Transcript Slide 1
The National Burden of Revision
Spinal Fusion:
A Focus on Patient
Characteristics and Complications
Sean S. Rajaee MS
Linda E. A. Kanim MA
Hyun W. Bae MD
Cedars-Sinai Spine Center. Los Angeles, CA
Tufts University School of Medicine. Boston, MA
The National Burden of Revision Spinal
Fusion: A Focus on Patient
Characteristics and Complications
My disclosure is in the Final Program
Book and in the AAOS database.
I have no potential conflicts
with this presentation.
Spinal Fusion Trends, 1998-2008
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Rates of spinal fusion
increasing
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% Increase 1998-2008:
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Cervical: 90%
Thoracic: 61%
Lumbar: 141%
? Increase in Revisions
Rajaee & Bae et al, Spine 2012
Reasons for Revision Fusion
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Persistent pain
Failure to achieve
osseous fusion
Complications from
surgical implants
Progressive
degeneration
Image from
http://orthoinfo.aaos.org
/topic.cfm?topic=A00594
Risk Factors
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Older age
Primary fusion of multiple levels
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Pre-surgical emotional status
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Carpenter et al, JBJS, 1996
Trief et al, Spine, 2006
Systemic diseases
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Trief et al, Spine, 2006
Workers compensation status
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www.dnainfo.com
Smoking
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Kim et al, Spine, 2005
Bendo et Al, Am J Orthop, 2002
Medication use (NSAIDS, steroids)
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Dimar et al, Spine, 1996
Microsoft Office
Study Purpose
Trends
in revision fusion are lacking
Mission
1.
Present National trends in revision spinal fusion
2. Compare patient characteristics and
complications between primary spinal fusion and
revision
3. Compare the use of BMP, interbody devices, and
fusion of multiple levels
4. Present the most common pre-op diagnosis for
revision fusion
Study Design
Retrospective analysis using a national
administrative dataset:
Nationwide Inpatient Sample (NIS)
Nationwide Inpatient Sample
Largest all-payer inpatient care database
in the U.S.
Data from 8 million hospital stays each
year, 20-percent sample of U.S. hospitals.
Produces national estimates
Methods: Selection of Discharges
Spinal Fusion Discharges
Primary
(ICD9: 81.00-81.08)
Revision
(ICD9: 81.30-81.39)
Trends 2002-2009
Population
Adjusted
Rate
Trends, 2002-2009
% of all
fusions that
were
‘revisions’
annually
LOS and Charges, 2009
Mean Length of Stay (LOS)
Mean Hospital Charges
4.2 Days
$4700
3.8 Days
Surgical Factors, 2009
Table 2: Univariate analyses of surgical related factors in 2009
Primary
Revision
Unadjusted OR
Autogenous Bone Graft
35.1%
40.3%
1.15 (1.1-1.2)
BMP
27.6%
39.7%
1.73 (1.6-1.8)
Interbody Device
53.5%
41.7%
0.55 (0.5-0.6)
> 4 Levels Fused
17.2%
27.3%
1.70 (1.6-1.8)
Surgical Factors, 2009
Adjusted OR, 2009
Comorbidities, Adjusted OR
Complications, Adjusted OR
Diagnosis
• Most common inpatient diagnosis for revision
fusion was: ICD9 996.49
– “Mechanical complication of internal orthopedic
device, implant, and graft”
– 46.4% of cervical refusions
– 46.7% of thoracic refusions
– 39.6% of lumbar refusions.
Conclusions: Epidemiologic Trends
• Revision spinal fusions have increased, but
at a lower rate than primary fusions from
2002-2009
Conclusions: Surgical Differences
• Revision Fusions had significantly higher
rates of BMP use (40% vs 28%)
– Lad et al, Spine 2011: National BMP Use ~ 31%
• Fusion of four or more levels occurred at
higher rates in spinal refusion cases (27.3%
vs 17.2%)
Conclusions: Patient Differences
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Depression (odds ratio 1.53)
Psychotic disorders (odds ratio 1.49)
Tobacco use (odds ratio 1.10)
Deficiency anemias (odds ratio 1.35)
All were more common in refusion discharges.
Conclusions: Complication Differences
– Dural tears (OR 1.4)
– Surgical site infections (OR 2.3)
– Wound dehiscence (OR 3.4)
All were more common in refusion discharges.
Final Remarks
– Given that the most common diagnosis for revisions was
‘mechanical complication of internal orthopedic device”
• Further research in different surgical factors is warranted (BMP,
fusion multiple levels, interbody devices, etc)
– Patient characteristics and co-morbidites identified should be
carefully reviewed upon primary surgical evaluation
– Higher rate of certain complications should further educate
the community on the increased complexity of revision
fusions
Thank You.
Tufts University