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Copyright of Canadian Journal of Surgery is the property of CMA Impact Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Study Design: This study is a mixed methods approach. Objectives: Intraoperative spinal cord injury (ISCI) is a challenging complication in spine surgery. Intra-operative neuromonitoring (IONM) has been developed to detect changes in neural function. We report on the first multidisciplinary, international effort through AO Spine and the Praxis Spinal Cord Institute to develop a comprehensive guideline and care pathway for the prevention, diagnosis, and management of ISCI. Methods: Three literature reviews were registered on PROSPERO (CRD 42022298841) and performed according to PRISMA guidelines: (1) Definitions, frequency, and risk factors for ISCI, (2) Meta-analysis of the accuracy of IONM for diagnosis of ISCI, (3) Reported management approaches for ISCI and related events. The results were presented in a consensus session to decide the definition of IONM and recommendation of its use in high-risk cases. Based on a literature review of management strategies for ISCI, an intra-operative checklist and overall care pathway was developed by the study team. Results: An operational definition and high-risk patient categories for ISCI were established. The reported incidence of deficits was documented to be higher in intramedullary tumour spine surgery. Multimodality IONM has a high sensitivity and specificity. A guideline recommendation of IONM to be employed for high-risk spine cases was made. The different sections of the intraoperative checklist include surgery, anaesthetic and neurophysiology. The care pathway includes steps (1) initial clinical assessment, (2) pre-operative planning, (3) surgical/anaesthetic planning, (4) intra-operative management, and (5) post-operative management. Conclusions: This is the first evidence based comprehensive guideline and care pathway for ISCI using the GRADE methodology. This will facilitate a reduction in the incidence of ISCI and improved outcomes from this complication. We welcome the wide implementation and validation of these guidelines and care pathways in prospective, multicentre studies. [ABSTRACT FROM AUTHOR]

Study Design: Systematic review and meta-analysis. Objectives: In an effort to prevent intraoperative neurological injury during spine surgery, the use of intraoperative neurophysiological monitoring (IONM) has increased significantly in recent years. Using IONM, spinal cord function can be evaluated intraoperatively by recording signals from specific nerve roots, motor tracts, and sensory tracts. We performed a systematic review and meta-analysis of diagnostic test accuracy (DTA) studies to evaluate the efficacy of IONM among patients undergoing spine surgery for any indication. Methods: The current systematic review and meta-analysis was performed using the Preferred Reporting Items for a Systematic Review and Meta-analysis statement for Diagnostic Test Accuracy Studies (PRISMA-DTA) and was registered on PROSPERO. A comprehensive search was performed using MEDLINE, EMBASE and SCOPUS for all studies assessing the diagnostic accuracy of neuromonitoring, including somatosensory evoked potential (SSEP), motor evoked potential (MEP) and electromyography (EMG), either on their own or in combination (multimodal). Studies were included if they reported raw numbers for True Positives (TP), False Negatives (FN), False Positives (FP) and True Negative (TN) either in a 2 × 2 contingency table or in text, and if they used postoperative neurologic exam as a reference standard. Pooled sensitivity and specificity were calculated to evaluate the overall efficacy of each modality type using a bivariate model adapted by Reitsma et al, for all spine surgeries and for individual disease groups and regions of spine. The risk of bias (ROB) of included studies was assessed using the quality assessment tool for diagnostic accuracy studies (QUADAS-2). Results: A total of 163 studies were included; 52 of these studies with 16,310 patients reported data for SSEP, 68 studies with 71,144 patients reported data for MEP, 16 studies with 7888 patients reported data for EMG and 69 studies with 17,968 patients reported data for multimodal monitoring. The overall sensitivity, specificity, DOR and AUC for SSEP were 71.4% (95% CI 54.8-83.7), 97.1% (95% CI 95.3-98.3), 41.9 (95% CI 24.1-73.1) and.899, respectively; for MEP, these were 90.2% (95% CI 86.2-93.1), 96% (95% CI 94.3-97.2), 103.25 (95% CI 69.98-152.34) and.927; for EMG, these were 48.3% (95% CI 31.4-65.6), 92.9% (95% CI 84.4-96.9), 11.2 (95% CI 4.84-25.97) and.773; for multimodal, these were found to be 83.5% (95% CI 81-85.7), 93.8% (95% CI 90.6-95.9), 60 (95% CI 35.6-101.3) and.895, respectively. Using the QUADAS-2 ROB analysis, of the 52 studies reporting on SSEP, 13 (25%) were high-risk, 10 (19.2%) had some concerns and 29 (55.8%) were low-risk; for MEP, 8 (11.7%) were high-risk, 21 had some concerns and 39 (57.3%) were low-risk; for EMG, 4 (25%) were high-risk, 3 (18.75%) had some concerns and 9 (56.25%) were low-risk; for multimodal, 14 (20.3%) were high-risk, 13 (18.8%) had some concerns and 42 (60.7%) were low-risk. Conclusions: These results indicate that all neuromonitoring modalities have diagnostic utility in successfully detecting impending or incident intraoperative neurologic injuries among patients undergoing spine surgery for any condition, although it is clear that the accuracy of each modality differs. PROSPERO Registration Number: CRD42023384158 [ABSTRACT FROM AUTHOR]

Study Design: Scoping Review. Objective: To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). Methods: MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. Results: Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. Conclusion: There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae. [ABSTRACT FROM AUTHOR]

We conducted a systematic review with meta-analysis and qualitative synthesis. This study aims to characterize pseudarthrosis after long-segment fusion in spinal deformity by identifying incidence rates by etiology, risk factors for its development, and common features. Pseudarthrosis can be a painful and debilitating complication of spinal fusion that may require reoperation. It is poorly characterized in the setting of spinal deformity. The MEDLINE, EMBASE, and Cochrane databases were searched for clinical research including spinal deformity patients treated with long-segment fusions reporting pseudarthrosis as a complication. Meta-analysis was performed on etiologic subsets of the studies to calculate incidence rates for pseudarthrosis. Qualitative synthesis was performed to identify characteristics of and risk factors for pseudarthrosis. The review found 162 articles reporting outcomes for 16,938 patients which met inclusion criteria. In general, the included studies were of medium to low quality according to recommended reporting standards and study design. Meta-analysis calculated an incidence of 1.4% (95% CI 0.9–1.8%) for pseudarthrosis in adolescent idiopathic scoliosis, 2.2% (95% CI 1.3–3.2%) in neuromuscular scoliosis, and 6.3% (95% CI 4.3–8.2%) in adult spinal deformity. Risk factors for pseudarthrosis include age over 55, construct length greater than 12 segments, smoking, thoracolumbar kyphosis greater than 20°, and fusion to the sacrum. Choice of graft material, pre-operative coronal alignment, post-operative analgesics, and sex have no significant impact on fusion rates. Older patients with greater deformity requiring more extensive instrumentation are at higher risk for pseudarthrosis. Overall incidence of pseudarthrosis requiring reoperation is low in adult populations and very low in adolescent populations. [ABSTRACT FROM AUTHOR]

Reports on osteoconductive matrices such as allograft, calcium or ceramic preparations as potential bone graft alternatives to achieve fusion in spinal surgery. Focus on osteoinductive materials such as demineralized bone matrix, recombinant bone morphogenetic proteins and bone marrow aspirates or blood product concentrates; Limitations of supply and morbidity associated with the harvest of autograft, the gold standard bone graft material.

Degenerative lumbar spondylolisthesis (DLS) is a debilitating condition associated with poor preoperative functional status. Surgical intervention has been shown to improve functional outcomes in this population though the optimal surgical procedure remains controversial. The importance of maintaining and/or improving sagittal and pelvic spinal balance parameters has received increasing interest in the recent DLS literature. However, little is known about the radiographic parameters most associated with improved functional outcomes among patients undergoing surgery for DLS. To identify the effect of postoperative sagittal spinal alignment on functional outcome after DLS surgery. Retrospective cohort study. Two-hundred forty-three patients in the Canadian Spine Outcomes and Research Network (CSORN) prospective DLS study database. Baseline and 1-year postoperative leg and back pain on the 10-point Numeric Rating Scale and baseline and 1-year postoperative disability on the Oswestry Disability Index (ODI). All enrolled study patients had a DLS diagnosis and underwent decompression in isolation or with posterolateral or interbody fusion. Global and regional radiographic alignment parameters were measured at baseline and 1-year postoperatively including sagittal vertical axis (SVA), pelvic incidence and lumbar lordosis (LL). Both univariate and multiple linear regression was used to assess for the association between radiographic parameters and patient-reported functional outcomes with adjustment for possible confounding baseline patient factors. Two-hundred forty-three patients were available for analysis. Among participants, the mean age was 66 with 63% (153/243) female with the primary surgical indication of neurogenic claudication in 197/243 (81%) of patients. Worse pelvic incidence-LL mismatch was correlated with more severe disability [ODI, 0.134, p<.05), worse leg pain (0.143, p<.05) and worse back pain (0.189, p<.001) 1-year postoperatively. These associations were maintained after adjusting for age, BMI, gender, and preoperative presence of depression (ODI, R2 0.179, β, 0.25, 95% CI 0.08, 0.42, p=.004; back pain R2 0.152 (β, 0.05, 95% CI 0.022, 0.07, p<.001; leg pain score R2 0.059, β, 0.04, 95% CI 0.008, 0.07, p=.014). Likewise, reduction of LL was associated with worse disability (ODI, R2 0.168, β, 0.04, 95% CI -0.39, -0.02, p=.027) and worse back pain (R2 0.135, β, -0.04, 95% CI -0.06, -0.01, p=.007). Worsened SVA correlated with worse patient reported functional outcomes (ODI, R2 0.236, β, 0.12, 95% CI 0.05, 0.20, p=.001). Similarly, an increase (worsening) in SVA resulted in a worse NRS back pain (R2 0.136, β, 0.01, 95% CI.001, 0.02, p=.029) and worse NRS leg pain (R2 0.065, β, 0.02, 95% CI 0.002, 0.02, p=.018) scores regardless of surgery type. Preoperative emphasis on regional and global spinal alignment parameters should be considered in order to optimize functional outcome in lumbar degenerative spondylolisthesis treatment. [ABSTRACT FROM AUTHOR]

Background Context: There are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period.Purpose: To systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery.Study Design: Systematic review, meta-analysis, evidence synthesis.Methods: A systematic review conforming to PRIMSA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The GRADE approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach.Results: Forty-one studies (nine RCT, 32 cohort studies) were included. In the setting of preincisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48 hours postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type and duration, suture and staple management, and postoperative nutrition for SSI prophylaxis in spine surgery.Conclusions: Despite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese, and diabetic populations, and for traumatic and oncological indications are urgently required. [ABSTRACT FROM AUTHOR]

Background Context: Transforaminal lumbar interbody fusion (TLIF) is a widely accepted surgical procedure, but cage migration (CM) and cage retropulsion (CR) are associated with poor outcomes.Purpose: This study seeks to identify risk factors associated with these serious events.Study Design: A prospective observational longitudinal study.Patient Sample: Over a 5-year period, 881 lumbar levels in 784 patients were treated using TLIF at three spinal surgery centers.Outcome Measures: We evaluated the odds ratio of the risk factors for CM with and without subsidence and CR in multivariate analysis.Methods: Our study classified CM into two subgroups: CM without subsidence and CM with subsidence. Cases of spinal canal and/or foramen intrusion of the cage was defined separately as CR. Patient records, operative notes, and radiographs were analyzed for factors potentially related to CM with subsidence, CM without subsidence, and CR.Results: Of 881 lumbar levels treated with TLIFs, CM without subsidence was observed in 20 (2.3%) and CM with subsidence was observed in 36 (4.1%) patients. Among the CM cases, CR was observed in 17 (17/56, 30.4%). The risk factors of CM without subsidence were osteoporosis (OR 8.73, p < .001) and use of a unilateral single cage (OR 3.57, p < .001). Osteoporosis (OR 5.77, p < .001) and endplate injury (OR 26.87, p < .001) were found to be significant risk factors for CM with subsidence. Risk factors of CR were osteoporosis (OR 7.86, p < .001), pear-shaped disc (OR 8.28, p = .001), endplate injury (OR 18.70, p < .001), unilateral single cage use (OR 4.40, p = .03), and posterior cage position (OR 6.45, p = .04). A difference in overall fusion rates was identified, with a rate of 97.1% (801 of 825) for no CM, 55.0% (11 of 20) for CM without subsidence, 41.7% (15 of 36) for CM with subsidence, and 17.6% (3 of 17) for CR at 1.5 years postoperatively.Conclusions: Our results suggest that osteoporosis is a significant risk factor for both CM and CR. In addition, a pear-shaped disc, posterior positioning of the cage, the presence of endplate injury and the use of a single cage were correlated with the CM with and without subsidence and CR. [ABSTRACT FROM AUTHOR]

Translational research on the importance of secondary injury mechanisms has promoted development of management strategies for patients with acute spinal cord injuries (SCIs). These findings have been adopted in guidelines such as the 2013 AANS/CNS and the 2017 AOSpine guidelines on SCI management. However, despite these guidelines, uncertainty remains regarding optimal hemodynamic management, timing of surgical decompression and the use of steroids. The goal of this study was to examine knowledge, adoption and barriers to guideline implementation around these three key areas of SCI management. We sought to examine the current international practices of spine care professionals regarding the acute administration of steroids, hemodynamic management, and timing of surgical decompression in acute SCI. A survey was distributed to all members of AOSpine International on October 1st, 2021. The questionnaire was structured into (1) demographic data and preferred practices surrounding (2) steroid use, (3) hemodynamic management and (4) timing of surgical decompression. Data were analyzed in Stata version 16.1. A total of 593 members completed the survey including orthopaedic surgeons (54,3%, n=319), neurosurgeons (35.6%; n=209), and traumatologists (8.4%; n=49). Most [61.2% (n=352)] respondents were from low and middle-income countries (LICs and MICs) with 38.8% (n=223) from high income countries (HICs). There was a bimodal distribution with regard to the administration of steroids with 53.6% using this neuroprotective option (n=256) and 46.4% (n=222) not. Respondents from LICs and MICs were more likely to administer steroids than HICs (178 vs 78, p <.001). Interestingly, when steroids were given, AIS A patients were less likely to receive steroids (72.6%; n=185), than AIS B (82.8%; n=211) and AIS C patients (76.5%; n=195). A total of 331 respondents (81.5%) answered that patients would receive mean arterial pressure (MAP) targeted treatment in the intensive care unit or an analogous setting. Whereas 24.2% (n=51) of orthopedic surgeons would not use MAP targeted treatment at their institutions; this was the case in only 12.8% (n=20) for neurosurgeons, (p <.05). In LICs and MICs, SCI patients were less likely to be provided with MAP-targeted treatment (76.9%, n=193) as compared to HICs, (89%, n=138; p <.05). The majority of respondents (87.8%) reported that patients with SCIs would benefit from early decompression. Despite overwhelming evidence and surgeons' responses that would offer early surgery, 231 (62.4%) stated they encounter logistical barriers in their institutions. This was particularly evident in LICs and MICs, where 129 respondents (57.9%) indicated that early intervention would be rather unlikely to accomplish (p <.001). This survey highlights challenges in the implementation of standardized practice regarding the use of steroids, hemodynamic management and practical use of early surgical intervention, despite clear evidence for surgeon preference to implement a "Time is Spine" approach. This work highlights the importance of continuing to refine SCI guidelines. Moreover, future research efforts will need to address barriers of guideline implementation, such as logistic hurdles in the implementation of early decompressive surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Abstract: Background context: There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I&D) in deciding need for single or multiple I&Ds or more complex wound management such as vacuum-assisted closure dressing or soft-tissue flaps. Purpose: The purpose of this study was to build a predictive model that stratifies patients with spinal SSI, allowing us to determine which patients will need single versus multiple I&D. The model will be validated and will serve as evidence to support a scoring system to guide treatment. Study design: A consecutive series of 128 patients from a tertiary spine center (collected from 1999 to 2005) who required I&D for spinal SSI were studied based on data from a prospectively collected outcomes database. Methods: More than 30 variables were identified by extensive literature review as possible risk factors for SSI and tested as possible predictors of risk for multiple I&D. Logistic regression was conducted to assess each variable''s predictability by a “bootstrap” statistical method. A prediction model was built in which single or multiple I&D was treated as the “response” and risk factors as “predictors.” Next, a second series of 34 different patients meeting the same criteria as the first population were studied. External validation of the predictive model was performed by applying the model to the second data set, and predicted probabilities were generated for each patient. Receiver operating characteristic curves were constructed, and the area under the curve (AUC) was calculated. Results: Twenty-four of one hundred twenty-eight patients with spinal SSI required multiple I&D. Six predictors: anatomical location, medical comorbidities, specific microbiology of the SSI, the presence of distant site infection (ie, urinary tract infection or bacteremia), the presence of instrumentation, and the bone graft type proved to be the most reliable predictors of need for multiple I&D. Internal validation of the predictive model yielded an AUC of 0.84. External validation analysis yielded AUC of 0.70 and 95% confidence interval of 0.51 to 0.89. By setting a probability cutoff of .24, the negative predictive value (NPV) for multiple I&D was 0.77 and positive predictive value (PPV) was 0.57. A probability cutoff of .53 yielded a PPV of 0.85 and NPV of 0.46. Conclusions: Patients with positive methicillin-resistant Staphylococcus aureus culture or those with distant site infection such as bacteremia were strong predictors of need for multiple I&D. Presence of instrumentation, location of surgery in the posterior lumbar spine, and use of nonautograft bone graft material predicted multiple I&D. Diabetes also proved to be the most significant medical comorbidity for multiple I&D. The validation of this predictive model revealed excellent PPV and good NPV with appropriately chosen probability cutoff points. This study forms the basis for an evidence-based classification system, the Postoperative Infection Treatment Score for the Spine that stratifies patients who require surgery for SSI, based on specific spine, patient, infection, and surgical factors to assess a low, indeterminate, and high risk for the need for multiple I&D. [Copyright &y& Elsevier]

Abstract: Background context: To date, most reports on the incidence of adverse events (AEs) in spine surgery have been retrospective and dependent on data abstraction from hospital-based administrative databases. To our knowledge, there have been no previous rigorously performed prospective analysis of all AEs occurring in the entire population of patients presenting to an academic quaternary referral center. Purpose: To determine the mortality and true incidence and severity of morbidity (major and minor, medical and surgical) in adults undergoing complex spinal surgery, both trauma and elective, in a quaternary referral center. To examine the influence of the introduction of a dedicated weekly multidisciplinary rounds, and a formal abstraction tool, on the recording of this prospective perioperative morbidity data. To examine the validity and inter- and intraobserver reliability of a dedicated Spine AdVerse Events Severity system, version 2 (SAVES V2) AE abstraction tool. Study design: Ours is an academic quaternary referral center serving a population of 4.5 million people. Beginning in April 2008, a spine-specific AE-recording instrument, entitled SAVES V2, was introduced at our center for reporting, categorization, and classification of AEs. The use of this system remains an ongoing prospective study. Patient sample: All adult patients admitted to the spine service of a quaternary referral center for a 12-month period. Outcome measures: A validity and an inter- and intraobserver reliability examination of the SAVES V2 system, as used at our institution. Morbidity and inhospital deaths, unplanned second surgeries during index admission, wound infections requiring reoperation, and readmissions during the same calendar year. We also examined in detail all intraoperative and nonsurgical postoperative AEs, as well as hospital length of stay (LOS). Methods: Data on all patients undergoing surgery over a 12-month period were prospectively collected using a perioperative morbidity abstraction tool at weekly dedicated mortality and morbidity rounds. This tool allows identification of each specific AE and grades the severity. Before the introduction of this system, and using the hospital inpatient database, our documented perioperative morbidity rate (major and minor, medical and surgical) was 23%. Diagnosis, operative data, hospital data, major and minor complications both medical and surgical, and deaths were recorded. Results: One hundred percent of all patients discharged from the unit had complete data available for analysis. Nine hundred forty-two patients with an age range of 16 to 90 years (mean, 54 years; mode, 38 years) were identified. There were 552 males and 390 females. Around 58.5% of patients had undergone elective surgery. Thirty percent of patients were American Spinal Injury Association class D or worse on admission. The average LOS was 13.5 days (range, 1–221 days). Eight hundred twenty-two (87%) patients had at least one documented complication. Thirty-nine percent of these adversely affected hospital LOS. There were 14 mortalities during the study period. The rate of intraoperative surgical complication was 10.5% (4.5% incidental durotomy and 1.9% hardware malposition requiring revision and 2.2% blood loss >2 L). The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%). Conclusions: Major spinal surgery in the adult is associated with a high incidence of intra- and postoperative complications. We identified a very high rate of previously unrecognized postoperative complications, which adversely affect LOS. Without strict adherence to a prospective data collection system, the true complexity of this surgery may be greatly underestimated. [Copyright &y& Elsevier]

Frailty, defined as a state of decreased reserve and susceptibility to external stressors, has previously been shown to negatively effect postoperative outcome in an elective spine surgery population. This study sought to determine the effect of frailty on patient outcome after traumatic spinal cord injury (tSCI). This prospective cohort study took place at a single quaternary spinal referral center. A total of 634 patients. Inpatient length of stay, in-hospital mortality, adverse events. All patients with tSCI were identified in our prospectively collected database from 2007-2016. Analysis was conducted to examine correlations between patient age, total motor score (TMS) on admission, and mFI on patient outcome variables including acute length of stay (LOS), number of adverse events (AEs) and in-hospital mortality. Bivariate analysis revealed multiple statistically significant associations. mFI was a strong predictor of increased acute LOS (corr =0.163; p<.0001), number of AEs (corr=0.1664; p<.0001) and in-hospital mortality (corr=0.155; p<.0001). Age at injury was also significantly correlated with acute LOS (corr=0.0809; p=0.0418), number of AEs (corr=0.0937; p=0.0231) and in-hospital mortality (corr=0.2639; p<.0001). Lastly, motor score on admission was also predictive of acute LOS (corr=-0.4749; p<.0001), number of AEs (corr=-0.3069; p<.0001), and in-hospital mortality (corr=-0.2249; p<.0001). Subgroup analysis was then performed on patients aged >65 years. Mean frailty index was not predictive of acute LOS (p=0.1533), number of AEs (p=0.2337) or in-hospital mortality (p=0.6593). Age at injury was not predictive of acute LOS (p=0.0571), however remained significant for number of AEs (p=0.0058), and in-hospital mortality (p<.0001). This was also true for motor score on admission, which was predictive of acute LOS (p<.0001), number of AEs (p=.0038) and in-hospital mortality (p<.0001). Age, mFI and TMS on admission are important determinants of outcome in patients with tSCI. Furthermore, frailty score is predictive of outcome in the general tSCI population, but not in the elderly. This suggests that younger, "frail" individuals have significantly poorer outcomes than young, healthy individuals, however the inter-relationship between advanced age and decreased physiologic reserve is not as clear. Identification of frailty in a younger population as a pre-injury risk factor may be useful for perioperative optimization, risk stratification and patient counseling. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Incidence rates of surgical site infection (SSI) following instrumented spine surgery vary from 1-9%. We have previously reported significant variability in SSI prevention practice amongst CSS members. Patient skin and nasal cavity colonization with MSSA remains a major risk factor. The purpose of this study was to investigate the efficacy and cost effectiveness of chlorhexidine skin decolonization (CSD) and nasal photo-disinfection therapy (nPDT) on surgical site infection. This prospective cohort study was performed at a single quaternary spine referral center. SSI rates, microbiological data, treatment data and costs were prospectively recorded. Amongst the spine surgery cases, age, BMI, comorbidities, spine surgery invasiveness index (SSII), blood loss and adverse events (AE) were recorded using the SAVES2 system. Since 2009, as a local QI initiative at a quaternary referral center, all patients undergoing high risk surgery (including instrumented spine surgery, vascular, cardiothoracic and ortho trauma) received CSD and nPDT preoperatively. Data were prospectively collected in terms of outcome measures. From 2009 to 2017 the SSI rate for spine cases decreased from 7.2% to 1.6%, the greatest magnitude of reduction of all surgery types (p<0.01). The Absolute Risk Reduction for spine was 5.6%, and the number needed to treat (NNT) to prevent one infection, 18 patients. This resulted in an average of 53 fewer cases of SSI per year. CSD/nPDT costs CAD $45-55 per person. The estimated annual cost saving was CAD $4.24 Million. CSD/nPDT was most effective in diabetics (relative risk, RR 2.1), BMI > 35 (RR 2.25), midline lumbar surgery vs cervical or thoracic (RR 2.2), cervical vs thoracic (RR 1.9), revision surgery (RR 2.9) and in those undergoing more complex instrumentation (SSII> 21) (RR 3.35). The use of CSD / nPDT was not associated with any additional AE's. CSD / nPDT is both efficacious and cost-effective in preventing surgical site infection, particularly in complex instrumented cases in the highest risk patients. Given the minimal resource cost, we recommend the routine use of this technology for SSI prevention. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

The Spinal Surgery AdVerse Events System (SAVES) was developed in 2008 with the intention of assessing the frequency and impact of postoperative adverse events (AEs) following spinal surgery. Over the study period this system identified a number of "minor" adverse events (Grade 1 and 2) occurring frequently; electrolyte imbalance, medication related issues, postoperative ileus and nausea. In daily practice. these may often be dismissed as trivial. However, growing evidence shows the accumulation of minor AEs may have a larger than anticipated consequence. In 2012 an ICU outreach program was developed where high dependency postoperative spine patients were reviewed daily by an intensive care physician. The purpose of this study was to examine the efficacy and cost-effectiveness of the introduction an ICU outreach program on adverse events in postoperative high dependency spine patients. This prospective cohort study took place at a single quaternary spine referral center. All surgical patients admitted to a quaternary spine center for the outlined study periods. The frequency of postoperative AEs was recorded during each period, as identified by the SAVES framework. Data was prospectively collected during the 4-year period before (2008-2012) and after (2012-2016) the introduction of the ICU outreach program. Previous research has determined the cost of AEs which was applied to the data set. Over the study period the mean number of patients admitted per year was 984 (912-1090). The introduction of the ICU outreach team lead to a dramatic decrease in the number of AEs reported during the postoperative period. The percentage of patients with electrolyte imbalance decreased by 35% from 46% to 30%. Medication-related events decreased by 70% from 40% to 12%, ileus/constipation 46% from 26% to 14%, nausea by 64% from 22% to 8%, cardiac complications by 55% from 18% to 8%, pulmonary by 65% from 17% to 6% and delirium/psychiatric by 62.5% from 12% to 4.5% (P-values <0.05). Previous work has established the mean cost of a grade 1 AE is $6,370 and grade 2 AE is $21,500. Before the introduction of the ICU outreach program the top two AEs were electrolyte imbalance and medication related. Introduction of the program prevented 285 cases of medication related AE with total cost savings of $2,895,884 and 157 cases of electrolyte imbalance for total cost savings of $1,595,276. Overall total cost savings for reducing Grade 1 and 2 AE's was $9,927,294. The introduction of an ICU outreach program to review postoperative high dependency spine patients reduces the incidence of minor adverse events and can lead to substantial cost savings. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]