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Background: Surgical site infection (SSI) following spine surgery is associated with increased morbidity, reoperation rates, hospital readmissions, and cost. The incidence of SSI following posterior cervical spine surgery is higher than anterior cervical spine surgery, with rates from 4.5% to 18%. It is well documented that higher body mass index (BMI) is associated with increased risk of SSI after spine surgery. There are only a few studies that examine the correlation of BMI and SSI after posterior cervical instrumented fusion (PCIF) using national databases, however, none that compare trauma and nontraumatic patients.Purpose: The purpose of this study is to determine the odds of developing SSI with increasing BMI after PCIF, and to determine the risk of SSI in both trauma and nontraumatic adult patients.Study Design: This is a retrospective cohort study of a prospective surgical database collected at one academic institution.Patient Sample: The patient sample is from a prospectively collected surgical registry from one institution, which includes patients who underwent PCIF from April 2011 to October 2017.Outcome Measures: A SSI that required return to the operating room for surgical debridement.Methods: This is a retrospective cohort study using a prospectively collected database of all spine surgeries performed at our institution from April 2011 to October 2017. We identified 1,406 patients, who underwent PCIF for both traumatic injuries and nontraumatic pathologies using International Classification of Diseases 9 and 10 procedural codes. Thirty-day readmission data were obtained. Patient's demographics, BMI, presence of diabetes, preoperative diagnosis, and surgical procedures performed were identified. Using logistic regression analysis, the risk of SSI associated with every one-unit increase in BMI was determined. This study received no funding. All the authors in this study report no conflict of interests relevant to this study.Results: Of the 1,406 patients identified, 1,143 met our inclusion criteria. Of those patients, 688 had PCIF for traumatic injuries and 454 for nontraumatic pathologies. The incidence of SSI for all patients, who underwent PCIF was 3.9%. There was no significant difference in the rate of SSI between our trauma group and nontraumatic group. There was a higher rate of infection in patients, who were diabetic and with BMI≥30 kg/m2. The presence of both diabetes and BMI≥30 kg/m2 had an added effect on the risk of developing SSI in all patients, who underwent PCIF. Additionally, logistic regression analysis showed that there was a positive difference measure between BMI and SSI. Our results demonstrate that for one-unit increase in BMI, the odds of having a SSI is 1.048 (95% CI: 1.007-1.092, p=.023).Conclusions: Our study demonstrates that our rate of SSI after PCIF is within the range of what is cited in the literature. Interestingly, we did not see a statistically significant difference in the rate of infection between our trauma and nontrauma group. Overall, diabetes and elevated BMI are associated with increased risk of SSI in all patients, who underwent PCIF with even a higher risk in patient, who are both diabetic and obese. Obese patients should be counseled on elevated SSI risk after PCIF, and those with diabetes should be medically optimized before and after surgery when possible to minimize SSI. [ABSTRACT FROM AUTHOR]

Spinal epidural abscess (SEA) is a rare and life-threatening infection within the epidural space with significant functional impairment and morbidity. Active debate remains over whether to operate for SEAs, with limited existing data comparing the long-term survivability after surgical versus nonsurgical management. This study aims to determine the long-term survival of patients who underwent surgical and nonsurgical management for SEA. Retrospective cohort study. A total of 250 consecutive SEA patients. Survival and mortality rates, complications. All patients treated at a tertiary medical center for a primary SEA from January 2000 to June 2020 are identified. Data collection is by retrospective chart review. Cox proportional hazards regression models are used for all survival analyses while controlling for potential confounding variables and with multiple testing corrections. A total of 35 out of 250 patients died with an overall all-cause mortality of 14%. More than half of all deaths occurred within 90 days after treatment. The 90-day, 3-year, and 5-year survival rates are 92.8%, 89.2%, and 86.4%, respectively. Among surgery patients, the all-cause mortality was 13.07%, compared to 16.22% for medically-managed patients. Surgical treatment (decompression, fusion, debridement) significantly reduced the risk of death by 62.4% compared to medical therapy (p=.03), but surgery patients experienced a significantly longer mean length of stay (p=.01). Risk factors of short-term mortality included hypoalbuminemia (<3.5 g/dL), American Society of Anesthesiologists (ASA) 4+, and cardiac arrest. Risk factors of long-term mortality were immunocompromised state, elevated WBC count >12,000, sepsis, septic shock, ASA 4+, and cardiac arrest (p<.05). In terms of complications, surgically-managed patients experienced a higher proportion of deep vein thrombosis (p<.05). The overall long-term survivability of SEA treatment is relatively high at (86% at 5-year) in this study. The following SEA mortality risk factors were identified: hypoalbuminemia (short-term), immunocompromised state (long-term), leukocytosis (long-term), sepsis and septic shock (long-term), ASA 4+ and cardiac arrest (overall). For primary SEA patients, surgical management may reduce mortality risk compared to nonsurgical management. [ABSTRACT FROM AUTHOR]

Background Context: Tandem spinal stenosis (TSS) refers to a narrowing of the spinal canal in distinct, noncontiguous regions. TSS most commonly occurs in the cervical and lumbar regions. Decompressive surgery is indicated for those with cervical myelopathy or persistent symptoms from lumbar stenosis despite conservative management. Surgical management typically involves staged procedures, with cervical decompression taking precedence in most cases, followed by lumbar decompression at a later time. However, several studies have shown favorable outcomes in simultaneous decompression.Purpose: The aim of this study is to provide a literature review and compare surgical outcomes in patients undergoing staged vs simultaneous surgery for TSS.Study Design/setting: Systematic literature review.Methods: A systematic review using PRISMA guidelines to identify original research articles for tandem spinal stenosis. PubMed, Cochrane, Ovid, Scopus, and Web of Science were used for electronic literature search. Original articles from 2005 to 2021 with more than eight adult patients treated surgically for cervical and lumbar TSS in staged or simultaneous procedures were included. Articles including pediatric patients, primarily thoracic stenosis, stenosis secondary to neoplasm or infectious disease, minimally invasive surgery, and non-English language were excluded. Demographic, perioperative, complications, functional outcome, and neurologic outcome data including mJOA (modified Japanese Orthopaedic Association), Nurick grade (NG), and ODI (Oswestry disability index), were extracted and summarized.Results: A total of 667 articles were initially identified. After preliminary screening, 21 articles underwent full-text screening. Ten articles met our inclusion criteria. A total of 831 patients were included, 571 (68%) of them underwent staged procedures, and 260 (32%) underwent simultaneous procedures for TSS. Mean follow-ups ranged from 12 to 85 months. There was no difference in estimated blood loss (EBL) between staged and simultaneous groups (p=.639). Simultaneous surgeries had shorter surgical time than staged surgeries (p<.001). Mean changes in mJOA, NG, and ODI was comparable between staged and simultaneous groups. Complications were similar between the groups. There were more major complications reported in simultaneous operations, although this was not statistically significant (p=.301).Conclusion: Staged and simultaneous surgery for TSS have comparable perioperative, functional, and neurologic outcomes, as well as complication rates. Careful selection of candidates for simultaneous surgery may reduce the length of stay and consolidate rehabilitation, thereby reducing hospital-associated costs. [ABSTRACT FROM AUTHOR]

Acute postoperative surgical site infections (SSI) following instrumented lumbar spine fusions are a relatively infrequent occurrence. Treatment of an SSI with prompt surgical debridement and prolonged, parenteral antibiotics is generally effective and most often results in eradication of the infection and maintenance of the instrumentation. However, it is not clear what the long-term effect of an SSI may be on clinical outcome and more specifically the potential for development of a symptomatic nonunion or instrumentation failure. To evaluate the long-term clinical and radiographic outcomes of patients who underwent an instrumented lumbar fusion complicated by an acute postoperative SSI that necessitated surgical debridement and prolonged parenteral antibiotics. A retrospective review of consecutively patients. A total of 1,602 patients were included. Multiple perioperative clinical and radiographic factors of patients who developed an SSI were compared with a cohort of patients who underwent a similar procedure during the same time period but did not develop an infection. Analysis of variants analysis was employed to assess significance of these factors. Multiple perioperative clinical and radiographic factors of patients who developed an SSI were compared with a cohort of patients who underwent a similar procedure during the same time period but did not develop an infection. Analysis of variants analysis was employed to assess significance of these factors. An acute surgical site infection occurred in 39 patients (2.8%). Significant risk factors for the development of an early SSI included age greater than 80, BMI > 30, diabetes, osteoporosis and prior decompressive surgery. Notable nonsignificant factors included length of surgery, preoperative deformity diagnosis (degenerative spondylolisthesis or degenerative scoliosis), use of iliac crest autograft or allograft, duration of postoperative suction drain, or occurrence of an incidental durotomy requiring repair. Mean length of hospital stay was significantly longer in patients with an SSI, 3.2 days versus 7.2 days (p=.02). Long-term follow-up revealed revision surgery to address symptomatic nonunion was slightly greater in the SSI cohort, 6 patients (15%) versus 15 patients (12%) in the non-infected cohort, but this did not reach significance. Radiographic evidence of a nonunion or loose instrumentation was not significantly different between the 2 cohorts at latest follow-up. At 6-month follow-up, clinical outcomes were consistently better in the non-infected cohort: VAS back (p=.04), VAS leg (p=.03) and ODI (p=.04), as were patient reported satisfaction (p=.04) and willingness to repeat the index procedure (p=.04). However, by one-year postoperatively and thereafter to the latest follow-up, no significant difference was noted in clinical outcome, patient reported satisfaction or willingness to repeat the index surgery. In this study of 1,602 patients undergoing an instrumented lumbar fusion, there was a 2.8% incidence of an acute postoperative infection requiring surgical debridement. Older, obese, diabetic patients were more at higher and the initial 6-month clinical outcomes were inferior to patients without an SSI. However, long-term follow-up showed no significant difference clinically or radiographically between those with and without an infection. Late revision surgeries were not more common with a history of an SSI. Recognition of a postoperative infection, especially in high risk patients, followed by prompt surgical intervention and appropriate parenteral antibiotics allows for maintenance of instrumentation and favorable clinical outcomes. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Patients with a spinal epidural abscess (SEA) and associated sepsis and neurologic deterioration require immediate evaluation and prompt surgical intervention. The goals of surgery are life preservation, eradication of the infectious nidus, and restoration of neurologic function. The focus of treatment in these critically ill patients is to achieve these immediate goals. There has been limited attention given to the long-term status of patients who have survived this life threatening condition. To identify the survivability and long-term outcome of patients who underwent emergent surgical management for a SEA with associated sepsis and neurologic decline. A retrospective review of all consecutive patients with a SEA, sepsis and neurologic decline treated at a single, tertiary referral medical center from 2000-2010. Fifty-four patients. Survival/mortality, neurologic improvement (ASIA Grade), need for further spine surgery. All patients were clinically septic and had documented neurologic deterioration directly related to a spinal epidural abscess. Surgery was performed emergently from the time of notification of the spine service. Surgical approach was determined by the location of the abscess in relation to the thecal sac; 8 occurred in the cervical spine (all anterior), 20 in the thoracic spine (7 anterior, 13 posterior) and 26 in the lumbar spine (9 anterior, 17 posterior). All cervical SEA underwent an anterior decompression and fusion with structural grafting and plating, while anterior SEA within the thoracic or lumbar spines underwent anterior decompression and fusion with structural grafting followed by a staged, posterior instrumented fusion. Posterior SEA in the thoracic or lumbar spine underwent decompression and abscess evacuation only. Preoperative neurologic status was ASIA B in 20 patients, C in 20, and D in 10. The mean time of neurologic deterioration documented in the medical record was 24 hours (range: 6 hours-5 days). Stepwise multiple regression analysis was performed to identify risk factors for survival and neurologic improvement. Long-term survival was assessed using the institution's electronic medical record and subsequently confirmed by direct patient contact. All patients survived the surgery, although 6 (11%) died within one month. Significant risk factors for early mortality included age >70 (p=.01), hospitalization >5 days prior to surgery (p=.02), ASIA D (p=.02), diabetes (p=.02), end stage renal disease (p=.02), and MRSA sepsis (p=.02). Of the surviving patients, the mean neurologic improvement was 2.4 ASIA grades. Of surviving patients, 92% (44/48) regained the ability to ambulate. Significant factors for neurologic improvement included age <70 (p=.01), documented neurologic decline <24 hours (p=.01), non-diabetic (p=.02), a cervical abscess (p=.01), a thoracic or lumbar abscess not requiring fusion (p=.02), and preoperative ASIA D (p=.01). At the 10-year follow-up, 88% (42/48) of the patients who survived their perioperative course were still alive. The six non-surviving patients had died of causes unrelated to their spine infections. At the 10-year follow-up, all 42 patients were noted to have maintained their level of neurologic recovery, with none having evidence of recurrent neurologic deficits or loss of ambulatory ability. Ten percent (4/42) of the long-term surviving patients had undergone additional spine surgery, 2 for removal of painful segmental instrumentation and 2 for extension of fusions for symptomatic adjacent level disease. None of the long-term survivors required additional surgery for a recurrent spine infection. Advanced imaging (MRI or CT scan) was available for 30 of the surviving patients. Aside from the 2 patients requiring surgery for adjacent level stenosis, there were no instances of residual infectious spinal column involvement, segmental instability or sagittal plane deformity in any patient. Spinal epidural abscesses in patients with sepsis and neurologic deterioration can be effectively managed when diagnosed promptly and treated with emergent surgery. In this series, the majority of patients survived, had neurologic recovery and regained independent ambulation. However, there was a notable early mortality rate (11%), with older, diabetic patients with prolonged neurologic deficits most susceptible. Long-term survival occurred in 88% of patients, with evidence of sustained neurologic improvement, permanent eradication of the spine infection, and relatively uncommon need for additional surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Incidental durotomies (ID) are a known occurrence in lumbar spine surgery. In most cases, an ID can be effectively managed with direct repair that is often supplemented by fibrin glue or a synthetic or biologic patch. Generally, there is minimal adverse effect to the patient other than a longer than expected postoperative hospitalization accounting for a period of recumbence following the dural repair. However, on occasion, a recurrent CSF leak occurs postoperatively which can cause troubling symptoms and may require additional surgery to repair. To identify the frequency of recurrent CSF leaks in patients who underwent surgery for lumbar spinal stenosis that was complicated by a dural tear and subsequently to both define risk factors for the occurrence of a recurrent leak and to assess the effect upon the ultimate clinical outcome. A retrospective analysis of a prospectively-treated cohort of patients. A total of 1,480 consecutive patients who underwent elective, primary surgery for lumbar spinal stenosis over a 5-year period by one of four surgeons at a single academic, tertiary care medical center. Clinical follow-up was a minimum of 2 years (range: 2-8 years). VAS Score (1-10) for back and leg pain, Oswestry Disability Index, Patient Satisfaction Assessment, and Retrospective Willingness to Repeat Surgery. A dural tear (DT) occurred in 103 of 1,481 patients (7%). Fourteen of 103 patients (14%) developed a symptomatic, postoperative CSF leak requiring additional surgery. Overall, a recurrent CSF leak occurred in 14 of the 1,481 patients (0.9%) who underwent a primary lumbar decompression for spinal stenosis who were evaluated in the study. All dural tears were identified at the time of the index surgery. Dural repairs were directly repaired with either a 4-0 silk or 6-0 polypropylene suture in a water tight fashion and assessed with a Valsalva maneuver prior to closure. Repairs were augmented with fibrin glue in 70% of cases, a collagen patch in 32%, and both in 20%. Patients were kept on bedrest following surgery for 1-3 days. A subfascial drain was employed in 82% of patients. Choice of suture, augmentation of repair, use of drain and duration of bedrest were based on surgeon discretion. Multi-variate regression analysis was employed to identify significant risk factors for a postoperative CSF leak. Of the 14 patients with a recurrent CSF leak, symptoms arose during the postoperative hospitalization in 11 patients (79%) and after discharge in 3 (21%). Each patient had a palpable subcutaneous mass and 4 patients (29%) had a percutaneous CSF leak. Each patient was symptomatic with postural headache and 10(71%) experienced photophobia. Significant risk factors for development of a CSF leak included age > 70, body mass index > 30 (obese), history of diabetes and chronic use of corticosteroids. Notable factors not significant included duration of surgery, the additional diagnosis of degenerative spondylolisthesis or degenerative scoliosis, presence of a fusion, numbers of levels decompressed or fused, use of BMP or particular bone graft choice, nor preoperative use of pharmacologic anticoagulation. The likelihood of a recurrent leak was not significantly affected by a particular type of surgical dural repair, the suture material employed, nor the use of a synthetic patch or fibrin glue. As well, the use of a postoperative, subfascial drain nor the duration of recumbancy after the initial surgery did not significantly affect the development of a recurrent CSF leak. At 3-month follow-up, two patient reported outcomes (ODI, patient satisfaction) were slightly less in patients who had a recurrent CSF leak, compared with both durotomy patients with no recurrent leak and those with no durotomy, although this did not reach statistical significance. At 6 month, 12 month, and final follow-up, there were no statistical differences in patient-reported outcomes between the recurrent CSF leak, durotomy without recurrent leak, and no durotomy cohorts. Length of hospitalization was an average of 4.2 days longer in patients with a recurrent CSF leak compared with patients with no durotomy and 2.2 days longer than patients with a durotomy but no recurrent leak. Cost of hospitalization was $65,000 greater in patients with a recurrent leak compared to those with no durotomy and $35,000 greater than those with a durotomy but no recurrent leak. Incidental durotomy is a relatively uncommon occurrence in primary surgery to treat lumbar spinal stenosis. Recurrent CSF leak following repair of a durotomy is also uncommon, with an incidence of 14% of patients with a durotomy in this large single center study. Prompt recognition of a recurrent CSF leak and subsequent surgical repair effectively treats this problem and adverse sequelae did not occur and ultimate clinical outcomes were not altered compared to those without a durotomy or a recurrent CSF leak. Hospital length of stay and cost were greater in those with this uncommon complication. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The development of a postoperative epidural hematoma following lumbar spinal stenosis surgery is an uncommon but potentially devastating complication. It is unclear of the long-term clinical and economic impact related to the additional surgical care needed to treat these adverse events. To define the incidence of acute postoperative epidural hematomas requiring subsequent surgical evacuation following primary decompressive laminectomy surgery, as well as the perioperative risk factors, effect on short and long-term outcomes, and the economic impact due to the need for the additional care required. A retrospective analysis of prospectively collected patients. A total of 610 consecutive patients. Patient recorded outcomes including visual analog pain scores, Oswestry Disability Index, patient satisfaction, willingness to repeat surgery, hospital length of stay and estimated cost. Patients who developed a symptomatic epidural hematoma within the acute postoperative period (4 weeks from the index procedure) were evaluated. Perioperative risk factors were assessed for significance with a multivariate regression analysis. The clinical and economic impact of the need for a second surgery was compared to the cohort of patients who underwent surgery during the same time period but did not develop a hematoma. An acute postoperative epidural hematoma occurred in 21 patients (3.7%). The presence of a symptomatic hematoma occurred at an average of 6.5 days (range 3-21 days) postoperatively. The most common symptoms associated with a hematoma were worsening back pain (100% of patients), increased leg pain (90%), new onset leg weakness (52%) and urinary retention (29%). An MRI confirmed the clinical diagnosis in 11 of 21 patients (52%). Clinical risk factors significant (p<.05) for the development of a hematoma included age greater than 80 years old, body mass index greater than 30, history of diabetes, rheumatoid arthritis, a connective tissue disorder requiring preoperative steroid and osteoporosis. Notable factors not significant included duration of surgery, the need for a spine fusion, number of surgical levels fused or decompressed, a diagnosis of degenerative scoliosis or degenerative spondylolisthesis, the preoperative use of pharmacologic anticoagulation and the use of BMP or other bone graft substitutes. No significant correlation could be found between the development of an epidural hematoma and the use of a postoperative subfascial drain, the amount of postoperative drainage, nor the duration the drain was kept in place. At 3-month followup, all patient reported outcome measures were significantly less favorable in those patients who had an epidural hematoma. However, by 6 months following surgery and at the time of latest followup (minimum 10 years), there was no significant difference in any patient reported outcome measure. Length of stay was increased an average of 4.3 days and cost of hospitalization was greater by an average of $140,000. A postoperative epidural hematoma following lumbar spinal stenosis surgery occurred in 3.7% of 610 consecutive patients. Older, unhealthier patients were more prone to the development of a hematoma. With the need for surgical evacuation, the initial patient reported outcome measures and patient satisfaction rates were significantly lower, but ultimately no long-term difference was noted when compared with a cohort of patients without a hematoma. Prompt identification and surgical evacuation appears to be effective in lowering any long-term morbidity associated with the development of a postoperative epidural hematoma. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Degenerative cervical myelopathy (DCM) represents a collection of age-related degenerative processes of the cervical spine that can result in motor, sensory and autonomic dysfunction, leading to significant reductions in quality of life. Older individuals, and in particular octogenarians, with advanced myelopathy pose unique clinical challenges, as they may be severely compromised and while they may benefit from surgery, the extent of neurologic improvement may be unpredictable and the risk of adverse events may be higher than younger patients. The aim of this study was to better characterize outcomes following cervical spine surgery in octogenarians with advanced myelopathy. A retrospective analysis of a consecutively treated patients older than age 80 with degenerative cervical myelopathy who underwent cervical decompression surgery at a single institution over a 10-year period (2010-2019). A total of 57 patients. Nurick grade, mJOA scores, patient-reported satisfaction. All patients experienced myelopathic features and exhibited multi-level spinal cord compression on preoperative MRI. Surgical techniques employed were based on location of the compressive neural pathology, spinal alignment and the presence of segmental instability. The average followup duration was 3.50 ± 1.56 years. Paired t-tests and Wilcoxon-signed rank tests were used to compare Nurick and mJOA scores before and after surgery. Multiple preoperative clinical and radiographic variables were evaluated to assess their effect on postoperative outcome. A multivariate analysis of variants was employed to assess the significance of these variables. Fifty of 57 (88%) patients noted improvement in both Nurick grade and mJOA score postoperatively. The mean Nurick grade improved from 4.15 ± 0.21 to 2.02 ± 0.72 (p < 0.001, paired t-test; 95% CI -2.08 to -1.71). The mean mJOA score improved from 9.48 ± 1.31 to 14.50 ± 1.37 (p < 0.001, paired t-test; 95% CI 2.59 to 3.45). Eleven of 14 patients (78%) who were nonambulatory prior to surgery regained the ability to ambulate. Significant risk factors for the 12% of patients who did not improve included preoperative symptoms greater than 1 year, diabetes, residing in an assisted living environment, preoperative nonambulation. Notable factors not significantly affecting outcome included type of surgical procedure, number of levels of preoperative cord compression, or presence of myelomalacia. Adverse events requiring additional surgery occurred in 4 patients (8%), including anterior plate displacement in 1 patient, persistent dysphagia requiring temporary gastrostomy tube in 1 patient, and additional posterior surgery for instrumentation failure and development of kyphotic deformity. In comparison with a cohort of nonoctogenarians undergoing myelopathy surgery, adverse events and need for further surgery were not significantly different. Our study demonstrated that elderly patients with severe forms of DCM experienced significant improvement in neurological function following cervical decompression surgery. These improvements indicate that cervical decompression surgery is effective in this patient population and while consideration of the effect of age in elderly patients must always be given consideration, it is not a contraindication for surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]