In-Hospital Complications and Resource Utilization Following Lumbar Spine Surgery in Patients with Parkinson Disease: Evaluation of the National Inpatient Sample Database

doi:10.1016/j.wneu.2017.07.006

World Neurosurgery

Volume 106, October 2017, Pages 470-476

https://doi.org/10.1016/j.wneu.2017.07.006 Get rights and content

Background

Previous reports suggest that patients with Parkinson disease (PD) have elevated rates of complications following spine surgery; however, these reports are limited by small patient series. In this study, we used the National Inpatient Sample (NIS) database to compare in-hospital complications following elective lumbar spine surgery in patients with a diagnosis of PD and patients without PD.

Methods

The NIS database was accessed to identify patients with PD and those without PD who underwent lumbar spine surgery. All patients identified had a diagnosis code consistent with degenerative lumbar spine pathology. The patients were evaluated for the presence or absence of PD and divided into 4 lumbar spine procedure groups: decompression alone, lateral fusion, posterior fusion, and anterior fusion technique. Propensity score matching (PSM) was performed for the PD versus non-PD patients in each procedure group to control for confounding demographic variables, and in-hospital complications were compared between the 2 groups.

Results

Between 2001 and 2012, a total of 613,522 lumbar spine surgery patient episodes were identified, of which 4492 (0.7%) involved a diagnosis of PD. Following PSM for patient age, sex, and race, the patients with PD were at increased risk for acute postoperative hemorrhagic anemia, increased blood transfusion requirements, and increased genitourinary, neurologic, and cardiac complications compared with the patients without PD.

Conclusions

PSM analysis of the NIS database demonstrated that patients with PD are at increased risk for acute in-hospital complications and greater blood transfusion requirements than those without PD. Surgeons should be aware of the increased risks and differing requirements when treating spinal pathology in patients with PD.

Introduction

Parkinson disease (PD), a neurodegenerative disorder resulting from lesions in the basal ganglia, is increasingly prevalent in older adults and is now the second-most common degenerative neurologic disorder in the elderly population.¹ With disease progression, PD results in a functional decline with reduced mobility, typified by a slow, shuffling gait and increased muscular rigidity.2, 3 Despite advances in medical treatment for PD, the natural history of the disease remains one of progressive decline.⁴ Patients with PD may also suffer common degenerative disorders that afflict the individuals without PD, including degenerative disorders of the joints and spine. These degenerative conditions can place an added physiological burden on patients with PD, whose mobility is already compromised.

Little data exist on patient outcomes following spine surgery in the PD population.5, 6, 7, 8, 9, 10, 11 The few reports available highlight increased complication rates, increased rates of revision surgery, and increased risk of instrumentation or construct failure in patients with PD.5, 6, 7, 9, 11, 12 Early complications, including infection, have been reported at a rate of almost 20%, whereas other reports suggest a greater risk of poor postoperative outcomes following spine surgery.12, 13 Nonetheless, there remains a relative lack of published information relating to surgical complications and outcomes following spine surgery for patients with PD. In addition, previous reports surgical treatment of spinal pathologies in patients with PD have been limited by small samples.6, 7, 9, 11, 12, 13, 14 Although these previous reports contribute to the knowledge pool, larger database analysis may provide a broader picture with greater generalizability.

In the present study, we used the National Inpatient Sample (NIS) database to evaluate in-hospital complication rates for patients with PD (PD group) and patients without PD (NONPD group) undergoing surgery for lumbar spine degenerative conditions. We hypothesized that compared with the NONPD group, the PD group would have a greater risk for complications following elective lumbar spine surgery.

Section snippets

Methods

The NIS, an all-payer database available by the US Agency for Healthcare Research and Quality, is the largest database of its type available. Approximately 1000 hospitals across 45 states provide NIS data, representing a 20% sample of nonfederal hospitals nationwide. Approximately 8 million hospital stays are recorded annually. For each discharge, a number of clinical and nonclinical event points are recorded in addition to procedural and diagnostic codes according to the International

Results

A total of 613,522 patients met our study inclusion criteria, including 4950 patients with PD (0.7% of all lumbar procedures). Before the PSM analysis, compared with the NONPD group, the PD group was older (70.6 years vs. 58.9 years; P < 0.001) and had a greater percentage of males (59.3% vs. 46.8%; P < 0.001). There were no differences in terms of race between the 2 groups. Following PSM, all evaluated demographic variables were similar in the PD and NONPD groups for each procedure subgroup.

Discussion

Previous reports have indicated that surgical treatment of spinal pathology in patients with PD is associated with greater postoperative complication rates compared with patients without PD.6, 7, 9, 11 Little comparative data exist on acute in-hospital complications for patients with PD and those without PD. In this study, using a large national database and PSM to control for confounding demographic variables, we found that patients with PD were more likely than those without PD to have acute

Conclusion

In summary, using the largest available inpatient database, we found that the presence of PD was associated with an increased risk of in-hospital, postoperative complications, including cardiac, genitourinary, and neurologic complications; acute blood loss anemia; and the resulting need for transfusion of blood products following elective lumbar spine surgery. A multidisciplinary approach is suggested to appropriately manage patients with PD undergoing spine surgery. Future studies should

References (28)

C.M. Tanner et al.
Epidemiology of Parkinson's disease
Neurol Clin
(1996)
I. Benatru et al.
Postural disorders in Parkinson's disease
Neurophysiol Clin
(2008)
H.J. Choi et al.
Coronal plane spinal malalignment and Parkinson's disease: prevalence and associations with disease severity
Spine J
(2015)
C.A. Sarkiss et al.
To operate or not?: a literature review of surgical outcomes in 95 patients with Parkinson's disease undergoing spine surgery
Clin Neurol Neurosurg
(2015)
L. Katus et al.
Perioperative management of patients with Parkinson's disease
Am J Med
(2014)
Y. Sato et al.
Coagulation-fibrinolysis abnormalities in patients receiving antiparkinsonian agents
J Neurol Sci
(2003)
T.A. Boonstra et al.
Gait disorders and balance disturbances in Parkinson's disease: clinical update and pathophysiology
Curr Opin Neurol
(2008)
H.H. Fernandez
2015 Update on Parkinson disease
Cleve Clin J Med
(2015)
H. Koller et al.
Spinal surgery in patients with Parkinson's disease: experiences with the challenges posed by sagittal imbalance and the Parkinson's spine
Eur Spine J
(2010)
S.H. Moon et al.
Surgical outcome of lumbar fusion surgery in patients with Parkinson disease
J Spinal Disord Tech
(2012)

A.C. Peek et al.

Thoracolumbar spinal fixation for camptocormia in Parkinson's disease

J Neurol Neurosurg Psychiatry

(2009)

J.K. Oh et al.

Sagittal spinopelvic malalignment in Parkinson disease: prevalence and associations with disease severity

Spine (Phila Pa 1976)

(2014)

A. Bourghli et al.

Posterior spinal fusion from T2 to the sacrum for the management of major deformities in patients with Parkinson disease: a retrospective review with analysis of complications

J Spinal Disord Tech

(2012)

G. Sapkas et al.

Spinal surgery in patients with Parkinson's disease: unsatisfactory results, failure and disappointment

Open Orthop J

(2014)

Cited by (19)

Association of Postoperative Delirium and Parkinson Disease After Common United States Surgical Procedures
2023, Journal of Surgical Research
To determine the association of Parkinson disease (PD) and postoperative delirium following common surgical procedures.
We performed a retrospective database analysis of the National Inpatient Sample. We used a matched sample of patients with and without PD who underwent any of ten common surgical procedures in the US, 2005-2014. Primary outcome measure was postoperative delirium for patients with and without PD. Secondary measures included disposition, length of stay, and hospital costs.
There were 3,235,866 patients receiving any of the ten most common operative procedures, 2005-2014. There were 35,743 patients with and without PD matched based on age, sex, elective admission status, Charlson Comorbidity index, and presence of dementia. Median age was 77 y (interquartile range 72-82), median Charlson Comorbidity index was 1 (standard deviation 0-2), 46.6% were female, and 46.8% were admitted electively. The three most common operative procedures were hip arthroplasty (28.5%), knee arthroplasty (16.1%), and percutaneous coronary angioplasty (14.9%). Postoperative delirium was present in 1519 patients with PD compared to 828 matched patients without PD (4.2% versus 2.3%; P < 0.001). The adjusted odds ratio of postoperative delirium for PD compared to the matched cohort without PD was 1.88 (95% confidence interval 1.73-2.05). Those undergoing spinal fusion (adjusted odds ratio 2.99, 95% confidence interval 2.06-4.38) had the greatest odds of delirium. For patients with PD, adjusted length of stay, adjusted hospital costs, and adjusted odds of postacute care facility discharge were greater compared to the matched cohort without PD.
Patients with PD are more likely to develop postoperative delirium and have a more complicated postoperative course with longer length of stay and greater hospitalization costs.
Orthopedic Care of Patients with Parkinson Disease
2020, Clinics in Geriatric Medicine
Citation Excerpt :
Lumbar deformities and medical complications related to the diagnosis of PD may increase complications of lumbar spinal surgeries in the PD population. A cross-sectional analysis of complications from decompression or decompression and lumbar fusion using the National Inpatient Sample (NIS) was performed through the US Agency for Healthcare Research and Quality from 2001 to 2012.12 The NIS is the largest all-payer database of US hospital admissions, composed of a stratified sample of 20% of hospitalizations in 1000 hospitals annually.
Patients with Parkinson Disease Experience Increased Perioperative Complications Following Cervical Decompression and Fusion: A Retrospective Review of the National Inpatient Sample
2019, World Neurosurgery
Citation Excerpt :
Yet, the recent literature discussing putative benefits of surgery in this population is controversial. Alongside the inherent risks of anesthesia and surgery, PD may impart a heightened complication risk in the perioperative period.9-11 This complication risk may be heightened further in the setting of deformity repair.12
Despite improved medical management, the incidence of spinal pathology remains high in patients with Parkinson disease (PD). Several studies have investigated lumbar spine surgery in this population, but data regarding costs and perioperative complications for patients undergoing cervical decompression/fusion on a nationwide scale are lacking.
Cases of cervical spinal decompression, fusion, or exploration in years 2008–2014 were collected via the Healthcare Cost and Utilization Project National Inpatient Sample. Demographics, complications, outcome, and total charges were compared in patients with and without PD (NPD). Confounding variables were identified for multivariate analysis.
Data were available for 195,341 cervical spine cases, of which PD was prevalent in 779 cases (0.4%). Cases with PD experienced greater overall complication rates (12.5 vs. 7.6%; P < 0.001). Multivariate analysis revealed longer lengths of stay for the PD cohort (mean = 1.21 days longer; P < 0.001) and decreased routine discharge (odds ratio = 0.308; P < 0.001). There was no significant difference in mean total charges between PD and NPD (–$1532; P = 0.337). Mortality rates did not significantly differ for either group.
Although patients with PD experience greater complication rates and non-home discharges following cervical spine surgery compared with NPD patients, the overall clinical impact of these results may be minimal relative to surgery at other spinal levels in this population.
Does Parkinson Disease Increase the Risk of Perioperative Complications After Total Hip Arthroplasty? A Nationwide Database Study
2018, Journal of Arthroplasty
Citation Excerpt :
Now that this study has specified the increased inpatient complications for PD patients, further studies should use a different database, which contains this outpatient data, to analyze longer term outcomes. The findings of this study are broadly comparable to those of prior studies that have reported on the postoperative course of PD patients [20–27]. Increased rates of postoperative delirium, UTI, and overall complication in patients who had PD have been demonstrated by Oichi et al. [21] in spine surgery and by Huang et al. [24] in non-neurological surgery.
Parkinson disease (PD) is the second most common neurodegenerative disorder in the United States, affecting over 1 million people. As part of the disease process, PD can cause poor bone quality and other musculoskeletal problems that can affect a patient's quality of life. With advances in treatment, PD patients can be more active and may be candidates for total hip arthroplasty (THA). However, there is a paucity of literature on the outcomes of THA in PD patients. Therefore, the purpose of this study was to evaluate the perioperative outcomes of PD patients who underwent THA. Specifically, we assessed: (1) perioperative surgical and medical complications; (2) lengths of stay (LOSs); and (3) total hospital charges.
Using the Nationwide Inpatient Sample, patients who had PD and underwent THA between 2002 and 2013 were identified. With the use of propensity scores, PD patients were matched in a 1:3 ratio to patients without PD by the year of surgery, age, gender, race, Charlson/Deyo score, and insurance type. This yielded a total of 10,519 PD and 31,679 non-PD THA patients. Regression analyses were used to compare the risk of perioperative complications (any, surgical, medical), the percent differences in mean LOS, and the percent differences in total hospital charges.
Compared with the matched cohort, PD patients had a 52% higher risk for any complication (odds ratio [OR] = 1.52; 95% confidence interval [CI], 1.37-1.69), a 30% higher risk for any surgical complication (OR = 1.30; 95% CI: 0.88-1.91), and a 54% higher risk for any medical complication (OR = 1.54; 95% CI, 1.38-1.71). Specifically, PD patients were more likely to have postoperative delirium (OR = 2.61; 95% CI: 1.77-3.85), altered mental status (OR = 3.01; 95% CI: 1.35-6.71), urinary tract infection (OR = 1.34; 95% CI: 1.09-1.76), and blood transfusion (OR = 1.62; 95% CI: 1.44-1.82). Also, PD patients had a mean LOS that was 8.57% longer (P < .0001), and mean total hospital charges that were 3.85% higher (P < .0001).
Orthopedic surgeons and neurologists should be involved in the preoperative counseling of PD patients regarding their potential increased risks associated with THA, which could help optimize their preoperative care. Furthermore, the risk of complications and higher costs could potentially lead to the development of different reimbursement methods in this population of patients.
Impact of deep brain stimulation therapy on the vertebral sagittal balance in Parkinson’s disease patients
2024, Neurosurgical Review
Impact of Deep Brain Stimulation therapy on the vertebral sagittal balance in Parkinson’s disease patients
2023, Research Square

View all citing articles on Scopus

: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

View full text

Original ArticleIn-Hospital Complications and Resource Utilization Following Lumbar Spine Surgery in Patients with Parkinson Disease: Evaluation of the National Inpatient Sample Database

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Neurol Clin

Neurophysiol Clin

Spine J

Clin Neurol Neurosurg

Am J Med

J Neurol Sci

Gait disorders and balance disturbances in Parkinson's disease: clinical update and pathophysiology

Curr Opin Neurol

2015 Update on Parkinson disease

Cleve Clin J Med

Spinal surgery in patients with Parkinson's disease: experiences with the challenges posed by sagittal imbalance and the Parkinson's spine

Eur Spine J

Surgical outcome of lumbar fusion surgery in patients with Parkinson disease

J Spinal Disord Tech

Thoracolumbar spinal fixation for camptocormia in Parkinson's disease

J Neurol Neurosurg Psychiatry

Sagittal spinopelvic malalignment in Parkinson disease: prevalence and associations with disease severity

Spine (Phila Pa 1976)

Posterior spinal fusion from T2 to the sacrum for the management of major deformities in patients with Parkinson disease: a retrospective review with analysis of complications

J Spinal Disord Tech

Spinal surgery in patients with Parkinson's disease: unsatisfactory results, failure and disappointment

Open Orthop J

Original Article
In-Hospital Complications and Resource Utilization Following Lumbar Spine Surgery in Patients with Parkinson Disease: Evaluation of the National Inpatient Sample Database