MAST/MISS TLIFeffect of Age, BMI & Comorbidity in 200 patients      Petrus Stone, Neurosurgeon, Bloemfontein              ...
Disclosures MAST/MISS  Teaching on behalf  of Medtronic No funding/  compensation for  this study or  presentation No a...
Background - Motivation for study  Expected small   incisions to be like   tips of iceberg i.e.   pretty on the surface  ...
Literature OPEN surgery   Age – more    complicated   BMI – more    complicated   Comorbidity - more    complicated M...
Family debate– open vs MISS Advantages (theoretical)    Cosmesis,    Pain,    Hospital Stay,    Blood Loss,    Infec...
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 ComplicationsMajor local complications                 %             Major systemic complications             ...
Significant ComplicationsMajor local complications      %decompression same stay       1.0%fusion extension same stay    0...
Outcomes/Effects of:AgeBMIComorbidity
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 ...
Gender effectGroup name                  Gender                                                   SummarySubgroup names   ...
Revision effectGroup name                     Revision SurgeryGroup values                                           De No...
Levels operatedGroup name                  Levels                                                                     Wors...
More complex surgery (n = 125)Group name                  Orange River TLIF class (n = 125)Subgroup names                 ...
Application- using probabilities &median values                              S3977               S4073               S4095...
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 - 2012-10-06 - SA Neurosurgery Congress, Somerset West, South Africa
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MI-TLIF - effect of Age, BMI & Comorbidity - 2012-10-06 - SA Neurosurgery Congress, Somerset West, South Africa

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Review of effect of Age, Morbid Obesity & Medical Comorbidity upon sshort term outcome after minimally invasive TLIF procedure

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MI-TLIF - effect of Age, BMI & Comorbidity - 2012-10-06 - SA Neurosurgery Congress, Somerset West, South Africa

  1. 1. MAST/MISS TLIFeffect of Age, BMI & Comorbidity in 200 patients Petrus Stone, Neurosurgeon, Bloemfontein 2012-10-06
  2. 2. Disclosures MAST/MISS Teaching on behalf of Medtronic No funding/ compensation for this study or presentation No animals were harmed
  3. 3. Background - Motivation for study  Expected small incisions to be like tips of iceberg i.e. pretty on the surface but …  Unexpectedly plain sailing (anaesthesia & hospital) for older & sicker patients  Quantify this suspicion
  4. 4. Literature OPEN surgery  Age – more complicated  BMI – more complicated  Comorbidity - more complicated MI/MAST  Age – some studies (Mendeley Group: TLIF)  BMI – some studies  Co-morbidity – no comparisons
  5. 5. Family debate– open vs MISS Advantages (theoretical)  Cosmesis,  Pain,  Hospital Stay,  Blood Loss,  Infection Disadvantages (theoretical)  Fusion Rate,  Steep Learning Curve,  Irradiation exposure
  6. 6. 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)
  7. 7. Patients / Materials AndMethods 200 consecutive degenerative TLIF cases since 2009-08-31 Review case notes, hospital notes (myself; Mediclinic 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 UOFS statistician
  8. 8. 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 (range 1.5 to 23) • Remove instrumentation
  9. 9. 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%
  10. 10. Significant ComplicationsMajor 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%Moderate local complications % Moderate systemic complications %durotomies 7.5%superficial sepsis 1.0% respiratory (chest infection, atelectasis,iatrogenic end plate damage --> extra screws 0.5% sleep apnoea) 4.5%partial L5 weakness 1 (0.5%) 0.5%persisting dysesthetic leg pain 0.5% arrhythmia 0.5%plunge with PAK needle (uncomplicated) 0.5%screw too deep, Hb drop 0.5% quadriceps hematoma 0.5% 11.0% 5.5% Summary all significant complications % Complications (Major/moderate; Systemic/Local) 21.0% Cases (Major and/or Moderate) 18.5%
  11. 11. Significant ComplicationsMajor local complications %decompression same stay 1.0%fusion extension same stay 0.5%severe L4 nerve root damage 0.5% 2.0%
  12. 12. Outcomes/Effects of:AgeBMIComorbidity
  13. 13. 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 -
  14. 14. 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
  15. 15. 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
  16. 16. Gender effectGroup name Gender SummarySubgroup names Female MaleFisher’s Exact Test % % pTransfusion required 2.65 4.60 0.4713 WorseDurotomy/CSF leak 7.08 8.05 0.7939 • LOS: 4.1 vs 3.7 daysLocal (major) 1.77 2.30 1.0000 • Radiation exposure: 2.5 vs 2.9Local (moderate) 11.50 10.34 0.8243Local (minor) 0.88 0.00 1.0000 minutesLocal (All: M, M, M) 14.15 12.64 0.9635Systemic (major) 2.65 2.30 1.0000 SimilarSystemic (moderate) 5.31 5.75 1.0000 • ComplicationsSystemic (minor) 23.01 16.09 0.2851Systemic (all) 30.97 24.14 0.6038 • Theater/Cutting timeLocal or Systemic (major) 4.42 4.60 1.0000 • ICU/High care useLocal or Systemic (moderate) 16.81 16.09 1.0000Local or Systemic (minor) 23.89 16.09 0.2851ICU - zero nights 10.62 19.77ICU - one night 79.65 70.93 0.2075ICU - two night 9.73 9.30Kruskal-Wallis Test mean mean pLOS postop (days) 4.10 3.70 0.0028Theater Time (hours) 4.30 4.00 0.2124Cutting Time (hours) 3.20 2.90 0.2744ICU stay (hours) 21.50 19.90 0.1832Radiation Exposure (mins) 3.50 2.90 0.0395
  17. 17. Revision effectGroup name Revision SurgeryGroup values De Novo Scar IxFisher’s Exact Test p-value significance % % %Transfusion required 0.1926 - 2.72 4.35 14.29Durotomy/CSF leak 0.0038 Yes 4.08 19.57 0.00Local (major) 1.0000 - 2.04 2.17 0.00Local (moderate) 0.0080 Yes 6.80 23.91 14.29Local (minor) 1.0000 - 0.68 0.00 0.00Local (All: M, M, M) 0.0421 Yes 9.52 26.08 14.29 WorseSystemic (major) 0.0573 - 1.36 4.35 14.29 • DurotomySystemic (moderate) 0.5293 - 4.76 8.70 0.00Systemic (minor) 0.4722 - 18.37 26.09 14.29 • Theater time (but notSystemic (all) 0.1817 - 24.49 39.14 28.58 cutting time)Local or Systemic (major) 0.1580 - 3.40 6.52 14.29 SimilarLocal or Systemic (moderate) 0.0068 Yes 11.56 32.61 14.29 • Cutting time (? Numbers)Local or Systemic (minor) 0.4722 - 18.37 26.09 14.29 • Transfusion requirementsICU nights 0.8029 - • Systemic complicationsGroup values De Novo Scar Ix De Novo Other local Ix • Scar complicationsKruskal-Wallis Test p-value sig? median1 median2 median3 LOS mean2 •mean1 mean3LOS postop (days) 0.4061 - 3.80 4.00 3.90 • 4.6ICU stay (hours & nights) 5 5.2Theater Time (hours) 0.0071 Yes 4.00 4.40 5.80 4.2 4.7 5.8Cutting Time (hours) 0.0800 - 2.90 3.30 4.70 3.1 3.5 4.1ICU stay (hours) 0.6516 - 21.20 21.00 19.60 23 20.9 20Radiation Exposure (mins) 0.1912 - 3.00 3.80 3.50 4.1 4.4 3.9
  18. 18. Levels operatedGroup name Levels WorseSubgroup names 1 level 2 level 3 levelFisher’s Exact Test p-value sig? % % % • DurotomiesTransfusion required 0.1012 - 1.77 5.00 14.29 • ((Theater, Cutting, RadiationDurotomy/CSF leak 0.0315 Yes 3.54 12.50 14.29 time))Local (major) 0.1582 - 1.77 1.25 14.29 • LOS & ICU stayLocal (moderate) 0.0019 Yes 4.42 20.00 14.29Local (minor) 0.435 - 0.00 1.25 0.00Local (All: M, M, M) 0.0015 Yes 6.19 22.50 28.58 SameSystemic (major) 0.7082 - 1.77 3.75 0.00 • Systemic complicationsSystemic (moderate) 0.2784 - 3.54 8.75 0.00 • Local complications exceptSystemic (minor) 0.5822 - 17.70 22.50 28.57Systemic (all) 0.535 - 23.01 35.00 28.57 durotomyLocal or Systemic (major) 0.3304 - 3.54 5.00 14.29Local or Systemic (moderate) 0.0025 Yes 7.96 28.75 14.29Local or Systemic (minor) 0.5822 - 17.70 23.75 28.57ICU nights 0.0001 YesKruskal-Wallis Test Median Median MedianLOS postop (days) 0.0229 Yes 3.70 4.70 4.70Theater Time (hours) 0.0001 Yes 3.20 5.00 6.50Cutting Time (hours) 0.0001 Yes 2.20 3.80 5.20ICU stay (hours) 0.0071 Yes 20.30 21.40 21.20Radiation Exposure (mins) 0.0001 Yes 2.70 3.70 5.50
  19. 19. More complex surgery (n = 125)Group name Orange River TLIF class (n = 125)Subgroup names 1a 1b 1c 1d 2a 2b 2c 2d 3a 3cFisher’s Exact Test p-value (Chi-Square) sig? % % % % % % % % % %Local or Systemic (major) 0.5377 (Chi-Square) - 8.2 6.7 0.0 0.0 2.9 9.1 16.7 50.0 0.0 0.0Local or Systemic (moderate) 0.3234 (Chi-Square) - 4.1 26.7 33.3 0.0 11.8 18.2 0.0 0.0 0.0 0.0Local or Systemic (minor) 0.3831 (Chi-Square) - 12.2 13.3 0.0 0.0 8.8 9.1 16.7 0.0 0.0 100.0Significant blood loss 0.0032 (Chi-Square) yes 4.1 40.0 0.0 50.0 35.3 18.2 50.0 50.0 0.0 100.0LOS postop (days) 0.0389 (Kruskal-Wallis Test) yes 3.7 4.5 3.9 3.1 4.5 6.6 4.9 5.7 6.3 5.7
  20. 20. Application- using probabilities &median values S3977 S4073 S4095Age 30 53 70BMI 38 33Comorbidity (ASA) 1 1 2Gender Female Male FemalePrevious surgery Scar (laminectomy None Instrumentation L4-S1 same level)Transitional vertebra no lumbarized S1 (work no higher up though)Plan L5/S1 TLIF & IX L5/6 TLIF & Ix L3/4 TLIF, wide dekompression, remove some of L4-S1 Ix; consider vertebroplastyOrange Class 1a 1a 1d Bottom line: S3977 S4073 S4095 Prepare theater time 4.1 3.0 6.2 Prepare 2 nights in ICU/High Care 14.3% 12.6% 31.4% Prepare physician due to major/moderate systemic complications 52.0% 43.4% 74.4% Prepare transfusion 15.2% 15.6% 31.2%
  21. 21. 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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