Adult Spinal Deformity Complications Eric Klineberg, MD Associate - PDF document

Adult Spinal Deformity Complications Eric Klineberg, MD Associate Professor Department of Orthopaedics UC DAVIS University of California, S PINE C ENTER Davis Speaking: AO, Depuy/Synthes Fellowship Funding: Depuy/Synthes, OREF Grants: AO Foundation I have no financial interest with any company regarding this subject UC DAVIS Eric Klineberg, S PINE C ENTER MD 1

Introduction  Surgical intervention can have a significant impact  Complications can be significant UC DAVIS S PINE C ENTER Introduction Deformity Surgery – Considered to have higher risks – Perioperative complications are frequent (up to 40%) UC DAVIS Glassman et al. Spine 2007 S PINE C ENTER 2

What is a complication?  com·pli·ca·tion  noun \ ˌ käm- 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 UC DAVIS S PINE C ENTER What is a complication? Complication List Infection  Major  o Deep, Pneumonia, Sepsis Gastrointestinal  Minor   Major  o Superficial, UTI, C Diff infection o Obstruction, Perforation, Bleed requiring surgery, Pancreatitis/Cholecystitis requiring surgery, Liver Implant Failure, SMA Syndrome  Major   Minor  o Hook dislodgement, Interbody fracture/migration, Rod fracture/dislodgement, Screw fracture o Ileus, Bleed not requiring surgical intervention, Pancreatitis/Cholecystitis no surgery  Minor  o Painful/promininent, Screw malposition/loosening, Interbody subsidence/dislodgement Renal  Major  Radiographic o Acute Renal failure requiring dialysis  Major   Minor  o DJK, PJK, Pseudoarthrosis o Acute Renal failure requiring medical intervention  Minor  Operative o Coronal/Sagittal imbalance, Curve decompensation, HO, Adjacent segment degeneration  Major  Neurologic o Retained sponge/instrument, Wrong surgical level, Unintended extension of fusion, Vascular injury,  Major  Visceral injury, EBL >4L o Visual deficit/blindness, Brachial plexus injury, CVA/Stroke, Spinal cord injury, Nerve root injury  Minor  with weakness, Retrograde ejaculation, Bowel/Bladder deficit o Dural tear, Fixation failure (hook/screw), Pedicle fracture, Posterior element fracture, Vertebral body  Minor  fracture o Neuropathy or sensory deficit, Pain (radiculopathy), Peripheral nerve palsy, Delirium Wound Problems Mortality  Major   All major  o Dehiscence requiring surgery, Hematoma/seroma requiring surgery +/- neurological deficit, Cardiopulmonary Incisional hernia  Minor   Major  o Cardiac arrest, PE, Respiratory arrest, DVT, MI, Reintubation, ARDS o Hematoma/seroma not requiring surgery, Hernia  Minor  o Coagulopathy, Arrhythmia, Pleural effusion, Hypotension, CHF Does it matter? UC DAVIS S PINE C ENTER 3

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. UC DAVIS S PINE C ENTER What is a complication?  Physician and patient dependent UC DAVIS S PINE C ENTER 4

Prevention  Medical Optimization – Cardiac – Pulmonary – Nutritional – Metabolic – Bone Quality – What about consent? UC DAVIS S PINE C ENTER  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. UC DAVIS S PINE C ENTER 5

Prevention  Medical Optimization – Cardiac – Pulmonary – Nutritional – Metabolic – Bone Quality UC DAVIS S PINE C ENTER Cardiac  Clearance – Inc risk with:  Unstable coronary sx  Decompensated CHF  Arrhythmias  Severe valvular disease  PMH – MI, CHF, stroke , DM, Renal insuff, poor exercise tolerence  Perfusion Studies  Rx: beta blocker UC DAVIS S PINE C ENTER 6

Pulmonary  Pre-op – CXR  Poor exercise tolerance > 2 min bicycle  PFT  Post-op – Mobilization – Minimize vent time UC DAVIS S PINE C ENTER Nutrition  Pre-op maximize – Risk factors: < 60yo, DM, Osteomyelitis, SCI – Labs: albumin, pre-albumin, TLC count  Feed early if possible – Nutrition Consult – Feeding tube – G-tube  Take 6-12 weeks for nutrition to return to baseline UC DAVIS S PINE C ENTER 7

Metabolic  Optimize Diabetes – Serum glucose 110 mg/dL  Pre-op and intra-op  High blood glucose associated with increase in complications – Infection, pneumonia UC DAVIS S PINE C ENTER Bone Quality  Pre-operative prevention, treatment – Osteoporosis < 2.5 STD – Risk factors:  age > 50, smoking, Caucasian, Hx of Fx – Rx: Bisphosphonates – Forteo?  Fracture  PJK vs PJF – Who needs revision after? UC DAVIS S PINE C ENTER 8

Intra-Operative  Blood loss – TXA, Amicar – Hypotension  Two Surgeons? – UCSF group and others UC DAVIS S PINE C ENTER Surgical Strategy UC DAVIS S PINE C ENTER 9

Surgical Strategy UC DAVIS S PINE C ENTER Surgical Strategy UC DAVIS S PINE C ENTER 10

Do Complications affect 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 UC DAVIS S PINE C ENTER Baseline Pre-OP Demographics � 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� 75.0� 73.0� 80.6� 70.6� 0.853� � Surgery� (%) � �  Similar distribution for Age, BMI, and ASA, as well as Pre-OP spinopelvic parameters.  Sig lower Charlson Comorbidity Index for the no complication group. UC DAVIS S PINE C ENTER 11

Operative Summary � � 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�  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. – UC DAVIS S PINE C ENTER Baseline/1 Year HRQoL All� No� � Major� Minor� Both� P� values� Complication� Complication� Baseline� ODI� 42.5� � � � � � � � 41.3� � � � � � � � 46.4� 39.5� 42.5� NS� (Std)� (19.6)� (19.5)� (17)� (19.5)� (16.9)� 1� year� ODI� � 28.3� � � � � � � � � 26.6� � � � � � � � � � � 29.9� 26.9� 28.1� NS� (Std)� (20.2)� (18.6)� (20)� (20.0)� (19.5)� Baseline� PCS� 32.9� � � � � � � � 32.9� � � � � � � � � � � � � 31.1� 33.9� 31.8� NS� (Std)� (10.3)� (9.75)� (8.8)� (10.3)� (9.9)� 1� year� PCS� 39.5� � � � � � � � � 41.3� � � � � � � � � 38.0� 40.7� 39.8� NS� (Std)� (11.1)� (10.9)� (12)� (10.8)� (11.3)� � Significant improvement in All groups from Baseline to 1 year No differences between groups for any of the outcome measures, regardless of complication UC DAVIS S PINE C ENTER 12

1 Year HRQoL � No� Readmission� Readmission� P� Value� 1� year� ODI� 24.5� 39.5� P� <� 0.01� 1� year� PCS� 41.3� 31.9� P� <� 0.01� � No� Reoperation� Reoperation� � 1� year� ODI� 24.8� 37.1� P� <� 0.01� 1� year� PCS� 41.1� 33.9� P� <� 0.01� � Resolution� Of� � No� Resolution� Complication� 1� year� ODI� 24.5� 39.5� P� <� 0.01� 1� year� PCS� 41.3� 31.9� P� <� 0.01� � Significant impact on ODI and PCS for readmission, reoperation and no complication resolution. UC DAVIS S PINE C ENTER Discussion  We found that baseline metrics were similar for complication and non-complication groups except for Charslon  Increased complexity of surgery (BMP, EBL, OR time) correlated with complications. – Perhaps a function of increased deformity UC DAVIS S PINE C ENTER 13