Pathological evaluation of intervertebral disc tissue specimens after routine cervical and lumbar decompression. A cost-benefit analysis retrospective study

VERTEBROMETRY AND DISCOMETRY OF THE LUMBAR FUNCTIONAL SEGMENT (REBATÚ-MURGUÍA TECHNIQUE)

ABSTRACT Surgical treatment of intervertebral disc degeneration aims to restore the height of the disc space and the release of involved neurological structures. Like any surgical treatment in orthopedics, the success or failure of the lumbar procedure involves the possibility of performing an adequate planning of each particular event. In the case of lumbar stabilization surgery with interbody fusion, it is essential to know the ideal height of the disc space for the fusion to be successful. Objective: To demonstrate that the ideal height of the disc space corresponds approximately to one third of the height of the vertebral body. Methods: X-ray images were taken in AP and lateral views of hospital residents to measure L4-L5 vertebral bodies as well as the disc space. The rule of three was used to check the height of the disc and vertebral bodies. Results: It was verified that the disc space corresponds to 31% of the size of the vertebral body, taking 0.31 as the constant. Conclusions: The size of the disc corresponds to one third of the vertebral body, taking 0.31 as the constant. The multiplication of the constant by the height of the vertebral body results in the exact height of the disc. Thus, in the presence of degeneration of the intervertebral disc, it is possible to know the size of the disc and, therefore, the size of the interbody cage.

Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty

BACKGROUND

The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice.

METHODS

This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis.

RESULTS

We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78.

DISCUSSION/CONCLUSION

Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.

Costs Versus Benefits of Routine Histopathological Examination in Total Ankle Replacement

BACKGROUND

Routine histopathological examination has previously been scrutinized as a source of extraneous cost in orthopedic foot and ankle care. As an increasingly prevalent joint replacement operation, total ankle replacement poses a notable cost to the health care market in an era of cost containment. The purpose of this study was to compare the costs and benefits of routine histopathological examination of specimens removed during total ankle replacement. We hypothesized that a new diagnosis would rarely be found and such examination would seldom alter patient care.

METHODS

A retrospective review was conducted of all total ankle replacement operations between 2006 and July 2014 at the investigators' institution. Medical records for 90 patients, undergoing a total of 95 total ankle replacement operations, were reviewed to determine the clinical and pathological diagnoses for each operation and, subsequently, the rates of discrepancy and discordance. Professional charges were determined using estimated reimbursement rates for the Current Procedural Terminology (CPT) codes billed: 88304 (level III microscopic examination), 88305 (level IV microscopic examination), and 88311 (decalcification).

RESULTS

Degenerative joint disease was diagnosed by the pathologist in 93.7% of cases (89/95), pseudogout in 4.2% (4/95), and rheumatoid arthritis in 2.1% (2/95). The 4 diagnoses of pseudogout were the only cases of new diagnoses based on pathological review. A total of $16,536.81 was spent for examination of all specimens, for an estimated $4,134.20 spent per discrepant diagnosis. Patient care was unaffected by pathological examination.

CONCLUSION

A new diagnosis was rarely found by histopathological examination, and patient care remained unaltered in all cases. The costs of routine histopathological examination of tissue specimens removed during total ankle replacement, therefore, outweigh clinical benefits, and such examination should be left to the discretion of the operating surgeon.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Routine Examination of Pathology Specimens Following Knee Arthroscopy: A Cost-Effectiveness Analysis

BACKGROUND

While the clinical value of routine pathologic examination of tissues removed during orthopaedic procedures has not been determined, limited cost-effectiveness and a low prevalence of findings that alter patient management have been previously demonstrated with arthroscopy. The purpose of this study was to examine the clinical value and cost-effectiveness of routine histological examination of knee arthroscopy specimens.

METHODS

Retrospective chart analysis of 3797 consecutive knee arthroscopies by two surgeons from 2004 to 2013 at three affiliated hospitals within one health-care system was undertaken. Pathology reports regarding tissue removed during partial meniscectomies and anterior cruciate ligament reconstructions were reviewed to determine if the results altered patient care. The total costs of histological examination were estimated in 2012-adjusted U.S. dollars. The cost per health effect was determined by calculating the cost per discrepant and discordant diagnosis.

RESULTS

The prevalence of concordant diagnoses was 99.3% (3769 of 3797), the prevalence of discrepant diagnoses was 0.7% (twenty-seven of 3797), and the prevalence of discordant diagnoses was 0.026% (one of 3797). The total cost of histological examinations was estimated to be $371,810. The total cost of the pathology cost per discrepant diagnosis was $13,771, and the cost per discordant diagnosis was $371,810.

CONCLUSIONS

Routine pathological examination of surgical specimens from patients undergoing knee arthroscopy had limited cost-effectiveness because of the low prevalence of findings that altered patient management. Histological examination of surgical specimens from arthroscopic knee surgery did not alter patient care and increased costs. We suggest that gross and histological examination of tissue removed during knee arthroscopy should be done at the discretion of the orthopaedic surgeon rather than being mandatory.

Publication patterns of comparative effectiveness research in spine neurosurgery

OBJECT

The purpose of this study was to investigate publication patterns for comparative effectiveness research (CER) on spine neurosurgery.

METHODS

The authors searched the PubMed database for the period 1980-2012 using the key words "cost analysis," "utility analysis," "cost-utility," "outcomes research," "practical clinical research," "comparator trial," and "comparative effectiveness research," linked with "effectiveness" and "spine neurosurgery."

RESULTS

From 1980 through April 9, 2012, neurosurgery CER publications accounted for 1.38% of worldwide CER publications (8657 of 626,330 articles). Spine neurosurgery CER accounted for only 0.02%, with 132 articles. The journal with the greatest number of publications on spine neurosurgery CER was Spine, followed by the Journal of Neurosurgery: Spine. The average annual publication rate for spine neurosurgery CER during this period was 4 articles (132 articles in 33 years), with 68 (51.52%) of the 132 articles being published within the past 5 years and a rising trend beginning in 2008. The top 3 contributing countries were the US, Turkey, and Japan, with 68, 8, and 7 articles, respectively. Only 8 regular articles (6.06%) focused on cost analysis.

CONCLUSIONS

There is a paucity of publications using CER methodology in spine neurosurgery. Few articles address the issue of cost analysis. The promotion of continuing medical education in CER methodology is warranted. Further investigations to address cost analysis in comparative effectiveness studies of spine neurosurgery are crucial to expand the application of CER in public health.

Histologic examinations of arthroplasty specimens are not cost-effective: a retrospective cohort study

BACKGROUND

Many hospitals require all operative specimens be sent to pathologists for routine examination. Although previous studies indicate this practice increases medical cost, it remains unclear whether it alters patient management and whether it is cost-effective.

QUESTIONS/PURPOSES

We therefore (1) determined the rate of discordance between clinical and histologic examinations of routine operative specimens during elective primary arthroplasties, (2) determined the cost of routine histologic screening, and (3) estimated its cost-effectiveness in terms of cost per quality-adjusted life year gained, as compared with gross examination or no examination.

METHODS

We retrospectively reviewed medical records of 1247 patients who underwent 1363 routine elective primary total joint arthroplasties between January 18, 2006 and March 15, 2010. We compared preoperative, postoperative, and histologic diagnoses for each patient and categorized them into three classes: concordant (clinical and histologic diagnoses agreed), discrepant (diagnoses differed but with no resultant change in treatment), and discordant (diagnoses differed with resultant change in treatment). Medicare reimbursements were determined through the pathology department's administrative office.

RESULTS

In 1363 cases, 1335 (97.9%) clinical and histologic diagnoses were concordant, 28 (2.1%) were discrepant, and none were discordant. Total reimbursement for routine pathological examination was $139,532, or $102.37 per specimen. The average cost to identify each discrepant case was $4983.29. Routine histologic examination did not alter patient management, and there was no direct gain in quality-adjusted life years.

CONCLUSIONS

Our observations show routine histologic examinations of routine operative specimens during elective primary arthroplasties increase medical cost but rarely alter patient management and are not cost-effective.

LEVEL OF EVIDENCE

Level I, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Histological analysis of surgical lumbar intervertebral disc tissue provides evidence for an association between disc degeneration and increased body mass index

Background

Although histopathological grading systems for disc degeneration are frequently used in research, they are not yet integrated into daily care routine pathology of surgical samples. Therefore, data on histopathological changes in surgically excised disc material and their correlation to clinical parameters such as age, gender or body mass index (BMI) is limited to date. The current study was designed to correlate major physico-clinical parameters from a population of orthopaedic spine center patients (gender, age and BMI) with a quantitative histologic degeneration score (HDS).

Methods

Excised lumbar disc material from 854 patients (529 men/325 women/mean age 56 (15-96) yrs.) was graded based on a previously validated histologic degeneration score (HDS) in a cohort of surgical disc samples that had been obtained for the treatment of either disc herniation or discogenic back pain. Cases with obvious inflammation, tumor formation or congenital disc pathology were excluded. The degree of histological changes was correlated with sex, age and BMI.

Results

The HDS (0-15 points) showed significantly higher values in the nucleus pulposus (NP) than in the annulus fibrosus (AF) (Mean: NP 11.45/AF 7.87), with a significantly higher frequency of histomorphological alterations in men in comparison to women. Furthermore, the HDS revealed a positive significant correlation between the BMI and the extent of histological changes. No statistical age relation of the degenerative lesions was seen.

Conclusions

This study demonstrated that histological disc alterations in surgical specimens can be graded in a reliable manner based on a quantitative histologic degeneration score (HDS). Increased BMI was identified as a positive risk factor for the development of symptomatic, clinically significant disc degeneration.

Histopathological examination of intervertebral disc specimens: a cost-benefit analysis

OBJECT

Routine histopathological examination of intervertebral disc specimens is commonly performed in North American hospitals, but recent studies have questioned the utility of this practice in cases where the indication for surgery is a benign process such as degenerative disc disease. In this study, we have performed a cost-benefit analysis of this practice.

METHODS

We performed a cost-benefit analysis of routine histopathological examination of 1775 routine (non-neoplastic and non-infectious indications for surgery) and 70 non-routine (suspected neoplastic or infectious indications for surgery) discectomy specimens obtained over an eight-year period (1996 and 2004). Chart reviews were used to determine if any histopathology findings were clinically significant (i.e., affected subsequent patient care). Total costs were calculated. A literature review was conducted to compare our results with other published series.

RESULTS

We found four unexpected histopathology results among 1775 specimens obtained from routine cases, one of which was clinically significant. We calculated costs of $42,165.25 per unexpected histopathological finding and $168,625 per clinically significant histopathological finding. For non-routine surgeries, the cost per abnormal pathological finding was $116.67.

CONCLUSIONS

In routine cases, histopathological examination of disc specimens is not justified. The decision to send specimens for pathological examination should be based on the surgeon's judgment.

Incidence of unusual and clinically significant histopathological findings in routine discectomy

OBJECT

Routine histopathological examination of discectomy specimens remains common practice in many hospitals, although it rarely detects unsuspected clinically significant disease. Controversy exists as to the effectiveness of this practice. The objectives of this study were to compare the authors' experience with a review of the literature.

METHODS

In a retrospective database analysis the authors identified all intervertebral disc specimens obtained during spinal procedures over an 8-year period (1996-2004). Cases of benign (nonneoplastic and noninfectious) indications for surgery were included in the study, whereas cases of nonbenign indications were excluded. The final pathological diagnoses were reviewed, and a chart review was performed to determine whether any unexpected findings affected subsequent patient care. A total of 1858 discectomy specimens were identified: 1775 of these were obtained in 1719 routine discectomy procedures. Unexpected histopathological findings were identified in four cases, and none was clinically significant.

CONCLUSIONS

Routine histopathological examination of disc specimens is not justified. The decision to send specimens for pathological examination should be determined on a case-by-case basis after consideration of the clinical presentation, results of laboratory and imaging studies, and intraoperative findings.

Frequency of unexpected and important histopathological findings in routine intervertebral disc surgery

Object

The value of routine histopathological examination of intervertebral disc tissue has been questioned, but sufficient numbers of studies have yet to be conducted to provide a definitive sense of its importance. The aim of this study was to investigate the nature and frequency of unexpected histopathological findings in intervertebral disc surgery.

Methods

The authors conducted a retrospective examination of consecutive surgical specimens obtained in patients with benign indication for discectomy at four neurosurgical centers.

Surgical specimens obtained during 2102 operations (2177 intervertebral discs) in 2017 patients were evaluated. In addition to one case of cavernous malformation, two specimens (obtained in 0.1% of patients) revealed unexpected pathological diagnoses of malignancy (metastasized prostate carcinoma and diffuse large B-cell lymphoma).

Conclusions

The results of this retrospective study suggest that routine histopathological examination of specimens obtained during intervertebral disc procedures is both justified and cost effective.

Cost-effectiveness, cost-utility, and cost-benefit studies in rheumatology: a review of the literature, 2001-2002

Economic analyses of prevention and treatment interventions in rheumatology are potentially powerful tools for evaluating many complex decisions facing clinical and public policy makers. Cost-effectiveness, cost-utility, and cost-benefit analyses allow for the assessment of the trade-offs between expended resources and expected health benefits. This review describes 12 cost-effectiveness analyses done in the past year. Each relates to a different intervention for a variety of rheumatologic conditions including osteoporosis, rheumatoid arthritis, the use of cyclooxygenase-II inhibitors, infected total joint replacements, back pain, and Lyme disease. While cost-effectiveness analyses of the use of the new biologic agents in rheumatoid arthritis have been presented at national meetings, these have yet to be published. Proper use of cost-effectiveness analysis could provide valuable evidence about treatment decisions for clinical and public policy makers in rheumatology.