Passias Peter G, Poorman Gregory W, Vasquez-Montes Dennis, Kummer Nicholas, Mundis Gregory, Anand Neel, Horn Samantha R, Segreto Frank A, Passfall Lara, Krol Oscar, Diebo Bassel, Burton Doug, Buckland Aaron, Gerling Michael, Soroceanu Alex, Eastlack Robert, Kojo Hamilton D, Hart Robert, Schwab Frank, Lafage Virginie, Shaffrey Christopher, Sciubba Daniel, Bess Shay, Ames Christopher, Klineberg Eric
Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA.
Int J Spine Surg. 2022 Apr;16(2):291-299. doi: 10.14444/8174.
More sophisticated surgical techniques for correcting adult spinal deformity (ASD) have increased operative times, adding to physiologic stress on patients and increased complication incidence. This study aims to determine factors associated with operative time using a statistical learning algorithm.
Retrospective review of a prospective multicenter database containing 837 patients undergoing long spinal fusions for ASD. Conditional inference decision trees identified factors associated with skin-to-skin operative time and cutoff points at which factors have a global effect. A conditional variable-importance table was constructed based on a nonreplacement sampling set of 2000 conditional inference trees. Means comparison for the top 15 variables at their respective significant cutoffs indicated effect sizes.
Included: 544 surgical ASD patients (mean age: 58.0 years; fusion length 11.3 levels; operative time: 378 minutes). The strongest predictor for operative time was institution/surgeon. Center/surgeons, grouped by decision tree hierarchy, a and b were, on average, 2 hours faster than center/surgeons c-f, who were 43 minutes faster than centers g-j, all < 0.001. The next most important predictors were, in order, approach (combined vs posterior increases time by 139 minutes, < 0.001), levels fused (<4 vs 5-9 increased time by 68 minutes, < 0.050; 5-9 vs 10 increased time by 47 minutes, < 0.001), age (age <50 years increases time by 57 minutes, < 0.001), and patient frailty (score <1.54 increases time by 65 minutes, < 0.001). Surgical techniques, such as three-column osteotomies (35 minutes), interbody device (45 minutes), and decompression (48 minutes), also increased operative time. Both minor and major complications correlated with 66 minutes of increased operative time. Increased operative time also correlated with increased hospital length of stay (LOS), increased estimated intraoperative blood loss (EBL), and inferior 2-year Oswestry Disability Index (ODI) scores.
Procedure location and specific surgeon are the most important factors determining operative time, accounting for operative time increases <2 hours. Surgical approach and number of levels fused were also associated with longer operative times, respectively. Extended operative time correlated with longer LOS, higher EBL, and inferior 2-y ODI outcomes.
We further identified the poor outcomes associated with extended operative time during surgical correction of ASD, and attributed the useful predictors of time spent in the operating room, including site, surgeon, surgical approach, and the number of levels fused.
用于矫正成人脊柱畸形（ASD）的更复杂手术技术增加了手术时间，加重了患者的生理应激并增加了并发症发生率。本研究旨在使用统计学习算法确定与手术时间相关的因素。
对一个前瞻性多中心数据库进行回顾性分析，该数据库包含837例接受ASD长节段脊柱融合术的患者。条件推断决策树确定了与皮肤切开至皮肤缝合手术时间相关的因素以及这些因素产生整体影响的临界点。基于2000棵条件推断树的无放回抽样集构建了一个条件变量重要性表。对前15个变量在各自显著临界点处的均值比较显示了效应大小。
纳入544例接受手术治疗的ASD患者（平均年龄：58.0岁；融合节段长度为11.3个节段；手术时间：378分钟）。手术时间的最强预测因素是机构/外科医生。按决策树层次分组的中心/外科医生，a组和b组平均比c - f组快2小时，c - f组比g - j组快43分钟，差异均<0.001。接下来最重要的预测因素依次为手术入路（联合入路与后路相比手术时间增加139分钟，<0.001）；融合节段数（<4个节段与5 - 9个节段相比手术时间增加68分钟，<0.050；5 - 9个节段与10个节段相比手术时间增加47分钟，<0.001）；年龄（年龄<50岁手术时间增加57分钟，<0.001）；以及患者虚弱程度（评分<1.54手术时间增加65分钟，<0.001）。手术技术，如三柱截骨术（35分钟）、椎间融合器植入（45分钟）和减压术（48分钟），也会增加手术时间。轻微和严重并发症均与手术时间增加66分钟相关。手术时间增加还与住院时间延长、估计术中失血量增加以及2年时较低的Oswestry功能障碍指数（ODI）评分相关。
手术地点和特定外科医生是决定手术时间的最重要因素，可解释手术时间增加<2小时的情况。手术入路和融合节段数也分别与较长的手术时间相关。延长的手术时间与更长的住院时间、更高的术中失血量以及较差的2年ODI结果相关。
我们进一步确定了ASD手术矫正过程中与延长手术时间相关的不良结果，并确定了手术室时间的有用预测因素，包括手术部位外科医生、手术入路和融合节段数。
