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MAST/MISS TLIFeffect of Age, BMI & Comorbidity in 200 patients     Petrus Stone, Neurosurgeon, Private Practice           ...
Disclosures MAST/MISS  Teaching on behalf  of Medtronic Sponsored  attendance/travel Study at my own  expense No anima...
Literature OPEN surgery   Age – more    complicated   BMI – more    complicated   Comorbidity - more    complicated M...
Family debate– MISS Pros & Cons Advantages (theoretical)    Cosmesis,    Pain,    Hospital Stay,    Blood Loss,    I...
Objective To what degree does  co-morbidity affect  (short term) outcome Use of Information    Patient/procedure     se...
Patients / Materials AndMethods 200 consecutive degenerative TLIF  cases since 2009-08-31 Review case notes, hospital no...
Descriptive Stats – The Procedures Surgical Time     Median 3 hours (1h25-9h30) (case      no 9; 3 levels) Levels opera...
Descriptive Stats – Short term OutcomeMajor                              Duration follow up: 30-880• threatening to life ...
Significant ComplicationsModerate local complications                     %                                               ...
Age effectGroup name                     Age Group 2Subgroup names                        <65               >65Fisher’s Ex...
BMI effectGroup name                  BMI                          BMI Group 3Subgroup names              <35        >35  ...
Comorbidity (ASA) effectGroup name                     ASA score                                 ASA_Ex_BMISubgroup names ...
Summary Age   >70: longer LOS (4 vs 6 days)   >70: transfusion more likely    (15 vs 2%)   >65: ICU stay (hours not   ...
MI-TLIF - effect of age, BMI& comorbidity - 2013-04-06 - global spine congress, hong kong
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MI-TLIF - effect of age, BMI& comorbidity - 2013-04-06 - global spine congress, hong kong

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How safe is the Minimally Invasive TLIF procedure in old, obese & sick individuals? We know the open TLIF is not as safe for these patients ...

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Transcript of "MI-TLIF - effect of age, BMI& comorbidity - 2013-04-06 - global spine congress, hong kong"

  1. 1. MAST/MISS TLIFeffect of Age, BMI & Comorbidity in 200 patients Petrus Stone, Neurosurgeon, Private Practice Bloemfontein, South Africa 2013-04-06
  2. 2. Disclosures MAST/MISS Teaching on behalf of Medtronic Sponsored attendance/travel Study at my own expense No animals were harmed
  3. 3. Literature OPEN surgery  Age – more complicated  BMI – more complicated  Comorbidity - more complicated MI/MAST  Age – some studies  BMI – some studies  Co-morbidity – no comparisons
  4. 4. Family debate– MISS Pros & Cons Advantages (theoretical)  Cosmesis,  Pain,  Hospital Stay,  Blood Loss,  Infection Disadvantages (theoretical)  Fusion Rate,  Steep Learning Curve,  Irradiation exposure
  5. 5. Objective To what degree does co-morbidity affect (short term) outcome Use of Information  Patient/procedure selection  Resource allocation (length of stay, High Care nights, transfusion, Physicians)
  6. 6. Patients / Materials AndMethods 200 consecutive degenerative TLIF cases since 2009-08-31 Review case notes, hospital notes (myself; senior nurse) Excluded 6 cases  1x conversion to open  1x aborted procedure (revision of open TLIF; screw holes too big)  1x cancellation on table (medical aid interference)  3 trauma thoraco-lumbar cases Stat analysis by UFS statistician
  7. 7. Descriptive Stats – The Procedures Surgical Time  Median 3 hours (1h25-9h30) (case no 9; 3 levels) Levels operated / Orange River TLIF Class  1: 56.5%  A: 39%  B-F: 15%  2: 40%  A: 24.5% TLIF sub-classes to accommodate for extra  B-F: 15.5% work  3: 3.5% • a – no extra work  A: 2.5% • b – 30 minutes • c – 60 minutes  B-F: 1.0% • Etc Medtronic : n = 181 (90.5%) Examples • Vertebroplasty; Navigation: n = 8 (4%) • adjacent level discectomy; Radiation exposure: median 3.1 • Same level wide decompression/lami; minutes • Remove instrumentation
  8. 8. Descriptive Stats – Short term OutcomeMajor  Duration follow up: 30-880• threatening to life or limb days function• Early revision surgery  Length of ICU/High CareModerate stay• prolonged hospital stay or  0 nights: 14,5% outpatient treatment requiredMinor  1 night: 75.5%• inconvenient  2 nights: 9.5%  Length of postoperative hospital stay  Median 3.9 days (0.9 to 17.9)  Need for transfusion  3.5%
  9. 9. Significant ComplicationsModerate local complications % Moderate systemic complications %durotomies 7.5%superficial sepsis 1.0% respiratory (chest infection, atelectasis, sleep apnoea) 4.5%iatrogenic end plate damage --> extra screws 0.5%partial L5 weakness 1 (0.5%) 0.5% arrhythmia 0.5%persisting dysesthetic leg pain 0.5%plunge with PAK needle (uncomplicated) 0.5% quadriceps hematoma 0.5%screw too deep, Hb drop 0.5% 11.0% 5.5%Major local complications % Major systemic complications %decompression same stay 1.0% Pulmonary embolism 1.5%fusion extension same stay 0.5% Unexpected epileptic fit 0.5%severe L4 nerve root damage 0.5% tachy-arythmia -> cardioversion 0.5% 2.0% 2.5%
  10. 10. Age effectGroup name Age Group 2Subgroup names <65 >65Fisher’s Exact Test % % p-value Sig? WorseTransfusion required 2.41 8.82 0.0969 - • Transfusion if >70:Durotomy/CSF leakLocal (major) 6.63 1.81 11.76 0.2918 - 2.94 0.5284 - 15.8%Local (moderate) 9.64 17.65 0.2241 - • LOS if >70: 3.8 vsLocal (minor) 0.60 0.00 1.0000 - 3.9 vs 5.7 days • ICU stay (hours notLocal (All: M, M, M) 12.05 20.59 0.4077 -Systemic (major) 2.41 2.94 1.0000 -Systemic (moderate) 4.82 8.82 0.4028 - nights) if >65Systemic (minor) 18.07 29.41 0.1577 -Systemic (all) 25.30 41.17 0.1415 -Local or Systemic (major) 4.22 5.88 0.6515 - SimilarLocal or Systemic (moderate) 14.46 26.47 0.1914 - • ComplicationsLocal or Systemic (minor) 18.67 29.41 0.1577 - • Theater, Cutting,Significant blood loss 1 night: 75.9%; 2 1 night: 75.76%; 2 Radiation time nights: 6.63%ICU nights nights 24.24% 0.0005 YesKruskal-Wallis Test Median Median p-value Sig?LOS postop (days) 3.80 4.90 0.0451 YesTheater Time (hours) 4.10 4.30 0.4115 -Cutting Time (hours) 3.00 3.10 0.5770 -ICU stay (hours) 20.50 21.70 0.0020 YesRadiation Exposure (mins) 3.10 3.10 0.6888 -
  11. 11. BMI effectGroup name BMI BMI Group 3Subgroup names <35 >35 <35 35-40 >40Fisher’s Exact Test % % p-value % % % p-valueTransfusion required 3.45 3.64 1.0000 3.45 0.00 7.69 0.2114Durotomy/CSF leak 8.28 5.45 0.7642 8.28 6.90 3.85 0.9088Local (major) 1.38 3.64 0.3038 1.38 6.90 0.00 0.1821 Worse • ICU nightsLocal (moderate) 12.41 7.27 0.4478 12.41 10.34 3.85 0.5757Local (minor) 0.00 1.82 0.2750 0.00 0.00 3.85 0.1300 • Theater, Cutting, RELocal (All: M, M, M) 13.79 12.73 0.1729 13.79 17.24 7.70 0.1149Systemic (major) 2.76 1.82 1.0000 2.76 0.00 3.85 0.6015Systemic (moderate)Systemic (minor) 4.83 18.62 7.27 23.64 0.4985 4.83 6.90 7.69 0.6770 0.4338 18.62 24.14 23.08 0.6583 timeSystemic (all) 26.21 32.73 0.8746 26.21 31.04 34.62 0.9190Local or Systemic (major) 4.14 5.46 0.7084 4.14 6.90 3.85 0.8519Local or Systemic(moderate) 17.24 14.54 0.6623 17.24 17.24 11.54 0.9036 SimilarLocal or Systemic (minor)ICU - zero nights 18.62 17.36 25.46 7.27 0.4338 18.62 24.14 26.93 0.6583 17.36 13.79 0.00 • ComplicationsICU - one night 75.69 76.36 0.0381 75.69 68.97 84.62 0.0312 6.94 17.24 15.38 • Hospital LOSICU - two night 6.94 16.36ICU nightsKruskal-Wallis Test median median p-value p-valueLOS postop (days) 3.90 4.00 0.1588 3.90 3.90 4.40 0.3392Theater Time (hours) 4.00 4.70 0.0209 4.00 4.60 5.20 0.0245Cutting Time (hours) 2.80 3.50 0.0163 2.80 3.20 3.80 0.0216ICU stay (hours) 21.00 22.00 0.1765 21.00 20.40 23.00 0.1687Radiation Exposure (mins) 3.00 3.70 0.0153 3.00 3.00 5.30 0.0012
  12. 12. Comorbidity (ASA) effectGroup name ASA score ASA_Ex_BMISubgroup names ASA 1 ASA 2 ASA 3 ASA 1 ASA 2 ASA 3Fisher’s Exact Test % % % p-value % % % p-valueTransfusion required 1.89 4.55 3.39 0.8867 1.59 4.69 0.00 0.5883Durotomy/CSF leak 9.43 7.95 5.08 0.6999 7.94 7.81 0.00 1.0000Local (major) 0.00 2.27 3.39 0.5810 0.00 3.13 0.00 0.4221 SummaryLocal (moderate) 15.09 11.36 6.78 0.3714 14.29 10.16 0.00 0.5071Local (minor) 0.00 0.00 1.69 0.5600 0.00 0.78 0.00 1.0000 More likelyLocal (All: M, M, M) 15.09 13.63 11.86 0.4548 14.29 14.07 0.00 0.6124Systemic (major) 3.77 2.27 1.69 0.7278 3.17 2.34 0.00 0.7349 • Minor & ModerateSystemic (moderate) 1.89 6.82 6.78 0.4513 1.59 6.25 22.22 0.0491 systemic CxSystemic (minor) 13.21 21.59 23.73 0.3462 11.11 22.66 44.44 0.0255 • Theater & CuttingSystemic (all) 18.87 30.68 32.20 0.6372 15.87 31.25 66.66 0.0358 timeLocal or Systemic (major) 3.77 4.54 5.08 1.0000 3.17 5.47 0.00 0.8168Local or Systemic (moderate) 16.98 18.18 13.56 0.6589 15.88 16.41 22.22 0.7344 • ICU stay? (integarLocal or Systemic (minor) 13.21 21.59 25.42 0.3462 11.11 23.44 44.44 0.0255 nights; not hours)ICU - zero nights 26.42 12.64 6.78 26.98 9.45 0.00ICU - one night 66.04 81.61 76.27 0.0115 66.67 81.10 66.67 0.0034 Similar occurrence • Local CxICU - two night 7.55 5.75 16.95 6.35 9.45 33.33Kruskal-Wallis Test median median median p-value p-valueLOS postop (days) 3.80 3.90 4.00 0.2550 3.60 4.00 4.00 0.0857 • Major Systemic CxTheater Time (hours) 3.60 4.20 4.70 0.0063 3.50 4.50 4.10 0.0008 • TransfusionCutting Time (hours) 2.60 2.90 3.50 0.0153 2.40 3.30 2.90 0.0045 • ICU nights (hours not nights)ICU stay (hours) 20.20 21.10 22.00 0.1933 20.20 21.10 25.20 0.0362Radiation Exposure (mins) 2.90 3.00 3.70 0.0509 2.90 3.30 2.90 0.1182 • LOS
  13. 13. Summary Age  >70: longer LOS (4 vs 6 days)  >70: transfusion more likely (15 vs 2%)  >65: ICU stay (hours not nights)  ISQ complications BMI  Longer procedure, theater time, irradiation time  More ICU nights  ISQ complications & LOS Comorbidity (ASA score)  Longer procedure  ISQ complications & LOS
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