Spine Degenerative Conditions and Their Treatments: National Trends in the United States of America

Association of Lumbar Degenerative Disease and Revision Rate following Total Knee Arthroplasty

Recently, a variety of studies have analyzed the potential correlation between lumbar degenerative disease (LDD) and inferior clinical outcomes after total hip arthroplasty. However, there has been limited data concerning the role of LDD as a risk factor for failure after total knee arthroplasty (TKA). The aim of our study was to determine: (1) what is the association of LDDs with TKA failure (all-cause revision) within 2 years of index arthroplasty and (2) if patients with LDD and lumbar fusion are at increased risk of TKA revision within 2 years compared with LDD patients without fusion. Data were collected from the Humana insurance database using the PearlDiver database from 2007 to 2017. To assess aim 1, patients were stratified into two groups based on a prior history of LDD (International Classification of Diseases [ICD]-9 or -10 diagnostic codes). To analyze aim 2, patients within the LDD cohort were stratified based on the presence of lumbar fusion (lumbar fusion Current Procedural Terminology code). All-cause revision rate was 3.4% among LDD patients versus 2.4% of patients with non-LDD (p < 0.001) at 2 years. Following multivariate analysis, LDD patients were at increased risk of all-cause revision surgery at 2 years (odds ratio [OR]: 1.361; 95% confidence interval [CI]: 1.238-1.498; p < 0.001) as well as aseptic loosening (OR: 1.533; 95% CI: 1.328-1.768; p < 0.001), periprosthetic joint infection (OR: 1.245; 95% CI: 1.129-1.373; p < 0.001), and periprosthetic fracture (OR: 1.521; 95% CI: 1.229-1.884; p < 0.001). Among LDD patients, patients who have a lumbar fusion had an all-cause revision rate of 5.0%, compared with 3.2% among LDD with no lumbar fusion patients at 2 years (p = 0.021). Following multivariate analysis, lumbar fusion patients were at increased risk of all-cause revision surgery (OR: 1.402; 95% CI: 1.362-1.445; p = 0.028), aseptic loosening (OR: 1.432; 95% CI: 1.376-1.489; p = 0.042), and periprosthetic fracture (OR: 1.302; 95% CI: 1.218-1.392; p = 0.037). Based on these findings, TKA candidates with preoperative LDD should be counseled that TKA outcome may be impaired by the coexistence of lumbar spine degenerative disease. This is Level III therapeutic study.

Lumbar canal stenosis in "young" - How does it differ from that in "old" - An analysis of 116 surgically treated cases

Objective:

Patients treated for lumbar canal stenosis (LCS) were retrospectively analyzed to evaluate the differences in clinical management in those below (Group A) and those above (Group B) the age of 50 years. All patients were treated with the premise that instability is the nodal point of the pathogenesis of LCS and “only-stabilization” is the surgical treatment.

Materials and Methods:

During the period June 2014 to June 2020, 116 cases were diagnosed to have LCS and surgically treated by the Goel modification of Camille's transarticular screw fixation technique.

Results:

Twenty-four patients in Group A and six patients in Group B had a history of “significant” injury to the back at the onset of clinical symptoms. The indices suggested that the intensity of symptoms was relatively more severe in Group A than in Group B. Unilateral leg symptoms were more common in Group A (68%) than in Group B (31.8%). Neurological motor deficits were more common in Group A (28%) than in Group B (12%) patients. Spinal segments surgically treated in Group A ranged from 1 to 4 (average 2 levels) and in Group B it ranged from 2 to 5 (average 3 levels). During the follow-up period that ranged from 6 to 72 months (average 37 months), 100% of patients had varying degrees of relief from symptoms.

Conclusions:

LCS is confined to a lesser number of spinal segments in the Group A patients. The symptoms were radicular in nature and relatively severe in Group A than in Group B patients.

Comparison of Two-level Cervical Disc Replacement Versus Two-level Anterior Cervical Discectomy and Fusion in the Outpatient Setting

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to evaluate the safety of two-level cervical disc replacement (CDR) in the outpatient setting.

SUMMARY OF BACKGROUND DATA

Despite growing interest in CDR, limited data exist evaluating the safety of two-level CDR in the outpatient setting.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried for all two-level anterior cervical discectomy and fusion (ACDF) and CDR procedures between 2015 and 2018. Demographics, comorbidities, and 30-day postoperative complication rates of outpatient two-level CDR were compared to those of inpatient two-level CDR and outpatient two-level ACDF. Radiographic data are not available in the NSQIP.

RESULTS

A total of 403 outpatient CDRs were compared to 408 inpatient CDRs and 4134 outpatient ACDFs. Outpatient CDR patients were older and more likely to have pulmonary comorbidities compared to inpatient CDR (P < 0.03). Outpatient CDR patients were less likely to have an American Society of Anesthesiologists class ≥2 and have hypertension compared to outpatient ACDF patients (P < 0.0001). Outpatient CDR had a lower 30-day readmission rate (0.5% vs. 2.5%, P = 0.02) and lower 30-day reoperation rate (0% vs. 1%, P = 0.047) compared to inpatient CDR. Outpatient CDR had a lower readmission rate (0.5% vs. 2.1%, P = 0.03) compared to outpatient ACDF, but there was no difference in reoperation rates between the two procedures (0% vs. 0.8%, P = 0.07). Outpatient CDR had an overall complication rate of 0.2%, inpatient CDR had a complication rate of 0.9%, and outpatient ACDF had a complication rate of 1.3%. These differences were not significant.

CONCLUSION

To our knowledge, this is the largest multicenter study examining the safety of two-level outpatient CDR procedures. Outpatient two-level CDR was associated with similarly safe outcomes when compared to inpatient two-level CDR and outpatient two-level ACDF. This suggests that two-level CDR can be performed safely in the outpatient setting.Level of Evidence: 3.

Development of Episode-Based Cost Measures for the US Medicare Merit-based Incentive Payment System

Importance

The Merit-based Incentive Payment System (MIPS), established as part of the Quality Payment Program, is a Medicare value-based payment program that evaluates clinicians' performance across 4 categories: quality, cost, promoting interoperability, and improvement activities. The cost category includes novel episode-based measures designed for targeted evaluation of the resource use of specific conditions. This report describes the development of episode-based cost measures and their role in the shift from volume-based to value-based purchasing.

Objectives

Episode-based cost measures focus on resource use related to the treatment of a specific condition or procedure. The measures exclude health care costs unrelated to the condition or procedure of focus. The episode-based cost measures provide a nuanced examination of resource use that can be used alongside quality metrics to identify opportunities to improve the value by capturing costs that are clinically related to the care being delivered within a given patient-clinician relationship of care delivered to patients. These measures were developed with the input of clinical committees composed of over 320 clinicians from 127 specialty societies and stakeholder organizations. The MIPS program currently evaluates clinician cost category performance based on 2 population-based cost measures (Medicare spending per beneficiary and total per capita costs) in addition to 18 episode-based cost measures. Additional episode-based cost measures are currently under development.

Conclusions and Relevance

The transition to value-based payment requires an accurate assessment of clinician effect on health care quality and cost. The use of episode-based cost measures to assess clinician influence on health care costs for high-priority conditions and procedures is an important step. The Centers for Medicare & Medicaid Services is introducing MIPS Value Pathways that will align episode-based cost measures with related quality measures to further incentivize the transition from fee-for-service to value-based care.

Enhanced Recovery After Surgery Pathway for Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion Decreases Length of Stay and Opioid Consumption

BACKGROUND

Opioid requirements in the perioperative period in patients undergoing lumbar spine fusion surgery remain problematic. Although minimally invasive surgery (MIS) techniques have been developed, there still remain substantial challenges to reducing length of hospital stay (LOS) because of postoperative opioid requirements.

OBJECTIVE

To study the effect of implementing an enhanced recovery after surgery (ERAS) pathway in patients undergoing a 1-level MIS transforaminal lumbar interbody fusion (MIS TLIF) at our institution.

METHODS

We implemented an ERAS pathway in patients undergoing an elective single-level MIS TLIF for degenerative changes at a single institution. Consecutive patients were enrolled over a 20-mo period and compared with a pre-ERAS group prior to the implementation of the ERAS protocol. The primary outcome was LOS. Secondary outcomes included reduction in morphine milligram equivalent units (MME), pain scores, postoperative urinary retention (POUR), and incidence of postoperative delirium. Patients were compared using the chi-square and Welch's 2-sample t-tests.

RESULTS

A total of 299 patients were evaluated in this study: 87 in the ERAS group and 212 in the pre-ERAS group. In the ERAS group, there was a significant reduction in LOS (3.13 ± 1.53 vs 3.71 ± 2.07 d, P = .019), total admission MME (252.74 ± 317.38 vs 455.91 ± 498.78 MME, P = .001), and the number of patients with POUR (48.3% vs 65.6%, P = .008). There were no differences in pain scores.

CONCLUSION

This is the largest ERAS MIS fusion cohort published to date evaluating a single cohort of patients in a generalizable manner. This ERAS pathway has shown a substantial decrease in LOS and opioid requirements in the immediate perioperative and postoperative period. There is further work to be done to evaluate patients undergoing other complex spine surgical interventions.

A New Hope in Spinal Degenerative Diseases: Piezo1

As a newly discovered mechanosensitive ion channel protein, the piezo1 protein participates in the transmission of mechanical signals on the cell membrane and plays a vital role in mammalian biomechanics. Piezo1 has attracted widespread attention since it was discovered in 2010. In recent years, studies on piezo1 have gradually increased and deepened. In addition to the discovery that piezo1 is expressed in the respiratory, cardiovascular, gastrointestinal, and urinary systems, it is also stably expressed in cells such as mesenchymal stem cells (MSCs), osteoblasts, osteoclasts, chondrocytes, and nucleus pulposus cells that constitute vertebral bodies and intervertebral discs. They can all receive external mechanical stimulation through the piezo1 protein channel to affect cell proliferation, differentiation, migration, and apoptosis to promote the occurrence and development of lumbar degenerative diseases. Through reviewing the relevant literature of piezo1 in the abovementioned cells, this paper discusses the effect of piezo1 protein expression under mechanical stress stimuli on spinal degenerative disease, providing the molecular basis for the pathological mechanism of spinal degenerative disease and also a new basis, ideas, and methods for the prevention and treatment of this degenerative disease.

Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the Affordable Care Act, 2006-2014

BACKGROUND CONTEXT

Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients.

PURPOSE

To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA.

STUDY DESIGN

Retrospective analysis.

PATIENT SAMPLE

Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014.

OUTCOME MEASURES

Racial disparities in discharge rates before versus after ACA passage.

METHODS

Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders.

RESULTS

All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001).

CONCLUSION

Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage.

A large database study of hospitalization charges and follow-up re-admissions in US lumbar fusion surgeries using a cellular bone allograft (CBA) versus recombinant human bone morphogenetic protein-2 (rhBMP-2)

Background

The objective of this study was to retrospectively compare initial procedure and 12-month follow-up hospitalization charges and resource utilization (lengths of stay; LOS) for lumbar fusion surgeries using either recombinant human bone morphogenetic protein-2 (rhBMP-2) or a cellular bone allograft comprised of viable lineage-committed bone cells (V-CBA) via a large US healthcare system database. Potentially relevant re-admissions during the follow-up period were also assessed.

Methods

A total of 16,172 patients underwent lumbar fusion surgery using V-CBA or rhBMP-2, of whom 3503 (21.66%) patients had follow-up re-admission data. Initial patient, procedure, and hospital characteristics were assessed to determine confounding factors. Multivariate regression modeling compared differences in hospitalization charges (in 2018 US dollars) and LOS (in days) between the groups, as well as incidences of potentially relevant re-admissions during the 12-month follow-up period.

Results

The adjusted mean initial procedure and 12-month follow-up hospital charges were significantly lower in the V-CBA group versus the rhBMP-2 group ($109,061 and $108,315 versus $160,191 and $130,406, respectively; P < 0.0001 for both comparisons). This disparity remained in an ad hoc comparison of charges for initial single-level treatments only (V-CBA = $103,064, rhBMP-2 = $149,620; P < 0.0001). The adjusted mean initial LOS were significantly lower in the V-CBA group (3.77 days) versus the rhBMP-2 group (3.88 days; P < 0.0001), but significantly higher for the cumulative follow-up hospitalizations in the 12-month follow-up period (7.87 versus 7.46 days, respectively; P < 0.0001). Differences in rates of follow-up re-admissions aligned with comorbidities at the initial procedure. Subsequent lumbar fusion rates were comparable, but significantly lower for V-CBA patients who had undergone single-level treatments only, in spite of V-CBA patients having significantly higher rates of initial comorbidities that could negatively impact clinical outcomes.

Conclusions

The results of this study indicate that use of V-CBA for lumbar fusion surgeries performed in the US may result in substantially lower overall hospitalization charges versus rhBMP-2, with both exhibiting similar rates of 12-month re-admissions and subsequent lumbar fusion procedures.

Cervical spine degenerative disease is an independent risk factor for increased revision rate following total knee arthroplasty

INTRODUCTION

The relationship between cervical degenerative pathology and total knee arthroplasty (TKA) revision rates is not well understood. The aim of the study was to determine whether cervical spine degenerative diseases have a role in complications following TKA within 2 years.

METHODS

Data were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2007-2017. Patients who had a primary TKA were identified using Current Procedural Terminology (CPT) code 27,447, and patients with degenerative cervical disease were identified using CPT and International Classification of Diseases (ICD) codes. Data on patients' demographics, comorbidities and postoperative complications were recorded and analyzed with univariate and multivariate analysis with significance set at p < 0.05. A Kaplan-Meier analysis was conducted to estimate the 1- and 2-year rates of survival free from revision.

RESULTS

A total of 81,873 patients were included in this study. Following multivariate analysis, cervical spine degenerative disease patients were at increased risk of all-cause revision surgery following 1 year (OR: 1.342 95% CI: 1.149-1.569; p < 0.001) and 2 year (OR: 1.338; 95% CI: 1.184-1.512; p < 0.001). At 2 years, patients with cervical spine degenerative disease had a survival rate of 97.7%, while the survival rate was 99.2% among the non-cervical degenerative cohort.

CONCLUSIONS

Based on these results, patients with cervical spine degenerative pathology should be counseled that their spinal pathology may impair outcomes following TKA.

Development of AOSpine BOnE (Bone Osteobiologics and Evidence) Classification

STUDY DESIGN

Classification development.

OBJECTIVES

The aim of our study was to develop a 3-tier classification for the levels of evidence for osteobiologics and provide a description of the principles by which osteobiologics can be evaluated. BOnE (Bone Osteobiologics and Evidence) classification evaluates each osteobiologic based on the available evidence, and if the published evidence is based on clinical, in vivo or in vitro studies.

METHODS

The process of establishing the BOnE classification included 5 face-to-face meetings and 2 web calls among members of the AOSpine Knowledge Forum Degenerative.

RESULTS

The 3 levels of evidence were determined based on the type of data on osteobiologics: level A for human studies, level B for animal studies, and level C for in vitro studies, with level A being the highest level of evidence. Each level was organized into 4 subgroups (eg, A1, A2, A3, and A4).

CONCLUSIONS

The use and the variety of osteobiologics for spine fusion has dramatically increased over the past few decades; however, literature on their effectiveness is inconclusive. Several prior systematic reviews developed by AOSpine Knowledge Forum Degenerative reported low level of evidence primarily due to the high risk of bias, small sample size, lack of control groups, and limited patient-reported outcomes. BOnE classification will provide a universal platform for research studies and journal publications to classify a new or an existing product and will allow for creating decision-making algorithms for surgical planning.

Parafusos pediculares e violação facetária – A importância do ângulo entre a faceta e o parafuso

Objective  To verify whether, regardless of the screw placement technique, there is a safe distance or angle in relation to the facets that can prevent violation of the facet joint when the screws are placed.

Methods  Retrospective, single, comparative, non-randomized center. We evaluated by axial computed tomography: the angle of the screw/rod in relation to the midline, the angle of the center of the facets in relation to the midline, the distance between the head of the screw/rod to the midline, and the distance from the center of the facets to the midline; the violation of the facet joint will be evaluated in a gradation of 0 to 2. Also will be measured the difference between the angle os the facets and the angle of the screws (Δ Angle) and, the difference between the facet distance and the screw distance (Δ Distance).

Results  A total of 212 patients and 397 facets were analyzed (196 on the left and 201 on the right). Of these, 303 were not violated (grade 0), corresponding to 76,32%, and 94 suffered some type of violation (grade 1 and 2), corresponding to 23,68%. The mean of Δ angle was 9.87° +/− 4.66° (grade 0), and of 3.77° +/− 4.93° in facets (grade 1 and 2) ( p  < 0.001), and the Δ mean distance in cases in which there was no violation was 0.94 arbitrary units (a.u.) +/− 0.39 a.u., while the Δ distance in G1 and G2 cases was 0.56 a.u. +/− 0.25 a.u. ( p  < 0.001).

Conclusion  The measurements of angle and distance between facet and screw can help in the placement of screws. These parameters can be used as safety measures with the most frequent use of surgical navigation techniques.

Lumbar canal stenosis: analyzing the role of stabilization and the futility of decompression as treatment

OBJECTIVEThe authors report their current experience with their previously published novel form of treatment in 70 cases of lumbar canal stenosis. The treatment consisted of only fixation of the spinal segments by the transarticular screw fixation technique. No bone, ligament, osteophyte, or disc resection was done for spinal canal and neural foraminal decompression. The proposed treatment is based on the concept that vertical instability that results in telescoping of the facets on physical activity forms the nodal point of pathogenesis of lumbar canal stenosis.METHODSDuring the period June 2014 to May 2018, 70 patients presenting with the classically described symptoms of lumbar canal stenosis were treated surgically by only fixation of involved spinal segments. Apart from clinical and radiological guides, instability was diagnosed on the basis of physical observation of the status of articulation by direct manipulation of bones of the region. The operation involved transarticular insertion of 2 or 3 screws for each articulation. The Oswestry Disability Index and visual analog scale were used to assess the patients before and after surgery and at follow-up. Additionally, a personalized patient satisfaction score was used to assess the outcome of surgery.RESULTSClinical symptomatic recovery was observed in all patients in the immediate postoperative period. During the average follow-up period, 100% of patients had varying degrees of symptomatic relief. The patient satisfaction score suggested that all patients were very satisfied with the surgical procedure. The transarticular fixation technique provided strong spinal segment fixation and a reliable ground for bone arthrodesis. No patient needed any additional modality of treatment or reoperation for recurrence of symptoms.CONCLUSIONSSpinal instability is the nodal point of pathogenesis of spinal degeneration-related lumbar canal stenosis. Only fixation of the involved spinal segments is necessary-decompression by bone or soft-tissue resection is not necessary.

Systematic Review: Is Intradiscal Injection of Bone Marrow Concentrate for Lumbar Disc Degeneration Effective?

Current studies evaluating the outcomes of an intradiscal injection of bone marrow concentrate (BMC) for lumbar disc degeneration are limited. The purpose of this review was to determine if an intradiscal injection of BMC for lumbar disc degeneration results in a statistically significant improvement in clinical outcomes. A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Levels I-IV investigations of intradiscal BMC injections in symptomatic lumbar disc degeneration were included in the analysis. Modified Coleman Methodology Scores (MCMS) were used to analyze study methodological quality. Only outcome measurements used by more than 50% of included studies, with a minimum follow-up of 12 months, were eligible for final data analysis. Pre-injection and post-injection visual analog scale (VAS) and Oswestry disability index (ODI) were compared using two-sample Z-tests. Seven articles (97 subjects (47 males, 38 females, 12 unspecified), mean age 33.9 ± 14.3 years, mean follow-up 44.4 ± 25.4 months) were analyzed. Six articles were level IV evidence and one article was level II. Mean MCMS was 56.6 ± 9.1. All subjects received single injections into the nucleus pulposus of one or more affected discs. VAS (66.0 mm to 20.9 mm; p<0.001) and ODI (44.4 to 19.1; p<0.001) significantly improved following the intradiscal BMC injection. One patient (1.0%) experienced herniated nucleus pulposus (HNP) following treatment. No other complications or re-injections were reported. In conclusion, despite our skepticism regarding the efficacy of the procedure, intradiscal injection of BMC for lumbar disc degeneration resulted in statistically significant improvement in VAS and ODI with low re-injection and complication rates in the studies assessed. Given that this study is limited to level IV evidence, the findings suggest that further randomized controlled studies may be worthwhile to evaluate the true efficacy of this treatment.

Ceramic Biologics for Bony Fusion-a Journey from First to Third Generations

PURPOSE OF REVIEW

To provide information on characteristics and use of various ceramics in spine fusion and future directions.

RECENT FINDINGS

In most recent years, focus has been shifted to the use of ceramics in minimally invasive surgeries or implementation of nanostructured surface modification features to promote osteoinductive properties. In addition, effort has been placed on the development of bioactive synthetics. Core characteristic of bioactive synthetics is that they undergo change to simulate a beneficial response within the bone. This change is based on chemical reaction and various chemical elements present in the bioactive ceramics. Recently, a synthetic 15-amino acid polypeptide bound to an anorganic bone material which mimics the cell-binding domain of type-I collagen opened a possibility for osteogenic and osteoinductive roles of this hybrid graft material. Ceramics have been present in the spine fusion arena for several decades; however, their use has been limited. The major obstacle in published literature is small sample size resulting in low evidence and a potential for bias. In addition, different physical and chemical properties of various ceramics further contribute to the limited evidence. Although ceramics have several disadvantages, they still hold a great promise as a value-based graft material with being easily available, relatively inexpensive, and non-immunogenic.

Predicting Trends in Cervical Spinal Surgery in the United States from 2020 to 2040

OBJECTIVE

We sought to predict surgical volumes for 2 common cervical spine procedures from 2020 to 2040.

METHODS

Using the National Inpatient Sample from 2003-2016, nationwide estimates of anterior cervical diskectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) volumes were calculated using International Classification of Diseases, Ninth and Tenth Revision (ICD-9, ICD-10) procedure codes. With data from the U.S. Census Bureau, estimates of the U.S. population were used to create Poisson models controlling for age and sex. Age was categorized into ranges (<25 years old, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and >85), and estimates of surgical volume for each age group were created.

RESULTS

From 2020-2040, increases in surgical volume from 13.3% (153,288-173,699) and 19.3% (29,620-35,335) are expected for ACDF and PCDF, respectively. For ACDF, the largest increases are expected in the 45-54 (42,077-49,827) and 75-84 (8065-14,862) age groups, whereas for PCDF, the largest increases will be seen in the 75-84 (3710-6836) age group. In accordance with an aging population, modest increases will be seen for ACDF (858-1847) and PCDF (730-1573) in the >85-year-old cohort.

CONCLUSIONS

As expected, large growth in cervical spine surgical volumes is likely to be seen, which could indicate a need for increased numbers of spinal neurosurgeons and orthopedic surgeons. Further studies are needed to investigate the needs of the field in light of these expected increases in volume.

Identifying the Characteristics of Patients With Cervical Degenerative Disease for Surgical Treatment From 17-Year Real-World Data: Retrospective Study

Background

Real-world data (RWD) play important roles in evaluating treatment effectiveness in clinical research. In recent decades, with the development of more accurate diagnoses and better treatment options, inpatient surgery for cervical degenerative disease (CDD) has become increasingly more common, yet little is known about the variations in patient demographic characteristics associated with surgical treatment.

Objective

This study aimed to identify the characteristics of surgical patients with CDD using RWD collected from electronic medical records.

Methods

This study included 20,288 inpatient surgeries registered from January 1, 2000, to December 31, 2016, among patients aged 18 years or older, and demographic data (eg, age, sex, admission time, surgery type, treatment, discharge diagnosis, and discharge time) were collected at baseline. Regression modeling and time series analysis were conducted to analyze the trend in each variable (total number of inpatient surgeries, mean age at surgery, sex, and average length of stay). A P value <.01 was considered statistically significant. The RWD in this study were collected from the Orthopedic Department at Peking University Third Hospital, and the study was approved by the institutional review board.

Results

Over the last 17 years, the number of inpatient surgeries increased annually by an average of 11.13%, with some fluctuations. In total, 76.4% (15,496/20,288) of the surgeries were performed in patients with CDD aged 41 to 65 years, and there was no significant change in the mean age at surgery. More male patients were observed, and the proportions of male and female patients who underwent surgery were 64.7% (13,126/20,288) and 35.3% (7162/20,288), respectively. However, interestingly, the proportion of surgeries performed among female patients showed an increasing trend (P<.001), leading to a narrowing sex gap. The average length of stay for surgical treatment decreased from 21 days to 6 days and showed a steady decline from 2012 onward.

Conclusions

The RWD showed its capability in supporting clinical research. The mean age at surgery for CDD was consistent in the real-world population, the proportion of female patients increased, and the average length of stay decreased over time. These results may be valuable to guide resource allocation for the early prevention and diagnosis, as well as surgical treatment of CDD.

Cervical spine pathology and treatment: a global overview

Cervical spine pathology is becoming increasingly prevalent with an aging world population and is associated with significant morbidity, affecting all areas of the world. This review was undertaken to provide a global perspective on cervical spine pathology, including epidemiology, burden of disease, access to care, and plan of care in both developed and developing low- and middle-income countries (LMICs). We found that epidemiology, access to care, plan of care, and health outcomes were relatively similar between nations with similar economies. However, these aspects change dramatically when comparing developing nations to LMICs, with LMICs displaying substantial barriers to care and subsequently higher rates of morbidity and mortality. There is currently a need for large-scale, global, prospective multicenter studies that analyze not only the epidemiology and treatment of cervical spine pathology, but also consider patient outcomes.

Demographic Trends in Paddle Lead Spinal Cord Stimulator Placement: Private Insurance and Medicare Beneficiaries

Objective

Although spinal cord stimulators (SCS) continue to gain acceptance as a viable nonpharmacologic option for the treatment of chronic back pain, recent trends are not well established. The aim of this study was to evaluate recent overall demographic and regional trends in paddle lead SCS placement and to determine if differences in trends exist between private-payer and Medicare beneficiaries.

Methods

A retrospective review of Medicare and private-payer insurance records from 2007–2014 was performed to identify patients who underwent a primary paddle lead SCS placement via a laminectomy (CPT-63655). Each study cohort was queried to determine the annual rate of SCS placements and demographic characteristics. Yearly SCS implantation rates within the study cohorts were adjusted per 100,000 beneficiaries. A chi-square analysis was used to compare changes in annual rates.

Results

A total of 31,352 Medicare and 2,935 private-payer patients were identified from 2007 to 2014. Paddle lead SCS placements ranged from 5.9 to 17.5 (p < 0.001), 1.9 to 5.9 (p < 0.001), and 5.2 to 14.5 (p < 0.001) placements per 100,000 Medicare, private-payer, and overall beneficiaries respectively from 2007 to 2014. SCS placements peaked in 2013 with 19.6, 7.1, and 16.8 placements per 100,000 Medicare, private-payer, and overall patients.

Conclusion

There was an overall increase in the annual rate of SCS placements from 2007 to 2014. Paddle lead SCS placements peaked in 2013 for Medicare, private-payer, and overall beneficiaries. The highest incidence of implantation was in the Southern region of the United States and among females. Yearly adjusted rates of SCSs were higher among Medicare patients at all time points.

The Gait Deviation Index as an indicator of gait abnormality among degenerative spinal pathologies

INTRODUCTION

The Gait Deviation Index (GDI) is a composite measure of gait abnormality derived from lower-limb joint range-of-motion which is increasingly being reported for clinical gait analysis among neurologic and orthopedic patients. A GDI score of 100 is representative of healthy individuals and decreasing scores represent a greater abnormality. Preliminary data is needed to help assess the utility of GDI as a measure of compromised gait among spine patients and to provide reference values for commonly treated pathologies.

METHODS

GDI scores were obtained from healthy adults and four symptomatic degeneration groups: cervical spondylotic myelopathy (CSM), adult degenerative scoliosis (ADS), and single-level lumbar degeneration (LD). Clinical gait analysis was done using a three-dimensional motion tracking system. Evaluations were done 1 week prior to surgical intervention for degeneration groups. Two-sample t-tests were used to compare degenerative cohorts to healthy controls and for inter-cohort comparisons. Pearson correlations were used to test for significant relationships between GDI and walking speed.

RESULTS

Degenerative cohorts all showed significantly lower (worse) GDI scores compared to healthy (all p < 0.001). CSM patients showed the best GDI scores with an average of 90, and LD patients showed the worst GDI scores with an average of 86. Worsening GDI significantly correlated with decreased walking speed among ADS patients.

CONCLUSION

Composite metrics like GDI provide a tempting means to summarize nuanced and complex gait characteristics into a single, comparable value among cohorts. The results of this study provide preliminary GDI scores for common degenerative spine pathologies. These slides can be retrieved under Electronic Supplementary Material.

IMPROVEMENT OF ODI AND SF-36 QUESTIONNAIRES SCORE AFTER ONE YEAR OF PLIF OR TLIF

ABSTRACT Objective: Determine if patients undergoing PLIF or TLIF surgery achieved improvement in the score of ODI and SF-36 questionnaires one year after surgery. Methods: Retrospective, single-center and non-randomized study. Patients submitted to spinal surgery using the PLIF or TLIF technique were included who completed the ODI and SF-36 questionnaires at least at the preoperative visit, and one year after surgery. Patients were divided into two groups, Group 1 (1 surgery level) and Group 2 (> 1 surgery level) and the ODI and SF-36 scores were compared for improvement. Results: The mean age was 47 years, with 52% of males (13/25) and mean of 5 days of hospital stay. Patients presented a significant improvement of ODI questionnaire (p<0.001) and in all SF-36 domains except in General Health State (p=0.58). In each group, it was observed that patients submitted to more than one level of surgery had greater blood loss and shorter hospital stay; however, the improvement obtained in ODI and SF-36 compared to the one-level surgery group was similar. Conclusions: PLIF and TLIF techniques are effective and lead to improved scores in ODI and SF-36 questionnaires one year after surgery. Patients undergoing two or more levels of instrumentation showed significant and similar improvement in ODI and SF-36. Level of evidence II, Single-Center Retrospective Study.

Dissociation between the growing opioid demands and drug policy directions among the U.S. older adults with degenerative joint diseases

We aim to examine temporal trends of orthopedic operations and opioid-related hospital stays among seniors in the nation and states of Oregon and Washington where marijuana legalization was accepted earlier than any others.As aging society advances in the United States (U.S.), orthopedic operations and opioid-related hospital stays among seniors increase in the nation.A serial cross-sectional cohort study using the healthcare cost and utilization project fast stats from 2006 through 2015 measured annual rate per 100,000 populations of orthopedic operations by age groups (45-64 vs 65 and older) as well as annual rate per 100,000 populations of opioid-related hospital stays among 65 and older in the nation, Oregon and Washington states from 2008 through 2017. Orthopedic operations (knee arthroplasty, total or partial hip replacement, spinal fusion or laminectomy) and opioid-related hospital stays were measured. The compound annual growth rate (CAGR) was used to quantify temporal trends of orthopedic operations by age groups as well as opioid-related hospital stays and was tested by Rao-Scott correction of χ for categorical variables.The CAGR (4.06%) of orthopedic operations among age 65 and older increased (P < .001) unlike the unchanged rate among age 45 to 64. The CAGRs of opioid-related hospital stays among age 65 and older were upward trends among seniors in general (6.79%) and in Oregon (10.32%) and Washington (15.48%) in particular (all P < .001).Orthopedic operations and opioid-related hospital stays among seniors increased over time in the U.S. Marijuana legalization might have played a role of gateway drug to opioid among seniors.

Perioperative Invasive Vascular Catheterization Associated With Increased Risk of Postoperative Infection in Lumbar Spine Surgery: An Analysis of 114,259 Patient Records

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

This study's objective was to determine whether perioperative invasive vascular catheter placement, independent of comorbid conditions, modified the risk of postoperative infection in lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Infection is a risk inherent to lumbar spine surgery, with overall postoperative infection rates of 0.86%-8.5%. Patients experiencing postoperative infection have higher rates of mortality, revision surgeries, pseudarthrosis, and worsening pain and disability.

METHODS

Data were collected for patients undergoing lumbar spine surgery between January 2007 and October 2015 with records in the nationwide Humana private insurance database. Patients receiving fusion, laminectomy, and discectomy were followed for 3 months from the date of surgery for surgical site infection (SSI), 6 months for subsequent incision and drainage (I&D), and 1 year for vertebral osteomyelitis (VO). Risk factors investigated included central venous catheter and arterial-line placement.

RESULTS

Analysis of 114,259 patient records showed an overall SSI rate of 3.2% within 1 month and 4.5% within 3 months, overall vertebral osteomyelitis rate of 0.82%-0.83% within 1 year, and overall I&D rate of 2.8% within 6 months. Patients receiving a first-time invasive vascular catheter on the day of surgery were more likely to experience SSI within 1 month [risk ratios (RR), 2.5, 95% confidence interval (CI): 2.3-2.7], SSI within 3 months (RR, 2.4; 95% CI: 2.3-2.7), osteomyelitis within 1 year (RR, 4.2-4.3; 95% CI: 3.7-4.5), and undergo an I&D within 6 months (RR, 1.9; 95% CI: 1.8-2.0). These trends were consistent by procedure type and independent of the patient's weighted comorbidity index score (Charlson Comorbidity Index).

CONCLUSIONS

Perioperative invasive vascular catheterization was significantly associated with an increased the risk of postoperative infections in lumbar spine surgery, independent of a patient's concomitant comorbidities. Therefore, in patients with an indication for invasive catheterization, surgeons should consider risks and benefits of surgery carefully.

LEVEL OF EVIDENCE

Level III.

Trends of surgical treatment for spinal degenerative disease in China: a cohort of 37,897 inpatients from 2003 to 2016

Purpose

Given the aging Chinese population and the inevitable degenerative process of the spine, more elderly patients with spinal degenerative disease (SDD) are surgical candidates, placing a significant burden on health care resources. Few studies have investigated recent trends in hospital admissions and procedures for SDD in China. This study aimed to identify the trends, if any, in the number of surgical procedures undertaken for SDD in a large patient cohort.

Materials and methods

This retrospective cohort analysis used data from inpatient medical records at Peking University Third Hospital between 2003 and 2016. Descriptive statistical analysis, regression models, and a Holt–Winters seasonal model were used to analyze trends.

Results

Altogether, 38,676 surgery records from 37,897 SDD patients who had undergone surgical treatment were included in our study, among whom 49.60%, 47.81%, and 2.59% were treated because of cervical, lumbar, and thoracic degenerative disease, respectively. There was an increasing trend for spinal surgery performance with an increasing mean age at surgery, from 50.65 years of age in 2003 to 55.29 years in 2016. We also revealed interesting seasonal variation in our study – that is, most of the spinal procedures were performed during the winter and spring months.

Conclusion

Our study showed a significantly increasing surgical workload for addressing SDD in China. Both the public and the health care system should be aware of this increase in chronic degenerative disease in the aging population.

The future of disc surgery and regeneration

Low back and neck pain are among the top contributors for years lived with disability, causing patients to seek substantial non-operative and operative care. Intervertebral disc herniation is one of the most common spinal pathologies leading to low back pain. Patient comorbidities and other risk factors contribute to the onset and magnitude of disc herniation. Spine fusions have been the treatment of choice for disc herniation, due to the conflicting evidence on conservative treatments. However, re-operation and costs have been among the main challenges. Novel technologies including cage surface modifications, biologics, and 3D printing hold a great promise. Artificial disc replacement has demonstrated reduced rates of adjacent segment degeneration, need for additional surgery, and better outcomes. Non-invasive biological approaches are focused on cell-based therapies, with data primarily from preclinical settings. High-quality comparative studies are needed to evaluate the efficacy and safety of novel technologies and biological therapies.

Critical aspects and challenges for intervertebral disc repair and regeneration-Harnessing advances in tissue engineering

Low back pain represents the highest burden of musculoskeletal diseases worldwide and intervertebral disc degeneration is frequently associated with this painful condition. Even though it remains challenging to clearly recognize generators of discogenic pain, tissue regeneration has been accepted as an effective treatment option with significant potential. Tissue engineering and regenerative medicine offer a plethora of exploratory pathways for functional repair or prevention of tissue breakdown. However, the intervertebral disc has extraordinary biological and mechanical demands that must be met to assure sustained success. This concise perspective review highlights the role of the disc microenvironment, mechanical and clinical design considerations, function vs mimicry in biomaterial‐based and cell engineering strategies, and potential constraints for clinical translation of regenerative therapies for the intervertebral disc.

What is a normal pharynx? A videofluoroscopic study of anatomy in older adults

PURPOSE

Structural and functional pharyngeal changes occur with age. How these affect swallowing in healthy older adults is not well defined. This study presents quantitative pharyngeal anatomic features in healthy adults using videofluoroscopic study of swallowing (VFSS). This will help our understanding of the normal changes in swallowing that occur with age and illustrate what may constitute normal variation compared with abnormal swallow function.

METHODS

138 mixed gender adults with no history of dysphagia were recruited and underwent a standardized VFSS protocol. Parameters including age, BMI, and gender were correlated with the presence of a cricopharyngeal bar, spinal changes and pharyngeal wall thickness at rest.

RESULTS

46% of participants had notable spinal changes. 8% of participants demonstrated cricopharyngeal bars and 12% of subjects revealed osteophytes. Age positively correlated with the presence of a cricopharyngeal bar (r_s = 0.281, p < 0.001) and presence of osteophytes (r_s = 0.334, p < 0.001). The incidence of cricopharyngeal bars in adults over 70 years old was 16%.

CONCLUSIONS

A significant number of healthy adults with no swallowing complaints have variant pharyngeal anatomic findings such as cervical vertebral osteophytes and cricopharyngeal bars. This must be taken into account when assessing patients with dysphagia complaints to avoid misattribution of symptoms to these potentially asymptomatic variants. This ensures correct recommendations are made regarding management including diet modification, compensatory strategies, and surgical intervention.