Oral Posters: Thoraco-lumbar Degenerative

Presented by: R. Duculan - View Audio/Video Presentation (Members Only)

Author(s):

C.A. Mancuso(1,2), R. Duculan(3), F.P. Cammisa(3), A.A. Sama(3), A.P. Hughes(3), D.R. Lebl(3), F.P. Girardi(3)

(1) Hospital for Special Surgery, Research, New York, NY, United States
(2) Weill Cornell Medical College, Medicine, New York, NY, United States
(3) Hospital for Special Surgery, Orthopedics, New York, NY, United States

Abstract

Purpose: Effective management of patients after lumbar surgery requires acknowledging the complexities of co-existing physical and psychosocial variables. Preoperatively identifying these variables, particularly those leading to greater resource utilization, would facilitate in-hospital and discharge management. While effects of surgical and medical variables are well known and there are standard methods to measure them, less is known about the role of psychosocial variables and how to measure them preoperatively. The goal of this analysis was to assess whether preoperatively measured psychosocial variables predict longer length of stay and special discharge requirements after lumbar surgery, independent of surgical and medical variables.

Methods: This was a prospective cohort study of 532 consecutive patients undergoing lumbar surgery for diverse diagnoses. Several days before surgery patients completed several surveys, including the Geriatric Depression Scale, the Spielberg State Anxiety Inventory, and a question about tangible social support (“during the past four weeks, was someone available to help you if you needed and wanted help” with five response options ranging from “yes, as much as I wanted” to “no, not at all”). Medical comorbidity was scored according to the Charlson Comorbidity Index, and extent of surgery was described according to the Spine Surgical Invasiveness Index, a validated instrument accounting for vertebral levels, fusion, instrumentation, and approach. The primary outcomes were hospital length of stay (LOS), dichotomized according to routine hospital stay of ≤ 3 days or > 3 days; and requiring services at discharge, dichotomized as to home or to an institution/home with services. Two logistic regression models were considered with LOS and required services at discharge as dependent variables.

Results: Mean age was 56 years, 55% were men, 79% had a chronic spine diagnosis, 40% had a positive screen for depression, 62% had greater anxiety than population norms, 77% reported as much social support as they wanted, 2% reported no support, 30% had major medical comorbidity, and 35% were obese. Surgical invasiveness was not normally distributed and was divided into quartiles. 53% has LOS > 3days; in multivariable analysis, longer LOS was predicted by a positive screen for depression and less social support. 17% required services at discharge; in multivariable analysis, requiring services was associated with a positive screen for depression, greater anxiety than population norms, and less social support. Models accounted for mean age, sex, medical comorbidity, obesity and extent of surgery.

Conclusions: Psychosocial variables predicted LOS and requiring services after discharge independent of medical comorbidity and extent of surgery. Our analysis is unique because it included psychosocial variables, particularly social support, in the analysis of perioperative outcomes. Our study demonstrated that patients undergoing lumbar surgery are complex in terms of the variables that affect outcomes. In addition, our study showed that these variables can be measured relatively simply and thus can be used proactively to plan perioperative resource utilization.

Complexity Study Table