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Thread: No kidding - patient characteristics mostly predict complications

  1. #1
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    No kidding - patient characteristics mostly predict complications

    As I suspected, 5 of the top 6 predictors of complications were associated entirely with the patient. Only anterior approach is under the control of surgeons.

    The knee-jerk reaction to blame the surgeon when something bad happens is not supported by this research. These guys are just taking these patients as they come and trying to help. I hope people take this on board.

    The Fusion Risk Score: Evaluating Baseline Risk in Thoracic and Lumbar Fusion Surgery

    Hartin, Nathan L.; Mehbod, Amir A.; Joglekar, Siddharth B.; More

    Spine., POST ACCEPTANCE, 21 August 2013

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    Study Design. Retrospective cohort study

    Objective. The Fusion Risk Score is introduced to assess baseline risk of spine fusion surgery preoperatively. An objective method of stratifying risk allows the surgeon to control risk through tailoring intervention and explain differences in complication profile in high-complexity practice.

    Summary of Background Data. Research has identified an elevated risk of serious complications performing spine fusion surgery in the elderly, yet the rate of such surgery continues to increase. A range of comorbidities and surgical factors are demonstrated predictors of perioperative risk.

    Methods. Retrospective review was made of 364 consecutive fusion surgeries in patients over age 65 in an 18 month period. Logistic regression analysis was performed to identify factors predictive for the occurrence of perioperative events. The predictive variables were incorporated in a weighted fashion into the Fusion Risk Score (FRS) scaled from 1 to 20. Patient demographics and co-morbidities were incorporated into the FRS Patient Score (maximum 10) and surgical approach, levels and osteotomies into the FRS Procedure Score (maximum 10).

    Results. Multivariate analysis demonstrated chronic kidney disease (OR = 5.3, 95% CI 1.5-18.6, p = 0.008), chronic obstructive pulmonary disease (OR = 5.3, 95% CI 2.0-14.2, p<0.001), ischemic heart disease (OR = 4.1, 95% CI 2.0-8.4, p<0.001), an open anterior approach (OR = 3.6, 95% CI 1.4-9.3, p = 0.010), diabetes (OR = 3.0, 95% CI 1.4-6.4, p = 0.004), previous spinal surgery at the same site (OR = 2.6, 95% CI 1.3-4.9, p = 0.005), age (OR = 1.07, 95% CI 1.01-1.13, p = 0.019) and the number of motion segments fused (p = 0.049) to be predictive of perioperative events. When applied, the FRS was highly predictive of perioperative events, ICU admission, operative time, blood loss and length of stay (all p<0.0001). A score over threshold 9 carries a greater than 50% risk of perioperative events.

    Conclusions. The Fusion Risk Score predicts the risk of complications after spine fusion surgery based on patient and surgery characteristics. It also predicts the risk of ICU admission and correlates with operative time, blood loss and postoperative length of stay. By balancing the FRS Procedure Score to the individual FRS Patient Score, the surgeon can quantify and control perioperative risk.

    (C) 2013 by Lippincott Williams & Wilkins
    Sharon, mother of identical twin girls with scoliosis

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  2. #2
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    Maybe I'm interpreting this wrong (I don't know why I didn't see this post before). But these risk factors don't seem to be ones that the patient has any control over. They are just pre-existing conditions that indicate that just maybe these particular patients should NOT undergo this procedure. When they do, bad things are likely to happen. If I'm getting this right, it would be up to the surgeon to explain to these patients that they are at a very high risk of complications before the decision to have surgery is made. This would save the surgeon from malpractice lawsuits, perhaps?
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  3. #3
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    If surgeons stopped operating on patients with >1 comorbidity, the number of adult scoliosis surgeons would drop drastically. This looks like an interesting article. Will print out the whole paper to see what I can pull out of it.

    Sharon, it's my impression, at least for the UCSF ortho spine surgeons, that perioperative complications don't really have an impact on long-term outcomes. That is, patients with periop complications usually end up just as happy as patients without periop complications, when you look at the data 6-12 months postop.

    --Linda
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  4. #4
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    Quote Originally Posted by LindaRacine View Post
    If surgeons stopped operating on patients with >1 comorbidity, the number of adult scoliosis surgeons would drop drastically. This looks like an interesting article. Will print out the whole paper to see what I can pull out of it.
    Yes I just thought it would be illuminating that it is really the patients as they come that mostly determines complications, not particularly surgeon skill (if limiting to experienced guys). I think most people assume surgical mistakes are to blame when in fact it's just surgeons taking people as they come. I have long suspected that based on the complication rates of kids versus adults. It's not just because they are younger... it's because they have less else going on. Like the possibility of lumbar involvement in T curves, I think people need to understand all the possibilities that can happen just from waiting so that can be factored into their decision. Delay can be a double-edged sword unfortunately.

    Sharon, it's my impression, at least for the UCSF ortho spine surgeons, that perioperative complications don't really have an impact on long-term outcomes. That is, patients with periop complications usually end up just as happy as patients without periop complications, when you look at the data 6-12 months postop.

    --Linda
    There have been a few abstracts posted about how the vast majority of complications are temporary and therefore don't figure into the outcome though they are worrisome at the time.
    Last edited by Pooka1; 03-18-2014 at 07:30 AM.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  5. #5
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    When I went to see the chief of neurosurgery to get my referral to the scoliosis doctor and he explained why adult surgeries are far more difficult. He started talking about osteotomies, stiffer curves, more procedures that have to be done DURING the operation. That's pretty self-explanatory then why kids have an easier time. Age is NEVER on our side when it comes to having major surgery. I never even gave that a second thought and just thought it was common knowledge that the more wrong going in, the more likely you will have complications. My hospital is in the top 100 hospitals in the nation for some things. They just don't have a spine ortho that is qualified to do these complex surgeries. They HAD one that did kids, but I see the results of her work in my DIL. I think she could have had a better surgeon.

    The question I have here is why don't they see the same results from anterior procedures? It shouldn't make a difference, unless they aren't doing the other more invasive things like osteotomies and obviously laminectomies from the anterior. So, maybe I just answered my own question. Duh.
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  6. #6
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    Quote Originally Posted by rohrer01 View Post

    The question I have here is why don't they see the same results from anterior procedures?
    To which results are you referring?
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation
    ---------------------------------------------------------------------------------------------------------------------------------------------------
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  7. #7
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    The intraoperative complications.
    Be happy!
    We don't know what tomorrow brings,
    but we are alive today!

  8. #8
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    Rohrer...

    I'd have to look it up, but I think open anterior procedures (versus posterior and/or minimally invasive anterior procedures) carry a fairly high risk of periop complications (e.g., pulmonary, vascular, etc.). Since relatively few open anterior procedures are done any more, I think it's possible that the anterior procedures included in the study are actually older than the posterior procedures.

    --Linda
    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Dilbert
    I'm sarcastic... what's your super power? --Unknown
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    Surgery 2/10/93 A/P fusion T4-L3
    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation
    ---------------------------------------------------------------------------------------------------------------------------------------------------
    If you've signed up and are having trouble posting, please check your spam folder. An email was sent to the email address which you subscribed. You have to follow the instructions in that email. Done that and still having trouble posting? Contact Joe O'Brien at jpobrien@scoliosis.org.

  9. #9
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    excuse me....i HATE the title of this thread...
    sounds like "blaming the patient..."
    maybe it should be blaming the pre existing conditions...NOT
    the patient...
    because if you just read the title of this thread, it sounds like
    it is just whining, immature patients that contribute to post op
    complications...
    and i hate anything that sounds like blaming the patient.

    so does Sparky...but in his case, he dislikes anything that sounds
    like blaming the doggie!

    jess...and Sparky
    P.S. your private message box is full, Sharon
    Last edited by jrnyc; 03-20-2014 at 01:15 PM.

  10. #10
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    Quote Originally Posted by jrnyc View Post
    excuse me....i HATE the title of this thread...
    sounds like "blaming the patient..."
    maybe it should be blaming the pre existing conditions...NOT
    the patient...
    because if you just read the title of this thread, it sounds like
    it is just whining, immature patients that contribute to post op
    complications...
    and i hate anything that sounds like blaming the patient.

    so does Sparky...but in his case, he dislikes anything that sounds
    like blaming the doggie!

    jess...and Sparky
    P.S. your private message box is full, Sharon
    Jess you're right. I should have said pre-existing conditions.

    I am just trying to suggest that the tendency to blame the surgeons when things go wrong is probably off base.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  11. #11
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    I emptied the box.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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