• Cole A Bortz, Peter G Passias, Frank Segreto, Samantha R Horn, Virginie Lafage, Justin S Smith, Breton Line, Gregory M Mundis, Khaled M Kebaish, Michael P Kelly, Themistocles Protopsaltis, Daniel M Sciubba, Alexandra Soroceanu, Eric O Klineberg, Douglas C Burton, Robert A Hart, Frank J Schwab, Shay Bess, Christopher I Shaffrey, and Christopher P Ames.
• Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York.
• Neurosurgery. 2019 Sep 1; 85 (3): E509-E519.

BackgroundNonroutine discharge, including discharge to inpatient rehab and skilled nursing facilities, is associated with increased cost-of-care. Given the rising prevalence of cervical deformity (CD)-corrective surgery and the necessity of value-based healthcare, it is important to identify indicators for nonroutine discharge.ObjectiveTo identify factors associated with nonroutine discharge after CD-corrective surgery using a statistical learning algorithm.MethodsA retrospective review of patients ≥18 yr with discharge and baseline (BL) radiographic data. Conditional inference decision trees identified factors associated with nonroutine discharge and cut-off points at which factors were significantly associated with discharge status. A conditional variable importance table used nonreplacement sampling set of 10 000 conditional inference trees to identify influential patient/surgical factors. The binary logistic regression indicated odds of nonroutine discharge for patients with influential factors at significant cut-off points.ResultsOf 138 patients (61 yr, 63% female) undergoing surgery for CD (8 ± 5 levels; 49% posterior approach, 16% anterior, and 35% combined), 29% experienced nonroutine discharge. BL cervical/upper-cervical malalignment showed the strongest relationship with nonroutine discharge: C1 slope ≥ 14°, C2 slope ≥ 57°, TS-CL ≥ 57°. Patient-related factors associated with nonroutine discharge included BL gait impairment, age ≥ 59 yr and apex of CD primary driver ≥ C7. The only surgical factor associated with nonroutine discharge was fusion ≥ 8 levels. There was no relationship between nonhome discharge and reoperation within 6 mo or 1 yr (both P > .05) of index procedure. Despite no differences in BL EQ-5D (P = .946), nonroutine discharge patients had inferior 1-yr postoperative EQ-5D scores (P = .044).ConclusionSevere preoperative cervical malalignment was strongly associated with nonroutine discharge following CD-corrective surgery. Age, deformity driver, and ≥ 8 level fusions were also associated with nonroutine discharge and should be taken into account to improve patient counseling and health care resource allocation.Copyright © 2019 by the Congress of Neurological Surgeons.

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