Month: September 2015

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Impact of Age on Short-term Outcomes After Lumbar Fusion

Three-Dimensional Computed Tomography-Based Spinal Navigation in Minimally Invasive Lateral Lumbar Interbody Fusion4

Neurosurgery 77:347–354, 2015

The safety and efficacy of spinal fusion in the elderly population remains uncertain with conflicting data.

OBJECTIVE: To determine if elderly patients undergoing instrumented lumbar fusion have increased 30-day complication rates compared to younger patients.

METHODS: The American College of Surgeons National Surgical Quality Improvement Program was used to identify all patients undergoing instrumented posterolateral lumbar fusion between 2005 and 2011. Patients were stratified by decade cohorts as follows: ,65, 65 to 75, 75 to 85, and $85 years old. All 30-day complications were grouped as overall composite morbidity and were compared using multivariate analysis.

RESULTS: A total of 1395 patients were identified and the overall 30-day complication rate was 11.47%. The complication rates were 9.04% and 14.05% for patients younger than 65 and older than 65, respectively. When stratified by decade cohorts, the complication rates were 9.04% for the ,65 cohort, 13.46% for the 65 to 75 cohort, 16.17% for the .75 to 85 cohort, and 4.00% for the $85 cohort. Multivariable regression analysis revealed no statistically significant difference between the ,65 and $65 age cohorts (odds ratio = 1.26; 95% confidence interval: 0.87-2.19). After stratifying into age cohorts, multivariable analyses revealed no difference in odds of postoperative complication occurrence for any age cohort when compared with the referent group (,65 years of age).

CONCLUSION: Patients older than 65 years of age have significantly higher rates of complications after lumbar fusion when compared to younger patients. However, multivariable analysis revealed that age was not an independent risk factor for complication occurrence after lumbar fusion.

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High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes

Cerebral arterial fenestrations- a common phenomenon in unexplained subarachnoid haemorrhage

Neurosurgery 77:462–470, 2015

High-volume centers have better outcomes than low-volume centers when managing complex conditions including subarachnoid hemorrhage (SAH).

OBJECTIVE: To quantify SAH volume-outcome association and determine the extent to which this association is influenced by aggressiveness of care.

METHODS: A serial cross-sectional retrospective study using the Nationwide Inpatient Sample for 2002 to 2010 was performed. Included were all adult (older than 18 years of age) discharged patients with a primary diagnosis of SAH admitted from the emergency department or transferred to a discharging hospital; cases of trauma or arteriovenous malformation were excluded. Survey-weighted descriptive statistics estimated temporal trends. Multilevel logistic regression estimated volume-outcome associations for inpatient mortality and discharge home. Models were adjusted for demographic characteristics, year, transfer status, insurance status, all individual Charlson comorbidities, intubation, and all patient-refined, diagnosis-related group mortality. Analyses were repeated, excluding cases in which aggressive care was not pursued.

RESULTS: A total of 32336 discharges were included; 13398 patients underwent clipping (59.1%) or coiling (40.9%). The inpatient mortality rate decreased from 32.2% in 2002 to 22.2% in 2010; discharge home increased from 28.5% to 40.8% during the same period. As SAH volume decreased from 100/year, the mortality rate increased from 18.7% to 19.8% at 80/year, 21.7% at 60/year, 24.5% at 40/year, and 28.4% at 20/ year. As SAH patient volume decreased, the probability of discharge home decreased from 40.3% at 100/year to 38.7% at 60/year, and 35.3% at 20/year. Better outcomes persisted in patients receiving aggressive care and in those not receiving aggressive care.

CONCLUSION: Short-term SAH outcomes have improved. High-volume hospitals have more favorable outcomes than low-volume hospitals. This effect is substantial, even for hospitals conventionally classified as high volume.

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