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Radiographic and Clinical Outcomes of Anterior and Transforaminal Lumbar Interbody Fusions: Which is Better?
S260
NASS 32nd Annual Meeting Proceedings / The Spine Journal 17 (2017) S176–S272
PATIENT SAMPLE: Patients undergoing elective laminectomy and fusion, performed by seven surgeons, were analyzed. OUTCOME MEASURES: Ninety-day cost and 90-day patient-reported outcomes. METHODS: Total 90-day cost included the hospital cost, surgeons’ professional cost and post-discharge resource utilization. Multivariate regression model was built for high-cost surgery (above third quartile) and a separate linear regression model was built to derive comorbidity adjusted 90-day costs. RESULTS: A total of 752 patients were analyzed. There were significant differences in patient-specific and surgery-specific variables, hospital cost, surgeons’ professional costs and post-discharge resource utilization among the surgeons. In multivariable model, surgeons #4(P<0.0001), and #6(p=.002), had higher odds of performing high-cost fusion surgery. The comorbidityadjusted costs were higher than the actual 90-day costs for surgeons #1(p=.08), #3(p=.002), #5(p<0.0001), and #7(p<0.0001), whereas they were lower than the actual costs for surgeons #2(p=.128), #4(p<0.0001) and #6(p=.44). CONCLUSIONS: Our study provides valuable insight into variations in patient- and surgery-related characteristics, outcomes, and 90-day costs among the surgeons performing lumbar laminectomy/fusions at a single institution. Specific surgeons were found to have greater odds of performing high cost surgeries. Adjusting for preoperative comorbidities, however, led to costs that were higher than the actual costs for certain surgeons and lower than the actual costs for others. Patient’s preoperative comorbidities must therefore be accounted for when crafting value-based bundled payment models. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.08.188
P188. Radiographic and Clinical Outcomes of Anterior and Transforaminal Lumbar Interbody Fusions: Which is Better? Remi M. Ajiboye, MD, MPH1, Haddy Alas2, Gina Mosich, MD3, Akshay Sharma4, Sina Pourtaheri, MD1; 1UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA, USA; 2USA; 3 UCLA Department of Orthopaedic Surgery, Los Angeles, CA, USA; 4Case Western Reserve University School of Medicine, Cleveland, OH, USA BACKGROUND CONTEXT: Anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) are two methods of achieving spinal arthrodesis. There are conflicting reports with no consensus on the optimal interbody technique to achieve successful radiographic and clinical outcomes. PURPOSE: The goal of this was to compare the radiographic and clinical outcomes of ALIF to TLIF. STUDY DESIGN/SETTING: Systematic review and meta-analysis. PATIENT SAMPLE: Comparative studies on ALIF and TLIF. OUTCOME MEASURES: Radiographic outcome measures included segmental and overall lumbar lordosis and fusion rates. Clinical outcomes measures included Oswestry disability index (ODI) and visual analog scale (VAS) score for back pain. METHODS: A systematic search of multiple medical reference databases was conducted for studies comparing ALIF to TLIF. Studies that reported on clinical and radiographic outcomes of ALIF and TLIFwith pedicle screw fixation were included. Studies that included stand-alone ALIFs with no pedicle screw fixation were excluded. Case reports, noncomparative studies and studies that did not report on clinical and radiographic outcomes were also excluded. Meta-analysis was performed using the random effects model for heterogeneity. RESULTS: The search yielded 7 studies totaling 811 patients (ALIF=448, TLIF=363). ALIF was superior to TLIF in restoring segmental lumbar lordosis at L4-5 and L5-S1((L4-5; SMD=4.655, 95% CI: 2.76 - 8.31, p=.013), (L5-S1; SMD=3.728, 95% CI: 1.710 - 5.746, p<.001)). ALIF was also superior to TLIF in restoring overall (T12 or L1-S1) lumbar lordosis (SMD=4.022, 95% CI: 2.71 - 5.333, p<.001). However, no significant differences in fusion rates were noted between both techniques (OR=0.905, 95% CI: 0.458 - 1.789, p=.775). Additionally, ALIF and TLIF were comparable
with regards to ODI and VAS scores ((ODI; SMD=1.782, 95% CI: -0.849 - 4.413, p=.184), (VAS; SMD=0.00784, 95% CI: -0.732 - 0.748, p=.983)). CONCLUSIONS: In patients with sagittal imbalance whereby restoration of lumbar lordosis is paramount, ALIF is superior to TLIF. However, for patients with degenerative spinal pathologies without significant deformity, TLIF is comparable to ALIF with regards to fusion rate and clinical outcomes. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.08.189
P189. Determinants of Intraoperative Transfusions in Adult Spinal Deformity Patients Sandesh Rao, MD1, Varun Puvanesarajah, BS2, Hamid Hassanzadeh, MD3, Khaled M. Kebaish, MD1; 1Baltimore, MD, USA; 2Johns Hopkins Medicine, Baltimore, MD, USA; 3Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA, USA BACKGROUND CONTEXT: Adult spinal deformity (ASD) surgeries are known to have significant morbidity. Blood loss is a major concern and often results in high transfusion rates. Transfusions may be associated with increased infection risks and transfusion reactions. The goal of this study was to determine predictors of allogeneic packed red blood cell (pRBC) transfusion in ASD patients. PURPOSE: To determine which preoperative and intraoperative parameters, including operative time and extent of the osteotomy, play a significant role in determining intraoperative transfusion rates. STUDY DESIGN/SETTING: Retrospective review of institutional patient records. PATIENT SAMPLE: Retrospecutive cohort of consecutive patients undergoing posterior spinal fusion of 4 levels or greater for spinal deformity from 2010 to 2016. OUTCOME MEASURES: Preoperative and intra-operative parameters that determine intraoperative transfusion rates. METHODS: An institutional database of ASD patients treated by a single, experienced spine surgeon from 2010 to 2016 was retrospectively analyzed. Patients were included if they were 18 years or older and were treated with surgery of 4 levels or greater for deformity. Patients were excluded if preoperative hemoglobin values were not recovered or if they were diagnosed with polio or spina bifida. Data regarding intraoperative transfusions (up to 10 days postoperatively), demographics, comorbidities and surgical factors were analyzed with a linear regression model. For all comparisons, p<.05 was significant. RESULTS: A total of 171 patients were analyzed for this study. Age ranged from 20 to 86 years (mean: 60.5±12.9 years). A total of 48.5% of procedures were revision surgeries. The median number of levels fused was 8 (mean: 9.2±4.0). Three column osteotomies, operative time and age were significantly associated with increased intraoperative transfusions. Schwab grade 3 or 4 osteotomies were associated with 1.6 additional units (p=.013), while Schwab 5 or 6 osteotomies were associated with 2.2 additional units (p=.016) of pRBCs transfused intraoperatively. A preoperative hemoglobin of 14.0 g/ dl or greater was associated with 1.8 less units transfused intraoperatively, when compared to those with preoperative hemoglobin levels below 11.5 g/ dl (p=.02). CONCLUSIONS: ASD surgeries often require transfusions. Our goal was to establish which perioperative parameters are associated with increased transfusions in the ASD population. Schwab grade 3 and higher osteotomies, operative time and age were associated with increased intraoperative transfusions, while hypertension and preoperative hemoglobin greater than 14.0 g/dl were associated with decreased intraoperative transfusions. In summary, if preoperative planning predicts use of three column osteotomies, increased rates of intra-operative transfusions can be expected. Preoperative hemoglobin level may be an important target for decreasing intraoperative transfusions. Ultimately, preoperative risk stratification can predict perioperative transfusion needs in ASD patients.
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.
NASS 32nd Annual Meeting Proceedings / The Spine Journal 17 (2017) S176–S272
PATIENT SAMPLE: Patients undergoing elective laminectomy and fusion, performed by seven surgeons, were analyzed. OUTCOME MEASURES: Ninety-day cost and 90-day patient-reported outcomes. METHODS: Total 90-day cost included the hospital cost, surgeons’ professional cost and post-discharge resource utilization. Multivariate regression model was built for high-cost surgery (above third quartile) and a separate linear regression model was built to derive comorbidity adjusted 90-day costs. RESULTS: A total of 752 patients were analyzed. There were significant differences in patient-specific and surgery-specific variables, hospital cost, surgeons’ professional costs and post-discharge resource utilization among the surgeons. In multivariable model, surgeons #4(P<0.0001), and #6(p=.002), had higher odds of performing high-cost fusion surgery. The comorbidityadjusted costs were higher than the actual 90-day costs for surgeons #1(p=.08), #3(p=.002), #5(p<0.0001), and #7(p<0.0001), whereas they were lower than the actual costs for surgeons #2(p=.128), #4(p<0.0001) and #6(p=.44). CONCLUSIONS: Our study provides valuable insight into variations in patient- and surgery-related characteristics, outcomes, and 90-day costs among the surgeons performing lumbar laminectomy/fusions at a single institution. Specific surgeons were found to have greater odds of performing high cost surgeries. Adjusting for preoperative comorbidities, however, led to costs that were higher than the actual costs for certain surgeons and lower than the actual costs for others. Patient’s preoperative comorbidities must therefore be accounted for when crafting value-based bundled payment models. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.08.188
P188. Radiographic and Clinical Outcomes of Anterior and Transforaminal Lumbar Interbody Fusions: Which is Better? Remi M. Ajiboye, MD, MPH1, Haddy Alas2, Gina Mosich, MD3, Akshay Sharma4, Sina Pourtaheri, MD1; 1UCLA Medical Center, Department of Orthopaedic Surgery, Los Angeles, CA, USA; 2USA; 3 UCLA Department of Orthopaedic Surgery, Los Angeles, CA, USA; 4Case Western Reserve University School of Medicine, Cleveland, OH, USA BACKGROUND CONTEXT: Anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF) are two methods of achieving spinal arthrodesis. There are conflicting reports with no consensus on the optimal interbody technique to achieve successful radiographic and clinical outcomes. PURPOSE: The goal of this was to compare the radiographic and clinical outcomes of ALIF to TLIF. STUDY DESIGN/SETTING: Systematic review and meta-analysis. PATIENT SAMPLE: Comparative studies on ALIF and TLIF. OUTCOME MEASURES: Radiographic outcome measures included segmental and overall lumbar lordosis and fusion rates. Clinical outcomes measures included Oswestry disability index (ODI) and visual analog scale (VAS) score for back pain. METHODS: A systematic search of multiple medical reference databases was conducted for studies comparing ALIF to TLIF. Studies that reported on clinical and radiographic outcomes of ALIF and TLIFwith pedicle screw fixation were included. Studies that included stand-alone ALIFs with no pedicle screw fixation were excluded. Case reports, noncomparative studies and studies that did not report on clinical and radiographic outcomes were also excluded. Meta-analysis was performed using the random effects model for heterogeneity. RESULTS: The search yielded 7 studies totaling 811 patients (ALIF=448, TLIF=363). ALIF was superior to TLIF in restoring segmental lumbar lordosis at L4-5 and L5-S1((L4-5; SMD=4.655, 95% CI: 2.76 - 8.31, p=.013), (L5-S1; SMD=3.728, 95% CI: 1.710 - 5.746, p<.001)). ALIF was also superior to TLIF in restoring overall (T12 or L1-S1) lumbar lordosis (SMD=4.022, 95% CI: 2.71 - 5.333, p<.001). However, no significant differences in fusion rates were noted between both techniques (OR=0.905, 95% CI: 0.458 - 1.789, p=.775). Additionally, ALIF and TLIF were comparable
with regards to ODI and VAS scores ((ODI; SMD=1.782, 95% CI: -0.849 - 4.413, p=.184), (VAS; SMD=0.00784, 95% CI: -0.732 - 0.748, p=.983)). CONCLUSIONS: In patients with sagittal imbalance whereby restoration of lumbar lordosis is paramount, ALIF is superior to TLIF. However, for patients with degenerative spinal pathologies without significant deformity, TLIF is comparable to ALIF with regards to fusion rate and clinical outcomes. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2017.08.189
P189. Determinants of Intraoperative Transfusions in Adult Spinal Deformity Patients Sandesh Rao, MD1, Varun Puvanesarajah, BS2, Hamid Hassanzadeh, MD3, Khaled M. Kebaish, MD1; 1Baltimore, MD, USA; 2Johns Hopkins Medicine, Baltimore, MD, USA; 3Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA, USA BACKGROUND CONTEXT: Adult spinal deformity (ASD) surgeries are known to have significant morbidity. Blood loss is a major concern and often results in high transfusion rates. Transfusions may be associated with increased infection risks and transfusion reactions. The goal of this study was to determine predictors of allogeneic packed red blood cell (pRBC) transfusion in ASD patients. PURPOSE: To determine which preoperative and intraoperative parameters, including operative time and extent of the osteotomy, play a significant role in determining intraoperative transfusion rates. STUDY DESIGN/SETTING: Retrospective review of institutional patient records. PATIENT SAMPLE: Retrospecutive cohort of consecutive patients undergoing posterior spinal fusion of 4 levels or greater for spinal deformity from 2010 to 2016. OUTCOME MEASURES: Preoperative and intra-operative parameters that determine intraoperative transfusion rates. METHODS: An institutional database of ASD patients treated by a single, experienced spine surgeon from 2010 to 2016 was retrospectively analyzed. Patients were included if they were 18 years or older and were treated with surgery of 4 levels or greater for deformity. Patients were excluded if preoperative hemoglobin values were not recovered or if they were diagnosed with polio or spina bifida. Data regarding intraoperative transfusions (up to 10 days postoperatively), demographics, comorbidities and surgical factors were analyzed with a linear regression model. For all comparisons, p<.05 was significant. RESULTS: A total of 171 patients were analyzed for this study. Age ranged from 20 to 86 years (mean: 60.5±12.9 years). A total of 48.5% of procedures were revision surgeries. The median number of levels fused was 8 (mean: 9.2±4.0). Three column osteotomies, operative time and age were significantly associated with increased intraoperative transfusions. Schwab grade 3 or 4 osteotomies were associated with 1.6 additional units (p=.013), while Schwab 5 or 6 osteotomies were associated with 2.2 additional units (p=.016) of pRBCs transfused intraoperatively. A preoperative hemoglobin of 14.0 g/ dl or greater was associated with 1.8 less units transfused intraoperatively, when compared to those with preoperative hemoglobin levels below 11.5 g/ dl (p=.02). CONCLUSIONS: ASD surgeries often require transfusions. Our goal was to establish which perioperative parameters are associated with increased transfusions in the ASD population. Schwab grade 3 and higher osteotomies, operative time and age were associated with increased intraoperative transfusions, while hypertension and preoperative hemoglobin greater than 14.0 g/dl were associated with decreased intraoperative transfusions. In summary, if preoperative planning predicts use of three column osteotomies, increased rates of intra-operative transfusions can be expected. Preoperative hemoglobin level may be an important target for decreasing intraoperative transfusions. Ultimately, preoperative risk stratification can predict perioperative transfusion needs in ASD patients.
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.