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Tarawneh OH, Narayanan R, McCurdy M, Issa TZ, Lee Y, Opara O, Pohl NB, Tomlak A, Sherman M, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma. BRAIN & SPINE 2024; 4:102780. [PMID: 38510641 PMCID: PMC10951764 DOI: 10.1016/j.bas.2024.102780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/12/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024]
Abstract
Introduction As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase. Research question To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care. Materials and methods We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition. Results A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility. Discussion and conclusions Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.
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Affiliation(s)
- Omar H. Tarawneh
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rajkishen Narayanan
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael McCurdy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tariq Z. Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Olivia Opara
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas B. Pohl
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexa Tomlak
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Sherman
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose A. Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan S. Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
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Crawford AM, Striano BM, Gong J, Simpson AK, Schoenfeld AJ. Does the Stopping Opioids After Surgery Score Perform Well Among Racial and Socioeconomic Subgroups? Clin Orthop Relat Res 2023; 481:2343-2351. [PMID: 37159263 PMCID: PMC10642872 DOI: 10.1097/corr.0000000000002697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND The Stopping Opioids After Surgery (SOS) score is a validated tool that was developed to determine the risk of sustained opioid use after surgical interventions, including orthopaedic procedures. Despite prior investigations validating the SOS score in diverse contexts, its performance across racial, ethnic, and socioeconomic subgroups has not been assessed. QUESTIONS/PURPOSES In a large, urban, academic health network, did the performance of the SOS score differ depending on (1) race and ethnicity or (2) socioeconomic status? METHODS This retrospective investigation was conducted using data from an internal, longitudinally maintained registry of a large, urban, academic health system in the Northeastern United States. Between January 1, 2018, and March 31, 2022, we treated 26,732 adult patients via rotator cuff repair, lumbar discectomy, lumbar fusion, TKA, THA, ankle or distal radius open reduction and internal fixation, or ACL reconstruction. We excluded 1% of patients (274 of 26,732) because of missing length of stay information, 0.06% (15) for missing discharge information, 1% (310) for missing medication information related to loss to follow-up, and 0.07% (19) who died during their hospital stay. Based on these inclusion and exclusion criteria, 26,114 adult patients were left for analysis. The median age in our cohort was 63 years (IQR 52 to 71), and most patients were women (52% [13,462 of 26,114]). Most patients self-reported their race and ethnicity as non-Hispanic White (78% [20,408 of 26,114]), but the cohort also included non-Hispanic Black (4% [939]), non-Hispanic Asian (2% [638]), and Hispanic (1% [365]) patients. Five percent (1295) of patients were of low socioeconomic status, defined by prior SOS score investigations as patients with Medicaid insurance. Components of the SOS score and the observed frequency of sustained postoperative opioid prescriptions were abstracted. The performance of the SOS score was compared across racial, ethnic, and socioeconomic subgroups using the c-statistic, which measures the capacity of the model to differentiate between patients with and without sustained opioid use. This measure should be interpreted on a scale between 0 and 1, where 0 represents a model that perfectly predicts the wrong classification, 0.5 represents performance no better than chance, and 1.0 represents perfect discrimination. Scores less than 0.7 are generally considered poor. The baseline performance of the SOS score in past investigations has ranged from 0.76 to 0.80. RESULTS The c-statistic for non-Hispanic White patients was 0.79 (95% CI 0.78 to 0.81), which fell within the range of past investigations. The SOS score performed worse for Hispanic patients (c-statistic 0.66 [95% CI 0.52 to 0.79]; p < 0.001), where it tended to overestimate patients' risks of sustained opioid use. The SOS score for non-Hispanic Asian patients did not perform worse than in the White patient population (c-statistic 0.79 [95% CI 0.67 to 0.90]; p = 0.65). Similarly, the degree of overlapping CIs suggests that the SOS score did not perform worse in the non-Hispanic Black population (c-statistic 0.75 [95% CI 0.69 to 0.81]; p = 0.003). There was no difference in score performance among socioeconomic groups (c-statistic 0.79 [95% CI 0.74 to 0.83] for socioeconomically disadvantaged patients; 0.78 [95% CI 0.77 to 0.80] for patients who were not socioeconomically disadvantaged; p = 0.92). CONCLUSION The SOS score performed adequately for non-Hispanic White patients but performed worse for Hispanic patients, where the 95% CI nearly included an area under the curve value of 0.5, suggesting that the tool is no better than chance at predicting sustained opioid use for Hispanic patients. In the Hispanic population, it commonly overestimated the risk of opioid dependence. Its performance did not differ among patients of different sociodemographic backgrounds. Future studies might seek to contextualize why the SOS score overestimates expected opioid prescriptions for Hispanic patients and how the utility performs among more specific Hispanic subgroups. CLINICAL RELEVANCE The SOS score is a valuable tool in ongoing efforts to combat the opioid epidemic; however, disparities exist in terms of its clinical applicability. Based on this analysis, the SOS score should not be used for Hispanic patients. Additionally, we provide a framework for how other predictive models should be tested in various lesser-represented populations before implementation.
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Affiliation(s)
| | | | - Jonathan Gong
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew K. Simpson
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Yang YF, Yu JC, Xiao Z, Kang YJ, Zhou B. Role of Pre-Operative Nutrition Status on Surgical Site Infection After Posterior Lumbar Interbody Fusion: A Retrospective Study. Surg Infect (Larchmt) 2023; 24:942-948. [PMID: 38016129 DOI: 10.1089/sur.2023.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
Background: A retrospective case-control study to determine the role of pre-operative systemic and local nutritional factors on patients developing a surgical site infection (SSI) after posterior lumbar interbody fusion (PLIF). Surgical site infection after PLIF remains a substantial cause of morbidity. The literature demonstrates the prognosis of surgical patients is associated with pre-operative nutritional status that not only includes systemic nutritional factors, such as prognostic nutritional index (PNI), body mass index (BMI), and serum albumin, but also local nutritional factors, such as subcutaneous fat thickness at the surgical site, including absolute fat thickness and relative fat thickness. However, the role of pre-operative nutrition status in SSI after PLIF surgery remains unclear. Patients and Method: A retrospective review was performed on a consecutive cohort of 766 consecutive adult patients who underwent PLIF surgery for lumbar degenerative conditions between 2020 and 2021 at Second Xiangya Hospital. Previously identified risk factors as well as systemic and local nutritional factors nutritional factors were collected. Results: Among the 766 patients, 38 had post-operative SSI including 15 superficial SSI and 23 deep SSI. Univariable analysis showed that body weight, BMI, PNI, serum albumin, and relative fat thickness differed between the SSI and non-SSI groups. Multivariable logistic regression analysis showed that pre-operative PNI and relative fat thickness were independently associated with SSI after PLIF surgery. Conclusions: Lower pre-operative PNI and higher relative fat thickness are independent risk factors for developing deep SSI after PLIF.
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Affiliation(s)
- Yi-Fan Yang
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jun-Cheng Yu
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhen Xiao
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi-Jun Kang
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Bin Zhou
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
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Crawford AM, Striano BM, Gong J, Koehlmoos TP, Simpson AK, Schoenfeld AJ. Validation of the Stopping Opioids After Surgery (SOS) Score for the Sustained Use of Prescription Opioids Following Orthopaedic Surgery. J Bone Joint Surg Am 2023; 105:1403-1409. [PMID: 37410854 DOI: 10.2106/jbjs.23.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND The Stopping Opioids after Surgery (SOS) score was developed to identify patients at risk for sustained opioid use following surgery. The SOS score has not been specifically validated for patients in a general orthopaedic context. Our primary objective was to validate the SOS score within this context. METHODS In this retrospective cohort study, we considered a broad array of representative orthopaedic procedures performed between January 1, 2018, and March 31, 2022. These procedures included rotator cuff repair, lumbar discectomy, lumbar fusion, total knee and total hip arthroplasty, open reduction and internal fixation (ORIF) of ankle fracture, ORIF of distal radial fracture, and anterior cruciate ligament reconstruction. The performance of the SOS score was evaluated by calculating the c-statistic, receiver operating characteristic curve, and the observed rates of sustained prescription opioid use (defined as uninterrupted prescriptions of opioids for ≥90 days) following surgery. For our sensitivity analysis, we compared these metrics among various time epochs related to the COVID-19 pandemic. RESULTS A total of 26,114 patients were included, of whom 51.6% were female and 78.1% were White. The median age was 63 years. The observed prevalence of sustained opioid use was 1.3% (95% confidence interval [CI], 1.2% to 1.5%) in the low-risk group (SOS score of <30), 7.4% (95% CI, 6.9% to 8.0%) in the medium-risk group (SOS score of 30 to 60), and 20.8% (95% CI, 17.7% to 24.2%) in the high-risk group (SOS score of >60). The performance of the SOS score in the overall group was strong, with a c-statistic of 0.82. The performance of the SOS score showed no evidence of worsening over time. The c-statistic was 0.79 before the COVID-19 pandemic and ranged from 0.77 to 0.80 throughout the waves of the pandemic. CONCLUSIONS We validated the use of the SOS score for sustained prescription opioid use following a diverse array of orthopaedic procedures across subspecialties. This tool is easy to implement for the purpose of prospectively identifying patients in musculoskeletal service lines who are at higher risk for sustained opioid use, thereby enabling the future implementation of upstream interventions and modifications to avert opioid abuse and to combat the opioid epidemic. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Crawford AM, Striano BM, Giberson-Chen CC, Xiong GX, Lightsey HM, Schoenfeld AJ, Simpson AK. Projected Lifetime Cancer Risk Associated With Intraoperative Computed Tomography for Lumbar Spine Surgery. Spine (Phila Pa 1976) 2023; 48:893-900. [PMID: 37040462 DOI: 10.1097/brs.0000000000004685] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023]
Abstract
STUDY DESIGN Retrospective cross-sectional study. OBJECTIVE (1) To determine the incremental increase in intraoperative ionizing radiation conferred by computed tomography (CT) as compared with conventional radiography; and (2) to model different lifetime cancer risks contextualized by the intersection between age, sex, and intraoperative imaging modality. SUMMARY OF BACKGROUND DATA Emerging technologies in spine surgery, like navigation, automation, and augmented reality, commonly utilize intraoperative CT. Although much has been written about the benefits of such imaging modalities, the inherent risk profile of increasing intraoperative CT has not been well evaluated. MATERIALS AND METHODS Effective doses of intraoperative ionizing radiation were extracted from 610 adult patients who underwent single-level instrumented fusion for lumbar degenerative or isthmic spondylolisthesis from January 2015 through January 2022. Patients were divided into those who received intraoperative CT (n=138) and those who underwent conventional intraoperative radiography (n=472). Generalized linear modeling was utilized with intraoperative CT use as a primary predictor and patient demographics, disease characteristics, and preference-sensitive intraoperative considerations ( e.g. surgical approach and surgical invasiveness) as covariates. The adjusted risk difference in radiation dose calculated from our regression analysis was used to prognosticate the associated cancer risk across age and sex strata. RESULTS (1) After adjusting for covariates, intraoperative CT was associated with 7.6 mSv (interquartile range: 6.8-8.4 mSv; P <0.001) more radiation than conventional radiography. (2) For the median patient in our population (a 62-year-old female), intraoperative CT use increased lifetime cancer risk by 2.3 incidents (interquartile range: 2.1-2.6) per 10,000. Similar projections for other age and sex strata were also appreciated. CONCLUSIONS Intraoperative CT use significantly increases cancer risk compared with conventional intraoperative radiography for patients undergoing lumbar spinal fusions. As emerging technologies in spine surgery continue to proliferate and leverage intraoperative CT for cross-sectional imaging data, strategies must be developed by surgeons, institutions, and medical technology companies to mitigate long-term cancer risks.
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Affiliation(s)
- Alexander M Crawford
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brendan M Striano
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Carew C Giberson-Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Grace X Xiong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Harry M Lightsey
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Andrew K Simpson
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
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Crawford AM, Striano BM, Lightsey HM, Gong J, Simpson AK, Schoenfeld AJ. Intraoperative CT for Lumbar Fusion Is Not Associated with Improved Short- or Long-Term Complication Profiles. Spine J 2023; 23:791-798. [PMID: 36870450 DOI: 10.1016/j.spinee.2023.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND CONTEXT The use of intraoperative CT has continued to grow in recent years, as various techniques leverage the promise of improved instrumentation accuracy and the hope for decreased complications. Nonetheless, the literature regarding the short- and long-term complications associated with such techniques remains scant and/or confounded by indication and selection bias. PURPOSE To use causal inference techniques to determine whether intraoperative CT use is associated with an improved complication profile as compared to conventional radiography for single-level lumbar fusions, an increasingly commonplace application for this technology. STUDY DESIGN/SETTING Inverse probability weighted retrospective cohort study carried out within a large integrated healthcare network PATIENT SAMPLE: Adult patients who underwent surgical treatment of spondylolisthesis via lumbar fusion from January 2016 through December 2021 OUTCOME MEASURES: Our primary outcome was the incidence rate of revision surgery. Our secondary outcome was the incidence of composite 90-day complications (deep and superficial surgical site infection, venous thromboembolic events, and unplanned readmissions). METHODS Demographics, intraoperative information, and postoperative complications were abstracted from electronic health records. A propensity score was developed utilizing a parsimonious model to account for covariate interaction with our primary predictor, intraoperative imaging technique. This propensity score was utilized in the creation of inverse probability weights to adjust for indication and selection bias. The rate of revisions within 3 years as well as the rate of revisions at any time-point were compared between cohorts using Cox regression analysis. The incidence of composite 90-day complications were compared using negative binomial regression. RESULTS Our patient population consisted of 583 patients, with 132 who underwent intraoperative CT and 451 who underwent conventional radiographic techniques. There were no significant differences between cohorts following inverse probability weighting. No significant differences were detected in 3-year revision rates (HR 0.74 [95% CI 0.29, 1.92]; p=0.5), overall revision rates (HR 0.54 [95% CI 0.20, 1.46]; p=0.2), or 90-day complications (RC -0.24 [95% CI -1.35, 0.87]; p=0.7). CONCLUSIONS Intraoperative CT use was not associated with an improved complication profile in either the short- or long-term for patients undergoing single-level instrumented fusion. This observed clinical equipoise should be weighed against resource and radiation-related costs when considering intraoperative CT for low complexity fusions.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
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Crawford AM, Striano BM, Lightsey HM, Zhu JS, Xiong GX, Schoenfeld AJ, Simpson AK. Projected lifetime cancer risk for patients undergoing spine surgery for isthmic spondylolisthesis. Spine J 2023; 23:824-831. [PMID: 36736738 DOI: 10.1016/j.spinee.2023.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/15/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND CONTEXT Radiographs, fluoroscopy, and computed tomography (CT) are increasingly utilized in the diagnosis and management of various spine pathologies. Such modalities utilize ionizing radiation, a known cause of carcinogenesis. While the radiation doses such studies confer has been investigated previously, it is less clear how such doses translate to projected cancer risks, which may be a more interpretable metric. PURPOSE (1) Calculate the lifetime cancer risk and the relative contributions of preference-sensitive selection of imaging modalities associated with the surgical management of a common spine pathology, isthmic spondylolisthesis (IS); (2) Investigate whether the use of intraoperative CT, which is being more pervasively adopted, increases the risk of cancer. STUDY DESIGN/SETTING Retrospective cross-sectional study carried out within a large integrated health care network. PATIENT SAMPLE Adult patients who underwent surgical treatment of IS via lumbar fusion from January 2016 through December 2021. OUTCOME MEASURES (1) Effective radiation dose and lifetime cancer risk associated with each exposure to ionizing radiation; (2) Difference in effective radiation dose (and lifetime cancer risk) among patients who received intraoperative CT compared to other intraoperative imaging techniques. METHODS Baseline demographics and differences in surgical techniques were characterized. Radiation exposure data were collected from the 2-year period centered on the operative date. Projected risk of cancer from this radiation was calculated utilizing each patient's effective radiation dose in combination with age and sex. Generalized linear modeling was used to adjust for covariates when determining the comparative risk of intraoperative CT as compared to alternative imaging modalities. RESULTS We included 151 patients in this cohort. The range in calculated cancer risk exclusively from IS management was 1.3-13 cases of cancer per 1,000 patients. During the intraoperative period, CT imaging was found to significantly increase radiation exposure as compared to alternate imaging modalities (adjusted risk difference (ARD) 12.33mSv; IQR 10.04, 14.63mSv; p<.001). For a standardized 40 to 49-year-old female, this projects to an additional 0.72 cases of cancer per 1,000. For the entire 2-year perioperative care episode, intraoperative CT as compared to other intraoperative imaging techniques was not found to increase total ionizing radiation exposure (ARD 9.49mSv; IQR -0.83, 19.81mSv; p=.072). The effect of intraoperative imaging choice was mitigated in part due to preoperative (ARD 13.1mSv, p<.001) and postoperative CTs (ARD 22.7mSv, p<.001). CONCLUSIONS Preference-sensitive imaging decisions in the treatment of IS impart substantial cancer risk. Important drivers of radiation exposure exist in each phase of care, including intraoperative CT and/or CT scans during the perioperative period. Knowledge of these data warrant re-evaluation of current imaging protocols and suggest a need for the development of radiation-sensitive approaches to perioperative imaging.
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Affiliation(s)
- Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Jimmy S Zhu
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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The Variability and Contributions to Cost of Anterior Cervical Discectomy and Fusion Constructs. Clin Spine Surg 2022:01933606-990000000-00054. [PMID: 35943872 DOI: 10.1097/bsd.0000000000001371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 06/29/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE To characterize the variability in cost for anterior cervical discectomy and fusion (ACDF) constructs and to identify key predictors of procedural cost. SUMMARY OF BACKGROUND DATA ACDF is commonly performed for surgical treatment of cervical radiculopathy and myelopathy. Numerous biomechanical constructs and graft/biological options are available, with most demonstrating relatively equivalent clinical results. Despite the substantial focus on value in spine care, the differences and contributions to procedural cost in ACDF have not been well defined. MATERIALS AND METHODS We evaluated the records of patients who underwent a single level ACDF from 2016 to 2020 at 4 hospitals in a major metropolitan area. We abstracted demographics, insurance status, operative time, diagnosis, surgeon, institution, and components of procedural costs. Costs based on construct were compared using multivariable adjusted analyses using negative binomial regression. The primary outcome measures were cost differences between ACDF techniques. RESULTS Two hundred sixty-four patients were included, with procedures by 13 surgeons across 4 institutions. The total procedural cost for ACDF had a mean of US$2317 with wide variation (range, US$967-US$7370). Multivariable analysis revealed body mass index and use of polyether ether ketone to be correlated with increased cost while carbon fiber and autograft correlated with decreased cost. When comparing standalone device constructs to cases with anterior instrumentation (plate/screws), the total cost was significantly higher in the plate/screw group (US$2686±US$921 vs. US$1466±US$878, P<0.001). CONCLUSIONS We encountered wide variation in procedural costs associated with ACDF, including as much as an 8-fold difference in the cost of constructs. The most important drivers included instrumentation type and implant materials. Here, we identify potential targets of opportunity for health care organizations that are looking to reduce variance in procedural expenditures to improve health care savings associated with the performance of ACDF.
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Lightsey HM, Pisano AJ, Striano BM, Crawford AM, Xiong GX, Hershman S, Schoenfeld AJ, Simpson AK. ALIF Versus TLIF for L5-S1 Isthmic Spondylolisthesis: ALIF Demonstrates Superior Segmental and Regional Radiographic Outcomes and Clinical Improvements Across More Patient-reported Outcome Measures Domains. Spine (Phila Pa 1976) 2022; 47:808-816. [PMID: 35125462 DOI: 10.1097/brs.0000000000004333] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of this study was to compare segmental and regional radiographic parameters between anterior interbody fusion (ALIF) and posterior interbody fusion (TLIF) for treatment of L5-S1 isthmic spondylolisthesis, and to assess for changes in these parameters over time. Secondarily, we sought to compare clinical outcomes via patient-reported outcome measures (PROMs) between techniques and within groups over time. SUMMARY OF BACKGROUND DATA Isthmic spondylolistheses are frequently treated with interbody fusion via ALIF or TLIF approaches. Robust comparisons of radiographic and clinical outcomes are lacking. METHODS We reviewed pre- and postoperative radiographs as well as Patient-Reported Outcomes Measurement Information System (PROMIS) elements for patients who received L5-S1 interbody fusions for isthmic spondylolisthesis in the Mass General Brigham (MGB) health system (2016-2020). Intraclass correlation testing was used for reliability assessments; Mann-Whitney U tests and Sign tests were employed for intercohort and intracohort comparative analyses, respectively. RESULTS ALIFs generated greater segmental and L4-S1 lordosis than TLIF, both at first postoperative visit (mean 26 days [SE = 4]; 11.3° vs. 1.3°, P < 0.001; 6.2° vs. 0.3°, P = 0.005) and at final follow-up (mean 410days [SE = 45]; 9.6° vs. 0.2°, P < 0.001; 7.9° vs. 2.1°, P = 0.005). ALIF also demonstrated greater increase in disc height than TLIF at first (9.6 vs. 5.5 mm, P < 0.001) and final follow-up (8.7 vs. 3.6 mm, P < 0.001). Disc height was maintained in the ALIF group but decreased over time in the TLIF cohort (ALIF 9.6 vs. 8.7 mm, P = 0.1; TLIF 5.5 vs. 3.6 mm, P < 0.001). Both groups demonstrated improvements in Pain Intensity and Pain Interference scores; ALIF patients also improved in Physical Function and Global Health - Physical domains. CONCLUSION ALIF generates greater segmental lordosis, regional lordosis, and restoration of disc height compared to TLIF for treatment of isthmic spondylolisthesis. Additionally, ALIF patients demonstrate significant improvements across more PROMs domains relative to TLIF patients.Level of Evidence: 3.
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Affiliation(s)
- Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Alfred J Pisano
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA
| | - Stuart Hershman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, mA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, mA
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Qu S, Sun M, Sun H, Hu B. C-reactive protein to albumin ratio (CAR) in predicting surgical site infection (SSI) following instrumented posterior lumbar interbody fusion (PLIF). Int Wound J 2022; 20:92-99. [PMID: 35579095 PMCID: PMC9797921 DOI: 10.1111/iwj.13843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/06/2022] [Accepted: 05/07/2022] [Indexed: 01/07/2023] Open
Abstract
Identification of novel markers would contribute to the individualised risk assessment and development of a risk prediction model. This study aimed to investigate the role of the C-reactive protein to albumin ratio (CAR) in predicting surgical site infection (SSI) following instrumented posterior lumbar interbody fusion (PLIF) of lumbar degenerative diseases. This study enrolled patients who underwent PLIF and instrumentation for treatment of lumbar degenerative diseases between 2015 and 2020. Electronic medical records were inquired for data collection, with follow-up register for identifying SSI cases. The optimal cut-off for CAR was determined by constructing the receiver operator characteristic (ROC) curve. Patients with high- or low-CAR value were compared using the univariate analyses, and the association between CAR and the risk of SSI was investigated using multivariate logistics regression analysis. A total of 905 patients were enrolled, twenty-nine (3.2%) had developed an SSI with 72.4% occurring during index hospitalisation, and 11 (1.2%) had deep and 18 (2.0%) superficial SSIs. An SSI was associated with additional 10.7 days of index total hospital stay (P = .001). The CAR was 0-5.43 (median, 0.05), and the optimal cut-off was 0.09 and area under the curve was 0.720 (P < .001). 336 (37.1%) patients had a CAR ≥0.09 and 22 (6.5%) developed an SSI, with a crude risk of 5.6 relative to those with a low CAR. The multivariate analyses showed CAR ≥0.09 was associated with 8.06-fold increased risk of SSI, together with diabetes (P = .018), while hypertension was identified as a protective factor (OR, 0.34; 95%CI, 0.11-1.00, P = .049). High CAR is found to significantly predict the incident SSI following instrumented PLIF of lumbar degenerative diseases, and can be considered as a useful index in practice only after it is verified by future high-level evidences.
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Affiliation(s)
- Shaozheng Qu
- Department of orthopaedic surgeryYantai Yuhuangding HospitalYantaiChina
| | - Mingchuan Sun
- Department of orthopaedic surgeryYantai Yuhuangding HospitalYantaiChina
| | - Hongliang Sun
- Department of orthopaedic surgeryYantai Yuhuangding HospitalYantaiChina
| | - Baiqiang Hu
- Department of orthopaedic surgeryYantai Yuhuangding HospitalYantaiChina
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Xiong GX, Crawford AM, Goh BC, Striano BM, Bensen GP, Schoenfeld AJ. Does Operative Management of Epidural Abscesses Increase Healthcare Expenditures up to 1 Year After Treatment? Clin Orthop Relat Res 2022; 480:382-392. [PMID: 34463660 PMCID: PMC8747673 DOI: 10.1097/corr.0000000000001967] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The incidence of spinal epidural abscesses is increasing. What is more, they are associated with high rates of morbidity and mortality. Advances in diagnostic imaging and antibiotic therapies have made earlier diagnosis and nonoperative management feasible in appropriately selected patients. Nonoperative treatment also has the advantage of lower immediate healthcare charges; however, it is unknown whether initial nonoperative care leads to higher healthcare charges long term. QUESTIONS/PURPOSES (1) Does operative intervention generate higher charges than nonoperative treatment over the course of 1 year after the initial treatment of spinal epidural abscesses? (2) Does the treatment of spinal epidural abscesses in people who actively use intravenous drugs generate higher charges than management in people who do not? METHODS This retrospective comparative study at two tertiary academic centers compared adult patients with spinal epidural abscesses treated operatively and nonoperatively from January 2016 through December 2017. Ninety-five patients were identified, with four excluded for lack of billing data and one excluded for concomitant intracranial abscess. Indications for operative management included new or progressive motor deficit, lack of response to nonoperative treatment including persistent or progressive systemic illness, or initial sepsis requiring urgent source control. Of the included patients, 52% (47 of 90) received operative treatment with no differences in age, gender, BMI, and Charlson comorbidity index between groups, nor any difference in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Furthermore, 29% (26 of 90) of patients actively used intravenous drugs and were younger, with a lower BMI and lower Charlson comorbidity index, with no differences in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Cumulative charges at the index hospital discharge and 90 days and 1 year after discharge were compared based on operative or nonoperative management and secondarily by intravenous drug use status. Medical records, laboratory results, and hospital billing data were reviewed for data extraction. Demographic factors including age, gender, region of abscess, intravenous drug use, and comorbidities were extracted, along with clinical factors such as symptoms and ambulatory function at presentation, spinal instability, intensive care unit admission, and complications. The primary outcome was charges associated with care at the index hospital discharge and 90 days and 1 year after discharge. All covariates extracted were included in this analysis using negative binomial regression that accounted for confounders and the nonparametric nature of charge data. Results are presented as an incidence rate ratio with 95% confidence intervals. RESULTS After adjusting for demographic and clinical variables such as age, gender, BMI, ambulatory status, presence of mechanical instability, and intensive care unit admission among others, we found higher charges for the group treated with surgery compared with those treated nonoperatively at the index admission (incidence rate ratio [IRR] 1.62 [95% CI 1.35 to 1.94]; p < 0.001) and at 1 year (IRR 1.36 [95% CI 1.10 to 1.68]; p = 0.004). Adjusted analysis also showed that active intravenous drug use was also associated with higher charges at the index admission (IRR 1.57 [95% CI 1.16 to 2.14]; p = 0.004) but no difference at 1 year (IRR 1.11 [95% CI 0.79 to 1.57]; p = 0.55). CONCLUSION Multidisciplinary teams caring for patients with spinal epidural abscesses should understand that the decreased charges associated with selecting nonoperative management during the index admission persist at 1 year with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. On the other hand, patients with active intravenous drug use have higher index admission charges that do not persist at 1 year, with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. These results suggest possible economic benefit to nonoperative management of epidural abscesses without increases in readmission or mortality rates, further tipping the scale in an evolving framework of clinical decision-making. Future studies should investigate if these economic implications are mirrored on the patient-facing side to determine whether any financial burden is shifted onto patients and their families in nonoperative management. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Grace X. Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Alexander M. Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Brian C. Goh
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Brendan M. Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Gordon P. Bensen
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Xiong GX, Greene NE, Hershman SH, Schwab JH, Bono CM, Tobert DG. Nasal screening for methicillin-resistant Staphylococcus aureus does not reduce surgical site infection after primary lumbar fusion. Spine J 2022; 22:113-125. [PMID: 34284131 DOI: 10.1016/j.spinee.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/07/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Preoperative methicillin-resistant Staphylococcus aureus (MRSA) testing and decolonization has demonstrated success for arthroplasty patients in surgical site infections (SSIs) prevention. Spine surgery, however, has seen varied results. PURPOSE The purpose of this study was to determine the impact of nasal MRSA testing and operative debridement rates on surgical site infection after primary lumbar fusion. STUDY DESIGN/SETTING Retrospective cohort study and/or Consolidated medical enterprise PATIENT SAMPLE: Adult patients undergoing primary instrumented lumbar fusions from January 2015 to December 2019 were reviewed. OUTCOME MEASURES The primary outcome was incision and drainage performed in the operating room within 90 days of surgery. METHODS MRSA testing <90-day's before surgery, mupirocin prescription <30-day's before surgery, perioperative antibiotics, and Elixhauser comorbidity index were collected for each subject. Bivariate analysis used Wilcoxon rank-sum testing and logistic regression modeling Multivariable logistic regression modeling assessed for associations with MRSA testing, intravenous vancomycin use, and I&D rate. RESULTS The study included 1,884 patients for analysis, with mean age of 63.1 (SE 0.3) and BMI 29.5 (SE 0.1). MRSA testing was performed in 755 patients (40.1%) and was more likely to be performed in patients with lower Elixhauser index scores (OR 0.98, 95% CI 0.96-0.99, p=.021) on multivariable analysis. Vancomycin use increased significantly over time (OR 1.49 and/or year, 95% CI 1.3-1.8, p<.001) despite no change in mupirocin or I&D rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on I&D rates. I&D risk was associated with higher BMI (OR 1.06, 95% CI 1.02-1.12, p=.009) and higher number of blood product units transfused (OR 1.23, 95% CI 1.03-1.46, p=.022). CONCLUSIONS The present study demonstrates no impact on surgical I&D rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative I&D rates for surgical site infection. As a result of the hospital directive, vancomycin use increased over time with no associated change in infection rates, underscoring the need for focused interventions, and engagement with antibiotic stewardship programs.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopedic Residency Program, Boston, MA, USA
| | | | - Stuart H Hershman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel G Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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