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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•
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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