Duration of Surgery and Intraoperative Blood Pressure Management Are Modifiable Risk Factors for Postoperative Neurocognitive Disorders After Spine Surgery: Results of the Prospective CONFESS Study.
Journal
Spine
ISSN: 1528-1159
Titre abrégé: Spine (Phila Pa 1976)
Pays: United States
ID NLM: 7610646
Informations de publication
Date de publication:
15 Aug 2023
15 Aug 2023
Historique:
received:
04
04
2023
accepted:
09
05
2023
medline:
31
7
2023
pubmed:
17
5
2023
entrez:
17
5
2023
Statut:
ppublish
Résumé
Prospective quasi-experimental observational study. The objective of this study was to evaluate whether duration of surgery is a modifiable risk factor for postoperative delirium (POD) after spine surgery and explore further modifiable risk factors. In addition, we sought to investigate the association between POD and postoperative cognitive dysfunction and persistent neurocognitive disorders. Advances in spine surgery enable technically safe interventions in elderly patients with disabling spine disease. The occurrence of POD and delayed neurocognitive complications ( e.g. postoperative cognitive dysfunction/persistent neurocognitive disorder) remain a concern since these contribute to inferior functional outcomes and long-term care dependency after spine surgery. This prospective single-center study recruited patients aged 60 years or above and scheduled for elective spine surgery between February 2018 and March 2020. Functional (Barthel Index, BI) and cognitive outcomes [Consortium to Establish a Registry for Alzheimer's Disease (CERAD) test battery; telephone Montréal Cognitive Assessment] were assessed at baseline, three (V3), and 12 months postoperatively. The primary hypothesis was that the duration of surgery predicts POD. Multivariable predictive models of POD included surgical and anesthesiological parameters. Twenty-two percent of patients developed POD (n=22/99). In a multivariable model, duration of surgery [OR adj =1.61/h (95% CI, 1.20-2.30)], age [OR adj =1.22/yr (95% CI, 1.10-1.36)], and baseline deviations of intraoperative systolic blood pressure [25th percentile: OR adj =0.94/mm Hg (95% CI, 0.89-0.99); 90th percentile: OR adj =1.07/mm Hg (95% CI, 1.01-1.14)] were significantly associated with POD. Postoperative cognitive scores generally improved (V3, ΔCERAD total z -score: 0.22±0.63). However, this positive group effect was counteracted by POD [beta: -0.87 (95% CI, -1.31 to 0.42)], older age [beta: -0.03/yr (95% CI, -0.05 to 0.01)], and lack of functional improvement [ΔBI; beta: -0.04/point (95% CI, -0.06 to 0.02)]. Cognitive scores at twelve months remained inferior in the POD group, adjusted for baseline cognition/age. This study identified distinct neurocognitive effects after spine surgery, which are influenced by perioperative risk factors. Potential cognitive benefits are counteracted by POD, rendering its prevention critical in an aging population.
Sections du résumé
STUDY DESIGN
METHODS
Prospective quasi-experimental observational study.
OBJECTIVE
OBJECTIVE
The objective of this study was to evaluate whether duration of surgery is a modifiable risk factor for postoperative delirium (POD) after spine surgery and explore further modifiable risk factors. In addition, we sought to investigate the association between POD and postoperative cognitive dysfunction and persistent neurocognitive disorders.
SUMMARY OF BACKGROUND DATA
BACKGROUND
Advances in spine surgery enable technically safe interventions in elderly patients with disabling spine disease. The occurrence of POD and delayed neurocognitive complications ( e.g. postoperative cognitive dysfunction/persistent neurocognitive disorder) remain a concern since these contribute to inferior functional outcomes and long-term care dependency after spine surgery.
MATERIALS AND METHODS
METHODS
This prospective single-center study recruited patients aged 60 years or above and scheduled for elective spine surgery between February 2018 and March 2020. Functional (Barthel Index, BI) and cognitive outcomes [Consortium to Establish a Registry for Alzheimer's Disease (CERAD) test battery; telephone Montréal Cognitive Assessment] were assessed at baseline, three (V3), and 12 months postoperatively. The primary hypothesis was that the duration of surgery predicts POD. Multivariable predictive models of POD included surgical and anesthesiological parameters.
RESULTS
RESULTS
Twenty-two percent of patients developed POD (n=22/99). In a multivariable model, duration of surgery [OR adj =1.61/h (95% CI, 1.20-2.30)], age [OR adj =1.22/yr (95% CI, 1.10-1.36)], and baseline deviations of intraoperative systolic blood pressure [25th percentile: OR adj =0.94/mm Hg (95% CI, 0.89-0.99); 90th percentile: OR adj =1.07/mm Hg (95% CI, 1.01-1.14)] were significantly associated with POD. Postoperative cognitive scores generally improved (V3, ΔCERAD total z -score: 0.22±0.63). However, this positive group effect was counteracted by POD [beta: -0.87 (95% CI, -1.31 to 0.42)], older age [beta: -0.03/yr (95% CI, -0.05 to 0.01)], and lack of functional improvement [ΔBI; beta: -0.04/point (95% CI, -0.06 to 0.02)]. Cognitive scores at twelve months remained inferior in the POD group, adjusted for baseline cognition/age.
CONCLUSIONS
CONCLUSIONS
This study identified distinct neurocognitive effects after spine surgery, which are influenced by perioperative risk factors. Potential cognitive benefits are counteracted by POD, rendering its prevention critical in an aging population.
Identifiants
pubmed: 37195031
doi: 10.1097/BRS.0000000000004722
pii: 00007632-202308150-00002
pmc: PMC10368215
doi:
Types de publication
Observational Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1127-1137Informations de copyright
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.
Déclaration de conflit d'intérêts
The authors report no conflicts of interest.
Références
The 2021 Ageing Report: Economic and Budgetary Projections for the EU Member States (2019-2070) 3-7 (2021).
GBD. 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–22.
Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303:1259–65.
Mahanna-Gabrielli E, Schenning KJ, Eriksson LI, et al. State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. Br J Anaesth. 2019;123:464–478.
Gou RY, Hshieh TT, Marcantonio ER, et al. One-year medicare costs associated with delirium in older patients undergoing major elective surgery. JAMA Surg. 2021;156:430–42.
Rudolph JL, Marcantonio ER, Culley DJ, et al. Delirium is associated with early postoperative cognitive dysfunction. Anaesthesia. 2008;63:941–7.
Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367:30–9.
Ashley EA. The precision medicine initiative: a new national effort. JAMA. 2015;313:2119–220.
Muller J, Nowak S, Vogelgesang A, et al. Evaluating mechanisms of postoperative delirium and cognitive dysfunction following elective spine surgery in elderly patients (CONFESS): protocol for a Prospective Observational Trial. JMIR Res Protoc. 2020;9:e15488.
Geldsetzer P, Fawzi W. Quasi-experimental study designs series-paper 2: complementary approaches to advancing global health knowledge. J Clin Epidemiol. 2017;89:12–6.
Khan KS, Ball E, Fox CE, Meads C. Systematic reviews to evaluate causation: an overview of methods and application. Evid Based Med. 2012;17:137–41.
American College of Surgeons. COVID-19: guidance for triage of non-emergent surgical procedures: Elective Surgery Acuity Scale (ESAS). Updated March 17, 2020. Accessed January 07, 2022, https://www.facs.org/covid-19/clinical-guidance/triage
Hargrave A, Bastiaens J, Bourgeois JA, et al. Validation of a nurse-based delirium-screening tool for hospitalized patients. Psychosomatics. 2017;58:594–603.
Grinnon ST, Miller K, Marler JR, et al. National Institute of Neurological Disorders and Stroke. Common Data Element Project—approach and methods. Clin Trials. 2012;9:322–9.
Steverink N. Measuring frailty: developing and testing the GFI (Groningen Frailty Indicator). Gerontologist. 2001;41:236.
Martin J, Heymann A, Bäsell K, et al. Guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Sedierung und Delirmanagement in der Intensivmedizin–Kurzversion. 2010;8:1–31.
Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61–5.
Stein J, Luppa M, Luck T, et al. The assessment of changes in cognitive functioning: age-, education-, and gender-specific reliable change indices for older adults tested on the CERAD-NP battery: results of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe). Am J Geriatr Psychiatry. 2012;20:84–97.
Seo EH, Lee DY, Lee JH, et al. Total scores of the CERAD neuropsychological assessment battery: validation for mild cognitive impairment and dementia patients with diverse etiologies. Am J Geriatr Psychiatry. 2010;18:801–9.
Pendlebury ST, Welch SJ, Cuthbertson FC, Mariz J, Mehta Z, Rothwell PM. Telephone assessment of cognition after transient ischemic attack and stroke: modified telephone interview of cognitive status and telephone Montreal Cognitive Assessment versus face-to-face Montreal Cognitive Assessment and neuropsychological battery. Stroke. 2013;44:227–9.
van Smeden M, Moons KG, de Groot JA, et al. Sample size for binary logistic prediction models: beyond events per variable criteria. Stat Methods Med Res. 2019;28:2455–74.
Epstein NE. Spine surgery in geriatric patients: sometimes unnecessary, too much, or too little. Surg Neurol Int. 2011;2:188.
Aranake-Chrisinger A, Avidan MS. Postoperative delirium portends descent to dementia. Br J Anaesth. 2017;119:285–8.
Inouye SK, Marcantonio ER, Kosar CM, et al. The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients. Alzheimers Dement. 2016;12:766–75.
Devinney MJ, Mathew JP, Berger M. Postoperative delirium and postoperative cognitive dysfunction: two sides of the same coin? Anesthesiology. 2018. doi:10.1097/ALN.0000000000002338
doi: 10.1097/ALN.0000000000002338
Vasunilashorn SM, Ngo LH, Chan NY, Zhou W, Dillon ST, Otu HH, et al. Development of a Dynamic Multi-Protein Signature of Postoperative Delirium. J Gerontol A Biol Sci Med Sci. 2018;74:261–268
Berger M, Nadler JW, Browndyke J, et al. Postoperative cognitive dysfunction: minding the gaps in our knowledge of a common postoperative complication in the elderly. Anesthesiol Clin. 2015;33:517–20.
Tani N, Yaegaki T, Nishino A, et al. Functional connectivity analysis and prediction of cognitive change after carotid artery stenting. J Neurosurg. 2018;131:1709–15.
Wang J, Li Z, Yu Y, Li B, Shao G, Wang Q. Risk factors contributing to postoperative delirium in geriatric patients postorthopedic surgery. Asia Pac Psychiatry. 2015;7:375–82.
Seo JS, Park SW, Lee YS, Chung C, Kim YB. Risk factors for delirium after spine surgery in elderly patients. J Korean Neurosurg Soc. 2014;56:28–33.
Brown CHt, LaFlam A, Max L, et al. Delirium after spine surgery in older adults: incidence, risk factors, and outcomes. J Am Geriatr Soc. 2016;64:2101–08.
Pires PW, Dams Ramos CM, Matin N, Dorrance AM. The effects of hypertension on the cerebral circulation. Am J Physiol Heart Circ Physiol. 2013;304:H1598–614.
Schulz KF, Altman DG, Moher D, Group C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c332.
Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology. 2018;129:829–851.
Taylor J, Payne T, Casey C, et al. Sevoflurane dose and postoperative delirium: a prospective cohort analysis. Br J Anaesth. 2023;130:e289–97.