PURPOSE: To evaluate the 30-day complication rates after arthroscopic meniscus repair and meniscectomy using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, with subgroup analysis of patients aged > 40 years. METHODS: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing arthroscopic meniscus repair (CPT 29882, 29883) and meniscectomy (29880, 29881). The following 30-day complications were assessed: pulmonary embolism (PE), venous thromboembolism (VTE), surgical site infection (SSI), reoperation, and readmission. Complications rates between treatment groups were compared using multivariate logistic regression analyses adjusted for sex, age, steroid use, and smoking/dyspnoea/COPD. A subgroup analysis was performed for patients aged > 40 years. RESULTS: A total 6354 meniscus repairs and 99,372 meniscectomies were identified. Complication rates were < 1% for both meniscus repair and meniscectomy. Meniscus repair was associated with significantly higher rates of PE, VTE, and readmission compared to meniscectomy: PE (0.2% vs 0.1%, p < 0.001), VTE (0.8% vs 0.4%, p < 0.001), superficial SSI (0.1% vs 0.2%, n.s), deep SSI (0.07% vs 0.1%, n.s), reoperation (0.5% vs 0.4%, n.s), and readmission (0.9% vs 0.8%, p = 0.003). Among patients aged > 40 years, complication rates were < 1.3% for both meniscus repair and meniscectomy. Similar trends and rates were found in patients aged > 40 years undergoing meniscus repair versus meniscectomy: PE (0.38% vs 0.12%, p < 0.001), VTE (1.07% vs 0.46%, p < 0.001), superficial SSI (0.03% vs 0.19%, n.s), deep SSI (0.1% vs 0.06%, n.s), reoperation (0.48% vs 0.43%, n.s), and readmission (1.2% vs 0.85%, p = 0.01). CONCLUSION: Arthroscopic meniscus repair and meniscectomy are both low-risk procedures with 30-day complication rates < 1% overall and < 1.3% among patients aged > 40 years. These findings support meniscus repair whenever feasible in the setting of preserved articular cartilage. Understanding of the short-term complication rates after arthroscopic meniscus repair and meniscectomy can aid surgeons in providing comprehensive preoperative counselling to patients considering such treatments, specifically when discussing the risks and benefits of meniscus repair. LEVEL OF EVIDENCE: III.

BACKGROUND CONTEXT: COVID-19 has been shown to adversely affect multiple organ systems, yet little is known about its effect on perioperative complications after spine surgery or the optimal timing of surgery after an infection. We used the NIH National COVID Cohort Collaborative (N3C) database to characterize the risk profile in patients undergoing spine surgery during multiple time windows following COVID-19 infection. METHODS: We queried the National COVID Cohort Collaborative, a database of 17.4 million persons with 6.9 million COVID-19 cases, for patients undergoing lumbar spinal fusion surgery. Patients were stratified into those with an initial documented COVID-19 infection within 3 time periods: 0 to 2 weeks, 2 to 6 weeks, or 6 to 12 weeks before surgery. RESULTS: A total of 60,541 patients who underwent lumbar spinal fusion procedures were included. Patients who underwent surgery within 2 weeks of their COVID-19 diagnosis had a significantly increased risk for venous thromboembolic events (OR 2.29, 95% CI 1.58-3.32), sepsis (OR 1.56, 95% CI 1.03-2.36), 30-day mortality (OR 5.55, 95% CI 3.53-8.71), and 1-year mortality (OR 2.70, 95% CI 1.91-3.82) compared with patients who were COVID negative during the same period. There was no significant difference in the rates of acute kidney injury or surgical site infection. Patients undergoing surgery between 2 and 6 weeks or between 6 and 12 weeks from the date of COVID-19 infection did not show significantly elevated rates of any complication analyzed. CONCLUSIONS: Patients undergoing lumbar spinal fusion within 2 weeks from initial COVID-19 diagnosis are at increased risk for perioperative venous thromboembolic events and sepsis. This effect does not persist beyond 2 weeks, however, so it may be warranted to postpone non-urgent spine surgeries for at least 2 weeks following a COVID-19 infection or to consider a more aggressive VTE chemoprophylaxis regimen for urgent surgery in COVID-19 patients.

Study design

Retrospective Review.

Objectives

Compare clinical outcomes and radiographic correction of adult degenerative scoliosis (ADS) patients treated with lateral lumbar interbody fusion (LLIF), combined either with percutaneous (no laminectomy) versus open laminectomy/pedicle screw instrumentation.

Methods

Twenty-two ADS patients undergoing combined LLIF and posterior instrumentation were divided into two groups: thirteen patients underwent LLIF with open laminectomy and posterior pedicle instrumentation (Group-1, six revision); nine patients underwent LLIF with percutaneous pedicle instrumentation (no decompression) (Group-2). Radiographs, CT/MRI, peri-operative complications, VAS, SF-12, and ODI were measured.

Results

Average follow up was 22 months. In Group-1 and Group-2, respectively: Mean coronal Cobb angle corrected 12.6° and 5.8°; Mean regional lumbar lordosis improved 11.1° and 3.8°; Pelvic incidence minus lumbar lordosis mismatch corrected to within +/-9° in 46% and 0% of patients; Mean VAS improved from 5.4 to 2.8 and 6.3 to 1; Mean ODI improved 19% and 22%. Improvements were found in SF-12 PCS and MCS scores.

Conclusions

Both open and percutaneous posterior techniques following LLIF significantly improved clinical outcomes. Open procedures resulted in significantly better radiographic improvements but also higher complication rates. LLIF with percutaneous posterior fixation, without decompression, should be considered part of the algorithm in select ADS patients with remaining compensatory mechanisms and understanding that greater degrees of correction may require an open, more extensive approach.

STUDY DESIGN: Retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program database from 2010 to 2020. PURPOSE: To compare the short-term complication rates of anterior cervical decompression and fusion (ACDF), posterior cervical laminoplasty (LP), and posterior cervical laminectomy and fusion (PCF) in a geriatric population. OVERVIEW OF LITERATURE: The geriatric population in the United States has increased significantly. Degenerative cervical myelopathy (DCM) is caused by cervical spinal stenosis, and its prevalence increases with age. Therefore, the incidence of multilevel DCM requiring surgical intervention is likely to increase. ACDF, LP, and PCF are the most commonly used surgical techniques for treating multilevel DCM. However, there is uncertainty regarding the optimal surgical technique for the decompression of DCM in geriatric patients. METHODS: Patients aged 65 years who had undergone either multilevel ACDF, LP, or PCF for the treatment of DCM were analyzed. Additional analysis was performed by standardizing the data for the American Society of Anesthesiologists classification scores and preoperative functional status. RESULTS: A total of 23,129 patients were identified. Patients with ACDF were younger, more often female, and preoperatively healthier than those in the other two groups. The estimated postoperative mortality and morbidity, mean operation time, and length of hospital stay were the lowest for ACDF, second lowest for LP, and highest for PCF. The readmission and reoperation rates were comparable between ACDF and LP; however, both were significantly lower than PCF. CONCLUSIONS: PCF is associated with the highest risk of mortality, morbidity, unplanned reoperation, and unplanned readmission in the short-term postoperative period in patients aged 65 years. In contrast, ACDF carries the lowest risk. However, some disease-specific factors may require posterior treatment. For these cases, LP should be included in the preoperative discussion when determining the ideal surgical approach for geriatric patients.

Background

Bone graft extenders are being used more in spine surgery as a substitute for iliac crest bone graft. However, potential conflict of interest could impact average fusion rates. The purpose of this study was to evaluate whether fusion rates reported in the literature were different in papers evaluating bone graft substitutes and extenders when there was potential conflict of interest versus no potential conflict of interest.

Methods

Pubmed was searched for studies evaluating fusion rates when bone graft extenders including demineralized bone matrix, hydroxyapatite, and tricalcium sulfate were used. Studies were screened for one or two level fusions and for degenerative spinal conditions. The average fusion rates of subgroups were compared using unpaired Student's t-tests.

Results

1928 studies were evaluated. 86 studies were included in the study. The fusion rates varied from 4 to 100%. There were 24 studies with a potential conflict of interest and 62 studies with no conflict of interest. The average fusion rate of all the studies was 84.63% with standard deviation of 18.33%. The average fusion rates of those studies with conflict of interest was 80.93% versus 86.06% without conflict of interest. This was not statistically significant (p>0.07). The average fusion rate of studies evaluated by CT scan was 79.8% versus 87.9% without CT. The average fusion rate of studies that employed an independent reviewer to evaluate the fusion was 82.61% versus 85.63% for studies with no independent reviewer.

Conclusion

There is a great variability in the reported fusion rates of bone graft extenders. Counter to expectations, average fusion rates were lower in the studies where there was a potential conflict of interest. The use of CT scans and an independent reviewer seem to account for the lower reported fusion rates, and may be a means of negating the potential conflicts of interest in fusion studies.

Level of evidence

2.

Study design

Biomechanical, cadaveric study.

Objective

To compare the fixation strength of a novel S1 pedicle screw insertion technique in a revision setting to a standard S1 pedicle screw and an L5 pedicle screw.

Summary of background data

Fusions to the sacrum remain a difficult clinical challenge. Very few salvage techniques exist when a nonunion occurs.

Methods

The biomechanical integrity of three screw fixations, L5 pedicle screws, a standard S1 pedicle screw, and an S1 pedicle screw placed via a superior articulating process entry point (SAP S1), was characterized by performing pullout tests using cadaveric specimens including L5 and sacrum.

Results

SAP S1 constructs (735.5 ± 110.1 N/mm) were significantly stiffer than standard S1 (P = 0.005) and L5 (P = 0.02) constructs. There was no statistically significant difference between the L5 constructs and the standard S1 constructs for linear stiffness. There was no statistical difference between the three fixations for yield load, displacement at yield load, and energy absorbed to yield load.The ultimate pullout force for the SAP S1 was statistically higher than the standard S1 (1213.7 ± 579.6 vs. 478.6 ± 452.9 N; P = 0.004). Displacement at ultimate load was significantly greater for L5 screw fixation (3.3 ± 1.1 mm) compared to the other two constructs. Both the L5 (2277.4 ± 1873.3 N-mm) and SAP S1 (2628.2 ± 2054.4 N-mm) constructs had significantly greater energy absorbed to ultimate load than the standard S1 construct (811.7 ± 937.6 N-mm), but there was no statistical difference between the L5 and SAP S1 constructs.

Conclusion

S1 pedicle screw fixation via an SAP entry point provides biomechanical advantages compared to screws placed via the standard S1 or L5 entry point and may be a viable option for revision of a failed L5-S1 fusion with a compromised standard S1 entry point.

Level of evidence

N/A.

Study design

Retrospective database study.

Objective

To investigate the impact obstructive sleep apnea (OSA) has on perioperative complications, inpatient mortality, and costs in patients undergoing spinal fusions.

Methods

Hospitalizations for spinal fusion surgery between the years 2009 and 2011 were identified using the Nationwide Inpatient Sample and grouped into patients with and without OSA. Patient demographic data, comorbidities, hospital characteristics, hospitalization outcomes, and costs were extracted and compared. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing spinal fusion with and without OSA.

Results

A total of 107 451 (7.7%) OSA patients who underwent spinal fusions were identified from 2009 to 2011. Compared with patients without OSA, OSA patients were significantly older, more likely to be male, and have significantly greater comorbidity burden. Multivariable regression analysis demonstrated that OSA had a significant independent association with slightly increased respiratory (odds ratio [OR] = 1.13, confidence interval [CI] = 1.09-1.16; P < .001), urinary and renal (OR = 1.11, CI = 1.07-1.16; P < .001) or overall inpatient complications (OR = 1.05, CI = 1.02-1.05; P < .001). OSA was also independently associated with significantly lower inpatient mortality (OR = 0.39, CI = 0.33-0.45; P < .001).

Conclusions

While OSA confers greater comorbidity burden and is associated with slightly higher inpatient complication rates following spinal fusions, diagnosed OSA was not an independent predictor of inpatient mortality. A cautious interpretation of this finding is that on a national level, the current methods of preoperative medical optimization and inpatient management of OSA are satisfactory.

Background

Previous studies show an increasing incidence of gram-negative organisms in surgical site infections after spine surgery. This study is looking for the association of the post-operative prophylactic use of Bactrim and the gram-negative surgical site infection after lumbar spine surgery.

Methods

Patients who underwent lumbar spine surgery between August 2010 and December 2019 at the institution were retrospectively reviewed.

Results

There were 11 infections out of 511 cases where no oral antibiotics were given (2.2%). There were 2 infections out of 84 cases where Bactrim was given (2.4%). This was not statistically significant (P=0.89). The organisms cultured from the no oral antibiotic group were 8 cases of methicillin sensitive Staphylococcus aureus (MSSA), 1 case of E. coli, 1 case of Pseudomonas aeruginosa, 1 case of MRSA. The organisms cultured from the Bactrim group were 1 case of MRSA, and 1 case of combined Citrobacter freundii and methicillin sensitive Staphylococcus aureus (MSSA).

Conclusion

There was no statistically significant difference in SSIs when Bactrim was given for two weeks after surgery. However, two subjects who developed infection from the Bactrim group were paradoxically affected by gram-negative and antibiotic resistant organisms. So, clinicians should be judicious in their use of oral antibiotics after spine surgery. Level of Evidence: III.

Study design

Biomechanical, cadaveric study.

Objectives

To compare the relative stiffness of unilateral C1 lateral mass-C2 intralaminar fixation to intact specimens and bilateral C1 lateral mass-C2 intralaminar constructs.

Methods

The biomechanical integrity of a unilateral C1 lateral mass-C2 intralaminar screw construct was compared to intact specimens and bilateral C1 lateral mass-C2 intralaminar screw constructs. Five human cadaveric specimens were used. Range of motion and stiffness were tested to determine the stiffness of the constructs.

Results

Unilateral fixation significantly decreased flexion/extension range of motion compared to intact (P < .001) but did not significantly affect axial rotation (P = .3) or bending range of motion (P = .3). There was a significant decrease in stiffness in extension for both unilateral and bilateral fixation techniques compared to intact (P = .04 and P = .03, respectively). There was also a significant decrease in stiffness for ipsilateral rotation for the unilateral construct compared to intact (P = .007) whereas the bilateral construct significantly increased ipsilateral rotation stiffness compared to both intact and unilateral fixation (P < .001).

Conclusion

Bilateral constructs did show improved biomechanical properties compared to the unilateral constructs. However, unilateral C1-C2 fixation using a C1 lateral mass and C2 intralaminar screw-rod construct decreased range of motion and improved stiffness compared to the intact state with the exception of extension and ipsilateral rotation. Hence, a unilateral construct may be acceptable in clinical situations in which bilateral fixation is not possible, but an external orthosis may be necessary to achieve a fusion.

Background

Pyogenic spinal infections (PSIs) are a group of uncommon but serious infectious diseases that are characterized by inflammation of the endplate-disc unit. PSIs are considered more prevalent and aggressive among patients with chronic immunocompromised states. Association between PSIs and liver disease has not been systematically analyzed. The authors performed a systematic review to study baseline characteristics, clinical presentation, and mortality of patients with PSI in the setting of chronic liver disease.

Observations

The authors presented the case of a 72-year-old female patient with chronic liver disease who presented with severe low back pain and bilateral lower weakness. Imaging studies showed T10-11 spondylodiscitis. The patient received decompression and fusion surgery with partial neurological improvement. The authors performed a systematic literature search of spondylodiscitis and liver disease, and eight published articles met the studies inclusion and exclusion criteria. These studies featured a total of 144 patients, of whom 129 met inclusion criteria (mean age, 60.5 years, range 40 to 83 years; 62% males). Lumbar infection was the most common report (67%), with Staphylococcus aureus (48%) as the main causative microorganism. Neurological compromise was present in 69% of patients. Surgical intervention occurred in 70.5% of patients, and the average duration of antibiotic treatment was 69.4 days. Postoperative complication rate was 28.5%, with a 30- and 90-day mortality of 17.2% and 24.8%, respectively.

Lessons

Pyogenic spondylodiscitis in patients with liver disease was associated with a high rate of neurological compromise, postoperative complications, and mortality.