Time spent per patient in lumbar spinal stenosis surgery

Association of Neurosurgical Work Relative Value Units with Objective Markers of Operative Complexity

OBJECTIVE

Relative value units (RVUs) form the backbone of health care service reimbursement calculation in the United States. However, it remains unclear how well RVUs align with objective measures of procedural complexity within neurosurgery.

METHODS

The 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for neurosurgical procedures with >50 patients, using Current Procedural Terminology (CPT) codes. Length of stay (LOS), operative time, mortality, and readmission and reoperation rates were collected for each code and a univariate correlation analysis was performed, with significant predictors entered into a multivariate logistic regression model, which generated predicted work RVUs, which were compared with actual RVUs to identify undervalued and overvalued procedures.

RESULTS

Among 64 CPT codes, LOS, operative time, mortality, readmission, and reoperation were significant independent predictors of work RVUs and together explained 76% of RVU variance in a multivariate model (R² = 0.76). Using a difference of >1.5 standard deviations from the mean, procedures associated with greater than predicted RVU included surgery for intracranial carotid circulation aneurysms (CPTs 61697 and 61700; residual RVU = 12.94 and 15.07, respectively), and infratemporal preauricular approaches to middle cranial fossa (CPT 61590; residual RVU = 15.39). Conversely, laminectomy/foraminotomy for decompression of additional spinal cord, cauda equina, and/or nerve root segments (CPT 63048; residual RVU = -21.30), transtemporal craniotomy for cerebellopontine angle tumor resection (CPT 61526; residual RVU = -9.95), and brachial plexus neuroplasty (CPT 64713; residual RVU = -11.29) were associated with lower than predicted RVU.

CONCLUSIONS

Work RVUs for neurosurgical procedures are largely predictive of objective measures of surgical complexity, with few notable exceptions.

Transforaminal Endoscopic Discectomy and Foraminoplasty for Treating Central Lumbar Stenosis

Objective

Lumbar spinal stenosis is a medical condition characterized by the narrowing of the spinal canal as a consequence of bone and soft tissue degeneration, including disc herniation, facet and ligamentum flavum hypertrophy, and osteophyte formation. The percutaneous transforaminal endoscopic discectomy (PTED) technique is one of the emerging surgical alternatives for treating central lumbar stenosis. The present study aims to describe the present techniques of PTED and foraminoplasty for central lumbar stenosis, and discuss the feasibility and advantages of this technique.

Methods

A total of 55 patients with an average age of 50 years were recruited in this study. They were operated on between August 2017 and June 2018 by a single surgeon for symptomatic lumbar stenosis using the PTED and foraminoplasty technique, along with a detailed description of the present technique. The retrospective analysis of 55 patients operated between August 2017 and June 2018 by a single surgeon for symptomatic lumbar stenosis using the PTED and foraminoplasty techniques, and the detailed description of the present technique were the focus of the present study. For all patients, the PTED and foraminoplasty procedure was performed under local anesthesia in the lateral position on a radiolucent table using C‐arm fluoroscopy. The retrospective analysis evaluated the outcomes of symptoms through follow‐up interviews at six weeks, six months, and one year after surgery. The analyzed parameters included surgery time, intraoperative blood loss, postoperative complications, visual analog scale (VAS) score, Japan Orthopedic Association (JOA) score, and the Oswestry Disability Index (ODI). The modified MacNab criteria were adopted.

Results

The average duration of symptoms was 15.6 weeks. The mean operative time was 161 minutes. The mean volume of intraoperative blood loss was 21 mL. The mean follow‐up period was 14.6 months. The average preoperative VAS score for leg pain and low back pain was 6.8 and 5.5, respectively. The preoperative ODI and JOA score was 49.2 and 14.6, respectively. At the final follow‐up, all 55 patients had an average VAS score of 1.1 for leg pain and 0.5 for low back pain. At the same time, the average ODI and JOA score was seven and 24.5, respectively. The statistical analysis showed that the VAS score, ODI value, and JOA score were significantly lower in all time‐points at post‐operation, when compared to those at pre‐operation. For the modified MacNab criteria, the final outcome results were excellent in 39 patients (70.9%), good in nine patients (16.4%), fair in four patients (7.3%), and poor in two patients (3.6%), and the overall success rate was 89.1%. Two patients underwent a second operation during the follow‐up period, and their symptoms were released after the reoperation.

Conclusion

PTED and foraminoplasty technique showed promising outcomes in the treatment of central lumbar stenosis in a 1‐year follow‐up period. It suggested that PTED and foraminoplasty might be applied as a safe and effective therapeutic option for patients with lumbar stenosis.

Intraspinal Lumbar Juxtaarticular Cyst Treatment Through CT-Guided Percutaneus Induced Rupture Results in a Favorable Patient Outcome

Juxta-articular cysts are synovial cysts originating from the facet joints or the flava ligaments. If they grow intra-spinally they can compress nervous structures and cause a variety of symptoms. Micro-neurosurgery is usually the treatment of choice. Alternatively to surgical treatment the cyst can be approached and treated with a CT guided percutaneous injection inducing rupture. After fulfilling strict selection criteria twenty patients (25% of all treated lumbar synovial cyst patients), were treated minimally invasive by this method from 2010-2016. The facet joint was punctured under CT guidance and a mixture of a local anesthetic and contrast liquid was injected until the cyst was blasted. The mean follow-up period was 1.1 years (range 2 weeks - 5 years).

Fifteen of twenty procedures were successful and cyst rupture was confirmed by CT-scans. Twelve of these fifteen patients experienced a significant improvement of their symptoms and needed no further intervention or surgical procedure up until now, three patients showed no clinical improvement and were treated surgically within one week after cyst rupture. In five patients it was technically not possible to rupture the cyst. These patients were treated microsurgically by cyst resection and dynamic stabilization or fusion procedures. The percutaneus rupture of juxtaarticular cysts has fewer risks and is cost effective compared to microsurgical resection. It may be an alternative to surgical treatment for a selected group of patients. However there are some limitations to the procedure though, such as difficult patient selection, unpredictable outcome or technical problems due to highly degenerated facet joints.