Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA, 21287.
Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA, 55905.
Spine J. 2022 Aug;22(8):1345-1355. doi: 10.1016/j.spinee.2022.03.005. Epub 2022 Mar 24.
BACKGROUND CONTEXT: Intramedullary spinal cord tumors (IMSCTs) are rare tumors associated with significant morbidity and mortality. Surgical resection is often indicated for symptomatic lesions but may result in new neurological deficits and decrease quality of life. Identifying predictors of these adverse outcomes may help target interventions designed to reduce their occurrence. Nonetheless, most prior studies have employed population-level datasets with limited granularity. PURPOSE: To determine independent predictors of nonroutine discharge, prolonged length of stay (LOS), and 30 day readmission and reoperation, and to deploy these results as a web-based calculator. STUDY DESIGN: Retrospective cohort study PATIENT SAMPLE: A total of 235 patients who underwent resection of IMSCTs at a single comprehensive cancer center. OUTCOME MEASURES: Nonroutine discharge, prolonged LOS, 30 day readmission, and 30 day reoperation METHODS: Patients who underwent surgery from June 2002 to May 2020 at a single tertiary center were included. Data was collected on patient demographics, clinical presentation, tumor histology, surgical procedures, and 30 day readmission and reoperation. Functional status was assessed using the Modified McCormick Scale (MMS) and queried preoperative neurological symptoms included weakness, urinary and bowel dysfunction, numbness, and back and radicular pain. Variables significant on univariable analysis at the α≤0.15 level were entered into a stepwise multivariable logistic regression model. RESULTS: Of 235 included cases, 131 (56%) experienced a nonhome discharge and 68 (29%) experienced a prolonged LOS. Of 178 patients with ≥ 30 days of follow-up, 17 (9.6%) were readmitted within 30 days and 13 (7.4%) underwent reoperation. Wound dehiscence (29%) was the most common reason for readmission. Nonhome discharge was independently predicted by older age (OR=1.03/year; p<.01), thoracic location of the tumor (OR=2.36; p=.01), presenting with bowel dysfunction (OR=4.09; p=.03), and longer incision length (OR=1.44 per level; p=.03). Independent predictors of prolonged LOS included presenting with urinary incontinence (OR=2.65; p=.05) or a higher preoperative white blood cell count (OR=1.08 per 10/μL); p=.01), while GTR predicted shorter LOS (OR=0.40; p=.02). Independent predictive factors for 30 day unplanned readmission included experiencing ≥1 complications during the first hospitalization (OR=6.13; p<.01) and having a poor (A-C) versus good (D-E) baseline neurological status on the ASIA impairment scale (OR=0.23; p=.03). The only independent predictor of unplanned 30 day reoperation was experiencing ≥1 inpatient complications during the index hospitalization (OR=6.92; p<.01). Receiver operating curves for the constructed models produced C-statistics of 0.67-0.77 and the models were deployed as freely available web-based calculators (https://jhuspine5.shinyapps.io/Intramedullary30day). CONCLUSIONS: We found that neurological presentation, patient demographics, and incision length were important predictors of adverse perioperative outcomes in patients with IMSCTs. The calculators can be used by clinicians for risk stratification, preoperative counseling, and targeted interventions.
背景:脊髓髓内肿瘤(IMSCTs)是一种发病率和死亡率都很高的罕见肿瘤。手术切除通常是针对有症状的病变,但可能导致新的神经功能缺损和降低生活质量。识别这些不良结果的预测因素有助于针对旨在减少其发生的干预措施。尽管如此,大多数先前的研究都采用了粒度有限的人群水平数据集。
目的:确定非常规出院、延长住院时间( LOS )和 30 天再入院和再手术的独立预测因素,并将这些结果作为一个基于网络的计算器。
研究设计:回顾性队列研究
患者样本:在一个综合性癌症中心接受 IMSCT 切除术的 235 名患者。
观察指标:非常规出院、延长 LOS 、30 天再入院和 30 天再手术。
方法:包括 2002 年 6 月至 2020 年 5 月在一家三级中心接受手术的患者。收集患者的人口统计学、临床表现、肿瘤组织学、手术程序以及 30 天再入院和再手术的数据。使用改良 McCormick 量表(MMS)评估功能状态,并询问术前神经症状,包括无力、尿和肠功能障碍、麻木以及背部和神经根疼痛。在 α≤0.15 水平的单变量分析中具有统计学意义的变量被纳入逐步多变量逻辑回归模型。
结果:在 235 例纳入病例中,131 例(56%)经历了非家庭出院,68 例(29%)经历了延长 LOS。在 178 例有≥30 天随访的患者中,17 例(9.6%)在 30 天内再次入院,13 例(7.4%)再次手术。伤口裂开(29%)是再次入院的最常见原因。非家庭出院的独立预测因素包括年龄较大(OR=1.03/年;p<.01)、肿瘤位于胸段(OR=2.36;p=.01)、出现肠功能障碍(OR=4.09;p=.03)和更长的切口长度(OR=每增加 1 个水平 1.44;p=.03)。延长 LOS 的独立预测因素包括出现尿失禁(OR=2.65;p=.05)或术前白细胞计数较高(OR=每 10/μL 增加 1.08;p=.01),而 GTR 预测 LOS 缩短(OR=0.40;p=.02)。30 天非计划性再入院的独立预测因素包括在首次住院期间经历≥1 种并发症(OR=6.13;p<.01)和在 ASIA 损伤量表上具有较差(A-C)而非良好(D-E)基线神经状态(OR=0.23;p=.03)。计划外 30 天再手术的唯一独立预测因素是在指数住院期间经历≥1 种住院并发症(OR=6.92;p<.01)。构建模型的受试者工作特征曲线产生了 0.67-0.77 的 C 统计量,并将模型作为免费的基于网络的计算器进行部署(https://jhuspine5.shinyapps.io/Intramedullary30day)。
结论:我们发现,神经学表现、患者人口统计学和切口长度是 IMSCT 患者围手术期不良结果的重要预测因素。这些计算器可由临床医生用于风险分层、术前咨询和有针对性的干预。
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