Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review

Sociodemographic characteristics and outcomes of surgically managed central cord syndrome patients

Introduction

Undiagnosed cervical spine stenosis is a risk factor for central cord syndrome (CCS), especially in vulnerable individuals. Social determinants of health (SDOH) are correlated with health outcomes. The aim of this study was to characterize the sociodemographic characteristics and outcomes in surgically-treated central cord syndrome (CCS) patients, and explore potential associations between them.

Methods

This is a retrospective cohort study of surgically-treated CCS patients at a Level-1 trauma center between 2015 and 2021. Patient demographics, radiological findings, and clinical outcomes were collected. SDOH were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI). Descriptive statistics and regression analyses assessed associations between SDI/ADI, demographics and clinical outcomes.

Results

Of 56 patients, 75 % were insured by Medicare/Medicaid and 70 % were discharged to care facilities. Mean SDI was 66.4 ± 24.4, and mean ADI was 7.4 ± 2.2. Three patients required reoperation for post-operative complications. Post-operative neurologic outcomes varied, with 60.7 % stable, 30.4 % improved, and 8.9 % declined. While SDI/ADI did not correlate with outcomes, higher ADI quartiles were associated with decreased likelihood of home discharge (p = 0.048). Decline in neurologic function was associated with Medicare/Medicaid or Military insurance (p = 0.011).

Conclusions

The results of this study indicated that CCS patients typically come from lower socioeconomic backgrounds, as indicated by high SDI and ADI scores. Despite this, we did not find significant correlations between SDI or ADI with post-operative outcomes, and most patients had stable or improved neurological function post-surgery in our cohort. Future studies with larger sample sizes will provide a more comprehensive understanding of these findings.

The Effect of Community-Level Socioeconomic Status on Surgical Outcomes Following Revision Lumbar Fusion

BACKGROUND

The purpose of this study is to determine the impact of community-level socioeconomic status (SES) on surgical outcomes and patient-reported outcome measures (PROMs) following revision lumbar fusion.

METHODS

Adult patients who underwent revision lumbar fusion surgery from 2011-2021 were grouped by Distressed Community Index (DCI) into Prosperous, Comfortable, Mid-tier, and At-Risk/Distressed cohorts. Demographics, surgical information, and PROMs were compared based on DCI community status. Outcome measures were collected preoperatively, 3 months postoperatively, and 1 year postoperatively.

RESULTS

Eight hundred fifty three patients were included in the final cohort. There was no difference in terms of surgical approach or utilization of a staged procedure between the patient groups. Readmission (P = 0.752) and reoperation rates (P = 0.467) were similar across all community groups. Furthermore, for patients who required reoperation, the incision and drainage or revision surgery rate in each cohort was not statistically different (P = 0.902). Prosperous community patients reported significantly lower Visual Analog Scale Back pain preoperatively in comparison to patients from other DCI communities. All groups experienced a similar degree of postoperative improvement in Visual Analog Scale Back scores (P = 0.271). There were no other differences in preoperative or postoperative PROMs analyzed.

CONCLUSIONS

While there are socioeconomic differences based on DCI, community-level SES was not predictive of worse surgical outcomes following revision lumbar fusion. Patients from the most distressed communities were able to achieve similar improvement after revision surgery. This should encourage spine surgeons to feel comfortable discussing an indicated revision lumbar procedure with patients, and not view SES as a barrier to successful outcomes.

Disparities in Patient-reported Outcome Measure Completion Rates and Baseline Function in Newly Presenting Spine Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

The purpose of this study was to evaluate disparities in patient-reported outcome measures (PROM) completion rates and baseline function scores among newly presenting spine patients.

SUMMARY OF BACKGROUND DATA

Prior studies have demonstrated that minority patients and those of low socioeconomic status may present with worse physical and mental health on PROMs. As PROMs are increasingly used in clinical care, research, and health policy, accurate assessment of health status among populations relies on the successful completion of PROM instruments.

METHODS

A retrospective review of 10,803 consecutive new patients presenting to a single multidisciplinary spine clinic from June 2020 to September 2022 was performed. Univariate statistics were performed to compare demographics between patients who did and did not complete PROMs. Multivariable analysis was used to compare PROM instrument completion rates by race, ethnicity, and Social Vulnerability Index (SVI) and baseline scores among responders.

RESULTS

A total of 68.4% of patients completed PROMs at the first clinic visit. After adjusting for age, sex, body mass index, and diagnosis type, patients of non-White race (OR=0.661, 95% CI=0.599-0.729, P <0.001), Hispanic ethnicity (OR=0.569, 95% CI=0.448-0.721, P <0.001), and increased social vulnerability (OR=0.608, 95% CI=0.511-0.723, P <0.001) were less likely to complete PROMs. In the multivariable models, patients of non-White race reported lower levels of physical function (β=-6.5, 95% CI=-12.4 to -0.6, P =0.032) and higher levels of pain intensity (β=0.6, 95% CI=0.2-1.0, P =0.005). Hispanic ethnicity (β=1.5, 95% CI=0.5-2.5, P =0.004) and increased social vulnerability (β=1.1, 95% CI=0.4-1.8, P =0.002) were each associated with increased pain intensity.

CONCLUSIONS

Among newly presenting spine patients, those of non-White race, Hispanic ethnicity, and with increased social vulnerability were less likely to complete PROMs. As these subpopulations also reported worse physical function or pain intensity, additional strategies are needed to better capture patient-reported health status to avoid bias in clinical care, outcomes research, and health policy.

LEVEL OF EVIDENCE

4.

A Review of the Public Health Literature Examining the Roles of Socioeconomic Status and Race/Ethnicity on Health Outcomes in the United States

This review of reviews examines the role of socioeconomic status (SES) indicators on health inequities among different racial and ethnic groups in the United States (US) between 2019 and 2023. Of the 419 articles, 27 reviews met the inclusion criteria and were aggregated into seven categories: COVID-19 and respiratory pandemic disparities; neighborhoods, gentrification, and food environment; surgical treatments; mental, psychological, and behavioral health; insurance, access to care, and policy impact; cancers; and other topics. The findings revealed a documented impact of SES indicators on racial/ethnic health inequities, with racial/ethnic minority communities, especially Black Americans, consistently showing poor health outcomes associated with lower SES, regardless of the outcome or indicator examined. These findings call attention to the importance of policies and practices that address socioeconomic factors and systemic racial/ethnic inequities affecting the social determinants of health affecting racial/ethnic inequities to improve health outcomes in the US population.

The impact of socioeconomic determinants on the access to care and survival in patients with spinal chordomas- a national cancer database analysis

PURPOSE

Chordomas are rare malignant neoplasms primarily treated surgically. Disparities related to race and socioeconomic status, may affect patient outcomes. This study aims to identify prognostic factors for access to care and survival in patients with spinal chordomas.

METHODS

The NCDB database was queried between the years 2004 and 2017. Kaplan-Meier curves were constructed to compare survival probabilities among different groups, based on race and socioeconomic determinents.

RESULTS

1769 patients were identified, with 87% being White, 5% Hispanic, 4% Black, and Asian each. The mean age was 61.3 years. Most patients received care at academic/research centers and lived in a large metropolitan area, with no difference between races. A significantly higher percentage of Black patients did not undergo surgery (p < 0.001), with no statistically significant difference in survival between races (p = 0.97). A higher survival probability was seen in patients with other government insurances (p < 0.0001), in higher income quartiles (p < 0.0001), in metropolitan areas (p = 0.023), and at an academic/research center (p < 0.0001). A lower survival probability was seen in patients who are uninsured, in rural areas, and at community cancer programs (p < 0.0001).

CONCLUSION

This study highlights disparities in access to surgical intervention for patients with spinal chordomas, especially among Black individuals. It emphasizes the significant impact of insurance status and income on access to surgical care and highlights geographical and institutional variations in survival rates. Addressing socioeconomic differences is crucial for fostering equity in neurosurgical outcomes.

Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting

BACKGROUND CONTEXT

Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated.

PURPOSE

This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021.

OUTCOME MEASURES

Thirty-day rates of serious and minor adverse events, readmission, reoperation, nonhome discharge, and mortality.

METHODS

A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) nonhome discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences.

RESULTS

Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs 11.8%) and OP (92.7% vs 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and nonhome discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, nonhome discharge, or death (p>.050 for all).

CONCLUSIONS

Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.

Social determinants of health and disparities in spine surgery: a 10-year analysis of 8,565 cases using ensemble machine learning and multilayer perceptron

BACKGROUND CONTEXT

The influence of SDOH on spine surgery is poorly understood. Historically, researchers commonly focused on the isolated influences of race, insurance status, or income on healthcare outcomes. However, analysis of SDOH is becoming increasingly more nuanced as viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDOH on healthcare delivery.

PURPOSE

The aim of this study was to evaluate the effects of patient social history on length of stay (LOS) and readmission within 90 days following spine surgery using ensemble machine learning and multilayer perceptron.

STUDY DESIGN

Retrospective chart review.

PATIENT SAMPLE

8,565 elective and emergency spine surgery cases performed from 2013 to 2023 using our institution's database of longitudinally collected electronic medical record information.

OUTCOMES MEASURES

Patient LOS, discharge disposition, and rate of 90-day readmission.

METHODS

Ensemble machine learning and multilayer perceptron were employed to predict LOS and readmission within 90 days following spine surgery. All other subsequent statistical analysis was performed using SPSS version 28. To further assess correlations among variables, Pearson's correlation tests and multivariate linear regression models were constructed. Independent sample t-tests, paired sample t-tests, one-way analysis of variance (ANOVA) with post-hoc Bonferroni and Tukey corrections, and Pearson's chi-squared test were applied where appropriate for analysis of continuous and categorical variables.

RESULTS

Black patients demonstrated a greater LOS compared to white patients, but race and ethnicity were not significantly associated with 90-day readmission rates. Insured patients had a shorter LOS and lower readmission rates compared to non-insured patients, as did privately insured patients compared to publicly insured patients. Patients discharged home had lower LOS and lower readmission rates, compared to patients discharged to other facilities. Marriage decreased both LOS and readmission rates, underweight patients showcased increased LOS and readmission rates, and religion was shown to impact LOS and readmission rates. When utilizing patient social history, lab values, and medical history, machine learning determined the top 5 most-important variables for prediction of LOS -along with their respective feature importances-to be insurance status (0.166), religion (0.100), ICU status (0.093), antibiotic use (0.061), and case status: elective or urgent (0.055). The top 5 most-important variables for prediction of 90-day readmission-along with their respective feature importances-were insurance status (0.177), religion (0.123), discharge location (0.096), emergency case status (0.064), and history of diabetes (0.041).

CONCLUSIONS

This study highlights that SDOH is influential in determining patient length of stay, discharge disposition, and likelihood of readmission following spine surgery. Machine learning was utilized to accurately predict LOS and 90-day readmission with patient medical history, lab values, and social history, as well as social history alone.

Exploring Differences in Intraoperative Medication Use Between African American and Non-Hispanic White Patients During General Anesthesia: Retrospective Observational Cohort Study

This study aimed to explore whether differences exist in anesthesia care providers' use of intraoperative medication between African American and non-Hispanic White patients in adult surgical patients who underwent noncardiothoracic nonobstetric surgeries with general anesthesia. A retrospective observational cohort study used electronic health records between January 1, 2018 and August 31, 2019 at a large academic health system in the southeastern United States. To evaluate the isolated impact of race on intraoperative medication use, inverse probability of treatment weighting using the propensity scores was used to balance the covariates between African American and non-Hispanic White patients. Regression analyses were then performed to evaluate the impact of race on the total dose of opioid analgesia administered, and the use of midazolam, sugammadex, antihypotensive drugs, and antihypertensive drugs. Of the 31,790 patients included in the sample, 58.9% were non-Hispanic Whites and 13.6% were African American patients. After adjusting for significant covariates, African American patients were more likely to receive midazolam premedication (p < .0001; adjusted odds ratio [aOR] = 1.17, 99.9% CI [1.06, 1.30]), and antihypertensive drugs (p = .0002; aOR = 1.15, 99.9% CI [1.02, 1.30]), and less likely to receive antihypotensive drugs (p < .0001; aOR = 0.85, 99.9% CI [0.76, 0.95]) than non-Hispanic White patients. However, we did not find significant differences in the total dose of opioid analgesia administered, or sugammadex. This study identified differences in intraoperative anesthesia care delivery between African American and non-Hispanic White patients; however, future research is needed to understand mechanisms that contribute to these differences and whether these differences are associated with patient outcomes.

Trends in avascular necrosis and related arthroplasties in hospitalized patients with systemic lupus erythematosus and rheumatoid arthritis

OBJECTIVE

Avascular necrosis (AVN) is a devastating complication often necessitating arthroplasty, particularly common in systemic lupus erythematosus (SLE). Limited research exists on arthroplasty trends since new steroid-sparing agents. We analyzed trends and characteristics associated with AVN and AVN-related arthroplasties among SLE and RA hospitalizations using two decades of data from the U.S. National Inpatient Sample (NIS).

METHODS

This cross-sectional study used NIS (2000-2019) to identify hospitalized adults with SLE and RA, with or without AVN, using ICD codes. AVN was further grouped by arthroplasty status. Primary outcomes were AVN and AVN-related arthroplasty rates and time trends in SLE and RA. Baseline sociodemographics and comorbidities were compared. Analyses used STATA and Joinpoint regression to calculate annual percent change (APC).

RESULTS

Overall, 42,728 (1.3 %) SLE and 43,600 (0.5 %) RA hospitalizations had concomitant AVN (SLE-AVN and RA-AVN). Of these, 16,724 (39 %) and 25,210 (58 %) underwent arthroplasties, respectively. RA-AVN increased (APC: 0.98*), with a decrease in arthroplasties (APC: -0.82*). In contrast, SLE-AVN initially increased with a breakpoint in 2011 (APC 2000-2011: 1.94* APC 2011-2019 -2.03), with declining arthroplasties (APC -2.03*). AVN hospitalizations consisted of individuals who were younger and of Black race; while arthroplasties were less likely in individuals of Black race or Medicaid coverage.

CONCLUSION

We report a breakpoint in rising SLE-AVN after 2011, which may relate to newer steroid-sparing therapies (i.e., belimumab). AVN-associated arthroplasties decreased in SLE and RA. Fewer AVN-associated arthroplasties were noted for Black patients and those with Medicaid, indicating potential disparities. Further research should examine treatment differences impacting AVN and arthroplasty rates.

Racial Disparities in Opioid Use and Lumbar Spine Surgery for Chronic Pain and in Pain and Function Over 3 Years: A Retrospective Cohort Study

This study aims to compare treatments and outcomes among Black and White patients with chronic low back pain in the United States. A retrospective cohort study was conducted within a pain research registry, including 1,443 participants with up to 3 years of follow-up. Pain treatments were measured at quarterly research encounters using reported current opioid use and prior lumbar spine surgery. Pain intensity and functional disability were also measured quarterly with a numerical rating scale and the Roland-Morris Disability Questionnaire, respectively. Longitudinal data were analyzed with generalized estimating equations, including multivariable models to measure temporal trends and adjust for potential confounders. The mean baseline age of participants was 53.5 years (SD, 13.1 years); 1,074 (74.4%) were female, and 260 (18.0%) were Black. In longitudinal multivariable analyses, Black participants reported more frequent current opioid use (odds ratio, 1.40; 95% confidence interval [CI], 1.03-1.91; P = .03) and less frequent lumbar spine surgery (odds ratio, .45; 95% CI, .28-.72; P < .001). Black participants also reported greater pain intensity (mean, 6.6; 95% CI, 6.3-6.9 vs mean, 5.6; 95% CI, 5.4-5.8; P < .001) and functional disability (mean, 15.3; 95% CI, 14.6-16.0 vs mean, 13.8; 95% CI, 13.2-14.3; P = .002). Racial disparities were clinically important (risk ratio = 1.28 and risk ratio = .49, respectively, for opioid use and surgery; and d = .46 and d = .24, respectively, for pain and function). Racial disparities in pain and function also widened over time. Thus, barriers to guideline-adherent and specialized pain care among Black patients may affect pain and function outcomes. Greater efforts are needed to address the observed racial disparities. PERSPECTIVE: Widening racial disparities in pain and function over time indicate that new approaches to chronic pain management are needed in the United States. Considering race as a social framework represents an emerging strategy for planning and improving pain treatment services for Black patients.

Socioeconomic Status Correlates With Initial Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) Scores but Not the Likelihood of Spine Surgery

Objective To explore how socioeconomic status and patient characteristics may be associated with initial self-reports of pain and determine if there was an increased association with undergoing spine surgery. Methods Patients at an academic center between 2015 and 2021 who completed the Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) questionnaire were included. Multivariable linear regression models were used to determine the association between insurance type and patient factors with initial reports of pain. Multivariable logistic regression models were used to determine the association between PI and the likelihood of surgery in two time periods, three and 12 months. Results The study included 9,587 patients. The mean PROMIS-PI scores were 61.93 (SD 7.82) and 63.74 (SD 6.93) in the cervical and lumbar cohorts, respectively. Medicaid and Workers' Compensation insurance patients reported higher pain scores compared to those with private insurance: Medicaid (cervical: 2.77, CI (1.76-3.79), p<0.001; lumbar (2.05, CI (1.52-2.59), p<0.001); Workers' Compensation (cervical: 2.12, CI (0.96-3.27), p<0.001; lumbar: 1.51, CI (0.79-2.23), p<0.001). Black patients reported higher pain compared to White patients (cervical: 1.50, CI (0.44-2.55), p=0.01; lumbar: 1.51, CI (0.94-2.08), p<0.001). Higher PROMIS-PI scores were associated with a higher likelihood of surgery. There was no increased association of likelihood of surgery in Black, Medicaid, or Workers' Compensation patients when controlling for pain severity. Conclusion Black patients and patients with Medicaid and Workers' compensation insurance were likely to report higher pain scores. Higher initial pain scores were associated with an increased likelihood of surgery. However, despite increased pain scores, Black patients and those with Medicaid and Workers' Compensation insurance did not have a higher likelihood of undergoing surgery.

Increased Time to Fixation After Traumatic Spinal Cord Injury Influenced by Race and Insurance Status

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

Although the optimal timing of surgical intervention for traumatic spinal cord injury (TSCI) is controversial, early intervention has been recognized as being beneficial in several studies. The objective of this study was to evaluate the socioeconomic factors that may delay time to surgical fixation in the management of TSCI.

METHODS

The present study utilized the Trauma Quality Improvement Program (TQIP) dataset to identify patients aged greater than 18 undergoing spinal fusion for TSCI from 2007-2016. Patients were divided into subgroups based on race and insurance types. Multivariable linear regression was used to compare time to procedure based on race and payer type while adjusting for demographic and injury-specific factors. Significance was set at P < .05.

RESULTS

Using multivariable analysis, Hispanic and Black patients were associated with significantly increased time to fixation of 12.1 h (95% CI 5.5-18.7, P < .001), and 20.1 h (95% CI 12.1-28.1, P < .001), respectively compared to White patients. Other cohorts based on racial status did not have significantly different times to fixation (P > .05). Medicaid was associated with an increased time to fixation compared to private insurance (11.6 h, 95% CI 3.9-19.2, P = .003).

CONCLUSIONS

Black and Hispanic race and Medicaid were associated with statistically significant increases in time to fixation following TSCI, potentially compromising quality of patient care and resulting in poorer outcomes. More research is needed to elucidate this relationship and ensure equitable care is being delivered.

The Impact of Neighborhood Socioeconomic Disadvantage on Operative Outcomes after Single-Level Lumbar Fusion

INTRODUCTION

The relationship between socioeconomic status and neurosurgical outcomes has been investigated with respect to insurance status or median household income, but few studies have considered more comprehensive measures of socioeconomic status. This study examines the relationship between Area Deprivation Index (ADI), a comprehensive measure of neighborhood socioeconomic disadvantage, and short-term postoperative outcomes after lumbar fusion surgery.

METHODS

1861 adult patients undergoing single-level, posterior-only lumbar fusion at a single, multihospital academic medical center were retrospectively enrolled. An ADI matching protocol was used to identify each patient's 9-digit zip code and the zip code-associated ADI data. Primary outcomes included 30- and 90-day readmission, emergency department visits, reoperation, and surgical complication. Coarsened exact matching was used to match patients on key demographic and baseline characteristics known to independently affect neurosurgical outcomes. Odds ratios (ORs) were computed to compare patients in the top 10% of ADI versus lowest 40% of ADI.

RESULTS

After matching (n = 212), patients in the highest 10% of ADI (compared to the lowest 40% of ADI) had significantly increased odds of 30- and 90-day readmission (OR = 5.00, P < 0.001 and OR = 4.50, P < 0.001), ED visits (OR = 3.00, P = 0.027 and OR = 2.88, P = 0.007), and reoperation (OR = 4.50, P = 0.039 and OR = 5.50, P = 0.013). There was no significant association with surgical complication (OR = 0.50, P = 0.63).

CONCLUSIONS

Among otherwise similar patients, neighborhood socioeconomic disadvantage (measured by ADI) was associated with worse short-term outcomes after single-level, posterior-only lumbar fusion. There was no significant association between ADI and surgical complications, suggesting that perioperative complications do not explain the socioeconomic disparities in outcomes.

Efficacy of an Opioid-Sparing Perioperative Multimodal Analgesia Protocol on Posterior Lumbar Fusion in a Hispanic Population: A Randomized Controlled Trial

INTRODUCTION

Posterior lumbar fusion surgery has become more common amid an aging population, with degenerative disease as its most common indication. Historically, postoperative pain control for spine surgery has relied on opioids. However, opioid use is associated with adverse effects such as dependence, respiratory depression, and altered cognition. Our study aimed to determine whether an opioid-sparing multimodal analgesia regimen (ketorolac, orphenadrine, and gabapentin) could be a viable alternative to diminish opioid use compared with a standard opioid-based regimen in Hispanic patients undergoing posterior lumbar spinal fusion.

METHODS

This was a randomized controlled trial of Hispanic patients scheduled to undergo elective posterior spinal fusion. Inclusion criteria included age 30 to 85 years, Hispanic ethnicity, lumbar stenosis between L1 and S1, elective posterior spinal fusion with instrumentation, American Society of Anesthesiologists Score <2, and consent to participate in the study. Patients were randomized into two groups, an experimental multimodal analgesia and control (opioid-based) treatment groups, and outcomes such as morphine milligram equivalents used, visual analog scale score, and length of hospital stay were compared between the groups.

RESULTS

The MMA experimental group used significantly lower amounts of opioid (measured with morphine milligram equivalent) than the opioid-based group during the 12-hour and 24-hour postoperative periods ( P -value = 0.023 and P -value = 0.033, respectively). No statistically significant difference was observed in opioid use in the 48-hour postoperative period between both groups ( P -value = 0.066). The MMA group had significantly lower VAS scores reported at the 12-hour, 24-hour, and 48-hour postoperative periods compared with the opioid-based group ( P -values = 0.016, 0.020, and 0.020, respectively). No difference was observed in the length of hospital stay between groups ( P -value = 0.169).

DISCUSSION

Implementing an MMA protocol in Hispanic patients undergoing posterior lumbar fusion resulted in decreased overall opioid use and decreased pain intensity compared with the opioid-based group. MMA is an effective alternative for pain control in patients who want to avoid opioid use.

CLINICAL TRIAL REGISTRATION

Identifier: NCT05413902.

Disparities in anterior cervical discectomy and fusion provision and outcomes for cervical stenosis

Background

Disparities in neurosurgical care have emerged as an area of interest when considering the impact of social determinants on access to health care. Decompression via anterior cervical discectomy and fusion (ACDF) for cervical stenosis (CS) may prevent progression towards debilitating complications that may severely compromise one's quality of life. This retrospective database analysis aims to elucidate demographic and socioeconomic trends in ACDF provision and outcomes of CS-related pathologies.

Methods

The Healthcare Cost and Utilization Project National Inpatient Sample database was queried between 2016 and 2019 using International Classification of Diseases 10th edition codes for patients undergoing ACDF as a treatment for spinal cord and nerve root compression. Baseline demographics and inpatient stay measures were analyzed.

Results

Patients of White race were significantly less likely to present with manifestations of CS such as myelopathy, plegia, and bowel-bladder dysfunction. Meanwhile, Black patients and Hispanic patients were significantly more likely to experience these impairments representative of the more severe stages of the degenerative spine disease process. White race conferred a lesser risk of complications such as tracheostomy, pneumonia, and acute kidney injury in comparison to non-white race. Insurance by Medicaid and Medicare conferred significant risks in terms of more advanced disease prior to intervention and negative inpatient. Patients in the highest quartile of median income consistently fared better than patients in the lowest quartile across almost every aspect ranging from degree of progression at initial presentation to incidence of complications to healthcare resource utilization. All outcomes for patients age > 65 were worse than patients who were younger at the time of the intervention.

Conclusions

Significant disparities exist in the trajectory of CS and the risks associated with ACDF amongst various demographic cohorts. The differences between patient populations may be reflective of a larger additive burden for certain populations, especially when considering patients' intersectionality.

Diversity in Orthopaedic Surgery Medical Device Clinical Trials: An Analysis of the Food and Drug Administration Safety and Innovation Act

INTRODUCTION

Demographic factors contribute markedly to orthopaedic surgery outcomes. However, women and minorities have been historically excluded from clinical trials. The United States passed the Safety and Innovation Act (Food and Drug Administration Safety and Innovation Act [FDA-SIA]) in 2012 to increase study diversity and mandate reporting of certain demographics. The purpose of this study was to investigate demographic reporting and analysis among high-risk orthopaedic medical device trials and evaluate the effectiveness of the FDA-SIA in increasing diversity of study enrollment.

METHODS

The premarket approval database was queried for all original submissions approved by the Orthopedic Advisory Committee from January 1, 2003, to July 1, 2022. Study demographics were recorded. Weighted means of race, ethnicity, and sex were compared before and after FDA-SIA implementation with the US population.

RESULTS

We identified 51 orthopaedic trials with unique study data. Most Food and Drug Administration device trials reported age (98.0%) and sex (96.1%), but only 49.0% and 37.3% reported race and ethnicity, respectively. Only 23 studies analyzed sex, six analyzed race, and two analyzed ethnicity. Compared with the US population, participants were overwhelmingly White (91.36% vs. 61.63%, P < 0.001) with a significant underrepresentation of Black (3.65% vs. 12.41%, P = 0.008), Asian (0.86% vs. 4.8%, P = 0.030), and Hispanic participants (3.02% vs. 18.73%, P < 0.001) before 2013. The FDA-SIA increased female patient enrollment (58.99% vs. 47.96%, P = 0.021) but did not increase the enrollment of racial or ethnic minorities.

CONCLUSION

Despite efforts to increase the generalizability of studies within the FDA-SIA, orthopaedic medical devices still fail to enroll diverse populations and provide demographic subgroup analysis. The study populations within these trials do not represent the populations for whom these devices will be indicated in the community. The federal government must play a stronger role in mandating study diversity, enforcing appropriate statistical analysis of the demographic subgroups, and executing measures to ensure compliance.

LEVEL OF EVIDENCE

I.

Patients From Socioeconomically Distressed Communities Experience Similar Clinical Improvements Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

The aim was to compare patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF) when categorizing patients based on socioeconomic status. Secondarily, we sought to compare PROMs based on race.

SUMMARY OF BACKGROUND DATA

Social determinants of health are believed to affect outcomes following spine surgery, but there is limited literature on how combined socioeconomic status metrics affect PROMs following ACDF.

MATERIALS AND METHODS

The authors identified patients who underwent primary elective one-level to four-level ACDF from 2014 to 2020. Patients were grouped based on their distressed community index (DCI) quintile (Distressed, At-Risk, Mid-tier, Comfortable, and Prosperous) and then race (White or Black). Multivariate regression for ∆PROMs was performed based on DCI group and race while controlling for baseline demographics and surgical characteristics.

RESULTS

Of 1204 patients included in the study, all DCI groups improved across all PROMs, except mental health component score (MCS-12) for the Mid-tier group ( P =0.091). Patients in the Distressed/At-Risk group had worse baseline MCS-12, visual analog scale (VAS) Neck, and neck disability index (NDI). There were no differences in magnitude of improvement between DCI groups. Black patients had significantly worse baseline VAS Neck ( P =0.002) and Arm ( P =0.012) as well as worse postoperative MCS-12 ( P =0.016), PCS-12 ( P =0.03), VAS Neck ( P <0.001), VAS Arm ( P =0.004), and NDI ( P <0.001). Multivariable regression analysis did not identify any of the DCI groupings to be significant independent predictors of ∆PROMs, but being White was an independent predictor of greater improvement in ∆PCS-12 (β=3.09, P =0.036) and ∆NDI (β=-7.32, P =0.003).

CONCLUSIONS

All patients experienced clinical improvements regardless of DCI or race despite patients in Distressed communities and Black patients having worse preoperative PROMs. Being from a distressed community was not an independent predictor of worse improvement in any PROMs, but Black patients had worse improvement in NDI compared with White patients.

LEVEL OF EVIDENCE

3.