Procedural Terminology codes were captured for each patient. Direct costs were estimated from a societal perspective, using 2008 Medicare rates of reimbursement. A multivariable analysis was performed to assess the impact of specific patient comorbidities and complications on total health care costs. RESULTS: A total of 226 cases were analyzed. The mean cost of care for cases with complications was greater than that for cases without complications ($13,518.35 [95% confidence interval (CI), $9378.80-$17,657.90]; P < 0.0001). These results were consistent across degenerative, traumatic, and tumor/infection preoperative diagnoses. Cases with major complications were more costly than those with minor complications ($13,714.88 [CI, $6353.02-$21,076.74]; P = 0.0001). Systemic malignancy and preoperative neurological comorbidity were each associated with an increase in the cost of care ($7919 [CI, $2073-$15,225]; P = 0.006] and $5508 [CI, $814-$11,198; P = 0.02]), respectively, when compared with a baseline cost of care derived from all cases in the database. The cost of care was increased by pulmonary complications ($7233 [CI, $3982.53-$11,152.88]; P < 0.0001), instrumentation malposition ($6968 [CI, $1705.90-$14,277.16]; P = 0.0062), new neurological deficit ($4537 [CI, $863.95-$9274.30]; P = 0.013), and by wound infection ($4067 [CI, $1682.79-$6872.39]; P = 0.0004), after adjustment for covariates. CONCLUSION: Both minor and major complications were found to increase the cost of care in a prospective assessment of spine surgery complications. Specific patient comorbidities and perioperative complications are associated with significant increases in the total cost of care to society.
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Costos de la Atención en Salud , Hiperlipidemias/economía , Hipertensión/economía , Enfermedades Pulmonares/economía , Ortopedia , Complicaciones Posoperatorias/economía , Columna Vertebral/cirugía , Adulto , Anciano , Comorbilidad , Costos y Análisis de Costo , Grupos Diagnósticos Relacionados/economía , Femenino , Estudios de Seguimiento , Humanos , Reembolso de Seguro de Salud/economía , Masculino , Medicare/economía , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Estudios Retrospectivos , Estados UnidosRESUMEN
OBJECT: Present attempts to control health care costs focus on reducing the incidence of complications and hospital-acquired conditions (HACs). One approach uses restriction or elimination of hospital payments for HACs. Present approaches assume that all HACs are created equal and that payment restrictions should be applied uniformly. Patient factors, and especially patient comorbidities, likely impact complication incidence. The relationship of patient comorbidities and complication incidence in spine surgery has not been prospectively reported. METHODS: The authors conducted a prospective assessment of complications in spine surgery during a 6-month period; an independent auditor and a validated definition of perioperative complications were used. Initial demographics captured relevant patient comorbidities. The authors constructed a model of relative risk assessment based on the presence of a variety of comorbidities. They examined the impact of specific comorbidities and the cumulative effect of multiple comorbidities on complication incidence. RESULTS: Two hundred forty-nine patients undergoing 259 procedures at a tertiary care facility were evaluated during the 6-month duration of the study. Eighty percent of the patients underwent fusion procedures. One hundred thirty patients (52.2%) experienced at least 1 complication, with major complications occurring in 21.4% and minor complications in 46.4% of the cohort. Major complications doubled the median duration of hospital stay, from 6 to 12 days in cervical spine patients and from 7 to 14 days in thoracolumbar spine patients. At least 1 comorbid condition was present in 86% of the patients. An increasing number of comorbidities strongly correlated with increased risk of major, minor, and any complications (p = 0.017, p < 0.0001, and p < 0.0001, respectively). Patient factors correlating with increased risk of specific complications included systemic malignancy and cardiac conditions other than hypertension. CONCLUSIONS: Comorbidities significantly increase the risk of perioperative complications. An increasing number of comorbidities in an individual patient significantly increases the risk of a perioperative adverse event. Patient factors significantly impact the relative risk of HACs and perioperative complications.
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Complicaciones Intraoperatorias/epidemiología , Procedimientos Ortopédicos/efectos adversos , Complicaciones Posoperatorias/epidemiología , Enfermedades de la Columna Vertebral/epidemiología , Columna Vertebral/cirugía , Adulto , Anciano , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/cirugía , Comorbilidad , Humanos , Incidencia , Tiempo de Internación , Enfermedades Pulmonares/epidemiología , Enfermedades Pulmonares/cirugía , Enfermedades Metabólicas/epidemiología , Enfermedades Metabólicas/cirugía , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/epidemiología , Enfermedades del Sistema Nervioso/cirugía , Estudios Prospectivos , Enfermedades de la Columna Vertebral/cirugíaRESUMEN
OBJECT: Prospective examination of perioperative complications in spine surgery is limited in the literature. The authors prospectively collected data on patients who underwent spinal fusion at a tertiary care center and evaluated the effect of spinal fusion and comorbidities on perioperative complications. METHODS: Between May and December 2008 data were collected prospectively in 248 patients admitted to the authors' institution for spine surgery. The 202 patients undergoing spine surgery with instrumentation were further analyzed in this report. Perioperative complications occurring within the initial 30 days after surgery were included. All adverse occurrences, whether directly related to surgery, were included in the analysis. RESULTS: Overall, 114 (56.4%) of 202 patients experienced at least one perioperative complication. Instrumented fusions were associated with more minor complications (p = 0.001) and more overall complications (0.0024). Furthermore, in the thoracic and lumbar spine, complications increased based on the number of levels fused. Advanced patient age and certain comorbidities such as diabetes, cardiac disease, or a history of malignancy were also associated with an increased incidence of complications. CONCLUSIONS: Using a prospective methodology with a broad definition of complications, the authors report a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery.
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Complicaciones Posoperatorias/etiología , Fusión Vertebral/efectos adversos , Fusión Vertebral/instrumentación , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Ortopédicos/efectos adversos , Procedimientos Ortopédicos/instrumentación , Atención Perioperativa/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Enfermedades de la Columna Vertebral/diagnóstico , Enfermedades de la Columna Vertebral/epidemiología , Enfermedades de la Columna Vertebral/cirugíaRESUMEN
OBJECTIVE: To compare outcomes in the setting of spontaneous intracerebral hemorrhage (ICH) in patients taking aspirin (acetylsalicylic acid [ASA]) versus patients taking clopidogrel before hospitalization. METHODS: Patients admitted to the neurosurgical service with a spontaneous ICH while taking an antiplatelet agent were prospectively identified and retrospectively reviewed. Two groups of 28 consecutive patients taking ASA or clopidogrel on admission were ultimately evaluated. RESULTS: Patients in the clopidogrel group had a mean age of 72.6 years, and patients in the ASA group had a mean age of 65.8 years (P=0.04). Patients taking clopidogrel before hospitalization were significantly more likely than patients taking ASA to experience an increase in hematoma volume (P=0.05). Patients in the ASA group trended toward being discharged to home more frequently than other destinations (P=0.07). The in-hospital mortality rates in this series were 14.3% for the ASA group and 28.6% for the clopidogrel group. However, this association did not reach statistical significance (P=0.19). CONCLUSIONS: In this study, patients taking clopidogrel showed more hematoma expansion, higher in-hospital mortality rates, and a decreased likelihood of a home discharge compared with patients taking ASA alone.
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Hemorragia Cerebral/terapia , Inhibidores de Agregación Plaquetaria/efectos adversos , Transfusión de Plaquetas , Ticlopidina/análogos & derivados , Anciano , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Aspirina/efectos adversos , Aspirina/antagonistas & inhibidores , Aspirina/uso terapéutico , Hemorragia Cerebral/etiología , Clopidogrel , Interpretación Estadística de Datos , Quimioterapia Combinada , Servicios Médicos de Urgencia , Femenino , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/uso terapéutico , Estudios Prospectivos , Estudios Retrospectivos , Ticlopidina/efectos adversos , Ticlopidina/uso terapéutico , Derivación Ventriculoperitoneal , Ventriculostomía , Warfarina/efectos adversos , Warfarina/uso terapéuticoRESUMEN
STUDY DESIGN: Prospective observational cohort study. OBJECTIVE: To determine the incidence of early complications with thoracolumbar spine surgery and its correlation with preoperative diagnosis. SUMMARY OF BACKGROUND DATA: The reported incidence of early complications associated with thoracolumbar surgery is highly variable. Varying definitions of what constitutes a "complication" and varying study methodologies make evaluation and comparison of the literature difficult. No large study has investigated the effect of preoperative diagnosis and patient comorbidities on early postoperative complications in thoracolumbar surgery. METHODS: One-hundred twenty-eight consecutive patients who underwent thoracolumbar surgery by the neurosurgical service at the Thomas Jefferson University Hospital were prospectively entered into a central database from May to December 2008. An earlier-described, binary definition of major and minor complication was used. Data on preoperative diagnosis, comorbidities, body mass index, surgical procedure, length of stay (LOS), and early complication was examined using χ and time-to-discharge survival analysis. RESULTS: The overall complication incidence was 59.4%, with a minor complication incidence of 52.3% and a major complication incidence of 24.2%. The highest incidences of complications occurred in patients with the diagnosis of infection and tumor, where incidence exceeded 70%; this difference did not achieve statistical significance. The overall median LOS was 7 days; LOS was longer in patients with traumatic pathology (17 d) and patients with neoplastic pathology (14 d) (P<0.05). CONCLUSIONS: A higher incidence of complications than earlier studies was noted. A trend toward higher complication incidence in patients with infectious or neoplastic disease was observed. The severity of patient pathology, the broader definitions of complication used, and the elimination of recall bias by the use of a prospective study design accounts for the higher incidence of complications reported in this series. However, a large, prospective study using clear definitions is needed to elucidate the true incidence of early complications in thoracolumbar surgery.
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Vértebras Lumbares/cirugía , Procedimientos Neuroquirúrgicos/efectos adversos , Procedimientos Ortopédicos/efectos adversos , Complicaciones Posoperatorias/epidemiología , Vértebras Torácicas/cirugía , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVE: To investigate whether hypoxia regulates Notch signaling, and whether Notch plays a role in intervertebral disc cell proliferation. METHODS: Reverse transcription-polymerase chain reaction and Western blotting were used to measure expression of Notch signaling components in intervertebral disc tissue from mature rats and from human discs. Transfections were performed to determine the effects of hypoxia and Notch on target gene activity. RESULTS: Cells of the nucleus pulposus and annulus fibrosus of rat disc tissue expressed components of the Notch signaling pathway. Expression of Notch-2 was higher than that of the other Notch receptors in both the nucleus pulposus and annulus fibrosus. In both tissues, hypoxia increased Notch1 and Notch4 messenger RNA (mRNA) expression. In the annulus fibrosus, mRNA expression of the Notch ligand Jagged1 was induced by hypoxia, while Jagged2 mRNA expression was highly sensitive to hypoxia in both tissues. A Notch signaling inhibitor, L685458, blocked hypoxic induction of the activity of the Notch-responsive luciferase reporters 12xCSL and CBF1. Expression of the Notch target gene Hes1 was induced by hypoxia, while coexpression with the Notch-intracellular domain increased Hes1 promoter activity. Moreover, inhibition of Notch signaling blocked disc cell proliferation. Analysis of human disc tissue showed that there was increased expression of Notch signaling proteins in degenerated discs. CONCLUSION: In intervertebral disc cells, hypoxia promotes expression of Notch signaling proteins. Notch signaling is an important process in the maintenance of disc cell proliferation, and thus offers a therapeutic target for the restoration of cell numbers during degenerative disc disease.
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Hipoxia/metabolismo , Disco Intervertebral/metabolismo , Receptores Notch/metabolismo , Transducción de Señal/fisiología , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Animales , Western Blotting , Ciclo Celular/fisiología , Proliferación Celular , Células Cultivadas , Humanos , Inmunohistoquímica , Disco Intervertebral/citología , Persona de Mediana Edad , ARN Mensajero/genética , ARN Mensajero/metabolismo , Ratas , Receptores Notch/genética , Reacción en Cadena de la Polimerasa de Transcriptasa InversaRESUMEN
BACKGROUND: Aneurysms of the carotid-ophthalmic artery present unique challenges to cerebrovascular neurosurgeons given their proximity to vital anatomic structures. OBJECTIVE: To report our experience with a combined-modality treatment of unruptured carotid-ophthalmic aneurysms over a 12-year period. METHODS: A retrospective review of 161 patients who underwent open, endovascular, or combined treatment of 170 aneurysms from January 1997 to July 2009 was conducted. Medical records, operative reports, office notes, and follow-up angiograms were reviewed to obtain data on patient demographics, angiographic results, and clinical outcomes. RESULTS: One hundred forty-seven aneurysms were treated via endovascular techniques; 17 aneurysms (10%) were treated with microsurgical clip ligation; and 6 aneurysms (3.5%) were treated with a combined approach. Of the aneurysms treated via an endovascular approach alone, 81.6% of aneurysms had evidence of ≥ 95% occlusion on initial angiogram. There was a 1.4% rate of major complications associated with the initial procedure. Twenty-six of these aneurysms (18.9%) required further intervention on the basis of early angiographic results. Major complications occurred after 6 of 23 open microsurgical procedures (26.1%), including 2 instances of permanent visual loss. Nine clipped patients had long-term angiographic follow-up; none required further intervention. CONCLUSION: Endovascular treatment of carotid-ophthalmic aneurysms with modern endovascular techniques can be performed safely and efficaciously in the elective setting.
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Arteria Carótida Interna/diagnóstico por imagen , Arteria Carótida Interna/cirugía , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Arteria Oftálmica/diagnóstico por imagen , Arteria Oftálmica/cirugía , Estudios de Cohortes , Procedimientos Endovasculares/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Infection is a significant cause of morbidity with cranioplasty procedures. However, few studies have investigated the effect of specific surgical practices on cranioplasty infection. OBJECTIVE: To analyze the literature on the effect of early surgery (within 3 months of craniectomy), implant material, and method of flap preservation on cranioplasty infections, and to perform a subanalysis of the effect of early surgery on overall complications associated with cranioplasty. METHODS: A systematic search of the PubMed, Cochrane, SCOPUS, and CINAHL databases was conducted. Comparative studies that reported on timing of surgery, implant material (autograft vs allograft), or method of flap preservation (subcutaneous vs extracorporeal), and infection or complication rates were selected for detailed analysis. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each analysis. RESULTS: Eighteen articles (2254 data points) met criteria for inclusion. There was no difference in infection rates (OR, 1.35; 95% CI, 0.53-3.41; P = .53) or overall complication rates (OR, 0.57; 95% CI, 0.29-1.11; P = .10) between early or later surgery. Fourteen studies (n = 1582) compared infection rates between autograft and allograft materials; there was no difference in infection rates between the two (OR, 0.81; 95% CI, 0.40-1.66; P = .57). There was no significant difference in infection rates between subcutaneous or extracorporeal preservation (OR, 0.35; 95% CI, 0.09-1.35; P = .13). CONCLUSION: Analysis of the best current evidence suggests that early surgery, implant material, and method of flap preservation have no effect on the rate of cranioplasty infections.
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Craniectomía Descompresiva/efectos adversos , Colgajos Quirúrgicos/efectos adversos , Infección de la Herida Quirúrgica/etiología , Animales , Humanos , Estudios Retrospectivos , Colgajos Quirúrgicos/microbiología , Infección de la Herida Quirúrgica/epidemiología , Factores de TiempoRESUMEN
OBJECT: large studies of ICD-9-based complication and hospital-acquired condition (HAC) chart reviews have not been validated through a comparison with prospective assessments of perioperative adverse event occurrence. Retrospective chart review, while generally assumed to underreport complication occurrence, has not been subjected to prospective study. It is unclear whether ICD-9-based population studies are more accurate than retrospective reviews or are perhaps equally susceptible to bias. To determine the validity of an ICD-9-based assessment of perioperative complications, the authors compared a prospective independent evaluation of such complications with ICD-9-based HAC data in a cohort of patients who underwent spine surgery. For further comparison, a separate retrospective review of the same cohort of patients was completed as well. METHODS: a prospective assessment of complications in spine surgery over a 6-month period (May to December 2008) was completed using an independent auditor and a validated definition of perioperative complications. The auditor maintained a prospective database, which included complications occurring in the initial 30 days after surgery. All medical adverse events were included in the assessment. All patients undergoing spine surgery during the study period were eligible for inclusion; the only exclusionary criterion used was the availability of the auditor for patient assessment. From the overall patient database, 100 patients were randomly extracted for further review; in these patients ICD-9-based HAC data were obtained from coder data. Separately, a retrospective assessment of complication incidence was completed using chart and electronic medical record review. The same definition of perioperative adverse events and the inclusion of medical adverse events were applied in the prospective, ICD-9-based, and retrospective assessments. RESULTS: ninety-two patients had adequate records for the ICD-9 assessment, whereas 98 patients had adequate chart information for retrospective review. The overall complication incidence among the groups was similar (major complications: ICD-9 17.4%, retrospective 19.4%, and prospective 22.4%; minor complications: ICD-9 43.8%, retrospective 31.6%, and prospective 42.9%). However, the ICD-9-based assessment included many minor medical events not deemed complications by the auditor. Rates of specific complications were consistently underreported in both the ICD-9 and the retrospective assessments. The ICD-9 assessment underreported infection, the need for reoperation, deep wound infection, deep venous thrombosis, and new neurological deficits (p = 0.003, p < 0.0001, p < 0.0001, p = 0.0025, and p = 0.04, respectively). The retrospective review underestimated incidences of infection, the need for revision, and deep wound infection (p < 0.0001 for each). Only in the capture of new cardiac events was ICD-9-based reporting more accurate than prospective data accrual (p = 0.04). The most sensitive measure for the appreciation of complication occurrence was the prospective review, followed by the ICD-9-based assessment (p = 0.05). CONCLUSIONS: an ICD-9-based coding of perioperative adverse events and major complications in a cohort of spine surgery patients revealed an overall complication incidence similar to that in a prospectively executed measure. In contrast, a retrospective review underestimated complication incidence. The ICD-9-based review captured many medical events of limited clinical import, inflating the overall incidence of adverse events demonstrated by this approach. In multiple categories of major, clinically significant perioperative complications, ICD-9-based and retrospective assessments significantly underestimated complication incidence. These findings illustrate a significant potential weakness and source of inaccuracy in the use of population-based ICD-9 and retrospective complication recording.
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Clasificación Internacional de Enfermedades/estadística & datos numéricos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Gestión de Riesgos/estadística & datos numéricos , Enfermedades de la Columna Vertebral/cirugía , Adulto , Anciano , Sesgo , Estudios de Cohortes , Estudios Transversales , Femenino , Hospitales Universitarios/estadística & datos numéricos , Humanos , Incidencia , Masculino , Auditoría Médica/estadística & datos numéricos , Persona de Mediana Edad , Philadelphia , Estudios Prospectivos , Estudios Retrospectivos , Fusión Vertebral/estadística & datos numéricos , Espondilosis/cirugíaRESUMEN
STUDY DESIGN: Prospective observational cohort study. OBJECTIVE: To determine the incidence of early postoperative complications in patients undergoing cervical spine surgery and its correlation with preoperative diagnosis. SUMMARY OF BACKGROUND DATA: The reported incidence of complications and adverse events in cervical spine surgery is highly variable. Inconsistent definitions and varying methodologies have made the interpretation of earlier reports difficult. No large study has analyzed the overall early morbidity of cervical spine surgery in a prospective fashion or attempted to correlate preoperative diagnosis and comorbidities with perioperative complications. METHODS: Data on 121 consecutive patients, who underwent cervical spine surgery at the Thomas Jefferson University Hospital from May to December 2008, was prospectively collected. Complication definition and gradations of complication severity were validated by a survey of spine surgeons and spine surgery patients. An independent assessor prospectively audited complication incidence in the patient cohort. Data on diagnosis, comorbidities, BMI, complications, and length of stay were prospectively collected and assessed using stepwise multivariate analysis. RESULTS: The overall incidence of early complications was 47.1% with a 40.5% incidence of minor complications and an 18.2% incidence of major complications. Major complication incidence was greater in cases of infection (20.0%) and spinal oncologic procedures (30.0%), although this difference was not of statistical significance (P=0.07). Total number of complications recorded was greater in cases of infection and neoplasm (P=0.05). CONCLUSIONS: Complications in cervical spine procedures occurred most frequently in cases involving trauma and spinal oncologic procedures. This study illustrates that the incidence of early complications in cervical spine procedures is greater than appreciated earlier. This difference likely arises owing to the use of a broad definition of perioperative complications, elimination of recall bias through use of a prospective assessment, and overall case complexity. Accurate assessment of the incidence of early complications in cervical spine surgery is important for patient counseling and in design of prospective quality improvement programs.
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Vértebras Cervicales/cirugía , Procedimientos Ortopédicos/efectos adversos , Complicaciones Posoperatorias/epidemiología , Enfermedades de la Columna Vertebral/cirugía , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Procedimientos Ortopédicos/estadística & datos numéricos , Estudios Prospectivos , Enfermedades de la Columna Vertebral/diagnósticoRESUMEN
OBJECT: Using strict biochemical remission criteria, the authors assessed surgical outcomes after endoscopic transsphenoidal resection of growth hormone (GH)-secreting pituitary adenomas and identified preoperative factors that significantly influence the rate of remission. METHODS: A retrospective review of a prospectively maintained database was performed. The authors reviewed cases in which an endoscopic resection of GH-secreting pituitary adenomas was performed. The cohort consisted of 26 patients who had been followed for 3-60 months (mean 24.5 months). The thresholds of an age-appropriate, normalized insulin-like growth factor-I concentration, a nadir GH level after oral glucose load of less than 1.0 µg/l, and a random GH value of less than 2.5 µg/l were required to establish biochemical cure postoperatively. RESULTS: Overall, in 57.7% of patients undergoing a purely endoscopic transsphenoidal pituitary adenectomy for acromegaly, an endocrinological cure was achieved. The mean clinical follow-up duration was 24.5 months. In patients with microadenomas (4 cases) the cure rate was 75%, whereas in patients harboring macroadenomas (22 cases) the cure rate was 54.5%. Cavernous sinus invasion (Knosp Grades 3 and 4) was associated with a significantly lower remission rate (p = 0.0068). Hardy Grade 3 and 4 tumors were also less likely to achieve biochemical cure (p = 0.013). The overall complication rate was 11.5% including 2 incidents of transient diabetes insipidus and 1 postoperative CSF leak, which were treated nonoperatively. CONCLUSIONS: A purely endoscopic transsphenoidal approach to GH-secreting pituitary adenomas leads to similar outcome for noninvasive macroadenomas compared with traditional microsurgical techniques. Furthermore, this approach may often provide maximal visualization of the tumor, the pituitary gland, and the surrounding neurovascular structures.
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Acromegalia/cirugía , Endoscopía/métodos , Adenoma Hipofisario Secretor de Hormona del Crecimiento/cirugía , Hormona de Crecimiento Humana/metabolismo , Adenoma/cirugía , Adulto , Anciano , Femenino , Hormona de Crecimiento Humana/sangre , Humanos , Factor I del Crecimiento Similar a la Insulina/análisis , Estudios Longitudinales , Masculino , Microcirugia/métodos , Persona de Mediana Edad , Invasividad Neoplásica , Procedimientos Neuroquirúrgicos/métodos , Neoplasias Hipofisarias/cirugía , Inducción de Remisión , Hueso Esfenoides , Resultado del TratamientoRESUMEN
OBJECT: The reported incidence of complications in spine surgery varies widely. Variable study methodologies may open differing avenues for potential bias, and unclear definitions of perioperative complication make analysis of the literature challenging. Although numerous studies have examined the morbidity associated with specific procedures or diagnoses, no prospective analysis has evaluated the impact of preoperative diagnosis on overall early morbidity in spine surgery. To accurately assess perioperative morbidity in patients undergoing spine surgery, a prospective analysis of all patients who underwent spine surgery by the neurosurgical service at a large tertiary care center over a 6-month period was conducted. The correlation between preoperative diagnosis and the incidence of postoperative complications was assessed. METHODS: Data were prospectively collected on 248 consecutive patients undergoing spine surgery performed by the neurosurgical service at the Thomas Jefferson University Hospital from May to December 2008. A standardized definition of minor and major complications was applied to all adverse events occurring within 30 days of surgery. Data on diagnosis, complications, and length of stay were retrospectively assessed using stepwise multivariate analysis. Patients were analyzed by preoperative diagnosis (neoplasm, infection, degenerative disease, trauma) and level of surgery (cervical or thoracolumbar). RESULTS: Total early complication incidence was 53.2%, with a minor complication incidence of 46.4% and a major complication incidence of 21.3%. Preoperative diagnosis correlated only with the occurrence of minor complications in the overall cohort (p = 0.02). In patients undergoing surgery of the thoracolumbar spine, preoperative diagnosis correlated with presence of a complication and the number of complications (p = 0.003). Within this group, patients with preoperative diagnoses of infection and neoplasm were more often affected by isolated and multiple complications (p = 0.05 and p = 0.02, respectively). Surgeries across the cervicothoracic and thoracolumbar junctions were associated with higher incidences of overall complication than cervical or lumbar surgery alone (p = 0.04 and p = 0.03, respectively). Median length of stay was 5 days for patients without a complication. Length of stay was significantly greater for patients with a minor complication (10 days, p < 0.0001) and even greater for patients with a major complication (14 days, p < 0.0001). CONCLUSIONS: The incidence of complications found in this prospective analysis is higher than that reported in previous studies. This association may be due to a greater accuracy of record-keeping, absence of recall bias via prospective data collection, high complexity of pathology and surgical approaches, or application of a more liberal definition of what constitutes a complication. Further large-scale prospective studies using clear definitions of complication are necessary to ascertain the true incidence of early postoperative complications in spine surgery.