Complications, Readmissions, and Reoperations in Posterior Cervical Fusion.
METHODS
Retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2012.


OBJECTIVE
Minimizing the morbidity of posterior cervical fusion can be improved with identification of patient risk factors.


BACKGROUND
Posterior cervical fusion is an effective technique for treating a variety of pathology. Stability and neurological improvement have been well documented. The increasing frequency of these procedures necessitates further investigation into the factors that may negatively impact perioperative care.


METHODS
The American College of Surgeons National Surgical Quality Improvement Program was queried for all patients undergoing posterior cervical fusion in 2011 and 2012. Preoperative and intraoperative variables were investigated for correlation to complications, readmissions, prolonged intubation, reintubation, and reoperation. A frailty-based score was used to assess preoperative risk. Regression models for prediction were performed.


RESULTS
The study identified 5627 patients of posterior cervical fusion in 2011 and 2012. Of these, 2029 patients (36.1%) had any of our identified complications. Transfusion was the most common in 1482 (26.3%) patients. Excluding transfusion, the complication rate was 9.8%. Prolonged intubation greater than 48 hours occurred in 83 (1.5%) patients. Reintubation occurred in 72 (1.3%) patients. Readmission occurred in 398 (7.8%) patients. Reoperation was necessary in 273 (4.9%) patients with postoperative infection being the most common reason. The frailty-based score was shown to be predictive of any of the above events (P < 0.0001). The majority of patients (54.9%) in the group that had complications was found to have a frailty score of 1 or higher.


CONCLUSIONS
The predictors for any event included female sex, increased surgical time, combined anterior-posterior procedures, preoperative inpatient status, diabetes, smoking, American Society of Anesthesiologists class 3 or higher, and increasing age. The frailty-based score is a viable option to predict morbidity in posterior cervical fusion.Level of Evidence: 3.
Department of Orthopedic Surgery, George Washington University Medical Center, Washington, DC.
Gleb
G
Medvedev
Eastern Virginia Medical School, Norfolk, VA.
Charles
C
Wang
Department of Orthopedic Surgery, George Washington University Medical Center, Washington, DC.
Mathew
M
Cyriac
Department of Orthopedic Surgery, George Washington University Medical Center, Washington, DC.
Richard
R
Amdur
Department of Orthopedic Surgery, George Washington University Medical Center, Washington, DC.
Joseph
J
O'Brien
Anderson PA, Henley MB, Grady MS, et al. Posterior cervical arthrodesis with AO reconstruction plates and bone graft. Spine 1991; 16:S72–S79.
Hwang IC, Kang DH, Han JW, et al. Clinical experiences and usefulness of cervical posterior stabilization with polyaxial screw-rod system. J Korean Neurosurg Societ 2007; 42:311–316.
Kuhns CA, Geck MJ, Wang JC, et al. An outcomes analysis of the treatment of cervical pseudarthrosis with posterior fusion. Spine 2005; 30:2424–2429.
Takeshima Y, Nishimura F, Park YS, et al. Fusion surgery for recurrent cerebellar infarctions due to bilateral atlantoaxial rotational vertebral artery occlusion. Spine 2014; 39:E860–E863.
Lad SP, Patil CG, Berta S, et al. National trends in spinal fusion for cervical spondylotic myelopathy. Surg Neurolog 2009; 71:66–69.discussion 69.
Buerba RA, Fu MC, Grauer JN. Anterior and posterior cervical fusion in patients with high body mass index are not associated with greater complications. Spine J 2014; 14:1643–1653.
Kim BD, Smith TR, Lim S, et al. Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients. J Neurosurg Spine 2014; 20:606–616.
Nandyala SV, Marquez-Lara A, Park DK, et al. Incidence, risk factors, and outcomes of postoperative airway management after cervical spine surgery. Spine 2014; 39:E557–563.
Scheer JK, Tang JA, Smith JS, et al. Reoperation rates and impact on outcome in a large, prospective, multicenter, adult spinal deformity database. J Neurosurg Spine 2013; 19:464–470.
Schoenfeld AJ, Carey PA, Cleveland AW 3rd, et al. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J 2013; 13:1171–1179.
Kwon B, Yoo JU, Furey CG, et al. Risk factors for delayed extubation after single-stage, multi-level anterior cervical decompression and posterior fusion. J Spinal Disord Tech 2006; 19:389–393.
Goldstein CL, Bains I, Hurlbert RJ. Symptomatic spinal epidural hematoma after posterior cervical surgery: incidence and risk factors. Spine J 2015; 15:1179–1187.
Belmont PJ Jr, Davey S, Orr JD, et al. Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2911 patients from the national surgical quality improvement program. J Am Coll Surg 2011; 213:370–378.
Koch CG, Li L, Hixson E, et al. What are the real rates of postoperative complications: elucidating inconsistencies between administrative and clinical data sources. J Am Coll Surg 2012; 214:798–805.
Shiloach M, Frencher SK Jr, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 2010; 210:6–16.
Belmont PJ Jr, Goodman GP, Waterman BR, et al. Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients. J Bone Joint Surg 2014; 96:20–26.
Schoenfeld AJ, Ochoa LM, Bader JO, et al. Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3475 patients from the National Surgical Quality Improvement Program. J Bone Joint Surg 2011; 93:1577–1582.
Nemshah YS, Amdur R, Ashby B, et al. A novel frailty based vascular risk score for prediction of poor outcomes in peripheral vascular intervention. J Am Coll Cardiol 2014; 63 (12 Supplement):A2033.
Ratliff JK, Lebude B, Albert T, et al. Complications in spinal surgery: comparative survey of spine surgeons and patients who underwent spinal surgery. J Neurosurg Spine 2009; 10:578–584.
Campbell PG, Yadla S, Malone J, et al. Early complications related to approach in cervical spine surgery: single-center prospective study. World Neurosurg 2010; 74:363–368.
Wang MC, Kreuter W, Wolfla CE, et al. Trends and variations in cervical spine surgery in the United States: Medicare beneficiaries, 1992 to 2005. Spine 2009; 34:955–961.discussion 962-953.
Wang MC, Shivakoti M, Sparapani RA, et al. Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries. Spine J 2012; 12:902–911.
Hart RA, Tatsumi RL, Hiratzka JR, et al. Perioperative complications of combined anterior and posterior cervical decompression and fusion crossing the cervico-thoracic junction. Spine 2008; 33:2887–2891.